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Unofficial Cheat Sheet

by Paul C Lee MD (Cardiology Fellow, Mount Sinai School of Medicine, NY) revised 4/13/01
http://acls2000.org
Significant changes from previous ACLS are underlined. Class reflects level of evidence, not antiarrhythmic Class

Disclaimer: Writer not responsible for any errors, please check package insert

Comprehensive Cardiac arrest algorithm                                                                             acls2000.org unofficial guide
Note new emphasis on the basic and secondary "ABCD"
Step 1. Cardiac arrest (assess Unresponsive)>,basic CPR/ABCD (A=open airway;B= Two Breath;C= check pulse/compression*** ;D=attach monitor/defibrillator)
Step 2. Assess rhythm> (1) If VT/VF attempt 3 defibrillations then 2nd ABCD ; (2)If non VT/VF (asystole or PEA/EMD)> basic CPR
Step 3. Proceed quickly to Secondary ABCD:
A: airway device (intubate if skilled, laryngeal mask, OR cuffed oropharyngeal airway)
B: confirm (e.g. with end tidal CO2 devices and O2 saturation)* and secure airway to prevent dislodgement (holder preferred)
C: IV**, monitor, rhythm appropriate medications, pacer or buffer if needed, plus
Adrenergic agents:   VT/VF: Epinephrine 1 mg iv q3-5min**** +/- Vasopressin 40U iv x 1 only
    Non VT/VF: Epinephrine 1 mg iv q3-5 min
D: Differential Diagnosis: Find reversible cause
*False negative in arrest patient with no metabolism/CO2 production
**Peripheral line preferred initially. Consider central line.
***Interposed abdominal compression CPR may be more effective if trained personnel available, maybe contraindicated in pregnancy, recent surgery, abdominal aneurysm (Class 2b)
****High dose epinephrine is no longer recommended

VF/pulseless VT
Step 1. Basic CPR/ABCD> defibrillation x 3 (200J,200J-300J,360J OR equivalent biphasic shocks(biphasic 150J-150J-150J) may be superior to standard monophasic defib))> if unsuccessful:
Step 2. Secondary ABCD then
Step 3. Vasopressin 40 U iv x 1 only (preferred first agent, Class 2b) or epinephrine1mg q3-5min (Class Indeterminant)
Step 4. Defibrillate at 360J or biphasic shock
Step 5. Antiarrhythmics: First-tier: amiodarone 300 mg iv push, can consider repeat 150 mg iv x 1 (Class 2b)
                                   Second tier: Lidocaine 1.0-1.5mg/kg (e.g. 70-100mg) ivp q3-5 min up to 3 mg/kg (e.g. 210mg) (Class Inderterminate)
                                                    Magnesium 1-2 g iv if polymorphic VT or hypomagnesiumic (Class 2b)
                                                    Procainamide 30 mg/min up to 17mg/kg "acceptable but not recommended" in refractoryVF (but still class 2b)
            OR bicarbonate: prolonged arrest (Class 2b), high K (Class 1), bicarbonate responsive acidosis (2a), tricyclic OD (2a), to alkinalize urine for aspirin OD (2a); not for hypercarbia
                 Note: bretylium remains acceptable but no longer recommended in ACLS.
Step 6. Defibrillate 360J or biphasic shock
Step 7 Go back to step 3

Pulseless Electrical Activity/EMT
Step 1. Basic CPR/ABCD
Step 2.Secondary ABCD (C: rule out pseudo-PEA ( handheld doppler to look for cardiac mechanical activities: if present must be aggressively treated))
Step 3 Rule out most common etiology: 5H 5T (Hypovolemia,Hypoxia,Hydrogen (acidosis),Hyper/hypokalemia,Hypothermia; "Tablets" (OD),Tamponade,Tension Pneumothorax,Thrombosis of coronary, Thrombosis of pulmonary)
Consider fluid challenge empirically
Consider bicarbonate: prolonged arrest (Class 2b), high K (Class 1), bicarbonate responsive acidosis (2a), tricyclic OD (2a), to alkinalize urine for aspirin OD (2a);not for hypercarbic acidosis
(Hint: Wide QRS: massive myocardium damage, high K, hypoxia,hypothermia; Wide QRS+Slow: consider OD of tricyclic, betablocker, Ca-blocker,Digoxin; Narrow complex: suggest intact heart, DDx:hypovolemia,infection,PE,tamponade)
Step 4 Epinephrine 1 mg q3-5 min iv
Step 5 If HR slow, Atropine 1 mg iv q3-5 min up to 0.04mg/kg (such as 3mg)

Asystole
Step 1: BAsic CPR/ABCD
Step 1a. make sure patient is not DNR and not clinically dead so that resucitation is futile
Step 2: Secondary ABCD (confirm asystole: check monitor,lead,power and change leads)
Consider bicarbonate: prolonged arrest (Class 2b), high K (Class 1), bicarbonate responsive acidosis (2a), tricyclic OD (2a), to alkinalize urine for aspirin OD (2a);not for hypercarbia
Step 3: Transcutaneous pacing, if used must be considered early, routine use not necessary
Step 4: Epinephrine 1mg iv q3-5min
Step 5: Atropine 1 mg iv q3-5 min up to 0.04mg/kg (such as 3mg)
Step 6:   Review quality of resucitation attempt
        Review atypical feature (e.g. Hypothermia, drug overdose)
        If patient had >10min adequate resucitative effort and no atypical features present, consider cessation (in out of hospital asystole: if protocol allows)

Vasopressin in Asystole (NEJM 350(2), Jan 8 2004)

40 U IV Q3 x 2 doses, then switch to Epi 1 mg Q 3-5 minutes

Bradycardia
Step 1. Basic ABCD
Step 2. Secondary ABCD: assess need for airway, oxygen-IV-monitor-fluids, vitals+pulse ox, 12 leads ECG, Hx+P/E, consider DDx)
Step 3. Serious signs or symptoms of bradycardia? if yes, then do the sequence:
Atropine 0.5mg-1 mg iv q3-5 min up to 0.04mg/kg (such as 3mg)
then transcutaneous pacing
then dopamine 5-20 mcg/kg/min
then epinephrine 2-10 mcg/min
Step 4. Is Type 2 second degree AV block or third degree AV block present? If yes: standby transcutaneous pacemaker, prepare for transvenous pacemaker.
Do not use lidocaine to treat escape slow wide complex rhythm.

Non-arrest tachycardia Overview:
Step 1. Is the patient stable or unstable (chest pain,dyspnea,decreased level of conciousness, low BP, CHF, AMI)?
If unstable: establish HR as cause of symptom (almost always HR>150), cardiovert
If stable: then classify arrhythmia and go to individual algorithm:
A fib or flutter
Narrow complex tachycardia
Wide complex-tachycardia: unknown type
Stable VT

Atrial fibrillation/flutter: (This protocol is new)
1. Is patient stable or unstable? Proceed more urgently in unstable patient.
2. Is the cardiac function impaired? If yes, drugs limited to digoxin, diltiazem, and amiodarone. Avoid verapamil, bata-blockers, ibutilide, procainamide (and propafenone/flecainide).
3. Wolff-Parkinson White present (WPW; e.g. delta wave on resting EKG, in very young patient, HR>300 suggestive of bypass tract)? Avoid adenosine, beta-blocker, Ca-channel blocker, digoxin.
4. Is the onset of atrial fibrillation less than 48 hours? If not, avoid cardioversion or drugs that may cardiovert unless guided by TEE or after 3 weeks of adequate anticoagulaton

Note: new ALCS doe not allow mixing antiarrhythmics for A fib/flutter.
Tx: control rate, consider rhythm conversion, anticoagulate base on 3 categories

Category 1. Normal EF
A. Rate control: one of: Ca-blocker, beta-blocker.
B. Cardiovert:
If onset < 48 hours, consider DC cardioversion OR with one of the following agents: Amiodarone, ibutilide, procainamide, (flecainide,propafenone),sotalol.
If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone). Either:
Delayed cardioversion: anticoagulate adequately x 3weeks then Cardiovert then anticoagulate x 4 weeks
Early Cardioversion: iv heparin, TEE, then cardioversion within 24 hours then anticoagulate x 4 weeks
C. Anticoagulate if not contraindicated, if A fib > 48 hrs

Category 2. EF<40% or CHF
A. Rate control: digoxin, diltizaem, amiodarone (avoid if onset of AF > 48 hours)
B. Cardiovert: same as Category 1, except the only conversion agent allowed is amiodarone.
C. Anticoagulate, if A fib > 49 hr.

Catepory 3. WPW A fib
Must not use adenosine, beta-blocker, Ca-blocker, Digoxin
If < 48 hour:
If EF normal: one of the following for both rate control and cardioversion: amiodarone, procainamide, propafenone,sotalol,flecainide
If EF abnormal or CHF: amiodarone or cardioversion
If > 48 hour
Medication listed above may be associated with risk of emboli. Anticoagulate and DC cardioversion as in Category 1.

Stable narrow complex SVT
“focus is on making a specific diagnosis”, and management focus on EF. Notice no cardioversion allowed for stable SVT with low EF. Note this algorithm is for "STABLE" patient only
Step 1. 12 leads ECG, clinical exam
Step 2. Vagal stimulation, adenosine. Consider esophageal lead
Step 3. Make a specific diagnosis.

PSVT (Note new emphasis on knowing EF and re-emphasis on Ca-blocker. New agents also introduced)
EF normal: Priority: Ca-blocker> beta-blocker> digoxin> DC Cardioversion.
Consider procainamide, sotalol, amiodarone. If unstable proceed to cardioversion
EF<40%, CHF: Priority: No Cardioversion. Digoxin or amiodarone or diltiazem. If unstable proceed to cardioversion.

Multifocal atrial tachycardia New!
No cardioversion
EF normal: Ca-blocker, beta-blocker, amiodarone
ER<40%, CHF: amiodarone, diltiazem

Junctional tachycardia New!
(rare, most commonly misdiagnosed PSVT, think Digoxin/theophylline OD, catecholamine state). No cardioversion.
EF normal: Amiodarone, beta-blocker, Ca-blocker
EF<40%, CHF: Amiodarone

Wide complex tachycardia, type unknown, STABLE
Step 1. Attempt to establish specific diagnosis: 12 leads, esophageal lead, Clinical info
Note: the use of adenosine to differentiate SVT vs VT is now de-emphasized.
Step 2: If unable to make Dx:
EF normal: DC cardioversion or procainamide or amiodarone
EF<40%,CHF: DC Cardioversion or amiodarone (again note new emphasis on knowing EF)

Note: no lidocaine and bretylium in protocol.

Stable VT
Note new emphasis on morhology, EF, and baseline QT
Step 1. May proceed directly to cardioversion
Step 2. Determine Monomorphic VT vs Polymorphic VT

Monomorphic VT (May proceed directly to cardioversion)
EF normal: one of the following procainamide (2a), sotalol (2a) OR amiodaorn 92b), lidocaine (2b)
EF poor: Step 1. amiodarone 150 mg iv or 10 min OR lidocaine 0.5-0.75 mg/kg iv push
Step 2. Synchromized cardioversion

Polymorphic VT: (new) (May proceed directly to cardioversion)
Step 1. What is baseline QT?.
Normal QT (?ischemia,electrolyte). Treat ischemia. Correct electrolyte.
EF normal: Try: betablocker or lidocaine or amiodarone or procainamide or sotalol.
EF poor: Step 1. amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75 mg/kg iv push; Step 2. Synchromized cardioversion
Prolonged QT baseline (torsade). Correct electrolyte. Try: Magnesium, overdrive pacing, isoproterenol, phenytoin, lidocaine

Synchronized Cardioversion
For tachycardia with serious signs and symptoms. If HR>150, prepare for immediate cardioversion. May give brief drug trial. Generally not needed for HR<150.
Step 1. Prepare equipment: O2 monitor, Suction, IV, Intubation
equipment.
Step 2. Medicate if possible (ideal: call anesthesia service; alternative: sedative +/- analgesic. E.g. Midazolam +/- fetanyl)
Step 3. Synchronized Cardioversion: (monomorphic** VT with pulse, PSVT, A fib, A flutter) 100-200-300-360 J* or equivalent biphasic (biphasic 70, 120, 150, and 170 J)

*note: may try 50J for PSVT or A flutter first.
** polymorphic VT: use VT/VF algorithm
*** if machine unable to sync and patient critical, defibrillate

Appendix:
ACLS Drug Reference

Adenosine: 6-12-12 mg iv push with saline flush q 5 min.                             SE: A fib, sob,chest discomfort
amiodarone: (non-cardiac arrest) load 15 mg/min over 10 min (150 mg) (mix 150 mg in 100cc D5W in PVC or Glass, infuse over 10 min)
then 1 mg/min x 6 hrs (mix 900 mg in 500 cc D5W)
then 0.5 mg/min x 18 hrs and beyond;
supplemental bolus: 15 mg/min x 10 min
                      (Cardiac arrest) 300 mg iv push (diluted in 20 cc D5W), can consider repeat 150 mg iv x 1
atropine: 0.5-1 mg to 0.04 mg/kg (e.g. 3mg)
epinephrine: 1 mg q3-5 min iv
Diltiazem: 0.25mg/kg (over 2 min,e.g.20mg) then 0.35mg/kg (over 2 min,eg 25mg) in 15 min, infuse 5-15 mg per hour
Ibutilde: >60 kg 1 mg; <60 kg 0.01 mg/kg    over 10 min. May repeat x 1 Make sure K>4.0 and Mg normal. Not recommended for low EF..
lidocaine 1 mg/kg bolus, 0.5 mg/kg q8-10 min, max 3 mg/kg. Then infuse 1-4 mg/min         SE: paraesthesia, seizure,confusion
Magnesium sulfate: 1-2g over 5-60 min.
procainamide 20 mg/min up to 17 mg/kg (1000 mg), then infuse 1-4 mg/min             SE: HTN,torsade
vasopressin: 40 IU x 1 dose only (for pulseless VT/VF)
verapamil 2.5-5-10 mg bolus

dofetilide 250 mcg bid po (CrCl 40-60 ml/min); 250 mcg qd (crCl 20-40 ml/min) "Prescriber requires certification by manufacturer"
(NEJM 99 Danish investigator: 1518 pt NYHA III-IV or PND. low EF based on echo 16 segment score. no diff in survival. More stays in sinus or converted to sinus (12% of A fib vs 1% in one month + maintained). Less exaceberation3.3% risk of torsade.)
Exclude: hr<50, 2-3 deg block av, qtc>460 (500 if BBB), SBP,80 or DBP>115, K<3.6or>5.5, on other class I or III drug, CrCl<30 or severe liver disorder