Ventricular Fibrillation (VF) / Pulseless Ventricular ...



ACLS Summary Revised February 2019

Epinephrine: 1 mg (10,000 concentration) q-3 – 5 minutes (no max dosage) used in cardiac arrest for the following rhythms: Asystole, Ventricular Fibrillation (VF), Pulseless Electrical Activity (PEA), Ventricular Tachycardia (VT) without a pulse.

A = Amiodarone: (Cordarone) V-Fib/pulseless VT: Dose 300 mg, (q-5 minutes) repeat 150 mg

Amiodarone: Stable VT or Stable SVT (patient with a pulse) – 150 mg over 10 minutes

A = Atropine: 0.5mg for symptomatic Bradycardia (total dose of 3 mg) (This medication may be beneficial in the presence of AV nodal block or ventricular asystole). Will not be effective for infranodal (Mobitz type II) block, or Third degree heart blocks with a ventricular escape complexes (wide QRS complex >120ms).

A = Adenosine: (adenocard) Stable SVT or Monomorphic VT 6mg, repeat dose of 12 mg. Should not be used for wide irregular rhythms. (note: this medication may cause paradoxical increase in the ventricular response).

A = Aspirin: oral dose in the event of an ACS is 160 – 325 mg

Dopamine Drip: (intropin) for hypotension and/or refractory symptomatic Bradycardia 2 – 10 mcg/kg/min

Magnesium Sulfate: 1-2 g IV/IO in 10 mL (eg, D5W, NS) over 5-20 minutes

Epinephrine Drip: 2 – 10 mcg/min

Capnography:

NOTE: In cardiac arrest the capnography or (PETCO2) needs to be greater than 10 mmHg, if 10 mmHg.

Normal capnogram is 35 – 40 mmHg.

Hypotension:

Note: if you obtain ROSC and your patient is hypotensive consider administering 1 – 2 liters of crystalloids (normal saline/LR)

NOTE: If your patient is hypotensive after fluid replacement then consider Dopamine 2 – 10 mcg/kg/min or Epinephrine/Norepinephrine Drip 0.1 – 0.5 mcg/kg/min.

NOTE: your goal is to achieve a systolic BP of 90 mmHg

ECG rhythms without a pulse:

|ECG Rhythms with No pulse |Medications for pulseless Rhythms |

|Ventricular Fibrillation (VF) |Epinephrine 1 mg & Amiodarone 300mg – 150mg |

|Ventricular Tachycardia (VT) |Epinephrine 1 mg & Amiodarone 300mg – 150mg |

|Note: the above 2 ECG rhythms are the only conditions that required defibrillation |

|Asystole |Epinephrine 1 mg |

|Pulseless Electrical Activity (PEA) |Epinephrine 1 mg |

|Note: a normal appearance ECG rhythm without a pulse | |

CPR:

ROSC – Return of Spontaneous Circulation

CAB = Circulation – Airway - Breathing

Switch CPR compressors every 2 minutes.

Don’t interrupt CPR longer than 5-10 seconds.

Limit your time evaluating for a pulse in the unresponsive patient between 5-10 seconds.

Agonal gasping respiratory effort is a good sign of a victim going into cardiac arrest (unresponsive).

CPR is usually indicated after each defibrillation attempt. (confirm the ECG rhythm)

Chest compression should be performed at a rate between 100 to 120/minute.

**Targeted Temperature Management (Hypothermia) range for specific patient’s after ROSC – 320 C to 360 C for 24 hours.**

Airway:

If your patient has an advanced airway in place, ventilate at a rate of 1 breath every 6 – 8 seconds

or 8 – 10 /minute. (target your PETCO2 of 35-40 mm Hg)- Avoid excessive ventilations.

If your patient is apneic with a pulse and no ET in place, ventilate at a rate of 1 breath every 5 – 6 seconds. (Excessive ventilation could potentially cause a decrease in cardiac output).

Adult chest compressions (2” or 1/3 of the chest wall in depth)

The current rate of chest compressions is 100-120/minute

To improve the outcome for STEMI patient’s. The recommended maximum goal time from ED door-to-door balloon inflation time for PCI is 90 minutes.

In the event of a successful pre-hospital resuscitation, a goal would be to transport your patient to a medical facility that has PCI capabilities

Electrical Interventions:

Unsynchronized shocks energy levels are based upon the manufacturing device.

ECG Rhythms that require synchronized Cardioversion:

a. Unstable supraventricular tachycardia (SVT) 50-100 joules

b. Unstable ventricular Tachycardia (VT) 100 joules

c. Unstable Atrial Fibrillation with RVR 120-200 joules

ECG Rhythms that require unsynchronized defibrillation: (Patient’s with NO pulse)

1.

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Ventricular Fibrillation (VF)

2.

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Monomorhpic Ventricular Tachycardia (VT)

3.

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Polymorhpic Ventricular Tachycardia (Torsades de Pointes)

Heart Block Criteria

1st degree HB – PRI >0.20 sec or 200 ms (5 little boxes or 1 large box, (Rhythm is Regular) (note: there is only 1 P-wave for every QRS complex)

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2nd degree HB Type I (Wenckebach) – PRI progressively gets long then drops a beat. (Rhythm is Irregular)

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2nd degree HB Type II – PRI is constant, with extra p-waves or p-waves without QRS complexes (Rhythm is regular and/or irregular) look for 2:1 conduction

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3rd degree HB (CHB) - No relationship between P and QRS (Ventricular Rhythm is regular) P waves are dancing (note: there are more P waves than QRS complexes)

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Symptomatic Bradycardia treatment options:

1. Atropine 0.5 mg

2. Transcutaneous Pacing (TCP)

3. Dopamine Drip 2-10 mcg/kg/min

4. Epinephrine Drip 2-10 mcg/min

5. Norepinephrine Drip 0.1 – 0.5 mcg/kg/minute

Tachycardia - Heart rate > 160/minute

(patient’s with a pulse)

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1. Monomorphic Ventricular Tachycardia (VT)

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2. Supraventricular Tachycardia (SVT)

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3. Atrial Fibrillation with Rapid Ventricular Rate (RVR)

Reversible Causes: H’s & T’s

Hypovolemia –Hypoxia - Hypothermia

Hydrogen Ion (acidosis) - Hypo-/hyperkalemia

Tension Pneumothorax - Tamponade, Cardiac

Toxins-Thrombosis- Pulmonary Thrombosis, Coronary

Pacing Technique

1. Position pacing electrodes on chest per package instructions

2. Apply limb leads to appropriate position on the patient

3. Turn on pacer

4. Set demand rate to approximately 60-80/minute

5. Set current (mA) output as follows for Bradycardia: increase current from minimum setting until consistent capture is achieved (characterized by a widening QRS and a broad T wave after each pacer spike)

6. Evaluate mechanical capture (assessing peripheral pulses).

7. Evaluate patient BP.

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Medications and the effect of prolong QT

In general, if a QTc is greater than 460ms it is considered prolonged at any heart rate. If you determine the QTc is greater than 460ms, then the patient should be cardioverted in the event of a stable fast heart rate >160/minute.

Synchronized cardioversion is the only therapy for a tachycardia that does not prolong the QT or possibly make the arrhythmia worse.

Note: when evaluating the QTc be sure all ECG limb leads and truly are on the limbs and NOT on the torso region for an accurate reading.

|Amiodarone |Zithromax |Cocaine |Erythromycin |

|Propulsid |Cipro |Haloperidol |Zofran |

|Inapsine |Levaquin |Methadone |Propofol |

|Seldane |Mellaril |Procainamide |Hydrocodone |

|Phenergan |Quinidine |Levitra |Amitriptyline |

|Amphetamine |Thorazine | | |

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Bill’s ECG Criteria Summary

|Rhythm |Rate – range |Regular/Irregular |Criteria |

|NSR |60-100/minute |Regular |1 p-wave for each QRS |

| | | |PRI- 0.12 - .20 sec |

|Sinus Bradycardia |< 60/minute |Regular |1 p-wave for each QRS |

| | | |PRI- 0.12 - .20 sec |

|Sinus Tachycardia |100-160/minute |Regular |1 p-wave for each QRS |

| | | |PRI- 0.12 - .20 sec |

|Sinus Arrhythmia |60-100/minute |Irregular |1 p-wave for each QRS |

| | | |PRI- 0.12 - .20 sec |

| | | |Caused by intrathoracic pressure changes |

|Sinus Block (SA) |60-100/minute |Irregular |1 p-wave for each QRS |

| | | |PRI- 0.12 - .20 sec |

| | | |A block or a pause between 2 normal beats, does |

| | | |not disrupt the normal rhythm |

|Sinus Arrest |60-100/minute |Irregular |1 p-wave for each QRS |

| | | |PRI- 0.12 - .20 sec |

| | | |A block or a pause between 2 normal beats, does |

| | | |disrupt the normal rhythm |

|Atrial Flutter |Ventricular Rate varies |regular/Irregular |Description of a sawtooth pattern with p-waves |

|Atrial Fibrillation |Ventricular Rate varies |Irregular |No identifiable p-waves |

|SVT |160/min |Regular |No identifiable p-waves, which are buried inside |

| | | |the T-wave, usually a narrow QRS complex |

|Wandering Atrial Pacemaker (WAP) |60-100/minute |Irregular |3 different morphology or shapes of P-waves |

|Junctional Rhythm |40-60/minute |Regular |P-waves are either absent, inverted or behind the|

| | | |QRS complex, Narrow QRS complex |

|Accelerated Junctional |60-100/minute |Regular |P-waves are either absent, inverted or behind the|

| | | |QRS complex, Narrow QRS complex |

| | | | |

|Junctional Tachycardia |100/minute |Regular |P-waves are either absent, inverted or behind the|

| | | |QRS complex. Narrow QRS complex |

|1st Degree HB | .20 sec or 5 little boxes or 1 large |

| | | |box |

|2nd Degree HB Type I | ................
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