ACLS Cardiac Arrest Circular Algorithm – 2018 Update

This figure conveys the Adult Cardiac Arrest Circular Algorithm, which was updated in 2015. It includes a graphic on the left and a table of related information on the right. The graphic on the left consists of a box of origin at the top that points downward to a circular graphic, which has an output arrow to the right. The top box, which is blue, is labeled “Start CPR.” It contains two points of text:
  • Give oxygen.
  • Attach monitor or defibrillator.
A downward arrow leads to a red diamond that is overlaid at the top of a circular graphic with a thick blue border and green center. The red diamond says, “Check Rhythm.” Moving to the right of the red diamond, there’s a small white box with a red lightning bolt. It contains the text “If VF/pVT, Shock.” [“VF/pVT” stands for Ventricular Fibrillation and Pulseless Ventricular Tachycardia.”] From this box, there are a series of arrows and text that flow in a clockwise direction around the blue border of the circle. “Continuous CPR” points to “Monitor CPR Quality,” which leads to “Continuous CPR.” It points back to the red diamond at the top. To the left of the diamond, a black line labeled “2 minutes” indicates how long it takes to complete one cycle in this algorithm. Between the red diamond and the red lightning bolt at the top right of the circle, there is a green arrow that originates at the blue border and points to the right. Above the arrow, text states, “Return of Spontaneous Circulation (ROSC).” The arrow itself is labeled “Post-Cardiac Arrest Care.” As mentioned, the core of the circle is green. There are three horizontal bands in varying shades of green. Each band contains text. The top band is titled “Drug Therapy.” It contains the text, “IV or I.O. access.” (“IV” is short for “Intravenous,” and “I.O.” stands for “intraosseous.”) Epinephrine every 3 to 5 minutes. Amiodarone or lidocane for refractory VF/pVT.” The middle band is titled “Consider Advanced Airway.” It also contains the text, “Quantitative waveform capnography.” The bottom band is titled “Treat Reversible Causes.” The table on the right contains bulleted text related to six different topics. The first topic is “CPR Quality.” The corresponding text states:
  • Push hard (at least 2 inches or 5 centimeters) and fast (100 to 120 compressions per minute) and allow complete chest recoil.
  • Minimize interruptions in compressions.
  • Avoid excessive ventilation.
  • Rotate compressor every 2 minutes, or sooner if fatigued.
  • If no advanced airway, use a 30-to-2 compression-to-ventilation ratio.
  • Quantitative waveform capnography: If PETCO2 is less than 10 millimeters of mercury, attempt to improve CPR quality.
  • Intra-arterial pressure: If relaxation phase (diastolic) pressure is less than 20 millimeters of mercury, attempt to improve CPR quality.
The second topic is “Shock Energy for Defibrillation.” The related text says:
  • Biphasic: Manufacturer recommendation (for example, initial dose of 120 to 200 Joules); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered.
  • Monophasic: 360 Joules.
The third topic is “Drug Therapy.” The associated text states:
  • Epinephrine IV or I.O. dose: 1 milligram every 3 to 5 minutes.
  • Amiodarone IV or I.O. dose: First dose: 300 milligram bolus. Second dose: 150 milligrams.
  • Or Lidocaine IV or I.O. dose: First dose: 1 to 1.5 milligrams. Second dose: 0.5 to 0.75 milligrams.
The fourth topic is “Advanced Airway.” The corresponding text says:
  • Endotracheal intubation or supraglottic advanced airway.
  • Waveform capnography or capnometry to confirm and monitor E.T. tube placement.
  • Once advanced airway is in place, give 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions.
The fifth topic is “Return of Spontaneous Circulation, or ROSC.” The related text states:
  • Pulse and blood pressure.
  • Abrupt sustained increase in PETCO2 (typically greater than or equal to 40 millimeters of mercury).
  • Spontaneous arterial pressure waves with intra-arterial monitoring.
The final topic is “Reversible Causes.” The associated text says:
  • Hypovolemia.
  • Hypoxia.
  • Hydrogen ion (acidosis).
  • Hypo- or hyperkalemia.
  • Hypothermia.
  • Tension pneumothorax.
  • Tamponade, cardiac.
  • Toxins.
  • Thrombosis, pulmonary.
  • Thrombosis, coronary.
This figure is copyright 2015 by the American Heart Association.