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ACLS
ALGORITHMS
Acute Pulmonary Edema / Hypotension / Shock Algorithm
Clinical signs of hypoperfusion, congestive
heart failure, acute pulmonary edema
Assess ABC’s
Assess vitals
Secure airway
Review history
Administer O2
Perform physical exam
Start IV
12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff
Figure 8
What is the nature of the problem?
Volume problem
Includes PVR problems
Administer
• Fluids
• Blood transfusions
• Cause-specific interventions
• Consider vasopressors
Systolic BP
< 70
Signs of shock
Pump Problem
Rate Problem
What is the BP ?
Systolic BP
70 - 100 mmHg
Signs of shock
Too Slow
Go to Fig 5
Systolic BP
70 - 100 mmHg
No Signs of shock
Too Fast
Go to Fig 6
Systolic BP
> 100 mmHg
Bradycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABC’s
Assess vitals
Secure airway
Review history
Administer O2
Perform physical exam
Start IV
12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff
Figure 5
Bradycardia, either absolute
(<60 BPM) or relative
Serious signs and symptoms?a,b
Yes
No
Type II second-degree AV heart block
or
Third-degree AV heart Block?e
No
Observe
Yes
• Prepare for transvenous pacer
• Use TCP as a bridge device
Intervention sequence
• Atropine 0.5 - 1.0 mcg,d (I and IIa)
• TCP, if available (I)
• Dopamine 5 - 20 mcg/kg/min (IIb)
• Epinephrine 1 - 10 mcg/min (IIb)
• Norepinephrine 0.5 –30 mcg/min (IIb)
Tachycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABC’s
Assess vitals
Secure airway
Review history
Administer O2
Perform physical exam
Start IV
12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff
Figure 6
If ventricular rate > 150 BPM
Yes • Prepare for cardioversion
Unstable, with serious signs or symptoms?a
No
Atrial Fibrillation
Atrial Flutter
Paroxysmal
Supraventricular
Tachycardia
(PSVT)
• May give brief trial of Rx
• Immediate cardioversion is seldom
needed for heart rates < 150 BPM
Wide-complex
tachycardia of
uncertain type
Ventricular
Tachycardia (VT)
Pulseless Electrical Activity (PEA) Algorithm
(Electromechanical Dissociation [EMD])
Figure 3
Includes
Electromechanical dissociation (EMD) Postdefibrillation idioventricular rhythms
Pseudo - EMD
Bradyasystolic rhythms
Idioventricular rhythms
Ventricular escape rhythms
• Continue CPR / Intubate at once / Obtain IV Access
• Assess blood flow using Doppler ultrasound, endtidal CO2,
echocardiography, or arterial line
Consider possible causes
Hypovolemia (volume infusion)
Drug overdoses - tricyclics, digitalis
Hypoxia (ventilation)
Beta-blockers, calcium channel blockers
Cardiac tamponade (pericardiocentesis)
Hyperkalemia
Tension Pneumothorax
Acidosis
Hypothermia ( see hypothermia algorithm)
Massive acute myocardial infarction
Massive pulmonary embolism (surgery, lysine)
Massive acute MI (go to Fig 9)
Epinephrine 1 mg IV push,a,c repeat q 3 - 5 min
• If absolute bradycardia (< 60 BPM) or relative bradycardia
• give atropine 1 mg IV
• Repeat q 3 -5 min to a total of 0.03 - 0.04 mg/kg
Asystole Treatment Algorithm
•
•
•
•
Continue CPR
Intubate at once
Obtain IV Access
Confirm asystole in more than 1 lead
Consider possible causes
Hypoxia
Pre-existing acidosis
Hyperkalemia Drug Overdose
Hypokalemia Hypothermia
Consider immediate
transcutaneous pacing (TCP)a
Figure 4
• Epinephrine 1mg IV push,b,c
repeat q 3 - 5 min
• Atropine 1 mg IV push
repeat q 3 - 5 min up to a total
of 0.03 - 0.04 mg/kgd,e
Consider termination of efforts
Ventricular Fibrillation (VF)
Figure 2
&
Pulseless Ventricular Tachycardia (VT)
•ABCs
•Perform CPR until defibrillator Arrives
• VF/VT present on defibrillator
Defibrillate up to 3 times if needed for persistent VF/VT
200 J, 200 - 300 J, 360 J
Rhythm after the first 3 shocks? b
VF/VT
ROSC
PEA
Go to Fig 3
Asystole
Go to Fig 4
VF & Pulseless VT
• Continue CPR
• Intubate / IV Access
Epinephrine c,d
1 mg/IV
2 mg/ETT
q 3 - 5 min
Defibrillate 360 J
within 30 - 60 sec
Administer Rx Class IIa
probable benefit f, g
Defibrillate 360 J,
30 - 60 sec after Rx
Figure 2