ACLS

Question 1

Cardiac Arrest Rhythms (Pulseless):
Rhythm is NOT Shockable

Pulseless Electrical Activity (PEA)

Treatment for asystole and PEA consists of early identification and treatment of reversible causes and excellent CPR with vasopressor administration

Answer 1

Circulation (high quality, uninterrupted CPR immediately), Airway, Breathing

CPR for 2 minutes while establish IV access

Give epinephrine 1 mg IVP every 3-5 minutes OR
vasopressin 40 units IVP to replace 1st or 2nd dose of epinephrine

CPR for 2 minutes; check for shockable rhythm and give epinephrine or vasopressin

Check for shockable rhythm continue CPR
CORRECT UNDERLYING CAUSES

Question 2

Pulseless Electrical Activity (PEA)

Answer 2

The myocardium is exhibiting electrical activity but the ventricles are unable to contract

Results from a variety of causes (H’s and T’s)

Cardiac Arrest Rhythms (Pulseless):
Rhythm is NOT Shockable

Question 3

Asystole

Lack of electrical activity (flat line)

End stage terminal rhythm after treatment fails in prolonged VF or PEA

Poorest prognosis

Answer 3

Cardiac Arrest Rhythms (Pulseless):

Rhythm is NOT Shockable

Question 4

Underlying Reversible Causes of Asystole and PEA

Drugs

Answer 4

Opioids, B-Blockers, calcium channel blockers, digoxin, cocaine, tricyclic antidepressants, local anesthetics, carbon monoxide, and cyanide

OVERDOSE

Question 5

Underlying Reversible Causes of Asystole and PEA

H’s and T’s

Answer 5

H’s 
Hypovolemia***
Hypoxemia
Hydrogen Ion (Acidosis)
Hypokalemia/ Hyperkalemia***
Hypothermia
Hypoglycemia

T’s 
Toxin (drug overdose)*
Tamponade (cardiac)
Thrombosis (coronary and pulmonary)
Tension pneumothorax
Trauma

Question 6

Pulseless Cardiac Arrest Rhythms

Pulseless VT/VF -shocks should be delivered promptly

Answer 6

High-quality CPR is key!

Question 7

Pulseless Cardiac Arrest Rhythms

Shockable Rhythm

Pulseless VT

Answer 7

VT can also cause the heart to beat irregularly, causing the ventricles to “quiver.”
Pulseless VT/VF is considered a MEDICAL EMERGENCY

Circulation (high quality, uninterrupted CPR immediately), Airway, Breathing

• 1 shock via defibrillator and continue CPR for 2 minutes while establish IV access
• Immediately resume CPR for 2 minutes and check rhythm
• 1 shock via defibrillator and continue CPR for 2 minutes
• Identify and treat possible reversible causes f cardiac arrest
• Give epinephrine 1 mg IVP every 3-5 minutes OR
• vasopressin 40 units IVP to replace 1st or 2nd dose of epinephrine**
• CPR for 2 minutes; check rhythm and give epinephrine or vasopressin
• Consider amiodarone 300 mg IVP x 1 can repeat 150 mg IVP in 3- 5 minutes if patient remains in pulseless VT/ VF*
• If torsades de pointes give magnesium 1-2 grams IVP**

Question 8

Defibrillation of Pulseless VT/ VF

Biphasic Technology:Dosing protocol should be:
200J-300J-360J

Answer 8

Biphasic waveform sends current one way at the start of the shock and then reverses it so the current flows in the opposite direction.

Question 9

Epinephrine

Answer 9

1 mg IV push or IO

Can also be given via ET tube 2–2.5 mg (diluted in 10 mL sterile water)

Repeat every 3 to 5 minutes

Question 10

Vasopressin

Answer 10

Dose:
40 units x 1 dose IV/IO (also can give via ET tube)
Half-life is 10- 20 minutes, therefore repeat dosing is not indicated

May replace either 1st or 2nd epinephrine dose

Question 11

Antiarrhythmics

If VF/pulseless VT exists after 2 –3 shocks plus CPR and administration of a vasopressor, consider antiarrhythmic medication

Amiodarone and Lidocaine

Answer 11

Amiodarone and Lidocaine

Amiodarone is considered 1st line -1st line antiarrhythmic agent for pulseless VT/ VF

No effect on survival to hospital discharge

Question 12

Amiodarone

AE

Answer 12

Hypotension, bradycardia, AV block, QT prolongation

Polyvinyl chloride bags absorb amiodarone

Concentrations > 2 mg /mL require a central line for administration (phlebitis)

Question 13

Amiodarone

Answer 13

Initial bolus dose: 300 mg IVP

Additional bolus (if required): 150 mg IVP if pulseless VT/ VF continues

Continuous IV Infusion: return of spontaneous circulation and once stable rhythm occurs

Question 14

Lidocaine

Answer 14

Alternative to amiodarone if not available

Question 15

Treatment of Torsades de Pointes

Remove and correct underlying causes (i.e. medications which increasing QT interval)

(2)Treat electrolyte abnormalities (i.e. magnesium and potassium repletion

Potassium Chloride

Normal potassium level
(3.5- 5.0 mEq/L)

Answer 15

CODE situation can administer 10 mEq IVP of potassium over 5 minutes

Potassium IV continuous infusion: only

Potassium IV continuous infusion: only
–>Rate should NOT exceed 10 mEq/hour when administering it via PERIPHERAL line and 20 mEq/hour when administered via CENTRAL line

Maximum:Generally check potassium levels after giving 40 mEq IV

Question 16

Magnesium Sulfate

Effective for TdP, even in the absence of hypomagnesemia

Answer 16

Dose: 1-2 grams IV

Question 17

CPR Quality

Answer 17

If no advanced airway, 30:2
compression-ventilation ratio

If advanced airway (i.e. endotracheal tube), continuous compressions (100 compressions/minute) and ventilate 8-10 times/minute or 1 breath every 6-8 seconds

Question 18

Tachycardia with a Pulse

NO CPR

Answer 18

Stable narrow QRS complex tachycardia (with a pulse and hemodynamically stable) Supraventricular Tachycardia (SVT)

Airway, Breathing, Circulation**

Attempt vagal maneuvers

Adenosine 6 mg IVP (repeat dosing in 1-2 minutes) flush with IV bolus of NS
Repeat with Adenosine 12 mg IVP
Continuous IV β- blockers (i.e. esmolol IV infusion) OR

Continuous IV calcium channel blockers (i.e. diltiazem IV infusion)

Treat underlying causes

Question 19

Tachycardia with a Pulse

Special orders

Answer 19

Attempt vagal maneuvers

Vagel maneuuvers– slows down the conduction of AV nerve. Bare down like your having a bowel movement.

Question 20

Adult Tachycardia with Pulse

Adenosine

Answer 20

Dose: 6 mg IVP followed by IV bolus of NS flush; repeat with 12 mg IVP after 1-2 minutes if needed

Adverse effects (common and transient): chest pain, flushing, headache, and dyspnea

Question 21

Adult Tachycardia with Pulse

Consider continuous IV β- blocker (i.e. esmolol) or IV calcium channel blocker (i.e. diltiazem)

Answer 21

Esmolol

Diltiazem

Question 22

Arrhythmia Management

ACLS chain of survival: Interventions to PREVENT cardiac arrest:

Bradycardia

Tachycardia: Supraventricular Tachycardia (SVT)

Answer 22

Atropine

Drug of choice for acute symptomatic bradycardia
i.e. altered mental status, chest pain, hypotension

Dose: 0.5 mg IV bolus, repeat every 3- 5 minutes (max 3 mg)

Atropine doses

Question 23

Adult Bradycardia with a pulse:

Answer 23

Adult Bradycardia with a pulse:

HR

Question 24

Endotracheal Tube (ET)

LAST LINE

Answer 24

NAVEL- medications absorbed by trachea

Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine

Doses required are 2- 2.5 times of IV dose

Question 25

IV Push (IVP)

Peripheral Line
Central Line

Answer 25

Preferred route of administration–CENTRAL

Central line preferred but must hold CPR for insertion

Fast and convenient-PERIPHERAL-Elevate the arm for 10- 20 seconds (i.e. peripheral line)

After administration of medication must flush with a IV bolus of normal saline(NS) (10- 20 mL) and elevate arm for 10- 20 seconds for peripheral line administration

Use IV and IO routes if possible

Continue CPR while medications are being administered