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Assess responsiveness (speak loudly, gently

shake patient if no trauma - "Annie, Annie,

are you OK?").
Call for help/crash cart if unresponsive.
Airway Open airway, look, listen, and feel for
Breathing If not breathing, slowly give 2 rescue
Check pulse. If pulseless, begin chest compressions at
100/min, 15:2 ratio. Consider no defibrillator nearby
Attach monitor, determine rhythm. If VF or pulseless
VT: shock up to 3 times. If not, basic CPR.
Then, move quickly to Secondary Survey.

After initial (primary) assessment done
Another set of ABCDs
Establish and secure an airway device (ETT, LMA,
COPA, Combitube, etc.).
Ventilate with 100% O2. Confirm airway placement
(exam, ETCO2, and SpO2). Remember, no
metabolism/circulation = no blue blood to lungs = no
Evaluate rhythm, pulse. If pulseless continue CPR,
obtain IV access, give rhythm-appropriate medications
Differential Diagnosis
Identify and treat reversible causes.
Consider bicarb, pacing early
Bicarb (NaHCO3)
Epinephrine 1 mg IV q3-5 min
Atropine 1 mg IV q3-5 min. Max 0.04 mg/kg

Consider possible causes
Hypoxia, Hyperkalemia, Hypothermia, Drug
overdose (e.g., tricyclics), Myocardial Infarction
Consider termination. If patient had >10min
with adequate resucitative effort and no
treatable causes present

Always Primary Survey - Secondary Survey: Confirm
rhythm (check monitor, power, different lead)

Primary Survey
Secondary Survey
assess need for airway, oxygen, IV, monitor, fluids,
vitals, pulse ox
12-lead ECG, Consider Dx
If AV block:
2nd degree (type 2) or 3rd degree: standby TCP, prepare for
transvenous pacing.
If serious signs or symptoms,
0.5-1.0 mg IV push q 3-5 min. max 0.04 mg/kg
Use transcutaneous pacing (TCP) immediately if sx severe
Dopamine 5-20 g/kg/min
Epinephrine 2-10 g/min

Primary Survey, Secondary Survey: Is patient
stable or unstable?
stable: determine rhythm, treat accordingly
=chest pain, dyspnea, decreased level of
conciousness, low BP, CHF, AMI
If HR is cause of symptom (almost always HR>150):
Specific Rhythms
Atrial fib/flutter
Narrow-Complex (Supraventricular) Tachycardia
Wide-Complex Tachycardia, Unknown Type
Stable Ventricular Tachycardia

Generally not needed for HR<150.
If HR>150, prepare for immediate cardioversion.
May give brief drug trial.
Prepare emergency equipment
Medicate if possible
monomorphic VT with pulse, PSVT, A fib, A flutter:
100-200-300-360 J* (Synchronized)
may try 50J first for PSVT or A flutter
may use equivalent biphasic (biphasic 70, 120, 150, and 170
if machine unable to synchronize and patient critical,
polymorphic VT: use VT/VF algorithm
Management: Control rate, consider rhythm
cardioversion, and anticoagulate as shown below,
according to Category: 1, 2 or 3
Category 1. Normal EF
Rate control: Ca-blocker or beta-blocker.
If onset < 48 hours, consider DC cardioversion OR with
one of the following agents: amiodarone, ibutilide,
procainamide, (flecainide, propafenone), sotalol.
If onset > 48 hours: avoid drugs that may cardiovert
(e.g. amiodarone). Either:
Delayed Cardioversion: anticoagulate adequately x 3 weeks,
then cardioversion, then anticoagulate x 4 weeks
Early Cardioversion: iv heparin, then TEE, then cardioversion
within 24 hours, then anticoagulate x 4 weeks

Transesofageal ekokardiogram
Category 2. EF< 40% or CHF
Rate control:
digoxin, diltizaem, amiodarone
avoid verapamil, beta-blockers, ibutilide,
procainamide (and propafenone/flecainide)

Category 3. WPW A fib
Suggested by: delta wave on resting EKG, very
young patient, HR>300
Avoid adenosine, beta-blocker, Ca-blocker, or
If < 48 hour:
If EF normal: one of the following for both rate control
and cardioversion: amiodarone, procainamide,
propafenone, sotalol, flecainide
If EF abnormal or CHF: amiodarone or cardioversion
If > 48 hour
Medication listed above may be associated with risk of
Anticoagulate and DC cardioversion as in Category 1.

Sindrom Wolff Parkinson White

If unstable, cardiovert
No cardioversion for stable SVT with low EF.
12-lead ECG, clinical exam
Vagal stimulation, adenosine. Consider esophageal
Treat according to specific rhythm:

EF normal
Refleks Vagal
Ca-blocker> beta-blocker> digoxin> DC
Consider procainamide, sotalol, amiodarone.
If unstable proceed to cardioversion

EF < 40%, CHF
No Cardioversion. Digoxin or amiodarone or
If unstable proceed to cardioversion
EF normal: amiodarone, beta-blocker, Ca-

EF < 40%, CHF: amiodarone
rare, most commonly misdiagnosed PSVT.
likely digoxin or theophylline OD, catecholamine
no cardioversion

If unstable, cardiovert
Attempt to establish specific diagnosis
12 leads, esophageal lead, Clinical info
Note: the use of adenosine to differentiate SVT vs
VT is now de-emphasized.
If unable to make Dx, treat according to EF:
EF normal: DC cardioversion or procainamide or
EF < 40%, CHF: DC cardioversion or amiodarone
Note: no lidocaine and bretylium in protocol

May proceed directly to cardioversion
If not, treat according to morphology:
Monomorphic VT
EF normal: one of the following:
procainamide (2a), sotalol (2a) OR
amiodarone (2b), lidocaine (2b)
EF poor
amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75
mg/kg iv push
Synchromized cardioversion

Polymorphic VT
Baseline QT Normal
Possible ischemia (treat) or electrolyte (esp. low K, Mg)
abnormality (correct)
EF normal: betablocker, amiodarone, procainamide, or
EF poor
amiodarone 150 mg iv over 10 min
synchromized cardioversion
Prolonged QT baseline (torsade)
Correct electrolyte abnormalities.

Treatment options: magnesium, overdrive
pacing, isoproterenol
Primary Survey, then Secondary Survey: rule
out pseudo-PEA (handheld doppler: look for
cardiac mechanical activities. If present treat
Search for the probable cause ...
Wide QRS: suggests massive myocardial injury,
hyperkalemia, hypoxia, hypothermia
Wide QRS+Slow: consider drug OD (tricyclics, beta-
blockers, Ca-blockers, digoxin)
Narrow complex: suggests intact heart; consider
hypovolemia, infection, PE, tamponade
... and treat as needed

Consider fluid challenge empirically
Consider bicarbonate
hyperkalemia K (Class 1)
bicarbonate responsive acidosis, tricyclic OD, to alkinalize
urine for aspirin OD (Class2a)
prolonged arrest (Class 2b)
not for hypercarbic acidosis
Epinephrine: 1 mg IV q3-5 min
If bradycardia, 1 mg IV q3-5 min
max 0.04 mg/kg

If you prefer a mechanistic approach (and are
used to thinking about MAP, CO, SVR, etc.)
think of things that affect forward flow...
Decreased Preload: Hypovolemia, Tamponade,
Tension Pneumothorax
Increased Afterload: Pulmonary Embolus
Decreased Contractility: Hypoxia, Hypothermia,
Acidosis, Myocardial Ischemia
Altered Rate/Rhythm: Hyperkalemia, Drug Overdose

Assess: Collapsed vasculature
Tx: Fluids
Assess: Airway, cyanosis, ABGs
Tx: Oxygen, ventilation
Hydrogen ion (acidosis)
Assess: Diabetic patient, ABGs
Tx: Bicarb 1 mEq/kg, hyperventilation
Hyperkalemia (preexisting)
Assess: Renal patient, EKG, serum K level
Tx: Bicarb, CaCl, albuterol neb, insulin/glucose, dialysis,
diuresis, kayexalate
Assess: Core temperature
Tx: Hypothermia Algorithm

Tablets/toxins overdose
Assess: Hx of medications, drug use
Tx: Treat accordingly
Tamponade, cardiac
Assess: No pulse w/ CPR, JVD, narrow pulse pressure
prior to arrest
Tx: Pericardiocentesis
Tension pneumothorax
Assess: No pulse w/ CPR, JVD, tracheal deviation
Tx: Needle thoracostomy
Thrombosis, coronary
Assess: History, EKG
Tx: Acute Coronary Syndrome algorithm
Thrombosis, pulmonary embolism
Assess: No pulse w/ CPR, JVD
Tx: Thrombolytics, surgery
Remember: initial stacked shocks are part of the
primary survey
Implement the secondary survey after your stacked
Meds: Shock-drug-shock-drug-shock pattern.
Continue CPR while giving meds, and shock (360J or
150J if biphasic) within 30-60 seconds. Evaluate
rhythm and check for pulse immediately after
Epi or vasopressin big drugs (may give either one as
first choice).
If VF/PVT persists, may move on to antiarrhythmics and
sodium bicarb
max out one antiarrhythmic before proceeding to the next
in order to limit pro-arrhythmic drug-drug interactions.

Shock 200J*
If VF or VT is shown on monitor: shock immediately.
Do not lift paddles from chest after shocking -
simultaneously charge at next energy level and evaluate
Shock 200-300J*
If VF or VT persists on monitor, shock immediately.
Do not check pulse, do not continue CPR, do not lift
paddles from chest.
After shocking, simultaneously charge at next energy
level and evaluate rhythm.
Shock 360J*
If VF or VT persists, shock immediately.
1 mg IV q3-5 min.
High dose epinephrine is no longer recommended
40 U IV
one time dose (wait 5-10 minutes before starting epi).
Preferred first drug?
Shock 360J*
Amiodarone (Class 2b)
300mg IV push.
May repeat once at 150mg in 3-5 min
max cumulative dose = 2.2g IV/24hrs
Shock 360J*
Magnesium Sulfate (Class 2b)
1-2 g IV (over 2 min) for suspected
hypomagnesemia or torsades de pointes
(polymorphic VT)

Shock 360J*
1 mEq/kg IV for reasons below:
Class 1: hyperkalemia
Class 2a: bicarbonate-responsive acidosis, tricyclic
OD, to alkinalize urine for aspirin OD
Class 2b: prolonged arrest
Not for hypercarbia-related acidosis, nor for routine
use in cardiac arrest