ACLS

Advanced Cardiac Life SupportAdvanced Cardiac Life Support

RC 275RC 275

Defibrillation

External depolarization of the heart to External depolarization of the heart to stop Vfib or Vtach (that has not stop Vfib or Vtach (that has not responded to other maneuvers)responded to other maneuvers)

Automated External Defibrillator

Defibrillation Procedure

Position paddlesPosition paddles ““Clear” the patientClear” the patient Shock and then Shock and then

resume CPR for 5 resume CPR for 5 cycles then re-analyze cycles then re-analyze after each shockafter each shock

Prepare drug therapyPrepare drug therapy

ACLS Drug Therapy

Routes of Administration

Peripheral IV – easiest to insert during CPRPeripheral IV – easiest to insert during CPR Central IV – fast onset of actionCentral IV – fast onset of action Intratracheally (down an ET tube)Intratracheally (down an ET tube) Intraosseous – alternative IV route in pedsIntraosseous – alternative IV route in peds

Oxygen

FIO2 100%FIO2 100% Assist VentilationAssist Ventilation O2 Toxicity should not be a concern during O2 Toxicity should not be a concern during

ACLSACLS

IV Fluids

Volume Expanders – crystalloids , eg Volume Expanders – crystalloids , eg Ringer’s lactate, N/S, or colloids, eg Ringer’s lactate, N/S, or colloids, eg Albumin or HetastarchAlbumin or Hetastarch

TKO – D5W, N/STKO – D5W, N/S

Morphine Sulfate

Drug of choice for painDrug of choice for pain Also decreases pre-loadAlso decreases pre-load IV dose – 2-4 mg as often as every 5 IV dose – 2-4 mg as often as every 5

minutesminutes PrecautionsPrecautions

May cause respiratory depressionMay cause respiratory depression

The Following Drugs Help to Control Heart Rate & Rhythm

Lidocaine

Indications: Indications: PVCs, Vtach, VfibPVCs, Vtach, Vfib Can be toxic so no longer given prophylacticallyCan be toxic so no longer given prophylactically

IV dose :IV dose : 1-1.5 mg/kg bolus then continuous infusion of 1-1.5 mg/kg bolus then continuous infusion of

2-4 mg/min2-4 mg/min Can be given down ET tubeCan be given down ET tube

Signs of toxicity: Signs of toxicity: slurred speech, seizures, altered consciousnessslurred speech, seizures, altered consciousness

Amiodarone (Cordarone) Indications:Indications:

Like Lidocaine – Vtach, VfibLike Lidocaine – Vtach, Vfib IV Dose:IV Dose:

300 mg in 20-30 ml of N/S or D5W300 mg in 20-30 ml of N/S or D5W Supplemental dose of 150 mg in 20-30 ml of N/S or D5WSupplemental dose of 150 mg in 20-30 ml of N/S or D5W Followed with continuous infusion of 1 mg/min for 6 hours Followed with continuous infusion of 1 mg/min for 6 hours

than .5mg/min to a maximum daily dose of 2 gramsthan .5mg/min to a maximum daily dose of 2 grams Contraindications:Contraindications:

Cardiogenic shock, profound Sinus Bradycardia, and 2Cardiogenic shock, profound Sinus Bradycardia, and 2ndnd and 3and 3rdrd degree blocks that do not have a pacemaker degree blocks that do not have a pacemaker

Procainamide (Pronestyl)

Indications:Indications: Like lidocaine (is usually a second choice)Like lidocaine (is usually a second choice) Uncontrolled Afib or Atrial flutter if no signs of Uncontrolled Afib or Atrial flutter if no signs of

heart failureheart failure Dose :Dose :

continuous IV infusion. Initially 20mg/min continuous IV infusion. Initially 20mg/min then titrated down to 1-4 mg/minthen titrated down to 1-4 mg/min

Side effectsSide effects HypotensionHypotension Widening of the QRSWidening of the QRS

Atropine Indications:Indications:

Symptomatic sinus bradycardiaSymptomatic sinus bradycardia Second Degree Heart Block Mobitz I Second Degree Heart Block Mobitz I May be tried in asystoleMay be tried in asystole Organophosphate poisoningOrganophosphate poisoning

IV Dose:IV Dose: .5 – 1 mg every 3-5 minutes.5 – 1 mg every 3-5 minutes Max dose is .04mg/kgMax dose is .04mg/kg Can be given down ET tubeCan be given down ET tube

Side Effects:Side Effects: May worsen ischemiaMay worsen ischemia

Isoproterenol (Isuprel)

Indications:Indications: Temporary stimulant prior to pacemakerTemporary stimulant prior to pacemaker Bradycardia refractory to atropineBradycardia refractory to atropine Torsades de Pointes refractory to Torsades de Pointes refractory to

magnesium sulfatemagnesium sulfate IV dose:IV dose:

Continuous infusion of 2-10 Continuous infusion of 2-10 micrograms/ml of infusion fluidmicrograms/ml of infusion fluid

Adenosine Indication: Indication:

PSVTPSVT IV Dose:IV Dose:

6 mg bolus followed by 12 mg in 1-2 minutes if needed6 mg bolus followed by 12 mg in 1-2 minutes if needed Side Effects:Side Effects:

FlushingFlushing DyspneaDyspnea Chest PainChest Pain Sinus BradySinus Brady PVCsPVCs

Verapamil

Indications:Indications: Is a calcium channel blocker that may terminate Is a calcium channel blocker that may terminate

PSVT (is a backup to Adenosine) as well as PSVT (is a backup to Adenosine) as well as atrial flutter and uncontrolled atrial fibatrial flutter and uncontrolled atrial fib

IV Dose:IV Dose: 2.5-5 mg over 2 minutes up to 20 mg2.5-5 mg over 2 minutes up to 20 mg

Side Effects:Side Effects: HypotensionHypotension N & VN & V

Magnesium

Used for refractory Vfib or Vtach caused by Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointeshypomagnesemia and Torsades de Pointes

Dose:Dose: 1-2 grams over 2 minutes1-2 grams over 2 minutes

Side EffectsSide Effects HypotensionHypotension Asystole!Asystole!

Propranolol

Beta blocker that may be useful for Vfib Beta blocker that may be useful for Vfib and Vtach that has not responded to other and Vtach that has not responded to other therapiestherapies Very useful for patients whose cardiac Very useful for patients whose cardiac

emergency was precipitated by emergency was precipitated by hypertensionhypertension

Also used for Afib, Aflutter, & PSVTAlso used for Afib, Aflutter, & PSVT

The Following Drugs Improve Cardiac Output &Blood Pressure

Epinephrine Because of alpha, beta-1, and beta-2 stimulation, it increases Because of alpha, beta-1, and beta-2 stimulation, it increases

heart rate,stroke volume and blood pressureheart rate,stroke volume and blood pressure Helps convert fine vfib to coarse VfibHelps convert fine vfib to coarse Vfib May help in asystoleMay help in asystole Also PEA and symptomatic bradycardiaAlso PEA and symptomatic bradycardia

IV Dose:IV Dose: 1 mg every 3-5 minutes1 mg every 3-5 minutes Can be given down the ET tubeCan be given down the ET tube Can also be given intracardiacCan also be given intracardiac May increase ischemia because of increased O2 demand May increase ischemia because of increased O2 demand

by the heartby the heart

Vasopressin (ADH)

Similar effects to Epinephrine Similar effects to Epinephrine without as without as much cardiovascular side effects!much cardiovascular side effects!

IV dose = 40 IUIV dose = 40 IU Can be given down ET tubeCan be given down ET tube May May be better for asystolebe better for asystole

Norepinephrine (Levarterenol)

Similar in effect to epinephrineSimilar in effect to epinephrine Used for severe hypotension that is NOT due to Used for severe hypotension that is NOT due to

hypovolemiahypovolemia Cardiogenic shockCardiogenic shock Administered as a continuous infusionAdministered as a continuous infusion

Adult rate is usually 2-12 micrograms/minAdult rate is usually 2-12 micrograms/min Range is .5-1 microgram up to 30!Range is .5-1 microgram up to 30!

Side effects:Side effects: Like epinephrine, it may worsen ischemiaLike epinephrine, it may worsen ischemia Extravasation causes tissue necrosisExtravasation causes tissue necrosis

Dopamine

Used for hypotension (not due to hypovolemia)Used for hypotension (not due to hypovolemia) Usually tried before norepinephrineUsually tried before norepinephrine Has alpha, beta, and dopaminergic propertiesHas alpha, beta, and dopaminergic properties

Dopaminergic dilates renal and mesenteric arteriesDopaminergic dilates renal and mesenteric arteries Second choice for bradycardia (after Atropine)Second choice for bradycardia (after Atropine) IV Dose:IV Dose:

1-20 micrograms/kg1-20 micrograms/kg Side effects:Side effects:

Ectopic beatsEctopic beats N & VN & V

Dobutamine

Actions similar to DopamineActions similar to Dopamine Used for CHF with hypotensionUsed for CHF with hypotension IV Dose:IV Dose:

2-20 micrograms/minute2-20 micrograms/minute Side effects:Side effects:

TachycardiaTachycardia N & VN & V HeadacheHeadache TremorsTremors

Digitalis (Digoxin)

Slows conduction through A-V node and increases Slows conduction through A-V node and increases force of contractionforce of contraction

Used in CHF and chronic atrial fib/flutterUsed in CHF and chronic atrial fib/flutter Can be given orally or IVCan be given orally or IV Side effects:Side effects:

ArrhythmiasArrhythmias N & V, diarrheaN & V, diarrhea AgitationAgitation

Nitroglycerin

Vasodilator that helps relieve pain from angina Vasodilator that helps relieve pain from angina pectorispectoris

Can be given IV, sublingually, as an ointment or a Can be given IV, sublingually, as an ointment or a slow release patchslow release patch

Side effects:Side effects: HeadacheHeadache HypotensionHypotension SyncopeSyncope V/Q mismatchV/Q mismatch

Sodium Nitroprusside (Nipride)

Vasodilator used for hypertensive crisisVasodilator used for hypertensive crisis IV dose:IV dose:

Loading dose of 50 –100 mg followed by Loading dose of 50 –100 mg followed by infusion of .5-8 micrograms/kg/mininfusion of .5-8 micrograms/kg/min

Is light sensitive so IV bag must be wrapped in Is light sensitive so IV bag must be wrapped in tin foiltin foil

Side effects:Side effects: Hypotension so patient must have continuous Hypotension so patient must have continuous

hemodynamic monitoringhemodynamic monitoring

Sodium Bicarbonate

Used for Used for METABOLICMETABOLIC acidosis hyperkalemia acidosis hyperkalemia H + HCO3 >H2CO3>H2O and CO2H + HCO3 >H2CO3>H2O and CO2 Airway and ventilation have to be functional!Airway and ventilation have to be functional!

IV Dose:IV Dose: 1 mEq/kg 1 mEq/kg If ABGs, [BE] x wt in kg/6If ABGs, [BE] x wt in kg/6

Side effects:Side effects: Metabolic alkalosisMetabolic alkalosis Increased CO2 productionIncreased CO2 production

Thrombolytics

Used to improve coronary blood flow by Used to improve coronary blood flow by lysing clots, ie coronary thrombosislysing clots, ie coronary thrombosis Best if given within six hours of onset of Best if given within six hours of onset of

chest painchest pain Examples: TPA/Alteplase(Activase), Examples: TPA/Alteplase(Activase),

StreptokinaseStreptokinase Side effects:Side effects:

BleedingBleeding

ACLS Scenario

You Run the Code!You Run the Code!

A 62 year old female is admitted to the ER with chest pain, dyspnea, and moist, gurgling crackles. She appears in acute distress and is cyanotic. Vital signs are: P =110, R = 20, BP = 80/40.

Cardiac monitoring is initiated and the following EKG is observed:

What is the patients arrhythmia and probable What is the patients arrhythmia and probable medical problem?medical problem?

What therapies should be done? Explain each one.What therapies should be done? Explain each one.

The EKG began to show:

What is occurring in the heart to cause this What is occurring in the heart to cause this arrhythmia?arrhythmia?

How is this treated?How is this treated? What other arrhythmias may occur now?What other arrhythmias may occur now?

The patient suddenly becomes lifeless and the EKG shows:

Uh oh! What now?Uh oh! What now?

The treatment(s) are unsuccessful and the following EKG appears:

What should be done now and why?What should be done now and why?

Finally, the following EKG is obtained. However, BP is 40/0

What needs to be done now?What needs to be done now?

You saved her! The course is complete!

Bretylium Tosylate (Bretylol)

Indications: Indications: Same as lidocaine and procainamide (usually Same as lidocaine and procainamide (usually

when condition doesn’t respond to these two)when condition doesn’t respond to these two) IV dose:IV dose:

5-10mg/kg bolus followed by continuous 5-10mg/kg bolus followed by continuous infusion of 1-2 kg/mininfusion of 1-2 kg/min

Side Effects:Side Effects: N & VN & V HypotensionHypotension

Amrinone

Similar to dobutamineSimilar to dobutamine Used for refractory CHFUsed for refractory CHF IV Dose:IV Dose:

2-15 micrograms/kg/min2-15 micrograms/kg/min Side effects:Side effects:

May worsen ischemiaMay worsen ischemia N & VN & V ThrombocytopeniaThrombocytopenia