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ALGORITHMS
Figure 8
Rate Problem
Figure 5
Yes
No
Observe
Yes
Prepare for transvenous pacer Use TCP as a bridge device
Intervention sequence Atropine 0.5 - 1.0 mcg,d (I and IIa) TCP, if available (I) Dopamine 5 - 20 mcg/kg/min (IIb) Epinephrine 1 - 10 mcg/min (IIb) Norepinephrine 0.5 30 mcg/min (IIb)
Figure 6
If ventricular rate > 150 BPM May give brief trial of Rx Immediate cardioversion is seldom needed for heart rates < 150 BPM
Includes Electromechanical dissociation (EMD) Postdefibrillation idioventricular rhythms Pseudo - EMD Bradyasystolic rhythms Idioventricular rhythms Ventricular escape rhythms
Figure 3
Continue CPR / Intubate at once / Obtain IV Access Assess blood flow using Doppler ultrasound, endtidal CO2, echocardiography, or arterial line
Consider possible causes Hypovolemia (volume infusion) Drug overdoses - tricyclics, digitalis Hypoxia (ventilation) Beta-blockers, calcium channel blockers Cardiac tamponade (pericardiocentesis) Hyperkalemia Tension Pneumothorax Acidosis Hypothermia ( see hypothermia algorithm) Massive acute myocardial infarction Massive pulmonary embolism (surgery, lysine) Massive acute MI (go to Fig 9)
Continue CPR Intubate at once Obtain IV Access Confirm asystole in more than 1 lead
Consider possible causes Hypoxia Pre-existing acidosis Hyperkalemia Drug Overdose Hypokalemia Hypothermia
Figure 4
Epinephrine 1mg IV push,b,c repeat q 3 - 5 min
Atropine 1 mg IV push repeat q 3 - 5 min up to a total of 0.03 - 0.04 mg/kgd,e Consider termination of efforts
Defibrillate up to 3 times if needed for persistent VF/VT 200 J, 200 - 300 J, 360 J
Rhythm after the first 3 shocks? b
VF/VT
ROSC
PEA Go to Fig 3
Asystole Go to Fig 4
Figure 2