• Basic life support (BLS) algorithm—emphasis on maintaining cardiac/cerebral perfusion through early, high-quality chest compressions with minimal interruption, rapid defibrillation when appropriate, and avoiding delays in establishing a definitive airway and excessive ventilation. Use of vasopressors and antiarrhythmic agents is deemphasized

   ○ Check the carotid pulse for 5–10 s

   ○ If no pulse within 10 s, start high-quality cardiopulmonary resuscitation (CPR) with chest compressions

   ○ Push hard and fast (at least 100 compressions/min) at a depth of at least 2 in.

   ○ Allow full chest recoil after each compression

   ○ Minimize interruptions in CPR (any interruption > 10 s) including pulse checks

   ○ One CPR cycle is equal to 30 compressions then two breaths (30:2)

     ■ Five cycles administered every 2 min

     ■ If possible, compressor should change every 2 min

   ○ Avoid excessive ventilation leading to harmful elevations in intrathoracic pressure

   ○ Continuous chest compressions with advanced airway. Administer 8–10 breaths per minute for cardiac arrest or 10–12 breaths per minute for respiratory arrest, and check rhythm every 2 min

   ○ The AHA recommends continuous waveform capnography (in addition to bedside assessment) as the most reliable method of confirming correct endotracheal tube placement

     ■ End tidal CO₂ (PETCO₂) less than 10 mmHg indicates poor blood flow and unlikely return of spontaneous circulation (ROSC); improvement in CPR quality is advised

     ■ A sustained abrupt rise in PETCO₂ (especially to normal values of 35–40 mmHg or greater) is usually indicative of ROSC and a rhythm/pulse check is advisable

   ○ If intra-arterial diastolic pressure is less than 20 mmHg, then attempt to improve CPR quality

• ROSC—pulse/BP, PETCO₂ greater than 40 mmHg, spontaneous waves if using arterial line

• Give oxygen when available

• Attach defibrillator/monitor as soon as possible

• Assess rhythm → shockable rhythm?

   ○ Ventricular fibrillation/pulseless ventricular tachycardia (shock advised)—proceed to Table 1.2

   ○ Pulseless electrical activity (no shock)—proceed to Table 1.3

   ○ Asystole (no shock)—proceed to Table 1.4

• Basic life support (BLS) algorithm → give high-quality cardiopulmonary resuscitation (CPR) stopping only for shock delivery, brief rhythm checks, brief pulse checks if organized rhythm, and to facilitate placement of an advanced airway

• Give oxygen

• Give one unsynchronized shock

   ○ Biphasic (device specific): 120–200 J (if unknown use 200 J)

   ○ Monophasic: 360 J

• Immediately after the shock, resume CPR for five cycles (about 2 min)

• When vascular access established (intact PVL > emergent PVL, interosseous [IO] access > emergent CVL), administer vasopressor during CPR (before or after the shock)

   ○ Epinephrine 1 mg intravenous push (IVP) or IO, repeat every 3–5 min

   ○ Vasopressin 40 units IVP/IO × one dose only, may replace the first or second dose of epinephrine

• Check rhythm after five cycles (about 2 min) of CPR. Shockable rhythm—repeat shock using equivalent or higher energy

• Resume CPR immediately after the shock

   ○ Consider antiarrhythmics (before or after the shock)

     ■ Amiodarone 300 mg IVP/IO × one dose (first-line agent)

       □ May administer one repeat dose of 150 mg IVP/IO in 3–5 min

     ■ Lidocaine 1–1.5 mg/kg IVP/IO × one dose, then 0.5–0.75 mg/kg IV every 5–10 min to a maximum of 3 mg/kg. May consider if amiodarone is not available

     ■ Magnesium 1–2 g in 10 mL of D5W IVP/IO over 5 min for torsades de pointes or severe hypomagnesemia

• Resume CPR immediately for five cycles (about 2 min)

• Repeat cycles of shock (if persistent VF/pulseless VT) and epinephrine administration as aforementioned every 3–5 min

• If ROSC, then proceed with post-cardiac arrest care

• Review most frequent causes (see Table 1.12). Hypovolemia and hypoxia are the two most common causes of PEA arrest

• Basic life support (BLS) algorithm → give high-quality cardiopulmonary resuscitation (CPR)

• Epinephrine 1 mg intravenous push (IVP) or intraosseous (IO), repeat every 3–5 min

• Vasopressin 40 units IVP/IO × one dose only, may replace the first or second dose of epinephrine

• Check rhythm after five cycles (about 2 min) of CPR. If shockable rhythm then proceed with the VF/VT algorithm in Table 1.2

• The AHA has removed atropine from the 2010 guidelines, as it is unlikely to have a therapeutic benefit

• If ROSC, then proceed with post-cardiac arrest care

• Validate the rhythm (look for loose leads, low signal, loss of power)

• Identify and correct an underlying cause if present

• Basic life support (BLS) algorithm → give high-quality cardiopulmonary resuscitation (CPR)

• Epinephrine 1 mg intravenous push (IVP) or intraosseous (IO), repeat every 3–5 min

• Vasopressin 40 units IVP/IO × one dose only, may replace the first or second dose of epinephrine

• Check rhythm after five cycles (about 2 min) of CPR. If shockable rhythm then proceed with the VF/VT algorithm in Table 1.2

• The AHA has removed atropine from the 2010 guidelines, as it is unlikely to have a therapeutic benefit

• The AHA recommends against attempted pacing in the 2010 guidelines, as it is unlikely to have a therapeutic benefit

• An initial defibrillation may be warranted if it is unclear if the rhythm is fine VF or asystole

• If ROSC, then proceed with post-cardiac arrest care

• Assess airway, breathing, and signs/symptoms of bradycardia

• Give oxygen if hypoxemic (maintain oxygen saturation ≥ 94 %)

• Monitor blood pressure, pulse oximetry, and establish IV access

• Obtain and review 12-lead electrocardiogram (ECG)

• Consider causes and differential diagnosis

Serious signs or symptoms owing to bradycardia are present

• Atropine 0.5 mg intravenous push (IVP) every 3–5 min up to a total of 0.04 mg/kg or 3 mg total

   ○ Administer every 3 min in urgent circumstances

   ○ Use 1 mg doses in obese patients to avoid paradoxical bradycardia

   ○ Will not work in denervated transplanted hearts

• Transcutaneous pacing: provide analgesia and/or sedation if benefit outweighs any risk; set the demand rate to 60 beats/min; set the current milliamperes output to 2 mA above the current at which consistent electrical and mechanical capture is achieved

• Dopamine continuous IV infusion 2–10 mcg/kg/min

• Epinephrine continuous IV infusion 2–10 mcg/min

• Consider glucagon 2–10 mg IV bolus followed by a 2–10 mg/h continuous IV infusion in β-adrenergic blocker or calcium channel blocker-induced bradycardia not responsive to atropine

• Prepare for possible transvenous pacing if the above measures are ineffective

Evaluate patient

• Assess airway, breathing, and signs/symptoms of tachycardia

• Give oxygen if hypoxemic (maintain oxygen saturation ≥ 94 %)

• Establish IV access

• Obtain 12-lead electrocardiogram (ECG)

• Identify and treat etiology

• Questions to address:

   ○ Is the patient unstable or stable?

   ○ Are there serious signs or symptoms as a result of the tachycardia?

     ■ Including hypotension, hypoperfusion, heart failure, angina, pre-syncope/syncope, acute dyspnea, or hypoxemia

     ■ Ventricular rates less than 150/min rarely are responsible for serious signs or symptoms

   ○ Is the rhythm regular or irregular?

   ○ Is the QRS complex narrow or wide? What is the morphology if wide?

Unstable patient (serious signs or symptoms)

• Prepare for immediate synchronized cardioversion (see Table 1.10)

Stable patient (no serious signs or symptoms as a result of the tachycardia)

• Atrial fibrillation/atrial flutter

   ○ Evaluate

     ■ Cardiac function (i.e., can the patient tolerate negative inotropic medications?)

     ■ Suspicion or known of Wolff–Parkinson–White Syndrome (WPW)

     ■ Duration (less than or greater than 48 h)

   ○ See atrial fibrillation/atrial flutter algorithm (Table 1.7)

     ■ Rate control

     ■ Rhythm control

     ■ Consider early anticoagulation

• Narrow-complex tachycardias (QRS < 0.12 s)

   ○ See Table 1.8

• Stable wide-complex tachycardia with a regular rhythm

   ○ If ventricular tachycardia or uncertain rhythm (see Table 1.9)

   ○ If SVT with aberrancy, give adenosine (see Table 1.8)

• Stable wide-complex tachycardia with an irregular rhythm

   ○ If atrial fibrillation with aberrancy (see Table 1.7)

   ○ If atrial fibrillation with WPW (see Table 1.7)

   ○ If polymorphic ventricular tachycardia (see Table 1.9)

Normal cardiac function

• β-adrenergic blockers

• Consider synchronized cardioversion or

• Diltiazem

• Amiodarone

• Verapamil

• Ibutilide

• Flecainide

• Propafenone

• Procainamide

EF < 40 %

• Digoxin

• Consider synchronized cardioversion or