3: ACLS Guidelines for Adult Emergency Cardiac Care Algorithms

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Section III ACLS Guidelines for Adult Emergency Cardiac Care Algorithms

Pulseless Ventricular Tachycardia (VT)/Ventricular Fibrillation (VF)

Basic life support

Perform BLS Primary Survey

• Assess responsiveness.

• Call for help/Call for defibrillator.

Airway

• Open the airway.

Breathing

• Deliver two rescue breaths; administer oxygen as soon as it is available.

Circulation

• Perform high quality chest compressions until monitor/AED becomes available.

Do not interrupt CPR for more than 5–10 seconds for any reason

Defibrillation

• On arrival of AED/monitor/defibrillator, evaluate cardiac rhythm.

• If PEA or asystole, continue CPR and go to appropriate algorithm.

• If pulseless VF/VT, shock one time using 200 J biphasic if manufacturer’s suggested energy is unknown or 360 J monophasic.

• Resume CPR immediately after shock delivered.

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Advanced life support

Reevaluate Cardiac Rhythm after 2 minutes (about 5 cycles) of CPR

• If PEA or asystole, continue CPR and go to appropriate algorithm.

• If a non-shockable rhythm is present, attempt to palpate a pulse. The pulse check should take no more than 10 seconds.

• For persistent VF/pulseless VT, give one shock and immediately resume chest compressions after the shock.

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Pattern becomes CPR-shock-drug

Breathing

• Provide ventilation via bag-mask-valve device.

• Continue bag-mask-valve ventilation until condition allows for intubation.

• Two ventilations should be delivered after each cycle of 30 chest compressions.

Circulation

• Establish IV/IO access and administer a vasopressor during CPR.

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Epinephrine (Class Indeterminate)—1 mg (1:10,000 solution) IV every 3–5 minutes.

or

Vasopressin (Class IIb)—40 units IV bolus (administer only once). (If no response to vasopressin, may resume epinephrine after 10–20 minutes; epinephrine dose 1 mg every 3–5 minutes.)

• Give one shock and immediately resume chest compressions after the shock.

• Re-evaluate cardiac rhythm after 2 minutes (5 cycles) of CPR.

Consider antiarrhythmics (avoid use of multiple antiarrhythmics because of potential proarrhythmic effects).

• Amiodarone (Class IIb)—Initial bolus: 300 mg IV/IO bolus diluted in 20–30 mL of NS or D5W. Consider repeat dose (150 mg IV bolus) in 3–5 minutes. If defibrillation successful, follow with 1 mg/min IV infusion for 6 hours (mix 900 mg in 500 mL NS), then decrease infusion rate to 0.5 mg/min IV infusion for 18 hours. Maximum daily dose 2.2 g IV/24 hr.

• Lidocaine (Class Indeterminate)—1.0–1.5 mg/kg IV/IO bolus, consider repeat dose (0.5–0.75 mg/kg) in 5 minutes; maximum IV bolus dose 3 mg/kg. (The 1.5 mg/kg dose is recommended in cardiac arrest.)

• Magnesium (Class IIb if hypomagnesemia present)—1–2 g IV/IO (2–4 mL of a 50% solution) diluted in 10 mL of D5W if torsades de pointes or hypomagnesemia.

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Modified from Aehlert B: ACLS quick review study guide, ed 3, St. Louis, 2007, Mosby. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.

Asystole

Basic life support

Perform BLS Primary Survey

• Assess responsiveness.

• Call for help/Call for defibrillator.

Airway

• Open the airway.

Breathing

• Deliver two rescue breaths; administer oxygen as soon as it is available.

Circulation

• Perform high-quality chest compressions until monitor/AED becomes available.

• Scene survey—Documentation or other evidence of Do Not Attempt Resuscitation (DNAR)?

• Obvious signs of death? If yes, do not start/attempt resuscitation.

Advanced life support

Breathing

• Provide ventilation via bag-mask-valve device.

• Continue bag mask ventilation with minimal interruption to chest compressions until condition allows for intubation. Two ventilations should be provided after each cycle of 30 chest compressions.

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Possible causes of asystole: PATCH-4-MD Pulmonary embolism Acidosis Tension pneumothorax Cardiac tamponade Hypovolemia (most common cause) Hypoxia Heat/cold (hypothermia/ hyperthermia) Hypokalemia/ hyperkalemia (and other electrolytes) Myocardial infarction Drug overdose/accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digitalis)

Circulation

• Confirm presence of asystole (check lead/cable connections; ensure power to monitor is on, correct lead is selected, gain turned up; confirm asystole in second lead).

• Establish IV/IO access and administer appropriate medications.

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Differential Diagnosis

• Search for and treat reversible causes (PATCH-4-MD).

Epinephrine—1 mg (1:10,000 solution) IV every 3–5 minutes.

Atropine—1 mg IV every 3–5 minutes to maximum 0.04 mg/kg (class IIb).

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Consider termination of efforts:

• Evaluate the quality of the resuscitation attempt.

• Evaluate the cause of the arrest.

• Does support for cease-effort protocols exist?

Modified from Aehlert B: ACLS quick review study guide, ed 3, St Louis, 2007, Mosby. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.

Pulseless Electrical Activity (PEA)

Basic life support

Perform BLS Primary Survey

• Assess responsiveness.

• Call for help/Call for defibrillator.

Airway

• Open the airway.

Breathing

• Deliver two rescue breaths; administer oxygen as soon as it is available.

Circulation

• Perform high-quality chest compressions until monitor/AED becomes available.

Advanced life support

• Provide ventilation via bag-mask-valve device.

• Continue bag mask ventilation with minimal interruption to chest compressions until condition allows for intubation. Two ventilations should be provided after each cycle of 30 chest compressions.

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Possible causes of PEA: PATCH-4-MD Pulmonary embolism Acidosis Tension pneumothorax Cardiac tamponade Hypovolemia (most common cause) Hypoxia Heat/cold (hypothermia/ hyperthermia) Hypokalemia/hyperkalemia (and other electrolytes) Myocardial infarction Drug overdose/accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digitalis)

Circulation

• Establish IV/IO access.

• Assess blood flow with Doppler. (If blood flow detected with Doppler, treat using hypotension/shock algorithm.)

• Administer appropriate medications.

Differential Diagnosis

• Search for and treat reversible causes (PATCH-4-MD). (Fast narrow QRS—consider hypovolemia, tamponade, pulmonary embolism, tension pneumothorax; slow wide QRS—consider cyclic antidepressant overdose, calcium channel blocker, beta-blocker, or digitalis toxicity.)

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Epinephrine—1 mg (1:10,000 solution) IV/IO every 3–5 minutes.

Atropine (if the rate is slow)—1 mg IV/IO every 3–5 minutes to max 0.04 mg/kg (class IIb). Consider termination of efforts.

Modified from Aehlert B: ACLS quick review study guide, ed 3, St Louis, 2007, Mosby.Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.

Pulseless Electrical Activity (PEA): Clinical Signs and Treatment

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Symptomatic Bradycardia

Modified from Aehlert B: ACLS quick review study guide, ed 3, St Louis, 2007, Mosby. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.

Basic life support

Perform BLS Primary Survey

• Assess responsiveness.

• Call for help/Call for defibrillator.

Airway

• Open the airway.

Breathing

• Deliver two rescue breaths; administer oxygen as soon as it is available.

Circulation

• Perform high-quality chest compressions until monitor/AED becomes available.

image

Advanced life support

Perform Secondary BLS Survey

• Administer oxygen, establish IV/IO access, attach cardiac monitor, administer fluids as needed (O2, IV, monitor, fluids).

• Assess vital signs, attach pulse oximeter, and monitor BP.

• Obtain and review 12-lead ECG, portable chest x-ray film.

• Perform a focused history and physical exam.

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Identify the Patient’s Cardiac Rhythm

Is the patient experiencing serious signs and symptoms because of the bradycardia?

• Signs: Low BP, shock, pulmonary congestion, congestive heart failure, angina, acute myocardial infarction (MI), ventricular ectopy

• Symptoms: Chest pain, weakness, fatigue, dizziness, lightheadedness, shortness of breath, exercise intolerance, decreased level of responsiveness

• If no serious signs and symptoms are present, observe.

• If serious signs and symptoms are present, further intervention depends on the cardiac rhythm identified.

Is the QRS Narrow or Wide?

Narrow QRS bradycardia Wide QRS bradycardia

• Sinus bradycardia

• Second-degree AV block, type II

• Junctional rhythm

• Third degree (complete) AV block

• Second-degree AV block, type 1

• Ventricular escape (idioventricular) rhythm

• Third-degree (complete) AV block

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Medication Dosing

Narrow QRS bradycardia Wide QRS bradycardia

• Atropine IV—0.5 mg IV while awaiting pacemaker; may repeat every 3–5 minutes to a total dose of 3 mg.

• Transcutaneous pacemaker—As an interim device until transvenous pacing can be accomplished

• Transcutaneous pacemaker—Pacing should not be delayed while waiting for IV/IO access or for atropine to take effect.

• Dopamine infusion: 5–20 mcg/kg/min

• Dopamine infusion—2–10 mcg/kg/min.

• Epinephrine infusion: 2–10 mcg/min

• Epinephrine infusion—2–10 mcg/min.

• Isoproterenol infusion: 2–10 mcg/min (low dose)

• Isoproterenol infusion—2–10 mcg/min (low dose).

 

Narrow QRS Tachycardia

Modified from Aehlert B: ACLS quick review study guide, ed 2, St Louis, 2001, Mosby, pp 435–436. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.

Basic life support

Perform BLS Primary Survey

• Assess responsiveness.

• Call for help/Call for defibrillator.

Airway

• Open the airway.

Breathing

• Deliver two rescue breaths; administer oxygen as soon as it is available.

Circulation

• Perform high-quality chest compressions until monitor/AED becomes available.

image

Advanced life support

Perform Secondary BLS Survey

• Obtain and review 12-lead ECG.

• Perform a focused history and physical exam.

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• Is the patient stable or unstable?

• Is the patient experiencing serious signs and symptoms because of the tachycardia?

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Attempt to identify patient’s cardiac rhythm using:

• 12-lead ECG, clinical information

• Vagal maneuvers

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If tachycardia continues after 1–2 seconds of vagal maneuvers, administer adenosine 6 mg rapid IV bolus over 1–3 seconds:

• May repeat 12-mg dose in 1–2 minutes if needed.

• Follow each dose immediately with 20-mL IV flush of NS.

• Use of adenosine is relatively contraindicated in patients with asthma.

• Decrease dose in patients on dipyridamole (Persantine) or carbamazepine (Tegretol); consider increasing dose in patients taking theophylline or caffeine-containing preparations.

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Identify the Patient’s Cardiac Rhythm

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Medication Dosing

Amiodarone—150 mg IV/IO over 10 minutes followed by an infusion of 1 mg/min for 6 hours and then a maintenance infusion of 0.5 mg/min. Repeat supplementary infusions of 150 mg as necessary for recurrent or resistant dysrhythmias. Maximum total daily dose 2 g.

Beta-blockers—Esmolol: 0.5 mg/kg over 1 minute, followed by a maintenance infusion at 50 mcg/kg/min for 4 minutes. If inadequate response, administer a second bolus of 0.5 mg/kg over 1 minute and increase maintenance infusion to 100 mcg/kg/min. The bolus dose (0.5 mg/kg) and titration of the maintenance infusion (addition of 50 mcg/kg/min) can be repeated every 4 minutes to a maximum infusion of 300 mcg/kg/min. Metoprolol: 5 mg slow IV push over 5 minutes × 3 as needed to a total dose of 15 mg over 15 minutes.

Calcium channel blockers—Diltiazem: 0.25 mg/kg over 2 minutes (e.g., 15–20 mg). If ineffective, 0.35 mg/kg over 2 minutes (e.g., 20–25 mg) in 15 minutes. Maintenance infusion 5–15 mg/hr, titrated to HR if chemical conversion successful. Calcium chloride (2–4 mg/kg) may be given slow IV push if borderline hypotension exists before administration. Verapamil: 2.5–5.0 mg slow IV push over 2 minutes. May repeat with 5–10 mg in 15–30 minutes. Maximum dose 20 mg.

Digoxin—Loading dose 10–15 mcg/kg lean body weight.

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Type of countershock Dysrhythmia Recommended energy levels
Defibrillation Pulseless VF/VT 360 J or equivalent biphasic energy
Sustained polymorphic VT 360 J or equivalent biphasic energy

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