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ACLS PATIENT ALGORITHMS
Greg Cook’s version of a Phoenix Fire Dpt clasic

Ventricular Fibrillation & Pulseless Ventricular Tachycardia ABCD's Perform CPR until defibrillator available VF/VT present on defibrillator Defibrillate up to 3 times if needed @ 200J, 200-300J, 360J (Monophasic) 150 J, 150J, 150J (Biphasic) Persistent or recurrent VF/VT CPR if no pulse Intubate at once Establish IV access Epinephrine 1:10,000 1.0 mg q 3-5 min IVP or Vasopressin 40 U IVP (1 time single dose then return to epi) Defibrillate with up to 360 joules (150J Biphasic) within 30 - 60 seconds after each dose of medication Consider Antiarrhythmics Amiodarone 300mg IVP (2nd dose 150mg ) Lidocaine 1-1.5 mg/kg IVP q 3-5 min to a total dose of 3 mg/kg (Consider Mag Sulfate 1-2g IV) (Consider Procainamide 30mg/min) (Consider Bicarb 1 mEq/kg) Defibrillate 360 joules within 30 - 60 seconds after each dose of medication

Asystole

Pulseless Electrical Activity (PEA)

ABC's Initiate CPR Intubate at once Establish IV access Confirm asystole in 2 leads Consider possible causes hypoxia, hyperkalemia, hypokalemia, preexisting acidosis, OD, hypothermia Consider immediate transcutaneous external pacing (TEP) ê Epinephrine 1:10,000 1.0 mg q 3-5 min IVP ê Atropine 1 mg IVP. Repeat q 3-5 min up to a total dose of 0.04mg/kg (3 mg) ê Consider termination of efforts

PEA Includes: EMD, pseudo-EMD, ideoventricular rhythms, ventricular escape rhythms, bradysystolic rhythms ___________________________________ ABC's Initiate CPR Intubate at once Establish IV access Consider possible causes è hypovolemia, hypoxia, cardiac tamponade, tension pneumothorax, hypothermia, pulmonary embolism, drug overdose, hyperkalemia, acidosis, MI Epinephrine 1:10,000 1.0 mg q 3-5 min IVP If absolute bradycardia, (< 60 bpm) or relative bradycardia, give atropine 1 mg IVP and repeat every 3-5 min to a max total dose of 0.04 mg/kg (3 mg)

max. Lidocaine Unstable: Observe and transport. or until a total dose of 3 mg/kg is given Synchronized cardioversion 100 J.75 mg/kg IVP every 5 . 360 J ê Beta Blocker or Lidocaine 1 .5mg/kg (give at 10mg/min) Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs) Lidocaine 1 .flow oxygen IV access Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs) Lidocaine 0. 300J. 300 J.75 mg/kg IVP every 5 . Sustained Ventricular Tachycardia with a Pulse (Monomorphic) Stable: (no S/S Preserved Heart Function) Assess ABC's.10 min until VT resolves. Overdrive Pacing. Torsades) Correct Electrolytes Consider: Mag Sulfate 1-2g IV. total 17 mg/kg Sotalol 1-1.5 . 300 J. secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs Bradycardia (HR < 60 beats / min Stable: (no S/S) Assess ABC's. ie.20 g/kg/min Epinephrine infusion 2 .0 mg IVP. Isoproterenol.0. 360 J Stable: (Long Baseline QT Intervanl. Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs) Procainamide 20 . 200 J. secure airway High -flow oxygen Establish IV access Attach to monitor and assess vital signs ACLS PATIENT ALGORITHMS Wide-complex Tachycardia of Uncertain Type (Polymorphic) Stable: (Normal Baseline QT Interval) Assess ABC's. max.5 .1. and 360 J .75 mg/kg IVP to a total dose of 3 mg/kg.1.5 mg/kg IVP. 200 J. Rebolus @ 0.0.10 g/min May consider isoproterenol 2-10 g/min Prepare for Transvenous Pacing If patient is unstable now or becomes hemodynamically unstable èPerform synchronized cardioversion @ 100 J. 360 J Unstable: (Poor Ejection Fraction) Pulse present High .5 minutes up to a total of 2 mg (may use up to 3 mg total in severe cases) Transcutaneous external pacing (TEP) Dopamine 5 . Phenytoin. total 17 mg/kg Sotalol 1-1.2.10 min. 200 J.5 mg/kg q 5 .5 .30 mg/min. 300 J. secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs Procainamide 20 mg/min.10 min until VT resolves.0. 200 J. be ready to use transcutaneous external pacing (TEP) Unstable: (S/S present) Atropine 0. may rebolus @ 0.5 .1. or until a total dose of 3 mg/kg is given Consider sedation Synchronized cardioversion 100 J.5mg/kg (give at 10mg/min) Synchronized cardioversion 100 J. If patient presents with Type II 2nd degree or third degree AV block. may repeat every 3 .

quinadine. the energy required for synchronized cardioversion begins with 50 J. 100 J. bradycardia. go to VF/VT algorithm If pulseless with electrical activity. shock / hypotension / pulmonary edema) If pulseless and in VF/VT on monitor.3 sec. -blockers. digoxin.3. 200 J.5 mg/kg IVP Procainamide 20 -30 mg/min. go to PEA algorithm. give 2 slow breaths and assess circulation ê If no pulse. 300 J. secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs Adult Emergency Cardiac Care Assess Responsiveness ê Activate EMS ê Call for defibrillator and assess breathing. and consider other appropriate treatment algorithms specific to the patient. If a pulse is present. may give a bolus of 12 mg. May repeat 12 mg bolus in 1 . Diltiazem. 300 J. maximum total 17 mg/kg Synchronized cardioversion Unstable: (heart rate > 150) Prepare for synchronized cardioversion (consider sedation) Synchronized Cardioversion at 50 J. 360 J In cases of atrial flutter. high-flow 02..3 sec. -blockers. anticoagulants Unstable: Prepare for synchronized cardioversion (consider sedation) ê synchronized cardioversion @ 100 J. rapid IVP over 1 . ê Consider use of following: Diltiazem. rapid IVP over 1 . If no electrical activity. 200 J.10 mg IVP (in 15 . begin CPR until defibrillator is available. procainamide.5 . MI. and 360 J . go to asystole algorithm.5 mg IVP Verapamil 5 .2 minutes. begin sequence of ABC's. verapamil. If no breathing present. Consider complex width: Narrow Complex Normal or elevated BP Varapamil 2.30 minutes) Consider Digoxin. If no response.1. secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs Vagal maneuvers Adenosine 6 mg. tachycardia.e. ACLS PATIENT ALGORITHMS Atrial Fibrillation and Atrial Flutter Stable: Assess ABC's. (i. Supraventricular Tachycardia Stable: Do not shock Junctional/multifocal Assess ABC's. Ameodorone synchronized cardioversion (unless it's Junctinal) Narrow Complex èlow or unstable BP synchronized cardioversion Wide complexèLidocaine 1 .

ect.0 g/kg/min) _________________________________________________________________ _ Consider other actions (especially for patients in pulmonary edema) First Line: Second Line: Third Line: Lasix IV 0.0 mg/kg Morphine IV 1-3 mg Nitroglycerine SL 0 2 / Intubate PRN Ntg IV (if SBP>100) Nipride IV (if SBP>100) Dopamine IV (if SBP <100) Dobutamine IV (if SBP>100) Amrinone 0.5 . Thrombolytics.75 mg/kg then 5-15 g/kg/min Consider Aminophylline.4. cardiac monitor.60 minutes ê Immediate Assessment: Treatment to consider if -vital signs evidence of coronary -02 saturation thrombosis: -start IV -high flow 02 -12 lead ECG -nitroglycerine (SL.) ê Thrombolytic therapy to be initiated within 30 .1-5.100 1) Dopamine (2. IV. cardiologist. cause-specific interventions.5-20 g/kg/min) DBP>100 1) Dobutamine (2-20 g/kg/min) 2) Add Norepi if: 2) Nitroprusside dopamine > 20 g/kg/min (0. high -flow oxygen.0 g/kg/min) . & Digoxin SBP 70 .1. Call Fast. Hypotension and Pulmonary Edema Assess ABC's.500 cc fluid challenge 2) Norepinephrine (0. obtain IV access Attach to monitor and assess vital signs ê Define nature of the problem Acute Myocardial Infarction Community emphasis on "Call First.-blockers -IV heparin -PTCA -routine lidocaine is not recommended for all MIs Rate: Go to the tachycardia or bradycardia algorithm Volume: Administer fluids.5-30 g/min) 3) Dopamine (5. Call 911 ê EMS System Oxygen.0-20 g/kg/min) DBP>110 Nitroglycerine (10-20 g/min) 2) Nitroprusside (0. secure airway. vital signs Nitroglycerine Pain relief with narcotics Notification of emergency center Rapid transportation and pre hospital screening for thrombolytic therapy Initiation of thrombolytic therapy ê Emergency Center "Door to Drug" team protocol approach with rapid triage of patients with chest pain and clinical decision maker established (emergency physician. consider vasopressors Pump: What is the blood pressure SBP<70 1) 250 .1-5. ACLS PATIENT ALGORITHMS Shock. paste or -brief history / physical spray if SBP >90) -decide if eligible for thrombolytics -IV morphine Soon as possible -PO aspirin -chest X-ray -thrombolytics -blood studies -IV nitroglycerine -consult .