Cardiac Arrest:
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CPR
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Shock VF/VT
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Epinephrine 1 mg q3-5min
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One of the following may be considered for shock refractory VF/VT:
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Amiodarone 300mg IV/IO bolus (1st dose), 150 mg IV/IO (2nd dose)
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Lidocaine 1-1.5 mg/kg IV/IO (1st dose), 0.5 – 0.75 m/kg IV/IO (2nd dose)
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- 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:
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Evaluate if symptomatic – hypotension, AMS, shock, chest pain, heart failure
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Atropine 0.5 mg q3-5 min up to 3mg total
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Dopamine 2-10 mcg/kg/min infusion
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Epinephrine 2-10 mcg/kg/min infusion
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Transcutaneous pacing
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Transvenous pacing
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Treat reversible causes:
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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
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Differentiate Stable vs Unstable, Narrow vs Wide (>0.12 sec) QRS
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Narrow Complex Rhythms (<0.12 sec QRS):
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Sinus tachycardia
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Atrial fibrillation
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Atrial flutter
-
AV nodal reentry
-
Accessory pathway mediated
-
Atrial tachycardia
-
Multifocal atrial tachycardia
-
Junctional tachycardia
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- Wide Complex Rhythms (>0.12 sec QRS)
-
Ventricular tachycardia
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Ventricular fibrillation
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SVT with aberrancy
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Pre-excitation tachycardia (WPW)
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Ventricular pacing
-
-
Synchronized cardioversion for unstable patients.
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Narrow regular 50-100j
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Narrow Irregular 120-200j (biphasic), 200j monophasic
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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