Section III ACLS Guidelines for Adult Emergency Cardiac Care Algorithms
Pulseless Ventricular Tachycardia (VT)/Ventricular Fibrillation (VF)
Do not interrupt CPR for more than 5–10 seconds for any reason
Pattern becomes CPR-shock-drug
Circulation
Epinephrine (Class Indeterminate)—1 mg (1:10,000 solution) IV every 3–5 minutes.
Vasopressin (Class IIb)—40 units IV bolus (administer only once). (If no response to vasopressin, may resume epinephrine after 10–20 minutes; epinephrine dose 1 mg every 3–5 minutes.)
• Give one shock and immediately resume chest compressions after the shock.
• Re-evaluate cardiac rhythm after 2 minutes (5 cycles) of CPR.
Consider antiarrhythmics (avoid use of multiple antiarrhythmics because of potential proarrhythmic effects).
• Amiodarone (Class IIb)—Initial bolus: 300 mg IV/IO bolus diluted in 20–30 mL of NS or D5W. Consider repeat dose (150 mg IV bolus) in 3–5 minutes. If defibrillation successful, follow with 1 mg/min IV infusion for 6 hours (mix 900 mg in 500 mL NS), then decrease infusion rate to 0.5 mg/min IV infusion for 18 hours. Maximum daily dose 2.2 g IV/24 hr.
• Lidocaine (Class Indeterminate)—1.0–1.5 mg/kg IV/IO bolus, consider repeat dose (0.5–0.75 mg/kg) in 5 minutes; maximum IV bolus dose 3 mg/kg. (The 1.5 mg/kg dose is recommended in cardiac arrest.)
• Magnesium (Class IIb if hypomagnesemia present)—1–2 g IV/IO (2–4 mL of a 50% solution) diluted in 10 mL of D5W if torsades de pointes or hypomagnesemia.
Modified from Aehlert B: ACLS quick review study guide, ed 3, St. Louis, 2007, Mosby. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.
Possible causes of asystole: PATCH-4-MD Pulmonary embolism Acidosis Tension pneumothorax Cardiac tamponade Hypovolemia (most common cause) Hypoxia Heat/cold (hypothermia/ hyperthermia) Hypokalemia/ hyperkalemia (and other electrolytes) Myocardial infarction Drug overdose/accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digitalis)
Modified from Aehlert B: ACLS quick review study guide, ed 3, St Louis, 2007, Mosby. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.
Pulseless Electrical Activity (PEA)
Possible causes of PEA: PATCH-4-MD Pulmonary embolism Acidosis Tension pneumothorax Cardiac tamponade Hypovolemia (most common cause) Hypoxia Heat/cold (hypothermia/ hyperthermia) Hypokalemia/hyperkalemia (and other electrolytes) Myocardial infarction Drug overdose/accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digitalis)
Differential Diagnosis
• Search for and treat reversible causes (PATCH-4-MD). (Fast narrow QRS—consider hypovolemia, tamponade, pulmonary embolism, tension pneumothorax; slow wide QRS—consider cyclic antidepressant overdose, calcium channel blocker, beta-blocker, or digitalis toxicity.)
Epinephrine—1 mg (1:10,000 solution) IV/IO every 3–5 minutes.
Atropine (if the rate is slow)—1 mg IV/IO every 3–5 minutes to max 0.04 mg/kg (class IIb). Consider termination of efforts.
Modified from Aehlert B: ACLS quick review study guide, ed 3, St Louis, 2007, Mosby.Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.
Modified from Aehlert B: ACLS quick review study guide, ed 3, St Louis, 2007, Mosby. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.
Advanced life support
Identify the Patient’s Cardiac Rhythm
Is the patient experiencing serious signs and symptoms because of the bradycardia?
• Signs: Low BP, shock, pulmonary congestion, congestive heart failure, angina, acute myocardial infarction (MI), ventricular ectopy
• Symptoms: Chest pain, weakness, fatigue, dizziness, lightheadedness, shortness of breath, exercise intolerance, decreased level of responsiveness
• If no serious signs and symptoms are present, observe.
• If serious signs and symptoms are present, further intervention depends on the cardiac rhythm identified.
Modified from Aehlert B: ACLS quick review study guide, ed 2, St Louis, 2001, Mosby, pp 435–436. Additional information modified from American Heart Association (AHA): Advanced cardiac life support provider manual, 2006, American Heart Association.
Advanced life support
Perform Secondary BLS Survey
• Obtain and review 12-lead ECG.
• Perform a focused history and physical exam.
• Is the patient stable or unstable?
• Is the patient experiencing serious signs and symptoms because of the tachycardia?
Attempt to identify patient’s cardiac rhythm using:
If tachycardia continues after 1–2 seconds of vagal maneuvers, administer adenosine 6 mg rapid IV bolus over 1–3 seconds:
• May repeat 12-mg dose in 1–2 minutes if needed.
• Follow each dose immediately with 20-mL IV flush of NS.
• Use of adenosine is relatively contraindicated in patients with asthma.
• Decrease dose in patients on dipyridamole (Persantine) or carbamazepine (Tegretol); consider increasing dose in patients taking theophylline or caffeine-containing preparations.
Medication Dosing
Amiodarone—150 mg IV/IO over 10 minutes followed by an infusion of 1 mg/min for 6 hours and then a maintenance infusion of 0.5 mg/min. Repeat supplementary infusions of 150 mg as necessary for recurrent or resistant dysrhythmias. Maximum total daily dose 2 g.
Beta-blockers—Esmolol: 0.5 mg/kg over 1 minute, followed by a maintenance infusion at 50 mcg/kg/min for 4 minutes. If inadequate response, administer a second bolus of 0.5 mg/kg over 1 minute and increase maintenance infusion to 100 mcg/kg/min. The bolus dose (0.5 mg/kg) and titration of the maintenance infusion (addition of 50 mcg/kg/min) can be repeated every 4 minutes to a maximum infusion of 300 mcg/kg/min. Metoprolol: 5 mg slow IV push over 5 minutes × 3 as needed to a total dose of 15 mg over 15 minutes.
Calcium channel blockers—Diltiazem: 0.25 mg/kg over 2 minutes (e.g., 15–20 mg). If ineffective, 0.35 mg/kg over 2 minutes (e.g., 20–25 mg) in 15 minutes. Maintenance infusion 5–15 mg/hr, titrated to HR if chemical conversion successful. Calcium chloride (2–4 mg/kg) may be given slow IV push if borderline hypotension exists before administration. Verapamil: 2.5–5.0 mg slow IV push over 2 minutes. May repeat with 5–10 mg in 15–30 minutes. Maximum dose 20 mg.
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| Type of countershock | Dysrhythmia | Recommended energy levels |
|---|---|---|
| Defibrillation | Pulseless VF/VT | 360 J or equivalent biphasic energy |
| Sustained polymorphic VT | 360 J or equivalent biphasic energy |