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Cardiac Arrest Algorithm

Note the key change in BLS sequence: begin early chest compressions.

BLS is no longer represented by A, B, C, and D; it is represented by 1, 2, 3, and 4.

Step 1: Assess responsiveness.

Step 2: Active emergency response and get AED.

Step 3. Check carotid pulse for 10 seconds. If no pulse, begin CPR, starting with chest
compressions then 2 breaths at a ratio of 30:2. Use bag valve mask for breaths, if available.

Step 4: Defibrillate if there is a shockable rhythm when defibrillator arrives. Continue CPR
while the defibrillator or AED is readied. Responders should follow the voice prompts.

Step 5: Proceed to ABCD of secondary survey.

1. Airway: Head tilt-chin-lift; use advanced airway if needed.


2. Breathing: Supplementary oxygen; maintain ventilation and oxygenation.
3. Circulation: Monitor CPR quality with waveform capnography.
o Attach monitor.
o Defibrillate/cardiovert.
o Obtain IV/IO access.
o Give appropriate drugs:
 Pressors: Epinephrine 1 mg IV q 3 -5 minutes. May substitute
Vasopressin 40 U IV for dose 1 or dose 2.
 Antiarrhythmics: Amiodarone 300 mg IV. May repeat a second dose of
150 mg IV
4. Differential diagnosis: Look for reversible causes. 5 H's and 5 T's.

Ventricular Fibrillation and Pulseless Ventricular


Tachycardia
Step 1: Cardiac Arrest Algorithm: BLS and AED.

Biphasic defibrillators - 120 to 200 J per manufacturer; 360 J monophasic defibrillator.

The 2010 Guidelines recommends interruption in chest compression only for ventilation
without an advanced airway, rhythm checks, and shock delivery.

The American Heart Association recommends shortening the interval between last
compression and shock.

The emphasis in ACLS is on high quality CPR. Monitor with qualitative waveform
capnography. If PETCO2 is less than 10 mm Hg, attempt to improve CPR quality.

Step 2: ACLS: Secondary survey.


Step 3: Vasopressin 40 U IV x 1 (Class 2b) or epinephrine 1 mg q 3-5 minutes (Class
Indeterminate.

Step 4: Defibrillate: Biphasic – 120 or 200, use manufacturer's instructions.

Step 5: Antiarrhythmic: Amiodarone 300 mg IV/IO; may repeat x 1 at 150 mg (Class 2b)
-Consider lidocaine if amiodarone is not available 1.0-1.5 mg/kg IV/IO first dose, then 0.5-
0.75 mg/kg IV/IO diluted in 10 ml D5@, NS) as IV/IO bolus over 5-20 minutes

Step 6: Defibrillate

Step 7: Go back to Step 3.

PEA/Asystole
Step 1: Cardiac Arrest Algorithm: BLS and AED.

Interrupt chest compressions only for ventilation without an advanced airway, rhythm
checks, and shock delivery. High quality CPR is emphasized.

Step 2: ACLS: Secondary survey: confirm asytole, do not delay CPR for pulse check.

Step 3: Rule out reversible causes: 5H's and 5 T's.

 Empiric fluid challenge


 Wide QRS suggests significant cardiac damage: hyperkalemia, hypoxia, hypothermia
 Wide QRS and slow rhythm: consider overdose , hypoxia
 Narrow complex suggests intact heart: consider hypovolemia, infection, PE,
tamponade
 Smaller complexes: Tamponade, acidosis
 Osborne J waves: Hypothermia
 Peaked T waves: Hyperkalemia
 Prominent U waves, wide WRS, flat T, prolonged QT; Hypokalemia
 “twisting” QRS complexes: Torsades de Pointes – Give Magnesium
 Q waves, ST segment changes and T waves inversion: AMI

Step 4: Epinephrine 1 mg IV q 3-5 minutes.

Step 5: Continue CPR.

Step 6: Atropine 0.5 mg q 3-5 minutes to 0.04 mg/kg: Consider if rhythm is slow.

Step 7: Continue CPR  Return of Spontaneous Circulation - Coordinated Post-arrest Care

*TCP no longer recommended in asystole.


Bradycardia Algorithm
Step 1: Cardiac Arrest Algorithm: BLS and AED.

Step 2: Heart rate

Step 3: ACLS: Secondary survey: airway, oxygen, IV, monitor, 12 lead, differential dx.

Step 4: Persistent bradyarrhythmia with signs of poor perfusion?If not, observe.

Step 5: Atropine 0.5 mg q 3-5 minutes, maximum 3 mg. If effective, monitor and observe.

Step 6: If ineffective, prepare for transcutaneous pacing or dopamine infusion or


epinephrine infusion.

 Dopamine IV infusion 2-10 mcg/kb/min


 Epinephrine IV infusion 2-10 mcg/min
 Sedate patient before pacing if time permits.

Step 7: Prepare patient for transvenous pacing if required. Obtain expert consultation.

Step 8: Type 2 second-degree AV block or third degree AVB? TCP and prepare for TVP.

Tachycardia with a Pulse Algorithm


Intervention is determined by presence of significant symptoms or unstable condition
that is caused by the tachycardia.

Step 1: Assess appropriateness for clinical condition. Usually > 150 bpm.

Step 2: ACLS : Secondary survey: airway, oxygen, IV, monitor, 12 lead, differential dx

Step 3: Persistent tachyarrhythmia with signs of poor perfusion?

If no, proceed to Step 4. If patient becomes unstable, do not delay treatment for detailed
rhythm analysis.

If yes, synchronized cardioversion.

 Sedate patient if time permits.


 Consider adenosine if regular narrow complex.

Step 4: Wide QRS? (greater than or equal to 0.12 second? If no, proceed to Step 5.

If yes, IV and ECG. Adenosine only if regular and monomorphic.

-antiarrhythmic infusions for stable wide QRS complex tachycardia:


 Procainamide IV: 20-50 mcg/minute until suppressed. Stop for hypotension, QRS
duration increase > 50%, or maximum dose 17/mg/kg.
 Maintenance infusion 1-4 mg/min.
 Avoid if prolonged QT or CHF.
 Amiodarone IV: 150 mg over 10 minutes, repeat as needed for VT.
 Maintenance 1-4 mg/min for 6 hours.
 Soltalol IV: 100 mg (1.5 mg/kg) over 5 minutes.
 Avoid if prolonged QT.*

Step 5: If QRS < 0.12 seconds, IV and ECG.

 Vagal maneuvers
 Adenosine (if regular)
 Beta-blocker or calcium channel blocker.
 Consider expert consultation.

*Drugs to avoid in patients with irregular wide complex tachycardia: AV Nodal Blocking
Agents:

 Adenosine
 Calcium channel blockers
 Digoxin
 Beta-blockers

**Avoid AV Nodal Blocking Agents in preexcitation atrial fibrillation and atrial flutter.

***Caution when combining AV Nodal Blocking Agents with longer duration of action.
Effects may overlap.

*Cardioversion:

 -Sedate all conscious patients unless unstable or deteriorating.


 -Turn on the defibrillator.
 -Attach leads to patient; ensure proper display and attaché adhesive conductor pads on
patient.
 -Press SYNC to engage synchronization mode.
 -Select appropriate energy level:
o -Doses: Narrow regular 50-100J
o Narrow irregular 120-200 J biphasic; 200 J monophasic
o Wide regular 100 J Increase stepwise (no evidence available)
o Wide irregular: defibrillate (not synchronized, defibrillation doses)
Acute Stroke Algorithm
Stroke chain of survival:

 Rapid recognition and reaction to signs of stroke


 Rapid dispatch of EMS
 Rapid transport by EMS and notification of receiving hospital
 Rapid diagnosis and treatment upon arrival

8 D's: Detection Dispatch, Delivery, Door, Data, Decision, Drug, Disposition

Step 1: Identify possible stroke signs and symptoms.

Step 2: Activate EMS

Step 3: Critical EMS actions:

 Support ABCs; give O2 prn


 Prehospital Stroke Assessment: Cincinnati Prehospital Stroke Scale*
 Establish time patient was last normal
 Triage to stroke center
 Alert receiving hospital
 Check glucose

Step 4: ED arrival and first 10 minutes: Assess and stabilize

 Assess ABCs and vital signs


 O2 if hypoxemic
 IV access and blood for lab
 Check glucose and treat if indicated
 Neurologic screening assessment
 Activate stroke team
 Emergent CT of brain: rule out intracranial hemorrhage
 12 lead ECG

Step 5: T=25 minutes: Neurologic assessment by stroke team or designee

 Patient history
 Symptom onset
 Neurologic evaluation (NIH Stroke Scale or Canadian Neurologic Scale)

Step 6: T=45: CT interpretation

If hemorrhage is present, consult neurologist or neurosurgeon, consider transfer if not


available.

If no hemorrhage, consider probable ischemic stroke and consider fibrinolytics.

 Check for exclusions to fibrinolytic therapy.


If exclusions exist, administer aspirin and go to Step 9.

If no exclusions, repeat neurologic exam. If symptoms are rapidly improving, administer


aspirin and go to Step 9.

Step 7: T=60:

 Review risks and benefits with family and patient. If acceptable, go to Step 8.

Step 8: T=60:

 Give tPA
 No anticoagulants or antiplatelet treatment for 24 hours

Step 9: Begin stroke pathway or hemorrhage pathway.

 Admit to stroke unit or intensive care unit.

Cincinnati Prehospital Stroke Scale:

3 findings:

 Facial droop: Patient shows teeth or smiles; abnormal=one side does not move as well
 Arm drift: Patient closes eyes and extends both arms straight out, with palms up for
10 seconds; abnormal=one arm does not move or drifts down compared with other
arm
 Abnormal speech: "You can't teach an old dog new tricks." Abnormal=patient slurs
words, uses the wrong words, or is unable to speak.

If 1 of 3 signs is abnormal, probability is 72%.

If 3 abnormal signs, probability is >85%.

Acute Coronary Syndrome Algorithm


Goals: Identify patients with STEMI and triage for early reperfusion.

 Relieve ischemic chest discomfort.


 Prevent MACE: death, nonfatal MI, need for urgent postinfarct PCI.
 Treat complications of ACS – arrhythmias.

Step 1: Confirm symptoms that suggest ischemia or infarction.

Step 2: EMS:

 Monitor, support ABCs. Prepare for CPR and defibrillation.


 Administer aspirin.
 Consider O2, NTG, and morphine if needed.
 Obtain 12-lead ECG; if STEMI, notify receiving hospital.
Step 3: ED (less than 10 minutes) concurrent assessment

 Vital signs, O2 saturation


 Establish IV access
 Brief, targeted H & P
 Review and complete fibrinolytic checklist; check contraindications.
 Obtain cardiac markers, electrolyte and coags.
 Portable chest x-ray (

Step 4: Immediate ED treatment:

 O2 if SaO2
 Aspirin 160325 mg if not given by EMS
 NTG SLT or spray
 Morphine IV (if chest discomfort not relieved by NTG)

Step 5: Interpret ECG

ST elevation or new/presumably new LBBB: STEMI: Go to Step 6.

ST depression or dynamic T wave inversion: UA/NSTEMI: Go to Step 10.

Normal or nondiagnostic ST/T changes: Low or intermediate risk ACS: Go to Step 13.

Step 6: Start adjunctive therapies as indicated and don't delay reperfusion.

Step 7: Time from symptom onset:

 less than or equal to 12 hours: Go to Step 8.


 greater than 12 hours: Go to step 10.

Step 8: Reperfusion therapy:

 Thrombolysis: door to needle 30 minutes


 Thrombolysis: door to balloon (PIC) 90 minutes

Step 10: Troponin elevated or high-risk patient:

Consider early invasive strategy:

 Refractory ischemic chest pain


 Persistent or recurrent ST deviation
 Ventricular tachycardia
 Hemodynamically unstable
 Evidence of heart failure

If not, go to Step 11.

Step 11: Adjunctive therapies:


 Nitroglycerin
 Heparin (UFH or LMWH)
 Consider po beta-blockers, clopidogrel, glycoprotein IIb/IIIa inhibitor.

Step 12: Admit to monitored bed, and assess risk. Continue ASA, heparin, and other therapies
as indicated.

High risk:

Consider ACE inhibitor/ARB; HMG CoA reductase inhibitor

Low risk: cardiology consult

Step 13: Consider admission to ED chest pain unit and follow serial cardiac markers, repeat
ECGs and consider non-invasive testing.

Step 14: Development of 1 or more:

 Clinical high-risk features


 Dynamic ECG changes consistent with ischemia
 Elevated Troponin

Go to Step 10. If not, go to Step 15.

Step 15: Abnormal noninvasive imaging or physiologic testing?

Go to Step 12. If not, go to Step 16.

Step 16: Without evidence of ischemia or infarction by testing, patient may be discharged
with follow-up.

ACLS Drugs/Doses
Adenosine: Initial bolus 6 mg IV over 1-3 seconds; follow with 20 ml bolus NS, elevate
extremity. May repeat 12 mg in 1-2 minutes.

Amiodarone: 300 mg IV/IO push. Second dose, if needed, 150 mg IV/IO push.

Atropine: 0,5 mg IV every 3 to 5 minutes; do not exceed 0.04 mg/kg.

Dopamine infusion: 2-10 mcg/kg/min; titrate to response.

Epinephrine: In cardiac arrest: I mg q 3-5 minutes, follow with 20 ml flush, elevate arm. In
beta-blocker or calcium channel blocker OD, may use up to 0.2 mg/kg. Continuous infusion:
0/1 to 0/5 mcg/kg/min. In profound bradycardia or hypotension: infuse at 2 to 10
mcg/minute; titrate to response.

Lidocaine: In cardiac arrest, alternative to amiodarone: 1-1.5 mg/kg; may give additional
0.5-0.75 mg/kg/IV push, repeat to maximum of 3 mg/kg.
Magnesium Sulfate: Only in cardiac arrest due to hypomagnesemia or Torsades de Pointes,
1-2 gm (2-4 ml of 50% soln diluted in 10 ml, IV/IO.) Torsades de Pointes with a pulse of
AMI with hypomagnesemia: Load 1-2 g diluted in 50-100 ml over 5 to 60 min IV. Follow
with 0.5 to 1 g per hour IV, titrated to control torsades.

Vasopressin: may replace 1st or 2nd dose of epinephrine. One dose of 40 units IV/IO push.