ACLS Cardiac Arrest Medications & Protocols

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in cardiac arrest when do you first introduce medical intervention? which drug?

after 2 rounds of CPR/shock

after 2nd shock give 1 mg epinephrine every 3-5 minutes

when do you introduce amiodarone during cardiac arrest?

after the 3rd shock give 300 mg bolus of amiodarone

if second dose is needed give 150mg as second dose

what rhythms are shockable in cardiac arrest

VF

VT

what rhythms are not shockable in cardiac arrest

asystole

PEA

if you are in an unshockable rhythm arrest when do you give epi

1mg epi every 3-5 minutes after 1st round of CPR

what do you do after return of spontaneous circulation

maintain O2 sat at 94%

treat hypotension (fluids vasopressor)

12 lead EKG

if in coma consider hypothermia

if not in coma and ekg shows STEMI or AMI consider re-perfusion

what are the 5 h's and 5 t's

hypovolemia

hypoxia

hydrogen ion (acidosis)

hypo/hyperkalemia

hypothermia

tension pneumothorax

tamponade, cardiac

toxins

thrombosis, pulmonary

thrombosis, coronary

how do you treat non-symptomatic bradycardia

monitor and observe

what constitutes symptomatic bradycardia

hypotension

altered mental status

signs of shock

chest pain

acute heart failure

how do you treat symptomatic bradycardia

1. give 0.5mg atropine every 3-5 mins to max of 3mg

if that doesn't work try one of the following:

transcutaneous pacing

2-10mcg/kg / minute dopamine infusion

2-10mcg/minute epinephrine infusion

what is considered a tachycardia requiring treatment

over 150 per minute

when do you consider cardioversion

if persistent tachycardia is causing:

hypotension

altered mental status

signs of shock

chest pain

acute heart failure

if persistent tachycardia does not present with symptoms what do you need to consider

wide QRS?

greater than 0.12 seconds

If persistent tachycardia without symptoms DOES have a wide QRS what to do you do?

IV access and 12 lead if available

6mg adenosine followed by NS flush only IF regular and monomorphic

consider anti-arrhythmic infusion:

- 20-50mg/min procainamide (max 17mg/kg)

- 150mg amiodarone over 10 minutes

- 100mg sotalol over 5 minutes

which anti-arrhythmic drugs can be used if prolonged QT

only amiodarone

150mg over 10 minutes, repeat if VT occurs

follow by maintenance infusion 1mg/min for first 6 hours

if persistent tachycardia without symptoms and without wide QRS what do you do

IV access and 12 lead EKG if available

vagal maneuvers

6mg adenosine followed by NS flush only IF regular

Beta blocker or calcium channel blocker

patient comes in with symptoms of ACS what do you do first

chew 325mg aspirin

O2

nitro

morphine

get 12 lead EKG

IV access

IF ACS patient has EKG showing ST elevation and symptoms are less than 12 hours then what

re-perfusion

door to balloon 90 minutes

door to needle 30 minutes

If ACS patient has EKG showing non ST elevation MI or high risk unstable angina then what

early invasive strategy?

adjunctive treatment?

-nitroglycerin

-heparin

-beta blockers

-clopidogrel

-glycoprotein IIb / IIIa inhibitor

what are the contraindications to fibrinolytics in ACS treatment

systolic > 180

diastolic > 100

right arm left arm systolic difference > 15

history of structural central nervous system disease

recent head/facial trauma

stroke more than 3 hours or less then 3 months ago

recent trauma, surgery or bleed

any history of intracranial hemorrhage

bleeding, clotting problem or on blood thinners

serious systemic disease

adenosine

used in tachy

6mg bolus followed by 20mL normal saline

12mg can be used after 1-2 minutes

amiodirone

In VF/VT arrest AFTER trying CPR shock and epi/vasopressin:

300mg then 150mg

In life threatening arrhythmias:

150mg over 10 minute infusion, every 10 minutes as needed

atropine sulfate

use as first line defense in sinus bradycardia

0.5mg every 3-5 minutes as needed MAX is 3mg ( think alive gets 0.5)

do not use if hypothermia

dopamine

2nd line drug for symptomatic bradycardia

use for hypotension with signs of shock

2-20 mcg/kg per minute

epinephrine

in cardiac arrest:

1mg every 3-5 minutes

in bradycardia or hypotension:

2-10mcg/minute infusion

lidocaine

alternative to amiodirone in cardiac arrest:

1-1.5 mg/kg IV

for stable VT, wide complex VT:

0.5 - 0.75 mg.kg every 5-10 minutes max of 3mg/kg

magnesium sulfate

use in cardiac arrest only if hypomagnesemia or torsades:

1-2g diluted in 10mL of D5W

use in torsades with a pulse or AMI with hypomagnesia:

1-2g in 50 to 100 mL of D5W

maintenance with 0.5g per hour infusion

vasopressin

cardiac arrest:

40 units can replace either 1st or 2nd dose of epi

what meds can go down the endotrachial tube

atropine

epinephrine

lidocaine

vasopressin

reentry supraventricular tachycardia

polymorphic ventricular tachycardia - aka torsades

atrial fibrilation

sinus tachycardia

reentry supraventricular tachycardia

sinus bradycardia

coarse ventricular fibrillation

atrial flutter

second degree AV block type 1 (wenckenbach)

reentry supraventricular tachycardia

sinus bradycardia

monomorphic ventricular tachycardia

fine ventricular fibrillation

second degree AV block mobitz type 2

second degree AV block mobitz type 2

coarse ventricular fibrillation

asystole

normal sinus rhythm

third degree AV block

hyperkalemia

1mEq of sodium bicarb

hypokalemia

10-20 mEq of potassium

hypomagnesemia

give mag sulfate 1-2g