The Emergency Cardiac Care Committee (ECC)

and the
International Liaison Committee on Resuscitation
(ILCOR) present the

American Heart Association

2020 Guidelines

ACLS 2020
Algorithms
Brought to you by:

FLORIDA HEART CPR*

AMERICAN HEART ASSOCIATION
BLS/ACLS/PALS TRAINING CENTER
VERO BEACH, FLORIDA
772-388-5252
www.floridaheartcpr.com

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Revised Oct. 2020
 Ventricular Fibrillation/Pulseless V-Tach
**Start Immediate High Quality CPR**
If un-witnessed code or down time > 4 minutes, 2 minutes of CPR prior to defibrillation
Defibrillate 200j*
*biphasic (or device specific dose)
↓
Secure the airway without Continue CPR immediately
prolonged intubation
attempts (BVM) and
 w/o pulse or rhythm check 100-120BPM
↓
maintain 02@92-98%
And establish IV or IO with Epinephrine 1mg
Saline or LR ↓
Defibrillate
↓
If Amiodarone is not available,
Amiodarone 300mg IVP →→ Lidocaine may be used. First
↓ dose is 1-1.5mg/kg IVP;
Defibrillate 2nd dose is 0.5-0.75mg/kg
↓
Epinephrine 1mg
↓
Defibrillate
↓
Amiodarone 150mg IVP
↓
Continue with Epi every 3-5 minutes (or q2-4 minutes to coincide with
rhythm checks) while searching for and treating reversible causes
✓ Considerations: Sodium Bicarbonate 1meq/kg if suspected acidosis, Tricyclic
overdose, hyperkalemia or extended down time.
✓ Consider Magnesium Sulfate 1-2 grams I.V. (if Torsades is present).
✓ DO NOT MIX antiarrhythmics (such as Amiodarone & Lidocaine) as it may
increase the chance of asystole.
✓ Upon return of spontaneous circulation (ROSC): V/S, Labs, 12 Lead EKG (if
STEMI call cath lab). Consider maintenance anti-arrhythmic bolus or infusion,
support B/P, consider targeted temperature management, maintain
capnography 35-40mmHg.

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Revised Oct. 2020
 Pulseless Electrical Activity (PEA)
& Asystole
HIGH QUALITY CPR
↓
Provide 02, IV or IO access
↓
Epinephrine 1 mg
(Repeat every 3 – 5 minutes (or q 2-4 to coincide with rhythm checks)
↓
Consider possible causes and correct
The 5 H’s and the 5 T’s, while beginning drug therapy

Hypoxia Toxins/overdose
Hypovolemia Thromboemboli-coronary
Hyper/hypokalemia Thromboemboli-pulmonary
Hypothermia Tension pneumothorax
Hydrogen ion/acidosis Tamponade (cardiac)

*Note: Repeated unsuccessful intubation attempts are not recommended. BVM

support of the airway is acceptable until advanced airway can be placed.

Several factors should be considered when making the decision to terminate

resuscitation efforts on a patient in extended Asystole:

Down Time Cause of death

Cold Water Drowning Chronic Medical Conditions
Age Skin Temperature
Blood Pooling Trauma
DNR, family wishes Co-morbidities

And most importantly……….quality of life!

*2020 Guidelines suggest to administer epinephrine as soon as reasonably possible in a

non-shockable pulseless patient.

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 Symptomatic Bradycardia
Heart rate <50bpm and inadequate for clinical condition, such as
altered mental status, chest pain, or signs of shock.

Assess, maintain ABC’s

↓
AIRWAY, MAINTAIN OXYGEN >92%
IV, Monitor, vitals, EKG
↓
Signs or symptoms of poor perfusion caused by the bradycardia?
↓ ↓
Adequate perfusion? Poor Perfusion?
↓ ↓
DRAW LABS Atropine 1 mg** IVP
OBSERVE/MONITOR
Consider expert consultation Place TCP pads
Consider fluids?
also consider Dopamine or epi drip
If the patient has serious signs to maintain hemodynamics
and symptoms, you may and increase the heart rate and
assume they are related to the blood pressure.
bradycardia. Signs and ↓
symptoms include altered If Dopamine or EPI is ineffective, consider
mental status, shortness of pacing. They are equally effective!
breath, chest pain or other
signs of shock.
Epinephrine (2-10ug/min) or Dopamine
(5-20ug/kg per minute**) infusion while awaiting
pacer or if pacing is ineffective.
Inotropes may be considered
before pacing if possible.

**change from 2015 guidelines

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 Supraventricular Tachycardia

STABLE UNSTABLE
Assess ABC’s
↓ Look for symptoms related to the
O2, Start IV, Assess vital signs tachycardia, such as chest pain, heart
↓ failure, shortness of breath altered
Review History mental status or hemodynamic
↓ instability.
Obtain 12 lead EKG ↓
↓ Assess ABC’s
Consider Vagal Maneuvers Administer oxygen
↓ Start IV
Adenosine 6 mg, then 12mg Assess vital signs
Attach monitor and pulse ox
If rhythm persists, consider
beta blocker (Lopressor) Synchronized Cardioversion
Start at 50-100 joules*
↓
NOTE: Adenosine is given as rapidly as
If rhythm does not convert, continue
possible, followed by a saline flush!
↓
You may also use Adenosine as a Adenosine 6mg
diagnostic test to diagnose A-fib or ↓
A-flutter if you cannot interpret the Adenosine 12mg
rhythm.
*2020 Guidelines suggest using the
Manufacturer’s recommendations for
the Biphasic energy dose, or you may
use the clinically equivalent
monophonic energy dose. Be sure to
have suction, IV line established,
intubation, and pulse oximetry
available.

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Revised Oct. 2020
 Ventricular Tachycardia
STABLE UNSTABLE

Assess ABC’s, Secure airway and provide Assess ABC’s, vitals

oxygen, 12 Lead EKG Administer oxygen
Start IV, draw labs Start IV
↓
AMIODARONE Perform immediate Synchronized
150 mg (mixed in a 100mL bag given over Cardioversion
10min) bolus (15 mg/min) Start at 100 joules*
or ADENOSINE 6mg, 12mg (Pre-medicate whenever possible)
↓
Assess vital signs, attach pulse ox IF SUCCESSFUL TERMINATION OF
If rhythm does not resolve, consider V-TACH DO NOT CONTINUE
Synchronized Cardioversion ↓
Start at 100 joules* To prevent reoccurrence,
(Pre-medicate whenever possible) consider an Amiodarone bolus,
↓ 150 mg over 10 minutes
IF SUCCESSFUL TERMINATION OF
(15 mg/min)
V-TACH DO NOT CONTINUE
↓ Do not mix antiarrythmics. If you
If Polymorphic V-Tach choose to use Amiodarone, for
(Torsades de Pointes) example, do not give any other
1-2 grams of Magnesium sulfate antiarrhythmic. (increases chances of
Some clinicians may choose DC asystole)
cardioversion as their first treatment for *2020 Guidelines suggest using the
all wide complex tachycardias manufacturer’s recommended Biphasic
regardless of cardiac function. Do not energy dose, or you may use the
mix antiarrythmics. If you choose to use clinically equivalent monophasic
Amiodarone for example, do not give energy dose
any other antiarrhythmic

**Amiodarone should never be given

IVP unless the patient is pulseless!

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Revised Oct. 2020
 Atrial Fibrillation/Atrial Flutter

Stable w/uncontrolled rate Unstable w/uncontrolled

rate and symptomatic
Assess ABC’s, obtain 12 lead EKG
↓ Assess ABC’s, obtain 12 lead EKG
Start IV, vital signs, BP, Sa02 ↓
↓ Start IV, vital signs, BP, Sa02
Review history of A-fib/flutter ↓
↓ Provide oxygen if needed and review
Cardizem 0.25 mg/kg (bolus) patient’s history,
↓
A Cardizem drip will then be If determined a new onset,
administered per doctor’s orders as consider synchronized
a maintenance infusion, usually
5-15 mg/hr
cardioversion @
120-200 joules for a-fib,
Consider expert consultation 50-100 joules for a-flutter
(Consider Sedation)
*Note: never delay cardioversion in lieu of
OR CONSIDER
sedation if the patient is unstable. (You can always
↓
apologize later)
If rhythm has been present for >48 hours, a risk of Cardizem 0.25 mg/kg (given over
systemic embolization exists with conversion to two minutes). Consider re-
sinus rhythm unless patients are adequately evaluating BP halfway through to
anticoagulated. Electrical cardioversion and the avoid drop in BP
use of antiarrhythmic agents should be avoided
unless the patient is unstable or hemodynamically
compromised. Cardizem must be given over 2
minutes to avoid a drop in blood pressure.

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Revised Oct. 2020
 Chest Pain of Cardiac Origin
STEMI/Acute Coronary Syndrome (ACS)

Assess ABC’s
2 IV lines, pulse oximetry, titrate 02 >92% Sa02
Draw baseline labs,
Review history
(O.P.Q.R.S.T. - A.S.P.N)*
↓
IMMEDIATE 12 LEAD EKG FOR EVALUATION BY PHYSICIAN WITHIN 10 MINUTES
OF ARRIVAL
↓
Aspirin 160-325 mg PO
↓
Nitroglycerin 0.4 mg SL x 3
(Systolic BP must be >90)
Document pain/BP between doses
↓
If pain is not relieved, Morphine 2-4 mg
(Systolic BP must be > 90)
(May be repeated up to 10 mg)
↓
Perform Thrombolytic / Fibrinolytic Screening
(See ACLS text for criteria)
And consider patient for immediate catheterization
Pre-hospital: Notify hospital/interventionalist
or cath lab early if presumed STEMI

*O.P.Q.R.S.T. Onset, Provocation, Quality, Radiation, Severity, Time

A.S.P.N. Associated Symptoms, Pertinent Negatives

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