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Acls Algorithms 2012

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ACLS algorithms.
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   Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital CPR International ACLS Guidelines 2010 updated 2012   Ventricular Fibrillation/ Pulseless Ventricular Tachycardia SHOCK FIRST x 1 ( If defibrillator not immediately available start CPR then shock ASAP ) 200 J Biphasic, 360 J Monophasic    High Quality CPR* x 2 min (  prior to rhythm or pulse check) (Ventilate, IV/IO Access)    SHOCK    CPR x 2 min (Intubate, Drugs-give during CPR) Treat reversible causes    EPINEPHRINE 1 mg IV  (may be given after 1 st  or 2 nd  shock) (REPEAT Q 3-5 MIN) ( Vasopressin 40 U IV may be an alternate to 1 st  or 2 nd  dose of epinephrine)      SHOCK       CPR x 2 min AMIODARONE 300 mg IV bolus (Preferred) (may give 2 nd  dose 150 mg IV)   or    LIDOCAINE  1.5 mg/kg IV (REPEAT in 3-5 min) (Max. 3 mg/kg) or MAGNESIUM SULFATE  2 G IV  (with torsades)    SHOCK    *High Quality CPR: Push hard ( ≥2 inches) and fast (≥100/min), complete chest recoil, minimize interruptions, avoid excessive ventilations (8-10/min), change compressors q2min, monitor end-tidal C02 Hypothermia (32-34ºC) recommended for resuscitated v. fib. patients who remain comatose and intubated with a BP >90. Treat Reversible Causes: hypovolemia, hypoxia, acidosis, K, hypothermia, toxins, ischemia   Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital International ACLS Guidelines 2010   WIDE COMPLEX TACHYCARDIA ASSESS ABC’S IF STABLE, O2, MONITOR, O2 SAT, VITALSIGNS (Hx, P/E, EC G, CXR) Unstable   Stable (Chest pain, SOB, LOC, low BP, CHF, AMI) (consider cardioversion first, as meds only work about 30% of the time )  Likely VT Regular, monomorphic, uncertain srcin Procainamide  20-50 mg/min (max 17mgkg) no change Adenosine  6-12 mg OR (defibrillator at bedside) Amiodarone*  150 mg over 10 min (repeat prn) Infusion: 1 mg/min x 6 hrs, then 0.5 mg/min over 24 hrs (Max: 2.2m in 24 hrs) Prepare for cardioversion Consider premedication SYNCHRONIZED Biphasic : 100-150-200 CARDIOVERSION Monophasic: 200  –  300  –  360  If Ventricular Tachycardia is polymorphic (Torsades) consider: magnesium 2 gm, overdrive pacing, isoproterenol, Phenytoin, Lidocaine, amiodorone. * Avoid giving multiple antidysrhythmics sequentially (to prevent proarrhythmias). If one antidysrhythmic fails, go to electrical cardioversion.   Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital International ACLS Guidelines 2010   PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (AVnRT, AVRT) STABLE  UNSTABLE CARDIOVERSION (Consider premedication) VAGAL MANOEUVRES Adenosine 6 mg IV over 3 seconds, may repeat 12 mg in 1-2 min (Class I) -may be preferred option due to short 10 second half life and no effects on BP or Diltiazem  20 mg IV over 2 min, may repeat 25 mg IV in 15 min (Class I) or Metoprolol  5 mg IV, may repeat x 2: max 15 mg total (Class I) or Verapamil  2.5  –   5 MG I.V. over 2 min, may repeat 5-10 mg in 10 minutes (Class I) Others to consider: Procainamide  30mg/min to 17/kg (Class IIa) Amiodarone 150 mg over 10 min (Class IIa) or SYNCHRONIZED CARDIOVERSION (consider premedication) Monophasic:,100,200,300 j Biphasic: 70, 100, 150 j   Dr. Brian Weitzman, Department of Emergency Medicine, Ottawa Hospital International ACLS Guidelines 2010 Atrial Fibrillation or Atrial Flutter * STABLE UNSTABLE  CARDIOVERSION -higher risk of stroke if a.fib/flutter>48 hrs and  patient not anticoagulated 1)   Control Heart Rate if > 120  Narrow Complex Wide Complex (WPW or BBB) Diltiazem 20 mg IV Procainamide 30 mg/min to 17mg/kg 2  Verapamil 2.5-5mg IV 1  Amiodarone 150 mg over 10 min 2  Metoprolol 5 mg IV 1  Amiodarone 150 mg over 10 min 2 Digoxin 0.5 mg IV 1) Do not use verapamil or metoprolol if LV function is impaired (<40%). 2) Do not use amiodarone or procainamide if fibrillation or flutter present for > 48 hours as these medications may convert the rhythm back to sinus. 2) Convert rhythm back to NSR -atrial flutter < 48 hours requires electrical cardioversion A fib < 48 hours A. fib or flutter > 48 hrs  duration   Cardiovert Electrically or with Drugs 1) Anticoagulate x 3 weeks prior to and 4 weeks Procainamide (drug of choice for IV route) after cardioversion Amiodarone (less effective for acute conversion) OR Heparinize, do TEE, cardiovert if no clot, Propafenone 600 mg po or then anticoagulate x 4 wks post cardioversion 2) Long term rate control with beta or calcium channel blocker Consider long term anticoagulation with recurrent episodes, if in high risk group for stroke: CHAD2 score > 1-2: previous stroke or TIA, diabetes, CHF, age > 75 *N.B. Medications are not effective in converting atrial flutter back to NSR and the treatment of choice is electrical cardioversion if < 48 hrs duration

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