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Advanced Cardiac Life Support

(ACLS)

Novita Sari

I1A007066

TUGAS UJIAN



Pendahuluan

• Penyebab kematian mendadak paling banyak disebabkan

masalah jantung atau Kematian Jantung Mendadak yang

berkaitan dengan penyakit jantung koroner, dan gangguan irama

jantung.

• Kasus yang paling sering adalah fibrilasi ventrikel 75-80% kasus,dan bradiaritmia sekitar 5-10%.

• Insiden kematian jantung mendadak dilaporkan 0.36 - 1.28 per

1000 penduduk di negara barat per tahun.



Pendahuluan

• Advanced Cardiovascular Life Support adalah serangkaian

penanganan klinis Resusitasi orang/pasien dengan henti jantung,

dalam upaya mengembalikan sirkulasi ke sirkulasi spontan

dengan tekanan darah yang adekwat secara langsung berkaitan

dengan jantung dan pembuluh darah (Kardiovaskuler).



Automated External Defibrillator



Defibrillation Procedure

• Position paddles

• “Clear” the patient

• Shock and then

resume CPR for 5cycles then re-

analyze after each

shock

• Prepare drug

therapy



Routes of Administration

• Peripheral IV – easiest to insert during CPR

• Central IV – fast onset of action

• Intratracheally (down an ET tube)

• Intraosseous – alternative IV route in peds







Basic Rhythm Analysis

• Rate – too fast or too slow?

• Rhythm – regular or irregular?

• Is there a normal looking QRS? Is it wide or narrow?

• Are P waves present?

9



Lethal Rhythms

• Shockable (Defibrillation)

– Ventricular fibrillation

– Pulseless ventricular tachycardia

• Non-shockable

– Asystole

– Pulseless electrical activity

10



Non-Lethal Rhythms

• Too fast (tachycardias)

– Sinus

– Supraventricular (including a-fib/flutter)

– Ventricular

• Too slow (bradycardias)

– Sinus

– Heart block (1°, 2°, 3° AV block)

11



Ventricular Fibrillation

• Rapid and irregular

• No normal P waves or QRS complexes

12



VF / Pulseless VT

13



Ventricular Tachycardia

• Rapid and regular

• No P waves

• Wide QRS complexes14



Treatment of VT

• If pulseless - follow VF algorithm

• If stable try anti-arrhythmics

– Amiodarone

– Lidocaine

– Procainamide?

15



Pulseless Electrical Activity

• Any organized (or semi-organized) electrical activity in a patient without a

detectable pulse

• Non-perfusing

• Treat the patient NOT the monitor

• Find and treat the cause!!!!!

16



PEA and Asystole

17



So what causes PEA?

• #1 cause of PEA in adults is hypovolemia

• #1 cause in children is hypoxia/respiratory arrest

• Other causes?

18



Reversible Causa

The H’s and T’s

• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hyper-/hypokalemia• Hypothermia

• Hypoglycemia

• Toxins

• Tamponade

• Tension pneumothorax

• Thrombosis (coronary orpulmonary)

• Trauma

19



Treat the H’s and T’s

• Hypovolemia – Volume – IVF, PRBC’s

• Hypoxia – Oxygenate/Ventilate

• Hydrogen ion (acidosis)

– Sodium bicarbonate – Hyperventilation

• Hyper-/hypokalemia – Sodium bicarbonate

– Insulin/glucose

– Calcium

• Hypothermia – Warm -- invasive

• Hypoglycemia – Dextrose

• Toxins – Check levels

– Charcoal

– Antidotes

• Tamponade

– pericardiocentesis• Tension pneumothorax – Needle decompression

– Tube thoracostomy

• Thrombosis (coronary or pulmonary) – Thrombolytics

– OR/cath lab• Trauma

20



Tachycardia

Lots of options

based on rhythm

Stable?

Shock

Unstable?

Evaluate Patient

• Treat the patient NOT the monitor!!!

21



Stable Tachycardias

• Narrow complex?

– Regular rhythm

• Sinus tachycardia

• SVT

• AV nodal reentry

– Irregular rhythm

• Atrial fibrillation

• Atrial flutter

• Wide complex?

– Uncertain rhythm – assume

VT

– Narrow complex tachycardia

with aberrancy

– Ventricular tachycardia

• Monomorphic or polymorphic

22



Atrial fibrillation/flutter

• May be rapid

• Irregular (fib) or more regular (flutter)

• No P waves, narrow QRS

23



Atrial fibrillation/flutter

• Treatment based on patient’s clinical picture

– Unstable = Immediate electrical cardioversion

– Stable

• Control the rate – Diltiazem

– Esmolol (not if EF < 40%)

– Digoxin

• Provide anticoagulation

• Treat the patient NOT the monitor!!!

24



Supraventricular Tachycardia

• Rapid (usually 150-250 bpm) and regular• P waves cannot be positively identified

• QRS narrow

25Displaced, Wikimedia Commons

http://commons.wikimedia.org/wiki/File:SVT_Lead_II.JPG

http://commons.wikimedia.org/wiki/File:SVT_Lead_II.JPG



Treatment of Stable SVT

• Consider vagal maneuvers

– Carotid sinus massage

– Valsalva

– Eyeball massage

– Ice water to face

– Digital rectal exam

• Adenosine

– 6 mg, 12 mg, 12 mg

26



Treatment of Unstable SVT

• Electrical Cardioversion

• Cardioversion is not defibrillation

• Use defibrillator in “sync” mode

– prevents delivering energy in the wrong part of the cardiac cycle (R on

T phenomenon)

27



Electrical Cardioversion

• Energy level – somewhat controversial

• 100 J→200J→300J→360J

• Atrial flutter may convert with lower energy

– 50J

• For polymorphic VT – start with 200J

• The EP guys tend to start with 360J

28



Electrical Cardioversion

• Be prepared

– Patient on monitor, IV, Oxygen

– Suction ready and working

– Airway supplies ready

• Pre-medicate whenever possible

– Conscious sedation

– Electrical shocks are painful!

29



Bradycardias

• Many possible causes

– Enhanced parasympathetic tone

– Increased ICP.

– Hypothyroidism

– Hypothermia

– Hyperkalemia

– Hypoglycemia

– Drug therapy

30



Bradycardias

• Treat only symptomatic bradycardias

– Ask if the bradycardia causing the symptoms

• Recognize the red flag bradycardias

– Second degree type II block

– Third degree block

31



Source unknown32





Bradycardia Treatment

• Medications

– Vagolytic

• Atropine

– Adrenergic

• Epinephrine

• Dopamine

34







The Following Drugs Help to Control Heart

Rate & Rhythm



Lidocaine

• Indications:

– PVCs, Vtach, Vfib

– Can be toxic so no longer given

prophylactically• IV dose :

– 1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min

– Can be given down ET tube• Signs of toxicity:

– slurred speech, seizures, alteredconsciousness



Amiodarone (Cordarone)

• Indications: – Like Lidocaine – Vtach, Vfib

• IV Dose:

– 300 mg in 20-30 ml of N/S or D5W

– Supplemental dose of 150 mg in 20-30 ml of N/S or D5W

– Followed with continuous infusion of 1 mg/minfor 6 hours than .5mg/min to a maximum dailydose of 2 grams

• Contraindications: – Cardiogenic shock, profound Sinus

Bradycardia, and 2nd and 3rd degree blocksthat do not have a pacemaker



Procainamide (Pronestyl)

• Indications: – Like lidocaine (is usually a second choice)

– Uncontrolled Afib or Atrial flutter if no signs of heart failure

• Dose : – continuous IV infusion. Initially 20mg/min

then titrated down to 1-4 mg/min

• Side effects

– Hypotension – Widening of the QRS



Atropine

• Indications:

– Symptomatic sinus bradycardia

– Second Degree Heart Block Mobitz I

– May be tried in asystole – Organophosphate poisoning

• IV Dose:

– .5 – 1 mg every 3-5 minutes

– Max dose is .04mg/kg – Can be given down ET tube

• Side Effects:

– May worsen ischemia



Isoproterenol (Isuprel)

• Indications:

– Temporary stimulant prior to pacemaker

– Bradycardia refractory to atropine

– Torsades de Pointes refractory to magnesium sulfate

• IV dose: – Continuous infusion of 2-10 micrograms/ml of infusion fluid



Adenosine

• Indication:

– PSVT

• IV Dose:

– 6 mg bolus followed by 12 mg in 1-2 minutes if needed

• Side Effects:

– Flushing

– Dyspnea

– Chest Pain

– Sinus Brady

– PVCs



Verapamil

• Indications:

– Is a calcium channel blocker that mayterminate PSVT (is a backup to Adenosine) aswell as atrial flutter and uncontrolled atrial fib

• IV Dose:

– 2.5-5 mg over 2 minutes up to 20 mg

• Side Effects:

– Hypotension – N & V



Magnesium

• Used for refractory Vfib or Vtach caused by hypomagnesemia

and Torsades de Pointes

• Dose:

– 1-2 grams over 2 minutes• Side Effects

– Hypotension

– Asystole!



Propranolol

• Beta blocker that may be useful for Vfib and Vtach that has not

responded to other therapies

– Very useful for patients whose cardiac emergency was

precipitated by hypertension

– Also used for Afib, Aflutter, & PSVT



The Following Drugs Improve Cardiac

Output &Blood Pressure



Epinephrine

• Because of alpha, beta-1, and beta-2stimulation, it increases heart rate,strokevolume and blood pressure

– Helps convert fine vfib to coarse Vfib

– May help in asystole – Also PEA and symptomatic bradycardia

• IV Dose:

– 1 mg every 3-5 minutes

– Can be given down the ET tube – Can also be given intracardiac

– May increase ischemia because of increasedO2 demand by the heart



Vasopressin (ADH)

• Similar effects to Epinephrine without as much cardiovascular

side effects!

• IV dose = 40 IU

• Can be given down ET tube

• May be better for asystole



Norepinephrine (Levarterenol)

• Similar in effect to epinephrine

• Used for severe hypotension that is NOT due tohypovolemia

• Cardiogenic shock

• Administered as a continuous infusion – Adult rate is usually 2-12 micrograms/min

– Range is .5-1 microgram up to 30!

• Side effects:

– Like epinephrine, it may worsen ischemia – Extravasation causes tissue necrosis



Dopamine

• Used for hypotension (not due to hypovolemia) – Usually tried before norepinephrine

– Has alpha, beta, and dopaminergic properties

• Dopaminergic dilates renal and mesentericarteries

• Second choice for bradycardia (after Atropine)

• IV Dose:

– 1-20 micrograms/kg

• Side effects:

– Ectopic beats

– N & V



Dobutamine

• Actions similar to Dopamine• Used for CHF with hypotension

• IV Dose:

– 2-20 micrograms/minute

• Side effects:

– Tachycardia

– N & V

– Headache – Tremors



Digitalis (Digoxin)

• Slows conduction through A-V node and increases

force of contraction

• Used in CHF and chronic atrial fib/flutter

• Can be given orally or IV• Side effects:

– Arrhythmias

– N & V, diarrhea – Agitation



Nitroglycerin

• Vasodilator that helps relieve pain from anginapectoris

• Can be given IV, sublingually, as an ointment or aslow release patch

• Side effects:

– Headache

– Hypotension

– Syncope – V/Q mismatch



Sodium Nitroprusside (Nipride)

• Vasodilator used for hypertensive crisis

• IV dose:

– Loading dose of 50 –100 mg followed by infusion

of .5-8 micrograms/kg/min – Is light sensitive so IV bag must be wrapped intin foil

• Side effects:

– Hypotension so patient must have continuoushemodynamic monitoring



Sodium Bicarbonate

• Used for METABOLIC acidosis hyperkalemia

– H + HCO3 >H2CO3>H2O and CO2

– Airway and ventilation have to be functional!

• IV Dose: – 1 mEq/kg

– If ABGs, [BE] x wt in kg/6

• Side effects:

– Metabolic alkalosis

– Increased CO2 production





THANK YOU

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