Figure 1 : Universal/International ACLS Algorithm

Adult Cardiac Arrest Adult Cardiac Arrest

A A B B C C D D

Primary ABCD Survey Primary ABCD Survey Focus : basic CPR and defibrillation Focus : basic CPR and defibrillation Check responsiveness Check responsiveness Activate emergency response system Activate emergency response system Call for defibrillator Call for defibrillator Airway : open the airway Airway : open the airway Breathing : Check for breathing, Look, Listen & Feel Breathing : Check for breathing, Look, Listen & Feel Circulation : Check pulse, start chest compressions Circulation : Check pulse, start chest compressions Defibrillation : attach ECG monitor / defibrillator Defibrillation : attach ECG monitor / defibrillator

Assess rhythm Assess rhythm

VF/VT VF/VT

Attempt Attempt defibrillation x 1 defibrillation x 1 as necessary as necessary

CPR CPR 1-2 minutes 1-2 minutes

Secondary ABCD Survey Secondary ABCD Survey Focus : more advanced assessments & treatments Focus : more advanced assessments & treatments A Airway A Airway place airway device as soon as possible place airway device as soon as possible B Breathing B Breathing confirm airway device placement by examination confirm airway device placement by examination (confirmation device is recommended) (confirmation device is recommended) secure airway device secure airway device confirm effective oxygenation and ventilation confirm effective oxygenation and ventilation C Circulation C Circulation establish IV / IO / Central Line Access establish IV / IO / Central Line Access identify & monitor rhythm identify & monitor rhythm administer drugs appropriate for rhythm & condition administer drugs appropriate for rhythm & condition D Differential Diagnosis D Differential Diagnosis search for & treat identified reversible causes search for & treat identified reversible causes

Non-VF/VT Non-VF/VT

CPR CPR 1-2 minutes 1-2 minutes

Consider causes that are potentially reversible Consider causes that are potentially reversible Hypovolemia Tablets (drug OD, accidents) Hypovolemia Tablets (drug OD, accidents) Hypoxia Tamponade, cardiac Hypoxia Tamponade, cardiac Hydrogen ion - acidosis Tension pneumothorax Hydrogen ion - acidosis Tension pneumothorax Hyper-/hypokalemia, other metabolic Thrombosis, coronary (ACS) Hyper-/hypokalemia, other metabolic Thrombosis, coronary (ACS) Hypothermia Thrombosis, pulmonary (embolism) Thrombosis, pulmonary (embolism) Hypothermia

1 April 2011

Figure 2 : Ventricular Fibrillation/Pulseless VT Algorithm

Primary ABCD Survey

Assess Rhythm

Pulseless VF / VT

Defibrillate x 1st shock (360 J for Monophasic or equivalent 150J 200 J for Biphasic) CPR 1-2 mins Rhythm after first 1st shock?

Persistent or recurrent VF/VT

Return of spontaneous circulation

PEA Go to Fig 3

Asystole Go to Fig 4

Secondary ABCD Survey Place airway device Confirm & secure airway device Establish IV / IO / Central Line Access Differential Diagnosis

Assess vital signs Support airway Support breathing Provide medications appropriate for blood pressure, heart rate, & rhythm

Adrenaline 1 mg IV push CPR Defibrillate within 1 min CPR Adrenaline 1 mg IV push CPR Defibrillate within 1 min CPR Lignocaine 50-100mg IV push CPR Defibrillate within 1min CPR Lignocaine 50-100mg IV push CPR Mg SO4 1-2 g IV if polymorphic VT/ Torsades Defibrillate within 1 min CPR Note : CPR must be continued at all times & also when drugs are given Stop CPR briefly only for analyzing rhythm If IV access is unavailable, do not delay shock. Continue CPR-drug-shock or Amiodarone 300 mg IV push CPR Defibrillate within 1 min CPR Amiodarone 150 mg IV push If rhythm is VF, continue with VF algorithm Check rhythm after CPR.

If VF is converted, follow algorithm for ROSC, PEA or Asystole.

Continue CPR Give appropriate medication as indicated Defibrillate 360 J monophasic or 150-200 J biphasic within 1 min after each dose of medication. For subsequent shocks for biphasic, can escalate energy level gradually up to a max of 360 J Pattern should be CPR-drug-shock, CPR-drug shock
1 April 2011

Figure 3 : Pulseless Electrical Activity Algorithm

Primary ABCD Survey Primary ABCD Survey

Assess rhythm Assess rhythm

Pulseless Electrical Activity Pulseless Electrical Activity (PEA = rhythm on monitor, without detectable pulse (PEA = rhythm on monitor, without detectable pulse

Secondary ABCD Survey Secondary ABCD Survey

Review for most frequent cases & treat accordingly Review for most frequent cases & treat accordingly Hypovolemia Tablets (drug OD, accidents) Hypovolemia Tablets (drug OD, accidents) Hypoxia Tamponade, cardiac Hypoxia Tamponade, cardiac Hydrogen ion - acidosis Tension pneumothorax Hydrogen ion - acidosis Tension pneumothorax Hyper-/hypokalemia Thrombosis, coronary (ACS) Hyper-/hypokalemia Thrombosis, coronary (ACS) Hypothermia Thrombosis, pulmonary (embolism) Hypothermia Thrombosis, pulmonary (embolism)

Adrenaline 1 mg IV push, Adrenaline 1 mg IV push, repeat every 3 to 5 minutes. repeat every 3 to 5 minutes.

1 April 2011

Figure 4 : Asystole: The Silent Heart Algorithm

Primary ABCD Survey Primary ABCD Survey

Assess rhythm Assess rhythm

Asystole Asystole

Confirm Asystole in more than one lead Confirm Asystole in more than one lead

Secondary ABCD Survey Secondary ABCD Survey

Adrenaline 1 mg IV push, Adrenaline 1 mg IV push, repeat every 3 to 5 minutes. repeat every 3 to 5 minutes.

Search for & correct reversible causes Search for & correct reversible causes (Refer to PEA algorithm) (Refer to PEA algorithm)

1 April 2011

Figure 5 : Bradycardia Algorithm

Primary ABCD Survey Primary ABCD Survey

Assess rhythm Assess rhythm

Bradycardia Bradycardia Slow (absolute bradycardia = rate<60 bpm Slow (absolute bradycardia = rate<60 bpm or or Relatively slow (rate less than expected Relatively slow (rate less than expected relative to underlying condition or cause) relative to underlying condition or cause)

Secondary ABCD Survey Secondary ABCD Survey

Serious signs or symptons? Serious signs or symptons? Due to the bradycardia? Due to the bradycardia? No Yes

Type II second-degree AV block Type II second-degree AV block or or Third-degree AV block? Third-degree AV block?

Intervention sequence Intervention sequence Atropine 0.6 mg a a Atropine 0.6 mg Transcutaneous pacing if available Transcutaneous pacing if available Dopamine 2 to 20 mcg/kg per min Dopamine 2 to 20 mcg/kg per min Adrenaline 2 to 10 mcg/min Infusion Adrenaline 2 to 10 mcg/min Infusion Yes

No

Observe Observe

Prepare for transvenous pacer Prepare for transvenous pacer If symptoms develop, use If symptoms develop, use transcutaneous pacemaker transcutaneous pacemaker until transvenous pacer placed until transvenous pacer placed

Note a. Atropine is given in a dose of 0.6 mg intravenously & may be repeated every 3-5 min up to a maximum dose of 2.4 mg.

23 August 2011

Figure 6 : Tachycardia Algorithm

Assess responsive Assess responsive Call for help/defibrillator Call for help/defibrillator Assess ABCs Assess ABCs Administer oxygen Administer oxygen Establish IV Establish IV ECG monitor ECG monitor Assess vital signs Assess vital signs Review history Review history Perform physical examination Perform physical examination Do 12 Lead ECG Do 12 Lead ECG

Unstable, with serious signs or symptoms Unstable, with serious signs or symptoms ie : Heart Failure, SBP<90, in shock ie : Heart Failure, SBP<90, in shock
No

Yes

Immediate synchronised Immediate synchronised Cardioversion Cardioversion

Narrow Complex Narrow Complex Tachycardia Tachycardia

Wide Complex Wide Complex Tachycardia Tachycardia

Polymorphic VT Polymorphic VT

Atrial Atrial fibrillation fibrillation Atrial flutter Atrial flutter

Paroxysmal Paroxysmal supraventricular supraventricular tachycardia (PSVT) tachycardia (PSVT)

If strongly suspect aberrancy

If suspect VT or uncertain WCT

Adenosine 6mg Adenosine rapid iv push 6mg rapid iv push

Lignocaine Lignocaine 50-100 mg IV50-100 mg push IV push

Amiodarone Amiodarone 150 mg IV 150 mg push overIV push over 10 mins 10 mins

Use rate control drugs Use rate control eg: amiodarone, drugs eg: amiodarone, Diltiazem, Verapamil orDiltiazem,Consider Digoxin. Verapamil or Digoxin. Consider anti-cogulation/aspirin anti-cogulation/aspirin

Vagal maneuvers Vagal maneuvers Adenosine 12mg Adenosine rapid iv push 12mg rapid iv push Lignocaine Lignocaine 50-100 mg IV50-100 mg push IV push Amiodarone Amiodarone 150 mg IV 150 mg over 10 IV over mins 10 mins

* Adenosine 6 mg * Adenosine rapid IV push 6 mg rapid IV push Adenosine Adenosine 12mg rapid iv push 12mg rapid iv push

* Verapamil 1 mg * Verapamil 1 mg / min (up to max / mg) 20 min (up to max 20 mg)

If still VT, If still VT, synchronised synchronised cardioversion cardioversion

What
* either drug depending on availability and experience

Correct abnormal Correct abnormal electrolytes electrolytes Treat ischemia if present Treat ischemia Medications: if present Medications: Magnesium Magnesium Consider overdrive Consider overdrive pacing if bradycardia pacing related if bradycardia related

1 April 2011