Advanced Cardiac Life Support

Basic Life Support Algorithm Assess Responsiveness No movement or response Call for code team and Defibrillator Open the airway, look, listen and feel for breathing) If Not Breathing, give 2 breaths that make chest rise Check pulse PULSE Give oxygen by bag mask. One breath every 5 to 6 seconds. Recheck pulse every 2 minutes Secure IV access Determine probable etiology of arrest based on history, physical exam, cardiac monitor, vital signs, and 12 lead ECG. Hypotension/shock, acute pulmonary edema. Go to fig 5 NO PULSE Initiate CPR at cycles of 30 compressions and 2 breaths until defibrillator arrives.

Defibrillator arrives. Check Rhythm Shockable rhythm? Shockable

Not shockable Asystole or Pulseless Electrical Activity Go to Fig 2

Arrhythmia

Ventricular Tachycardia or Ventricular Fibrillation Go to Fig 2

Bradycardia Go to Fig 3

Tachycardia Go to Fig 4

Fig 1 - Basic Life Support Algorithm

PULSELESS ARREST 1 Assess Airway, Breathing, Circulation, Differential Diagnosis; call for help Give CPR and oxygen Attach monitor/defibrillator Shockable 3 Ventricular Fibrillation or Ventricular Tachycardia 4 Give 1 shock Manual biphasic: 120-200 J Monophasic: 360 J Resume CPR 5 Give 5 cycles of CPR No 2 Check rhythm Shockable rhythm? Not Shockable 9 Asystole or Pulseless Electrical Activity 10 Resume CPR for 5 cycles When IV/IO available, give vasopressor Epinephrine 1 mg IV/IO or May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine Consider atropine 1 mg IV/IO for asystole or slow PEA rate. Repeat every 3 to 5 min, up to 3 doses Give 5 cycles of CPR Check rhythm Shockable rhythm?

Check rhythm Shockable rhythm?

Shockable 6 Continue CPR Give 1 shock Manual biphasic: same as first shock or higher dose Monophasic: 360 J Resume CPR Give vasopressor during CPR Epinephrine 1 mg IV/IO. Repeat every 3 to 5 min or May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine Give 5 cycles of CPR 7 No Check rhythm Shockable rhythm? 8 Shockable

If asystole, go to Box 10 If electrical activity, check pulse. If no pulse, go to No box 10 Ifpulse present, begin postresusitation care

Shockable Go to Box 4

Continue CPR Give 1 shock Manual biphasic: Same as first shock or higher dose. Monophasic: 360 J Resume CPR Consider antiarrhythmicsduring CPR: Amiodarone 300 mg IV/IO once, then 150 mg IV/IO once or Lidocaine 1-1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, max 3 doses or 3 mg/kg Consider magnesium, loading dose 1 to 2 g IV/IO for torsades de pointes After 5 cycles of CPR, go to box 5 above

Fig 2 - Pulseless Arrest Algorithm

BRADYCARDIA

Bradycardia (<60 beats/min) and inadequate for clinical condition

Maintain patent Airway, assist Breathing as needed Give oxygen Monitor ECG, pulse oximeter and blood pressure

Secure IV access Review history

Signs or symptoms of Poor Perfusion caused by bradycardia? (eg, onfusion, delirium, lethargy, chest pain, hypotension or other signs of shock) Adequate Perfusion Observe and Monitor

Poor Perfusion

Reminders If pulseless arrest develops, go to Pulseless Arrest Algorithm Search for and treat possible contributing factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia, increased ICP)

Initiate transcutanous pacing for highdegree block (type II second or 3rd degree heart block, wide complex escape beats, MI/ischemia, denervated heart (transplant),new bundle branch block) Consider atropine 0.5 mg IV, repeat q5min to a total dose of 3 mg. Initiate pacing if bradycardia continues. Consider epinephrine 2-10 mcg/min IV infusion or dopamine 2-10 mcg/kg per min IV infusion while awaiting pacer or if pacing ineffective

Initiate transvenous pacing Treat contributing causes Obtain cardiology consultation

Fig 3 - Bradycardia Algorithm (with patient not in cardiac arrest).

TACHYCARDIA With Pulses Assess and support Airway, Breathing, Circulation Give 100% oxygen Monitor ECG and identify rhythm. Monitor oximeter, blood pressure Identify and treat reversible causes Review history and examine patient

Is the patient stable? Unstable includes, hypotension, heart failure, chest pain, decreased mental status, or other signs of shock Stable

Unstable

IMMEDIATE SYNCHRONIZED CARDIOVERSION Establish IV access and give midazolam (Versed) 2-5 mg IVP if patient is conscious; do not delay cardioversion Cardiovert atrial flutter with 50 J, paroxysmal supraventricular tachycardia 50 J, atrial fibrillation 100 J, monomorphic ventricular tachycardia100 J. Polymorphic V tachycardia 360 J unsynchronized. If pulseless arrests develops, see Pulseless Arrest Algorithm, figure 2.

Establish IV access Obtain 12-lead ECG Is QRS narrow (<0.12 sec)? Wide ( $0.12 sec) Narrow NARROW QRS: Is Rhythm Regular? Regular Irregular WIDE QRS: Is Rhythm Regular? Regular Irregular

Attempt vagal maneuvers Give adenosine 6 mg rapid IV push. If no conversion, give 12 mg rapid IV push; may repeat 12 mg dose once

Irregular Narrow-Complex Tachycardia Probable atrial fibrillation or possible atrial flutter or multifocal atrial tachycardia Control rate (eg, diltiazem, betablockers)

If ventrucular tachycardia or uncertain rhythm Amiodarone 150 mg IV over 10 min. Repeat as needed to max 2.2 g/24 hours Prepare for elective synchronized cardioversion If SVT with aberrancy Give adenosine 6 mg, rapid IV push (may repeat 12 mg once)

Does rhythm convert? Converts Does Not Convert

If atrial fibrillation with aberrrancy See Irregular Narrow-Complex Tachycardia If pre-excited atrial fibrillation (AF + WPW) Avoid AV nodal blocking agents (eg, adenosine, digoxin, diltiazem, verapamil) Consider amiodarone150 mg IV over 10 min If recurrent polymorphic VT, seek cardiology consultation If torsades de pointes, give magnesium load of 1-2 g over 560 min, then infuse 3-10 mg/min for 7-48h

If rhythm converts, probable reentry supraventricular tachycardia: Observe for recurrence Treat recurrence with adenosine or longer-acting AV nodal blocking agents (eg, diltiazem, betablockers)

If rhythm does NOT convert, possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia: Control rate (eg diltiazem, beta-blockers) Treat underlying cause

Treat contributing factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia

Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma (hypovolemia, increased ICP)

Figure 4 Tachycardia With Pulses

Acute Coronary Syndromes Algorithm Chest discomfort suggestive of ischemia

Immediate Emergency Department Assessment Check vital signs; evaluate oxygen saturation Establish IV access Obtain/review 12-lead ECG Perform brief, targeted history, physical exam Complete fibrinolytic checklist; check contraindications Obtain initial cardiac marker levels, initial electrolyte and coagulation studies Obtain portable chest x-ray

Immediate Emergency Department treatment Oxygen at 4 L/min; maintain O2 sat >90% Aspirin 160-325 mg (if not given by EMS) Nitroglycerine sublingual spray, or IV Morphine IV if pain not relieved by nitroglycerine

Review initial 12-lead ECG

ST elevation or new or presumably new LBBB; strongly suspicious for injury ST-Elevation MI (STEMI)

ST depression or dynamic T-wave inversion; strongly suspicious for ischemia High-Risk Unstable Angina/ Non-ST-Elevation MI (UA/NSTEMI)

Normal or nondiagnostic changes in ST segment or T wave Intermediate/Low-Risk Unstable Angina

Start adjunctive treatments as indicated Do not delay reperfusion beta-Adrenergic receptor blockers Clopidogrel Heparin (unfractionated or low molecular weight heparin)

Start adjunctive treatments as indicated Nitroglycerine beta-Adrenergic receptor blockers Clopidogrel Heparin (unfractionated or low molecular weight heparin) Glycoprotein IIb/IIIa inhibitor

Develops high or intermediate risk criteria (refractory chest pain, pulmonary edema, mitral regurgitation, hypotension, etc) OR Troponin-positive

Time from onset of symptoms #12 hours? #12 hours

$12 hours

Admit to monitored bed Assess risk status

Consider admission to ED chest pain unit or to monitored bed in ED Follow: Serial cardiac markers (including troponin) Repeat ECG/continuous ST segment monitoring Consider stress test

Reperfusion strategy Reperfusion goals: Door-to-balloon inflation (PCI) goal of 90 min Door-to-needle (fibrinolysis) goal of 30 min Continue adjunctive therapies and: ACE inhibitors/angiotensin receptor blocker within 24 hours of symptom onset HMGCoA reductase inhibitor (statin)

High-risk patient Refractory ischemic chest pain Recurrent/persistent ST deviation Ventricular tachycardia Hemodynamic instability Signs of pump failure Early invasie strategy, including catheterization and revascularization for shock within 48 hours of an AMI Continue ASA, heparin, and other therapies as indicated. ACE inhibitor/ARB HMGCoA reductase inhibitor (statin)

Develops high or intermediate risk criteria (refractory chest pain, pulmonary edema, mitral regurgitation, hypotension, etc) OR Troponin-positive

If no evidence of ischemia or infarction, can discharge with follow-up

Figure 6 - Acute Coronary Syndromes Algorithm

HYPOTENSION,SHOCK,ANDACUTEPULMONARYEDEMA Signs and symptoms of congestive heart failure, acute pulmonary edema. Assess ABCD's, secure airway, administer oxygen; secure IV access. Monitor ECG, pulse oximeter, blood pressure, order 12-lead ECG, portable chest X-ray Check vital signs, review history, and examine patient. Determine differential diagnosis. Determine underlying cause

Hypovolemia Administer Fluids, Blood Consider vasopressors Apply hemostasis; treat underlying problem

Pump Failure Determine blood pressure Systolic BP >100 mm Hg and diastolic BP normal Dobutamine 2.0-20 mcg/kg per min IV Furosemide IV 0.5-1.0 mg/kg Morphine IV 1-3 mg Nitroglycerin SL 0.4 mg tab q3-5min x3 Oxygen

Bradycardia or Tachycardia Bradycardia Go to Fig 3 Tachycardia Go to Fig 4

Systolic BP <70 mm Hg

Systolic BP 70-100 mm Hg

Diastolic BP >110 mm Hg

Norepinephrine 0.530 mcg/min IV or Dopamine 5-20 mcg/kg per min

Dopamine 2.5-20 mcg/kg per min IV (add norepinephrine if dopamine is >20 mcg/kg per min)

If ischemia and hypertension: Nitroglycerin10-20 mcg/min IV, and titrate to effect and/or Nitroprusside 0.1-5.0 mcg/kg/min IV

Figure 6 - Hypotension, Shock, and Acute Pulmonary Edema