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| == Recommendations ==
| | ''See [[critical care quick reference]] for drug doses and equipment size by weight. |
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| *Routine use of cricoid pressure is NOT recommended
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| *Airway adjunct is recommended while performing ventilation
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| *Pulse/rhythm checks should only occur q2min
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| *Most critical component is high-quality compressions
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| *Atropine and cardiac pacing are NOT recommended for asystole/PEA
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| == BLS ==
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| *Compressions
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| **Push hard (2cm) and fast (100pm)
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| **Do everything possible to minimize compression interruption
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| *Ventilation
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| **30:2 ratio when do not have advanced airway
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| ***Do not overventilate! (leads to decr venous return)
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| **8-10 breaths per min when intubated
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| == ECG Analysis ==
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| | ==ECG Analysis== |
| #Is the rhythm fast or slow? | | #Is the rhythm fast or slow? |
| #Are the QRS complexes wide or narrow? | | #Are the QRS complexes wide or narrow? |
| #Is the rhythm regular or irregular? | | #Is the rhythm regular or irregular? |
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| == Ventricular fibrillation and pulseless ventricular tachycardia == | | ==Algorithms== |
| | | *[[Adult Pulseless Arrest]] |
| *Shock as quickly as possible | | *[[ACLS: Bradycardia]] (with pulse) |
| **Resume CPR immediately after shocking | | **Use [[Adult Pulseless Arrest]] algorithm if no pulse = PEA |
| **Biphasic - 200J
| | *[[ACLS: Tachycardia]] |
| **Monophasic - 360 J
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| *Give Epi 1mg if shock + 2min of CPR fails to convert the rhythm
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| *Consider aniarrhytmic if 2nd shock + 2min CPR again fails
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| **Amiodarone 300mg w/ repeat dose of 150mg as indicated
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| **Magnesium 2g IV, followed by maintenance infusion
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| ***Only for polymorphic Vtach
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| == Asystole and PEA ==
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| *Give Epi 1mg q3-5min
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| *Consider H's and T's
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| **Hypovolemia
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| **Hypoxia
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| **Hydrogen ion
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| **Hypo/hyperkalemia
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| **Hypothermia
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| **Tension pneumo
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| **Tamponade
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| **Toxins
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| **Thrombosis, pulmonary
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| **Thrombosis, coronary
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| == Bradycardia ==
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| *Only intervene if pt is symptomatic
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| **Hypotension, AMS, chest pain, pulm edema
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| *1st Line
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| *Transcutaneous pacing
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| *Chronotropes
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| **Dopamine 2-10mcg/kg/min
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| **Epineprhine 2-10mcg/min
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| *2nd Line
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| **Atropine 0.5mg q3-5m can be given as temporizing measure
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| ***Do not give if Mobitz type II or 3rd degree block is present
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| *TransQ pacing and chronotropes ineffective = need for transvenous pacing
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| == Tachycardia ==
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| 3 questions
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| #Is the pt in a sinus rhythm?
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| #Is the QRS wide or narrow?
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| #Is the rhythm regular or irregular?
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| === Regular Narrow ===
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| *1. Sinus Tachycardia
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| **Treat underlying cause
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| *2. SVT
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| **Vagal maneuvers (convert up to 25%)
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| **Adenosine 6mg IVP (can follow with 12mg if initially fails)
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| ***If adenosine fails initiate rate control with CCB or BB
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| ****Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
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| ****Metoprolol 5mg IVP x 3 followed by 50mg PO
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| === Irregular Narrow ===
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| *1. MAT
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| **Treat underlying cause (hypoK, hypomag)
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| *2. Sinus Tachycardia w/ frequent PACs
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| *3. A Fib / A Flutter w/ variable conduction
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| **Rate control with:
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| ***Dilt
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| ***MTP (good in setting of ACS)
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| ***Amiodarone (good in setting of hypotension, CHF)
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| ***Digoxin (good in setting of CHF)
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| === Regular Wide Complex ===
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| *1. V-Tach (until proven otherwise!)
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| *If stable:
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| **Antiarrhytmics
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| ***Procainamide 20mg/min
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| ****Cont until rhythm suppressed, hypotensive, or max dose (17mg/kg)
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| ****Avoid if prolonged QT | |
| ***Amiodarone 150mg over 10min, repeated as needed
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| ***Sotalol 100mg IV over 5min
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| ****Avoid if prolonged QT
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| **Elective synchronized cardioversion
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| **Adenosine may be used for diagnosis and treatment only if:
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| ***Rhythm is regular and monomorphic
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| *2. SVT w/ aberrancy
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| === Irregular Wide Comlex === | |
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| *DO NOT use AV nodal blockers!
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| **Can precipitate V-Fib
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| *1. A fib w/ preexcitation
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| **1st line - electric cardioversion
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| **2nd line - Procainamide, amiodarone, or sotalol
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| *2. A fib w/ aberrancy
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| *3. Polymorphic V-Tach / Torsades
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| **Emergent defibrillation
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| **Correct electrolyte abnormalities
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| ***HypoK, hypoMag
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| **Stop prolonged QT meds | |
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| === Treatable Conditions ===
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| {| cellspacing="0" style="text-align: left; border-right-color: rgb(0, 0, 0); border-right-width: 1px; border-right-style: solid; font-size: 0.75em; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; width: 1012px; "
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| | class="subtitle1" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: middle; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(0, 0, 0); border-bottom-width: 3px; border-bottom-style: solid; padding-top: 0.8em; padding-right: 0.6em; padding-bottom: 0.3em; padding-left: 0.6em; text-align: center; font-size: 1.2em; font-weight: bolder; background-image: initial; background-attachment: initial; background-origin: initial; background-clip: initial; background-color: rgb(238, 238, 238); background-position: initial initial; background-repeat: initial initial; " | Condition
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| | class="subtitle1" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: middle; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(0, 0, 0); border-bottom-width: 3px; border-bottom-style: solid; padding-top: 0.8em; padding-right: 0.6em; padding-bottom: 0.3em; padding-left: 0.6em; text-align: center; font-size: 1.2em; font-weight: bolder; background-image: initial; background-attachment: initial; background-origin: initial; background-clip: initial; background-color: rgb(238, 238, 238); background-position: initial initial; background-repeat: initial initial; " | Common clinical settings
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| | class="subtitle1" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: middle; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(0, 0, 0); border-bottom-width: 3px; border-bottom-style: solid; padding-top: 0.8em; padding-right: 0.6em; padding-bottom: 0.3em; padding-left: 0.6em; text-align: center; font-size: 1.2em; font-weight: bolder; background-image: initial; background-attachment: initial; background-origin: initial; background-clip: initial; background-color: rgb(238, 238, 238); background-position: initial initial; background-repeat: initial initial; " | Corrective actions
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| | rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Acidosis
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| | rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Preexisting acidosis, DM, diarrhea, drugs and toxins, prolonged resuscitation, renal disease, shock
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Reassess adequacy of oxygenation, and ventilation; reconfirm endotracheal-tube placement
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Hyperventilate
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Consider intravenous bicarbonate if pH <7.20 after above actions have been taken
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| |- class="divider_top"
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| | rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Cardiac tamponade
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| | rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hemorrhagic diathesis, cancer, pericarditis, trauma, after cardiac surgery or MI
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Give fluids; obtain bedside echocardiogram
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Perform pericardiocentesis. Immediate surgical intervention is appropriate if pericardiocentesis is unhelpful but cardiac tamponade is known or highly suspected.
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| |- class="divider_top"
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| | rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypothermia
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| | rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | 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
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | 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.
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | If moderate (temperature 30-34°C), proceed with resuscitation (space medications at intervals greater than usual), actively rewarm truncal body areas
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| | rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypovolemia, hemorrhage, anemia
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| | rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Major burns, DM, GI losses, hemorrhage, hemorrhagic diathesis, cancer, pregnancy, shock, trauma
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Give fluids
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Transfuse pRBCs if hemorrhage or profound anemia is present
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Thoracotomy is appropriate when pt has cardiac arrest from penetrating trauma and a cardiac rhythm and the duration of cardiopulmonary resuscitation before thoracotomy is <10 min
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypoxia
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Consider in all patients with cardiac arrest
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Reassess technical quality of cardiopulmonary resuscitation, oxygenation, and ventilation; reconfirm ETT placement
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypomagnesemia
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Alcohol abuse, burns, DKA, severe diarrhea, diuretics, drugs (eg, cisplatin, cyclosporine, pentamidine)
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| | style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Give 1-2 g magnesium sulfate intravenously over 2 min
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| | ==See Also== |
| | *[[AHA ACLS Recommendation Changes by Year]] |
| | *[[ACLS (Treatable Conditions)]] |
| | *[[BLS (Main)]] |
| | *[[Critical care quick reference]] |
| | *[[Post cardiac arrest]] |
| | *[[PALS (Main)]] |
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| == Source == | | ==References== |
| | <references/> |
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| *AHA 2010 Guidelines for ACLS | | ==External Links== |
| | *[http://www.blog.numose.com/emed-basics/pulseless Numose EMed: The Pulseless Patient] |
| | *[http://www.blog.numose.com/emed-cardiology/bradycardia Numose EMed: ACLS Bradycardia] |
| | *[http://www.blog.numose.com/emed-cardiology/svt Numose EMed: ACLS Narrow Complex Tachycardia] |
| | *[http://www.blog.numose.com/emed-cardiology/wct Numose EMed: ACLS Wide Complex Tachycardia] |
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| <br/>[[Category:Airway/Resus]] <br/><br/>
| | [[Category:Cardiology]] |
| | [[Category:EMS]] |
| | [[Category:Critical Care]] |
