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Excerpted from Handbook of Anesthesiology CD-ROM, 2004 Edition by Mark Ezekiel, Mark Ezekiel. Copyright © 2003. Reprinted by permission. All rights reserved.
Resuscitation Algorithms (ACLS)
Primary And Secondary ABCD Survey
1. Primary ABCD survey
A. Focus: basic CPR and defibrillation.
B. Airway: assess and manage the airway with noninvasive devices.
C. Breathing: assess and manage breathing (look, listen, and feel). If the patient is not breathing, give two slow breaths.
D. Circulation: assess and manage the circulation; if no pulse, start CPR.
E. Defibrillation: assess and manage rhythm/defibrillation; shock VF/VT up to 3 times (200 J, 300 J, 360 J, or equivalent biphasic) if necessary.
2. Secondary ABCD survey
A. Focus: more advanced assessments and treatments
B. Airway: place airway device as soon as possible.
C. Breathing: assess adequacy of airway device placement and performance; secure airway device; confirm effective oxygenation and ventilation.
D. Circulation: establish IV access; administer drugs appropriate for rhythm and condition.
E. Differential Diagnosis: search for and treat identified reversible causes.
A. Potentially reversible causes include: hypoxia, hypovolemia, hyperkalemia, hypokalemia and metabolic disorders, hypothermia, tension pneumothorax, tamponade, toxic/therapeutic disturbances, and thromboembolic/mechanical obstruction.
Ventricular Fibrillation And Pulseless Ventricular Tachycardia
1. Primary ABCD
2. Assess rhythm after 3 shocks; continue CPR for persistent or recurrent VF/VT.
3. Secondary ABCD
4. Epinephrine 1.0 mg IVP, repeat every 3-5 minutes, or vasopressin 40 units IV, single dose, 1 time only.
5. Resume attempts to defibrillate, 360 J within 30-60 seconds.
6. Consider antiarrhythmics.
A. Amiodarone 300 mg IVP or
B. Lidocaine 1.5 mg/kg IVP, repeat every 3-5 minutes to a total loading dose of 3 mg/kg or
C. Magnesium sulfate 1-2 grams IV (if Torsades de Pointes or suspected hypomagnesemic state or severe refractory VF) or
D. Procainamide (if above ineffective) 30 mg/min to max total of 17 mg/kg.
7. Defibrillate 360 J, 30-60 sec after each dose of medication.
8. Repeat Amiodarone 150 mg IVP (if recurrent VF/VT), up to max cumulative dose of 2200 mg IV in 24 hours
9. Consider bicarbonate 1 mEq/kg (if known preexisting bicarbonate responsive acidosis, overdose with tricyclic antidepressant, if intubated and continued long arrest interval, hypoxic lactic acidosis, or hypercarbic acidosis).
1. Primary ABCD survey.
2. Confirm asystole in two or more leads. If rhythm is unclear and possible ventricular fibrillation, defibrillate as for VF.
3. Secondary ABCD survey.
4. Consider possible causes: hypoxia, hyperkalemia, hypokalemia, hypothermia, preexisting acidosis, drug overdose and myocardial infarction.
5. Consider transcutaneous cardiac pacing (if considered, perform immediately)
6. Epinephrine 1.0 mg IVP, repeat every 3-5 minutes.
7. Atropine 1.0 mg IV, repeat every 3-5 minutes up to total dose of 0.04 mg/kg.
8. If asystole persists, consider withholding or ceasing resuscitative efforts.
A. Before terminating resuscitative efforts consider quality of resuscitation, if atypical clinical features are present, or if support for cease-efforts protocols are in place.