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Activate response team - call for HELP or 911 !        Remember the A-B-C-D Approach  

Advanced Cardiac Life Support in Cardiac Arrest   

Ventricular Fibrillation or Pulseless Ventricular Tachycardia     See ACLS | Asystole  

Ventricular Fibrillation or Pulseless Ventricular Tachycardia Rx

(Shock - CPR- Drug - CPR / Shock - CPR- Drug - CPR -  .....)  

 

  • SHOCK:  
    Electrical defibrillation of Biphasic 120-200 Joules one shock (or Monophasic 360 Joules as needed); or AED device specific shock.  

    CPR:  
    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

  • DRUG:  
    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)

    CPR:  
    Resume 5 cycles of CPR  (30 compresssions-2 breathes) immediately ! the Check rhythm - any shockable rhythm?


  • SHOCK:  
    Electrical defibrillation of Biphasic 200 Joules one shock

    CPR:  
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately ! then Check rhythm.

  • DRUG:
    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

    CPR:  
    Resume 5 cycles of CPR  (30 compresssions-2 breathes in pt without advanced airway) immediately !
    then Check rhythm - any shockable rhythm?


  • SHOCK:  
    Repeat Electrical defibrillation of Biphasic 200 Joules one shock


    CPR:
    CPR 5 cycles

    DRUG:
    May repeat Epinephrine dose  

    CPR:
    CPR 5 cycles



    Repeat 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).

       

Look for and Correct Reversible Causes of Cardiac Arrest  !  
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?

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 !

  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