American AMERICAN

i Doses/Details for the Cardiac Arrest Algorithms l Cardiac Arrest Algorithm

.r ASSOCIATION
Heart OJ CRITICAL-CARE
Association.. NURSES Shout for Help/ Activate Emergency Response
CPR Quality Drug Therapy
• Push hard (;;,2 inches [5 em]) and • Epinephrine IV/10 Dose:
fast (;;,100/min) and allow complete 1 mg every 3-5 minutes
Cardia c Arrest,

ACLS A rrhythmias, and

T heir Treatment
chest recoil
• Minimize interruptions in
compressions
• Avoid excessive ventilation
• Vasopressin IV/10 Dose:
40 units can replace first or
second dose of epinephrine
• Amiodarone IV/10 Dose:
Rhythm shockable?

ardiac Arrest Circular Algorithm • Rotate compressor every First dose: 300 mg bolus.
2 minutes Second dose: 150 mg .
• If no advanced airway, 30:2
Advanced Airway
Shout for Help/Activate Emergency Response compression-ventilation ratio
• Supraglottic advanced airway
• Quantitative waveform
or endotracheal intubation
capnography
• Waveform capnography to confirm
Start CPR - If PETC02 <10 mm Hg, attempt
and monitor ET tube placement
o Give oxygen to improve CPR quality
• 8-1 0 breaths per minute with
o Attach monitor/ defibrillator • Intra-arterial pressure
continuous chest compressions
- If relaxation phase (diastolic)
pressure <20 mm Hg, attempt Reversible Causes
2 minutes - Hypovolemia
to improve CPR quality
- Hypoxia
Return of Spontaneous
- Hydrogen ion (acidosis)
Circulation (ROSC)
- Hypo-/ hyperkalemia
• Pulse and blood pressure
- Hypot hermia
• Abrupt sustained increase
- Tension pneumothorax
Drug Therapy in PETC0 2 (typically ;;,40 mm Hg)
- Tamponade, cardiac
IV/10 access • Spontaneous arterial pressure
- Toxins
Epinephrine every 3-5 minutes waves with intra-arterial
- Thrombosis, pu lmonary
A miodarone for refractory VFNT monitoring
- Th rombosis, coronary
Shock Energy No
• Biphasic: Manufacturer
Consider Advanced Airway recommendation (eg, initial
Quantit ative waveform capno grap hy dose of 120-200 J); if unknown , No
use maximum avai lable.
Second and subsequent doses 8 11
should be eqUiva en_, and higher
C PR 2 min
doses may be considered . • Treat reversible causes
• Monopl!_asic: 3.§9 J

12 r-_________ L_ _ _ _ _ __

• If no signs of return of
spontaneous circulation
(ROSC), go to 10 or 11
• If ROSC , go t o
Post-Cardiac Arrest Care Go to 5 or 7
90-1012 (1 of 2) ISBN 978-1-61669-01 3-7 5/11 C 2011 American Heart Association Printed In the USA
mmediate Post-Cardiac Arrest Care Algorithm I Bradycardia With a Pulse Algorithm ! Tachycardia With a Pulse Algorithm

I
I
Assess appropriateness for clinical condition.
Return of Spontaneous Circulation (ROSC) Assess appropriateness for c linical condition.
Heart rate typically ~ 150/min if tachyarrhythmia.
Heart rate typically <50/min if bradyarrhythmia.

Optim ize ventilation and oxygenation

!
Identify and treat underlying cause
Identify and treat underlying cause
• Maintain oxygen saturation ~94 % • Maintain patent airway; assist breathing
• Consider advanced airway and • Maintain patent airway; assist breathing as necessary as necessary Doses/Details
waveform capnography • Oxygen {if hypoxemic) • Oxygen (if hypoxemic) Synchronized
Doses/Details
• Do not hyperventilate • Cardiac monitor to identify rhythm ; monitor blood • Cardiac monitor to identify rhythm; Cardioversion
Ventilation/ Oxygenation pressure and oximetry monitor blood pressure and oximetry Initial recommended doses:
Avoid excessive ventilation . • Narrow regular: 50-1 00 J
• IV access
Start at 10-12 breaths/min • Narrow irregular:
• 12-Lead EGG if available; don 't delay therapy
and titrate to target PETC02 120-200 J biphasic or
of 35-40 mm Hg. 200 J monophasic
Treat hypotension Persistent
When feasible, titrate F102 • Wide regular: 100 J
tachyarrhythmia
(SBP <90 mm Hg) to minimum necessary to • Wide irregular:
causing:
• IV/10 bolus achieve Spe, ~94%. Synchronized defibrillation dose
Persistent bradyarrhythmia • Hypotension? cardioversion (NOT synchronized)
• Vasopressor infusion IV Bolus Yes
causing: • Acutely altered • Consider sedation Adenosine IV Dose:
• Consider treatable 1-2 L normal saline ;---+
Monitor mental status? • If regular narrow First dose: 6 mg rapid IV push;
causes or lactated Ringer's. • Hypotension?
and • Signs of shock? complex, consider follow with NS flush.
• 12-Lead EGG If inducing hypothermia, • Acutely altered mental status?
may use 4•c fluid . observe • Ischemic chest adenosine Second dose: 12 mg
• Signs of shock? discomfort? if required.
Epinephrine IV Infusion: • Ischemic chest discomfort? • Acute heart
0.1-0.5 meg/kg per minute • Acute heart failure? failure? Antiarrhythmic Infusions
(in 70-kg adult: 7-35 meg • IV access and
for Stable Wide-QRS
per minute) 12-lead EGG
Tachycardia
No if available
Dopamine IV Infusion: Procainamide IV Dose:
Doses/Details • Consider
5-1 0 meg/kg per minute 20-50 mg/min until
adenosine only
arrhythmia suppressed,
)
Norepinephrine
IV Infusion:
0.1-0.5 meg/kg per minute
Atropine
If atropine ineffective:
Atropine IV Dose:
First dose:
0.5 mg bolus
( WideQRS?
:?:0.12 second J
Yes if regular and
monomorphic
• Consider
hypotension ensues, ORS
duration increases >50%, or
• Transcutaneous pacing maximum dose 17 mglkg
On 70-kg adult: 7-35 meg Repeat every antiarrhythmic given. Maintenance infusion:
OR
STEM I per minute) 3-5 minutes infusion 1-4 mg/min. Avoid ~ prolonged
• Dopamine infusion No
OR Reversible Causes Maximum: 3 mg • Consider expert QTorCHF.
OR
high suspicion - Hypovolemia consultation Amiodarone IV Dose:
• Epinephrine infusion Dopamine
of AMI - Hypoxia IV Infusion: First dose: 150 mg over
- Hydrogen ion (acidosis) 2-1 0 meg/kg per 10 minutes. Repeat as
• IV access and 12-lead EGG needed if VT recurs. Follow
- Hypo-/hyperkalemia minute if available by maintenance infusion of
- Hypothermia
No Epinephrine • Vagal maneuvers 1 mg/min tor first 6 hours.
- Tension pneumothorax
Consider: IV Infusion: • Adenosine (if regular)
- Tamponade, cardiac Sotalol IV Dose:
Advanced critical care
I - Toxins
- Thrombosis, pulmonary
• Expert consultation
• Transvenous pacing
2-1 0 m£9 pe
mm te
• ~ - Blocker or calcium
channel blocker
• Consider expert consultation
100 mg (1.5 mglkg)
over 5 minutes. Avoid if
- Thrombosis, coronary prolonged QT.
 Acute Coronary Syndromes Algorithm (continued)
A m erican AMERICAN
..r ASSOCIATION
Heart ~ CRmCAL-CARE
Asso ciat ion. NURSES

ST elevation or new or ST depression or dynamic Normal or

presumably new LBBB; T-wave inversion; strongly nondiagnostic changes

ACLS Acute Coronary

Syndromes and Stroke
strongly suspicious
for injury
ST-elevation Ml (STEMI)
suspicious for ischemia
H1gh-risk unstable ang1na/
non-ST-elevation Ml
(UAINSTEMI)
in ST segment
orTwave
low-/intermediate-nsk
ACS

Acute Coronary Syndromes Algorithm

• Start adjunctive Troponin elevated or Consider admission
therapies as 1nd1cated high-risk patient to ED chest pain unit
or to appropriate bed
I Symptoms suggestive of ischemia or infarction I • Do not delay
reperfusion
Cons1der early 1nvas1ve
strategy if: and follow:
• Serial cardiac markers
• Refractory ischemic
chest dtscomfort (including tropon1n)
• RecurrenVpersistent • Repeat EGG/continuous
>1 2 ST-segment monitoring
hours ST deviation
Time from • Cons1der noninvasive
• Ventricular
EMS assessment and care and hospital preparation onset of diagnostic test
tachycardia
• Monttor, support ABCs. Be prepared to provtde CPR and defibrillation symptoms
• Hemodynamic
• Administer asptnn and consider oxygen, nitroglycerin, and morphine tf needed S12 hours?
Instability
• Obtatn 12-lead ECG; tf ST elevation: • Signs of heart failure
- Nottfy recetvtng hospital wtth transmtssion or Interpretation; note time of
onset and first medical contact S12 hours
• Nottfied hospttal should mobilize hospital resources to respond to STEMI
• If considenng prehospttal fibnnolys1s, use fibrinolytic checklist Develops 1 or more:
• Clinical high-risk
Start adjunctive features
treatments as indicated ....___ • Dynamic ECG
• Nitroglycenn changes
• Heparin (UFH or LMWH) Yes consistent with
• Cons1der: PO 13-blockers ischemia
Concurrent ED assessment (<10 minutes) Immediate ED general treatment • Consider: Clopidogrel • Troponin elevated
• Check vttal signs; evaluate oxygen • If 0 sat <94%, start oxygen at • Cons1der: Glycoprotetn
saturation 4 Um1n, titrate lib/lila inhibitor
• Establish IV access • Aspirin 160 to 325 mg
• Perform brief, targeted history, (if not given by EMS) Reperfusion goals: No
physical exam • Nitroglycerin sublingual or spray Therapy defined by
• Rev1ew/complete fibrinolytiC checklist; • Morphine IV 1f discomfort not patient and center
check contratndications relieved by nitroglycenn
Abnormal
cnteria Yes diagnostic
• Obtain 1n1t1al card1ac marker levels, • Door-to-balloon Admit to monitored bed
inttial electrolyte and coagulation studies Assess risk status noninvasive
inflation (PCI) goal
Continue ASA, heparin, imaging or
• Obtain portable chest x-ray (<30 min) of 90 minutes
and other therapies as physiologic
• Door-to-needle
indicated testing?
(fibrinolysis) goal
of 30 minutes • ACE inhibitor/ARB
• HMG CoA reductase
No
inhibitor (stalin therapy)
ECG interpretation } Not at high risk:
cardiology to nsk strat1fy If no evidence
of ischemia or
infarction by
testing, can
discharge with
follow-up
90-1012 (2 of 2) ISBN 978-1-61669-013-7 5/11 C 2011 American Heart Association Printed In the USA
 Has patient experienced chest discomfort for Contraindications for fibrinolytic use in STEMI consistent with ACCIAHA
Step 1
greater than 15 minutes and less than 12 hours? 2007 Focused Update•

Absolute Contraindication&
• Any prior intracranial hemorrhage
Does ECG show STEMI or new or • Known structural cerebral vascular lesion (eg, arteriovenous
presumably new LBBB? malformation)
• Known malignant intracranial neoplasm (primary or metastatic)
• Ischemic stroke within 3 months EXCEPT acute ischemic stroke
within 3 hours
Are there contraindications to fibrinolysis?
Step2 • Suspected aortic dissection
If ANY one of the following is checked YES,
fibrinolysis MAY be contraindicated. • Active bleeding or bleeding diathesis (excluding menses)
• Significant closed head trauma or facial trauma within 3 months
Systolic BP > 180 to 200 mm Hg or diastolic BP > 100 to
110mm Hg ) YES ) NO
) YES ) NO
Relative Contraindication&
Right vs left arm systolic BP difference > 15 mm Hg
History of structural central nervous system disease ) YES ) NO • History of chronic, severe, poorly controlled hypertension
Significant closed head/facial trauma within the
previous 3 weeks ) YES ) NO
• Severe uncontrolled hypertension on presentation
Stroke >3 hours or <3 months ) YES ) NO (SSP > 180 mm Hg or DBP > 11 0 mm Hg)t
Rebent (within 2-4 weeks) major trauma, surgery • History of prior ischemic stroke >3 months, dementia, or known
(including laser eye surgery), GI/GU bleed ) YES ) NO intracranial pathology not covered in contraindications
Any history of intracranial hemorrhage ) YES ) NO
Bleeding, clotting problem, or blood thinners ) YES "J NO • Traumatic or prolonged (> 10 minutes) CPR or major surgery
Pregnant female ) YES :> NO (<3 weeks)
Serious systemic disease (eg, advanced cancer, • Recent (within 2 to 4 weeks) internal bleeding
severe liver or kidney disease) ) YES ) NO
• Noncompressible vascular punctures
Is patient at high risk?
• For streptokinase/anistreplase: prior exposure (>5 days ago) or
Step3 If ANY one of the following is checked YES, prior allergic reaction to these agents
consider transfer to PCI facility.
• Pregnancy
Heart rate ~ 1 00/min AND systolic BP <1 00 mm Hg .) YES ) NO • Active peptic ulcer
Pulmonary edema (rales) ) YES .) NO
) YES ) NO • Current use of anticoagulants: the higher the INA, the higher the
Signs of shock (cool, clammy)
Contraindications to fibrinolytic therapy J vest ) NO risk of bleeding
Required CPR ) YES ) NO
'Contra1ndications for fibrinolytiC use 1n STEM I cons1stent w1th "ThrombolytiC Therapy and Balloon 'Viewed as advisory for clinical decision making and may not be all-inclusive or definitive.
Angioplasty 1n Acute ST Elevation Myocard1allnfarction (STEMI)" at Agency for Healthcare Research
tCould be an absolute contraindication in low-risk patients with myocardial infarction.
and Quality National Gu1dehne Clearinghouse (www.Guidel1nes.gov).
tCons1der transport to pnmary PCI fac1hty as destination hosprtal.
Suspected Stroke Algorithm:
Goals for Management of Stroke
I Stroke Assessment I

I Identify signs and symptoms of possible stroke

Activate Emergency Response
I The Cincinnati Prehospital Stroke Scale

t Facial Droop (have patient show teeth or smile):

Critical EMS assessments and actions
NINDS • Support ABCs; g1ve oxygen If needed e Normal- both sides of
TIME • Perform prehospltal stroke assessment face move equally
GOALS • Establish t1me of symptom onset (last normaQ
• Tnage to stroke center
• Alert hospital
e Abnormal-one side of
ED • Check glucose if possible face does not move
Arrival

10
•
Immediate general assessment and stabilization
• Assess ABCs, v1tal stgns • Perform neurologic screenirtg
as well as the other side

mm
• Prov1de oxygen 1f hypoxemic
• Obtam IV access and perform
laboratory assessments
ED • Check glucose: treat if indiCated
assessment
• Activate stroke team
• Order emergent CT or MAl of bram
• Obtaln 12-lead ECG

t Left: Normal. Right: Stroke patient

Immediate neurologic assessment by stroke team or designee with facial droop (right side of face).
• Review patient history
• Establish time of symptom onset or last known normal
• Perform neurologic examination (NIH Stroke Scale or Arm Drift (patient closes eyes and extends both arms straight out,
25 mm
Canadian Neurological Scale) with palms up, for 10 seconds):
ED
Arrival t e Normal- both arms move
r-------------~

(Does CT 8CM1 show hemontlage?} the same or both arms do

No HemorTh1111e HemorTh1111e not move at all (other findings,
such as pronator drift, may
t t
Probable acute ischemic stroke;
c onsider fibrinolytic therapy
I Consult neurolog1st or neurosurgeon:
conSider transfer if not available
be helpful)
e Abnormal-one arm does
• Check for fibnnolytic exclusions
• Repeat neurolog1c exam: are defic1ts not move or one arm drifts
rapidly improving to normal? down compared with the
t other
Not a
ED ( Patient retnlllnS CMKI#dafe Candidate
Arrival for flbrlnolytJc tltwapy? J : Administer aspirin Left: Normal. Right: One-sided
motor weakness (right arm).

•
60 min
f Candidate ~

Review risks/benefits with patient • Beg1n stroke or

and family. If acceptable:
Abnormal Speech (have the patient say "you can't teach an old dog
hemorTtlage pathway
• G1ve rtPA • Admit to stroke un1t or new tricks"):
• No anticoagulants or anllpiatelet lntens1ve care un1t
Stroke treatment for 24 hours e Normal-patient uses correct words with no slurring
Admission
3 hours t e Abnormal-patient slurs words, uses the wrong words, or is unable
• Beg1n post-rtPA stroke pathway to speak
• Aggressively mon1tor.
- BP per protocol Interpretation: If any 1 of these 3 signs is abnormal, the probability of a
- For neurologiC detenoration
• Emergent admission to stroke un1t stroke is 72%.
or Intensive care un1t Modrfoed from Kothari AU. PanciOir A, Uu T, Brott T, Broderick J. Crncinnati Prehosprtal Stroke Scale: reproducobthty and
vahdoty. Ann Emerg Mad. 1999;33:373-378. W~h permission from 8sevrer.
Patients Who Could Be Treated With rtPA Within 3 Hours
From Symptom Onset*
Inclusion Criteria
• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms <3 hours before beginning treatment
• Age ~18 years
Exclusion Criteria
• Head trauma or prior stroke in previous 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
• Elevated blood pressure (systolic >185 mm Hg or diastolic >11 0 mm Hg)
• Evidence of active bleeding on examination
• Acute bleeding diathesis, including but not limited to
- Platelet count <100 OOO/mm3
- Heparin received within 48 hours, resulting in aPTT >upper limit of normal
- Current use of anticoagulant with INA >1.7 or PT > 15 seconds
• Blood glucose concentration <50 mg/dl (2. 7 mmoVL)
• CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere)
Relative Exclusion Criteria
Recent experience suggests that under some circumstances-with careful
consideration and weighing of risk to benefit-patients may receive fibrinolytic
therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA
administration carefully if any one of these relative contraindications is present:
• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Seizure at onset with postictal residual neurologic impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)
Patients Who Could Be Treated With rtPA From 3 to 4.5 Hours
From Symptom Onsett
Inclusion Criteria
• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms 3 to 4.5 hours before beginning treatment
Exclusion Criteria
• Age >80 years
• Severe stroke (NIHSS >25)
• Taking an oral anticoagulant regardless of INA
• History of both diabetes and prior ischemic stroke
Notes
• The checklist includes some US FDA-approved indications and contraindications for administratiOO
of rtPA for acute ischemic stroke. Recent AHNASA guideline revisions may differ slightly from
FDA criteria. A physician with expertise in acute stroke care may modify this list.
• Onset t ime is either witnessed or last known normal.
• In patients without recent use of oral anticoagulants or heparin, treatment with rtPA can be
initiated before availability of coagulation study results but should be discontinued if INA 1s
> 1.7 or PT is elevated by local laboratory standards.
• In patients without history of thrombocytopenia, treatment with rtPA can be init iated before
availability of platelet count but should be discontinued if platelet count is <100 000/mm•.
Abbreviations: aPTT, activated partial thromboplastin time; FDA, Food and Drug Administration;
INA, international normalized ratio; NIHSS, Nat1onal Institutes of Health Stroke Scale; PT,
prothrombin time; rtPA, recombinant tissue plasminogen activator.
Potential Approaches to Arterial Hypertension in
Acute Ischemic Stroke Patients Who Are Potential Candidates
for Acute Reperfusion Therapy*
Patient otherwise eligible for acute reperfusion therapy except that blood pressure
is >185/ 110 mm Hg:
• Labetalol 10-20 mg IV over 1-2 minutes, may repeat x 1, or
• Nicardipine IV 5 mg per hour, titrate up by 2.5 mg per hour every 5-15 minutes,
maximum 15 mg per hour; when desired blood pressure is reached, lower to
3 mg per hour, or
• Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
If blood pressure is not maintained at or below 185/11 0 mm Hg, do not administer rtPA.
Management of blood pressure during and after rtPA or other acute reperfusion
therapy:
Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA
therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours.
If systolic blood pressure 180-230 mm Hg or diastolic blood pressure
105- 120 mm Hg:
• Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg per minute, or
• Nicardipine IV 5 mg per hour, titrate up to desired effect by 2.5 mg per hour
every 5-15 minutes, maximum 15 mg per hour
If blood pressure not controlled or diastolic blood pressure > 140 mm Hg, consider
sodium nitroprusside.
Approach to Arterial Hypertension In Acute Ischemic Stroke
Patients Who Are Not Potential Candidates for Acute
Reperfusion Therapy*
Consider lowering blood pressure in patients with acute ischemic stroke if systolic
blood pressure >220 mm Hg or diastolic blood pressure > 120 mm Hg.
Consider blood pressure reduction as indicated for other concomitant organ
system injury:
• Acute myocardial infarction
• Congestive heart failure
• Acute aortic dissection
A reasonable target is to lower blood pressure by 15% to 25% within the first day.
'Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Fur1an A, Grubb RL, H1gashlda AT, Jauch EC,
Kidwell C, Lyden PO, Morgenstern LB, Qureshi AI, Rosenwasser RH. Scott PA, W1J(i1Cks EFM. Gu1delines
for the ear1y management of adults w1th ischermc stroke: a guldel1ne from the Amencan Heart Association/
Amencan Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and
Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in
Research Interdisciplinary Working Groups. Stroke. 2007;38:1655-1711 .
tdel Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr; on behalf of the AmeriCan Heart Association Stroke
Council. Expansion of the t1me w1rldow for treatment of acute 1schemic stroke w1th Intravenous t1ssue
plasm~nogen actiVator: a science advisory from the Amencan Heart Associat10n/Amencan Stroke Associat1011
Sttoke. 2009;40:2945-2948.