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
Central IV fast onset of action
Intratracheally (down an ET tube)
Intraosseous alternative IV route in peds

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

IV Fluids
Volume Expanders crystalloids , eg
Ringers lactate, N/S, or colloids, eg
Albumin or Hetastarch
TKO D5W, N/S

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

The Following Drugs Help to

Control Heart Rate & Rhythm

Lidocaine

Indications:
PVCs, Vtach, Vfib
Can be toxic so no longer given
prophylactically
IV dose :
1-1.5 mg/kg bolus then continuous infusion of
2-4 mg/min
Can be given down ET tube
Signs of toxicity:
slurred speech, seizures, altered consciousness

Amiodarone (Cordarone)

Indications:
Like Lidocaine Vtach, Vfib
IV Dose:
300 mg in 20-30 ml of N/S or D5W
Supplemental dose of 150 mg in 20-30 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:
Cardiogenic shock, profound Sinus
Bradycardia, and 2nd and 3rd degree blocks that
do not have a pacemaker

Procainamide (Pronestyl)

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

Atropine

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

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

Adenosine

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

Verapamil

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:
2.5-5 mg over 2 minutes up to 20 mg
Side Effects:
Hypotension
N &V

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

Propranolol

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
Helps convert fine vfib to coarse Vfib
May help in asystole
Also PEA and symptomatic bradycardia
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!
IV dose = 40 IU
Can be given down ET tube
May be better for asystole

Norepinephrine (Levarterenol)

Similar in effect to epinephrine

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

Dopamine

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)
IV Dose:
1-20 micrograms/kg
Side effects:
Ectopic beats
N &V

Dobutamine

Actions similar to Dopamine

Used for CHF with hypotension
IV Dose:
2-20 micrograms/minute
Side effects:
Tachycardia
N &V
Headache
Tremors

Digitalis (Digoxin)

Slows conduction through A-V node and increases

force of contraction
Used in CHF and chronic atrial fib/flutter
Can be given orally or IV
Side effects:
Arrhythmias
N & V, diarrhea
Agitation

Nitroglycerin

Vasodilator that helps relieve pain from angina

pectoris
Can be given IV, sublingually, as an ointment or a
slow release patch
Side effects:
Headache
Hypotension
Syncope
V/Q mismatch

Sodium Nitroprusside (Nipride)

Vasodilator used for hypertensive crisis

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:
Hypotension so patient must have continuous
hemodynamic monitoring

Sodium Bicarbonate

Used for METABOLIC acidosis hyperkalemia

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

Thrombolytics
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:
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:
Same as lidocaine and procainamide (usually
when condition doesnt respond to these two)
IV dose:
5-10mg/kg bolus followed by continuous
infusion of 1-2 kg/min
Side Effects:
N &V
Hypotension

Amrinone

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