Transcript ACLS

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
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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
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Oxygen
FIO2 100%
 Assist Ventilation
 O2 Toxicity should not be a concern during
ACLS
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IV Fluids
Volume Expanders – crystalloids , eg
Ringer’s lactate, N/S, or colloids, eg
Albumin or Hetastarch
 TKO – D5W, N/S
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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
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The Following Drugs Help to
Control Heart Rate & Rhythm
Lidocaine
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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)
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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)
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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
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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
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Adenosine
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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
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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!
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Propranolol
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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
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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
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Norepinephrine (Levarterenol)
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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
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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
Dobutamine
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Actions similar to Dopamine
Used for CHF with hypotension
IV Dose:
 2-20 micrograms/minute
Side effects:
 Tachycardia
N &V
 Headache
 Tremors
Digitalis (Digoxin)
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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
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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)
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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
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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
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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:
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What is the patients arrhythmia and probable
medical problem?
What therapies should be done? Explain each one.
The EKG began to show:
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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:
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Uh oh! What now?
The treatment(s) are unsuccessful
and the following EKG appears:
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What should be done now and why?
Finally, the following EKG is
obtained. However, BP is 40/0
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What needs to be done now?
You saved her! The course is complete!
Bretylium Tosylate (Bretylol)
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Indications:
 Same as lidocaine and procainamide (usually
when condition doesn’t 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
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Similar to dobutamine
Used for refractory CHF
IV Dose:
 2-15 micrograms/kg/min
Side effects:
 May worsen ischemia
N &V
 Thrombocytopenia