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Defibrillation
External depolarization of the heart to
stop Vfib or Vtach (that has not
responded to other maneuvers)
Defibrillation Procedure
Position paddles
Clear the patient
Shock and then
resume CPR for 5
cycles then re-analyze
after each shock
Prepare drug therapy
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
FIO2 100%
Assist Ventilation
O2 Toxicity should not be a concern during
ACLS
IV Fluids
Volume Expanders crystalloids , eg
Ringers lactate, N/S, or colloids, eg
Albumin or Hetastarch
TKO D5W, N/S
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
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 24 mg/min
Can be given down ET tube
Signs of toxicity:
slurred speech, seizures, altered consciousness
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 2 nd
and 3rd degree blocks that do not have a pacemaker
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
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)
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
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
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
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
Epinephrine
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)
Dopamine
Dobutamine
Digitalis (Digoxin)
Nitroglycerin
Sodium Bicarbonate
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
You Run the Code!
Indications:
Same as lidocaine and procainamide (usually
when condition doesnt 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
Similar to dobutamine
Used for refractory CHF
IV Dose:
2-15 micrograms/kg/min
Side effects:
May worsen ischemia
N &V
Thrombocytopenia