ACLS PALS (Study Guide version)

Cardiac Arrest vs. Myocardial Infarction (MI)

• which is electric and ischemic

• Can one lead to the other

• CA: Sudden, abrupt loss of heart function (cardiac electrical malfunction) w/ unexpected timing

  • Electrical system malfunction

• MI: Death/dysfunction of myocardial tissue due to ischemia

  • Ischemic tissue damage

• MI is a predisposing heart condition that can trigger cardiac arrest

List the 5 Hs and Ts (underlying causes of cardiac arrest)

Hypovolemia	Toxins
Hypoxia	Tamponade (cardiac)
Hydrogen ion (acidosis)	Tension pneumothorax
Hyper/Hypokalemia	Thrombosis (coronary/MI)
Hypothermia	Thrombosis (pulmonary/PE)

What are the steps in cardiac arrest Chain of Survival

• Early recognition/activation of emergency response

• Early high quality CPR

• Rapid defibrillation

• Basic and advanced EMS/resuscitation

• Post-arrest care

How does timing affect outcomes

• Earlier each link occurs, the better the outcome

• Survival drops rapidly with delays in CPR/defibrillation

Adult BLS healthcare provider steps

• Ensure scene safety

• Check responsiveness

• Shout for help/activate emergency response

• Retrieve AED (automated external defibrillator)

• Check breathing & pulse

• Immediately begin CPR

  • 2 person CPR when 2nd rescuer arrives

• Apply AED, follow prompts to shock

When/who should get AED

• Lone rescuer retrieves AED first

  • If not alone, send someone else and start CPR

• Apply as soon as available and shock if rhythm is shockable

Which cardiac arrest rhythms are shockable

• Ventricular Fibrillation (VF)

• Pulseless Ventricular Tachycardia (pVT)

Which cardiac arrest rhythms are non-shockable

• Asystole

• Pulseless Electrical Activity (PEA)

Cardiac arrest medication

• 1^st: Epinephrine 1mg IVP Q 3-5min (no max dose)

• 2^nd: Amiodarone 300mg first dose, may repeat once with 150mg (max 2.2g/day)

  • given after first round of epinephrine

• Alternative: Lidocaine

What do you check for with each cycle

Rhythm (every 2 mins) and pulse

HR typically at or above how many bpm

• Tachycardia ≥ 100bpm

  • Symptomatic/unstable ≥ 150bpm

Main non-pharm intervention for tachycardia

• Synchronized cardioversion

• Vagal maneuvers

  • for Supraventricular Tachycardia (SVT) specifically

Initial medication to slow conduction (HR)

Adenosine

Beta blockers/ND-CCBs for what type of arrythmias

• Stable, narrow complex tachyarrhythmias

  • Afib

  • Aflutter

  • SVT

  • Sinus tachycardia

Bradycardia is HR below how many bpm

HR < 50bpm (causing symptoms)

Main non-pharm intervention for bradycardia

• Transcutaneous pacing (TCP)

  • Transvenous pacing (TVP) may be used if not responsive to TCP

Medications to increase HR

• Atropine

  • Dopamine and Epinephrine if persistent bradyarrhythmia with symptoms

Main difference with pediatric cardiac arrest

• Weight based dosing throughout

• Lower initial defibrillation energy (2J/kg up to 4J/kg, max 10J/kg)

• Epinephrine dosed 0.01 mg/kg

• ECPR considered for in hospital arrest w/ a cardiac diagnosis

Define the following

• Appropriate compression rate

• Compression depth

• Compression to ventilation ratio for adult patient

• 100-120/min

• At least 2 inches

• No advanced airway- 30:2

  • Advanced airway- 1 breath every 6 seconds

Describe Extracorporeal Membrane Oxygenation & Extracorporeal CPR (ECMO/ECPR)

• ECMO- temporary life support machine that pumps and oxygenates a patient's blood outside the body

• ECPR- emergency procedure that uses a specific type of ECMO during a cardiac arrest

  • Venoarterial ECMO used during cardiac arrest

    • requires adequate vascular access and specialized equipment

• Replaces chest compressions and the advanced airway/rescue breaths

Are ECMO/ECPR preferred/recommended over an advanced airway

NO

• insufficient evidence to rec routine use

• may be considered where it can be rapidly implemented

What are the four cardiac arrest rhythms

Which are shockable and non-shockable

Shockable

• Ventricular Fibrillation (VF)

• Pulseless Ventricular Tachycardia (pVT)

Non-Shockable

• Asystole

• Pulseless Electrical Activity (PEA)

Epinephrine

• Class

• Indications- Emergency situation & Rhythms

• ADRs

• Sympathomimetic

• Used in any pulseless cardiac arrest (emergency situation) and all rhythms

• Tachyarrhythmias, Myocardial ischemia, Hypokalemia, Tremors

Amiodarone

• Class

• Indications- Emergency situation & Rhythms

• ADRs

• Antiarrhythmic (Class III)

• Used in cardiac arrest after first round of Epi

  • Shockable rhythms: VF or pVT

• Hypotension, Bradycardia, Negative inotropic effects

Lidocaine

• Class

• Indications- Emergency situation & Rhythms

• ADRs

• Antiarrhythmic (sodium channel blocker)

• Alternative to amiodarone

  • Cardiac arrest and shockable rhythms (VF & pVT)

• Hypotension, Bradycardia, Negative inotropic effects

What is used for Hypovolemia

• Fluid boluses (NS, LR)

• Colloids (albumin)

What is used for Hyperkalemia

• Calcium chloride

• Insulin plus dextrose

• Sodium bicarbonate

What is used for Metabolic Acidosis

Sodium Bicarbonate

What is used for Thrombosis

Thrombolytics (e.g. Tenecteplase)

Epinephrine dosing Adult vs. Pediatric

• Adult: 1mg IVP every 3-5 min (no max)

• Pediatric: 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO every 3-5 min

  • ET route 0.1 mg/kg (0.1 mL/kg of 1:1000)

What is the preferred route of administration

IV

• Central line preferred

• Peripheral IV acceptable if no central access

First alternative route of administration

• IO (intraosseous)

Last option route (for some meds)

ET (endotracheal) - last resort

Treatment for Torsades de Pointes

• Polymorphic ventricular tachycardia

  • QTc Prolongation is precursor

• Magnesium Sulfate 1-2g IVP over 1-2 min (may repeat)

Types of tachycardia

• Atrial vs. Ventricular

• Narrow vs. Wide complex (wide ≥0.12 sec)

• Regular vs. Irregular

• Monomorphic vs. Polymorphic

How do differences impact non-pharm and pharm treatment in tachycardia

• Narrow/Regular is treated w/ adenosine or vagal maneuvers

• Wide/Irregular gets unsynchronized defibrillation

• Stable narrow complex gets Beta blockers/ND-CCBs

• Cardioversion energy differs by width/regularity

  • Narrow Regular: 50-100J

  • Narrow Irregular: 12-200J

  • Wide Regular: 100J

Types of Bradycardia

• Sinus bradycardia

• 1^st degree AV block

• 2^nd degree AV block Type I (Wenckebach)

• 2^nd degree AV block Type II

• 3^rd degree (complete) AV block

How do differences impact non-pharm and pharm treatment in bradycardia

• All types can be treated w/ Atropine/pacing if symptomatic

  • Higher grade blocks (2^nd Type II & 3^rd) more likely to need pacing since they are less responsive to atropine