ACLS (Main)

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  • Routine use of cricoid pressure is NOT recommended
  • Airway adjunct is recommended while performing ventilation
  • Pulse/rhythm checks should only occur q2min
  • Most critical component is high-quality compressions
  • Atropine and cardiac pacing are NOT recommended for asystole/PEA


  • Compressions
    • Push hard (2cm) and fast (100pm)
    • Do everything possible to minimize compression interruption
  • Ventilation
    • 30:2 ratio when do not have advanced airway
      • Do not overventilate! (leads to decr venous return)
    • 8-10 breaths per min when intubated

ECG Analysis

  1. Is the rhythm fast or slow?
  2. Are the QRS complexes wide or narrow?
  3. Is the rhythm regular or irregular?

V-Fib and Pulseless V-Tach

  • Shock as quickly as possible and resume CPR immediately after shocking
    • Biphasic - 200J
    • Monophasic - 360 J
  • Give Epi 1mg if (shock + 2min of CPR) fails to convert the rhythm
  • Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
    • 1st line: Amiodarone 300mg IVP w/ repeat dose of 150mg as indicated
    • 2nd line: Lidocaine 1-1.5 mg/kg then 0.5-0.75 mg/kg q5-10min
    • Magnesium 2g IV, followed by maintenance infusion
      • Only for polymorphic V-tach

Asystole and PEA

  • Give Epi 1mg q3-5min
  • Consider H's and T's
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion
    • Hypo/hyperkalemia
    • Hypothermia
    • Tension pneumo
    • Tamponade
    • Toxins
    • Thrombosis, pulmonary
    • Thrombosis, coronary


  • Only intervene if pt is symptomatic
    • Hypotension, AMS, chest pain, pulm edema
  • 1st Line
    • Transcutaneous pacing
    • Chronotropes
      • Dopamine 2-10mcg/kg/min
      • Epineprhine 2-10mcg/min
  • 2nd Line
    • Atropine 0.5mg q3-5m can be given as temporizing measure
      • Do not give if Mobitz type II or 3rd degree block is present
  • TransQ pacing and chronotropes ineffective = need for transvenous pacing


3 questions:

  1. Is the pt in a sinus rhythm?
  2. Is the QRS wide or narrow?
  3. Is the rhythm regular or irregular?

Narrow Regular

  1. See also Tachycardia (Narrow)
  2. Sinus Tachycardia
    1. Treat underlying cause
  3. SVT
    1. Vagal maneuvers (convert up to 25%)
    2. Adenosine 6mg IVP (can follow with 12mg if initially fails)
      1. If adenosine fails initiate rate control with CCB or BB
        1. Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
        2. Metoprolol 5mg IVP x 3 followed by 50mg PO
    3. Synchronized cardioversion (50-100J)

Narrow Irregular

  1. MAT
    1. Treat underlying cause (hypoK, hypomag)
  2. Sinus Tachycardia w/ frequent PACs
  3. A fib / A Flutter w/ variable conduction
    1. Rate control with:
      1. Dilt
      2. MTP (good in setting of ACS)
      3. Amiodarone (good in setting of hypotension, CHF)
      4. Digoxin (good in setting of CHF)
    2. Synchronized cardioversion (120-200 J)

Wide Regular

  • If unstable: (hypotension, AMS, shock, ischemic chest discomfort, acute heart failure)
    • Shock (synchronized 100J)
  • If stable:
    • Procainamide
      • 20-50mg/min; then maintenance infusion of 1mg/min x6hr
      • Tx until arrhythmia suppressed, QRS duration increases >50%, hypotension, 17m/kg given
      • Avoid if prolonged QT or CHF
    • Amiodarone
      • 150mg over 10min (repeat as needed); then maintenance infusion of 1mg/min x6hr
    • Elective synchronized cardioversion (100J)
    • Adenosine
      • May be considered for diagnosis and treatment only if rhythm is regular and monomorphic

Wide Irregular

  • DO NOT use AV nodal blockers
    • Can precipitate V-Fib

  1. A fib w/ preexcitation
    1. 1st line - Electric cardioversion
    2. 2nd line - Procainamide, amiodarone, or sotalol
  2. A fib w/ aberrancy
  3. Polymorphic V-Tach / Torsades
    1. Emergent defibrillation (NOT synchronized)
    2. Correct electrolyte abnormalities
      1. HypoK, hypoMag
    3. Stop prolonged QT meds

See Also


  • AHA 2010 Guidelines for ACLS