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ACLS

ALGORITHMS

Acute Pulmonary Edema / Hypotension / Shock Algorithm


Clinical signs of hypoperfusion, congestive heart failure, acute pulmonary edema Assess ABCs Assess vitals Secure airway Review history Administer O2 Perform physical exam Start IV 12 lead ECG, chest x-ray Attach monitor, pulse oximetry and B/P Cuff

Figure 8

What is the nature of the problem?


Volume problem Includes PVR problems
Administer Fluids Blood transfusions Cause-specific interventions Consider vasopressors

Pump Problem What is the BP ?

Rate Problem

Too Slow Go to Fig 5

Too Fast Go to Fig 6

Systolic BP < 70 Signs of shock

Systolic BP 70 - 100 mmHg Signs of shock

Systolic BP 70 - 100 mmHg No Signs of shock

Systolic BP > 100 mmHg

Bradycardia Algorithm (Patient is not in Cardiac Arrest)


Assess ABCs Assess vitals Secure airway Review history Administer O2 Perform physical exam Start IV 12 lead ECG, chest x-ray Attach monitor, pulse oximetry and B/P Cuff

Figure 5

Bradycardia, either absolute (<60 BPM) or relative

Serious signs and symptoms?a,b


No
Type II second-degree AV heart block or Third-degree AV heart Block?e

Yes

No
Observe

Yes
Prepare for transvenous pacer Use TCP as a bridge device

Intervention sequence Atropine 0.5 - 1.0 mcg,d (I and IIa) TCP, if available (I) Dopamine 5 - 20 mcg/kg/min (IIb) Epinephrine 1 - 10 mcg/min (IIb) Norepinephrine 0.5 30 mcg/min (IIb)

Tachycardia Algorithm (Patient is not in Cardiac Arrest)


Assess ABCs Assess vitals Secure airway Review history Administer O2 Perform physical exam Start IV 12 lead ECG, chest x-ray Attach monitor, pulse oximetry and B/P Cuff

Figure 6

Yes Prepare for cardioversion Unstable, with serious signs or symptoms?a No

If ventricular rate > 150 BPM May give brief trial of Rx Immediate cardioversion is seldom needed for heart rates < 150 BPM

Atrial Fibrillation Atrial Flutter

Paroxysmal Supraventricular Tachycardia (PSVT)

Wide-complex tachycardia of uncertain type

Ventricular Tachycardia (VT)

Includes Electromechanical dissociation (EMD) Postdefibrillation idioventricular rhythms Pseudo - EMD Bradyasystolic rhythms Idioventricular rhythms Ventricular escape rhythms

Pulseless Electrical Activity (PEA) Algorithm (Electromechanical Dissociation [EMD])

Figure 3

Continue CPR / Intubate at once / Obtain IV Access Assess blood flow using Doppler ultrasound, endtidal CO2, echocardiography, or arterial line
Consider possible causes Hypovolemia (volume infusion) Drug overdoses - tricyclics, digitalis Hypoxia (ventilation) Beta-blockers, calcium channel blockers Cardiac tamponade (pericardiocentesis) Hyperkalemia Tension Pneumothorax Acidosis Hypothermia ( see hypothermia algorithm) Massive acute myocardial infarction Massive pulmonary embolism (surgery, lysine) Massive acute MI (go to Fig 9)

Epinephrine 1 mg IV push,a,c repeat q 3 - 5 min


If absolute bradycardia (< 60 BPM) or relative bradycardia give atropine 1 mg IV Repeat q 3 -5 min to a total of 0.03 - 0.04 mg/kg

Asystole Treatment Algorithm

Continue CPR Intubate at once Obtain IV Access Confirm asystole in more than 1 lead

Consider possible causes Hypoxia Pre-existing acidosis Hyperkalemia Drug Overdose Hypokalemia Hypothermia

Consider immediate transcutaneous pacing (TCP)a

Figure 4
Epinephrine 1mg IV push,b,c repeat q 3 - 5 min

Atropine 1 mg IV push repeat q 3 - 5 min up to a total of 0.03 - 0.04 mg/kgd,e Consider termination of efforts

Ventricular Fibrillation (VF) Figure 2 & Pulseless Ventricular Tachycardia (VT)


ABCs Perform CPR until defibrillator Arrives VF/VT present on defibrillator

Defibrillate up to 3 times if needed for persistent VF/VT 200 J, 200 - 300 J, 360 J
Rhythm after the first 3 shocks? b

VF/VT

ROSC

PEA Go to Fig 3

Asystole Go to Fig 4

VF & Pulseless VT Continue CPR Intubate / IV Access

Figure 2

Epinephrine c,d 1 mg/IV 2 mg/ETT q 3 - 5 min


Defibrillate 360 J within 30 - 60 sec Administer Rx Class IIa probable benefit f, g Defibrillate 360 J, 30 - 60 sec after Rx