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Note the key change in BLS sequence: begin early chest compressions.
Step 3. Check carotid pulse for 10 seconds. If no pulse, begin CPR, starting with chest
compressions then 2 breaths at a ratio of 30:2. Use bag valve mask for breaths, if available.
Step 4: Defibrillate if there is a shockable rhythm when defibrillator arrives. Continue CPR
while the defibrillator or AED is readied. Responders should follow the voice prompts.
The 2010 Guidelines recommends interruption in chest compression only for ventilation
without an advanced airway, rhythm checks, and shock delivery.
The American Heart Association recommends shortening the interval between last
compression and shock.
The emphasis in ACLS is on high quality CPR. Monitor with qualitative waveform
capnography. If PETCO2 is less than 10 mm Hg, attempt to improve CPR quality.
Step 5: Antiarrhythmic: Amiodarone 300 mg IV/IO; may repeat x 1 at 150 mg (Class 2b)
-Consider lidocaine if amiodarone is not available 1.0-1.5 mg/kg IV/IO first dose, then 0.5-
0.75 mg/kg IV/IO diluted in 10 ml D5@, NS) as IV/IO bolus over 5-20 minutes
Step 6: Defibrillate
PEA/Asystole
Step 1: Cardiac Arrest Algorithm: BLS and AED.
Interrupt chest compressions only for ventilation without an advanced airway, rhythm
checks, and shock delivery. High quality CPR is emphasized.
Step 2: ACLS: Secondary survey: confirm asytole, do not delay CPR for pulse check.
Step 6: Atropine 0.5 mg q 3-5 minutes to 0.04 mg/kg: Consider if rhythm is slow.
Step 3: ACLS: Secondary survey: airway, oxygen, IV, monitor, 12 lead, differential dx.
Step 5: Atropine 0.5 mg q 3-5 minutes, maximum 3 mg. If effective, monitor and observe.
Step 7: Prepare patient for transvenous pacing if required. Obtain expert consultation.
Step 8: Type 2 second-degree AV block or third degree AVB? TCP and prepare for TVP.
Step 1: Assess appropriateness for clinical condition. Usually > 150 bpm.
Step 2: ACLS : Secondary survey: airway, oxygen, IV, monitor, 12 lead, differential dx
If no, proceed to Step 4. If patient becomes unstable, do not delay treatment for detailed
rhythm analysis.
Step 4: Wide QRS? (greater than or equal to 0.12 second? If no, proceed to Step 5.
Vagal maneuvers
Adenosine (if regular)
Beta-blocker or calcium channel blocker.
Consider expert consultation.
*Drugs to avoid in patients with irregular wide complex tachycardia: AV Nodal Blocking
Agents:
Adenosine
Calcium channel blockers
Digoxin
Beta-blockers
**Avoid AV Nodal Blocking Agents in preexcitation atrial fibrillation and atrial flutter.
***Caution when combining AV Nodal Blocking Agents with longer duration of action.
Effects may overlap.
*Cardioversion:
Patient history
Symptom onset
Neurologic evaluation (NIH Stroke Scale or Canadian Neurologic Scale)
Step 7: T=60:
Review risks and benefits with family and patient. If acceptable, go to Step 8.
Step 8: T=60:
Give tPA
No anticoagulants or antiplatelet treatment for 24 hours
3 findings:
Facial droop: Patient shows teeth or smiles; abnormal=one side does not move as well
Arm drift: Patient closes eyes and extends both arms straight out, with palms up for
10 seconds; abnormal=one arm does not move or drifts down compared with other
arm
Abnormal speech: "You can't teach an old dog new tricks." Abnormal=patient slurs
words, uses the wrong words, or is unable to speak.
Step 2: EMS:
O2 if SaO2
Aspirin 160325 mg if not given by EMS
NTG SLT or spray
Morphine IV (if chest discomfort not relieved by NTG)
Normal or nondiagnostic ST/T changes: Low or intermediate risk ACS: Go to Step 13.
Step 12: Admit to monitored bed, and assess risk. Continue ASA, heparin, and other therapies
as indicated.
High risk:
Step 13: Consider admission to ED chest pain unit and follow serial cardiac markers, repeat
ECGs and consider non-invasive testing.
Step 16: Without evidence of ischemia or infarction by testing, patient may be discharged
with follow-up.
ACLS Drugs/Doses
Adenosine: Initial bolus 6 mg IV over 1-3 seconds; follow with 20 ml bolus NS, elevate
extremity. May repeat 12 mg in 1-2 minutes.
Amiodarone: 300 mg IV/IO push. Second dose, if needed, 150 mg IV/IO push.
Epinephrine: In cardiac arrest: I mg q 3-5 minutes, follow with 20 ml flush, elevate arm. In
beta-blocker or calcium channel blocker OD, may use up to 0.2 mg/kg. Continuous infusion:
0/1 to 0/5 mcg/kg/min. In profound bradycardia or hypotension: infuse at 2 to 10
mcg/minute; titrate to response.
Lidocaine: In cardiac arrest, alternative to amiodarone: 1-1.5 mg/kg; may give additional
0.5-0.75 mg/kg/IV push, repeat to maximum of 3 mg/kg.
Magnesium Sulfate: Only in cardiac arrest due to hypomagnesemia or Torsades de Pointes,
1-2 gm (2-4 ml of 50% soln diluted in 10 ml, IV/IO.) Torsades de Pointes with a pulse of
AMI with hypomagnesemia: Load 1-2 g diluted in 50-100 ml over 5 to 60 min IV. Follow
with 0.5 to 1 g per hour IV, titrated to control torsades.
Vasopressin: may replace 1st or 2nd dose of epinephrine. One dose of 40 units IV/IO push.