ACLS
Algorithms
Determinants of Survival
from
Cardiopulmonary Arrest
1) Time until Discovery
2) Time until implementation of ACLS
3) Precipitating Cause
4) Mechanism of the Arrest
Mechanism
of
Cardiopulmonary Arrest
Definition
PRIMARY MECHANISM
SECONDARY MECHANISM
(Post-Conversion)
Primary Mechanism of cardiac arrest
Ventricular Fibrillation
Bradycardia / EMD / Asystole
Ventricular Tachycardia
Secondary Mechanism of cardiac arrest
Ventricular Fibrillation
Bradycardia / EMD / Asystole
Supraventricular Tachyarrhythmias
STABLE Supraventricular Rhythms
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Prognostic Implications
of
Cardiopulmonary Arrest
Impact of the INITIAL Mechanism on Prognosis
Prognosis
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The MECHANISM of cardiopulmonary
arrest is a KEY determinant of prognosis
Sustained VT
Ventricular Fibrillation
Asystole
- Best Px
- Intermediat Px
- Poorest Px
The GOAL is to get to the pt EARLY
Prognosis
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Ventricular Fibrillation
(Initial approach)
Defibrillation ASAP !!!!!
Countershock X 3 (200j - 300j - 360j)
CPR / Establish IV / Intubation
EPINEPHRINE (SDE / HDE) as indicataed
Countershock (360j)
LIDOCAINE (Antifibrillatory Therapy)
50 - 100 mg IV bolus - circulate with CPR
Consider starting IV infusion @ 2 mg / min
Countershock (360j) - if persist ...
Ventricular Fibrillation
IF Patient converted out of VF:
bolus with LIDOCAINE ( 50 - 100 mg )
and begin IV infusion @ 2 mg / min
Ventricular Fibrillation
Persistent Ventricular Fibrillation
Look for a potentially reversible cause of VF !
Continue EPINEPHRINE (Use HDE )
Consider Sodium Bicarbonate ( ? )
Consider 2nd Lidocaine bolus ( 50 - 75 mg )
REPEAT Countershock ( 200 - 360j)
Consider Additional ANTIFIBRILLATORY measures
Ventricular Fibrillation
Additional ANTIFIBRILLATORY
measures :
Magnesium Sulfate (1-2 g IV over 1-2 min; may repeat)
Bretylium Tosylate (500 mg by IV bolus; may follow
with 10 mg/kg/ IV bolus up to 30 mg/kg)
IV Propranolol (0.5-1 mg by slow IV - up to 5 mg)
Amiodarone (150-500 mg IV)
Ventricular Fibrillation
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Wide QRS Tachycardia
(of ? Etiology )
Presence of a regular (or almost regular ) wide-complex tachy
cardia without normal P wave morphology
ASSUME the rhythm is GUILTY (VT) until
PROVEN otherwise !!!!
Wide QRS Tachycardia
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Wide QRS Tachycardia
(of ? Etiology )
Differential Diagnosis:
1) VT
2) VT
3) VT = VENTRICULAR TACHYCARDIA
4) SVT with peexisting BBB
5) SVT with aberrant conduction
Wide QRS Tachycardia
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Ventricular Tachycardia
Determine HEMODYNAMIC Status !
Is There a Pulse ?
If NO - treat as for VF (unsynchronized SHOCK @
200-360 j)
If there IS a pulse : Is Pt Hemodynamically STABLE?
Wide QRS Tachycardia
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Ventricular Tachycardia
Definition of HEMODYNAMIC STABILITY
Implies a normal BP ( 90 mm Hg ) & toleration of the arrhythmia
Hemodynamic stability may be present
EVEN if pt is unconscious
Wide QRS Tachycardia
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Ventricular Tachycardia
Is Patient Hemodynamically STABLE ?
Patient UNSTABLE
Immediately CARDIOVERT
(with 100-200j)
Wide QRS Tachycardia
Patient STABLE
Lidocain / Procainamide
Bretylium / Cardioversion
Other measures (IV etablocker, Magnesium
Sulfate)
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Bradyarrhythmias
Treatment depends on:
Clinical setting
Specific type of bradyarrhythmias
sinus bradycardia
Mobitz I
Mobitz II
Slow IVR
etc
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Bradyarrhythmias
Control AIRWAY / Optimize VENTILATION
( Use PRESSORS ONLY if all else fails ! )
CPR ( if Clinically indicated - if Pt NOT perfusing)
ATROPINE (0.5 - 1 mg IV; up to 2 mg)
PACEMAKER Therapy (Apply external pacemaker ASAP;
transvenous pacer if / when available
Temporizing Therapy ( = Pressors of YOURCHOICE ) Stopgap measures - until Pacemaker is available
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Asystole
EPINEPHRINE - and then MORE Epi .
CPR
EPINEPHRINE
Initially consider SDE ( 1 mg by IV or ET )
RAPIDLY increase dose ( to HDE ) if no response !
ATROPINE ( I mg IV; may repeat )
PACEMAKER Therapy
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Asystole
Be SURE to check rhythm in several leads to rule
out fine VF
REMEMBER you cant overdose on EPI - early
pacing may beneficial
Sodium Bicarb could (?) be considered if other
measures fail
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Electromechanical Dissociation
(EMD)
There is NO pulse !!!
ECG rhythm is seen, BUT it is NOT associated with
palpable mechanical activity
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Electromechanical Dissociation
(EMD)
FIND & CORRECT (if at all possible) the
UNDERLYING Cause of EMD !!!
CPR
EPINEPHRINE
Initially consider SDE ( 1 mg by IV or ET )
RAPIDLY increase dose ( to HDE ) if no response !
FIND / CORRRECT an UNDERLYING CAUSE
CONSIDER - Fluid challenge (!) / Atropin / Bicarb (?)
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Narrow QRS Tachycardia
1) Be SURE the QRS is truly NARROW !
2) Be SURE the pt is hemodynamically STABLE !
3) Determine the MECHANISM of the arrhythmias
(ie, PSVT - AF - A Flutter - MAT - ST - etc
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Narrow QRS Tachycardia
1) Ensure that the QRS complex is truly NARROW !
(examine the rhythm in MORE than 1 lead )
2) If pt is NOT hemodynamically STABLE Immediate CARDIOVERSION
3) If the pt IS hemodynamically stable, the KEY to
treatment will depend on the MECHANISM of the
SVT
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Narrow QRS Tachycardia
Dx of the MECHANISM is the KEY to Rx
PSVT
Try vagal maneuver
VERAPAMIL (3-5 mg initially; may give 5-10 mg IV in
15-20 min if no response)
may repeat vagal maneuver
Consider Calcium pre-treatment (500-1000 mg IV)
And / or
ADENOSINE (6 mg by IV push). Follow with saline
flush. If no response in 1-2 min, give 12 mg - and then a
final 12 mg (if needed)
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PSVT
Try vagal maneuver
VERAPAMIL (3-5 mg initially; may give 5-10 mg IV in
15-20 min if no response)
May repeat vagal maneuver
Consider Calcium pre-treatment (500-1000 mg IV)
And / or
ADENOSINE (6 mg by IV push). Follow with saline
flush. If no response in 1-2 min, give 12 mg - and then a
final 12 mg (if needed)
Narrow QRS Tachycardia
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PSVT
Other measures
Sedation
Digoxin / IV -blocker / Cardioversion
Narrow QRS Tachycardia
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Sinus Tachycardia
MAT
Treat the underlying cause
Treat the underlying cause
VERAPAMIL- if rate control is needed
AF / A Flutter
Consider treatment if the rate is rapid
DIGOXIN (load with 0.25-0.5 mg IV; then 0.125-0.25
mg IV q2-6 hrs - as needed up to 0.75 -1.5 mg total
And / or
VERAPAMIL (3-5 mg IV initially; may give 5-10 mg IV
in 15-30 min if no response, or DILTIAZEM
Narrow QRS Tachycardia
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AF / A Flutter
IV -Blocker
CARDIOVERSION (Use 200j for AF 50j for A Flutter)
Narrow QRS Tachycardia
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