VF/Pulseless VTach

ACLS.net ACLS 2005 Ventricular Fibrillation (VF)/

Pulseless Ventricular Tachycardia (PVT) Algorithm

The following acronym directs AHA accepted actions after the Primary
ABCDs have been enacted and an AED or Manual Defibrillator arrives and a
shockable rhythm (VF or PVT) is present:
SCREAM
Letter Intervention Note
S Shock 360J* monophasic, 1st and subsequent shocks.
(Shock every 2 minutes if indicated)
C CPR After shock, immediately begin chest compressions
followed by respirations (30:2 ratio) for 2 minutes.
(Do not check rhythm or pulse)
R Rhythm Rhythm check after 2 minutes of CPR (and after every
2 minutes of CPR thereafter) and shock again if
indicated. Check pulse only if an organized or non-
shockable rhythm is present.
Implement the Secondary ABCD Survey. Continue this algorithm if indicated.
Give drugs during CPR before or after shocking. Minimize interruptions in chest
compressions to <10 seconds. Consider Differential Diagnosis.
E Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once,
in place of the 1st or 2nd dose of epi.
A Antiarrhythmic Consider antiarrhythmics. (Any Legitimate Medication)
M Medications Amiodarone 300mg IV/IO, may repeat once at 150mg
in 3-5 min. if VF/PVT persists or
Lidocaine (if amiodarone unavailable) 1.0-1.5 mg/kg
IV/IO, may repeat X 2, q5-10 min. at 0.5-0.75 mg/kg,
(3mg/kg max. loading dose) if VF/PVT persists,or
Magnesium Sulfate1-2 g IV/IO diluted in 10mL D5W
(5-20 min. push) for torsades de pointes or suspected/
known hypomagnesemia.
 .

ACLS.net ACLS 2005 Tachycardia Algorithm

The following directs AHA accepted actions after tachycardia with symptoms
due to the fast rate is discovered: Start the Secondary ABCDs with
emphasis on oxygenation, IV, VS, and EKG, and consider the following
questions:
1. Stable? Yes No, unstable = Immediate
↓ next question electrical cardioversion

2. Narrow? Yes No, wide = Consult an expert

↓ next question (QRS ≥0.12 sec)

3. Regular? Yes No, irregular = Consult an expert

↓ see mnemonic

Yes 1-2-3, think SVT, then V-A-C

↓
Vagal maneuvers, if this fails..
↓
Adenosine 6mg rapid IV p ush
(may repeat x2, q1-2min. at 12mg)
↓
Cardizem (diltiazem) managed by an expert if
stable, narrow, regular tachyarrhythmia continues

Perform immediate electrical cardioversion if a patient becomes unstable at

any time. For sinus tachycardia consider possible causes and treat
accordingly.

Consult an Expert
Most stable tachycardia rhythms require management by an expert due to
the challenge of accurately determining and safely treating
tachyarrhythmias. A sampling of rhythms and possible expert interventions
are listed below.

Stable Narrow Irregular Tachycardia

Atrial Fibrillation, Multifocal Atrial Tachycardia, possibly Atrial Flutter
Rate Control: diltiazem or beta blocker

Stable Narrow Regular Tachycardia

Recurrent SVT, Atrial Flutter, Junctional or Ectopic Atrial Tachycardia
Rate Control: diltiazem or beta blocker

Stable Wide Irregular Tachycardia

(Avoid calcium channel blockers and digoxin due to possible AF+WPW)
Consider amiodarone. Magnesium 2g IV over 5min. for torsades

Stable Wide Regular Tachycardia

If VT, amiodarone 150mg IV over 10min. repeat prn (max 2.2g IV/24hr),
elective synchronized cardioversion

`
 ACLS.net ACLS 2005 Pulseless Electrical Activity (PEA)
Algorithm

The following directs AHA accepted actions as part of the Secondary ABCDs for
pulselessness with an organized cardiac rhythm. Provide 2 minute cycles of
CPR-rhythm/pulse checks and think:
PEA
Letter Intervention
P Problem search (see Differential Diagnosis Table). Treat accordingly.
Continue this algorithm if indicated.
E Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in
place of the 1st or 2nd dose of epi.
A Atropine, with a slow heart rate, 1 mg IV/IO q3-5 min. (3mg max.)

ACLS.net ACLS 2005 Asystole Algorithm

The following directs AHA accepted actions as part of the Secondary ABCDs for
pulselessness when properly functioning equipment shows asystole. If the
patient is a candidate for resuscitation provide 2 minute cycles of CPR-rhythm
checks and think:
PEA
Letter Intervention
P Problem search (see Differential Diagnosis Table). Treat accordingly.
Continue this algorithm if indicated.
E Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in
place of the 1st or 2nd dose of epi.
A Atropine 1 mg IV/IO q3-5 min. (3mg max.)
Consider termination of efforts if asystole persists despite appropriate
interventions.
 ACLS.net Synchronized and Unsynchronized
Electrical Cardioversion

It is essential that ACLS Providers know the indications for

electrical cardioversion and receive proper training using their
equipment before attempting to perform this risky procedure.
Only experts should manage synchronized electrical
cardioversion of a stable patient.

Synchronized Electrical Cardioversion

As part of the Secondary ABCDs the following mnemonic directs
preparations for synchronized electrical cardioversion of unstable
tachycardia with circulatory compromise due to the fast rate (do not
delay shocking if seriously unstable):
Oh Say It Isn't So
Mnemonic Preparation
Oh O2 Saturation monitor
Say Suctioning equipment
It IV line
Isn't Intubation equipment
So Sedation and possibly analgesics

Synchronized Electrical Cardioversion *Energy Levels:

The initial synchronized shock is 100J monophasic (50J for SVT/A-
Flutter) with increasing energy, i.e., 200J, 300J, 360J, if successive
shocks are needed.

Unsynchronized Electrical Cardioversion

Give unsynchronized shocks at VF/PVT *energy levels without delay for
unstable tachycardia with critical circulatory compromise due to the fast
rate. Also give unsynchronized shocks if you cannot synchronize, or if
polymorphic VT is present.

If VF/PVT develops, immediately defibrillate at *360J per the VF/PVT

Algorithm.

*Or biphasic equivalent

 ACLS.net Synchronized and Unsynchronized
Electrical Cardioversion

It is essential that ACLS Providers know the indications for

electrical cardioversion and receive proper training using their
equipment before attempting to perform this risky procedure.
Only experts should manage synchronized electrical
cardioversion of a stable patient.

Synchronized Electrical Cardioversion

As part of the Secondary ABCDs the following mnemonic directs
preparations for synchronized electrical cardioversion of unstable
tachycardia with circulatory compromise due to the fast rate (do not
delay shocking if seriously unstable):
Oh Say It Isn't So
Mnemonic Preparation
Oh O2 Saturation monitor
Say Suctioning equipment
It IV line
Isn't Intubation equipment
So Sedation and possibly analgesics

Synchronized Electrical Cardioversion *Energy Levels:

The initial synchronized shock is 100J monophasic (50J for SVT/A-
Flutter) with increasing energy, i.e., 200J, 300J, 360J, if successive
shocks are needed.

Unsynchronized Electrical Cardioversion

Give unsynchronized shocks at VF/PVT *energy levels without delay for
unstable tachycardia with critical circulatory compromise due to the fast
rate. Also give unsynchronized shocks if you cannot synchronize, or if
polymorphic VT is present.
If VF/PVT develops, immediately defibrillate at *360J per the VF/PVT
Algorithm
 ACLS.net ACLS 2005 Bradycardia Algorithm

The following mnemonic directs AHA accepted actions after absolute

(<60bpm) or relative (slower rate than expected) bradycardia with circulatory
compromise due to the slow rate is discovered. Start the Secondary
ABCDs and remember:
*Pacing Always Ends Danger
Mnemonic Intervention Note
Pacing **TCP Immediately prepare for transcutaneous
pacing (TCP) with serious circulatory
compromise due to bradycardia (especially
high-degree blocks) or if atopine failed to
increase rate.
Consider medications while pacing is readied.
1st-line drug, 0.5 mg IV/IO q3-5 min.
Always Atropine
(max. 3mg)
Epinephrine 2nd-line drugs to consider if atropine and/or
Ends
2-10 µg/min TCP are ineffective. Use with extreme
caution.
Dopamine
Danger
2-10 µg/kg/min

*Pacing does not "always end danger" in bradyarrhythmias. If the above

measures do not improve circulatory stability the bradycardia may merely be
an indication of a pathological process, think Differential Diagnosis!
**Prepare for transvenous pacing (TVP), managed by an expert, if TCP fails.