Adult Basic Life Support (BLS) Algorithm

Adult BLS Health Providers

See also:
Simplified Adult BLS Algorithm (American Heart Association, 2010)
BLS Healthcare Provider Algorithm (American Heart Association, 2010)

Adapted from: Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF,
Lerner EB, Rea TD, Sayre MR, Swor RA. Part 5: adult basic life support: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010 Nov 2;122(18 Suppl 3):S685-705.

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Glasgow Coma Scale

Score
Spontaneous 4
To speech 3
Eye opening
To pain 2
None 1
Oriented 5
Confused 4
Best verbal response Inappropriate Words 3
Incomprehensible sounds 2
None 1
Obeys
6
Localizes
5
Withdraws
4
Best motor response Abnormal flexion to pain
3
Extensor response to pain
2
1
None

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Revised Trauma Score

The Revised Trauma Score (RTS) is made up of a combination of results from three categories:

Glasgow Coma Scale

Systolic Blood Pressure
Respiratory rate

All of these results can be quickly assessed with minimal equipment: a flashlight, a watch and a
sphygmomanometer since systolic pressure can be obtained through arterial palpation.

The score range is 0-12. In START triage, a patient with an RTS score of

12 is labeled DELAYED (walking wounded)

11 is URGENT (intervention is required but the patient can wait a short time)
10-3 is IMMEDIATE (immediate intervention is necessary)
<3 is MORGUE, which is given to seriously injured people. These people should not
receive certain care because they are unlikely to survive. The reasoning is that diverting
scarce resources away from people with a little chance of survival increases the chances
of survival of others who are inherently more likely to survive.

Glasgow Coma Scale Systolic Blood Pressure Respiratory Rate Coded

(GCS) (mmHg) (breaths/min) Value
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0

Add the value of each characteristic. Highest possible total score is 12, and the lowest possible
total score is 0.

Champion et al., A Revision of the Trauma Score. Journal of Trauma. 1989:29(5): pg. 623-9

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ATLS Hemorrhage Classification

 Estimated Blood Loss Based on Patient's Initial Presentation
Class I Class II Class III Class IV
Blood loss (ml) Up to 750 750-1500 1500-2000 >2000
Blood loss
Up to 15 15-30 30-40 >40
(% blood volume)
Pulse Rate (bpm) <100 100-120 120-140 >140
Blood Pressure Normal Normal Decreased Decreased
Normal or
Pulse Pressure (mmHg) Decreased Decreased Decreased
increased
Respiratory Rate
14-20 20-30 30-40 >35
(breaths/min)
Urine Output >30 20-30 5-15 Neglible
Anxious, Confused,
CNS/Mental status Slightly anxious Mildly anxious
confused lethargic
Crystalloid and Crystalloid and
Fluid replacement Crystalloid Crystalloid
blood blood

For a 70kg male

Taken from ATLS handbook

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Part 8: Adult Advanced Cardiovascular Life Support

Table 1.

Treatable Causes of Cardiac Arrest: The H's and T's

H's T's

Hypoxia Toxins

Hypovolemia Tamponade (cardiac)

Hydrogen ion (acidosis) Tension pneumothorax

Hypo-/hyperkalemia Thrombosis, pulmonary

Hypothermia Thrombosis, coronary

 For further explanation of the H's and T's, see Part 12: Special Resuscitation Situations.

Part 10: Acute Coronary Syndromes

Table 2.

Likelihood That Signs and Symptoms Represent ACS Secondary to CAD

Intermediate Likelihood Low Likelihood Absence of

High Likelihood Any of the Absence of high-likelihood high- or intermediate-
Feature
following: features and presence of likelihood features but may
any of the following: have the following:

Chest or left arm pain or Probable ischemic symptoms

Chest or left arm pain or
discomfort as chief symptom in absence of any
discomfort as chief
History reproducing prior documented intermediate-likelihood
symptom; age >70 years;
angina; known history of CAD characteristics; recent cocaine
male sex; diabetes mellitus
including MI use

Transient MR murmur,
Extracardiac vascular Chest discomfort reproduced
Examination hypotension, diaphoresis,
disease by palpation
pulmonary edema, or rales

New or presumably new

Fixed Q waves ST T-wave flattening or inversion
transient ST-segment deviation
ECG depression 0.5 to 1 mm or <1 mm in leads with dominant
(1 mm) or T-wave inversion in
T-wave inversion >1 mm R waves Normal ECG
multiple precordial leads

Cardiac Elevated cardiac TnI, TnT, or CK-

Normal Normal
markers MB

CAD indicates coronary artery disease; CK-MB, MB fraction of creatine kinase; ECG,
electrocardiogram; MI, myocardial infarction; MR, mitral regurgitation; TnI, troponin I;
and TnT, troponin T.

Modified from Braunwald E, et al. Unstable Angina: Diagnosis and Management.

1994;3-1-AHCPR Publication No 94-0602:1-154. In the public domain.127
Part 10: Acute Coronary Syndromes
Table 3.

TIMI Risk Score for Patients With Unstable Angina and NonST-Segment Elevation MI:
Predictor Variables

Predictor Point Value of

Definition
Variable Variable

Age 65 years 1

Risk factors

Family history of CAD

Hypertension
3 risk factors
1
for CAD Hypercholesterolemia

Diabetes

Current smoker
Aspirin use in
1
last 7 days

Recent, severe
symptoms of 1 2 anginal events in last 24 hours
angina

Elevated
1 CK-MB or cardiac-specific troponin level
cardiac markers

ST depression >0.5 mm is significant; transient ST elevation 0.5 mm for

ST deviation <20 minutes is treated as ST-segment depression and is high risk; ST
1
0.5 mm elevation 1 mm for more than 20 minutes places these patients in the
STEMI treatment category

Prior coronary
artery stenosis 1 Risk predictor remains valid even if this information is unknown
50%

Risk of 1
Calculated Primary End
Risk Status
TIMI Risk Score Point* in 14
Days
Predictor Point Value of
Definition
Variable Variable

0 or 1 5% Low

2 8% Low

3 13% Intermediate

4 20% Intermediate

5 26% High

* Primary end points: death, new or recurrent MI, or need for urgent revascularization.

Part 10: Acute Coronary Syndromes

Table 4.

Selection of Initial Treatment Strategy for Patients With Non-ST-Elevation ACS: Invasive Versus
Conservative Strategy*

Preferred
Patient Characteristics
Strategy

Invasive Recurrent angina or ischemia at rest or with low-level activities despite

intensive medical therapy

Elevated cardiac biomarkers (TnT or TnI)

New or presumably new ST-segment depression

Signs or symptoms of HF or new or worsening mitral regurgitation

High-risk findings from noninvasive testing

Hemodynamic instability

Sustained ventricular tachycardia

PCI within 6 months

Prior CABG
Preferred
Patient Characteristics
Strategy

High-risk score (eg, TIMI, GRACE)

Reduced LV function (LVEF less than 40%)

Low-risk score (eg, TIMI, GRACE)
Conservative
Patient or physician preference in absence of high-risk features
CABG indicates coronary artery bypass graft surgery; GRACE, Global Registry of Acute
Coronary Events; HF, heart failure; LV, left ventricular; LVEF, left ventricular ejection
fraction; PCI, percutaneous coronary intervention; TIMI, Thrombolysis in Myocardial
Infarction; TnI, troponin I; and TnT, troponin T.

* Adapted from the ACC/AHA 2007 UA/NSTEMI Guidelines.

Part 10: Acute Coronary Syndromes

Table 5.

Fibrinolytic Therapy

Contraindications and cautions for fibrinolytic use in STEMI from ACC/AHA 2004 Guideline Update *

Absolute Contraindications

Any prior intracranial hemorrhage

Known structural cerebral vascular lesion (eg, AVM)

Known malignant intracranial neoplasm (primary or metastatic)

Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours

Suspected aortic dissection

Active bleeding or bleeding diathesis (excluding menses)

Significant closed head trauma or facial trauma within 3 months

Relative Contraindications

History of chronic, severe, poorly controlled hypertension

Severe uncontrolled hypertension on presentation (SBP >180 mm Hg or DBP >110 mm
 Hg)

History of prior ischemic stroke >3 months, dementia, or known intracranial pathology
not covered in contraindications

Traumatic or prolonged (>10 minutes) CPR or major surgery (<3 weeks)

Recent (within 2 to 4 weeks) internal bleeding

Noncompressible vascular punctures

For streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic reaction to
these agents

Pregnancy

Active peptic ulcer

Current use of anticoagulants: the higher the INR, the higher the risk of bleeding
CPR, cardiopulmonary resuscitation; AVM indicates arteriovenous malformation; SBP,
systolic blood pressure; DBP, diastolic blood pressure; INR, International Normalized
Ratio.

* Viewed as advisory for clinical decision making and may not be all-inclusive or
definitive.

Could be an absolute contraindication in low-risk patients with myocardial infarction.