Tachycardia Algorithm

i
Screened boxes 9, 10, 11, 13, and
14 are designed for n-hospital use
TACHYCARDIA I
with expert consultaton available.

With Pulses |
2
i
Assess and support ABCs as needed
Give oxygen
Monitor ECG (dentify rhythm), blood pressure, oximetry
Identify and treat reversible causes 4
Perform immediate
rsist
5
3 y synchronized cardioversion
Establish IV access and
^ Is patient stable? ^
* Establish IV access
give sedation if patient is
Unstable signs include
Obtain 12-iead ECG
conscious; do not delay
altered mental status, ongoing
(when available)
nstabl. cardioversion
or rhythm strip

chest pain, hypotension or

Consider expert
other signs of shock
Is QRS narrow
consultation
(<0.12sec)?

Note: Rate-related
 tf pulseless arrest
V j symptoms uncommon
if heart rate <150/min
develops, see Pulseless
Arrest Algorithm
- t*0...
6 >J
'
12 *
NARROW QRS*: WIDE QRS*: Is Rhythm regular
Is Rhythm regular? Expert consultation advised
Attempt vagal
Irregular Narrow-If ventricular If atrial fibrillation with
maneuvers
Complex Tachycardia tachycardia or aberrancy
Give adenosine
Probable atrial fibrillation uncertain rhythm See Irregular Narrow

6 mg rapid IV push.
or possible atrial flutter * Amiodarone Complex Tachycardia
If no conversion,
or MAT (multifocal atnal 150 mg IV over 10 min (Box 11)
give 12 mg rapid IV
tachycardia) Repeat as needed
push; may repeat
» Cons der expert 1o maximum dose of If pre-excKed atrial
12 mg dose once
consultation 2.2 g/24 hours fibrillation (AF + WPW)
* Control rate (eg, Prepare for elective Expert consultation
a |
diltiazem, p-blockers; synchronized advised
use p-blockers with cardioversion * Avoid AV nodal
[
[
Does rhythm ^ blocking agents (eg,
convert? 1
disease or CHF) If SVT with aberrancy adenosine, digoxin,
Note: Consider 1
Give adenosine diltiazem, verapamil)
expert consultation 1
(go to Box 7) Consider antiarrhythmics
(eg, amlodarone
150 mg IV over 10 min)
« ion verts Does Not Convert
If recurrent polymorphic
VT, seek expert consultation
9 t 10 f
If torsades de pointes,

If rhythm converts, (f rhythm does NOT convert,

give magnesium
probable reentry SVT possible atrial flutter, ectoplc
(load with 1 2 g over
(reentry sitpraventricular atrial tachycardia, or
5-60 min. then infusion)
tachycardia^: junetlonal tachycardia:
Observe 'or recurrence Control rate (eg, diltiazem,
Treat recurrence with (i-biockers; use (5-blockers with
adenosine or longer-caution in pulmonary disease
acting AV nodal b ocking or CHF)
agents (eg, dilttazem, Treat under y ng cause
fS-bloekers) Consider expert consultation
During Evaluation Treat poss. ble contribi ting factors:

Secure, verify airway - Hypovole mia - Toxins

and vascular access - Hypoxia - Tamponade, cardiac
when possible ion (acidos
*Note: If patient Consider expert consu tation - Hypo-/hy ^erkatem a - Thrombosi
s (coronary
becomes unstable, Prepare for cardioversi }n - Hypoglyc emia or pulmonary)
go to Box 4.
- Hypothe - Trauma (hypovoiemia)
American Heart
Association
«*-«* AACN
AMERICAN ASSOCIATION
OF CRITICAL-CARE NURSES
Learn and Live*
Cardiac Arrest,
Arrhythmias &
Their Treatment
ACLS
ECC is a dynamic science check package insert for changes in drug doses and uses.
Bradycardia Algorithr
BRADYCARDIA
Heart rate 60 bpm and
inadequate for clinical condition

Maintain patent airway; assist breathing as needed

Give oxygen
1 Monitor ECG (identify rhythm), blood pressure, oximetry
1 Establish IV access

Signs or symptoms of poor perfusion

caused by the bradycardia?
(eg, acute altered mental status, ongoing chest pain,
hypotension or other signs of shock)
Adequate
, Perfusion Perfusion Prepare for transcutaneous pacing;
Observe/ 1
use without delay for high-degree
Monitor f

block (type II second-degree block or

third-degree AV block)
Consider atropine 0.5 mg IV while
Reminders
awaiting pacer. May repeat to a
If pulseless arrest develops, go total dose of 3 mg. If ineffective,
to Pulseless Arrest Algorithm begin pacing
* Search for and treat possible Consider epinephrine (2 to 10 ug/min)
contributing factors:
or dopamine (2 to 10 ug/kg per
- Hypovolemia
minute) infusion while awaiting pacer
- Hypoxia
or if pacing ineffective
- Hydrogen ion (acidosis)
- Hypo-/hyperkalemia
- Hypoglycemia
- Hypothermia
i
>
- Toxins
- Tamponade, cardiac
« Prepare for transvenous pacing
- Tension pneumothorax
Treat contributing causes
- Thrombosis (coronary or
Consider expert consultation
pulmonary)
- Trauma (hypovolemia,
increased ICP)
© 2006 American Heart Association 80-1092 (1 of 2) 8/06
BLS Healthcare Provider Algorithm
Pulseless Arrest Algorithm
No movement or response
PHONE 911 or emergency number
Get AED

or send second rescuer (if available) to do this

Open AIRWAY, check BREATHING
If not breathing, give 2 BREATHS that make chest rise
.1 Definite
If no response, check pulse: IDo you DEFINITELY feel I
pulse within 10 seconds? ,
Pulse Give 1 breath every
5 to 6 seconds
Recheck pulse every
2 minutes
Give cycles of 30 COMPRESSIONS and 2 BREATHS
until AED/defibril!ator arrives, ALS providers take over, or
victim starts to move
Push hard and fast (100/min) and release completely
Minimize interruptions in compressions
AED/defibrillator ARRIVES
Check rhythm
Shockable rhythm?

Give 1 shock Resume CPR immediately

Resume CPR immediately for 5 cycles
for 5 cycles Check rhythm every
5 cycles; continue until ALS
providers take over or
victim starts to move
PULSELESS ARREST
BLS Algorithm: Call for help, give CPR
Give oxygen when available
Attach monitor/defibrillator when available
( Check rhythm
~l Shockable rhythm?
Give 1 shock
Manual biphasic: device specific (typically 120 to 200 J)
Note: If unknown, use 200 J
AED: device specific
Monophasic: 360 J
Resume CPR immediately
Check rhythm
Shockafale rhythm?
Continue CPR while defibrillator is charging
Give 1 shock

Manual biphasic: device specific

(same as first shock or higher dose}
Note: If unknown, use 200 J
AED: device specific
Monophasic: 360 J
Resume CPR immediately after the shock
When IV/IO available, give vasopressor during
CPR (before or after the shock)
Epinephrine 1 mg IV/IO
Repeat every 3 to 5 min
or

May give 1 dose of vasopressin 40 U IV/IO

to replace first or second dose of epinephrine
f Check rhythm
V^Shockabte rhythm?
Continue CPR while defibriliator is charging
Give 1 shock

Manual biphasic: device specific

(same as first shock or higher dose}
Note: If unknown, use 200 J
AED: device specific
Monophasic: 360 J
Resume CPR immediately after the shock
Consider antiarrhythmics: give during CPR
(before or after the shock)
amiodarone (300 mg IV/IO once, then
consider additional 150 mg IV/IO once) or
lidocaine (1 to 1.5 mg/kg first dose then
0.5 to 0.75 mg/kg IV/IO, maximum 3 doses
or 3 mg/kg)
Consider magnesium, loading dose
1 to 2 g IV/IO for torsades de potntes
After 5 cycles of CPR,* check rhythm
Not Shockable
Asystole/PEA
Resume CPR immediately for 5 cycles
When IV/IO available, give vasopressor
Epinephrine 1 mg IV/IO
Repeat every 3 to 5 min
or
May give 1 dose of vasopressin 40 U
IV/IO to replace first or second dose of
epinephrine
Consider atropine 1 mg IV/IO
for asystole or slow PEA rate
Repeat every 3 to 5 min (up to 3 doses)
If asystole, go to Asystole/PEA
If electrical activity, check pulse.
If no pulse, go to Asystole/PEA
If pulse present, begin
postresuscitation care
During CPR
1 Push hard and fast (100/min) Rotate compressors
> Ensure full chest recoil every 2 minutes with
> Minimize interruptions in rhythm checks
chest compressions Search for and treat
One cycle of CPR: possible contributing
30 compressions factors:
then 2 breaths; 5 cycles - Hypovolemia
- 2 min - Hypoxia

Avoid hyperventilation - Hydrogen ion (acidosis)

Secure airway and confirm - Hypo-/hyperkalemia
placement - Hypoglycemia
After an advanced airway - Hypothermia
is placed, rescuers no longer - Toxins
deliver "cycles" of CPR. - Tamponade, cardiac
Give continuous chest -Tension pneumothorax
compressions without pauses - Thrombosis (coronary
for breaths. Give 8 to or pulmonary)
10 breaths/minute. Check - Trauma
rhythm every 2 minutes.