This document presents algorithms for advanced cardiac life support (ACLS) developed by a working group in British Columbia, Canada. It lists the clinical leaders and project facilitator who developed version 1.0 of the algorithms in December 2001. The algorithms provide guidance for treatment of conditions like ventricular fibrillation, asystole, pulseless electrical activity, bradycardia, tachycardias, atrial fibrillation/flutter, and a table of ACLS drugs and their dosages. The algorithms are meant to reflect current medical practice and guidelines in BC while still relying on clinical judgment.

1. Developed by:
Members of the "ACLS Working Group"
Contacts:
Clinical Leader: Ross Berringer, M.D.
Project Facilitator: Chris Sims, R.N.
Version 1.0
December, 2001
B.C. ACLS Algorithms
Version 1.0
Sandy Barabe
Tracy Barill
Ross Berringer
Penny Clarke Richardson
Michael Dare
Alan Holmes
Alec Ritchie
Ryan Shellborn
Chris Sims
Sherry Stackhouse
Ron Straight

2. Ventricular Fibrillation/Pulseless Ventricular Tachycardia
• Check responsiveness
• Activate emergency response system
• Call for monitor/defibrillator
• CPR until defibrillator arrives
VF/PULSELESS VT
RAPID DEFIBRILLATION 200,300,360 J
PULSE Yes
ABC'S
Diagnostics
No
Epinephrine 1 mg IV push every 3-5 minutes
or
{Vasopressin 40 units IV push (not repeated)}
Defibrillate 360 J within 30-60 seconds
CONSIDER:
Amiodarone 300 mg bolus, followed by repeat 150 mg bolus after 10 minutes.
Lidocaine 1.5 mg/kg (maximum 3 mg/kg)
Procainamide 17mg/kg as 100 mg boluses every 3 min.
Magnesium Sulfate 2 g bolus (if indicated)
Buffers (if indicated)
• Continue attempts to defibrillate every 1-2 minutes
• Defibrillation does not have to be tied to drug administration
PRIMARY ABCD SURVEY
Airway: airway device placement
Breathing: confirm tube placement, oxygenate, ventilate
Circulation: continue CPR, IV access, administer drugs, confirm rhythm
Differential Diagnosis: search and treat reversible causes
SECONDARY ABCD SURVEY
This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.

3. This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.
VF/Pulseless VT
Notes:
NOTES:
• If rhythm changes after defibrillation, go to appropriate algorithm
• Treatable causes:
- infarction. ischemia
- drug overdose (TCA, cocaine, antiarrythmics)
- electrolyte disturbances (potassium, calcium, magnesium)
• Groups of three shocks at 360 J are acceptable for each defibrillation after the initial
escalating stacked shocks
• Biphasic defibrillation 150 J is as efficacious as monophasic defibrillation 360 J
• Buffers are indicated when hyperkalemia is suspected (renal failure) or TCA overdose

4. This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.
ASYSTOLE
ASYSTOLE
• confirm in three leads
• assess DNR status
Consider TCP in witnessed short " down time" arrests
Epinephrine 1 mg every 3-5 minutes
Atropine 3 mg bolus (maximum 0.04 mg/kg)
CONSIDER EARLY TERMINATION
NOTES:
• Look for reasons not to start resuscitation
• Vasopressin not recommended
• If the patient remains asystolic 5 minutes after all ACLS interventions are complete,
the arrest should be discontinued unless extenuating circumstances are present.
• Check responsiveness
• Activate emergency response system
• Call for monitor/defibrillator
• CPR until defibrillator arrives
PRIMARY ABCD SURVEY
Airway: airway device placement
Breathing: confirm tube placement, oxygenate, ventilate
Circulation: continue CPR, IV access, administer drugs, confirm rhythm
Differential Diagnosis: search and treat reversible causes
SECONDARY ABCD SURVEY

5. PULSELESS ELECTRICAL ACTIVITY (PEA)
(PEA is anything on the monitor EXCEPT Ventricular Fibrillation, Ventricular Tachycardia, Asystole)
PEA
EPINEPHRINE 1 mg every 3-5 minutes
ATROPINE 1 mg every 3-5 minutes, if heart rate < 60
NOTES:
• Narrow complex PEA has a better prognosis than wide complex, be diligent in searching for causes.
Consider cardioversion in narrow complex PEA with rates greater than 160
• Vasopressin not recommended pressor
• Assess for low flow states: doppler blood pressure, heart sounds, echocardiogram
(if available), agonal respirations.
REVERSIBLE CAUSES and TREATMENT
HYPOVOLEMIA: saline bolus, +/- blood
HYPOXIA: intubation, 100% oxygen
HYDROGEN ION (ACIDOSIS): intubation hyperventilation, +/- Bicarb
HYPER/HYPOKALEMIA: use appropriate medical protocol
HYPOTHERMIA: active core re-warming
TABLETS (OVERDOSE): use appropriate medical protocol
TAMPONADE: pericardiocentsis
TENSION PNEUMO: needle thoracostomy or chest tube
THROMBOSIS CORONARY: consider thrombolytics, PTCA or IABP
THROMBOSIS PULMONARY: consider thrombolytics
• Check responsiveness
• Activate emergency response system
• Call for monitor/defibrillator
• CPR until defibrillator arrives
PRIMARY ABCD SURVEY
Airway: airway device placement
Breathing: confirm tube placement, oxygenate, ventilate
Circulation: continue CPR, IV access, administer drugs, confirm rhythm
Differential Diagnosis: search and treat reversible causes
SECONDARY ABCD SURVEY
This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.

6. This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.
BRADYCARDIA
PRIMARY ABCD SURVEY
• Assess airway, breathing, circulation
• monitor
NOTES:
• Atropine may be used in all unstable bradycardias, including heart blocks, although
it may not be effective in type II second degree and third degree blocks.
• If cause is found, such as an inferior MI, treat the cause and the rate.
SECONDARY ABCD SURVEY
• Oxygen, vital signs, IV access
• 12 lead EKG
• Focused history and physical
Is patient stable or unstable?
signs/symptoms hemodynamic compromise =
hypotension, new onset or worsening CHF, ischemic
chest pain, new onset of decreased level of consciousness
STABLE UNSTABLE
Type II, second degree heart block?
Third degree heart block?
NO YES
• Prepare for transvenous pacemaker
• If symptoms develop, use
transcutaneous pacemaker until
transvenous pacer placed
Observe
• Atropine 0.5 to 1.0 mg
• Transcutaneous Pacing, if available
• Dopamine 5-20 ug/kg/min
• Epinephrine 2-10 ug/min
• Prepare for transvenous pacemaker

7. TACHYCARDIAS
• Are there serious symptoms or signs due to the rate?
(hypotension, new onset or worsening CHF, ischemic chest pain,
new onset of decreased level of consciousness)
NOTES:
• If Adenosine reveals presence of flutter waves, go to the Atrial Fibrillation/Flutter algorithm
• Electricity is rarely a bad choice in wide complex tachycardias
• If polymorphic ventricular tachycardia (torsade) is present, consider Magnesium, Isoproterenol, overdrive pacing,
and correction of electrolyte disturbances. Type 1A antiarrythmics (Procainamide, Quinidine, Disopyramide) are
dangerous in this condition.
• If old EKG shows bundle branch block with QRS morphology identical to current QRS morphology,
then likely the rhythm is atrial flutter or SVT. Adenosine may be useful as a diagnostic agent in this situation.
• When in doubt, treat wide complex of unknown origin as ventricular tachycardia.
• Rate related signs and symptoms rarely occur at rates < 150 beats per minute.In patients with known
preexisting impaired LV function (EF < 40%), cardioversion can be used with caution
STABLE UNSTABLE
ATRIAL FIB/FLUTTER
Go to Atrial Fib/Flutter
Algorithm
NARROW COMPLEX
• 12 lead EKG
• Clinical history
• Vagal maneuvers
• Adenosine
• Amiodarone
• Diltiazem/Verapamil
• Procainamide
WIDE COMPLEX
• 12 lead EKG
• Clinical history
• Esophageal lead,
(if available)
• Old EKG
DC Cardioversion OR
• Amiodarone OR
• Lidocaine OR
• Procainamide
EVALUATE THE PATIENT
Consider sedation
CARDIOVERSION
(100, 200, 300, 360 J)
This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.

8. This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.
ATRIAL FIBRILLATION/FLUTTER
• Stable/unstable (hypotension, new onset or worsening CHF,
ischemic chest pain, new onset of decreased level of consciousness)
• History of WPW?
• Duration of arrhythmia
• Ejection fraction known or unknown
• Current medications (beware of antiarrythmics and Sotalol)
NOTES:
• Electricity is rarely the wrong choice
• Err on the side of caution
• Consider anticoagulation for all patients prior to cardioversion (low molecular weight heparin +/- Coumadin)
• Use only one antiarrythmic when attempting chemical conversion
• Suspect WPW when rate is > 200 or wide complex
• Beware of Calcium Channel Blockers in WPW
STABLE UNSTABLE
< 48 hours
Conversion
• Shock
or one of the following:
• Amiodarone
• Procainamide
• Propafenone
> 48 hours
Rate control and elective
cardioversion after anticoagulation
• Digoxin
• Diltiazem
• Metroprolol
< 48 hours
Conversion
• Shock
or
• Amiodarone
> 48 hours
Rate control and elective
cardioversion after anticoagulation
• Amiodarone
• Digoxin
Known impaired LV function or
new onset or worsening of CHFNORMAL HEART
EVALUATE THE PATIENT
Consider sedation
CARDIOVERSION
(100, 200, 300, 360 J)

9. This algorithm is based upon current Heart and Stroke Foundation of Canada guidelines and has been modified
to reflect current medical practice in British Columbia. It should not replace sound medical judgement.
ACLS DRUGS
DRUG INTRAVENOUS DOSAGE
Adenosine • 6 mg as initial dose IV push as rapidly as possible, if not successful, 12 mg IV push
Adrenaline/ • 1 mg boluses every 3 minutes
Epinephrine • may increase dose to 3-5 mg every 3 minutes, if indicated
• as an infusion for bradycardia: 2-10 ug/minute
Amiodarone • in V. Fib: bolus 300 mg, followed by 150 mg 5 – 10 minutes later
• in perfusing rhythms: 150 mg over 10 minutes followed by 1 mg/min over 6 hours,
then 0.5 mg/min over 18 hours.
• maximum: 2.2 gm in 24 hours
Atropine • maximum: 0.04 mg/kg
• in Asystole: single dose of 3 mg
• in Bradycardia: 0.5-1.0 mg every 5 minutes
Digoxin • 0.5 mg bolused, followed by 0.25 mg every 2-3 hours to a maximum of 1 mg
Diltiazem • 15-25 mg over 1-2 minutes (may be repeated)
Dopamine • 5-20 ug/kg/min
Lidocaine • in V.Fib: 1.5 mg/kg boluses to a maximum of 3 mg/kg
• in perfusing rhythms: 1 mg/kg every 5 minutes to a maximum of 3 mg/kg
Magnesium • 2 g as a bolus
Sulphate
Metoprolol • 5-10 mg over 5 minutes (may be repeated)
Procainamide • in V. Fib: boluses of 100 mg every 3 minutes to a maximum of 17 mg/kg
• in perfusing rhythms (A. Fib, wide complex): 17 mg/kg at 20 mg/min
Propafenone • 300 mg as initial dose, followed by 600 mg in 8 hours
Sodium • 1-2 meq/kg
Bicarbonate • average adult is 2- 3 amps (each ampule has 44 meq)
Vasopressin • 40 units IV push as a single dose only in V.Fib/pulseless V.Tach
Verapamil • 2.5- 5 mg over 2-3 minutes