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BLS AND ACLS ALGORITHMS
ADULT

Figure 1. 2020 American Heart Association Chains of

Survival for IHCA and OHCA.
CPR indicates cardiopulmonary resuscitation; IHCA, in-hospital
cardiac arrest; and OHCA, out-of-hospital cardiac arrest.

Figure 3. Adult Cardiac Arrest Algorithm.

CPR indicates cardiopulmonary resuscitation; ET,
endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless
electrical activity; pVT, pulseless ventricular tachycardia; and
VF, ventricular fibrillation.

Figure 2. Adult BLS Algorithm for Healthcare Providers.

AED indicates automated external defibrillator; ALS, advanced
life support; BLS, basic life support; and CPR, cardiopulmonary
resuscitation.

Figure 4. Adult Cardiac Arrest Circular Algorithm.

CPR indicates cardiopulmonary resuscitation; ET,
endotracheal; IO, intraosseous; IV, intravenous; pVT, pulseless
ventricular tachycardia; and VF, ventricular fibrillation.
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Components include venous cannula, a pump, an oxygenator,
and an arterial cannula. ECPR indicates extracorporeal
cardiopulmonary resuscitation.

Figure 5. Adult basic life support termination of

resuscitation rule.

Figure 6. Adult advanced life support termination of

resuscitation rule.

Figure 7. Schematic representation of ALS

recommendations for use of advanced airways during
CPR.

Figure 8. Schematic depiction of components of

extracorporeal membrane oxygenator circuit as used for
ECPR.
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Figure 9. Adult Post–Cardiac Arrest Care Algorithm. Figure 15. Cardiac Arrest in Pregnancy In-Hospital ACLS
Algorithm.
CT indicates computed tomography; ROSC, return of ACLS indicates advanced cardiovascular life support; BLS,
spontaneous circulation; and STEMI, ST-segment elevation basic life support; CPR, cardiopulmonary resuscitation; ET,
myocardial infarction. endotracheal; IV, intravenous; and ROSC, return of
spontaneous circulation.

PEDIATRIC

Figure 13. Opioid-Associated Emergency for Lay

Responders Algorithm. Figure 1. Pediatric Chains of Survival for in-hospital (top)
AED indicates automated external defibrillator; CPR, and out-of-hospital (bottom) cardiac arrest.
cardiopulmonary resuscitation; and EMS, emergency medical CPR indicates cardiopulmonary resuscitation.
services

Figure 4. Pediatric BLS for lay rescuers.

Figure 14. Opioid-Associated Emergency for Healthcare
Providers Algorithm.
AED indicates automated external defibrillator; and BLS, basic
life support.
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Figure 5. Pediatric Basic Life Support Algorithm for
Healthcare Providers—Single Rescuer.

Figure 8. Post–cardiac arrest care checklist

Figure 6. Pediatric Basic Life Support Algorithm for
Healthcare Providers—2 or More Rescuers.
AED indicates automated external defibrillator; ALS, advanced
life support; CPR, cardiopulmonary resuscitation; and HR, heart
rate.

Figure 10. Opioid-Associated Emergency for Lay

Responders Algorithm.
AED indicates automated external defibrillator; CPR,
cardiopulmonary resuscitation; and EMS, emergency medical
services.

Figure 7. Pediatric Cardiac Arrest Algorithm.

ASAP indicates as soon as possible; CPR, cardiopulmonary
resuscitation; ET, endotracheal; HR, heart rate; IO,
intraosseous; IV, intravenous; PEA, pulseless electrical activity;
and VF/pVT, ventricular fibrillation/pulseless ventricular
tachycardia.
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Figure 11. Opioid-Associated Emergency for Healthcare Figure 13. Pediatric Tachycardia With a Pulse Algorithm.
Providers Algorithm. CPR indicates cardiopulmonary resuscitation; ECG,
AED indicates automated external defibrillator; BLS, basic life electrocardiogram; IO, intraosseous; and IV, intravenous.
support; and CPR, cardiopulmonary resuscitation.
NEONATAL

Figure 12. Pediatric Bradycardia With a Pulse Algorithm.

ABC indicates airway, breathing, and circulation; AV,
atrioventricular; BP, blood pressure; CPR, cardiopulmonary
Figure. Neonatal Resuscitation Algorithm.
resuscitation; ECG, electrocardiogram; HR, heart rate; IO,
CPAP indicates continuous positive airway pressure; ECG,
intraosseous; and IV, intravenous.
electrocardiographic; ETT, endotracheal tube; HR, heart rate;
IV, intravenous; O2, oxygen; Spo2, oxygen saturation; and
UVC, umbilical venous catheter.

ADVANCED CARDIAC LIFE SUPPORT

• Minimum of 5 roles during ACLS

• CODE BLUE
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TEAM LEADER ▪ Atropine Sulfate
• DOSE: 0.5 mg
• Gives instruction to other members of the group • MAX: 3 mg
• Knows how to read ECG rhythms • TOTAL: 6 doses
• Knows what to the interventions for the next scenario • INT: 3-5 mins
• Effective? Fast HR
DECOMPRESSOR & MONITOR, DEFIB ▪ Transcutaneous Pacing –
Procedure. Delivery of small
• Magkapartner electrical current to temporarily
• Changes role if napagod ang compressor restore electrical activity of the heart.
• DEFIB – checks cardiac monitor and provides shock Similar to defib.
• DEMAND TCP: Delivers
AIRWAY electrical stimulus only
when needed
• FIXED RATED TCP:
• Oxygenation
Delivers electrical stimuli at
a selected rate regardless
INPUT/OUTPUT of patient’s intrinsic cardiac
activity
• Medications • How to deliver? Pacer in
• IV/IO the cardiac monitor.
▪ Dopamine Infusion
TIMER/RECORDER • Renal = 2 mcg/kg/min
• Cardiac = 5 mcg/kg/min
• Documents the procedure • Vasopressin (Constricts
blood vessels) = 10
mcg/kg/min
▪ Epinephrine Infusion
• Titrate to response –
Dependent dosage to the
client’s response
• INITIAL: 2 mcg/min
• MAX: 10 mcg/min
• If the rhythms are fast: supraventricular tachycardia,
atrial fibrillation
o Stable? BP: > 90 (P.P)
▪ Physiologic (Natural interventions):
Vagal Maneuver: Carotid Massage,
Cough (Simulates vagal maneuver)
▪ Pharmacologic: Adenosine – 1st
dose: 6 mg, 2nd dose: 12 mg
o Unstable? BP: < 90 (S.S)
▪ Sedate: Diazepam: 5 mg,
ASSESS RHYTHM Midazolam: 5 mg, Demerol: 50 mg
▪ Synchronized Cardioversion
• After assessing the rhythm, what is the next (administer electrical current to pt,
intervention? painful): SVT = 50j, AFib = 120j
• How to assess rhythm? Look at the cardiac monitor • Ventricular fibrillation, Pulseless Ventricular
tachycardia
o Defib then HQCPR
• If the rhythms are asystole or pulseless electrical
activity PEA (there is rhythm in the monitor but there is
no pulse when checked)
o ex: SVT Nakita sa cardiac monitor but when
we checked the pulse, negative.
o Epinephrine then HQCPR

HEALTH ASSESSMENT REVIEW – FUNDAMENTALS

OBJECTIVE SUBJECTIVE
Observed Subject
Verifiable Patient
Explicit Implicit
• If the rhythms are slow: sinus bradycardia, av blocks Signs Symptoms
o ATDE
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OBJECTIVE: Empirical (Measured)
Explicit: Shown
SUBJECTIVE: Implicit (Covered)
Ask the patient
OPPA ASSESSMENT
• Observe: Less intrusive
• Palpate
• Percuss
• Auscultate
BODY SYSTEMS
• THORAX: Respiratory, ABG
• CIRCULATION: Cardiovascular, Fluid and Electrolytes
• COORDINATION: Neurologic
• MOVEMENT: Musculo-skeletal
NEUROLOGIC ASSESSMENT
“You feed all my senses and being”
ASSESSMENT: (MCSMR)
MENTAL

Clock drawing test: Mental assessment for seniors

Functional screening: asks open ended questions
• Orientation to person – What is your name?
• Orientation to other people – Do you have a boyfriend?
• Orientation to time -
• Orientation to place – Where are you now?
• Memory – Kumain ka na ba?
• Remote memory – Kailan pa wala?
• Recent memory
• General knowledge – Who is the current president?
• Attention span and calculation skills – What is 4x3? SENSORY
CRANIAL • Pain
• Touch
• Position
• Vibration
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MOTOR FLUID AND ELECTROLYTES

1. Look at the middle

• Water always follows sodium
• Sodium affects mental function
• Potassium affects pumping of the heart
• Calcium affects the bones
• Magnesium affects muscle of respiration
• Phosphates has inverse relationship with calcium ( ↑
PO4 ↓ CA, ↓ PO4, ↑ CA)
2. Look sa gilid.
• “Wet” – Reduce amount of water. Administer diuretics
• “Dry” – Intake of fluid, IV
• Hypernatremia – Symptoms: dry + swollen. Sip of
REFLEXES water (water follows sodium)
• Hyponatremia – Symptoms: seizure/coma. Introduce
normal saline IV
• Hyperkalemia – Symptom: Tall T wave in ECG.
Administer laxatives
• Hypokalemia – Symptom: Prominent U wave. Give
green and leafy vegetables

• Hypercalcemia – Symptoms: Development of calcium

stones. Assess pain. IV
• Hypocalcemia – Signs of tetany.

ABNORMAL

• Hypermagnesemia – Calm deep tendon reflex.

Diuretics
• Hypomagnesemia – wild deep tendon reflex. Leafy
veggies
• Hyperphosphatemia – causes hypocalcemia. Diuretics
• Hypophosphatemia – causes hypercalcemia. Meats.
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• Pulmonary Perfusion - blood flow from the right side
of the heart, through the pulmonary circulation, and into
the left side of the heart. MESO
• Diffusion - gas movement from an area of greater to
lesser concentration through a semipermeable
membrane. MICRO: occurs at cellular level.

Most oxygen collected in the lungs binds with hemoglobin to

form oxyhemoglobin; however, a small portion of it dissolves in
the plasma. The portion of oxygen that dissolves in the plasma
can be measured as the partial pressure of arterial oxygen
(PaO2) in blood. After oxygen binds to hemoglobin, RBCs carry
it by way of the circulatory system to tissues throughout the
body. Internal respiration occurs by cellular diffusion when
RBCs release oxygen and absorb the carbon dioxide produced
by cellular metabolism. The RBCs then transport the carbon
dioxide back to the lungs for removal during expiration.
RESPIRATION PROCESS REVIEWED
• Unoxygenated blood becomes oxygenated thru
“You are the air that I breathe” pulmonary perfusion. This oxygenated blood will be
ASSESSMENT: pumped thru parts of the body by the left side of the
heart.
• SUBJECTIVE: Ask about a history of breathing • 2 scenarios: oxygen will be dissolved in plasma (pao2),
problems, disease, lifestyle and current issues oxygen binds with rbc which causes cellular diffusion
• OBJECTIVE: OPPA between rbc and cells of human body.
o Release of oxygen and absorbs co2 for
excretion.
o Co2 dissolves in blood. Form carbonic acid or
bicarbonate. Buffer system.
o If carbon dioxide binds with water (plasma), it
will form carbonic acid (acidic). If
nagbreakdown ang 1 hydrogen sa
compound, it will form bicarbonate
(basic/alkaline)
RESPIRATORY PATTERNS

LUNG SOUNDS

Three external respiration processes are needed to maintain

adequate oxygenation and acid-base balance:
• Ventilation - gas distribution into and out of the
pulmonary airways. MACRO: body and environment.
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CHEST INSPECTION oxygen tension (PaO2), carbon dioxide tension (PaCO2), and
pH using a blood gas analyzer.
Indications: Mechanical ventilation, CTT, post-cardiac arrest
NORMAL ABG VALUES

The following are common chest abnormalities:

• BARREL round and bulging
• PIGEON with a sternum that protrudes beyond the
front of the abdomen
• FUNNEL funnel-shaped depression on all of or part of
the sternum
• KYPHOSCOLIOSIS spine curves to one side and the
vertebrae are rotated. Common in ladies
Pressure: unit will always be mmHg
OBTAINING ARTERIAL BLOOD SAMPLE
Arterial blood is required for an ABG. In most critical care units,
a doctor, respiratory therapist, or specially trained critical care
nurse draws ABG samples through an [a] arterial line or [b]
percutaneous puncture (radial, brachial or femoral artery). In
percutaneous puncture, an Allen’s test must be performed.
Modified Allen’s test: to check patency between radial and
ulnar artery before puncturing. Do not hyperextend the hands.
SITE (site selection) - choice is radial artery of nondominant
wrist; clean site

THE ACID AND THE BASE materials preparation - sterile and non-sterile gloves;
gauze pad, goggles, ABG kit (heparinized syringe – to
“You are the force that nourish” prevent blood clotting); cup of ice
Because carbon dioxide is 20 times more soluble than oxygen, INSERT (needle insertion) - 30-60 angle
it dissolves in the blood, where most of it forms bicarbonate (a
base) and smaller amounts form carbonic acid. DRAW (2 ml of blood) - automatic syringe fill and place
container in ice; apply pressure after for 5 minutes
The lungs control bicarbonate levels by converting bicarbonate
to carbon dioxide and water for excretion. In response to signals ENSURE (test and monitor) - ABG analysis should be done
from the medulla, the lungs can change the rate and depth of within 10 minutes; monitor patient for nerve damage
ventilation. This controls acid-base balance by adjusting the INTERPRETING ABG VALUES
amount of carbon dioxide that’s lost.
STEP 1: Know the normal values
In metabolic alkalosis, which results from excess bicarbonate
retention, the rate and depth of ventilation decrease so that
carbon dioxide is retained. This increases carbonic acid levels.
In metabolic acidosis (resulting from excess acid retention or
excess bicarbonate loss), the lungs increase the rate and depth
of ventilation to exhale excess carbon dioxide, thereby reducing
carbonic acid levels. STEP 2: Check characteristics of pH, paC02, HCO3;
ARTERIAL BLOOD GAS Check which matches the pH
Arterial Blood Gas (ABG) monitoring is frequently performed STEP 3: Identify Compensation
in critically ill clients to assess acid-base balance, ventilation
and oxygenation. An arterial blood sample is analyzed for
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fingertip. A photodetector (also called a sensor or transducer)
slipped over the finger measures the transmitted light as it
passes through the vascular bed, detects the relative amount
of color absorbed by arterial blood, and calculates the
saturation without interference from the venous blood, skin, or
Example: pH = 7.23; paC02 = 50; HC03 = 29 – Partially connective tissue.
Compensated Respiratory Acidosis

Nursing Considerations:
• Nurses: Place the sensor over the finger or other site,
such as the toe, bridge of the nose, or earlobe, so that
the light beams and sensors are opposite each other.
• Protect the sensor from exposure to strong light,
such as fluorescent lighting, because it interferes with
I will go to ROME with 3 friends. Will eat breakfast at around results.
7:35-7:45. Budget is 6.6 dollars split into 3. • Check if pulse rate on the oximeter corresponds to
the patient’s actual pulse. If not, reposition the sensor.
Breakfast:
• Rotate the sensor every 4 hours.
• PH • Normal reading is 95-100%; oxygen saturation
• English = Pancake, Choco, Orange (PaCO2, Respi) readings are usually within 2% of ABG values.
• American = Ham, Cheese, Orange (HCO3, Metabolic) • Pulse oximetry isn’t used when carbon monoxide
poisoning is suspected because the oximeter
Budget: doesn’t differentiate between oxygen and carbon
monoxide bound to hemoglobin. An ABG analysis
• 2-2-2.6 should be performed in such cases.
• HCO3: 22-26
ROME
• PH: Below: Acidosis, Above: Alkalosis
• Respiratory Opposite PH, Metabolic Equal PH

Mixed Venous Oxygen Saturation [SvO2]

Partially compensated: Both abnormal SvO2 reflects the oxygen saturation level of venous blood. Can
be determined by measuring the amount of oxygen extracted
RESPIRATORY: BEDSIDE TESTING PROCEDURES and used or consumed by the body’s tissues.
Common diagnostic tests used at the bedside to evaluate
respiratory function are (1) pulse oximetry, (2) mixed venous
oxygen saturation (SvO2), and (3) end-tidal carbon dioxide
(ETCO2) monitoring.
Pulse Oxymetry [SpO2; SaO2]
This is used to monitor arterial oxygen saturation non-invasively.
It’s performed either intermittently or continuously. In pulse
oximetry, arterial oxygen saturation values are usually denoted
with the symbol SpO2. Arterial oxygen saturation values, which
are measured invasively via ABG analysis, are denoted by the
symbol SaO2.
Procedure:
Procedure:
Ideally, the SvO2 sample is obtained from the most distal port of
In this procedure, two diodes send red and infrared light the pulmonary artery (PA) catheter, which contains the ideal mix
through a pulsating arterial vascular bed such as the one in the of all venous blood in the heart. Samples may be drawn from a
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central catheter if a PA catheter isn’t available. Continuous
SvO2 monitoring is done using the SvO2 or oximetric PA
catheter.
Nursing Considerations:
• During catheter insertion, monitor the patient’s vital
signs, heart rhythm and ventilatory function.
• Apply a sterile dressing or sterile transparent dressing
over the catheter insertion site.
• Closely monitor the patient’s hemodynamic status.
Troubleshoot the catheter for problems that can
interfere with accurate testing, such as loose
connections, balloon rupture, or clot formation on the
tip of the catheter.
End Tidal Carbon Dioxide (ETCO2)
ETCO2 is used to measure the carbon dioxide concentration at
end expiration. Indications for ETCO2 monitoring include: (1)
monitoring patency of the airway, (2) early detection of CO2
production and elimination, (3) assessing effectiveness of
interventions (e.g. mechanical ventilator)
Capnogram – CO2 waveform at hemodynamic monitor
Procedure:
In ETCO2 monitoring, a photodetector measures the amount of
infrared light absorbed by the airway during inspiration and
expiration. An ETCO2 monitor may be a separate monitor or
part of the patient’s bedside hemodynamic monitoring system.
The monitor converts these data to a carbon dioxide value and
a corresponding waveform, or capnogram.
Summarily, monitoring ETCO2 falls under three major
categories:
(1) colorimetric - use of pH sensitive strips, (2) capnometric -
numerical display, and (3) capnographic - wave display.
Nursing Considerations:
• Normal PaCO2 is 35-45 mmHg.
• Normal ETCO2 is 30-43 mmHg. (2-5 lower than
PaCO2)
• Notify the practitioner of a 10% increase or decrease in
readings.
MECHANICS OF BREATHING
Mechanical forces, such as movement of the diaphragm and
intercostal muscles, drive the breathing process. The primary
muscles used in breathing are the diaphragm and the external
intercostal muscles. These muscles contract when the patient
inhales and relax when the patient exhales.
The respiratory center in the medulla initiates each breath by
sending messages over the phrenic nerve to the primary
respiratory muscles.
MECHANICAL VENTILATION
Mechanical ventilation involves the use of a machine to move
air into a patient’s lungs. Mechanical ventilators use either
positive or negative pressure to ventilate patients. Negative-
pressure ventilators work by creating negative pressure, which
pulls the thorax outward and allows air to flow into the lungs.
Indications of mechanical ventilator include: (1) acute
respiratory failure, (2) respiratory center depression, (3)
neuromuscular disturbances.
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MODES OF VENTILATORY CONTROL
• Volume-cycled - delivers a preset volume of air each
time, regardless of the amount of lung resistance; most
common
• Pressure-cycled - generates flow until the machine
reaches a preset pressure, regardless of the volume
delivered or the time required to achieve the pressure
• Time-cycled - generates flow for a preset amount of
time.
NURSING CONSIDERATIONS
• Provide emotional support to the patient during all
phases of mechanical ventilation to reduce anxiety
and promote successful treatment. Even if the patient
is unresponsive, continue to explain all procedures and
treatments.
• Turn on the ventilator alarms at all times to alert you
to potentially hazardous conditions and changes in the
patient’s status. If an alarm sounds and the problem
can’t be easily identified, disconnect the patient from
the ventilator and use a handheld resuscitation bag
• Assess cardiopulmonary status frequently, at least
every 2 to 4 hours or more often, if indicated. Assess
vital signs and auscultate breath sounds. Monitor
pulse oximetry or ETCO2 levels and hemodynamic
parameters as ordered.
• Be alert for the development of complications
associated with mechanical ventilation. These
complications include decreased cardiac output,
trauma, pneumothorax, oxygen toxicity, stress ulcers,
and ventilator-associated pneumonia (VAP).
VENTILATOR SETTINGS
VENTILATOR ALARMS
COMMON MECHANICAL VENTILATION COMPLICATIONS
• Barotrauma – alveolar trauma due to high airway
pressure in the alveoli.
• Volutrauma – alveolar trauma due to overdistention of
the alveoli
• Atelectrauma - tissue trauma in the alveoli caused by
inadequate pressure within alveolar units
• Hypotension - decreased venous return due to
increased intra-thoracic pressure
• Gastrointestinal problems - peptic ulcers, bleeding,
inadequate nutrition, paralytic ileus
WEANING
The patient’s body quickly comes to depend on artificial
ventilation and must gradually be reintroduced to normal
breathing. Successful weaning depends on a strong
spontaneous respiratory effort, arterial blood gas levels
within normal limits, a stable cardiovascular system, and
sufficient respiratory muscle strength and LOC to sustain
spontaneous breathing. Criteria must be individualized.
• Intermittent Mandatory Ventilation (IMV) - the
number of breaths produced by the ventilator is
gradually reduced, allowing the patient to breathe
independently.
• Pressure Support Ventilation (PSV) - may be used
alone or as an adjunct to IMV in the weaning process.
In this procedure, a set burst of pressure is applied
during inspiration with the patient’s normal breathing
pattern, allowing the patient to build respiratory muscle
strength
• Spontaneous Breathing Trials - placing the patient
on minimum pressure support, using continuous
positive airway pressure