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ACLS Summary

February 22, 2019
Sam Ashoo
Cardiac Arrest: 
  • CPR
  • Shock VF/VT
  • Epinephrine 1 mg q3-5min
  • One of the following may be considered for shock refractory VF/VT:
    • Amiodarone 300mg IV/IO bolus (1st dose), 150 mg IV/IO (2nd dose)
    • Lidocaine 1-1.5 mg/kg IV/IO (1st dose), 0.5 – 0.75 m/kg IV/IO (2nd dose)
  • Treat reversible causes:
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion (acidosis)
    • Hypo / Hyperkalemia
    • Hypothermia
    • Tension pneumothorax
    • Toxin
    • Thrombosis (PE, MI)
  • Notes:
    • High dose epinephrine – No benefit.
    • Vasopressin – No benefit.
    • Procainamide – No benefit.
    • Magnesium – Possible benefit in polymorphic VT with Long QT only (Torsades de Pointe). 1-2gm IV diluted in 10 ml D5W
    • No antiarrythmic drugs have been shown to improve survival or neurologic outcome.
    • Extracorporeal CPR (ECMO- extracorporeal membrane oxygenation) – No evidence to support or refute routine use.
Bradycardia <50 bpm:
  • Evaluate if symptomatic – hypotension, AMS, shock, chest pain, heart failure
  • Atropine 0.5 mg  q3-5 min up to 3mg total
  • Dopamine 2-10 mcg/kg/min infusion
  • Epinephrine 2-10 mcg/kg/min infusion
  • Transcutaneous pacing
  • Transvenous pacing
  • Treat reversible causes:
    • Medication overdose (beta blocker or Ca channel blockers
    • Renal failure / hyper K
    • MI / ACS
Tachycardia > 150 bpm: 
  • Evaluate if symptomatic – hypotension, AMS, shock, chest pain, heart failure
  • Differentiate Stable vs Unstable, Narrow vs Wide (>0.12 sec) QRS
  • Narrow Complex Rhythms (<0.12 sec QRS):
    • Sinus tachycardia
    • Atrial fibrillation
    • Atrial flutter
    • AV nodal reentry
    • Accessory pathway mediated
    • Atrial tachycardia
    • Multifocal atrial tachycardia
    • Junctional tachycardia
  • Wide Complex Rhythms (>0.12 sec QRS)
    • Ventricular tachycardia
    • Ventricular fibrillation
    • SVT with aberrancy
    • Pre-excitation tachycardia (WPW)
    • Ventricular pacing
  • Synchronized cardioversion for unstable patients.
    • Narrow regular 50-100j
    • Narrow Irregular 120-200j (biphasic), 200j monophasic
    • Wide regular 100j
    • Wide irregular (defibrillate, not synchronized)
  • Adenosine 6mg, 12mg, 12mg for narrow complex tachycardia.
  • Beta Blockers
    • Effective in narrow complex stable tachycardias like atrial fibrillation and flutter.
    • Longer acting that adenosine for regular SVT.
  • Calcium Channel Blockers
    • Effective in narrow complex stable tachycardias like atrial fibrillation and flutter
    • Diltiazem – 15 mg to 20 mg (0.25 mg/kg) IV over 2 minutes; repeat in 15 minutes with additional dose of 20 mg to 25 mg (0.35 mg/kg). Infusion dose is 5 mg/hour to 15 mg/hour, titrated to heart rate.
  • Procainamide
    • Wide complex stable irregular tachycardia, presumed to be due to pre-excitation (WPW)
    • 20-50 mg/min IV until arrhythmia suppressed.
    • May cause hypotension
    • Stop if QRS duration increases >50%
    • Max dose 17 mg/kg total.
    • Maintenance infusion 1-4 mg/min
    • Avoid if long QT or CHF
  • Amiodarone
    • Wide complex stable tachycardia
    • 150 mg IV over 10 minutes
    • Repeat if ventricular tachycardia recurs.
    • Maintenance infusion 1 mg/min for first 6 hours.
  • Sotalol
    • Wide complex stable tachycardia
    • 100 mg IV (1.5 mg/kg) over 5 minutes
    • Avoid if long QT.
References: 
AHA 2010 Guidelines Full Text
AHA 2015 update Full Text
AHA 2018 update Full Text

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