ACLS Study Guide 2010 Copy

Emergency Medical Training Services is an approved training center to provide American Heart Association emergency cardiac care courses. T raining Division of EMTS

Main Training Center100 N. Central Suite L-15Richardson, TX 75080EMTS(972) 527-3687 www.emts911.comCPR Training and More...(214) 324-1119 www.cprtrainingandmore.com

ACLSAdvanced Cardiac Life Support2010 GuidelinesBring this study packet to class.May not copy this packet without permission.Packet is for classroom application only.

To help participants better prepare for the program theAHA offers an online pre-exam/self assessment. Theself assessment covers basic ACLS knowledge to beobtained upon successful completion of the program.The web page and login code can befound on the inside cover of the AHAcourse textbook and/or the confirmatione-mail participants receive oncesuccessfully registered.Contact our office if you have any questions.

Table of Content GENERAL TOPICS 2 Advanced Airway Management2 Airway Care Prior to Advanced AirwayPlacement2 Airway Placement Confirmation3 Automated External Defibrillator 1 Basic Airway Management3 Cardioversion9 Conveying News of Death to Family3 Defibrillation8 Electrical Shock & Lightning Strikes3 Emergency Pharmacology2 Endotracheal Tube Intubation2 Esophageal-Tracheal Combitube1 Evaluating Airway Delivery & Tools7 Hypoperfusion/Shock7 Hypothermia2 Laryngeal Mask Airway3 Monophasic vs. Biphasic1 Mouth-to-Mask & Bag-Valve-Mask9 Miscellaneous ACLS Information1 Nasopharyngeal Airway7 Near-Drowning1 Opening the Airway1 Oropharyngeal Airway3 Pacing (TCP)2 Pharyngotracheal Lumen Airway3 Precordial Thump8 Pregnancy & Cardiac Arrest2 Sellicks (Criocoid Pressure) Maneuver7 Special Resuscitation Situations8 Stroke2 Suction1 Tidal Volume & Inspiratory Times8 Traumatic Cardiac Arrest3 Vascular Access10 12-Lead EKG (Basics Only) PHARMACOLOGY 4 ADENOSINE5 AMIODARONE4 ATROPINE SULFATE5 BETA-BLOCKERS5 CALCIUM CHANNEL BLOCKER5 CALCIUM CHLORIDE5 CARDIZEM (Calcium Channel Blocker)5 DILTIAZEM (Calcium Channel Blocker)5 DISOPYRAMIDE6 DOBUTAMINE6 DOPAMINE4 EPINEPHRINE5 ESMOLOL (Beta-Blocker)6 FUROSEMIDE5 LIDOCAINE

6 MAGNESIUM SULFATE5 METOPROLOL (Beta-Blocker)6 MORPHINE SULFATE6 NITROGLYCERIN6 NOREPINEPHRINE4 OXYGEN5 PROCAINAMIDE5 PROPRANOLOL (Beta-Blocker)6 SODIUM BICARBONATE6 THROMBOLYTIC AGENTS4 VASOPRESSIN5 VERAPAMIL (Calcium Channel Blocker) ALGORITHMS11 V-Fib & Pulseless V-Tach12 Asystole13 Pulseless Electrical Activity14 Bradycardia15 Narrow Complex Tachycardia16 V-Tach: Monomorphic & Polymorphic17 Pulmonary Edema, Hypotension, & ShockIt is recommended that participantspurchase the Handbook of EmergencyCardiovascular Care for HealthcareProviders. This pocket reference hasmore specific information than what isprovided in this study packet. It also listsall the algorithms in greater detail. Thebook can be ordered by calling EMTS orCPR Training and More...The information, instructions and algorithms withinthis packet are educational tools only to build alearning foundation to aid in successful completion ofthe course and should not be considered to be thestandard of care for patient use. Algorithms in thispacket are to assist learners to complete this courseonly. Healthcare professionals must follow theirfacilities/employers specific policies/procedures andalgorithms. Patients may need care not included withinthis packet and when clinically appropriate, alterationsin care giving is acceptable. This packet is intended asa study packet and/or review learning tool only. Thispacket does not replace the need for the AmericanHeart Association's "Textbook of Advanced CardiacLife Support". By contacting our office we can makethe book available to participants for a fee. Any feescharged do not represent income to the AmericanHeart Association. References: EMTS staff (generalknowledge), Mosby-Nursing Assessment, Para EmerCare Pharmacology)-Brady.

ACLS Survey - Airway ManagementOpening the AirwayBasic airway management begins with opening andmaintaining the airway. The main goal is to preventthe tongue from blocking the airway. For a non-trauma patient a head-tilt chin-lift method ispreferred. For a trauma patient the jaw-thrust withspinal neutralization method is used.

Head-tilt, Chin-Lift Jaw ThrustEvaluating the AirwayEvaluating the airway is always a top priority. Normalrespirations should be quiet, effortless, and with equalchest rise. Ventilatory assistance is required if thepatient is breathing less than 8 times per minute. A non-breathing patient should receive two slow andsmooth breaths lasting 1 second in length to evaluatethe airway passage for a blockage.Basic Airway Delivery Tools and CareOropharyngeal Airway (OPA)An oropharyngeal (OPA) airway is used to helpestablish a patients airway when a gag reflex is notpresent. OPAs come in many sizes. To ensure propersize the rescuer should measure by placing one end ofthe device on the corner of the mouth and the otherend to the earlobe. To insert the OPA, hold the deviceat its flange end and insert it into the mouth with thetip pointing toward the roof of the patients mouth. Once the distal end of the OPAreaches the posterior wall of thepharynx, rotate the OPA 180degrees so that it is positionedover the tongue. The flangeshould rest on the lips whenproperly inserted. Use of the OPAdoes not eliminate the need formaintaining proper head position.Nasopharyngeal Airway (NPA)The NPA is used when the oral pharynx is notaccessible or the patient has a gag reflex. The device iscontraindicated in patients with facial fractures andused with caution if skull fractures are present. Toensure proper size the rescuer should measure fromthe corner of the nose to the earlobe. Lubricate thedevice prior to placement with a water based substance. When inserting the NPA in an emergency one should pick the largest and straightest nostril.

Place the bevel of the NPA to thenasal septum. Hold the device likeyou would a pencil and slowly insertthe NPA into the patients nostriluntil the flange is flush with thenostril. Do not force the device. Useof the NPA does not eliminate theneed for maintaining proper head position.Mouth-to-Mask and Bag-Valve-MaskMouth-to-mask breathing is the preferred method ofventilating a nonbreathing patient. It is a simple oneperson device, and because of thetwo-handed mask seal it providesexcellent ventilatory volumes. Thedevice when not connected tosupplemental oxygen will deliver16% oxygen to the patient. Whenattached to >10 LPM ofsupplemental oxygen the devicedelivers approximately 50%oxygen. The bag-valve-mask (BVM) consists of a one-wayvalve, self-inflating bag, oxygen reservoir, and atransparent mask. The device delivers 21% oxygenconcentration with room air and once connected tohigh flow supplemental oxygen it can deliver up to 80to 100% oxygen concentration. The BVM techniquecommonly creates a poor seal around the patientsmouth and is designed for two trained rescuers to use. The BVM typically delivers less volume than mouth-to-mask technique. When using aBVM during a cardiac arrestthe rescuer needs to be awareof the pop-off valve statusbecause greater ventilatorypressure is usually required. This device is most effectivewhen the patient is intubatedand the BVM is attached to anendotracheal tube (ETT) because the trachea is thenisolated. Tidal Volumes and Inspiratory TimesIf supplemental oxygen is not available, tidal volumesand inspiratory times should be approximately 8-10mL/kg (800mL) and delivered over 1 second whichis sufficient to make the chest rise. At room air deliver1 breath every 5 to 6 seconds. With supplemental O2and advanced airway in place deliver 1 breath every 6to 8 seconds. ETCO2 (Capnography) goals in an arrest patient is >10 torr. In a perfusing patient in respiratory arresttitrate to 35 to 40 torr. SpO2 goal is >94%. Emergency Medical Training Services Page 1

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Sellicks Maneuver (Cricoid Pressure)Sellicks maneuver reduces gastric inflation duringventilatory efforts. By placing downward pressureon the cricoid cartilage the diameter of thee s o p h a g u s i sdecreased thereforerestricting the flow ofair into the stomach.The routine use ofcricoid pressure incardiac arrest is notrecommended. SuctionIf a patients airway is compromised by fluids, turnthe victims head to one side and remove largeparticles. Once suction is available the remainingfluids and fine particles should be removed. Fororal suctioning the pressure should be set atapproximately 300mmHg and suction limited to 15seconds. For tracheal suctioning the pressureshould be around 80 to 120mmHg and suction timelimited to 5 seconds. Only suction on the way outand always measure for proper advancement depthof the suction catheters. Advanced Airway ManagementEsophageal-Tracheal Combitube (ETC)The ETC allows ventilation of the lungs and reducesthe risk of aspiration of gastric contents. The deviceis blindly inserted to ventilate the trachea,regardless of esophageal or tracheal placement. Ifthe tube is placed in the trachea the distal cuff isinflated with up to 15mL of air. If the ETC wasplaced in the esophagus inflate the proximal cuffwith up to 100mL of air toseal the pharynx and inflatethe distal cuff with up to15mL of air to seal theesophagus. Air will then bedirected to the trachea.Contraindications: gag reflexpresent, suspected esophagealdisease, ingestion of causticsubstance and patients less than 4 feet tall.Pharyngotracheal Lumen Airway (PTL)A duel-lumen tube that allows either tracheal oresophageal placement. The PTL is blindly insertedjust like the ETC. Consists of two parallel tubes ofequal length and two balloon cuffs that inflatesimultaneously when air isblown into the inflation portwith a bag-valve device. Wheninflated one cuff closes theoropharynx and the other cuffsecures the esophagus ortrachea depending on distal

placement. Contraindications: gag reflex present, patientsless than 5 feet tall, patients less than 14 years old,suspected esophageal disease, and ingestion of causticsubstance. Laryngeal Mask Airway (LMA)The LMA may be used as an alternative to either theendotracheal tube (ETT) or the face mask with eitherspontaneous or positive-pressure ventilation. The LMAmay be used as the primary airway, as a channel for anETT, or as an option in the management of a difficultairway when intubation is unsuccessful. The deviceconsists of a tube that is fused to a elliptical, spoon-shapedmask at a 30-degree angle. When inserted, the tubeprotrudes from the patients mouth and is connected to aventilation device. The mask isadvanced until resistance is felt. Then the mask is inflated, itprovides a low-pressure sealaround the laryngeal inlet. When the LMA is properlyplaced, the black line on thetube should rest in the midlineagainst the patients upper lip.The LMA is contraindicated if arisk of aspiration exists.Endotracheal Tube (ETT) IntubationETT intubation is the airway of choice for all criticalpatients who cannot protect their own airway. Tubeadvancement is directly into the trachea and a cuff isinflated with up to 10mL of air to secure the trachea. Advantages to ETT intubation are isolation of the trachea,reduction in the risk of aspiration, eliminates the need tomaintain a mask seal, direct route for tracheal suction andcertain medications can be administered via the ETT. Disadvantages are that it takes more skill than otherairway devices, ETT can be dislodged easily, and takesmore equipment than other methods to secure an airway.It is also recommended to use a commercial grade tube tiedevice to secure the ETT. Most reliable assessment tool formonitoring correct placement is capnography.Prior to Advanced Airway PlacementNon-cardiac arrest patients should be hyperventilated andwell oxygenated for 1 to 2 minutes before placement of anadvanced airway device. The attempt to establish theairway device should take no longer than 30 seconds tocomplete. If the device cannot be established within 30seconds the patient should be hyperventilated again for 1to 2 minutes before the next attempt.Airway Placement ConfirmationWhenever airway assistance is being provided the rescuershould ensure proper ventilation of the patient two ways:with primary confirmation techniques and secondaryconfirmation techniques. Emergency Medical Training Services Page 2

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Primary confirmation techniques include 5-pointauscultation, bilateral chest expansion, and mask ortube condensation. In secondary confirmationtechniques, esophageal detector devices arepreferred for intubation confirmation in adultcardiac arrests; end-tidal CO2 detectors(capnography, capnometry, capnometer) arepreferred in non-cardiac arrest victims. Defibrillation, Cardioversion, and AEDDefibrillation and Precordial ThumpThe most common lethal arrhythmia in an adultcardiac arrest is ventricular fibrillation (V-fib). V-fib and pulseless ventricular tachycardia (V-tach)should be defibrillated immediately at 360J (orequivalent Biphasic defibrillation ((approx 120-200J)) followed by 2 minutes of immediate CPR. Transthoracic resistance to electrical currenttherapy is reduced with the use of a conductivemedium, increased paddle pressure (or use ofhands-free defibrillation pads), and successiveshocks. Precordial thumps are seldom effective and areusually reserved for witnessed cardiac arrests if adefibrillator is not readily available. Defibrillation and cardioversion on children is at amuch lower energy level and is determined byweight. CardioversionCardioversion, also known as synchronizedshocking, is indicated for lethal rhythms with apulse, such as, V-tach with a pulse andsupraventricular tachycardia (SVT). By usingsynchronized cardioversion on a patient, one isavoiding the R on T phenomenon that may result inV-fib. *A-fib first shock at 120 to 200J biphasic. *SVT first shock at 50 to 100J biphasic.*Monomorphic V-Tach at 100J biphasic.All monophasic energy starts at 200J. If additionalshocks are needed increase the dose in a stepwisefashion. The rescuer should also evaluate for a pulseafter each shock. AEDAutomated External Defibrillators (AED) are verypopular in both the healthcare and public settings. This device requires minimal training, is easy to use,and is very safe to the rescuer. The device is placedon a patient who is over 8 years of age once they aredetermined to be in cardiac arrest. Thedefibrillation pads are placed on the chest whichresults in the AED analyzing the patients cardiacrhythm. If V-fib or V-tach is present the machinewill defibrillate at 360J (or equivalent Biphasicdefibrillation) one time followed by 2 minutes of

immediate CPR. If the cardiac rhythm is not a shockablerhythm the machine will instruct the rescuer to perform 2minutes of CPR if no pulse is present. After 2 minute themachine will then re-analyze to see if shocks are nowindicated and so on.4 Alternative electrode placement positions:*Apex / sternum (most common)*Anterioposterior (sandwich the heart)*Left anterior / left infrascapular*Left anterior / right infrascapular Monphasic vs. Biphasic Energy Many studies are now suggesting that Biphasic delivery ofenergy requires a lower energy setting and fewer shocks toconvert. Energy is delivered in waveforms that flowbetween two electrodes or paddles. Monophasic means theenergy flows one direction. Biphasic energy is delivered intwo phases by passing through the heart and then backagain. At this time the American Heart Association (AHA)still acknowledges Monophasic energy in the algorithms. Until more data is collected the AHA does supportBiphasic use at this time, if available, at energy levels setby the manufactures. Pacing (TCP) Transcutaneous cardiac pacing (TCP) is the preferredinitial ACLS pacing method of choice as it can beestablished rapidly and is the least invasive techniques. Pacing is indicated for unstable patients with bradycardiasespecially for high degree heart blocks (Mobitz 2 and 3rddegree AV blocks). Override pacing to slow a cardiacrhythm is usually not recommended as an initial treatmentfor a tachyarrhythmia. The energy used to pace a patientis different than shocking a patient, therefore it is safe totouch a patient while pacing them. Vascular AccessThe largest and most accessible vein that does not interferewith resuscitation efforts is the best choice. Theantecubital vein is the preferred IV site in most cardiacarrests for initial IV placement. Complications includeextravasation, thrombosis and tissue trauma. An addedconcern with IV establishment is catheter shear. Under thecurrent guidelines intraosseous (IO) is now acceptable onany aged patient, if needed as a last resort. Emergency PharmacologyMany ACLS drugs are delivered asrecommended standard doses, but most shouldbe administered based on body weight whenpossible. Related to the goals of this course participants should focuson First Line Cardiac Drugs. Emergency Medical Training Services Page 3

The acronym LEAN is used to identify medicationsthat can be delivered via the ETT or other devicesthat allow isolation and direct access to the lungs.L - Lidocaine -last option not well absorbed via lungsA - AtropineE - Epinephrine -last option not well absorbed via lungsN - Narcan Drugs delivered via the ETT should be 2-2.5 timesthe IV amount and in a total solution of 8-10mL.When a drug is given down the ETT the maximumdose is also increased 2-2.5 times the IV maximumdose.Oxygen - First Line Cardiac DrugThe highest oxygen concentration should beadministered as soon as possible to all patients inrespiratory or cardiac arrest and patients suspectedof hypoxemia regardless of cause including COPD.The administration of enriched oxygen increases theoxygen concentration in the alveoli, whichsubsequently increases the oxygen saturation ofavailable hemoglobin. Indications: Hypoxia. Dose:Oxygen administration should be monitored by useof pulse oximetry. 100% oxygen for cardiac arrestand other critical patients and titrate to effect onothers, but when in doubt give high flow oxygen.Titrate SpO2 >94% and PETCO2 approx 40 torr.Epinephrine 1:10,000 - First Line Cardiac DrugEpinephrine is a naturally occurring catecholamine.It is a potent alpha and beta adrenergic stimulant,however its effect on beta receptors is moreprofound. Epinephrine can stimulate spontaneousfiring of myocardial conduction cells. In theemergency setting, it is used to convert fineventricular fibrillation to coarse ventricularfibrillation. In asystole, it is used to initiateelectrical activity in the myocardium. The effects ofepinephrine usually appear within 90 seconds ofadministration and they are usually of shortdurations. Therefore, it must be administered every3-5 minutes to maintain therapeutic levels. Theeffects of epinephrine include increased heart rate,increased cardiac contractile force, increasedelectrical activity in myocardium, increased bloodpressure, and increased automaticity. Indications:Cardiac arrest (asystole, ventricular fibrillation,pulseless ventricular tachycardia, pulselesselectrical activity). Dose: Epinephrine can beadministered IV, IO, and ETT. The American HeartAssociation recommends l mg doses every 3-5minutes. Vasopressin - First Line Cardiac DrugVasopressin is equivalent to epinephrine forpulseless arrest. The initial agent for refractory V-

Fib or pulseless V-Tach can be either epinephrine orvasopressin. As a vasoconstrictor, vasopressin appears aseffective as epinephrine, with fewer negative effects on theheart. Despite decades of use, the effectiveness ofepinephrine in human cardiac arrest has not been shownin prospective, randomized human clinical trials. Vasopressin lasts much longer (10 to 20 minutes);therefore, only 1 dose is recommended. 40 Units IV bolusgiven only once. By consensus, vasopressin can besubstituted for the first or second dose of epinephrine.Atropine Sulfate - First Line Cardiac DrugAtropine is a parasympatholytic that is derived from partsof the Atropa Belladonna plant. Atropine is a potentparasympatholytic and is used to increase the heart rate inhemodynamical ly s igni f icant bradycard ias .Hemodynamically significant bradycardias are those slowheart rates accompanied by hypotension, shortness ofbreath, chest pain, altered mental status, congestive heartfailure, and shock. Atropine acts by blocking acetylcholinereceptors thus inhibiting parasympathetic stimulation.Indications: Hemodynamically significant bradycardias.Dose: Atropine can be administered IV, IO and ETT. TheAmerican Heart Association recommends 0.5 mg dosesevery 3-5 minutes with a maximum dose of 3mg or0.04mg/kg. Precautions: Atropine may actually worsen thebradycardias associated with second-degree type II andthird degree AV blocks. In these cases, go straight totranscutaneous pacing when available instead of tryingatropine.Adenosine (Adenocard) - First Line Cardiac DrugAdenosine is a naturally occurring nucleoside that slowsAV conduction through the AV node. It has anexceptionally short half-life and a relatively good safetyprofile. Adenosine decreases conduction of the electricalimpulses thought the AV node and interrupts AV re-entrypathways in supraventricular arrhythmias such as PSVT.The half-life of adenosine is approximately 5 seconds. Dueto its short half-life the administration of adenosine issometimes referred to as "chemical cardioversion."Adenosine does not appear to cause hypotension to thesame degree as does verapamil (described below).Indications: SVT (including that associated with WolffParkinson-White syndrome) refractory to common vagalmaneuvers. Dose: The initial dose of adenosine is 6mggiven as a rapid IV bolus over a 1-2 second period with aflush. To be certain that the drug rapidly reaches thecentral circulation, it should be given directly into a vein orinto a proximal medication port of a functioning IV line. Ifthe initial dose does not result in conversion of the SVTwithin 1 to 2 minutes, a 12mg dose may be given.

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Calcium Channel BlockersCalcium channel blockers cause a relaxation ofvascular smooth muscle and slows conductionthrough the AV node. The advantages are twofold.First, it will inhibit arrhythmias caused by are-entry mechanism such as with PSVT. Second, itwill decrease the rapid ventricular response seenwith atrial tachyarrhythmias such as atrial flutterand fibrillation. This class of drug also reducesmyocardial oxygen demand because of its negativeinotropic effects and causes coronary andperipheral vasodilation. Indications: PSVTrefractory to adenosine. Precautions: Can causesystemic hypotension. Calcium chloride can be usedto prevent the hypotensive effects of calciumchannel blockers and in the management of calciumchannel blocker overdose. Calcium channel blockersshould not be administered to patients receiving IVbeta blockers because of an increase risk of CHF,bradycardia, and asystole. Dose: Verapamil isadministered IV and the initial dose is 2.5-5mgduring a 2-3 minute interval. A repeat dose of5-10mg can be given in 15-30 minutes if PSVTpersists. The total dose of verapamil should notexceed 30mg in 30 minutes. Diltiazem/cardizem .25mg/kg over 2 minutes. Disopyramide (Norpace)Inhibits sodium influx through fast sodium channelsin the cell membrane of the myocardium, decreasesmyocardial conduction velocity, excitability, andcontractibility. Indications: Patients with atrialfibrillation/atrial flutter and normal left ventricularfunction, and stable V-tach. Dose: 2mg/kg over 15minutes, then 1 to 2mg/kg by infusion over 45minutes. Beta-BlockersEsmolol 0.5mg/kg over 1 minute, metoprolol 5mg IVpush over 5 minutes, and propranolol maysignificantly reduce the occurrence of ventricularfibrillation in post MI patients. Precautions:Bradycardias, AV delays and hypotension.Calcium ChlorideCalcium chloride replaces calcium in cases ofhypocalcemia. Calcium chloride causes a significantincrease in the myocardium contractile force andappears to increase ventricular automaticity.Indications: Hyperkalemia, hypocalcemia, calciumchannel blocker toxicity. Dose: Standard dose is2-4mg/kg IV. Repeated every l0 minutes asrequired.Amiodarone (Cordarone) - First Line Cardiac DrugBlocks sodium channels, inhibits sympatheticstimulation, and blocks potassium channels as wellas calcium channels. Slows conduction through theHis-Purkinje system and in patients with Wolff-Parkinson-White syndrome. Inhibits both alpha

and beta receptors and possesses both vagolytic andcalcium channel blocking properties. Indications: Shock-refractory pulseless V-tach/V-fib, Polymorphic V-tach,wide complex tachycardia of uncertain origin, stable V-tach when cardioversion unsuccessful, and conversion ofatrial fibrillation. Dose: Pulseless V-tach/V-fib - 300mg IVbolus diluted in 20 to 30mL of NS or D5W. Repeat dose of150mg every 3 to 5 minutes. If defibrillation successful,follow with 1mg/min IV infusion for 6 hours. Maximumdaily dose 2.0g IV/24 hours. Other protocol doses if patienthas a pulse are 150mg IV bolus over 10 minutes. Mayrepeat every 10 minutes as needed. After conversion infuse360mg over next 6 hours.Lidocaine (Xylocaine) - First Line Cardiac DrugLidocaine is indicated in this course only if Amiodarone isnot available. Lidocaine is an amide-type local anesthetic.It is frequently used to treat life-threatening ventriculardysrhythmias. Lidocaine isprobably the mos tf r e q u e n t l y u s e dantiarrhythmic agent inthe treatment if lifethreatening cardiacemergencies. Moreover, ithas been shown to beeffective in suppressingpremature ventricular contractions, treating ventriculartachycardia and some cases of ventricular fibrillation, andincreasing the fibrillation threshold in acute myocardialinfarction. Lidocaine depresses depolarization andautomaticity in the ventricles. It has very little effect onatrial tissues. Lidocaine is most apt to suppress ventriculararrhythmias only when the level of the drug in the blood isbetween 1.5 and 6.0mcg/ml of blood. A 75-100mg bolus oflidocaine will maintain adequate blood levels for only 20minutes. Therefore, once a ventricular arrhythmia issuppressed, a lidocaine bolus should be followed by a 1-4mg/min infusion to maintain therapeutic blood levels.Indications: Ventricular tachycardia, ventricularfibrillation and premature ventricular contraction(malignant; more than six unifocal PVC's per minute,multifocal PVC's, couplets, runs of PVC's, and R on Tphenomena). Dose: Lidocaine can be given IV, IO andETT. Ventricular fibrillation and pulseless ventriculartachycardia is 1-1.5mg/kg every 3-5 minutes. Ventriculartachycardia with a pulse and malignant PVC's is1-1.5mg/kg initial dose every 5-10 minutes and repeat dosesare half the initial dose. The maximum dose of this drug is3mg/kg. Procainamide (Pronestyl) Procainamide is an ester-type local anesthetic. It isfrequently uses to treat life-threatening ventriculardysrhythmias Procainamide is effective in suppressingventricular ectopy.Emergency Medical Training Services Page 5

It may be effective in cases where lidocaine and/oramiodarone has not suppressed the ventriculararrhythmia. Procainamide reduces the automaticityof the various pacemaker sites in the heart.Procainamide slows intraventricular conduction toa much greater degree than lidocaine. Indications:Persistent cardiac arrest due to ventricularfibrillation, premature ventricular contractions, andventricular tachycardias. Dose: In treating PVC's orventricular tachycardia, 100mg should beadministered every 5 minutes at a rate of20-50mg/min. This should be discontinued if any ofthe following occur; arrhythmia is suppressed,hypotension ensues, QRS has widened by 50% of itsoriginal width and a total of 17mg/kg maximumdose is reached. A maintenance infusion ofprocainamide is 1-4mg/min. Precaution: If therhythm is suspected to be Torsades de Pointesmagnesium is the preferred drug of choice. Avoidadministering procainamide if the rhythm is aknown Torsades de Pointes rhythm.Magnesium Sulfate - First Line Cardiac DrugMagnesium is the treatment of choice for Torsadesde Pointes and it may be used in refractoryventricular tachycardia and ventricular fibrillation.Indication: Ventricular fibrillation, ventriculartachycardia and Torsades de Pointes. Dose: 1-2g in10mL given IV push. Several studies support use inAMI patients as an infusion. Sodium BicarbonateVentilation is the initial treatment priority toacid-base balance during early cardiac arrests.Hyperventilation influences respiratory acidosis byremoving CO2. Sodium bicarbonate is indicated formetabolic acidosis (DKA), hyperkalemia, andoverdoses (tricyclic, phenobarbital). Sodiumbicarbonate may be beneficial after prolongedhypoperfusion or cardiac arrest situations. It isgenerally not used within the first 10-15 minutes ofarrest unless diagnostic tools and/or historysupports metabolic acidosis is present. Indications:Tricyclic overdose, phenobarbital overdose, andsevere acidosis refractory to hyperventilation. Dose:Usual dose of sodium bicarbonate is 1mEq/kg canbe repeated every 10 minutes at half the originaldose. Precaution: Most catecholamines andvasopressors (i.e. dopamine, epinephrine) can bedeactivated by alkalotic solutions. Make sure thatIV lines are flushed before and after administeringsodium bicarbonate. Dopamine (Intropin) - First Line Cardiac DrugDopamine is a naturally occurring catecholamine. Itis a chemical precursor of norepinephrine. It acts onalpha, beta and dopaminergic adrenergic receptors.Its affects on alpha receptors is dose-dependent.Indications: Hemodynamically significant

hypotension (70-100mmHg) not resulting fromhypovolemia and is also indicated for cardiogenic shock.Dose: Intial dose: Low dose (2-10mcg/kg/min) stimulatesdopaminergic receptors causing dilation of mesentery,coronary and cerebral areas. Medium dose(10-15mcg/kg/min) stimulates beta effects for rate andforce. High dose (15-20mcg/kg/min) introduces alphaeffects and vasoconstriction.Norepinephrine (Levophed) - First Line Cardiac DrugA natural occurring alpha and beta agonist. It is indicatedin patients with severe hypotension (less than 70mmHg)otherwise dopamine should be used. Norepinephrineshould be used cautiously due to its potent alphastimulation. Dose: IV infusion 0.5-30mcg/min.Dobutamine (Dobutrex)A synthetic catecholamine and a potent inotropic agentused in treating heart failure patients. Dobutamineincreases the force of the systolic contraction (positiveinotropic effect) with little chronotropic activity. Dose:2-20mcg/kg/min Furosemide (Lasix)A potent diuretic that inhibits sodium and chloridereabsorption in the kidneys. This drug is used to treatpulmonary edema and lower blood pressure. The effectsmay occur within 5-20 minutes. Dose: 0.5-1 mg/kg slow IV.Blood pressure must be able to support the fluid shift.Nitroglycerin (Nitrostat) - First Line Cardiac DrugNitroglycerin is a potent smooth muscle relaxant used inthe treatment of angina pectoris. Nitroglycerin reducescardiac work load, and to a lesser degree, dilates thecoronary arteries. This results in increased coronary bloodflow and improved perfusion of the ischemic myocardium.Indications: Chest pain with angina, chest pain with AMI,and acute pulmonary edema (unless hypotensive). Dose:0.4mg sublingual for routine angina pectoris. Repeated 3-5minutes as required. IV infusion nitroglycerin is10-20mcg/min.Morphine Sulfate - First Line Cardiac DrugMorphine is a central nervous system depressant that actson opiate receptors in the brain, providing both analgesiaand sedation. It increases peripheral venous capacitanceand decreases venous return. This effect is sometimescalled a "chemical phlebotomy." Morphine also decreasesmyocardial oxygen demand. Indications: Severe painassociated with MI. Pulmonary edema either with orwithout associated pain (monitor for hypotension). Dose:There are many different approaches to the administrationof morphine. An initial dose of 2-10mg IV is standard. Thiscan be augmented with additional doses of 2mg every fewminutes until pain is relieved, respiratory depressionoccurs, or hypotension is noted.Emergency Medical Training Services Page 6

Clot Buster - Fibrinolytic AgentsStreptokinase, urokinase and tissue plasminogenactivator (tPA) are common agents. Therapy shouldbe initiated within 8 hours of onset of pain when allof the following symptoms are presenting; STelevation 2mm in 2 contiguous leads, symptoms andST elevation post SL NTG therapy.Contraindications may include hemorrhage, aorticdissections, prolonged CPR, HTN, CVA, recenttrauma, liver dysfunction and many more. Special Resuscitation SituationsSeveral special situations are associated withcardiopulmonary arrest that require the rescuer tochange their approach to resuscitation. Emergencypersonnel should note carefully the differences intriage, emphasis, and techniques.Hypoperfusion/ShockShock is defined as inadequate tissue perfusion. It isimportant to identify and treat the causes whilekeeping the body hemodynamically stable. Rate problems associated with tachycardias andbradycardias can attributed to backing up of fluids.Pump Problems could include MI, chordaetendineae damage, valvular damage, myocarditis,aortic aneurysm, pulmonary edema, cardiactamponade, and others. Volume complications fromhemorrhage or other fluid losses along with relativevasodilation, redistribution, and drug inducedinfluences. In treating a hypotensive patient the"CardiovascularTriad" is applied. Rate, rhythm and lastly bloodpressure. Signs and symptoms of hypotension may include butare not limited to altered mental status, diaphoresis,cool, pale skin, decreased distal pulses, dyspnea,tachycardias, and decreased blood pressure. Care includes ABC, EKG, pulse oximetry, IV,history, physical exam, 12 lead and chest x-ray.Treat rate, rhythm, and finally blood pressure inmost cases. For further information refer tohypotension algorithm.Hypothermia - Non-medically inducedHypothermia is defined as a body temperature lessthan 95 degrees Fahrenheit. Severe hypothermia isa body temperature below 85 degrees and isassociated with depression of cerebral blood flowand oxygen requirements, reduced cardiac outputand decreased arterial pressure. The patientsperipheral pulses and breathing efforts may bedifficult to identify and assess. Try to remove theperson from the environment or situation causingthe decrease in body temperature (weather, wet

clothes). One of the most important goalsin saving ahypothermic patient is to prevent further heat loss. Rescue breathing should be initiated if not breathing. Pulsechecks should last 30-45 seconds to compensate for thedecreased cardiac function. For body temperaturesbetween 85 to 93 degrees, apply external warming devicesto the trunk areas only. Airway management andtransportation should be handled as gently as possible todecrease the possibility of ventricular fibrillation. Movepatient in a horizontal position to avoid aggravatinghypotension. If the body temperature is below 85 degreesand the patient is in ventricular fibrillation or pulselessventricular tachycardia, only one round of shocks areadvised until the body temperature is above 85 degrees andrewarming is established. Also avoid certain medicationsuntil body temperature is increased. Rewarming can be done by warmed humidified oxygen,warm packs to the torso region, warmed IV fluids,peritoneal lavage, extracorporeal blood warming andesophageal rewarming tubes. As a rule, victims should notbe considered dead until they have a near normal coretemperature. Since severe hypothermia is frequently preceded by otherdisorders (drug overdoses, alcohol use, trauma, and others)the healthcare provider must look for and treat underlyingconditions while simultaneously treating the hypothermia.All cachectic, malnourished, or alcoholic patients shouldreceive thiamine (100mg) early during rewarmingprocedures. Near-DrowningThe most significant concernregarding a drowning victim ishypoxemia. Therefore, rescuersshould restore ventilation andperfusion as quickly as possible. The initial treatment for anon-breathing drowning victimis delivering rescue breaths.Also suspect hypothermia andhead, neck, and back injurieswith diving accidents. THERE IS NO NEED TO CLEARTHE AIRWAY OF ASPIRATED WATER. At most onlya modest amount of water is aspirated by a majority ofboth freshwater and seawater drowning victims. Somepatients do not aspirate at all due to laryngospasms.Maintain the victim horizontal and protect for possiblehead, neck or back injuries when removing victim fromwater. If the victim is not breathing and pulses are absent beginCPR. Intubation should be initiated as soon as possible.End-tidal CO2 determinations may be helpful in makingthe decision to continue resuscitation efforts. Aggressiveattempts to resuscitate should be made for a drowningvictim in icy water.Emergency Medical Training Services Page 7

Pregnancy and Cardiac ArrestCardiac arrest ofpregnant patients is notc o m m o n . C a r d i a coutput increases up to30-50%. Heart rate,ventilatory rate, ando x y g e n d e m a n d sincrease. Respiratory function decreases due todramatic anatomical changes. Systemic andpulmonary vascular resistance decrease as well.Pregnant patients are more prone to majorcardiovascular and respiratory injuries than anon-pregnant patient. The uterus may compress thevena cava, aorta and others vessels resulting insupine hypotension syndrome which may result ina 20-25% decrease in cardiac output. Standard life saving measures are recommended forall severely unstable patients. Position the uterus tothe left side of the abdomen. Vasopressor drugsshould not be withheld as well as otherpharmacological agents. At less than 23 weeksgestation, focus efforts on saving the mothers's life. If after ACLS intervention there is no patientresponse and there is possible viability of the fetus,a cesarean section may be considered. Deliveryattempts should take place within 5 minutes of thearrest when possible. Cesarean section may increasethe chances of survival for both patients.Electrical Shock and Lightning StrikesElectrical shock is associated with a fatality rate of0.5 per 100,000 population per year in the UnitedStates. It accounts for 1,000 deaths annually andcauses an additional 5,000 patients to requireemergency care. Electrical shock victims mayexperience transient unpleasant sensation frombrief exposure to low-intensity current to cardiacarrest. Electrical injuries result from current passingthrough the body and converting into heat energy.Factors to consider include magnitude of energydelivered, resistance to current flow, type ofcurrent, duration of contact and current pathway.High-tension current causes the most seriousinjuries. Alternating current at 60 cycles per secondmay cause tetanic skeletal contraction and deliveryof current to the myocardium resulting in anincreased chance of ventricular fibrillation.Hand-to-hand pathways are more fatal thanhand-to-foot and foot-to-foot pathways.Cardiopulmonary arrest is the primary cause ofimmediate death due to electrical injury.Ventricular fibrillation or ventricular asystole mayoccur as a result of electric shock. Respiratoryarrest may occur secondary to electrical currentpassing through the brain and causing inhibition of

the medullary respiratory center function, tetaniccontraction of the diaphragm and chest wall musculatureloss. It is important that the rescuers be certain that rescueefforts will not put him or her in danger. As soon aspossible secure an airway and oxygenate. CPR andprecautions for head, neck and back injuries as needed.Transfer to a burn center may be indicated.Traumatic Cardiac ArrestPatients who develop cardiacarrest in association withtrauma are treated differentlythan non-trauma patients.Cardiac arrest resulting fromtrauma has many causes toconsider ranging from but notlimited to; severe central neurological injury, hypoxiaresulting from pneumothorax, obstructions and crushingwounds to the airway, hypovolemia, and pericardialtamponade. The following suggest an approach of care for an injuredpatient in cardiac arrest; treat ventricular fibrillation,identify and treat potential reversible injuries, rapidtransport, and rewarming therapy. Treatment includes identifying lethal dysrhythmias,maintaining spinal alignment, intubation, CPR, surgicalairway, pericardiocentisis, seal open chest wounds, and IVtherapy. Many BLS and ACLS interventions are of nobenefit if surgical interventions are not provided quickly.StrokeA sudden onset caused by blockageor aneurism of a cerebral bloodvessel. Ischemic strokes are causedby thrombotic or embolicocclusion. Hemorrhagic strokes arecaused by a rupture of a vesselresulting in blood and brain cellscoming into direct contact leadingto a more violent insult to thebrain. Common signs and symptoms include; AMS, headaches,aphasia, facial weakness, asymmetry, ataxia, vertigo,unilateral hearing loss, monocular blindness, N/V andothers. Care includes ABC's, V/S trending, generalmedical/trauma assessment, physical and neurologicalexams. Continued carewill consist of EKG monitoring, pulse oximetry, IV access,lateral C-spine x-rays, arterial blood gases, 12 lead EKG,chest x-ray, CBC, coagulant studies and electrolytemonitoring. Further evaluation and continuation oftreatment includes neurological consult, IV therapy (NS orLR at

Antihypertensive drugs (criteria and medicationchoices will vary upon situation). Anticonvulsantdrugs prn (phenytoin, diazepam, phenobarbital).Intracranial pressure can be addressed byhyperventilation (PETCO2, 30mmHg) andanti-inflammatory medications (mannitol 1-2g/kgover 5-10 minutes). Conveying News of a Sudden Death to Family Call the family if they have not been notified.Explain that their loved one has been admitted tothe ED or critical care unit and that the situation isserious. If possible, survivors should be told of thedeath in person, not over the telephone. Obtain as much information as possible about thepatient and the circumstances surrounding thedeath. Carefully go over the events as theyhappened in the ED. Ask someone to take familymembers to a private area. Walk in, introduceyourself, and sit down. Address the closest relative. Briefly describe the circumstances leading to the death. Go over the sequence of events in the ED. Avoid euphemisms such as "he's passed on," "she'sno longer with us," or "he's left us." Instead use thewords "death," "dying," or "dead." Allow time forthe shock to be absorbed. Make eye contact, touch,and share. Convey your feelings with a phrase suchas "You have my (our) sincere sympathy. Immediate Post-Cardiac Arrest CareReturn of Spontaneous Circulation (ROSC):*Maintain a PETCO2 or PaCO2 of approx35-40 torr. SPO2 >94%.*Maintain BP >90mmHg.-IV Bolus-Dopamine drip -Norepinephrine drip-Epinephrine drip*If comatose after ROSC induce hypothermia.-1 to 2 L (30mL/kg) isotonic solution at4 degrees Celsius. Maintain temperature of 32to 34 degrees Celsius for 12 to 24 hrs.*If MI cause consider PCI/Cathlab ASAP.Miscellaneous ACLS InformationMONA greets all heart attach victims at the door. Morphine, Oxygen, Nitro, and Aspirin. Whenever a patient is moved the airway should bere-evaluated. CPR is 30 compressions to 2 ventilations unless thepatient is intubated. If advanced airway is placedventilator provides 8 to 10 ventilations per minute

and compressor provides compressions at a rate of at least100 per minute without interruption. Rescue breathing is at a rate of 12 to 15 per minute (8 to 10if advanced airway is in use) and hyperventilation is 24 perminute.BLS versus ACLS Survey*BLS Survey is step 1-2-3-4. It is used for CPR.-1 Check for response-2 Start compressions-3 Open Airway and give breathes-4 AED*ACLS Survey is a more indepth assessment when not inarrest. The traditional ABCD-A Airway-B Breathing-C Circulation-D Diagnostic deferentialNotes:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


12-LEAD EKG (Basics Only)The precipitating event in acutemyocardial infarction is occlusion ofa coronary artery and interruption ofblood flow to a portion of themyocardium it supplies. It is at thismoment that the clock startsrunning. TIME IS MYOCARDIUM! Initially, following coronaryocclusion, the affected tissue willbecome deprived of oxygen and othernutrients and will become ischemic.Myocardial ischemia can often bedemonstrated on the EKG as STsegment depression and T waveinversion. The larger the quantity ofischemic tissue, the more significant,as a rule, will be the EKG findings. Ifallowed to progress untreated, tissueat the center of the myocardial injurywill transition from ischemic toinjury. The ST segment will becomeelevated in the affected leads. Inaddition, T waves in the affectedleads will become more peaked. After approximately 6 hours andprovided blood supply has not beenrestored, the injured tissue will beginto die. As the infarction becomescomplete over the next 48-72 hours,most ischemic and injured tissue willhave been replaced by infarctedtissue causing decreased ST segmentelevation. A significant Q waveusually persists and is an indicationof an old infarction. Each EKG lead is designed tovisualize a part of the heart. Thefollowing is a generalized descriptionof the various EKG lead groupings. Anterior: leads VI, V2, V3, V4 Lateral: leads I, aVL, V5, V6 Inferior: leads II, III, aVF(A finding in two or more leads pergrouping could be viewed as apositive finding.) Page10

Primary Assessment Airway (basic) - Breathing - Circulation (CPR) Defibrillate at 360J (or equivalent Biphasic energy ((120-200J)) followed by 2 minutes of immediate CPRSecondary AssessmentAirway (advanced)Breathing (confirm by at least 2 methods)Circulation (IV/IO access)Differential (search for and treat causes)

AntiarrhythmicsAmiodarone - 300mg IV bolus diluted in 20-30mL of NS. Consider repeat dose of 150mg in 3-5 minutes. If defibrillation successful start 1mg/min infusion for 6 hours.or Lidocaine (only if Amiodarone is not available) - 1.5mg/kg bolus. Repeat at 1.5mg/kg 3-5 minutes after first dose. If defibrillation successful start 1-4mg/min infusion.

Epinephrine 1mg every 3-5 minutes.orVasopressin 40 U IV bolus given once. May substitute 1st or 2nd dose of EPI.May resume epinephrine after 3-5 minutes.

Ventricular Fibrillation & Pulseless Ventricular Tachycardia

Note: ETT drugs - double dose in 10mL.Note: Vasopressors are given on its own time schedule.Note: Every 2 minutes reassess if additional defibrillation is needed. V-Fib V-Tach


Primary Assessment Airway (basic) - Breathing - Circulation (CPR)Epinephrine 1mg every 3-5 minutesorVasopressin 40 U IV bolus given once. May substitute 1st or 2nd dose of EPI.May resume epinephrine after 5-10 minutes.Secondary AssessmentAirway (advanced)Breathing (confirm by at least 2 methods) Circulation (IV access)Differential (search for and treat causes) PATCH-5-MD

Consider termination of efforts

Asystole

MOST COMMON CAUSES OF RAPID DETERIORATION OF PATIENT CONDITIONP pulmonary embolism Consult neededA acidosis 1mEq/kg Sodium BicarbT tension pneumo Needle chest decompressionC cardiac tamponade Pericardiosentesis H hypovolemia Fluid bolus 250-500mL may repeatH hypoxia Oxygen deliveryH heat/cold Monitor and maintain based on conditionH hyper/hypokalemia Consult needed H hypoglycemia Glucose administrationM MI STEMI protocolD drug overdose Narcan 2mg may repeatAsystole


Primary Assessment Airway (basic) - Breathing - Circulation (CPR)Secondary AssessmentAirway (advanced)Breathing (confirm by at least 2 methods) Circulation (IV access)Differential (search for and treat causes) PATCH-5-MD

Epinephrine 1mg every 3-5 minutesorVasopressin 40 U IV bolus given once. May substitute 1st or 2nd dose of EPI.May resume epinephrine after 5-10 minutes.Consider termination of efforts

Pulseless Electrical Activity

Note: ETT drugs - double dose in 10mL.Note: Epinephrine is given on its own time schedule.Note: After rate adjustment fails consider dopamine.Note: PEA is any pulseless rhythm other than asystole, V-tach, or V-FibP pulmonary embolismA acidosisT tension pneumoC cardiac tamponadeH hypovolemiaH hypoxiaH heat/coldH hyper/hypokalemiaH hypoglycemiaM MID drug overdose


Primary Assessment Airway (basic) - Breathing - CirculationSecondary AssessmentAirway (advanced)Breathing (confirm by at least 2 methods) Circulation (IV access)Differential (search for and treat causes)

Determine if STABLE or UNSTABLEIf stable continue work-up.If unstable continue with algorithm.

Atropine 0.5mg IV every 3-5 minutes to maxdose of 0.04mg/kg

Narrow QRS BradycardiaSinus BradyJunctional Rhythm2 Degree AV Block, type 1Complete AV BlockWide QRS Bradycardia2 Degree AV Block, type 2Complete AV BlockIdioventricular Rhythm

TCP as soon as possibleTCP

(Rate) Dopamine 2-10mcg/kg/min(BP) Dopamine 10-20mcg/kg/minand/orEpinephrine Drip - 2-10mcg/minhenIsoproterenol Drip - 2-10mcg/min(Rate) Dopamine 2-10mcg/kg/min(BP) Dopamine 10-20mcg/kg/minand/orEpinephrine Drip - 2-10mcg/minthenIsoproterenol Drip - 2-10mcg/min

Bradycardia



If Stable continue with algorithm.If Unstable go to bottom box.Attempt therapeutic diagnostic maneuverA Vagal stimulationA Adenosine 6mg rapid push IV, may repeat in 1-2 minutes at 12mg.

Normal Cardiac FunctionA B-BlockerA Ca2+ channel blocker Normal Cardiac FunctionA B-BlockerA Ca2+ channel blockerNormal Cardiac FunctionPriority order: A Ca2+ channel blocker A B-Blocker A Digoxin A DC cardioversion

Stable Ectopic or Multifocal Atrial TachycardlaStable Paroxysmal SVT Stable Junctional tachycardia

If hemodynamically unstable, synchronize cardioversion:*SVT 50-100J biphasic*A-Fib 120-200J biphasic*If using monophasic energy start at 200JAFTER FIRST SHOCK ESCALATE AS NEEDED.Remember to check for a pulse after each shock.

Narrow Complex Tachycardia



If Stable continue with algorithm.If Unstable go to bottom box.

Normal baseline QT interval &Normal Cardiac Function A Treat ischemia A Correct electrolytesMedications: any one A B-Blockers or A Lidocaine or A Amiodarone or A Procainamide or A SotalolNormal baseline QT interval &Impaired Cardiac FunctionAmiodaroneA 150 mg IV bolus over 10 minutesorLidocaine (if Amiodarone is notavailable)A 0.5 to 1mg/kg IV pushthen useA Defibrillation not synchronizedcardioversion.Prolonged baseline QT interval(suggests torsades)A Correct abnormal electrolytesMedications: any oneA MagnesiumA Overdrive pacingA Phenytoin

Note!!!!! May go directly tocardioversionStable Monomorphic V-tachA Is cardiac function impaired? Stable Polymorphic V-tachAIs QT baseline interval prolonged?Normal Cardiac FunctionAmiodaroneA 150 mg IV bolus over 10 minutesorLidocaine (if Amiodarone is notavailable)A 0.5 to 1mg/kg IV pushthen useA Synchronized cardioversion at100J biphasic or 200Jmonophasic. Then escalate asneeded.

If hemodynamically unstable, deliver electrical therapy as described above.Remember to check for a pulse after each shock.

Ventricular Tachycardia: Monomorphic and Polymorphic

Note: To determine the QT Interval measure two consecutive R-Rwaves. Then measure the QT Interval from the Q wave to the startof the T wave. If the QT Interval is less than half the R-Rmeasurement the QT Interval is considered normal. If the QTInterval measurement of more than half of the R-R measurement itis considered long.Note: Once a patient has received electrical therapy all ventriculardrugs should then be followed by another shock


Clinical signs: Shock, Hypoperfusion, CHF, Acute Pulmonary EdemaMost likely the problem?Rate ProblemPump ProblemPulmonary Edema

Go to Bradycardia or TachycardiaalgorithmsSystolic BP 70 to 100 mmHg s/s of shockDopamine 2 to 20 mcg/kg/min IV

BloodPressure?Volume Problem

AdministerA FluidsA Blood transfusionsA Cause-specificinterventionsConsider vasopressors1st - Acute pulmonary edemaA Furosemide IV 0.5 to 1.0mg/kg A Morphine IV 2 to 4mgA Nitroglycerin SLA O2/CPAP/intubation as needed

Systolic BPBP defines 2ndline of action Systolic BP 100 mmHgA Dopemine if BP = 70 to 100 mmHg, signs/symptoms of shockA Dobutamine if BP >100 mmHg, no signs/symptoms of shockSystolic BP 70 to 100 mmHg No s/s of shockDobutamine 2 to 20 mg/kg/min IV

Systolic BP >100 mmHgNitroglycerin 10 to 20 mcg/min IVconsiderNitroprusside 0.1 to 5.0 mcg/kg/min IV

Acute Pulmonary Edema, Hypotension, Shock


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