Advanced Cardiac Life Support (ACLS, 2015 Guidelines)

Cardiac Arrest Algorithm

ACLS


Bradycardia

  • Definition: HR <50 + associated symptoms (hypotension, altered mental status, shock, chest pain, congestive heart failure)
  • Treat Reversible Causes
    • Metabolic Acidosis
    • Hypovolemia
    • Hypoxia
    • Hypokalemia/Hyperkalemia
    • Hypothermia
    • Hypoglycemia
    • Tension Pneumothorax
    • Tamponade
    • Intoxication
    • Pulmonary Embolism
    • Acute Myocardial Infarction
    • Trauma
  • Atropine (see Atropine, [[Atropine]])
    • Physiology: vagolytic
    • Dose: 0.5 mg IV q3-5 min (via ETT: 2 mg in 10 ml normal saline)
      • Max Dose: 3 mg IV
    • Contraindications
      • Heart Transplant: heart transplants lack vagal innervation
  • Chronotropic Therapies
    • Transcutaneous Pacing
    • Dopamine Drip (see Dopamine, [[Dopamine]])
    • Epinephrine Drip (see Epinephrine, [[Epinephrine]])

Tachycardia (HR >150 with Associated Pulse)

Narrow-Complex

Regular (SVT, A-Flutter)

  • Stable
    • Carotid Massage
    • If Regular
      • Adenosine (see Adenosine, [[Adenosine]]): 6 mg -> 12 mg via peripheral IV
        • Use initial dose 50% less if given via central venous catheter, heart transplant, tegretol, dipyridamole
    • Beta Blockers (see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]])
      • Metoprolol (see Metoprolol, [[Metoprolol]]): 5 mg IV
    • Calcium Channel Blockers (see Calcium Channel Blockers, [[Calcium Channel Blockers]])
      • Diltiazem (see Diltiazem, [[Diltiazem]]): 5 mg IV
  • Unstable
    • Consider Adenosine (see Adenosine, [[Adenosine]]): 6 mg -> 12 mg via peripheral IV
      • Use initial dose 50% less if given via central venous catheter, heart transplant, tegretol, dipyridamole
    • Synchronized Cardioversion: Biphasic 50-100 J

Irregular (AF, MAT, Occasionally A-Flutter)

Wide-Complex

Regular (VT, SVT with Aberrancy)

  • Stable (VT, SVT with Aberrancy)
    • Only If Regular + Monomorphic: Adenosine (see Adenosine, [[Adenosine]]) 6 mg -> 12 mg via peripheral IV
      • Use initial dose 50% less if given via central venous catheter, heart transplant, tegretol, dipyridamole
    • Amiodarone (see Amiodarone, [[Amiodarone]]): 150 mg Over 10 min (max: 2.2 g/24 hrs) -> Drip 1 mg/min x 6 hrs, then 0.5 mg/min x 18 hrs
  • Unstable (Usually VT)
    • Synchronized Cardioversion: 100 J

Irregular (AF with Aberrrancy, AF with WPW, Torsade)

  • Stable
    • If Known AF with Aberrancy
      • Metoprolol (see Metoprolol, [[Metoprolol]]): 5 mg IV
      • Diltiazem (see Diltiazem, [[Diltiazem]]): 5 mg IV
    • If Torsades: Magnesium Sulfate (MgSO4) (see Magnesium Sulfate, [[Magnesium Sulfate]]): 1-2 IV over 1-2 min
    • If Unknown or AF with WPW: Amiodarone (see Amiodarone, [[Amiodarone]]) 150 mg over 10 min (max: 2.2 g/24 hrs) -> Drip 1 mg/min x 6 hrs, then 0.5 mg/min x 18 hrs
      • Avoid AV nodal blocking agents with irregular wide-complex tachycardia of unknown etiology (ie: possible WPW), as these can cause paradoxical increase in HR or degeneration to VF in WPW
  • Unstable
    • Defbrillate: 200 J
    • If Torsades: Magnesium Sulfate (MgSO4) (see Magnesium Sulfate, [[Magnesium Sulfate]]): 1-2 IV over 1-2 min

Multifocal Atrial Tachycardia (MAT) (see Multifocal Atrial Tachycardia, [[Multifocal Atrial Tachycardia]])

  • Not part of ACLS recommendations
  • Treat Underlying Causes
    • Lung Disease
    • Theophylline
    • Hypoxemia
    • Lactic Acidosis
    • Congestive Heart Failure (CHF)
    • Renal Failure
  • Calcium Channel Blockers (see Calcium Channel Blockers, [[Calcium Channel Blockers]]): useful
  • Amiodarone (see Amiodarone, [[Amiodarone]]): useful for cases with rapid HR
    • Type III agent with modest beta-blocking properties

Cardiopulmonary Resuscitation (CPR) Quality

  • Rate of Chest Compressions: 100-120 compressions/min
  • Depth of Chest Compressions: at least 2-2.4 in (5-6 cm)
  • Chest Compression Fraction: >60% (to avoid long interruptions in chest compressions and maximize coronary perfusion and blood flow during CPR)

Known/Suspected Opiate Intoxication (see Opiates, [[Opiates]])

  • Naloxone (Narcan) (see Naloxone, [[Naloxone]])
    • Intramuscular: xxx
    • Intranasal: xxx

Prognostic Factors During CPR

  • Low End-Tidal pCO2 In Intubated Patients After 20 min of CPR: strongly associated with failure of resuscitation
    • Not to be used in non-intubated patients
    • Not to be used in isolation to determine if resuscitation should be discontinued

Extra-Corporeal Membrane Oxygenation (ECMO)/Percutaneous Cardiopulmonary Support (CPS) (see Percutaneous Cardiopulmonary Support, [[Percutaneous Cardiopulmonary Support]])

  • May Be Considered for Select Patients with Refractory Cardiac Arrest

Use of Vasopressors During Cardiac Arrest

  • To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of VF, pulseless VT, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge
  • There is evidence, however, that the use of vasopressor agents is associated with an increased rate of return of spontaneous circulation

Endotracheal Drug Administration (Via ETT) During Cardiac Arrest

  • Generally Considered to be Inferior to Intravenous Drug Administration
  • Typical ETT Drug Dose is 2.5x the Intravenous Dose
  • Lidocaine, Epinephrine, Atropine, Naloxone, and Vasopressin are Absorbed via ETT Administration
    • There is no data regarding using amiodarone via ETT

Endotracheal Intubation During Cardiac Arrest

Timing of Intubation During CPR

  • Some Studies Demonstrate Improved Survival with Intubation in <12 min
  • Some Studies Demonstrate No Increase in Return of Spontaneous Circulation, but Improved 24 hr Survival with Intubation in <5 min

Advantages of Intubation During CPR

  • Elimination of the Need for Pauses in Chest Compressions for Ventilation
  • Potentially Improved Ventilation and Oxygenation
  • Reduction in the Risk of Aspiration
  • Ability to Use Quantitative Waveform Capnography During CPR
    • To Monitor Quality of CPR
    • To Optimize Chest Compressions
    • To Allow Detection of Return of Spontaneous Circulation During Chest Compressions or When a Rhythm Check Reveals an Organized Rhythm

Disadvantages of Intubation During CPR

  • Interruptions in Chest Compression During Intubation
  • Risk of Unrecognized Esophageal Intubation

Confirmation of Endotracheal Tube (ETT) Placement During CPR

  • Continuous Waveform Capnography: Class I Recommendation
  • Tracheal Ultrasound

References

  • Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S315-67. doi: 10.1161/CIR.0000000000000252 [MEDLINE]
  • Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S368-82. doi: 10.1161/CIR.0000000000000253 [MEDLINE]
  • Part 3: Ethical Issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S383-96. doi: 10.1161/CIR.0000000000000254 [MEDLINE]
  • Part 4: Systems of Care and Continuous Quality Improvement: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S397-413. doi: 10.1161/CIR.0000000000000258 [MEDLINE]
  • Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S414-35. doi: 10.1161/CIR.0000000000000259 [MEDLINE]
  • Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S436-43. doi: 10.1161/CIR.0000000000000260 [MEDLINE]
  • Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S444-64. doi: 10.1161/CIR.0000000000000261 [MEDLINE]
  • Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S465-82. doi: 10.1161/CIR.0000000000000262 [MEDLINE]
  • Part 9: Acute Coronary Syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S483-500. doi: 10.1161/CIR.0000000000000263 [MEDLINE]
  • Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S501-18. doi: 10.1161/CIR.0000000000000264 [MEDLINE]
  • Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S519-25. doi: 10.1161/CIR.0000000000000265 [MEDLINE]
  • Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S526-42. doi: 10.1161/CIR.0000000000000266 [MEDLINE]
  • Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S543-60. doi: 10.1161/CIR.0000000000000267 [MEDLINE]
  • Part 14: Education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S561-73. doi: 10.1161/CIR.0000000000000268 [MEDLINE]