Basic Life Support (BLS) Primary Survey

for Respiratory Arrest

The main focus of the BLS Primary Survey (see Figure 1) is on early CPR and early
defibrillation, if needed. For a patient in respiratory arrest, however, the focus is on
breathing and airway issues. The process is to assess the patient, and then perform an
appropriate action. Each step in the survey has an assessment and actions to follow.

Figure 1. Basic Life Support Decision Tree

Assessment Action
Is the patient breathing? Look for the rise and fall of the patient's chest.
Does the patient have a The healthcare provider can take 5-10 seconds to check
pulse? for a pulse.
When the AED arrives, place it on the patient and follow
AED
the prompts

Is the patient breathing NORMALLY? (small gasping breaths are not considered normal.
If no Pulse BEGIN COMPRESSIONS at a rate of 100/min to 120/min
If not sure if a pulse is present, BEGIN COMPRESSIONS at a rate of 100/min to 120/min
If pulse is present and breathing absent, begin ventilation at a rate of 10 per minute or once
every 6 seconds using mouth to mouth or bag valve mask.
The last step, defibrillation, is part of the primary survey, but is not required for
respiratory arrest, as the patient has a pulse for this case. Therefore the AED will advise the
user "no shock advised, continue CPR if necessary."
 ACLS Secondary Survey for a Patient
in Respiratory Arrest

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
To open the airway for unconscious patients, use the head-tilt,
Is the patient's airway chin lift. Insert an oropharyngeal airway (OPA) or a
obstructed? 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
No. If bag-mask ventilation is adequate, defer the insertion of
Is an advanced airway an advanced airway until it becomes essential (patient fails to
indicated? 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 Confirm correct placement of advanced airway device by a
airway device placed observing the patient, confirming the presence of lung sounds
properly? in at least 4 lung fields and using waveform capnography.
Secure the advanced airway device so it does not dislodge,
Is the advanced
especially in patients who are at risk for movement. Secure
airway device secured
the ET tube with tape or a commercial device. Do not use
correctly?
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 amiodarone, lidocaine, atropine) and blood pressure (eg,
rhythm or blood Dopamine or Epinephrine (used with caution as it increases
pressure 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.
 Acute Coronary Syndromes Algorithm

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.

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

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
 Using the Pulseless Arrest Algorithm for Managing PEA

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 Asystole

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.
 BLS Healthcare Provider Algorithm for Managing VF
and Pulseless VT

Using the BLS Healthcare Provider Algorithm for Managing VF and Pulseless VT
The BLS (basic life support) Primary Survey is used in all cases of cardiac arrest. For any
emergency, you first see if the patient is responsive, call EMS, and find an AED. For this
case, you assess a person without a pulse; you do not have an emergency care team to work
with you.

Initial Assessment:
Make sure the scene is safe.
Tap shoulder and ask, "Are you all right?"
If the patient does not respond, call for help. Activate EMS
Get the automated external defibrillator (AED) or send someone for it, if someone is
available.
Perform the ABCDs in the primary survey:
Breathing
Use a barrier device if you have one.
Give each breath over 1 second.
Ventilate the patient once every 6 seconds or 10 times per minute.

Airway
Watch for the patient's chest to rise and fall. Assess the patient for NORMAL
breathing.

Circulation
Check the patient's carotid pulse (take at least 5 seconds but not more than 10 seconds).
No definite pulse? Start cycles of 30 chest compressions and 2 breaths until the AED arrives.
Push hard and fast (100-120/min) and release completely.
Perform compressions at a depth of 2 inches to 2.4 inches (5-6cm).
Let the chest to completely recoil.
Minimize interruptions to less than 10 seconds.
Defibrillation using and AED
After the AED arrives, attach AED pads to the patient's chest (see AED section for
details). Turn on the AED. Follow prompts.
Is the rhythm shockable?
If the AED advises a shock, make sure bystanders or other helpers stay clear.
Give one shock.
Resume CPR immediately for 5 cycles (approximately 2 minutes). The AED will advise
you when to stop so it can analyze the rhythm. Deliver a shock if instructed to do so. Repeat
cycle of CPR. If rhythm is not shockable, resume CPR immediately for 5 cycles. Check
rhythm every 5 cycles. Continue until ALS providers take over or the patient starts to move.

Unclear if the patient has a pulse?

Begin CPR immediately. Do not waste time trying to be certain about a pulse. It is better
to begin CPR that is unnecessary than to neglect compressions when they are needed. Do
compressions on a patient with a pulse is not harmful. However, delaying CPR for a pulseless
patient reduces the patient's chances of being successfully resuscitated.
 Pulseless Arrest Algorithm for Managing VF and
Pulseless VT

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 Follow treatment for PEA or
WITH no pulse
rhythm is present asystole
If a shockable rhythm Continue CPR while
WITHOUT a pulse
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.
 ACLS Bradycardia Algorithm

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.
 ACLS Tachycardia Algorithm for Managing
Unstable Tachycardia

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
Control patient's rate with diltiazem or beta-blockers. Use beta-
Irregular rhythm 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.
Amiodarone 150 mg IV over 10 min; repeat as needed to
If patient is in
maximum dose of 2.2 g in 24 hours Prepare for elective
ventricular
synchronized cardioversion. The half life of Amiodarone is very
tachycardia or
long. If possible consult a Cardiologist before using in a stable
uncertain rhythm
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
with aberrancy rapid 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.
 ACLS Tachycardia Algorithm for Managing
Stable Tachycardia

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.
 Follow the Pulseless Arrest Algorithm.
Patient has a pulseless ventricular
Deliver unsynchronized high-energy
tachycardia.
shocks.
Treat the rhythm as ventricular
Patient has polymorphic ventricular
fibrillation. Deliver unsynchronized
tachycardia AND the patient is unstable.
high-energy shocks.

STEPS
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).
Control patient's rate with diltiazem or beta-blockers. Use beta-
The patient's rhythm
blockers with caution for patients with pulmonary disease or
is irregular.
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
sec) QRS complex AND Patient's Expert consultation is advised.
rhythm is regular.
Amiodarone 150 mg IV over 10 min; repeat as
Patient is in ventricular tachycardia
needed to maximum dose of 2.2 g in 24 hours.
or uncertain rhythm.
Prepare for elective synchronized cardioversion.
Adenosine 6 mg rapid IV push If no conversion,
Patient is in supraventricular
give adenosine 12 mg rapid IV push; may repeat
tachycardia with aberrancy.
12 mg dose once.
Patient's rhythm has wide (> 0.12)
QRS complex AND Patient's Seek expert consultation.
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.
 ACLS Suspected Stroke Algorithm

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
using the CPSS or the Give oxygen as needed.
LAPSS.
Last Known Well Time: set the time when the patient was
Establish last known last known to be neurologically normal. If the patient was
well time 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
stroke center, if Transport the patient quickly.
possible.
Assess neurological Bring a family member or witness to confirm last known
status while the patient well
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).
Repeat the neurological exam (NIHSS or
Consider transfer, if available.
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

Active internal bleeding or
Age: 18 yrs or Evidence of intracranial
acute trauma, such as a
older hemorrhage from CT scan
fracture
Diagnosis of an Acute bleeding diathesis,
Clinical presentation suggestive of a
ischemic stroke including the following but
subarachnoid hemorrhage, even
with neurologic may include other
with normal CT
deficit manifestations:
Intraspinal surgery, serious
Time from onset Evidence of multilobar infarction in
head trauma, or previous
of symptoms is more than one-third of the cerebral
stroke within the past 3
within 3 hours hemisphere on CT
months
Arterial puncture at a non-
History of intracranial hemorrhage 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
pressure Treatment
level, mm Hg
Observe patient unless there is other end-organ involvement. Treat the
Systolic 220
patient's other symptoms of stroke (headache, pain, nausea, etc). Treat
or diastolic
other acute complications of stroke, including hypoxia, increased
120
intracranial pressure, seizures, or hypoglycemia.
Labetalol 10 to 20 mg IV for 12 minmay repeat or double every
Systolic > 220 10 min to a maximum dose of 300 mg OR Nicardipine 5 mg/hr IV
or diastolic infusion as initial dose; titrate to desired effect by increasing 2.5
121 to 140 mg/hr every 5 min to max of 15 mg/hr Aim for a 10% to 15%
reduction in blood pressure
Diastolic > Nitroprusside 0.5 g/kg per min IV infusion as initial dose with
140 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 pressure Check blood pressure every 15 min for 2 hrs, then every 30
 min for 6 hrs, and finally every hr for 16 hrs
Sodium nitroprusside 0.5 g/kg per minute IV infusion as
Diastolic > 140
initial dose and titrate to desired blood pressure
Labetalol 10 mg IV for 12 minmay repeat or double
every 10 min to maximum dose of 300 mg or give initial
labetalol dose and then start labetalol drip at 2 to 8 mg/min
Systolic > 230 or
OR Nicardipine 5 mg/hr IV infusion as initial dose and
diastolic 121 to 140
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
Labetalol 10 mg IV for 12 minmay repeat or double
Systolic 180 to 230 or every 10 to 20 min to a maximum dose of 300 mg or give
diastolic 105 to 120 initial labetalol dose, then start labetalol drip at 2 to 8
mg/min