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Defibrillation
External depolarization of the heart to stop Vfib or Vtach (that has not responded to other maneuvers)
Defibrillation Procedure
Position paddles Clear the patient Shock and then resume CPR for 5 cycles then re-analyze reafter each shock Prepare drug therapy
Routes of Administration
Peripheral IV easiest to insert during CPR Central IV fast onset of action Intratracheally (down an ET tube) Intraosseous alternative IV route in peds
Oxygen
FIO2 100% Assist Ventilation O2 Toxicity should not be a concern during ACLS
IV Fluids
Volume Expanders crystalloids , eg Ringers lactate, N/S, or colloids, eg Albumin or Hetastarch TKO D5W, N/S
Morphine Sulfate
Drug of choice for pain Also decreases pre-load pre IV dose 2-4 mg as often as every 5 minutes Precautions May cause respiratory depression
Lidocaine
Indications: PVCs, Vtach, Vfib Can be toxic so no longer given prophylactically IV dose : 1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min Can be given down ET tube Signs of toxicity: slurred speech, seizures, altered consciousness
Amiodarone (Cordarone)
Indications: Like Lidocaine Vtach, Vfib IV Dose: 300 mg in 20-30 ml of N/S or D5W 20 Supplemental dose of 150 mg in 20-30 ml of 20N/S or D5W Followed with continuous infusion of 1 mg/min for 6 hours than .5mg/min to a maximum daily dose of 2 grams Contraindications: Cardiogenic shock, profound Sinus Bradycardia, and 2nd and 3rd degree blocks that do not have a pacemaker
Procainamide (Pronestyl)
Indications: Like lidocaine (is usually a second choice) Uncontrolled Afib or Atrial flutter if no signs of heart failure Dose : continuous IV infusion. Initially 20mg/min then titrated down to 1-4 mg/min 1Side effects Hypotension Widening of the QRS
Atropine
Indications: Symptomatic sinus bradycardia Second Degree Heart Block Mobitz I May be tried in asystole Organophosphate poisoning IV Dose: .5 1 mg every 3-5 minutes 3 Max dose is .04mg/kg Can be given down ET tube Side Effects: May worsen ischemia
Isoproterenol (Isuprel)
Indications: Temporary stimulant prior to pacemaker Bradycardia refractory to atropine Torsades de Pointes refractory to magnesium sulfate IV dose: Continuous infusion of 2-10 2micrograms/ml of infusion fluid
Adenosine
Indication: PSVT IV Dose: 6 mg bolus followed by 12 mg in 1-2 minutes if 1needed Side Effects: Flushing Dyspnea Chest Pain Sinus Brady PVCs
Verapamil
Indications: Is a calcium channel blocker that may terminate PSVT (is a backup to Adenosine) as well as atrial flutter and uncontrolled atrial fib IV Dose: 2.5-5 mg over 2 minutes up to 20 mg 2.5Side Effects: Hypotension N& V
Magnesium
Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes Dose: 1-2 grams over 2 minutes Side Effects Hypotension Asystole!
Propranolol
Beta blocker that may be useful for Vfib and Vtach that has not responded to other therapies Very useful for patients whose cardiac emergency was precipitated by hypertension Also used for Afib, Aflutter, & PSVT
Epinephrine
Because of alpha, beta-1, and beta-2 stimulation, it betabetaincreases heart rate,stroke volume and blood pressure Helps convert fine vfib to coarse Vfib May help in asystole Also PEA and symptomatic bradycardia IV Dose: 1 mg every 3-5 minutes 3 Can be given down the ET tube Can also be given intracardiac May increase ischemia because of increased O2 demand by the heart
Vasopressin (ADH)
Similar effects to Epinephrine without as much cardiovascular side effects! IV dose = 40 IU Can be given down ET tube May be better for asystole
Norepinephrine (Levarterenol)
Similar in effect to epinephrine Used for severe hypotension that is NOT due to hypovolemia Cardiogenic shock Administered as a continuous infusion Adult rate is usually 2-12 micrograms/min 2 Range is .5-1 microgram up to 30! .5Side effects: Like epinephrine, it may worsen ischemia Extravasation causes tissue necrosis
Dopamine
Used for hypotension (not due to hypovolemia) Usually tried before norepinephrine Has alpha, beta, and dopaminergic properties Dopaminergic dilates renal and mesenteric arteries Second choice for bradycardia (after Atropine) IV Dose: 1-20 micrograms/kg Side effects: Ectopic beats N& V
Dobutamine
Actions similar to Dopamine Used for CHF with hypotension IV Dose: 2-20 micrograms/minute Side effects: Tachycardia N& V Headache Tremors
Digitalis (Digoxin)
Slows conduction through A-V node and increases Aforce of contraction Used in CHF and chronic atrial fib/flutter Can be given orally or IV Side effects: Arrhythmias N & V, diarrhea Agitation
Nitroglycerin
Vasodilator that helps relieve pain from angina pectoris Can be given IV, sublingually, as an ointment or a slow release patch Side effects: Headache Hypotension Syncope V/Q mismatch
Vasodilator used for hypertensive crisis IV dose: Loading dose of 50 100 mg followed by infusion of .5-8 micrograms/kg/min .5 Is light sensitive so IV bag must be wrapped in tin foil Side effects: Hypotension so patient must have continuous hemodynamic monitoring
Sodium Bicarbonate
Used for METABOLIC acidosis hyperkalemia H + HCO3 >H2CO3>H2O and CO2 Airway and ventilation have to be functional! IV Dose: 1 mEq/kg If ABGs, [BE] x wt in kg/6 Side effects: Metabolic alkalosis Increased CO2 production
Thrombolytics
Used to improve coronary blood flow by lysing clots, ie coronary thrombosis Best if given within six hours of onset of chest pain Examples: TPA/Alteplase(Activase), Streptokinase Side effects: Bleeding
ACLS Scenario
A 62 year old female is admitted to the ER with chest pain, dyspnea, and moist, gurgling crackles. She appears in acute distress and is cyanotic. Vital signs are: P =110, R = 20, BP = 80/40.
What is the patients arrhythmia and probable medical problem? What therapies should be done? Explain each one.
What is occurring in the heart to cause this arrhythmia? How is this treated? What other arrhythmias may occur now?
Indications: Same as lidocaine and procainamide (usually when condition doesnt respond to these two) IV dose: 5-10mg/kg bolus followed by continuous infusion of 1-2 kg/min 1Side Effects: N& V Hypotension
Amrinone
Similar to dobutamine Used for refractory CHF IV Dose: 2-15 micrograms/kg/min Side effects: May worsen ischemia N& V Thrombocytopenia