Electrical Therapy and ACLS Algorithms – Flashcards

A specific form of direct current countershock that "removes" fibrillation from the heart by stopping all electrical activity in the myocardium so the heart can (hopefully) begin normal electrical operation.

A specific form of direct current countershock where the energy delivered stops all electrical activity in the myocardium so the heart can (hopefully) begin normal electrical operation. Usually synchronized to the patient's current heart rate. (Synchronized to shock on peak of "R" wave).

Rhythmic application of electricity, stimulating individual contractions of the myocardium. Intended to supplement or replace the heart's natural pacemaker.

Quarter sized units implanted in shoulder or groin, operate for up to five years on a single battery.

Temporary unit, used until internal pacemaker can be implanted.

Emergent devices, used to treat serious cardiac irregularities.

Ventricular fibrillation and pulseless ventricular tachycardia.

Unstable tachydysrhythmias.

Bradycardia, may be used for "overdrive" pacing of tachycardia.

Right side: sub-clavicular, on mid-clavicular line. Left side: mid-axillary, above xiphoid line. Anterior-posterior preferred for pacing.

Delivers entire shock in one direction.

Separates energy. Impedance compensating, lower shock strength, less potential damage to cells, more efficient.

Skin surface (especially if dry), use of conductive material, hair, fat, paddle/electrode size, paddle/electrode position, phase of patient's respiration, paddle pressure, selected energy

Never

360 J

Manufacturer's settings, 120-200 J. If amount unknown, maximum available (200 J). Escalate with subsequent shocks.

Initial shock = 2 J/kg Second shock = 4 J/kg Subsequent shocks = >4 J/kg, max of 10 J/kg or adult dose

120-200 J for biphasic, 200 J for monophasic

100 J, increasing stepwise as needed (with biphasic or monophasic)

50-100 J, increasing stepwise as needed (biphasic or monophasic)

Set rate at about 70-80 bpm and advance current until mechanical capture.

IV-peripheral, IV-PICC, IV-central, intraosseous, endotracheal tube

Peripheral, venous access, preferred over IO or ETT. 1-2 minutes to reach central circulation. Inject meds as bolus, followed by 20 ml bolus of fluid and raise the extremity.

Peripherally inserted central cathether (at saphenous vein or antecubital vein). No risk of pneumothorax or arrhythmias (IV-central) and less chance of being dislodged like peripheral IV.

Preferred route in CPR, fastest response. Subclavian vein or internal jugular. Possible complications are pneumothorax or arrhythmias.

Access in bone marrow, achieved in 30-60 seconds. Sites include upper part of humerus, tibia right below knee, distal tibia, distal femur in children.

Last route, if nothing else is obtainable. Give 2-2.5 times the IV dose diluted in 5-10 ml of water or normal saline. Actual dosage given less predictable than IV or IO.

Lidocaine, epinephrine, atropine, naloxone (narcan), vasopressin

Given for severe, crushing chest pain not relieved by nitroglycerin. 1-3 mg by IV q5 minutes.

Given for angina, most often sublingually. Relieves pain of acute MI. Can cause hypotension, do not use with Digitalis patients.

Unresponsive patient, no breathing/normal breathing. 1. Activate emergency response system, get AED/defibrillator (or have second rescuer do this) 2. Check pulse. If definite pulse within 10 seconds, give 1 breath every 5-6 seconds and recheck pulse every 2 minutes. If no pulse within 10 seconds... 3. Begin cycles of 30 compressions and 2 breaths. 4. Once AED/defibrillator arrives, check rhythm. -shockable rhythm = give 1 shock and resume CPR immediately for 2 minutes -no shockable rhythm = resume CPR immediately for 2 minutes, check rhythm every 2 minutes. Continue until ALS providers take over or victim starts to move.

1. IV 2. Drugs 3. Airway

5 Hs = Hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia 5 Ts = Tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), thrombosis (coronary)

Return of spontaneous circulation. Pulse and blood pressure, abrupt sustained increase in PetCO2 (typically > 40 mmHg), spontaneous arterial pressure waves with intra-arterial monitoring.

Push hard (>2 in.) and fast (>100 bpm) and ensure full chest recoil. Minimize interruptions in compressions. Rotate compressor every 2 minutes. If no advanced airway, 30:2 compression: ventilation ratio. If PetCO2 < 10 mmHg or intra-arterial diastolic pressure < 20 mmHg, attempt to improve CPR quality.

1. Epinephrine (after 2 shocks of shockable rhythm or if not a shockable rhythm), 1 mg IV/IO every 3-5 minutes. OR Vasopressin 40 U IV/IO to replace 1st OR 2nd dose of epinpehrine 2. Amiodarone (after 3 shocks and epi), first dose 300 mg IV/IO bolus, second dose 150 mg.

With supraglottic advanced airway or endotracheal intubation, have waveform capnography to confirm and monitor ET tube placement and give 8-10 breaths per minute with continuous chest compressions.

Shout for help and/or activate emergency response. Give oxygen, attach monitor/defibrillator and look for/treat reversible causes. If initial rhythm is shockable... -Shock, resume CPR immediately. CPR for 2 minutes and get IV/IO access. If rhythm is shockable, shock and resume CPR for 2 minutes, then give epinephrine every 3-5 minutes, plus consider advanced airway and capnography. If next rhythm is shockable, shock and resume CPR for 2 minutes, give amiodarone and treat reversible cause. -If at any time the rhythm is unshockable, CPR for 2 minutes, IV/IO access and epinephrine every 3-5 minutes. Consider advanced airway and capnography. If rhythm still not shockable, CPR for 2 minutes and treat reversible causes. -If ROSC, go to post-cardiac arrest care.

1. Optimize ventilation and oxygenation. Maintain oxygen saturation >94%, consider advanced airway and waveform capnography, do not hyperventilate. Start at 10-12 bpm and titrate to target PetCO2 of 35-40 mmHg. 2. Treat hypotension (systolic BP < 90 mmHg). IV/IO bolus, vasopresser infusion, consider treatable causes, 12-lead ECG. 3. -If the patient does not follow commands, consider induced hypothermia. -If the patient follows commands and no STEMI or high suspicion of AMI, coronary reperfusion. -If the patient follows commands and STEMI or high suspicion of AMI, advanced critical care.

1-2 L normal saline or lactated Ringer's. If inducing hypothermia, may use 4 degrees C fluid.

1. Epinephrine - 0.1-0.5 micrograms/kg/minute (in 70 kg adult, 7-35 micrograms/minute) 2. Dopamine - 5-10 micrograms/kg/minute 3. Norepinephrine - 0.1-0.5 micrograms/kg/minute (in 70 kg adult, 7-35 micrograms/minute)

Use caution managing bradycardias and tachycardias in the initial minutes post resuscitation. Manage with fluid and oxygen first and allow to stabilize before stressing injured heart.

1. Assess appropriateness for clinical condition. Heart rate typically <50 bpm if bradydysrhythmia. 2. Identify and treat underlying cause. Maintain patient airway; assist breathing as necessary. Give oxygen if hypoxemic. Cardiac monitor to identify rhythm; monitor blood pressure and oximetry. Establish IV access and attach 12-lead ECG if available; don't delay therapy for this. 3. - If persistent bradydysrhythmia is NOT causing hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort or acute heart failure, monitor and observe. - If persistent bradydysrhythmia is causing those symptoms, give atropine. If atropine ineffective, transcutaneous pacing OR dopamine infusion OR epinephrine infusion. Then consider expert consultation and/or transvenous pacing. Ask yourself: is the rhythm causing the problem (treat rhythm) or is the problem causing the rhythm (treat problem).

First dose: 0.5 mg bolus Repeat every 3-5 minutes, with maximum of 3 mg. Does not work for second or third degree heart block. Atropine can lead to tachycardia, v-fib and decreased vagal response.

Dopamine IV infusions: 2-10 micrograms/kg/minute Epinephrine IV infusions: 2-10 micrograms/minute

1. Assess appropriateness for clinical condition. Heart rate typically > 150 bpm if tachydysrhythmia. Identify and treat underlying cause. Maintain patient airway; assist breathing as necessary. Oxygen if hypoxemic. Cardiac monitor to identify rhythm; monitor blood pressure and oximetry. IV access (if time and condition permit). 2. - If persistent tachydysrhythmia causing hypotension, acutely altered mental status, signs of shock, ischemic chest discomfort and/or acute heart failure, synchronized cardioversion. If regular, narrow complex, consider adenosine. - If persistent tachydysrhythmia without symptoms and no wide QRS complex, IV access and 12-lead ECG if available, vagal maneuvers, adenosine (if regular), beta blocker or calcium channel blocker and consider expert consultation. - If persistent tachydysrhthmia without symptoms and wide QRS complex, IV access and 12-lead ECG if available, consider adenosine only if regular and monomorphic, consider antidysrhythmic infusion, consider expert consultation.

50-100 J

120-200 J biphasic or 200 J monophasic (ex. atrial fibrillation)

100 J

Defibrillation dose, not synchronized

First dose: 6 mg rapid IV push followed by normal saline flush Second dose: 12 mg if required

Procainamide IV dose: 20-50 mg/min until dysrhythmia suppressed, hypotension ensues, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion of 1-4 mg/min (avoid if prolonged QT or CHF) Amiodarone IV dose: First dose - 150 mg over 10 minutes. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for first 6 hours. Sotalol IV dose: 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

Pulse ox, suction device, IV line, intubation equipment. Also, premedicate whenever possible. Versed it sedative of choice.

Lidocaine, 1-1.5 mg/kg IV, repeated in 5-10 minutes at 0.5-0.75 mg/kg to a maximum of 3.0 mg/kg. A single repeat dose of 1.5 mg/kg is acceptable in VF. A maintenance drip of 2-4 mg/min should be established on rhythm conversion. Magnesium, 1-2 g IV, diluted to 10 ml. Procainamide, 20 mg/min IV infusion (50 mg/min acceptable). Maximum dose of 17 mg/kg. 100 mg IV push doses, given every 5 minutes are acceptable in VF. Sodium Bicarb, 1 mEq/kg IV repeated at half doses every 10 minutes, especially if known preexisting hyperkalemia, diabetic ketoacidosis or overdose.

Atropine, 1 mg IV. Repeat every 3-5 minutes, to a maximum dose of 0.03 to 0.04 mg/kg. Sodium Bicarb, 1 mEq/kg IV repeated at half doses every 10 minutes, especially if known preexisting hyperkalemia, diabetic ketoacidosis or overdose.

Isoproterenol, 2-10 microgram/min infusion. Use only when ALL other therapies have failed, when external pacemaker is not available.

Magnesium (for Torsades), 1-2 g IV, diluted to 100 ml and given over 5-60 minutes. Follow with 0.5-1 g/hr drip. Isoproterenol (for Torsades), 2-10 micrograms/min infusion. Titrate to increase heart rate until V tach is suppressed. Lidocaine, 0.5-0.75 mg/kg IV. Repeated in 5-10 minutes at 0.5-0.75 mg/kg to a maximum of 3.0 mg/kg. A single repeat dose of 1.5 mg/kg is acceptable in VF. A maintenance drip of 2-4 mg/min should be established on rhythm conversion. Verapamil, 2.5-5 mg IV. Give over 2 minutes. May repeat in 15-30 minutes at 5-10 mg to a max dose of 20 mg. Contraindicated in patients with Wolff-Parkinson-White syndrome.