ACLS Comprehensive - All Adult Cardiac Codes

AHA 2020 Guidelines Compliance

Source: American Heart Association Guidelines for CPR and ECC

Last Updated: November 5, 2024 | Version: 2020 Guidelines

Key ACLS Principle: Quality Compressions

Deliver quality compressions for at least 60% of resuscitation time

Continuous compressions except during defibrillation

ACLS Algorithm Components

Adult Cardiac Arrest Algorithm

AHA Key Principle

Cornerstone of successful resuscitation: Deliver quality compressions for the highest percentage of time possible (at least 60%)

Shockable Rhythms (VF/pVT)

⏱️ Every 2 minutes

Shock → CPR 2 min → Rhythm check → Medications

Immediate Actions

1. Begin CPR Immediately

Push hard and fast at 100-120 beats per minute

2. Attach Monitor/Defibrillator

Check for shockable rhythm as soon as possible

3. Defibrillate if VF/pVT

200J → 300J → 360J (biphasic) or maximum available

4. Resume CPR for 2 minutes

Minimize interruptions, focus on quality compressions

💊 Medications for VF/pVT

Epinephrine

1 mg IV/IO every 3-5 minutes

First-line vasopressor for all cardiac arrest rhythms. Give as soon as IV/IO access established.

Amiodarone

300 mg IV/IO first dose, then 150 mg

For VF/pVT unresponsive to defibrillation. Give after 3rd shock.

Lidocaine (Alternative)

1-1.5 mg/kg IV/IO, then 0.5-0.75 mg/kg

Alternative to amiodarone for VF/pVT. Maximum total dose: 3 mg/kg.

Non-Shockable Rhythms (PEA/Asystole)

⏱️ Every 2 minutes

CPR 2 min → Rhythm check → Medications → Treat reversible causes

Management Strategy

1. High-Quality CPR

100-120 compressions/min, 2+ inches depth

2. Epinephrine

1 mg IV/IO every 3-5 minutes

3. Advanced Airway

Consider endotracheal intubation or supraglottic airway

4. Identify & Treat Reversible Causes

H's and T's approach

Reversible Causes (H's and T's)
                                H's
                                Hypovolemia
Hypoxia
Hydrogen ions (Acidosis)
Hyperkalemia/Hypokalemia
Hypothermia

                            

                                T's
                                Toxins
Tamponade (Cardiac)
Tension Pneumothorax
Thrombosis (Coronary)
Thrombosis (Pulmonary)

                            

Post-Cardiac Arrest Care

Immediate Goals

Optimize cardiopulmonary function and perfusion
Transport to appropriate facility
Identify and treat precipitating causes
Control temperature (avoid hyperthermia)
Optimize ventilation and oxygenation

Targeted Temperature Management

32-36°C for 12-24 hours

For comatose patients after ROSC from VF/pVT or other rhythms.

Continuous Monitoring

12-lead ECG
Arterial blood gas
Chest X-ray
Laboratory studies
Neurological assessment

Adult Bradycardia Algorithm

Bradycardia Definition

Heart rate < 50 bpm with symptoms of poor perfusion

Assessment

Signs of poor perfusion: Altered mental status, chest pain, shortness of breath
Life-threatening symptoms: Shock, pulmonary edema, altered consciousness
ECG interpretation: Identify rhythm and QRS width

Treatment Sequence

Support ABCs

Give oxygen, establish IV access, monitor

Atropine

0.5 mg IV every 3-5 minutes (max 3 mg)

Transcutaneous Pacing

If available and patient is symptomatic

Dopamine/Epinephrine

If pacing not available or ineffective

💊 Bradycardia Medications

Atropine

0.5 mg IV every 3-5 minutes (max 3 mg)

First-line medication for symptomatic bradycardia.

Dopamine

2-20 mcg/kg/min IV infusion

Chronotropic and inotropic support for bradycardia.

Epinephrine

2-10 mcg/min IV infusion

Alternative chronotropic agent for severe bradycardia.

Adult Tachycardia Algorithm

Tachycardia Definition

Heart rate > 100 bpm - assess for stability and QRS width

Unstable (Serious Signs/Symptoms)

Immediate Synchronized Cardioversion

• 100-200J (start low)
• Increase energy if needed
• Sedate if possible
• Consider antiarrhythmic

Stable

Narrow QRS: Vagal maneuvers, adenosine

Wide QRS: Adenosine, amiodarone, procainamide

💊 Tachycardia Medications

Adenosine

6 mg rapid IV push, then 12 mg if needed

For narrow complex tachycardia. Give rapidly with saline flush.

Amiodarone

150 mg IV over 10 minutes

For wide complex tachycardia or refractory narrow complex.

Procainamide

20-50 mg/min IV until arrhythmia suppressed

Alternative for wide complex tachycardia.

Verapamil

2.5-5 mg IV over 2 minutes

For narrow complex tachycardia (avoid in wide complex).

Post-Cardiac Arrest Care

Post-ROSC Management

Comprehensive care after return of spontaneous circulation

Immediate Post-ROSC Care

Optimize oxygenation: Maintain SpO2 94-98%
Blood pressure management: SBP >90 mmHg, MAP >65 mmHg
12-lead ECG: Identify STEMI or other acute coronary syndrome
Laboratory studies: CBC, chemistry, cardiac markers
Neurological assessment: Glasgow Coma Scale, pupil response

Targeted Temperature Management (TTM)

Indication: Comatose patients after ROSC from VF/pVT
Temperature: 32-36°C for 12-24 hours
Method: Surface cooling or intravascular cooling
Shivering control: Sedation, paralysis if needed
Rewarming: 0.25-0.5°C per hour

💊 Post-Arrest Medications

Vasopressors

Norepinephrine 0.1-2 mcg/kg/min

Maintain adequate blood pressure and perfusion.

Antiarrhythmics

Amiodarone 1 mg/min for 6 hours

Prevent recurrent arrhythmias.

Antiplatelet/Anticoagulation

Aspirin 325 mg, heparin if indicated

For suspected acute coronary syndrome.

                ACLS Key Principles
                Quality compressions are the cornerstone of successful resuscitation (≥60% time)
Early defibrillation for shockable rhythms
Epinephrine 1 mg every 3-5 minutes for all cardiac arrest rhythms
Amiodarone for refractory VF/pVT
Identify and treat reversible causes (H's and T's)
Post-cardiac arrest care with targeted temperature management

            

Reference Information

Source: American Heart Association Guidelines for CPR and ECC

Guidelines: 2020 American Heart Association Guidelines for CPR and ECC

Note: ACLS builds upon BLS foundation. Ensure BLS proficiency before ACLS training.