Drug Therapy in VF and Pulseless VT • Amiodarone o 1st line antiarrythmic given during cardiac arrest o Consider for VF or pulseless

VT unresponsive to CPR, defibrillation, vasopressor therapy Initial Dose: 300mg IV/IO followed by 150mg IV/IO • Lidocaine o Lidocaine has not demonstrated improved rates of ROSC compared with amiodarone o May be considered if amiodarone is not available o Initial Dose: 1-1.5mg/kg IV, if persists: Additional doses of 0.5-0.75mg/kg IV push Administered at 5-10 minute intervals to a max dose of 3mg/kg Interventions Not Effective during Cardiac Arrest • Atropine o Routine use of atropine during PEA or asystole unlikely to benefit • Sodium Bicarbonate o Majority of studies showed no benefit or found a relationship with poor outcome o Disadvantages: Compromise CPP by reduction systemic vascular resistance Exacerbate central venous acidosis Create extracellular alkalosis (shifting oxyhemoglobin curve left) Produces excess CO2 (which contributes to intracellular acidosis of myocardial and cerebral tissue)

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Advantages Preexisting metabolic acidosis Hyperkalemia Tricyclic antidepressant overdose Calcium Routine administration is not recommended

Monitoring During CPR o Mechanical parameters o Physiologic paramenters o Pulse o End-Tidal CO2 (Intubated) o Correlate with cardiac output and myocardial blood flow o Normal 35-40 mmHg o If <10 mmHg Optimize compression, change provider o Coronary perfusion pressure and arterial pressure o Relaxation Pressure o Central Venous Oxygen Saturation o Pulse Oximetry

Management of Symptomatic Bradycardia Provider must evaluate patient’s symptoms, clinical signs: ventilation, oxygenation, heart rate, blood pressure, level of consciousness, signs of inadequate organ perfusion Unstable: Vital organ function is impaired or cardiac arrest is imminent o Immediate intervention is indicated Symptomatic: Patient is stable and not in imminent danger o Palpitations, lightheadedness, dyspnea

Atropine: o First line druge for acute symptomatic bradycardia o Improved heart rate, symptoms, signs of bradycardia

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Should be considered a temporizing measure while awaiting a transcutaneous or transvenous pacemaker Caution: o Doses < 0.5mg may paradoxically cause bradycardia o Cautious use in presence of acute coronary ischemia o Ineffective in cardiac transplantation patients (vagotomy) o

Pacing: RCT show atropine and glycopyrrolate were compared with TCP showed few differences in outcome and survival o TCP is painful in conscious patients o HCP should initiate TCP in unstable patients who do not respond to atropine o Immediate pacing might be considered in unstable patients with high-degree AV block when IV access is not available o IF patient does not respond to drugs or TCP transvenous pacing is probably indicated Alternative Drugs (2nd Line if Atropine Fails): o Dopamine hydrochloride o Catecholamine with a and b adrenergic actions o At lower doses 2-10mcg/kg/min = inotropy o At higher doses 10-20mcg/kg/min= vasoconstrictive o Useful if bradycardia is associated with hypotension o Epinephrine o Infusion at 2-10mcg/min and titrate to patient response o Useful if bradycardia is associated with hypotension o Isoproterenol o B-adrenergic agent with B1 and B2 effects o Increase heart rate and vasodilation o Infusion at 2-10mcg/min and titrate to patient response

Management of Symptomatic Tachycardia Narrow QRS Complex Tachycardias QRS<0.12s Sinus Tachycardia Atrial fibrillation Atrial Flutter AV nodal reentry Accessory pathway mediated tachycardia Atrial tachycardia (incl. automatic and reentry)

Wide QRS Complex Tachycardias QRS>0.12s Ventricular Tachycardia Ventricular Fibrillation SVT with aberrancy Pre-excited tachycardias (WPW) Ventricular paced rhythms

Synchronized Cardioversion o If cardioversion is needed and it is impossible to synchronize a shock use high-energy unsynchronized shocks o Synchronization recommended for: o Unstable SVT o Unstable Atrial Fibrillation Cardioversion is 120-200J o Unstable Atrial Flutter Initial energy 50-100J (if 50 fails increase dose)

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Cardioversion with monophasic begins at 200J (increase if fails) Unstable monomorphic (regular) VT Responds well to monophasic or biphasic with initial energies of 100J

Vagal Maneuvers o Terminates up to 25% of PSVTs o For other SVTs o May transiently slow the ventricular rate o Potentially assist rhythm diagnosis but will not usually terminate such arrhythmias Adenosine o If PSVT doesn’t respond to vagal maneuvers o 6mg IV adenosine as a rapid IV push followed by 20ml saline flush o If doesn’t convert within 1-2 min give 12mg o Because of the possibility of initiating AF with rapid ventricular rates in a patient with WPW a defibrillator should be available Narrow Complex Irregular Tachycardia o Atrial fibrillation with uncontrolled ventricular response o MAT o Sinus rhythm/tachycardia with frequent atrial premature beats Therapy o Management of AF should focus on: o Rate control Unstable: Electric Cardioversion Stable: • IV nondihydropyridine calcium channel blockers: Diltiazem for atrial fibrillation and rapid ventricular response • Digoxin and amiodarone (used in patients with CHF) • Amiodarone: risk of conversion to sinus rhythm o Rhythm control (unstable afib sinus) o Patient with an atrial fibrillation duration of 48 hours o Increased risk for cardioembolic events o Electric or pharmacologic cardioversion should not be attempted in these patients unless the patient is unstable o OR perform cardioversion following anticoagulation with heparin and TEE to ensure the absence of a left atrial thrombus Therapy for Regular Wide-Complex Tachycardias If the etiology of the rhythm cannot be determined o QRS monomorphic, regular o IV adenosine is relatively safe for both treatment and diagnosis o However, should not be given for unstable or irregular or polymorphic wide complex tachycardias (may cause degeneration of arrhythmia into VF) Adenosine o If it proves to be SVT with aberrancy (transiently slows or converts to sinus rhythm) o If due to VT there will be no effect o When given for undifferentiated wide complex tachycardia defibrillator should be available

Verapamil o Contraindicated for wide-complex tachycardias unless known to be of supraventricular origin o Profound hypotension in 11/25 patients treated for VT IV Antiarrhythmic Drugs o Stable with likely VT o Amiodarone o Effective in preventing recurrent monomorphic VT o Treating refractory ventricular arrhythmias in patients with coronary artery disease and poor ventricular function o 150mg IV over 10 minutes (repeat as needed to a max of 2.2g IV per 24h) o Procainamide o Sotalol o Procainamide and sotalol should be avoided in patients with prolonged QT, CHF o Lidocaine o Less effective in terminating VT than procainamide, sotalol, amiodorone o Considered 2nd line for monomorphic VT o 1-1.5 mg/kg IV bolus o Maintenance infusion is 1-4mg/min Wide complex Irregular Rhythm Should be considered preexcited atrial fibrillation, expert consultation advised Avoid AV nodal blocking agents o Adenosine, calcium channel blockers, and possibly beta-blockers o Paradoxical increase in the ventricular response Polymorphic (Irregular) VT First step o Stop medications known to prolong the QT interval o Correct electrolyte imbalance o Acute precipitants: drug overdose or poisoning Prolonged QT interval (Torsade de pointes) o IV magnesium 1-2g IV over 15 minutes Normal QT Interval o Most common cause is myocardial ischemia o IV amiodarone and beta-blocker may reduce the frequency of arrhythmia recurrence If patient has polymorphic VT, treat the rhythm as VF and deliver high-energy unsynchronized shocks

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