Algoritmos AHA 2015
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This document provides guidelines for cardiac arrest treatment in adults. It outlines the steps of cardiopulmonary resuscitation (CPR), use of an automated external defibrillator, and management of shockable versus non-shockable rhythms. Key interventions include high-quality chest compressions, use of an advanced airway with capnography, epinephrine and amiodarone administration, and treatment of reversible causes of cardiac arrest.
![No
2
9
Yes No
Adult Cardiac Arrest Algorithm—2015 Update
4
6
8
Yes
Yes
10
No
12
Yes
No
No Yes
Shock
Shock
Shock
11
5
7
1
3
Rhythm
shockable?
Rhythm
shockable?
Rhythm
shockable?
Rhythm
shockable?
Rhythm
shockable?
• If no signs of return of
spontaneous circulation
(ROSC), go to 10 or 11
• If ROSC, go to
Post–Cardiac Arrest Care
Go to 5 or 7
VF/pVT Asystole/PEA
CPR Quality
• Push hard (at least 2 inches
[5 cm]) and fast (100-120/min)
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,
30:2 compression-ventilation
ratio.
• Quantitative waveform
capnography
– If Petco2
10 mm Hg, attempt
to improve CPR quality.
• Intra-arterial pressure
– If relaxation phase (dia-
stolic) pressure 20 mm Hg,
attempt to improve CPR
quality.
Shock Energy for Defibrillation
• Biphasic: Manufacturer
recommendation (eg, initial
dose of 120-200 J); if unknown,
use maximum available.
Second and subsequent doses
should be equivalent, and higher
doses may be considered.
• Monophasic: 360 J
Drug Therapy
• Epinephrine IV/IO dose:
1 mg every 3-5 minutes
• Amiodarone IV/IO dose: First
dose: 300 mg bolus. Second
dose: 150 mg.
Advanced Airway
• Endotracheal intubation or
supraglottic advanced airway
• Waveform capnography or
capnometry to confirm and
monitor ET tube placement
• Once advanced airway in place,
give 1 breath every 6 seconds
(10 breaths/min) with continuous
chest compressions
Return of Spontaneous
Circulation (ROSC)
• Pulse and blood pressure
• Abrupt sustained increase in
Petco2
(typically ≥40 mm Hg)
• Spontaneous arterial pressure
waves with intra-arterial
monitoring
Reversible Causes
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• Hypothermia
• Tension pneumothorax
• Tamponade, cardiac
• Toxins
• Thrombosis, pulmonary
• Thrombosis, coronary
© 2015 American Heart Association
Start CPR
• Give oxygen
• Attach monitor/defibrillator
CPR 2 min
• IV/IO access
• Epinephrine every 3-5 min
• Consider advanced airway,
capnography
CPR 2 min
• Epinephrine every 3-5 min
• Consider advanced airway,
capnography
CPR 2 min
• Amiodarone
• Treat reversible causes
CPR 2 min
• Treat reversible causes
CPR 2 min
• IV/IO access](https://image.slidesharecdn.com/algoritmosaha2015-160304183826/85/Algoritmos-AHA-2015-1-320.jpg)
![© 2015 American Heart Association
CPR Quality
• Push hard (at least 2 inches [5 cm]) and fast (100-120/min) 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, 30:2 compression-ventilation ratio.
• Quantitative waveform capnography
– If Petco2
10 mm Hg, attempt to improve CPR quality
• Intra-arterial pressure.
– If relaxation phase (diastolic) pressure 20 mm Hg, attempt to
improve CPR quality.
Shock Energy for Defibrillation
• Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 J);
if unknown, use maximum available. Second and subsequent doses
should be equivalent, and higher doses may be considered.
• Monophasic: 360 J
Drug Therapy
• Epinephrine IV/IO dose: 1 mg every 3-5 minutes
• Amiodarone IV/IO dose: First dose: 300 mg bolus. Second dose: 150 mg.
Advanced Airway
• Endotracheal intubation or supraglottic advanced airway
• Waveform capnography or capnometry to confirm and monitor
ET tube placement
• Once advanced airway in place, give 1 breath every 6 seconds
(10 breaths/min) with continuous chest compressions
Return of Spontaneous Circulation (ROSC)
• Pulse and blood pressure
• Abrupt sustained increase in Petco2
(typically ≥40 mm Hg)
• Spontaneous arterial pressure waves with intra-arterial monitoring
Reversible Causes
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• Hypothermia
• Tension pneumothorax
• Tamponade, cardiac
• Toxins
• Thrombosis, pulmonary
• Thrombosis, coronary
Adult Cardiac Arrest Circular Algorithm—
2015 Update
Return of Spontaneous
Circulation (ROSC)
Check
Rhythm
Drug Therapy
IV/IO access
Epinephrine every 3-5 minutes
Amiodarone for refractory VF/pVT
Consider Advanced Airway
Quantitative waveform capnography
Treat Reversible Causes
Start CPR
• Give oxygen
• Attach monitor/defibrillator
2 minutes
If VF/pVT
Shock
Post–Cardiac
Arrest Care
ContinuousCPR
ContinuousCPR
Monitor CPR Quality](https://image.slidesharecdn.com/algoritmosaha2015-160304183826/85/Algoritmos-AHA-2015-2-320.jpg)
Algoritmos AHA 2015
- 1. No 2 9 Yes No Adult Cardiac Arrest Algorithm—2015 Update 4 6 8 Yes Yes 10 No 12 Yes No No Yes Shock Shock Shock 11 5 7 1 3 Rhythm shockable? Rhythm shockable? Rhythm shockable? Rhythm shockable? Rhythm shockable? • If no signs of return of spontaneous circulation (ROSC), go to 10 or 11 • If ROSC, go to Post–Cardiac Arrest Care Go to 5 or 7 VF/pVT Asystole/PEA CPR Quality • Push hard (at least 2 inches [5 cm]) and fast (100-120/min) 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, 30:2 compression-ventilation ratio. • Quantitative waveform capnography – If Petco2 10 mm Hg, attempt to improve CPR quality. • Intra-arterial pressure – If relaxation phase (dia- stolic) pressure 20 mm Hg, attempt to improve CPR quality. Shock Energy for Defibrillation • Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered. • Monophasic: 360 J Drug Therapy • Epinephrine IV/IO dose: 1 mg every 3-5 minutes • Amiodarone IV/IO dose: First dose: 300 mg bolus. Second dose: 150 mg. Advanced Airway • Endotracheal intubation or supraglottic advanced airway • Waveform capnography or capnometry to confirm and monitor ET tube placement • Once advanced airway in place, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions Return of Spontaneous Circulation (ROSC) • Pulse and blood pressure • Abrupt sustained increase in Petco2 (typically ≥40 mm Hg) • Spontaneous arterial pressure waves with intra-arterial monitoring Reversible Causes • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary © 2015 American Heart Association Start CPR • Give oxygen • Attach monitor/defibrillator CPR 2 min • IV/IO access • Epinephrine every 3-5 min • Consider advanced airway, capnography CPR 2 min • Epinephrine every 3-5 min • Consider advanced airway, capnography CPR 2 min • Amiodarone • Treat reversible causes CPR 2 min • Treat reversible causes CPR 2 min • IV/IO access
- 2. © 2015 American Heart Association CPR Quality • Push hard (at least 2 inches [5 cm]) and fast (100-120/min) 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, 30:2 compression-ventilation ratio. • Quantitative waveform capnography – If Petco2 10 mm Hg, attempt to improve CPR quality • Intra-arterial pressure. – If relaxation phase (diastolic) pressure 20 mm Hg, attempt to improve CPR quality. Shock Energy for Defibrillation • Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered. • Monophasic: 360 J Drug Therapy • Epinephrine IV/IO dose: 1 mg every 3-5 minutes • Amiodarone IV/IO dose: First dose: 300 mg bolus. Second dose: 150 mg. Advanced Airway • Endotracheal intubation or supraglottic advanced airway • Waveform capnography or capnometry to confirm and monitor ET tube placement • Once advanced airway in place, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions Return of Spontaneous Circulation (ROSC) • Pulse and blood pressure • Abrupt sustained increase in Petco2 (typically ≥40 mm Hg) • Spontaneous arterial pressure waves with intra-arterial monitoring Reversible Causes • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary Adult Cardiac Arrest Circular Algorithm— 2015 Update Return of Spontaneous Circulation (ROSC) Check Rhythm Drug Therapy IV/IO access Epinephrine every 3-5 minutes Amiodarone for refractory VF/pVT Consider Advanced Airway Quantitative waveform capnography Treat Reversible Causes Start CPR • Give oxygen • Attach monitor/defibrillator 2 minutes If VF/pVT Shock Post–Cardiac Arrest Care ContinuousCPR ContinuousCPR Monitor CPR Quality
- 3. Adult Immediate Post–Cardiac Arrest Care Algorithm—2015 Update 1 2 3 45 Yes No 6 7 8 No Yes Doses/Details Ventilation/oxygenation: Avoid excessive ventilation. Start at 10 breaths/min and titrate to target Petco2 of 35-40 mm Hg. When feasible, titrate Fio2 to minimum necessary to achieve Spo2 ≥94%. IV bolus: Approximately 1-2 L normal saline or lactated Ringer’s Epinephrine IV infusion: 0.1-0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute) Dopamine IV infusion: 5-10 mcg/kg per minute Norepinephrine IV infusion: 0.1-0.5 mcg/kg per minute (in 70-kg adult: 7-35 mcg per minute) Reversible Causes • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary Return of spontaneous circulation (ROSC) Advanced critical care Optimize ventilation and oxygenation • Maintain oxygen saturation ≥94% • Consider advanced airway and waveform capnography • Do not hyperventilate Follow commands? 12-Lead ECG: STEMI OR high suspicion of AMI Treat hypotension (SBP 90 mm Hg) • IV/IO bolus • Vasopressor infusion • Consider treatable causes Initiate targeted temperature management Coronary reperfusion © 2015 American Heart Association
- 4. Adult Bradycardia With a Pulse Algorithm 1 2 3 4 5 6 Yes No Doses/Details Atropine IV dose: First dose: 0.5 mg bolus. Repeat every 3-5 minutes. Maximum: 3 mg. Dopamine IV infusion: Usual infusion rate is 2-20 mcg/kg per minute. Titrate to patient response; taper slowly. Epinephrine IV infusion: 2-10 mcg per minute infusion. Titrate to patient response. Persistent bradyarrhythmia causing: • Hypotension? • Acutely altered mental status? • Signs of shock? • Ischemic chest discomfort? • Acute heart failure? Assess appropriateness for clinical condition. Heart rate typically 50/min if bradyarrhythmia. Consider: • Expert consultation • Transvenous pacing Monitor and observe Atropine If atropine ineffective: • Transcutaneous pacing or • Dopamine infusion or • Epinephrine infusion Identify and treat underlying cause • Maintain patent airway; assist breathing as necessary • Oxygen (if hypoxemic) • Cardiac monitor to identify rhythm; monitor blood pressure and oximetry • IV access • 12-Lead ECG if available; don’t delay therapy © 2015 American Heart Association
- 5. Yes Yes Adult Tachycardia With a Pulse Algorithm 1 2 3 4 5 6 7 No No Doses/Details Synchronized cardioversion: Initial recommended doses: • Narrow regular: 50-100 J • Narrow irregular: 120-200 J biphasic or 200 J monophasic • Wide regular: 100 J • Wide irregular: defibrillation dose (not synchronized) Adenosine IV dose: First dose: 6 mg rapid IV push; follow with NS flush. Second dose: 12 mg if required. Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia Procainamide IV dose: 20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases 50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF. Amiodarone IV dose: First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours. Sotalol IV dose: 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT. Persistent tachyarrhythmia causing: • Hypotension? • Acutely altered mental status? • Signs of shock? • Ischemic chest discomfort? • Acute heart failure? Wide QRS? ≥0.12 second • IV access and 12-lead ECG if available • Vagal maneuvers • Adenosine (if regular) • ß-Blocker or calcium channel blocker • Consider expert consultation • IV access and 12-lead ECG if available • Consider adenosine only if regular and monomorphic • Consider antiarrhythmic infusion • Consider expert consultation Identify and treat underlying cause • Maintain patent airway; assist breathing as necessary • Oxygen (if hypoxemic) • Cardiac monitor to identify rhythm; monitor blood pressure and oximetry Assess appropriateness for clinical condition. Heart rate typically ≥150/min if tachyarrhythmia. Synchronized cardioversion • Consider sedation • If regular narrow complex, consider adenosine © 2015 American Heart Association
- 6. • Start adjunctive therapies as indicated • Do not delay reperfusion ST elevation or new or presumably new LBBB; strongly suspicious for injury ST-elevation MI (STEMI) EMS assessment and care and hospital preparation: • Monitor, support ABCs. Be prepared to provide CPR and defibrillation • Administer aspirin and consider oxygen, nitroglycerin, and morphine if needed • Obtain 12-lead ECG; if ST elevation: – Notify receiving hospital with transmission or interpretation; note time of onset and first medical contact • Notified hospital should mobilize hospital resources to respond to STEMI • If considering prehospital fibrinolysis, use fibrinolytic checklist 12 hours 1 2 3 6 5 Symptoms suggestive of ischemia or infarction 4 7 11≤12 hours ST depression or dynamic T-wave inversion; strongly suspicious for ischemia High-risk non–ST-elevation ACS (NSTE-ACS) 9 Normal or nondiagnostic changes in ST segment or T wave Low-/intermediate-risk ACS 11 Troponin elevated or high-risk patient Consider early invasive strategy if: • Refractory ischemic chest discomfort • Recurrent/persistent ST deviation • Ventricular tachycardia • Hemodynamic instability • Signs of heart failure Start adjunctive therapies (eg, nitroglycerin, heparin) as indicated 10 Reperfusion goals: Therapy defined by patient and center criteria • Door-to–balloon inflation (PCI) goal of 90 minutes • Door-to-needle (fibrinolysis) goal of 30 minutes 8 Consider admission to ED chest pain unit or to appropriate bed for further monitoring and possible intervention. 12 Acute Coronary Syndromes Algorithm—2015 Update Time from onset of symptoms ≤12 hours? ECG interpretation Concurrent ED assessment (10 minutes) • Check vital signs; evaluate oxygen saturation • Establish IV access • Perform brief, targeted history, physical exam • Review/complete fibrinolytic checklist; check contraindications • Obtain initial cardiac marker levels, initial electrolyte and coagulation studies • Obtain portable chest x-ray (30 minutes) Immediate ED general treatment • If O2 sat 90%, start oxygen at 4 L/min, titrate • Aspirin 160 to 325 mg (if not given by EMS) • Nitroglycerin sublingual or spray • Morphine IV if discomfort not relieved by nitroglycerin © 2015 American Heart Association
- 7. 12 American Heart Association Figura 5 Algoritmo de paro cardíaco en adultos para profesionales de la salud que proporcionan SVB/BLS: actualización de 2015 No, no es desfibrilable Sí, es desfibrilable Hay pulso pero no respira con normalidad Llega el DEA. Comprobar el ritmo. ¿El ritmo es desfibrilable? Administrar 1 descarga. Reanudar la RCP de inmediato durante aproximadamente 2 minutos (hasta que lo indique el DEA para permitir la comprobación del ritmo). Continuar hasta que le sustituyan los profesionales de soporte vital avanzado o la víctima comience a moverse. Proporcionar ventilación de rescate: 1 ventilación cada 5-6 segundos, o unas 10-12 ventilaciones por minuto. • Activar el sistema de respuesta a emergencias (si no se ha hecho antes) al cabo de 2 minutos. • Continuar con la ventilación de rescate; comprobar el pulso cada 2 minutos aproximadamente. Si no hay pulso, iniciar la RCP (ir al recuadro “RCP”). • Si se sospecha la presencia de sobredosis de opiáceos, administrar naloxona si está disponible siguiendo el protocolo. Reanudar la RCP de inmediato durante aproximadamente 2 minutos (hasta que lo indique el DEA para permitir la comprobación del ritmo). Continuar hasta que le sustituyan los los profesionales de soporte vital avanzado o la víctima comience a moverse. Entrenamiento en Iniciar ciclos de 30 compresiones y 2 ventilaciones. Utilizar el DEA tan pronto como esté disponible. Controlar hasta que lleguen los reanimadores de emergencias. Confirmar la seguridad de la escena. La víctima no responde. Pedir ayuda en voz muy alta a las personas que se encuentren cerca. Activar el sistema de respuesta a emergencias a través de un dispositivo móvil (si corresponde). Obtener un DEA y equipo para emergencias (o enviar a otra persona para que lo traiga). Comprobar si la víctima no respira o solo jadea/boquea y comprobar el pulso (al mismo tiempo). ¿Se detecta pulso con certeza al cabo de 10 segundos? Respiración normal, hay pulso Sin respiración o solo jadea/ boquea; sin pulso En este punto, en todos los escenarios, se activa el sistema de respuesta a emergencias o la asistencia y se busca un DEA y equipo de emergencias o se pide a alguien que lo traiga. Algoritmo de paro cardíaco en víctimas pediátricas para profesionales de la salud de SVB/BLS - Actualización de 2015 12 American Heart Association