Adult Cardiac Arrest Algorithm

1
CPR Quality
Start CPR
• Give oxygen • Push hard (at least 2 inches
• Attach monitor/defibrillator [5 cm]) and fast (100-120/min)
and allow complete chest recoil.
• Minimize interruptions in
compressions.
Yes No • Avoid excessive ventilation.
Rhythm • Change compressor every
shockable? 2 minutes, or sooner if fatigued.
• If no advanced airway, 30:2
2 9 compression-ventilation ratio,
VF/pVT Asystole/PEA or 1 breath every 6 seconds.
• Quantitative waveform
capnography
– If Petco2 is low or decreasing,
reassess CPR quality.
3 Shock Epinephrine
ASAP Shock Energy for Defibrillation

4 10 • Biphasic: Manufacturer
recommendation (eg, initial
CPR 2 min CPR 2 min dose of 120-200 J); if unknown,
• IV/IO access use maximum available.
• IV/IO access
• Epinephrine every 3-5 min Second and subsequent doses
• Consider advanced airway, should be equivalent, and higher
capnography doses may be considered.
• Monophasic: 360 J
Rhythm No
shockable? Drug Therapy

Rhythm Yes • Epinephrine IV/IO dose:

Yes 1 mg every 3-5 minutes
shockable?
• Amiodarone IV/IO dose:
5 Shock First dose: 300 mg bolus.
Second dose: 150 mg.
No or
6 Lidocaine IV/IO dose:
CPR 2 min First dose: 1-1.5 mg/kg.
• Epinephrine every 3-5 min Second dose: 0.5-0.75 mg/kg.
• Consider advanced airway, Advanced Airway
capnography
• Endotracheal intubation or su-
praglottic advanced airway
• Waveform capnography or cap-
Rhythm No nometry to confirm and monitor
ET tube placement
shockable? • Once advanced airway in place,
give 1 breath every 6 seconds
Yes (10 breaths/min) with continu-
ous chest compressions
7 Shock
Return of Spontaneous
Circulation (ROSC)
8 11
• Pulse and blood pressure
CPR 2 min CPR 2 min • Abrupt sustained increase in
• Amiodarone or lidocaine Petco2 (typically ≥40 mm Hg)
• Treat reversible causes
• Treat reversible causes • Spontaneous arterial pressure
waves with intra-arterial
monitoring

No Rhythm Yes Reversible Causes

shockable? • Hypovolemia
• Hypoxia
12 • Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• If no signs of return of Go to 5 or 7 • Hypothermia
spontaneous circulation • Tension pneumothorax
(ROSC), go to 10 or 11 • Tamponade, cardiac
• If ROSC, go to • Toxins
• Thrombosis, pulmonary
Post–Cardiac Arrest Care
• Thrombosis, coronary
• Consider appropriateness
of continued resuscitation
© 2020 American Heart Association
Adult Cardiac Arrest Circular Algorithm

CPR Quality

• Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and
allow complete chest recoil.
• Minimize interruptions in compressions.
• Avoid excessive ventilation.
• Change compressor every 2 minutes, or sooner if fatigued.
Start CPR • If no advanced airway, 30:2 compression-ventilation ratio.
• Give oxygen • Quantitative waveform capnography
• Attach monitor/defibrillator – If Petco2 is low or decreasing, reassess CPR quality.

Return of Spontaneous Shock Energy for Defibrillation

2 minutes Circulation (ROSC)
• Biphasic: Manufacturer recommendation (eg, initial dose of
Check Post–Cardiac 120-200 J); if unknown, use maximum available. Second and
Rhythm Arrest Care subsequent doses should be equivalent, and higher doses may
If VF/pVT
Shock be considered.
• Monophasic: 360 J
Drug Therapy Drug Therapy
IV/IO access
Co
R

Epinephrine every 3-5 minutes

uous CP

• Epinephrine IV/IO dose: 1 mg every 3-5 minutes

Amiodarone or lidocaine
ntinuous CP

for refractory VF/pVT • Amiodarone IV/IO dose: First dose: 300 mg bolus. Second
dose: 150 mg.
or
Consider Advanced Airway • Lidocaine IV/IO dose: First dose: 1-1.5 mg/kg. Second dose:
Quantitative waveform capnography
ntin

0.5-0.75 mg/kg.

Advanced Airway
o

Treat Reversible Causes

R
C

• Endotracheal intubation or supraglottic advanced airway

• Waveform capnography or capnometry to confirm and monitor
Mo
nitor C lity ET tube placement
PR Qua • Once advanced airway in place, give 1 breath every 6 seconds
(10 breaths/min) with continuous chest compressions

Return of Spontaneous Circulation (ROSC)

• Pulse and blood pressure

• Abrupt sustained increase in Petco2 (typically ≥40 mm Hg)
• Spontaneous arterial pressure waves with intra-arterial
monitoring

Reversible Causes

• Hypovolemia • Tension pneumothorax

• Hypoxia • Tamponade, cardiac
• Hydrogen ion (acidosis) • Toxins
• Hypo-/hyperkalemia • Thrombosis, pulmonary
• Hypothermia • Thrombosis, coronary
© 2020 American Heart Association
Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm

Continue BLS/ACLS Maternal Cardiac Arrest

• High-quality CPR
• Defibrillation when indicated • Team planning should be done in
• Other ACLS interventions collaboration with the obstetric,
(eg, epinephrine) neonatal, emergency,
anesthesiology, intensive care,
and cardiac arrest services.
• Priorities for pregnant women
Assemble maternal cardiac arrest team in cardiac arrest should include
provision of high-quality CPR and
relief of aortocaval compression with
lateral uterine displacement.
Consider etiology • The goal of perimortem cesarean
of arrest delivery is to improve maternal and
fetal outcomes.
• Ideally, perform perimortem cesarean
delivery in 5 minutes, depending on
Perform maternal interventions Perform obstetric provider resources and skill sets.
• Perform airway management interventions
• Administer 100% O2, avoid • Provide continuous lateral Advanced Airway
excess ventilation uterine displacement
• Place IV above diaphragm • Detach fetal monitors • In pregnancy, a difficult airway
• If receiving IV magnesium, stop and • Prepare for perimortem is common. Use the most
cesarean delivery experienced provider.
give calcium chloride or gluconate
• Provide endotracheal intubation or
supraglottic advanced airway.
• Perform waveform capnography or
Continue BLS/ACLS Perform perimortem capnometry to confirm and monitor
cesarean delivery ET tube placement.
• High-quality CPR
• Once advanced airway is in place,
• Defibrillation when indicated • If no ROSC in 5 minutes, give 1 breath every 6 seconds
• Other ACLS interventions consider immediate (10 breaths/min) with continuous
(eg, epinephrine) perimortem cesarean delivery chest compressions.

Potential Etiology of Maternal

Neonatal team to receive neonate Cardiac Arrest

A Anesthetic complications
B Bleeding
C Cardiovascular
D Drugs
E Embolic
F Fever
G General nonobstetric causes of
cardiac arrest (H’s and T’s)
H Hypertension
© 2020 American Heart Association
ACLS Healthcare Provider
Post–Cardiac Arrest Care Algorithm

ROSC obtained Initial Stabilization Phase

Resuscitation is ongoing during the

post-ROSC phase, and many of these
Manage airway activities can occur concurrently.
Early placement of endotracheal tube However, if prioritization is
necessary, follow these steps:
• Airway management:
Manage respiratory parameters
Waveform capnography or
Initial Start 10 breaths/min
capnometry to confirm and monitor
Stabilization Spo2 92%-98%
endotracheal tube placement
Phase Paco2 35-45 mm Hg
• Manage respiratory parameters:
Titrate Fio2 for Spo2 92%-98%; start
Manage hemodynamic parameters at 10 breaths/min; titrate to Paco2 of
Systolic blood pressure >90 mm Hg 35-45 mm Hg
Mean arterial pressure >65 mm Hg • Manage hemodynamic parameters:
Administer crystalloid and/or
vasopressor or inotrope for goal
Obtain 12-lead ECG systolic blood pressure >90 mm Hg
or mean arterial pressure >65 mm Hg

Continued Management and

Consider for emergent cardiac intervention if Additional Emergent Activities
• STEMI present
These evaluations should be done
• Unstable cardiogenic shock
concurrently so that decisions on
• Mechanical circulatory support required
targeted temperature management
(TTM) receive high priority as
cardiac interventions.
• Emergent cardiac intervention:
Follows commands?
Early evaluation of 12-lead
No Yes
Continued electrocardiogram (ECG); consider
Management hemodynamics for decision on
and Additional Comatose Awake cardiac intervention
Emergent • TTM Other critical care • TTM: If patient is not following
Activities • Obtain brain CT management commands, start TTM as soon as
• EEG monitoring possible; begin at 32-36°C for 24
• Other critical care hours by using a cooling device with
management feedback loop
• Other critical care management
– Continuously monitor core
temperature (esophageal,
rectal, bladder)
Evaluate and treat rapidly reversible etiologies
– Maintain normoxia, normocapnia,
Involve expert consultation for continued management euglycemia
– Provide continuous or intermittent
electroencephalogram (EEG)
monitoring
– Provide lung-protective ventilation

H’s and T’s

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypokalemia/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
© 2020 American Heart Association
Adult Bradycardia Algorithm

Assess appropriateness for clinical condition.

Heart rate typically <50/min if bradyarrhythmia.

Identify and treat underlying cause

• Maintain patent airway; assist breathing as necessary
• Oxygen (if hypoxemic)
• Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
• IV access
• 12-Lead ECG if available; don’t delay therapy
• Consider possible hypoxic and toxicologic causes

Persistent
bradyarrhythmia causing:
No • Hypotension?
Monitor and observe • Acutely altered mental status?
• Signs of shock? Doses/Details
• Ischemic chest discomfort? Atropine IV dose:
• Acute heart failure? First dose: 1 mg bolus.
Repeat every 3-5 minutes.
Yes Maximum: 3 mg.
Dopamine IV infusion:
Usual infusion rate is
Atropine
5-20 mcg/kg per minute.
If atropine ineffective: Titrate to patient response;
• Transcutaneous pacing taper slowly.
and/or Epinephrine IV infusion:
• Dopamine infusion
2-10 mcg per minute infusion.
or Titrate to patient response.
• Epinephrine infusion
Causes:
• Myocardial ischemia/
infarction
• Drugs/toxicologic (eg,
calcium-channel blockers,
Consider: beta blockers, digoxin)
• Hypoxia
• Expert consultation
• Electrolyte abnormality
• Transvenous pacing (eg, hyperkalemia)
© 2020 American Heart Association
Adult Tachycardia With a Pulse Algorithm

Assess appropriateness for clinical condition. Doses/Details

Heart rate typically ≥150/min if tachyarrhythmia. Synchronized cardioversion:
Refer to your specific device’s recommended energy level to
maximize first shock success.
Adenosine IV dose:
First dose: 6 mg rapid IV push; follow with NS flush.
Second dose: 12 mg if required.
Identify and treat underlying cause Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia
• Maintain patent airway; assist breathing as necessary Procainamide IV dose:
• Oxygen (if hypoxemic) 20-50 mg/min until arrhythmia suppressed, hypotension ensues,
• Cardiac monitor to identify rhythm; monitor blood QRS duration increases >50%, or maximum dose 17 mg/kg given.
pressure and oximetry Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF.
• IV access
Amiodarone IV dose:
• 12-lead ECG, if available
First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs.
Follow by maintenance infusion of 1 mg/min for first 6 hours.
Sotalol IV dose:
100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

Persistent
tachyarrhythmia causing:
Synchronized cardioversion
• Hypotension? Yes
• Acutely altered mental status? • Consider sedation
• Signs of shock? • If regular narrow complex, If refractory, consider
• Ischemic chest discomfort? consider adenosine
• Underlying cause
• Acute heart failure?
• Need to increase
energy level for next
No cardioversion
• Addition of anti-
Yes Consider arrhythmic drug
Wide QRS?
• Adenosine only if • Expert consultation
≥0.12 second
regular and monomorphic
• Antiarrhythmic infusion
No • Expert consultation

• Vagal maneuvers (if regular)

• Adenosine (if regular)
• β-Blocker or calcium channel blocker
• Consider expert consultation
© 2020 American Heart Association
Adult Basic Life Support Algorithm for Healthcare Providers

Verify scene safety.

• Check for responsiveness.

• Shout for nearby help.
• Activate emergency response
system via mobile device
(if appropriate).
• Get AED and emergency equipment
(or send someone to do so).

Normal No normal • Provide rescue breathing,

breathing, breathing, 1 breath every 6 seconds or
Look for no breathing
pulse felt pulse felt 10 breaths/min.
Monitor until or only gasping and check
• Check pulse every 2 minutes;
emergency pulse (simultaneously).
if no pulse, start CPR.
responders arrive. Is pulse definitely felt
• If possible opioid overdose,
within 10 seconds?
administer naloxone if
available per protocol.

No breathing
or only gasping,
pulse not felt

By this time in all scenarios, emergency

response system or backup is activated,
and AED and emergency equipment are
retrieved or someone is retrieving them.
Start CPR
• Perform cycles of 30 compressions
and 2 breaths.
• Use AED as soon as it is available.

AED arrives.

Check rhythm.
Shockable rhythm?
Yes, No,
shockable nonshockable

• Give 1 shock. Resume CPR • Resume CPR immediately for

immediately for 2 minutes 2 minutes (until prompted by AED
(until prompted by AED to allow to allow rhythm check).
rhythm check). • Continue until ALS providers take
• Continue until ALS providers take over or victim starts to move.
over or victim starts to move.

© 2020 American Heart Association

Opioid-Associated Emergency for Lay Responders Algorithm

1
Suspected opioid poisoning
• Check for responsiveness.
• Shout for nearby help.
• Activate the emergency response system.
• Get naloxone and an AED if available.

2
Yes Is the No
person breathing
normally?

3 5
Prevent deterioration Start CPR*
• Tap and shout. • Give naloxone.
• Reposition. • Use an AED.
• Consider naloxone. • Resume CPR until EMS arrives.
• Continue to observe until
EMS arrives.

4
Ongoing assessment of
responsiveness and breathing
Go to 1.

*For adult and adolescent victims, responders should perform compressions and rescue breaths for
opioid-associated emergencies if they are trained and perform Hands-Only CPR if not trained to perform
rescue breaths. For infants and children, CPR should include compressions with rescue breaths.
© 2020 American Heart Association