1.

Adult ACLS Secondary Survey ABCDs (abbreviated)

A Airway: *Establish appropriate airway management.
B Breathing: Ventilate with O2. Assess adequacy of ventilation, e.g.,
by exam, chest rise, SaO2 monitor, CO2 detector, esophageal
detector, as indicated.
C Circulation: IV/IO. Attach monitor leads. Follow appropriate ACLS
algorithm. Give rhythm-appropriate medications. Get vital
signs/EKG/labs. Continue effective **CPR as indicated. Minimize
chest compression interruptions to <10 seconds.
D Differential Diagnosis: Attempt to identify and treat reversible
causes. See Differential Diagnosis table.
* Okay to briefly delay advanced airway early in cardiac arrest if bagmask ventilation is adequate in order to minimize chest compression
interruptions.
** After advanced airway management is established, CPR =
uninterrupted chest compressions at 100/min with 8-10 breaths/min.
2. Differential Diagnosis Table
The acronym "PATCH(4) MDs" provides a guide to problem search.
Problem
Assess
Possible Interventions
Pulmonary
Embolism

No pulse w/ CPR,
JVD

Thrombolytics, surgery

Acidosis
(preexisting)

Diabetic/renal patient, Sodium bicarbonate,

ABGs
hyperventilation

Tension
No pulse w/ CPR,
pneumothorax JVD, tracheal
deviation

Needle thoracostomy

Cardiac
Tamponade

Pericardiocentesis

No pulse w/ CPR,
JVD, narrow pulse
pressure prior to
arrest

Hyperkalemia Renal patient, EKG,

(preexisting) serum K level

Sodium bicarbonate,
calcium chloride, albuterol
nebulizer, insulin/glucose,
dialysis, diuresis,

Kayexalate
Hypokalemia

EKG, serum K level

Treat with great prudence

after careful assessment of
the cause. K can kill.

Hypovolemia

Collapsed
vasculature

Fluids

Hypoxia

Airway, cyanosis,
ABGs

Oxygen, ventilation

Myocardial
infarct

History, EKG

Acute Coronary Syndrome

algorithm

Drugs

Medications, illicit
drug use, toxins

Treat accordingly

Shivering

Core temperature

Hypothermia Algorithm

If trauma is present then proceed with ATLS protocol.

Symptoms:
Signs:

3. Circulatory Compromise Scale

shortness of breath, chest pain, altered level/loss of
consciousness
mild hypotension, pulmonary congestion, CHF,
hypotensive shock
<----------------------------------------------------------------------------------------->
Mild
(Severity)
Critical

4. 1. Asystole Algorithm
"Asystole .....

Acronym
T

Check me in another lead,

then let's have a cup of TEA."
Intervention
Comments/Dose
Transcutaneous Only effective with early
Pacing (TCP)
implementation along with
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appropriate interventions
and medications.
NOTE: Not effective with
prolonged down time.
E

Epinephrine

1 mg IV q3-5 min.

1 mg IV q3-5 min. (max.

dose 0.04 mg/kg)
Consider termination of efforts if asystole persists despite
appropriate interventions.
A

Atropine

4.2. Asystole Algorithm

The following directs AHA accepted actions as part of the Secondary
ABCDs for pulselessness when properly functioning equipment
shows asystole. If the patient is a candidate for resuscitation provide
2 minute cycles of CPR-rhythm checks and think:
PEA
Letter
Intervention
P

Problem search (see Differential Dg Table).

Treat accordingly.
Continue this algorithm if indicated.

Epinephrine 1 mg IV/IO q3-5 min. Or

vasopressin 40 U IV/IO, once, in place of the 1st
or 2nd dose of epi.

Atropine 1 mg IV/IO q3-5 min. (3mg max.)

Consider termination of efforts if asystole persists despite
appropriate interventions.

5.1. Bradycardia Algorithm

The material presented here is for informational purposes only and
is not a substitute for formal ACLS training, nor is it intended as
advice or directions for delivering medical treatment. Established
practices at your institution may vary from the information presented
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here.
Treatments for absolute bradycardia (<60 bpm) or relative
bradycardia (slower than expected) with serious signs or symptoms
due to the bradycardia are guided by the mnemonic:
All Trained Dogs Eat Iams
(The sequence reflects interventions for increasingly severe
bradycardia)
5.2. Bradycardia Algorithm
The following mnemonic directs AHA accepted actions after
absolute (<60bpm) or relative (slower rate than expected)
bradycardia with circulatory compromise due to the slow rate
is discovered. Start the Secondary ABCDs and remember:
*Pacing Always Ends Danger
Mnemonic Intervention
Pacing

**TCP

Note
Immediately prepare for transcutaneous
pacing (TCP) with serious circulatory
compromise due to bradycardia
(especially high-degree blocks) or if
atopine failed to increase rate.

Consider medications while pacing is readied.

Always
Ends
Danger

Atropine

1st-line drug, 0.5 mg IV/IO q3-5 min.

(max. 3mg)

Epinephrine 2nd-line drugs to consider if atropine

2-10 g/min and/or TCP are ineffective. Use with
Dopamine extreme caution.
2-10
g/kg/min

*Pacing does not "always end danger" in bradyarrhythmias. If

the above measures do not improve circulatory stability the
bradycardia may merely be an indication of a pathological
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process, think Differential Diagnosis!

**Prepare for transvenous pacing (TVP), managed by an expert,
if TCP fails.
6. Tachycardia Algorithm
The following directs AHA accepted actions after tachycardia with
symptoms due to the fast rate is discovered:
Start the Secondary ABCDs with emphasis on oxygenation, IV, VS,
and EKG, and consider the following questions:
1. Stable?

Yes
No, unstable = Immediate
next question electrical cardioversion

2. Narrow?

Yes
No, wide = Consult an expert
next question (QRS 0.12 sec)

3. Regular?

Yes
No, irregular = Consult an
see mnemonic expert

Yes 1-2-3, think SVT, then V-A-C

Vagal maneuvers, if this fails..

Adenosine 6mg rapid IV push

(may repeat x2, q1-2min. at 12mg)

Cardizem (diltiazem) managed by an expert if

stable, narrow, regular tachyarrhythmia continues
Perform immediate electrical cardioversion if a patient becomes
unstable at any time. For sinus tachycardia consider possible
causes and treat accordingly.
Consult an Expert
Most stable tachycardia rhythms require management by an expert
due to the challenge of accurately determining and safely treating

tachyarrhythmias.
A sampling of rhythms and possible expert interventions are listed
below.
Stable Narrow Irregular Tachycardia
Atrial Fibrillation, Multifocal Atrial Tachycardia, possibly Atrial Flutter
Rate Control: diltiazem or beta blocker
Stable Narrow Regular Tachycardia
Recurrent SVT, Atrial Flutter, Junctional or Ectopic Atrial
Tachycardia
Rate Control: diltiazem or beta blocker
Stable Wide Irregular Tachycardia
(Avoid calcium channel blockers and digoxin due to possible
AF+WPW)
Consider amiodarone. Magnesium 2g IV over 5min. for torsades
Stable Wide Regular Tachycardia
If VT, amiodarone 150mg IV over 10min. repeat prn
(max 2.2g IV/24hr),
elective synchronized cardioversion

7.Synchronized and Unsynchronized

Electrical Cardioversion

Only experts should manage synchronized electrical

cardioversion of a stable patient.

7.1. Synchronized Electrical Cardioversion

Synchronized Cardioversion
The following mnemonic directs preparations for synchronized
electrical cardioversion: "Oh Say It Isn't So"
As part of the Secondary ABCDs the following mnemonic directs
preparations for synchronized electrical cardioversion of unstable
tachycardia with circulatory compromise due to the fast rate (do not
delay shocking if seriously unstable):
Oh Say It Isn't So
Mnemonic

Preparation

Oh

O2 Saturation monitor

Say

Suctioning equipment

It

IV line

Isn't

Intubation equipment

So

Sedation and possibly analgesics

Synchronized Electrical Cardioversion *Energy Levels:

The initial synchronized shock is 100J monophasic (50J for SVT/AFlutter) with increasing energy, i.e., 200J, 300J, 360J, if successive
shocks are needed.
Synchronized Cardioversion Energy Level: Unless otherwise
specified, successive energy levels are *100J, *200J, *300J, *360J if
needed. If the patient's condition becomes critical or if you are
unable to synchronize then proceed with immediate unsynchronized
shocks.

Rhythm Special Notes:

Treat polymorphic V-tach like V-fib: successive
V-tach unsynchronized shocks at *200J, *200-300J, *360J if
needed.
PSVT
start with *50J
A-fib
standard energy levels
A-flutter start with *50J
*Or biphasic equivalent
Note: If V-fib develops, immediately defibrillate following the VF
algorithm.

7.2. Unsynchronized Electrical Cardioversion

Give unsynchronized shocks at VF/PVT *energy levels without delay
for unstable tachycardia with critical circulatory compromise due to
the fast rate. Also give unsynchronized shocks if you cannot
synchronize, or if polymorphic VT is present.
If VF/PVT develops, immediately defibrillate at *360J per the
VF/PVT Algorithm.
*Or biphasic equivalent
8. PEA Algorithm
Pulseless Electrical Activity may be discovered during the primary
ABCD survey when a monitor is attached to a pulseless patient and
a rhythm is shown.
As part of the secondary ABCD survey, a doppler should be used to
confirm pulselessness.
Interventions for pulseless electrical activity are guided by the
letters P-E-A:
Intervention
Problem

Comments/Dose
Search for the probable cause and

intervene accordingly.
(see PEA Problem Table )
Epinephrine 1 mg IV q3-5 min.
Atropine

With slow heart rate, 1 mg IV q3-5 min.

(max. dose 0.04 mg/kg)

The following directs AHA accepted actions as part of the

Secondary ABCDs for pulselessness with an organized cardiac
rhythm. Provide 2 minute cycles of CPR-rhythm/pulse checks
and think:
PEA
Letter

Intervention

Problem search (see Differential Diagnosis

Table). Treat accordingly. Continue this
algorithm if indicated.

Epinephrine 1 mg IV/IO q3-5 min. Or

vasopressin 40 U IV/IO, once, in place of the 1st
or 2nd dose of epi.

Atropine, with a slow heart rate, 1 mg IV/IO q35 min. (3mg max.)
9. 1. Ventricular Fibrillation (VF)/
Pulseless Ventricular Tachycardia (PVT) Algorithm
The following mnemonic directs AHA accepted
actions after the primary survey ABC's
Please Shock-Shock-Shock, EVerybody Shock,
And Let's Make Patients Better

Chant

Intervention

Please

Precordial
Thump

Shock

200J*

Note
May be performed immediately after
determining pulselessness in a
witnessed arrest with no defibrillator
immediately available. Check pulse
after thump.
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 rhythm.

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.

Implement the secondary ABCD survey. Do not continue with this

algorithm if an intervention results in the return of spontaneous
circulation.
NOTE: When giving med's, do so in a drug-shock-drug-shock
sequence. Continue CPR while giving meds, and shock within 3060 seconds. Evaluate the rhythm and check for a pulse in the
period immediately after shocking.
Everybody

Epinephrine 1 mg IV q3-5 min.

or

eVerybody Vasopressin 40 U IV, one time dose.

(wait 10-20 minutes before starting epi)
If VF/PVT persists, "CONSIDER" antiarrhythmics and sodium
bicarb.
NOTE: always "max out" one antiarrhythmic before proceeding to
the next in order to limit pro-arrhythmic drug-drug interactions.

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And

Amiodarone
(First Choice) 300mg IV push. May repeat once at
150mg in 3-5 min. (max. cumulative
dose: 2.2g IV/24hrs.)

Let's

Lidocaine

1.0-1.5 mg/kg IV. May repeat in 3-5 min.

(max. loading dose: 3 mg/kg)

Make

Magnesium 1-2 g IV (2 min. push) for suspected

Sulfate
hypomagnesemia or torsades de
pointes.

Patients

Procainamide 30 mg/min, or 100 mg boluses q 5 min.

for refractory VF. (max. dose: 17 mg/kg)
NOTE: Besides having a pro-arrhythmic
drug-drug interaction with amiodarone,
procainamide is of limited value in an
arrest situation due to a lengthy
administration time.

Consider buffers
Better

Bicarbonate 1 mEq/kg IV for preexisting

hyperkalemia, bicarb-responsive
acidosis, some drug overdoses,
protracted code (intubated), or return of
spontaneous circulation after long code
with effective ventilation.
NOTE: Not useful for acidosis due to
ineffective ventilation, and not
recommended for routine use in cardiac
arrest.

*Or equivalent biphasic energy level.

9.2. Ventricular Fibrillation (VF)/
Pulseless Ventricular Tachycardia (PVT) Algorithm
The following acronym directs AHA accepted actions after the
Primary ABCDs have been enacted and an AED or Manual
Defibrillator arrives and a shockable rhythm (VF or PVT) is present:
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SCREAM
Letter

Intervention

Note

Shock

360J* monophasic, 1st and subsequent

shocks.
(Shock every 2 minutes if indicated)

CPR

After shock, immediately begin chest

compressions followed by respirations
(30:2 ratio) for 2 minutes.
(Do not check rhythm or pulse)

Rhythm

Rhythm check after 2 minutes of CPR (and

after every 2 minutes of CPR thereafter)
and shock again if indicated. Check pulse
only if an organized or non-shockable
rhythm is present.

Implement the Secondary ABCD Survey. Continue this algorithm if

indicated. Give drugs during CPR before or after shocking.
Minimize interruptions in chest compressions to <10 seconds.
Consider Differential Diagnosis.
E

A
M

Epinephrine

1 mg IV/IO q3-5 min. Or vasopressin 40 U

IV/IO, once, in place of the 1st or 2nd dose
of epi.

Antiarrhythmic
Consider antiarrhythmics. (Any Legitimate
Medications
Medication)
Amiodarone 300mg IV/IO, may repeat
once at 150mg in 3-5 min. if VF/PVT
persists or
Lidocaine (if amiodarone unavailable) 1.01.5 mg/kg IV/IO, may repeat X 2, q5-10
min. at 0.5-0.75 mg/kg, (3mg/kg max.
loading dose) if VF/PVT persists,or
Magnesium Sulfate1-2 g IV/IO diluted in
10mL D5W
(5-20 min. push) for torsades de pointes or

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suspected/ known hypomagnesemia.

* Biphasic energy level is device dependent, follow the
manufacturer's recommendation. If recommendation is unknown,
use 200J for 1st shock and the same or higher energy level for
subsequent shocks.

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