B.C. ACLS Algorithms
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1 B.C. ACLS Algorithms Version 1.0 Contacts: Clinical Leader: Ross Berringer, M.D. Project Facilitator: Chris Sims, R.N. Version 1.0 December, 2001 Developed by: Members of the "ACLS Working Group" Sandy Barabe Tracy Barill Ross Berringer Penny Clarke Richardson Michael Dare Alan Holmes Alec Ritchie Ryan Shellborn Chris Sims Sherry Stackhouse Ron Straight
2 Ventricular Fibrillation/Pulseless Ventricular Tachycardia PRIMARY ABCD SURVEY Check responsiveness Activate emergency response system Call for monitor/defibrillator CPR until defibrillator arrives VF/PULSELESS VT RAPID DEFIBRILLATION 200,300,360 J PULSE Yes ABC'S Diagnostics No Airway: Breathing: Circulation: Differential Diagnosis: SECONDARY ABCD SURVEY airway device placement confirm tube placement, oxygenate, ventilate continue CPR, IV access, administer drugs, confirm rhythm search and treat reversible causes Epinephrine 1 mg IV push every 3-5 minutes or {Vasopressin 40 units IV push (not repeated)} Defibrillate 360 J within seconds CONSIDER: Amiodarone 300 mg bolus, followed by repeat 150 mg bolus after 10 minutes. Lidocaine 1.5 mg/kg (maximum 3 mg/kg) Procainamide 17mg/kg as 100 mg boluses every 3 min. Magnesium Sulfate 2 g bolus (if indicated) Buffers (if indicated) Continue attempts to defibrillate every 1-2 minutes Defibrillation does not have to be tied to drug administration
3 VF/Pulseless VT Notes: If rhythm changes after defibrillation, go to appropriate algorithm Treatable causes: - infarction. ischemia - drug overdose (TCA, cocaine, antiarrythmics) - electrolyte disturbances (potassium, calcium, magnesium) Groups of three shocks at 360 J are acceptable for each defibrillation after the initial escalating stacked shocks Biphasic defibrillation 150 J is as efficacious as monophasic defibrillation 360 J Buffers are indicated when hyperkalemia is suspected (renal failure) or TCA overdose
4 ASYSTOLE PRIMARY ABCD SURVEY Check responsiveness Activate emergency response system Call for monitor/defibrillator CPR until defibrillator arrives ASYSTOLE confirm in three leads assess DNR status Airway: Breathing: Circulation: Differential Diagnosis: SECONDARY ABCD SURVEY airway device placement confirm tube placement, oxygenate, ventilate continue CPR, IV access, administer drugs, confirm rhythm search and treat reversible causes Consider TCP in witnessed short " down time" arrests Epinephrine 1 mg every 3-5 minutes Atropine 3 mg bolus (maximum 0.04 mg/kg) CONSIDER EARLY TERMINATION Look for reasons not to start resuscitation Vasopressin not recommended If the patient remains asystolic 5 minutes after all ACLS interventions are complete, the arrest should be discontinued unless extenuating circumstances are present.
5 PULSELESS ELECTRICAL ACTIVITY (PEA) (PEA is anything on the monitor EXCEPT Ventricular Fibrillation, Ventricular Tachycardia, Asystole) PRIMARY ABCD SURVEY Check responsiveness Activate emergency response system Call for monitor/defibrillator CPR until defibrillator arrives PEA Airway: Breathing: Circulation: Differential Diagnosis: SECONDARY ABCD SURVEY airway device placement confirm tube placement, oxygenate, ventilate continue CPR, IV access, administer drugs, confirm rhythm search and treat reversible causes REVERSIBLE CAUSES and TREATMENT HYPOVOLEMIA: saline bolus, +/- blood HYPOXIA: intubation, 100% oxygen HYDROGEN ION (ACIDOSIS): intubation hyperventilation, +/- Bicarb HYPER/HYPOKALEMIA: use appropriate medical protocol HYPOTHERMIA: active core re-warming TABLETS (OVERDOSE): use appropriate medical protocol TAMPONADE: pericardiocentsis TENSION PNEUMO: needle thoracostomy or chest tube THROMBOSIS CORONARY: consider thrombolytics, PTCA or IABP THROMBOSIS PULMONARY: consider thrombolytics EPINEPHRINE 1 mg every 3-5 minutes ATROPINE 1 mg every 3-5 minutes, if heart rate < 60 Narrow complex PEA has a better prognosis than wide complex, be diligent in searching for causes. Consider cardioversion in narrow complex PEA with rates greater than 160 Vasopressin not recommended pressor Assess for low flow states: doppler blood pressure, heart sounds, echocardiogram (if available), agonal respirations.
6 BRADYCARDIA PRIMARY ABCD SURVEY Assess airway, breathing, circulation monitor SECONDARY ABCD SURVEY Oxygen, vital signs, IV access 12 lead EKG Focused history and physical Is patient stable or unstable? signs/symptoms hemodynamic compromise = hypotension, new onset or worsening CHF, ischemic chest pain, new onset of decreased level of consciousness STABLE UNSTABLE Type II, second degree heart block? Third degree heart block? NO Observe YES Prepare for transvenous pacemaker If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed Atropine 0.5 to 1.0 mg Transcutaneous Pacing, if available Dopamine 5-20 ug/kg/min Epinephrine 2-10 ug/min Prepare for transvenous pacemaker Atropine may be used in all unstable bradycardias, including heart blocks, although it may not be effective in type II second degree and third degree blocks. If cause is found, such as an inferior MI, treat the cause and the rate.
7 TACHYCARDIAS EVALUATE THE PATIENT Are there serious symptoms or signs due to the rate? (hypotension, new onset or worsening CHF, ischemic chest pain, new onset of decreased level of consciousness) STABLE UNSTABLE Consider sedation CARDIOVERSION (100, 200, 300, 360 J) ATRIAL FIB/FLUTTER NARROW COMPLEX WIDE COMPLEX Go to Atrial Fib/Flutter Algorithm 12 lead EKG Clinical history Vagal maneuvers Adenosine Amiodarone Diltiazem/Verapamil Procainamide 12 lead EKG Clinical history Esophageal lead, (if available) Old EKG DC Cardioversion OR Amiodarone OR Lidocaine OR Procainamide If Adenosine reveals presence of flutter waves, go to the Atrial Fibrillation/Flutter algorithm Electricity is rarely a bad choice in wide complex tachycardias If polymorphic ventricular tachycardia (torsade) is present, consider Magnesium, Isoproterenol, overdrive pacing, and correction of electrolyte disturbances. Type 1A antiarrythmics (Procainamide, Quinidine, Disopyramide) are dangerous in this condition. If old EKG shows bundle branch block with QRS morphology identical to current QRS morphology, then likely the rhythm is atrial flutter or SVT. Adenosine may be useful as a diagnostic agent in this situation. When in doubt, treat wide complex of unknown origin as ventricular tachycardia. Rate related signs and symptoms rarely occur at rates < 150 beats per minute.in patients with known preexisting impaired LV function (EF < 40%), cardioversion can be used with caution
8 ATRIAL FIBRILLATION/FLUTTER EVALUATE THE PATIENT Stable/unstable (hypotension, new onset or worsening CHF, ischemic chest pain, new onset of decreased level of consciousness) History of WPW? Duration of arrhythmia Ejection fraction known or unknown Current medications (beware of antiarrythmics and Sotalol) STABLE UNSTABLE Consider sedation CARDIOVERSION (100, 200, 300, 360 J) NORMAL HEART < 48 hours Conversion Shock or one of the following: Amiodarone Procainamide Propafenone > 48 hours Rate control and elective cardioversion after anticoagulation Digoxin Diltiazem Metroprolol Known impaired LV function or new onset or worsening of CHF < 48 hours Conversion Shock or Amiodarone > 48 hours Rate control and elective cardioversion after anticoagulation Amiodarone Digoxin Electricity is rarely the wrong choice Err on the side of caution Consider anticoagulation for all patients prior to cardioversion (low molecular weight heparin +/- Coumadin) Use only one antiarrythmic when attempting chemical conversion Suspect WPW when rate is > 200 or wide complex Beware of Calcium Channel Blockers in WPW
9 ACLS DRUGS DRUG Adenosine Adrenaline/ Epinephrine Amiodarone Atropine Digoxin Diltiazem Dopamine Lidocaine Magnesium Sulphate Metoprolol Procainamide Propafenone Sodium Bicarbonate Vasopressin Verapamil INTRAVENOUS DOSAGE 6 mg as initial dose IV push as rapidly as possible, if not successful, 12 mg IV push 1 mg boluses every 3 minutes may increase dose to 3-5 mg every 3 minutes, if indicated as an infusion for bradycardia: 2-10 ug/minute in V. Fib: bolus 300 mg, followed by 150 mg 5 10 minutes later in perfusing rhythms: 150 mg over 10 minutes followed by 1 mg/min over 6 hours, then 0.5 mg/min over 18 hours. maximum: 2.2 gm in 24 hours maximum: 0.04 mg/kg in Asystole: single dose of 3 mg in Bradycardia: mg every 5 minutes 0.5 mg bolused, followed by 0.25 mg every 2-3 hours to a maximum of 1 mg mg over 1-2 minutes (may be repeated) 5-20 ug/kg/min in V.Fib: 1.5 mg/kg boluses to a maximum of 3 mg/kg in perfusing rhythms: 1 mg/kg every 5 minutes to a maximum of 3 mg/kg 2 g as a bolus 5-10 mg over 5 minutes (may be repeated) in V. Fib: boluses of 100 mg every 3 minutes to a maximum of 17 mg/kg in perfusing rhythms (A. Fib, wide complex): 17 mg/kg at 20 mg/min 300 mg as initial dose, followed by 600 mg in 8 hours 1-2 meq/kg average adult is 2-3 amps (each ampule has 44 meq) 40 units IV push as a single dose only in V.Fib/pulseless V.Tach mg over 2-3 minutes
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