ACLS algorithm

Cardiac
Arrest
Epidemiology
• Nearly 400,000 out-of-hospital sudden cardiac arrests occur
annually
• 88 percent of cardiac arrests occur at home
• Failure to act in cardiac emergency can lead to unnecessary
deaths
• Effective bystander CPR provided immediately after sudden
cardiac arrest can double or triple a victim’s chance of
survival.
• Less than 8 percent of people who suffer cardiac arrest
outside the hospital survive.
Cardiac Arrest
Before conducting the BLS or ACLS survey,
look to make sure the scene is safe

• Check responsiveness
• Activate the emergency
response system/get AED
• Circulation (CPR)
• Defibrillation
Electrical
Therapies
 • Early defibrillation is critical to survival from
sudden cardiac arrest
• Purpose of defibrillation
– Does not restart the heart
– Defibrillation briefly terminates all electrical activity
(including VT and VF)

• Principle of early defibrillation

– A common initial rhythm in out-of-hospital witnessed
sudden cardiac arrest
Defibrillation – Electrical defibrillation is the most effective way to
treat VF
– The probability of successful defibrillation decreases
quickly over time

• The earlier defibrillation occurs, the higher the

survival rate.
Shock 1st or CPR 1 st ?
• Healthcare provider who treat cardiac arrest in hospital
should provide immediate CPR until defibrillator is ready
for use
• Use the defibrillator as soon as it is available.
• AHA strongly recommends performing CPR while a
defibrillator or AED is readied for use and while charging
for all patients in cardiac arrest.
VF or
Pulseless VT
ACLS Cardiac Arrest Algorithm.
Managing VF/Pulseless VT

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.
Managing VF/Pulseless VT
Managing VF/Pulseless VT
Managing VF/Pulseless VT
Managing VF/Pulseless VT
ACLS Cardiac Arrest Algorithm.
Managing VF/Pulseless VT

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.
Application of the Cardiac Arrest Algorithm: VF/VT Pathway
Minimal Interruption of Chest Compression
•Team member should continue to perform high-quality CPR until defibrillator arrives and attached to
patient
•Chest compressions should ideally be interrupted only for ventilation (unless an advanced airway is
placed), rhythm checks, and shock delivery.

Deliver 1 Shock
•The appropriate energy dose is determined by the identity of defibrillator – monophasic or biphasic.
•Monophasic: a single 360-J shock
•Biphasic: use the manufacturer’s recommended energy dose (eg, initial dose 120 – 200 J)
•Immediately after the shock, resume CPR. Give 2 minutes (about 5 cycles) of CPR.

Resume CPR
Application of the Cardiac Arrest Algorithm: Delivering Shock
Clearing for Defibrillation
• To ensure safety during defibrillation, always announce the shock warning
• State the warning firmly and in a forceful voice before delivering each shock
• “Clear. I am going to shock on three”
• Check to make sure you are clear of contact with patient with patient, the stretcher, or
other equipment.
• Make a visual check to ensure that no one is touching the patient or stretcher.
• “One, two, three. Shocking”
• When pressing the SHOCK button, the defibrillator operator should face the patient, not
the machine.

Rhythm Check
• Conduct a rhythm check after 2 minutes (about 5 cycles) of CPR
• The pause in chest compressions to check the rhythm should not exceed 10 seconds.
• Perform a pulse check -- preferably during rhythm analysis – only if an organized rhythm
is present
Tachycardia Algorithm
Rhythms for Tachycardia
• Atrial fibrillation
• Atrial flutter
• Reentry supraventricular tachycardia (SVT)
• Monomorphic VT
• Polymorphic VT
• Wide-complex tachycardia of uncertain type
TACHYCARDIA

Unstable
Stable
 Approach to Unstable Tachycardia
• Unstable tachycardia exists when the heart rate is too fast for the patient’s clinical
condition and the excessive heart rate causes symptoms or an unstable condition
because
– The heart is beating so fast  cardiac output is reduced
– The heart is beating ineffectively  cardiac output is reduced

• Unstable tachycardia sign and symptoms

– Hypotension
– Acutely altered mental status
– Signs of shock
– Ischemic chest discomfort
– Acute heart failure (AHF)
You must quickly determine whether the patient’s
tachycardia is producing hemodynamic
instability and serious signs and symptoms or
whether the signs and symptoms (eg, the pain
and distress of an AMI) are producing the
tachycardia

Expert suggest
- Instability with heart rate is <150/min  unlikely caused by
tachycardia
- Heart rate >150/min  unlikely caused by physiologic stress
Immediate Synchronized Cardioversion
• If possible, establish IV access before cardioversion and administer sedation if the
patient is conscious
• Do NOT delay cardioversion if the patient is extremely unstable
Synchronized cardioversion
• Synchronized cardioversion uses a sensor
to deliver a shock that is synchronized with
a peak of the QRS complex (eg. The highest
point of the R wave)
• Synchronization avoids the delivery of a
shock during cardiac repolarization (a
period of vulnerability in which a shock
can precipitate VF)
• Synchronize cardioversion uses a lower
energy level than attempted defibrillation.
When to use synchronized cardioversion
• Unstable AF

• Unstable SVT

• Unstable Atrial Flutter

• Unstable regular monomorphic tachycardia with

pulses
 Energy dose for cardioversion
• For unstable Atrial Fibrillation (AF)
– Monophasic cardioversion: deliver an initial 200-J synchronized shock
– Biphasic cardioversion: deliver an initial 120-200 J synchronized shock
– In either case, increase the energy dose in a stepwise fashion for any subsequent
cardioversion attempts

• For unstable Atrial Flutter and SVT

– An initial energy dose of 50 J-100 J with a monophasic or biphasic waveform
– If the initial dose fails, increase the dose in a stepwise fashion

• For monomorphic VT
– An initial energy dose of 100 J
– If there is no response to the first shock, increase the dose in a stepwise fashion.

• Polymorphic VT
– Treat as VF with high energy shock (defibrillation dose)
When to use Unsynchronized Shocks
• For patient who is pulseless
• For patient demonstrating clinical deterioration (in
prearrest), such as those with severe shock or
polymorphic VT
• When you are unsure whether monomorphic or
polymorphic VT is present in the unstable patient
Approach to
Stable
Tachycardia
 Approach to Stable Tachycardia
• If the patient with tachycardia is stable, you have time to evaluate the rhythm and
decide on treatment options.

Narrow Regular
QRS

Wide Irregular
QRS
Wide Complex Tachycardia

• Ventricular • Atrial Fibrillation with

abberancy
Tachycardia • Pre-excited atrial fibrillation
• Supraventricular (AF with accessory pathyway)
Tachycardia with • Polymorphic VT/Torsade de
pointes
abberancy

Regular Irregular
These are advanced rhythms requiring additional expertise or expert
consultation
Narrow Complex Tachycardia
• Supraventricular Tachycardia
• Atrial flutter
• Ectopic atrial tachycardia
• Junctional tachycardia
• Atrial Fibrillation
• Multifocat atrial tachycardia
• Atrial flutter

Regular Irregular
These are advanced rhythms requiring additional expertise or expert
consultation
Narrow QRS, Regular Rhythm
• The therapy for narrow QRS with regular rhythm is:
– Attempt vagal maneuver
– Give adenosine 6 mg as a rapid IV push in a large vein over 1 second follow with a 20
mL saline flush and elevate the arm immediately
– If SVT does not convert within 1 to 2 minutes, give a second dose of adenosine 12 mg
rapid IV push following the same procedure above.
– Adenosine is safe, but should not be given to patient with asthma.
– IF the rhythm does not convert with adenosine, obtain expert consultation about
diagnosis and treatment.
 If at any point you become uncertain
or uncomfortable during the treatment
of a stable patient, seek expert
consultation. The treatment of stable
patients may await expert consultation
because treatment has the potential for
harm