Dr.
Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
CPR
International ACLS Guidelines 2010 updated 2012
Ventricular Fibrillation/ Pulseless Ventricular Tachycardia
SHOCK FIRST x 1
(If defibrillator not immediately available start CPR then shock ASAP)
200 J Biphasic, 360 J Monophasic
High Quality CPR* x 2 min
(prior to rhythm or pulse check)
(Ventilate, IV/IO Access)
SHOCK
CPR x 2 min
(Intubate, Drugs-give during CPR)
Treat reversible causes
EPINEPHRINE 1 mg IV (may be given after 1
st
or 2
nd
shock)
(REPEAT Q 3-5 MIN)
(Vasopressin 40 U IV may be an alternate to 1
st
or 2
nd
dose of epinephrine)
SHOCK
CPR x 2 min
AMIODARONE 300 mg IV bolus (Preferred)
(may give 2
nd
dose 150 mg IV)
or
LIDOCAINE 1.5 mg/kg IV
(REPEAT in 3-5 min) (Max. 3 mg/kg)
or
MAGNESIUM SULFATE 2 G IV
(with torsades)
SHOCK
*High Quality CPR: Push hard (2 inches) and fast (100/min), complete chest
recoil, minimize interruptions, avoid excessive ventilations (8-10/min), change
compressors q2min, monitor end-tidal C02
Hypothermia (32-34C) recommended for resuscitated v. fib. patients who remain
comatose and intubated with a BP >90.
Treat Reversible Causes: hypovolemia, hypoxia, acidosis, K, hypothermia, toxins,
ischemia
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
WIDE COMPLEX TACHYCARDIA
ASSESS ABCS IF STABLE, O2, MONITOR, O2 SAT, VITALSIGNS (Hx, P/E, ECG, CXR)
Unstable Stable
(Chest pain, SOB, LOC, low BP, CHF, AMI) (consider cardioversion first, as meds
only work about 30% of the time)
Likely VT Regular, monomorphic,
uncertain origin
Procainamide
20-50 mg/min (max 17mgkg) no change
Adenosine 6-12 mg
OR (defibrillator at bedside)
Amiodarone*
150 mg over 10 min (repeat prn)
Infusion: 1 mg/min x 6 hrs,
then 0.5 mg/min over 24 hrs
(Max: 2.2m in 24 hrs)
Prepare for cardioversion
Consider premedication
SYNCHRONIZED Biphasic: 100-150-200
CARDIOVERSION Monophasic: 200300360
If Ventricular Tachycardia is polymorphic (Torsades) consider: magnesium 2 gm,
overdrive pacing, isoproterenol, Phenytoin, Lidocaine, amiodorone.
*Avoid giving multiple antidysrhythmics sequentially (to prevent proarrhythmias). If one
antidysrhythmic fails, go to electrical cardioversion.
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
(AVnRT, AVRT)
STABLE UNSTABLE CARDIOVERSION
(Consider premedication)
VAGAL MANOEUVRES
Adenosine 6 mg IV over 3 seconds, may repeat 12 mg in 1-2 min (Class I)
-may be preferred option due to short 10 second half life and no effects on BP
or Diltiazem 20 mg IV over 2 min, may repeat 25 mg IV in 15 min (Class I)
or Metoprolol 5 mg IV, may repeat x 2: max 15 mg total (Class I)
or Verapamil 2.5 5 MG I.V. over 2 min, may repeat 5-10 mg in 10 minutes (Class I)
Others to consider:
Procainamide 30mg/min to 17/kg (Class IIa)
Amiodarone 150 mg over 10 min (Class IIa)
or
SYNCHRONIZED CARDIOVERSION (consider premedication)
Monophasic:,100,200,300 j
Biphasic: 70, 100, 150 j
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
Atrial Fibrillation or Atrial Flutter *
STABLE UNSTABLE CARDIOVERSION
-higher risk of stroke if a.fib/flutter>48 hrs and
patient not anticoagulated
1) Control Heart Rate if > 120
Narrow Complex Wide Complex (WPW or BBB)
Diltiazem 20 mg IV Procainamide 30 mg/min to 17mg/kg
2
Verapamil 2.5-5mg IV
1
Amiodarone 150 mg over 10 min
2
Metoprolol 5 mg IV
1
Amiodarone 150 mg over 10 min
2
Digoxin 0.5 mg IV
1) Do not use verapamil or metoprolol if LV function is impaired (<40%).
2) Do not use amiodarone or procainamide if fibrillation or flutter present for > 48 hours as these
medications may convert the rhythm back to sinus.
2) Convert rhythm back to NSR
-atrial flutter < 48 hours requires electrical cardioversion
A fib < 48 hours A. fib or flutter > 48 hrs duration
Cardiovert Electrically or with Drugs
1) Anticoagulate x 3 weeks prior to and 4 weeks
Procainamide (drug of choice for IV route) after cardioversion
Amiodarone (less effective for acute conversion) OR Heparinize, do TEE, cardiovert if no clot,
Propafenone 600 mg po or then anticoagulate x 4 wks post cardioversion
2) Long term rate control with beta or calcium
channel blocker
Consider long term anticoagulation with recurrent episodes, if in high risk group for stroke: CHAD2
score > 1-2: previous stroke or TIA, diabetes, CHF, age > 75
*N.B. Medications are not effective in converting atrial flutter back to NSR
and the treatment of choice is electrical cardioversion if < 48 hrs duration
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
ELECTRICAL CARDIOVERSION ALGORITHM
INDICATIONS:
- TACHYCARDIA should be > 150/min (with signs and/or symptoms)
- Ex. PSVT (it is uncommon to have to cardiovert a patient with SVT)
ATRIAL FIBRILLATION
ATRIAL FLUTTER
VENTRICULAR TACHYCARDIA
CHECK:
- IV LINE
- SUCTION
- O2 SAT
- B.V. MASK
- INTUBATION EQUIPMENT
SEDATE: APPROPRIATELY ex 1) Midazolam 1-5 mg, with or without Fentanyl 50-200 mcgm
2) Propofol 50-150 mg IV
3) Ketamine 0.25-1.5 mg/kg IV
4) Etomidate 20 mg IV
SYNCHRONIZED CARDIOVERSION:
PSVT-ATRIAL FLUTTER Monophasic: 100 - 200 - 300 360 Joules
Biphasic: 50- 100- 150
V. TACH, A. FIB. Monophasic: 200 300 360 Joules
Biphasic: 100-200 joules
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
ASYSTOLE
ASYSTOLE SHOULD BE CONFIRMED IN TWO LEADS
Witnessed Arrest NO ACLS Futile
Consider pronouncing death
Yes.
CONTINUE CPR
INTUBATE
ESTABLISH IV ACCESS
CONSIDER POSSIBLE CAUSES
- Hypoxia
- Hyperkalemia
- Hypokalemia
- Acidosis
- Drug Overdose
- Hypothermia
EPINEPHRINE, 1 mg IV PUSH Q 3 5 MIN
(Vasopressin 40 U IV may replace 1
st
or 2
nd
dose of epinephrine)
CONSIDER EARLY TERMINATION OF EFFORTS IF REVERSIBLE CAUSE NOT
FOUND
.
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
PULSELESS ELECTRICAL ACTIVITY
PEA
Continue CPR
Intubate, IV access
TREAT REVERSIBLE CAUSES
(eg. cardioversion for shockable rhythms and pacing for bradycardias)
CONSIDER POSSIBLE CAUSES
(5 Hs and 5 Ts)
Hypovolemia Tablets (overdose)
Hypoxia Tamponade, cardiac
Hydrogen ion-acidosis Tension pneumothorax
Hyper/hypokalemia Thrombosis, coronary
Hypothermia Thrombosis, pulmonary
EPINEPHRINE 1 mg IV PUSH Q 3-5 MIN
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
International ACLS Guidelines 2010
BRADYCARDIA (SLOW H.R. < 60/MIN)
ASSESS ABCS, O2, I.V. MONITOR
BRADYCARDIA (< 60/MIN)
SERIOUS SIGNS OR SYMPTOMS?
- Hypotension
- Chest pain, dyspnea, LOC
- CHF, acute MI
NO YES
TYPE II 2 AV BLOCK ATROPINE 0.5 mg q 3-5 MIN
OR 3 AV BLOCK (MAX 3 mg) (0.04 mg/kg)
(atropine is not effective for 3
o
heart block with wide
complex escape idioventricular rhythm)
- Transcutaneous Pacing
NO YES (if available)
(PREPARE FOR IV PACING)
OR
- DOPAMINE 2 10 microgm/kg/min
OR
OBSERVE PREPARE FOR - EPINEPHRINE 2 10 microgm/min
TRANSVENOUS PACING
APPLY TRANSCUTANEOUS
PACING PADS UNTIL TRANVENOUS PACING AVAILABLE
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
RULE OF 250 FOR DRUG INFUSIONS
Mix one ampoule of any drug into 250 cc and run at:
30 cc/hr 3 cc/hr
Antiarrhythmics Vasodilators
Lidocaine (1 gm) 2 mg/min Nitroglycerin (50 mg) 10 micgm/min
Procainamide (1gm) 2 mg/min Nitroprusside (50mg) 10 micgm/min
Mag S04 (5gm) 0.6 gm/hr
Adrenergic agents
Epinephrine (1mg) 2 micgm/min
Dopamine (200 mg) 5 micgm/kg/min (70 kg)
Dobutamine (250 mg) 7 micgm/kg/min (70 kg)
Norepinephrine (4mg) 8 micgm/min
______________________________________________________________________________
Drugs Given By the Endotracheal Tube (2x the dose) Note: The IV or Intraosseos route is preferred.
N naloxone
A atropine
V valium, ventolin,versed (midazolam)
E epinephrine
L lidocaine
Chest Pain Nemonic
M morphine
O oxygen
N nitrates
A aspirin
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
ABCs
Anaphylaxis Algorithm
(Multisystmeic involvement: respiratory distress, hyptotension, airway swelling)
If NO or INADEQUATE
response after 5 minutes
If poor response after another 5 minutes,
CALL FOR BACK-UP (snr medical resident/anaesthesia/ or rapid response team}
Continue with IV fluids and epinephrine infusion
*Never use SC Epinephrine due to
inconsistent absorption.
Administer IM, deltoid or thigh.
In patients on Beta-blockers,
beware of poor response to
epinephrine; use Glucagon 1 mg
IV/IM instead.)
Repeat IM Epinephrine 0.3 mL or continue IV infusion 5-15 mcg/min
If hypotension persists: Repeat 1 Litre NS bolus
0.3 mL (0.3 mg) Epinephrine 1:1,000 IM (or 5-15
mcg/min IV-especially with shock) plus
Diphenhydramine (Benadryl) 50 mg IV
Ranitidine 50 mg IV
Methylprednisolone (Solu-Medrol) 125 mg IV
Cardiac Monitor (if available) plus 1 Litre NS bolus
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
CORE PHARMACOLOGY REFERENCE FOR ACLS
ADENOSINE
6 mg IV RAPID PUSH over 3 seconds.
May repeat at 12 mg IV and then another 12 mg IV if first dose is not effective.
IV rapid push always followed by 20 cc NS bolus. May repeat in 2-3 min.
AMIODARONE
300 mg IV push for cardiac arrest, and may then give 150 mg if initial dose is
not effective. 150 mg IV over 8-10 min for VT, PSVT, Atrial Fibrillation/Flutter with either
good or impaired LV function. After bolus, infusion should be started immediately at 1 mg/min for 6 hours,
then 0.5 mg/min for 18 hours.
ATROPINE 0.5-1.0 mg IV fast push to max of 0.04 mg/kg 2-2.5 times IV dose down ETT in 10 ml
NS. Drug should be given quickly to offset paradoxical effect (if given too slowly). Caution should be
used in high level blocks.
CALCIUM CHANNEL BLOCKER
Diltiazem: 0.25 mg/kg slow IV push over 2 minutes, repeat dose of 0.35 mg/kg in 15-30 min
Verapamil: 2.5 -5mg IV push
Caution: Common calcium channel blocker side effects: Hypotension.
Do not use in WPW with AFib or where a delta wave or short PR is apparent, sick sinus syndrome, AV block, CHF or
bundle branch block.
EPINEPHRINE 1 mg IV Q 3-5 min (no maximum ) 2-2.5 mg in 10 ml NS ET followed by hyperventilation when IV not
available (Intermediate and high dose IV epinephrine treatment is not recommended.) Continuous infusion may be
appropriate for symptomatic bradyarrhythmias.
LIDOCAINE 1-1.5 mg/kg and repeat at 0.5 - 0.75 mg/kg Q 5-10 min to max dose 3 mg/kg.
1.0 mg/kg for stable Ventricular Tachycardia. Maintenance infusion may be used after rhythm is
successfully converted.
MAGNESIUM 1-2 g IV push diluted in 10 ml NS Give for known or suspected magnesium
deficiency or for torsade des pointes. May cause rapid drop in BP. Caution in renal failure.
PROCAINAMIDE 20-30 mg/min IV dose to max of 17mg/kg then 1-4 mg/min as maintenance
infusion (Can mix 100 mg at a time in a syringe to give over 5 min.). Class I antiarrhythmic that can be given as rapidly as
50 mg/min in urgent situations. Administer until: dysrhythmia is suppressed,
QRS widens >50%, max dose reached, hypotension occurs--watch QT Interval. Has pro-arrhythmic effects as well!
Maintenance infusion may be used after rhythm is successfully converted.
SODIUM BICARBONATE
1 mEq/kg IV and may repeat (half dose) in 10 min. Give for known metabolic acidosis, TCA or
Barbiturate OD, long code endpoint.
VASOPRESSIN 40 units IV for cardiac arrest. 1-2 doses used before epinephrine. Is equivalent choice to epinepherine for
cardiac arrest management.
Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital
BLS Recommendations 2010 (HCP = Health Care Providers)
Component Adults Children Infants
Recognition Unresponsive (for all ages)
No breathing or no normal
breathing (ie, only gasping)
No breathing or only gasping
No pulse palpated within 10 seconds for all ages (HCP only)
CPR sequence
C-A-B
Compression rate
At least 100/min
Compression depth
At least 2 inches (5 cm) At least 1/3 AP diameter
About 2 inches (5 cm)
At least 1/3 AP diameter
About 1 inches (4 cm)
Chest wall recoil
Allow complete recoil between compressions
HCPs rotate compressors every 2 minutes
Compression
interruptions
Minimize interruptions in chest compressions
Attempt to limit interrruptions to <10 seconds
Airway
Head tiltchin lift (HCP suspected trauma: jaw thrust)
Compression-to-
ventilation ratio (until
advanced airway
placed)
30:2
1 or 2 rescuers
30:2
Single rescuer
15:2
2 HCP rescuers
Ventilations: when
rescuer untrained or
not proficient
Compressions only
Ventilations with
advanced airway (HCP)
1 breath every 6-8 seconds (8-10 breaths/min)
Asynchronous with chest compressions
About 1 second per breath
Visible chest rise
Defibrillation
Attach and use AED as soon as available. Minimize interruptions in chest compressions
before and after shock; resume CPR beginning with compressions immediately after
each shock.
