ACLS

1 Keep up to date with advanced cardiac life support (ACLS) recommendations (i.e., maintain your knowledge base).

2 Promptly defibrillate a patient with ventricular fibrillation (V fib), or pulseless or symptomatic ventricular tachycardia (V tach).

  • Pulseless VT or VF 
    • CPR till defibrillator comes
    • Rhythm check Q2min
    • Defibrillate ASAP & repeat after every rhythm check if shockable
    • Epinephrine 1mg IV/IO Q3-5min
    • Amiodarone 300mg bolus IV/IO (alternate with Epinephrine)
      • 150mg for the second dose
  • VT with pulse: Amiodarone 150mg IV over 10 min and prepare for synchronized cardioversion
  • Asystole / PEA 
    • CPR with rhythm check Q2min
    • Can’t defibrillate
    • Tx with epinephrine 1mg IV/IO Q3-5min
    • Vasopressin 40u IV/IO can replace 1st or 2nd dose of epinephrine

3 Diagnose serious arrhythmias (V tach, V fib, supraventricular tachycardia, atrial fibrillation, or second- or third-degree heart block), and treat according to ACLS protocols.

  • Ventricular tachycardia occurs when electrical impulses originating from the ventricles cause rapid ventricular depolarization (140-250 beats per minute)
    • Use Brugada algorithm
  • Ventricular fibrillation occurs when parts of the ventricles depolarize repeatedly in an erratic, uncoordinated manner. The EKG in ventricular fibrillation shows random, apparently unrelated waves. Usually, there is no recognizable QRS complex
  • 2nd degree HB
    • Mobitz type 1(Wenckebach): characterised by progressively increasing PR interval culminating in a dropped beat
    • Mobitz type 2: drop beats in a constant ratio – more ominous
      • need pacemaker
  • 3rd degree HB: There is complete dissociation of atria and ventricles
    • need pacemaker
  • A fib – no discernable P wave, check V1-V3 for possible A flutter
    • irregular irregular rhythm
    • Narrow complex
  • SVT
    • Narrow complex (<0.12s), aberrant pacemaker (atrial, AV, ectopic)
    • Various P wave anomalies
    • Tx: Vagal maneuver, Adenosine 6mg IV push, then 12 mg
    • Consider beta blocker or diltiazem if no conversion with adenosine

4 Suspect and promptly treat reversible causes of arrhythmias (e.g., hyperkalemia, digoxin toxicity, cocaine intoxication) before confirmation of the diagnosis.

6Hs and 6Ts
  • Hypovolemia
  • Hypothermia
  • Hydrogen ion (acidosis)
  • Hypoglycemia
  • Hypoxia
  • Hyper/Hypokalemia
  • Tamponade
  • Tension pneumothorax
  • Toxins
  • Thrombus, coronary (MI)
  • Thrombus, pulmonary (PE)
  • Trauma (hypovolemia, increased ICP)
Hyperkalemia
  • clinically weak and ECG shows tall peaked T waves, increased PR interval, and wide QRS
  • Tx
    • Calcium gluconate 2 amps IV
    • Insulin 10U with 1-2 amps D50W
    • furosemide 40mg IV
    • Ventolin 5mg neb
    • Kexalate 60gms PO/PR (weak evidence)
    • Last resort / emergency: Hemodialysis
Cocaine intoxication
  • mydriasis, euphoria, agitation, elevated HR and BP, sweating, tremors, confusion, seizures
  • Tx
    • ABC, diazepam 5mg IV (Sz)
    • Avoid betablocker to tx HtN/ tachcarida
      • unopposed alpha can cause unopposed vasoconstriction of coronary artery
Digoxin intoxication
  • ST scooped-like depression, mild PR prolongation
  • Inverted T in V5 & V6, Short QT segment
  • Tx: Digibind (very effective)

5 Ensure adequate ventilation (i.e., with a bag valve mask), and secure the airway in a timely manner.

6 In patients requiring resuscitation, assess their circumstances (e.g., asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation.)

7 In patients with serious medical problems or end-stage disease, discuss code status and end-of-life decisions (e.g., resuscitation, feeding tubes, levels of treatment), and readdress these issues periodically.

8 Attend to family members (e.g., with counselling, presence in the code room) during and after resuscitating a patient.

9 In a pediatric resuscitation, use appropriate resources ( e.g., Broselow tape, the patient’s weight) to determine the correct drug doses and tube sizes.

Broselow tape

  • estimate a child’s weight – determine weight-based drug doses
  • select the correct size emergency or resuscitation equipment
ET tube sizes:
  • ET tube size = (age/4) + 4
  • Male: 8-8.5 cuffed & Female: 7.5-8 cuffed

References:
  • 2010 Circulation Nov2, 2010, Vol 122 Issue 18
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