Clinical Crisis Protocols

CRITICAL

Cardiac Arrest — ACLS 2023 Algorithm

SHOCKABLE: VF / pVT

1

CPR → Rhythm Check
High-quality CPR: Rate 100–120/min, Depth 5–6cm
Minimize interruptions (<10s for rhythm checks)

2

SHOCK — Biphasic 200J
Resume CPR immediately × 2 min
IV/IO access during CPR

3

SHOCK → Epinephrine 1mg IV q3–5min
After 2nd shock if still VF/pVT

4

SHOCK → Amiodarone
1st dose: 300mg IV bolus 2nd dose: 150mg IV
Alt: Lidocaine 1–1.5 mg/kg, then 0.5–0.75 mg/kg

5

Treat Reversible Causes (Hs & Ts)
Continue 2-min CPR cycles between shocks

NON-SHOCKABLE: PEA / Asystole

1

CPR immediately
NO shock. Confirm asystole in ≥2 leads.
If rhythm organized → check pulse (PEA)

2

Epinephrine 1mg IV ASAP
Repeat q3–5 min throughout resuscitation
Early epi improves ROSC in non-shockable

3

Advanced Airway
ETT or SGA. Waveform capnography mandatory.
ETCO₂ <10 mmHg after 20 min → poor prognosis

4

Identify & Treat Reversible Causes

REVERSIBLE CAUSES — The Hs & Ts

// Hs

▸ Hypovolemia — Volume resuscitation, blood
▸ Hypoxia — Oxygenate, secure airway
▸ Hydrogen ion (Acidosis) — NaHCO₃ consider
▸ Hypo/Hyperkalemia — Ca²⁺, insulin/dextrose, kayexalate
▸ Hypothermia — Active rewarming, warm fluids

// Ts

▸ Tension Pneumothorax — Needle decompression 2nd ICS MCL
▸ Tamponade (Cardiac) — Pericardiocentesis / OR
▸ Toxins — Specific antidotes, lipid emulsion
▸ Thrombosis (Coronary) — PCI / thrombolytics
▸ Thrombosis (Pulmonary) — tPA 50mg bolus in arrest

POST-ROSC CARE — Immediately After Return of Circulation

Hemodynamics

MAP ≥65 mmHg target
Norepinephrine 0.1–0.5 mcg/kg/min first-line
Volume if preload responsive (PLR/IVC)

Oxygenation

SpO₂ 92–98% (avoid hyperoxia)
PaCO₂ 35–45 mmHg (normocapnia)
Mechanical ventilation, 6–8 mL/kg IBW

Neuroprotection

TTM 32–36°C × 24h (AHA 2023)
Avoid hyperthermia aggressively
12-lead ECG → emergent cath if STEMI

TIME-CRITICAL

Acute Coronary Syndrome / STEMI Protocol

⏱ DOOR-TO-BALLOON TARGET: <90 MINUTES

00:00:00

STEMI — IMMEDIATE MANAGEMENT

// MONA-B is outdated — current evidence-based approach:
RECOGNIZE: ST elevation ≥1mm in ≥2 contiguous leads (≥2mm in V1-V3)
New LBBB with clinical suspicion = STEMI equivalent

STEP 1: Aspirin 325mg PO chewed (non-enteric)
STEP 2: P2Y12 inhibitor — Ticagrelor 180mg PO preferred
Alt: Clopidogrel 600mg if ticagrelor contraindicated
STEP 3: Heparin — UFH 60 U/kg bolus (max 4000U) + 12 U/kg/hr
Or: Enoxaparin 0.5mg/kg IV bolus if going to PCI
STEP 4: Nitroglycerin 0.4mg SL × 3 (if SBP >90, no RV infarct, no PDE5i)
STEP 5: Morphine ONLY if persistent pain despite NTG
⚠ Morphine may ↓ P2Y12 absorption — use cautiously
STEP 6: Beta-blocker within 24h if stable (Metoprolol 25mg PO)
⚠ AVOID if: HR<60, SBP<100, signs of HF, PR>0.24s
STEP 7: ACTIVATE CATH LAB → Primary PCI is gold standard

NSTEMI / UNSTABLE ANGINA — Risk Stratification

GRACE Score → Guides Timing

▸ Very High Risk — Immediate invasive (<2h): Hemodynamic instability, cardiogenic shock, recurrent/refractory angina, life-threatening arrhythmias, mechanical complications
▸ High Risk — Early invasive (<24h): GRACE >140, dynamic ST/T changes, rise/fall troponin
▸ Intermediate — Invasive <72h: DM, eGFR <60, LVEF <40%, early post-infarction angina, prior PCI/CABG, GRACE 109-140

Anticoagulation in NSTEMI

▸ Fondaparinux 2.5mg SC daily — Best safety profile (ESC preferred if no urgent PCI)
▸ Enoxaparin 1mg/kg SC q12h — If CrCl >30; dose-adjust renal
▸ UFH — If PCI planned within hours
▸ ⚠ Do NOT switch anticoagulants — ↑ bleeding risk

KILLIP CLASSIFICATION — Bedside Heart Failure Assessment

I

No HF signs
Mortality ~6%

II

Rales, S3, JVP↑
Mortality ~17%

III

Acute pulmonary edema
Mortality ~38%

IV

Cardiogenic shock
Mortality ~81%

CRITICAL

Shock — Classification & ICU Management

CARDIOGENIC SHOCK

// Hemodynamic Profile
CI <2.2 L/min/m² | PCWP >18 mmHg
SBP <90 for >30min OR vasopressors needed

First-line: Norepinephrine (SOAP II trial)
Inotrope: Dobutamine 2–20 mcg/kg/min
Mechanical: IABP / Impella / ECMO
⚠ AVOID dopamine — ↑ arrhythmia risk (SOAP II)

SEPTIC SHOCK — SSC 2021

// Hour-1 Bundle
Lactate | Blood cultures × 2 BEFORE abx
Broad-spectrum abx within 1 HOUR
30 mL/kg crystalloid if hypotensive/lactate ≥4

Vasopressor: Norepinephrine first-line, target MAP ≥65
Refractory: Add vasopressin 0.03 U/min (MAX 0.04)
Then: Epinephrine if still refractory
Steroids: Hydrocortisone 200mg/day if ≥2 vasopressors

ANAPHYLACTIC SHOCK

EPINEPHRINE IS THE ONLY FIRST-LINE

IM Epinephrine 0.3–0.5mg (1:1000) anterolateral thigh
Repeat q5–15 min if no response
IV Epi infusion: 1–10 mcg/min if refractory
Fluids: 1–2L NS rapid bolus (distributive shock)
⚠ Steroids/antihistamines are ADJUNCTS not first-line
⚠ Biphasic reaction risk — observe 6–12 hours minimum

OBSTRUCTIVE SHOCK

Tension Pneumothorax:
Needle decompression → 14G needle, 2nd ICS MCL
Followed by chest tube (28–32 Fr) 5th ICS MAL

Massive PE:
Systemic thrombolysis: tPA 100mg IV over 2h
Or alteplase 0.6 mg/kg (max 50mg) over 15min
UFH bolus 80 U/kg → 18 U/kg/hr infusion

Cardiac Tamponade:
Pericardiocentesis (echo-guided subxiphoid)
⚠ Volume loading as bridge (↑ preload)

VASOPRESSOR & INOTROPE QUICK REFERENCE

Drug	Dose Range	α₁	β₁	β₂	Primary Use
Norepinephrine	0.1–1 mcg/kg/min	+++	++	−	Septic/Cardiogenic shock 1st line
Vasopressin	0.01–0.04 U/min	V1	−	−	Adjunct in refractory septic shock
Dobutamine	2–20 mcg/kg/min	+	+++	++	Low CO states, inotropic support
Epinephrine	1–10 mcg/min	+++	+++	++	Anaphylaxis, refractory shock
Milrinone	0.375–0.75 mcg/kg/min	−	PDE3i	PDE3i	Acute decompensated HF, inotropy + vasodilation

URGENT

Arrhythmia — Acute Management Protocols

SVT — Narrow Complex Tachycardia

IF STABLE:
1. Vagal maneuvers (modified Valsalva — legs elevated 45°)
2. Adenosine 6mg rapid IV push + 20mL NS flush
3. Adenosine 12mg if no response (may repeat × 1)
4. Diltiazem 0.25mg/kg IV over 2min (if no WPW)
or Verapamil 5mg IV over 2min

IF UNSTABLE (hypotension, AMS, chest pain, acute HF):
→ Synchronized cardioversion 50–100J biphasic

⚠ AVOID AV nodal blockers if irregular wide-complex (? AF + WPW)

ATRIAL FIBRILLATION — Acute Rate vs Rhythm

// Rate Control (Target HR <110 at rest)
• Metoprolol 5mg IV q5min × 3, then 25–50mg PO
• Diltiazem 0.25mg/kg IV → infusion 5–15mg/hr
• Digoxin 0.5mg IV if HFrEF (slow onset)

// Rhythm Control (if <48h or anticoagulated)
• Amiodarone 150mg IV/10min → 1mg/min × 6h → 0.5mg/min × 18h
• Flecainide 2mg/kg IV (NO structural heart disease)
• Cardioversion 120–200J biphasic (synchronized)

// Anticoagulation — CHA₂DS₂-VASc
• Score ≥2 (men) / ≥3 (women): DOAC preferred
• If >48h or unknown duration: TEE or 3wk anticoag before cardioversion

WIDE COMPLEX TACHYCARDIA / VT with Pulse

RULE: Wide + Regular + Unknown = TREAT AS VT

STABLE:
1. Amiodarone 150mg IV over 10min → infusion
2. Procainamide 20–50mg/min until: arrhythmia suppressed,
hypotension, QRS widens >50%, or max 17mg/kg
3. Lidocaine 1–1.5mg/kg IV, then 0.5–0.75mg/kg q5-10min

UNSTABLE or POLYMORPHIC VT:
→ Synchronized cardioversion 100J biphasic (monomorphic)
→ DEFIBRILLATION 200J (polymorphic VT = treat as VF)

⚠ Polymorphic VT + long QT = Torsades → Magnesium 2g IV

SYMPTOMATIC BRADYCARDIA

STEP 1: Atropine 1mg IV q3–5min (max 3mg)
Ineffective in infranodal block / transplanted heart

STEP 2 (if atropine fails):
• Transcutaneous pacing — set rate 60–80, ↑ mA until capture
• Dopamine 5–20 mcg/kg/min
• Epinephrine 2–10 mcg/min

STEP 3: Transvenous pacing if sustained

Specific Reversals:
• Beta-blocker OD → Glucagon 3–10mg IV
• CCB OD → Calcium gluconate 3g IV + High-dose insulin (HDI)
• Digoxin toxicity → DigiFab (Digibind)

CRITICAL

Airway Management & Mechanical Ventilation

RAPID SEQUENCE INTUBATION (RSI)

// The 7 Ps of RSI
Preparation → Equipment check, suction, BVM, backup (bougie, LMA)
Preoxygenation → 3–5 min 100% FiO₂, NRB or apneic oxygenation (15L NC)
Pretreatment → Fentanyl 1–3 mcg/kg if ↑ICP (optional, controversial)
Paralysis with induction:
INDUCTION:
• Ketamine 1.5–2 mg/kg IV (hemodynamically neutral, preferred in shock)
• Etomidate 0.3 mg/kg IV (may suppress adrenals — single dose acceptable)
• Propofol 1–2 mg/kg IV (AVOID in hypotension)
PARALYTIC:
• Succinylcholine 1.5 mg/kg IV (onset 45s, duration 6–10min)
• Rocuronium 1.2 mg/kg IV (onset 60s, longer duration — Sugammadex reversal)
Placement → Direct/Video laryngoscopy, confirm with ETCO₂ waveform
Post-intubation → CXR, secure tube, ventilator settings, sedation
Prove → Continuous waveform capnography (GOLD STANDARD for confirmation)

INITIAL VENTILATOR SETTINGS

LUNG PROTECTIVE (ARDS Network)

Mode: AC/VC or AC/PC
Vt: 6 mL/kg IBW (4–8 range)
RR: 14–22 /min (titrate to pH)
PEEP: Start 5–10 cmH₂O (↑ per ARDSNet table)
FiO₂: Titrate SpO₂ 88–95%
Pplat: <30 cmH₂O (measure q4h)
Driving Pressure: <15 cmH₂O (Pplat − PEEP)

IBW CALCULATOR (for Vt)

Male: 50 + 2.3 × (height in inches − 60) kg
Female: 45.5 + 2.3 × (height in inches − 60) kg

Sex: Ht(cm):

FAILED AIRWAY / CAN'T INTUBATE CAN'T OXYGENATE (CICO)

Attempt 1: Reposition + Bougie Attempt 2: Video laryngoscopy Attempt 3: Supraglottic airway (LMA) CICO → Front-of-neck access (eFONA)

Emergency Cricothyrotomy: Scalpel-bougie-tube technique
Identify CTM (cricothyroid membrane) → Horizontal stab incision → Bougie → 6.0 ETT or cuffed tracheostomy tube
Maximum 3+1 intubation attempts before declaring failed airway (DAS 2015/NAP4)

REFERENCE

Cardiac Arrest — ACLS 2023 Algorithm

SHOCKABLE: VF / pVT

NON-SHOCKABLE: PEA / Asystole

REVERSIBLE CAUSES — The Hs & Ts

POST-ROSC CARE — Immediately After Return of Circulation

Acute Coronary Syndrome / STEMI Protocol

⏱ DOOR-TO-BALLOON TARGET: <90 MINUTES

STEMI — IMMEDIATE MANAGEMENT

NSTEMI / UNSTABLE ANGINA — Risk Stratification

KILLIP CLASSIFICATION — Bedside Heart Failure Assessment

Shock — Classification & ICU Management

CARDIOGENIC SHOCK

SEPTIC SHOCK — SSC 2021

ANAPHYLACTIC SHOCK

OBSTRUCTIVE SHOCK

VASOPRESSOR & INOTROPE QUICK REFERENCE

Arrhythmia — Acute Management Protocols

SVT — Narrow Complex Tachycardia

ATRIAL FIBRILLATION — Acute Rate vs Rhythm

WIDE COMPLEX TACHYCARDIA / VT with Pulse

SYMPTOMATIC BRADYCARDIA

Airway Management & Mechanical Ventilation

RAPID SEQUENCE INTUBATION (RSI)

INITIAL VENTILATOR SETTINGS

FAILED AIRWAY / CAN'T INTUBATE CAN'T OXYGENATE (CICO)

Emergency Drug Quick Doses — ICU / Code Cart