Using the ACLS Primary Survey for a Patient in

Respiratory Arrest
The ACLS Secondary Survey takes you through the advanced assessments and actions you need
to accomplish for a patient in respiratory arrest (see Figure 1). Placing an advanced airway interrupts
chest compressions and takes many seconds. If the patient is pulseless, advanced airway should be
deferred until return of spontaneous circulation (absent special situations, like aspiration risk, etc.
)Your assessment guides you in finding the answers and taking appropriate next steps.

The assessments follow the CAB format of the primary

survey:
Circulation

Airway

Breathing

If a cervical spine injury is suspected and you are familiar with the technique, you should utilize a jaw
thrust to open the airway while maintaining cervical stabilization

Figure 1. Advanced Cardiac Life Support Secondary

Survey
Assessment Action

Is the patient's airway To open the airway for unconscious patients, use the head-
obstructed? tilt, chin lift. Insert an oropharyngeal airway (OPA) or a
nasopharyngeal airway (NPA) if needed to keep the airway
open.

Does the patient need If yes, use an LMA, Combitube, or endotracheal intubation to
an advanced airway? secure the airway.

Is the patient Give bag valve mask ventilations every 6 seconds or 10

breathing? breaths per minute
Is an advanced airway No. If bag-mask ventilation is adequate, defer the insertion of
indicated? an advanced airway until it becomes essential (patient fails
to respond to initial CPR or until spontaneous circulation
returns). Yes. Insert the advanced airway device that is most
apprppriate to your scope of practice.

Is the advanced airway Confirm correct placement of advanced airway device by a

device placed observing the patient, confirming the presence of lung
properly? sounds in at least 4 lung fields and using waveform
capnography.

Is the advanced airway Secure the advanced airway device so it does not dislodge,
device secured especially in patients who are at risk for movement. Secure
correctly? the ET tube with tape or a commercial device. Do not use
devices to secure the airway device that are circumferential.

What was the patient's Attach ECG leads. Identify patient's rhythm.
initial cardiac rhythm?

What is the patient's Monitor patient for arrhythmias or cardiac arrest rhythms
current cardiac (ventricular fibrillation, pulseless ventricular tachycardia,
rhythm? asystole, and PEA).

Does the patient need Establish IV or IO access.

an IV?

Does the patient need Start IV/IO fluids, if needed, using a crystalloid
fluid?

Does the patient need Give appropriate medications to manage rhythm (eg,
medications for rhythm amiodarone, lidocaine, atropine) and blood pressure (eg,
or blood pressure Dopamine or Epinephrine (used with caution as it increases
control? myocardial oxygen demand).
Is a reversible cause Search for reversible causes of the arrest. Find and treat
responsible for the reversible causes of the arrest.
arrest?

If the patient is not deeply unconscious, you must use a nasoparhygeal airway as an OPA will
activate the gag reflex

The appropriate airway will depend not only on the patients condition, but the experience level of the
provider as well.

Avoid commercial devices that are circumferential

If the patient is in cardiac arrest, placing an advanced airway is a significant interruption to chest
compressions. You must weigh the need for an advanced airway against the need for continued
chest compressions. If bag-mask ventilation is working and seems adequate, you may want to put
off inserting an advanced airway until the patient fails to respond to initial CPR and defibrillation, or
until spontaneous circulation returns.

Using the Acute Coronary Syndromes Algorithm for

Managing the Patient
The Acute Coronary Syndromes Algorithm outlines the steps for assessment and management of a
patient with ACS. The algorithm begins with the assessment of chest pain and whether it is
indicative of ischemia. The assessment and management begin with the EMS responder outside of
the hospital who can, initiate care. An initial 12-lead ECG can also be obtained early in the
assessment of the patient which will help to determine the appropriate destination facility. Treatment
and assessment continues when the patient arrives at the hospital, following the time sequences
suggested in the algorithm.

Out-of-Hospital Care
Decision 1: Does the patient have chest discomfort suggestive of ischemia?

An affirmative answer starts the algorithm.

Assess and care for the patient using the primary and secondary surveys.

Early on in the care of the patient, facility destination should be considered. In the patient who is
infarcting it is imperative that they be transported to a facility capable of percutaneous transluminal
coronary intervention if within 90 minutes and the patients condition permits transport to that facility.

1. Monitor and support ABCs (airway, breathing, and circulation).

o Take vital signs.

o Monitor rhythm.

o Be prepared to administer CPR if the need arises. Watch for it.

o Use a defibrillator if necessary.

2. If the patients pulse oximetry is less than 94% administer oxygen at a level that increases
the saturation to between 94 and 99%. If the patient has a history of COPD administer
oxygen if their pulse ox falls below 90% on room air

3. If the patient is short of breath, administer oxygen no what the oxygen saturation reveals.

4. Obtain a 12-lead ECG.

5. Interpret or request an interpretation of the ECG. If ST elevation is present, transmit the

results to the receiving hospital. Hospital personnel gather resources to respond to STEMI. If
unable to transmit the trained prehospital provider should interpret the ECG and the cardiac
catheterization laboratory should be notified based upon that interpretation.

In-Hospital Care
Within the first 10 minutes that the patient is in the Emergency Department (ED), work through the
following:

1. Check vital signs.

2. Evaluate oxygen saturation. If less than 94% or the patient is short of breath, administer
oxygen as needed to increase oxygen saturation to between 94 and 99%.

3. Establish IV access.

4. Obtain or review a 12-lead ECG (if not established in the field).

5. Look for risk factors for ACS, cardiac history, signs and symptoms of heart failure by taking a
brief, targeted history.
 6. Perform a physical exam.

7. Obtain a portable x-ray (less than 30 minutes)

Begin general treatment in the ED:

1. If the patient did not receive aspirin from the EMS provider, give aspirin (160 to 325 mg).

2. Administer nitroglycerin 0.4mg q 5 minutes, either sublingual, spray. Withhold Nitroglycerin

on the patient who is experiencing Right Ventricular Infarction.

3. Give the patient a narcotic pain reliever such as Fentanyl, Morphine or Dilaudid if pain is not
relieved by nitroglycerin. Morphine is the drug of choice for infarction, but should be used
with caution in the unstable angina patient.

Decision 2: Classify the patient according to presentation of ST-segment.

The 12-lead ECG is at the heart of the decision pathway in the management of ischemic chest pain
and is the only means of identifying STEMI.

Note: The ECG classification of ischemic syndromes is not meant to be exclusive.

STEMI (ST-segment High-risk unstable angina Intermediate or low risk UA

elevation myocardial (UA) or NSTEMI (non-ST-
infarction) segment elevation
myocardial infarction)

Definition: ST Definition: Ischemic ST- Definition: Normal or non-

segment elevation segment depression of 0.5 diagnostic changes in ST
greater than 1 mm mm (0.5 mV) or greater - segment or T wave that are
(0.1 mV) in 2 or more OR- Dynamic T wave inconclusive and require
contiguous precordial inversion with pain or further risk stratification /
leads or 2 or more discomfort / Transient ST Includes people with normal
adjacent limb leads - elevation of 0.5 mm or ECGs and those who have ST-
OR- New or greater for less than 20 segment deviation in either
presumed new left minutes direction that is less than 0.5
bundle branch block mm or T wave inversion of 2
mm or 0.2 mV or less
Classification: Classification: ISCHEMIA Classification: NORMAL?
INFARCTION

Management is based on the results of the ECG.

ECG shows ST-segment elevation.

Confirm how much time has passed since the onset of symptoms.

If less than 12 hours has elapsed, do the following:

Develop a reperfusion strategy based on the patient's and the hospital's criteria. Unless
impossible, the patient should be taken to the cardiac catheterization laboratory for PCI

Continue adjunctive therapies.

If indicated, add the following treatments:

o ACE inhibitors/angiotensin receptor blocker (ARB) within 24 hours of symptom onset

o HMG-CoA reductase inhibitor (statin therapy)

Results of cardiac markers, chest x-ray, and laboratory studies should not delay reperfusion therapy
unless there is a clinical reason.

Start adjunctive treatments for STEMI, as indicated:

Beta-adrenergic receptor blocker

Clopidogrel

Heparin (unfractionated heparin or low-molecular-weight heparin / UFH or LMWH)

If the patient is classified with NSTEMI or high-risk unstable angina, follow this
section of the algorithm.
Decision 2: Classify the patient according to presentation of ST-segment.

ECG shows ST depression or dynamic T-wave inversion

Start adjunctive treatments for NSTEMI, as indicated:

Nitroglycerin

Beta-adrenergic receptor blocker

Clopidogrel
 Heparin (UFH or LMWH)

Glycoprotein IIb/IIIa inhibitor

If more than 12 hours has passed since the patient's onset of symptoms, do the following:

1. Admit patient to the hospital

2. Assess risk status

Continue ASA, heparin, and other therapies as indicated (ACE inhibitors, statins) for the high-risk
patient characterized by:

Refractory ischemic chest pain

Recurrent or persistent ST deviation

Ventricular tachycardia

Hemodynamic instability

Signs of pump failure

Decision 2: Classify the patient according to presentation of ST-segment.

ECG shows normal ECG or nonspecific ST-T wave changes

Consider admitting the patient to hospital or to a monitored bed in ED

Pulseless Arrest Algorithm for Managing

Asystole
Jan 6, 2017

Version control: This document is current with respect to 2015 American Heart Association
Guidelines for CPR and ECC. These guidelines are current until they are replaced on October
2020. If you are reading this page after October 2020, please contact ACLS Training Center at
support@acls.net for an updated document.

Management of a patient in cardiac arrest with asystole follows the same pathway as
management of PEA. The top priorities stay the same: Following the steps in the ACLS Pulseless
Arrest Algorithm and identifying and correcting any treatable, underlying causes for the asystole.
The algorithm assumes that scene safety has been assured, personal protective equipment is
being used, and no signs of obvious death are present.

Begin with the primary survey to assess the patient's condition:

In the absence of respirations and a pulse in the presence of asystole (present in two
leads) consideration of termination of efforts should take place

Follow the ACLS Pulseless Arrest Algorithm for asystole:

Check the patient's rhythm, taking less than 10 seconds to assess.

Verify the presence of asystole in at least two leads

Resume CPR at a compression rate from 100-120 per minute. Rotate team members
every 2 minutes with rhythm breaks to help maintain high quality CPR.

As soon as IV or IO access is available, administer epinephrine 1mg IV/IO. Do not stop

CPR to administer drugs.

During CPR, search for and treat possible contributing causes (H's and T's in Figure 1).

Check rhythm.

o If no electrical activity is present (patient is in asystole), resume CPR.

o If electrical activity is present, see if the patient has a pulse.

o If the patient does not have a pulse or there is some doubt about the pulse, resume
CPR.

o If a good pulse is present and the rhythm is organized, begin post-resuscitative

care.

IV/IO access is a priority over advanced airway management. If an advanced airway is placed,
change to continuous chest compressions without pauses for breaths. Give 10 breaths per minute
(once every 6 seconds) and check rhythm every 2 minutes.

Without a pulse or electrical activity on the ECG, the emergency care team needs to decide when
resuscitation efforts should stop. The patient's wishes and the family's concerns need to be
considered.
Using the Pulseless Arrest Algorithm for
Managing PEA
Jan 6, 2017

Version control: This document is current with respect to 2015 American Heart Association
Guidelines for CPR and ECC. These guidelines are current until they are replaced on October
2020. If you are reading this page after October 2020, please contact ACLS Training Center at
support@acls.net for an updated document.

Patients with PEA have poor outcomes. Their best chance of returning to a perfusing rhythm is
through the quick identification of an underlying reversible cause and correct treatment. As you
use the algorithm to manage the PEA patient, remember to consider all the H's and T's,
particularly hypovolemia, which is the most common cause of PEA. Also look for drug
overdoses or poisonings.

Begin with the primary survey to assess the patient's condition:

1. Pulseless Electrical Activity (PEA) occurs when you see a rhythm on the monitor that
would normally be associated with a pulse, however the patient is pulseless.

2. The rhythm can be anything, at any heart rate

3. There is something preventing the heart from generating a pulse, such as being empty
(Hypovolemia) something pushing against it (Tamponade)

4. Re-assess the patient frequently for the return of pulses

Follow the ACLS Pulseless Arrest Algorithm
1. Begin CPR as soon as pulselessness is recognized. Continue CPR at a rate of 100 to 120
per minute throughout the resuscitation without interuptions of more than 10 seconds to
evaluate for pulses.

2. Compressors should be switched every 2 minutes to ensure efficacy of compressions

3. Ventilate the patient using a Bag Valve Mask (or advanced airway if already in place) at
a rate of 10 per minute
 4. Waveform capnography should be utilized to monitor efficacy of compressions (should
generate at least 10) and the return of pulses (will cause an increase in capnography to
40)

5. Obtain IV/IO access

6. Administer Epinephrine 1 mg IV/IO every 3-5 minutes

7. Find and treat underlying causes.

Two management priorities are maintaining high quality CPR and searching simultaneously for a
treatable cause of the patient's PEA. Stop CPR only when absolutely necessary for pulse and
rhythm checks. Establishing IV/IO access is a priority over advanced airway management. If an
advanced airway is placed, change to continuous chest compressions without pauses for breaths.
Give 10 breaths per minute and check rhythm every 2 minutes.

Pulseless Arrest Algorithm for Managing VF

and Pulseless VT
Jan 6, 2017

Version control: This document is current with respect to 2015 American Heart Association
Guidelines for CPR and ECC. These guidelines are current until they are replaced on October
2020. If you are reading this page after October 2020, please contact ACLS Training Center at
support@acls.net for an updated document.

PDF Version
 Post-arrest

Order the full set of

printed crash cart cards

Order now $40

Using the Pulseless Arrest Algorithm for Managing VF and

Pulseless VT
The ACLS Pulseless Arrest Algorithm is the most important algorithm to know when
resuscitating adults. The algorithm steps through the assessment and management of a patient
with no pulse who does not respond to the interventions of the primary survey, including an
initial shock from an automated external defibrillator (AED). Pulseless VT is included in the
algorithm with VF. For treatment purposes, pulseless VT is treated the same as ventricular
fibrillation

The Pulseless Arrest Algorithm picks up after the primary

survey has already been conducted:
The emergency response system has been activated
 CPR is being performed

An AED has been attached

The first shock has been given

Steps
Maintain CPR. Interrupt chest compressions only for ventilation, rhythm checks, and actual
shock delivery. CPR should never be interrupted for more than 10 seconds. Remind team
members that they can prepare the drugs used ahead of time and minimize patient's time without
CPR.

1. Begin 5 cycles of CPR (approximately 2 minutes) immediately after the first shock. Each
cycle contains 30 chest compressions followed by 2 breaths.

2. Attach the patient to the monitor/defibrillator and analyze the patients rhythm.

3. Check the patient's rhythm in less than 10 seconds.

Rhythm Condition Action

If non-shockable AND QRS complexes appear Check for a pulse

rhythm is present regular and narrow

If non-shockable WITH no pulse Follow treatment for PEA

rhythm is present or asystole

If a shockable rhythm WITHOUT a pulse Continue CPR while

is present defibrillator is charging

1. Continue CPR until the defibrillator has been charged.

o Turn oxygen away from the patient's chest OR turn it off.

o Make sure the source of oxygen is removed from the patient when you clear to
shock.

o Check to see that no caregivers are touching the patient.

o Shock. If using biphasic, use manufacturer recommended dosage.

 Press the shock button.

2. Immediately resume CPR for 5 cycles.

3. If IV/IO is available, administer Epinephrine 1mg IV/IO during the CPR cycle (see drug
administration in PDF file on right).

4. Check rhythm in less than 10 seconds.

5. If a shockable rhythm is present, give 1 shock.

o Continue CPR while the defibrillator is charging.

o Clear the patient for shock .

o Deliver the shock.

o Resume CPR immediately after shock, 5 cycles.

Following the sequence in the algorithm is the best scientific approach to restore spontaneous
circulation.

Using the ACLS Bradycardia Algorithm for Managing

Bradycardia
The ACLS Bradycardia Algorithm outlines the steps for assessing and managing a patient who
presents with symptomatic bradycardia. It begins with the decision that the patient's heart rate is
< 60 bpm and symptomatic.

Steps
1. Decision: Heart rate is < 60 bpm and is symptomatic.

2. Assess and manage the patient using the primary and secondary surveys:

o Maintain patent airway.

o Assist breathing as needed.

o Give oxygen if oxygen saturation is less than 94% or the patient is short of breath

o Monitor blood pressure and heart rate.

o Obtain a 12-lead ECG.

 o Review patient's rhythm.

o Establish IV access.

o Take a problem-focused history and physical exam.

o Search for and treat possible contributing factors.

3. Answer two questions to help you decide if the patient's signs and symptoms of poor
perfusion are caused by the bradycardia (see Figure 2).

o Are the signs or symptoms serious, such as hypotension, pulmonary congestion,

dizziness, shock, ongoing chest pain, shortness of breath, congestive heart failure,
weakness or fatigue, or acute altered mental status?

o Are the signs and symptoms related to the slow heart rate?

4. There may be another reason for the patients symptoms other than the slow heart rate.

5. Decide whether the patient has adequate or poor perfusion, since the treatment sequence
is determined by the severity of the patient's clinical presentation.

o If perfusion is adequate, monitor and observe the patient.

o If perfusion is poor, move quickly through the following actions:

Prepare for transcutaneous pacing. Do not delay pacing. If no IV is

present pacing can be first.

Consider administering atropine 0.5 mg IV if IV access is available Repeat

every 3 to 5 minutes up to 3mg or 6 doses.

If the atropine is ineffective, begin pacing.

Consider epinephrine or dopamine while waiting for the pacer or if pacing

is ineffective.

Epinephrine 2 to 10 g/min

Dopamine 2 to 10 g/kg per minute

Progress quickly through these actions as the patient could be in pre-cardiac arrest and need
multiple interventions done in rapid succession: pacing, IV atropine, and infusion of dopamine or
epinephrine.
Using the ACLS Tachycardia Algorithm for Managing
Unstable Tachycardia
Two keys to managing patients with unstable tachycardia are, first, quickly recognizing that the
patient has significant symptoms and is unstable, and second, quickly recognizing that the patient's
signs and symptoms are caused by the tachycardia. You need to decide if the tachycardia is
producing the hemodynamic instability and serious signs and symptoms or if the signs and
symptoms are producing the tachycardiafor example, the pain and distress of an acute MI could
be causing the tachycardia. Making this decision can be difficult. Generally, a heart rate between
100 bpm and approximately 150 bpm is usually caused by an underlying process that is represented
as sinus tachycardia (see Stable Tachycardia module for more information on sinus tachycardia).
Heart rates > 150 bpm may be symptomatic. The higher the rate, the more likely the symptoms are a
result of the tachycardia. Underlying heart disease or other problems can cause symptoms at lower
heart rates. Keep in mind the following considerations:

If the patient is seriously ill or has cardiovascular disease, the patient may have symptoms at
lower rates

If the patient's heart rate is above 150 bpm and the patient is unstable (has symptoms),
cardioversion is often required.

Sinus tachycardia is always a compensatory response to an underlying condition that

creates a need for increased cardiac output. Sinus tachycardia does not respond to
cardioversion, and a shock may actually increase the patient's heart rate. The treatment for
sinus tachycardia is aimed at fixing the underlying cause, such as relieving pain, replacing
volume, or relieving axiety.

Overview
The ACLS Tachycardia Algorithm is organized around the following questions:

1. Is the patient stable or unstable?

2. Is the QRS wide or narrow?

3. Is the ventricular rhythm regular or irregular?

Steps
Does the patient have a pulse? If no, the patients rhythm is PEA and should be treated as
such.

If yes:

Assess the patient using the primary and secondary surveys:

1. Check airway, breathing, and circulation.

2. Give oxygen if the oxygen saturation is less than 94% or the patient is short of breath.

3. Perform a 12 Lead ECG if the patient is stable.

4. Identify rhythm.

5. Check blood pressure.

6. Identify and treat reversible causes if the rhythm is sinus tachycardia.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember: Rate-related symptoms are uncommon if heart rate is less than 150 bpm.

If the signs and symptoms continue after you have given oxygen and supported the airway and
circulation AND if significant symptoms are due to the tachycardia, then the tachycardia is
UNSTABLE and immediate cardioversion is indicated.

If you determine that the patient has an unstable tachycardia, perform immediate synchronized
cardioversion. This is not a decision to take lightly as it carries with it a significant risk of stroke.

1. Start an IV.

2. Give sedation if the patient is conscious.

3. Do not delay cardioversion.

4. Consider expert consultation.

If you determine that the patient has a stable tachycardia, start an IV and obtain a 12-lead ECG

For a patient with a stable tachycardia, decide if the QRS complex is wide or narrow and if the
rhythm is regular.
Patient has Treatment

Narrow (< 0.12 sec) QRS complex Try vagal maneuvers

Regular rhythm Give adenosine 6 mg rapid IV push

Repeat 12 mg dose once if necessary

Does the patient's rhythm convert? If it does, the rhythm was atrial in origin. The conversion of a
rhythm by Adenosine is considered diagnostic of atrial arrhythmia. At this point you watch for a
recurrence. If the tachycardia resumes, treat with adenosine or longer-acting AV nodal blocking
agents, such as diltiazem or beta-blockers.

Patient has Treatment

Narrow (< 0.12 Consider expert consultation

sec) QRS
complex

Irregular rhythm Control patient's rate with diltiazem or beta-blockers. Use beta-
blockers with caution for patients with pulmonary disease or
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial fibrillation, possible
atrial flutter, or multi-focal atrial tachycardia.

Patient has Treatment

Wide (>0.12 sec) Expert consultation is advised.

QRS complex

Regular rhythm Expert consultation advised.

If patient is in Amiodarone 150 mg IV over 10 min; repeat as needed to

ventricular maximum dose of 2.2 g in 24 hours Prepare for elective
tachycardia or synchronized cardioversion. The half life of Amiodarone is very
uncertain rhythm long. If possible consult a Cardiologist before using in a stable
patient. Another choice would be to use Procainamide.

If patient is in SVT Adenosine 6 mg rapid IV push If no conversion, give 12 mg rapid

with aberrancy IV push; may repeat 12 mg dose once

Patient has Treatment

Wide (> 0.12) QRS complex

Irregular rhythm Seek expert consultation

If pre-excited atrial fibrillation Avoid AV nodal blocking agents such as adenosine,

(AF + WPW) digoxin, diltiazem, verapamil

Consider amiodarone 150 mg IV over 10 min

If recurrent polymorphic VT Seek expert consultation

If torsades de pointes Seek expert consultation

You may not always be able to tell from the ECG whether the rhythm is ventricular or
supraventricular. Most wide-complex tachycardias originate in the ventricles (particularly if the
patient is older or has underlying heart disease). If the patient does not have a pulse, treat the
rhythm as ventricular fibrillation and follow the Pulseless Arrest Algorithm.

If the patient is unstable and has a wide-complex tachycardia, assume the rhythm is VT until you can
prove otherwise.

Using the ACLS Tachycardia Algorithm for Managing

Stable Tachycardia
The key to managing a patient with any tachycardia is to check if pulses are present, decide if the
patient is stable or unstable, and then treat the patient based on the patient's condition and rhythm. If
the patient does not have a pulse, follow the ACLS Pulseless Arrest Algorithm. If the patient has a
pulse, manage the patient using the ACLS Tachycardia Algorithm.

Definition of Stable Tachycardia

For a diagnosis of stable tachycardia, the patient meets the following criteria:

The patient's heart rate is greater than 100 bpm.

The patient does not have any serious signs or symptoms as a result of the increased heart
rate.

Overview
Find out if significant symptoms are present. Evaluate the symptoms and decide if they are caused
by the tachycardia or other systemic conditions. Use these questions to guide your assessment:

Does the patient have symptoms?

Is the tachycardia causing the symptoms?

Is the patient stable or unstable?

Is the QRS complex narrow or wide?

Is the rhythm regular or irregular?

Is the rhythm sinus tachycardia?

Guidelines
Situation Assessment and Actions

Patient has significant signs or symptoms of The tachycardia is unstable. Immediate

tachycardia AND they are being caused by cardioversion is indicated.
the arrhythmia.

Patient has a pulseless ventricular Follow the Pulseless Arrest Algorithm.

tachycardia. Deliver unsynchronized high-energy
 shocks.

Patient has polymorphic ventricular Treat the rhythm as ventricular

tachycardia AND the patient is unstable. fibrillation. Deliver unsynchronized high-
energy shocks.

Steps for Managing Stable Tachycardia

Does the patient have a pulse?

Yes, the patient has a pulse. Complete the following:

1. Assess the patient using the primary and secondary surveys.

2. Check the airway, breathing, and circulation

3. Give oxygen and monitor oxygen saturation.

4. Get an ECG.

5. Identify rhythm.

6. Check blood pressure.

7. Identify and treat reversible causes.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember: Rate-related symptoms are uncommon if heart rate is < 150 bpm.

Yes, the patient is stable. Take the following actions:

1. Start an IV.

2. Obtain a 12-lead ECG or rhythm strip.

Is the QRS complex wide or narrow?

Patient Treatment

The patient's QRS is Try vagal maneuvers. Give adenosine 6 mg rapid IV push. If
narrow and rhythm is patient does not convert, give adenosine 12 mg rapid IV push.
regular. May repeat 12 mg dose of adenosine once.

Does the patient's rhythm convert? If it does, it was probably reentry supraventricular tachycardia. At
this point you watch for a recurrence. If the tachycardia resumes, treat with adenosine or longer-
acting AV nodal blocking agents, such as diltiazem or beta-blockers.

Patient Treatment

The patient's QRS is Consider an expert consultation.

narrow (< 0.12 sec).

The patient's rhythm Control patient's rate with diltiazem or beta-blockers. Use beta-
is irregular. blockers with caution for patients with pulmonary disease or
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial fibrillation, possible
atrial flutter, or multi-focal atrial tachycardia.

Patient Treatment

Patient's rhythm has wide (> 0.12 Expert consultation is advised.

sec) QRS complex AND Patient's
rhythm is regular.

Patient is in ventricular tachycardia Amiodarone 150 mg IV over 10 min; repeat as

or uncertain rhythm. needed to maximum dose of 2.2 g in 24 hours.
Prepare for elective synchronized cardioversion.

Patient is in supraventricular Adenosine 6 mg rapid IV push If no conversion,

tachycardia with aberrancy. give adenosine 12 mg rapid IV push; may repeat
12 mg dose once.

Patient's rhythm has wide (> 0.12) Seek expert consultation.

QRS complex AND Patient's
rhythm is irregular.

If pre-excited atrial fibrillation Avoid AV nodal blocking agents such as

(Atrial Fibrillation in Wolff- adenosine, digoxin, diltiazem, verapamil.
Parkinson-White Syndrome)

Consider amiodarone 150 mg IV over 10 min.

Patient has recurrent polymorphic Seek expert consultation,

VT

If patient has torsades de pointes Give magnesium (load with 1-2 g over 5-60 min;
rhythm on ECG then infuse.

Caution: If the tachycardia has a wide-complex QRS and is stable, consult with an expert.
Management and treatment for a stable tachycardia with a wide QRS complex and either a regular
or irregular rhythm should be done in the hospital setting with expert consultation available.
Management requires advanced knowledge of ECG and rhythm interpretation and anti-arrhythmic
therapy.

Considerations:
You may not be able to distinguish between a supraventricular wide-complex rhythm and a
ventricular wide-complex rhythm. Most wide-complex tachycardias originate in the ventricles.

If the patient becomes unstable, proceed immediately to treatment. Do not delay while you
try to analyze the rhythm.

If the patient becomes unstable, proceed immediately to treatment. Do not delay while you
try to analyze the rhythm.

Using the ACLS Tachycardia Algorithm for Managing

Stable Tachycardia
The key to managing a patient with any tachycardia is to check if pulses are present, decide if the
patient is stable or unstable, and then treat the patient based on the patient's condition and rhythm. If
the patient does not have a pulse, follow the ACLS Pulseless Arrest Algorithm. If the patient has a
pulse, manage the patient using the ACLS Tachycardia Algorithm.

Definition of Stable Tachycardia

For a diagnosis of stable tachycardia, the patient meets the following criteria:

The patient's heart rate is greater than 100 bpm.

The patient does not have any serious signs or symptoms as a result of the increased heart
rate.
The patient has an underlying cardiac electrical abnormality that is generating the
arrhythmia.

Overview
Find out if significant symptoms are present. Evaluate the symptoms and decide if they are caused
by the tachycardia or other systemic conditions. Use these questions to guide your assessment:

Does the patient have symptoms?

Is the tachycardia causing the symptoms?
Is the patient stable or unstable?
Is the QRS complex narrow or wide?
Is the rhythm regular or irregular?
Is the rhythm sinus tachycardia?

Guidelines
Situation Assessment and Actions

Patient has significant signs or symptoms of The tachycardia is unstable. Immediate

tachycardia AND they are being caused by cardioversion is indicated.
the arrhythmia.

Patient has a pulseless ventricular Follow the Pulseless Arrest Algorithm.

tachycardia. Deliver unsynchronized high-energy
shocks.

Patient has polymorphic ventricular Treat the rhythm as ventricular

tachycardia AND the patient is unstable. fibrillation. Deliver unsynchronized high-
energy shocks.
Steps for Managing Stable Tachycardia
Does the patient have a pulse?
Yes, the patient has a pulse. Complete the following:

1. Assess the patient using the primary and secondary surveys.

2. Check the airway, breathing, and circulation
3. Give oxygen and monitor oxygen saturation.
4. Get an ECG.
5. Identify rhythm.
6. Check blood pressure.
7. Identify and treat reversible causes.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember:Rate-related symptoms are uncommon if heart rate is < 150 bpm.

Yes, the patient is stable.Take the following actions:

1. Start an IV.
2. Obtain a 12-lead ECG or rhythm strip.

Is the QRS complex wide or narrow?

Patient Treatment

The patient's QRS is Try vagal maneuvers. Give adenosine 6 mg rapid IV push. If
narrow and rhythm is patient does not convert, give adenosine 12 mg rapid IV push.
regular. May repeat 12 mg dose of adenosine once.

Does the patient's rhythm convert? If it does, it was probably reentry supraventricular tachycardia. At
this point you watch for a recurrence. If the tachycardia resumes, treat with adenosine or longer-
acting AV nodal blocking agents, such as diltiazem or beta-blockers.

Patient Treatment

The patient's QRS is Consider an expert consultation.

narrow (< 0.12 sec).
The patient's rhythm Control patient's rate with diltiazem or beta-blockers. Use beta-
is irregular. blockers with caution for patients with pulmonary disease or
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial fibrillation, possible
atrial flutter, or multi-focal atrial tachycardia.

Patient Treatment

Patient's rhythm has wide (> 0.12 Expert consultation is advised.

sec) QRS complex AND Patient's
rhythm is regular.

Patient is in ventricular tachycardia Amiodarone 150 mg IV over 10 min; repeat as

or uncertain rhythm. needed to maximum dose of 2.2 g in 24 hours.
Prepare for elective synchronized cardioversion.

Patient is in supraventricular Adenosine 6 mg rapid IV push If no conversion,

tachycardia with aberrancy. give adenosine 12 mg rapid IV push; may repeat
12 mg dose once.

Patient's rhythm has wide (> 0.12) Seek expert consultation.

QRS complex AND Patient's
rhythm is irregular.

If pre-excited atrial fibrillation Avoid AV nodal blocking agents such as

(Atrial Fibrillation in Wolff- adenosine, digoxin, diltiazem, verapamil.
Parkinson-White Syndrome)

Consider amiodarone 150 mg IV over 10 min.

Patient has recurrent polymorphic Seek expert consultation,

VT

If patient has torsades de pointes Give magnesium (load with 1-2 g over 5-60 min;
rhythm on ECG then infuse.
Caution: If the tachycardia has a wide-complex QRS and is stable, consult with an expert.
Management and treatment for a stable tachycardia with a wide QRS complex and either a regular
or irregular rhythm should be done in the hospital setting with expert consultation available.
Management requires advanced knowledge of ECG and rhythm interpretation and anti-arrhythmic
therapy.

Considerations:
You may not be able to distinguish between a supraventricular wide-complex rhythm and a
ventricular wide-complex rhythm. Most wide-complex tachycardias originate in the ventricles.
If the patient becomes unstable, proceed immediately to treatment. Do not delay while you
try to analyze the rhythm.
If the patient becomes unstable, proceed immediately to treatment. Do not delay while you
try to analyze the rhythm.

Using the Suspected Stroke Algorithm for Managing Acute

Ischemic Stroke
The ACLS Suspected Stroke Algorithm emphasizes critical
actions for out-of-hospital and in-hospital care and treatment.

National Institute of Neurological Disorders and Stroke Critical

Time Goals
Included in the algorithm are critical time goals set by the National Institute of Neurological Disorders
(NINDS) for in-hospital assessment and management. These time goals are based on findings from
large studies of stroke victims:
Immediate general assessment by a stoke team, emergency physician, or other
expert within 10 minutes of arrival, including the order for an urgent CT scan

Neurologic assessment by stroke team and CT scan performed within 25 minutes of

arrival

Interpretation of CT scan within 45 minutes of ED arrival

Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours
from onset of symptoms. rTpa can be administered in well screened patients who are at
low risk for bleeding for up to 4.5 hours.

Door-to-admission time of 3 hours in all patients

Algorithm Steps
Step 1
Identify signs of a possible stroke.

Facial Droop (have patient show teeth or smile)

Arm Drift (patient closes eyes and extends both arms straight out, with palms up for 10
seconds)
Abnormal Speech (have the patient say you cant teach an old dog new tricks)

If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

Step 2
Call 911 immediately (activate EMS system). This is an important step because EMS responders
can transport the patient to a hospital that provides acute stroke care and notify the hospital that the
patient is coming. The hospital staff can then prepare for efficient evaluation and management of the
patient. Currently, half of all stroke victims are driven to the ED by family members or friends.

Step 3
Complete the following assessments and actions.

Assessment Actions

Define and recognize Support the ABC's (airway, breathing, and circulation).
the signs of stroke.

Assess the patient Give oxygen as needed.

using the CPSS or the
LAPSS.
Establish last known Last Known Well Time: set the time when the patient was
well time last known to be neurologically normal. If the patient was
sleeping and wakes up with symptoms, time last know well
(LKW)is the last time the patient was seen to be normal.

Consider triage to a Transport the patient quickly.

stroke center, if
possible.

Assess neurological Bring a family member or witness to confirm last known well
status while the patient
is being transported.

Alert the receiving hospital.

Check glucose levels.

General Assessment in the ED

NINDS time goal: 10 min

Step 4
Within 10 minutes of the patient's arrival in the ED, take the following actions:

Actions

Assess circulation, airway, breathing and evaluate vital signs.

Give oxygen if patient is hypoxemic (less than 94% saturation). Consider oxygen is
patient is not hypoxemic.

Make sure that an IV has been established.

Take blood samples for blood count, coagulation studies, and blood glucose. Check
the patient's blood glucose and treat if indicated. Give dextrose if the patient is
hypoglycemic. Give insulin if the patient's serum glucose is more than 300. Give
thiamine if the patient is an alcoholic or malnourished.

Assess the patient using a neurological screening assessment, such as the NIH Stroke
Scale (NIHSS).

Order a CT brain scan without contrast and have it read quickly by a qualified
specialist.

Obtain a 12-lead ECG and assess for arrhythmias.

Do not delay the CT scan to obtain the ECG. The ECG is taken to identify a recent or
ongoing acute MI or arrhythmia (such as atrial fibrillation) as a cause of embolic stroke.
Life-threatening arrhythmias can happen with or follow a stroke.

Immediate Neurological Assessment by Stroke Team

NINDS time goal: 25 min

Step 5
Within 25 minutes of the patient's arrival, take the following actions:

Actions

Review the patient's history, including past medical history.

Perform a physical exam.

Establish last known well if not already done.

Perform a neurological exam to assess patient's status using the NIHSS or the
Canadian Neurological Scale.
The CT scan should be completed within 25 minutes from the patient's arrival in the ED
and should be read within 45 minutes.

Treatment Decisions by Specialist

NINDS time goal: 45 min

Step 6
Within 45 minutes of the patient's arrival, the specialist must decide, based on the CT scan or MRI, if
a hemorrhage is present.

Take these actions if a Take these actions if a hemorrhage is NOT

hemorrhage is present present

Note that the patient is not a Decide if the patient is a candidate for
candidate for fibrinolytics. fibrinolytic therapy.

Arrange for a consultation with a Review criteria for IV fibrinolytic therapy by

neurologist or neurosurgeon. using the fibrinolytic checklist (see Figure 1).

Consider transfer, if available. Repeat the neurological exam (NIHSS or

Canadian Neurological Scale).

If the patient is rapidly improving and moving to normal, fibrinolytics may not be necessary.

Treatment
NINDS time goal: 60 min

If the patient is a candidate for fibrinolytic therapy, review the risks and benefits of therapy with the
patient and family (the main complication of IV tPA is intracranial hemorrhage) and give tissue
plasminogen activator (tPA).

Do not give anticoagulants or antiplatelet treatment for 24 hours after tPA until a follow-up CT scan
at 24 hrs does not show intracranial hemorrhage.

If the patient is NOT a candidate for fibrinolytic therapy, give the patient aspirin.
For both groups (those treated with tPA and those given aspirin), give the following basic stroke
care:

Begin stroke pathway.

Support patient's airway, breathing, and circulation.

Check blood glucose.

Watch for complications of stroke and fibrinolytic therapy.

Transfer patient to intensive care if indicated.

Patients with acute ischemic stroke who are hypoglycemic tend to have worse clinical outcomes, but
there is no direct evidence that active glucose control improves outcomes. Consider giving IV or
subcutaneous insulin to patients whose serum glucose levels are greater than 10 mmol/L (about 200
mg/dL).

Inclusion criteria Exclusion criteria Exclusion criteria

Age: 18 yrs or Evidence of intracranial Active internal bleeding or

older hemorrhage from CT scan acute trauma, such as a
fracture

Diagnosis of an Clinical presentation suggestive of Acute bleeding diathesis,

ischemic stroke a subarachnoid hemorrhage, even including the following but
with neurologic with normal CT may include other
deficit manifestations:

Time from onset Evidence of multilobar infarction in Intraspinal surgery, serious

of symptoms is more than one-third of the cerebral head trauma, or previous
within 3 hours hemisphere on CT stroke within the past 3
months
 History of intracranial hemorrhage Arterial puncture at a non-
compressible site within the
past 7 days

Uncontrolled hypertension based

on repeated measurements of >
185 mm Hg systolic pressure or >
110 mm Hg diastolic pressure

Known AV malformation,
neoplasm, or aneurysm

Witnessed seizure at stroke onset

Relative Contraindications/Precautions
Relative Contraindications/Precautions

Minor or rapidly improving stroke symptoms

Major surgery or serious trauma within the past 14 days

Recent gastrointestinal or urinary tract hemorrhage within the past 3 weeks

Post-myocardial infarction pericarditis

Recent acute myocardial infarction within the past 3 months

Abnormal blood sugar level < 50 mg/dl or > 400 mg/dl

Platelet count < 100,000/mm3

Heparin received within 48 hours prior to onset of stroke, with elevated activated partial
thromboplastin time (aPTT)

Current use of anticoagulant (e.g., warfarin) with an elevated international normalized ratio
(INR) > 1.7
Complications. The major complication of IV tPA is intracranial hemorrhage. Other bleeding
complications, ranging from minor to severe, may also happen. Angioedema and transient
hypotension also can occur.

Research. Several studies have shown that good to excellent outcomes are more likely when tPA is
given to adults with acute ischemic stroke within 3 hrs of onset of symptoms. However, these results
happened when tPA was given in hospitals with a stroke protocol that adheres closely to the
therapeutic regimen and eligibility requirements of the NINDS protocol. Evidence from prospective
randomized studies in adults documented a greater likelihood of benefit the earlier treatment begins.

Managing Hypertension in tPA Candidates

For patients who are candidates for fibrinolytic therapy, you need to control their blood pressure to
lower their risk of intracerebral hemorrhage following administration of tPA. See the general
guidelines in Figure 2.

Figure 2. Management guidelines for elevated blood pressure in patients with acute ischemic stroke

Candidates NOT eligible for fibrinolytic therapy

Blood Treatment
pressure
level, mm Hg

Systolic 220 Observe patient unless there is other end-organ involvement. Treat
or diastolic the patient's other symptoms of stroke (headache, pain, nausea, etc).
120 Treat other acute complications of stroke, including hypoxia,
increased intracranial pressure, seizures, or hypoglycemia.

Systolic > 220 Labetalol 10 to 20 mg IV for 12 minmay repeat or double every 10

or diastolic min to a maximum dose of 300 mg OR Nicardipine 5 mg/hr IV
121 to 140 infusion as initial dose; titrate to desired effect by increasing 2.5
mg/hr every 5 min to max of 15 mg/hr Aim for a 10% to 15%
reduction in blood pressure

Diastolic > 140 Nitroprusside 0.5 g/kg per min IV infusion as initial dose with
 continuous blood pressure monitoring

Aim for a 10% to 15% reduction in blood pressure

Stroke patients eligible for a fibrinolytic

PRETREATMENT

Systolic > 185 or Labetalol 10 to 20 mg IV for 12 minmay repeat 1 time or

diastolic > 110 nitropaste 12 inches

During or after
TREATMENT

Monitor blood Check blood pressure every 15 min for 2 hrs, then every 30
pressure min for 6 hrs, and finally every hr for 16 hrs

Diastolic > 140 Sodium nitroprusside 0.5 g/kg per minute IV infusion as
initial dose and titrate to desired blood pressure

Systolic > 230 or Labetalol 10 mg IV for 12 minmay repeat or double every

diastolic 121 to 140 10 min to maximum dose of 300 mg or give initial labetalol
dose and then start labetalol drip at 2 to 8 mg/min OR
Nicardipine 5 mg/hr IV infusion as initial dose and titrate to
desired effect by increasing 2.5 mg/hr every 5 min to
maximum of 15 mg/hr; if blood pressure is not controlled by
nicardipine, consider sodium nitroprusside

Systolic 180 to 230 or Labetalol 10 mg IV for 12 minmay repeat or double every

diastolic 105 to 120 10 to 20 min to a maximum dose of 300 mg or give initial
labetalol dose, then start labetalol drip at 2 to 8 mg/min