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Figure 1 : Universal/International ACLS Algorithm

Adult Cardiac Arrest


Adult Cardiac Arrest

A
A
B
B
C
C
D
D

Primary ABCD Survey


Primary ABCD Survey
Focus : basic CPR and defibrillation
Focus : basic CPR and defibrillation
Check responsiveness
Check responsiveness
Activate emergency response system
Activate emergency response system
Call for defibrillator
Call for defibrillator
Airway : open the airway
Airway : open the airway
Breathing : Check for breathing, Look, Listen & Feel
Breathing : Check for breathing, Look, Listen & Feel
Circulation : Check pulse, start chest compressions
Circulation : Check pulse, start chest compressions
Defibrillation : attach ECG monitor / defibrillator
Defibrillation : attach ECG monitor / defibrillator

Assess rhythm
Assess rhythm

VF/VT
VF/VT

Attempt
Attempt
defibrillation x 1
defibrillation x 1
as necessary
as necessary

CPR
CPR
1-2 minutes
1-2 minutes

Secondary ABCD Survey


Secondary ABCD Survey
Focus : more advanced assessments & treatments
Focus : more advanced assessments & treatments
A Airway
A Airway
place airway device as soon as possible
place airway device as soon as possible
B Breathing
B Breathing
confirm airway device placement by examination
confirm airway device placement by examination
(confirmation device is recommended)
(confirmation device is recommended)
secure airway device
secure airway device
confirm effective oxygenation and ventilation
confirm effective oxygenation and ventilation
C Circulation
C Circulation
establish IV / IO / Central Line Access
establish IV / IO / Central Line Access
identify & monitor rhythm
identify & monitor rhythm
administer drugs appropriate for rhythm & condition
administer drugs appropriate for rhythm & condition
D Differential Diagnosis
D Differential Diagnosis
search for & treat identified reversible causes
search for & treat identified reversible causes

Non-VF/VT
Non-VF/VT

CPR
CPR
1-2 minutes
1-2 minutes

Consider causes that are potentially reversible


Consider causes that are potentially reversible
Hypovolemia
Tablets (drug OD, accidents)
Hypovolemia
Tablets (drug OD, accidents)
Hypoxia
Tamponade, cardiac
Hypoxia
Tamponade, cardiac
Hydrogen ion - acidosis
Tension pneumothorax
Hydrogen ion - acidosis
Tension pneumothorax
Hyper-/hypokalemia, other metabolic
Thrombosis, coronary (ACS)
Hyper-/hypokalemia, other metabolic
Thrombosis, coronary (ACS)
Hypothermia
Thrombosis, pulmonary (embolism)
Thrombosis, pulmonary (embolism)
Hypothermia

1 April 2011

Figure 2 : Ventricular Fibrillation/Pulseless VT Algorithm


Primary ABCD Survey

Assess Rhythm

Pulseless VF / VT

Defibrillate x 1st shock (360 J for Monophasic or


equivalent 150J 200 J for Biphasic)
CPR 1-2 mins
Rhythm after first 1st shock?

Persistent or recurrent VF/VT

Return of spontaneous circulation

Secondary ABCD Survey


Place airway device
Confirm & secure airway device
Establish IV / IO / Central Line Access
Differential Diagnosis

PEA
Go to Fig 3

Asystole
Go to Fig 4

Assess vital signs


Support airway
Support breathing
Provide medications appropriate for
blood pressure, heart rate, & rhythm

Adrenaline 1 mg IV push
CPR
Defibrillate within 1 min
CPR
Adrenaline 1 mg IV push

Check rhythm after


CPR.

CPR
Defibrillate within 1 min
CPR
Lignocaine 50-100mg IV push
CPR

Amiodarone 300 mg IV push


or

Defibrillate within 1min

CPR
Defibrillate within 1 min

CPR

CPR

Lignocaine 50-100mg IV push

If rhythm is VF,
continue with VF
algorithm

If VF is converted,
follow algorithm for
ROSC, PEA or
Asystole.

Amiodarone 150 mg IV push


CPR

Mg SO4 1-2 g IV
if polymorphic
VT/ Torsades

Defibrillate within 1 min


CPR

Continue CPR
Give appropriate medication as indicated
Defibrillate 360 J monophasic or 150-200 J biphasic within 1 min
after each dose of medication. For subsequent shocks for
biphasic, can escalate energy level gradually up to a max of 360 J
Pattern should be CPR-drug-shock, CPR-drug shock
1 April 2011

Note :
CPR must be continued at all times & also when drugs
are given
Stop CPR briefly only for analyzing rhythm
If IV access is unavailable, do not delay shock.
Continue CPR-drug-shock

Figure 3 : Pulseless Electrical Activity Algorithm

Primary ABCD Survey


Primary ABCD Survey

Assess rhythm
Assess rhythm

Pulseless Electrical Activity


Pulseless Electrical Activity
(PEA = rhythm on monitor, without detectable pulse
(PEA = rhythm on monitor, without detectable pulse

Secondary ABCD Survey


Secondary ABCD Survey

Review for most frequent cases & treat accordingly


Review for most frequent cases & treat accordingly
Hypovolemia
Tablets (drug OD, accidents)
Hypovolemia
Tablets (drug OD, accidents)
Hypoxia
Tamponade, cardiac
Hypoxia
Tamponade, cardiac
Hydrogen ion - acidosis
Tension pneumothorax
Hydrogen ion - acidosis
Tension pneumothorax
Hyper-/hypokalemia
Thrombosis, coronary (ACS)
Hyper-/hypokalemia
Thrombosis, coronary (ACS)
Hypothermia
Thrombosis, pulmonary (embolism)
Hypothermia
Thrombosis, pulmonary (embolism)

Adrenaline 1 mg IV push,
Adrenaline 1 mg IV push,
repeat every 3 to 5 minutes.
repeat every 3 to 5 minutes.

1 April 2011

Figure 4 : Asystole: The Silent Heart Algorithm


Primary ABCD Survey
Primary ABCD Survey

Assess rhythm
Assess rhythm

Asystole
Asystole

Confirm Asystole in more than one lead


Confirm Asystole in more than one lead

Secondary ABCD Survey


Secondary ABCD Survey

Adrenaline 1 mg IV push,
Adrenaline 1 mg IV push,
repeat every 3 to 5 minutes.
repeat every 3 to 5 minutes.

Search for & correct reversible causes


Search for & correct reversible causes
(Refer to PEA algorithm)
(Refer to PEA algorithm)

1 April 2011

Figure 5 : Bradycardia Algorithm

Primary ABCD Survey


Primary ABCD Survey

Assess rhythm
Assess rhythm

Bradycardia
Bradycardia
Slow (absolute bradycardia = rate<60 bpm
Slow (absolute bradycardia = rate<60 bpm
or
or
Relatively slow (rate less than expected
Relatively slow (rate less than expected
relative to underlying condition or cause)
relative to underlying condition or cause)

Secondary ABCD Survey


Secondary ABCD Survey

Serious signs or symptons?


Serious signs or symptons?
Due to the bradycardia?
Due to the bradycardia?
No

Type II second-degree AV block


Type II second-degree AV block
or
or
Third-degree AV block?
Third-degree AV block?

No

Observe
Observe

Note a. Atropine is given in a dose of 0.6 mg


intravenously & may be repeated every 3-5 min up to a
maximum dose of 2.4 mg.

23 August 2011

Yes

Intervention sequence
Intervention sequence
Atropine 0.6 mg a a
Atropine 0.6 mg
Transcutaneous pacing if available
Transcutaneous pacing if available
Dopamine 2 to 20 mcg/kg per min
Dopamine 2 to 20 mcg/kg per min
Adrenaline 2 to 10 mcg/min Infusion
Adrenaline 2 to 10 mcg/min Infusion
Yes

Prepare for transvenous pacer


Prepare for transvenous pacer
If symptoms develop, use
If symptoms develop, use
transcutaneous pacemaker
transcutaneous pacemaker
until transvenous pacer placed
until transvenous pacer placed

Figure 6 : Tachycardia Algorithm


Assess responsive
Assess responsive
Call for help/defibrillator
Call for help/defibrillator
Assess ABCs
Assess ABCs
Administer oxygen
Administer oxygen
Establish IV
Establish IV

ECG monitor
ECG monitor
Assess vital signs
Assess vital signs
Review history
Review history
Perform physical examination
Perform physical examination
Do 12 Lead ECG
Do 12 Lead ECG

Unstable, with serious signs or symptoms


Unstable, with serious signs or symptoms
ie : Heart Failure, SBP<90, in shock
ie : Heart Failure, SBP<90, in shock

Yes

Immediate synchronised
Immediate synchronised
Cardioversion
Cardioversion

No

Narrow Complex
Narrow Complex
Tachycardia
Tachycardia

Atrial
Atrial
fibrillation
fibrillation
Atrial flutter
Atrial flutter

Wide Complex
Wide Complex
Tachycardia
Tachycardia

Paroxysmal
Paroxysmal
supraventricular
supraventricular
tachycardia (PSVT)
tachycardia (PSVT)

Use rate control drugs


Use
rate control drugs
eg:
amiodarone,
eg: amiodarone,
Diltiazem,
Verapamil
Verapamil
orDiltiazem,
Digoxin. Consider
or
Digoxin.
Consider
anti-cogulation/aspirin
anti-cogulation/aspirin

If strongly
suspect
aberrancy

If suspect VT or
uncertain WCT

Adenosine 6mg
Adenosine
rapid
iv push 6mg
rapid iv push

Lignocaine
Lignocaine
50-100
mg
IV50-100
push mg
IV push

Amiodarone
Amiodarone
150
mg IV
150 over
mg IV
push
10push
minsover
10 mins

Lignocaine
Lignocaine
50-100
mg
IV50-100
push mg
IV push

Amiodarone
Amiodarone
150
mg IV
15010
mg IV
over
over
mins 10
mins

Vagal maneuvers
Vagal maneuvers

* Adenosine 6 mg
* Adenosine
rapid
IV push 6 mg
rapid IV push

Adenosine 12mg
Adenosine
rapid
iv push 12mg
rapid iv push

* Verapamil 1 mg
* Verapamil
1 mg
/ min
(up to max
20/ min
mg) (up to max
20 mg)

If still VT,
If still VT,
synchronised
synchronised
cardioversion
cardioversion

Adenosine
Adenosine
12mg
rapid iv push
12mg rapid iv push

What
* either drug depending on
availability and experience

1 April 2011

Polymorphic VT
Polymorphic VT

Correct abnormal
Correct abnormal
electrolytes
electrolytes
Treat
ischemia if present
Treat ischemia if present
Medications:
Medications:
Magnesium
Magnesium
Consider
overdrive
Consider
overdrive
pacing
if bradycardia
pacing if bradycardia
related
related