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Adult BLS Primary Survey ABCDs
If scene is safe, assess responsiveness by gently tapping/speaking loudly. Activate
emergency response system if unresponsive. Get AED, if available, and return.
A Airway: *Open airway, look, listen, and feel for breathing in <10 seconds.
B Breathing: If not breathing adequately, give 2 rescue breaths, 1 second each.
C Circulation: Carotid pulse check, 5-10 seconds. If pulseless, begin **chest
compressions at 100/min. Push hard, allow full chest rebound. (30:2 CPR ratio)
D Defibrillation: Analyze rhythm (AED/quick-look paddles). Shock VF/PVT once,
immediately resume CPR for 2 minutes starting with chest compressions.
* Use appropriate C-spine precautions if trauma is present/suspected.
** Perform CPR until AED/Manual Defibrillator arrives, or victim starts moving.
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Adult ACLS Secondary Survey ABCD's
A Airway: *Establish appropriate airway management.
B Breathing: Ventilate with O2. Assess adequacy of ventilation, e.g., by exam, chest rise,
SaO2 monitor, CO2 detector, esophageal detector, as indicated.
C Circulation: IV/IO. Attach monitor leads. Follow appropriate ACLS algorithm. Give rhythm-appropriate medications. Get vital signs/EKG/labs. Continue effective **CPR as indicated.
Minimize chest compression interruptions to <10 seconds.
D Differential Diagnosis: Attempt to identify and treat reversible causes.
* Okay to briefly delay advanced airway early in cardiac arrest if bag-mask ventilation is
adequate in order to minimize chest compression interruptions.
** After advanced airway management is established, CPR = uninterrupted chest
compressions at 100/min with 8-10 breaths/min.
Differential Diagnosis Table
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The acronym "PATCH(4) MDs" provides a guide to problem search.
| Problem |
Assess |
Possible Interventions |
| Pulmonary Embolism |
No pulse w/ CPR, JVD |
Thrombolytics, surgery |
Acidosis
(preexisting) |
Diabetic/renal patient, ABGs |
Sodium bicarbonate,
hyperventilation |
| Tension pneumothorax |
No pulse w/ CPR, JVD, tracheal deviation |
Needle thoracostomy |
Cardiac
Tamponade |
No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest |
Pericardiocentesis |
Hyperkalemia
(preexisting) |
Renal patient, EKG, serum K level |
Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, Kayexalate |
| Hypokalemia |
EKG, serum K level |
Treat with great prudence after careful assessment of the cause. K can kill. |
| Hypovolemia |
Collapsed vasculature |
Fluids |
| Hypoxia |
Airway, cyanosis, ABGs |
Oxygen, ventilation |
Myocardial
infarct |
History, EKG |
Acute Coronary Syndrome algorithm |
| Drugs |
Medications, illicit drug use, toxins |
Treat accordingly |
| Shivering |
Core temperature |
Hypothermia Algorithm |
| If trauma is present then proceed with ATLS protocol. | |
V-FIB / Pulseless V-Tach
SCREAM |
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| 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. |
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Implement the Secondary SurveyContinue this algorithm if indicated. Give drugs during CPR before or after shocking. Minimize interruptions in chest compressions to <10 seconds. |
| 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. |
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A
M |
Antiarrhythmic
Medications |
Consider antiarrhythmics. (Any Legitimate Medication)
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. |
* Biphasic energy level is device dependent, follow the manufacturer's recommendation. If recommendation is unknown, use 200J for 1st shock and the same or higher energy level for subsequent shocks. |
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Asystole / P E A
The following directs AHA accepted actions as part of the Secondary ABCD's 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:
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| 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.) | |
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Consider termination of efforts if asystole persists despite appropriate interventions.
Tachycardia |
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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:
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| 1. Stable? |
Yes
↓ next question |
No, unstable = Immediate electrical cardioversion |
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| 2. Narrow? |
Yes
↓ next question |
No, wide = Consult an expert
(QRS ≥0.12 sec) |
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| 3. Regular? |
Yes
↓ see mnemonic |
No, irregular = Consult an expert |
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| Yes 1-2-3, think SVT, then V-A-C |
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↓ |
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Vagal maneuvers, if this fails.. |
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↓ |
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Adenosine 6mg rapid IV push
(may repeat x2, q1-2min. at 12mg) |
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↓ |
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Cardizem (diltiazem) managed by an expert if
stable, narrow, regular tachyarrhythmia continues | |
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Perform immediate electrical cardioversion if a patient becomes unstable at any time. For sinus tachycardia consider possible causes and treat accordingly. |
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| Consult an Expert |
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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. |
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Stable Narrow Irregular Tachycardia
Atrial Fibrillation, Multifocal Atrial Tachycardia, possibly Atrial Flutter
Rate Control: diltiazem or beta blocker |
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Stable Narrow Regular Tachycardia
Recurrent SVT, Atrial Flutter, Junctional or Ectopic Atrial Tachycardia
Rate Control: diltiazem or beta blocker |
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Stable Wide Irregular Tachycardia
(Avoid calcium channel blockers and digoxin due to possible AF+WPW)
Consider amiodarone. Magnesium 2g IV over 5min. for torsades |
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Stable Wide Regular Tachycardia
If VT, amiodarone 150mg IV over 10min. repeat prn (max 2.2g IV/24hr),
elective synchronized cardioversion
Bradycardia |
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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
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| 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. |
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Consider medications while pacing is readied. |
| Always |
Atropine |
1st-line drug, 0.5 mg IV/IO q3-5 min. (max. 3mg) |
| Ends |
Epinephrine
2-10 µg/min |
2nd-line drugs to consider if atropine and/or TCP are ineffective. Use with extreme caution. |
| Danger |
Dopamine
2-10 µg/kg/min | |
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*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.
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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. | |
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Synchronized Electrical
Cardioversion |
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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
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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: |
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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. |
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Unsynchronized Electrical
Cardioversion |
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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 | |
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