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Pulseless Arrest Algorithm

 

Pulseless Arrest (Cardiac Arrest) Algorithm

The Pulseless Arrest Algorithm which is now known as the Cardiac Arrest Algorithm takes its place as the most important algorithm in the ACLS Protocol. There are 4 rhythms that are seen with pulseless cardiac arrest. These four rhythms are pulseless ventricular tachycardia (VT), ventricular fibrillation (VF), asystole, and pulseless electrical activity (PEA). Visit the links above for detailed information about each of the rhythms and their treatment in the ACLS protocol.

The majority of patients that experience sudden cardiac arrest will be treated with the Cardiac Arrest Algorithm. Therefore, mastery of this algorithm is very important. There are 2 branches to the Cardiac Arrest Algorithm, the left and right branch. The left branch is used for the treatment of pulseless ventricular tachycardia and ventricular fibrillation, and the right branch is used for the treatment of PEA and Asystole. Watch Part 1 and Part 2 of the Cardiac Arrest Video Review.

Also, In 2010 the AHA released new ACLS guidelines that simplified the pulseless arrest algorithm. Use this link to watch a short video that reviews the 2010 Simplified Pulseless Arrest Algorithm.

  52 Responses to “Pulseless Arrest Algorithm”

  1. I was currently taught in a recent intensive course that we should give epinephrine during the first CPR cycle. They said that it is more helpful and “synergistic” if you would give it during the first cycle of CPR whether it be PEA, Asystole, VFIB or Pulseless V-tach. Is this true? They stated that the Defibrillation is still carried out the same (rapid defib on the first cycle) as before but the epinephrine administration should be given during the first cycle. Do you have any reference for this? Thanks.

    • Hi Ramon,

      Thanks for the question. You asked:”I was currently taught in a recent intensive course that we should give epinephrine during the first CPR cycle. They said that it is more helpful and “synergistic” if you would give it during the first cycle of CPR whether it be PEA, Asystole, VFIB or Pulseless V-tach. Is this true? They stated that the Defibrillation is still carried out the same (rapid defib on the first cycle) as before but the epinephrine administration should be given during the first cycle. Do you have any reference for this? Thanks.”

      Reply:
      There is no evidence to support that epinephrine is more synergistic or more effective when given during the first cycle of CPR. There is also no evidence to show that it is more effective when given during the second cycle of CPR.
      In fact, there is no evidence that epinephrine or vasopressin improve survival to hospital discharge inpatients that experience cardiac arrest.
      Epinephrine is used in ACLS simply because we know how epinephrine affects the cardiovascular system, and because of this we continue to use it for its ability to reduce peripheral circulation and increase coronary and cerebral perfusion pressures and therefore increase oxygen exchange at the cellular level.

      It is my experience in codes that we give epinephrine as soon as we can. If we have time, we usually give epinephrine before the first shock is given. While CPR is being performed and the defibrillator is being attached, somebody is usually pushing epinephrine. This is my experience.

      This would not be the same as the American Heart Association guidelines, but guidelines are just guidelines. You would not be breaking any rules by giving epinephrine during the first cycle of CPR, but there is no clinical evidence to support that it is somehow better.

      Kind regards,
      Jeff

  2. Hi I would ask about the role of Magnesium and Calcium in ACLS

    • Here is a quote from AHA about Calcium:
      “Although calcium ions play a critical role in myocardial contractile performance and impulse formation, retrospective and prospective studies in the cardiac arrest setting have not shown benefit from the use of calcium. In addition, there is concern on a theoretical basis that the high blood levels induced by calcium administration may be detrimental. When hyperkalemia, hypocalcemia (eg, after multiple blood transfusions), or calcium channel blocker toxicity is present, use of calcium is probably helpful (Class IIb). Otherwise, calcium should not be used (Class III). When necessary, a 10% solution of calcium chloride can be given in a dose of 2 to 4 mg/kg and repeated as necessary at 10-minute intervals. (The 10% solution contains 1.36 mEq of calcium per 100 mg of salt per milliliter.) Calcium gluceptate can be given in a dose of 5 to 7 mL and calcium gluconate in a dose of 5 to 8 mL.” AHA Website Source

      Here is a quote from AHA about Magnesium:
      “Two observational studies showed that IV magnesium can effectively terminate torsades de pointes (irregular/polymorphic VT associated with prolonged QT interval). One small adult case series in adults showed that isoproterenol or ventricular pacing can be effective in terminating torsades de pointes associated with bradycardia and drug-induced QT prolongation. Magnesium is not likely to be effective in terminating irregular/polymorphic VT in patients with a normal QT interval.

      When VF/pulseless VT cardiac arrest is associated with torsades de pointes, providers may administer magnesium sulfate at a dose of 1 to 2 g diluted in 10 mL D5W IV/IO push, typically over 5 to 20 minutes (Class IIa for torsades). When torsades is present in the patient with pulses, the same 1 to 2 g is mixed in 50 to 100 mL of D5W and given as a loading dose. It can be given more slowly (eg, over 5 to 60 minutes IV) under these conditions. See Part 7.3: “Management of Symptomatic Bradycardia and Tachycardia” for additional information about management of torsades de pointes not associated with cardiac arrest.” AHA Source

      Kind regards,
      Jeff

  3. i need the ACLS Algorithm & ACLS Drugs (recent changes) thanks

  4. Hi Jeff. This will be my first time to do ACLS. My question is: Are there ACLS drugs that are not to be used during a cardiac arrest of a pregnant patient. Thank you.

  5. Hi!
    First of all i would like to say that this website is amazing. Thank you for the endless resources! I just have a quick question in regards to your answer to the above question. I thought that VT with a pulse would warrant using the other side of the Cardiac Arrest algorithm (shock, CPR, epi, amiodarone,etc.) instead of just treating with the tachycardia algorithm which I take to mean treating with vagal maneuvers, beta blockers, and adenosine depending on how high the heart rate is. Was just wondering if you could clarify your answer.
    Thanks again,
    Audra

    • If a person has VT with a pulse then the treatment would being using the tachycardia algorithm. If they are unstable but have a pulse, the tachycardia algorithm would call for synchronized cardioversion.
      The tachycardia algorithm deals with both narrow and wide QRS tachycardia and both unstable and stable tachycardia.
      The pulseless arrest algorithm deals with the treatment of pulseless arrest.

      Hope this makes sense,
      Kind regards,
      Jeff

  6. Is there a ventricular tachycardia with a pulse?

  7. Hi Jeff,

    Thank you so much for the endless effort you are making on this site to help people so that ACLS is easily understandable. I build up my confidence since I join your site!!!
    I have one Q… If the only choice we have is Vasopressin during adult cardiac arrest algorism managing VT/VF , can we administer Vasopressin every 3-5 minutes as much as we needed? or is there any max dose we have to administer like Epinephrine.

    • Vasopressin should only be administered once because, the half-life of vasopressin is 10-35 minutes. This means that it will remain in the system for at least 20 minutes.
      The reason why epinephrine is give every 3-5 minutes is that the half-life of is 2-3 minutes. This means that it will remain in the system for at least 4 minutes.
      Vasopressin should only need to be given once during a code.

      Kind regards,
      Jeff

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