ACLS

ALGORITHMS

Acute Pulmonary Edema / Hypotension / Shock Algorithm

Clinical signs of hypoperfusion, congestive
heart failure, acute pulmonary edema
Assess ABCs
Assess vitals
Secure airway
Review history
Administer O2
Perform physical exam
Start IV
12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff

Figure 8

What is the nature of the problem?

Volume problem
Includes PVR problems
Administer
Fluids
Blood transfusions
Cause-specific interventions
Consider vasopressors

Systolic BP
< 70
Signs of shock

Pump Problem

Rate Problem

What is the BP ?

Systolic BP
70 - 100 mmHg
Signs of shock

Too Slow
Go to Fig 5

Systolic BP
70 - 100 mmHg
No Signs of shock

Too Fast
Go to Fig 6

Systolic BP
> 100 mmHg

Bradycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABCs
Assess vitals
Secure airway
Review history
Administer O2
Perform physical exam
Start IV
12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff

Figure 5

Bradycardia, either absolute

(<60 BPM) or relative

Serious signs and symptoms?a,b

Yes

No
Type II second-degree AV heart block
or
Third-degree AV heart Block?e

No
Observe

Yes
Prepare for transvenous pacer
Use TCP as a bridge device

Intervention sequence
Atropine 0.5 - 1.0 mcg,d (I and IIa)
TCP, if available (I)
Dopamine 5 - 20 mcg/kg/min (IIb)
Epinephrine 1 - 10 mcg/min (IIb)
Norepinephrine 0.5 30 mcg/min (IIb)

Tachycardia Algorithm
(Patient is not in Cardiac Arrest)
Assess ABCs
Assess vitals
Secure airway
Review history
Administer O2
Perform physical exam
Start IV
12 lead ECG, chest x-ray
Attach monitor, pulse oximetry and B/P Cuff

Unstable, with serious signs or symptoms?a

No

Atrial Fibrillation
Atrial Flutter

Paroxysmal
Supraventricular
Tachycardia
(PSVT)

Figure 6

If ventricular rate > 150 BPM

Yes Prepare for cardioversion
May give brief trial of Rx
Immediate cardioversion is seldom
needed for heart rates < 150 BPM

Wide-complex
tachycardia of
uncertain type

Ventricular
Tachycardia (VT)

Pulseless Electrical Activity (PEA) Algorithm

(Electromechanical Dissociation [EMD])

Figure 3

Includes
Electromechanical dissociation (EMD) Postdefibrillation idioventricular rhythms
Pseudo - EMD
Bradyasystolic rhythms
Idioventricular rhythms
Ventricular escape rhythms

Continue CPR / Intubate at once / Obtain IV Access

Assess blood flow using Doppler ultrasound, endtidal CO2,
echocardiography, or arterial line
Consider possible causes
Hypovolemia (volume infusion)
Drug overdoses - tricyclics, digitalis
Hypoxia (ventilation)
Beta-blockers, calcium channel blockers
Cardiac tamponade (pericardiocentesis)
Hyperkalemia
Tension Pneumothorax
Acidosis
Hypothermia ( see hypothermia algorithm)
Massive acute myocardial infarction
Massive pulmonary embolism (surgery, lysine)
Massive acute MI (go to Fig 9)

Epinephrine 1 mg IV push,a,c repeat q 3 - 5 min

If absolute bradycardia (< 60 BPM) or relative bradycardia
give atropine 1 mg IV
Repeat q 3 -5 min to a total of 0.03 - 0.04 mg/kg

Asystole Treatment Algorithm

Continue CPR
Intubate at once
Obtain IV Access
Confirm asystole in more than 1 lead

Consider possible causes

Hypoxia
Pre-existing acidosis
Hyperkalemia Drug Overdose
Hypokalemia Hypothermia

Consider immediate
transcutaneous pacing (TCP)a

Figure 4
Epinephrine 1mg IV push,b,c
repeat q 3 - 5 min

Atropine 1 mg IV push
repeat q 3 - 5 min up to a total
of 0.03 - 0.04 mg/kgd,e
Consider termination of efforts

Ventricular Fibrillation (VF)

Figure 2
&
Pulseless Ventricular Tachycardia (VT)
ABCs
Perform CPR until defibrillator Arrives
VF/VT present on defibrillator
Defibrillate up to 3 times if needed for persistent VF/VT
200 J, 200 - 300 J, 360 J
Rhythm after the first 3 shocks?

VF/VT

ROSC

PEA
Go to Fig 3

Asystole
Go to Fig 4

VF & Pulseless VT
Continue CPR
Intubate / IV Access
Epinephrine c,d
1 mg/IV
2 mg/ETT
q 3 - 5 min
Defibrillate 360 J
within 30 - 60 sec
Administer Rx Class IIa
probable benefit f, g
Defibrillate 360 J,
30 - 60 sec after Rx

Figure 2