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 • 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
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Adult Tachycardia With a Pulse Algorithm

Assess appropriateness for clinical condition. Doses/Details

Heart rate typically ≥150/min if tachyarrhythmia. 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:
Synchronized cardioversion
• Hypotension? Yes
• Acutely altered mental status? • Consider sedation
• Signs of shock? • If regular narrow complex, If refractory, consider
• Ischemic chest discomfort? consider adenosine
• Underlying cause
• 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
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
ACLS Healthcare Provider
Post–Cardiac Arrest Care Algorithm

ROSC obtained Initial Stabilization Phase

Resuscitation is ongoing during the

post-ROSC phase, and many of these
Manage airway activities can occur concurrently.
Early placement of endotracheal tube However, if prioritization is
necessary, follow these steps:
• Airway management:
Manage respiratory parameters
Waveform capnography or
Initial Start 10 breaths/min
capnometry to confirm and monitor
Stabilization Spo2 92%-98%
endotracheal tube placement
Phase Paco2 35-45 mm Hg
• Manage respiratory parameters:
Titrate Fio2 for Spo2 92%-98%; start
Manage hemodynamic parameters at 10 breaths/min; titrate to Paco2 of
Systolic blood pressure >90 mm Hg 35-45 mm Hg
Mean arterial pressure >65 mm Hg • Manage hemodynamic parameters:
Administer crystalloid and/or
vasopressor or inotrope for goal
Obtain 12-lead ECG systolic blood pressure >90 mm Hg
or mean arterial pressure >65 mm Hg

Continued Management and

Consider for emergent cardiac intervention if Additional Emergent Activities
• STEMI present
These evaluations should be done
• Unstable cardiogenic shock
concurrently so that decisions on
• Mechanical circulatory support required
targeted temperature management
(TTM) receive high priority as
cardiac interventions.
• Emergent cardiac intervention:
Follows commands?
Early evaluation of 12-lead
No Yes
Continued electrocardiogram (ECG); consider
Management hemodynamics for decision on
and Additional Comatose Awake cardiac intervention
Emergent • TTM Other critical care • TTM: If patient is not following
Activities • Obtain brain CT management commands, start TTM as soon as
• EEG monitoring possible; begin at 32-36°C for 24
• Other critical care hours by using a cooling device with
management feedback loop
• Other critical care management
– Continuously monitor core
temperature (esophageal,
rectal, bladder)
Evaluate and treat rapidly reversible etiologies
– Maintain normoxia, normocapnia,
Involve expert consultation for continued management euglycemia
– Provide continuous or intermittent
electroencephalogram (EEG)
monitoring
– Provide lung-protective ventilation

H’s and T’s

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypokalemia/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
© 2020 American Heart Association
2020 Science Summary Table
This table compares 2015 with 2020, providing a quick reference to what has changed and what is new in the
science of advanced cardiovascular life support.

Table. Topical Comparison of 2015 and 2020 ACLS Science

ACLS topic 2015 2020

Ventilation • 1 breath every 5 to 6 seconds for respiratory • 1 breath every 6 seconds for respiratory arrest
arrest, with a bag-mask device with or without an advanced airway and also for
• 1 breath every 6 seconds for ventilation with an cardiac arrest with an advanced airway (use this
advanced airway in place rate with a bag-mask device if your local protocol
is continuous compressions and asynchronous
ventilations for cardiac arrest)

Bradycardia • Atropine dose: 0.5 mg • Atropine dose: 1 mg

• Dopamine dosing: 2 to 20 mcg/kg per minute • Dopamine dosing: 5 to 20 mcg/kg per minute

Tachycardia • Synchronized cardioversion initial recommended • Follow your specific device’s recommended
doses: energy level to maximize the success of the
– Narrow QRS complex, regular rhythm: first shock
50 to 100 J • Wide QRS complex, irregular rhythm:
– Narrow QRS complex, irregular rhythm: defibrillation dose (not synchronized)
120 to 200 J
– Wide QRS complex, regular rhythm: 100 J
• Wide QRS complex, irregular rhythm:
defibrillation dose (not synchronized)

Post–Cardiac • Titrate oxygen saturation to 94% or higher • Titrate oxygen saturation to 92% to 98%
Arrest Care

Adult Chain of • 5 links for both chains (in-hospital cardiac arrest • 6 links for both chains (in-hospital cardiac arrest
Survival and out-of-hospital cardiac arrest) and out-of-hospital cardiac arrest): added a
Recovery link to the end of both chains

IV/IO Access • IV access and IO access are equivalent • IV preferred over IO access, unless IV fails
(then OK to proceed to IO)

ACLS topic 2020

Cardiac • Epinephrine 1 mg every 3 to 5 minutes or every 4 minutes as a midrange

Arrest (ie, every other 2-minute rhythm check)
• Amiodarone and lidocaine are equivalent for treatment (ie, either may be used)
• Added maternal cardiac arrest information and algorithms (in-hospital)
• Added ventricular assist device information (left and right ventricular assist device) and algorithm
• Added new prognostication diagram and information
• Recommend using waveform capnography with a bag-mask device

Stroke • Revised stroke algorithm

• New stroke triage algorithm for EMS destination
• Focus on large vessel occlusion for all healthcare providers
• Endovascular therapy: treatment window up to 24 hours (previously up to 6 hours)
• Both alteplase and endovascular therapy can be given/performed if time criteria and inclusion
criteria are met
• Consider having EMS bypass the emergency department and go straight to the imaging suite
(computed tomography [CT]/magnetic resonance imaging); initial assessment can be performed
there to save time
• Titrate oxygen saturation to >94%

© 2020 American Heart Association