Adult Cardiac Arrest Algorithm

Case: Patient was found unconscious.

1) Assess the patient

a) Check for response
- Tap and ask
- “Hello sir, can you hear me?”
- “No response”
b) Check for breathing
- Look at the chest for breathing for 2 seconds & hear for breathing
- “No breathing”
c) Check for pulse
- Check the carotid pulse for 5 seconds
- “No pulse”
d) Call for help
- “Code blue. I need resus trolley & a defibrillator”
e) Expose the patient
- Remove the top of the patient

*everybody arrives*

2) CPR (cardio pulmonary resuscitation)

a) Start chest compression
- “You, start chest compression immediately. Give high quality CPR”
(“Push hard, push fast
At least 5 cm deep, 100-120 compressions / minute
Allow full chest recoil
Minimize interruption
30:2 compression-ventilation ratio”
“Both of you please swap among yourself after every cycle of chest compression”
)
b) Give oxygen
- “Give 2 ventilations after every cycle of chest compression.
Avoid excessive ventilation by giving about 450 ml per bagging”
Should be 6ml/kg per bag, so 400ml per bagging is appropriate.
c) Prepare defibrillator
- Prepare the defibrillator.
Attach the leads on the patient. Red, yellow, green.
Press On, manual mode & lead II.
3) Access the rhythm
a) Shockable (VF / pVT)
i) 1st cycle
- “Stop CPR while I assess the rhythm”
Check the rhythm: VF & check for pulse: pulseless
“It’s a pulseless VF, shockable rhythm”
“Continue CPR while I prepare for defibrillation”
- “Apply gel on the patient”
Adjust to 200 J (biphasic) / 360 J (monophasic)
Put pads on the patient
“Charging at 200 J”
“I am going to shock on 3. 1, 2, 3.”
Reassess the rhythm.
“Still VF”
Shock the patient
“Shock delivered. Continue CPR”

1st cycle
“Please set line and do blood test to check for cardiac enzyme, electrolyte
and blood gas”
“Prepare 1 mg of adrenaline”

*2 minutes up*

ii) 2nd cycle

- “Stop CPR while I assess the rhythm”
Check the rhythm: VF & check for pulse: pulseless
“It’s a pulseless VF, shockable rhythm”
“Continue CPR while I prepare for defibrillation”
- “Apply gel on the patient”
Adjust to 200 J (biphasic) / 360 J (monophasic)
Put pads on the patient
“Charging at 200 J”
“I am going to shock on 3. 1, 2, 3.”
Reassess the rhythm.
“Still VF”
Shock the patient
“Shock delivered. Continue CPR”

“Give 1 mg of adrenaline every 3-5 minutes”

“Can you please intubate the patient”
Patient intubated, “do continuous chest compression”
Perform 5 points auscultation:
Epigastric, right base, left base, right apex, left apex.
“Attach to capnometer”
 “What is the capnometer reading?”
If ETCO2 < 10 mmHg: “Ensure high quality CPR… give ventilation once every 6
seconds”
Then reassess capnometer reading.
If ETCO2 > 10 mmHg: “You are doing a good job”

*2 minutes up*

iii) 3rd cycle

- “Stop CPR while I assess the rhythm”
Check the rhythm: VF & check for pulse: pulseless
“It’s a pulseless VF, shockable rhythm”
“Continue CPR while I prepare for defibrillation”
- “Apply gel on the patient”
Adjust to 200 J (biphasic) / 360 J (monophasic)
Put pads on the patient
“Charging at 200 J”
“I am going to shock on 3. 1, 2, 3.”
Reassess the rhythm.
“Still VF. Oxygen off.”
Shock the patient
“Shock delivered. Continue CPR”

“Give 300 mg of amiodarone bolus & prepare 150 mg amiodarone”

“May I know the blood results for pH (NR: 7.35-7.45)?”
If acidic: “Give 50 ml (F) / 100 ml (M) of sodium bicarbonate”
“May I know the blood results for potassium (NR: 3.5-5.5)?”
If hyperkalaemia: “Give in the order of calcium gluconate 10% 10ml,
dextrose 50% 50ml & insulin (actrapid) 10 units stat”

b) Non Shockable (Asystole / PEA)

i) 1st cycle
- “Stop CPR while I assess the rhythm”
Check the rhythm: Asystole & check for pulse: pulseless
“It’s a pulseless asystole, non-shockable rhythm”
“Continue CPR”
Initiate flat line protocol –
Ensure chest leads are properly attached, lead II is selected, enlarge ECG size,
check pulse

1st cycle
“Please set line and do blood test to check for cardiac enzyme, electrolyte
and blood gas”
“Prepare 1 mg of adrenaline”
 “Give 1 mg of adrenaline every 3-5 minutes”
“Can you please intubate the patient”
Patient intubated, “do continuous chest compression”
Perform 5 points auscultation:
Epigastric, right base, left base, right apex, left apex.
“Attach to capnometer”
“What is the capnometer reading?”
If ETCO2 < 10 mmHg: “Ensure high quality CPR… give ventilation once every 6
seconds”
Then reassess capnometer reading.
If ETCO2 > 10 mmHg: “You are doing a good job”

*2 minutes up*

ii) 2nd cycle

- “Stop CPR while I assess the rhythm”
Check the rhythm: Asystole & check for pulse: pulseless
“It’s a pulseless asystole, non-shockable rhythm”
“Continue CPR”

“May I know the blood results for pH (NR: 7.35-7.45)?”

If acidic: “Give 50 ml (F) / 100 ml (M) of sodium bicarbonate”
“May I know the blood results for potassium (NR: 3.5-5.5)?”
If hyperkalaemia: “Give in the order of calcium gluconate 10% 10ml,
dextrose 50% 50ml & insulin (actrapid) 10 units stat”
“If the above is normal, I would treat other reversible causes:
5H: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo / hyperkalaemia,
hypothermia
5T: tension pneumothorax, tamponade (cardiac), toxins, thrombosis (
pulmonary), thrombosis (coronary)”

*2 minutes up*

4) ROSC
- “Stop CPR while I assess the rhythm”
Check the rhythm: sinus rhythm & check for pulse: pulse present
“This is return of spontaneous circulation. I would go for post resuscitation care”

Post resuscitation care

AB: “I would check for chest expansion (equal), 5 points auscultation, oxygen
saturation (≥94%), capnometer (35-40 mmHg) & stop bagging and attach the
patient to ventilator”
C: Please measure the patient’s blood pressure
 If hypotension: ”Please give normal saline 200 ml IV bolus, if still low, start
noradrenaline (vasopressor infusion)”
Consider treatable causes: ask 5H5T
D: Response: Sir, sir, can you hear me?
Obey 1 step command: Please lift up your right arm
If able: ”I would sedate the patient”
If unable: “Please initiate targeted temperature therapy (therapeutic
hypothermia)”

“I would order chest X ray, ECG, insert NG tube, insert CBD & give ranitidine”
Ranitidine: Stress Ulcer Prophylaxis (Off-label)
150 mg PO or NG q12hr

50 mg (2 mL) IM or intermittent IV bolus or infusion q6-8hr; not to exceed 400 mg/day;

alternatively, 6.25 mg/hr continuous infusion

CBD indicated for unconscious patient.

Normally patient will be mild tachycardic after an ACLS.

“How is the ECG?”

Deposition
STEMI: refer to cardiologist for PCI
Not MI: refer to ICU”

Adult Tachycardia with a Pulse Algorithm

Case: Patient came in with palpitation.

1) Assess the patient

a) Ask for name
- “Hello sir, what is your name?”
b) Ask for chief complaint
- “What brought you to hospital today?”
c) Call for help
- “Please take the defibrillator, resus trolley and procedure trolley.”
- Attach the leads to the patient’s body
d) Expose the patient
- Remove the top of the patient

*everybody arrives*

2) Access stability of patient

a) Acutely altered mental status
b) Ischemic chest discomfort
 - “Do you have chest pain?”
c) Acute heart failure
- “Do you have difficulty in breathing?”
- Auscultate for the lung bases for any crepitation. ”Are there any crepitation?”
d) Signs of shock
i) Temperature
- “I am holding on to the patient’s peripheries. Are the peripheries warm or cold?”
ii) Pulse volume
- “I am checking for the patient’s pulse volume. How is the pulse volume?”
iii) Capillary refill
- “I am checking for the patient’s capillary refill time. What is the capillary refill time?”
e) Hypotension
- “Please check for the patient’s blood pressure”

*Determine if the patient is stable or unstable*

3) Stable tachycardia
a) Comment ECG
Access the rhythm.
Comment on the rate, rhythm, size of QRS complex, and additional features
- “Now the patient is having stable SVT (narrow regular)”
b) Vagal manoeuvres
i) Carotid massage
- “Sir, you have very fast heartbeat, so I will massage your neck to reduce your
heartbeat.”
“Before that, I need to auscultate your neck first to hear for bruits." No bruits.
“I would check for carotid hyper-stimulation.”
(Gently press on carotid body, look at cardiac monitor)
No carotid hyper-stimulation (exaggerated response to carotid sinus
baroreceptor stimulation)
“I would proceed with carotid massage for 10 seconds”
“There is no change in the rhythm. Vagal manoeuvre have failed.”
ii) Blow through closed nose
iii) Put ice pack on the forehead

c) Adenosine (For narrow regular & monomorphic wide regular)

- “I would proceed with giving adenosine”
“Can you please insert a large bore branula (14G orange / 16G grey) with 3-way
stopcock at the right cubital fossa”
“Take the blood to check for electrolyte, cardiac enzyme and blood gas”
“Please prepare 6mg adenosine and 20cc saline”
“Sir, your heartbeat is still very fast. We tried to do the massage just now but it
did not work.”
 “I will be giving a special medication. This medication can cause chest discomfort
and difficulty in breathing. The purpose of it is to reduce your heart rate. It may
stop your heart. Usually it is not prolonged. But do not worry, we are here to do
chest compression if it is necessary. Usually it is not sustained.”

- “Do you have any allergies?” No.

“Do you have any lung problem, like asthma?” No.
Bronchial asthma, COPD
“Do you have any heart problem, which need to f/up with cardiologist?” No.
WPW syndrome, sick sinus syndrome
(If possible) “I would put the patient in Trendelenburg position”
“Now I am going to give the medication. On my count, 1, 2, 3. Push. Push. Lift arm
up”
Push 6 mg adenosine, push 20 cc normal saline, lift up arm.
Adenosine has short half-life of few seconds (~3s). Need to reach the heart quickly
.

- Reassess patient. Check for response, BP, rhythm.

“The 1st dose is not successful. I would give the 2nd dose of adenosine 12 mg”
Reassess patient.
“The 2nd dose is not successful. I would give the 3rd dose of adenosine 12 mg (max
)”

d) Antiarrhythmic infusion (wide QRS ≥0.12s)

Amiodarone IV dose:
First dose: 150 mg over 10 minutes.
Repeat as needed if VT recurs.
Follow by maintenance infusion of 1mg/min for the first 6 hours.

4) Unstable tachycardia (eg. Suddenly drop in BP)

a) Comment ECG
Access the rhythm.
Comment on the rate, rhythm, size of QRS complex, and additional features
SVT: sync cardiovert 50 J
“The rate is tachycardia, rhythm is regular, QRS complex is narrow, no P wave”
AF: sync cardiovertt 120 J
“The rate is tachycardia, rhythm is irregularly irregular, QRS complex is narrow”
VT: sync cardiover 100 J
“The rate is tachycardia, rhythm is regular, QRS complex is broad”

b) Synchronized cardioversion
- “The patient is having unstable SVT. I would need to give synchronized
cardioversion”
 “Sir, your blood pressure has started to become low due to your fast heart rate,
we need to give you a specialized energy to reduce your heartbeat. It is going to
cause some pain, but do not worry, I am going to give you some sedation and pain
killer”
“Please give the patient 2mg of midazolam and 50 mcg of fentanyl”

- “Apply gel on the patient”

“I would give the patient 50 J (narrow regular) / 120 (narrow irregular) / 100 J (
wide regular)”
Adjust to desired Joule.
Press SYNC button:
Arrows will be seen. So that shock is delivered at the point which it is supposed to
be delivered. If shock is delivered at refractory phase (w/o sync), patient will have
R on T phenomenon. When the heart is supposed to repolarize, it depolarizes,
causing the patient to have VF.
After charging, will take some time for the defibrillator to prepare for the
synchronized shock. Press and wait till change sound.
Put pads on the patient
“Charging at 50 J”
“I am going to shock on 3. 1, 2, 3.”
Reassess the rhythm.
“Still SVT.”
Press longer to shock the patient
“Shock delivered.”

- Reassess patient
Check response: “Sir, sir. Can you hear me?” Drowsy.
Check if stable: “Please check the patient’s blood pressure” 80/40 mmHg
Check rhythm: narrow regular & check pulse
If got pulse, shock again, escalate by 20 J / 50 J depending on machine, maximum
200 J. Proceed to shock, no need to give sedation or pain killer again, until sinus
rhythm is reached.
If pulseless, indicating PEA regardless rhythm, proceed to adult cardiac arrest
algorithm.
Adult Bradycardia with a Pulse Algorithm
1) Assess the patient
a) Ask for name
- “Hello sir, what is your name?”
b) Ask for chief complaint
- “What brought you to hospital today?”
c) Call for help
- “Please take the defibrillator, resus trolley and procedure trolley.”
- Attach the leads to the patient’s body
d) Expose the patient
- Remove the top of the patient

*everybody arrives*

2) Access stability of patient

a) Acutely altered mental status
b) Ischemic chest discomfort
- “Do you have chest pain?”
c) Acute heart failure
- “Do you have difficulty in breathing?”
- Auscultate for the lung bases for any crepitation. ”Are there any crepitation?”
d) Signs of shock
i) Temperature
- “I am holding on to the patient’s peripheries. Are the peripheries warm or cold?”
ii) Pulse volume
- “I am checking for the patient’s pulse volume. How is the pulse volume?”
iii) Capillary refill
- “I am checking for the patient’s capillary refill time. What is the capillary refill time?”
e) Hypotension
- “Please check for the patient’s blood pressure”

*Determine if the patient is stable or unstable*

3) Unstable bradycardia
a) Comment ECG
- 3rd degree bundle brunch block:
“The rate is bradycardia, rhythm is regular, QRS complex is wide, additional
features are P wave is moving although RR interval is regular, indicating AV
disassociation”
nd
- 2 degree type 2 bundle brunch block:
 “The rate is bradycardia, rhythm is regular, QRS complex is wide, additional
features are unpredictable non-conduction of P wave”

b) Atropine
- “Please insert a branula”
“Take blood for cardiac enzymes, electrolytes and blood gas”
“Give 0.5 mg atropine. repeat every 3-5 minutes, with a maximum of 3 mg “
Normally atropine would not work in both cases but still have to give.

c) Pacing (electrical / chemical)

- Reassess patient
Check response: “Sir, sir. Can you hear me?” Drowsy
Check if stable: “Please check the patient’s blood pressure” 80/40 mmHg
Check rhythm: “Bradycardia”

- “The blood pressure is still low. I would proceed with electrical/transcutaneous

pacing”
“Sir, the medication did not work. Because of your slow heart rate and blood
pressure is low, we need to give you a specialized energy. It is going to cause
some pain, but do not worry, I am going to give you some sedation and pain
killer”
“Please give the patient 2mg of midazolam 50 mcg of fentanyl”

- Put both pads on the patient

- Press PACER, set rate at 70 bpm, start, demand mode, output 0 mA.
- Increase the output until get electrical capture
“Electrical capture is achieved, which is defined as every spike followed by a QRS
complex and every QRS complex is preceded by a spike”
“After that, I will feel for femoral pulse to check for mechanical capture.
Mechanical capture has to be at the rate which I have set”
“Once I achieve the mechanical capture, I will increase one more point for safety
margin”

- 2 modes:
(1) Synchronous / demand:
If set 70 bpm, but patient 50 bpm, machine give extra 20 bpm, more
physiologically friendly, normally give this.
(2) Asynchronous / fixed:
If set 70 bpm, machine would not detect patient’s heart rate, would just pace
70 bpm, less physiologically friendly.

- Start with 0 mA. If notice spikes, means machine starting to give energy. Increase the
energy until get electrical capture.
- 2 types of capture:
 (1) Electrical capture:
Means that every spike followed by a QRS complex and every QRS complex is
preceded by a spike. However, need to check with mechanical capture.
(2) Mechanical capture:
Check for femoral pulse because it is most centrally located pulse and least
affected by pacer activity. Once start pacer activity, can see chest twitching. If
mechanical capture is attained, femoral pulse should be 70 bpm. If less than
that means not enough energy is given. Increase the pacer activity until 70
bpm is attained, reaching mechanical capture. Usual range is 30-40 mA.
Check the pulse for 15 seconds x 4.
Need to attain safety margin. Increase the pacer activity one more point
above to ensure if patient move around, blood pressure is safe.

- Reassess patient
Check response: “Sir, sir. Can you hear me?” Drowsy
Check if stable: “Please check the patient’s blood pressure” 120/80 mmHg
Check rhythm: “Sinus rhythm”

4) Stable bradycardia
- Monitor and observe

“The heart rate has raised, becoming narrow complex, means patient has recovered.”
“Please stop the pacer”

Last updated 25 October 2016, UMMP 2014/2019

Reference: 2015 American Heart Association Guidelines Update for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care
Rhythm Recognition

Sinus Rhythm

VF

VT
 SVT

Atrial Fibrillation

Atrial Flutter
Bradycardia

Pacer Mode