Asystole...

Check me in another lead, then let's have a cup of TEA." Comments/Dose Only effective with early implementation along with appropriate interventions and medications. Not effective with prolonged down time. E Epinephrine 1 mg IV q3-5 min. A Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg) Consider termination of efforts if asystole persists despite appropriate interventions. Acronym T Intervention Transcutaneous Pacing

Bradycardia...
All Trained Dogs Eat Iams (The sequence reflects interventions for increasingly severe bradycardia) Mnemonic All Trained Dogs Eat Iams Intervention Atropine TCP Dopamine Epinephrine Isoproterenol Comments/Dose 0.5-1.0 mg IV push q 3-5 min(max. dose 0.03-0.04 mg/kg) Use Transcutaneous Pacing (TCP) immediately with severely symptomatic patients 5-20 g/kg/min. 2-10 g/min. 2-10 g/min.

Synchronized Electrical Cardioversion

It is essential that ACLS Providers know the indications for synchronized electrical cardioversion and receive proper training on the equipment their institution uses before attempting to perform this intervention. The following mnemonic directs preparations for synchronized electrical cardioversion: "Oh Say It Isn't So" Mnemonic Oh Say It Isn't So Preparation O2 saturation monitor Suction equipment IV line Intubation equipment Sedation and possibly analgesics

Synchronized Electrical Cardioversion Energy Levels:

Unless otherwise specified in the table below, successive energy levels are *100J, and up to *200J, *300J, *360J, if needed. If the patient's condition becomes critical and your equipment will not synchronize, then proceed with immediate unsynchronized shocks. Rhythm Polymorphic V-tach PSVT, A-flutter Special Notes: *=Or biphasic equivalent Treat polymorphic V-tach like V-fib, i.e., successive unsynchronized shocks at *200J, and up to *200-300J, *360J, if needed. start with *50J

Note: If V-fib develops, immediately defibrillate following the VF algorithm. .

Interventions for pulseless electrical activity are guided by the letters P-E-A:
Intervention Problem Epinephrine Atropine Comments/Dose Search for the probable cause and intervene accordingly. (see PEA Problem Table ) 1 mg IV q3-5 min With slow heart rate, 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)

The acronym "PATCH(4) MD" directs the search for the problem.
Problem Pulmonary Embolism Acidosis (preexisting) Tension pneumothorax Cardiac Tamponade Hyperkalemia (preexisting) Hypothermia Hypovolemia Hypoxia Massive MI Drug Overdose Assess No pulse w/ CPR, JVD Diabetic/renal patient, ABGs No pulse w/ CPR, JVD, tracheal deviation No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest Renal patient, EKG, serum K level Core temperature Collapsed vasculature Airway, cyanosis, ABGs History, EKG Medications, illicit drug use Possible Interventions Thrombolytics, surgery Sodium bicarbonate, hyperventilation Needle thoracostomy Pericardiocentesis Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, kayexalate Hypothermia Algorithm Fluids Oxygen, ventilation Acute Coronary Syndrome algorithm Treat accordingly

Stable Tachycardia Algorithms

Think "O-M-I", (pronounced "oh my") Oxygen-Monitor-IV, even before you start your primary and secondary ABCD surveys. After the failure of one antiarrhythmic drug, electrical cardioversion is usually the next treatment of choice. If the rate is >150 and/or the patient is unstable with serious signs and symptoms due to the rhythm, prepare for immediate electrical cardioversion. Note that amiodarone is listed for most of the stable tachycardias. Knowing the exceptions for the use of amiodarone will aide in the implementation of the stable tachycardia algorithms.

Atrial Fibrillation/Flutter (with/without CHF)

Rate Control Rhythm Conversion *diltiazem Nonemergent chemical or DC cardioversion should be avoided, and when indicated, should only be performed by an experienced health care provider after careful evaluation and thromboembolic precautions are taken

Wolff-Parkinson-White (with/without CHF)

(avoid adenosine, beta blockers, calcium channel blockers, digoxin) Rate Control Rhythm Conversion *amiodarone Nonemergent chemical or DC cardioversion should be avoided, and when indicated, should only be performed by an experienced health care provider after careful evaluation and thromboembolic precautions are taken.

Narrow Complex Tachycardias

| vagal maneuvers | *adenosine / Junctional Tachycardia/Ectopic or Multifocal Atrial Tach (with/without CHF) *amiodarone (no DC Cardioversion) \ Paroxysmal Supraventricular Tachycardia (PSVT) No CHF: *verapamil | DC Cardioversion | *amiodarone With CHF: DC Cardioversion | *digoxin | *amiodarone | *diltiazem

Wide-Complex Tachycardia/Unknown Type

(with/without CHF) (avoid beta blockers, calcium channel blockers, digoxin) | DC Cardioversion or *amiodarone

Ventricular Tachycardia
| DC Cardioversion or trial of medication / \ Monomorphic (with/without CHF) *amiodarone | synchronized cardioversion Polymorphic Evaluate for electrolyte abnormality or drug toxicity and treat accordingly / \ Normal QTI Long QTI | | *amiodarone *magnesium | |

cardioversion

overdrive pacing

* Consult the drug package insert for the appropriate use and dosage. Other drugs or treatments may be indicated, consult your primary ACLS information source. The following mnemonic directs AHA accepted actions after the primary survey ABC's Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better Chant Please Note May be performed immediately after determining pulselessness in a witnessed arrest with no defibrillator immediately available. Check pulse after thump. Shock 200J* If VF or VT is shown on monitor, shock immediately, do not lift paddles from chest after shocking, simultaneously charge at next energy level and evaluate rhythm. Shock 200-300J* If VF or VT persists on monitor, shock immediately, do not check pulse, do not continue CPR, do not lift paddles from chest after shocking, simultaneously charge at next energy level and evaluate rhythm. Shock 360J* If VF or VT persists, shock immediately Implement the secondary ABCD survey. Do not continue with this algorithm if an intervention results in the return of spontaneous circulation. NOTE: When giving med's, do so in a drug-shock-drug-shock sequence. Continue CPR while giving meds, and shock within 30-60 seconds. Evaluate the rhythm and check for a pulse in the period immediately after shocking. Everybody Epinephrine 1 mg IV q3-5 min or eVerybody Vasopressin 40 U IV, one time dose. (wait 10-20 minutes before starting epi) If VF/PVT persists, "CONSIDER" antiarrhythmics and sodium bicarb. CAUTION: Using more than one antiarrhythmic may result in pro-arrhythmic drug-drug interactions. Shock 360J* And Amiodarone 300mg IV push. May repeat once at 150mg in 3-5 min. (max. cumulative (First Choice) dose: 2.2g IV/24hrs.) Let's Lidocaine 1.0-1.5 mg/kg IV. May repeat in 3-5 min. (max. loading dose: 3 mg/kg) Make Magnesium 1-2 g IV (2 min. push) for suspected hypomagnesemia or torsades de Sulfate pointes Patients Procainamide 20 mg/min, or 100 mg IV q 5 min. for refractory VF. (max. loading dose: 17 mg/kg) Consider buffers Better Bicarbonate 1 mEq/kg IV for preexisting hyperkalemia, bicarb-responsive acidosis, some drug overdoses, protracted code (intubated), or return of spontaneous circulation after long code with effective ventilation. Intervention Precordial Thump

*Or equivalent biphasic energy level.