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ACLS Algorithms

1 Survey Tachycardias:
2 Survey A fib/flutter
Asystole Narrow
Bradycardia Wide
PEA Stable VT
Drugs Unstable VT/VF
Classes (Sources)

Primary Survey
Assess responsiveness (speak loudly, gently shake patient if no trauma - "Annie, Annie,
are you OK?").
Call for help/crash cart if unresponsive.
ABCD's (sorry, can't get a much better mnemonic than that ... maybe "A Big Cruel Dude
[just beat me up and I coded?"] )
o Airway
Open airway, look, listen, and feel for breathing.
o Breathing
If not breathing, slowly give 2 rescue breaths.
o Circulation
Check pulse. If pulseless, begin chest compressions at 100/min, 15:2 ratio.
Consider precordial thump with witnessed arrest and no defibrillator
nearby. Interposed abdominal compression CPR may be more effective if
trained personnel available, maybe contraindicated in pregnancy, recent
surgery, abdominal aneurysm (Class 2b)
o Defibrillation
Attach monitor, determine rhythm. If VF or pulseless VT: shock up to 3
times. If not, basic CPR. (I think we now have AED's on our code carts
that will lead you through this.)
Then, move quickly to Secondary Survey.

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Secondary Survey
After initial (primary) assessment done
Another set of ABCD's - "A Bigger, Crueler Dude (tried to finish me off)"
o Airway
Establish and secure an airway device (ETT, LMA, COPA, Combitube,
o Breathing
Ventilate with 100% O2. Confirm airway placement (exam, ETCO2, and
SpO2). Remember, no metabolism/circulation = no blue blood to lungs =
no ETCO2.
o Circulation
Evaluate rhythm, pulse. If pulseless continue CPR, obtain IV access, give
rhythm-appropriate medications (see specific algorithms). PIV preferred
initially vs. central line.
o Differential Diagnosis
Identify and treat reversible causes.
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Primary Survey
Secondary Survey: Confirm rhythm (check monitor, power, different lead)
o Consider bicarb, pacing early
o Police officer Hank having just found a body: "Again (asystole)! Boy, This 'Ere's
o Bicarb (NaHCO3). Consider for indications below:
Class 1: hyperkalemia
Class 2a: bicarbonate-responsive acidosis, tricyclic OD, to alkinalize urine
for aspirin OD
Class 2b: prolonged arrest
Not for hypercarbia-related (respiratory) acidosis, nor for routine use in
cardiac arrest
o Transcutaneous Pacing (TCP)
Not shown to improve survival
If tried, try EARLY
o Epinephrine
1 mg IV q3-5 min
o Atropine
1 mg IV q3-5 min
Max 0.04 mg/kg
Consider possible causes (Officer Hank reporting in:"Agent (asystole) Hank Here ... He's
Dead, Marshall")
o Hypoxia
o Hyperkalemia
o Hypothermia
o Drug overdose (e.g., tricyclics)
o Myocardial Infarction
Consider termination. If patient had >10min with adequate resucitative effort and no
treatable causes present, consider cessation - it is, after all, the final rhythm.
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Primary Survey
Secondary Survey
o assess need for airway, oxygen, IV, monitor, fluids, vitals, pulse ox
o 12-lead ECG, Hx, P/E. Consider DDx
o If AV block:
2nd degree (type 2) or 3rd degree: standby TCP, prepare for transvenous
slow wide complex escape rhythm: Do NOT give lidocaine.
If serious signs or symptoms, treat even though "Bub (bradycardia), All People Die
o Atropine
0.5-1.0 mg IV push q 3-5 min
max 0.04 mg/kg
o Pacing
Use transcutaneous pacing (TCP) immediately if sx severe
o Dopamine
5-20 g/kg/min
o Epinephrine
2-10 g/min
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Primary Survey, Secondary Survey: Is patient stable or unstable?
o stable: determine rhythm, treat accordingly
o unstable
=chest pain, dyspnea, decreased level of conciousness, low BP, CHF,
Acute MI
If HR is cause of symptom (almost always HR>150): cardiovert
Specific Rhythms
o Atrial fib/flutter
o Narrow-Complex (Supraventricular) Tachycardia
o Wide-Complex Tachycardia, Unknown Type
o Stable Ventricular Tachycardia
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Atrial fibrillation/flutter
If unstable: proceed more urgently
Management: Control rate, consider rhythm cardioversion, and anticoagulate as shown
below, according to Category: 1, 2 or 3
Category 1. Normal EF
Rate control: Ca-blocker or beta-blocker.
o If onset < 48 hours, consider DC cardioversion OR with one of the following
agents: amiodarone, ibutilide, procainamide, (flecainide, propafenone), sotalol.
o If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone). Either:
Delayed Cardioversion: anticoagulate adequately x 3 weeks, then
cardioversion, then anticoagulate x 4 weeks
Early Cardioversion: iv heparin, then TEE, then cardioversion within 24
hours, then anticoagulate x 4 weeks
Anticoagulate if not contraindicated, if A fib > 48 hrs

Category 2. EF< 40% or CHF
Rate control:
o digoxin, diltizaem, amiodarone (avoid if onset of AF > 48 hours).
o avoid verapamil, beta-blockers, ibutilide, procainamide (and
Cardiovert: same as Category 1, except the only conversion agent allowed is amiodarone.
Anticoagulate, if A fib > 48 hr.

Category 3. WPW A fib
Suggested by: delta wave on resting EKG, very young patient, HR>300
Avoid adenosine, beta-blocker, Ca-blocker, or Digoxin
If < 48 hour:
o If EF normal: one of the following for both rate control and cardioversion:
amiodarone, procainamide, propafenone, sotalol, flecainide
o If EF abnormal or CHF: amiodarone or cardioversion
If > 48 hour
o Medication listed above may be associated with risk of emboli
o Anticoagulate and DC cardioversion as in Category 1.
Note: new ALCS does not allow mixing antiarrhythmics for A fib/flutter.
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Narrow-Complex SVT
If unstable, cardiovert
No cardioversion for stable SVT with low EF.
1. 12-lead ECG, clinical exam
2. Vagal stimulation, adenosine. Consider esophageal lead
3. Treat according to specific rhythm:
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EF normal
Ca-blocker> beta-blocker> digoxin> DC Cardioversion.
Consider procainamide, sotalol, amiodarone.
If unstable proceed to cardioversion
EF < 40%, CHF
No Cardioversion. Digoxin or amiodarone or diltiazem.
If unstable proceed to cardioversion.
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EF normal: Ca-blocker, beta-blocker, amiodarone
EF < 40%, CHF: amiodarone, diltiazem
Note: no cardioversion
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EF normal: amiodarone, beta-blocker, Ca-blocker
EF < 40%, CHF: amiodarone
o rare, most commonly misdiagnosed PSVT.
o likely digoxin or theophylline OD, catecholamine state
o no cardioversion
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Wide-Complex Tachycardia, Unknown Type
If unstable, cardiovert
Attempt to establish specific diagnosis
o 12 leads, esophageal lead, Clinical info
o Note: the use of adenosine to differentiate SVT vs VT is now de-emphasized.
If unable to make Dx, treat according to EF:
o EF normal: DC cardioversion or procainamide or amiodarone
o EF < 40%, CHF: DC cardioversion or amiodarone
o Note: no lidocaine and bretylium in protocol
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Stable VT
May proceed directly to cardioversion
If not, treat according to morphology:
o Monomorphic VT
EF normal: one of the following:
procainamide (2a), sotalol (2a) OR
amiodarone (2b), lidocaine (2b)
EF poor
1. amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75 mg/kg
iv push
2. Synchromized cardioversion
o Polymorphic VT
Baseline QT Normal
Possible ischemia (treat) or electrolyte (esp. low K, Mg)
abnormality (correct)
EF normal: betablocker, lidocaine, amiodarone, procainamide, or
EF poor
1. amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75
mg/kg iv push
2. synchromized cardioversion
Prolonged QT baseline (torsade)
Correct electrolyte abnormalities.
Treatment options: magnesium, overdrive pacing, isoproterenol,
phenytoin, lidocaine
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For tachycardia with serious signs and symptoms. Generally not needed for HR<150.
If HR>150, prepare for immediate cardioversion. May give brief drug trial.
o Prepare emergency equipment
o Medicate if possible
o Cardioversion
monomorphic VT with pulse, PSVT, A fib, A flutter: 100-200-300-360 J*
may try 50J first for PSVT or A flutter
may use equivalent biphasic (biphasic 70, 120, 150, and 170 J)
if machine unable to synchronize and patient critical, defibrillate
polymorphic VT: use VT/VF algorithm
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The "PEA" mnemonic may be even better than "ABCD!"
If not, "Please Eat Apples"
Primary Survey, then Secondary Survey: rule out pseudo-PEA (handheld doppler: look
for cardiac mechanical activities. If present treat agressively).
o Search for the probable cause ...
Wide QRS: suggests massive myocardial injury, hyperkalemia, hypoxia,
Wide QRS+Slow: consider drug OD (tricyclics, beta-blockers, Ca-
blockers, digoxin)
Narrow complex: suggests intact heart; consider hypovolemia, infection,
PE, tamponade
o ... and treat as needed
Consider fluid challenge empirically
Consider bicarbonate
hyperkalemia K (Class 1)
bicarbonate responsive acidosis, tricyclic OD, to alkinalize urine
for aspirin OD (Class2a)
prolonged arrest (Class 2b)
not for hypercarbic acidosis
Epinephrine: 1 mg IV q3-5 min
o If bradycardia, 1 mg IV q3-5 min
o max 0.04 mg/kg
Underlying Causes
5H's, 5T's
Or, if you prefer talking to fighting: He Hid His Huge Hammer, Then Thought To Try
Or, if you like food: Poor (PEA) Hungry Hanna (or Hank) Hurried Herself Here, Then
Tasted My Oh-so-good Pie ( P=PE, M=MI, O=Overdose ... if you'd like a more lurid
mnemonic, this one can easily be changed, as in "Heavenly Hanna ..." [use your
If you prefer a mechanistic approach (and are used to thinking about MAP, CO, SVR,
etc.) think of things that affect forward flow...
o Decreased Preload: Hypovolemia, Tamponade, Tension Pneumothorax
o Increased Afterload: Pulmonary Embolus
o Decreased Contractility: Hypoxia, Hypothermia, Acidosis, Myocardial Ischemia
o Altered Rate/Rhythm: Hyperkalemia, Drug Overdose
o Assess: Collapsed vasculature
o Tx: Fluids
o Assess: Airway, cyanosis, ABGs
o Tx: Oxygen, ventilation
Hydrogen ion (acidosis)
o Assess: Diabetic patient, ABGs
o Tx: Bicarb 1 mEq/kg, hyperventilation
Hyperkalemia (preexisting)
o Assess: Renal patient, EKG, serum K level
o Tx: Bicarb, CaCl, albuterol neb, insulin/glucose, dialysis, diuresis, kayexalate
o Assess: Core temperature
o Tx: Hypothermia Algorithm
Tablets/toxins overdose
o Assess: Hx of medications, drug use
o Tx: Treat accordingly
Tamponade, cardiac
o Assess: No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest
o Tx: Pericardiocentesis
Tension pneumothorax
o Assess: No pulse w/ CPR, JVD, tracheal deviation
o Tx: Needle thoracostomy
Thrombosis, coronary
o Assess: History, EKG
o Tx: Acute Coronary Syndrome algorithm
Thrombosis, pulmonary embolism
o Assess: No pulse w/ CPR, JVD
o Tx: Thrombolytics, surgery
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Unstable VT/VF
Remember: initial stacked shocks are part of the primary survey
Implement the secondary survey after your stacked shocks.
Meds: drug-shock-drug-shock pattern. Continue CPR while giving meds, and shock
(360J or 150J if biphasic) within 30-60 seconds. Evaluate rhythm and check for pulse
immediately after shocking.
Epi or vasopressin big drugs (may give either one as first choice).
o If VF/PVT persists, may move on to antiarrhythmics and sodium bicarb
o max out one antiarrhythmic before proceeding to the next in order to limit pro-
arrhythmic drug-drug interactions.
"Think Shock Shock Shock, EVerybody Shocks: Anna (nicole smith) Shocks, Lydia
(possner) Shocks, Madeleine (cox) Shocks, Pamela (anderson) Shocks, Bridget (hall)
Shocks" ... this one needs some work. I couldn't think of enough names, so did a quick
search for "models" and found a list - I recognized only a few names; choose your own
favorites (this page happens to have only females, I think)
Precordial Thump
o May be performed immediately after determining pulselessness in a witnessed
arrest with no defibrillator immediately available.
o Check pulse after thump.
Shock 200J*
o If VF or VT is shown on monitor: shock immediately.
o Do not lift paddles from chest after shocking - simultaneously charge at next
energy level and evaluate rhythm.
Shock 200-300J*
o If VF or VT persists on monitor, shock immediately.
o Do not check pulse, do not continue CPR, do not lift paddles from chest.
o After shocking, simultaneously charge at next energy level and evaluate rhythm.
Shock 360J*
o If VF or VT persists, shock immediately.
o 1 mg IV q3-5 min.
o High dose epinephrine is no longer recommended
o 40 U IV
o one time dose (wait 5-10 minutes before starting epi).
o Preferred first drug?
Shock 360J*
Amiodarone (Class 2b)
o 300mg IV push.
o May repeat once at 150mg in 3-5 min
o max cumulative dose = 2.2g IV/24hrs
Shock 360J*
Lidocaine (Class Inderterminate)
o 1.0-1.5 mg/kg IV q 3-5 min
o max 3 mg/kg
Shock 360J*
Magnesium Sulfate (Class 2b)
o 1-2 g IV (over 2 min) for suspected hypomagnesemia or torsades de pointes
(polymorphic VT)
Shock 360J*
Procainamide "Acceptable but not recommended" in refractory VF (Class 2b)
o 30 mg/min or 100 mg boluses q 5 min, up to 17 mg/kg.
o Besides having a pro-arrhythmic drug-drug interaction with amiodarone,
procainamide is of limited value in an arrest situation due to lengthy
administration time.
o Note: bretylium acceptable but no longer recommended in ACLS
Shock 360J*
o 1 mEq/kg IV for reasons below:
Class 1: hyperkalemia
Class 2a: bicarbonate-responsive acidosis, tricyclic OD, to alkinalize urine
for aspirin OD
Class 2b: prolonged arrest
o Not for hypercarbia-related acidosis, nor for routine use in cardiac arrest
Shock 360J*
* Or equivalent biphasic shocks (150J-150J-150J). Biphasic refers to pattern of energy wave,
which is first positive then negative, i.e. in opposite direction (vs. only positive in traditional
monophasic shocks). It requires less energy to achieve equivalent results. Lower energy
requirements = smaller, lighter, cheaper, longer-lasting defibrillators. All new ICDs, for
example, are biphasic. Newer defibrillators also monitor impedence, and compensate for
changes. Success rates may be higher with impedence-compensated biphasic defibrillation. See
this AHA site for details.
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ACLS Drugs
adenosine: 6-12 mg iv push with saline flush q 5 min
Non-cardiac arrest
o load 15 mg/min over 10 min (150 mg) (mix 150 mg in 100cc D5W in PVC or
Glass, infuse over 10 min)
o then 1 mg/min x 6 hrs (mix 900 mg in 500 cc D5W)
o then 0.5 mg/min x 18 hrs and beyond;
o supplemental bolus: 15 mg/min x 10 min
Cardiac arrest
o 300 mg iv push (diluted in 20 cc D5W)
o can consider repeat 150 mg iv x 1
Max dose: 2.2 gm in 24hrs
atropine: 0.5-1 mg, up to 0.04 mg/kg
epinephrine: 1 mg q3-5 min iv
load 0.25mg/kg iv over 2 min, then 0.35mg/kg over 2 min in 15 min
infuse 5-15 mg/hour
>60 kg 1 mg
<60 kg 0.01 mg/kg over 10 min
may repeat x 1
make sure K>4.0 and Mg normal.
not recommended for low EF
1 mg/kg bolus
additional 0.5 mg/kg q8-10 min, up to total 3 mg/kg.
Then infuse 1-4 mg/min
magnesium sulfate: 1-2g over 5-60 min
load 20 mg/min up to 17 mg/kg (1000 mg)
then infuse 1-4 mg/min
Side Effects: HTN, torsade
vasopressin: 40 IU x 1 dose only (for pulseless VT/VF)
verapamil: 2.5-5-10 mg bolus
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Class Definitions: I II III Indeterminant
Class I
Definitely recommended. Definitive, excellent evidence provides support.
Class I interventions are always acceptable, unquestionably safe, and definitely useful.
Proven in both efficacy and effectiveness.**
Must be used in the intended manner for proper clinical indications
Required Evidence
One or more Level 1 studies are present (with rare exceptions).
Study results are consistently positive and compelling.
Class IIa and IIb
Acceptable and useful
o Both Class IIa and IIb interventions are acceptable, safe, and considered
efficacious, but true clinical effectiveness is not yet confirmed definitively.
o Must be used in the intended manner for proper clinical indications.
Required Evidence
o Available evidence, in general, is positive.
o Level 1 studies are absent, inconsistent, or lack power.
o Classes IIa and IIb are distinguished by levels of available evidence and
consistency of results.
o No evidence of harm.
Class IIa
Acceptable and useful. Very good evidence provides support.
o Class IIa interventions are acceptable, safe, and useful in clinical practice.
o Considered interventions of choice.
Required Evidence
o Generally higher levels of evidence.
o Results are consistently positive.
Class IIb
Acceptable and useful. Fair-to-good evidence provides support
o Class IIb interventions are acceptable, safe, and useful in clinical practice.
o Considered optional or alternative interventions.
Required Evidence
o Generally lower or intermediate levels of evidence.
o Results are generally but not consistently positive.
Class III
Not acceptable, not useful, may be harmful
o Class III interventions are unacceptable, not useful in clinical practice, and may
be harmful.
Required Evidence
o Complete lack of positive data from higher levels of evidence.
o Some studies suggest or confirm harm.
Class Indeterminant
o A continuing area of research; no recommendation until further research is
Required Evidence
o Higher-level evidence unavailable; studies in progress, inconsistent, or
o Lower-level studies, when available, are not compelling.
**Efficacy versus effectiveness. Evidence-based medicine draws sharp distinctions between
efficacy and effectiveness, terms that initially seem synonymous. Drugs and other interventions
may produce a significant level of benefit in tightly designed, closely controlled, and rigidly
executed laboratory or clinical trials. These trials are a measure of efficacy--under the rigorous
conditions of a controlled clinical study, the intervention "seems to work." When applied in
actual practice, however, the intervention does not perform nearly as well. Effectiveness is the
degree to which the intervention continues to produce positive benefits when used as intended in
clinical practice--in the "real world." To communicate clearly, the term useful clinically is used
to mean effectiveness.
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Much of the information on this site comes from these unofficial sites: acls2000 and
Also, from the American Heart Association's site.
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