ACLS 2005 GUIDELINES

During CPR

- Push hard and fast (100 per minute)

- Ensure full chest recoil
- Minimize interruptions in chest compressions
- Avoid hyperventilation
- Secure the airway and confirm placement
- After advanced airway is placed, CPR goes from cycles of 30:2 to an
asynchronous practice (100 cpm/8-10 bpm)
- Rotate compressors every 2 minutes with the rhythm checks
- Search for and treat possible contributing causes (6 Hs and 5 Ts)
o Hypovolemia
o Hypoxia
o Hydrogen ion (acidosis)
o Hypo/hyperkalemia
o Hypoglycemia
o Hypothermia
o Toxins
o Tamponade (pericardial)
o Tension pneumothorax
o Thrombosis (coronary or pulmonary)
o Trauma

Use the 5 Quadrads approach to ACLS

1. Airway-breathing-circulation-defibrillator
2. Airway-breathing (advanced)-circulation (access)-differential
diagnosis
3. O2 –IV-monitor-fluid
4. Temp-HR-BP-R
5. Tank (size)-tank (volume)-pump-rate (consider the cause)

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 ACLS 2005 GUIDELINES
Comprehensive ECC Algorithm

Person collapses, possible cardiac arrest

Assess unresponsiveness
Activate emergency response system/call a code
Call for a defibrillator/AED
Assess/open the airway
Assess breathing, provide 2 slow breaths (1 second each)
Assess circulation, begin CPR until monitor arrives
Witnessed arrest, analyze rhythm, defibrillate if VF/PVT
Unwitnessed arrest, perform CPR for 2 minutes
(5 cycles 30:2)
If VF/PVT, defibrillate one time at 360 joules or equivalent
biphasic
If PEA/Asystole, perform CPR
Continue CPR for 2 minutes
(5 cycles 30:2)
Place and advanced airway, secure with commercial
purpose-built device
Gain access to the circulation for cardiovascular drugs
Differential diagnosis
Proceed to appropriate algorithm

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 ACLS 2005 GUIDELINES
Ventricular Fibrillation/Pulseless VentricularTachycardia

Primary ABCD
Defibrillate one time at 360 or equivalent biphasic
Perform CPR for 2 minutes (5 cycles 30:2)
Reassess patient and rhythm
Defibrillate at 360
Perform CPR for 2 minutes, simultaneously perform a
secondary ABCD and begin medication consideration
Administer a vasoconstrictor (Epinephrine or Vasopressin)
- Epinephrine 1 mg every 3 minutes
o Vasopressin 40 units may replace the first or
second dose of epineprhine
Reassess patient and rhythm
Defibrillate after each 2 minutes of CPR

Consider an antiarrhythmic
- Amiodarone 300 mg, may be repeated in 3-5 minutes
at 150 mg IVP
OR

- Lidocaine 1.0-1.5 mg/kg, may be repeated in 5

minutes at half the dose, maximum of 3 mg/kg
OR

- Magnesium 1-2 G, if hypomagnesemic

Drips to consider
- Amiodarone (1 mg/min) or Lidocaine (1-4 mg/min)

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 ACLS 2005 GUIDELINES
Pulseless Electrical Activity (PEA)

Primary ABCD
Perform CPR for 2 minutes (5 cycles 30:2), simultaneously
perform the Secondary ABCD
Focus on identifying and correcting causes (6 Hs, 5 Ts)
Administer a vasoconstrictor (Epinephrine or Vasopressin)
- Epinephrine 1 mg every 3 minutes
o Vasopressin 40 units may replace the first or
second dose of epineprhine
Atropine 1 mg every 3 minutes, up to a maximum of 3 mg
(if the PEA is less than 60 on the monitor)
Asystole

Primary ABCD, confirm in a second lead, (DNR?)

Perform CPR for 2 minutes (5 cycles 30:2), simultaneously
perform the Secondary ABCD

Focus on identifying and correcting causes (6 Hs, 5 Ts)

Administer a vasoconsitrictor (Epinephrine or Vasopressin)
- Epinephrine 1 mg every 3 minutes
o Vasopressin 40 units may replace the first or
second dose of epineprhine

Atropine 1 mg every 3 minutes, up to a maximum of 3 mg

Consider termination of efforts

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 ACLS 2005 GUIDELINES
Bradycardia

O2-IV-Monitor (12-lead)-Fluid (3rd Quadrad)

If narrow complex bradycardia with s/s
- Atropine 0.5 mg, repeated every 3-5 minutes, to a
maximum of 3 mg
and/or
- TCP
If wide complex bradycardia with s/s or denervated heart
- Consider going straight to TCP
Drips
- Epinephrine 2-10 mcg/min
- Dopamine 2-20 mcg/kg/min

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 ACLS 2005 GUIDELINES
Tachycardia with Pulses

O2-IV-Monitor (12-lead)-Fluid (3rd Quadrad)

Temp-HR-BP-R (4th Quadrad)
Narrow Tachycardias
Narrow Complex Tachycardia, Regular and Stable (SVT)
- Vagal maneuvers
- Adenosine 6 mg RIVP, may repeat twice at 12 mg in 1-2 minutes

If it converts (probably reentry SVT)

- Observe for reoccurrence, treat recurrence with adenosine, calcium
channel blockers or beta blockers

If it does not convert (probably automatic focus rhythm)

- Control rate with calcium channel blockers or beta blockers

Narrow Complex, Irregular and Stable (Afib/Aflutter or MAT)

- Control rate with calcium channel blockers or beta blockers
Wide Complex Tachycardias
Wide Complex, Regular, Stable (VT or WCT unknown origin)
- Amiodarone 150 mg IV over 10 minutes
- Prepare for elective cardioversion

Wide Complex, Irregular, Stable (Afib with aberrancy, Afib with

WPW or PMVT)
- Afib with aberrancy
o Control rate with calcium channel blockers or beta blocker
- Afib with WPW
o Avoid Adenosine, Digoxin, Diltiazem and Verapamil
o Consider Amiodarone (150 mg IV over 10 minutes)
- PMVT(TdP)
o Give Magnesium (1-2 g), if stable
o If unstable, proceed to the VF/PVT algorithm

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 ACLS 2005 GUIDELINES
Medications

ADENOSINE
- 6 mg, 12, mg, 12 mg RIVP

AMIODARONE
- 300 mg in cardiac arrest, may be repeated in 3-5 minutes at half dose
- 150 mg given over 10 minutes for tachycardias

ASPIRIN
- 81 mg to 324 mg chewable

ATENOLOL
- 5 mg slow IVP over 5 minutes, may be repeated in 10 minutes

ATROPINE
- 0.5 mg for bradycardia, may be repeated in 3-5 minutes to a maximum
dose of 3 mg
- 1 mg for pulseless patients, may be repeated in 3-5 minutes to a
maximum dose of 3 mg

CALCIUM CHLORIDE
- 500 mg to 1g for hyperkalemia and calcium channel blocker overdose

DIGOXIN
- 10 to 15 mcg/kg for impaired hearts

DILTIAZEM
- 15 to 20 mg over 2 minutes, may be repeated at 20 to 25 mg in 15
minutes

DOPAMINE
- 2 to 20 mcg/kg/min

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 ACLS 2005 GUIDELINES
Medications

EPINEPHRINE
- 1 mg every three minutes for the arrested patient
- 2 to 10 mcg/min as an infusion for bradycardiac patients

FLECANIDE
- Not for IV use in United States

FUROSEMIDE
- 0.5 to 1 mg/kg

HEPARIN (UFH)
- 60 IU/KG

IBUTILIDE
- 1 mg over 10 minutes for rate control of Afib/Aflutter

LIDOCAINE
- 1 to 1.5 mg/kg in VF/PVT, may be repeated at half dose in 5 minutes
- 1 to 1.5 mg/kg in WCT, may be repeated at half dose in 5 minutes
- Begin at 0.50 to 0.75 mg/kg for patients with WCT and impaired heart
function
- Maximum dose of 3 mg/kg
- Infusion of 1 to 4 mg/min

MAGNESIUM SULFATE
- 1 to 2 g

METOPROLOL
- 5 mg slow IVP, may be repeated every 5 minutes up to 15 mg
maximum

MORPHINE
- 2 to 4 mg increments for pain relief of ACS

NALOXONE
- 0.4 to 2 mg for narcotic overdose

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 ACLS 2005 GUIDELINES
Medications

NITROGLYCERIN
- 1 tablet or spray sublingual, may be repeated

NOREPINEPHRINE
- 0.5 to 1 mcg/min to improve BP

PROCAINAMIDE
- 20 to 50 mg/min for perfusing tachycardias

PROPAFENONE
- Not for IV use in the Untied States

SODIUM BICARBONATE
- 1 mEq/kg for metabolic acidosis and/or hyperkalemina

SOTALOL
- Not for IV use in the United States

VASOPRESSIN
- 40 units, one time to replace the first or second dose of epinephrine

VERAPAMIL
- 2.5 to 5 mg IVP over 2 minutes, may double the dose in 15 to 30
minutes

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 ACLS 2005 GUIDELINES
Electrical Therapy for Unstable Tachycardias

Cardioversion (synchronized)
- Narrow and Wide Complex Tachycardias with a pulse
o 100, 200, 300 and then 360 joules or equivalent
biphasic

PSVT and Atrial Flutter

- Begin at 50-100 joules or equivalent biphasic

Defibrillation (unsynchronized)
- Ventricular Fibrillation and Pulseless Ventricular
Tachycardia
o Defibrillate at 360 joules or equivalent biphasic
o Repeat after every 2 minutes of CPR, as needed

- Polymorphic Ventricular Tachycardia

o If unstable, should be treated like Ventricular
Fibrillation
Defibrillate at 360 joules or equivalent
biphasic
Repeat after every 2 minutes of CPR, as
needed

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