Advanced Cardiac Life Support
* * 2007 * *

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Algorithm Guide

Here is a very abbreviated guide for the ACLS algorithms. Once you understand and can apply the principles, this guide will help you stay on track. Remember: Patient treatment should be based upon institutional standards and not according to this guide alone. Approved guidelines are subject to change.

A few helpful mnemonics:
ABC=Airway, Breathing, Circulation
OMI=Oxygenation, Monitor(EKG), IV
ICEM=IV, CPR, ET intubation, Monitor(EKG)

Respiratory Arrest with a Pulse

• ABC's...call for code cart/equipment, call 911 if outside hospital
• OMI...begin oxygenation, Determine cardiac rythm with Monitor, establish IV
• Look for cause.

Acute Myocardial Infarction

• ABC's...call for code cart/equipment, call 911 if outside hospital
• OMI...begin oxygenization, Determine cardiac rhythm with Monitor, establish IV
• Use appropriate algorithm
• Administer aspirin
• Anyalgesia (consider location if infarct)
• Consider anti-coagulants
• Twelve Lead EKG, labs
• Consider thrombolytics (ST changes, History, Signs/symptoms)
• Consider adjunctive therapy prn.

Refractory VF/ Pulseless VT

• ABC's
• OMI
• ICEM...IV access, CPR, ET intubation, Monitors
• Electrical Intervention... "clear" before each shock)
• Parmacologic intervention
• Consider possible causes such as Acute MI, Hypoxia, Hypoglycemia, Acidosis, etc.

  • Electrical defibrillation (X 1)

  • 360 joules( monophasic)
  • 150-200 joules (biphasic with truncated exponential waveform)
  • 120 joules (biphasic with rectiliniar waveform)
  • 200 joules (biphasic unknown waveform)

  • CPR for 2 minutes, then rhythm check
  • Drugs may be administered in conjunction with CPR ! ! !

  • Epinephrine 1 mg IV, may repeat every 3-5 minutes
  • OR
  • Vasopressin 40 units VI single dose only

  • Repeat defibrillation if still unsuccessful

  • CPR for 2 minutes, then rhythm check

  • Amiodarone 300 mg IV bolus
  • OR
  • Lidocaine about 1- 1.5 mg mg/kg (as 75-100 mg) IV, may repeat 0.5 - 0.75 mg/kg in 5-10 min (Max: 3 mg/kg); If needed tracheal administration 2-4 mg/kg

  • Repeat defibrillation if still unsuccessful

  • CPR for 2 minutes, then rhythm check

  • May consider Magnesium sulfate 1-2 gm in 10 mL D5W if suspect hypomagnesemia
  • Procainamide 30 mg.min IV infusion (Max: 17 mg/kg)

  • Repeat defibrillation if still unsuccessful
  • May consider Na bicarbonate 1 ampule IV ? if suspect acidotic (best check ABG first)

Bradycardia

• ABC's
• OMI
• Consider possible causes such as Acute MI, Hypoxia, Hypoglycemia, Acidosis, etc.
• Parmacologic/Electrical Intervention

  If hemodynamically unstable, CPR for 2 minutes

  Atropine (.5 mg q 5 min...up to 3.0 mg total)

  Transcutaneous Pacing

  Initiate Dopamine drip (2-20 micrograms/kg/min)

  Initiate Epinephrine drip (2-20 micrograms/kg/min)

  If all above fails, Tranvenous Pacing

Second and Third Degree Blocks

• ABC's
• OMI
• Parmacologic/Electrical Intervention

  Consider possible causes such as Acute MI, Hypoxia, Hypoglycemia, Acidosis, etc.

  Transcutaneous Pacing

  Initiate Dopamine drip (2-20 micrograms/kg/min)

  Initiate Epinephrine drip (2-20 micrograms/kg/min)

  If all above fails, Tranvenous Pacing

Unstable Tachycardia

• ABC's
• OMI
• Sedate and Cardiovert

  Valium 2mg. IV increments (to 10 mg. max)

  OR

  Versed 2mg. IV increments (to 10 mg. max)

  VT & A-Fib- start at 100J

  A-Flutter & SVT- start at 50J

Stable Tachycardia

• ABC's
• OMI

Supraventricular Tachycardia (stable)

• ABC's
• OMI
• Vagal Maneuvers- Have patient "Bear-Down", or Carotid Massage)
• Adenosine- 6mg then 12mg (Max 18mg)
• Cardizem- .25 mg/kg/2min, 35mg/kg/2min after 15 min.
• Beta Blockers
• Verapamil- 2.5-5 mg/2 min...5-10 mg after 15 min.
• Digiatlis-(limited use in emergency situations)

Supraventricular Tachycardia (unstable)

• ABC's
• OMI
• Consider meds.
• If meds ineffective sedate and then cardiovert (50-100-200-300-360J)
• Sedate with Valium 2mg. IV increments (to 10 mg. max)
• OR
• Versed 2mg. IV increments (to 10 mg. max)

Atrial Fibrillation/ Flutter- Stable

• ABC's
• OMI
• Pharmacologic Intervention

  Cardizem- .25 mg/kg/2 min, .35 mg/kg/2 min after 15 min.

  Beta Blockers

  Verapamil- 2.5-5 mg/2 min...5-10 mg after 15 min.

  Procainamide- 20 mg/min up to 17mg/kg total.

  Digiatlis-(limited use in emergency situations)

Ventricular Tachycardia- Stable

• ABC's
• OMI
• Pharmacologic Intervention

  • In unstable hemodynamically, stat unsynchronized cardioversion with 50 -100 joules, then
  • 200, or to 360 joules.
  • In stable patients, may use synchronized cardioversion. with 100 J, then 200, 300, 360 J prn
    
  • *** Premedicate with sedatives whenever possible !!! ****
    
  • Amiodarone 150 mg IV bolus over 10 minutes or
  • Lidocaine 0.5 - 0.75 mg/kg IV , then 1- 4 mg/min infusion or
  • Procainamide 200 1000 mg IV at rate <25 50 mg/min.
  • Wide complex tachycardia VT vs SVT of uncertain etiology treat it as VT, & IV Procainamide is the drug of choice, &  ** IV Verapamil is contraindicated !

Pulseless Electrical Activity

• ABC's
• ICEM
• Consider possible causes such as Acute MI, Hypoxia, Hypoglycemia, Acidosis, etc.
• Pharmacologic Intervention

  CPR for 2 minutes

  Epinephrine- 1 mg q 3-5 min or

  Vasopressin- 40 U IV push (single dose)

  CPR for 2 minutes

  Consider termination of efforts after 10 minutes

Asystole

• ABC's
• ICEM confirm rythm in two leads.
• Pharmacologic Intervention
• Consider possible causes such as Acute MI, Hypoxia, Hypoglycemia, Acidosis, etc.

  CPR for 2 minutes

  Epinephrine 1.0 mg IV push, repeat every 3-5 minutes or

  Vasopressin- 40 U IV push (single dose)

  CPR for 2 minutes

  Atropine 1.0 mg IV push