Acls 2015 Algorithm And Anesthesia Acls.pdf

Cardiac Arrest * Circular Algorithm Shout for Help/Activate Emergency Response Start CPR Give Oxygen

Attach Monitor/Defibrillator

2 minutes

Return of Spontaneous Circulation (ROSC) Check Post-Cardiac Rhythm Arrest Care If VF/VT Shock

Drug Therapy Amiodarone for refractory VF / VT

Consider Advanced Airway Quantitative waveform capnography

Continuous CPR

uous CPR Contin

IV/IO access

Epinephrine every 3–5 minutes

Treat Reversible Causes Mo

y nitor CPR Qualit

Doses/Details for the Cardiac Arrest Algorithms CPR Quality Push hard (2” to 2.4” or 5–6cm) and fast (100–120/min) and allow complete chest recoil. Minimize interrruptions in compressions.** Avoid excessive ventilation Rotate compressor every 2 minutes If no advanced airway, 30:2 compression-ventilation ratio Quantative waveform capnography If PETCO2<10mm Hg, attempt to improve CPR quality If relaxation phase(diastolic) pressure<20mm Hg, attempt to improve CPR quality.

Drug Therapy Epinephrine IV/IO Dose: 1 mg every 3–5 minutes Amiodarone IV/IO Dose***: First dose: 300 mg bolus Second dose: 150 mg

Advanced Airway**** Supraglottic advanced airway or endotracheal intubation Waveform capnography to confirm and monitor ET tube placement 10 breaths per minute with continuous chest compressions

Return of Spontaneous Circulation(ROSC) Pulse and blood pressure Abrupt sustained increase in PETCO2 (typically ≥ 40 mm Hg) Spontaneous arterial pressure waves with intra-arterial monitoring

Shock Energy Biphasic: Manufacturer recommendation (eg. initial dose of 120–200 J): if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered Monophasic: 360 J

Reversible Causes Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/Hyperkalemia Hypothermia

Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary

* Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced cardiac life support. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015 132 (suppl 2):S444-S464 ** Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB Minimally Interrupted cardiac resuscitation by emergency medical services for out of hospital cardiac arrest. JAMA 2008;299:1158-1165 ***Dorian P, Cass D, Schwartz B, Cooper R. Gelaznikas R, Barr A. Amiodarone as compared with Lidocaine for shock resistant ventricular fibrillation N Engl J Med 2002;346:884-890. **** Dorges V, Wenzel V, Knacke P, Gerlach K, Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients. Crit Care Med. 2003;31:800-804

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 [email protected] for an updated document. Version 2018.02.a

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Cardiac Arrest Algorithm Shout for Help/Activate Emergency Response Start CPR 1 2

VF/VT

3

Shock*

4

CPR 2 min IV/IO access

Give Oxygen Attach Monitor/Defibrillator

Rhyhm Shockable?

Asystole/PEA

10

9

CPR 2 min IV/IO access Epinephrine every 3–5 min Consider advanced airway, capnography

Rhythm Shockable?

12 5

Shock

If no signs of return of spontaneous circulation (ROSC), go to 10 or 11.

CPR 2 min Epinephrine every 3-5 min Consider advanced airway, capnography

6

Rhyhm Shockable?

CPR 2 min Treat reversible causes

11

If ROSC, go to PostCardiac Arrest Care.

Rhyhm Shockable?

7

Rhyhm Shockable?

Shock CPR 2 min Amiodarone Treat reversible causes

8

Go to 5 or 7

* Link MS, Atkins DL, Plassman RS, Halperin HR, SAmson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3): S706-S719. http://circ. ahajournals.org/content/122/18_suppl_3/S706

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 [email protected] for an updated document. Version 2018.02.a

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Acute Coronary Syndromes Algorithm Syndroms Suggestive of Ischemia or Infarction EMS assessment and care and hospital prepartion*

Oxygen

Aspirin 160–325 mg

(If O sat< 94% or O Sat>90% with COPD) 2

2

12–Lead ECG

Immediate ED general treatment

Concurrent ED assessment (<10 minutes)

Check Vital Signs

Activate Cardiac Cath Lab

IV Access

Cardiac Marker Levels

Chest X-ray (<30 mins)

Pain Control

Activate Cardiac Cath Lab

Physical Exam

If O2 sat<94% Start Oxygen

Aspirin 160–325 mg

(If not already taken)

Pain Control

Nitroglycerin Sublingual or spray

12–Lead ECG

ECG Interpretation**

High-risk unstable angina/non-ST-elevation MI (UA/NSTEMI)

ST-elevation MI (STEMI) Start adjunctive therapies as indicated Do not delay reperfusion

Time from onset of symptoms

≤ 12 hours?

Troponin elevated or high-risk patient

>12 hours

Consider early invasive strategy if: Refractory ischemic chest discomfort Recument/persistent ST deviation Ventricular tachycardia Hemodynamic instability Signs of heart failure

Low-/Intermediate-risk ACS Consider admission to ED chest pain unit or to appropriate bed and follow: Serial cardiac markers (including troponin) Repeat ECG/continuous ST-segment monitoring Consider noninvasive diagnostic test

Develops 1 or more: Clinical high-risk features Dynamic ECG chages consistent with ischemia Troponin elevated

Start adjunctive treatments as indicated ≤12 hours

Reperfusion goals: Door-to-balloon inflation (PCI)*** goal of 90 minutes Door-to-needle (fibrinolysis) goal of 30 minutes

Nitroglycerin Heparin (UFH or LMWH) Consider: PO β-blockers Consider: Clopidogrel Consider: Glycoprotein llb/llla inhibitor

Admit to monitored bed Assess risk status Continue ASA heparin, and other therapies as indicated ACE inhibitor/ARB; HMG CoA reductase inhibitor (statin therapy) Not at high risk: cardiology to risk stratity

Abnormal diagnostic noninvasive imaging or physiologic testing?

If no evidence of ischemia or infarction by testing, can discharge with follow-up

* O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannopoulos D. “Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S787-S817. http://circ.ahajoumals.org/content/122/18_suppl_3/S787 **Afolabi BA, Novaro GM, Pinski SL, Fromkin KR, Bush HS. Use of the prehoapital ECG improves door to balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Emerg Med J. 2007;24:588-591 *** O’Connor, RE AL, Ali, brady , WJ, Ghaemmaghami CA, Menon V, Welsford M, shuster M. . Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132(suppl2):S483-S500

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 [email protected] for an updated document. Version 2018.02.a

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Tachycardia With a Pulse Algorithm Assess appropriateness for clinical condition. Heart rate typically ≥ 150/min if tachyarrhythmia. Identify and Treat Underlying Cause Maintain patient airway; assist breathing as necessary Oxygen (if O2 sat < 94%) Cardiac monitor to identify rhythm; monitor blood pressure and oximetry

Persistent Tachyarrhythmia Causing:

Synchronized Cardioversion* Consider sedation If regular narrow complex, consider adenosine

Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort? Acute heart failure?

Wide QRS? 0.12 second

IV access and 12–lead ECG if available. Consider adenosine only if regular and monomorphic. Consider antiarrhythmic infusion. Consider expert consultation.

IV access and 12–lead ECG if available. Vagal maneuvers. Adenosine (if regular) β-Blocker or calcium channel blocker. Consider expert consultation.

Doses/Details

Adenosine IV Dose:

Synchronized Cardioversion**

First dose : 6 mg rapid IV push;

Initial recommended doses: Narrow regular : 50–100 J Narrow irregular : 120–200 J biphasic or 200 J monophasic Wide regular : 100 J Wide irregular : Defibrillation dose (not synchronized)

follow with NS flush. Second dose : 12 mg if required

Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia Procainamide IV Dose:

Amiodarone IV Dose: First dose : 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours.

Sotalol IV Dose: 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases > 50% or maximum dose 17 mg/kg given. Maintenance infusion: 1–4 mg/min. Avoid if prolonged QT or CHF.

* Link MS, Atkins DL, Passman RS, Halperin HR, SAmson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerbenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3): S706-S719. http://circ.ahajournals.org/content/122/18_suppl_3/S706 ** Scholten M, Szili-Torok T, Klootwijk P, Jordaens L, Comparison of monophasic and biphasic shocks for transthoracic cardioversion of atrial fibrillation. Heart 2003;89:1032-1034

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 [email protected] for an updated document. Version 2018.02.a

[email protected] © ACLS Training Center 877-560-2940 Complete your ACLS recertification online with the highest quality course at http://www.acls.net and use promo code PDF2016 during checkout for 15% off.

Bradycardia With a Pulse Algorithm Assess appropriateness for clinical condition. Heart rate typically < 50/min if bradyarrhythmia.

Identify and treat underlying cause Maintain patent airway; assist breathing as necessary* Oxygen (if hypoxemic) Cardiac monitor to identify rhythm; monitor blood pressure and oximetry IV access 12–Lead ECG if available; don’t delay therapy

Persistent bradyarrhythmia causing: Monitor and observe

Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort? Acute heart failure?

Atropine IV Dose: First dose: 0.5 mg bolus Repeat every 3–5 minutes Maximum: 3 mg

If atropine ineffective: Transcutaneous pacing** OR Dopamine IV infusion: 2–20 mcg/kg per minute OR Epinephrine IV infusion: 2–10 mcg per minute

Consider: Expert consultation Transvenous pacing * Dorges V, Wenzel V, Knacke P, Gerlach K, Comparison of different airway management strategies to ventilate apneic, nonpreoxygenated patients. Crit Care Med. 2003;31:800-804 ** Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators, defillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010; 122(suppl 3):S706-S719. http://circ.ahajournals.org/content/122/18_suppl_3/S706

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 [email protected] for an updated document. Version 2018.02.a

[email protected] © ACLS Training Center 877-560-2940 Complete your ACLS recertification online with the highest quality course at http://www.acls.net and use promo code PDF2016 during checkout for 15% off.

Immediate Post-Cardiac Arrest Care Algorithm Return of Spontaneous Circulation (ROSC)*

Optimize Ventilation and Oxygenation

Treat Hypotension (SBP < 90 mm Hg) IV/IO bolus Vasopressor infusion Consider treatable causes 12-Lead ECG

Maintain oxygen saturation 94% Consider advanced airway waveform capnography Do not hyperventilate

Follow Commands ?

Induced Hypothermia** Cardiac Catheterization Laboratory

Advanced Critical Care

Doses/Details

Epinephrine IV Infusion

Dopamine IV Infusion

Ventilation/Oxygenation

0.1–0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute)

2–20 mcg/kg per minute

Avoid excessive ventilation Start at 10 94% breaths/min and titrate to target PETCO2 of 35–40 mm Hg. When feasible, titrate FIO2 to minimum necessary to achieve SpO2 ≥ 94%.

IV Bolus 1–2 L normal saline or lactated Ringer’s. If inducing hypothermia, may use 4°C fluid.

Reversible Causes Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo-/Hyperkalemia Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary

Norepinephrine IV Infusion 0.1–0.5 mcg/kg per minute (in 70–kg adult: 7–35mcg per minute)

* Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out of hospital cardiac arrest: a systematic review and metanalysis Circ Cardiovasc Qual Outcomes. 2010;3:63-81. ** Bruel C, Parienti JJ, Marie W, Arrot X, Mild hypothermia during advanced life support, a preliminary study in out of hospital cardiac arrest. Crit Care. 2008;12: R31 *** Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132(suppl2):S465-S482

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 [email protected] for an updated document. Version 2018.02.a

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Stroke Assessment The Cincinnati Prehospital Stroke Scale Facial Droop (have patient show teeth or smile)

NORMAL

ABNORMAL

Both sides of face move equally.

One side of face does not move as well as the other side.

Arm Drift (patient closes eyes and extends both arms straight out, with palms up for 10 seconds)

NORMAL

ABNORMAL

Both arms move the same or both arms do not move at all.

One arm does not move or one arm drifts down compared with the other.

Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”) Normal - Patient uses correct words with no slurring.

Abnormal - Patient slurs words, uses the wrong words, or is unable to speak.

If any 1 of these 3 signs is abnormal, the probability of a stroke is 72% 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 [email protected] for an updated document. Version 2018.02.a

[email protected] © ACLS Training Center 877-560-2940 Complete your ACLS recertification online with the highest quality course at http://www.acls.net and use promo code PDF2016 during checkout for 15% off.

Suspected Stroke Algorithm: Goals for Management of Stroke Identify Signs and Symptoms of Possible Stroke Active Emergency Response Critical EMS assessments and actions

Support ABCs: Give Oxygen if indicated

Perform prehospital stroke assessment

Check glucose

Establish time of symptom onset (last normal)

Triage to stroke center

Alert hospital

Activate stroke team

If onset >3 hours consider triage to hospital with interventional capabilities for stroke.

NINDS TIME GOALS

Immediate general assessment and stabilization* Assess ABCs, vital signs Provide oxygen if O sat <94% Obtain IV access and perform laboratory assessments Check glucose; treat if indicated Obtain 12–lead ECG Perform neurologic screening assessment Order emergent CT without contrast

Immediate neurologic assessment by stroke team or designee

2

Review patient history Establish time of symptom onset or last known normal Perform neurologic examination (NIH Stroke Scale or Canadian Neurological Scale)

Does CT Scan Show Hemorrhage? Hemorrhage

No hemorrhage

Probably acute ischemic stroke; consider fibrinolytic therapy

Consult neurologist or neurosurgeon; consider transfer if not available.

Check fibrinolytic exclusions Repeat neurologic exam: are deficits rapidly improving to normal?

Patient remains candidate for fibrinolytic therapy?

Begin stroke or hemorrhage pathway Admit to stroke unit or intensive care unit

Not a candidate

Administer aspirin

Candidate* Review risks/benefits with patient & family. If acceptable: Give rTPA** No anticoagulants or antiplatelet treatment for 24 hours

Begin post-rTPA stroke pathway Aggressively monitor: BP per protocol For neurologic deterioration Emergent admission to stroke unit or intensive care unit

* Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F, Gentile N, Hazinski MF. “ Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitationand Emergency Cardiovascular Care” . Circulation. 2010;122(suppl 3):S818-S828. http://circ.ahajournals.org/content/122/18_suppl_3/S818 ** Tissue Plasminogen Activator for Acute Ischemic Stroke. N Engl J Med. 1995:333(24)1581-1587

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 [email protected] for an updated document. Version 2018.02.a

[email protected] © ACLS Training Center 877-560-2940 Complete your ACLS recertification online with the highest quality course at http://www.acls.net and use promo code PDF2016 during checkout for 15% off.