A.

PRE-ARREST SURVEY (ACLS SURVEY)

1. Visualize 5. Monitor Pads

2. Verbalize 6. Intravenous/Intraosseous Access
3. Vital Signs 7. Treatment
4. Oxygen Saturation

I. First is to visualize your patient. If the patient is conscious, proceed to ACLS survey. If not, perform
BLS survey and start high-quality CPR.

II. Next is to verbalize by introducing yourself and by asking the patient’s symptoms in a PQRST manner.
● “Good morning. I am Clerk ----, how are you feeling today? What does the pain feel like?
Where is it located? Does the pain radiate? When did it start and how long did it last for?”
● Symptoms of CA are usually: Chest pain, dyspnea, palpitations, and fatigue

III. Take the vital signs, since I am the clerk I will be the one to measure the heart rate, blood pressure,
respiratory rate, O2 sat, and body temp. (or ask the nurse for the vital signs: “Ma’am/sir, what are the
vital signs?”)
● Normal values:
○ HR = 60-100 bpm
○ BP = 90 systolic
○ RR = 16-20 cpm
○ O2 sat = 95-100%, if it is below 95 then administer oxygen
○ Temp = 37 C

IV. If the oxygen is low, administer oxygen via nasal cannula which provides 2-4 L of oxygen per min
(others: face mask @ 6-10 L of O2/min , non-rebreather mask @ 11-15 L of O2/m)
● “I am going to administer oxygen via nasal cannula which provides 2-4 L of oxygen per min”
● 88-90: mask; 80 and below: non-rebreather

V. Attach the monitoring pads while remembering the mnemonics “White on the right, smoke over fire”
● If 3-lead ECG: “I am going to attach the monitoring pads now. White is placed at the 2nd ICS
RMCL, Black at the 2nd ICS LMCL, and Red at the 5th ICS LMCL”
● If 5-lead ECG: “I am going to attach the monitoring pads now. White is placed at the 2nd ICS
RMCL, Black at the 2nd ICS LMCL, Red at the 5th ICS LMCL, Green at the 5th ICS RMCL, and
Brown should be between black and red.”
VI. Start an Intravenous access through the cubital vein. After 2 failed attempts, use the Intraosseous
route via the proximal humerus or tibia.
● “I am going to start intravenous access now via the cubital vein”

VII. Next is treatment which depends on the ECG monitoring

SLOW RHYTHM: ATDE Sinus Bradycardia:

❖ Sinus Bradycardia - Normal upright P wave in lead II (sinus P wave)
❖ AV Block preceding every QRS complex. HR: < 60

1st Line: ATROPINE (max of 6 doses or 3mg)

● Increases HR and improves AV
conduction by blocking the
parasympathetic influence on the
heart
● “I’m going to give atropine with a dose
of 0.5 mg IV every 3 to 5 mins”

TRANSCUTANEOUS PACING

2nd Line: DOPAMINE

● Increases HR and circulating Epi and
Norepi levels, and stimulates
dopamine vascular receptors.
● “I am going to give a renal dose of 2
mcg/kg/min” Atrioventricular (AV) Block:
● “I am going to give a cardiac dose of - R is far from P, you have 1st degree
25mcg/kg/min” - Longer, longer, longer, drop! You have
● “I am going to give vasopressor dose Wenckebach
of 10 mcg/kg/min” - If some Ps don’t get through, you have Mobitz II
- If Ps and Qs don’t agree, you have 3rd degree
3rd Line: EPINEPHRINE
● Alpha and beta adrenergic agonist
(alpha increases pulmonary vascular
resistance thereby inc both systolic
and diastolic BP; beta can stimulate
bronchodilation)
● “I am going to give epinephrine with a
starting dose of 2 mcg/min”
● 2-10 mcg/min, start at lowest dose of
2 mcg

FAST RHYTHM: NARROW COMPLEX Supraventricular Tachycardia:

❖ Supraventricular Tachycardia - P waves are hidden in the QRS complexes
❖ Atrial Fibrillation - HR: usually >100 bpm (but can go as high as 250
bpm)
Check blood pressure first.
 ● “I am going to check the blood
pressure first to know whether the
patient is stable or not”
● Unstable: Systolic BP <90 mmHg
● Stable: Systolic BP >90 mmHg

If the patient is UNSTABLE:

● Sedate: “I am going to sedate the
patient using Diazepam with a dose of Atrial Fibrillation:
5 mg” (can also use Midazolam 5 mg) - No visible P wave and irregularly irregular rhythm
● Synchronized Cardioversion: “After - HR: 100 to 175 bpm
sedation, I will start the defibrillation.
Charging at *50 or 120* Joules. Clear.
Shocking on 3. 1, 2, 3. Shock
delivered”
○ 50 J - SVT
○ 120 J - Atrial Fib

If the patient is STABLE:

● Physiologic: “I am going to perform a
vagal maneuver by instructing the
patient to cough or by performing a
carotid massage.”
● Pharmacologic: “I am going to
administer Adenosine with a dose of 6
mg via rapid IV push for 3-5 mins,
then 12 mg rapid IV push if required.”

FAST RHYTHM: WIDE COMPLEX Ventricular Tachycardia:

❖ Ventricular Tachycardia (w/ pulse)
Check pulse and blood pressure first.
● “I am going to check the pulse and
blood pressure first to know whether
the patient is stable or not”
● Unstable: Systolic BP <90 mmHg
● Stable: Systolic BP >90 mmHg
- Absent P waves and PR interval
- Wide QRS complexes
- QRS duration beyond 120 milliseconds
- HR: usually 200 bpm (typically between 100-250
bpm)

If the patient is UNSTABLE:

● Sedate: “I am going to sedate the
patient using Diazepam with a dose of
5 mg” (can also use Midazolam 5 mg)
● Synchronized Cardioversion: “After
sedation, I will start the defibrillation.
Charging at 100 Joules. Clear.
 Shocking on 3. 1, 2, 3. Shock
delivered”

If the patient is STABLE:

● Pharmacologic: “I am going to
administer Amiodarone with a dose of
150 mg.”

B. ARREST (BLS SURVEY)

I. Check for responsiveness.

● “Hey are you okay? Are you okay? Patient is unresponsive.”

II. Check carotid for pulse and chest rise for breathing. Activate code blue and start high-quality CPR.
● “Patient has no pulse, no breathing. Activate code blue. I am now starting high-quality CPR.”

III. Team has arrived, you are the team leader.

● Class I = High-quality CPR
● Class IIa = Shock at 360 joules
● Class IIb = Administer medication

IV. Assign roles (compressor, defibrillator, airway, medication, recorder)

● “Compressor, please take over in 3. 1, 2, 3”

V. SHOCKABLE RHYTHMS (Ventricular tachycardia w/o pulse, Ventricular Fibrillation)

Recorder: 2 minutes

“Let’s stop, analyze, and switch roles”

The patient is still in ventricular tachycardia.
● Class I: “Please continue high-quality CPR”
● Class IIa: “Shock at 360 Joules”
○ Defibrillator: “Charging at 360 Joules, Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
“Please continue high-quality CPR and...”
● Class IIb: “Please prepare Epinephrine 1 mg at 1:10,000 dilution and 20 cc of NSS”

--

Recorder: 2 minutes

“Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high-quality CPR and shock at 360
Joules”
● Defibrillator: “Charging at 360 Joules. Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
● “Please continue high-quality CPR and please administer Epinephrine”
○ Medication: “Delivered Epinephrine 1 mg at 1:10,000 dilution and flushed with 20 cc of
NSS”
● “Please prepare Amiodarone 300 mg and 20 cc of NSS”
○ Medication: “Preparing Amiodarone 300 mg and 20 cc of NSS”

Recorder: 2 minutes

“Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high-quality CPR and shock at 360
Joules”
● Defibrillator: “Charging at 360 Joules. Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
● “Please continue high-quality CPR and please administer Amiodarone”
○ Medication: “Delivered Amiodarone 300 mg and flushed with 20 cc of NSS”
● “Please prepare Epinephrine 1 mg at 1:10,000 dilution and 20 cc of NSS”
○ Medication: “Preparing Epinephrine 1 mg at 1:10,000 dilution and 20 cc of NSS

Recorder: 2 minutes

“Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high-quality CPR and shock at 360
Joules”
● Defibrillator: “Charging at 360 Joules. Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
● “Please continue high-quality CPR and please administer Epinephrine”
○ Medication: “Delivered Epinephrine 1 mg at 1:10,000 dilution and flushed with 20 cc of
NSS”
● “Please prepare Amiodarone 150 mg and 20 cc of NSS”
○ Medication: “Preparing Amiodarone 150 mg and 20 cc of NSS”

Recorder: 2 minutes

“Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high-quality CPR and shock at 360
Joules”
● Defibrillator: “Charging at 360 Joules. Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
● “Please continue high-quality CPR and please administer Amiodarone”
○ Medication: “Delivered Amiodarone 150 mg and flushed with 20 cc of NSS”
 ● “Please prepare Epinephrine 1 mg at 1:10,000 dilution and 20 cc of NSS”
○ Medication: “Preparing Epinephrine 1 mg at 1:10,000 dilution and 20 cc of NSS

Recorder: 2 minutes

“Let’s stop, analyze, and switch roles.”

“The patient is still in ventricular tachycardia. Please continue high-quality CPR and shock at 360
Joules”
● Defibrillator: “Charging at 360 Joules. Clear. Shocking on 3. 1, 2, 3. Shock delivered.”
● “Please continue high-quality CPR and please administer Epinephrine”
○ Medication: “Delivered Epinephrine 1 mg at 1:10,000 dilution and flushed with 20 cc of
NSS”
● “Please prepare Amiodarone 150 mg and 20 cc of NSS”
○ Medication: “Preparing Amiodarone 150 mg and 20 cc of NSS”

VI. NON-SHOCKABLE RHYTHMS (Asystole, Pulseless Electrical Activity)

● If the last medication is Amiodarone, continue giving high-quality CPR and administer
Epinephrine every 3-5 minutes.
○ “The monitor reveals a non-shockable rhythm. Please check for a pulse… still without a
pulse. Please continue giving high-quality CPR and administer Epinephrine 1 mg at
1:10,000 dilution and 20 cc of NSS”
● If the last medication is Epinephrine, continue giving high-quality CPR and administer
Epinephrine after 3 minutes.
○ “The monitor reveals a non-shockable rhythm. Please check for a pulse… still without a
pulse. Please continue giving high-quality CPR”

VII. Check for pulse. If there is no pulse, it is a pulseless electrical activity (PEA), then give Epinephrine
and high-quality CPR.

Reversible causes of CA:

H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia
T’s: Tension pneumothorax, Tamponade, Toxins, Thrombosis pulmonary, Thrombosis coronary

VIII. Check for pulse. If there is pulse and normal sinus rhythm, this is the return of spontaneous
circulation (ROSC). Continue to post-arrest care.

C. ROSC/POST-ARREST CARE

I. Circulation: Check for pulse and blood pressure

● If BP is low or unstable, check first for pulmonary congestion by doing the 4-point
auscultation.
■ If no congestion: “I am going to give 1 to 2 L of PNSS or PLRS fast drip”
■ If with congestion: “I am going to administer Dopamine 10 mcg/kg/min,
Epinephrine 2-10 mcg/min, and Norepinephrine 2-10 mcg/min”

II. Airway: Check for breathing and O2 saturation.

 ○ If the patient is not breathing or the breathing is inadequate, provide ventilation via advance
airway such as endotracheal tube.
■ “I am going to provide ventilation via advance airway by inserting an endotracheal tube,”
■ If OPA or oropharyngeal airway: A proper size of OPA is when the flange is at the corner
of the mouth and the tip is at the angle of the mandible
○ Then check for placement of the ET tube by doing the 5-point auscultation.
■ If there are crackle and unequal breath sounds heard, or presence of gurgling sound at
the epigastric area, remove and re-insert the ET tube
■ If auscultation is clear, check waveform capnography.
● It must read 35-40 mmHg (there is already improvement in blood flow)
● The CO2 detector must also change from purple to yellow

III. Disability: Check if the patient is conscious

○ Ask to follow simple command like squeezing your hand
■ “Hello, I am Clerk ----. Please squeeze my hand to let me know that you are conscious”
■ If no response: patient is in GCS 3, proceed to TTM
○ Targeted Temperature Management (TTM) aka Therapeutic Hypothermia (old name)
■ Administer ice cold 4 deg C PNSS or PLRS at 30 cc/kg BW and run for 24 hours
■ This is to maintain core body temperature at 32-36 deg C

IV. Admission in the ICU: prepare patient for transport to the ICU
● Do the “sign of the cross”:
○ Insert NGT - for feeding access, to decrease gastric pressure after CPR (it may lead to
gastric inflation)
○ Insert CVP line - for medication access
○ Insert 12-lead ECG - to monitor heart rhythm
○ Conduct X-ray - to know if NGT and ET tube is placed properly, to check if there were
any fractures from the CPR (this may lead to pneumothorax)
○ Insert foley catheter - to monitor urine volume (normal: 30-60 mL/hr)