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
-
Assess responsiveness by speaking
loudly, or gently shaking the patient if there are no signs of trauma.
- If NO MOVEMENT or RESPONSE, then
-
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)
* 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:
-
atrial fibrillation with aberrancy or
Atrial fibrillation with WPW (delta wave)
-
MAT (Multi-Atrial Tachycardia)
-
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:
-
Ventricular tachycardia (VT) monomorphic
-
SVT with aberrancy
-
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
|
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|
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| http://www.acls.net/
http://www.americanheart.org/presenter.jhtml?identifier=3035517
/
http://circ.ahajournals.org/content/vol112/24_suppl/
|
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V.FIB |
ASYSTOLE
