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ACLS 2014 Unofficial Cheat Sheet

Significant changes from previous ACLS are bold. Classes mentioned reflect level of evidence.

Cardiac Arrest Algorithm

Note the key change in BLS sequence: begin early chest compressions.

BLS is no longer represented by A, B, C, and D; it is represented by 1, 2, 3, and 4.

Step 1: Assess responsiveness.

Step 2: Active emergency response and get AED.

Step 3. Check carotid pulse for 10 seconds. If no pulse, begin CPR, starting with chest compressions then 2 breaths at a ratio of 30:2. Use bag valve mask for breaths, if available.

Step 4: Defibrillate if there is a shockable rhythm when defibrillator arrives. Continue CPR while the defibrillator or AED is readied. Responders should follow the voice prompts.

Step 5: Proceed to ABCD of secondary survey.

  1. Airway: Head tilt-chin-lift; use advanced airway if needed.
  2. Breathing: Supplementary oxygen; maintain ventilation and oxygenation.
  3. Circulation: Monitor CPR quality with waveform capnography.
    • Attach monitor.
    • Defibrillate/cardiovert.
    • Obtain IV/IO access.
    • Give appropriate drugs:
      • Pressors: Epinephrine 1 mg IV q 3 -5 minutes. May substitute Vasopressin 40 U IV for dose 1 or dose 2.
      • Antiarrhythmics: Amiodarone 300 mg IV. May repeat a second dose of 150 mg IV
  4. Differential diagnosis: Look for reversible causes. 5 H's and 5 T's.

Ventricular Fibrillation and Pulseless Ventricular Tachycardia

Step 1: Cardiac Arrest Algorithm: BLS and AED.

Biphasic defibrillators - 120 to 200 J per manufacturer; 360 J monophasic defibrillator.

The 2010 Guidelines recommends interruption in chest compression only for ventilation without an advanced airway, rhythm checks, and shock delivery.

The American Heart Association recommends shortening the interval between last compression and shock.

The emphasis in ACLS is on high quality CPR. Monitor with qualitative waveform capnography. If PETCO2 is less than 10 mm Hg, attempt to improve CPR quality.

Step 2: ACLS: Secondary survey.

Step 3: Vasopressin 40 U IV x 1 (Class 2b) or epinephrine 1 mg q 3-5 minutes (Class Indeterminate.

Step 4: Defibrillate: Biphasic – 120 or 200, use manufacturer's instructions.

Step 5: Antiarrhythmic: Amiodarone 300 mg IV/IO; may repeat x 1 at 150 mg (Class 2b)
-Consider lidocaine if amiodarone is not available 1.0-1.5 mg/kg IV/IO first dose, then 0.5-0.75 mg/kg IV/IO diluted in 10 ml D5@, NS) as IV/IO bolus over 5-20 minutes

Step 6: Defibrillate

Step 7: Go back to Step 3.

PEA/Asystole

Step 1: Cardiac Arrest Algorithm: BLS and AED.

Interrupt chest compressions only for ventilation without an advanced airway, rhythm checks, and shock delivery. High quality CPR is emphasized.

Step 2: ACLS: Secondary survey: confirm asytole, do not delay CPR for pulse check.

Step 3: Rule out reversible causes: 5H's and 5 T's.

Step 4: Epinephrine 1 mg IV q 3-5 minutes.

Step 5: Continue CPR.

Step 6: Atropine 0.5 mg q 3-5 minutes to 0.04 mg/kg: Consider if rhythm is slow.

Step 7: Continue CPR  Return of Spontaneous Circulation - Coordinated Post-arrest Care

*TCP no longer recommended in asystole.

Bradycardia Algorithm

Step 1: Cardiac Arrest Algorithm: BLS and AED.

Step 2: Heart rate

Step 3: ACLS: Secondary survey: airway, oxygen, IV, monitor, 12 lead, differential dx.

Step 4: Persistent bradyarrhythmia with signs of poor perfusion?If not, observe.

Step 5: Atropine 0.5 mg q 3-5 minutes, maximum 3 mg. If effective, monitor and observe.

Step 6: If ineffective, prepare for transcutaneous pacing or dopamine infusion or epinephrine infusion.

Step 7: Prepare patient for transvenous pacing if required. Obtain expert consultation.

Step 8: Type 2 second-degree AV block or third degree AVB? TCP and prepare for TVP.

Tachycardia with a Pulse Algorithm

Intervention is determined by presence of significant symptoms or unstable condition that is caused by the tachycardia.

Step 1: Assess appropriateness for clinical condition. Usually > 150 bpm.

Step 2: ACLS : Secondary survey: airway, oxygen, IV, monitor, 12 lead, differential dx

Step 3: Persistent tachyarrhythmia with signs of poor perfusion?

If no, proceed to Step 4. If patient becomes unstable, do not delay treatment for detailed rhythm analysis.

If yes, synchronized cardioversion.

Step 4: Wide QRS? (greater than or equal to 0.12 second? If no, proceed to Step 5.

If yes, IV and ECG. Adenosine only if regular and monomorphic.

-antiarrhythmic infusions for stable wide QRS complex tachycardia:

Step 5: If QRS < 0.12 seconds, IV and ECG.

*Drugs to avoid in patients with irregular wide complex tachycardia: AV Nodal Blocking Agents:

**Avoid AV Nodal Blocking Agents in preexcitation atrial fibrillation and atrial flutter.

***Caution when combining AV Nodal Blocking Agents with longer duration of action. Effects may overlap.

*Cardioversion:

Acute Stroke Algorithm

Stroke chain of survival:

8 D's: Detection Dispatch, Delivery, Door, Data, Decision, Drug, Disposition

Step 1: Identify possible stroke signs and symptoms.

Step 2: Activate EMS

Step 3: Critical EMS actions:

Step 4: ED arrival and first 10 minutes: Assess and stabilize

Step 5: T=25 minutes: Neurologic assessment by stroke team or designee

Step 6: T=45: CT interpretation

If hemorrhage is present, consult neurologist or neurosurgeon, consider transfer if not available.

If no hemorrhage, consider probable ischemic stroke and consider fibrinolytics.

If exclusions exist, administer aspirin and go to Step 9.

If no exclusions, repeat neurologic exam. If symptoms are rapidly improving, administer aspirin and go to Step 9.

Step 7: T=60:

Step 8: T=60:

Step 9: Begin stroke pathway or hemorrhage pathway.

Cincinnati Prehospital Stroke Scale:

3 findings:

If 1 of 3 signs is abnormal, probability is 72%.

If 3 abnormal signs, probability is >85%.

Acute Coronary Syndrome Algorithm

Goals: Identify patients with STEMI and triage for early reperfusion.

Step 1: Confirm symptoms that suggest ischemia or infarction.

Step 2: EMS:

Step 3: ED (less than 10 minutes) concurrent assessment

Step 4: Immediate ED treatment:

Step 5: Interpret ECG

ST elevation or new/presumably new LBBB: STEMI: Go to Step 6.

ST depression or dynamic T wave inversion: UA/NSTEMI: Go to Step 10.

Normal or nondiagnostic ST/T changes: Low or intermediate risk ACS: Go to Step 13.

Step 6: Start adjunctive therapies as indicated and don't delay reperfusion.

Step 7: Time from symptom onset:

Step 8: Reperfusion therapy:

Step 10: Troponin elevated or high-risk patient:

Consider early invasive strategy:

If not, go to Step 11.

Step 11: Adjunctive therapies:

Step 12: Admit to monitored bed, and assess risk. Continue ASA, heparin, and other therapies as indicated.

High risk:

Consider ACE inhibitor/ARB; HMG CoA reductase inhibitor

Low risk: cardiology consult

Step 13: Consider admission to ED chest pain unit and follow serial cardiac markers, repeat ECGs and consider non-invasive testing.

Step 14: Development of 1 or more:

Go to Step 10. If not, go to Step 15.

Step 15: Abnormal noninvasive imaging or physiologic testing?

Go to Step 12. If not, go to Step 16.

Step 16: Without evidence of ischemia or infarction by testing, patient may be discharged with follow-up.

ACLS Drugs/Doses

Adenosine: Initial bolus 6 mg IV over 1-3 seconds; follow with 20 ml bolus NS, elevate extremity. May repeat 12 mg in 1-2 minutes.

Amiodarone: 300 mg IV/IO push. Second dose, if needed, 150 mg IV/IO push.

Atropine: 0,5 mg IV every 3 to 5 minutes; do not exceed 0.04 mg/kg.

Dopamine infusion: 2-10 mcg/kg/min; titrate to response.

Epinephrine: In cardiac arrest: I mg q 3-5 minutes, follow with 20 ml flush, elevate arm. In beta-blocker or calcium channel blocker OD, may use up to 0.2 mg/kg. Continuous infusion: 0/1 to 0/5 mcg/kg/min. In profound bradycardia or hypotension: infuse at 2 to 10 mcg/minute; titrate to response.

Lidocaine: In cardiac arrest, alternative to amiodarone: 1-1.5 mg/kg; may give additional 0.5-0.75 mg/kg/IV push, repeat to maximum of 3 mg/kg.

Magnesium Sulfate: Only in cardiac arrest due to hypomagnesemia or Torsades de Pointes, 1-2 gm (2-4 ml of 50% soln diluted in 10 ml, IV/IO.) Torsades de Pointes with a pulse of AMI with hypomagnesemia: Load 1-2 g diluted in 50-100 ml over 5 to 60 min IV. Follow with 0.5 to 1 g per hour IV, titrated to control torsades.

Vasopressin: may replace 1st or 2nd dose of epinephrine. One dose of 40 units IV/IO push.