ACLS (Main)

Recommendations

• Routine use of cricoid pressure is NOT recommended
• Airway adjunct is recommended while performing ventilation
• Pulse/rhythm checks should only occur q2min
• Most critical component is high-quality compressions
• Atropine and cardiac pacing are NOT recommended for asystole/PEA

BLS

• Compressions
  • Push hard (2cm) and fast (100pm)
  • Do everything possible to minimize compression interruption
• Ventilation
  • 30:2 ratio when do not have advanced airway
    • Do not overventilate! (leads to decr venous return)
  • 8-10 breaths per min when intubated

ECG Analysis

1. Is the rhythm fast or slow?
2. Are the QRS complexes wide or narrow?
3. Is the rhythm regular or irregular?

Ventricular fibrillation and pulseless ventricular tachycardia

• Shock as quickly as possible
  • Resume CPR immediately after shocking
  • Biphasic - 200J
  • Monophasic - 360 J
• Give Epi 1mg if shock + 2min of CPR fails to convert the rhythm
• Consider aniarrhytmic if 2nd shock + 2min CPR again fails
  • Amiodarone 300mg w/ repeat dose of 150mg as indicated
  • Magnesium 2g IV, followed by maintenance infusion
    • Only for polymorphic Vtach

Asystole and PEA

• Give Epi 1mg q3-5min
• Consider H's and T's
  • Hypovolemia
  • Hypoxia
  • Hydrogen ion
  • Hypo/hyperkalemia
  • Hypothermia
  • Tension pneumo
  • Tamponade
  • Toxins
  • Thrombosis, pulmonary
  • Thrombosis, coronary

Bradycardia

• Only intervene if pt is symptomatic
  • Hypotension, AMS, chest pain, pulm edema
• 1st Line
• Transcutaneous pacing
• Chronotropes
  • Dopamine 2-10mcg/kg/min
  • Epineprhine 2-10mcg/min
• 2nd Line
  • Atropine 0.5mg q3-5m can be given as temporizing measure
    • Do not give if Mobitz type II or 3rd degree block is present
• TransQ pacing and chronotropes ineffective = need for transvenous pacing

Tachycardia

3 questions

1. Is the pt in a sinus rhythm?
2. Is the QRS wide or narrow?
3. Is the rhythm regular or irregular?

Regular Narrow

• 1. Sinus Tachycardia
  • Treat underlying cause
• 2. SVT
  • Vagal maneuvers (convert up to 25%)
  • Adenosine 6mg IVP (can follow with 12mg if initially fails)
    • If adenosine fails initiate rate control with CCB or BB
      • Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
      • Metoprolol 5mg IVP x 3 followed by 50mg PO

Irregular Narrow

• 1. MAT
  • Treat underlying cause (hypoK, hypomag)
• 2. Sinus Tachycardia w/ frequent PACs
• 3. A Fib / A Flutter w/ variable conduction
  • Rate control with:
    • Dilt
    • MTP (good in setting of ACS)
    • Amiodarone (good in setting of hypotension, CHF)
    • Digoxin (good in setting of CHF)

Regular Wide Complex

• 1. V-Tach (until proven otherwise!)
• If stable:
  • Antiarrhytmics
    • Procainamide 20mg/min
      • Cont until rhythm suppressed, hypotensive, or max dose (17mg/kg)
      • Avoid if prolonged QT
    • Amiodarone 150mg over 10min, repeated as needed
    • Sotalol 100mg IV over 5min
      • Avoid if prolonged QT
  • Elective synchronized cardioversion
  • Adenosine may be used for diagnosis and treatment only if:
    • Rhythm is regular and monomorphic
• 2. SVT w/ aberrancy

Irregular Wide Comlex

• DO NOT use AV nodal blockers!
  • Can precipitate V-Fib
• 1. A fib w/ preexcitation
  • 1st line - electric cardioversion
  • 2nd line - Procainamide, amiodarone, or sotalol
• 2. A fib w/ aberrancy
• 3. Polymorphic V-Tach / Torsades
  • Emergent defibrillation
  • Correct electrolyte abnormalities
    • HypoK, hypoMag
  • Stop prolonged QT meds

Treatable Conditions

Condition	Common clinical settings	Corrective actions
Acidosis	Preexisting acidosis, DM, diarrhea, drugs and toxins, prolonged resuscitation, renal disease, shock	Reassess adequacy of oxygenation, and ventilation; reconfirm endotracheal-tube placement
		Hyperventilate
		Consider intravenous bicarbonate if pH <7.20 after above actions have been taken
Cardiac tamponade	Hemorrhagic diathesis, cancer, pericarditis, trauma, after cardiac surgery or MI	Give fluids; obtain bedside echocardiogram
		Perform pericardiocentesis. Immediate surgical intervention is appropriate if pericardiocentesis is unhelpful but cardiac tamponade is known or highly suspected.
Hypothermia	Alcohol abuse, burns, CNS  disease, debilitated or elderly patient, drowning, drugs and toxins, endocrine disease, history of exposure, homelessness, extensive skin disease, spinal cord disease, trauma	If severe (temperature <30°C), limit initial shocks for V-Fib or pulseless V-Tach to three; initiate active internal rewarming and cardiopulmonary support. Hold further resuscitation medications or shocks until core temperature is >30°C.
		If moderate (temperature 30-34°C), proceed with resuscitation (space medications at intervals greater than usual), actively rewarm truncal body areas
Hypovolemia, hemorrhage, anemia	Major burns, DM, GI losses, hemorrhage, hemorrhagic diathesis, cancer, pregnancy, shock, trauma	Give fluids
		Transfuse pRBCs if hemorrhage or profound anemia is present
		Thoracotomy is appropriate when pt has cardiac arrest from penetrating trauma and a cardiac rhythm and the duration of cardiopulmonary resuscitation before thoracotomy is <10 min
Hypoxia	Consider in all patients with cardiac arrest	Reassess technical quality of cardiopulmonary resuscitation, oxygenation, and ventilation; reconfirm ETT placement
Hypomagnesemia	Alcohol abuse, burns, DKA, severe diarrhea, diuretics, drugs (eg, cisplatin, cyclosporine, pentamidine)	Give 1-2 g magnesium sulfate intravenously over 2 min

Myocardial infarction	Consider in all patients with cardiac arrest, especially those with a history of coronary artery disease or prearrest acute coronary syndrome	Consider definitive care (eg, thrombolytic therapy, cardiac catheterization or coronary artery reperfusion, circulatory assist device, emergency cardiopulmonary bypass)
Poisoning	Alcohol abuse, bizarre or puzzling behavioral or metabolic presentation, classic toxicologic syndrome, occupational or industrial exposure, and psychiatric disease	Consult toxicologist for emergency advice on resuscitation and definitive care, including appropriate antidote
		Prolonged resuscitation efforts may be appropriate; immediate cardiopulmonary bypass should be considered, if available
Hyperkalemia	Metabolic acidosis, excessive administration of potassium, drugs and toxins, vigorous exercise, hemolysis, renal disease, rhabdomyolysis, tumor lysis syndrome, and clinically significant tissue injury	If hyperkalemia is identified or strongly suspected, treat with all of the following: 10 percent calcium chloride (5-10 mL by slow intravenous push; do not use if hyperkalemia is secondary to digitalis poisoning), glucose and insulin (50 mL of 50 percent dextrose in water and 10 units of regular insulin intravenously), sodium bicarbonate (50 mmoL intravenously; most effective if concomitant metabolic acidosis is present), and albuterol (15-20 mg nebulized or 0.5 mg by intravenous infusion)
Hypokalemia	Alcohol abuse, diabetes, use of diuretics, drugs and toxins, profound gastroinstestinal losses, hypomagnesemia	If profond hypokalemia (<2-2.5 mmoL of potassium per liter) is accompanied by cardiac arrest, initiate urgent intravenous replacement (2 mmoL/min intravenously for 10-15 mmoL), then reassess
Pulmonary embolism	Hospitalized patient, recent surgical procedure, peripartum, known risk factors for venous thromboembolism, history of venous thromboembolism, or prearrest presentation consistent with diagnosis of acute pulmonary embolism	Administer fluids; augment with vasopressors as necessary
		Confirm diagnosis, if possible; consider immediate cardiopulmonary bypass to maintain patient's viability
		Consider definitive care (eg, thrombolytic therapy, embolectomy by interventional radiology or surgery)
Tension pneumothorax	Placement of central catheter, mechanical ventilation, pulmonary disease (including asthma, chronic obstructive pulmonary disease, and necrotizing pneumonia), thoracentesis, and trauma	Needle decompression, followed by chest-tube insertion

Source

• AHA 2010 Guidelines for ACLS