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  ACLS Algorithms  1° SurveyTachycardias:   2° SurveyA fib/flutter Asystole    Narrow   Bradycardia   WidePEAStable VTDrugs   Unstable VT/VF   Classes   (Sources)   Home-Amb-Card-Crit- Neuro-OB-Orth-Pain-Ped-Reg-Tran-Vasc-Misc   Primary Survey      Assess responsiveness (speak loudly, gently shake patient if no trauma - Annie, Annie, are you OK? ).    Call for help/crash cart if unresponsive.    ABCD's (sorry, can't get a much better mnemonic than that ... maybe A Big Cruel Dude [just beat me up and I coded? ] ) o   A irway    Open airway, look, listen, and feel for breathing. o   B reathing    If not breathing, slowly give 2 rescue breaths. o   C irculation    Check pulse. If pulseless, begin chest compressions at 100/min, 15:2 ratio. Consider precordial thump with witnessed arrest and no defibrillator nearby. Interposed abdominal compression CPR may be more effective if trained personnel available, maybe contraindicated in pregnancy, recent surgery, abdominal aneurysm (Class 2b)  o   D efibrillation    Attach monitor, determine rhythm. If VF or pulseless VT: shock up to 3 times. If not, basic CPR. (I think we now have AED's on our code carts that will lead you through this.)    Then, move quickly to Secondary Survey.  Back to Top of Page  Secondary Survey       After initial (primary) assessment done    Another set of ABCD's - A Bigger, Crueler Dude (tried to finish me off) o   A irway    Establish and secure an airway device (ETT, LMA, COPA, Combitube, etc.). o   B reathing    Ventilate with 100% O2. Confirm airway placement (exam, ETCO2, and SpO2). Remember, no metabolism/circulation = no blue blood to lungs = no ETCO2. o   C irculation    Evaluate rhythm, pulse. If pulseless continue CPR, obtain IV access, give rhythm-appropriate medications (see specific algorithms). PIV preferred initially vs. central line. o   D ifferential Diagnosis    Identify and treat reversible causes. Back to Top of Page  Asystole      Primary Survey     Secondary Survey: Confirm rhythm (check monitor, power, different lead)    Treatment o   Consider bicarb, pacing early o   Police officer Hank having just found a body: Again (asystole)! Boy, This 'Ere's Awful! o   B icarb (NaHCO3). Consider for indications below:    Class 1: hyperkalemia    Class 2a: bicarbonate-responsive acidosis, tricyclic OD, to alkinalize urine for aspirin OD    Class 2b: prolonged arrest     Not for hypercarbia-related (respiratory) acidosis, nor for routine use in cardiac arrest o   T ranscutaneous Pacing (TCP)     Not shown to improve survival    If tried, try EARLY o   E  pinephrine    1 mg IV q3-5 min o   A tropine    1 mg IV q3-5 min    Max 0.04 mg/kg    Consider possible causes (Officer Hank reporting in: Agent (asystole) Hank Here ... He's Dead, Marshall ) o   H ypoxia o   H yperkalemia  o   H ypothermia o   D rug overdose (e.g., tricyclics) o   M yocardial Infarction    Consider termination. If patient had >10min with adequate resucitative effort and no treatable causes present, consider cessation - it is, after all, the final rhythm. Back to Top of Page  Bradycardia      Primary Survey     Secondary Survey  o   assess need for airway, oxygen, IV, monitor, fluids, vitals, pulse ox o   12-lead ECG, Hx, P/E. Consider DDx o   If AV block:    2nd degree (type 2) or 3rd degree: standby TCP, prepare for transvenous  pacing    slow wide complex escape rhythm: Do NOT give lidocaine.    If serious signs or symptoms, treat even though Bub (bradycardia), All People Die Eventually o   A tropine    0.5-1.0 mg IV push q 3-5 min    max 0.04 mg/kg o   P acing    Use transcutaneous pacing (TCP) immediately if sx severe o   D opamine    5-20 µg/kg/min o   E  pinephrine 2-10 µg/min Back to Top of Page  Tachycardias      Primary Survey, Secondary Survey: Is patient stable or unstable? o   stable: determine rhythm, treat accordingly o   unstable    =chest pain, dyspnea, decreased level of conciousness, low BP, CHF, Acute MI    If HR is cause of symptom (almost always HR>150): cardiovert     Specific Rhythms o   Atrial fib/flutter   o    Narrow-Complex (Supraventricular) Tachycardia  o   Wide-Complex Tachycardia, Unknown Type   o   Stable Ventricular Tachycardia Back to Top of Page  Atrial fibrillation/flutter      If unstable: proceed more urgently    Management: Control rate, consider rhythm cardioversion, and anticoagulate as shown  below, according to Category: 1, 2 or  3  Category 1. Normal EF    Rate control: Ca-blocker or beta-blocker.    Cardiovert: o   If onset < 48 hours, consider DC cardioversion OR with one of the following agents: amiodarone, ibutilide, procainamide, (flecainide, propafenone), sotalol. o   If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone). Either:    Delayed Cardioversion: anticoagulate adequately x 3 weeks, then cardioversion, then anticoagulate x 4 weeks    Early Cardioversion: iv heparin, then TEE, then cardioversion within 24 hours, then anticoagulate x 4 weeks    Anticoagulate if not contraindicated, if A fib > 48 hrs Category 2. EF< 40% or CHF    Rate control: o   digoxin, diltizaem, amiodarone (avoid if onset of AF > 48 hours). o   avoid verapamil, beta-blockers, ibutilide, procainamide (and  propafenone/flecainide)    Cardiovert: same as Category 1, except the only conversion agent allowed is amiodarone.    Anticoagulate, if A fib > 48 hr. Category 3. WPW A fib    Suggested by: delta wave on resting EKG, very young patient, HR>300    Avoid adenosine, beta-blocker, Ca-blocker, or Digoxin    If < 48 hour: o   If EF normal: one of the following for both rate control and cardioversion: amiodarone, procainamide, propafenone, sotalol, flecainide o   If EF abnormal or CHF: amiodarone or  cardioversion     If > 48 hour o   Medication listed above may be associated with risk of emboli o   Anticoagulate and DC cardioversion as in Category 1.
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