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
 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
 Oxygen
 FIO2 100%
 Assist Ventilation
 O2 Toxicity should not be a concern during
ACLS
 IV Fluids
 Volume Expanders – crystalloids , eg
Ringer’s lactate, N/S, or colloids, eg
Albumin or Hetastarch
 TKO – D5W, N/S
 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
The Following Drugs Help to
Control Heart Rate & Rhythm
 Lidocaine
 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)
 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 2 nd

and 3rd degree blocks that do not have a pacemaker

 Procainamide (Pronestyl)
 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
 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

 Adenosine
 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
 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!
 Propranolol
 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
 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
 Norepinephrine (Levarterenol)
 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
 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

N & V
 Dobutamine
 Actions similar to Dopamine
 Used for CHF with hypotension
 IV Dose:
 2-20 micrograms/minute

 Side effects:
 Tachycardia

N & V

 Headache

 Tremors
 Digitalis (Digoxin)
 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
 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)
 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
 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
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:

 What is the patients arrhythmia and probable

medical problem?
 What therapies should be done? Explain each one.
 The EKG began to show:

 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:

 Uh oh! What now?

The treatment(s) are unsuccessful
and the following EKG appears:

 What should be done now and why?

 Finally, the following EKG is
obtained. However, BP is 40/0

 What needs to be done now?

You saved her! The course is complete!
 Bretylium Tosylate (Bretylol)
 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
 Similar to dobutamine
 Used for refractory CHF
 IV Dose:
 2-15 micrograms/kg/min

 Side effects:
 May worsen ischemia

N & V

 Thrombocytopenia