ACLS Notes

Acute Coronary Syndrome:

 Assess ABC’s (be prepared to do cpr if needed)

 Obtain 12 lead ecg (look for ST elevation)
 Aspirin: 162-325mg
-contraindications: (allergies, history of bleeding)
 Nitro: “sublingual” 0.4mg each (Max 3 doses at least 5 mins apart)
-Check BP before each dose (systolic <90 mm Hg), ask about
erectile dysfunction meds in past 24-72 hours, check right side MI
 Morphine: IV 2-4mg up to 10 mg
-For pain if necessary, administer carefully

 **STEMI** (Activate STEMI team, fibrinolytic checklist, obtain

cardiac marker levels, blood count, coagulation studies)
 Symptoms less than 12 hours: FMC to balloon inflation goal (PCI)
90 minuets
-Door to needled (fibrinolysis) 30 minutes
 Symptoms more than 12 hours: Troponin elevated or high risk?
(Chest discomfort, vtach, BP unstable, signs of heart failure)
 Start adjunctive therapy (nitro, heparin as indicated)

 **Non STEMI** (TIMI or GRACE score)

-Consider admission to bed and seek expert advice
Stroke:
 Assess ABC’s (02 if needed)
 Initiate Stroke protocol (F.A.S.T) Face, Arms, Speech, Time
(facial droop, arm drift, slurred speech)
 Alert stroke unit
Review patients history (Fibrinolytic checklist: check family
history, check for recent strokes, head trauma, hypertension,
avoid aspirin 24 hours)
 Check Glucose (treat if indicated)

 Non contrast CT scan within 20 minuets of arrival

 Ischemic: Administer Alteplase *TPA* (if candidate)

 If not consider EVT (perform cta/ctp as indicated)
 EVT candidate: transport to cath lab or EVT center
(Admit to neurological ICU)

 Hemorrhagic: admit to stoke unit or higher level of care

Bradycardia: Pulse under 60 bpm

 Identify Bradycardia
 12 lead ECG, monitor BP, pulse oximetry
 O2 if necessary, start IV
 Consider possible causes
(Determine if patient is stable or unstable)

**STABLE: (Systolic BP above 90)

Asymptomatic (No symptoms): just monitor patient

 Symptomatic (chest pain, SOB, etc)

 Atropine: 1 mg IV (every 3-5 mins) max 3mg
(Blocks vagus nerve, increases firing from SA node,
conduction of AV node)
 Dopamine: 5-20mcg/kg/min (stronger contractions)
-or-
 Epinephrine: 2-10mcg/min

 UNSTABLE: (Systolic BP under 90)

 Seek expert advice
 Transcutaneous Pacing
 Set 30 bpm above current rate, set mA to 70
Tachycardia: Pulse above 100 bpm
 Identify Tachycardia

**Pulse under 150**

 Treat possible causes
 Vagal maneuvers
 O2 if necessary, establish IV, ECG
(Determine if patient is stable or unstable)

 STABLE (BP above 90) with a pulse above 150

**Determine if patient has narrow or wide QRS**
—Narrow QRS—
 SVT: Adenosine (1st dose 6mg/2nd dose 12mg)
(Rapid IV push)
 Atrial fibrillation/A flutter (beta/calcium channel blockers)

—Wide QRS—
 Vtach: Amiodarone (150mg/10 mins-repeat as needed,
followed by maintenance infusion 1mg/min for 6 hours)
Procainamide: (20-50mg/min) Maintenance 1-4mg/min
Sotalol: 100mg/5 mins (1.5mg/min)

 UNSTABLE (BP below 90) (C.A.S.H - chest pain, ams, sob,

hypotension)
 Seek expert advice
 Synchronized Cardioversion (50-200 joules)
Narrow/regular (SVT): 50-100j
Narrow/irregular (Afib/Aflutter): 120-200j
Wide/regular (Vtach): 100j
Wide/irregular (defibrillate)
***Cardiac Arrest***
 BLS:
 Carotid pulse check (5-10 sec), (Agonal gasp-start Cpr)
 30 compressions/2 breaths (2 inches/100-120 per min)
 Switch every 2 mins (Never stop compressions <10 sec)
 Establish airway: OPA (corner of mouth to mandible)
(Squeeze bag halfway – 500ml)
 Attach defibrillator, identify rhythm

PEA (pulseless electrical activity)/Asystole: NO SHOCK

 CPR (bls)
 Intubate: 1 breath every 6 sec (10 per min)
*switch to continuous compressions*
(capnography: comfirm ET tube placement)
(Monitor PETCO2: below 10mmhg compressions not
effective) Goal: 35-45 mmhg
(Excessive ventilation – decreases cardiac output)
 Establish IV: Epi (1mg 3-5 mins as needed)
 Look for reversible causes: H’s/T’s
(hypoxia, hypovolemia, hypoglycemia, hyperkalemia,
hydrogen ion acidosis, hypothermia)
(Toxins, thrombosis, tension pneumothorax, cardiac
tamponade, trauma)

Pulseless Vtach/V-Fib: Defibrillate (2 mins if needed)

 CPR (bls)
 Epi: 1 mg 3-5 minuets (alternate with ami or lidocaine)
 Amiodarone: 1st 300mg/2nd 150mg (alternate with epi)
 Lidocaine: 1st 1mg-1.5mg/kg/2nd 0.5mg-0.75mg/kg
 Intubate (capnography, PETCO2)
 H’s/T’s

***If no pulse repeat as needed and seek expert advice***

Post Cardiac Arrest:
 ROSC: Manage airway, respirations, BP (Coranary reperfusion)

—If not following commands—

 Temperature management (32-36c for 24hrs)
 Obtain brain CT

 Heartblocks

1. First Degree: monitor patient

 Consistent prolonged PR interval >0.20 sec
(delay in transmission from atria to ventricles)

2. Second Degree
 Type 1: Wenckebach – monitor, atropine
(PR gradually increases with dropped QRS)
“Longer, longer, drop rhymes with Wenckebach”
 Type 2: Mobitz II – transcutaneous pacing
(Only Dropped QRS complex – Fixed PR interval)
(Has potential to become complete heart block)

3. Third Degree: complete block (transcutaneous pacing)

 No relationship between P wave and QRS
(regularly irregular) P – QRS doing its own thing

 Other notes:
 Closed loop communication: repeat orders to confirm
 Stay within scope of practice (ask team leader for new task)
 Address mistakes immediately (but politely)
 Agonal gasp – sign of cardiac arrest