ACLS (Main)

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

ECG Analysis

1. Is the rhythm fast or slow?
2. Are the QRS complexes wide or narrow?
3. Is the rhythm regular or irregular?

V-Fib and Pulseless V-Tach

• 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 of CPR) again fails
  • Amiodarone 300mg w/ repeat dose of 150mg as indicated
  • Magnesium 2g IV, followed by maintenance infusion
    • Only for polymorphic V-tach

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
• TransQ pacing and chronotropes ineffective = need for transvenous pacing

Tachycardia

3 questions

1. Is the pt in a sinus rhythm?
2. Is the QRS wide or narrow?
3. Is the rhythm regular or irregular?

Narrow Regular

• 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

Narrow Irregular

• 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)

Wide Regular

• 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
  • Elective synchronized cardioversion (100J)
  • Adenosine may be used for diagnosis and treatment only if:
    • Rhythm is regular and monomorphic
• 2. SVT w/ aberrancy

Wide Irregular

• 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 (NOT synchronized)
  • Correct electrolyte abnormalities
    • HypoK, hypoMag
  • Stop prolonged QT meds

See Also

ACLS (Treatable Conditions)

Source

• AHA 2010 Guidelines for ACLS