ACLS Flashcards
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
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
Pulseless Electrical Activity (PEA)
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
Asystole
Lack of electrical activity (flat line)
End stage terminal rhythm after treatment fails in prolonged VF or PEA
Poorest prognosis
Cardiac Arrest Rhythms (Pulseless):
Rhythm is NOT Shockable
Underlying Reversible Causes of Asystole and PEA
Drugs
Opioids, B-Blockers, calcium channel blockers, digoxin, cocaine, tricyclic antidepressants, local anesthetics, carbon monoxide, and cyanide
OVERDOSE
Underlying Reversible Causes of Asystole and PEA
H’s and T’s
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
Pulseless Cardiac Arrest Rhythms
Pulseless VT/VF -shocks should be delivered promptly
High-quality CPR is key!
Pulseless Cardiac Arrest Rhythms
Shockable Rhythm
Pulseless VT
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**
Defibrillation of Pulseless VT/ VF
Biphasic Technology:Dosing protocol should be:
200J-300J-360J
Biphasic waveform sends current one way at the start of the shock and then reverses it so the current flows in the opposite direction.
Epinephrine
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
Vasopressin
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
Antiarrhythmics
If VF/pulseless VT exists after 2 –3 shocks plus CPR and administration of a vasopressor, consider antiarrhythmic medication
Amiodarone and Lidocaine
Amiodarone and Lidocaine
Amiodarone is considered 1st line -1st line antiarrhythmic agent for pulseless VT/ VF
No effect on survival to hospital discharge
Amiodarone
AE
Hypotension, bradycardia, AV block, QT prolongation
Polyvinyl chloride bags absorb amiodarone
Concentrations > 2 mg /mL require a central line for administration (phlebitis)
Amiodarone
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
Lidocaine
Alternative to amiodarone if not available
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)
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
Magnesium Sulfate
Effective for TdP, even in the absence of hypomagnesemia
Dose: 1-2 grams IV
CPR Quality
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
Tachycardia with a Pulse
NO CPR
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
Tachycardia with a Pulse
Special orders
Attempt vagal maneuvers
Vagel maneuuvers– slows down the conduction of AV nerve. Bare down like your having a bowel movement.
Adult Tachycardia with Pulse
Adenosine
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
Adult Tachycardia with Pulse
Consider continuous IV β- blocker (i.e. esmolol) or IV calcium channel blocker (i.e. diltiazem)
Esmolol
Diltiazem
Arrhythmia Management
ACLS chain of survival: Interventions to PREVENT cardiac arrest:
Bradycardia
Tachycardia: Supraventricular Tachycardia (SVT)
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
Adult Bradycardia with a pulse:
Adult Bradycardia with a pulse:
HR
Endotracheal Tube (ET)
LAST LINE
NAVEL- medications absorbed by trachea
Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine
Doses required are 2- 2.5 times of IV dose
IV Push (IVP)
Peripheral Line
Central Line
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
