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ACLS Primary Survey Assess responsiveness (speak loudly, gently shake patient if no trauma - "Annie, Annie, are you

u OK?"). Call for help/crash cart if unresponsive. ABCD's (sorry, can't get a much better mnemonic than that ... maybe "A Big Cruel Dude [just beat me up and I coded?"] ) Airway Open airway, look, listen, and feel for breathing. Breathing If not breathing, slowly give 2 rescue breaths. Circulation Check pulse. If pulseless, begin chest compressions at 100/min, 15:2 ratio. Consider precordial thump with witnessed arrest and no defibrillator nearby. Interposed abdominal compression CPR may be more effective if trained personnel available, maybe contraindicated in pregnancy, recent surgery, abdominal aneurysm (Class 2b) Defibrillation Attach monitor, determine rhythm. If VF or pulseless VT: shock up to 3 times. If not, basic CPR. (I think we now have AED's on our code carts that will lead you through this.) Then, move quickly to Secondary Survey. Back to Top of Page Secondary Survey After initial (primary) assessment done Another set of ABCD's - "A Bigger, Crueler Dude (tried to finish me off)" Airway Establish and secure an airway device (ETT, LMA,

COPA, Combitube, etc.). Breathing Ventilate with 100% O2. Confirm airway placement (exam, ETCO2, and SpO2). Remember, no metabolism/circulation = no blue blood to lungs = no ETCO2. Circulation Evaluate rhythm, pulse. If pulseless continue CPR, obtain IV access, give rhythm-appropriate medications (see specific algorithms). PIV preferred initially vs. central line. Differential Diagnosis Identify and treat reversible causes. Back to Top of Page Asystole Primary Survey Secondary Survey: Confirm rhythm (check monitor, power, different lead) Treatment Consider bicarb, pacing early Police officer Hank having just found a body: "Again (asystole)! Boy, This 'Ere's Awful!" Bicarb (NaHCO3). Consider for indications below: Class 1: hyperkalemia Class 2a: bicarbonate-responsive acidosis, tricyclic OD, to alkinalize urine for aspirin OD Class 2b: prolonged arrest Not for hypercarbia-related (respiratory) acidosis, nor for routine use in cardiac arrest Transcutaneous Pacing (TCP) Not shown to improve survival If tried, try EARLY Epinephrine 1 mg IV q3-5 min Atropine 1 mg IV q3-5 min

Max 0.04 mg/kg Consider possible causes (Officer Hank reporting in:"Agent (asystole) Hank Here ... He's Dead, Marshall") Hypoxia Hyperkalemia Hypothermia Drug overdose (e.g., tricyclics) Myocardial Infarction Consider termination. If patient had >10min with adequate resucitative effort and no treatable causes present, consider cessation - it is, after all, the final rhythm. Back to Top of Page Bradycardia Primary Survey Secondary Survey assess need for airway, oxygen, IV, monitor, fluids, vitals, pulse ox 12-lead ECG, Hx, P/E. Consider DDx If AV block: 2nd degree (type 2) or 3rd degree: standby TCP, prepare for transvenous pacing slow wide complex escape rhythm: Do NOT give lidocaine. If serious signs or symptoms, treat even though "Bub (bradycardia), All People Die Eventually" Atropine 0.5-1.0 mg IV push q 3-5 min max 0.04 mg/kg Pacing Use transcutaneous pacing (TCP) immediately if sx severe Dopamine 5-20 g/kg/min Epinephrine 2-10 g/min Back to Top of Page

Tachycardias Primary Survey, Secondary Survey: Is patient stable or unstable? stable: determine rhythm, treat accordingly unstable =chest pain, dyspnea, decreased level of conciousness, low BP, CHF, Acute MI If HR is cause of symptom (almost always HR>150): cardiovert Specific Rhythms Atrial fib/flutter Narrow-Complex (Supraventricular) Tachycardia Wide-Complex Tachycardia, Unknown Type Stable Ventricular Tachycardia Back to Top of Page Atrial fibrillation/flutter If unstable: proceed more urgently Management: Control rate, consider rhythm cardioversion, and anticoagulate as shown below, according to Category: 1, 2 or 3 Category 1. Normal EF Rate control: Ca-blocker or beta-blocker. Cardiovert: If onset < 48 hours, consider DC cardioversion OR with one of the following agents: amiodarone, ibutilide, procainamide, (flecainide, propafenone), sotalol. If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone). Either: Delayed Cardioversion: anticoagulate adequately x 3 weeks, then cardioversion, then anticoagulate x 4 weeks Early Cardioversion: iv heparin, then TEE, then cardioversion within 24 hours, then anticoagulate x 4 weeks

Anticoagulate if not contraindicated, if A fib > 48 hrs Category 2. EF< 40% or CHF Rate control: digoxin, diltizaem, amiodarone (avoid if onset of AF > 48 hours). avoid verapamil, beta-blockers, ibutilide, procainamide (and propafenone/flecainide) Cardiovert: same as Category 1, except the only conversion agent allowed is amiodarone. Anticoagulate, if A fib > 48 hr. Category 3. WPW A fib Suggested by: delta wave on resting EKG, very young patient, HR>300 Avoid adenosine, beta-blocker, Ca-blocker, or Digoxin If < 48 hour: If EF normal: one of the following for both rate control and cardioversion: amiodarone, procainamide, propafenone, sotalol, flecainide If EF abnormal or CHF: amiodarone or cardioversion If > 48 hour Medication listed above may be associated with risk of emboli Anticoagulate and DC cardioversion as in Category 1. Note: new ALCS does not allow mixing antiarrhythmics for A fib/flutter. Back to Tachycardias Back to Top of Page Narrow-Complex SVT If unstable, cardiovert No cardioversion for stable SVT with low EF. Management 1. 12-lead ECG, clinical exam 2. Vagal stimulation, adenosine. Consider esophageal lead 3. Treat according to specific rhythm: PSVT

MAT Junctional Back to Tachycardias Back to Top of Page PSVT EF normal Ca-blocker> beta-blocker> digoxin> DC Cardioversion. Consider procainamide, sotalol, amiodarone. If unstable proceed to cardioversion EF < 40%, CHF No Cardioversion. Digoxin or amiodarone or diltiazem. If unstable proceed to cardioversion. Back to Tachycardias Back to Top of Page MAT EF normal: Ca-blocker, beta-blocker, amiodarone EF < 40%, CHF: amiodarone, diltiazem Note: no cardioversion Back to Tachycardias Back to Top of Page Junctional EF normal: amiodarone, beta-blocker, Ca-blocker EF < 40%, CHF: amiodarone Notes rare, most commonly misdiagnosed PSVT. likely digoxin or theophylline OD, catecholamine state no cardioversion Back to Tachycardias Back to Top of Page Wide-Complex Tachycardia, Unknown Type If unstable, cardiovert Attempt to establish specific diagnosis 12 leads, esophageal lead, Clinical info Note: the use of adenosine to differentiate SVT vs VT is

now de-emphasized. If unable to make Dx, treat according to EF: EF normal: DC cardioversion or procainamide or amiodarone EF < 40%, CHF: DC cardioversion or amiodarone Note: no lidocaine and bretylium in protocol Back to Tachycardias Back to Top of Page Stable VT May proceed directly to cardioversion If not, treat according to morphology: Monomorphic VT EF normal: one of the following: procainamide (2a), sotalol (2a) OR amiodarone (2b), lidocaine (2b) EF poor amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75 mg/kg iv push Synchromized cardioversion Polymorphic VT Baseline QT Normal Possible ischemia (treat) or electrolyte (esp. low K, Mg) abnormality (correct) EF normal: betablocker, lidocaine, amiodarone, procainamide, or sotalol EF poor 1. amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75 mg/kg iv push 2. synchromized cardioversion Prolonged QT baseline (torsade) Correct electrolyte abnormalities. Treatment options: magnesium, overdrive pacing, isoproterenol, phenytoin, lidocaine Back to Tachycardias Back to Top of Page

Cardioversion For tachycardia with serious signs and symptoms. Generally not needed for HR<150. If HR>150, prepare for immediate cardioversion. May give brief drug trial. Steps: Prepare emergency equipment Medicate if possible Cardioversion monomorphic VT with pulse, PSVT, A fib, A flutter: 100-200-300-360 J* (Synchronized) may try 50J first for PSVT or A flutter may use equivalent biphasic (biphasic 70, 120, 150, and 170 J) if machine unable to synchronize and patient critical, defibrillate polymorphic VT: use VT/VF algorithm Back to Tachycardias Back to Top of Page PEA The "PEA" mnemonic may be even better than "ABCD!" If not, "Please Eat Apples" Primary Survey, then Secondary Survey: rule out pseudo-PEA (handheld doppler: look for cardiac mechanical activities. If present treat agressively). Problem Search for the probable cause ... Wide QRS: suggests massive myocardial injury, hyperkalemia, hypoxia, hypothermia Wide QRS+Slow: consider drug OD (tricyclics, beta-blockers, Ca-blockers, digoxin) Narrow complex: suggests intact heart; consider hypovolemia, infection, PE, tamponade ... and treat as needed

Consider fluid challenge empirically Consider bicarbonate hyperkalemia K (Class 1) bicarbonate responsive acidosis, tricyclic OD, to alkinalize urine for aspirin OD (Class2a) prolonged arrest (Class 2b) not for hypercarbic acidosis Epinephrine: 1 mg IV q3-5 min Atropine If bradycardia, 1 mg IV q3-5 min max 0.04 mg/kg Underlying Causes 5H's, 5T's Or, if you prefer talking to fighting: He Hid His Huge Hammer, Then Thought To Try Talking Or, if you like food: Poor (PEA) Hungry Hanna (or Hank) Hurried Herself Here, Then Tasted My Oh-so-good Pie ( P=PE, M=MI, O=Overdose ... if you'd like a more lurid mnemonic, this one can easily be changed, as in "Heavenly Hanna ..." [use your imagination]) If you prefer a mechanistic approach (and are used to thinking about MAP, CO, SVR, etc.) think of things that affect forward flow... Decreased Preload: Hypovolemia, Tamponade, Tension Pneumothorax Increased Afterload: Pulmonary Embolus Decreased Contractility: Hypoxia, Hypothermia, Acidosis, Myocardial Ischemia Altered Rate/Rhythm: Hyperkalemia, Drug Overdose Hypovolemia Assess: Collapsed vasculature Tx: Fluids Hypoxia Assess: Airway, cyanosis, ABGs Tx: Oxygen, ventilation Hydrogen ion (acidosis)

Assess: Diabetic patient, ABGs Tx: Bicarb 1 mEq/kg, hyperventilation Hyperkalemia (preexisting) Assess: Renal patient, EKG, serum K level Tx: Bicarb, CaCl, albuterol neb, insulin/glucose, dialysis, diuresis, kayexalate Hypothermia Assess: Core temperature Tx: Hypothermia Algorithm Tablets/toxins overdose Assess: Hx of medications, drug use Tx: Treat accordingly Tamponade, cardiac Assess: No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest Tx: Pericardiocentesis Tension pneumothorax Assess: No pulse w/ CPR, JVD, tracheal deviation Tx: Needle thoracostomy Thrombosis, coronary Assess: History, EKG Tx: Acute Coronary Syndrome algorithm Thrombosis, pulmonary embolism Assess: No pulse w/ CPR, JVD Tx: Thrombolytics, surgery Back to Top of Page Unstable VT/VF Remember: initial stacked shocks are part of the primary survey Implement the secondary survey after your stacked shocks. Meds: drug-shock-drug-shock pattern. Continue CPR while giving meds, and shock (360J or 150J if biphasic) within 30-60 seconds. Evaluate rhythm and check for pulse immediately after shocking. Epi or vasopressin big drugs (may give either one as first choice).

If VF/PVT persists, may move on to antiarrhythmics and sodium bicarb max out one antiarrhythmic before proceeding to the next in order to limit pro-arrhythmic drug-drug interactions. "Think Shock Shock Shock, EVerybody Shocks: Anna (nicole smith) Shocks, Lydia (possner) Shocks, Madeleine (cox) Shocks, Pamela (anderson) Shocks, Bridget (hall) Shocks" ... this one needs some work. I couldn't think of enough names, so did a quick search for "models" and found a list - I recognized only a few names; choose your own favorites (this page happens to have only females, I think) Precordial Thump May be performed immediately after determining pulselessness in a witnessed arrest with no defibrillator immediately available. Check pulse after thump. Shock 200J* If VF or VT is shown on monitor: shock immediately. Do not lift paddles from chest after shocking simultaneously charge at next energy level and evaluate rhythm. Shock 200-300J* If VF or VT persists on monitor, shock immediately. Do not check pulse, do not continue CPR, do not lift paddles from chest. After shocking, simultaneously charge at next energy level and evaluate rhythm. Shock 360J* If VF or VT persists, shock immediately. Epinephrine 1 mg IV q3-5 min. High dose epinephrine is no longer recommended Vasopressin 40 U IV one time dose (wait 5-10 minutes before starting epi). Preferred first drug?

Shock 360J* Amiodarone (Class 2b) 300mg IV push. May repeat once at 150mg in 3-5 min max cumulative dose = 2.2g IV/24hrs Shock 360J* Lidocaine (Class Inderterminate) 1.0-1.5 mg/kg IV q 3-5 min max 3 mg/kg Shock 360J* Magnesium Sulfate (Class 2b) 1-2 g IV (over 2 min) for suspected hypomagnesemia or torsades de pointes (polymorphic VT) Shock 360J* Procainamide "Acceptable but not recommended" in refractory VF (Class 2b) 30 mg/min or 100 mg boluses q 5 min, up to 17 mg/kg. Besides having a pro-arrhythmic drug-drug interaction with amiodarone, procainamide is of limited value in an arrest situation due to lengthy administration time. Note: bretylium acceptable but no longer recommended in ACLS Shock 360J* Bicarbonate 1 mEq/kg IV for reasons below: Class 1: hyperkalemia Class 2a: bicarbonate-responsive acidosis, tricyclic OD, to alkinalize urine for aspirin OD Class 2b: prolonged arrest Not for hypercarbia-related acidosis, nor for routine use in cardiac arrest Shock 360J* * Or equivalent biphasic shocks (150J-150J-150J). Biphasic refers to pattern of energy wave, which is first positive then negative, i.e. in opposite direction (vs. only positive in traditional monophasic shocks). It requires less energy to achieve equivalent results. Lower energy requirements =

smaller, lighter, cheaper, longer-lasting defibrillators. All new ICDs, for example, are biphasic. Newer defibrillators also monitor impedence, and compensate for changes. Success rates may be higher with impedence-compensated biphasic defibrillation. See this AHA site for details. Back to Top of Page ACLS Drugs adenosine: 6-12 mg iv push with saline flush q 5 min amiodarone: Non-cardiac arrest load 15 mg/min over 10 min (150 mg) (mix 150 mg in 100cc D5W in PVC or Glass, infuse over 10 min) then 1 mg/min x 6 hrs (mix 900 mg in 500 cc D5W) then 0.5 mg/min x 18 hrs and beyond; supplemental bolus: 15 mg/min x 10 min Cardiac arrest 300 mg iv push (diluted in 20 cc D5W) can consider repeat 150 mg iv x 1 Max dose: 2.2 gm in 24hrs atropine: 0.5-1 mg, up to 0.04 mg/kg epinephrine: 1 mg q3-5 min iv diltiazem: load 0.25mg/kg iv over 2 min, then 0.35mg/kg over 2 min in 15 min infuse 5-15 mg/hour ibutilde: >60 kg 1 mg <60 kg 0.01 mg/kg over 10 min may repeat x 1 make sure K>4.0 and Mg normal. not recommended for low EF lidocaine: 1 mg/kg bolus additional 0.5 mg/kg q8-10 min, up to total 3 mg/kg. Then infuse 1-4 mg/min magnesium sulfate: 1-2g over 5-60 min procainamide:

load 20 mg/min up to 17 mg/kg (1000 mg) then infuse 1-4 mg/min Side Effects: HTN, torsade vasopressin: 40 IU x 1 dose only (for pulseless VT/VF) verapamil: 2.5-5-10 mg bolus Back to Top of Page Class Definitions: I II III Indeterminant Class I Definitely recommended. Definitive, excellent evidence provides support. Definition Class I interventions are always acceptable, unquestionably safe, and definitely useful. Proven in both efficacy and effectiveness.** Must be used in the intended manner for proper clinical indications Required Evidence One or more Level 1 studies are present (with rare exceptions). Study results are consistently positive and compelling. Class IIa and IIb Acceptable and useful Definition Both Class IIa and IIb interventions are acceptable, safe, and considered efficacious, but true clinical effectiveness is not yet confirmed definitively. Must be used in the intended manner for proper clinical indications. Required Evidence Available evidence, in general, is positive. Level 1 studies are absent, inconsistent, or lack power. Classes IIa and IIb are distinguished by levels of available evidence and consistency of results. No evidence of harm. Class IIa Acceptable and useful. Very good evidence provides support. Definition Class IIa interventions are acceptable, safe, and useful in

clinical practice. Considered interventions of choice. Required Evidence Generally higher levels of evidence. Results are consistently positive. Class IIb Acceptable and useful. Fair-to-good evidence provides support Definition Class IIb interventions are acceptable, safe, and useful in clinical practice. Considered optional or alternative interventions. Required Evidence Generally lower or intermediate levels of evidence. Results are generally but not consistently positive. Class III Not acceptable, not useful, may be harmful Definition Class III interventions are unacceptable, not useful in clinical practice, and may be harmful. Required Evidence Complete lack of positive data from higher levels of evidence. Some studies suggest or confirm harm. Class Indeterminant Definition A continuing area of research; no recommendation until further research is available. Required Evidence Higher-level evidence unavailable; studies in progress, inconsistent, or contradictory. Lower-level studies, when available, are not compelling. **Efficacy versus effectiveness. Evidence-based medicine draws sharp distinctions between efficacy and effectiveness, terms that initially seem synonymous. Drugs and other interventions may produce a significant level of benefit in tightly designed, closely controlled, and rigidly executed laboratory or clinical trials. These trials are a measure of

efficacy--under the rigorous conditions of a controlled clinical study, the intervention "seems to work." When applied in actual practice, however, the intervention does not perform nearly as well. Effectiveness is the degree to which the intervention continues to produce positive benefits when used as intended in clinical practice--in the "real world." To communicate clearly, the term useful clinically is used to mean effectiveness. Back to Top of Page Much of the information on this site comes from these unofficial sites: acls2000 and Also, from the American Heart Association's site. Back to Top of Page