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. They each will be reviewed throughout this section of the course guide. These four rhythms are pulseless ventricular tachycardia (VT), ventricular fibrillation (VF), asystole, and pulseless electrical activity (PEA).
Click below to view the cardiac arrest algorithm diagram. When done click again to close the diagram.
Cardiac Arrest Diagram
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 of 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.
Medications for Cardiac Arrest
There are 3 medications that will be focused on within the Cardiac Arrest Algorithm, epinephrine, amiodarone, and Lidocaine. Magnesium will be mentioned briefly.
Epinephrine
Epinephrine is the primary drug used in the cardiac arrest algorithm. It is used for its potent vasoconstrictive effects and also for its ability to increase cardiac output. Epinephrine is considered a vasopressor.
Indications for Cardiac Arrest
- Vasoconstriction effects: epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels (arteries and veins) causing direct vasoconstriction, thus, improving perfusion pressure to the brain and heart.
- Cardiac Output: epinephrine also binds to beta-1-adrenergic receptors of the heart. This indirectly improves cardiac output by:
- Increasing heart rate
- Increasing heart muscle contractility
- Increasing conductivity through the AV node
Routes
During ACLS, epinephrine can be given 3 ways: intravenous; intraosseous, and endotracheal tube. The primary method used is intravenous. When given intravenously, always follow the IV push with a 20 ml normal saline flush.
Dosing
Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes.
Note: There is no clinical evidence that the use of epinephrine when used during cardiac arrest, increases rates of survival to discharge from the hospital. However, studies have shown that epinephrine and vasopressin improve rates of ROSC (return of spontaneous circulation).
Amiodarone
Indications for ACLS
Amiodarone is an antiarrhythmic that is used to treat both supraventricular arrhythmias and ventricular arrhythmias.
The mechanism of action of amiodarone remains unknown, but within the framework of ACLS, amiodarone is used primarily to treat ventricular fibrillation and ventricular tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors.
Amiodarone should only be used after defibrillation/cardioversion and epinephrine have failed to convert VT/VF.
Route
Amiodarone can be administered by intravenous or intraosseous route.
Dosing
The maximum cumulative dose in a 24 hour period should not exceed 2.2 grams.
Within the VT/VF pulseless arrest algorithm, the dosing is as follows:
300mg IV/IO push → (if no conversion) 150 mg IV/IO push → (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)
Infusions exceeding 2 hours must be administered in glass or polyolefin bottles containing D5W.
Amiodarone should only be diluted with D5W and given with an in-line filter.
Lidocaine
Lidocaine is an antiarrhythmic that can also be used and is considered equivalent to amiodarone in the treatment of ventricular fibrillation or pulseless ventricular tachycardia.
Dosing
Provide an initial dose of 1-1.5 mg/kg IV or IO. If pVT or VF persists the lidocaine may be repeated at 0.5-0.75 mg/kg over 5 to 10 minute intervals.
The maximum total dosage of lidocaine is 3 mg/kg.
Magnesium Sulfate
Magnesium sulfate can be used during cardiac arrest primaryly to treat torsades de pointes that is caused by a low serum magnesium level.
Dosing
Provide an initial dose of 1-2 grams IV or IO diluted in at least 10 ml of NS. Give the dose over 5 minutes.
Watch Part 1 and Part 2 of the Cardiac Arrest Video Review.
Within ACLS Protocol, there is also a Simplified Cardiac Arrest Algorithm that simplifies and streamlines uncomplicated cardiac arrest. Use this link to watch a short video that reviews the 2015 Simplified Cardiac Arrest Algorithm.
Top Questions Asked on This Page
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Q: Can precordial thump still be used for witnessed arrest?
A: This is the AHA position and it has not changed since 2010. “The precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is no immediately ready for use, but should not delay CPR and shock delivery. There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole.
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Q: How fast do you push the Amiodarone 300mg?
A: 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.
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Q: 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?
A: 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) shock and any time after 4th (150mg) shock.
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Q: If you give precordial thump, is it given just once?
A: 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.
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
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.”
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
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……
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
davedani777@gmail.com says
Jeff
why Nitroglycerine is contraindicated in tachycardia and bradycardia?
Thanks
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
Melissa says
Can you tell me if you should begin Targeted Temperature Management in a NON witnessed arrest?
Jeff with admin. says
Yes. If the patient remains unconscious in the post-arrest phase, you would begin TTM.
Kind regards,
Jeff
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
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
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.
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
Jeff with admin. says
I’m so glad that the site was helpful for you. Congratulations on a job well done for you! Kind regards, Jeff
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
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
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
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
Kind regards,
Jeff