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2015 GUIDELINES

Adult Advanced Cardiac Life Support


AR R HY T HM I A A C LS P ROT OCOL ZO LL PR O D U CT O PE R ATI O N

Shockable Adult Cardiac Arrest Algorithm1 – 2015 Update


MANUAL DEFIBRILLATION
Coarse Ventricular Fibrillation (Coarse VF) CPR Quality
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Start CPR • Push hard (at least 2 inches
[5 cm]) and fast (100-120/min) Anterior/Posterior with OneStep™
• Give oxygen and allow complete chest recoil.
• Attach monitor/defibrillator • Minimize interruptions in Complete Electrodes
compressions.
• Avoid excessive ventilation.
• Rotate compressor every 1. Apply electrodes to patient
Yes Rhythm No 2 minutes or sooner if fatigued.
2 • If no advanced airway,
• Press firmly to bare skin, moving any air pockets to outer edges
shockable?
9 30:2 compression-ventilation 2. Turn selector switch to DEFIB (R Series® ALS) or ON (R Series Plus)
Fine Ventricular Fibrillation (Fine VF) VF/pVT Asystole/PEA ratio.
• Quantitative waveform • Verify energy levels:
capnography
– If PETCO2 <10 mm Hg, attempt Biphasic: 120 J, 150 J, 200 J
3 to improve CPR quality. (Or follow site-specific protocols if applicable)
Shock • Intra-arterial pressure
4 – If relaxation phase (dia- 3. Push charge button
stolic) pressure <20 mm Hg,
attempt to improve CPR • Wait for ready tone and light
DEFIB R ILLAT ION

CPR 2 min quality.


4. Stand clear
• IV/IO access
Shock Energy for Defibrillation
Ventricular Tachycardia – Pulseless 5. Press and hold shock button on device
• Biphasic: Manufacturer
recommendation (eg, initial
Rhythm No dose of 120-200 J); if unknown,
shockable? use maximum available.
Second and subsequent doses
Yes should be equivalent, and higher
doses may be considered. Anterior-Anterior (Apex/Lateral-Sternum)
5 • Monophasic: 360 J
Shock with OneStep™ CPR Electrodes
6 10 Drug Therapy
Recommended for defibrillation, ventricular cardioversion
Polymorphic Ventricular Tachycardia CPR 2 min CPR 2 min • Epinephrine IV/IO dose:
1 mg every 3-5 minutes and ECG monitoring only. Not recommended for noninvasive
• Epinephrine every 3-5 min • IV/IO access • Amiodarone IV/IO dose: First
• Consider advanced airway, • Epinephrine every 3-5 min dose: 300 mg bolus. Second pacing. Non-invasive pacing with Anterior-Anterior electrode
capnography • Consider advanced airway, dose: 150 mg.
capnography placement can lead to decreased patient tolerance and
Advanced Airway increased capture thresholds.
• Endotracheal intubation or
Rhythm No Rhythm Yes supraglottic advanced airway STERNUM APEX/LATERAL
shockable? shockable? • Waveform capnography or
capnometry to confirm and
Yes monitor ET tube placement
Not Shockable 7 No
• Once advanced airway in place,
give 1 breath every 6 seconds
Shock (10 breaths/min) with continuous

HIGH-QUALITY CPR IS VITAL


chest compressions
8 11
Pulseless Electrical Activity (PEA) Return of Spontaneous
Circulation (ROSC)
CPR 2 min CPR 2 min
• Amiodarone • Pulse and blood pressure
• Treat reversible causes
• Treat reversible causes • Abrupt sustained increase in
PETCO2 (typically ≥40 mm Hg) Components of high-quality CPR include:
• Spontaneous arterial pressure
waves with intra-arterial
monitoring
• Ensuring chest compressions of adequate rate Recommendations are made for a simultaneous,
No Rhythm Yes Reversible Causes • Ensuring chest compressions of adequate depth choreographed approach to performance of
Asystole shockable?
• Hypovolemia chest compressions, airway management,
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• Hypoxia • Allowing full chest recoil between compressions
• Hydrogen ion (acidosis) rescue breathing, rhythm detection, and shock
• If no signs of return of Go to 5 or 7
spontaneous circulation
• Hypo-/hyperkalemia • Minimizing interruptions in chest compressions delivery (if indicated) by an integrated team of
• Hypothermia
(ROSC), go to 10 or 11 • Tension pneumothorax
• If ROSC, go to • Tamponade, cardiac • Avoiding excessive ventilation highly trained rescuers in applicable settings.3
Post–Cardiac Arrest Care • Toxins
• Thrombosis, pulmonary
• Thrombosis, coronary

Adult Bradycardia With a Pulse Algorithm2


NO N - IN VAS IV E PA C IN G

Sinus Bradycardia
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NON-INVASIVE PACING
Assess appropriateness for clinical condition.
Heart rate typically <50/min if bradyarrhythmia. Non-invasive Pacing with OneStep
2 Complete or OneStep Pacing Electrodes
Identify and treat underlying cause 1. Apply OneStepTM Complete or OneStep Pacing
• Maintain patent airway; assist breathing as necessary Multi-Function Electrodes to patient
• Oxygen (if hypoxemic) • Press electrodes firmly to skin, moving any air pockets to
• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry outer edges
2nd or 3rd Degree Atrioventricular (AV) Block • IV access
• 12-Lead ECG if available; don’t delay therapy 2. Select PACER Function Pacing Below Threshold: Pacing Above Threshold:
• Set pacing rate Stimulus Ineffective Effective Pacing (capture)
3 • Increase the Output mA until cardiac stimulation is Pacing Stimuli
effective (capture)
Persistent bradyarrhythmia
4 causing:
No • Hypotension?
Monitor and observe • Acutely altered mental status?
• Signs of shock?
• Ischemic chest discomfort?
• Acute heart failure? Doses/Details
5 Yes Atropine IV dose: Effective Pacing: Note the widened positive QRS, which looks like an
First dose: 0.5 mg bolus. ectopic beat. Note the inverted T-waves and absence of P-waves.
Atropine Repeat every 3-5 minutes.
If atropine ineffective: Maximum: 3 mg.
• Transcutaneous pacing
or Dopamine IV infusion:
• Dopamine infusion Usual infusion rate is
or 2-20 mcg/kg per minute. Non-invasive pacing with other ZOLL electrodes:
• Epinephrine infusion Titrate to patient response; 1. Apply ECG electrodes to patient
taper slowly. 2. Apply Multi-Function Electrodes to the patient
• Press electrodes firmly to skin, moving any air pockets to outer edges
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Epinephrine IV infusion: 3. Select PACER Function Effective Pacing: Note negative R-wave and large T-waves.
Consider: 2-10 mcg per minute • Set pacing rate
infusion. Titrate to patient • Increase the Output mA until cardiac stimulation is effective (capture)
• Expert consultation
response.
• Transvenous pacing

Ventricular Tachycardia Adult Tachycardia With a Pulse Algorithm2

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ADULT TACHYCARDIA ALGORITHM CARDIOVERSION
Assess appropriateness for clinical condition.
Heart rate typically ≥150/min if tachyarrhythmia.
Doses/Details 1. Apply electrodes or paddles to patient
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Synchronized Cardioversion 2. Turn selector switch to DEFIB (R Series ALS) or ON
Initial recommended doses:
Atrial Flutter Identify and treat underlying cause
• Narrow regular: 50-100 J
(R Series Plus)
• Maintain patent airway; assist breathing as necessary • Narrow irregular: 120-200 J biphasic 3. Press Sync On/Off
• Oxygen (if hypoxemic) or 200 J monophasic
CA R D IOV E R S IO N

• Cardiac monitor to identify rhythm; monitor blood • Follow your institution’s protocol for energy settings
• Wide regular: 100 J
pressure and oximetry 4. Verify that downward arrows ( ) display over R-waves
• Wide irregular: defibrillation dose
(not synchronized) and display reads SYNC
3 • Do not cardiovert if SYNC is OFF
4 Adenosine IV dose:
Persistent tachyarrhythmia First dose: 6 mg rapid IV push; follow 5. Press charge button
causing: Synchronized cardioversion with NS flush. Atrial Arrhythmias
Supraventricular Tachycardia Yes • Consider sedation Second dose: 12 mg if required.
• Wait for ready tone and light
• Hypotension?
• Acutely altered mental status? • If regular narrow complex, 6. Stand clear Female Patients:
• Signs of shock? consider adenosine Antiarrhythmic Infusions for Position electrode
7. Press and hold shock button on device under breast
• Ischemic chest discomfort? Stable Wide-QRS Tachycardia
• Acute heart failure? Procainamide IV dose:
6 20-50 mg/min until arrhythmia
No suppressed, hypotension ensues,
5 • IV access and 12-lead ECG QRS duration increases >50%, or
Wide QRS? Yes if available maximum dose 17 mg/kg given.
• Consider adenosine only if
Atrial Fibrillation (AF) ≥0.12 second
regular and monomorphic
Maintenance infusion: 1-4 mg/min.
Avoid if prolonged QT or CHF.
• Consider antiarrhythmic infusion
• Consider expert consultation Amiodarone IV dose:
7 No First dose: 150 mg over 10 minutes.
Repeat as needed if VT recurs. Recommended Anterior/Posterior Placement
Follow by maintenance infusion of
• IV access and 12-lead ECG if available 1 mg/min for first 6 hours. ECG waveform with sync markers
• Vagal maneuvers
Ventricular Arrhythmias
Sotalol IV dose:
• Adenosine (if regular) 100 mg (1.5 mg/kg) over 5 minutes.
• β-Blocker or calcium channel blocker Avoid if prolonged QT.
Narrow-Complex Supraventricular Tachycardia • Consider expert consultation

The information contained above summarizes the 2015 Adult Cardiac Arrest Protocol as published by the American Heart Association and is not meant as a
substitute for comprehensive ACLS training. ZOLL Medical Corporation assumes no liability for changes or local interpretations of standard protocols. Some
patients may require care not described herein. These guidelines should not limit treatment options. ZOLL Medical Corporation
Stable Ventricular Tachycardia: Monomorphic ©2016 ZOLL Medical Corporation. All rights reserved. OneStep, R Series, and ZOLL are trademarks or registered trademarks of ZOLL Medical Corporation in the 269 Mill Road
United States and/or other countries. All other trademarks are the property of their respective owners.
Chelmsford, MA 01824-4105
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Reprinted with permission 2015 American Heart Association Guidelines Update For CPR and ECC Part 7: Adult Advanced Cardiovascular Life Support.
Circulation. 2015;132[suppl 2]:S444-S464 ©2015, American Heart Association, Inc. 978-421-9655 • 800-348-9011
Reprinted with permission. ©2015 American Heart Association, Inc.
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www.zoll.com
Neumar RW, et al. Circulation. 2015;132(suppl 2):S315-S367.
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