ACLS from July
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| 5 rhythms and immediate steps | 1. VF/VT with no pulse = shock
2. VT/SVT & pulse = stable --> meds, unstable --> shock
3. PEA = reversible
4. Asystole = Epi
5. Bradycardia = stable?
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| 5 main steps to tx VF | 1. Shock (CPR x 2 if prolonged downtime/unwitnessed)
2. CPR
3. Epi (1 mg adult, 0.01 mg/kg peds)
4. Amiodarone (300mg adult, 10 mg/kg peds)
5. Amiodarone (150mg adult, 5 mg/kg peds) or lidocaine
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| PEA Reversible causes | A, B - Hypoxia, PTX
C - Hypovolemia, Tamponade
D - Toxic metabolic (think hyperK)
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| PEA Tx | 1. O2, ventilate, intubate if have help
2. IV access & small fluid bolus
3. Look at 3: ECG for hyperK, temp by touching (really hot or cold?), volume status (US IVC if available)
4. Epi - 1mg q3-5min
5. Look & r/o all 5 reversible causes
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| When not to give atropine for bradycardia | Can cause VF
1. Hypoxia
2. High ICP
3. Hypothermia
4. Wide complex
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| Tx for SVT (step 0 & 1) | Unstable = sync & cardiovert
Stable & not old
1. Vagal maneuvers
- valsalva 5 sec & release --> R sided carotid massage (push hard) 5 sec --> both --> ice water if young kid
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| Tx for SVT (step 2-5) | 2. Adenosine - 12g IVP through proximal IV (3mg through central line)
3. Adenosine - 18g IVP
4. Diltiazem - wt based at 0.25mg/kg (~ 20mg) over 1-2min
5. BB (Esmolol - 0.5 mg/kg loading, then 0.05 mg/kg infusion) or Procainamide (50 mg/min)
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| Who should you not give adenosine to (1-3) | 1. HR < 150 (= not PSVT)
2. HR that slows to vagal stim but returns to tachy (= not PSVT, PSVT will stop or not be affected, likely ST)
3. Irregular (PSVT = regular)
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| Who should you not give adenosine to (4-5) | 4. Hx of a-fib/a-flut/MAT
- don't give to a-fib with aberrant conduction b/c slows AVN so bypass tract speeds up
5. Hx CHF or COPD (these ppl don't often get PSVT)
Generally - don't give to sick older pts b/c they don't do well with AVN pause
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| Tx VT (steps 1-3) | No pulse --> shock & tx like VF
1. Unstable --> sedate & shock, then load with amio (150mg/10 min) or procainamide (35-100mg/min to max of 17mg/kg)
2. Stable --> can try lidocaine 1.5mg/kg over 15 sec (acts quickly)
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| Tx VT (steps 3) | 3. Amio (150mg/10 min) or procainamide (35-100mg/min to max 17mg/kg)
- Procainamide 100mg/1st min --> 100mg/2nd min --> 50 --> 50 --> 50 --> 35mg/min
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| Tx VT (steps 4-5) | 4. Mg 2g over 30 sec
5. Sedate & cardiovert
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| What % is VT vs SVT with aberrancy | 85% = VT, always assume & tx like VT
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| What to worry about with procainamide | 1. Can inc QTc (never give for arrhythmia caused by inc QT)
2. Can widen QRS = stop this if widens QRS more (given for wide QRS rhythms but stop if gets wider)
3. Can cause hypotension from dec myocardial contractility (same as amiodarone)
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| What are symptoms in symptomatic bradycardia | 1. AMS
2. Hypoxia
3. Pulm edema
4. CP or ECG evidence of ischemia
5. Dec peripheral perfusion
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| Tx symptomatic bradycardia or AVB (steps 1-2) | 1. Atropine 0.5mg IVP or TC Pacer - atropine preferred for SB & 1st deg AVB, pacer for other AVBs --> wait 1 min
2. Atropine 1.0 mg IVP or max TC Pacer energy
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| Tx symptomatic bradycardia or AVB (steps 3-5) | 3. Epi infusion - start at 2mcg/min & titrate to HR 70-80
4. Inc Epi as needed & request transvenous pacer
5. TV pacing
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| Asystole Tx | 1. Confirm - check monitor & leads (pt not breathing or moving)
2. Oxygenate/Ventilate & begin CPR
3. Begin Tx - Epi 1mg (0.01mg/kg in peds)
4. Cont Tx - Epi q3min
5. Re-evaluate
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| When to stop resuscitation in asystole | 1. 10 min ACLS with intubation and
2. 3 doses of Epi
3. 3 min apart
4. in pt with continued asystole
5. if ETCO2 shows no expired CO2
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| What energy levels should be used for defibrillation & sync cardioversion | VF, aFib, & anyone dying = 200 J
VT, A-flut, PSVT, & anyone stable = 100 then 200J
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| What are reversible causes of symptomatic PVCs to tx or r/o | 1. Hypoxia
2. Ischemia
3. HypoK - hypoMg
4. Profound alkalosis/acidosis
5. Hypersympathetic state (EtOH w/d, cocaine, hyperthyroid)
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| Tx for run of VT or multifocal ectopy | Amio (150mg/10min)
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| Tx for PVCs during acute ischemia | Metoprolol (5mg IV q5min x 3)
OR
Esmolol (0.5 mg/kg IVP - if successful --> 0.05mg/kg/min)
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| Tx for PVCs with prolonged QT or HypoK/Mg | Mg (2g / 5 min)
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| Tx for PVCs with EtOH w/d or cocaine | Ativan 1mg q5-10min
AND
Mg (2g / 5 min)
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| Tx for refractory ectopy not due to long QT | Procainamide as per VT
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