ACLS Summary 48 hrs of A FibA Flutter

ACLS Summary † <48 hrs of A. Fib/A. Flutter Rate Control: Diltiazem OR Metoprolol (VF preserved) Diltiazem OR Digoxin OR Amiodarone (VF impaired) DC Cardioversion >48 hrs of A. Fib/A. Flutter Rate Control: Diltiazem OR Metoprolol (VF preserved) Diltiazem OR Digoxin OR Amiodarone (VF REMEMBER § check pulses after each drug/maneuver/shock § Safety of team – always clear § Sync Monitor for cardioversion § Ensure CPR 100/min, Vents 10/min, check ETT ‡ Stable/Not Stable Vitals (low BP, low RR), Chest Pain, SOB, LOC, worsening CHF, Pulmonary Edema impaired) Urgent Cardiovert within 24 hrs – IV heparin prior; anticoag 4 wks Delayed Cardiovert – anticoag 3 wks, cardiovert, anticoag 4 wks Primary Survey ABCs Call for help / Call code O 2, IV, Monitors Pulse Present Bradycardic No Pulse Not breathing? Bag Ventilations (2 breaths) Tachycardic Start CPR – 15: 2 before ETT VF / pulseless VT Asystole Check leads, gain, machine (different lead) Non-sync’d Defibrillation Stable‡ Unstable‡ Consider Synd’d Early Cardioversion NO YES 200, 360 J Narrow Wide Consider sedation mcg Fentanyl Sync’d Cardioversion 100, 200, 360 J 12 lead ECG Adenosine 6 mg IVP + 20 cc NS, repeat 12 mg IVPx 2 12 lead ECG Epi 1 mg q 3 -5 min Search for Cause: Old ECG Hypovolemia TCP Amiodarone 150 mg IV over 10 min 1 mg/kg(6 h), 0. 5 mg/min(18 h) Sync Cardioversion Dopamine 5 -20 mcg/kg/min Diltiazem 0. 25 mg/kg slow IVP (2 min). Repeat 0. 35 mg/kg after 15 -30 min OR Procainamide* 20 -30 mg IVP Epi 2 -10 mcg/min Verapamil 2. 5 -5 mg IVP Isoprotenerol 2 -10 mcg/min Procainamide 20 -30 mg/min Prepare for TVP Metoprolol 5 mg IVP q 3 -5 min x 3 TCP (start 70 bpm 20 m. A) Epi 1 mg q 3 -5 min Atropine 1 mg q 3 -5 if HR <60 Atropine 1 mg (max 0. 04/kg) TVP Atropine 0. 5 - 1 mg q 5 min Intubate, IV 50 Vagal Maneuvers Observe Intubate, IV A. Fib/ A. Flutter† PEA Consider TCP if short “down time” Check Pulse Type II, 2 degree 3 degree heart block WPW no-no’s Adenosine β-blockers Ca 2+ Channel Blockers Digoxin Amiodarone – SAFE Procainamide if good VF Urgent/Delayed Cardiovert if >48 hrs Labetolol 10 mg IVP over 1 -2 min (max 150 mg) Digoxin 0. 1 -0. 5 mg IVP OR Amiodarone 150 mg IV(10 min) * Do not use if EF<40% Epi 1 mg IV q 3 min OR Hypoxia Vasopressin 40 units IVP once H+ acidosis (Defibrillate 360 J after each Epi/other drug) Hyper/Hypokalemia Consider: Hypothermia Amiodarone 300 mg bolus then 150 mg bolus after 3 -5 min Tablets Lidocaine 1. 5 mg/kg IV (max 3 mg/kg) Tension Pneumo Procainamide 50 mg/min IV (max 17 mg/kg) Mg. Sulfate 2 g bolus (if indicated) in 10 cc D 5 W Tamponade Thrombosis Coronary Thrombosis Pulmonary