ACLS Tachycardia Algorithm

The ACLS Tachycardia Algorithm is used for patients who have marked tachycardia, usually greater than 150
beats per minute, and a palpable pulse.
Some patients may have cardiovascular instability with tachycardia at heart rate less than 150 bpm. It is
important to consider the clinical context when treating adult tachycardia.
If a pulse cannot be felt after palpating for up to 10 seconds, move immediately to the ACLS Cardiac Arrest
VTach and VFib Algorithm to provide treatment for pulseless ventricular tachycardia.
The immediate response to an adult patient with tachycardia and a palpable pulse is
 To maintain an open airway
 Assist breathing if necessary
 Apply monitors to assess cardiac rhythm, blood pressure, blood oxygenation
 Provide supplement oxygen to maintain O2 saturation between 94% and 99%
The main assessment in adult patients with tachycardia is to determine whether the patient is stable or not.
Signs of cardiovascular instability are hypotension, signs of shock or acute heart failure (flash pulmonary
edema, jugular venous distention), altered mental status, or ischemic chest pain.
Cardioversion Rules

QRS narrow and regular 50-100 Joules

 Cardioversion Rules

QRS narrow and irregular 120-200 Joules

QRS wide and regular 100 Joules

QRS wide and irregular Turn off the synchronized mode and defibrillate immediately
Unstable patients with tachycardia should be treated with synchronized cardioversion as soon as possible.

Stable patients with tachycardia with a palpable pulse can be treated with more conservative measures first.
 Attempt vagal maneuvers
 If unsuccessful, administer adenosine 6 mg IV bolus followed by a rapid normal saline flush
 If unsuccessful, administer adenosine 12 mg IV bolus followed by a rapid normal saline flush
 Beta-blockers and calcium channel blockers may be considered for narrow QRS tachycardia (QRS <0.12
sec)
 For stable, wide QRS complex tachycardia (QRS ≥0.12 sec)
 Strongly consider expert consultation
 Consider procainamide 20-50 mg/min IV, OR
 Amiodarone 150 mg IV over 10 minutes, OR
 Sotalol 100 mg (1.5 mg/kg) over 5 minutes

ACLS Bradycardia Algorithm
Treatment for bradycardia should be based on controlling the symptoms and identifying the cause
using the Hs and Ts

1. Do not delay treatment but look for underlying causes of the bradycardia using the Hs and Ts.
2. Maintain the airway and monitor cardiac rhythm, blood pressure and oxygen saturation.
3. Insert an IV or IO for medications.
4. If the patient is stable, call for consults.
5. If the patient is symptomatic, administer atropine 1.0 mg IV or IO bolus and repeat the atropine
every 3 to 5 minutes to a total dose of 3 mg:
a. If atropine does not relieve the bradycardia, continue evaluating the patient to determine the
underlying cause and consider transcutaneous pacing
b. Consider an IV/IO dopamine infusion at 2-10 mcg/kg/minute
c. Consider an IV/IO epinephrine infusion at 2-10 mcg/minute.
6. In the cases of Mobitz type II second-degree heart block, third-degree AV block, or third-degree
AV block with new widened QRS complex, atropine is unlikely to be effective. Consider
transcutaneous pacing immediately or a beta-adrenergic infusion to increase heart rate.
Potential
Cause How to Identify Treatments

Rapid heart rate and narrow QRS on ECG; other

Hypovolemia symptoms of low volume Infusion of normal saline or Ringer’s lactate

Airway management and effective

Hypoxia Slow heart rate oxygenation

Hydrogen Ion
Excess Hyperventilation; consider sodium bicarbona
(Acidosis) Low amplitude QRS on the ECG bolus

Hypoglycemia Bedside glucose testing IV bolus of dextrose

Flat T waves and appearance of a U wave on the

Hypokalemia ECG IV Magnesium infusion

Consider calcium chloride, sodium

Peaked T waves and wide QRS complex on the bicarbonate, and an insulin and glucose
Hyperkalemia ECG protocol

Typically preceded by exposure to a cold

Hypothermia environment Gradual rewarming

Tension Slow heart rate and narrow QRS complexes on

Pneumothorax the ECG; difficulty breathing Thoracostomy or needle decompression

Tamponade – Rapid heart rate and narrow QRS complexes on

Cardiac the ECG Pericardiocentesis

Typically will be seen as a prolonged QT

interval on the ECG; may see neurological
Toxins symptoms Based on the specific toxin

Thrombosis
(pulmonary Rapid heart rate with narrow QRS complexes on Surgical embolectomy or administration of
embolus) the ECG fibrinolytics

Thrombosis
(myocardial ECG will be abnormal based on the location of
infarction) the infarction Dependent on extent and age of MI