1. Assess clinical condition. Perform an assessment for a clinical condition. A heart rate of 150 beats per minute is more likely to be symptomatic.
2. Identify and treat underlying cause. Identify and treat any underlying cause. Maintain the airway and give the patient oxygen if indicated. Place the patient on cardiac monitors to identify the rhythm and monitor blood pressure and oxygen saturation. Unstable patients require immediate cardioversion.
3. Is persistent tachyarrhythmia causing symptoms? If the tachycardia is persistent, check for symptoms that may be caused by the tachycardia such as hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort, or acute heart failure.
4. No. Wide QRS? If the tachyarrhythmia is not causing symptoms and the patient is stable, determine if the QRS is .12 or more.
   • Wide-complex tachycardia. Establish IV access and obtain a 12-lead ECG if it’s available. If the QRS is greater than .12, and if the patient’s rhythm is regular and monomorphic, consider administering adenosine. Antiarrhythmic infusion may also be effective. If the patient remains stable, consult an expert about further diagnosis and treatment.
   • Narrow QRS Establish IV access and obtain a 12-lead ECG if it’s available. If the QRS is less than .12 and the patient has a regular rhythm, attempt vagal maneuvers. If the SVT does not respond, administer adenosine. Consider using a beta blocker or calcium channel blocker if the tachycardia recurs. Consult an expert about further diagnosis and treatment.
5. Yes. Synchronized Cardioversion. If symptoms are present, the patient is unstable. Proceed with synchronized cardioversion. Establish IV access and administer sedation if the patient is conscious. If the patient is extremely unstable, do not delay the cardioversion. If the patient has a regular narrow complex rhythm or a monomorphic wide complex rhythm and is not hypotensive, consider administering adenosine while preparing for synchronized cardioversion.

1. Identify signs and symptoms of possible stroke and activate emergency response. Observe the patient for signs of a stroke. Use F-A-S-T to remember the warning signs: facial drooping, arm weakness, speech difficulties, and time. Call 911 immediately, or have someone else call, to activate the emergency response system.
2. Critical EMS assessments and actions. Support ABCs, giving the patient oxygen if needed, and perform a prehospital stroke assessment. Determine the time of stroke onset and triage the patient to a stroke center, alerting the hospital in advance so they can activate the stroke team. Consider directing the patient to CT scan, and if possible, check glucose levels.
3. Immediate general assessment and stabilization. Once the patient has arrived at the emergency department, and within 10 minutes of arrival, assess the vitals, providing oxygen if the patient is hypoxemic. Obtain IV access, run labs, check glucose, activate the stroke team, perform neurologic screening with emergent CT scan or MRI of the brain, and obtain a 12-lead ECG.
4. Immediate neurologic assessment by stroke team or designee. Within 25 minutes of arrival at the emergency department, the stroke team or designee should review the patient’s history, establish a timeline of symptom onset, and perform a neurologic examination using either the NIH Stroke Scale or the Canadian Neurological Scale.
5. Does CT scan show hemorrhage? Determine whether or not the CT scan shows hemorrhage within 45 minutes of the patient’s arrival at the emergency department.
6. Probable acute ischemic stroke; consider fibrinolytic therapy. If the CT scan shows no sign of hemorrhage, it is probable that the patient experienced an ischemic stroke and is a candidate for fibrinolytic therapy. Check for fibrinolytic exclusions such as significant head trauma or stroke in the previous 3 months, history of intracranial hemorrhage, elevated blood pressure, active internal bleeding, or a blood glucose concentration less than 50 milligrams per deciliter. Then repeat the neurologic exam.
7. Consult a neurologist or neurosurgeon. If the CT scan indicates hemorrhage, consult neurologists and neurosurgeons, and begin the stroke or hemorrhage pathway.
8. Administer aspirin. If the patient is not a candidate for fibrinolytic therapy, administer aspirin and begin the stroke or hemorrhage pathway.
9. Begin stroke or hemorrhage pathway. Begin the stroke or hemorrhage pathway and admit the patient to the stroke unit or intensive care unit.
10. Review risks/benefits with the patient and family. If the patient remains a candidate for fibrinolytic therapy, review the risks and benefits of the therapy with the patient and their family within 1 hour of arrival and 3 hours of symptom onset. If they agree to the treatment, administer rtPA and do not give the patient anticoagulants or antiplatelets for 24 hours.
11. Begin post-rtPA stroke pathway. Begin the post-rtPA stroke pathway within 3 hours of patient arrival to the emergency department. Admit the patient into the stroke unit or intensive care unit and aggressively monitor blood pressure and neurologic deterioration.

Learn more about post-cardia arrest treatment to improve patient outcomes with the ACLS post-cardiac arrest algorithm.

1. Return of spontaneous circulation (ROSC). Immediate management of post-cardiac care after the return of spontaneous circulation can improve survival rates and functional recovery in the patient.
2. Optimize ventilation and oxygenation. According to post-cardiac arrest guidelines, you should start with 10 breaths a minute, use the lowest inspired oxygen concentration necessary to maintain SATs of 94% or greater. Use continuous waveform capnography to confirm and monitor the correct placement of the ET tube if needed. Avoid hyperventilation.
3. Treat Hypotension (SBP <90 mm Hg). Treat hypotension when systolic blood pressure is less than 90. First obtain IV access if it’s not already established, and verify the patency of the IV lines. Then treat the hypotension with IV bolus and vasopressor infusion. Consider treating any reversible causes that may have precipitated the cardiac arrest.
4. 12-Lead ECG: STEMI. Obtain a 12-lead ECG as soon as possible after the return of spontaneous circulation to identify patients with STEMI or a high suspicion of acute myocardial infarction(AMI).
5. Coronary reperfusion. If STEMI is detected, EMS personnel should transport the patient to an appropriate facility quickly to reduce time to treatment. Hospital personnel should begin coronary reperfusion with percutaneous coronary intervention (PCI).
6. Follow Commands? If STEMI or AMI are not detected, determine the patient’s ability to follow commands.
7. Initiate targeted temperature management (TTM). If the patient is unable to follow commands or respond in a meaningful way, the high-performance team should initiate TTM.
8. Advanced critical care. Once TTM has been initiated, or if the patient is responsive and able to follow commands, the patient should be transferred to advanced critical care.

1. Assess and Activate First check the patient for unresponsiveness and call for help. If someone is available to help you, have them activate the emergency response system by calling 911, and send them to get naloxone and an AED. Observe the patient for breathing versus no breathing or only gasping.
2. Begin CPR If the patient is unresponsive with no breathing or is only gasping, perform a pulse check and begin CPR if it is appropriate for the patient’s condition. If you are alone, perform CPR for 2 minutes and then call 911 and get the naloxone and AED.
3. Administer Naloxene Give the patient naloxone as soon as it is available. Give 2 mg intranasal or 0.4 mg intramuscular. You may repeat the doses after 4 minutes.
4. Does the patient respond? Watch the patient for responsiveness. Do they move purposefully, breathe regularly, moan, or otherwise respond?
5. Stimulate and Reassess If the patient is responsive, continue to monitor until help arrives. If at any time the patient becomes unresponsive, perform a pulse check, ensure the airway remains open and begin CPR if the situation warrants, and repeat naloxone.
6. Use AED and continue CPR If the patient is unresponsive, perform a pulse check. If no pulse is present, immediately perform CPR and attach the AED to the patient. Ensure the airway is open and monitor the patient until help arrives. Administer a second dose of naloxone after 4 minutes have passed since the first dose, if the situation warrants.

Note: These guidelines are for an adult cardiac arrest algorithm. Review guidelines for the pediatric cardiac arrest algorithm with our free resources.

1. Start CPR. Start CPR with hard and fast compressions, around 100 to 120 per minute, allowing the chest to completely recoil. Give the patient oxygen and attach a monitor or defibrillator. Make sure to minimize interruptions in chest compressions and avoid excessive ventilation, using a 30 to 2 compression-to-ventilation ratio if no airway is established.
2. Rhythm shockable? Conduct a rhythm check, making sure the pause in chest compressions is not more than 10 seconds.
3. VF/pVT (Shockable rhythm). If a shockable rhythm is present, either v-fib or pulseless v-tach, begin the charging sequence on the defibrillator and resume chest compressions until the defibrillator is charged.
   1. Shock. When the defibrillator is charged, announce the shock warning and make sure no one is touching the patient. Shock the patient with an initial dose of 120 to 200 joules.
   2. CPR – 2 min. Immediately resume CPR for 2 minutes, and establish IV access.
   3. Rhythm Shockable? Check for pulse and rhythm for no more than 10 seconds every 2 minutes.
      • No. If the patient shows signs of return of spontaneous circulation, or ROSC, administer post-cardiac care. If a nonshockable rhythm is present and there is no pulse, continue with CPR and move to the algorithm for asystole or PEA.
      • Yes – Shock. If the rhythm is shockable, announce the shock warning and make sure no one is touching the patient. Administer the shock.
      • CPR – 2 min. Continue with CPR for 2 minutes. Give the patient a vasopressor such as epinephrine every 3 to 5 minutes, and consider advanced airway and capnography, giving 1 breath every 6 seconds once the advanced airway is in place.
   4. Rhythm Shockable? Check for pulse and rhythm for no more than 10 seconds every 2 minutes.
      • No. If the patient shows signs of return of spontaneous circulation, or ROSC, administer post-cardiac care. If a nonshockable rhythm is present and there is no pulse, continue with CPR and move to the algorithm for asystole or PEA.
      • Yes – Shock. If the rhythm is shockable, announce the shock warning and make sure no one is touching the patient. Administer the shock.
      • CPR – 2 min. Continue with CPR for 2 minutes. Consider giving the patient an antiarrhythmic drug such as amiodarone for refractory v-fib or pulseless v-tach, and treat reversible causes. Use Hs and Ts to remember: hypovolemic, hypoxia, hydrogen ions, hypo and hyperkalemia, hypothermia, tension pneumo, tamponade, toxins, and thrombosis.
4. Asystole/PEA. If a nonshockable rhythm is present, and the rhythm is organized, check for a pulse. Make sure the pause in chest compressions to check the rhythm is not more than 10 seconds.
   1. CPR – 2 min. Continue with CPR for 2 minutes, and establish IV access. Give the patient a vasopressor such as epinephrine every 3 to 5 minutes, and consider advanced airway and capnography, giving 1 breath every 6 seconds once the advanced airway is in place.
   2. Rhythm Shockable? Check for pulse and rhythm for no more than 10 seconds every 2 minutes.
      • Yes. If the rhythm changes to a V-fib or V-tach shockable rhythm, move to that algorithm and prepare to shock the patient.
      • CPR – 2 min. If a nonshockable rhythm is still present with no pulse, continue with CPR for 2 minutes, and treat reversible causes. Use Hs and Ts to remember: hypovolemic, hypoxia, hydrogen ions, hypo and hyperkalemia, hypothermia, tension pneumo, tamponade, toxins, and thrombosis.
   3. Rhythm Shockable? Check for pulse and rhythm for no more than 10 seconds every 2 minutes.
      • Yes. If the rhythm changes to a V-fib or V-tach shockable rhythm, move to that algorithm and prepare to shock the patient.
      • CPR – 2 min. If the patient shows signs of return of spontaneous circulation, or ROSC, administer post-cardiac care. If a nonshockable rhythm is present and there is no pulse, continue with CPR.

1. Assess clinical condition. Perform an assessment for a clinical condition. A heart rate less than 50 beats per minute is more likely to be symptomatic.
2. Identify and treat underlying cause. Maintain the airway and give the patient oxygen if indicated. Place the patient on cardiac monitors to identify the rhythm and monitor blood pressure and oxygen saturation. Next, obtain a 12-lead ECG and establish IV access.It’s important to determine whether the bradycardia is causing the patient’s symptoms or if some other illness is causing the bradycardia. Treat any underlying cause.
3. Is persistent bradyarrhythmia causing symptoms? Decide if the persistent bradyarrhythmia is causing signs or symptoms due to poor perfusion, such as hypotension, an altered mental state, shock, chest discomfort, or acute heart failure.
4. No. Monitor and observe. If the patient has adequate perfusion, monitor and observe.
5. Yes. Administer drug treatment. If the patient has poor perfusion, administer .5 milligrams of atropine through the IV every 3 to 5 minutes until a maximum of 3 milligrams have been given. If the atropine is ineffective, implement transcutaneous pacing or administer a dopamine infusion of 2 to 20 micrograms per kilogram per minute or an epinephrine infusion of 2 to 10 micrograms per minute. Titrate to the patient’s response.
6. Other considerations. Consult an expert for further diagnosis and treatment, and consider transvenous pacing.

1. Symptoms suggestive of ischemia or infarction. Perform an assessment of chest discomfort suggestive of ischemia or infarction
2. EMS assessment and care and hospital preparation. During the stabilization, triage, and transport of the patient to an appropriate facility, monitor and support airway, breathing, and circulation, providing CPR and defibrillation if needed. Administer aspirin, and provide oxygen if saturation levels are below 90%. Consider the use of nitrates and analgesics if indicated in the management of the patient’s condition.Obtain a 12-lead ECG and notify the hospital if ST elevation is identified. Notified hospital should mobilize hospital resources to respond to STEMI. Complete a fibrinolytic checklist if it’s indicated. Consider obtaining a 15-lead ECG if assessment of the patient and other diagnostic tools indicate the need for evaluation.
3. Concurrent ED assessment (<10 minutes) and immediate general treatment. Assessment and stabilization of the patient should occur within the first 10 minutes of arrival at the emergency department. Obtain and interpret a 12-lead ECG if that has not already been done. Assess the patient’s vitals and oxygen needs and establish an IV. Obtain a brief history, and perform a physical exam. Check for contraindications for fibrinolytic therapy if indicated, and obtain initial cardiac marker labs, coagulation studies, and electrolyte panel.If oxygen saturation is below 90%, start oxygen at 4 liters per minute. Administer 160 to 325 milligrams of aspirin to the patient if it has not already been given. Administer nitrates for chest pain if indicated. If the pain persists, consider the use of analgesics to manage the patient’s pain.Obtain and review a portable chest x-ray within 30 minutes of the patient’s arrival at the emergency department.
4. ECG interpretation. Classify the patient into one of three clinical groups: ST-elevation myocardial infarction, or STEMI; non-ST-elevation acute coronary syndrome; or low to intermediate risk acute coronary syndrome.
5. ST-elevation MI (STEMI). If ST elevation or new or presumably new lower bundle branch block is detected, begin treatment for STEMI. For EMS providers, activate a STEMI alert with the receiving hospital as soon as possible.
   • Start adjunctive therapies. Once STEMI has been determined, start adjunctive treatments if indicated, but do not delay reperfusion.
   • Time from onset of symptoms < 12 hours. If the time from onset of symptoms is 12 hours or less, proceed with reperfusion therapy. If the time from onset is greater than 12 hours, treat as a troponin elevated or high-risk patient.
   • Reperfusion goals. The door to balloon inflation goal for PCI is 90 minutes. The door to needle goal for fibrinolysis is 30 minutes.
6. High-risk non-ST-elevated ACS (NSTE-ACS). If ST depression or dynamic T-wave inversion is found, ischemia is highly suspected. Begin treatment for high-risk non-ST-elevated acute coronary syndrome.
   • Troponin elevated or high-risk patient. A troponin elevated or high-risk patient should be considered for early invasive strategy if they are experiencing refractory ischemic discomfort, recurrent ST deviation, unstable blood pressure, ventricular tachycardia, or signs of heart failure. Administer nitroglycerin and heparin as indicated.
7. Low- or intermedicate-risk ACS. If changes in the ST segment or T-wave are normal or nondiagnostic, begin treatment for low- or intermediate-risk acute coronary syndrome.
   • Consider admission to ED chest pain unit. For a patient with low- or intermediate-risk acute coronary syndrome, consider admission to an appropriate bed for further monitoring and possible intervention.

Hi. I’m Mark from ACLS Certification Institute. Welcome back to Rapid Algorithm Review. Today, tachycardia.

Now I’ll get into tachycardia rhythm. The first thing we’re looking for is the heart rate. Remember, tachycardia is any rate over 100, but in the ACLS algorithm, we’re looking for heart rates and pulses above 150.

Next, why is this patient tachycardic? Try to find a cause for this tachycardia. Begin supportive care: Maintain their airway—do we need to provide them an airway, do we need to bag the patient? Supply oxygen to the patient if they’re hypoxic. Check and maintain their blood pressure. Get a 12-lead EKG. Start your supportive care.

Is this tachycardia causing shock, hypoperfusion, altered mental status, ischemic chest pain? If so, immediate synchronized cardioversion. Sedation would be okay as long as it didn’t hold up immediate synchronized cardioversion. Remember, unstable patient: electricity, synchronized cardioversion. Synchronized cardioversion for a regular narrow-complex tachycardia: 50 to 100 J. If it’s an irregular narrow-complex tachycardia, like an A-fib with a rapid ventricular response, you’re going to start your synchronized a little higher, maybe 120 to 200 J.

Assess is this tachycardia wide or narrow? Again, we’re looking at the width of the QRS. If it’s greater than 0.12 seconds, we call this a wide-complex tachycardia. If it’s equal or less than 0.12 seconds, it’s a narrow-complex tachycardia. For narrow-complex tachycardias, first drug up is adenosine 6 mg rapid IV push, followed by 20 cc syringe bolus of saline. We have to get that drug to the heart. We have to get it there quickly because the half-life of adenosine is only a few seconds. Remember, adenosine should only be used in regular rhythms, not any irregular tachycardias; but in regular tachycardias, adenosine would be appropriate. If adenosine doesn’t work, consider a calcium channel blocker and get an expert involved quickly. If this is a wide-complex tachycardia, our first drug up is amiodarone. Start an infusion of 150 mg over 10 minutes. Remember, stable tachycardias: drugs; unstable tachycardias: immediate synchronized cardioversion.

Rapid-fire review. First, heart rate over 150. Next, why are they tachycardic? Try to figure that out. Next, ABCs: airway (provide them an airway), oxygen, IV, monitor their oximetry, supportive care. Next, is the patient stable or unstable? If they’re unstable and shocky, immediate synchronized cardioversion. It doesn’t matter if it’s narrow or wide, immediate synchronized cardioversion. If they’re stable, is the complex wide or narrow? Narrow-complex, first drug up is adenosine 6 mg rapid IV push. Wide complex, amiodarone 150 mg over 10 minutes.

I’m Mark for ACLS Certification Institute. This has been Rapid Algorithm Review for tachycardia. I’ll see you in the next algorithm.

Transcript:
Hi. I’m Mark for ACLS Certification Institute. Welcome to another Rapid Algorithm Review. Today we’re going to review stroke. There is nothing more time-sensitive than medical care during a stroke. Just like other algorithms, it all starts with the patient presentation. When assessing for stroke, a great pre-hospital or even hospital assessment is the Cincinnati Stroke Scale.

There are three components made up of:

1. Facial droop
2. Arm drift
3. Slurred speech

Facial droop. Ask the patient to smile. We’re looking for asymmetry in the face. Is the face drooping? If it is on one side, well that’s facial droop.

Arm drift. Have the patient extend their arms palm up and close their eyes. We’re going to watch them for 10 seconds. We’re looking to see if one of those arms starts to drift away. It’d be positive for arm drift.

Slurred speech. Ask the patient to repeat a sentence like ‘you can’t teach an old dog new tricks.’ Are they able to say that without slurring their speech?

If they present with any one of these deficits, chances of having a stroke are 72%. If they present with all three of these deficits, about 87%. It’s fast. It’s reliable. It can be done in about 60 seconds.

First, get your assessment done. Second, support your ABCs. Provide oxygen if they’re hypoxic. Check a blood glucose. Alert the hospital that you’re going to that you have a possible stroke coming in, so they can prepare to receive this patient. Another critical factor is to assess their last known normal. When was the last time anybody saw this patient without neuro deficits, they were acting normally, everything was fine? When was the last time that they were presenting normal? We need that time. Sometimes you don’t need the assessment. The patient presents as if they’re having a stroke. I was teaching at the hospital yesterday, and I bopped upstairs to the ER because a former student of mine had brought a patient in and I wanted to go say hi. I’m talking to him, and he had brought in a stroke patient. He was telling me what happened at the scene. He showed up and saw the patient. He could see the facial droop. He could see that she was paralyzed on one side. She had slurred speech. He skipped the exam. He knows what’s going on. His scene time was minutes. In EMS, it’s really important to know what we can do. It’s more important to know what we can’t do, and we can’t fix this. Definitive care for this patient is in the hospital. His scene time was minutes. Load her up and let’s get going. Then he did all the supportive care on the way. He got the blood sugar, got the IV, notified the hospital. He did everything he was supposed to do, but he did it on the way to the hospital and reduced that time to get that CT so we could treat this patient.

If you’re in the ER and you’re preparing to receive a patient, the suggested timeline, if you look at the algorithm, is about 10 minutes. When the patient hits the door, in that 10 minutes we want to reassess the patient, make sure they’re oxygenated, review their history, order a CT scan immediately (get that cooking), obtain vascular access. All this should be done within the first 10 minutes, and activate the stroke team if you have a stroke team in your hospital—get them coming, get the experts moving on this. When your patient comes to the ER, we need to do a more detailed neuro exam, maybe an NIH Stroke Scale, which was developed by the National Institute for Neurologic Disorders and Stroke, or the Canadian Stroke Scale. This is more detailed so we can see if there are subtle differences in this patient’s neuro status as they progress through their care at the hospital.

Looking at strokes, we can break them into two categories: ischemic and hemorrhagic. In an ischemic stroke, a clot has formed. Just like in a heart attack, a vessel in the brain has developed some plaque, the plaque ruptured, formed a clot, and occluded blood flow and oxygenation of that part of the brain. Or a clot formed somewhere downstream, floated to the brain, got wedged in a vessel, occluded blood flow and that caused a stroke. Those are ischemic strokes. They account for about 87% of all strokes. We can treat them with fibrinolytic therapy and bust up that clot and restore blood flow to the brain. The other category is hemorrhagic stroke. In this case, a blood vessel has ruptured in the brain and it’s bleeding. That’s why it’s so important to get that CT scan as quickly as we can to rule out a hemorrhagic event. If we administer fibrinolytic therapy in a hemorrhagic event, it would be fatal to the patient. If we’re going to administer fibrinolytic therapy in an ischemic stroke, we need to try to do this within three hours of the patient’s last known normal. That’s why it’s so important to get that information in the field and relay it to the people in the hospital. We’d like to give that medication within three hours. With some patients, we could extend it out and you see it getting longer all the time (four or four-and-a-half hours), but it’s from the time of their last known normal. If the patient meets the criteria to receive fibrinolytic therapy, we want to administer that as quickly as we can. Review the concerns, the risks, the possible hazards, with the patient, and then suggest that the patient shouldn’t receive any anticoagulant therapy for 24 hours after we’ve administered the fibrinolytic therapy. If the patient is having an ischemic event but does not meet the criteria to receive fibrinolytic therapy, the algorithm suggests we can still administer aspirin and admit them to the proper unit for evaluation by a neuro team. If your CT scan reveals a hemorrhagic event, obviously they’re not going to get fibrinolytic therapy. We need to get Neurology involved with this patient very quickly. We may be transporting them (driving them or flying them) to a facility that can manage this hemorrhagic event.

I’m Mark for ACLS Certification Institute. Thank you for watching this Rapid Algorithm Review. Remember to like us on Facebook and, please, become a subscriber to our YouTube channel. Thanks, and I’ll see you in the next algorithm.