Either bag-mask ventilation or an advanced airway strategy

may be considered during adult CPR in any setting

If advanced airway
is needed

Out-of-Hospital Setting In-Hospital Setting

High tracheal intubation

Low tracheal intubation Expert providers
success rate and/or optimal
success rate or minimal trained in advanced
training opportunities
training opportunities airway procedures:
for endotracheal tube
for endotracheal tube either supraglottic
placement: either supraglottic
placement: supraglottic airway or endotracheal
airway or endotracheal
airway can be used tube* can be used
tube* can be used

EMS systems performing prehospital intubation

should provide program of ongoing quality
improvement to minimize complications
and track overall supraglottic airway and
endotracheal tube placement success rates

*Frequent experience or frequent retraining is recommended for providers who

perform endotracheal intubation.
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 Termination of Resuscitation

Arrest not witnessed

No bystander CPR
No return of spontaneous circulation (before transport)
No shock was delivered (before transport)

If all criteria are present, If any criteria are missing,

consider termination continue resuscitation
of resuscitation and transport

© 2020 American Heart Association

BLS Termination of Resuscitation

Arrest not witnessed by emergency medical services personnel

No return of spontaneous circulation (before transport)
No AED shock was delivered (before transport)

If all criteria are present, If any criteria are missing,

consider termination continue resuscitation
of resuscitation and transport

© 2020 American Heart Association

Adult Basic Life Support Algorithm for Healthcare Providers

Verify scene safety.

• Check for responsiveness.

• Shout for nearby help.
• Activate emergency response
system via mobile device
(if appropriate).
• Get AED and emergency equipment
(or send someone to do so).

Normal No normal • Provide rescue breathing,

breathing, breathing, 1 breath every 6 seconds or
Look for no breathing
pulse felt pulse felt 10 breaths/min.
Monitor until or only gasping and check
• Check pulse every 2 minutes;
emergency pulse (simultaneously).
if no pulse, start CPR.
responders arrive. Is pulse definitely felt
• If possible opioid overdose,
within 10 seconds?
administer naloxone if
available per protocol.

No breathing
or only gasping,
pulse not felt

By this time in all scenarios, emergency

response system or backup is activated,
and AED and emergency equipment are
retrieved or someone is retrieving them.
Start CPR
• Perform cycles of 30 compressions
and 2 breaths.
• Use AED as soon as it is available.

AED arrives.

Check rhythm.
Shockable rhythm?
Yes, No,
shockable nonshockable

• Give 1 shock. Resume CPR • Resume CPR immediately for

immediately for 2 minutes 2 minutes (until prompted by AED
(until prompted by AED to allow to allow rhythm check).
rhythm check). • Continue until ALS providers take
• Continue until ALS providers take over or victim starts to move.
over or victim starts to move.

© 2020 American Heart Association

Neonatal Resuscitation Algorithm

Antenatal counseling
Team briefing and equipment check

Birth

Infant stays with mother for routine

Term gestation? Yes care: warm and maintain normal
Good tone? temperature, position airway, clear
Breathing or crying? secretions if needed, dry.
Ongoing evaluation
No

Warm and maintain normal temperature,

1 minute

position airway, clear secretions if

needed, dry, stimulate

No
Apnea or gasping? Labored breathing or
HR below 100/min? persistent cyanosis?

Yes Yes

PPV Position and clear airway

Spo2 monitor Spo2 monitor
Consider ECG monitor Supplementary O2 as needed
Consider CPAP

No Postresuscitation care
HR below 100/min?
Team debriefing
Yes

Check chest movement

Ventilation corrective steps if needed
Targeted Preductal Spo2
ETT or laryngeal mask if needed
After Birth

1 min 60%-65%
No
HR below 60/min? 2 min 65%-70%

Yes 3 min 70%-75%

Intubate if not already done 4 min 75%-80%

Chest compressions
5 min 80%-85%
Coordinate with PPV
100% O2 10 min 85%-95%
ECG monitor
Consider emergency UVC

HR below 60/min?

Yes

IV epinephrine
If HR persistently below 60/min
Consider hypovolemia
Consider pneumothorax
© 2020 American Heart Association
Pediatric Tachycardia With a Pulse Algorithm

Initial assessment and support Doses/Details

• Maintain patent airway; assist breathing as necessary Synchronized
• Administer oxygen cardioversion
• Cardiac monitor to identify rhythm; monitor pulse, Begin with 0.5-1 J/kg;
blood pressure, and oximetry if not effective, increase
• IV/IO access to 2 J/kg. Sedate if
• 12-Lead ECG if available needed, but don’t delay
cardioversion.

Drug Therapy
Probable sinus
tachycardia if Adenosine IV/IO dose
Evaluate rhythm
• P waves present/normal • First dose: 0.1 mg/kg
with 12-lead ECG
• Variable RR interval rapid bolus (maximum:
or monitor. 6 mg)
• Infant rate usually <220/min
• Child rate usually <180/min • Second dose:
0.2 mg/kg rapid bolus
(maximum second
dose: 12 mg)

Cardiopulmonary
Search for
compromise?
and treat cause. Yes No
• Acutely altered
mental status
• Signs of shock
• Hypotension

Narrow Wide Narrow Wide

(≤0.09 sec) (>0.09 sec) (≤0.09 sec) (>0.09 sec)
Evaluate Evaluate
QRS duration. QRS duration.

Probable supraventricular Possible ventricular Probable supraventricular Possible ventricular

tachycardia tachycardia tachycardia tachycardia
• P waves absent/abnormal • P waves absent/abnormal
• RR interval not variable • RR interval not variable
• Infant rate usually ≥220/min • Infant rate usually ≥220/min
• Child rate usually ≥180/min • Child rate usually ≥180/min
• History of abrupt rate change Synchronized • History of abrupt rate change If rhythm is regular and
cardioversion QRS monomorphic,
Expert consultation consider adenosine.
is advised before
additional drug
• If IV/IO access is present, therapies. Consider
give adenosine vagal maneuvers.
or Expert consultation
• If IV/IO access is not is recommended.
available, or if adenosine
is ineffective, perform
synchronized cardioversion If IV/IO access
is present, give
adenosine.
© 2020 American Heart Association
Pediatric Bradycardia With a Pulse Algorithm

Patient with bradycardia

Cardiopulmonary
compromise?
No
• Acutely altered
mental status
• Signs of shock
• Hypotension

Yes

Assessment and support • Support ABCs

• Maintain patent airway • Consider oxygen
• Assist breathing with positive • Observe
pressure ventilation and oxygen • 12-Lead ECG
as necessary • Identify and treat
• Cardiac monitor to identify rhythm; underlying causes
monitor pulse, BP, and oximetry

Start CPR if HR <60/min

despite oxygenation and
ventilation.

No
Bradycardia
persists?

Yes

• Continue CPR if HR <60/min

• IV/IO access
• Epinephrine Doses/Details
• Atropine for increased vagal
tone or primary AV block Epinephrine IV/IO dose:
0.01 mg/kg (0.1 mL/kg of the
• Consider transthoracic/ 0.1 mg/mL concentration).
transvenous pacing Repeat every 3-5 minutes.
• Identify and treat underlying If IV/IO access not available
causes but endotracheal (ET) tube
in place, may give ET dose:
0.1 mg/kg (0.1 mL/kg of the
1 mg/mL concentration).
Atropine IV/IO dose:
0.02 mg/kg. May repeat once.
Yes Check pulse Minimum dose 0.1 mg and
every 2 minutes. maximum single dose 0.5 mg.
Pulse present?
Possible Causes

No • Hypothermia
• Hypoxia
Go to Pediatric • Medications
Cardiac Arrest Algorithm.
© 2020 American Heart Association
Pediatric Cardiac Arrest Algorithm

1
CPR Quality
Start CPR
• Begin bag-mask ventilation and give oxygen • Push hard (≥⅓ of anteroposterior
• Attach monitor/defibrillator diameter of chest) and fast
(100-120/min) and allow complete
chest recoil
• Minimize interruptions in
Yes No compressions
Rhythm • Change compressor every
shockable? 2 minutes, or sooner if fatigued
• If no advanced airway, 15:2
2 9 compression-ventilation ratio
VF/pVT Asystole/PEA • If advanced airway, provide
continuous compressions and
give a breath every 2-3 seconds
Shock Energy for Defibrillation
3
Shock Epinephrine • First shock 2 J/kg
ASAP • Second shock 4 J/kg
4 10 • Subsequent shocks ≥4 J/kg,
maximum 10 J/kg or adult dose
CPR 2 min CPR 2 min
IV/IO access • IV/IO access Drug Therapy
• Epinephrine every 3-5 min
• Consider advanced • Epinephrine IV/IO dose:
0.01 mg/kg (0.1 mL/kg of the
airway and capnography 0.1 mg/mL concentration).
No Max dose 1 mg.
Rhythm Repeat every 3-5 minutes.
shockable? If no IV/IO access, may give
Yes endotracheal dose: 0.1 mg/kg
Yes Rhythm (0.1 mL/kg of the 1 mg/mL
shockable? concentration).
5 Shock • Amiodarone IV/IO dose:
5 mg/kg bolus during cardiac
arrest. May repeat up to
No
6 3 total doses for refractory
CPR 2 min VF/pulseless VT
or
• Epinephrine every 3-5 min
11 Lidocaine IV/IO dose:
• Consider advanced airway Initial: 1 mg/kg loading dose
CPR 2 min
Treat reversible causes Advanced Airway

No • Endotracheal intubation or
Rhythm
supraglottic advanced airway
shockable? • Waveform capnography or
No Yes capnometry to confirm and
Rhythm
Yes monitor ET tube placement
shockable?
Shock Reversible Causes
7
• Hypovolemia
8 • Hypoxia
• Hydrogen ion (acidosis)
CPR 2 min • Hypoglycemia
• Amiodarone or lidocaine
• Hypo-/hyperkalemia
• Treat reversible causes • Hypothermia
• Tension pneumothorax
• Tamponade, cardiac
• Toxins
12 • Thrombosis, pulmonary
• If no signs of return of spontaneous Go to 7. • Thrombosis, coronary
circulation (ROSC), go to 10
• If ROSC, go to Post–Cardiac Arrest
Care checklist
© 2020 American Heart Association
Pediatric Basic Life Support Algorithm for Healthcare Providers—2 or More Rescuers

Verify scene safety.

• Check for responsiveness.

• Shout for nearby help.
• First rescuer remains with the child.
Second rescuer activates emergency
response system and retrieves the
AED and emergency equipment.

Normal No normal
breathing, Look for no breathing breathing, • Provide rescue breathing,
Monitor until pulse felt or only gasping and check pulse felt 1 breath every 2-3 seconds,
emergency pulse (simultaneously). or about 20-30 breaths/min.
responders arrive. Is pulse definitely felt • Assess pulse rate for no
within 10 seconds? more than 10 seconds.

Yes HR <60/min No
with signs of poor
perfusion?
No breathing
or only gasping,
pulse not felt
Start CPR. • Continue rescue
breathing; check
pulse about
every 2 minutes.
• If no pulse, start
CPR.
Start CPR
• First rescuer performs cycles of
30 compressions and 2 breaths.
• When second rescuer returns,
perform cycles of 15 compressions
and 2 breaths.
• Use AED as soon as it is available.

Check rhythm.
Shockable rhythm?
Yes, No,
shockable nonshockable

• Give 1 shock. Resume CPR • Resume CPR immediately for

immediately for 2 minutes 2 minutes (until prompted by AED
(until prompted by AED to allow to allow rhythm check).
rhythm check). • Continue until ALS providers take
• Continue until ALS providers take over or the child starts to move.
over or the child starts to move.

© 2020 American Heart Association

Pediatric Basic Life Support Algorithm for Healthcare Providers—Single Rescuer

Verify scene safety.

• Check for responsiveness.

• Shout for nearby help.
• Activate the emergency response system
via mobile device (if appropriate).

Normal No normal • Provide rescue breathing,

breathing, breathing, 1 breath every 2-3 seconds,
Look for no breathing or about 20-30 breaths/min.
Monitor until pulse felt or only gasping and check pulse felt
• Assess pulse rate for no
emergency pulse (simultaneously). more than 10 seconds.
responders arrive. Is pulse definitely felt
within 10 seconds?
Yes HR <60/min No
with signs of poor
perfusion?

No breathing
or only gasping, Start CPR. • Continue rescue
pulse not felt breathing; check
pulse every 2
minutes.
• If no pulse, start
CPR.

Yes Activate emergency response

Witnessed system (if not already done),
sudden collapse? and retrieve AED/defibrillator.

No

Start CPR
• 1 rescuer: Perform cycles of
30 compressions and 2 breaths.
• When second rescuer arrives,
perform cycles of 15 compressions
and 2 breaths.
• Use AED as soon as it is available.

After about 2 minutes, if still alone, activate

emergency response system and retrieve AED
(if not already done).

Check rhythm.
Shockable rhythm?
Yes, No,
shockable nonshockable

• Give 1 shock. Resume CPR • Resume CPR immediately for

immediately for 2 minutes 2 minutes (until prompted by AED
(until prompted by AED to allow to allow rhythm check).
rhythm check). • Continue until ALS providers take
• Continue until ALS providers take over or the child starts to move.
over or the child starts to move.

© 2020 American Heart Association

Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm

Continue BLS/ACLS Maternal Cardiac Arrest

• High-quality CPR
• Defibrillation when indicated • Team planning should be done in
• Other ACLS interventions collaboration with the obstetric,
(eg, epinephrine) neonatal, emergency,
anesthesiology, intensive care,
and cardiac arrest services.
• Priorities for pregnant women
Assemble maternal cardiac arrest team in cardiac arrest should include
provision of high-quality CPR and
relief of aortocaval compression with
lateral uterine displacement.
Consider etiology • The goal of perimortem cesarean
of arrest delivery is to improve maternal and
fetal outcomes.
• Ideally, perform perimortem cesarean
delivery in 5 minutes, depending on
Perform maternal interventions Perform obstetric provider resources and skill sets.
• Perform airway management interventions
• Administer 100% O2, avoid • Provide continuous lateral Advanced Airway
excess ventilation uterine displacement
• Place IV above diaphragm • Detach fetal monitors • In pregnancy, a difficult airway
• If receiving IV magnesium, stop and • Prepare for perimortem is common. Use the most
cesarean delivery experienced provider.
give calcium chloride or gluconate
• Provide endotracheal intubation or
supraglottic advanced airway.
• Perform waveform capnography or
Continue BLS/ACLS Perform perimortem capnometry to confirm and monitor
cesarean delivery ET tube placement.
• High-quality CPR
• Once advanced airway is in place,
• Defibrillation when indicated • If no ROSC in 5 minutes, give 1 breath every 6 seconds
• Other ACLS interventions consider immediate (10 breaths/min) with continuous
(eg, epinephrine) perimortem cesarean delivery chest compressions.

Potential Etiology of Maternal

Neonatal team to receive neonate Cardiac Arrest

A Anesthetic complications
B Bleeding
C Cardiovascular
D Drugs
E Embolic
F Fever
G General nonobstetric causes of
cardiac arrest (H’s and T’s)
H Hypertension
© 2020 American Heart Association
Opioid-Associated Emergency for Lay Responders Algorithm

1
Suspected opioid poisoning
• Check for responsiveness.
• Shout for nearby help.
• Activate the emergency response system.
• Get naloxone and an AED if available.

2
Yes Is the No
person breathing
normally?

3 5
Prevent deterioration Start CPR*
• Tap and shout. • Give naloxone.
• Reposition. • Use an AED.
• Consider naloxone. • Resume CPR until EMS arrives.
• Continue to observe until
EMS arrives.

4
Ongoing assessment of
responsiveness and breathing
Go to 1.

*For adult and adolescent victims, responders should perform compressions and rescue breaths for
opioid-associated emergencies if they are trained and perform Hands-Only CPR if not trained to perform
rescue breaths. For infants and children, CPR should include compressions with rescue breaths.
© 2020 American Heart Association
Opioid-Associated Emergency for Healthcare Providers Algorithm

1
Suspected opioid poisoning
• Check for responsiveness.
• Shout for nearby help.
• Activate the emergency response system.
• Get naloxone and an AED if available.

2
Yes Is the No
person breathing
normally?

3
Prevent deterioration 5
Does the
• Tap and shout. Yes person have a pulse? No
• Open the airway and reposition. (Assess for ≤10
• Consider naloxone. seconds.)
• Transport to the hospital.

4 6 7
Ongoing assessment of Support ventilation Start CPR
responsiveness and breathing • Open the airway and • Use an AED.
Go to 1. reposition. • Consider naloxone.
• Provide rescue breathing or • Refer to the BLS/Cardiac
a bag-mask device. Arrest algorithm.
• Give naloxone.

© 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