ACLS ALGORITHMS ACLS ALGORITHMS

(CARDIAC ARREST) (BRADYCARDIA)

ASSESSMENT ACTION Using the ACLS Bradycardia Algorithm for Managing Bradycardia
Is the patient's airway To open the airway for unconscious patients, use The ACLS Bradycardia Algorithm outlines the steps for
obstructed? the head-tilt, chin lift. Insert an oropharyngeal assessing and managing a patient who presents with symptomatic
airway (OPA) or a nasopharyngeal airway (NPA) if bradycardia. It begins with the decision that the patient's heart rate is
needed to keep the airway open. The oral airway is < 60 bpm and that is the reason for the patients symptoms.
ONLY indicated in patients who are deeply
unconscious as they stimulate the gag reflex and Steps
thus cause risk of aspiration.
Does the patient need If yes, use the airway that is appropriate to your 1. Decision: Heart rate is < 60 bpm and is symptomatic.
an advanced airway? skill level. King Airway, LMA, Combitube, and or
2. Assess and manage the patient using the primary and
endotracheal intubation.
secondary surveys:
Is the patient Give bag valve mask ventilations every 6 seconds
breathing? or 10 breaths per minute.
Maintain patent airway.
If bag-mask ventilation is adequate, defer the Assist breathing as needed.
insertion of an advanced airway until it becomes
Administer oxygen if oxygen saturation is less than
essential (patient fails to respond to initial CPR or
94% or the patient is short of breath
until spontaneous circulation returns).
Monitor blood pressure and heart rate.
Is the advanced Confirm correct placement of advanced airway Obtain a 12-lead ECG.
airway device placed device by observing the patient, confirming the Review patient's rhythm.
properly? presence of lung sounds in at least 4 lung fields Establish IV access.
and using waveform capnography.
Complete a problem-focused history and physical
Is the advanced Secure the advanced airway device so it does not
exam.
airway device secured dislodge, especially in patients who are at risk for
correctly? movement. Secure the ET tube with tape or a Search and treat possible contributing factors.
commercial device. Do not use devices to secure
the airway device that are circumferential. 3. Answer two questions to help you decide if the patient's signs
What was the Attach ECG leads. Identify patient's rhythm. and symptoms of poor perfusion are caused by the
patient's initial bradycardia (see Figure 2).
cardiac rhythm?
Are the signs or symptoms serious, such as
What is the patient's Monitor patient for arrhythmias or cardiac arrest
hypotension, pulmonary congestion, dizziness,
current cardiac rhythms (ventricular fibrillation, pulseless
shock, ongoing chest pain, shortness of breath,
rhythm? ventricular tachycardia, asystole, and PEA).
congestive heart failure, weakness or fatigue, or
Does the patient need Establish IV or IO access.
acute altered mental status?
an IV?
Does the patient need Start IV/IO fluids, if needed, using a crystalloid. Are the signs and symptoms related to the slow
fluid? heart rate?
Does the patient need Give appropriate medications to manage rhythm 4. There may be another reason for the patients symptoms other
medications for (eg, amiodarone, lidocaine, atropine) and blood than the slow heart rate.
rhythm or blood pressure (eg, Dopamine or Epinephrine (used with
pressure control? caution as it increases myocardial oxygen
demand).
Is a reversible cause Search for reversible causes of the arrest. Find and
responsible for the treat reversible causes of the arrest.
arrest?

The appropriate airway will depend not only on the

patients condition, but the experience level of the provider as well.

If the patient is in cardiac arrest, placing an advanced

airway is a significant interruption to chest compressions. You must
weigh the need for an advanced airway against the need for continued
chest compressions. If bag-mask ventilation is working and seems
adequate, you may want to put off inserting an advanced airway until
the patient fails to respond to initial CPR and defibrillation, or until
spontaneous circulation returns.
 5. Decide whether the patient has adequate perfusion. The
treatment sequence is determined by the severity of the
patient's clinical presentation.
If perfusion is adequate, monitor and observe the
patient.
If perfusion is poor, move quickly through the
following actions:
Prepare for transcutaneous pacing. Do not
delay pacing. If no IV is present pacing
can be first.
Consider administering atropine 0.5 mg
IV if IV access is available. This may be
repeated every 3 to 5 minutes up to 3mg
or 6 doses.
If the atropine is ineffective, begin pacing.
Consider epinephrine or dopamine while
waiting for the pacer or if pacing is
ineffective.
Epinephrine 2 to 10 g/min
Dopamine 2 to 10 g/kg per
minute
Progress quickly through these actions as the patient could
be in pre-cardiac arrest and need multiple interventions done in rapid
succession: pacing, IV atropine, and infusion of dopamine or
epinephrine.
ACLS ALGORITHMS
(TACHYCARDIA - UNSTABLE)
Using the ACLS Tachycardia Algorithm for Managing Unstable
Tachycardia
Two keys to managing patients with unstable tachycardia
are, first, quickly recognizing that the patient has significant
symptoms and is unstable, and second, quickly recognizing that the
patient's signs and symptoms are caused by the tachycardia.
You need to decide if the tachycardia is producing the
hemodynamic instability and serious signs and symptoms or if the
signs and symptoms are producing the tachycardiafor example, the
pain and distress of an acute MI could be causing the tachycardia.
Making this decision can be difficult.
Generally, a heart rate between 100 bpm and approximately
150 bpm is usually caused by an underlying process that is
represented as sinus tachycardia (see Stable Tachycardia module for
more information on sinus tachycardia). Heart rates > 150 bpm may
be symptomatic.
The higher the rate, the more likely the symptoms are a
result of the tachycardia. Underlying heart disease or other problems
can cause symptoms at lower heart rates. Keep in mind the following
considerations:
If the patient is seriously ill or has cardiovascular disease,
the patient may have symptoms at lower rates
If the patient's heart rate is above 150 bpm and the patient
is unstable (has symptoms), cardioversion is often required.
Sinus tachycardia is always a compensatory response to an
underlying condition that creates a need for increased
cardiac output. Sinus tachycardia does not respond to
cardioversion, and a shock may actually increase the
patient's heart rate. The treatment for sinus tachycardia is
aimed at fixing the underlying cause, such as relieving
pain, replacing volume, or relieving anxiety.
Overview
The ACLS Tachycardia Algorithm is organized around the following
questions:
1. Is the patient stable or unstable?
2. Is the QRS wide or narrow?
3. Is the ventricular rhythm regular or irregular?
Steps
Does the patient have a pulse? If no, the patients rhythm is
PEA and should be treated as such.
If yes:
Assess the patient using the primary and secondary surveys:
1. Check airway, breathing, and circulation.
2. Give oxygen if the oxygen saturation is less than 94% or
the patient is short of breath.
3. Perform a 12 Lead ECG if the patient is stable.
4. Identify rhythm.
5. Check blood pressure.
6. Identify and treat reversible causes if the rhythm is sinus
tachycardia.
Is the patient stable?
Look for altered mental status, ongoing chest pain, hypotension, or
other signs of shock.
Remember: Rate-related symptoms are uncommon if heart rate is
less than 150 bpm.
If the signs and symptoms continue after you have given
oxygen and supported the airway and circulation AND if significant
symptoms are due to the tachycardia, then the tachycardia is
UNSTABLE and immediate cardioversion is indicated.
If you determine that the patient has an unstable tachycardia,
perform immediate synchronized cardioversion. This is not a decision
to take lightly as it carries with it a significant risk of stroke.
1. Start an IV.
2. Give sedation if the patient is conscious.
3. Do not delay cardioversion.
4. Consider expert consultation.
 If you determine that the patient has a stable tachycardia, start an Patient has Treatment
IV and obtain a 12-lead ECG
Wide (> 0.12) QRS complex
For a patient with a stable tachycardia, decide if the QRS
complex is wide or narrow and if the rhythm is regular. Irregular rhythm Seek expert consultation

Patient has Treatment If pre-excited atrial fibrillation Avoid AV nodal blocking agents such
(AF + WPW) as adenosine, digoxin, diltiazem,
Narrow Try vagal maneuvers verapamil
(< 0.12 sec) QRS
If recurrent polymorphic VT Seek expert consultation
complex
If torsades de pointes Seek expert consultation
Regular rhythm Give adenosine 6 mg rapid IV push

Repeat 12 mg dose once if necessary

Does the patient's rhythm convert? If it does, the rhythm
was atrial in origin. The conversion of a rhythm by
Adenosine is considered diagnostic of atrial arrhythmia. At
this point you watch for a recurrence. If the tachycardia
resumes, treat with adenosine or longer-acting AV nodal
blocking agents, such as diltiazem or beta-blockers.
You may not always be able to tell from the ECG whether
the rhythm is ventricular or supraventricular. Most wide-complex
tachycardias originate in the ventricles (particularly if the patient is
older or has underlying heart disease). If the patient does not have a
pulse, treat the rhythm as ventricular fibrillation and follow the
Pulseless Arrest Algorithm.
If the patient is unstable and has a wide-complex
tachycardia, assume the rhythm is VT until you can prove otherwise.

Patient has Treatment

ACLS ALGORITHMS
(TACHYCARDIA - STABLE)
Narrow (< 0.12 sec) Consider expert consultation
QRS complex Using the ACLS Tachycardia Algorithm for Managing Stable
Irregular rhythm Control patient's rate with diltiazem Tachycardia
or beta-blockers. Use beta-blockers
with caution for patients with The key to managing a patient with any tachycardia is to check
pulmonary disease or congestive if pulses are present, decide if the patient is stable or unstable, and
heart failure. then treat the patient based on the patient's condition and rhythm. If
the patient does not have a pulse, follow the ACLS Pulseless Arrest
Algorithm. If the patient has a pulse, manage the patient using the
ACLS Tachycardia Algorithm.
If the rhythm is irregular narrow-complex tachycardia, it is
probably atrial fibrillation, possible atrial flutter, or multi-
Definition of Stable Tachycardia
focal atrial tachycardia.
For a diagnosis of stable tachycardia, the patient meets the
Patient has Treatment following criteria:

The patient's heart rate is greater than 100 bpm.

Wide (>0.12 sec) QRS Expert consultation is advised.
complex The patient does not have any serious signs or symptoms as
Regular rhythm Expert consultation advised. a result of the increased heart rate.

The patient has an underlying cardiac electrical

If patient is in Amiodarone 150 mg IV over 10 min;
abnormality that is generating the arrhythmia.
ventricular repeat as needed to maximum dose of
tachycardia or 2.2 g in 24 hours Prepare for elective
uncertain rhythm synchronized cardioversion. The half life Overview
of Amiodarone is very long. If possible
Find out if significant symptoms are present. Evaluate the
consult a Cardiologist before using in a
symptoms and decide if they are caused by the tachycardia or other
stable patient. Another choice would be
systemic conditions. Use these questions to guide your assessment:
to use Procainamide.
If patient is in SVT Adenosine 6 mg rapid IV push If no Does the patient have symptoms?
with aberrancy conversion, give 12 mg rapid IV push;
may repeat 12 mg dose once Is the tachycardia causing the symptoms?

Is the patient stable or unstable?

 Is the QRS complex narrow or wide? Does the patient's rhythm convert? If it does, it was
probably reentry supraventricular tachycardia. At this point
Is the rhythm regular or irregular? you watch for a recurrence. If the tachycardia resumes,
treat with adenosine or longer-acting AV nodal blocking
Is the rhythm sinus tachycardia? agents, such as diltiazem or beta-blockers.

Guidelines Patient Treatment

Situation
Patient has significant signs or
symptoms of tachycardia and they
are being caused by the arrhythmia,
Patient has a pulseless ventricular
tachycardia.
Assessment and Actions
The tachycardia is unstable.
Immediate cardioversion is
indicated.
Follow the Pulseless Arrest
Algorithm Deliver unsynchronized
high-energy shocks.
The patients QRS is narrow
(<0.12 sec)
The patients rhythm is irregular.
Consider an expert consultation.
Control patients rate with
diltiazem or beta-blockers. Use
beta-blockers with caution for
patients with pulmonary disease
or congestive heart failure.

Patient has polymorphic ventricular Treat the rhythm as ventricular

tachycardia and the patient is
unstable.
If the rhythm pattern is irregular narrow-complex
fibrillation. Deliver unsynchronized
tachycardia, it is probably atrial fibrillation, possible atrial
high-energy shocks.
flutter, or multi-focal atrial tachycardia.

Patient Treatment
Steps for Managing Stable Tachycardia
Patients rhythm has wide (>0.12 Expert consultation is advised.
Does the patient have a pulse? sec) QRS complex and patients
rhythm is regular.
Yes, the patient has a pulse. Complete the following:

1. Assess the patient using the primary and secondary patient is in ventricular tachycardia Amiodarone 150mg IV over 10 min
surveys. or uncertain rhythm. repeat as needed to maximum dose
of 2.2g in 24 hours. Prepare for
2. Check the airway, breathing, and circulation elective synchronized cardioversion.

3. Give oxygen and monitor oxygen saturation. Patient is in supraventricular Adenosine 6mg rapid IV push if no
tachycardia with aberrancy. conversion. Give adenosine 12mg
4. Get an ECG.
rapid IV push, may repeat 12mg
5. Identify rhythm. dose once.

6. Check blood pressure. Patients rhythm has wide (>0.12) Seek expert consultation.
QRS complex and patients rhythm is
7. Identify and treat reversible causes. irregular.

Is the patient stable? if pre-excited atrial fibrillation (Atrial Avoid AV nodal blocking agents such
Fibrillation in Wolff-Parkinson- as adenosine, digoxin, diltiazem and
Look for altered mental status, ongoing chest pain, hypotension,
White-Syndrome) verapamil.
or other signs of shock.
Consider Amiodarone 150mg IV over
Remember: Rate-related symptoms are uncommon if heart rate is <
10 min
150 bpm.
Patient has recurrent polymorphic Seek expert consultation.
Yes, the patient is stable. Take the following actions:
VT.
1. Start an IV.
If patient has torsades de pointes Give magnesium (load with 1-2g
2. Obtain a 12-lead ECG or rhythm strip. rhythm on ECG over 5-60 min, then infuse

Is the QRS complex wide or narrow?

Patient
The patients QRS is narrow and
rhythm is regular,
Treatment
Try vagal maneuvers. Give adenosine
6mg rapid IV push. May repeat
12mg dose of adenosine once.
Caution: If the tachycardia has a wide-complex QRS and is stable,
consult with an expert. Management and treatment for a stable
tachycardia with a wide QRS complex and either a regular or
irregular rhythm should be done in the hospital setting with expert
consultation available. Management requires advanced knowledge of
ECG and rhythm interpretation and anti-arrhythmic therapy.
Considerations:

You may not be able to distinguish between a

supraventricular wide-complex rhythm and a ventricular
wide-complex rhythm. Most wide-complex tachycardias
originate in the ventricles.

If the patient becomes unstable, proceed immediately to

treatment. Do not delay while you try to analyze the
rhythm.

If the patient becomes unstable, proceed immediately to

treatment. Do not delay while you try to analyze the
rhythm.