ACLS Algorithm: Non shockable Rhythms (Asystole and Pulse Electric Activity or PEA)

Asystole/Pulseless Electrical Activity

• Begin continuous chest compressions
• Give epinephrine 1 mg IV/IO push every 3-5 minutes
• Rhythm Check every 2 minutes
• Identify and treat underlying cause (Hs & Ts) :
  • Fluid bolus for hypovolemia
  • Glucose for hypoglycemia
  • Sodium bicarbonate for severe acidosis
  • Naloxone for opioid overdose

The clinical pharmacist prepares medications, recommends appropriate drugs per algorithm, ensures correct dosing, and assists with identifying and treating underlying issues.

The H’s and T’s represent common underlying causes of cardiac arrest that pharmacists must recognize:

H’s:

• Hypoxia – Inadequate oxygenation.
• Hypovolemia – Reduced circulating volume.
• Hydrogen ion (acidosis) – Acid/base imbalance.
• Hyper/hypokalemia – Abnormal potassium levels.
• Hypoglycemia – Low blood glucose.
• Hypothermia – Low core body temperature.

T’s:

• Toxins – Drug overdose, poisoning.
• Tamponade – Fluid around the heart.
• Tension pneumothorax – Air in the pleural space.
• Thrombosis – Pulmonary embolism.
• Thrombosis – Cardiac.

These factors guide ACLS pharmacotherapy. For example, sodium bicarbonate for acidosis, calcium for hyperkalemia, dextrose for hypoglycemia, specific antidotes for toxins, and fluid/pressors for hypovolemia. Timely assessment and management of the H’s and T’s are crucial in identifying and treating the specific issues contributing to the arrest, thereby improving the chances of successful resuscitation.

The assessment and management of the H’s and T’s during cardiac arrest include:

• Hypovolemia:
  • History and physical examination.
  • Ultrasound.
  • Infusion of normal saline or Ringer’s lactate.
• Hypoxia:
  • Oxygen saturation.
  • Arterial Blood Gas.
  • Airway placement.
  • Oxygen administration.
• Hydrogen ion excess (acidosis):
  • Arterial Blood Gas.
  • Sodium bicarbonate administration.
• Hypoglycemia:
  • Bedside glucose testing.
  • IV bolus of dextrose.
• Hypokalemia:
  • Serum potassium levels.
  • Potassium supplementation.
• Hyperkalemia:
  • Serum potassium levels.
  • Calcium gluconate administration.
  • Sodium bicarbonate administration.
  • Insulin and glucose administration.
• Hypothermia:
  • Core body temperature measurement.
  • Active external or internal rewarming techniques.
• Tension pneumothorax:
  • Chest X-ray.
  • Ultrasound.
  • Needle thoracostomy.
  • Chest tube placement.
• Tamponade – Cardiac:
  • Ultrasound.
  • Pericardiocentesis.
  • Surgical intervention.
• Toxins:
  • History and clinical presentation.
  • Specific antidotes.
  • Supportive care.
  • Activated charcoal.
  • Gastric lavage.
• Thrombosis (pulmonary embolus):
  • Clinical suspicion.
  • Imaging (CT angiography, ventilation/perfusion scan).
  • Ultrasound findings (RV>LV, septal bowing).
  • Thrombolysis.
  • Surgical intervention.
• Thrombosis (myocardial infarction):
  • Initial EKG.
  • Cardiac biomarkers (Troponin, CK-MB).
  • Clinical suspicion.
  • Thrombolytics.
  • Percutaneous coronary intervention (PCI).

As a clinical pharmacist, being aware of these assessments and management strategies allows you to collaborate with the healthcare team and optimize medication selection and administration during ACLS protocols.

Assessment and Management of H’s and T’s during Cardiac Arrest

This table provides an overview of the assessment and management strategies for the common underlying causes of cardiac arrest, known as H’s and T’s. These assessments help identify and treat the specific issues contributing to the arrest, improving the chances of successful resuscitation. Clinical pharmacists can utilize this information to collaborate with the healthcare team and optimize medication selection and administration during Advanced Cardiovascular Life Support (ACLS) protocols.