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ACLS

Advanced Cardiac Life Support RC 275

Defibrillation
External depolarization of the heart to stop Vfib or Vtach (that has not responded to other maneuvers)

Automated External Defibrillator

Defibrillation Procedure
  

Position paddles Clear the patient Shock and then resume CPR for 5 cycles then re-analyze reafter each shock Prepare drug therapy

ACLS 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

The Following Drugs Help to Control Heart Rate & Rhythm

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

The Following Drugs Improve Cardiac Output &Blood Pressure

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

Sodium Nitroprusside (Nipride)


 

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

You Run the Code!

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.

Cardiac monitoring is initiated and the following EKG is observed:

What is the patients arrhythmia and probable medical problem? What therapies should be done? Explain each one.

The EKG began to show:

 

What is occurring in the heart to cause this arrhythmia? How is this treated? What other arrhythmias may occur now?

The patient suddenly becomes lifeless and the EKG shows:

Uh oh! What now?

The treatment(s) are unsuccessful and the following EKG appears:

What should be done now and why?

Finally, the following EKG is obtained. However, BP is 40/0

What needs to be done now?

You saved her! The course is complete!

Bretylium Tosylate (Bretylol)




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