Cardiac arrest algorithm | ACLS-Algorithms.com

Comments

  1. PETER REINIER FELICIANO says

    Hi Jeff,

    My question pertains to treatment of one of the Hs an Ts. Is Pericardiocentesis doable in the ER? or should it be done in the OR? A lot of medical professionals argue that it should be done in a completely sterile area, henceforth, in the OR. But I think it is pretty doable in the Emergency Room since the ACLS team have no time to waste in treating for reversible causes. Moreover, it is understandable that we have to stop chest compressions while doing the procedure. Is there a median time for the procedure? Thanks.

    Sincerely,

    Peter Feliciano

    • Jeff with admin. says

      Emergency pericardiocentesis can be performed in the ER as long as the tamponade is not being caused by chest trauma. In all likelihood, the bleeding from chest trauma cannot be managed with pericardiocentesis, and therefore a thoracotomy would need to be implemented.

      Thoracotomy would require an OR setting.

      I’m not too familiar with the timeframe for emergency pericardiocentesis but I have included a video from the New England Journal of Medicine that was quite informative.

      Emergency Pericardiocentesis Video

      Kind regards,
      Jeff

  2. bibhusan basnet says

    What do you say regarding terminating resuscitation now with the new guidelines in circulation by AHA. Please give your 2 cents.

    • Jeff with admin. says

      First I will give you my thoughts: In my experience, the length of time to continue a code can vary widely and is mostly dependent on the physician running the code. I have seen them last 15 minutes (which is reasonable) and I have seen them last 45 minutes (45 min. which is entirely too long). I have never seen anyone successfully resuscitated past about 18 minutes and I have not seen a good outcome for anyone who was resuscitated past about 15 minutes. That being said, I have heard of people who have remained in VF that have had positive outcomes after over 2 hours of resuscitation efforts! This is rare, but it does happen. Monitoring of ETCO2 will be a good indicator if ROSC is achievable.

      Now Here is what AHA says about Termination of resuscitation:
      (from Circulation 2010, 122:S665-S675)

      “Terminating Cardiac Arrest Resuscitative Efforts in Adult IHCA”
      In the hospital, the decision to terminate resuscitative efforts rests
      with the treating physician and is based on consideration of
      many factors, including witnessed versus unwitnessed arrest,
      time to CPR, initial arrest rhythm, time to defibrillation, comorbid
      disease, pre-arrest state, and whether there is ROSC at some
      point during the resuscitative efforts. Clinical decision rules for
      in-hospital termination of resuscitation may be helpful in reducing
      variability in decision making; however, the evidence for
      their reliability is limited, and rules should be prospectively
      validated before adoption.”

  3. Eva says

    Hello,
    – can you please tell me how to manage when patient passes from a non-shockable rhythm (e.g.. PEA) to a shockable one (eg. FV), in case 3 minutes have already passed from the previous dose of adrenaline?
    Should I give a new dose of adrenaline (according to the correct timing) soon after the shock, or should I wait after a second shock in order to ensure that the FV is refractory to the first shock?

    – second question: for the new 2015 guidelines, both adrenaline and amiodarone are still in iib (2b) class of recommendation?

    • Jeff with admin. says

      1. You should give the new dose of adrenaline according to the timeline that is already established. If three minutes has passed then go ahead and give the adrenaline. Once the first dose of adrenaline has been given during a code, the adrenaline is basically on its own timetable and can be given every 3 to 5 minutes as long as you remain within the cardiac arrest algorithm.

      2. That is correct. Both amiodarone and epinephrine are still IIb class recommendation.

      Kind regards,
      Jeff

  4. Dale Fulghum says

    First off, nice site, well put together. Back to rescusitative efforts and how long to run a code. I’m a Critical Care Paramedic in a very busy 9-1-1 service. ACLS is our bread and butter. I have run many ,many codes over the past 30 years both medical and trauma , in hospital and pre hospital, adult , child, and infant. I disagree with the doc disagreeing with your very accurate assessment of 15 to 18 min being a thorough code. The docs code was 45 min , but it was witnessed in house and ALS was initiated right away without delay. In a perfect world In prehospital emergency care, I will get to your family member in cardiac arrest in a nation wide average of 8 min after onset, with hopes of high quality CPR being done from the get go. Otherwise it’s a grim reality with usually a grim outcome to match. Now if I’m transporting a patient who deteriorated into cardiac arrest on route to hospital, Well now, that’s a witnessed arrest of a patient who was on a monitor, had an IV established, etc. We’re going to spend a bit more time on that code because ALS was started right away. But from the first call for help, to me arriving , unfortunately most with prehospital cardiac arrest deteriorate into Asystole before my arrival which brings us back to 15 min running the code presenting an Asystolic person to an awaiting code team who usually calls it on my arrival to their facility. Once again total code time 15 min, maybe 20. When I was on the trauma service at Brook Army Medical Center in Texas, I participated in a code that lasted for almost an hour but again the patient was the exception due to severe hypothermia of a soldier who survived but with severe anoxic brain injury. My assessment ; to many variables to put a time stamp on how long we should run a code in house or out in the streets.

    Cheers……

  5. sharshep says

    I just took ACLS renewal. Did fabulous thanks to this site! I have a question. In one of our practice scenario the rhythm we were initially treating was v-fib. Treated per usual algorithm and it converted to PEA after the epinephrine/cpr. It was not 3 minutes from the epi and the instructor stated to give the epi per the PEA algorithm anyway. When we questioned the time interval he said that it was not needed since we started a new algorithm. Is this true? I have never seen it done this way.

    Thanks,
    Sharon

    • Jeff with admin. says

      I’m so glad that the site was helpful for you.

      Regarding your question about giving epinephrine when starting fresh at the top of a new algorithm for PEA. That is correct. You can start fresh at the top of the algorithm and give epinephrine at the top and go from there with your every 3 to 5 minutes.

      It’s really not that critical if you wait until the three-minute mark coming from the V-fib algorithm, but most people start fresh at the top of the PEA algorithm and give epi.

      Kind regards,
      Jeff

    • Jeff with admin. says

      There is an increased risk for nitroglycerin to cause serious hypotension if tachycardia or bradycardia is present.

      Because of this risk AHA recommends that Nitroglycerine not be used for ACS/ischemic pain when tachycardia or bradycardia is present.

      Kind regards,
      Jeff

  6. Aoberlander says

    I see this was a question addressed a few years ago but I figured it’s worth asking again because I always get mixed answers. For example a pt in vfib you just shocked I understand you do 2 mins of cpr. 2 mins is up do you do a pulse check or check the rhythm ? The acls algorithm doesn’t really clarify this. I work in the MICU as an RN and see in real life a pulse is checked after 2 mins always but not sure this is correct. I just wanna make sure for the mega code I do this step right! Thank you

    • Jeff with admin. says

      You shock and then provide 2 minutes o f CPR. After this, you perform a rhythm check. Only if you see a change to a non-lethal rhythm do perform a pulse check. The rhythm check determines if a pulse check is needed.

      I do understand what you are saying about real life. With so many hands and eyes available, we often have someone performing a rhythm check and someone else has a hand on the femoral area to confirm a pulse if the rhythm has changed.

      Kind regards,
      Jeff

  7. Patricia12 says

    Thank you, Jeff, for this great website! I took the test today and passed thanks to all the hard work you’ve put into making your ACLS website complete, informative and a better way to study!

    Patricia

  8. Chritina says

    I would like to know when a patient is coding and goes in and out of PEA and V fib arrest, and has no pulse throughout the code, how long to run the code? And should code end only with asystole or can v fib can be the end rhythm? Thanks. I work in ICU.

    • Jeff with admin. says

      There is a lot of variability as to how long a code can go on before it is stopped and a patient pronounced deceased. Usually, this will be at some point when the patient has been asystole rather than a shockable rhythm. Vfib and pulseless VT indicate electrical activity in the heart and as such can be treated with the hopes of conversion to an organized electrical impulse and rhythm.
      There is not a cut and dry rule for stopping a code and the team running the code should work together to decide when all best efforts have been put forward in an attempt to reverse cardiac arrest. In my experience, the max code time is somewhere around 20-30 minutes. I have never seen a good outcome with a code lasting longer than 15 minutes. I have had several people on this site comment about codes with good outcomes that lasted longer than 15 minutes, but they are rare. I would say that the best suggestion is for the code team to put forth their best effort to reverse cardiac arrest and maintain ongoing dialog about when to stop resuscitative efforts.

      Kind regards,
      Jeff

      • T.C. says

        A consideration of a reversable cause is needed in each code situation.
        A code may be lengthy if a reversable cause is found, ie.. electrolyte imbalances.
        Jeff is right in his statement that statistics would show, the longer the code, the less likelyhood of a good outcome.

  9. Sherry Hess says

    Hi Jeff,
    I wanted to say thank you so much for this site. I’m a new graduate RN and just passed my first ever ACLS course. I rocked my megacode, but couldn’t have done it without your site. A great prep/review for anyone! Thanks again

  10. Mike says

    My only complaint is that I didn’t find your site sooner…I’m due to take the ACLS recert this Sunday.

    I’ll be returning, though.

    Thanks,

    Mike

  11. Alexandra says

    Hi, Jeff.
    I’d like to ask about the pediatric cardiac arrest algorithm. In AHA 2010, box 8, it is said to give amiodarone (which is an adrenergic inhibitor), whereas the epinephrine (adrenergic) was the drug of choice for cardiac arrest. Any rationale about that?
    Thanks

    • Jeff with admin. says

      Amiodarone is used in this case for its antiarrhythmic properties. As with the adult cardiac arrest algorithm, amiodarone is the preferred antiarrhythmic that can be used for cardiac arrest. Epinephrine is included in box 6 of the pediatric cardiac arrest algorithm and is give very 3-5 minutes after the first dose. As with adult cardiac arrest, epinephrine is given in pediatric cardiac arrest for its vasopressor affects.

      Kind regards,
      Jeff

  12. goar0701 says

    Is there a specific length of time when resuscitation maneuvers have to be stopped because the patient didn’t response to the protocols of cardiac arrest?

    • Jeff with admin. says

      First I will give you my thoughts: In my experience, the length of time to continue a code can vary widely and is mostly dependent on the physician running the code. I have seen them last 15 minutes (which is reasonable) and I have seen them last 45 minutes (45 min. which is entirely to long). I have never seen anyone successfully resuscitated past about 18 minutes and I have not seen a good outcome for anyone who was resuscitated past about 15 minutes.
      Now Here is what AHA says about Termination of resuscitation:
      (from Circulation 2010, 122:S665-S675)
      “Terminating Cardiac Arrest Resuscitative Efforts in Adult IHCA”
      In the hospital the decision to terminate resuscitative efforts rests
      with the treating physician and is based on consideration of
      many factors, including witnessed versus unwitnessed arrest,
      time to CPR, initial arrest rhythm, time to defibrillation, comorbid
      disease, pre-arrest state, and whether there is ROSC at some
      point during the resuscitative efforts. Clinical decision rules for
      in-hospital termination of resuscitation may be helpful in reducing
      variability in decision making; however, the evidence for
      their reliability is limited, and rules should be prospectively
      validated before adoption.”
      Hope this helps.
      Kind regards,
      Jeff

      • Erin Burnham, MD says

        I disagree with your assessment that 45 minutes is too long to resuscitate Vfib. We had a recent witnessed arrest in the hospital that received 45 minutes of ACLS including about 20 shocks, multiple doses of epinephrine, full dose of amiodarone who ultimately had ROSC and survived neurologically intact. Vfib is a resuscitatable rhythm, and with high quality CPR it is reasonable to continue efforts. If it were you or your family member, you would be very grateful for the effort.

      • Jeff with admin. says

        Wow! That is very impressive, and very rare. This is why the AHA just makes guidelines and a physician has the discretion to diverge away from the guidelines if they deem it necessary. I’m also glad the physician in this case continued. Kind regards, Jeff

  13. julezzz26 says

    Hi,
    I absolutely love your site, it is terrific. I have a few questions.
    1.A pt is in pulseless v tach or in v fib and are shocked at 120 and 200 and then convert to wide complex regular monomorphic vtach with a pulse do we synch cardiovert at 100 or would it be a higher synch dose? Would you want to give adenosine at this time as well?

    2. How fast can you push magnesium?

    Thank you so much!

    • Jeff with admin. says

      1. Since the patient is already connected to the defibrillator and is unstable, you would use cardioversion. You can start with the lower dose and increase in a step-wise fashion. Many providers would probably opt for the higher initial synchronized dose and that would be ok. As well. (since this started as an unstable situation, adenosine would not be indicated.)
      2. When magnesium is given during cardiac arrest for the treatment of Torsades, it should be started as soon as possible, AHA recommendations are over 5-20 minutes but it can be rapid pushed. It can be pushed rapidly over 60 seconds, but may cause hypotension due to a direct vasodilating effect.

      Kind regards,
      Jeff

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