Adult BLS Algorithm for Healthcare Providers Opioid-Associated Emergency Adult BLS in F Algorithm for

Algorithm lealthcare Provey

Hea
for Healthcare Providers
BLS
Basic Life Support
American
Heart
Association.
Verify scene safety. (1 Suspected opioid poisoning
Check for responsiveness.
Verify scene safety.

Reference Shout for nearby help. " Check for

responsiveness.
" Check for responsiveness. Activate the emergency response system. " Shout for nearby help.
" Shout for nearby helr Get naloxone and an AED if available. " Activate emergency response system via mobile
device (if
appropriate).
" Activate emergency response system -Alert them about maternal cardiac arrest.
via mobile device (if appropriate). " Get AED and emergency equipment (or send
someone to do so).
C-A-B " Get AED and

Normal
emergency equipment
(or send someone to do so). Normal breathing,
pulse felt
Look for no breathing
No normal breathing.
pulse felt
No normal Yes Is the No . Roll/wedge or only gasping and
breathing, " Provide rescue
person breathing Provide rescue
breathing, victim onto check pulse (simultaneously). breathing, 1 breath
pulse felt pulse felt breathing, 1 breath ls pulse definitely felt
every 6seconds or normally? left side. 10Secondsor
" Monitor until within 10 seconds?
Monitor Look for no breathing Dreaths/min.
emergency Check Dulse every
until or only gasping and check every
2 minutes: if n responders No 2 minutes; if no
emergency pulse (simultaneously). pulse, start CPR. arrive. breathing pulse, start CPR
responders Is pulse definitely felt or only
arrive. within 10 seconds? If possible opioid " If possible opioid
Overdose, administer 3 By this time in all scenarios, gasping, overdose, administer
Breaths Prevent deterioration (5)
Compressions Airway No breathing
naloxone if available
per protocol. Tap and shout. Yes
Does the
person have No
hacku ie actiated andaEd not felt naloxone if available
per proto col.
or only gasping. C o n i t y and reposition. a pulse? emergency equipment are retrieved
or someone is retrieving them.
pulse not felt By this time in all scenarios, ASSEsslOr

Critical Concepts Transport to the hospital. s10 seconds) Maternal Cardiac Arrest
emergeney es ED
and emergency equipment Start CPR Priorities for pregnant
" Perform cycles of 30 compressions Women in cardiac arrest
are retrieved or someone is
and 2 breaths. include
High-quality CPR improves a victim's chances of survival. The critical retrieving them. nuation of high
" Use AED as soon as it is available. quality CPR with attention
characteristics of high-quality CPR include the following: Start CPR to good ventilation
Start compressions within 10 seconds after recognizing cardiac 4 Lateral uterine
arrest.
" Perform cycles of 30 compressions and 2 breaths.
" Use AED as soon as it is available. Support
7 Start CPR If uterus is at or above the umbilicus and displacement to relieve
tof
Push hard and push fast: Compress at a rate of 100 to 120/min with ventilation Use an AED additional rescuers are present, perform
responsiveness open the airway Consider
vessels in the abdomen
adepth of and breathing continuous lateral uterine displacement. to help with blood flow
- At least 5 cm for adults AED arrives. " Provide o naloxone. . Rapid initiation of
Go to 1. Refer to the BLS/
At least one third the depth of the chest, emergency mealea
for children
approximately 5 cm, breathing or a varalac Arrest AED arrives.
bag-mask device. algorithm. and early transport to the
- At least one third the depth of the chest, appropriate facility
for infants
approximately 4 cm, Check rhythm. Give naloxone.
Shockable rhythm? No,
Allow complete chest recoil after each Yes, Check nyunn
"Minimize interruptions in compressionscompression. shockable nonshockable Shockable hythm?
No, nonshockable
(tryto limit Yes, shockable
interruptions to less than 10seconds). Give 1 shock. Resume CPR Resume CPR immediately for
"Give effective breathsthat make th¿ chest rise. immediately for 2 minutes 2 minutes (until prompted by AED Give 1 shock. Resume CPR " Resume CPR immediately for
2 minutes (until prompted by AED
" Avoid excessive ventilation. (until prompted by AED to allow to allow rhythm check). immediately for 2 minutes
to allow rhythm check).
rhythm check). " Continue until ALS providers take (until prompted by AED to allow "Continue untilALS providers take
Over or victim starts to move. rhythm check).
Original English edition 2020 American Heart Association. 20-1132 Continue until ALS providers take over or victim starts to move.
International English edition ©2020 American Heart Association. JN-1025. Printed in the Over or victím starts to move " Continue until ALS providers take
USA.Print date: 5/22 Over or victim starts to move.
 Providers Summary
Pediatric BLS Algorithm for Healthcare of High-Quality CPR
Pediatric BLS Algorithm for Healthcare Providers
Single Rescuer 2 or More Rescuers
for BLS Providers Components Relief of Foreign-Body Airway Obstruction

Verify scene safety. Verify scene safety. Component Adults and

adolescents
Children Infants
puberty) (age less than 1year
age 1 year to oubee
Verifying scene excluding newborns) Adults and Children Infants
safety Make sure the environment is safe for (age less than
rescuers and victim adolescents (age 1 year to puberty)
" Check for responsiveness 1year)
Check for responsiveness. Recognizing
outor freeroy heip. Shout for nearby help. cardiac arrest Check for responsveness
Activate the emergency response system via mobile device (f appropriate). activates emergency No breathing 1. Ask "Are you choking?
First rescuer remains with the child. Second rescuer No definite pulse feltwithin 1 n e u g Ask "Are you choking? 1. If the victim cannot
emergency equipment. (Breathing and pulse check can be performed simultarneously in less than 10 f the victim nods yes make any sounds
Normal breathing. No normal breathing. (io HD) response system and retrieves the AED and Activating seconds) If the victim nods yes
pulse felt pulse felt emergenc
Ifa mobile device is available, phone emergency services and cannot talk, severe and cannot talk, severe or breathe, severe
Provide rescue No normal breathing, response system airway obstruction is airway obstruction is alirway obstruction
Normal breathing, Ifyou are alone with Witnessed collapse
Look for no breat
ronv
Dreatning. 1 breath
pulse felt pulse felt leavo t h E Follow steps for adults and adolescents present present. Spresent.
Sseconds, activate the emergency on the left Take steps immedi Take steps immedi
oulse (simultaneously) or about " Provide rescue Uowit
ately to relieve the ately to relieve the
Is puise definitely felt 20-30 breaths/min. Look for no breathing breathing, 1 breath response systenand Give 2 mioutes of CpP
every 2-3 seconds, obstruction. obstruction.
within 10 seconds? Assess putse rate for or only gasping and check beginning CPB Leave the victím to activate the emergency
Monitor until no more 10 seconds. pulse (simultaneously). or about Otherwise, send response system and get the AE 2. Give abdominal thrusts 2. Give abdominal thrusts 2. Give up to5back
emergency 20-30 breaths/min. CDOOne and begin Retu
turn to the child or infant and resume CPR: to a victim who is to a victim who is slaps and up to
Is pulse definitely felt use as soon as it is available
responders within 10 seconds? "Assess pulse rate for the AED 2s soonasitie standing or sitting standing or sitting 5 chest thrusts.
arrive. Yes HR <60/min Monitor until no more 10 seconds. available or chest thrusts for or chest thrusts for
Start CPR. pregnant or obese obese victims.
Der
emergency Compression 1 or 2 rescuers 1rescuer
responders ratio wihot 30:2 30:2 victims.
No breathing YNo arrive 2or more rescuers
or only gasping. Yes HR <60min advanced airway 3. Repeat thrusts until 3. Repeat thrusts until 3. Repeat step 2 until
15:2
pulse not felt Continue rescue with signs of poor effective or the victim effective or the victim effective or the
Witnessed sudden
Yes
breathing; check
pulse every
2 minutes.
No breathing
or only gasping
perfusion?
No
comp
vonti
ratio with
advanced airway
ContinuOuS
compressions atarate
of 100-120/min
GVeDreatnevery
Continuous 100210ons at a rate of
Give 1 breath every 2-3 seconds
(20-30 breaths/min)
becomes unresponsive becomes unresponsive. victim becomes
unresponsive.
collapse? " If no pulse, start CPR. pulse not f (10 breaths/min) Victim becomes unresponsive
No Start CPR. " Continue rescue
|Compression rate 100-120/min
breathing; check
Start CPR Compression At least 5 cm At least one third AP At least one third AP 4. Activate the emergency response system via mobile device (if appropriate) or
pulse about every depth diameter of chest diameter of chest
" 1rescuer: Perform cycles of Activate emergency Start CPR 2 minutes. Approximately 5 cm Approximately 4 cm send someone to do so. After about 2 minutes of CPR, if you are alone with no
30 compressions and 2 breaths. response system mobile device, leave the victim to activate the emergency response system
" First rescuer performs cycles of " If no pulse, start CPR. Hand placement 2 hands on the 2 hands or 1 hand 1 rescuer
" When second rescuer arrives, perform (if not already 30 compressions and 2 breaths. if no one has already done so).
lowe taetrnum aTor very Smal nter of the
cycles of 15 compressions and 2 breaths. done), and retrieve Wnen second rescuer returns, perform brez
5. Lower the victim to the floor, Begin CPR, starting with chest compressions. Do not
" Use AED as soon as it is avalable. AED/defibrillator. of the chest, just below the
2breaths. breastbone (sternum) nipple line check fora pulse.
SSOon as it
6. Before you deliver breaths, look into the mouth. If you see a foreign body that can
After about 2 minutes, if stil alone, activate emergency hands in the center of be easily removed, remove it.
response system and retrieve AED (f not already done). the chesttjus low 7. Continue CPRuntil advanced providers arrive.
Check rhythm. If the rescuer is
Shockable rhythm? unable to achieve the
Check rhythm. Tecoehle to
Shockable rthythm?
No, nonshockable
Yes, shockable No, nonshockable use the heel o
Yes, shockable
one hand
" Give 1shock. Resume CPR Resume CPR immediately for Give 1shock. Resume CPR . Resume CPRimmedia Chest recoil Allow complete recoil of chest after each compression:
immediately for 2 minutes 2 minutes (until prompted by AED immediately for 2 mínutes idtely for do not lean on the chest after each compression
(until prompted by AED to allow to allowrhythmcheck). (until prompted by AED to allow 2 minutes (until pted by AED
to allow rhythm check) izin
Limit interruptions in chest compressions to less than
rhythm check. "Continue until ALSproviders take rhythm check). 10 seconds with a CCF goal of 809%
" Continue until ALS providers take interruotions
Continue until ALS providers take Over or the child starts to move. " Continue until ALS providers take
Over or the child starts to move. Over or the child starts to move. ssion depth should be no more than 6 cm. resuscitation
Over or the child starts to move. "Compressio anteroposterior CCF, chest compression fraction; CPR, cardiopulmonary
Abbreviations: AED, automated external defibrillator, AP,
 Doses/Details for the Cardiac Arrest Algorithms Adult Cardiac Arrest Algorithm
AMERICAN
American ASSOCIATION
Heart dCRITICAL-CARE
Association. NURSES Start CPR
CPRQuality Advanced Airway . Give oxygen
. Push hard (at least 5 cm) " Attach monitorldefibrillator
Endotracheal intubation or
Cardiac Arrest, and fast (100-120/min) and allow

ACLS Mite
CO chest recoil Supraglottic advanced airway
" Waveform capnography or
Arrhythmias, and einterruptions in compressions. capnometry to confirm and monitor
Yes
Rhythm shockable?
No

Their Treatment " Avoid

excessive ventilation. ET tube placement
Change compressor every 2 minutes, or Once advanced airway in place,
sooner if fatigued. gve 1 breath every6 seconds (10
VF/pVT Asystole/PEA
" If no advanced airway, 30:2 compression
Adult Cardiac Arrest Circular Algorithm ventilation ratio.
breaths/min) with continuouS chest
compressions
Quantitative waveform capnography Shock Epinephrime
If PETC0, is low or ASAP
decreasing, reassess Return of Spontaneous
CPR Quality. Circulation (ROSC)
Shock Energy for Defibrillation CPR 2 min
Start CPR " Pulse and blood pressure CPR2 min
" Biphasic: Manufacturer recommendation " Abrupt sustained increase in PETCO, " V/IO access VI0 access
Give oxygen Epinephrine every 3-5 min
"Attach monitor/defibrillator (eg, initial dose of120-200 J; if unknown, (typically 240 mm Hg)
use maximum available. Spontaeous arterial pressure waves Consider advänced airway,
Second and subsequentdoses should with intra-arterial monitoring capnography
No
2 minutes Return of Spontaneous be equivalent, anddhiaher
t doses may be Rhythm shockable?
Circulation (ROSC) considered. Reversible Causes
Monophasic: 360 J Yes Yes
Rhythm
Check Post-Cardiac Hypovolemia shockable?
Rhythm Arrest Care Drug Therapy Hypoxia Shock
If VE/pVT Hydrogen ion (acidosis)

continuOus
CPR
Shock
Shonunuo Epinephrine IV/IO dose:
1mg every 3-5 minutes
Amiodarone IV/IO dose:
Hypo-/hyperkalemia
Hypothermia
Tension pneumothoraxX
CPR 2 min
Ne

Drug Therapy First dose: 300 mg bolus. Tamponade, cardiac Epinephrine every 3-5 min
" Consider advanced airway.
VIO access Second dose: 150 mg. Toxins
Epinephrine every 3-5 minutes or
Thrombosis, pulmonary capnography
Amiodarone or lidocaine Lidocaine IV/IO dose: Thrombosis, coronary
for refractory VFlpVT First dose: 1-1.5 mg/kg.
Second dose: 0.5-0.75 mg/kg. Rhythm No
shockable?
Consider Advanced Airway Yes
Quantitative waveform capnography Shock

11
Treat Reversible Causes
CPR 2 min CPR 2 min
Amiodarone or lidocaine " Treat reversible causes
Treat reversible causes
Monitor CPR Quality
12
No Yes
"If no signs of return of Rhythm
spontaneous circulation shockable?
(ROSC), go to 10 or 11
" If ROSC. go to
Post-Cardiac Arrest Care Go to 5 or 7
Original English edition e 2020 American Heart Association. 20-1120 " Consider appropriateness
of continued resuscitation
ternational English edition e2020 American Heart Association. JN-1029 (1 of 3). Printed in the USA. Print date: 5/22
 Adult Post-Cardiac Arrest Care Algorithm Adult Bradycardia Algorithm AdultTachycardia With a Pulse Algorithm
Initial Stabilization Phase
ROSC obtained Assess appropriateness for clinical condition. Doses/Details
Heart rate typically <50/min if bradyarrhythmia. Assess appropriateness for clinical condition.
Resuscitation is ongoing during the
post-ROSC phase, and many of these Heart rate typically 2150/min if tachyarrhythmia. Synchronized
activities can occur concurrenty cardioversion:
Manage airway However, if prioritization is necessary. Refer to your specific
Early placement of follow these steps: device's recommended
endotracheal tube " Ainway management energy level to
pranhy or ldentify and treat underlying cause
cannometry to confirm and monitor Identify and treat underiying cause maximize first shock
endotracheal tube placement "Maintain patent airway; assist breathing as Success.
Initial Manage respiratory parameters . Manage respiratory parameters: Maintain patent airway; assist breathing as necessary necessary
Start 10 breaths/min Titrate FlO., for Spo, 92%-98%: start (if hypoxemic) "Oxygen (if hypoxemic) Adenosine IV dose:
Stabilization
Spo, 92%6-98% at 10 breaths/min; titrate to Pac0, of Cardiac monitor to identify rhythm; monitor blood pressure "Cardiac monitor to identify rhythm; monitor First dose: 6 mg rapid IV
Phase and oximetry push; follow with NS flush.
Paco, 35-45 mm Hg 35-45 mm Hg
" Manage hemodynamic parameters: . |V access blood pressure and oximetry
Second dose: 12 mg if
" IVaccess
Administer crystalloid and/or (Vitals 12-Lead ECG if available; don't delay therapy required.
vasopressor or inotrope t an mm Hg or " 12-lead ECG, if available
Manage hemodynamic parameters Consider possible hypoxic and toxicologic causes
Systolic blood pressure >90 mm Hg systolcarterial pres
mean birossure >65 mm Hg9 Antiarrhyythmic Infusions
Mean arterial pressure >65 mm Ha for Stable Wide-QRS
Continued Management and Tachycardia
Additional Emergent Activities Procainamide IV dose:
Persistent
20-50 mg/min until
Obtain 12-lead ECG These evaluations should be done tachyarrhythmia Yes arrhythmia suppressed,
concurrently so that decisions on causing:
Persistent hypotension ensues,
targeted temperature management "Hypotension?
(TTM) receive high priority as cardiac bradyarrhythmia causing: Synchronized QRS duration increases
interventions. " Hypotension? " Acutely altered cardioversion >50%, or maximum dose
Consider for emergent cardiac " Emergent cardiac intervention: mentalstatus? 17 mg/kg given.
intervention if Early evaluation of 12-lead " Acutely altered mental status?
" Signs of shock?
"Consider sedatíon
" Sians of shock? If regular narrow Maintenance infusion:
" STEMI present electrocardiogram (ECG): consider " Ischemic chest
emodynamics for decision on " Ischemic chest discomfort? complex, consider 1-4 mglmin. Avoid if
Unstable cardiogenic shock discomfort? prolonged QT or CHF.
" Acute heart failure? adenosine
"Mechanical circulatory TTM: If patient is not following " Acute heart
support required Amiodarone IV dose:
commands, start TTM as soon as failure?
possible; begin at 32-36°C for 24 No Yes
First dose: 150 mg over
hours by using a cooling device with 10 minutes. Repeat as
feedback loop No needed if VT recurs.
Follows Other critical care management Follow by maintenance
commands? - Continuously monitor core infusion of 1 mg/min for
No Yes temperature (esophageal, Consider first 6 hours.
rectal, bladder) Monitor Atropine Yes
Maintain normoxia, If atropine ineffective: "Adensine only Sotalol IV dose:
Continued and Wide QRS?
if regular and
normocapnia, euglycemia . Transcutaneous pacing 20.12 second 100 mg (1.5 mg/kg) over
Management ovibe Continuous observe monomorpl rphic
and
Comatose Awake and/or 5 minutes. Avoid if
"TTM Other " Dopamine infusion Antiarrhythmic prolonged QT.
Additional
"Obtain brain CT encephalogram (EEG)
electroenceoh infusion
critical care
Emergent "EEG monitoring management
monitoring
Provide lung-protective
or
" Epinephrine infusion No "Expert
Activities "Other ventilation consultation
critical care
H'sand T's
management
Hypovolemia
Hypoxia
Hydrogen ion (acidosis) " Vagal maneuvers (if regular) Ifrefractory, consider
" Hypokalemia/hyperkalemia Consider: " Adenosine (if regular) Underlying cause
reversiblerapidhv
Evaluate and "Hypothermia " B-Blocker or calcium Need to increase energy level for
" Tension pneumothorax " Expert consultation channel blocker next cardioversion
etiologies " Tamponade, cardiac " Transvenous pacing
Involve expert consultation for " Toxins " Consider expert consultation Addition of anti-arrhythmic drug
" Thrombosis, pulmonary Expert consultation
continued management
Thrombosis, coronary
 Acute Coronary Syndromes Algorithm (continued) Fibrinolytic Contraindications for STEMI

American
AMERICAN
ASSOCIATION
Heart dCRITICAL-CARE
NURSES Contraindications for fibrinolytic use in STEMI consistent with
Association.
the 2013 ACCFIAHA Guideline for the Management of ST-Elevation
Myocardial Infarction
Absolute Contraindications

ACLS Acute Coronary

Syndromes and Stroke
STel
SI elevaton or
presumably new
new or
strongly suspicious
for injury
ST-elevation MI (STEMI)
Non-ST-elevation ACS
(NSTE-ACS)
Determine risk using
validated score
(ie, TIMI or GRACE)
" Any prior intracranial hemorrhage
" Known structural cerebral vascular lesion (eg, arteriovenous
malformation)
Acute Coronary Syndromes Algorithm " Known malignant intracranial neoplasm (primary or metastatic)
" Ischemic stroke within 3 months
Exceptacute ischemic stroke within 4.5 hours
Symptoms suggestive of ischemia or infarction
Start adjunctive ST depression o Normal ECG or " Suspected aortic dissection
therapies as indicated yt
T-wave inversion, nondiagnostic changes " Active bleeding or bleeding diathesis (excluding menses)
Do not delay reperfusion ST elevation; strongly in ST segment or
suspicious for ischemia Twave: low-risk score Significant closed head trauma or facial trauma within 3 months
EMS assessment and care and hospital preparation and/or high-risk score Low-fintermediate " Intracranial or intraspinal surgery within 2 months
" Assess ABCs. Be prepared to provide CPR and defibrillation High-risk NSTE-ACS risk NSTE-ACS
" Administer aspirin and consider oxygen, nitroglycerin, and morphine if needed " Severe uncontrolled hypertension (unresponsive to emergency
Obtain 12-lead ECG; if ST elevation: therapy)
- Notify receiving hospital with transmíssion or interpretation: note time of onset
and first medical contact " For streptokinase, prior treatment within the previous 6 months
" Provide prehospital notification: on arrival, transport to ED/cath lab per protocol >12
Time from hours Troponin elevated or Consider admission Relative Contraindications
-Notified hospital should mobilize resources to respond to STEMI
" Ifconsidering prehospital fibrinolysis, use fibrinolytic checklist onset of high-risk patient to ED chest pain unit
symptoms Consider early invasive or to appropriate bed " History of chronic, severe, poorly controlled hypertension
S12 hours? strategy if: for further monitoring
Refractory ischemic and possible Significant hypertension on presentation (systolic blood pressure
chest discomfort intervention greater than 180 mm Hg or diastolic blood pressure greater than
ConcurrenttED/cath lab assessmerit ImmediateEDlcath lab S12 hours "Recurrent/persistent 110 mm Hg)
(<10 minutes) ST deviation
generaltreatment " History of prior ischemic stroke more than 3 months
" Activate STEMi team upon EMS notification " IfO, sat <90%6, Start oxygen at Ventricular tachycardia
4LImin, titrate " Hemodynamic " Dementia
" Assess ABCs: give oxygen if needed
-Establish IV access Aspirin 162 to 325 mg (if not instability
" Perform brief, targeted history, physical exam given by EMS) "Signs of heart failure " Known intracranial pathology not covered in absolute contraindications
"Reviewlcomplete fibrinolytic checklist: "Nitroglycerin sublingual or Start adjunctive therapies " Traumatic or prolonged (more than 10 minutes) CPR
check contraindications translingual (eg, nitroglycerin, heparin)
"Obtain initial cardiacmarker levels, complete "Morphine IVif discomfort not as indicated " Major surgery (less than 3 weeks)
blood courts, and Coagulation studies relieved by nitroglycerin See AHA/ACC NSTE-ACS
Recent (within 2 to4 weeks) internal bleeding
Obtain portable chesty-ray(<30 minutes): "Consider administration of Guidelines
do not delay transport to the cath lab P2Y, inhibitors Noncompressible vascular punctures
Reperfusion goals: " Pregnancy
Therapy defined by patient and Active peptic ulcer
center criteria
ECG interpretation " FMC-t0-balloon inflation " Oral anticoagulant therapy
(PCI) goal of s90 minutes
*Viewed as advisory for clinical decision making and may not be all-inclusive or definitive.
"Door-to-needle (fibrinolysis)
goal of 30 minutes Abbreviations: CPR,cardiopulmonarv resuscitation; STEMI, ST-elevation myocardial
Original English edition 2020 American Heart Association. 20-1120 infarction.
international English edition G 2020 American Heart Association. JN-1029 (2 of 3). Printed in the USA Print date: 5/22
Suspected Stroke Algorithm Emergency Medical Services
Acute Stroke Routing Hypertension Management in Acute Ischemic Stroke

Identify signs and symptoms of possible stroke Options to Treat Arterial Hypertension in Patients With Acute lschemic
Activate emergency response EMS Dispatch Stroke Who Are Candidates for Emergency Reperfusion Therapy!
per regional
stroke protocol COR 25 LOE C-EO
Critical EMS assessments and actions ldentfy and
transport to
" Assess ABCs; give oxygen if needed Perform
validated
nearest/closest Patient otherwise eligible for emergency reperfusion therapy except that
"Initiate stroke protocol certified stroke BP is >185/110 mm Hg:
"Perform physical exam stroke severity LVO Suspected? NO center (ASRH
Perform validated prehospital stroke screen and stroke severity
tool
EMS on scene:
tool used to
PSC, TSC CSC) " Labetalol 10-20 mg IV over 1-2 minutes,may repeat 1 time: or
Establish time of symptom onset (last known normal) Obtain
access for
potential large 2 Províde " Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes,
mostappropriate stroke center
Triage to
"Checkglucose; treat if indicated
vitals and vessel occlusion
YES
prehospital
notification
maximum 15 mg/h; when desired BP reached, adjust to maintain
brain imaging suite provide ABC (LVO) proper BP limits;or
* Provide prehospital notification: on arrival, transport to interventions
Note: Refer to the expanded EMS stroke algorithm. 2 Interview LKW<24
" Clevidipine 1-2 mg/h IV, titrate by doubling the dose every
NO
witnesses & Hours? 2-5 mínutes until desired BP reached; maximum 21 mg/h
obtain phone
ED or brain imaging suite" number Determine 1 Transport to "Other agents (eg, hydralazine, enalaprilat) may also be considered
Immediate general and neurologic assessment by hospital or stroke team 3 Perform Last Known Well nearest If BP is not maintained s185/110 mm Hg. do not administer alteplase
Activate stroke team upon EMS notification (LKW) AND time YES TSC if one
physical
"Prepare for emergent CTscan or MRIof brain upon arrival exam and of symptom is located
Management of BP during and after alteplase or other emergency
Stroke teammeets EMS on arrival validated discovery within 30 mins
Assess ABCS: give oxygen if needed prehospital
Transport time
to EVT-capable 2 lIf no CSC or TSC reperfusion therapy to maintain BPs180/105 mm Hg:
Obtain iVaccess and perform laboratory assessments stroke Stroke center will DNO meets algorithm " Monitor BP every 15 minutes for 2 hours from the start of alteplase
Check glucose; treat if indicated identification time parameters,
Reviewpatient history, medications, and procedures Screen
not disqualify for
transport to
therapy, then every 30 minutes for 6hours, and then every hour
4 Obtain POC
thrombolytic. nearest certified for 16 hours
Establish time of symptom onset or last known normal Initiate Stroke
Perform physical exam and neurologic examination, including NIH Stroke Scale blood glucose Protocol stroke center per
or Canadian Neurological Scale YES
regional stroke If systolic BP >180-230 mm Hg or diastolic BP >105-120 mm Hg:
systems of care
"Best practice is to bypass the ED and go straight to the brain imaging suite. protocol. " Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min; or
Total transport 3 Provide " Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every
Yes prehosptal
Does brain imaging Initiate
Stroke YES
time from scene
DNO notification
5-15 minutes, maximum 15 mg/h; or
to nearest CSC
show hemorrhage? intracranial
hemorrhage
Suspected? is s30 min total "Clevidipine 1-2 mg/h IV, titrate by doubling the dose every
Y No protocol
and within 2-5 minutes until desired BP reached; maximum 21 mg/h
maximum time
Consider alteplase permitted by EMS IfBP not controlled or diastolic BP >140 mm Hg, consider IV sodium
NO 1 Transport to the nitroprusside
Yes nearest CSC
Alteplase candidate? Abbreviations: AIS, acute ischemic stroke: BP, blood pressure; COR, Class of
YES 2 Provide Recommendation; IV, intravenous: LOE. Level of Evidence.
VNo Treat and prehospital
Administer alteplase
transport as notification Different treatment options may be appropriate in patients who have comorbid conditions
Consider EVT indicated
per patient
that may benefit from rapid reductions in BP, such as acute coronary heart failure, aortic
Perform CTA dissection, or preeclampsialeclampsia.
presentation
Perform CTP as indicated Data derived from Jauch et al.
1. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients
Yes No with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management
of acute ischemic stroke: a sfrom the American Heart
EVT candidate? guideline for
heaithearepo4-41g
Association/American Stroke Association. Stroke. 2019;
STR.0000000000000211
dok 10.1161/
Rapidly transport to cath lab or Admit to stroke unit or
transfer to EVT-capable center neurological iCU, or transfer 2. Jauch EC, Saver JL. Adams HP Jr, et al:; for the American Heart Association Stroke Council,
to higher level of care Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on
Clinical Cardiology. Guidelines for the early management of patients with acute ischemic
stroke: a guidelinetfor healthcare professionals from the American Heart Association/American
Admit to neurological ICU Stroke Association. Stroke, 2013;44(3):870-947. doi: 10.1161/STR.Ob013e318284056a
Cardiac Arrest in Pregnancy In-Hospital Algorithm
AMERICAN
American ASSOCIATION
Continue BLS/ACLS MaternalCardiac Arrest
Heart
Association.
dCRÍTICAL
NURSES
CARE
" High-quality CPR
"Defibrillation when " Team planning should be
indicated done in collaboration with
Cardiac Arrest in
ACLS
" Other ACLS interventions the obstetric, neonatal,
emergency, anesthesiology.
(eg,epinephrine) intensive care, and cardiac Select SpecialSituations
arrest services.
" Priorities for pregnant
and Neuroprognostication
women in cardiac arrest
Assemble maternal cardiac arrest team should include provision of
high-quality CPR and relief of
Opioid-Associated Emergency for
aortocaval compression with Healthcare Providers Algorithm
lateral uterine displacement.
The goal of perimortem
Consider cesarean delivery is to
etiology improve maternal and fetal Suspected opioid poisoning
of arrest outcomes. " Check for responsiveness.
Ideally, perform perimortem " Shout for nearby help.
cesarean delivery in " Activate the emergency response system.
5 minutes, depending on " Get naloxone and an AED if available.
provider resources and
Perform maternal Perform obstetric skill sets.
interventions interventions
"Perform airway "Provide Advanced Airway
management continuous Yes Is the No
" Administer 100% lateral uterine " In pregnancy, a difficult person breathing
O,, avoid excess displacement airway is common. Use the
most experienced provider. normally?
ventilation " Detach fetal
"Place IVabove monitors Provide endotracheal
diaphragm " Prepare for intubation or supraglottic
" Ifreceiving IV perimortem advanced airway. 3
" Perform waveform
magnesium, stop cesarean delivery Prevent deterioration 5 Does the
and give calcium capnography or capnometry Yes
to confirm and monitor ET "Tap and shout. person have a pulse?
chloride or (Assess for
tube placement. " Open the airway and
gluconate reposition. s10 seconds.)
Once advanced airway is in
Perform place, give 1breath every "Consider naloxone.
perimortem 6 seconds (10 breaths/ " Transport to the hospital.
No
min) with continuous chest
Continue BLS/ cesarean delivery Compressions.
ACLS "Ifno ROSC,
complete Potential Etiology of
" High-quality CPR perimortem MaternalCardiac Arrest
"Defibrilation when cesarean delivery
indicated ideally within 5 A Anesthetic complications Ongoing assessment Support ventilation Start CPR
" Other ACLS minutes after time B Bleeding
interventions C Cardiovascular
of responsiveness " Open the airway and " Use an AED,
of arrest and breathing reposition. " Consider naloxone.
leg, epinephrine) DDrugs Go to 1. " Provide rescue " Refer to the BLS/
E Embolic breathing or a bag Cardiac Arrest
F Fever mask device. algorithm.
G General nonobstetric " Give naloxone.
"Neonatal team to causes of cardiac arrest
receive neonate (H'sand T's)
H Hypertension Original English edition 2020 American Heart Association. 20-1120
International English edition O2020 American Heart Association. JN-1029 (3 of 3). Printed in the USA. Print date: 5/22
 Adult Ventricular Assist Device Algorithm Neuroprognostication Diagram

dlagnostic
tests
for
multimodal
Assist ventilation if necessary Incorporate
after
hours
normothermia
and assess perfusion least
at
" Normal skin colorand temperature?
-Normal capillary refill? 2

Burst
suppression light
Pupillary
reflex
Assess and treat Yes No Assess LVAD function possible status Corneal
reflex
non-LVAD causes Adequate "Look/listen for alarms epilepticus
for altered mental perfusion? " Listen for LVAD hum Controlled
normothermia Persistent
status, Such as as
analgesia
Hypoxia 72
hours
"Blood giucose
"Overdose and
"Stroke Yes
MAP >50 mm Hg sedation
LVAD
and/or
PETCO, >20 mm Hg? functioning?
Limit SSEP
N20
No MRI
EEG)
Yes No (record 48
hours
Attempt to restart LVAD Serum
NSE
" Driveline connected? myoclonus
" Power source connected? Rewarming
" Need to replace system
controller? Status

24
hours
Do not perform Perform No
LVAD
external chest externalchest restarted? possible)
Compressions Compressions

as
Yes soon CT
Head Time
after
ROSC
(as
TTM
Follow local EMS ROSC
and ACLS protocols
ManagementImaging
Clinical ElectrophysiologyExamination
Clinical Biomarkers

Notify VAD center

andlor medical
Control and transport

"The PETCo, cutoff of >20 mm Hg shouid be used only when an ET tube or tracheostomy is used to
vertilate the patient. Use of a supraglottic (eg, King) airway results in a falsely elevated PETCO, value.