1.

ACLS PATIENT ALGORITHMS

Greg Cooks version of a Phoenix Fire Dpt clasic

Ventricular Fibrillation & Pulseless Ventricular Tachycardia ABCD's Perform CPR until defibrillator available VF/VT present on defibrillator Defibrillate up to 3 times if needed @ 200J, 200-300J, 360J (Monophasic) 150 J, 150J, 150J (Biphasic) Persistent or recurrent VF/VT CPR if no pulse Intubate at once Establish IV access Epinephrine 1:10,000 1.0 mg q 3-5 min IVP or Vasopressin 40 U IVP (1 time single dose then return to epi) Defibrillate with up to 360 joules (150J Biphasic) within 30 - 60 seconds after each dose of medication Consider Antiarrhythmics Amiodarone 300mg IVP (2nd dose 150mg ) Lidocaine 1-1.5 mg/kg IVP q 3-5 min to a total dose of 3 mg/kg (Consider Mag Sulfate 1-2g IV) (Consider Procainamide 30mg/min) (Consider Bicarb 1 mEq/kg) Defibrillate 360 joules within 30 - 60 seconds after each dose of medication

Asystole

Pulseless Electrical Activity (PEA)

ABC's Initiate CPR Intubate at once Establish IV access Confirm asystole in 2 leads Consider possible causes hypoxia, hyperkalemia, hypokalemia, preexisting acidosis, OD, hypothermia Consider immediate transcutaneous external pacing (TEP) Epinephrine 1:10,000 1.0 mg q 3-5 min IVP Atropine 1 mg IVP. Repeat q 3-5 min up to a total dose of 0.04mg/kg (3 mg) Consider termination of efforts

PEA Includes: EMD, pseudo-EMD, ideoventricular rhythms, ventricular escape rhythms, bradysystolic rhythms ___________________________________ ABC's Initiate CPR Intubate at once Establish IV access Consider possible causes hypovolemia, hypoxia, cardiac tamponade, tension pneumothorax, hypothermia, pulmonary embolism, drug overdose, hyperkalemia, acidosis, MI Epinephrine 1:10,000 1.0 mg q 3-5 min IVP If absolute bradycardia, (< 60 bpm) or relative bradycardia, give atropine 1 mg IVP and repeat every 3-5 min to a max total dose of 0.04 mg/kg (3 mg)

2.
Sustained Ventricular Tachycardia with a Pulse (Monomorphic) Stable: (no S/S Preserved Heart Function)
Assess ABC's, secure airway High -flow oxygen Establish IV access Attach to monitor and assess vital signs

ACLS PATIENT ALGORITHMS

Wide-complex Tachycardia of Uncertain Type (Polymorphic) Stable: (Normal Baseline QT Interval)
Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

Bradycardia (HR < 60 beats / min Stable: (no S/S)

Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

Procainamide 20 mg/min, max. total 17 mg/kg Sotalol 1-1.5mg/kg (give at 10mg/min) Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs) Lidocaine 1 - 1.5 mg/kg IVP. Rebolus @ 0.5 - 0.75 mg/kg IVP every 5 - 10 min until VT resolves, or until a total dose of 3 mg/kg is given Synchronized cardioversion 100 J, 200 J, 300J, 360 J Unstable: (Poor Ejection Fraction) Pulse present High - flow oxygen IV access Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs) Lidocaine 0.5 - 0.75 mg/kg IVP every 5 - 10 min until VT resolves, or until a total dose of 3 mg/kg is given Consider sedation Synchronized cardioversion 100 J, 200 J, 300 J, 360 J

Beta Blocker or Lidocaine 1 - 1.5 mg/kg q 5 - 10 min, may rebolus @ 0.5 - 0.75 mg/kg IVP to a total dose of 3 mg/kg. Amiodorone 150 mg over 10 min (follow with infusion of 1mg/min X 6 hrs) Procainamide 20 - 30 mg/min, max. total 17 mg/kg Sotalol 1-1.5mg/kg (give at 10mg/min) Synchronized cardioversion 100 J, 200 J, 300 J, 360 J Stable: (Long Baseline QT Intervanl, ie. Torsades) Correct Electrolytes Consider: Mag Sulfate 1-2g IV, Overdrive Pacing, Isoproterenol, Phenytoin, Lidocaine Unstable:

Observe and transport. If patient presents with Type II 2nd degree or third degree AV block, be ready to use transcutaneous external pacing (TEP) Unstable: (S/S present) Atropine 0.5 - 1.0 mg IVP, may repeat every 3 - 5 minutes up to a total of 2 mg (may use up to 3 mg total in severe cases) Transcutaneous external pacing (TEP) Dopamine 5 - 20 g/kg/min Epinephrine infusion 2 - 10 g/min May consider isoproterenol 2-10 g/min Prepare for Transvenous Pacing

If patient is unstable now or becomes hemodynamically unstable Perform synchronized cardioversion @ 100 J, 200 J, 300 J, and 360 J

3.
Supraventricular Tachycardia Stable: Do not shock Junctional/multifocal
Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs Vagal maneuvers Adenosine 6 mg, rapid IVP over 1 - 3 sec. If no response, may give a bolus of 12 mg, rapid IVP over 1 - 3 sec. May repeat 12 mg bolus in 1 - 2 minutes. Consider complex width: Narrow Complex Normal or elevated BP Varapamil 2.5 - 5 mg IVP Verapamil 5 - 10 mg IVP (in 15 - 30 minutes) Consider Digoxin, -blockers, Diltiazem,

ACLS PATIENT ALGORITHMS

Atrial Fibrillation and Atrial Flutter Stable:
Assess ABC's, secure airway High -flow oxygen Obtain IV access Attach to monitor and assess vital signs

Adult Emergency Cardiac Care

Assess Responsiveness
Activate EMS Call for defibrillator and assess breathing. If no breathing present, give 2 slow breaths and assess circulation If no pulse, begin CPR until defibrillator is available, If a pulse is present, begin sequence of ABC's, high-flow 02, and consider other appropriate treatment algorithms specific to the patient. (i.e., tachycardia, bradycardia, MI, shock / hypotension / pulmonary edema) If pulseless and in VF/VT on monitor, go to VF/VT algorithm If pulseless with electrical activity, go to PEA algorithm. If no electrical activity, go to asystole algorithm.

Consider use of following: Diltiazem, -blockers, verapamil, digoxin, procainamide, quinadine, anticoagulants Unstable:
Prepare for synchronized cardioversion (consider sedation)

synchronized cardioversion @ 100 J, 200 J, 300 J, 360 J In cases of atrial flutter, the energy required for synchronized cardioversion begins with 50 J.

Ameodorone
synchronized cardioversion (unless it's Junctinal) Narrow Complex low or unstable BP synchronized cardioversion Wide complexLidocaine 1 - 1.5 mg/kg IVP Procainamide 20 -30 mg/min, maximum total 17 mg/kg Synchronized cardioversion Unstable: (heart rate > 150) Prepare for synchronized cardioversion (consider sedation) Synchronized Cardioversion at 50 J, 100 J, 200 J, 300 J, and 360 J

4.

ACLS PATIENT ALGORITHMS

Shock, Hypotension and Pulmonary Edema
Assess ABC's, secure airway, high -flow oxygen, obtain IV access Attach to monitor and assess vital signs Define nature of the problem

Acute Myocardial Infarction

Community emphasis on "Call First, Call Fast, Call 911 EMS System Oxygen, IV, cardiac monitor, vital signs Nitroglycerine Pain relief with narcotics Notification of emergency center Rapid transportation and pre hospital screening for thrombolytic therapy Initiation of thrombolytic therapy Emergency Center "Door to Drug" team protocol approach with rapid triage of patients with chest pain and clinical decision maker established (emergency physician, cardiologist, ect.) Thrombolytic therapy to be initiated within 30 - 60 minutes Immediate Assessment: Treatment to consider if -vital signs evidence of coronary -02 saturation thrombosis: -start IV -high flow 02 -12 lead ECG -nitroglycerine (SL, paste or -brief history / physical spray if SBP >90) -decide if eligible for thrombolytics -IV morphine Soon as possible -PO aspirin -chest X-ray -thrombolytics -blood studies -IV nitroglycerine -consult - -blockers -IV heparin -PTCA -routine lidocaine is not recommended for all MIs

Rate:

Go to the tachycardia or bradycardia algorithm

Volume: Administer fluids, cause-specific interventions, consider vasopressors Pump: What is the blood pressure SBP<70 1) 250 - 500 cc fluid challenge 2) Norepinephrine (0.5-30 g/min) 3) Dopamine (5.0-20 g/kg/min) DBP>110 Nitroglycerine (10-20 g/min) 2) Nitroprusside (0.1-5.0 g/kg/min) _________________________________________________________________ _ Consider other actions (especially for patients in pulmonary edema) First Line: Second Line: Third Line: Lasix IV 0.5 - 1.0 mg/kg Morphine IV 1-3 mg Nitroglycerine SL 0 2 / Intubate PRN Ntg IV (if SBP>100) Nipride IV (if SBP>100) Dopamine IV (if SBP <100) Dobutamine IV (if SBP>100) Amrinone 0.75 mg/kg then 5-15 g/kg/min Consider Aminophylline, Thrombolytics, & Digoxin SBP 70 - 100 1) Dopamine (2.5-20 g/kg/min) DBP>100 1) Dobutamine (2-20 g/kg/min)

2) Add Norepi if: 2) Nitroprusside dopamine > 20 g/kg/min (0.1-5.0 g/kg/min)