Primary Survey

• Assess responsiveness (speak loudly, gently shake patient if no trauma - "Annie, Annie, are you 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.

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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.

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.

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 µg/kg/min
• Epinephrine
2-10 µg/min

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

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

• 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.

Back to Tachycardias
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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

PSVT
EF normal

• Ca-blocker> beta-blocker> digoxin> DC Cardioversion.
• Consider procainamide, sotalol, amiodarone.
• If unstable proceed to cardioversion

• No Cardioversion.  Digoxin or amiodarone or diltiazem.
• If unstable proceed to cardioversion.

MAT

• EF normal: Ca-blocker, beta-blocker, amiodarone
• EF < 40%, CHF: amiodarone, diltiazem
• Note: no cardioversion

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

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

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
1. amiodarone 150 mg iv over 10 min OR lidocaine 0.5-0.75 mg/kg iv push
2. 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

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

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

• 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

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*

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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

• load 0.25mg/kg iv over 2 min, then 0.35mg/kg over 2 min in 15 min
• infuse 5-15 mg/hour

• >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

• 1 mg/kg bolus
• additional 0.5 mg/kg q8-10 min, up to total 3 mg/kg.
• Then infuse 1-4 mg/min

• load 20 mg/min up to 17 mg/kg (1000 mg)
• then infuse 1-4 mg/min
• Side Effects: HTN, torsade

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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.

• 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.

• 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.

• 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.

• 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.

• 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.

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Much of the information on this site comes from these unofficial sites: acls2000 and acls.net. Also, from the American Heart Association's site.

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