ACLS algorithms

Cardiac Arrest
Circular Algorithm
2 minutes
Drug Therapy
access
If VF/VT
Shock
Shout for Help/Activate Emergency Response
Doses/Details for the Cardiac Arrest Algorithms
Drug Therapy
Return of Spontaneous
Circulation (ROSC)
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/Hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
CPR Quality
Advanced Airway***
Supraglottic advanced airway or endotracheal intubation
Waveform capnography to confirm and monitor ET tube
placement
8-10 breaths per minute with continuous chest compressions
Epinephrine IV/IO Dose: 1 mg every 3-5 minutes
Vasopressin IV/IO Dose: 40 units can replace first or
second dose of epinephrine
Amiodarone IV/IO Dose**:First dose: 300 mg bolus.
second dose: 150 mg
Reversible Causes
Shock Energy
Biphasic: Manufacturer recommendation (eg, initial dose of
120-200 J): if unknown, use maximum available.
Second and subsequent doses should be equivalent, and
higher doses may be considered
Monophasic: 360 J
CPRSTART
Push hard ( 2 inches [5cm]) and fast ( 100/min) and allow
complete chest recoil.
Minimize interruptions in compressions.*
Avoid excessive ventilation
Rotate compressor every 2 minutes
If no advanced airway, 30:2 compression-ventilation ratio
Quantitative waveform capnography
If PETCO2 10mm Hg, attempt to improve CPR quality
Intra-arterial pressure
If relaxation phase (diastolic) pressure
20 mm Hg, attempt to improve CPR quality.
Pulse and blood pressure
Abrupt sustained increase in PETCO2 (typically
40 mm Hg)
Spontaneous arterial pressure waves with intra-arterial
monitoring
Post-Cardiac
Arrest Care
Circulation (ROSC)
Return of Spontaneous
Check
Rhythm
Attach Monitor/DefibrillatorGive Oxygen
Epinephrine every 3-5 minutes
Amiodarone for refractory VF / VT
Consider Advanced Airway
Quantitative waveform capnography
Treat Reversible Causes
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IV/IO

Epinephrine every 3-5 min
Consider advanced airway,
capnography
Amiodarone
Treat reversible causes
Start CP... R
Cardiac Arrest
Algorithm
YES
Shock*
Asystole/PEA
Treat reversible causes
NO
NO
YES
Attach Monitor/Defibrillator
Give Oxygen
Shout for Help/Activate Emergency Response
RhythmShockable?
RhythmShockable?
Shock
RhythmShockable?
RhythmShockable?
RhythmShockable?
Shock
Go to 5 or 7
If ROSC, go to Post-
Cardiac Arrest Care.
2
3
4
5
6
7
8
9
10
11
12
VF/VT
1
Y N
YY
N
N
YY
N
N
Y
YY
CPR 2 min
CPR 2 min CPR 2 min
CPR 2 min
IV/IO access
Epinephrine every 3-5 min
Consider advanced airway,
capnography
IV/IO access
If no signs of return of
spontaneous circulation
(ROSC), go to 10 or 11.
CPR 2 min

(c)
Symptoms Suggestive of Ischemia or Infarction
Oxygen
(If O sat <94%)2
Aspirin
160 - 325 mg
Fibrinolytic
Checklist
Check
Contraindications
Cardiac Marker
Levels
Chest X-ray
(<30 mins)
Check Vital
Signs
IV Access
Physical
Exam
Fibrinolytic
Checklist
ID
Tnl
CK-M
B
MYO
Pain
Control
Aspirin
160 - 325 mg
(If not already taken)
If O sat <94%
Start Oxygen
2
High-risk unstable angina/non-ST-elevation
MI (UA/NSTEMI)Start adjunctive therapies
as indicated
Do not delay reperfusion
Consider admission to ED chest pain unit
or to appropriate bed and follow:
heparin, and other therapies as indicated
If no evidence of ischemia or
infarction by testing, can
discharge with follow-up
N
N
Low-/Intermediate-risk ACS
Troponin elevated or high-risk patient
Consider early invasive strategy if:
Refractory ischemic chest discomfort
Ventricular tachycardia
Hemodynamic instability
Signs of heart failure
Recurrent/persistent ST deviation
Start adjunctive treatments as indicated
Develops 1 or more:
• Clinical high-risk features
• Dynamic ECG changes
consistent with ischemia
• Troponin elevated
Time from onset
of symptoms
12 hours?
Serial cardiac markers (including troponin)
Repeat ECG/continuous ST-segment monitoring
Consider noninvasive diagnostic test
Reperfusion goals:
Y
Y
Not at high risk: cardiology to risk stratify
ACE inhibitor/ARB; HMG CoA reductase inhibitor (statin therapy)
Nitroglycerin
Heparin (UFH or LMWH)
Consider: PO -blockers
Consider: Clopidogrel
Consider: Glycoprotein
Abnormal diagnostic
noninvasive imaging or
physiologic testing?
Acute Coronary
Syndromes Algorithm
ACLS Training Center 877-560-2940 support@acls.net
12
>12
hours
hours
Nitroglycerin
sublingual or
spray
Pain
Control
(c)
EMS assessment and care and hospital
preparation*
Immediate ED general treatment
Concurrent ED assessment
( 10 minutes)
12-Lead ECG
12-Lead ECG
ECG Interpretation*
llb/llla inhibitor
Admit to monitored bed Assess risk status Continue ASA
ST-elevation MI (STEMI)
Door-to-balloon inflation (PCI)**
goal of 90 minutes
Door-to-needle (fibrinolysis)
goal of 30 minutes

Pulseless Arrest Algorithm for Managing Asystole
Using the Pulseless Arrest Algorithm for
Managing Asystole
Version control: This document is current with respect to drug indications in 2010 American Heart
Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on
March 2016. If you are reading this page (printed or online) after March 2016, please contact ACLS
Training Center at support@acls.net for an updated document.
Management of a patient in cardiac arrest with asystole follows the same pathway as management of
PEA. The top priorities stay the same: Following the steps in the ACLS Pulseless Arrest Algorithm and
identifying and correcting any treatable, underlying causes for the asystole. The algorithm assumes that
scene safety has been assured, personal protective equipment is being used, and no signs of obvious
death are present.
Begin with the primary survey to assess the patient's
condition:
In the absence of respirations and a pulse in the presence of asystole (present in two leads)
consideration of termination of efforts should take place
Follow the ACLS Pulseless Arrest Algorithm for asystole:
Check the patient's rhythm, taking less than 10 seconds to assess.
Verify the presence of asystole in at least two leads
Resume CPR at a rate of at least 100/minute. Rotate team members every 2 minutes with rhythm
breaks to help maintain high quality CPR.
As soon as IV or IO access is available, administer epinephrine 1mg IV/IO. Do not stop CPR to
administer drugs.
During CPR, search for and treat possible contributing causes (H's and T's in Figure 1).

Check rhythm.
If no electrical activity is present (patient is in asystole), resume CPR.
If electrical activity is present, see if the patient has a pulse.
If the patient does not have a pulse or there is some doubt about the pulse, resume CPR.
If a good pulse is present and the rhythm is organized, begin postresuscitative care.
IV/IO access is a priority over advanced airway management. If an advanced airway is placed, change to
continuous chest compressions without pauses for breaths. Give 8 to 10 breaths per minute and check
rhythm every 2 minutes.
Without a pulse or electrical activity on the ECG, the emergency care team needs to decide when
resuscitation efforts should stop. The patient's wishes and the family's concerns need to be considered.

Pulseless Arrest Algorithm for Managing
Pulseless Electrical Activity (PEA)
Using the Pulseless Arrest Algorithm for Managing PEA
Version control: This document is current with respect to drug indications in 2010 American Heart
Association Guidelines for CPR and ECC. These guidelines are current until they are replaced on
March 2016. If you are reading this page (printed or online) after March 2016, please contact ACLS
Training Center at support@acls.net for an updated document.
Patients with PEA have poor outcomes. Their best chance of returning to a perfusing rhythm is through
the quick identification of an underlying reversible cause and correct treatment. As you use the algorithm
to manage the PEA patient, remember to consider all the H's and T's, particularly hypovolemia, which is
the most common cause of PEA. Also look for drug overdoses or poisonings.
Begin with the primary survey to assess the patient's
condition:
1. Pulseless Electrical Activity (PEA) occurs when you see a rhythm on the monitor that would
normally be associated with a pulse, however the patient is pulses.
2. The rhythm can be anything, at any heart rate
3. There is something preventing the heart from generating a pulse, such as being empty
(Hypovolemia) something pushing against it (Tamponate)
4. Reassess the patient frequently for the return of pulses
Follow the ACLS Pulseless Arrest Algorithm
1. Begin CPR as soon as pulselessness is recognized. Continue CPR at a rate of 100/min throughout
the resuscitation without interuptions of more than 10 seconds to evaluate for pulses.
2. Compressors should be switched every 2 minutes to ensure efficacy of compressions

3. Waveform capnography should be utilized to monitor efficacy of compressions (should generate at
least 10) and the return of pulses (will cause an increase in capnography to 40)
4. Obtain IV/IO access
5. Administer Epinephrine 1 mg IV/IO every 35 minutes
6. Find and treat underlying causes.
Two management priorities are maintaining high quality CPR and searching simultaneously for a
treatable cause of the patient's PEA. Stop CPR only when absolutely necessary for pulse and rhythm
checks. Establishing IV/IO access is a priority over advanced airway management. If an advanced airway
is placed, change to continuous chest compressions without pauses for breaths. Give 8 to 10 breaths
per minute and check rhythm every 2 minutes.

Ventilation/Oxygenation
IV Bolus
Epinephrine IV
Infusion
Dopamine IV
Infusion
Norepinephrine
IV InfusionReversible Causes
IV/IO bolus
Vasopressor infusion
Consider treatable causes
Immediate Post-Cardiac
Arrest Care Algorithm
Follow Commands? N
Y
STEMI or High Suspicion of AMI
Advanced Critical Care
Consider Induced Hypothermia**
Y
Coronary Reperfusion***
N
Return of Spontaneous Circulation (ROSC)*
Maintain oxygen saturation ≥ 94%
Consider advanced airway
waveform capnography
Do not hyperventilate
Treat Hypotension (SBP < 90 mm Hg)
Optimize Ventilation and
Oxygenation
12-Lead ECG
Doses/Details
Avoid excessive ventilation.
Start at 10-12 ≥ 94% breaths/min
and titrate to target PETCO2
of 35-40 mm Hg.
When feasible, titrate FIO2
to minimum necessary to
achieve SpO2 94%.
1-2 L normal saline or
lactated Ringer’s.
If inducing hypothermia,
may use 4 C fluid.
0.1-0.5 mcg/kg per minute
(in 70-kg adult: 7-35 mcg
per minute)
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/Hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
0.1-0.5 mcg/kg per minute
(in 70-kg adult: 7-35 mcg
per minute)
5-10 mcg/kg per minute

Identifyand treat underlying cause
Monitor and observe
Persistent bradyarrhythmia causing:
Hypotension?
Atropine IVDose:
First dose: 0.5 mg bolus
Maintain patent airway; assist breathing as necessary *
Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
Acutely altered mental status?
Signs of shock?
Ischemic chest discomfort?
Acute heart failure?
Repeat every 3-5 minutes
Maximum: 3 mg
Consider:
Expert consultation
IV access
12-Lead ECG if available; don't delay therapy
Bradycardia With
a Pulse Algorithm
If atropine ineffective:
Oxygen (if hypoxemic)
Y
N
Transcutaneous pacing**
OR
Dopamine IV infusion:
2-10 mcg/kg per minute
OR
Epinephrine IV infusion:
2-10 mcg per minute
Transvenous pacing
Assess appropriateness for clinical condition.
Heart rate typically 50/min if bradyarrhythmia.

Initial recommended doses:
Doses/Details
Second dose : 12 mg if required
Antiarrhythmic Infusions
for Stable Wide-QRS
Tachycardia
Procainamide IV Dose:
Maintenance infusion : 1-4 mg/min.
Avoid if prolonged QT or CHF.
Amiodarone IV
Dose:
Sotalol IV Dose:
100 mg (1.5 mg/kg ) over 5 minutes.
Avoid if prolonged QT.
Assess appropriateness for clinical condition.
Heart rate typically > 150/min if tachyarrhythmia.
Maintain patent airway; assist breathing as necessary
Oxygen (if O sat < 94%)
Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
Synchronized
Cardioversion*
Consider sedation
If regular narrow complex,
consider adenosine
IV access and 12-lead ECG if available.
Consider antiarrhythmic infusion.
Consider expert consultation.
Vagal Maneuvers.
Adenosine (if regular)
-Blocker or calcium channel blocker.
Consider expert consultation.
Identify and Treat Underlying Cause
Synchronized
Cardioversion**
2
Persistent Tachyarrhythmia Causing:
Hypotension?
Acutely altered mental status?
Signs of shock?
Ischemic chest discomfort?
Acute heart failure?
Wide QRS?
≥ 0.12 second
Tachycardia With a
Pulse Algorithm
Y
N
Y
N
Consider adenosine only if regular and
monomorphic.
IV access and 12-lead ECG if available.
Narrow irregular : 120-200 J
biphasic or 200 J monophasic
Narrow regular : 50-100 J
Wide irregular : Defibrillation
dose (NOT synchronized )
Wide regular : 100 J
Adenosine IV
Dose:
First dose : 6 mg rapid IV push;
follow with NS flush.
20-50 mg/min until arrhythmia
suppressed, hypotension ensues,
QRS duration increases 50% or
maximum dose 17 mg/kg given.
First dose : 150 mg over 10 minutes.
Repeat as needed if VT recurs.
Follow by maintenance infusion
of 1 mg/min for first 6 hours..

Abnormal Speech
(have the patient say “you can’t teach an old dog new tricks”)
Both sides of face move equally.
NORMAL ABNORMAL
Both arms move the same or
both arms do not move at all.
The Cincinnati Prehospital Stroke Scale
(patient closes eyes and extends both arms straight out, with palms up for 10 seconds)
Facial Droop
(have patient show teeth or smile)
One arm does not move or
one arm drifts down compared
with the other.
NORMAL ABNORMAL
Abnormal - Patient slurs
words, uses the wrong words,
or is unable to speak.
Arm Drift
Normal - Patient uses correct
words with no slurring.
If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%
Stroke Assessment
One side of face does not move
as well as the other side.

Administer aspirin
Critical EMS assessments and actions
Obtain 12-lead ECG
Assess ABCs, vital signs
Provide oxygen if O2 sat < 94%
Obtain IV access and perform laboratory
assessments
Check glucose; treat if indicated
Perform neurologic screening assessment
Order emergent CT or MRI of brain
Does CT Scan Show Hemorrhage?
Begin post-rtPA stroke pathway
Aggressively monitor:
- BP per protocol
- For neurologic deterioration
Emergent admission to stroke
unit or intensive care unit
Review risks/benefits with
patient & family. If acceptable:
treatment for 24 hours
Immediate general assessment and stabilization*
Immediate neurologic assessment by stroke team
or designee
No Hemorrhage Hemorrhage
Consult neurologist or neurosurgeon;
consider transfer if not available.
Identify Signs and Symptoms of Possible Stroke
Activate Emergency Response
Perform
prehospital stroke
assessment
Establish time
of symptom
onset (last normal)
Triage to
stroke centre
Alert hospitalCheck glucose
Support ABCs:
Give Oxygen
if needed
Give rtPA**
No anticoagulants or antiplatelet
Probable acute ischemic stroke; consider
fibrinolytic therapy
Goals for Management of Stroke
Suspected Stroke Algorithm:
Activate stroke
team
Review patient history
Establish time of symptom onset or last
known normal
Perform neurologic examination (NIH Stroke
Scale or Canadian Neurological Scale)
Begin stroke or hemorrhage
pathway
Admit to stroke unit or
intensive care unit
Check for fibrinolytic exclusions
Repeat neurologic exam: are deficits
rapidly improving to normal?
Patient remains candidate
for fibrinolytic therapy?
Not a Candidate
Candidate*
NINDS
TIME
GOALS
Within
10 min
of ED Arrival
Within
25 min
of ED Arrival
Within
45 min
of ED Arrival
Within
60 min
of ED Arrival
Stroke
Admission
within
3 hours

STOP
YES
YES
NO
NO
Are there contraindications to fibrinolysis? If ANY one of the following is
checked YES, fibrinolysis MAY be contraindicated. **
Fibrinolytic
Checklist for STEMI*
Heart rate >100/min AND systolic BP <100 mm Hg
YES NO
Pulmonary edema (rales)
Signs of shock (cool, clammy)
Required CPR
Systolic BP >180 to 200 mm Hg or diastolic BP >100 to 110 mm Hg
Right vs left arm systolic BP difference >15 mm Hg
History of structural central nervous system disease
Stroke >3 hours or <3 months
Recent (within 2-4 weeks)major trauma, surgery (including laser eye
surgery), GI/GU bleed
Bleeding, clotting problem, or blood thinners
Pregnant female
Serious systemic disease (eg, advanced cancer, severe liver or
kidney disease)
YES NO
***
Does ECG show STEMI or new or presumably new LBBB?
Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours?
Is patient at high risk? If ANY one of the following
is checked YES, consider transfer to PCI facility.
Significant closed head/facial trauma within the previous 3 months
Any history of intracranial hemorrhage
Contraindications to fibrinolytic therapy
Infarction (STEMI)” at Agency for Healthcare Research and Quality National Guideline Clearinghouse (www.Guidelines.gov).
***Consider transport to primary PCI facility as destination hospital.
** Contraindications for fibrinolytic use in STEMI consistent with “Thrombolytic Therapy and Balloon Angioplasty in Acute ST Elevation Myocardial

Fibrinolytic
Therapy for STEMI
Contraindications for fibrinolytic use in STEMI consistent with ACC/AHA 2007 Focused Update*
Any prior intracranial hemorrhage
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 months EXCEPT acute ischemic stroke
within 3 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
History of chronic, severe, poorly controlled hypertension
Severe uncontrolled hypertension on presentation (SBP >180 mm
Hg or DBP >110 mm Hg) ***
History of prior ischemic stroke >3 months, dementia, or known
intracranial pathology not covered in contraindications
Traumatic or prolonged (>10 minutes) CPR or major surgery
(< 3 weeks)
Recent (within 2 to 4 weeks) internal bleeding
Noncompressible vascular punctures
For streptokinase/anistreplase: prior exposure (>5 days ago) or
prior allergic reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the INR, the higher the
risk of bleeding
Absolute Contraindications**
Relative Contraindications
Significant closed head trauma or facial trauma within 3 months
Known structural cerebral vascular lesion (eg, arteriovenous malformation)

ALS Pharmacology Summary
Drugs indicated for use in Advanced Life Support cases[1]
Adenosine
(Adenocard)
15-30°C (59-86°F)
Do not refrigerate
Amiodarone
(Cordarone)
20-25°C (68-77°F)
Protect from light
Atropine Sulfate
(Hospira Inc.)
20-25°C (68-77°F)
Dopamine
(Dopamine HCl)
20-25°C (68-77°F)
Avoid excessive heat. Protect from freezing.
Epinephrine
(EpiPen)
20-25°C (68-77°F)
Protect from light. Do not refrigerate.
Lidocaine
(Xylocaine-MPF)
20-25°C (68-77°F)
Protect from light.
Magnesium Sulfate
(Ansyr)[3]
20-25°C (68-77°F)
Vasopressin
(Desmopressin Acetate)
20-25°C (68-77°F)
Drug Storage[3]
Saline
(0.9% NaCl)[1]
25°C (77°F)
Administer 4°C (39°F) for
therapeutic hypothermia

ACLS algorithms

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ACLS algorithms