ACLS Flashcards
Cardiac Arrest Algorithm (shockable)
- Start CPR [+give oxygen and attach monitor/defibrillator]
- Determine if rhythm is shockable
- If VF/pVT -> shock as soon as defibrillator is available
- CPR for 2 minutes [+IV/IO access]
- Conduct a rhythm check (and a pulse check).
- If VF/pVT -> shock
- Resume CPR for 2 minutes. Once IV/IO access is available and AFTER the second shock, give epinephrine every 3-5 minutes. [Consider advanced airway, capnography]
- Conduct a rhythm check (and a pulse check).
- If VF/pVT -> shock
- CPR for 2 minutes; give amiodarone (or lidocaine if not available). [Treat reversible causes]
- Return to step 5 until ROSC is achieved -> post-cardiac arrest care album
What rhythms are shockable?
VF and pVT
How does epinephrine work during
Beta-adrenergic effects - vasoconstriction to increase cerebral and coronary blood flow by increasing MAP and aortic diastolic pressure
Why is amiodarone used?
Shown to improve ROSC and hospital admission with refractory VF/pVT
Overall effect of amidoarone?
Lowers defibrillation threshold, making defib more effective; slows the heart
Blocks Na channels at rapid pacing frequencies (class I effect) and exerts a non-competitive anti-sympathetic action (class I effect), as well as lengthening of the cardiac action potential (class III effect)
How does lidocaine work?
Depresses the automaticity of Purkinje fibers, raising the stimulation threshold in the ventricular muscle fibers (decreases likelihood of fibrillation)
Blocks permeability of the neuronal membrane to Na, which results in inhibition of depolarization and the blockade of conduction
What rhythms are not shockable?
Asystole or pulseless electrical activity
Cardiac Arrest Algorithm (non-shockable)
- Start CPR [+give oxygen and attach monitor/defibrillator]
- Determine if rhythm is shockable
- If asystole/PEA -> continue CPR for 2 minutes [+IV/IO access +epinephrine every 3-5 minutes + consider advanced airway/capnography]
- If ever shockable -> other algorithm; if not, continue CPR for 2 minutes and treat reversible causes
- If ROSC -> post-cardiac arrest care algorithm
Bradycardia Algorithm
- Assess appropriateness for clinical condition - HR typically <50/min if bradyarrhythmia (and symptomatic)
- Identify and treat underlying cause; maintain patent airway; assist breathing as necessary, give oxygen if hypoxemic, cardiac monitor to identify rhythm; monitor blood pressure and oximetry; IV access; 12-lead EKG if available (do not delay therapy)
- Hypotension? Acute AMS? Signs of shock? Ischemic chest discomfort? Acute heart failure?
- If adequate perfusion -> monitor and observe.
- If inadequate perfusion -> administer atropine.
- If atropine is ineffective, prepare for transcutaneous pacing or dopamine infusion or epinephrine infusion
- If not efficacious, expert consultation, prepare for transvenous pacing, treat contributing causes
Sequence is determined by severity; may need to implement multiple interventions simultaneously
How does atropine work?
Anticholinergic; treats certain types of bradycardia.
-Blocks action of vagus nerve (increases HR)
What is TCP?
Uses electrodes on the patient’s chest to deliver electrical impulses and override the normal pacemaker
How does dopamine work?
Stimulates the beta-1 receptors, resulting in improved contractility, increased SA node rate, and enhanced impulse conduction in the heart.
Tachycardia algorithm?
If pulses are present, determine whether stable or unstable.
- Assess appropriateness for clinical condition; HR typically 150+
- If tachycardic + pulse present -> identify and treat underlying cause; maintain patent airway; assist breathing as necessary; oxygen if hypoxemic; cardiac monitor to identify rhythm, monitor BP and oximetry
- Unstable if rate related cardiovascular compromise - hypotension, acutely AMS, signs of shock, ischemic chest discomfort, heart failure
- Synchronized cardioversion; establish IV access beforehand if time permits. Consider sedation. Do not delay for this. If regular narrow complex, consider adenosine.
- If stable, evaluate the QRS complex (wide or narrow - 0.12s) and rhythm (irregular or regular)?
- If monomorphic wide-complex - expert consultation (treatment has the potential for harm), obtain IV access and 12-lead EKG, consider ADENOSINE ONLY IF REGULAR AND MONOMORPHIC; consider antiarrhythmic infusion
- If narrow-complex and regular - attempt vagal maneuvers; if unsuccessful, give adenosine. If successful, monitor for recurrence. If recurrence, give adenosine again or other AV nodal-blocking agents such as the non-dihydropyridine calcium channel blockers or beta-blockers. Expert consultation if recurrent.
What does synchronized cardioversion do?
Delivers a shock synchronized with a peak of the QRS complex, the highest point of the R wave; avoids the delivery of shock during repolarization (can precipitate VF)
How does adenosine work?
Slows conduction through the AV node and terminates ~90% of re-entrant tachyarrhythmias within 2 minutes
Does not terminate atrial flutter/fibrillation, but will slow AV conduction, allowing identification of these waves
If the rhythm converts with adenosine, it is most likely ___.
Re-entrant SVT.
When is adenosine contraindicated?
Unstable, irregular, or polymorphic wide-complex tachycardias because it may cause degeneration to VF
Immediate Post-Cardiac Arrest Care Algorithm?
- ROSC
- Ensure adequate airway and support breathing - maintain O2 94+% (use lowest O2 concentration); consider advanced airway and waveform capnography; do not hyperventilation
- Treat hypotension when SBP<90 (IV/IO bolus, vasopressor infusion, consider treatable causes)
- 12-lead EKG to identify STEMI or high suspicion of AMI
- If STEMI or high suspicion of AMI - coronary reperfusion
- If no STEMI, examine ability to follow commands.
- If no, consider initiating targeted temperature management protocols.
- Otherwise, transfer to ICU for advanced critical care
IO access points?
Proximal tibia
Humeral head
Medial malleolus
Sternum
Contraindications to IO access?
Fracture and crush injuries near the access site
Conditions with fragile bones
Previous attempts in the same bone
If infection is present in the overlying tissues
List the 6 team roles in ACLS.
- Compressor
- AED/Monitor/Defibrillator
- Airway
- Team Leader
- IV/IO/Medications
- Timer/Recorder
Doses of the 2 medications given in the arrest algorithm?
Epinephrine - 1 mg every 3-5 minutes
Amiodarone - 300 mg bolus (first dose) 150 mg (second dose)
Shock energy for defibrillation - biphasic vs. monophasic?
Biphasic - manufacturer recommendation; if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered
Monophasic - 360J
If PETCO2 is below ___mmHg, attempt to improve CPR quality.
10
List reversible causes of arrest.
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary
Indicators of ROSC
Pulse and BP
Abrupt sustained increase in PETCO2 (typically 40+ mmHg)
Spontaneous arterial pressure waves with intra-arterial monitoring
When ROSC is achieved, how should the patient be ventilated and oxygenated?
Start at 10 breaths/min and titrate to target PETCO2 for 35-40 mmHg
When feasible, titrate FiO2 to minimum necessary to achieve SPO2 94+%
When ROSC is achieved what IV bolus should be given?
1-2 L NS or LR
When ROSC is achieved, what epinephrine IV infusion should be started?
0.1-0.5 mcg/kg per minute
In a 70kg adult -> 7-35 mcg/minute
When ROSC is achieved, what dopamine IV infusion should be started?
5-10 mcg/kg/minute
When ROSC is achieved, what norepinephrine IV infusion should be started?
0.1-0.5 mcg/kg/minute (7-35 mcg/minute in 70 kg adult)
In bradycardia algorithm, what is the atropine dose?
First dose: 0.5 mg bolus
Repeat every 3-5 minutes
Maximum: 3 mg
In bradycardia algorithm, what is the dopamine IV infusion rate?
2-20 mcg/kg/minute; titrate to patient response, taper slowly
In bradycardia algorithm, what is the epinephrine IV infusion rate?
2-10 mcg/minute infusion, titrate to patient response
Synchronized cardioversion initial recommended doses in tachycardia algorithm?
Narrow regular: 50-100 J
Narrow irregular: 120-200 J biphasic or 200 J monophasic
Wide regular: 100 J
Wide irregular: defibrillation dose (not synchronized)
Adenosine dose in tachycardia algorithm?
First dose: 6 mg rapid IV push followed with NS flush
Second dose: 12 mg if required
Options for antiarrhythmic infusions for stable wide-QRS tachycardia?
- Procainamide IV dose
- Amiodarone IV dose
- Sotalol IV dose
Procainamide dose for stable wide-QRS tachycardia?
20-50 mg/min until arrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHF.
Amiodarone dose for stable wide-QRS tachycardia?
First dose: 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours.
Sotalol dose for stable wide-QRS tachycardia?
100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT
Steps in post-cardiac arrest care?
- Targeted temperature management
- Hemodynamic and ventilation optimization
- Immediate coronary reperfusion w/PCI for eligible patients
- Glycemic control
- Neurologic care and prognostication
Targeted temperature management?
Administer to comatose (ie, lacking meaningful response to verbal commands) adult patients w/ROSC - select and maintain a constant temperature between 32 and 36 C for at least 24 hours
Hemodynamic and ventilation optimization?
Titrate inspired O2 during post-arrest to the lowest level required to achieve an arterial O2 of 94+% when feasible (helps avoid O2 toxicity)
Avoid excessive ventilation by starting ventilation rates at 10/minute - normocarbia (PETCO2 of 30-40 mmHg or PaCO2 of 35-45) [helps avoid adverse hemodynamic effects of increased intrathoracic pressures, potential decreases in cerebral blood flow with lowered CO2)
- Higher PaCO2 may be permissible in those with acute lung injury or higher airway pressures
- Mild hypocapnia might be useful as a temperature measure when treating cerebral edema
- Note that when temperature is below normal, lab values for PaCO2 might be higher than actual values
Titrate fluids and vasoactive/inotropic agents as needed to optimize BP, CO, and systemic perfusion
Immediate coronary reperfusion w/PCI for eligible patients?
If coronary artery occlusion is suspected, transport the patient to a facility capable of PCI
Glycemic control?
Do not attempt to alter glucose concentration within a lower range due to risk of hypoglycemia; no specific range per AHA
Neurologic care and prognostication?
Reliable early prognostication of neurologic outcome is essential; in patients treated with TTM, delay until at least 72 hours after return of normothermia. For those not treated with TTM, the earliest time is 72 hours after cardiac arrest and potentially longer if the residual effect of sedation or paralysis confounds the clinical exam
Define high quality CPR.
- Push hard (at least 2” or 5cm) and fast (100-120/min) + allow complete chest recoil
- Minimize interruptions in compressions
- Avoid excessive ventilation
- Rotate compressor Q2 minutes or sooner if fatigued
- If no advanced airway, 30:2 compression:ventilation ratio
- Use quantitative waveform capnography - if PETCO2 <10, attempt to improve quality
- Intra-arterial pressure - if diastolic phase pressure <20, attempt to improve quality
Shock energy for defibrillation in arrest?
Biphasic: manufacturer recommendation (eg, initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent and higher doses may be considered.
Monophasic: 360 J (same dose for subsequent shocks)
Epinephrine dose and frequency?
1 mg IV/IO Q3-5 minutes
Amiodarone dose and frequency?
300 mg IV/IO bolus - first dose
150 mg IV/IO bolus - second dose
Clues to ROSC?
- Pulse and BP
- Abrupt sustained increase in PETCO2 [typically 40+]
- Spontaneous arterial pressure waves with intra-artierla monitoring
What is the role of vasopressin in the arrest pathway?
None - removed, as it offers no advantage as a substitute to epinephrine
Lidocaine dose if amio is not available?
1-1.5 mg/kg IV/IO first dose
0.75 mg/kg IV/IO at 5-10 minute intervals to a maximum dose of 3 mg/kg
What medication should be considered for torsades de pointes associated w/a long QT interval? What is another indication for this medication?
Magnesium sulfate
Patients with known or suspected low serum magnesium such as patients w/alcoholism or other conditions associated with malnutrition or hypomagnesemia
How does mag sulfate work?
Na/K pump agonist
Suppresses atrial L and T-type calcium channels and ventricular after depolarization
Remember that this prevents recurrent or treats persistent VT associated with torsades de pointes
Dose of mag sulfate?
Loading dose of 1-2 g IV/IO diluted in 10 mL (D5W or NS), given as IV/IO bolus, typically over 5-20 minutes
Treatment of VF/pVT in hypothermia?
Engage in active rewarming
If moderate hypothermia (30-34 C), give medications spaced at longer intervals and provide active core rewarming in addition to CPR and defibrillation
How should medications be delivered if via peripheral IV?
Takes 1-2 minutes to reach the central circulation
Give via bolus injection unless otherwise specified
Follow w/a 20 mL bolus of IV fluid
Elevate the extremity for about 10-20 seconds to facilitate delivery of the drug to the central circulation
Dose of naloxone to give if suspecting opioid-associated arrest?
2 mg IN or 0.4 mg IM; may repeat after 4 minutes
PEA encompasses a heterogenous group of rhythms that are organized or semiorganized but lack a palpable pulse and include…
- Idioventricular rhythms
- Ventricular escape rhythms
- Post-defibrillation idioventricular rhythms
- Sinus rhythm
- Other
Describe what happens in PEA.
Typically, there is weak contractile function insufficient to produce a pulse or effective CO; most common initial condition after a successful defibrillation. PEA also includes other conditions where the heart is empty due to inadequate preload (hypovolemia or decrease venous return)
IV/IO access takes priority over advanced airway management in PEA/asystole except in what situations?
BMV is ineffective
Arrest is 2/2 hypoxia
You need to confirm that a flat line on the monitor is true asystole and not what other 2 possible conditions?
Not another rhythm (eg, fine VF) masquerading as a flat line
Not the result of an operator error (confirm that leads are not loose and are indeed connected, that the power is on, and that the signal gain is sufficiently high)
Reasons to stop resuscitative efforts?
- Rigor mortis
- Indicators of DNAR status
- Threat to safety of providers
How can asystole be used as an end point?
Often represents the final rhythm; prolonged efforts are unnecessary or futile. Consider stopping if ETCO2 is <10 after 20 minutes of CPR
