This is a lecture by Rockefeller Oteng from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: ACLS Overview: Pulseless Arrest
Author(s): Rockefeller Oteng (University of Michigan), MD 2012
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3. PULSELESS ARREST
- Call for help, give CPR
- Give O2, attach monitor/defibrillator
Shockable
VF/VT
3
Give 1 shock, resume
CPR immediately
1
Not Shockable
- Check rhythm -> SHOCKABLE rhythm?
Asystole/PEA
9
4
2
- Resume CPR for 5 cycles
- Options: epinephrine,
vasopressin, atropine
5 cycles CPR
Check if rhythm is SHOCKABLE?
5 cycles CPR
5
Check if rhythm is SHOCKABLE? 11
- Give 1 shock, resume
CPR immediately
- Options: epinephrine,
vasopressin, atropine 6
5 cycles CPR
Check if rhythm is SHOCKABLE?
10
Not Shockable
7
Shockable
- Continue CPR while defibrillator is charging
- Give 1 shock
- Resume CPR immediately after the shock
- Consider anti-arrhythmics e.g.
amiodarone, lidocaine, etc
- Consider magnesium
- After 5 cycles CPR, go to Box 5 above
- If asystole, go to Box 10
- If electrical activity,
check pulse. No pulse,
go to Box 10
- If pulse present, begin
post-resuscitation care 12
Not Shockable
Shockable
Go to Box 4
During CPR (abbreviated)
- Push hard and fast (100/min)
- Ensure full chest recoil
- Minimize interruptions in chest compressions
8
3
13

4. Full Guidelines for CPR in Pulseless Arrest Algorithm
During CPR
- Push hard and fast (100/min)
- Ensure full chest recoil
- Minimize interruptions in chest compressions
- One cycle of CPR: 30 compressions + 2 breaths; 5
cycles, 2 mins
- Avoid hyperventilation
- Secure airway and confirm placement
** After advanced airway is placed, rescuers no longer
deliver cycles of CPR. Give continuous chest compressions
without pauses for breaths. Give 8-10 breaths/min. Check
rhythm every 2 minutes.
- Rotate compressors every 2 minutes with rhythm checks
- Search for and treat possible contributing factors
- HYPOVOLEMIA
- HYPOXIA
- HYDROGEN ION (ACIDOSIS)
- HYPO/HYPERKALEMIA
- HYPOGLYCEMIA
- HYPOTHERMIA
- TOXINS
- CARDIAC TAMPONADE
- TENSION PNEUMOTHORAX
- THROMBOSIS (CORONARY/PULMONARY)
- TRAUMA

5. PULSELESS ARREST
- BLS Algorithm: Call for help, give
CPR
- Give O2 when available
- Attach monitor/defibrillator when
available
Shockable
VF/VT
3
Glenlarson, Wikimedia Commons
- Check rhythm -> SHOCKABLE
rhythm?
1
Not Shockable
2
Asystole/PEA
Glenlarson, Wikimedia Commons
9
5

6. 9
Asystole/PEA
Not shockable
- Resume CPR immediately for 5 cycles
- Epinephrine, repeat every 3-5
min
- OR 1 dose of vasopressin
- OR consider atropine, repeat
every 3-5 min
10
5 cycles CPR
- Check rhythm -> SHOCKABLE
rhythm?
11
Glenlarson, Wikimedia Commons
6

7. - Resume CPR immediately for 5 cycles
- Epinephrine, repeat every 3-5
min
- OR 1 dose of vasopressin
- OR consider atropine, repeat
every 3-5 min
10
5 cycles CPR
- Check rhythm -> SHOCKABLE
rhythm?
- If asystole, go to Box 10
- If electrical activity, check pulse. No
pulse, go to Box 10
- If pulse present, begin postresuscitation care
Not Shockable
Shockable
11
Go to Box 4
13
12
7

8. PULSELESS ARREST
- Call for help, give CPR
- Give O2, attach monitor/defibrillator
Shockable
VF/VT
3
Give 1 shock, resume
CPR immediately
1
Not Shockable
- Check rhythm -> SHOCKABLE rhythm?
Asystole/PEA
9
4
2
- Resume CPR for 5 cycles
- Options: epinephrine,
vasopressin, atropine
5 cycles CPR
Check if rhythm is SHOCKABLE?
5 cycles CPR
5
Check if rhythm is SHOCKABLE? 11
- Give 1 shock, resume
CPR immediately
- Options: epinephrine,
vasopressin, atropine 6
5 cycles CPR
Check if rhythm is SHOCKABLE?
10
Not Shockable
7
Shockable
- Continue CPR while defibrillator is charging
- Give 1 shock
- Resume CPR immediately after the shock
- Consider anti-arrhythmics e.g.
amiodarone, lidocaine, etc
- Consider magnesium
- After 5 cycles CPR, go to Box 5 above
- If asystole, go to Box 10
- If electrical activity,
check pulse. No pulse,
go to Box 10
- If pulse present, begin
post-resuscitation care 12
Not Shockable
Shockable
Go to Box 4
During CPR
- Push hard and fast (100/min)
- Ensure full chest recoil
- Minimize interruptions in chest compressions
8
8
13

9. - Continue CPR while defibrillator is
charging
- Give 1 shock
- Resume CPR immediately after the
shock
- Epinephrine, repeat every 3-5
min
- OR 1 dose of vasopressin
6
5 cycles CPR
Not Shockable
- Check rhythm -> SHOCKABLE
rhythm?
7
- If asystole, go to Box 10
- If electrical activity, check pulse. No
pulse, go to Box 10
- If pulse present, begin postresuscitation care
12
Shockable
- Continue CPR while defibrillator is 8
charging
- Give 1 shock
- Resume CPR immediately after the
shock
- Consider anti-arrhythmics e.g.
amiodarone, lidocaine, etc
- Consider magnesium
- After 5 cycles CPR, go to Box 5 above

10. Shockable
3
VF/VT
- Give 1 shock
- Resume CPR immediately after the
shock
4
5 cycles CPR
- Check rhythm -> SHOCKABLE
rhythm?
5

11. Wide
Complex
Tachycardia
•
•
•
DDx:
– Ventricular Tachycardia (VT)
– SVT w/ BBB (often rate dependent)
– SVT w/ atrioventricular conduction via accessory pathway
How to differentiate:
– Concordance in leads V1-V6
– RS >100 ms in the precordial leads
– AV disassociation
When in doubt treat as VT
11

12. V
Tach
Ksheka, Wikimedia Commons
12

13. V
Fib
Jer5150, Wikimedia Commons
13

14. Wide
Complex
Tachycardia
•
•
Stable
– Amiodarone 150 mg over 10 min or other antiarrhythmic
– Prepare for synchronized cardioversion
Unstable
– ABC’s/Call for help/Start CPR
– Defibrillate: Biphasic 120-200 J (When in doubt pick 200 J),
monophasic 360 J
– Epinephrine 1 mg IV q3-5 min
– Vasopressin 40 Units IV
– May try amiodarone or lidocaine after 3 attempts at defibrillation
• Amiodarone 300 mg, may repeat w/ 150 mg x1
• Lidocaine 1-1.5 mg/kg, then 0.5-0.75 mg/kg, max is 3 mg/kg
14

15. - Continue CPR while defibrillator is
charging
- Give 1 shock
- Resume CPR immediately after the
shock
- Epinephrine, repeat every 3-5
min
- OR 1 dose of vasopressin
6
5 cycles CPR
- Check rhythm -> SHOCKABLE
rhythm?
7
Not Shockable
- If asystole, go to Box 10
- If electrical activity, check pulse. No
pulse, go to Box 10
- If pulse present, begin postresuscitation care
12
Shockable
- Continue CPR while defibrillator is 8
charging
- Give 1 shock
- Resume CPR immediately after the
shock
- Consider anti-arrhythmics e.g.
amiodarone, lidocaine, etc
- Consider magnesium
- After 5 cycles CPR, go to Box 5 above

16. torsades
de
pointes
Jer5150, Wikimedia Commons
16

17. Pulseless
Arrest
4
Basic
Rhythms
Shockable
V-­‐fib
V-­‐Tach
Non-­‐Shockable
Asystole
PEA
17

18. Shockable
Rhythms
• Ventricular
Tachycardia
• V-­‐Fib
– Shock
early
– ABC’s
• Tx
of
VT/VF
–
–
–
–
–
–
–
–
–
–
Shock-­‐
biphasic
200j,
monophasic
360j
(one
x)
CPR-­‐IV,
ETT
Shock
CPR-­‐epi/vasopressin
Shock
CPR-­‐Lido/amiodarone
Shock
CPR-­‐epi
Shock
CPR-­‐
lido/amio
18

19. NON-­‐Shockable
• PEA
• Asystole
• Tx
of
Asystole
&
PEA
– CPR-­‐IV,airway
– Meds-­‐vasopressin/epi
– CPR-­‐2
min
– Meds-­‐epi,atropine*
– CPR
– Meds-­‐epi,atro
– CPR
– *Atropine
used
in
PEA,
only
for
HR
<
60
19

20. Tachycardia’s
Stable
vs.
Unstable
• Stable
– MI
– 12
lead
– Narrow
complex
– Wide
complex
– Treat
causes
• Unstable
– Altered
MS
– CP
– Hypotension
– Signs
of
shock
• H’s
and
T’s
20

21. Contribuang
Factors
H’s
and
T’s
•
•
•
•
•
•
•
•
•
•
•
Hypovolemia
Hypoxia
Hydrogen
ion
(acidosis)
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
(drugs)
Tamponade
(cardiac)
Tension
PTX
Thrombosis
(coronary
or
pulmonary)
Trauma
21