Advanced Cardiac Life Support

Immediate

• Presumption: Out-of-hospital cardiac arrest with minimal resources
• Check pulse, if pulseless
• Begin CPR
• Attach monitor/defibrilator
• Rhythm shockable?
• Give oxygen if available
• Definitive treatment is transfer to nearest emergency department

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V-Fib and Pulseless V-Tach (Shockable)

ACLS Algorithm

• Shock as quickly as possible and resume CPR immediately after shocking
  • Biphasic - 200J
  • Monophasic - 360 J
• Give Epinephrine 1mg if (shock + 2min of CPR) fails to convert the rhythm
• Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
  • 1st line: Amiodarone 300mg IVP with repeat dose of 150mg as indicated
  • 2nd line: Lidocaine 1-1.5mg/kg then 0.5-0.75mg/kg q5-10min
  • Polymorphic V-tach: Magnesium 2g IV, followed by maintenance infusion

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Asystole and PEA (Non-Shockable)

• Epinephrine 1mg q3-5min

Mechanism of PEA

• Three major mechanisms of PEA (3 & 3 Rule)
  • Severe Hypovolemia (or dehydration in athletes)
  • Obstruction
    • Tension pneumothorax
    • Cardiac tamponade
    • Massive Pulmonary embolism
  • Pump Failure

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Treatable ACLS Conditions (H's and T's)

• Hypovolemia
• Hypoxemia
• Hydrogen ion (i.e. severe acidemia)
• Hypokalemia/Hyperkalemia
• Hypothermia/Heat Stroke
• Tension Pneumothorax
• Cardiac Tamponade
• Toxicology including Performance Enhancing Drugs‎
• Thrombosis, pulmonary
• Acute Coronary Syndrome

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PEA Evaluation by QRS

Differential based on QRS being narrow or wide and aided by ultrasound

QRS Narrow

• Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause
  • Cardiac Tamponade
  • Tension Pneumothorax
  • Deterioration after intubation
  • Pulmonary Embolism
  • Acute Coronary Syndrome

QRS Widened

• Metabolic LV Problem – Ultrasound should show hypokinetic LV
  • Hyperkalemia
  • Sodium-channel blocker toxicity (Ex. Tricyclic (TCA) toxicity)
  • Agonal rhythm
  • Acute Coronary Syndrome

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General

• A: Adjunct - Place oropharyngeal airway
• B: Breathing - Attach to bag valve mask (BVM)
• C: Compressions - Switch out providers q pulse check (ever 2 minutes)
• D: Defibrillation
  • May be ok to shock during compressions if wearing gloves and using biphasic device
  • Precharge prior to pulse & rhythm check to increase overall compression time
• E: Exposure
• Other
  • Consider placing IO if unable to obtain IV access
  • Use ultrasound to evaluate for possible correctable etiologies

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See Also

• Sudden Cardiac Death
• Cardiology (Main)

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