ACLS

Advanced Cardiac Life Support

RC 275

Defibrillation

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

Automated External Defibrillator

Defibrillation Procedure

Position paddles “Clear” the patient Shock and then

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

Prepare drug therapy

ACLS 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

Oxygen

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

ACLS

IV Fluids

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

TKO – D5W, N/S

Morphine Sulfate

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

minutes Precautions

May cause respiratory depression

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, altered consciousness

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/min for 6 hours than .5mg/min to a maximum daily dose of 2 grams

Contraindications: Cardiogenic shock, profound Sinus

Bradycardia, and 2nd and 3rd degree blocks that 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 pacemakerBradycardia refractory to atropineTorsades 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 may terminate

PSVT (is a backup to Adenosine) as well 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 EffectsHypotensionAsystole!

Propranolol

Beta blocker that may be useful for Vfib and Vtach that has not responded to other therapiesVery 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-2 stimulation, it

increases heart rate,stroke volume 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 increased O2

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 to

hypovolemia 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 mesenteric arteries

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 angina pectoris

Can be given IV, sublingually, as an ointment or a slow 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 in tin foil

Side effects: Hypotension so patient must have continuous

hemodynamic 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

Thrombolytics

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

chest painExamples: TPA/Alteplase(Activase),

Streptokinase Side effects:

Bleeding

ACLS Scenario

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 medical problem?

What therapies should be done? Explain each one.

The EKG began to show:

What is occurring in the heart to cause this arrhythmia?

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

The patient suddenly becomes lifeless and the EKG shows:

Uh oh! What now?

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

What should be done now and why?

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

What needs to be done now?

You saved her! The course is complete!

Bretylium Tosylate (Bretylol)

Indications: Same as lidocaine and procainamide (usually

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

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

Side Effects: N & V Hypotension

Amrinone

Similar to dobutamine Used for refractory CHF IV Dose:

2-15 micrograms/kg/min Side effects:

May worsen ischemia N & V Thrombocytopenia