Acute Coronary

Syndromes Algorithm
Syndroms Suggestive of Ischemia or Infarction
EMS assessment and care and hospital prepartion*

Oxygen
Aspirin (If O sat< 94% Activate Cardiac Pain
2
12–Lead ECG Control
160–325 mg or O Sat>90%
2
Cath Lab
with COPD)

Concurrent ED assessment Immediate ED general

(<10 minutes) treatment

Aspirin Nitroglycerin
Check Vital Physical If O2 sat<94% Pain
IV Access 160–325 mg Sublingual or
Signs Exam Start Oxygen (If not already taken) Control spray

Activate Cardiac Cardiac Marker Chest X-ray

Cath Lab 12–Lead ECG
Levels (<30 mins)

ECG Interpretation**

ST-elevation MI (STEMI) High-risk unstable angina/non-ST-elevation Low-/Intermediate-risk ACS

Start adjunctive therapies
MI (UA/NSTEMI)
Consider admission to ED chest pain unit
as indicated or to appropriate bed and follow:
Do not delay reperfusion Serial cardiac markers (including troponin)
Troponin elevated or high-risk patient Repeat ECG/continuous ST-segment monitoring
Consider early invasive strategy if: Consider noninvasive diagnostic test
Refractory ischemic chest discomfort
Time from onset Recument/persistent ST deviation
of symptoms
>12 Ventricular tachycardia
hours Develops 1 or more:
≤ 12 hours? Hemodynamic instability
Signs of heart failure Clinical high-risk features
Dynamic ECG chages
consistent with ischemia
Troponin elevated
Start adjunctive treatments as indicated
≤12 Nitroglycerin
hours Heparin (UFH or LMWH)
Consider: PO β-blockers
Consider: Clopidogrel Abnormal diagnostic
Consider: Glycoprotein llb/llla inhibitor noninvasive imaging or
physiologic testing?

Reperfusion goals:
Door-to-balloon inflation (PCI)*** Admit to monitored bed Assess risk status Continue
goal of 90 minutes ASA heparin, and other therapies as indicated If no evidence of ischemia or
Door-to-needle (fibrinolysis) ACE inhibitor/ARB; HMG CoA reductase inhibitor (statin therapy) infarction by testing, can
goal of 30 minutes Not at high risk: cardiology to risk stratity discharge with follow-up

* O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannopoulos D. “Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S787-S817. http://circ.ahajoumals.org/content/122/18_suppl_3/S787
**Afolabi BA, Novaro GM, Pinski SL, Fromkin KR, Bush HS. Use of the prehoapital ECG improves door to balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Emerg Med J. 2007;24:588-591
*** O’Connor, RE AL, Ali, brady , WJ, Ghaemmaghami CA, Menon V, Welsford M, shuster M. . Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation 2015;132(suppl2):S483-S500

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 Cardiac Arrest *
Circular Algorithm
Shout for Help/Activate Emergency Response

Start CPR
Give Oxygen Attach Monitor/Defibrillator
2 minutes Return of Spontaneous
Circulation (ROSC)
Check Post-Cardiac
Rhythm Arrest Care
If VF/VT
Shock
Drug Therapy
IV/IO access
Epinephrine every 3–5 minutes
uous CPR

Amiodarone for refractory VF / VT

Continuous CPR
Consider Advanced Airway
Quantitative waveform capnography
Contin

Treat Reversible Causes

Mo
nitor y
CPR Qualit

Doses/Details for the Cardiac Arrest Algorithms

CPR Quality Return of Spontaneous Circulation(ROSC)
Push hard (2” to 2.4” or 5–6cm) and fast (100–120/min) and allow Pulse and blood pressure
complete chest recoil. Abrupt sustained increase in PETCO2 (typically ≥ 40 mm Hg)
Minimize interrruptions in compressions.**
Spontaneous arterial pressure waves with intra-arterial
Avoid excessive ventilation monitoring
Rotate compressor every 2 minutes
If no advanced airway, 30:2 compression-ventilation ratio
Quantative waveform capnography
If PETCO2<10mm Hg, attempt to improve CPR quality
Shock Energy
If relaxation phase(diastolic) pressure<20mm Hg,
attempt to improve CPR quality. Biphasic: Manufacturer recommendation (eg. initial dose of
120–200 J): if unknown, use maximum available.
Second and subsequent doses should be equivalent, and
Drug Therapy higher doses may be considered
Monophasic: 360 J
Epinephrine IV/IO Dose: 1 mg every 3–5 minutes
Amiodarone IV/IO Dose***: First dose: 300 mg bolus
Second dose: 150 mg Reversible Causes
Hypovolemia Tension pneumothorax
Advanced Airway**** Hypoxia Tamponade, cardiac
Supraglottic advanced airway or endotracheal intubation Hydrogen ion (acidosis) Toxins
Waveform capnography to confirm and monitor ET tube placement Hypo-/Hyperkalemia Thrombosis, pulmonary
10 breaths per minute with continuous chest compressions Hypothermia Thrombosis, coronary

* Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced cardiac life support. 2015 American
Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015 132 (suppl 2):S444-S464
** Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB Minimally Interrupted cardiac resuscitation by emergency medical services for out of hospital cardiac arrest. JAMA 2008;299:1158-1165
***Dorian P, Cass D, Schwartz B, Cooper R. Gelaznikas R, Barr A. Amiodarone as compared with Lidocaine for shock resistant ventricular fibrillation N Engl J Med 2002;346:884-890.
**** Dorges V, Wenzel V, Knacke P, Gerlach K, Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients. Crit Care Med. 2003;31:800-804

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
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 Cardiac Arrest
Algorithm
Shout for Help/Activate Emergency Response

Start CPR
1 Give Oxygen
Attach Monitor/Defibrillator

2 VF/VT Rhyhm Shockable? Asystole/PEA 9

3 Shock*
CPR 2 min
Epi 1 amp iv, IV/IO access

4
CPR 2 min flush NaCl 20
cc, angkat
10 Epinephrine every 3–5 min
IV/IO access Consider advanced airway,
tangan capnography

Rhyhm Shockable?

12
Rhyhm Shockable?
5 Shock
If no signs of return of
spontaneous circulation
(ROSC), go to 10 or 11.
CPR 2 min
Epinephrine every 3-5 min CPR 2 min
6 Consider advanced airway, Treat reversible causes 11
capnography
If ROSC, go to Post-
Cardiac Arrest Care.

Rhyhm Shockable? Rhyhm Shockable?

7 Shock Pada pVT polimorfik

pertimbangkan MgSO4

CPR 2 min Amiodarone 300 mg bolus

Amiodarone 8 Dosis kedua 150 mg
Go to 5 or 7
Treat reversible causes

* Link MS, Atkins DL, Plassman RS, Halperin HR, SAmson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing:
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3): S706-S719.
http://circ. ahajournals.org/content/122/18_suppl_3/S706

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
If you are reading this page after October 2020, please contact ACLS Training Center at support@acls.net for an updated document. Version 2016.02.a

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 Bradycardia With
a Pulse Algorithm
Parameter : Assess appropriateness for clinical condition.
Nadi spontan Heart rate typically < 50/min if bradyarrhythmia.
Peningkatan udara di
capnografi
??
Parameter belum lengkap

Identify and treat underlying cause

Maintain patent airway; assist breathing as necessary*
Oxygen (if hypoxemic)
Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
IV access
12–Lead ECG if available; don’t delay therapy

Persistent bradyarrhythmia causing:

Monitor Hypotension?
and Acutely altered mental status?
Signs of shock?
observe
Ischemic chest discomfort?
Acute heart failure?

Atropine IV Dose:
First dose: 0.5 mg bolus
Repeat every 3–5 minutes
Maximum: 3 mg

If atropine ineffective:
Transcutaneous pacing**
OR
Dopamine IV infusion:
2–10 mcg/kg per minute
OR
Epinephrine IV infusion:
2–10 mcg per minute

Consider:
Expert consultation
Transvenous pacing

* Dorges V, Wenzel V, Knacke P, Gerlach K, Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients. Crit Care Med. 2003;31:800-804
** Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators, defillation, cardioversion, and pacing:
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010; 122(suppl 3):S706-S719. http://circ.ahajournals.org/content/122/18_suppl_3/S706

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
If you are reading this page after October 2020, please contact ACLS Training Center at support@acls.net for an updated document. Version 2016.02.a

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 Immediate Post-Cardiac
Arrest Care Algorithm
Return of Spontaneous Circulation (ROSC)*

Optimize Ventilation and

Oxygenation Treat Hypotension (SBP < 90 mm Hg)
Maintain oxygen saturation 94% IV/IO bolus
Consider advanced airway Vasopressor infusion
waveform capnography Consider treatable causes
Do not hyperventilate 12-Lead ECG

Follow Commands ?

Induced Hypothermia**

Cardiac Catheterization Laboratory

Advanced Critical Care

Doses/Details Epinephrine IV Dopamine IV

Infusion Infusion

0.1–0.5 mcg/kg per minute 2–10 mcg/kg per minute

Ventilation/Oxygenation (in 70-kg adult: 7-35 mcg
per minute)
Avoid excessive ventilation Norepinephrine
Start at 10 94% breaths/min IV Infusion
and titrate to target PETCO2 Reversible Causes
of 35–40 mm Hg.
When feasible, titrate FIO2 0.1–0.5 mcg/kg per minute
to minimum necessary to Hypovolemia (in 70–kg adult: 7–35mcg
achieve SpO2 ≥ 94%. Hypoxia per minute)
Hydrogen ion (acidosis)
Hypo-/Hyperkalemia
IV Bolus Hypothermia
Tension pneumothorax
1–2 L normal saline or Tamponade, cardiac
lactated Ringer’s. Toxins
If inducing hypothermia, Thrombosis, pulmonary
may use 4°C fluid. Thrombosis, coronary

* Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out of hospital cardiac arrest: a systematic review and metanalysis Circ Cardiovasc Qual Outcomes. 2010;3:63-81.
** Bruel C, Parienti JJ, Marie W, Arrot X, Mild hypothermia during advanced life support, a preliminary study in out of hospital cardiac arrest. Crit Care. 2008;12: R31
*** Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: post-cardiac arrest care: 2015 American Heart Association
Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132(suppl2):S465-S482

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
If you are reading this page after October 2020, please contact ACLS Training Center at support@acls.net for an updated document. Version 2016.02.a

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 Stroke Assessment

The Cincinnati Prehospital Stroke Scale

Facial Droop
(have patient show teeth or smile)

NORMAL ABNORMAL

Both sides of face move equally. One side of face does not move
as well as the other side.

Arm Drift
(patient closes eyes and extends both arms straight out, with palms up for 10 seconds)

NORMAL ABNORMAL

Both arms move the same or both One arm does not move or one
arms do not move at all. arm drifts down compared
with the other.

Abnormal Speech
(have the patient say “you can’t teach an old dog new tricks”)

Normal - Patient uses correct Abnormal - Patient slurs

words with no slurring. words, uses the wrong words,
or is unable to speak.

If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
If you are reading this page after October 2020, please contact ACLS Training Center at support@acls.net for an updated document. Version 2016.02.a

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 Suspected Stroke Algorithm:
Goals for Management of Stroke

Identify Signs and Symptoms of Possible Stroke

Active Emergency Response
Critical EMS assessments and actions

Support ABCs: Establish time of

Perform prehospital Triage to Activate stroke
Give Oxygen Check glucose symptom onset Alert hospital
stroke assessment stroke center team
if indicated (last normal)

NINDS TIME GOALS

If onset >3 hours consider triage to hospital
with interventional capabilities for stroke.

Immediate general assessment and stabilization* Immediate neurologic assessment by stroke team
or designee
Assess ABCs, vital signs
Provide oxygen if O sat <94%
2

Obtain IV access and perform laboratory Review patient history

assessments Establish time of symptom onset or last
Check glucose; treat if indicated known normal
Obtain 12–lead ECG Perform neurologic examination (NIH Stroke
Scale or Canadian Neurological Scale)
Perform neurologic screening assessment
Order emergent CT without contrast

Does CT Scan Show Hemorrhage?

No hemorrhage Hemorrhage

Probably acute ischemic stroke; Consult neurologist or neurosurgeon;

consider fibrinolytic therapy consider transfer if not available.

Check fibrinolytic exclusions

Repeat neurologic exam: are deficits Begin stroke or hemorrhage
rapidly improving to normal? pathway
Admit to stroke unit or
intensive care unit

Patient remains candidate Not a candidate

for fibrinolytic therapy? Administer aspirin

Candidate*

Begin post-rTPA stroke pathway

Review risks/benefits with patient & family. Aggressively monitor:
If acceptable: BP per protocol
Give rTPA** For neurologic deterioration
No anticoagulants or antiplatelet Emergent admission to stroke
treatment for 24 hours unit or intensive care unit

* Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F, Gentile N, Hazinski MF. “ Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitationand Emergency Cardiovascular
Care” . Circulation. 2010;122(suppl 3):S818-S828. http://circ.ahajournals.org/content/122/18_suppl_3/S818
** Tissue Plasminogen Activator for Acute Ischemic Stroke. N Engl J Med. 1995:333(24)1581-1587

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
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 Tachycardia With a
Pulse Algorithm
Assess appropriateness for clinical condition.
Heart rate typically ≥ 150/min if tachyarrhythmia.

Identify and Treat Underlying Cause

Maintain patient airway; assist breathing as necessary
Oxygen (if O2 sat < 94%)
Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

Persistent Tachyarrhythmia Causing:

Synchronized
Hypotension? Cardioversion*
Acutely altered mental status? Consider sedation
Signs of shock? If regular narrow complex,
Ischemic chest discomfort? consider adenosine
Acute heart failure?

IV access and 12–lead ECG if available.

Consider adenosine only if regular
Wide QRS? and monomorphic.
0.12 second Consider antiarrhythmic infusion.
Consider expert consultation.

B bloker di Indonesia
injeksi hanya
metoprolol Kalau adenosine
(vapressor)
CCB bisa dengan IV access and 12–lead ECG if available. tidak ada bisa
diltiazem inj 15-20 Vagal maneuvers. diganti ATP
mg, 15 mnt lagi 20-25, Adenosine (if regular) dengan dosis 2x
rumatan 5-15 mg/jam β-Blocker or calcium channel blocker. lipat
Consider expert consultation.

Doses/Details Adenosine IV Dose: Amiodarone IV Dose:

Synchronized First dose : 6 mg rapid IV push; First dose : 150 mg over 10 minutes.
Cardioversion** follow with NS flush.
Repeat as needed if VT recurs. Follow
Second dose : 12 mg if required by maintenance infusion of 1 mg/min
Initial recommended doses: for first 6 hours.
Narrow regular : 50–100 J Antiarrhythmic Infusions
Narrow irregular : 120–200 J for Stable Wide-QRS Sotalol IV Dose:
biphasic or 200 J monophasic Tachycardia
Wide regular : 100 J
Wide irregular : Defibrillation
Procainamide IV Dose: 100 mg (1.5 mg/kg) over 5 minutes.
Avoid if prolonged QT.
dose (not synchronized)
20-50 mg/min until arrhythmia
suppressed, hypotension ensues, QRS
TDP termasuk wide iregular duration increases > 50% or
maximum dose 17 mg/kg given.
Maintenance infusion: 1–4 mg/min.
Avoid if prolonged QT or CHF.

* Link MS, Atkins DL, Passman RS, Halperin HR, SAmson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerbenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators,
defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):
S706-S719. http://circ.ahajournals.org/content/122/18_suppl_3/S706
** Scholten M, Szili-Torok T, Klootwijk P, Jordaens L, Comparison of monophasic and biphasic shocks for transthoracic cardioversion of atrial fibrillation. Heart 2003;89:1032-1034

Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020.
If you are reading this page after October 2020, please contact ACLS Training Center at support@acls.net for an updated document. Version 2016.02.a

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