Protocols for Emergency Treatment
The following protocols represent the current ACLS guidelines published in Circ 2000;102:suppl I. Readers are strongly encouraged to study the comprehensive discussions of therapy that accompany the flowcharts in that volume; see also Nejm 2001;344:1304.
1.1 Basic Life Support for Adults
CPR Performed by 1 Rescuer
Assessment: Determine unresponsiveness (tap or gently shake pt and shout). If unresponsive, activate the EMS system.
Airway: Position pt and open the airway by the head tilt-chin lift or jaw-thrust maneuver.
Breathing: Assess breathing to identify absent or inadequate breathing.
If pt is unresponsive with normal breathing and spinal injury is not suspected, place pt in a recovery position, maintaining an open airway. If adult pt is unresponsive and not breathing, provide 2 initial breaths.
If you are unable to give initial breaths, reposition the head and reattempt ventilation. If you are still unsuccessful in making the chest rise with each ventilation after an attempt and reattempt, follow the unresponsive FBAO sequence.
Be sure the pt’s chest rises with each rescue breath you provide. Once you deliver the effective breaths, assess for signs of circulation.
Circulation: Check for signs of circulation; look for normal breathing, coughing, or movement and feel for a carotid pulse (take no more than 10 sec to do this). If there are no signs of circulation, begin chest compressions: 15 chest compressions at rate of ˜100/min, depressing chest 1½ to 2 in (4 to 5 cm) with each. Then open the airway and deliver 2 breaths; begin 15 more compressions at 100/min.
Reassessment: After 4 complete cycles of 15 compressions and 2 ventilations, reevaluatept, checking for signs of circulation. If there are no signs of circulation, resume CPR, beginning with chest compressions.
If signs of circulation are present, check for breathing. If breathing is present, place pt in a recovery position and monitor breathing and circulation. If breathing is absent but signs of circulation are present, provide rescue breathing at 10-12 times/min and monitor for signs of circulation every few min.
CPR Performed by 2 Rescuers
In 2-rescuer CPR, one person is positioned at the pt’s side and performs chest compressions while the other remains at the pt’s head, maintains an open airway, monitors the carotid pulse, and provides rescue breathing. Compression rate is 100/min; compression-ventilation ratio is 15:2 with a pause for ventilation of 2 sec after each compression until airway is secured.
1.2 Foreign Body Airway Occlusion
Finger Sweep and Tongue-Jaw Lift (should be used only in unresponsive/unconscious pt with complete FBAO): With pt face up, open pt’s mouth by grasping both the tongue and lower jaw between the thumb and fingers and lifting the mandible (tongue-jaw lift). This maneuver alone may be sufficient to relieve an obstruction.
Insert index finger of other hand deeply into pt’s throat to base of tongue. Use a hooking action to dislodge the foreign body and maneuver it into the mouth. It is sometimes necessary to use the index finger to push the foreign body against the opposite side of the throat to dislodge and remove it.
Relief of FBAO in a Responsive Pt Who Becomes Unresponsive: If you observe the pt’s collapse and you know it is caused by FBAO, activate the emergency response system, and perform the tongue-jaw lift and finger sweep to remove object; open the airway and try to ventilate.
If you cannot deliver effective breaths (the chest does not rise) even after attempts to reposition the airway, consider FBAO. Straddle the pt’s thighs and perform the Heimlich maneuver (up to 5 times). Repeat the sequence of tongue-jaw lift, finger sweep, attempt (and reattempt) to ventilate, and Heimlich maneuver until the obstruction is cleared and the chest rises with ventilation or advanced procedures are available (ie, Kelly clamp, Magill forceps, cricothyrotomy) to establish a patent airway.
To deliver abdominal thrusts to the unresponsive/unconsciouspt, kneel astride the pt’s thighs and place the heel of one hand against the pt’s abdomen, in the midline slightly above the navel and well below the tip of the xiphoid. Place second hand directly on top of the first, and press both hands into the abdomen with quick upward thrusts.
Relief of FBAO in a Pt Found Unresponsive: Activate the emergency response system; open the airway and attempt to provide rescue breaths.
If pt cannot be ventilated even after attempts to reposition the airway, straddle the pt’s knees and perform the Heimlich maneuver (up to 5 times). After 5 abdominal thrusts, open the pt’s airway using a tongue-jaw lift and perform a finger sweep to remove the object. Repeat the sequence of attempts (and reattempts) to ventilate, Heimlich maneuver, and tongue-jaw lift and finger sweep until the obstruction is cleared or advanced procedures are available to establish a patent airway.
In either case, if the FBAO is removed and the airway is cleared, check breathing. If the pt is not breathing, provide slow rescue breaths and check for signs of circulation (pulse check and evidence of breathing, coughing, or movement). If there are no signs of circulation, begin chest compressions.
1.3 Universal ACLS Algorithm
For adult cardiac arrest: initiate Basic Life Support (above); assess rhythm and check pulse.
If rhythm VT/VF, attempt to defibrillate up to 3 times as needed; then continue CPR for at least 1 min after shocks
or
and then
As an alternative,pts with VT/VF rhythms refractory to initial shocks may receive vasopressin 40 U iv one time only as initial agent, followed by epinephrine as needed.
Search for/treat potentially reversible conditions such as hypovolemia, hypoxia, metabolic disorders, hypothermia, tamponade, and tension pneumothorax (Circ 2000;102:I-144).
1.4 Asystole/Pulseless Electrical Activity Algorithm
Exclude and/or treat reversible causes (hypovolemia, hypoxia, acidosis, hyper- or hypokalemia, hypothermia, drug ingestion, cardiac tamponade, tension pneumothorax, acute coronary syndrome, pulmonary embolus).
Transcutaneous pacing for asystole (routine use not recommended).
NaHCO3 1 mEq/kg iv for hyperkalemia, tricyclic antidepressant or ASA overdose, prolonged arrest, or known acidosis.
1.5 Bradycardia Algorithm
1.6 Tachycardia Overview Algorithm
Determine if pt is hemodynamically stable and/or has sx. If pt is unstable or symptomatic, prepare for immediate cardioversion.
Otherwise:
If rhythm is Aflut/Afib, assess LV systolic function, presence of WPW, and duration of arrhythmia and initiate anticoagulation.
If duration > 48 hr or unknown:
Anticoagulation for 3-4 wk before cardioversion or iv heparin and TEE; may cardiovert if no thrombus seen. Control rate with β-blockers or slowing Ca++-channel blockers if LV function normal; diltiazem, digoxin, or amiodarone if LV function abnormal.
Anticoagulate minimum of 4 wk after cardioversion.
If duration < 48 hr:
If LV systolic function normal, may consider use of amiodarone, flecanide, propafenone, procainamide, sotalol, or DC cardioversion; may also use these agents if WPW present but should avoid use of adenosine, digoxin, β-blockers, or slowing Ca++-channel blockers.
If rhythm is narrow complex tachycardia:
Try to differentiate between PSVT, MAT, junctional tachycardia using EKG, vagal maneuvers, iv adenosine.
Proceed according to Stable Narrow Complex Tachycardia Algorithm (p 8).
If rhythm is stable wide complex tachycardia of unknown type:
Try to differentiate between aberrant conduction of SV rhythm using clinical data, EKG, esophageal lead.
If SVT confirmed, proceed according to Stable Narrow Complex Tachycardia Algorithm (p 8).
If uncertain, proceed with DC cardioversion or administration of amiodarone; procainamide also a choice if LV systolic function normal (EF > 40%, no clinical CHF) (Circ 2000;102:I-159).
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