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ACLS. Advanced Cardiac Life Support RC 275. Defibrillation. External depolarization of the heart to stop Vfib or Vtach (that has not responded to other maneuvers). Automated External Defibrillator. Defibrillation Procedure. Position paddles “Clear” the patient

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Acls

ACLS

Advanced Cardiac Life Support

RC 275


Defibrillation

Defibrillation

External depolarization of the heart to stop Vfib or Vtach (that has not responded to other maneuvers)


Automated external defibrillator

Automated External Defibrillator


Defibrillation procedure

Defibrillation Procedure

  • Position paddles

  • “Clear” the patient

  • Shock and then resume CPR for 5 cycles then re-analyze after each shock

  • Prepare drug therapy


Acls drug therapy

ACLS Drug Therapy


Routes of administration

Routes of Administration

  • Peripheral IV – easiest to insert during CPR

  • Central IV – fast onset of action

  • Intratracheally (down an ET tube)

  • Intraosseous – alternative IV route in peds


Oxygen

Oxygen

  • FIO2 100%

  • Assist Ventilation

  • O2 Toxicity should not be a concern during ACLS


Iv fluids

IV Fluids

  • Volume Expanders – crystalloids , eg Ringer’s lactate, N/S, or colloids, eg Albumin or Hetastarch

  • TKO – D5W, N/S


Morphine sulfate

Morphine Sulfate

  • Drug of choice for pain

  • Also decreases pre-load

  • IV dose – 2-4 mg as often as every 5 minutes

  • Precautions

    • May cause respiratory depression


The following drugs help to control heart rate rhythm

The Following Drugs Help to Control Heart Rate & Rhythm


Lidocaine

Lidocaine

  • Indications:

    • PVCs, Vtach, Vfib

    • Can be toxic so no longer given prophylactically

  • IV dose :

    • 1-1.5 mg/kg bolus then continuous infusion of 2-4 mg/min

    • Can be given down ET tube

  • Signs of toxicity:

    • slurred speech, seizures, altered consciousness


Amiodarone cordarone

Amiodarone (Cordarone)

  • Indications:

    • Like Lidocaine – Vtach, Vfib

  • IV Dose:

    • 300 mg in 20-30 ml of N/S or D5W

    • Supplemental dose of 150 mg in 20-30 ml of N/S or D5W

    • Followed with continuous infusion of 1 mg/min for 6 hours than .5mg/min to a maximum daily dose of 2 grams

  • Contraindications:

    • Cardiogenic shock, profound Sinus Bradycardia, and 2nd and 3rd degree blocks that do not have a pacemaker


Procainamide pronestyl

Procainamide (Pronestyl)

  • Indications:

    • Like lidocaine (is usually a second choice)

    • Uncontrolled Afib or Atrial flutter if no signs of heart failure

  • Dose :

    • continuous IV infusion. Initially 20mg/min then titrated down to 1-4 mg/min

  • Side effects

    • Hypotension

    • Widening of the QRS


Atropine

Atropine

  • Indications:

    • Symptomatic sinus bradycardia

    • Second Degree Heart Block Mobitz I

    • May be tried in asystole

    • Organophosphate poisoning

  • IV Dose:

    • .5 – 1 mg every 3-5 minutes

    • Max dose is .04mg/kg

    • Can be given down ET tube

  • Side Effects:

    • May worsen ischemia


Isoproterenol isuprel

Isoproterenol (Isuprel)

  • Indications:

    • Temporary stimulant prior to pacemaker

    • Bradycardia refractory to atropine

    • Torsades de Pointes refractory to magnesium sulfate

  • IV dose:

    • Continuous infusion of 2-10 micrograms/ml of infusion fluid


Adenosine

Adenosine

  • Indication:

    • PSVT

  • IV Dose:

    • 6 mg bolus followed by 12 mg in 1-2 minutes if needed

  • Side Effects:

    • Flushing

    • Dyspnea

    • Chest Pain

    • Sinus Brady

    • PVCs


Verapamil

Verapamil

  • Indications:

    • Is a calcium channel blocker that may terminate PSVT (is a backup to Adenosine) as well as atrial flutter and uncontrolled atrial fib

  • IV Dose:

    • 2.5-5 mg over 2 minutes up to 20 mg

  • Side Effects:

    • Hypotension

    • N & V


Magnesium

Magnesium

  • Used for refractory Vfib or Vtach caused by hypomagnesemia and Torsades de Pointes

  • Dose:

    • 1-2 grams over 2 minutes

  • Side Effects

    • Hypotension

    • Asystole!


Propranolol

Propranolol

  • Beta blocker that may be useful for Vfib and Vtach that has not responded to other therapies

    • Very useful for patients whose cardiac emergency was precipitated by hypertension

    • Also used for Afib, Aflutter, & PSVT


The following drugs improve cardiac output blood pressure

The Following Drugs Improve Cardiac Output &Blood Pressure


Epinephrine

Epinephrine

  • Because of alpha, beta-1, and beta-2 stimulation, it increases heart rate,stroke volume and blood pressure

    • Helps convert fine vfib to coarse Vfib

    • May help in asystole

    • Also PEA and symptomatic bradycardia

  • IV Dose:

    • 1 mg every 3-5 minutes

    • Can be given down the ET tube

    • Can also be given intracardiac

    • May increase ischemia because of increased O2 demand by the heart


Vasopressin adh

Vasopressin (ADH)

  • Similar effects to Epinephrine without as much cardiovascular side effects!

  • IV dose = 40 IU

  • Can be given down ET tube

  • May be better for asystole


Norepinephrine levarterenol

Norepinephrine (Levarterenol)

  • Similar in effect to epinephrine

  • Used for severe hypotension that is NOT due to hypovolemia

  • Cardiogenic shock

  • Administered as a continuous infusion

    • Adult rate is usually 2-12 micrograms/min

    • Range is .5-1 microgram up to 30!

  • Side effects:

    • Like epinephrine, it may worsen ischemia

    • Extravasation causes tissue necrosis


Dopamine

Dopamine

  • Used for hypotension (not due to hypovolemia)

    • Usually tried before norepinephrine

    • Has alpha, beta, and dopaminergic properties

      • Dopaminergic dilates renal and mesenteric arteries

  • Second choice for bradycardia (after Atropine)

  • IV Dose:

    • 1-20 micrograms/kg

  • Side effects:

    • Ectopic beats

    • N & V


Dobutamine

Dobutamine

  • Actions similar to Dopamine

  • Used for CHF with hypotension

  • IV Dose:

    • 2-20 micrograms/minute

  • Side effects:

    • Tachycardia

    • N & V

    • Headache

    • Tremors


Digitalis digoxin

Digitalis (Digoxin)

  • Slows conduction through A-V node and increases force of contraction

  • Used in CHF and chronic atrial fib/flutter

  • Can be given orally or IV

  • Side effects:

    • Arrhythmias

    • N & V, diarrhea

    • Agitation


Nitroglycerin

Nitroglycerin

  • Vasodilator that helps relieve pain from angina pectoris

  • Can be given IV, sublingually, as an ointment or a slow release patch

  • Side effects:

    • Headache

    • Hypotension

    • Syncope

    • V/Q mismatch


Sodium nitroprusside nipride

Sodium Nitroprusside (Nipride)

  • Vasodilator used for hypertensive crisis

  • IV dose:

    • Loading dose of 50 –100 mg followed by infusion of .5-8 micrograms/kg/min

    • Is light sensitive so IV bag must be wrapped in tin foil

  • Side effects:

    • Hypotension so patient must have continuous hemodynamic monitoring


Sodium bicarbonate

Sodium Bicarbonate

  • Used for METABOLIC acidosis hyperkalemia

    • H + HCO3 >H2CO3>H2O and CO2

    • Airway and ventilation have to be functional!

  • IV Dose:

    • 1 mEq/kg

    • If ABGs, [BE] x wt in kg/6

  • Side effects:

    • Metabolic alkalosis

    • Increased CO2 production


Thrombolytics

Thrombolytics

  • Used to improve coronary blood flow by lysing clots, ie coronary thrombosis

    • Best if given within six hours of onset of chest pain

    • Examples: TPA/Alteplase(Activase), Streptokinase

  • Side effects:

    • Bleeding


Acls scenario

ACLS Scenario

You Run the Code!


Acls

A 62 year old female is admitted to the ER with chest pain, dyspnea, and moist, gurgling crackles. She appears in acute distress and is cyanotic. Vital signs are: P =110, R = 20, BP = 80/40.


Cardiac monitoring is initiated and the following ekg is observed

Cardiac monitoring is initiated and the following EKG is observed:

  • What is the patients arrhythmia and probable medical problem?

  • What therapies should be done? Explain each one.


The ekg began to show

The EKG began to show:

  • What is occurring in the heart to cause this arrhythmia?

  • How is this treated?

  • What other arrhythmias may occur now?


The patient suddenly becomes lifeless and the ekg shows

The patient suddenly becomes lifeless and the EKG shows:

  • Uh oh! What now?


The treatment s are unsuccessful and the following ekg appears

The treatment(s) are unsuccessful and the following EKG appears:

  • What should be done now and why?


Finally the following ekg is obtained however bp is 40 0

Finally, the following EKG is obtained. However, BP is 40/0

  • What needs to be done now?


Acls

You saved her! The course is complete!


Bretylium tosylate bretylol

Bretylium Tosylate (Bretylol)

  • Indications:

    • Same as lidocaine and procainamide (usually when condition doesn’t respond to these two)

  • IV dose:

    • 5-10mg/kg bolus followed by continuous infusion of 1-2 kg/min

  • Side Effects:

    • N & V

    • Hypotension


Amrinone

Amrinone

  • Similar to dobutamine

  • Used for refractory CHF

  • IV Dose:

    • 2-15 micrograms/kg/min

  • Side effects:

    • May worsen ischemia

    • N & V

    • Thrombocytopenia


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