TOC |  STAT |  V.FIB  |  ASYSTOLE        

  ACLS  ADVANCED CARDIAC LIFE SUPPORT in CARDIAC ARREST  

  Activate response team - call for HELP or 911 !  

* Basic Questions:
Responsive or Unresponsive, Breathing or Not-breathing, Pulse or No Pulse, Stable or Unstable,
Regular or Irregular Rhythm, Tachycardia or Asystole/Bradycardia, Narrow or Wide QRX Complex
 

ACLS - Advanced Cardiac Life Support in Cardiac Arrest           See V.FIB  |  ASYSTOLE     

A-B-C-D Approach to an unresponsive or cardiac arrest patient          Basic Life Support 2005 Algorithm  

  1. Assess responsiveness by speaking loudly, or gently shaking the patient if there are no signs of trauma. - If NO MOVEMENT or RESPONSE, then
  2. Call for help (code blue or 911)/crash cart/AED (Automatic External Defibrillation) /Defibrillator if the patient is unresponsive - activate Emergency Medical Service.

Primary Survey ABCDs (Excerpt)

  • A - Airway: Open airway (head tilt-chin lift or jaw thrust), look, listen, and feel for breathing.

  • B - Breathing: If not breathing, slowly give 2 rescue breaths that make chest rise  .

  • C - Circulation: Check pulse.
    If no pulse within 10 seconds, begin chest compressions CPR at 100/min, 1.5 - 2 inches depth (Give cycles of 30 compressions and 2 breathes, 30:2 ratio with unprotected airway).Consider precordial thump in witnessed arrest with no defibrillator immediately available.
    If there is definite pulse - Give 1 breath every 5 to 6 seconds (10-12 breathes per min), recheck pulse every 2 minutes.  .

  • D - Defibrillation: Attach monitor/AED. Assess rhythm. Search for and Shock V.Fib (Ventricular Fibrillation)/ Pulseless V.Tachycardia    .

  • If no pulse or breathing, resume CPR, beginning with compression.

CPR Technique:

  • chest compressions at 100/min, 1.5 - 2 inches depth (cycles of 30 compressions and 2 breathes, 30:2 ratio with unprotected airway)
    5 cycles approximate 2 minutes
  • If there is a protected airway ET tube, give uninterrupted compressions 100/min with ventilation every 5-6 seconds, about 10-12 breathes/min


Secondary Survey ABCDs (Excerpt)

  • A - Airway: Establish and secure an airway device..

  • B - Breathing: Ventilate with 100% O2.  Confirm correct airway device placement by clinical exam, end-tidal CO2 monitor, and O2 saturation monitor. .

  • C - Circulation: Evaluate heart rhythm, check pulse and blood pressure; if pulseless, continue chest compressions 100/min (1 ventilation every 5-6 seconds with protected airway as ET tube in place = 10-12 breathes/min), obtain IV access and start IV fluid, give rhythm-appropriate medications.  .

  • D - Differential Diagnosis: Attempt to identify and treat reversible causes.
         H: Hypovolemia, Hypoxia, Hypokalemia, Hyperkalemia, Hypoglycemia, Hypothermia, Hydrogen ion (acidosis)
         T: Tension pneumothorax, Thrombosis (Coronary or Pulmonary-PE), Tamponade (cardiac), Toxins, Trauma.


Actions:
A - Airway & ET tube placement
B - Breathing, 100% O2, Mask   
C - Circulation, Pulse, Rhythm, CPR, IV Line , EKG Monitor , Oxymetry, BP, ECG, ABG  
D - Defibrillation & Diff-Dx

* IO (Intraosseous Route)
   - Use IO access kit and a rigid needle, it serves as a rapid, safe, and reliable route for administration of drugs, crystalloids, colloids, and blood during resuscitation.  It is preferred over the ET (Endotracheal) route.  
* ET (Endotracheal Route)
   -
The typical dose of drugs administered via the ET route is 2 to 2.5 time the IV route, dilute the dose in 5 to 10 mL of water or normal saline, inject the drugs directly into the trachea.  
      Drugs: as Epinephrine, Vasopressin, Atropine, Lidocaine, Naloxone.

Asystole / Pulseless Electrical Activity (PEA)  
Asystole or PEA Rx (* Confirm true asystole in 2 leads)
- The target of PEA Rx is correcting the underlying cause, not the rhythm)                                              
  • Start CPR for 5 cycles & Intubation & IV (See above Secondary Survey ABCD)
  • Epinephrine 1.0 mg IV/IO (Intraosseous) or 2-2.5 mg ETT (Endotracheal Tube route, not as effective) , may repeat every 3-5 minutes  
  • or Vasopressin 40 units IV/IO to replace the first or 2nd dose of epinephrine.  It can only be given once!  
    If vasopressin used, next dose of epinephrine is 10 minutes after vasopressin.
  • Consider Atropine 1 mg IV push or IO, or 2-3 mg ETT, repeat every 3-5 minutes (Up to 3 doses;  Max: 0.04 mg/kg)
  • Consider termination if clinically indicated.

    Transcutaneous pacing  (TCP) - not recommended for asystolic cardiac arrest, because several trials failed to show benefit for asystole.

*  Give 5 cycles of CPR [1 cycle of PCR = 30 compressions then 2 breaths (approx 2 minutes)]
    Check rhythm and pulse (any shockable rhythm?) and confirm asystole in two leads.

*  Consider cessation of efforts after reasonable trial of therapy. Chances of meaningful neurologic recovery with asystole is low.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.

   

Look for and Correct Reversible Causes of Cardiac Arrest or Asystole/PEA   !  
H: Hypovolemia (hemorrhage or dehydration), Hypoxia, Hypokalemia, Hyperkalemia, Hypoglycemia, Hypothermia, Hydrogen ion (acidosis),
     Hyperthyroidism, Hypothyroidism.
T: Tension pneumothorax, Thrombosis (Coronary MI or Pulmonary PE), Tamponade (cardiac), Toxins (Digoxin toxicity, Beta blockers, TCA's), Trauma (Cardiac tamponade, Tension pneumothorax, aortic aneurysm rupture).  
*   Foreign body choking?

Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Ventricular Fibrillation or Pulseless Ventricular Tachycardia Rx (Shock - CPR- Drug - CPR / Shock - CPR- Drug - CPR -  .....)  

 

  • Electrical defibrillation of Biphasic 120-200 Joules one shock (or Monophasic 360 Joules as needed); or AED device specific shock.  
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm .
  • Secondary ABCDs  [airway, breathing, circulation, differential dx]
    Place airway device (intubation) and confirm then secure; establish IV; CPR & attach cardiac monitor; search for reversible causes
  • Epinephrine 1 mg IV/IO, may repeat every 3-5 minutes (may also give 2-2.5 mg via ET Tube)
    or Vasopressin 40 units IV/IO
     (single dose only)
    Resume 5 cycles of CPR  (30 compresssions-2 breathes) immediately ! the Check rhythm - any shockable rhythm?

  • Electrical defibrillation of Biphasic 200 Joules one shock
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm.
  • Amiodarone 300 mg IV/IO push; may give 2nd dose of 150 mg in 3-5 min if VF/pulseless VT recurs;
    Max: 2.2 g/24h; Info: if pt stable, infuse 1 mg/min x6h then 0.5 mg/min x18h
    or Lidocaine about 1- 1.5 mg mg/kg (as 75-100 mg) IV, may repeat 0.5 - 0.75 mg/kg in 5-10 min (Max: 3 mg/kg);
    (may give 2-4 mg/kg via ET Tube);  Lidocaine IV Infusion 1-4 mg/min.  
    or Magnesium sulfate 1-2 gm in 10 mL D5W if suspect hypomagnesemia or Torsades de pointes
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm - any shockable rhythm?

  • Electrical defibrillation of Biphasic 200 Joules one shock
    CPR 5 cycles
    May repeat Epinephrine dose  

    Electrical defibrillation of Biphasic 200 Joules one shock
    CPR 5 cycles
    May try Lidocaine about 1- 1.5 mg mg/kg (as 75-100 mg) IV, may repeat 0.5 - 0.75 mg/kg in 5-10 min (Max: 3 mg/kg);
    (may give 2-4 mg/kg via ET Tube);  Lidocaine IV Infusion 1-4 mg/min.  
    or Magnesium sulfate 1-2 gm in 10 mL D5W if suspect hypomagnesemia or Torsades de pointes
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm

Procainamide  Loading dose: 15 mg/kg IV/IO over 30-60 min; 20-30 mg/min IV infusion (Max: 50 mg/min infusion; Total dose 17 mg/kg) for recurrent or refractory VT (with pulses), SVT.

May consider Na bicarbonate 1 ampule IV (~ 1 meq/kg IV) if suspect acidotic or prolonged arrest or hyperkalemic or tricyclic OD (best check ABG first)

* There is no evidence to date that routine use of any vasopressor drugs at any stage during Rx of pulseless VT, VF, or asystole increases rates of survival to hospital discharge.  
   But there is evidence that the use of vasopressors favors initial resuscitation with ROSC (Return of Spontaneous Circulation).

 

Tachycardia - Unstable Wide Complex (with pulse)
Tachycardia - Unstable Wide Complex (with pulse)

Determine Patient Stability

  • Patient is considered unstable if there is hypotension, poor skin signs, shortness of breath, chest pain, evidence of CHF, or decreased mentation [or any other symptom felt to be caused by the bradycardia].

1. Evaluate ABC's › Stabilize Airway/Breathing

  • Apply oxygen, Place cardioversion/defibrillation pads, Establish IV, Monitors (Rhythm, Oximetry, BP), Obtain 12 lead EKG, Code cart

2. Obtain history and perform physical examination , ECG, and consider causes:

  • Differential diagnosis  of the tachycardia types includes:
    • Ventricular tachycardia (Monomorphic)
    • Ventricular tachycardia (Polymorphic)
    • Atrial fibrillation w/ aberrancy
    • Atrial flutter w/ aberrancy
    • Supraventricular tachycardia (SVT ) w/ aberrancy
    • Pre-excited tachycardias with accessory pathway
  • Consider Causes – Acute myocardial infarction, pulmonary embolus
    • Hypovolemia/Hypoxia/Hypothermia
    • Metabolic: Thyroid disease, hyper/hypokalemia, hypercalcemia, acidosis, hypoglycemia
    • Drugs: Cocaine, Amphetamines, Decongestants, Ephedra, Ginseng
    • Pneumothorax or Tamponade
    • Cardiomyopathy/Valvular heart disease
    • Alcohol related ("Holiday heart")
    • Sepsis/Pneumonia

3. Treatment for unstable wide complex tachycardia:

  • Sedation: if possible and immediate cardioversion (most rhythms)/defibrillation (Polymorphic VT).
    • › Sedation: – If patient is conscious, provide sedation (agents such as Etomidate, Fentanyl or Midazolam are common choices)
  • RX: Synchronized cardioversion:
    • – Pads on patient (or paddles)
    • Press sync button (make sure to have 3 lead monitor leads attached to the defibrillator/cardiovertor)
    • Evaluate rhythm to determine appropriate initial Joule setting:
      • • Afib: 100-200J
      • • A-flutter/SVT: 50-100J
      • • VT monomorphic: 100J
  • RX: Defibrillation
    • – Pad on patient (or paddles)
    • For Polymorphic V.Tach: 120-200 J (biphasic) or 360 J (monophasic defibrillator)
  • Response to therapy
    • – If no rhythm conversion after Rx, increase joules for subsequent shocks in stepwise fashion up 200 J (biphasic)   
        For cardioversion, make sure to press the sync button prior to each shock.

4. Standard laboratory evaluation (if indicated):

  • CBC, Electrolytes, TSH, Cardiac enzymes and toxicology testing
  • CXR; EKG pre and post conversion (if conversion occurs)

5. Consultation and admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.

 

Tachycardia - Stable Irregular Wide Complex Tachycardia  
Tachycardia - Stable Irregular Wide Complex Tachycardia

Differential diagnosis includes:

  1. atrial fibrillation with aberrancy or
    Atrial fibrillation with WPW (delta wave)
  2. MAT (Multi-Atrial Tachycardia)
  3. Polymorphic VT/Torsades de Pointes.


Evaluate ABC's
    Confirm stability, pulses, adequate blood pressure, good skin signs and mentation to proceed with this algorithm.

Early measures:

  • Apply oxygen, Make sure defibrillator present (in case stability changes), Establish IV, Monitors (Rhythm, Oximetry, BP)
  • Obtain 12 lead EKG and confirm QRS >0.12 sec, Code cart

Consider Causes

  • – Drugs that prolong QT interval
  • – Acute myocardial infarction, pulmonary embolus
  • – Hypovolemia/Hypoxia/Hypothermia
  • – Metabolic: Thyroid disease, hyper/hypokalemia, hypercalcemia, acidosis
  • – Hypoglycemia
  • – Other drugs: Cocaine, Amphetamines, Decongestants, Ephedra, Ginseng
  • – Pneumothorax or Tamponade
  • – Cardiomyopathy/Valvular heart disease
  • – Alcohol related ("Holiday heart")
  • – Sepsis/Pneumonia
  • – WPW [beware don't use drugs if WPW]


Treatment for stable irregular wide complex tachycardia:   

1.  For rapid Afib w/ aberrancy  

  • The goal is rate control.
  • Choose 1 of the following (dosing listed below):
    • CCB's: Diltiazem or verapamil
    • Beta Blockers: Metoprolol, atenolol, esmolol, propranolol
      Note: Avoid beta blockers in patients with CHF or pulmonary disease   
  • Diltiazem: 0.25 mg/kg [Max 20 mg] IV over 2 minutes; may repeat with 0.35 mg/kg [Max 25 mg] IV in 15 minutes. May start infusion 5-15 mg/hr after either bolus.
  • Verapamil: 2.5-5 mg IV over 2 minutes; may repeat with 5-10 mg IV in 15-30 minutes until maximum cumulative dose of 20 mg given if needed.
  • Metoprolol: 5 mg given slow IV every 5 minutes × 3 doses.
  • Atenolol: 5 mg slow IV, may repeat in 10 minutes.
  • Esmolol: Loading dose of 500 mcg/kg given over 1 minute then 50 mcg/kg/minute × 4 minutes. If inadequate response, reload with 500 mcg/kg given over 1 minute and follow this with an increased rate of infusion of 100 mcg/kg/minute and adjust as needed (maximum rate is 300 mcg/kg/minute).
  • Propranolol: 0.1 mg/kg divided into 3 equal doses, each given IV at 2-3 minute intervals. May repeat the total dose × 1 if not successful.

2.  For pre-excited Afib w/ WPW:  

  • Avoid adenosine, digoxin, diltiazem & verapamil.
  • Consider amiodarone 150 mg IV over 10 minutes  

* For Afib with Rapid Response: Magnesium 1-2 grams in D5W over 30-60 minutes may be beneficial.

3.  For Polymorphic VT
Polymorphic VT therapy is complicated by whether the patient has a prolonged QT when in sinus rhythm (if so, then the rhythm is likely Torsades de pointes).
Polymorphic VT is likely to proceed to pulseless arrest and requires immediate treatment.

Torsades de pointes may be treated with 1-2 grams of Magnesium sulfate IV over 5-60 minutes followed by an infusion of 0.5-1 gram/hr.
Overdrive pacing or isoproterenol are also reasonable choices.

  • In the case of no prolonged QT interval at baseline, magnesium is unlikely to be effective.
    Amiodarone 150 mg IV over 10 minutes followed by an infusion may be effective.
  • Any signs of instability should lead to immediate high energy defibrillation with sedation if possible (monophasic 360 J; biphasic 120, 150 or 200 Joules depending upon device).
  • Stop medications/toxins that prolong QT, check electrolytes

5. Standard laboratory evaluation (if indicated):

  • CBC, Electrolytes, TSH, Cardiac enzymes and toxicology testing
  • CXR
  • EKG pre and post conversion (if conversion occurs)

6. Consultation and admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.

Tachycardia - Stable Regular Wide Complex
Tachycardia - Stable Regular Wide Complex Tachycardia

Differential diagnosis includes:

  1. Ventricular tachycardia (VT) monomorphic
  2. SVT with aberrancy
  3. Pre-excited tachycardias with accessory pathway

Treatment

a. Treatment for Monomorphic VT or uncertain rhythm:

  • Amiodarone: 150 mg IV over 10 minutes then 1 mg/minute infusion × 6 hours then 0.5 mg/minute × 18 hours  (Max: 2.2 g/24 hours).
  • Prepare for elective synchronized cardioversion.  
  • Anticipate deterioration and need to switch to unstable wide complex tachycardia algorithm  

b. Treatment for SVT w/ aberrancy:

– Initial Treatment

  • Vagal stimulation (Unilateral carotid massage &/or valsalva) or
  • Adenosine 6 mg rapid IV Push immediately followed by 20 mL Normal Saline IVP.
    If no rhythm conversion, may repeat × 2 at 1-2 minute intervals with 12 mg/dose IV Push.
  • • Adenosine dose to be reduced to 50% of that listed above if central line, carbamazepine (Tegretol) or dipyridamole (Persantine) use.
  • • If rhythm converts to NSR, is likely SVT.

– If converts to NSR (Normal Sinus Rhythm)

  • • Observe for recurrence
  • • If recurs treat with adenosine, calcium channel blocker or beta blocker (dosing listed below)

– If doesn't convert to NSR
   • Choose 1 of the following (dosing listed below) to control the heart rate:

  • CCB's: Diltiazem or verapamil
  • Beta Blockers: Metoprolol, atenolol, esmolol, propranolol
    Note: Avoid beta blockers in patients with CHF or pulmonary disease  
  • Diltiazem: 0.25 mg/kg [Max 20 mg] IV over 2 minutes; may repeat with 0.35 mg/kg [Max 25 mg] IV in 15 minutes. May start infusion 5-15 mg/hr after either bolus.
  • Verapamil: 2.5-5 mg IV over 2 minutes; may repeat with 5-10 mg IV in 15-30 minutes until maximum cumulative dose of 20 mg given if needed.
  • Metoprolol: 5 mg given slow IV every 5 minutes × 3 doses. Typically follow this with 50 mg PO after last IV dose.
  • Atenolol: 5 mg slow IV, may repeat in 10 minutes. Typically follow this with 50 mg PO after last IV dose.
  • Esmolol: Loading dose of 500 mcg/kg given over 1 minute then 50 mcg/kg/minute × 4 minutes. If inadequate response, reload with 500 mcg/kg given over 1 minute and follow this with an increased rate of infusion of 100 mcg/kg/minute and adjust as needed (maximum rate is 300 mcg/kg/minute).
  • Propranolol: 0.1 mg/kg divided into 3 equal doses, each given IV at 2-3 minute intervals. May repeat the total dose × 1 if not successful.

5. Standard laboratory evaluation (if indicated):

  • › CBC, Electrolytes, TSH, Cardiac enzymes and toxicology testing
  • › CXR
  • › EKG pre and post conversion (if conversion occurs)

6. Consultation and admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.

Ventricular Tachycardia (with pulse)
Ventricular Tachycardia (with pulse) Rx    
  • In unstable hemodynamically, stat unsynchronized cardioversion with 50 -100 joules, then 200, 300 or to 360 joules.
  • In stable patients, may use synchronized cardioversion. with 100 J, then 200, 300, 360 J prn  
    * Premedicate with sedatives whenever possible !
  • Amiodarone 150 mg IV bolus over 10 minutes (may repeat up to total 2.2 gm/24 hrs)  - especially for Low EF/ CHF patients or
  • Lidocaine 0.5 - 0.75 mg/kg IV (repeat up to 3 mg/kg max) , then 1- 4 mg/min infusion or
  • Procainamide 20 mg/min (up to 17 mg/kg total dose) IV at rate <50 mg/min.- may use for Normal Left Ventricle EF patients or
    Sotalol 1- 1.5 mg/kg at 10 mg/min
  • Wide complex tachycardia VT vs SVT of uncertain etiology treat it as VT, & IV Procainamide is the drug of choice, &  ** IV Verapamil is contraindicated !

Tachycardia - Unstable Narrow Complex
Tachycardia - Unstable Narrow Complex

Determine Patient Stability
Patient is considered unstable if there is hypotension, poor skin signs, shortness of breath, chest pain, evidence of CHF, or decreased mentation [or any other symptom felt to be caused by the bradycardia].

Differential diagnosis includes:

  • Atrial fibrillation w/ RVR
  • Atrial flutter
  • Supraventricular tachycardia (SVT )
  • Sinus tachycardia with underlying serious medical condition  
    * Do not treat Sinus Tachycardia with this protocol; identify underlying condition and treat *

Treatment for unstable narrow complex tachycardia:

  • Sedation if possible and immediate cardioversion.
    Sedation: – If patient is conscious, provide sedation (agents such as Etomidate, Fentanyl or Midazolam are common choices)
  • Synchronized cardioversion:
    • Pads on patient (or paddles)
    • Press sync button (make sure to have 3 lead monitor leads attached to the defibrillator/cardiovertor)
    • Evaluate rhythm to determine appropriate initial Joule setting:
      • For Afib: 100-200J
      • For A-flutter/SVT: 50-100J
    • Monitor for response to therapy; if needed, increase joules for subsequent shocks in stepwise fashion and make sure to press the sync button prior to each shock.

* biphasic waveform more effective than monophasic waveform for cardioversion shocks  
* initial energy of Biphasic 200 J more effective than initial energy of 100 J (in escalating protocol) for achieving first-shock success
* initial energy of Monophasic 360 joules (J) more effective than 100 or 200 J for elective cardioversion in persistent atrial fibrillation

Standard laboratory evaluation (if indicated):

  • CBC, Electrolytes, TSH, Cardiac enzymes and toxicology testing, CXR
  • EKG pre and post conversion (if conversion occurs)

Consultation and admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.


Thromboembolic prophylaxis before cardioversion in atrial fibrillation patient:  

  • with atrial fibrillation < 48 hours anticoagulation suggested unless contraindicated, but prolonged anticoagulation not necessary
  • with atrial fibrillation = 48 hours
    • standard approach for duration of anticoagulation: 3 weeks before cardioversion & 4 weeks after cardioversion
    • immediate cardioversion following adequate anticoagulation may be acceptable if no active thrombus seen on multiplanar transesophageal echocardiography (TEE)

Narrow complex tachycardia
For ACLS purposes narrow complex tachycardia is categorized into "Regular" or "Irregular" rhythm.

Regular narrow complex tachycardia

  • Sinus Tachycardia: P waves present (don't treat this with ACLS drugs) - Treat underlying Cause !
  • SVT: Regular, rate typically 150-220/min
  • Junctional tachycardia: May occasionally be narrow complex
  • Atrial flutter: If rapid rate, may appear regular and similar to SVT

Irregular narrow complex tachycardia

  • Atrial fibrillation
  • Atrial flutter
  • Multifocal atrial Tachycardia (MAT)


Tachycardia - Stable Irregular Narrow Complex Tachycardia

Diff-Diagnosis:

  • Atrial fibrillation
  • Atrial flutter
  • Multifocal atrial Tachycardia (MAT)

Obtain history and perform physical examination and consider causes:

  • Acute myocardial infarction, pulmonary embolus
  • Hypovolemia/Hypoxia/Hypothermia
  • Metabolic: Thyroid disease, hyper/hypokalemia, hypercalcemia, acidosis
  • Hypoglycemia
  • Drugs: Cocaine, Amphetamines, Decongestants, Ephedra, Ginseng
  • Pneumothorax or Tamponade
  • Cardiomyopathy/Valvular heart disease
  • COPD; Asthma; Carbon monoxide exposure
  • Alcohol related ("Holiday heart")
  • Sepsis/Pneumonia
  • WPW [beware don't use drugs if WPW]

Treatment for stable irregular narrow complex tachycardia.

  • The goal is rate control.
  • Choose 1 of the following (dosing listed below):
    • CCB's: Diltiazem or verapamil
    • Beta Blockers: Metoprolol, atenolol, esmolol, propranolol
         Note: Avoid beta blockers in patients with CHF or pulmonary disease
  • Diltiazem: 0.25 mg/kg [Max 20 mg] IV over 2 minutes; may repeat with 0.35 mg/kg [Max 25 mg] IV in 15 minutes. May start infusion 5-15 mg/hr after either bolus.
  • Verapamil: 2.5-5 mg IV over 2 minutes; may repeat with 5-10 mg IV in 15-30 minutes until maximum cumulative dose of 20 mg given if needed.
  • Metoprolol: 5 mg given slow IV every 5 minutes × 3 doses.
  • Atenolol: 5 mg slow IV, may repeat in 10 minutes.
  • Esmolol: Loading dose of 500 mcg/kg given over 1 minute then 50 mcg/kg/minute x 4 minutes.
    If inadequate response, reload with 500 mcg/kg given over 1 minute and follow this with an increased rate of infusion of 100 mcg/kg/minute and adjust as needed (maximum rate is 300 mcg/kg/minute).
  • Propranolol: 0.1 mg/kg divided into 3 equal doses, each given IV at 2-3 minute intervals. May repeat the total dose × 1 if not successful.
  • For Afib with Rapid Response; Magnesium 1-2 grams in D5W over 30-60 minutes may be beneficial.

Consultation and/or admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.


Tachycardia - Stable Regular Narrow Complex

Diff-Diagnosis:  

  • Sinus Tachycardia: P waves present (don't treat this with ACLS drugs) - Treat underlying Cause !
  • SVT: Regular, rate typically 150-220/min
  • Junctional tachycardia: May occasionally be narrow complex
  • Atrial flutter: If rapid rate, may appear regular and similar to SVT

Initial Treatment

  • Vagal stimulation (Unilateral carotid massage &/or valsalva) or
  • Adenosine 6 mg rapid IV Push immediately followed by 20 mL Normal Saline IVP. If ineffective, may repeat × 2 at 1-2 minute intervals with 12 mg/dose using same technique.
    Adenosine dose to be reduced to 50% of that listed above if central line, carbamazepine (Tegretol) or dipyridamole (Persantine) use.
  • If rhythm converts to NSR, it is likely SVT.

If converts to NSR (Normal Sinus Rhythm)

  • Observe for recurrence
  • If recurs treat with adenosine, calcium channel blocker or beta blocker (dosing listed below)

If doesn't convert to NSR

Choose 1 of the following (dosing listed below) to control heart rate:

  • CCB's: Diltiazem or verapamil
  • Beta Blockers: Metoprolol, atenolol, esmolol, propranolol
    Note: Avoid beta blockers in patients with CHF or pulmonary disease
  • Diltiazem: 0.25 mg/kg [Max 20 mg] IV over 2 minutes; may repeat with 0.35 mg/kg [Max 25 mg] IV in 15 minutes. May start infusion 5-15 mg/hr after either bolus.
  • Verapamil: 2.5-5 mg IV over 2 minutes; may repeat with 5-10 mg IV in 15-30 minutes until maximum cumulative dose of 20 mg given if needed.
  • Metoprolol: 5 mg given slow IV every 5 minutes × 3 doses. Typically follow this with 50 mg PO after last IV dose.
  • Atenolol: 5 mg slow IV, may repeat in 10 minutes. Typically follow this with 50 mg PO after last IV dose.
  • Esmolol: Loading dose of 500 mcg/kg given over 1 minute then 50 mcg/kg/minute × 4 minutes. If inadequate response, reload with 500 mcg/kg given over 1 minute and follow this with an increased rate of infusion of 100 mcg/kg/minute and adjust as needed (maximum rate is 300 mcg/kg/minute).
  • Propranolol: 0.1 mg/kg divided into 3 equal doses, each given IV at 2-3 minute intervals. May repeat the total dose × 1 if not successful.

If rhythm appears to be SVT and is still not converted

  • Amiodarone may be added if the rhythm is SVT and is has not been controlled with the use of vagal maneuvers, adenosine and either a CCB or Beta Blocker.
  • Amiodarone dosing: 150 mg IV over 10 minutes then 1 mg/minute infusion × 6 hours then 0.5 mg/minute × 18 hours.

Cardiology Consultation and/or admission to hospital if indicated.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.

Supraventricular Tachycardia with narrow QRS complex
Supraventricular Tachycardia with narrow QRS complex    
  • Vagal maneuvers: carotid sinus massage, cough, etc.
  • Adenosine 6 - 12 mg IV Push
  • DC Cardioversion: Synchronized cardioversion with 50 - 100 joules
  • Amiodarone 150 mg IV bolus over 10 minutes (may repeat up to total 2.2 gm/24 hrs)  - especially for Low EF/ CHF patients
  • Diltiazem 15 - 20 mg (0.25 mg/kg) IV over 2 minutes, may repeat in 15 min at 20 - 25 mg (0.35 mg/.kg) over 2 minutes. Maintenance infusion dose 5 - 15 mg/hour titrated per HR
  • Verapamil 5 - 10 mg IV, or
  • Digoxin 0.25 - 0.5 mg IV Push
  • Beta-blocker (in normal EF patients):
  • Esmolol 0.5 mg/kg over 1 min, followed by 0.05 mg/kg/min infusion, titrate the dose (Max: 0.3 mg/kg/min). Short half-life of 2-9 minutes.
  • Labetalol 10 mg IV Push over 1-2 minutes, may repeat every 10 min (Max 150 mg)
  • or 2 - 8 ug/min infusion
  • Atenolol 5 mg slow IV over 5 minutes, may repeat IV slowly after 10 minutes; if tolerated well may start PO 50 mg bid
  • Metoprolol 5 mg slow IV over 5 minutes, may repeat in 5 minutes (total dose 15 mg); if tolerated well may start PO 50 mg bid
  • Procainamide 200 - 1000mg IV at rate < 25 - 50 mg/min
  • * If suspect WPW (Wolff-Parkinson-White Syndrome) - avoid beta blockers, calcium channel blockers - diltiazem, Verapamil, digoxin, adenosine.

 

Bradycardia < 60/min 
Determine Patient Stability
  • Is bradycardia symptomatic?
  • Signs of instability include hypotension, poor skin signs, shortness of breath, chest pain, evidence of CHF, or decreased mentation.

Unstable Bradycardia with Symptoms (cardiac ischemia, CHF, hypotension symptoms, or decreased level of consciousness)  

  • Check airway, breathing, IV line, O2 status, ECG, blood pressure
  • Atropine 0.5 mg IV, may repeat  q 3-5 min up to 3 mg total
  • Pacemaker external  (transcutahneous) or transthoracic or transvenous.
  • Epinephrine infusion 2-10 mcg/min or Dopamine 2-5 mcg/kg/min IV infusion in hypotensive or severely symptomatic patients

Rx of AV Block rhythm

  • a. 1st degree AV block: Atropine 0.5 mg IVP every 3-5 minutes (Maximum cumulative dose is 3 mg). 
        Epinephrine Dosing: 2-10 mcg/minute IV infusion or
        Dopamine 2-10 mcg/kg/min infusion in hypotensive or severely symptomatic patients
  • b. 2nd degree AV block: Pacing or trial of atropine
  • c. 3rd degree AV block/Junctional: Pacing
  • d. Transplanted heart: Pacing, Dopamine and/or Epinephrine infusion

* Obtain history and perform physical examination and consider causes

 H: Hypovolemia (hemorrhage or dehydration), Hypoxia, Hypokalemia, Hyperkalemia, Hypoglycemia, Hypothermia, Hydrogen ion (acidosis)
 T: Tension pneumothorax, Thrombosis (Coronary MI or Pulmonary PE), Tamponade (cardiac), Toxins (Digoxin toxicity, Beta blockers, TCA's), Trauma (Cardiac tamponade, Tension pneumothorax, aortic aneurysm rupture).


Stable Bradycardia

Obtain & review EKG to determine the rhythm & examine for myocardial ischemia or infarction.

  • Sinus Bradycardia: Observe
  • 1st degree AV Block: Observe
  • 2nd/3rd degree AV block or junctional rhythm: Place pacer pads, but only utilize if patient becomes unstable.
    Cardiology Consult for possible transvenous pacer placement.
  • Have atropine available if 1st or 2nd degree AV block.

Check Oxygen, IV, Labs, Pulse Oximetry, CXR for any symptomatic patient or for any patient that may deteriorate.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.

 

  ACLS  ADVANCED CARDIAC LIFE SUPPORT in CARDIAC ARREST  

 

 http://www.acls.net/     

 http://www.americanheart.org/presenter.jhtml?identifier=3035517   /  http://circ.ahajournals.org/content/vol112/24_suppl/    

       

2009