Advanced Cardiac Life Support

Advanced Cardiac Life Support




EMERGENCY CARDIAC CARE





Assess Responsiveness



Unresponsive

Call for code team and Defibrillator

Assess breathing (open the airway, look,

listen and feel for breathing)





If Not Breathing,

give two slow breaths.

Assess Circulation

Initiate CPRPULSE NO PULSE



Give oxygen by bag mask

Secure IV access

Ventricular

fibrillation/tachycardia(VT/VF) present onmonitor?

If witnessed arrest, give

Determine probable etiology of arrestprecordial thump and

based on history, physical exam, cardiaccheck pulse. If absent,

monitor, vital signs, and 12 lead ECG. continue CPR







YES



Hypotension/shock,

acute pulmonaryedema.

Go to fig 8 NO

Intubate

Confirm tube placementDetermine rhythm and

cause. Arrhythmia

BradycardiaTachycardiaElectrical Activity?

Go to Fig 5 Go to Fig 6

YES NO

VT/VFGo to Fig 2

Pulseless electrical activityGo to Fig 3

AsystoleGo to Fig 4

Fig 1 - Algorithm for Adult Emergency Cardiac Care





VENTRICULAR FIBRILLATION AND PULSELESS

VENTRICULAR TACHYCARDIA





Continue CPR

Persistent or

recurrent VF/VT

Epinephrine 1 mgIV push, repeatq3-5min or 2 mg in10 ml NS via ET tube

q3-5min or

Vasopressin 40 U IVP x1 dose onlyDefibrillate 360 J

Continue CPR

Secure IV access

Intubate if no response

Defibrillate immediately, up to 3 times at 200 J, 200-300 J, 360 J.

Do not delay defibrillation

Return of

spontaneouscirculation

Pulseless Electrical

ActivityGo to Fig 3

Monitor vital signsSupport airwaySupport breathingProvide medications appropriate for bloodpressure, heart rate, and rhythm

Assess Airway, Breathing, Circulation, Differential DiagnosisAdminister CPR until defibrillator is ready (precordial thump if witnessed arrest)

Ventricular Fibrillation or Tachycardia present on defibrillator

AsystoleGo to Fig 4

Check pulse and Rhythm

Amiodarone (Cordarone) 300 mg IVP or

Lidocaine 1.5 mg/kg IVP, and repeat q3-5 min, up to total max of 3 mg/kg or

Magnesium sulfate (if Torsade de pointes or hypomagnesemic) 2 gms IVP or

Procainamide (if above are ineffective) 30 mg/min IV infusion to max 17 mg/kg

Continue CPR

Defibrillate 360 J, 30-60 seconds after each dose of medication

Repeat amiodarone (Cordarone) 150 mg IVP prn (if reurrent VF/VT) ,up to maxcumulative dose of 2200 mg in 24 hours

Continue CPR. Administer sodium bicarbonate 1 mEq/kg IVP if long arrest periodRepeat pattern of drug-shock, drug-shock

Note: Epinephrine, lidocaine, atropine may be given via endotracheal tube at



2-2.5 times the IV dose. Dilute in 10 cc of saline.

After each intravenous dose, give 20-30 mL bolus of IV fluid and elevateextremity.



Fig 2 - Ventricular Fibrillation and Pulseless Ventricular Tachycardia





PULSELESS ELECTRICAL ACTIVITY



Pulseless Electrical Activity Includes:

Electromechanical dissociation (EMD)

Pseudo-EMD

Idioventricular rhythmsVentricular escape rhythmsBradyasystolic rhythmsPostdefibrillation idioventricular rhythms



Epinephrine 1.0 mg IV bolus q3-5 min, or high doseepinephrine 0.1 mg/kg IV push q3-5 min; may give viaET tube.

Continue CPR

If bradycardia (<60 beats/min), give atroprine 1 mg IV, q3-5min, up to total of 0.04 mg/kgConsider bicarbonate, 1 mEq/kg IV (1-2 amp, 44 mEq/amp),

if hyperkalemia or other indications.

Determine differential diagnosis and treat underlying cause:

Hypoxia (ventilate)

Hypovolemia (infuse volume)

Pericardial tamponade (perform pericardiocentesis)

Tension pneumothorax (perform needle decompression)

Pulmonary embolism (thrombectomy, thrombolytics)

Drug overdose with tricyclics, digoxin, beta, or calcium blockersHyperkalemia or hypokalemiaAcidosis (give bicarbonate)

Myocardial infarction (thrombolytics)

Hypothemia (active rewarming)

Initiate CPR, secure IV access, intubate, assess pulse.

Fig 3 - Pulseless Electrical Activity





ASYSTOLE





Continue CPR. Confirm asystole byrepositioning paddles or by checking 2 leads.

Intubate and secure IV access.



Consider underlying cause, such as hypoxia,

hyperkalemia, hypokalemia, acidosis, drugoverdose, hypothermia. myocardial infarction.

Consider transcutaneous pacing (TCP)

Consider bicarbonate 1 mEq/kg (1-2 amp) ifhyperkalemia, acidosis, tricyclic overdose.

Consider termination of efforts.

Atropine 1 mg IV, repeat q3-5min up to a total of

0.04 mg/kg; may give via ET tube.

Epinephrine 1.0 mg IV push, repeat every 3-5 min;

may give by ET tube; high dose epinephrine 0.1mg/kg IV push q5min (1:1000 sln).

Fig 4 - Asystole







BRADYCARDIA



Assess Airway, Breathing, Circulation, Assess vital signs

Differential Diagnosis Review history

Secure airway and give oxygen Perform brief physical exam

Secure IV access Order 12-lead ECG

Attach monitor, pulse oximeter and





automatic sphygmomanometer





Bradycardia (<60 beats/min)

Serious Signs or Symptoms?

Observe

Fig 5 - Bradycardia (with patient not in cardiac arrest).

Too slow (<60 beats/min)



Yes



No



If type II second or 3rd degree heart block,

block or third degree AV heart





Type II second degree AV heart



wide complex escape beats, MI/ischemia,

block?



denervated heart (transplant),new bundlebranch block: Initiate Pacing(transcutanousor venous)



If type I second degree heart block, giveatropine 0.5-1.0 mg IV, repeat q5min, theninitiate pacing if bradycardia.



Dopamine 5-20 mcg/kg per min IV infusionEpinephrine 2-10 mcg/min IV infusionIsoproterenol 2-10 mcg/min IV infusion



No Yes



Consider transcutaneous pacing or transvenouspacing.







No or borderline

Yes

Assess Airway, Breathing, Circulation, Differential DiagnosisAssess Vitals, Secure AirwayReview history and examine patient.

Give 100% oxygen, secure IV access.

Attach ECG monitor, pulse oximeter, blood pressure monitor.

Order 12-lead ECG, portable chest x-ray.

UNSTABLE, with serious signs or symptoms?

Unstable includes, hypotension, heart failure, chest pain, myocardialinfarction, decreased mental status, dyspnea

TACHYCARDIA



IMMEDIATE CARDIOVERSION



Atrial flutter 50 J, paroxysmal supraventricular tachycardia

50 J, atrial fibrillation 100 J, monomorphic ventriculartachycardia100 J, polymorphic V tach 200 J.



Premedicate with midazolam (Versed) 2-5 mg IVP when





possible.



Atrial fibrillation

Atrial flutter

Paroxysmalsupraventricularnarrow complextachycardia(PSVT)

Determine Etiology: Hypoxia, ischemia,

MI, pulmonary embolus,

hyperthyroidism, electrolyte abnomality,

theophylline, inotropes.

Adenosine

6 mg, rapid IVpush over 1-3 sec

1-2 min

Cardioversion of atrial fibrillation to sinus rhythm:

If less than 2 days and rate controlled:

Procainamide or amiodarone, followed bycardioversion

If more than 2 days: Coumadin for 3 weeks;

control rate, start antiarrythmic agent, thenelectrical cardioversion.

Control Rate: Diltiazem,verapamil, digoxinesmolol, metoprolol

Fig 6 Tachycardia

Vagal maneuvers:

Carotid sinus

massage if nobruits

Wide-complex



tachycardia of



uncertain type





If uncertain if V tach,

give Adenosine 6



mg rapid IV push



over 1-3 sec



1-2 min



Adenosine



12 mg, rapid IV



push over 1-3 sec



(may repeat once



in 1-2 min)





Ventricular



tachycardia (VT)

with pulse



present



Torsade de pointes(polymorphic VT)

with pulse present

Correct underlying



cause: Hypokalemia, drug overdose (tricyclic,

phenothiazine,

antiarrhythmicclass Ia, Ic, III)



Amiodarone 150300 mg IV over 10



20 min







Diltiazem

Overdrive

pacing





Lidocaine



Adenosine 12 mg, rapid IV



1-1.5 mg/kg IV push.



push over 1-3 seconds (may



Repeat



repeat once in 1-2 min); max



mg/kg IVP q5-10min



total 30 mg



to max total 3 mg/kg





Overdrive

(cutaneous or venous)

Isoproterenol 2-20 mcg/min





Wide



OR



Phenytoin 15 mg/kg IV at 50If



mg/minOR

syndrome,



Lidocaine 1.0-1.5 mg/kg IVP(Cordarone) 150-300 mg IVCardioversion 200 J



Low-unstable



over 10-20 min



Magnesium 2-4 gm IVover 5-10 min

Lidocaine 1.0-1.5 mg/kg IVP

Procainamide

mg/min IV to max

Procainamide total 17 mg/kg







20-30 mg/min, maxtotal 17 mg/kg;

followed by 2-4 mg/min







If WPW, avoid adenosine, beta-

blockers,

digoxin







Complex

Narrow

Synchronized cardioversion 100 J

Normal or elevated pressure

Verapamil2.5-5 mg IV

15-30 min

Verapamil5-10 mg IV

Consider

DigoxinBeta

Blood Pressure ?

Fig 6 - Tachycardia





STABLE TACHYCARDIA



If ventricular rate is >150 beats/min, prepare for immediate cardioversion.

Treatment of Stable Patients is based on Arrhythmia Type :

Ventricular Tachycardia:

Procainamide (Pronestyl) 30 mg/min IV, up to a total max of 17 mg/kg,

or

Amiodarone (Cordarone) 150-300 mg IV over 10-20 min, orLidocaine 0.75 mg/kg. Procainamide should be avoided if ejection

fraction is <40%.

Paroxysmal Supraventricular Tachycardia: Carotid sinus pressure (ifbruits absent), then adenosine 6 mg rapid IVP, followed by 12 mg rapidIVP x 2 doses to max total 30 mg. If no response, verapamil 2.5-5.0 mgIVP; may repeat dose with 5-10 mg IVP if adequate blood pressure; orEsmolol 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion, andtitrate up to 200 mcg/kg/min IV infusion.

Atrial Fibrillation/Flutter:

Ejection fraction $40%: Diltiazem (Cardiazem) 0.25 mg/kg IV over 2min; may repeat 0.35 mg/kg IV over 2 min prn x 1 to control rate. Then

give procainamide (Pronestyl) 30 mg/min IV infusion, up to a total maxof 17 mg/kgEjection fraction <40%: Digoxin 0.5 mg IVP, then 0.25 mg IVP q4h x 2

to control rate. Then give amiodarone (Cordarone) 150-300 mg IV over

10-20 min.

Stable tachycardia with serious signs andsymptoms related to the tachycardia. Patient

not in cardiac arrest.

Check oxygen saturation, suction device,

intubation equipment. Secure IV access

Premedicate whenever possible with Midazolam (Versed)

2-5 mg IVP or sodium pentothal 2 mg/kg rapid IVP

Fig 7 - Stable Tachycardia (not in cardiac arrest)

Synchronized cardioversionAtrial flutter 50 J

PSVT 50 J

Atrial fibrillation 100 J

Monomorphic V-tach 100 J

Polymorphic V tach 200 J



HYPOTENSION, SHOCK, AND ACUTE PULMONARY EDEMA



Signs and symptoms of congestive heart failure, acute pulmonary edema.



Assess ABCD's, secure airway, administer oxygen; secure IV access. Monitor ECG, pulse oximeter,

blood pressure, order 12-lead ECG, portable chest X-ray



Check vital signs, review history, and examine patient. Determine differential diagnosis.





Determine underlying cause

Systolic BP

70-100 mm Hg

Dopamine 2.5-20mcg/kg per min IV(add norepinephrineif dopamine is >20mcg/kg per min)

Norepinephrine 0.5-

30 mcg/min IV orDopamine 5-20mcg/kg per min

BradycardiaGo to Fig 5

Systolic BP >100 mm Hgand diastolic BP normal

Systolic BP<70 mm Hg

Diastolic BP >110 mm Hg

Dobutamine 2.0-20

mcg/kg per min IV

Furosemide IV 0.5-1.0 mg/kgMorphine IV 1-3 mgNitroglycerin SL 0.4 mg tabq3-5min x3Oxygen

TachycardiaGo to Fig 6 Determine blood pressure

Hypovolemia Pump Failure Bradycardia or Tachycardia

Administer Fluids, Blood

Consider vasopressorsApply hemostasis; treat

underlying problem

If ischemia and hypertension:

Nitroglycerin10-20

IV, and titrate to effect and/orNitroprusside 0.1-5.0mcg/kg/min IV

Fig 8 - Hypotension, Shock, and Acute Pulmonary Edema