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Advanced Cardiac Life Support

Geraldine G. Garrido-Pon, M.D.

Adult BLS Sequence

1. Check for response - tap on the shoulder and ask are you alright? 2. Activate the EMS System if available 3. Open the airway = head tilt- chin lift maneuver; if with possible spinal injury, use jaw thrust w/o head extension 4. Check breathing if you do not detect adequate breathing within 10 sec, give 2 rescue breaths, each over 1 second with enough volume (500-600ml) to produce visible chest rise a. mouth-to-mouth: open the airway, pinch the nose, create an airtight mouth-to-mouth seal b. mouth to nose used if unable to ventilate through the mouth

c. ventilation with bag and mask may be used with room air or oxygen; provides positive-pressure ventilation - lone rescuer should be able to simultaneously open the airway with a jaw lift, hold the mask tightly against the patients face and squeeze the bag - for 2 rescuers, 1 lifts the jaw and seals the mask over the face while the other squeezes the bag 1/3 to 2/3 its volume - if O2 is available, 40% O2 given at flow rate of 10-12L/min d. ventilation with an advanced airway (eg. ET) give continuous chest compressions at 100/min without pauses for ventilation; the other rescuer deliver ventilation at 8 to 10 breaths per minute

5. Pulse check rescuer should not take more than 10sec to check for a pulse; if a pulse is not definitely felt in 10 sec, proceed with chest compressions Chest compressions: - effective chest compression is essential to provide blood flow - to be effective, push hard and push fast - compress at a rate of 100 compressions per minute, with a compression depth of - 2 inches (4 5 cm); for single rescuer with no advanced airway, compression-ventilation ratio of 30:2 is recommended - allow the chest to recoil completely after each compression and allow equal compression and relaxation times - technique: victim should lie supine on a hard surface with the rescuer kneeling beside the victims thorax; place the heel of the hand on the sternum in the center of the chest between the nipples and then place the heel of the second had on top of the first so that the hands overlapped and parallel

ECG Recognition
Rhythms to recognize: 1. Normal sinus rhythm 2. Sinus bradycardia 3. Atrioventricular blocks 4. Premature atrial complexes 5. Supraventricular tachycardia (SVT) 6. Preexcited arrhythmias (assocd with accessory pathway) 7. Premature ventricular complexes 8. Ventricular tachycardia (VT) 9. Ventricular fibrillation (VF) 10. Ventricular asystole

Cardiovascular Pharmacology - Agents used in Asystole/PEA1. Epinephrine mech of action: increased systemic vascular resistance (SVR); increased BP; increased electrical activity in the myocardium; increased strength of myocardial contraction indication: cardiac arrest from VF or pulseless VT; asystole and PEA dosage: 1mg IV initially, repeat every 3-5min

- Agents used in Asystole/PEA 2. Atropine mech of action: enhanced sinus node automaticity; increased AV conduction indications: initial Tx for symptomatic bradycardia; 1st degree AV block; Mobitz type 1 AV block; with caution in 3rd degree AV block; asystole and PEA dosage: 0.5 to 1mg IV, may repeat every 5 min for a total of 2-3mg

- Agents to Optimize BP (Inotropes) 1. Dopamine mech of action: increased myocardial contractility; increased HR indications: hypotension; post-resuscitation shock dosage: renal dose: 2-4ug/kg/min inotropic effect: 5-10ug/kg/min -receptor effect: 10-20ug/kg/min - 400mg Dopamine in 250ml D5W produces 1600ug/ml Dopamine

2. Dobutamine mech of action: predominant b-adrenergic receptor stimulating effects increasing myocardial contractility leading to increased stroke volume indication: severe systolic heart failure dosage: 5 20 ug/kg per min

Anti-arrhythmic Agents
1. Lidocaine mech of action: decreased automaticity; prevents emergence of wavefronts from zones of ischemic myocardium; prolongs conduction and refractoriness in ischemic tissue indications: VT and VF dosage: initial- 1 1.5mg/kg infusion: 2 4mg/min

Anti-arrhythmic Agents
2. Amiodarone mech of action: alters conduction through the accessory pathway; blocks K channels (Class III anti-arrhythmia) indication: agent of choice in narrow-complex tachycardias with impaired cardiac function (EF < 40%); unstable VT; persistent VT or VF after defibrillation dosage: 150mg IV bolus over 10 min followed by infusion of 1mg/min for 6hrs then 0.5mg/min

Anti-arrhythmic Agents
3. Verapamil (Ca+ channel blocker) mech of action: slows AV nodal conduction; increased refractoriness in the AV node indications: control of ventricular response in AF, atrial flutter of MAT; for narrow complex PSVT dosage: 2.5 to 5mg IV over 2 min, repeat every 15-30min to a max of 20mg

Anti-arrhythmic Agents
4. Beta-blocking agents (beta blockers) indications: rate control in AF or atrial flutter, ectopic atrial tachycardias and polymorphic VT dosage: metoprolol: 5mg slow IV at 5-min intervals for a total 15mg then 50mg p.o. 2x daily esmolol: 0.5mg/kg as loading dose then maintenance infusion of 50ug/kg/min

Anti-arrhythmic Agents
5. Digitalis (Digoxin) mech of action: decreased ventricular rate by slowing AV nodal conduction indications: to control ventricular rate in AF and atrial flutter 6. Magnesium indication: refractory VF sec to hypoMg or may be used in torsades de pointes dosage: 1-2gm diluted in 100ml D5W given over 1-2min followed by infusion of 0.5 1gm/hr

Tachycardia Algorithm
With pulse

Assess and support ABCs as needed Give oxygen Monitor ECG (identify rhythm, BP, oxymetry) Identify and treat reversible causes
Symptoms persist

Establish IV access Obtain 12L ECG or rhythm strip Is QRS narrow (<0.12sec)?


Is patient stable? Unstable signs include altered mental status, ongoing chest pain, hypotension, signs of shock


Perform immediate synchronized cardioversion Establish IV access and give

sedation Consider expert consultation If pulseless arrest develops, see Pulseless Arrest Algorithm

Narrow QRS
Is rhythm regular?

Wide QRS
Is rhythm regular?

Contd: Tachycardia Algorithm

Narrow QRS
Is rhythm regular?

Irregular narrow complex tachycardia Probable atrial fibrillation or possible atrial flutter or Multifocal atrial tachycardia Consider expert consultation Control rate (eg., diltiazem, blockers) Does not convert If rhythm does not convert, possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia Control rate (eg. Diltiazem, blockers*) Treat underlying cause Consider expert consultation

Attempt vagal maneuvers Give adenosine 6mg rapid IV push, if no conversion, give 12mg rapid IV push, may rpt 12mg dose once

Does rhythm converts? Converts If rhythm converts, possible reentry SVT: Observe for recurrence Treat recurrence with adenosine or longer-acting AV nodal blocking agents (eg, diltiazem or blockers*) * Use blockers with caution in pulmonary edema or CHF)

Wide QRS



If VT or uncertain rhythm: Amiodarone 150mg IV over 10min repeat as needed to a max of 2.2g/24h Prepare for elective synchronized cardioversion If SVT with aberrancy, give adenosine

If AF with aberrancy- see irreg narrow complex tach If pre-excited AF expert consultation

Algorithm for Pulseless Arrest

1 Pulseless Arrest
BLS Algorithm Attach to cardiac monitor

2 3 VF/VT 4
Give 1 shock Biphasic 200j Monophasic 360j
Give 5 cycles of CPR

Check Rhythm


10 Give CPR immediately for 5 cycles

Epinephrine 1mg IV every 3-5min Consider Atropine 1mg IV for asystole or slow PEA rate every 35min for 3 doses only

Check Rhythm Shockable 6 Give 1 shock Resume CPR immediately after the shock - Epinephrine 1mg IV q 3-5min


Check rhythm

Check rhythm

Give 5 cycles of CPR

Contd, Algorithm for Pulseless Arrest

7 Check rhythm

11 Check rhythm No 12
If asystole, go to BOX 10 If electrical activity, check pulse - if no pulse, go to Box 10 If pulse is present, begin postresuscitation care
Shockable Not Shockable

8 Continue CPR
Give 1 shock: 200j biphasic 360j monophasic Resume CPR immediately after the shock - consider antiarrhythmics, give during CPR: Amiodarone 300mg slow IV Lidocaine 1- 1.5mg/kg 1st dose then 0.5 0.75mg/kg IV Consider Mg for torsades

13 Go to Box 4

After 5 cycles of CPR, go to box 5