Pulseless Arrest Algorithm
Pulseless Arrest Algorithm
The Pulseless Arrest Algorithm takes its place as the most important algorithm in the ACLS Protocol. There are 4 rhythms that produce pulseless 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 this algorithm. Therefore, it is very important to master the pulseless arrest algorithm. 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 revised algorithm.
When your patient is in pulse less vib or vtach do you do a pulse check before or after a shock 2 years sgo I failed and had to redo my mega c ode because the ER RN who was doing it said always after not before shocking. When I redid the mega code the next day the instructor said always before not after so what is it? I was always told to do a quick less then 10 sec after the shock
You would not do a pulse check unless you see a rhythm that could be a perfusing rhythm. Rhythm checks are always performed after 5 cycles of cpr. So if you perform a shock, you would then complete 5 cycles (2 min.) of CPR before checking a rhythm and if needed a pulse check.
example: Patient with VF has just been shocked. ALWAYS Perform 5 cycles of CPR then do a rhythm check. If you see a change to a rhythm that could be a perfusing rhythm, then you would perform a pulse check.
Many times providers make the mistake of looking at the monitor just after shocking. If they see a rhythm change, they check a pulse. This is incorrect because there is a good chance that the patient will have no pulse. Chest compressions should continue for 2 minutes after the shock. This increases the likelihood of return of spontaneous circulation.
Kind regards,
Jeff
In a pulseless state, (pre and post CPR) no BP reading can be recorded??
What is the maxium dose of of atropine given during cpr
You would not give atropine during CPR to treat pulseless arrest. Atropine is given for symptomatic bradycardia.
The maximum total dosage to be given when treating bradycardia is 3mg.
Kind regards,
Jeff
If you give precordial thump, just once?
Yes, the precordial thump is attempted only one time. it is effective only if used near the onset of VF or pulseless VT, and so should be used only when the arrest is witnessed or monitored and only at the outset. . About 25% of patients in cardiac arrest who received a thump on the precordium regained cardiac function according to one study. There is no evidence that the precordial thump improves recovery in unwitnessed cardiac arrest.
Kind regards,
Jeff
I have been enjoying studying for ACLS. I wish you would create the site for PALS.
During CPR we use art line pressure readings for compression monitoring and improvement, if the pt has an art line. I have never been in a resuscitation and used cuff pressures during cpr. Would this even work? would it be accurate and would it be useful information? I guess you could autocycle it every 3 min…
It is going to be very hard to monitor any type of blood pressure whether it is with an arterial line or BP cuff. Both are peripheral blood pressures. I can’t say that I have ever seen a blood pressure watched closely or even recorded until we obtained some type of rhythm change or pulse. Now there have been times in the critical care setting on patient’s with an arterial line when we have watched a patient’s BP tank, responded to the drop in BP, and then the patient coded. In these times it seems that we did use the arterial line BP to watch for any changes in the right direction. Still I would say that the BP is more pre. and post arrest.
Kind regards,
Jeff
V tach without a pulse is not considered PEA by academic definition, however, if the V tach is pulseless due to hypovolemia and we are running fluids during the resuscitation we may end up with a pulse. Thus, checking a pulse during your 10 sec rhythm checks (even though we started with pulseless v tach) doesn’t seem unreasonable. Pulse check with V F seems unnecessary and inconsequential ….. any thoughts on that ??
I agree. IF you are dealing with a pulseless state that is related to hypovolemia, pulse checks WITH the rhythm checks would be wise. However, I would not delay chest compressions for a pulse check. If you have to choose between chest compressions and a pulse check. Choose chest compressions. A few extra chest compressions will not hurt if the patient has a pulse. If the patient does not have a pulse, the chest compressions will most definitely help. Also, you should have some idea whether or not you are dealing with hypovolemia. (usually blood loss).
Kind regards,
Jeff
Is there a rule of thumb to remember whether or not a rhythm is shockable? I ask because in the algorhithms it is a step to consider. Thanks for your time.
There are two types of shock that can be delivered. Unsynchronized shock (defibrillation) and Synchronized shock. For this question, I will assume that you are asking about defibrillation.
Defibrillation is used for Ventricular Fibrillation and Pulseless VT. If you see either of these rhythms and you do not feel a pulse, you will defibrillate.
That is a simple rule of thumb for defibrillation.
Kind regards, Jeff
Jeff-
Is it advisable to give 2 or 3 doses of Epi with alternating rounds of CPR and shocking prior to the first dose of Amiodarone, or is is up to the code team leader as to how many doses of Epi is given before giving Amiodarone? What is the standard of care?
According to AHA ACLS Guidelines, the first dose of epinephrine is given after the 2nd shock during CPR. After the first dose, the epinephrine is given every 3-5 minutes. This is because the half-life of epinephrine is 2 minutes.
After the first dose epinephrine is essentially on its own timetable.
The first dose of amiodarone should be administered after the 3rd shock during CPR.
This is per the AHA ACLS guidelines which is considered the standard of care.
Kind regards,
Jeff
I keep getting confused about when to return to administration of epinephrine following the initial dose and admin of 300/150 amiodarone…is it based on time (q 3-5 min)? Any suggestions on how to keep this straight?
After the first dose of epinephrine, it is essentially on its own time table. Just remember to give epinephrine every 3-5 minutes after the first dose. Amiodarone is given after the 3rd (300mg) and 4th (150mg) shock.
Kind regards, Jeff
Thanks Jeff, now it is clear.
How fast do you push the Amiodarone 300mg?
In a cardiac emergency, you will push amiodarone as fast as you can push the plunder of the syringe. Essentially the same as you would push any drug in a cardiac emergency.
Kind regards,
Jeff
Here is a question about the right side of the Pulseless Arrest Algorithm. We know that epinephrine or vasopressin may be used in Asystole/PEA but I made some notes in my 2008 AHA handbook that don’t make sense.
- The handbook states (Pulseless Arrest Algorithm, page 7, box 10): “May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine”
- My handwritten note states: “If vasopressin is used in the first cycle of CPR do not follow with the use of epinephrine in the second round of CPR. Wait four minutes and be sure to use atropine 1mg IV/IO instead.”
What is the reasoning behind not using epinephrine after vasopressin? Why would an ACLS instructor emphasize that? What are the consequences of ignoring that instruction?
Vasopressin may be given directly as part of the pulseless arrest algorithm. I am not aware of a reason behind not using epinephrine after vasopressin and this is not part of the algorithm. Vasopressin should be used to replace the 1st or 2nd dose of epinephrine.
Also note, atropine is no longer included in the right branch of the pulseless arrest algorithm.
Kind regards,
Jeff
I notice in the video that it emphasizes minimal interruption of compressions yet still states 30/2 as the correct compression/ventilation ratio. Isn’t this a contradiction?
Awesome site. I’m amazed at the logic and thoroughness of it. Thanks for taking our money and giving us a much greater value in return when the opposite is nearly always the case at other sites.
Dwayne
Hi Dwayne,
Thanks for the encouragement and feedback. With regard to the minimal interruption of chest compressions and the 30/2 compression to ventilation ratio. I would not say this is a contradiction if you have multiple rescuers. Until multiple rescuers are present in the room it would be appropriate to just do compressions according to the guidelines, but once a second rescuer is present, the 30/2 ventilation ratio could be maintained w/o much of an interruption in chest compressions.—regards, Jeff
I watched a pt go flat line when he went pale and passed out after a cataract surgery. I called for help, lowered the hob, and while I was lowering the height of the bed, I gave a precordial thump. There was a spike from the thump as witnessed by another nurse and immediate return of pulse. By the time the bed was at a height to do CPR, pt’s color was already returning, and there was a pulse. This precordial thump worked well.
wow thats great! thanks for sharing
Is that recommended tho, I don’t see that as a recommended treatment?
SO VASOPRESSIN IS TO BE GIVEN ONLY ONE TIME DURING THE WHOLE CODE?
correct
I really like this site even though all tachycardia algorithms are not done. i do have a question that i could not find. is pre cordial thump still in if wittnessed arrest?
Hi Mike,
To use precordial thump the arrest must be witness and monitored.
Here is what AHA now says. I could not find any info in the AHA manual about precordial thump, in a review of the following I found this. This information came form the 2010 AHA Highlights found at this link:
http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadabl
e/ucm_317350.pdf
“2010 (New): The precordial thump should not be used for
unwitnessed out-of-hospital cardiac arrest. The precordial
thump may be considered for patients with witnessed,
monitored, unstable VT (including pulseless VT) if a defibrillator
is not immediately ready for use, but it should not delay CPR
and shock delivery.”
(Highlights of the 2010 AHA Guidelines for CPR and ECC; pg. 11)
Kind Regards,
Jeff
acls-algorithms.com
This is a great site, very instructional and easy to follow.
very conveninet to have available