2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science

Advanced cardiovascular life support (ACLS) impacts multiple key links in the chain of survival that include interventions to prevent cardiac arrest, treat cardiac arrest, and improve outcomes of patients who achieve return of spontaneous circulation (ROSC) after cardiac arrest. ACLS interventions aimed at preventing cardiac arrest include airway management, ventilation support, and treatment of bradyarrhythmias and tachyarrhythmias. For the treatment of cardiac arrest, ACLS interventions build on the basic life support (BLS) foundation of immediate recognition and activation of the emergency response system, early CPR, and rapid defibrillation to further increase the likelihood of ROSC with drug therapy, advanced airway management, and physiologic monitoring. Following ROSC, survival and neurologic outcome can be improved with integrated postcardiac arrest care.

Key changes from the 2005 ACLS Guidelines include

Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement. Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of highquality CPR (including chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions and avoiding excessive ventilation). Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole. There is an increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC. Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia. Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide-complex tachycardia.

Chain of Survival
The term Chain of Survival provides a useful metaphor for the elements of the ECC systems concept. The 5 links in the adult Chain of Survival are
Immediate recognition of cardiac arrest and activation of the emergency response system

Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions

 Rapid defibrillation Effective advanced life support Integrated post-cardiac arrest care A strong Chain of Survival can improve chances of survival and recovery for victims of heart attack, stroke and other emergencies.

BLS For Healthcare Providers

This hub introduces the basics of Basic Life Support for healthcare providers, also known as CPR, basic airway management, and use of the AED. The information was taken from the American Heart Association's BLS for Healthcare Providers student manual. Quality CPR improves a patient's chance for survival, although this depends on how effective the CPR being delivered is. The provider must push hard and fast, allow full chest recoil, minimize interruptions, and avoid hyperventilation. CPR itself consists of four main parts: Airway,Breathing, Circulation, and Defibrillation. The Big Picture There are four links in the adult Chain of Survival: early access, early CPR, early defibrillation, early advanced care. Likewise there are four links in the pediatric Chain of Survival: prevention of arrest, early and effective CPR, rapid activation of EMS, early and effective ALS.
1-Rescuer CPR for Adults (Puberty and Older) Assessment (Step 1)- Make sure the scene is safe and check to see if the victim is unconscious by tapping the victim's shoulder and shouting "Are you alright?"

Activate emergency Response System and Get and AED (Step 2)- Activate the emergency response system by shouting for help or calling 911 and retrieving an AED if available. Open Airway and Check Breathing (Step 3)- You must look, listen and feel for breathing. To do this you open the victim's airway with a head tilt-chin lift maneuver and place you ear near the victim's mouth and nose. In this position you look for chest rise, and listen and feel for air movement. This whole step should take between 5 and 10 seconds. Give 2 Rescue Breaths (Step 4)- If there is no adequate breathing, apply a barrier device and give two breaths of one second each while looking for chest rise. Pulse Check (Step 5)- After giving two breaths, a healthcare provider should check for a carotid pulse. You must check for between 5 and 10 seconds. To locate a carotid pulse maintain a head tiltchin lift with on hand, locate the trachea with two or three fingers on the other hand, slide these fingers into the groove between the trachea and the neck muscles. Gently feel for the pulse. Begin Cycles of 30 Chest Compressions and 2 Breaths (Step 6)- If you cannot palpate a carotid pulse, or you are not sure if you feel one, start giving chest compressions. To do so you position yourself at the victim's side and make sure he is on his back on a hard, flat surface with all clothing

removed from his chest. Put the heel of one hand between the nipples, and the heel of your other hand on top of the first hand. Straighten your arms with your shoulders directly above your hands and push HARD and FAST (1 to 2 inches at a rate of 100 compressions per minute). Make sure the chest recoils completely before you push again. Keep interruptions to less than 10 seconds except for intubation, defibrillation, or moving the victim from danger. A slight recap on 1-Rescuer Adult CPR: Check for response, open the airway (heat tilt-chin lift), check for adequate breathing (look, listen, and feel), give two breaths (make the chest rise), check pulse (carotid artery for 5-10 seconds), cycles of 30 compressions and 2 breaths (push hard and fast for 5 cycles). 1-Rescuer CPR for Children (Age 1 Year to Puberty) All CPR follows the same basic algorithm. There are only subtle differences for the physiology of different aged patients. The differences in children's CPR: amount of air for breaths (until the chest rises), possible need to try more than twice to deliver 2 breaths that make the chest rise, depth of compressions (1/3 to 1/2 the depth of the chest), may use one handed compressions for very small children, what to do when the child's pulse is under 60 beats per minute (start CPR), when to attach an AED (after five cycles of CPR), when to activate the emergency response system (after five cycles of CPR unless you witness the child collapsing). Because respiratory problems are the main cause of cardiac arrest in pediatric patients, if you are engaged in 2-rescuer CPR compress and ventilate at a ratio of 15:2. A slight recap on 1-Rescuer Children's CPR: Check for response, open the airway (head tilt-chin lift), check for adequate breathing (look, listen, and feel), give two breaths (make the chest rise, may need to try more than twice), check pulse (carotid artery for 5-10 seconds), cycles of 30 compressions and 2 breaths (push hard and fast for 5 cycles), if alone activate the emergency response system and get the AED. 1-Rescuer CPR for Infants (up to 1 year old) Infant CPR closely follows Children's CPR except for how you perform a head tilt-chin lift (into the neutral sniffing position), and where you check for a pulse (brachial pulse, press two fingers into the infant's arm midway between the shoulder and elbow). In infants too small for normal chest compressions, the rescuer may use a two thumb encircling hands technique. Here you place your thumbs just below the nipple line and place your other four fingers of each hand behind the back. Then use your thumbs to depress the breastbone 1/3 to 1/2 the depth of the infants chest. Do not use an AED on infants. Automated External Defibrillators Only used when victims have the following three clinical findings: no response, no breathing, no pulse. All AEDs are created to be operated the same way. Even then, they have instructions with pictures printed on them so everyone can operate one with little or no experience. The basic actions are as follows: power on the AED (this will activate a voice that gives you directions for all subsequent steps), attach the electrodes to the patients bare chest (choose the correct pad and apply it to the patients bare chest with no sweat or dirt, apply the appropriate one to the upper right chest just below the collar bone, and the other one to the left of the nipple a few inches below the arm pit), "clear" the victim and analyze the rhythm (no one touches the patient during this step and the next step), the AED will then advise you if a shock is needed, shout a clear the patient warning and visualize that no one is touching the patient before you press the shock button, begin two minutes of CPR, then the AED will repeat steps 3 and 4 if necessary.

A quick summary of CPR for Adults, Children, and Infants Adult is defined as puberty and older, child is defined as one year old to puberty, and infant is defined as less than one year old. Establish that the victim does not respond- activate your emergency response system Adult- activate your emergency response system as soon as the victim is found Child/Infant- activate your emergency response system after giving 5 cycles of CPR Open the Airway- use head tilt-chin lift Adult/Child/Infant- head tilt-chin lift (suspected trauma: jaw thrust) Check Breathing- if the victim is not breathing, give 2 breaths that make the chest rise Adult/Child/Infant- Open the airway, look, listen, and feel. Take at least five seconds and no more than ten seconds. First 2 breaths Adult/Child/Infant- Give 2 breaths (1 second each) Check Pulse- at least five seconds and no more than ten seconds Adult- Carotid Pulse (if no pulse, start CPR) Child- Carotid Pulse (if no pulse or pulse is <60 bpm with signs of poor perfusion, start CPR) Infant- Brachial Pulse (if no pulse or pulse is <60 bpm with signs of poor perfusion, start CPR) Start CPR Compression Location Adult/Child- center of breastbone between nipples Infant- just below nipple line on breastbone Compression Method Adult/Child- heel of 1 hand, other hand on top (or 1 hand for small victims) Infant- 2 fingers (2 thumb-encircling hands for 2-rescuer CPR) Compression Depth Adult- 1 to 2 inches Child/Infant- 1/3 to 1/2 depth of chest Compression Rate 100 per minute Compression-Ventilation Ratio Adult- 30:2 (1- or 2-rescuer CPR) Child/Infant- 30:2 for 1-rescuer CPR (15:2 for 2-rescuer CPR)

Advanced Cardiac Life Support guidelines 2011.

Abstract The main emphasis in the Advanced Cardiac Life Support (ACLS) guidelines are in the areas of good quality chest compressions, ensuring normoventilation, removal of atropine from the cardiac arrest algorithm, removal of the use of the endotracheal route for drug administration, and renewed focus on the care provided after return of spontaneous circulation. In addition, the need for monitoring of quality of the various care procedures is emphasized. While the various ACLS procedures are being carried out, there is a need to minimize interruptions to chest compressions for maintenance of coronary perfusion pressures. In addition, the resuscitation team needs to continually look out for reversible causes of the cardiac arrest. ACLS is designed for healthcare professionals who either direct or participate in the management of cardiopulmonary arrest and other cardiovascular emergencies. This includes personnel in emergency response, emergency medicine, intensive care and critical care units.

Defibrillation and Cardioversion

Description Defibrillation - is the treatment for immediately life-threatening arrhythmias with which the patient does not have a pulse, i.e. ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Cardioversion - is any process that aims to convert an arrhythmia back to sinus rhythm. Electrical cardioversion is used when the patient has a pulse but is either unstable, or chemical cardioversion has failed or is unlikely to be successful. These scenarios may be associated with chest pain, pulmonary oedema, syncope or hypotension. It is also used in less urgent cases, e.g. atrial fibrillation (AF) to try to revert the rhythm back to sinus. This article only deals with electrical cardioversion. The aim in both is to deliver electrical energy to the heart to stun the heart momentarily and thus allow a normal sinus rhythm to kick in via the heart's normal electricity centre, i.e. the sinoatrial node.

Cardiac Medications Anticoagulant (Also known as Blood Thinners.) Commonly prescribed include:

Dalteparin (Fragmin), Danaparoid (Orgaran) Enoxaparin (Lovenox) Heparin (various) Tinzaparin (Innohep) Warfarin (Coumadin)

What the Medication Does Decreases the clotting (coagulating) ability of the blood. Sometimes called blood thinners, although they do not actually thin the blood. They do NOT dissolve existing blood clots. Used to treat certain blood vessel, heart and lung conditions. Reason for Medication

Helps to prevent harmful clots from forming in the blood vessels. May prevent the clots from becoming larger and causing more serious problems. Often prescribed to prevent first or recurrent stroke.

Antiplatelet Agents Commonly prescribed include:

Aspirin Ticlopidine Clopidogrel Dipyridamole

What the Medication Does Keeps blood clots from forming by preventing blood platelets from sticking together. Reason for Medication

Helps prevent clotting in patients who have had a heart attack, unstable angina, ischemic strokes, TIA(transient ischemic attacks, or "little strokes") and other forms of cardiovascular disease. Usually prescribed preventively when plaque buildup is evident but there is not yet a large obstruction in the artery.

Angiotensin-Converting Enzyme (ACE) Inhibitors Commonly prescribed include:

Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

What the Medication Does Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart's work easier or more efficient. Reason for Medication

Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure.

Angiotensin II Receptor Blockers (or Inhibitors) (Also known as ARBs, Angiotensin-2 Receptor Antagonists and AT-2) Commonly prescribed include:

Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar) Telmisartan (Micardis) and Valsartan (Diovan)

What the Medication Does Rather than lowering levels of angiotensin II (as ACE inhibitors do) angiotensin II receptor blockers prevent this chemical from having any effects on the heart and blood vessels. This keeps blood pressure from rising. Reason for Medication

Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure.

Beta Blockers (Also known as Beta-Adrenergic Blocking Agents) Commonly prescribed include:

Acebutolol (Sectral) Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol/hydrochlorothiazide (Ziac) Bisoprolol (Zebeta) Carteolol (Cartrol) Metoprolol (Lopressor, Toprol XL) Nadolol (Corgard) Propranolol (Inderal) Sotalol (Betapace) Timolol (Blocadren)

What the Medication Does Decreases the heart rate and cardiac output, which lowers blood pressure and makes the heart beat more slowly and with less force. Reason for Medication

Used to lower blood pressure. Used with therapy for cardiac arrhythmias (abnormal heart rhythms) and in treating chest pain (angina). Used to prevent future heart attacks in patients who have had a heart attack.

Calcium Channel Blockers (Also known as Calcium Antagonists or Calcium Blockers) Commonly prescribed include:

Amlodipine (Norvasc, Lotrel) Bepridil (Vascor) Diltiazem (Cardizem, Tiazac) Felodipine (Plendil) Nifedipine (Adalat, Procardia) Nimodipine (Nimotop) Nisoldipine (Sular) Verapamil (Calan, Isoptin, Verelan)

What the Medication Does Interrupts the movement of calcium into the cells of the heart and blood vessels. May decrease the heart's pumping strength and relax blood vessels. Reason for Medication

Used to treat high blood pressure, chest pain (angina) caused by reduced blood supply to the heart muscle and some arrhythmias (abnormal heart rhythms).

Diuretics (Also known as Water Pills) Commonly prescribed include:

Amiloride (Midamor) Bumetanide (Bumex) Chlorothiazide (Diuril) Chlorthalidone (Hygroton) Furosemide (Lasix) Hydro-chlorothiazide (Esidrix, Hydrodiuril) Indapamide (Lozol) and Spironolactone (Aldactone)

What the Medication Does Causes the body to rid itself of excess fluids and sodium through urination. Helps to relieve the heart's workload. Also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Reason for Medication

Used to help lower blood pressure. Used to help reduce swelling (edema) from excess buildup of fluid in the body.

Vasodilators (Also known as Nitrates. Nitroglycerin tablets are a form of vasodilator.) Commonly prescribed include:

Isosorbide dinitrate (Isordil) Nesiritide (Natrecor) Hydralazine (Apresoline) Nitrates Minoxidil

What the Medication Does Relaxes blood vessels and increases the supply of blood and oxygen to the heart while reducing its workload. Can come in pills to be swallowed, chewable tablets and as a topical application (cream). Reason for Medication

Used to ease chest pain (angina).

Digitalis Preparations (Also known as Digoxin and Digitoxin) Commonly prescribed include:

Lanoxin

What the Medication Does Increases the force of the heart's contractions, which can be beneficial in heart failure and for irregular heart beats.

Reason for Medication

Used to relieve heart failure symptoms, especially when the patient isn't responding to ACE inhibitors and diuretics. Also slows certain types of irregular heartbeat (arrhythmias), particularly atrial fibrillation.

Statins Common types of cholesterol-lowering drugs include:

statins resins nicotinic acid (niacin) gemfibrozil clofibrate

What the Medication Does Various medications can lower blood cholesterol levels. They may be prescribed individually or in combination with other drugs. They work in the body in different ways. Some affect the liver, some work in the intestines and some interrupt the formation of cholesterol from circulating in the blood. Reason for Medication

Used to lower LDL ("bad") cholesterol, raise HDL ("good") cholesterol and lower triglyceride levels.

Emergency cardiac drugs: Essential facts for med-surg nurses In the hospital setting, emergencies typically occur in emergency departments (EDs) and intensive care units (ICUs). But many also take place in progressive care units or general nursing units. And when they do, they can cause marked anxiety for nursesespecially those unfamiliar or inexperienced with the drugs used in these emergencies. Generally, the goal of using emergency drugs is to prevent the patient from deteriorating to an arrest situation. This article helps nurses who dont work in ICUs or EDs to understand emergency drugs and their use. Under normal circumstances, a registered nurse (RN) needs a physicians order to administer medications. In emergencies, RNs with advanced cardiac life support (ACLS) certification can give selected drugs based on standing orders, relying on algorithms that outline care for certain emergencies. Wherever possible, nurses should strive to maintain proficiency in basic life support (BLS), as the latest research shows the importance of effective cardiopulmonary resuscitation. Some non-ICU nurses may want to pursue ACLS training as well. Drugs for acute coronary syndrome Acute coronary syndrome (ACS) refers to a spectrum of clinical manifestations associated with acute myocardial infarction and unstable angina. In ACS, a plaque in a coronary artery ruptures or becomes eroded, triggering the clotting cascade. A blood clot forms, occluding the artery and interrupting blood and oxygen flow to cardiac muscle. Many healthcare providers use the acronym MONA to help them remember the initial medical treatment options for a patient with ACS.

M: morphine O: oxygen N: nitroglycerin A: aspirin. But keep in mind that while MONA might be easy to remember, the drugs arent given in the MONA sequence. Theyre given in the order of OANM. Oxygen Oxygen (O2) is given first in ACS, regardless of the patients O2 saturation level. The heart uses 70% to 75% of the oxygen it receives, compared to skeletal muscle, which uses roughly 20% to 25%. Aspirin The standard recommended aspirin dosage to treat ACS is 160 to 325 mg, given as chewable baby aspirin to speed absorption. Aspirin slows platelet aggregation, reducing the risk of further occlusion or reocclusion of the coronary artery or a recurrent ischemic event. Nitroglycerin To help resolve chest pain from ACS, nitroglycerin 0.4 mg is given sublingually via a spray or rapidly dissolving tablet. If the first dose doesnt reduce chest pain, the dose can be repeated every 3 to 5 minutes for a total of three doses. A potent vasodilator, nitroglycerin relaxes vascular smooth-muscle beds. It works well on coronary arteries, improving blood flow to ischemic areas. It also decreases myocardial oxygen consumption, allowing the heart to work with a lower oxygen demand. In peripheral vascular beds, nitroglycerin causes vasodilation and reduces preload and afterload, resulting in decreased cardiac workload. If chest pain recurs once the initial pain resolves or decreases, the patient may be placed on a continuous I.V. infusion of nitroglycerin. Because of the drugs vasodilatory effects, be sure to institute continuous blood-pressure monitoring. Morphine If chest pain doesnt resolve with sublingual or I.V. nitroglycerin, morphine 2 to 4 mg may be given every 5 to 15 minutes via I.V. push. An opioid acting primarily on receptors that perceive pain, morphine also acts as a venodilator, reducing ventricular preload and cardiac oxygen requirements. As with nitroglycerin, the patients blood pressure needs to be monitored continuously. If hypotension occurs, elevate the patients legs, give I.V. fluids as ordered, and monitor for signs and symptoms of pulmonary congestion.

Other medications for ACS Metoprolol may be used in the initial treatment of ACS. A cardioselective (beta1 receptor) drug, its a beta-adrenergic blocker that dilates peripheral vascular beds, in turn reducing blood pressure, decreasing cardiac workload, and lowering cardiac oxygen demands. It also may have a mild analgesic effect in ACS-related chest pain. The patients blood pressure must be monitored. (See Be cautious with beta blockers by clicking on the PDF icon above.) A primary goal of ACS treatment is to minimize muscle cell damage, which necessitates restoring blood flow to cardiac muscle. Drugs that may be used to reduce expansion of the arterial occlusion or restore blood flow to cardiac muscle include:

heparin or enoxaparin (a low-molecular-weight heparin), which helps prevent the original arterial clot from expanding and allows it to break down on its own; as a result, the vessel opens and new clot formation is inhibited. glycoprotein IIB-IIIa inhibitors, such as abciximab (Reopro). These drugs bind to glycoprotein IIb-IIIa receptor sites on platelets, preventing further aggregation and stopping expansion of the original clot or formation of new clots. fibrinolytics, such as reteplase (Retavase) and alteplase (Activase). These agents break down the original clot, opening the vessel for blood flow. (See Drugs used to treat acute coronary syndrome by clicking on the PDF icon above.)

Drugs for arrhythmias Bradycardias and tachycardias commonly arise during medical emergencies. The primary goal of drug therapy for these arrhythmias is to return the heart rate and rhythm to normal, thereby maximizing cardiac pumping and restoring hemodynamic stability. To achieve this goal, antiarrhythmics are given to slow, speed, or block conduction of the hearts electrical impulses. A combination of drugs in the proper dosages may resolve bradycardias and tachycardias. (See Drugs used to treat arrhythmias by clicking on the PDF icon above.) Intervening for bradycardia In bradycardia, the heart rate slows to a critical point and hemodynamic instability occurs. Usually, bradycardia is defined as a heart rate slower than 60 beats/minute (bpm). But in some patients, hemodynamic instability may occur at faster rates. This instability may manifest as dizziness, lightheadedness, nausea, vomiting, hypotension, syncope, chest pain, and altered mental status. Atropine, epinephrine, and dopamine may be used to treat bradycardia, with dosages depending on the acuity and severity of hemodynamic instability. For symptomatic patients, the healthcare team must determine the cause of bradycardia. In many cases, bradycardia results from use of other drugs, specifically other antiarrhythmicsfor instance, beta blockers and calcium channel blockers. So those drugs may need to be withheld temporarily until their effects wear off. Beta blockers reduce circulating catecholamine levels, decreasing both the heart rate and blood pressure. Typically, atropine is the drug of choice for symptomatic bradycardia. An anticholinergic and potent belladonna alkaloid, it increases the heart rate, which improves hemodynamic stability. Epinephrine may be used as a secondary measure if atropine and temporary heart pacing dont improve hemodynamic stability. Among other actions, epinephrine stimulates beta1 receptors, causing cardiac stimulation, which in turn increases the heart rate.

Dopamine also may be used to support hemodynamic status by correcting hypotension. It enhances cardiac output, minimally increasing oxygen consumption and causing peripheral vasoconstriction. If your patient is receiving these I.V. drugs, be sure to monitor for extravasation, which could lead to tissue damage. If possible, use a central line to deliver epinephrine and dopamine. Intervening for tachycardia Tachycardia, which usually refers to a heart rate faster than 100 bpm, may result from various cardiac mechanisms. The first step in choosing the right drug is to identify the origin of the arrhythmia. Most tachycardias are classified as one of two types:

narrow-QRS-complex tachycardias (for instance, atrial fibrillation, atrial flutter, or atrial or multifocal atrial tachycardia) wide-QRS-complex tachycardias (for example, ventricular tachycardia or supraventricular tachycardia with aberrancy).

Each type calls for a slightly different treatment. Narrow-QRS-complex tachycardias with a regular rate generally are treated with adenosine, along with beta blockers, calcium channel blockers, and/or amiodarone or ibutilide. With a wide-QRS-complex tachycardia, the first step is to determine if the arrhythmia is a ventricular tachycardia or is conducted with aberrancy. Wide-QRS-complex tachycardias with aberrancy call for the same treatment as narrow-QRS-complex tachycardias. On the other hand, ventricular tachycardia in a patient with a pulse is treated with amiodarone alone or with amiodarone in conjunction with synchronized cardioversion. Adenosine. This general antiarrhythmic is used mainly as a diagnostic agent to identify the origin of an underlying narrow-QRS-complex tachycardia. It briefly depresses the atrioventricular (AV) node and sinus node activity. When given by rapid I.V. bolus, the drugs primary action is to slow electrical impulse conduction through the AV node. Be aware that adenosine commonly causes a few seconds of asystole, but because of its short half-life (6 to 10 seconds), the asystole usually is brief. The drug sometimes restores a normal sinus rhythm; if it doesnt, calcium channel blockers and beta blockers may be given immediately to control the heart rate while amiodarone or ibutilide may be used to help restore a normal sinus rhythm. Diltiazem. A first-line agent in controlling heart rate in narrow QRS-complex tachycardias, this drug can be used both in patients with preserved cardiac function and in those with impaired ventricular function (ejection fraction below 40%) or heart failure. (Verapamil, another calcium channel blocker, should be used only in patients with preserved cardiac function.) A calcium channel blocker, diltiazem slows and/or blocks electrical impulse conduction through the AV node, reducing the number of impulses that arrive at the ventricular tissue and slowing the heart rate. It may cause hypotension secondary to vascular smooth-muscle relaxation. Also, it may block impulses in some narrow-QRS-complex tachycardias that involve AV nodal reentry, thereby terminating the rhythm and restoring normal sinus rhythm. Other drugs. Occasionally, selected beta blockers are used to help control the heart rate associated with narrow-QRS-complex tachycardias. They include metoprolol, atenolol, propranolol, and esmolol.

Propranolol isnt cardioselective and can affect pulmonary function, so its used less often. Typically, esmolol is given only in the ICU. Atenolol is administered as a 5-mg I.V. bolus over 5 minutes. If the patient tolerates the dose and the arrhythmia persists after 10 minutes, an additional bolus of 5 mg may be given over 5 minutes. Metoprolol also is administered I.V. in 5-mg increments over 5 minutes; the dose may be repeated twice, to a total of 15 mg. Dont give beta blockers or calcium channel blockers to patients with narrow-QRS-complex tachycardias suspected of being pre-excitation arrhythmias, such as Wolff-Parkinson-White (WPW) syndrome. Such arrhythmias allow impulses to flow from the atria to the ventricles through an accessory or alternate pathway. Beta blockers and calcium channel blockers may increase the number of impulses arriving at ventricular tissue, further speeding the heart rate. Amiodarone. This drug is used to treat certain narrow- and wide-QRS complex tachycardias identified as ventricular tachycardia or tachycardias of unknown origin. Although a class III antiarrhythmic, it has some properties of all antiarrhythmic classes. Its primary action is to block potassium channels in the cell, but it also prolongs the action potential duration, depresses conduction velocity, slows conduction through and prolongs refractoriness in the AV node, and has some alpha-, beta-, and calcium-channel blocking capabilities. Dosing depends on circumstances. When used to treat ventricular tachycardia in patients with a pulse, runs of paroxysmal ventricular tachycardia, or narrow-QRS-complex tachycardias, amiodarone is given as a bolus of 150 mg over 10 minutes, followed by a continuous I.V. infusion starting at 1 mg/minute for 6 hours and then 0.5 mg/minute for 18 hours. If the patient is on nothing-by-mouth status for an extended time, the infusion can be kept running at 0.5 mg/minute. Otherwise, an oral dose usually is started before the infusion ends. Any time, any place Cardiac emergencies can occur at any time in any patient. Being familiar with the actions, dosages, and rationales for commonly used emergency drugs will help you manage any crisis with confidence and efficiency.