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Handbook of Anesthesiology[1]

Handbook of Anesthesiology[1]

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Handbook ofAnesthesiology
2008 Edition
Mark R. Ezekiel, MD, MS
 © 2008 Mark R. Ezekiel, MD. All rights reserved. Thisbook, or any parts thereof, may not be reproduced,photocopied, or stored in an information retrieval networkwithout the written permission of the publisher. Thereader is advised to consult the drug package insert andother references before using any therapeutic agent. Nowarranty exists, expressed or implied, for errors oromissions in this text.
Resuscitation Algorithms(ACLS)
Primary and Secondary ABCD Survey
1.Primary ABCD surveyA.Airway:
assess and manage the airway withnoninvasive devices.
assess and manage breathing (look,listen, and feel). If the patient is not breathing, givetwo rescue breaths, 1 second each.
: if no pulse, start chest compressionsat 100/min
: analyze rhythm; shock VF/VT oncethen resume CPR
2.Secondary ABCD surveyA.Airway:
establish appropriate airway management.
ventilate with O
; confirm effectiveoxygenation and ventilation.
establish IV/IO access; administerdrugs appropriate for rhythm and condition;continue CPR; minimize chest compression inter-ruptions.
D.Differential Diagnosis:
search for and treatidentified reversible causes.
Potentially reversible causes include: hypoxia,hypovolemia, hyperkalemia, hypokalemia andmetabolic disorders, hypothermia, tensionpneumothorax, tamponade, toxic/therapeuticdisturbances, and thromboembolic/mechanicalobstruction.
Ventricular Fibrillation and Pulseless VT
1.Primary ABCs2.CPR:
continue CPR for 2 minutes prior to shock.
3.Assess rhythm:
if VF or VT defibrillate 1 time only(360 J)
.4.Resume CPR5.
Intubate, IV access, and prepare drugs.
6.Assess rhythm:
if VF or VT defibrillate 1 time only(360 J).
Continue CPR for 2 minutes.
1.0 mg IVP, repeat every 3-5 minutes,or vasopressin 40 units IV, single dose, 1 time only.
360 J 1 time.
10.Continue CPR11.Consider antiarrhythmicsA.
Amiodarone 300 mg IVP
Lidocaine 1.5 mg/kg IVP, repeat x2 q5-10 minutesto a total loading dose of 3 mg/kg
Magnesium sulfate 2 grams IV (especially ifTorsade de pointes or suspectedhypomagnesemic state or severe refractory VF).
360 J, 30-60 sec after each dose ofmedication.
Repeat Amiodarone 150 mg IVP (if recurrent VF/VT),up to max cumulative dose of 2200 mg IV in 24 hours
Consider bicarbonate 1 mEq/kg (if known preexistingbicarbonate responsive acidosis, overdose withtricyclic antidepressant, if intubated and continuedlong arrest interval, hypoxic lactic acidosis, orhypercarbic acidosis).
1.Primary ABCD survey2.Confirm asystole in two or more leads.
If rhythm isunclear and possible ventricular fibrillation, defibrillateas for VF.
3.Secondary ABCD survey4.Consider possible causes:
hypoxia, hyperkalemia,hypokalemia, hypothermia, preexisting acidosis, drugoverdose and myocardial infarction.
Consider transcutaneous cardiac pacing (ifconsidered, perform immediately)
Epinephrine 1.0 mg IVP, repeat every 3-5 minutes.
Atropine 1.0 mg IV, repeat every 3-5 minutes up tototal dose of 0.04 mg/kg.
If asystole persists, consider withholding or ceasingresuscitative efforts.
Before terminating resuscitative efforts considerquality of resuscitation, if atypical clinical featuresare present, or if support for cease-effortsprotocols are in place.
Pulseless Electrical Activity (PEA)
1.Pulseless electrical activity:
rhythm on monitor,without detectable pulse.
2.Primary ABCD survey3.Secondary ABCD survey4.Consider possible causes:
hypoxia, hypovolemia,hyper-/hypokalemia and metabolic disorders,hypothermia, hydrogen ion acidosis, tension pneumo-thorax, cardiac tamponade, toxic/therapeuticdisturbances (such as tricyclics, digitalis, beta-blockers, calcium channel blockers), pulmonaryembolism, and acute myocardial infarction.
Epinephrine 1 mg IVP, repeat every 3 to 5 minutes.
Atropine 1 mg IVP (if PEA rate less then 60 bpm),repeat every 3 to 5 minutes as needed, to a total doesof 0.04 mg/kg.
Slow (absolute bradycardia <60 bpm) or relatively slow(rate less than expected relative to underlyingconditions or cause).
2.Primary ABCD survey3.Secondary ABCD survey4.If unstable
(considered unstable if chest pain,shortness of breath, decreased level ofconsciousness, hypotension, shock, pulmonarycongestion, congested heart failure or acute MI arepresent) interventional sequence:
Atropine 0.5-1.0 mg IVP repeated every 3-5 minutesup to 0.04 mg/kg (denervated transplanted heartswill not respond to atropine, go immediately to TCP,catecholamine infusion or both).
Transcutaneous pacing (TCP) if available: if patientis symptomatic, do not delay TCP while awaiting IVaccess or atropine to take effect.
Dopamine 5-20 mcg/kg/min.
Epinephrine 2-10 mcg/min.
Isoproterenol 2-10 mcg/min
5.If stableA.
And not in type II or type III AV heart block, observe.
If in type II or type III AV heart block, prepare fortransvenous pacer or use transcutaneouspacemaker until transvenous pacer is placed.
Tachycardia Overview
1.Assess and evaluate patient.
Is patient stable orunstable? Are there serious signs and symptoms dueto tachycardia?
Consider unstable if chest pain, hypotension, CHF,myocardial infarction, ischemia, decreased level ofconsciousness, shock, dyspnea or pulmonarycongestion are present.
2.If unstable, prepare for immediate cardioversion.A.
Establish rapid heart rate as cause of signs andsymptoms. If ventricular rate is >150 bpm, preparefor immediate cardioversion.
Rate-related signs and symptoms seldom occur atrates <150 bpm. May consider brief trial ofmedications based on specific arrhythmias.Immediate cardioversion is generally not needed ifheart rate is <150 bpm.
C.Have available:
oxygen saturation monitor, suctiondevice, IV line, intubation equipment.
Premedicate whenever possible.
E.Synchronized cardioversion1.
Cardiovert with 100 J, 200 J, 300 J, 360 J. (PSVTand atrial flutter often respond to lower energylevels; start with 50 J).
If delays in synchronization occur and clinicalcondition is critical, go immediately tounsynchronized shocks.
May need to resynchronize after eachcardioversion.
3.If stable, treat according to arrhythmia.A.
Atrial fibrillation/atrial flutter.
Narrow-complex tachycardias.
Stable wide-complex tachycardia: unknown type.
Stable monomorphic VT.
Torsade de pointes (polymorphic VT).
Tachycardia: Atrial Fibrillation and AtrialFlutter
1.Evaluation focus: clinical featuresA.
Patient clinically unstable?
Cardiac function impaired?
Wolf-Parkinson-White (WPW) present?
Duration <48 hours or >48 hours?
2.Treatment focus: clinical evaluationA.
Treat unstable patients urgently.
Control heart rate.
Convert the rhythm.
Provide anticoagulation.
3.Treatment of atrial fibrillation/atrial flutterA.Rate control1.If AF >48 hours
duration, use agents to convertrhythm with extreme caution in patients notreceiving adequate anticoagulation because ofpossible embolic complications.
2.Preserved cardiac function:
use only one of thefollowing agents: calcium channel blockers orbeta-blockers.
3.Impaired heart (EF<40% or CHF):
use only oneof the following agents: digoxin, diltiazem, oramiodarone.
4.WPW with preserved heart function:
DCcardioversion or use one of the following primaryantiarrhythmic agents: amiodarone, flecainide,procainamide, or sotalol.
5.WPW with impaired heart (EF <40% or CHF):
DC cardioversion or amiodarone.
B.Convert rhythm1.Preserved cardiac function with duration <48hours:
consider cardioversion or any one of thefollowing agents: amiodarone, ibutilide,flecainide, propafenone, or procainamide.
2.Preserved cardiac function with duration >48hoursA.No cardioversion.
Conversion of AF to NSRwith drugs or shock may cause embolizationof atrial thrombi unless patient has adequateanticoagulation. Use antiarrhythmic agentswith extreme caution.
B.Delayed cardioversion:
anticoagulation for 3weeks at proper levels before cardioverting,continue anticoagulation for 4 weeks.
C.Early cardioversion:
begin IV heparin atonce, TEE to exclude atrial clot, thencardioversion with 24 hours, continue anti-coagulation for 4 weeks.
3.Impaired heart (EF <40% or CHF) duration <48hours:
consider DC cardioversion oramiodarone.
4.Impaired heart (EF <40% or CHF) duration >48hours:
anticoagulation (as described above)followed by DC cardioversion.
5.WPW with preserved heart function:
DCcardioversion or use one of the following primaryantiarrhythmic agents: amiodarone, flecainide,procainamide, or sotalol.
6.WPW with impaired heart (EF <40% or CHF):
DC cardioversion or amiodarone.
Narrow-Complex SupraventricularTachycardia, Stable
1.Attempt therapeutic diagnostic maneuverA.
Vagal maneuvers (carotid sinus pressure iscontraindicated in patients with carotid bruits; avoidice water immersion in patients with ischemic heartdisease).
Adenosine 6 mg rapid IVP (over 1-3 seconds); mayrepeat with 12 mg rapid IVP in 1-2 minutes for atotal of 30 mg.
2.Junctional tachycardia

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