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Adult Basic Life Support and Cardiopulmonary Resuscitation (CPR)

  1. Unresponsive, no pulse, and not breathing

    1. Activate emergency response

    2. Obtain defibrillator; when available, attach and activate

    3. Begin CAB resuscitation (compressions, airway, breathing)

      1. Compressions: 100/min, 2 inches depth, allow recoil, minimize interruptions

      2. Airway: Head tilt, chin lift; jaw thrust if trauma

      3. Breathing: Compressions only; if second trained rescuer available, 30:2 ratio; with advanced airway, 8–10 breaths per minute

    4. Every 2 minutes, reassess, rotate compressors, and resume compressions promptly

Adult Advanced Cardiac Life Support

  1. Cardiac arrest

    1. Activate emergency response

    2. Begin CPR while obtaining rhythm assessment

    3. Non-shockable rhythm (asystole, pulseless electrical activity)

      1. CPR 2-minute cycles

      2. Give epinephrine every 3–5 minutes

      3. Reassess for shockable rhythm at end of each CPR cycle

      4. Treat reversible causes

    4. Shockable rhythm (ventricular fibrillation, pulseless ventricular tachycardia)

    5. Shock

    6. Resume CPR immediately, 2-minute cycles

    7. Reassess for shockable rhythm at end of each CPR cycle; shock if appropriate

    8. Give epinephrine every 3–5 minutes

    9. Consider amiodarone or lidocaine if no ROSC after epinephrine and shock

    10. Treat reversible causes

  2. ROSC: Begin postarrest care


  1. Neumar RW, Shuster M, Callaway CW, et al. Part 1: Executive summary. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S315–S367. []


Initial Assessment (ESC 2012)

  1. Draw serum markers routinely, but do not wait for results to initiate reperfusion therapy

Acute Medical Management

  1. Antiplatelet therapy (ACC/AHA 2013, ESC 2012, NICE 2013)

    1. Give aspirin (162–325 mg) at presentation

    2. If treating with PCI, give a loading dose of an ADP-receptor inhibitor (clopidogrel 600 mg, prasugrel1 60 mg, or ticagrelor 180 mg)2 as early as possible

    3. If treating with fibrinolytics, give a loading dose of clopidogrel (300 mg; 75 mg if >75 years of age) with aspirin

  2. Beta blockers

    1. ACC/AHA: If hypertensive or having ongoing ischemia, give beta blocker at time of presentation, unless contraindicated

  3. Oxygen

    1. ESC: Give supplemental oxygen to treat hypoxia (SaO2 <95%), breathlessness, or acute heart failure

  4. Analgesics

    1. ESC: Give IV opioids to relieve pain

  5. Anticoagulation (ACC/AHA 2013, ESC 2012, NICE 2013)

    1. If patient will receive primary PCI, give anticoagulation with unfractionated heparin (UFH), enoxaparin, or bivalirudin3; a glycoprotein IIb/IIIa inhibitor (abciximab, eptifibatide, tirofiban) may be added to UFH

    2. If patient will receive fibrinolytics, give anticoagulation until hospital discharge (minimum 48 hours, up to 8 days) or until revascularization is performed; options include UFH (titrated to a PTT of 1.5–2.0 times control), enoxaparin (IV bolus followed in 15 minutes by subcutaneous injection), or fondaparinux (initial IV dose followed in 24 hours by subcutaneous therapy)

Coronary Reperfusion Therapy

  1. PCI (ACC/AHA 2013, ESC 2012, NICE 2013)

    1. Initiate reperfusion therapy (PCI, if experienced operators are available ...

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