ACUTE CORONARY SYNDROMES ALGORITHM CARDIAC ARREST ALGORITHM

Patient has signs suggestive of ischemia or infarction

01 START CPR
Give Oxygen
Attach monitor / Defibrillator

1 MONITOR & SUPPORT ABC’S 4 STEMI RESPONSE

EMS Prepare to provide CPR or defibrillate if needed Notified hospital should mobilize
hospital resources
ASSESSMENT, 2 ADMINISTER ASPIRIN
Consider oxygen, nitroglycerin, and 5 COMPLETE FIBRINOLYTIC CHECKLIST
CARE, AND
morphine If considering prehospital fibrinolysis,
HOSPITAL 3 OBTAIN 12-LEAD ECG: INTERPRET/TRANSMIT use fibrinolytic checklist 02 VF/pVT YES NO 09 PEA / Asystole
PREPARATION If ST elevation, note time of onset and first
medical contact and notify receiving hospital.
CHECK RHYTHM.
03 SHOCK SHOCKABLE?

CHECK VITAL SIGNS & OXYGEN SAT START OXYGEN

ESTABLISH IV ACCESS At 4 L/min, titrate if O2 sat <90%

CONCURRENT BRIEF HISTORY & PHYSICAL ADMINISTER ASPIRIN

IMMEDIATE ED 04 CPR (2 Minutes) 10 CPR (2 Minutes)
160 to 325 mg (if not given by EMS)
ED ASSESSMENT COMPLETE FIBRINOLYTIC CHECKLIST
ADMINISTER NITROGLYCERIN GENERAL Gain IV/IO Access Gain IV/IO access
(<10 MINUTES) OBTAIN INITIAL CARDIAC MARKERS Sublingual or spray TREATMENT Epinephrine: 1mg every 3-5 Min
Decide: advanced airway, capnography
And initial electrolyte and coagulation studies ADMINISTER MORPHINE IV
PORTABLE CHEST X-RAY (<30 MIN) If nitroglycerin doesn’t relieve discomfort CHECK RHYTHM.
NO
SHOCKABLE? YES NO CHECK RHYTHM. YES
SHOCKABLE?
ECG Interpretation
05 SHOCK

ST-Elevation MI (STEMI) Low/Intermediate-Risk ACS

ST elevation or new or presumably new
LBBB; strongly suspicious for injury High-Risk Non-ST-Elevation ACS
Normal or nondiagnostic changes in ST
segment or T wave 06 CPR (2 Minutes) 11 CPR (2 Minutes)
ST depression or dynamic T-wave inversion; Look for and treat reversible causes
Epinephrine: 1mg every 3-5 Min
strongly suspicious for ischemia Decide: advanced airway, capnography

Start adjunctive therapies as indicated Admission OR Monitoring

Consider admission to ED chest pain unit or to CHECK RHYTHM. CHECK RHYTHM. YES
Don’t delay reperfusion NO NO
Troponin Elevated OR appropriate bed for further monitoring and SHOCKABLE? SHOCKABLE?
possible intervention YES
High-Risk Patient
Consider Early invasive strategy if:

Time from onset of symptoms is:

> 12
Refractory ischemic chest discomfort
Recurrent / persistent ST deviation
07 SHOCK
Hours
Ventricular tachycardia
≤ 12 Hours Hemodynamic instability
Signs of heart failure
If no signs of return of

Reperfusion Goals:
Start Adjunctive Therapies 08 CPR (2 Minutes) 12 spontaneous circulation
(ROSC), go to 10 or 11
GO TO 5 OR 7

eg. Nitroglycerin, heparin as indicated
Therapy defined by patient & center criteria
See AHA/ACC NSTE-ACS guidelines Amiodarone: 300mg If ROSC, go to Post-Cardiac Arrest Care
Door-to-balloon inflation (PCI) Look for and treat reversible causes
Goal: 90 Minutes
Door-to-needle fibrinolysis)
Goal: 30 Minutes

This Algorithm is based on the latest (2015) American Heart Association standards and guidelines. This Algorithm is based on the latest (2015) American Heart Association standards and guidelines.

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POST-CARDIAC ARREST CARE ALGORITHM CARDIAC ARREST CIRCULAR ALGORITHM

START Give Oxygen

Return of spontaneous circulation (ROSC) CPR Attach monitor / Defibrillator

OPTIMIZE CHECK
2M

MAINTAIN OXYGEN SATURATION ≥ 94%

VENTILATION RHYTHM POST-CARDIAC
IN

CONSIDER ADVANCED AIRWAY AND

UT

AND WAVEFORM CAPNOGRAPHY ARREST CARE

ES

OXYGENATION DO NOT HYPERVENTILATE

Drug Therapy
IV/IO Access
TREAT IV/IO BOLUS
HYPOTENSION VASOPRESSOR INFUSION Epinephrine Every 3-5 Minutes
(SBP <90 mm Hg) CONSIDER TREATABLE CAUSES Amiodarone for refractory VF/pVT

Consider Advanced Airway

Quantitative waveform capnography
12-Lead ECG: STEMI
YES
Coronary reperfusion OR high suspicion of AMI
Treat Reversible Causes
NO

Does Patient Initiate targeted

NO
Follow Commands? temperature management
DOSES & DETAILS
YES

CPR QUALITY ADVANCED AIRWAY

• Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow
Advanced Critical Care complete chest recoil.
• Endotracheal intubation or supraglottic advanced airway
• Waveform capnography or canometry to confirm and monitor ET
• Minimize interruptions in compressions.
tube placement
• Avoid excessive ventilation.
DOSES & DETAILS • Rotate compressor every 2 minutes, or sooner if fatigued.
• Once advanced airway in place, give 1 breath every 6 seconds (10-
12 breaths/min) with continuous chest compressions
• If no advanced airway, 30:2 compression-ventilation ratio.
• Quantitative waveform capnography
VENTILATION/OXYGENATION DOPAMINE IV INFUSION o If PETCO2 <10mm HG, attempt to improve CPR quality
RETURN OF SPONTANEOUS CIRCULATION (ROSC)
• Avoid excessive ventilation. • Intra-arterial pressure
• 5-10 mcg/kg per minute
• Start at 10 breaths/min and titrate to target PETCO2 of 35-40 mm o If relaxation phase (diastolic) pressure <20 mm Hg, • Pulse and blood pressure
Hg. attempt to improve CPR quality • Abrupt sustained increase in PETCO2 (typically ≥40mm Hg)
• When feasible, titrate FIO2 to minimum necessary to achieve NOREPINEPHRINE IV INFUSION • Spontaneous arterial pressure waves with intra-arterial monitoring
SPO2 ≥94%
• 0.1 – 0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute) SHOCK ENERGY FOR DEFIBRILLATION
• Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 REVERSIBLE CAUSES
IV BOLUS J); if unknown, use maximum available. Second and subsequent
REVERSIBLE CAUSES doses should be equivalent, and higher doses may be considered. H’s T’s
• Approximately 1-2 L normal saline or lactated Ringer’s
• Monophasic: 360 J • Hypovolemia • Tension pneumothorax
H’s T’s
• Hypovolemia • Tension pneumothorax • Hypoxia • Tamponade (cardiac)
EPINEPHRINE IV INFUSION • Hypoxia • Tamponade (cardiac) DRUG THERAPY • Hydrogen ion (acidosis) • Toxins
• Hydrogen ion (acidosis) • Toxins • Epinephrine IV/IO Dose: 1 mg every 3-5 minutes • Hypo-/hyperkalemia • Thrombosis (pulmonary)
• 0.1 – 0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute)
• Hypo-/hyperkalemia • Thrombosis (pulmonary) • Amiodarone IV/IO Dose: First dose: 300mg bolus. Second dose: • Hypothermia • Thrombosis (coronary)
• Hypothermia • Thrombosis (coronary) 150mg.

This Algorithm is based on the latest (2015) American Heart Association standards and guidelines. This Algorithm is based on the latest (2015) American Heart Association standards and guidelines.

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TACHYCARDIA WITH A PULSE ALGORITHM BRADYCARDIA WITH A PULSE ALGORITHM

Assess appropriateness for clinical condition

Heart rate typically ≥ 150/min if tachyarrhythmia Assess appropriateness for clinical condition
Heart rate typically < 50bpm if bradyarrhythmia

IDENTIFY AND MAINTAIN PATENT AIRWAY

Assist breathing as necessary MAINTAIN PATENT AIRWAY
TREAT Assist breathing as necessary
OXYGEN (IF HYPOXEMIC)
UNDERLYING IDENTIFY AND OXYGEN (IF HYPOXEMIC)
CARDIAC MONITOR TO IDENTIFY RHYTHM
CAUSE Monitor blood pressure and oximetry TREAT UNDERLYING CARDIAC MONITOR TO IDENTIFY RHYTHM
CAUSE Monitor blood pressure and oximetry
OBTAIN 12-LEAD ECG
ESTABLISH IV ACCESS
HYPOTENSION?
IS PERSISTENT ACUTELY ALTERED MENTAL STATUS?
NO YES
TACHYARRHYTHMIA SIGNS OF SHOCK?
CAUSING: HYPOTENSION?
ISCHEMIC CHEST DISCOMFORT?
IS PERSISTENT ACUTE ALTERED MENTAL STATUS (AMS)?
ACUTE HEART FAILURE? NO YES
BRADYARRHYTHMIA SIGNS OF SHOCK?
CAUSING: ISCHEMIC HEART DISCOMFORT?
Is the QRS wide or narrow YES
(≥ 0.12 second) ACUTE HEART FAILURE?

NO

Monitor and observe

IV ACCESS AND 12-LEAD ECG IV ACCESS AND 12-LEAD ECG
Atropine (0.5 mg IV)
Synchronized Cardioversion the patient
Only if available Only if available Consider:
ADENOSINE CONSIDER ADENOSINE If Atropine ineffective:
CONSIDER SEDATION Transcutaneous pacing
Only if regular Only if regular and monomorphic Consultation with expert
If regular narrow complex, consider OR
VAGAL MANEUVERS CONSIDER ANTIARRHYTHMIC adenosine Transvenous pacing Dopamine infusion (2-10 mcg/kg/min)
BETA-BLOCKER OR CALCIUM INFUSION OR
CHANNEL BLOCKER CONSIDER EXPERT Epinephrine infusion (2-10 mcg/min)
CONSIDER EXPERT CONSULTATION CONSULTATION

DOSES & DETAILS

ATROPINE IV DOSE
SYNCHRONIZED CARDIOVERSION ANTIARRYTHMIC INFUSIONS FOR STABLE WIDE-QRS First dose
Initial recommended doses: TACHYCARDIA • 0.5 mg bolus
• Narrow regular: 50-100 J Procainamide IV dose: • Repeat every 3-5 minutes
• Narrow irregular: 120-200 J biphasic or 200 J • 20-50 mg/min until arrhythmia suppressed, hypotension • Maximum: 3 mg.
monophasic ensues, QRS duration increased > 50%, or maximum dose
• Wide regular: 100 J 17mg/kg given.
• Wide irregular: defibrillation dose (not • Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT
or CHF. DOPAMINE IV INFUSION
synchronized)
Usual infusion rate is 2-20mcg/kg/min
AMIODARONE IV DOSE • Titrate to patient response; taper slowly.
ADENOSINE IV DOSE First dose:
First dose: • 150 mg over 10 minutes. Repeat as needed if VT recurs.
• 6 mg rapid IV push; follow with NS flush • Follow by maintenance infusion of 1 mg/min for first 6 hours EPINEPHRINE IV INFUSION
Second dose:
12 mg if required 2-10mcg/min infusion.
• SOTALOL IV DOSE • Titrate to patient response.
• 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT

This Algorithm is based on the latest (2015) American Heart Association standards and guidelines. This Algorithm is based on the latest (2015) American Heart Association standards and guidelines.

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SUSPECTED STROKE ALGORITHM

Activate Emergency Response (EMS)

Identify signs and symptoms of possible stroke

1 SUPPORT ABC’s 4 TRIAGE TO STROKE CENTER

CRITICAL EMS Give oxygen if needed
5 ALERT HOSPITAL
ASSESSMENTS 2 PREHOSPITAL STROKE ASSESSMENT Consider direct transfer to CT scan
AND ACTIONS 3 ESTABLISH TIME OF SYMPTOM ONSET 6 CHECK GLUCOSE IF POSSIBLE
When they were last normal
NINDS Time Goals
ED Arrival
IMMEDIATE ASSESS ABC’S, VITAL SIGNS NEUROLIGIC SCREENING ASSESSMENT
GENERAL PROVIDE OXYGEN IF HYPOXEMIC ACTIVATE STROKE TEAM
ASSESSMENT ORDER EMERGENT CT SCAN OR MRI OF BRAIN
IV ACCESS AND LAB ASSESSMENTS
AND
CHECK GLUCOSE; TREAT IF INDICATED OBTAIN 12-LEAD ECG
STABILIZATION

ED Arrival
IMMEDIATE REVIEW PATIENT HISTORY
NEUROLOGIC ESTABLISH TIME OF SYMPTOM ONSET
ASSESSMENT BY OR LAST KNOWN NORMAL
STROKE TEAM PERFORM NEUROLOGIC EXAMINATION
NIH Stroke Scale or Canadian Neurological Scale
OR DESIGNEE
ED Arrival

No Hemorrhage Hemorrhage
Hemorrhage shown by CT Scan?

Probable acute ischemic stroke

Consider fibrinolytic therapy Is patient a candidate for fibrinolytic therapy?
Check for fibrinolytic exclusions and repeat
neurologic exam YES NO

ED Arrival ASK: Are deficits rapidly improving to normal?

Review risks and benefits with Administer Aspirin

patient and family
If acceptable
Give rtPA
Not anticoagulants or antiplatelet Consultation
treatment for 24 hours
ED Arrival Consult neurologist or neurosurgeon and
3 HOURS
consider transfer if not available

Begin post-rtPA stroke pathway

Aggressively monitor:
BP per protocol Begin stroke or hemorrhage pathway
For neurologic deterioration
Emergent admission to stroke unit Admit to stroke or intensive care unit
or intensive care unit

This Algorithm is based on the latest (2015) American Heart Association standards and guidelines.

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