Adult Cardiac Arrest Algorithm

1
CPR Quality
Start CPR
• Give oxygen • Push hard (at least 2 inches
• Attach monitor/defibrillator [5 cm]) and fast (100-120/min)
and allow complete chest recoil.
• Minimize interruptions in
compressions.
Yes No • Avoid excessive ventilation.
Rhythm • Change compressor every
shockable? 2 minutes, or sooner if fatigued.
• If no advanced airway, 30:2
2 9 compression-ventilation ratio,
VF/pVT Asystole/PEA or 1 breath every 6 seconds.
• Quantitative waveform
capnography
– If Petco2 is low or decreasing,
reassess CPR quality.
3 Shock Epinephrine
ASAP Shock Energy for Defibrillation

4 10 • Biphasic: Manufacturer
recommendation (eg, initial
CPR 2 min CPR 2 min dose of 120-200 J); if unknown,
• IV/IO access use maximum available.
• IV/IO access
• Epinephrine every 3-5 min Second and subsequent doses
• Consider advanced airway, should be equivalent, and higher
capnography doses may be considered.
• Monophasic: 360 J
Rhythm No
shockable? Drug Therapy

Rhythm Yes • Epinephrine IV/IO dose:

Yes 1 mg every 3-5 minutes
shockable?
• Amiodarone IV/IO dose:
5 Shock First dose: 300 mg bolus.
Second dose: 150 mg.
No or
6 Lidocaine IV/IO dose:
CPR 2 min First dose: 1-1.5 mg/kg.
• Epinephrine every 3-5 min Second dose: 0.5-0.75 mg/kg.
• Consider advanced airway, Advanced Airway
capnography
• Endotracheal intubation or su-
praglottic advanced airway
• Waveform capnography or cap-
Rhythm No nometry to confirm and monitor
ET tube placement
shockable? • Once advanced airway in place,
give 1 breath every 6 seconds
Yes (10 breaths/min) with continu-
ous chest compressions
7 Shock
Return of Spontaneous
Circulation (ROSC)
8 11
• Pulse and blood pressure
CPR 2 min CPR 2 min • Abrupt sustained increase in
• Amiodarone or lidocaine Petco2 (typically ≥40 mm Hg)
• Treat reversible causes
• Treat reversible causes • Spontaneous arterial pressure
waves with intra-arterial
monitoring

No Rhythm Yes Reversible Causes

shockable? • Hypovolemia
• Hypoxia
12 • Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• If no signs of return of Go to 5 or 7 • Hypothermia
spontaneous circulation • Tension pneumothorax
(ROSC), go to 10 or 11 • Tamponade, cardiac
• If ROSC, go to • Toxins
• Thrombosis, pulmonary
Post–Cardiac Arrest Care
• Thrombosis, coronary
• Consider appropriateness
of continued resuscitation
© 2020 American Heart Association
Adult Bradycardia 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
• Consider possible hypoxic and toxicologic causes

Persistent
bradyarrhythmia causing:
No • Hypotension?
Monitor and observe • Acutely altered mental status?
• Signs of shock? Doses/Details
• Ischemic chest discomfort? Atropine IV dose:
• Acute heart failure? First dose: 1 mg bolus.
Repeat every 3-5 minutes.
Yes Maximum: 3 mg.
Dopamine IV infusion:
Usual infusion rate is
Atropine
5-20 mcg/kg per minute.
If atropine ineffective: Titrate to patient response;
• Transcutaneous pacing taper slowly.
and/or Epinephrine IV infusion:
• Dopamine infusion
2-10 mcg per minute infusion.
or Titrate to patient response.
• Epinephrine infusion
Causes:
• Myocardial ischemia/
infarction
• Drugs/toxicologic (eg,
calcium-channel blockers,
Consider: beta blockers, digoxin)
• Hypoxia
• Expert consultation
• Electrolyte abnormality
• Transvenous pacing (eg, hyperkalemia)
© 2020 American Heart Association
Adult Tachycardia With a Pulse Algorithm

SVT
Doses/Details
Assess appropriateness for clinical condition.
Heart rate typically ≥ 0 min i tac yarr yt mia Synchronized cardioversion:
Refer to your specific device’s recommended energy level to
maximize first shock success.
Adenosine IV dose:
First dose: 6 mg rapid IV push; follow with NS flush.
Second dose: 12 mg if required.
Identify and treat underlying cause Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia
• Maintain patent airway; assist breathing as necessary Procainamide IV dose:
• Oxygen (if hypoxemic) 20-50 mg/min until arrhythmia suppressed, hypotension ensues,
• Cardiac monitor to identify rhythm; monitor blood QRS duration increases >50%, or maximum dose 17 mg/kg given.
pressure and oximetry Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF.
• IV access
Amiodarone IV dose:
• 12-lead ECG, if available
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.

Persistent
tachyarrhythmia causing:
biopetasm• Synchronized cardioversion
Hypotension? Yes
• Acutely altered mental status? • Consider sedation
3am •• Signs of shock?
Ischemic chest discomfort?
• If regular narrow complex,
consider adenosine
If refractory, consider
• Underlying cause
coffers • Acute heart failure?
• Need to increase
energy level for next
No cardioversion
• Addition of anti-
Yes Consider arrhythmic drug
Wide QRS?
• Adenosine only if • Expert consultation
≥0.12 second
regular and monomorphic
• Antiarrhythmic infusion
No • Expert consultation

• Vagal maneuvers (if regular)

• Adenosine (if regular)
• β-Blocker or calcium channel blocker
• Consider expert consultation
© 2020 American Heart Association