ACLS (Main): Difference between revisions
No edit summary |
|||
Line 1: | Line 1: | ||
==Recommendations== | == Recommendations == | ||
*Routine use of cricoid pressure is NOT recommended | *Routine use of cricoid pressure is NOT recommended | ||
*Airway adjunct is recommended while performing ventilation | *Airway adjunct is recommended while performing ventilation | ||
Line 6: | Line 7: | ||
*Atropine and cardiac pacing are NOT recommended for asystole/PEA | *Atropine and cardiac pacing are NOT recommended for asystole/PEA | ||
==BLS== | == BLS == | ||
*Compressions | *Compressions | ||
**Push hard (2cm) and fast (100pm) | **Push hard (2cm) and fast (100pm) | ||
Line 15: | Line 17: | ||
**8-10 breaths per min when intubated | **8-10 breaths per min when intubated | ||
==ECG Analysis== | == ECG Analysis == | ||
#Is the rhythm fast or slow? | #Is the rhythm fast or slow? | ||
#Are the QRS complexes wide or narrow? | #Are the QRS complexes wide or narrow? | ||
#Is the rhythm regular or irregular? | #Is the rhythm regular or irregular? | ||
==Ventricular fibrillation and pulseless ventricular tachycardia== | == Ventricular fibrillation and pulseless ventricular tachycardia == | ||
*Shock as quickly as possible | *Shock as quickly as possible | ||
**Resume CPR immediately after shocking | **Resume CPR immediately after shocking | ||
Line 32: | Line 36: | ||
==Asystole and PEA== | |||
== Asystole and PEA == | |||
*Give Epi 1mg q3-5min | *Give Epi 1mg q3-5min | ||
*Consider H's and T's | *Consider H's and T's | ||
Line 46: | Line 52: | ||
**Thrombosis, coronary | **Thrombosis, coronary | ||
==Bradycardia== | == Bradycardia == | ||
*Only intervene if pt is symptomatic | *Only intervene if pt is symptomatic | ||
**Hypotension, AMS, chest pain, pulm edema | **Hypotension, AMS, chest pain, pulm edema | ||
Line 60: | Line 67: | ||
==Tachycardia== | |||
== Tachycardia == | |||
3 questions | 3 questions | ||
#Is the pt in a sinus rhythm? | #Is the pt in a sinus rhythm? | ||
#Is the QRS wide or narrow? | #Is the QRS wide or narrow? | ||
#Is the rhythm regular or irregular? | #Is the rhythm regular or irregular? | ||
===Regular Narrow=== | === Regular Narrow === | ||
*1. Sinus Tachycardia | *1. Sinus Tachycardia | ||
**Treat underlying cause | **Treat underlying cause | ||
Line 76: | Line 87: | ||
****Metoprolol 5mg IVP x 3 followed by 50mg PO | ****Metoprolol 5mg IVP x 3 followed by 50mg PO | ||
===Irregular Narrow=== | === Irregular Narrow === | ||
*1. MAT | *1. MAT | ||
**Treat underlying cause (hypoK, hypomag) | **Treat underlying cause (hypoK, hypomag) | ||
Line 87: | Line 99: | ||
***Digoxin (good in setting of CHF) | ***Digoxin (good in setting of CHF) | ||
===Regular Wide Complex=== | === Regular Wide Complex === | ||
*1. V-Tach (until proven otherwise!) | *1. V-Tach (until proven otherwise!) | ||
*If stable: | *If stable: | ||
Line 93: | Line 106: | ||
***Procainamide 20mg/min | ***Procainamide 20mg/min | ||
****Cont until rhythm suppressed, hypotensive, or max dose (17mg/kg) | ****Cont until rhythm suppressed, hypotensive, or max dose (17mg/kg) | ||
****Avoid if prolonged QT | ****Avoid if prolonged QT | ||
***Amiodarone 150mg over 10min, repeated as needed | ***Amiodarone 150mg over 10min, repeated as needed | ||
***Sotalol 100mg IV over 5min | ***Sotalol 100mg IV over 5min | ||
Line 102: | Line 115: | ||
*2. SVT w/ aberrancy | *2. SVT w/ aberrancy | ||
===Irregular Wide Comlex=== | === Irregular Wide Comlex === | ||
*DO NOT use AV nodal blockers! | *DO NOT use AV nodal blockers! | ||
**Can precipitate V-Fib | **Can precipitate V-Fib | ||
Line 114: | Line 128: | ||
***HypoK, hypoMag | ***HypoK, hypoMag | ||
**Stop prolonged QT meds | **Stop prolonged QT meds | ||
=== Treatable Conditions === | |||
{| cellspacing="0" style="text-align: left; border-right-color: rgb(0, 0, 0); border-right-width: 1px; border-right-style: solid; font-size: 0.75em; padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; width: 1012px; " | |||
|- | |||
| class="subtitle1" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: middle; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(0, 0, 0); border-bottom-width: 3px; border-bottom-style: solid; padding-top: 0.8em; padding-right: 0.6em; padding-bottom: 0.3em; padding-left: 0.6em; text-align: center; font-size: 1.2em; font-weight: bolder; background-image: initial; background-attachment: initial; background-origin: initial; background-clip: initial; background-color: rgb(238, 238, 238); background-position: initial initial; background-repeat: initial initial; " | Condition | |||
| class="subtitle1" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: middle; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(0, 0, 0); border-bottom-width: 3px; border-bottom-style: solid; padding-top: 0.8em; padding-right: 0.6em; padding-bottom: 0.3em; padding-left: 0.6em; text-align: center; font-size: 1.2em; font-weight: bolder; background-image: initial; background-attachment: initial; background-origin: initial; background-clip: initial; background-color: rgb(238, 238, 238); background-position: initial initial; background-repeat: initial initial; " | Common clinical settings | |||
| class="subtitle1" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: middle; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(0, 0, 0); border-bottom-width: 3px; border-bottom-style: solid; padding-top: 0.8em; padding-right: 0.6em; padding-bottom: 0.3em; padding-left: 0.6em; text-align: center; font-size: 1.2em; font-weight: bolder; background-image: initial; background-attachment: initial; background-origin: initial; background-clip: initial; background-color: rgb(238, 238, 238); background-position: initial initial; background-repeat: initial initial; " | Corrective actions | |||
|- | |||
| rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Acidosis | |||
| rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Preexisting acidosis, DM, diarrhea, drugs and toxins, prolonged resuscitation, renal disease, shock | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Reassess adequacy of oxygenation, and ventilation; reconfirm endotracheal-tube placement | |||
|- | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Hyperventilate | |||
|- | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Consider intravenous bicarbonate if pH <7.20 after above actions have been taken | |||
|- class="divider_top" | |||
| rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Cardiac tamponade | |||
| rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hemorrhagic diathesis, cancer, pericarditis, trauma, after cardiac surgery or MI | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Give fluids; obtain bedside echocardiogram | |||
|- | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Perform pericardiocentesis. Immediate surgical intervention is appropriate if pericardiocentesis is unhelpful but cardiac tamponade is known or highly suspected. | |||
|- class="divider_top" | |||
| rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypothermia | |||
| rowspan="2" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Alcohol abuse, burns, CNS disease, debilitated or elderly patient, drowning, drugs and toxins, endocrine disease, history of exposure, homelessness, extensive skin disease, spinal cord disease, trauma | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | If severe (temperature <30°C), limit initial shocks for V-Fib or pulseless V-Tach to three; initiate active internal rewarming and cardiopulmonary support. Hold further resuscitation medications or shocks until core temperature is >30°C. | |||
|- | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | If moderate (temperature 30-34°C), proceed with resuscitation (space medications at intervals greater than usual), actively rewarm truncal body areas | |||
|- class="divider_top" | |||
| rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypovolemia, hemorrhage, anemia | |||
| rowspan="3" style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Major burns, DM, GI losses, hemorrhage, hemorrhagic diathesis, cancer, pregnancy, shock, trauma | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Give fluids | |||
|- | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Transfuse pRBCs if hemorrhage or profound anemia is present | |||
|- | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; " | Thoracotomy is appropriate when pt has cardiac arrest from penetrating trauma and a cardiac rhythm and the duration of cardiopulmonary resuscitation before thoracotomy is <10 min | |||
|- class="divider_top" | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypoxia | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Consider in all patients with cardiac arrest | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Reassess technical quality of cardiopulmonary resuscitation, oxygenation, and ventilation; reconfirm ETT placement | |||
|- class="divider_top" | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Hypomagnesemia | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Alcohol abuse, burns, DKA, severe diarrhea, diuretics, drugs (eg, cisplatin, cyclosporine, pentamidine) | |||
| style="font-family: Verdana, Arial, Helvetica, sans-serif; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; vertical-align: top; border-left-color: rgb(0, 0, 0); border-left-width: 1px; border-left-style: solid; border-bottom-color: rgb(221, 221, 221); border-bottom-width: 1px; border-bottom-style: solid; padding-top: 0.4em; padding-right: 0.6em; padding-bottom: 0.6em; padding-left: 0.6em; border-top-color: rgb(0, 0, 0); border-top-width: 1px; border-top-style: solid; " | Give 1-2 g magnesium sulfate intravenously over 2 min | |||
|} | |||
== Source == | |||
*AHA 2010 Guidelines for ACLS | |||
[[Category:Airway/Resus]] | <br/>[[Category:Airway/Resus]] <br/><br/> |
Revision as of 05:30, 16 April 2011
Recommendations
- Routine use of cricoid pressure is NOT recommended
- Airway adjunct is recommended while performing ventilation
- Pulse/rhythm checks should only occur q2min
- Most critical component is high-quality compressions
- Atropine and cardiac pacing are NOT recommended for asystole/PEA
BLS
- Compressions
- Push hard (2cm) and fast (100pm)
- Do everything possible to minimize compression interruption
- Ventilation
- 30:2 ratio when do not have advanced airway
- Do not overventilate! (leads to decr venous return)
- 8-10 breaths per min when intubated
- 30:2 ratio when do not have advanced airway
ECG Analysis
- Is the rhythm fast or slow?
- Are the QRS complexes wide or narrow?
- Is the rhythm regular or irregular?
Ventricular fibrillation and pulseless ventricular tachycardia
- Shock as quickly as possible
- Resume CPR immediately after shocking
- Biphasic - 200J
- Monophasic - 360 J
- Give Epi 1mg if shock + 2min of CPR fails to convert the rhythm
- Consider aniarrhytmic if 2nd shock + 2min CPR again fails
- Amiodarone 300mg w/ repeat dose of 150mg as indicated
- Magnesium 2g IV, followed by maintenance infusion
- Only for polymorphic Vtach
Asystole and PEA
- Give Epi 1mg q3-5min
- Consider H's and T's
- Hypovolemia
- Hypoxia
- Hydrogen ion
- Hypo/hyperkalemia
- Hypothermia
- Tension pneumo
- Tamponade
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
Bradycardia
- Only intervene if pt is symptomatic
- Hypotension, AMS, chest pain, pulm edema
- 1st Line
- Transcutaneous pacing
- Chronotropes
- Dopamine 2-10mcg/kg/min
- Epineprhine 2-10mcg/min
- 2nd Line
- Atropine 0.5mg q3-5m can be given as temporizing measure
- Do not give if Mobitz type II or 3rd degree block is present
- Atropine 0.5mg q3-5m can be given as temporizing measure
- TransQ pacing and chronotropes ineffective = need for transvenous pacing
Tachycardia
3 questions
- Is the pt in a sinus rhythm?
- Is the QRS wide or narrow?
- Is the rhythm regular or irregular?
Regular Narrow
- 1. Sinus Tachycardia
- Treat underlying cause
- 2. SVT
- Vagal maneuvers (convert up to 25%)
- Adenosine 6mg IVP (can follow with 12mg if initially fails)
- If adenosine fails initiate rate control with CCB or BB
- Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
- Metoprolol 5mg IVP x 3 followed by 50mg PO
- If adenosine fails initiate rate control with CCB or BB
Irregular Narrow
- 1. MAT
- Treat underlying cause (hypoK, hypomag)
- 2. Sinus Tachycardia w/ frequent PACs
- 3. A Fib / A Flutter w/ variable conduction
- Rate control with:
- Dilt
- MTP (good in setting of ACS)
- Amiodarone (good in setting of hypotension, CHF)
- Digoxin (good in setting of CHF)
- Rate control with:
Regular Wide Complex
- 1. V-Tach (until proven otherwise!)
- If stable:
- Antiarrhytmics
- Procainamide 20mg/min
- Cont until rhythm suppressed, hypotensive, or max dose (17mg/kg)
- Avoid if prolonged QT
- Amiodarone 150mg over 10min, repeated as needed
- Sotalol 100mg IV over 5min
- Avoid if prolonged QT
- Procainamide 20mg/min
- Elective synchronized cardioversion
- Adenosine may be used for diagnosis and treatment only if:
- Rhythm is regular and monomorphic
- Antiarrhytmics
- 2. SVT w/ aberrancy
Irregular Wide Comlex
- DO NOT use AV nodal blockers!
- Can precipitate V-Fib
- 1. A fib w/ preexcitation
- 1st line - electric cardioversion
- 2nd line - Procainamide, amiodarone, or sotalol
- 2. A fib w/ aberrancy
- 3. Polymorphic V-Tach / Torsades
- Emergent defibrillation
- Correct electrolyte abnormalities
- HypoK, hypoMag
- Stop prolonged QT meds
Treatable Conditions
Condition | Common clinical settings | Corrective actions |
Acidosis | Preexisting acidosis, DM, diarrhea, drugs and toxins, prolonged resuscitation, renal disease, shock | Reassess adequacy of oxygenation, and ventilation; reconfirm endotracheal-tube placement |
Hyperventilate | ||
Consider intravenous bicarbonate if pH <7.20 after above actions have been taken | ||
Cardiac tamponade | Hemorrhagic diathesis, cancer, pericarditis, trauma, after cardiac surgery or MI | Give fluids; obtain bedside echocardiogram |
Perform pericardiocentesis. Immediate surgical intervention is appropriate if pericardiocentesis is unhelpful but cardiac tamponade is known or highly suspected. | ||
Hypothermia | Alcohol abuse, burns, CNS disease, debilitated or elderly patient, drowning, drugs and toxins, endocrine disease, history of exposure, homelessness, extensive skin disease, spinal cord disease, trauma | If severe (temperature <30°C), limit initial shocks for V-Fib or pulseless V-Tach to three; initiate active internal rewarming and cardiopulmonary support. Hold further resuscitation medications or shocks until core temperature is >30°C. |
If moderate (temperature 30-34°C), proceed with resuscitation (space medications at intervals greater than usual), actively rewarm truncal body areas | ||
Hypovolemia, hemorrhage, anemia | Major burns, DM, GI losses, hemorrhage, hemorrhagic diathesis, cancer, pregnancy, shock, trauma | Give fluids |
Transfuse pRBCs if hemorrhage or profound anemia is present | ||
Thoracotomy is appropriate when pt has cardiac arrest from penetrating trauma and a cardiac rhythm and the duration of cardiopulmonary resuscitation before thoracotomy is <10 min | ||
Hypoxia | Consider in all patients with cardiac arrest | Reassess technical quality of cardiopulmonary resuscitation, oxygenation, and ventilation; reconfirm ETT placement |
Hypomagnesemia | Alcohol abuse, burns, DKA, severe diarrhea, diuretics, drugs (eg, cisplatin, cyclosporine, pentamidine) | Give 1-2 g magnesium sulfate intravenously over 2 min |
Source
- AHA 2010 Guidelines for ACLS