BLS arrest

figure 1. Basic Life Support Primary Survey

Assessment Action

Is the airway Open airway using head-tilt, chin-lift or jaw thrust

open?

Is the patient Look for the rise and fall of the patient's chest.
breathing?
Listen for breath sounds.

Use your cheek to feel the flow of air from the patient's
breath.

If the patient is not breathing or the breathing is inadequate, give 2

breaths, each one lasting about 1 second and making the chest rise.
Give 1 breath about every 5 to 6 seconds or 10 to 12 breaths per
minute. Use a barrier device if you have one.

Does the patient

have a pulse?

The last step, defibrillation, is part of the primary survey, but is not required for
respiratory arrest, as the patient has a pulse for this case.

ACLS Secondary Survey for a Patient in

Respiratory Arrest
Using the ACLS Primary Survey for a Patient in
Respiratory Arrest
The ACLS Secondary Survey takes you through the advanced assessments and actions
you need to accomplish for a patient in respiratory arrest (see Figure 1). Placing an
advanced airway interrupts chest compressions and takes many seconds. You decide if
an advanced airway is necessary for the patient to maintain respirations. Your
assessments guide you in finding answers and taking appropriate next steps.

The assessments follow the ABCD format of the

primary survey:
Airway

Breathing

Circulation

Differential diagnosis

Figure 1. Advanced Cardiac Life Support

Secondary Survey

Assessment Action

Is the patient's airway To open the airway for unconscious patients, use the head-
obstructed? tilt, chin lift. Insert an oropharyngeal airway (OPA) or a
nasopharyngeal airway (NPA) if needed to keep the airway
open.

Does the patient need an If yes, use an LMA, Combitube, or endotracheal intubation,
advanced airway? among others.

Is the patient breathing? Give bag-mask ventilations every 5 to 6 seconds (about 10

to 12 breaths per minute without chest compressions).
Is an advanced airway No. If bag-mask ventilation is adequate, defer the insertion
indicated? of an advanced airway until it becomes essential (patient
fails to respond to initial CPR or until spontaneous
circulation returns). Yes. Insert an advanced airway device.

Is the advanced airway Confirm correct placement of advanced airway device by a

device placed properly? observing the patient and using a confirmation device, such
as an exhaled CO2 detector or an esophageal detector.

Is the advanced airway Secure the advanced airway device so it does not dislodge,
device secured correctly? especially in patients who are at risk for movement. Secure
the ET tube with tape or a commercial device.

What was the patient's Attach ECG leads. Identify patient's rhythm.
initial cardiac rhythm?

What is the patient's Monitor patient for arrhythmias or cardiac arrest rhythms
current cardiac rhythm? (ventricular fibrillation, pulseless ventricular tachycardia,
asystole, and PEA).

Does the patient need an Establish IV or IO access.

IV?

Does the patient need Start IV/IO fluids, if needed.

fluid?

Does the patient need Give appropriate medications to manage rhythm (eg,
medications for rhythm or amiodarone, lidocaine, atropine, magnesium) and blood
blood pressure control? pressure (eg, epinephrine, vasopressin, dopamine).

Is a reversible cause Search for reversible causes of the arrest. Find and treat
responsible for the
 arrest? reversible causes of the arrest.

Acute Coronary Syndromes Algorithm

Using the Acute Coronary Syndromes Algorithm

for Managing the Patient
The Acute Coronary Syndromes Algorithm outlines the steps for assessment and
management of a patient with ACS. The algorithm begins with the assessment of chest
pain and whether it is indicative of ischemia. The assessment and management begin
with the EMS responder outside of the hospital who can give oxygen, aspirin,
nitroglycerin, and morphine (if needed for pain). An initial 12-lead ECG can also be
obtained. Treatment and assessment continues when the patient arrives at the hospital,
following the time sequences suggested in the algorithm. Serial cardiac markers (CK-
MB, cardiac troponins) provide additional information and allow refined stratification and
treatment recommendations.

Out-of-Hospital Care

Decision 1: Does the patient have chest discomfort

suggestive of ischemia?
An affirmative answer starts the algorithm.

Assess and care for the patient using the primary

and secondary surveys.

Prepare patient for hospital admission.

 1. Monitor and support ABCs (airway, breathing, and circulation).

o Take vital signs.

o Monitor rhythm.

o Be prepared to administer CPR if the need arises. Watch for it.

o Use a defibrillator if necessary.

2. Think MONA: Administer oxygen, aspirin, nitroglycerin, and morphine, if needed.

3. If possible, obtain a 12-lead ECG.

4. Interpret or request an interpretation of the ECG.

If ST elevation is present, transmit the results to the receiving hospital.

Hospital personnel gather resources to respond to STEMI.

5. Start filling out a fibrinolytic checklist.

In-Hospital Care

Within the first 10 minutes that the patient is in the

Emergency Department (ED), work through the
following:
1. Check vital signs.

2. Evaluate oxygen saturation.

3. Establish IV access.

4. Get or review a 12-lead ECG.

5. Look for risk factors for ACS, cardiac history, signs and symptoms of heart failure
by taking a brief, targeted history.

6. Perform a physical exam.

 7. Complete a fibrinolytic checklist and check contraindication

8. Obtain a portable x-ray (less than 30 minutes).

Begin general treatment in the ED:

1. Start oxygen at 4 L/min and maintain oxygen saturation > 90%.

2. If the patient did not take aspirin while with the EMS provider, give aspirin (160 to
325 mg).

3. Administer nitroglycerin, either sublingual, spray, or IV.

4. Give the patient morphine (IV) if pain is not relieved by nitroglycerin.

Decision 2: Classify the patient according to

presentation of ST-segment.
The 12-lead ECG is at the heart of the decision pathway in the management of ischemic
chest pain and is the only means of identifying STEMI.

Note:The ECG classification of ischemic syndromes is not meant to be exclusive.

STEMI (ST-segment High-risk unstable Intermediate or low risk UA

elevation myocardial angina (UA) or
infarction) NSTEMI (non-ST-
segment elevation
myocardial infarction)

Definition: ST segment Definition: Definition:

elevation greater than 1 mm
(0.1 mV) in 2 or more Ischemic ST-segment Normal or non-diagnostic
contiguous precordial leads depression of 0.5 mm changes in ST segment or T
or 2 or more adjacent limb (0.5 mV) or greater wave that are inconclusive and
leads require further risk stratification
OR
OR Includes people with normal
Dynamic T wave
 New or presumed new left inversion with pain or ECGs and those who have ST-
bundle branch block discomfort segment deviation in either
direction that is less than 0.5
Transient ST elevation mm or T wave inversion of 2
of 0.5 mm or greater mm or 0.2 mV or less
for less than 20
minutes

Classification: INJURY Classification: Classification: NORMAL?

ISCHEMIA

Management is based on the results of the ECG.

ECG shows ST-segment elevation.

Confirm how much time has passed since the onset of symptoms.

If less than 12 hours has elapsed, do the following:

Develop a reperfusion strategy based on the patient's and the hospital's criteria.

Continue adjunctive therapies.

If indicated, add the following treatments:

o ACE inhibitors/angiotensin receptor blocker (ARB) within 24 hours of

symptom onset

o HMG CoA reductase inhibitor (statin therapy)

Results of cardiac markers, chest x-ray, and laboratory studies should not delay
reperfusion therapy unless there is a clinical reason.

Start adjunctive treatments for STEMI, as indicated:

Beta-adrenergic receptor blocker

Clopidogrel
 Heparin (UFH or LMWH)

If the patient is classified with NSTEMI or high-risk

unstable angina, follow this section of the
algorithm.

Decision 2: Classify the patient according to

presentation of ST-segment.

ECG shows ST depression or dynamic T-wave

inversion
Start adjunctive treatments for NSTEMI, as indicated:

Nitroglycerin

Beta-adrenergic receptor blocker

Clopidogrel

Heparin (UFH or LMWH)

Glycoprotein IIb/IIIa inhibitor

If more than 12 hours has passed since the

patient's onset of symptoms, do the following:
1. Admit patient to the hospital

2. Assess risk status

Continue ASA, heparin, and other therapies as indicated (ACE inhibitors, statins) for the
high-risk patient characterized by:

Refractory ischemic chest pain

 Recurrent or persistent ST deviation

Ventricular tachycardia

Hemodynamic instability

Signs of pump failure

Decision 2: Classify the patient according to

presentation of ST-segment.

ECG shows normal ECG or nonspecific ST-T wave

changes
Consider admitting the patient to hospital or to a monitored bed in ED

Monitor ECG continually for changes in ST-T.

Obtain serial cardiac markers, including troponin.

Consider stress test.

Pulseless Arrest Algorithm for Managing

Asystole
Using the Pulseless Arrest Algorithm for Managing
Asystole
Management of a patient in cardiac arrest with asystole follows the same pathway as
management of PEA. The top priorities stay the same: Following the steps in the ACLS
Pulseless Arrest Algorithm and identifying and correcting any treatable, underlying
causes for the asystole. The algorithm assumes that scene safety has been assured,
personal protective equipment is being used, and no signs of obvious death are present.

Begin with the primary survey to assess the

patient's condition:
Tap the patient on the shoulder and ask, "Are you all right?"

If the patient does not respond, call for help.

Give 2 minutes (5 cycles) of CPR before leaving patient to call for help.

Open airway.

Listen, check for breathing. Give 2 breaths that make the chest rise.

Check for a pulse.

If the patient does not have a pulse or any other signs of life, begin CPR, 30
compressions to 2 respirations. (Push hard and fast--100/minute. Release chest
completely.)

Start an IV.

Begin oxygen.

Attach a monitor.

Follow the ACLS Pulseless Arrest Algorithm for

asystole:
Check the patient's rhythm, taking less than 10 seconds to assess.

You see that the rhythm is not shockable.

 Resume CPR (5 cycles). Rotate team members every 2 minutes with rhythm
breaks to help maintain high quality CPR.

As soon as IV or IO access is available, administer epinephrine or vasopressin

during CPR cycle. Do not stop CPR to administer drugs.

Consider administering atropine. (See qualifying note in Drug Therapies section.)

During CPR, search for and treat possible contributing causes (H's and T's in
Figure 1).

Check rhythm.

o If no electrical activity is present (patient is in asystole), resume CPR.

o If electrical activity is present, see if the patient has a pulse.

o If the patient does not have a pulse or there is some doubt about the
pulse, resume CPR.

o If a good pulse is present and the rhythm is organized, begin post-

resuscitative care.

IV/IO access is a priority over advanced airway management. If an advanced airway is

placed, change to continuous chest compressions without pauses for breaths. Give 8 to
10 breaths per minute and check rhythm every 2 minutes.

Without a pulse or electrical activity on the ECG for the patient, the emergency care
team needs to decide when resuscitation efforts should stop. The patient's wishes and
the family's concerns need to be considered, particularly if the patient has a Do Not
Attempt Resuscitation Order in effect.
Pulseless Arrest Algorithm for Managing
Pulseless Electrical Activity (PEA)

Using the Pulseless Arrest Algorithm for Managing

PEA
Patients with PEA have poor outcomes. Their best chance of returning to a perfusing
rhythm is through the quick identification of an underlying reversible cause and correct
treatment. As you use the algorithm to manage the PEA patient, remember to consider
all the H's and T's, particularly hypovolemia, which is the most common cause of PEA.
Also look for drug overdoses or poisonings.

Begin with the primary survey to assess the

patient's condition:
1. Tap the patient on the shoulder and ask, "Are you all right?"

2. If the patient does not respond, call for help.

3. Give 2 minutes (5 cycles) of CPR before leaving patient to call for help.

4. Open airway.

5. Listen, check for breathing. Give 2 breaths that make the chest rise.

6. Check for a pulse.

7. If the patient does not have a pulse or any other signs of life, begin CPR, 30
compressions to 2 respirations. (Push hard and fast--100/minute. Release chest
completely.)

8. Start an IV.
 9. Begin oxygen.

10. Attach a monitor.

11. Assess rhythm in less than 10 seconds.

o Too fast or too slow?

o Regular or irregular?

o Wide or narrow QRS complex?

12. Resume CPR. Check rhythm every 2 minutes (after 5 cycles of CPR)

13. ECG waves seen? Yes.

Follow the ACLS Pulseless Arrest Algorithm.

The algorithm is divided into two arms: one for VT/VT and one for PEA and asystole. A
patient with a rhythm that is not shockable requires treatment listed on the PEA or
asystole side of the algorithm.

1. Check the rhythm. It is not shockable.

2. Resume CPR (5 cycles). During CPR, give the patient epinephrine or

vasopressin.

1. If the patient's rate is slow, consider giving atropine.

2. Assess the patient's rhythm again. If rhythm is still not shockable, resume
CPR (5 cycles).

3. During CPR, search for and treat possible treatable causes (H's and T's in
Figure 1).

4. Check pulse. No pulse is felt.

5. Continue searching for reversible causes.

6. Continue CPR.

7. Check pulse. If there is a pulse and the rhythm is organized, begin post-
resuscitation care.
Two management priorities are maintaining high quality CPR and searching
simultaneously for a treatable cause of the patient's PEA. Stop CPR only when
absolutely necessary for pulse and rhythm checks. Establishing IV/IO access is a priority
over advanced airway management. If an advanced airway is placed, change to
continuous chest compressions without pauses for breaths. Give 8 to 10 breaths per
minute and check rhythm every 2 minutes.

BLS Healthcare Provider Algorithm for

Managing VF and Pulseless VT

Using the BLS Healthcare Provider Algorithm for

Managing VF and Pulseless VT
The BLS (basic life support) Primary Survey is used in all cases of cardiac arrest. For
any emergency, you first see if the patient is responsive, call EMS, and find an AED.
Next you go through the ABCDs. For this case, you assess a person without a pulse; you
do not have an emergency care team to work with you.

Initial Assessment:
Make sure the scene is safe.

Tap shoulder and ask, "Are you all right?"

If the patient does not respond, call for help. Activate EMS

Get the automated external defibrillator (AED) or send someone for it, if someone
is available.

Perform the ABCDs in the primary survey:

 Watch for the patient's chest to rise and fall. Listen for air
Airway escaping. Feel for expired air against your cheek. Open
patient's airway using the head-tilt, chin-lift or jaw thrust (if
trauma is suspected)

Check breathing (take at least 5 seconds but not more than

Breathing 10 seconds). Patient is not breathing. Give 2 rescue breaths.

Use a barrier device if you have one.

Give each breath over 1 second.

Each breath should make the chest rise. Be careful

not to hyperventilate the patient (rate too fast or
volume too much).

Check the patient's carotid pulse (take at least 5 seconds but

Circulation not more than 10 seconds). No definite pulse? Start cycles of
30 chest compressions and 2 breaths until the AED arrives.

Push hard and fast (100/min) and release completely.

Perform compressions at a depth of 1.5 to 2 inches.

Let the chest to completely recoil.

Minimize interruptions.

After the AED arrives, attach AED pads to the patient's chest
Defibrillatio (see AED section for details). Turn on the AED. Follow
prompts. Check rhythm.
n using and
AED Is the rhythm shockable?
If the AED advises a shock, make sure bystanders or
other helpers stay clear.

Give one shock.

 Resume CPR immediately for 5 cycles (approximately 2
minutes). Check rhythm again. Give one shock. Repeat cycle
of CPR. If rhythm is not shockable, resume CPR immediately
for 5 cycles. Check rhythm every 5 cycles. Continue until
ALS providers take over or the patient starts to move.

Unclear if the patient has a pulse?

Begin CPR immediately. Do not waste time trying to be certain about a pulse. It is better
to begin CPR that is unnecessary than to neglect compressions when they are needed.
Applying CPR to a patient with a pulse is not harmful. However, delaying CPR for a
pulseless patient reduces the patient's chances of being successfully resuscitated.

ACLS Bradycardia Algorithm

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Using the ACLS Bradycardia Algorithm for

Managing Bradycardia
The ACLS Bradycardia Algorithm outines the steps for assessing and managing a
patient who presents with symptomatic bradycardia. It begins with the decision that the
patient's heart rate (< 60 bpm) is too slow to be physiologically appropriate for the
person.

Steps
1. Decision: Heart rate is < 60 bpm and is inadequate for patient's clinical condition.

2. Assess and manage the patient using the primary and secondary surveys:

o Maintain patent airway.

o Assist breathing as needed.

o Give oxygen; monitor oxygen saturation.

o Monitor blood pressure and heart rate.

o Obtain a 12-lead ECG.

o Review patient's rhythm.

o Establish IV access.

o Take a problem-focused history and physical exam.

 o Search for and treat possible contributing factors.

3. Answer two questions to help you decide if the patient's signs and symptoms of
poor perfusion are caused by the bradycardia (see Figure 2).

o Are the signs or symptoms serious, such as hypotension, pulmonary

congestion, dizziness, shock, ongoing chest pain, shortness of breath,
congestive heart failure, weakness or fatigue, and acute altered mental
status?

o Are the signs and symptoms related to the slow heart rate?

There may be another reason for the slow heart rate. For example, the patient's
low blood pressure may be caused by a dysfunctional myocardium, rather than by
a slow heart rate.

2. Decide whether the patient has adequate or poor perfusion, since the treatment
sequence is determined by the severity of the patient's clinical presentation.

o If perfusion is adequate, monitor and observe the patient.

o If perfusion is poor, move quickly through the following actions:

Prepare for transcutaneous pacing. Do not delay pacing if rhythm

is Mobitz type II second-degree block or third-degree AV block

Consider administering atropine 0.5 mg IV during the interval

before pacing starts. Repeat PRN every 3 to 5 minutes up to 3
doses.

If the atropine is ineffective, begin pacing.

Consider epinephrine or dopamine while waiting for the pacer or if

pacing is ineffective.

Epinephrine 2 to 10 g/min

Dopamine 2 to 10 g/kg per minute

Progress quickly through these actions as the patient could be in pre-cardiac arrest and
need multiple interventions done in rapid succession: pacing, IV atropine, and infusion of
dopamine or epinephrine.
ACLS Tachycardia Algorithm for
Managing Unstable Tachycardia

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Using the ACLS Tachycardia Algorithm for
Managing Unstable Tachycardia
Two keys to managing patients with unstable tachycardia are, first, quickly recognizing
that the patient has significant symptoms and is unstable, and second, quickly
recognizing that the patient's signs and symptoms are caused by the tachycardia. You
need to decide if the tachycardia is producing the hemodynamic instability and serious
signs and symptoms or if the signs and symptoms are producing the tachycardiafor
example, the pain and distress of an acute MI could be causing the tachycardia. Making
this decision can be difficult. Generally, a heart rate between 100 bpm and approximately
130 bpm is usually caused by an underlying process that is represented as sinus
tachycardia (see Stable Tachycardia module for more information on sinus tachycardia).
Heart rates > 150 bpm may be symptomatic. The higher the rate, the more likely the
symptoms are a result of the tachycardia. Underlying heart disease or other problems
can cause symptoms at lower heart rates. Keep in mind the following considerations:

If the patient is seriously ill or has cardiovascular disease, the patient may have
symptoms at lower rates

If the patient's heart rate is above 150 bpm and the patient is unstable (has
symptoms), cardioversion is often required.

Sinus tachycardia is usually a response to an underlying condition that creates a

need for increased cardiac output. Sinus tachycardia does not respond to
cardioversion, and a shock may actually increase the patient's heart rate.

Atrial flutter typically has a heart rate of 150 bpm, but it is often stable for a
patient who does not have heart disease or other serious conditions.

Overview
The ACLS Tachycardia Algorithm is organized around the following four questions:

If the patient does not have a pulse and his or her rhythm is a tachycardia, follow the
ACLS Pulseless Arrest Algorithm.

If a pulse is present, answer these three questions to help determine treatment options
for tachycardia:
 1. Does the patient have a pulse?

o If the patient does not have a pulse and his or her rhythm is a tachycardia,
follow the ACLS Pulseless Arrest Algorithm

o If a pulse is present, answer these three questions to help determine

treatment options for tachycardia:

2. Is the patient stable or unstable?

3. Is the QRS wide or narrow?

4. Is the ventricular rhythm regular or irregular?

Steps

Does the patient have a pulse?

If yes:
Assess the patient using the primary and secondary surveys:

1. Check airway, breathing, and circulation.

2. Give oxygen and monitor oxygen saturation.

3. Get an ECG

4. Identify rhythm.

5. Check blood pressure.

6. Identify and treat reversible causes.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember:rate-related symptoms are uncommon if heart rate is less than 150 bpm.
If the signs and symptoms continue after you have given oxygen and supported the
airway and circulation AND if significant symptoms are due to the tachycardia, then the
tachycardia is UNSTABLE and immediate cardioversion is indicated.

If you determine that the patient has an unstable tachycardia, perform immediate
synchronized cardioversion.

1. Start an IV.

2. Give sedation if the patient is conscious.

3. Do not delay cardioversion.

4. Consider expert consultation.

If you determine that the patient has a stable tachycardia, start an IV and obtain a 12-
lead ECG

For a patient with a stable tachycardia, decide if the QRS complex is wide or narrow and
if the rhythm is regular.

Patient has Treatment

Narrow (< 0.12 sec) QRS complex Try vagal maneuvers

Regular rhythm Give adenosine 6 mg rapid IV push

Repeat 12 mg dose once if necessary

Does the patient's rhythm convert? If it does, it was probably reentry supraventricular
tachycardia. At this point you watch for a recurrence. If the tachycardia resumes, treat
with adenosine or longer-acting AV nodal blocking agents, such as diltiazem or beta-
blockers.

Patient has Treatment

 Narrow (< 0.12 Consider expert consultation
sec) QRS complex

Irregular rhythm Control patient's rate with diltiazem or beta-blockers. Use beta-
blockers with caution for patients with pulmonary disease or
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial

fibrillation, possible atrial flutter, or multi-focal atrial tachycardia.

Patient has Treatment

Wide (< 0.12 sec) QRS Expert consultation is advised.

complex

Regular rhythm Expert consultation advised.

If patient is in ventricular Amiodarone 150 mg IV over 10 min; repeat as needed to

tachycardia or uncertain maximum dose of 2.2 g in 24 hours Prepare for elective
rhythm synchronized cardioversion

If patient is in SVT with Adenosine 6 mg rapid IV push If no conversion, give 12

aberrancy mg rapid IV push; may repeat 12 mg dose once

Patient has Treatment

Wide (>0.12) QRS complex

Irregular rhythm Seek expert consultation

 If pre-excited atrial fibrillation Avoid AV nodal blocking agents such as adenosine,
(AF + WPW) digoxin, diltiazem, verapamil

Consider amiodarone 150 mg IV over 10 min

If recurrent polymorphic VT Seek expert consultation

If torsades de pointes Give magnesium (load with 1-2 g over 5-60 min; then
infuse

ou may not always be able to tell from the ECG whether the rhythm is ventricular or
supraventricular. Most wide-complex tachycardias originate in the ventricles (particularly
if the patient is older or has underlying heart disease). If the patient does not have a
pulse, treat the rhythm as ventricular fibrillation and follow the Pulseless Arrest
Algorithm.

If the patient is unstable and has a wide-complex tachycardia, assume the rhythm is VT
until you can prove otherwise.

CLS Tachycardia Algorithm for

Managing Stable Tachycardia

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Using the ACLS Tachycardia Algorithm for

Managing Stable Tachycardia
The key to managing a patient with any tachycardia is to check if pulses are present,
decide if the patient is stable or unstable, and then treat the patient based on the
patient's condition and rhythm. If the patient does not have a pulse, follow the ACLS
Pulseless Arrest Algorithm. If the patient has a pulse, manage the patient using the
ACLS Tachycardia Algorithm.

Definition of Stable Tachycardia

For a diagnosis of stable tachycardia, the patient meets the following criteria:
 The patient's heart rate is greater than 100 bpm.

The patient does not have any serious signs or symptoms as a result of the
increased heart rate.

The patient has an underlying cardiac electrical abnormality that is generating the
arrhythmia.

Overview
Find out if significant symptoms are present. Evaluate the symptoms and decide if they
are caused by the tachycardia or other systemic conditions. Use these questions to
guide your assessment:

Does the patient have symptoms?

Is the tachycardia causing the symptoms?

Is the patient stable or unstable?

Is the QRS complex narrow or wide?

Is the rhythm regular or irregular?

Is the rhythm sinus tachycardia?

Guidelines

Situation Assessment and Actions

Patient has significant signs or symptoms of The tachycardia is unstable. Immediate

tachycardia AND they are being caused by cardioversion is indicated.
the arrhythmia.

Patient has a pulseless ventricular Follow the Pulseless Arrest Algorithm.

tachycardia. Deliver unsynchronized high-energy
shocks.
 Patient has polymorphic ventricular Treat the rhythm as ventricular fibrillation.
tachycardia AND the patient is unstable. Deliver unsynchronized high-energy
shocks.

Steps for Managing Stable Tachycardia

Does the patient have a pulse?

Yes, the patient has a pulse. Complete the following:

1. Assess the patient using the primary and secondary surveys.

2. Check the airway, breathing, and circulation

3. Give oxygen and monitor oxygen saturation.

4. Get an ECG.

5. Identify rhythm.

6. Check blood pressure.

7. Identify and treat reversible causes.

Is the patient stable?

Look for altered mental status, ongoing chest pain, hypotension, or other signs of shock.

Remember:Rate-related symptoms are uncommon if heart rate is < 150 bpm.

Yes, the patient is stable.Take the following actions:

1. Start an IV.

2. Obtain a 12-lead ECG or rhythm strip.

Is the QRS complex wide or narrow?

 Patient Treatment

The patient's QRS is Try vagal maneuvers. Give adenosine 6 mg rapid IV push. If
narrow and rhythm is patient does not convert, give adenosine 12 mg rapid IV push.
regular. May repeat 12 mg dose of adenosine once.

Does the patient's rhythm convert? If it does, it was probably reentry supraventricular
tachycardia. At this point you watch for a recurrence. If the tachycardia resumes, treat
with adenosine or longer-acting AV nodal blocking agents, such as diltiazem or beta-
blockers.

Patient Treatment

The patient's QRS is Consider an expert consultation.

narrow (< 0.12 sec).

The patient's rhythm Control patient's rate with diltiazem or beta-blockers. Use beta-
is irregular. blockers with caution for patients with pulmonary disease or
congestive heart failure.

If the rhythm pattern is irregular narrow-complex tachycardia, it is probably atrial

fibrillation, possible atrial flutter, or multi-focal atrial tachycardia.

Patient Treatment

Patient's rhythm has wide (> 0.12 Expert consultation is advised.

sec) QRS complex AND Patient's
rhythm is regular.

Patient is in ventricular tachycardia CAmiodarone 150 mg IV over 10 min; repeat as

or uncertain rhythm. needed to maximum dose of 2.2 g in 24 hours.
 Prepare for elective synchronized cardioversion.

Patient is in supraventricular Adenosine 6 mg rapid IV push If no conversion,

tachycardia with aberrancy. give adenosine 12 mg rapid IV push; may repeat
12 mg dose once.

Patient's rhythm has wide (> 0.12) Seek expert consultation.

QRS complex AND Patient's
rhythm is irregular.

If pre-excited atrial fibrillation (AF + Avoid AV nodal blocking agents such as

WPW) adenosine, digoxin, diltiazem, verapamil.

Consider amiodarone 150 mg IV over 10 min.

Patient has recurrent polymorphic Seek expert consultation,

VT

If patient has torsades de pointes Give magnesium (load with 1-2 g over 5-60 min;
rhythm on ECG then infuse.

Caution: If the tachycardia has a wide-complex QRS and is stable, consult with an
expert. Management and treatment for a stable tachycardia with a wide QRS complex
and either a regular or irregular rhythm should be done in the hospital setting with expert
consultation available. Management requires advanced knowledge of ECG and rhythm
interpretation and anti-arrhythmic therapy.

Considerations:
You may not be able to distinguish between a supraventricular wide-complex
rhythm and a ventricular wide-complex rhythm. Most wide-complex tachycardias
originate in the ventricles.
 If the patient becomes unstable, proceed immediately to treatment. Do not delay
while you try to analyze the rhythm.

If the patient becomes unstable, proceed immediately to treatment. Do not delay

while you try to analyze the rhythm.