Advanced cardiac life support (ACLS)

[ Old Guidelines ]    (Medication dosing only)

Epinephrine 1 mg IVpush  q3-5min.(use 1:10,000).  Epinephrine strengthens myocardial contraction and increases cardiac output, which will help improve myocardial and cerebral blood flow. Continuous infusion: 1 to 4 mcg/min (range: 1-10 mcg/min). Add 1 mg/250 ml D5W or NS. Drip rate (ml/hr)= mcg/min x 15. Endotracheal tube: Give 2 to 2.5 x IV dose. (Dilute up to 10 ml with normal saline) [If ineffective, administer medications of probable benefit. Medications are used to help boost the patients response to the shocks. 1st line=epi // 2nd-line agents include: Lidocaine— Magnesium sulfate — procainamide (in that order).]  UPDATE
Lidocaine 1 to 1.5 mg/kg q3-5min. Maximum total: 3 mg/kg. Decrease by 50% in elderly, CHF or patients with hepatic disease. Side effects: Convulsions, hypotension, bradycardia. Do not exceed 3 mg/kg in a 1 hour period. Continuous infusion: 1 to 4 mg/min. Add 1 gram/250 ml. Rate (ml/hr)= mg/min x 15. Endotracheal tube: Give 2 to 2.5 x IV dose. Dilute up to 10ml with normal saline.
Procainamide Give 20-30 mg/min  until (maximum total of 17 mg/kg)  or side effects occur or arrhythmia subsides. //   Side effects: Severe hypotension with rapid infusion; bradycardia; AV block; V-fib.//      Loading regimen: 20-30 mg/min. Add 1 gram/250 ml D5W. Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/hr. Continuous infusion: 2 to 6 mg/min. Add 1 gram/250 ml D5W. Rate (ml/hr)= mg/min x 15
Asystole: Absence of both atrial and ventricular electrical activity manifested by a flat line on EKG. Etiology: Severe ischemic myocardial damage, complete heart block, and severe metabolic disorders, eg, hyperkalemia, hypokalemia, acidosis, hypoxia., Occasionally some drugs: phenytoin, lidocaine, beta-blockers, amiodarone. Findings: full cardiac arrest without  BP or pulse, cyanosis and dilated pupils. Differential diagnosis: disconnected leads; fine V-fib. Mortality: Fewer than 2% of patients with asystolic arrest survive to hospital discharge.
Epinephrine 1 mg IVpush q3-5min.(use 1:10,000)
Atropine REMOVED IN 2010 ACLS UPDATE.  1 mg rapid IV. Repeat q3-5 minutes up to maximum total dose of 0.04 mg/kg.  IV route unavailable–endotracheal tube: Give 2 to 2.5 x IV dose. (Dilute up to 10ml with normal saline). Adverse reactions: CNS toxicity: tremor, delirium. Hypo/hypertension.
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PSVT) If ventricular rate>150 BPM or serious sign/symptoms prepare for immediate cardioversion. May give brief trial of medications. Presentation: Regular, rapid rate (120-300 bpm); narrow complex with possible varying degrees of AV block .Etiology: May occur spontaneously. May be associated with stress; anxiety; fatigue; excess alcohol; hypoglycemia; mitral valve prolapse; digoxin toxicity; CAD; COPD; hypertensive heart disease. UPDATE
Adenosine 6 mg rapid IV, followed by saline flush. If no response in 1-2 minutes give 12 mg rapid IV. May repeat in 1-2 minutes if needed.  Complex width (wide?): If complex width is wide, consider lidocaine 1 to 1.5 mg/kg IV——-Procainamide 20-30 mg/min (max total: 17 mg/kg)——–Synchronized cardioversion: 50j—100j- (Premedicate: sedative +/-analgesic.)   Complex width (narrow?): Continue below. BP low or unstable: Synchronized cardioversion as above
Verapamil 2.5 to 5 mg IV over 2 minutes. May repeat dose of 5-10mg 15-30 minutes after 1st dose. Alternative initial choice in stable patients. Decrease dose by 30-50% in hepatic insufficiency. Adverse reactions: Severe hypotension; bradycardia; ventricular standstill in digitalized patients; asystole; respiratory failure. Hypotension can be reversed with calcium chloride  0.5-1 gram over 5 minutes.
 Diltiazem 0.25 mg/kg over 2 minutes. If no response within  15 minutes, give second bolus of 0.35 mg/kg over 2 minutes. Subsequent doses should be individualized. If effective start continuous infusion: 5-15 mg/hr
Digoxin (For patients not on digoxin): 0.25 to 0.5 mg IV. May follow with 0.125 to 0.25 mg IV q2-6h until 0.75 to 1.5 mg is given over 24hrs. [Loading: 10 to 15 mcg/kg IBW in divided doses (q4-8h) over 12-24hrs.]   Digoxin is considered to be a 3rd line drug in stable patients who fail to respond to adenosine/verapamil/esmolol. Not preferred drug for PSVT because it is not rapidly effective (may take up to 60 minutes). Adverse reactions: sinus bradyarrhythmias; AV block; N/V/D; yellow vision and hallucinations; supra and ventricular arrhythmias.   Contraindications: V-fibrillation; hypokalemia; WPW syndrome with wide complex.
Esmolol (note: IV beta blockers should not be given within 30 minutes of verapamil): 500 mcg/kg IV over 1 minute,  followed by 50 mcg/kg/minute over 4 minutes.  If ineffective, repeat load of 500 mcg/kg, followed by 100 mcg/kg/min. If needed,  may repeat process of loading dose + increase infusion by another 50 mcg/kg/min (up to max of 200 mcg/kg/min).   Half life: 10 minutes.   Contraindicated in: sinus bradycardia; > 1st degree heart block; overt cardiac failure. Adverse reactions: dose related hypotension; ventricular arrhythmias; heart failure. Drip preparation: Add 2.5 grams/ 250 ml D5W or NS [Drip rate (ml/hr)= wt(kg) x mcg/min x 0.006 ]
Atrial Fibrillation: EKG: Irregularly irregular rhythm without recognizable P-wave activity. Etiology: alcoholism, AMI, hypotension ,pulmonary disease, valvular heart disease, head or cardiac trauma, metabolic causes(hypokalemia, hypomagnesemia), hyperthyroidism, hypoglycemia. Paroxysmal form may occur without underlying cardiac disease. Atrial rate is usually  350-600 bpm. VR: 150-200 bpm (untreated). Suspect digoxin toxicity if there is a regular ventricular response. Ventricular response depends on refractoriness of the AV node. Atrial flutter: Rarely occurs in absence of heart disease.   Etiology: CAD, alcoholism, thyrotoxicosis, pulmonary disease, cardiac trauma, digoxin or quinidine toxicity, atrial septal defect. May result from quinidine or procainamide effect on A-fib. Atrial rate: 250-300 bpm. Ventricular rate: 75-150 bpm.   Rhythm: variable. P wave: May show sawtooth or undulating pattern. Narrow QRS complex.    Unstable patient: (Serious signs/symptoms: include hypotension (SBP<80), heart failure, chest pain, MI, decreased mental status, dyspnea) and VR>110.    (1) Administer sedative such as valium 5-10mg  (2) synchronous cardioversion(decreased energy requirements) 75-100j x1;  repeat with higher charge up to 360j if needed.  (3) If a-fib>24hr start anticoagulation therapy. UPDATE
Rate Control:
Verapamil 2.5 to 5 mg IV over 2 min. May repeat dose of 5-10mg 15-30min after 1st dose.
Diltiazem or esmolol. See above
Digoxin Load with 0.5 mg IV, repeat in 30min, then administer 0.25mg IV q2h until rate is 80-90 bpm. [Loading: 10 to 15 mcg/kg IBW in divided doses (q4-8h) over 12-24hrs.]
Rhythm Control:
Procainamide 20-30 mg/min (max total 17 mg/kg) or side effects.
Ibutilide 1mg IV over 10min. May repeat x 1 in 10 minutes if needed. Approved for acute termination. Monitor ECG for at least 4hr . Effective in @30% of patients.  FDA-approved for acute termination of A-flutter/A-fib (may be alternative to cardioversion). Major adverse reactions: proarrhythmic events: VT, PVC’s, BC, AV block, torsades de pointes, etc. IVPB: 0 to 1 mg/50 ml D5W or NS over 10 minutes.  If patient is < 60kg give 0.01 mg/kg over 10 minutes.  May repeat x 1
Ventricular Tachycardia
Stable patients: consider cough conversion followed by a trial of antiarrhythmic drug therapy (lidocaine—–procainamide——-bretylium); in unstable patients, immediate cardioversion should be performed: 100j. If recurrent, add lidocaine and cardiovert again starting at the energy level that was previously successful, then give procainamide or bretylium. If pt has hypotension, pulmonary edema, or unconsciousness is present, use lidocaine if cardioversion alone is unsuccessful, followed by bretylium. In all other patients, the recommended order of treatment is lidocaine-procainamide-bretylium.  UPDATE
Lidocaine (not uniformly effective in sustained VT, especially in patients without acute myocardial ischemia or infarction. Dosing: 1 to 1.5 mg/kg IV bolus, may repeat 0.5 to 0.75 mg/kg q5-10min until VT resolves or max of 3 mg/kg. (after initial bolus start infusion at rate of 2 mg/min up to 4 mg/min).Adverse effects: May cause significant heart block, convulsions, respiratory depression or arrest, muscle twitching. Decrease by 50% in elderly/CHF/ or hepatic disease. Do not exceed 3 mg/kg in a 1 hour period. Continuous infusion: 1 to 4 mg/min. Add 1 gram/250 ml. Rate (ml/hr)= mg/min x 15. Endotracheal tube: Give 2-2.5 x IV dose. Dilute up to 10ml c NS
Procainamide 2nd line drug in stable patients when lidocaine not effective. Dosing: 20-30mg/min in 100mg increments until one of following occurs  (a)Max total of 17 mg/kg    (b) arrhythmia is suppressed   (c)Hypotension develops  (d)QRS widens by 50% > baseline.     If loading regimen is successful, start continuous infusion: 2 mg/min. Side effects: Severe hypotension with rapid infusion; bradycardia; AV block; V-fib. Loading regimen: 20-30 mg/min. Add 1 gram/250 ml D5W. Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/hr. Continuous infusion: 2 to 6 mg/min. Add 1 gram/250 ml D5W. Rate (ml/hr)= mg/min x 15
Bradycardia:  If no pulse is present with bradycardia–treat as EMD.  CPR is rarely needed unless without pulse or severe refractory hypotension.  UPDATE
Atropine 0.5 to 1mg IV q3-5min until adequate response or until 0.04 mg/kg  (@ 2-3mg) has been given. Decrease dose in renal disease
Dopamine Indications: shock, hypotension. Preferred initial pressor. If patient has had no response to atropine and pacemaker is not immediately available, a pressor agent should be started. Dosing (initially): 2-5 mcg/kg/min (may increase up to 20 mcg/kg/min). Calculation of drip rate: (ml/hr) 400mg/250 ml : wt(kg) x mcg/min x 0.0375
Epinephrine Indications: Hemodynamically significant bradycardia unresponsive to atropine, volume infusion, or pacemaker therapy. First line drug for EMD or asystole. Dosing: 1 mg q3-5min.
PULSELESS ELECTRICAL ACTIVITY (PEA)/ (EMD)           PEA includes: (1) Electromechanical dissociation (2) Idioventricular rhythms (3) Ventricular escape rhythms (4) Bradyasystolic rhythms (5) Post-defibrillation idioventricular rhythms. Consider possible causes: hypovolemia; hypoxia; cardiac tamponade; hypothermia; massive PE; Drug overdoses( digoxin, beta blockers, calcium channel blockers; TCA’s); hyperkalemia; massive MI; acidosis.
Epinephrine 1 mg IVpush q3-5min.(use 1:10,000) UPDATE