Documente Academic
Documente Profesional
Documente Cultură
AMERICAN
ASSOCIATION
OJ CRITICAL-CARE
NURSES
American
.r
Heart
Association..
ACLS
Cardia c Arrest,
A rrhythmias, and
T heir Treatment
2 minutes
CPR Quality
Push hard (;;,2 inches [5 em]) and
fast (;;,100/min) and allow complete
chest recoil
Minimize interruptions in
compressions
Avoid excessive ventilation
Rotate compressor every
2 minutes
If no advanced airway, 30:2
compression-ventilation ratio
Quantitative waveform
capnography
- If PETC02 <10 mm Hg, attempt
to improve CPR quality
Intra-arterial pressure
- If relaxation phase (diastolic)
pressure <20 mm Hg, attempt
to improve CPR quality
Return of Spontaneous
Circulation (ROSC)
Pulse and blood pressure
Abrupt sustained increase
in PETC0 2 (typically ;;,40 mm Hg)
Spontaneous arterial pressure
waves with intra-arterial
monitoring
Drug Therapy
IV/10 access
Epinephrine every 3-5 minutes
A miodarone for refractory VFNT
Shock Energy
Biphasic: Manufacturer
recommendation (eg, initial
dose of 120-200 J); if unknown ,
use maximum avai lable.
Second and subsequent doses
should be eqUiva en_, and higher
doses may be considered .
Monopl!_asic: 3.9 J
Drug Therapy
Epinephrine IV/10 Dose:
1 mg every 3-5 minutes
Vasopressin IV/10 Dose:
40 units can replace first or
second dose of epinephrine
Rhythm shockable?
No
No
11
C PR 2 min
Treat reversible causes
12 r-_________ L_ _ _ _ _ __
If no signs of return of
spontaneous circulation
90-1012 (1 of 2)
5/11
(ROSC), go to 10 or 11
If ROSC , go t o
Post-Cardiac Arrest Care
Go to 5 or 7
Doses/Details
Ventilation/ Oxygenation
Avoid excessive ventilation .
Start at 10-12 breaths/min
and titrate to target PETC02
of 35-40 mm Hg.
When feasible, titrate F102
to minimum necessary to
achieve Spe, ~94%.
Treat hypotension
(SBP <90 mm Hg)
IV/10 bolus
Vasopressor infusion
Consider treatable
causes
12-Lead EGG
IV Bolus
1-2 L normal saline
or lactated Ringer's.
If inducing hypothermia,
may use 4c fluid .
Epinephrine IV Infusion:
0.1-0.5 meg/kg per minute
(in 70-kg adult: 7-35 meg
per minute)
Norepinephrine
IV Infusion:
0.1-0.5 meg/kg per minute
On 70-kg adult: 7-35 meg
per minute)
STEM I
OR
high suspicion
of AMI
No
Reversible Causes
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
Persistent
tachyarrhythmia
causing:
Persistent bradyarrhythmia
causing:
Monitor
and
observe
Hypotension?
Acutely altered
mental status?
Signs of shock?
Ischemic chest
discomfort?
Acute heart
failure?
Hypotension?
Acutely altered mental status?
Signs of shock?
Ischemic chest discomfort?
Acute heart failure?
Yes
;---+
Synchronized
cardioversion
Consider sedation
If regular narrow
complex, consider
adenosine
No
Dopamine IV Infusion:
5-1 0 meg/kg per minute
Doses/Details
Atropine
If atropine ineffective:
Transcutaneous pacing
OR
Dopamine infusion
OR
Epinephrine infusion
Consider:
Expert consultation
Transvenous pacing
Atropine IV Dose:
First dose:
0.5 mg bolus
Repeat every
3-5 minutes
Maximum: 3 mg
Dopamine
IV Infusion:
2-1 0 meg/kg per
minute
Epinephrine
IV Infusion:
2-1 0 m9 pe
mm te
WideQRS?
:?:0.12 second
)
J
Yes
No
IV access and
12-lead EGG
if available
Consider
adenosine only
if regular and
monomorphic
Consider
antiarrhythmic
infusion
Consider expert
consultation
Doses/Details
Synchronized
Cardioversion
Initial recommended doses:
Narrow regular: 50-1 00 J
Narrow irregular:
120-200 J biphasic or
200 J monophasic
Wide regular: 100 J
Wide irregular:
defibrillation dose
(NOT synchronized)
Adenosine IV Dose:
First dose: 6 mg rapid IV push;
follow with NS flush.
Second dose: 12 mg
if required.
Antiarrhythmic Infusions
for Stable Wide-QRS
Tachycardia
Procainamide IV Dose:
20-50 mg/min until
arrhythmia suppressed,
hypotension ensues, ORS
duration increases >50%, or
maximum dose 17 mglkg
given. Maintenance infusion:
1-4 mg/min. Avoid ~ prolonged
QTorCHF.
Amiodarone IV Dose:
First dose: 150 mg over
10 minutes. Repeat as
needed if VT recurs. Follow
by maintenance infusion of
1 mg/min tor first 6 hours.
Sotalol IV Dose:
100 mg (1.5 mglkg)
over 5 minutes. Avoid if
prolonged QT.
A m erican
Heart
Asso ciat ion.
AMERICAN
..r
ASSOCIATION
~ CRmCAL-CARE
NURSES
ACLS
Acute Coronary
Syndromes and Stroke
ST elevation or new or
presumably new LBBB;
strongly suspicious
for injury
ST-elevation Ml (STEMI)
Normal or
nondiagnostic changes
in ST segment
orTwave
low-/intermediate-nsk
ACS
ST depression or dynamic
T-wave inversion; strongly
suspicious for ischemia
H1gh-risk unstable ang1na/
non-ST-elevation Ml
(UAINSTEMI)
Start adjunctive
therapies as 1nd1cated
Do not delay
reperfusion
ECG interpretation
90-1012 (2 of 2)
ISBN 978-1-61669-013-7
5/11
Time from
onset of
symptoms
S12 hours?
>1 2
hours
Troponin elevated or
high-risk patient
Cons1der early 1nvas1ve
strategy if:
Refractory ischemic
chest dtscomfort
RecurrenVpersistent
ST deviation
Ventricular
tachycardia
Hemodynamic
Instability
Signs of heart failure
Consider admission
to ED chest pain unit
or to appropriate bed
and follow:
Serial cardiac markers
(including tropon1n)
Repeat EGG/continuous
ST-segment monitoring
Cons1der noninvasive
diagnostic test
S12 hours
Start adjunctive
treatments as indicated
Nitroglycenn
Heparin (UFH or LMWH)
Cons1der: PO 13-blockers
Consider: Clopidogrel
Cons1der: Glycoprotetn
lib/lila inhibitor
Reperfusion goals:
Therapy defined by
patient and center
cnteria
Door-to-balloon
inflation (PCI) goal
of 90 minutes
Door-to-needle
(fibrinolysis) goal
of 30 minutes
....___
Yes
Develops 1 or more:
Clinical high-risk
features
Dynamic ECG
changes
consistent with
ischemia
Troponin elevated
No
Abnormal
Admit to monitored bed
Assess risk status
Continue ASA, heparin,
and other therapies as
indicated
ACE inhibitor/ARB
HMG CoA reductase
inhibitor (stalin therapy)
Not at high risk:
cardiology to nsk strat1fy
Yes
diagnostic
noninvasive
imaging or
physiologic
testing?
No
If no evidence
of ischemia or
infarction by
testing, can
discharge with
follow-up
Step 1
Absolute Contraindication&
) YES
) YES
) YES
) NO
) NO
) NO
) YES
) YES
) NO
) NO
)
)
)
)
)
)
"J
:>
YES
YES
YES
YES
) YES
NO
NO
NO
NO
) NO
Relative Contraindication&
.) YES
) YES
) YES
J vest
) YES
Pregnancy
)
.)
)
)
)
NO
NO
NO
NO
NO
'Contra1ndications for fibrinolytiC use 1n STEM I cons1stent w1th "ThrombolytiC Therapy and Balloon
Angioplasty 1n Acute ST Elevation Myocard1allnfarction (STEMI)" at Agency for Healthcare Research
and Quality National Gu1dehne Clearinghouse (www.Guidel1nes.gov).
tCons1der transport to pnmary PCI fac1hty as destination hosprtal.
I Stroke Assessment
NINDS
TIME
GOALS
ED
Arrival
10
mm
ED
Abnormal-one side of
face does not move
as well as the other side
t
Immediate neurologic assessment by stroke team or designee
Review patient history
Establish time of symptom onset or last known normal
Perform neurologic examination (NIH Stroke Scale or
Canadian Neurological Scale)
25 mm
ED
Arrival
(Does CT
t
8CM1 show
t
Probable acute ischemic stroke;
c onsider fibrinolytic therapy
Arm Drift (patient closes eyes and extends both arms straight out,
with palms up, for 10 seconds):
r-------------~
hemontlage?}
No HemorTh1111e
t
(
Candidate
Stroke
Admission
3 hours
G1ve rtPA
No anticoagulants or anllpiatelet
treatment for 24 hours
t
Beg1n post-rtPA stroke pathway
Aggressively mon1tor.
- BP per protocol
- For neurologiC detenoration
Emergent admission to stroke un1t
or Intensive care un1t
HemorTh1111e
t
Consult neurolog1st or neurosurgeon:
conSider transfer if not available
ED
Arrival
60 min
Not a
Candidate
: Administer aspirin
Beg1n stroke or
hemorTtlage pathway
Admit to stroke un1t or
lntens1ve care un1t
Abnormal Speech (have the patient say "you can't teach an old dog
new tricks"):
e
Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms 3 to 4.5 hours before beginning treatment
Exclusion Criteria
Age >80 years
Severe stroke (NIHSS >25)
Taking an oral anticoagulant regardless of INA
History of both diabetes and prior ischemic stroke
Notes
The checklist includes some US FDA-approved indications and contraindications for administratiOO
A reasonable target is to lower blood pressure by 15% to 25% within the first day.
of rtPA for acute ischemic stroke. Recent AHNASA guideline revisions may differ slightly from
FDA criteria. A physician with expertise in acute stroke care may modify this list.
Onset t ime is either witnessed or last known normal.
In patients without recent use of oral anticoagulants or heparin, treatment with rtPA can be
initiated before availability of coagulation study results but should be discontinued if INA 1s
> 1.7 or PT is elevated by local laboratory standards.
In patients without history of thrombocytopenia, treatment with rtPA can be init iated before
availability of platelet count but should be discontinued if platelet count is <100 000/mm.
Abbreviations: aPTT, activated partial thromboplastin time; FDA, Food and Drug Administration;
INA, international normalized ratio; NIHSS, Nat1onal Institutes of Health Stroke Scale; PT,
prothrombin time; rtPA, recombinant tissue plasminogen activator.
Consider lowering blood pressure in patients with acute ischemic stroke if systolic
blood pressure >220 mm Hg or diastolic blood pressure > 120 mm Hg.
'Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Fur1an A, Grubb RL, H1gashlda AT, Jauch EC,
Kidwell C, Lyden PO, Morgenstern LB, Qureshi AI, Rosenwasser RH. Scott PA, W1J(i1Cks EFM. Gu1delines
for the ear1y management of adults w1th ischermc stroke: a guldel1ne from the Amencan Heart Association/
Amencan Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and
Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in
Research Interdisciplinary Working Groups. Stroke. 2007;38:1655-1711 .
tdel Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr; on behalf of the AmeriCan Heart Association Stroke
Council. Expansion of the t1me w1rldow for treatment of acute 1schemic stroke w1th Intravenous t1ssue
plasm~nogen actiVator: a science advisory from the Amencan Heart Associat10n/Amencan Stroke Associat1011
Sttoke. 2009;40:2945-2948.