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ACLS PATIENT ALGORITHMS

Greg Cook’s version of a Phoenix Fire Dpt clasic

Ventricular Fibrillation & Pulseless Ventricular Tachycardia

Asystole

Pulseless Electrical Activity (PEA)

ABCD's

Defibrillate up to 3 times if needed @ 200J,

Persistent or recurrent VF/VT

ABC's

Consider possible causes

PEA Includes:

Perform CPR until defibrillator available VF/VT present on defibrillator

200-300J, 360J (Monophasic) 150 J, 150J, 150J (Biphasic)

Initiate CPR Intubate at once Establish IV access Confirm asystole in 2 leads

hypoxia, hyperkalemia, hypokalemia, preexisting acidosis, OD, hypothermia

EMD, pseudo-EMD, ideoventricular rhythms, ventricular escape rhythms, bradysystolic rhythms ___________________________________

ABC's Initiate CPR Intubate at once

Consider possible causes è

CPR if no pulse Intubate at once Establish IV access

Consider immediate transcutaneous external pacing (TEP) ê

Establish IV access

hypovolemia, hypoxia, cardiac tamponade,

Epinephrine 1:10,000 1.0 mg q 3-5 min IVP

Epinephrine 1:10,000 1.0 mg q 3-5 min IVP ê

tension pneumothorax, hypothermia, pulmonary embolism, drug overdose,

or

Atropine 1 mg IVP. Repeat q 3-5 min up to a

hyperkalemia, acidosis, MI

Vasopressin 40 U IVP (1 time single dose

total dose of 0.04mg/kg (3 mg)

then return to epi)

ê Consider termination of efforts

Epinephrine 1:10,000 1.0 mg q 3-5 min IVP

Defibrillate with up to 360 joules (150J Biphasic) within 30 - 60 seconds after each dose of medication

If absolute bradycardia, (< 60 bpm) or relative bradycardia, give atropine 1 mg IVP and repeat every 3-5 min to a max total dose of 0.04 mg/kg (3 mg)

Consider Antiarrhythmics Amiodarone 300mg IVP (2nd dose 150mg )

Lidocaine 1-1.5 mg/kg IVP q 3-5 min to a total dose of 3 mg/kg

(Consider Mag Sulfate 1-2g IV) (Consider Procainamide 30mg/min) (Consider Bicarb 1 mEq/kg)

Defibrillate 360 joules within 30 - 60 seconds after each dose of medication

2.

ACLS PATIENT ALGORITHMS

Sustained Ventricular Tachycardia with a Pulse (Monomorphic)

Wide-complex Tachycardia of Uncertain Type (Polymorphic)

Bradycardia (HR < 60 beats / min

Stable: (no S/S Preserved Heart Function)

Stable: (Normal Baseline QT Interval)

Stable:

(no S/S)

Assess ABC's, secure airway High -flow oxygen Establish IV access Attach to monitor and assess vital signs

Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

Procainamide 20 mg/min, max. total 17 mg/kg Sotalol 1-1.5mg/kg (give at 10mg/min) Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs)

ê Beta Blocker or Lidocaine 1 - 1.5 mg/kg q 5 - 10 min, may rebolus @ 0.5 - 0.75 mg/kg IVP to a total dose of 3 mg/kg.

Observe and transport. If patient presents with Type II 2nd degree or third degree AV block, be ready to use transcutaneous external pacing (TEP)

Lidocaine 1 - 1.5 mg/kg IVP. Rebolus @ 0.5

Unstable: (S/S present)

 

- 0.75 mg/kg IVP every 5 - 10 min until VT resolves, or until a total dose of 3 mg/kg is given

Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs)

Atropine 0.5 - 1.0 mg IVP, may repeat every 3 - 5 minutes up to a total of 2 mg (may use

Transcutaneous external pacing (TEP)

Synchronized cardioversion 100 J, 200 J, 300J, 360 J

Procainamide 20 - 30 mg/min, max. total 17 mg/kg

up to 3 mg total in severe cases)

Unstable:

(Poor Ejection Fraction)

Pulse present

Sotalol 1-1.5mg/kg (give at 10mg/min)

Synchronized cardioversion

Dopamine 5 - 20

g/kg/min

g/kg/min

 

100 J, 200 J, 300 J, 360 J

Epinephrine infusion 2 - 10

Epinephrine infusion 2 - 10 g/min

g/min

 

High - flow oxygen IV access

Stable: (Long Baseline QT Intervanl, ie.

Correct Electrolytes

Unstable:

May consider isoproterenol 2-10

May consider isoproterenol 2-10

g/min

Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs)

Torsades)

Prepare for Transvenous Pacing

Lidocaine 0.5 - 0.75 mg/kg IVP every 5 - 10 min until VT resolves, or until a total dose of 3 mg/kg is given

Consider: Mag Sulfate 1-2g IV, Overdrive Pacing, Isoproterenol, Phenytoin, Lidocaine

 

Consider sedation

If patient is unstable now or becomes

Synchronized cardioversion 100 J, 200 J, 300 J, 360 J

hemodynamically unstable èPerform synchronized cardioversion @ 100 J, 200 J, 300 J, and 360 J

3.

ACLS PATIENT ALGORITHMS

Supraventricular Tachycardia

 

Atrial Fibrillation and Atrial Flutter

Adult Emergency Cardiac Care

Stable: Do not shock Junctional/multifocal

Stable:

Assess Responsiveness

Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

 

Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

ê Activate EMS ê Call for defibrillator and assess breathing. If

 

Vagal maneuvers

 

ê Consider use of following:

no breathing present, give 2 slow breaths and assess circulation

 

Diltiazem,

-blockers, verapamil, digoxin,

-blockers, verapamil, digoxin,

ê If no pulse, begin CPR until defibrillator is

Adenosine 6 mg, rapid IVP over 1 - 3 sec. If no response, may give a bolus of 12 mg, rapid IVP

procainamide, quinadine, anticoagulants

available, If a pulse is present, begin sequence

over 1 - 3 sec.

May repeat 12 mg bolus in 1 - 2 minutes.

over 1 - 3 sec. May repeat 12 mg bolus in 1 - 2 minutes .

Consider complex width:

Unstable:

Prepare for synchronized cardioversion

of ABC's, high-flow 0 2 , and consider other appropriate treatment algorithms specific to the patient. (i.e., tachycardia, bradycardia, MI, shock / hypotension / pulmonary edema)

 

(consider sedation)

ê

Narrow Complex Normal or elevated BP Varapamil 2.5 - 5 mg IVP Verapamil 5 - 10 mg IVP (in 15 - 30 minutes)

synchronized cardioversion @ 100 J, 200 J, 300 J, 360 J

If pulseless and in VF/VT on monitor, go to VF/VT algorithm

Consider Digoxin,

-blockers, Diltiazem,

-blockers, Diltiazem,

In cases of atrial flutter, the energy required for

If pulseless with electrical activity, go to PEA

 

Ameodorone

 

algorithm.

synchronized cardioversion (unless it's Junctinal)

synchronized cardioversion begins with 50 J.

Narrow Complex èlow or unstable BP synchronized cardioversion

If no electrical activity, go to asystole algorithm.

Wide complexèLidocaine 1 - 1.5 mg/kg IVP Procainamide 20 -30 mg/min, maximum total 17 mg/kg Synchronized cardioversion

 

Unstable: (heart rate > 150)

 

Prepare for synchronized cardioversion (consider sedation)

 

Synchronized Cardioversion at 50 J, 100 J, 200 J, 300 J, and 360 J

4.

ACLS PATIENT ALGORITHMS

Shock, Hypotension and Pulmonary Edema

 

Acute Myocardial Infarction

Assess ABC's, secure airway, high -flow oxygen, obtain IV access Attach to monitor and assess vital signs

Community emphasis on "Call First, Call Fast, Call 911 ê

ê

 

EMS System

 

Define nature of the problem

 

Oxygen, IV, cardiac monitor, vital signs Nitroglycerine

Rate:

Go to the tachycardia or bradycardia algorithm

Pain relief with narcotics

Volume: Administer fluids, cause-specific interventions, consider vasopressors

 

Notification of emergency center Rapid transportation and pre hospital screening for thrombolytic therapy Initiation of thrombolytic therapy ê

Pump: What is the blood pressure

 

Emergency Center

 

"Door to Drug" team protocol approach with rapid triage of patients with chest

SBP<70

1)

250 - 500 cc

SBP 70 - 100

 

DBP>100

pain and clinical decision maker established

Thrombolytic therapy to be initiated within 30 - 60 minutes

1) Dopamine

 

1) Dobutamine

 

(emergency physician, cardiologist, ect.)

fluid challenge

(2.5-20

g/kg/min)

g/kg/min)

 

(2-20

(2-20 g/kg/min)

g/kg/min)

ê

2) Norepinephrine

2) Add Norepi if:

 

2) Nitroprusside

 

ê

(0.5-30

(0.5-30 g/min) 3) Dopamine

g/min)

3) Dopamine

dopamine > 20

g/kg/min

g/kg/min

(0.1-5.0

(0.1-5.0

g/kg/min)

Immediate Assessment:

-vital signs -0 2 saturation

Treatment to consider if evidence of coronary thrombosis:

(5.0-20

(5.0-20 g/kg/min)

g/kg/min)

-start IV

-high flow 0 2

-high flow 0

DBP>110

-12 lead ECG -brief history / physical

-nitroglycerine (SL, paste or spray if SBP >90)

Nitroglycerine

-decide if eligible for thrombolytics

-IV morphine

(10-20

(10-20 g/min)

g/min)

Soon as possible

-PO aspirin

2) Nitroprusside (0.1-5.0 g/kg/min) _________________________________________________________________ _ Consider other actions (especially for patients in pulmonary edema)

2) Nitroprusside (0.1-5.0 g/kg/min) _________________________________________________________________ _ Consider other actions (especially for patients in pulmonary edema) First

First Line:

-chest X-ray -blood studies -consult

-thrombolytics -IV nitroglycerine - -blockers -IV heparin -PTCA -routine lidocaine is not recommended for all MIs

Second Line:

Third Line:

Lasix IV 0.5 - 1.0 mg/kg Nitroglycerine SL Ntg IV (if SBP>100)

Morphine IV 1-3 mg 0 2 / Intubate PRN Nipride IV (if SBP>100)

Morphine IV 1-3 mg 0 / Intubate PRN Nipride IV (if SBP>100)
 

Dopamine IV (if SBP <100) Amrinone 0.75 mg/kg then 5-15

Dobutamine IV (if SBP>100) g/kg/min

Consider Aminophylline, Thrombolytics, & Digoxin