Advanced Cardiac Life Support EMERGENCY CARDIAC CARE Assess Responsiveness Unresponsive Call for code team and Defibrillator Assess breathing (open the airway, look, listen and feel for breathing) If Not Breathing, give two slow breaths. Assess Circulation PULSE
NO PULSE
Give oxygen by bag mask Secure IV access Determine probable etiology of arrest based on history, physical exam, cardiac monitor, vital signs, and 12 lead ECG.
If witnessed arrest, give precordial thump and check pulse. If absent, continue CPR Ventricular fibrillation/tachycardia (VT/VF) present on monitor?
Hypotension/shock, acute pulmonary edema. Go to fig 8
YES
NO Intubate Confirm tube placement Determine rhythm and cause.
Arrhythmia
Bradycardia Go to Fig 5
Initiate CPR
Tachycardia Go to Fig 6
VT/VF Go to Fig 2
Electrical Activity?
YES Pulseless electrical activity Go to Fig 3
NO Asystole Go to Fig 4
Fig 1 - Algorithm for Adult Emergency Cardiac Care
VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA
Assess Airway, Breathing, Circulation, Differential Diagnosis Administer CPR until defibrillator is ready (precordial thump if witnessed arrest) Ventricular Fibrillation or Tachycardia present on defibrillator Defibrillate immediately, up to 3 times at 200 J, 200-300 J, 360 J. Do not delay defibrillation Check pulse and Rhythm Persistent or recurrent VF/VT
Continue CPR Epinephrine 1 mg IV push, repeat q3-5min or 2 mg in 10 ml NS via ET tube q3-5min or Vasopressin 40 U IVP x 1 dose only Defibrillate 360 J
Continue CPR Secure IV access Intubate if no response Return of spontaneous circulation
Pulseless Electrical Activity Go to Fig 3
Asystole Go to Fig 4
Monitor vital signs Support airway Support breathing Provide medications appropriate for blood pressure, heart rate, and rhythm
Amiodarone (Cordarone) 300 mg IVP or Lidocaine 1.5 mg/kg IVP, and repeat q3-5 min, up to total max of 3 mg/kg or Magnesium sulfate (if Torsade de pointes or hypomagnesemic) 2 gms IVP or Procainamide (if above are ineffective) 30 mg/min IV infusion to max 17 mg/kg
Continue CPR Defibrillate 360 J, 30-60 seconds after each dose of medication
Repeat amiodarone (Cordarone) 150 mg IVP prn (if reurrent VF/VT) ,up to max cumulative dose of 2200 mg in 24 hours
Continue CPR. Administer sodium bicarbonate 1 mEq/kg IVP if long arrest period Repeat pattern of drug-shock, drug-shock
Note: Epinephrine, lidocaine, atropine may be given via endotracheal tube at 2-2.5 times the IV dose. Dilute in 10 cc of saline. After each intravenous dose, give 20-30 mL bolus of IV fluid and elevate extremity.
Fig 2 - Ventricular Fibrillation and Pulseless Ventricular Tachycardia
PULSELESS ELECTRICAL ACTIVITY
Pulseless Electrical Activity Includes: Electromechanical dissociation (EMD) Pseudo-EMD Idioventricular rhythms Ventricular escape rhythms Bradyasystolic rhythms Postdefibrillation idioventricular rhythms Initiate CPR, secure IV access, intubate, assess pulse.
Determine differential diagnosis and treat underlying cause: Hypoxia (ventilate) Hypovolemia (infuse volume) Pericardial tamponade (perform pericardiocentesis) Tension pneumothorax (perform needle decompression) Pulmonary embolism (thrombectomy, thrombolytics) Drug overdose with tricyclics, digoxin, beta, or calcium blockers Hyperkalemia or hypokalemia Acidosis (give bicarbonate) Myocardial infarction (thrombolytics) Hypothemia (active rewarming)
Epinephrine 1.0 mg IV bolus q3-5 min, or high dose epinephrine 0.1 mg/kg IV push q3-5 min; may give via ET tube. Continue CPR
If bradycardia (
