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ACLS

TACHYCARDIA: HR>150 UNSTABLE: Hypotension, AMS, shock, ischemic chest pain, acute HF
Synchronized cardioversion a. O2 saturation monitor b. IV Access c. Intubation kit, Suction d. Midazolam (Versed) 2mg IVP e. Fentanyl 100-300ug IVP, titrate to effect NARROW COMPLEX Irregular: 120-200J biphasic, or 200J monophasic Regular: 50-100J WIDE COMPLEX Regular: 100J Irregular: Defibrillate (NOT synchronized)

STABLE

1. Oxygen 2. IV access 3. Pulse Ox 4. BP 5. 12-Lead EKG, Cardiac monitor NARROW COMPLEX Irregular Rhythm: Atrial fibrilliation, Atrial flutter, Multifocal Atrial Tach -Diltiazem 15-20mg IV over 2min, 20-25mg over 2min 15min later if needed. Infusion: 5-15mg/hr in NS or D5W titrated to effect. -Metoprolol Tartrate 5mg slow IV q 5min, up to x3. Begin oral regimen to follow IV dose with 50mg PO; titrate to effect. Regular Rhythm: 1. Vagal Maneuvers: bearing down, coughing, blowing in syringe 2. Adenosine 6mg rapid IVP then 20cc NS bolus, 12mg IVP q2min x2 if needed. If responds likely AVNRT or AVRT. 3. -Diltiazem 15-20mg IV over 2min, 20-25mg over 2min 15min later if needed. Infusion: 5-15mg/hr in NS or D5W titrated to effect. -Metoprolol Tartrate 5mg slow IV q 5min, up to x3. Begin oral regimen to follow IV dose with 50mg PO; titrate to effect. WIDE COMPLEX Irregular Rhythm DO NOT GIVE ADENOSINE 1. -Amiodarone 150mg IV over 10min. Repeat as needed. Infusion at 1mg/min for first 6hrs. -Procainamide 50 mg/min until suppression or max dose of 17mg/kg at (avoid if decreased EF) 2. If torsades, Mg 2g IV over 5min, consider overdrive pacing 3. Prepare for defibrillation, have next to bedside. Regular Rhythm 1. -Amiodarone 150mg IV over 10min. Repeat as needed. Infusion at 1mg/min for first 6hrs. -Procainamide 50 mg/min until suppression or max dose of 17mg/kg at (avoid if decreased EF) 2. Prepare for synch cardioversion, have next to bedside.

ACLS.

BRADYCARDIA: HR<50
1. Oxygen 2. IV access 3. Pulse Ox 4. BP 5. 12-Lead EKG, Cardiac monitor

UNSTABLE: Hypotension, shock, AMS, chest pain

1. Prepare for transcutaneous pacing, use without delay for Second degree Type II or Third degree AV Block. 2. Atropine 0.5mg IV q3-5min, max 6 doses (3mg) 3.-Transcutaneous pacing set at 80/min, increase current until capture is achieved (wide QRS and broad T wave after each pacing spike). -Dopamine 2-10ug/kg/min -Epinephrine 2-10ug/min 4. Call cardiology, ask about transvenous pacing.

STABLE

1. Oxygen, Assist breathing as necessary 2. IV Fluids if indicated 3. Monitor and observe 4. Prepare for transcutaneous pacing, Dopamine 2-10ug/kg/min, OR Epinephrine 2-10ug/min, if worried.