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 after each shock Prepare drug therapy

ACLS Drug Therapy

Routes of Administration Peripheral IV – easiest to insert during CPR Peripheral IV – easiest to insert during CPR Central IV – fast onset of action Central IV – fast onset of action Intratracheally (down an ET tube) Intratracheally (down an ET tube) Intraosseous – alternative IV route in peds Intraosseous – alternative IV route in peds

Oxygen FIO2 100% FIO2 100% Assist Ventilation Assist Ventilation O2 Toxicity should not be a concern during ACLS O2 Toxicity should not be a concern during ACLS

IV Fluids Volume Expanders – crystalloids, eg Ringer’s lactate, N/S, or colloids, eg Albumin or Hetastarch Volume Expanders – crystalloids, eg Ringer’s lactate, N/S, or colloids, eg Albumin or Hetastarch TKO – D5W, N/S TKO – D5W, N/S

Morphine Sulfate Drug of choice for pain Drug of choice for pain Also decreases pre-load Also decreases pre-load IV dose – 2-4 mg as often as every 5 minutes IV dose – 2-4 mg as often as every 5 minutes Precautions Precautions  May cause respiratory depression

The Following Drugs Help to Control Heart Rate & Rhythm

Lidocaine Indications: Indications:  PVCs, Vtach, Vfib  Can be toxic so no longer given prophylactically IV dose : IV dose :  mg/kg bolus then continuous infusion of 2-4 mg/min  Can be given down ET tube Signs of toxicity: Signs of toxicity:  slurred speech, seizures, altered consciousness

Amiodarone (Cordarone) Indications: Indications:  Like Lidocaine – Vtach, Vfib IV Dose: IV Dose:  300 mg in ml of N/S or D5W  Supplemental dose of 150 mg in ml of N/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: Contraindications:  Cardiogenic shock, profound Sinus Bradycardia, and 2 nd and 3 rd degree blocks that do not have a pacemaker

Procainamide (Pronestyl) Indications: Indications:  Like lidocaine (is usually a second choice)  Uncontrolled Afib or Atrial flutter if no signs of heart failure Dose : Dose :  continuous IV infusion. Initially 20mg/min then titrated down to 1-4 mg/min Side effects Side effects  Hypotension  Widening of the QRS

Atropine Indications: Indications:  Symptomatic sinus bradycardia  Second Degree Heart Block Mobitz I  May be tried in asystole  Organophosphate poisoning IV Dose: IV Dose: .5 – 1 mg every 3-5 minutes  Max dose is.04mg/kg  Can be given down ET tube Side Effects: Side Effects:  May worsen ischemia

Isoproterenol (Isuprel) Indications: Indications:  Temporary stimulant prior to pacemaker  Bradycardia refractory to atropine  Torsades de Pointes refractory to magnesium sulfate IV dose: IV dose:  Continuous infusion of 2-10 micrograms/ml of infusion fluid

Adenosine Indication: Indication:  PSVT IV Dose: IV Dose:  6 mg bolus followed by 12 mg in 1-2 minutes if needed Side Effects: Side Effects:  Flushing  Dyspnea  Chest Pain  Sinus Brady  PVCs

Verapamil Indications: 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: IV Dose:  mg over 2 minutes up to 20 mg Side Effects: Side Effects:  Hypotension  N & V

Magnesium Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes Dose: Dose:  1-2 grams over 2 minutes Side Effects Side Effects  Hypotension  Asystole!

Propranolol Beta blocker that may be useful for Vfib and Vtach that has not responded to other therapies 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 increases heart rate,stroke volume and blood pressure Because of alpha, beta-1, and beta-2 stimulation, it increases 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: IV Dose:  1 mg every 3-5 minutes  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! Similar effects to Epinephrine without as much cardiovascular side effects! IV dose = 40 IU IV dose = 40 IU Can be given down ET tube Can be given down ET tube May be better for asystole May be better for asystole

Norepinephrine (Levarterenol) Similar in effect to epinephrine Similar in effect to epinephrine Used for severe hypotension that is NOT due to hypovolemia Used for severe hypotension that is NOT due to hypovolemia Cardiogenic shock Cardiogenic shock Administered as a continuous infusion Administered as a continuous infusion  Adult rate is usually 2-12 micrograms/min  Range is.5-1 microgram up to 30! Side effects: Side effects:  Like epinephrine, it may worsen ischemia  Extravasation causes tissue necrosis

Dopamine Used for hypotension (not due to hypovolemia) 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) Second choice for bradycardia (after Atropine) IV Dose: IV Dose:  1-20 micrograms/kg Side effects: Side effects:  Ectopic beats  N & V

Dobutamine Actions similar to Dopamine Actions similar to Dopamine Used for CHF with hypotension Used for CHF with hypotension IV Dose: IV Dose:  2-20 micrograms/minute Side effects: Side effects:  Tachycardia  N & V  Headache  Tremors

Digitalis (Digoxin) Slows conduction through A-V node and increases force of contraction Slows conduction through A-V node and increases force of contraction Used in CHF and chronic atrial fib/flutter Used in CHF and chronic atrial fib/flutter Can be given orally or IV Can be given orally or IV Side effects: Side effects:  Arrhythmias  N & V, diarrhea  Agitation

Nitroglycerin Vasodilator that helps relieve pain from angina pectoris Vasodilator that helps relieve pain from angina pectoris Can be given IV, sublingually, as an ointment or a slow release patch Can be given IV, sublingually, as an ointment or a slow release patch Side effects: Side effects:  Headache  Hypotension  Syncope  V/Q mismatch

Sodium Nitroprusside (Nipride) Vasodilator used for hypertensive crisis Vasodilator used for hypertensive crisis IV dose: IV dose:  Loading dose of 50 –100 mg followed by infusion of.5-8 micrograms/kg/min  Is light sensitive so IV bag must be wrapped in tin foil Side effects: Side effects:  Hypotension so patient must have continuous hemodynamic monitoring

Sodium Bicarbonate Used for METABOLIC acidosis hyperkalemia Used for METABOLIC acidosis hyperkalemia  H + HCO3 >H2CO3>H2O and CO2  Airway and ventilation have to be functional! IV Dose: IV Dose:  1 mEq/kg  If ABGs, [BE] x wt in kg/6 Side effects: Side effects:  Metabolic alkalosis  Increased CO2 production

Thrombolytics Used to improve coronary blood flow by lysing clots, ie coronary thrombosis 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: 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: Indications:  Same as lidocaine and procainamide (usually when condition doesn’t respond to these two) IV dose: IV dose:  5-10mg/kg bolus followed by continuous infusion of 1-2 kg/min Side Effects: Side Effects:  N & V  Hypotension

Amrinone Similar to dobutamine Similar to dobutamine Used for refractory CHF Used for refractory CHF IV Dose: IV Dose:  2-15 micrograms/kg/min Side effects: Side effects:  May worsen ischemia  N & V  Thrombocytopenia