ACLS (Main)

See critical care quick reference for drug doses and equipment size by weight. This page is for adult patients. For pediatric patients, see: PALS (Main).

Background

• A series of clinical algorithms created by the AHA/ASA used in the treatment of cardiovascular/neurological emergencies.
• Involves airway management, IV access, and ECG interpretation.

ECG Analysis

• What is the atrial and ventricular rate?
• Is the rhythm regular or irregular?
  • If irregular, does it follow any repeatable pattern?
• What is the axis?
  • ERAD often seen in VT but not SVT
• What is the P wave amplitude, duration, morphology, and synchrony with QRS complex?
  • Is the P wave positive in Lead II
• What is the QRS complex amplitude, duration, morphology?
• What is the T wave amplitude, duration, morphology?
  • Is the T wave positive in Lead II
• What is the length of PR and QT intervals?
• Is there ST Elevation/Depression or Hyperacute T waves?
  • If yes, does it follow any anatomical pattern or is it diffuse?
• Is there anything else abnormal about this ECG?
  • Pacemaker Spikes
  • Hypertrophy of atrial/ventricles

Algorithms

• Adult Pulseless Arrest
  • Pulseless Ventricular Tachycardia/Ventricular Fibrillation
  • Pulseless Electrical Activity/Asystole
  • Cardiac Arrest In Pregnancy
• Adult Post-Cardiac Arrest Care
• Termination of Resuscitation
• ACLS: Bradycardia (with pulse)
• ACLS: Tachycardia (with pulse)
• Acute coronary syndrome
• Suspected cerebrovascular event

Treatable Conditions

Condition	Common clinical settings	Corrective actions
Acidosis	Preexisting acidosis, DM, diarrhea, drugs and toxins, prolonged resuscitation, renal disease, shock	Reassess adequacy of oxygenation, and ventilation; reconfirm endotracheal-tube placement Hyperventilate Consider intravenous bicarbonate if pH <7.20 after above actions have been taken
Cardiac tamponade	Hemorrhagic diathesis, cancer, pericarditis, trauma, after cardiac surgery or MI	Give fluids; obtain bedside echocardiogram Perform pericardiocentesis. Immediate surgical intervention is appropriate if pericardiocentesis is unhelpful but cardiac tamponade is known or highly suspected.
Hypothermia	Alcohol abuse, burns, CNS disease, debilitated or elderly patient, drowning, drugs and toxins, endocrine disease, history of exposure, homelessness, extensive skin disease, spinal cord disease, trauma	If severe (temperature <30°C), limit initial shocks for V-Fib or pulseless V-Tach to three; initiate active internal rewarming and cardiopulmonary support. Hold further resuscitation medications or shocks until core temperature is >30°C. If moderate (temperature 30-34°C), proceed with resuscitation (space medications at intervals greater than usual), actively rewarm truncal body areas
Hypovolemia, hemorrhage, anemia	Major burns, DM, GI losses, hemorrhage, hemorrhagic diathesis, cancer, pregnancy, shock, trauma	Give fluids Transfuse pRBCs if hemorrhage or profound anemia is present Thoracotomy is appropriate when patient has cardiac arrest from penetrating trauma and a cardiac rhythm and the duration of cardiopulmonary resuscitation before thoracotomy is <10 min
Hypoxia	Consider in all patients with cardiac arrest	Reassess technical quality of cardiopulmonary resuscitation, oxygenation, and ventilation; reconfirm ETT placement
Hypomagnesemia	Alcohol abuse, burns, DKA, severe diarrhea, diuretics, drugs (eg, cisplatin, cyclosporine, pentamidine)	Give 1-2 g magnesium sulfate intravenously over 2 min
Myocardial infarction	Consider in all patients with cardiac arrest, especially those with a history of coronary artery disease or prearrest acute coronary syndrome	Consider definitive care (eg, thrombolytic therapy, cardiac catheterization or coronary artery reperfusion, circulatory assist device, emergency cardiopulmonary bypass)
Poisoning	Alcohol abuse, bizarre or puzzling behavioral or metabolic presentation, classic toxicologic syndrome, occupational or industrial exposure, and psychiatric disease	Consult toxicologist for emergency advice on resuscitation and definitive care, including appropriate antidote Prolonged resuscitation efforts may be appropriate; immediate cardiopulmonary bypass should be considered, if available
Hyperkalemia	Metabolic acidosis, excessive administration of potassium, drugs and toxins, vigorous exercise, hemolysis, renal disease, rhabdomyolysis, tumor lysis syndrome, and clinically significant tissue injury	If hyperkalemia is identified or strongly suspected, treat with all of the following: 10% calcium chloride (5-10 mL by slow intravenous push; do not use if hyperkalemia is secondary to digitalis poisoning), glucose and insulin (50 mL of 50% dextrose in water and 10 units of regular insulin intravenously), sodium bicarbonate (50 mmoL intravenously; most effective if concomitant metabolic acidosis is present), and albuterol (15-20mg nebulized or 0.5mg by intravenous infusion)
Hypokalemia	Alcohol abuse, diabetes, use of diuretics, drugs and toxins, profound gastrointestinal losses, hypomagnesemia	If profound hypokalemia (<2-2.5 mmoL of potassium per liter) is accompanied by cardiac arrest, initiate urgent intravenous replacement (2 mmoL/min intravenously for 10-15 mmoL), then reassess
Pulmonary embolism	Hospitalized patient, recent surgical procedure, peripartum, known risk factors for venous thromboembolism, history of venous thromboembolism, or prearrest presentation consistent with diagnosis of acute pulmonary embolism	Administer fluids; augment with vasopressors as necessary Confirm diagnosis, if possible; consider immediate cardiopulmonary bypass to maintain patient's viability Consider definitive care (eg, thrombolytic therapy, embolectomy by interventional radiology or surgery)
Tension pneumothorax	Placement of central catheter, mechanical ventilation, pulmonary disease (including asthma, chronic obstructive pulmonary disease, and necrotizing pneumonia), thoracentesis, and trauma	Needle decompression, followed by chest-tube insertion

See Also

• AHA ACLS Recommendation Changes by Year
• ACLS (Treatable Conditions)
• BLS (Main)
• Critical care quick reference
• Post cardiac arrest
• PALS (Main)

External Links

• 2020 AHA Guidelines
• Numose EMed: The Pulseless Patient
• Numose EMed: ACLS Bradycardia
• Numose EMed: ACLS Narrow Complex Tachycardia
• Numose EMed: ACLS Wide Complex Tachycardia