ERC

ALS UNIVERSAL

TREATMENT ALGORITHM

ERC

Objectives

To understand:

• Treatment of patients in:

– ventricular fibrillation and

pulseless ventricular
tachycardia

– asystole or pulseless electrical

activity (non-VF/VT rhythms)

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Cardiac Arrest

Precordial Thump if appropriate

BLS Algorithm if appropriate

Attach Defib-Monitor

Assess

Rhythm

+/- Check Pulse

VF/VT

Non-VF/VT

Defibrillate X 3

as necessary

CPR 1 min

CPR 3 min*

* 1 min if immediately

after defibrillation

During CPR

Correct reversible causes
If not already:

•check electrodes, paddle
position and contact
•attempt / verify airway & O

2

i.v. access

•give epinephrine every 3 min
Consider:
amiodarone, atropine / pacing
buffers

Potential reversible causes:

•Hypoxia

•Hypovolaemia

•Hypo/hyperkalaemia & metabolic disorders

•Hypothermia

•Tension pneumothorax

•Tamponade

•Toxic/therapeutic disorders

•Thrombo-embolic & mechanical obstruction

Universal ALS

Algorithm

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Precordial thump

• Indication:

– witnessed

or
monitored
cardiac
arrest

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Cardiac Arrest

Precordial Thump if appropriate

BLS Algorithm if appropriate

Attach Defib-Monitor

Assess

Rhythm

+/- Check Pulse

VF/VT

Non-VF/VT

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Assess

Rhythm

+/- Check Pulse

VF/VT

Defibrillate X 3

as necessary

CPR 1 min

Ventricular Fibrillation/
Pulseless Ventricular
Tachycardia

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VF/VT

Shock 200 J*

Shock 200 J*

Shock 360 J*

*or biphasic equivalent

• Deliver 3 shocks, if

required, in < 1 minute

• Do not interrupt shock

sequence for BLS

• After shock/s, palpate

carotid pulse only if
waveform compatible
with a cardiac output

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During CPR

Correct reversible causes

If not already:

• check electrodes, paddle position and
contact
• attempt / verify: airway & O

2

i.v. access

• give epinephrine every 3 min

Consider:
amiodarone, atropine / pacing, buffers

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Chest compressions,

airway and ventilation

• Secure airway:

– tracheal tube
– LMA
– Combitube

• Once airway secured, do not

interrupt chest compressions for
ventilation

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Insertion of tracheal

tube

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LMA Insertion

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Ventilation with the

Combitube

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Intravenous access and drugs

VF/VT

• Central veins versus peripheral
• Epinephrine 1 mg i.v. or 2-3 mg

tracheal tube

• Consider amiodarone 300 mg if

VF/VT persists after 3rd shock

• Alternatively - lidocaine 100 mg
• Consider magnesium 8 mmol

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Epinephrine

Dose:
• 1 mg intravenous 10 ml 1:10,000 (1 ml

1:1,000) every 2-3 mins during
resuscitation

• 2-3 mg via tracheal tube
• 2–10 mcg min

-1

for atropine resistant

bradycardia

• 0.5ml 1:1,000 i.m., 3-5 ml 1:10,000 i.v.

in anaphylaxis, depending on severity

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Atropine

Dose:
• Asystole / PEA (rate < 60 beats min

-1

)

– 3 mg i.v., once only
– 6 mg via tracheal tube

• Bradycardia

– 0.5 mg i.v., repeated as necessary,

maximum 3 mg

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Amiodarone

Indications:

• Refractory VF / Pulseless VT
• Haemodynamically stable VT
• Other resistant tachyarrhythmias

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Amiodarone

Dose:

• Refractory VF / Pulseless VT

– 300 mg in 20 ml 5% dextrose, bolus i.v.

• Stable tachyarrhythmias

– 150 mg in 20 ml 5% dextrose over 10 mins
– Repeat 150 mg if necessary
– 300 mg in 100 ml 5% dextrose over 1 hour

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Amiodarone

Actions:

• Lengthens duration of action

potential

• Prolongs Q-T interval
• Mild negative inotrope - may cause

hypotension

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Magnesium

Indications:

• Shock refractory VF

(with possible hypomagnesaemia)

• Ventricular tachyarrhythmias

(with possible hypomagnesaemia)

• Torsades de pointes

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Magnesium

Dose:

Shock Refractory VF
• 2–4 ml 50% (4–8 mmol) i.v. over 1-2 mins
• Can be repeated after 10-15 minutes

Other circumstances
• 5 ml of 50% (10 mmol) i.v. over 30 mins

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Magnesium

Actions:

• Depresses neurological and

myocardial function

• Acts as a physiological calcium

blocker

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Lidocaine

Dose:
• Refractory VF / Pulseless VT

– 100 mg i.v.
– further boluses of 50 mg, max 200 mg

• Haemodynamically stable VT

– 50 mg i.v.
– further boluses of 50 mg, max 200 mg

• Reduce dose in elderly or hepatic failure

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Sodium Bicarbonate

Dose:

• 50 mmol (50 ml of 8.4% solution)

i.v.

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Calcium

Indications:
• Pulseless electrical activity caused by:

– severe hyperkalaemia
– severe hypocalcaemia
– overdose of calcium channel blocking drugs

Dose
• 10 ml 10% calcium chloride (6.8 mmol)

Do not give immediately before or after

sodium bicarbonate

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Shock 360 J*

Shock 360 J*

Shock 360 J*

*or biphasic equivalent

VF/VT (continued)

• Epinephrine every 3

minutes

• Consider

bicarbonate 50
mmol if pH < 7.1

• Consider paddle

positions

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Non-VF/VT

CPR 3 min*

* 1 min if immediately

after defibrillation

Assess

Rhyth

m

+/- Check Pulse

Asystole
Pulseless Electrical
Activity

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Non-VF/VT immediately

after defibrillation

• Withhold epinephrine/atropine - check

rhythm and pulse after 1 minute of CPR

– Delay in recovery of monitor display
– Electrical stunning - few seconds of

true asystole after defibrillation

– Myocardial stunning - temporarily

impaired contractility

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Potential reversible causes:

•Hypoxia

•Hypovolaemia

•Hypo/hyperkalaemia & metabolic disorders

•Hypothermia

•Tension pneumothorax

•Tamponade

•Toxic/therapeutic disorders

•Thrombo-embolic & mechanical
obstruction

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Asystole

• Confirm:

– check leads - view via leads I and II
– check gain

• Epinephrine 1 mg every 3 minutes
• Atropine 3 mg i.v. or 6 mg via

tracheal tube

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Spurious asystole

• When monitoring with paddle-gel

pads

• More likely with increasing number

of shocks and high chest impedance

• Displays apparent “asystole”
• Confirm rhythm with monitoring

leads

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Pulseless electrical

activity

• Exclude/treat reversible causes
• Epinephrine 1 mg every 3 minutes
• Atropine 3 mg if PEA with rate < 60

min

-1

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Summary

• In patients in VF/pulseless VT

attempt defibrillation without
delay

• In patients in refractory VF or

with a non-VF/VT rhythm
identify and treat any
reversible cause