ACLS: Advanced Cardiac Life Support provides a structured, evidence-based approach for managing life-threatening cardiovascular emergencies. These algorithms, endorsed by the American Heart Association, guide healthcare providers through critical steps—emphasizing high-quality CPR, early defibrillation, and systematic identification of reversible causes.
Core ACLS Algorithms
- Cardiac Arrest Algorithm
- Bradycardia Algorithm
- Tachycardia Algorithm
- Acute Coronary Syndrome (ACS) Algorithm
- Suspected Stroke Algorithm
- Post–Cardiac Arrest Care Algorithm
1. Cardiac Arrest Algorithm
- Begin high-quality CPR immediately—compress at 100–120/min and minimize interruptions
- Assess rhythm:
- Shockable (VF/pulseless VT): deliver defibrillation, resume CPR, administer epinephrine every 3–5 minutes, consider amiodarone
- Non-shockable (asystole/PEA): continue CPR, give epinephrine, identify and treat reversible “Hs and Ts”
- Cycle rhythm checks and interventions until return of spontaneous circulation (ROSC) or termination criteria met.
2. Bradycardia Algorithm
- Identify symptomatic bradycardia (HR < 60 bpm with hypotension, altered mental status, ischemic chest discomfort)
- First-line: atropine 0.5 mg IV every 3–5 minutes (max 3 mg)
- If atropine ineffective: consider transcutaneous pacing, dopamine infusion (2–20 mcg/kg/min), or epinephrine infusion (2–10 mcg/min)
- Monitor hemodynamics and prepare for possible advanced airway support.
3. Tachycardia Algorithm
- Differentiate stable vs unstable:
- Unstable (hypotension, altered mental status, shock): synchronized cardioversion
- Stable: narrow-complex SVT—vagal maneuvers, adenosine; wide-complex VT—antiarrhythmics (amiodarone, procainamide)
- Always assess for underlying causes and treat accordingly (electrolytes, ischemia).
4. Acute Coronary Syndrome (ACS) Algorithm
- Early 12-lead ECG within 10 minutes of presentation
- STEMI: immediate reperfusion via PCI or fibrinolysis
- Non-STEMI/unstable angina: risk stratification, antiplatelet and anticoagulant therapy, serial enzymes and ECGs
- Monitor for arrhythmias, optimize oxygenation, blood pressure, and pain control.
5. Suspected Stroke Algorithm
- Rapid neurologic assessment (e.g., FAST exam)
- Non-contrast head CT or MRI to exclude hemorrhage
- If ischemic and within time window: administer IV fibrinolytic therapy (e.g., alteplase) or consider endovascular thrombectomy
- Manage blood pressure and glucose, prepare for neurocritical care transfer.
6. Post–Cardiac Arrest Care Algorithm
- After ROSC, optimize ventilation (PaO₂ > 94%), hemodynamics (systolic BP > 90 mmHg), and temperature
- Implement targeted temperature management (32–36 °C) for comatose patients
- Perform necessary diagnostics: 12-lead ECG, echocardiography, neurologic evaluation
- Transfer to ICU with continuous monitoring and treat underlying etiology.
Algorithm Comparison Table
| Algorithm | Indication | Key Intervention |
|---|---|---|
| Cardiac Arrest | VF/pVT, asystole/PEA | High-quality CPR + defibrillation |
| Bradycardia | HR < 60 bpm with symptoms | Atropine → pacing/vasopressors |
| Tachycardia | HR > 150 bpm | Unstable: cardioversion<br>Stable: vagal/adenosine or antiarrhythmics |
| Acute Coronary Syndrome (ACS) | Chest pain, ST-segment changes | 12-lead ECG → reperfusion therapy |
| Suspected Stroke | Acute neurologic deficit | CT → fibrinolysis/thrombectomy |
| Post–Cardiac Arrest Care | ROSC achieved | TTM, hemodynamic/ventilation support |
Special Considerations for ACLS Algorithms
Standard ACLS protocols form the backbone of cardiac arrest management. However, certain clinical scenarios demand tailored modifications to address unique pathophysiology and improve outcomes. Early recognition and adaptation can markedly increase survival rates.
1.Pregnancy (Maternal Cardiac Arrest)
Representing two lives—mother and fetus—maternal arrest requires both standard ACLS and obstetric-specific interventions.
- Common causes (BEAU-CHOPS mnemonic):
- Bleeding (postpartum hemorrhage)
- Embolism (amniotic fluid/PE)
- Anesthesia complications
- Uterine atony
- Cardiac disease (peripartum cardiomyopathy)
- Hypertension (preeclampsia/eclampsia)
- Other Hs & Ts (e.g., hypoxia, toxins)
- Placental abruption
- Sepsis
Key Modifications:
- Displace uterus to the left (manual or 15–30° tilt) to relieve aortocaval compression.
- If no ROSC by 4 minutes, perform perimortem cesarean delivery, targeting fetal delivery by 5 minutes to maximize both maternal and fetal survival.
2. Toxicological Emergencies
Toxins can disrupt cardiac conduction, oxygenation, or perfusion. Standard ACLS must be coupled with specific antidotes.
| Toxin | ECG Findings | Antidote/Treatment |
|---|---|---|
| Opioids (e.g., fentanyl) | Bradycardia, hypoventilation | Naloxone 0.4–2 mg IV/IM every 2–3 min (max 10 mg) |
| Beta-blockers | Bradycardia, AV block | Glucagon 5 mg IV; high-dose insulin infusion |
| Calcium channel blockers | Bradycardia, hypotension | Calcium chloride/gluconate; insulin therapy |
| Tricyclic antidepressants | Wide QRS, prolonged QT | Sodium bicarbonate 1–2 mEq/kg IV |
| Organophosphates | Bradycardia, SLUDGE signs | Atropine + pralidoxime (2-PAM) |
Always integrate toxin‐specific therapy with CPR and ACLS drugs resuscitation alone won’t reverse poisoning
REFERENCES
- Algorithms, American Heart Association CPR & First Aid, https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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