ACLS

Adenosine Injection Technique

1. Record rhythm strip during administration. 2. Draw up adenosine dose & obtain a flush 3. Attach both syringes (med syringe and flush syringe) to the IV injection port closest to the pt 3. Clamp IV tubing above injection port 4. Push IV adenosine as QUICKLY as possible (1-3 sec). 5. While maintaining pressure on adenosine plunger, push NS flush as RAPIDLY as possible after adenosine 6. Unclamp IV tubing

List of Drugs for Tachycardia

Adenosine Diltiazem (cardizem) Beta-Blockers Amiodarone Digoxin Verapamil Magnesium

Amiodarone (Role of)

Amiodarone is considered a class III antiarrhythmic agent and is used for various types tachyarrhythmias. Because of its associated toxicity and serious side-effects it should be used cautiously and care should be taken to ensure that cumulative doses are not exceeded.Amiodarone is an antiarrhythmic that is used to treat both supraventricular arrhythmias and ventricular arrhythmias.Wthin the framework of ACLS, amiodarone is used primarily to treat ventricular fibrillation and ventricular tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors.Amiodarone should only be used after defibrillation/cardioversion and first line drugs such as epinephrine and vasopressin have failed to convert VT/VF.

List of Drugs for Bradycardia

Atropine Epinephrine Dopamine

Atropine (Role of)

Atropine is the FIRST drug used to treat bradycardia in the bradycardia algorithm. It is classified as an anticholinergic drug and increases firing of the SA Node by blocking the action of the vagus nerve on the heart resulting in an increased heart rate. Atropine increases firing of the sinoatrial node (atria) and conduction through the atrioventricular node (AV) of the heart by blocking the action of the vegus nerve.

Atropine Doses

Bradycardia (with or without ACS): 0.5mg IV every 3-5minutes as needed, not to exceed total dose of 0.04mg/kg (total 3mg). Use shorter dosing interval (3min) & higher doses in severe clinical conditions. Routes: IV or endotracheal

Epinephrine Indications

Cardiac arrest: VF, pulseless VT, asystole, & PEA. Symptomatic Bradycardia Severe Hypotension: can be used when pacing & atropine fail, or when hypotension accompanies bradycardia. Anaphylaxis, severe allergic rxns: combine with large fluid volume, corticosteroids, antihistamines.

If persistent tachyarrhythmia is regular, narrow complex, what do you consider?

Consider Adenosine 1st dose: 6mg RAPID IV push, follow with NS flush. 2nd dose: 12 mg if required

Synchronized Cardioversion doses/details

Consider sedation Synchronized cardioversion initial recommended doses: narrow regular: 50-100J narrow irregular: 120-200J biphasic or 200J monophasic Wide regular: 100 J wide irregular: defibrillation dose (not synchronized)

Dopamine Precautions

Correct hypovolemia with volume replacement before initiating dopamine. Use with caution in cardiogenic shock with accompanying CHF May cause tachyarrhythmias, excessive vasoconstriction. Do not mix with sodium bicarb.

Dopamine Indications

Dopamine is a SECOND LINE drug for symptomatic bradycardia, and should be used AFTER ATROPINE. It is also used for hypotension, which is a systolic blood pressure of less than or equal to 70-100 mm Hg with signs and symptoms of shock.

Dopamine (Role of )

Dopamine is a neurotransmitter, which causes constriction of blood vessels, increase in heart rate, and increase in the heart's contraction force.

List of Drugs for Asystole/PEA

Epinephrine Vassopressin

List of Drugs for V-fib/V-tach

Epinephrine Vassopressin Amiodarone Lidocaine Magnesium

Atropine Indications

FIRST drug for symptomatic sinus bradycardia. May be beneficial in presence of AV nodal block of ventricular asystole. WILL NOT BE EFFECTIVE FOR MOBITZ TYPE II BLOCK OR COMPLETE HEART BLOCK, reason why: With 3rd degree block there is a complete block and disassociation of the electrical activity that is occurring in the atria and ventricles. Since atropine's affect is primarily on the SA node in the atria, 3rd degree block would prevent its affect on the SA node from influencing the rate of ventricular contraction which is needed to improve perfusion. With Mobitz-II, aka, Second-degree AV Block Type II, the situation is similar. There is a partial block in the electrical impulses from the atria (SA) to the ventricles, and thus the affects of atropine would not significantly change the status of the ventricles. This block can also rapidly progress to 3rd degree block. It is important to note that Mobitz II and Complete Heart Block may be associated with acute myocardial ischemia. In this case, if atropine is used and it increases the heart rate there is a high potential for worsening of the myocardial ischemia due to the increased oxygen consumption. The increased heart rate will also reduce diastolic filling time which may worsen coronary perfusion. Since new onset mobitz II and Complete Heart Block are commonly associated with myocardial infarction, it would be ideal to keep the HR slow (50-60) to increase diastolic filling time. Anytime you increase HR, the diastolic filling time is what takes the biggest hit.

Adenosine Indications

First drug for most forms of stable narrow-complex SVT. Effective in terminating those due to reentry involving AV node or sinus node. Adenosine may be considered for unstable narrow-complex tachycardia while preparations are made for cardioversion. Adenosine should be used within the tachycardia algorithm when vagal maneuvers fail to terminate stable narrow-complex SVT. Adenosine is the primary drug used in the treatment of stable narrow-complex SVT (supraventricular Tachycardia). It can now also be used for regular monomorphic wide-complex tachycardia. DOES NOT CONCERT A-FIB/A-FLUTTER/OR VT.

Bradycardia with a pulse algorithm

HR typically <50/min Idenitify & treat underlying cause: mainatain patent airway, assist breathing if necessary oxygen (if hypovolemic) cardiac monitor to identify rhythm; monitor BP and oximetry IV access 12-lead EKG if avail - don't delay therapy If persistent bradycarrhythmia causes the following: Hypotension, acute AMS, signs of shock, ischemic chest discomfort, or acute heart failure, do the following: 1.) Atropine - 1st dose 0.5mg bolus IV, repeat Q 3-5 min. MAX 3 mg. If atropine is ineffective: transcutaneous pacing or dopamine infusion, or epic infusion Dopamine IV infusion: 2-10mcg/kg/min Epinephrine IV infusion: 2-10mcg/min Consider expert consultation & transcutaneous pacing If bradyarrhythmia is asymptomatic (none of the signs listed above), then monitor/observe.

Tachycardia with a pulse algorithm

HR typically > or = to 150/min Identify & treat underlying cause: maintain patient airway,assist breathing if necessary, oxygen (if hypovolemic), cardiac monitor to identify rhythm, monitor BP and oximetry.

If persistent tachyarrhythmia is SYMPTOMATIC with a WIDE QRS > or = to 0.12sec, what do you do?

IV access & 12 lead EKG (if avail.) Consider adenosine ONLY if REGULAR and MONOMORPHIC (appearance of all beats match each other in each lead of a 12 lead EKG). Consider antiarrhythmic infusion consider expert consultation

For asymptomatic tachyarrhythmia WITHOUT a wide QRS, what do you do?

IV access & 12 lead EKG if avail. Vagal maneuvers Adenosine (IF REGULAR) Beta-blocker or Ca-Channel Blocker Consider expert consultation

Dopamine Doses/Route

IV infusion: initial rate is 2-20mcg/kg/min. Titrate to pt's response; taper slowly.

Epinephrine Doses/Routes

IV/IO dose: 1mg (10ml 0f 1: 10 000 solution) admin every 3-5min during resuscitation. Follow with 20l NS flush, elevate arm 10-20 sec after the dose. IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or D5W. The infusion should run at 2-10 micrograms/min (titrated to effect). Continuous Infusion: initial rate: 0.1-0.5mcg/kg per min (for example a 70kg adult: 7-35 mcg/min would be given); titrate to response Endotracheal route: 2-2.5mg diluted in 10ml NS

When would cardioversion be considered in a persistent tachycarrhythmia?

If the persistent tachyarrhythmia is causing: hypotension acute AMS signs of shock chest pain acute heart failure

Vassopressin (Role of)

In high concentrations, it raises blood pressure by inducing moderate vasoconstriction, and it has been shown to be more effective than epinephrine in asystolic cardiac arrest. One major indication for vasopressin over epinephrine is its lower risk for adverse side effects when compared with epinephrine. With epinephrine, some studies have shown a risk of increased myocardial oxygen consumption and post arrest arrhythmias because of an increase in heart rate and contractility (beta 1 effects). Vasopressin also is thought to cause cerebral vessel dilation and theoretically increase cerebral perfusion.

Epinephrine Precautions

Increasing BP & increasing HR may cause mayocardial ischemia, angina, & increased myocardial oxygen demand. High doses do not improve survival or neurologic outcome & may contribute to post-resuscitation myocardial dysfunction. High doses may be required to treat poison/drug-induced shock.

List of Drugs for Acute Coronary Syndromes

Oxygen Aspirin Nitroglycerin Morphine Fibrinolytic therapy Heparin Beta-Blockers

Doses/info of antiarrhythmic infusions for STABLE WIDE COMPLEX QRS TACHYCARDIA

Procainamide IV dose: 20-50mg/min until arrhythmia is suppressed, hypotension ensues, QRS duration increases >50%, or max dose 17 mg/kg given. Maintenance infusion of procainamide: 1-4mg/min. AVOID IF PROLONGED QT OR CHF. Amiodarone IV dose: 1st dose 150mg over 10 min; repeat as needed if VT occurs. Follow by maintenance infusion of 1mg/min for 1st 6 hrs. Sotatol IV dose: 100mg (1.5mg/kg) over 5min. AVOID IF PROLONGED QT.

Adenosine Dosage/Route

Rapid IV push: place pt in reverse trendelenburg position before admin of the drug. Initial (1st) bolus of 6mg given RAPIDLY over 1-3 sec followed by NS bolus of 20mL - then elevate the extremity. A 2nd dose (12mg) can be given in 1-2 min if needed.

List of Drugs for Acute Stroke

T-PA Plasminopgen Activator Glucose (D50) Labetaolol Nitroprusside Nicardipine Aspirin

Adenosine Precautions/contraindications/side effects

Transient side effects: BRIEF SYSTOLE OR BRADYCARDIA, flushing,chest pain/tightness, vernacular ectopy. Contraindicated in poison/drug-induced tachycardia or 2nd or 3rd degree heart block less effective (larger doses may be required) for pets taking theophylline or caffeine Reduce initial dose to 3mg in pts receiving dipyridamole or carbamazepine (these two medications potentiate the effects of adenosine), in heart transplant pts, or if given by central venous access. Also, prolonged asystole has been seen with the use of normal doses of adenosine in heart transplant patients and central line use. Therefore, the lower dose (3mg) may be considered for patients with a central venous line or a history of heart transplant. If administered for irregular polymorphic wide complex tachycardia/ VT, may cause deterioration (including hypotension). Transient periods of sinus brady and ventricular extopy are common after termination of SVT. Safe and effective in pregnancy.

Amiodarone Doses/Routes

VF/VT unresponsive to CPR, shock, & vasopressor: 1st dose: 300mg IV/IO push. 2nd dose (if needed): 150mg IV/IO push. Life threatening arrhythmias: max cumulative dose: 2.2g IV over 24hrs. May be administered as follows: Rapid infusion:150mg IV over 1st 10 minutes (15g per min). May repeat rapid infusion (150mg IV every 10 minutes as needed). Slow infusion: 360mg IV over 6 hrs (1mg per min). Maintenance infusion: 540mg IV over 18 hrs (o.5mg per min).

Amiodarone Indications

VF/pulseless VT, unresponsive to shock delivery, CPR, & a vasopressor. Recurrent, hemodynamically unstable VT. With expert consultation, amiodarone can be used to treat some atrial & ventricular arrhythmias.

Vassopressin Doses/Routes

Vasopressin may be given IV/IO or by endotracheal tube. IV/IO: 1 dose of 4o units IV/IO push may replace either 1st or 2nd dose of epi. Epi can be adin every 3-5 min during cardiac arrest. vasodilatory shock: continuous IV infusion of 0.02-0.04 units per min.

Epinephrine (Role of)

Vassopressor drug that increases cardiac output, improving perfusion to the brain & heart. It improves cardiac output by: increasing the heart rate, increasing heart muscle contractility, & increases conductivity through the AV Node.

Adenosine (Role of)

When given as a rapid IV bolus, adenosine slows cardiac conduction particularly effecting conduction through the AV node (AV node regulates signals to the ventricles to prevent rapid conduction. AV node takes signal from SA node & regulates it & sends impulses from the atria to the ventricles). The rapid bolus of adenosine also interrupts reentry (SVT causing) pathways through the AV node and restores sinus rhythm in patients with SVT. When injected into the body, adenosine is rapidly absorbed by red blood cells and blood vessel endothelial cells and metabolized for natural uses throughout the body. In light of this adenosine should be administered by RAPID intravenous bolus so that a significant bolus of adenosine reaches the heart before it is metabolized.

Vassopressin Indications

may be used as an alternative pressor to epi in treatment of adult shock-refractory VF. May be useful alternative to epi in asystole & PEA. Hemodynamic support in vasodilatory shock (ex. Septic Shock).

Amiodarone Precautions

rapid infusion may lead to hypotension. With multiple dosing, cumulative doses greater than 2.2g over 24 hrs are associated with significant hypotension. Do not administer with other drugs that prolong the QT interval (electrical depolarization and repolarization of the ventricles.) ex: procainamide. Terminal elimination is extremely long (half-life lasts up to 40 days).