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ACLS
Advanced Cardiac Life Support
RC 275
Defibrillation
External depolarization of the heart to
stop Vfib or Vtach (that has not
responded to other maneuvers)
Automated External Defibrillator
Defibrillation Procedure
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Position paddles
“Clear” the patient
Shock and then
resume CPR for 5
cycles then re-analyze
after each shock
Prepare drug therapy
ACLS Drug Therapy
Routes of Administration
Peripheral IV – easiest to insert during CPR
 Central IV – fast onset of action
 Intratracheally (down an ET tube)
 Intraosseous – alternative IV route in peds
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Oxygen
FIO2 100%
 Assist Ventilation
 O2 Toxicity should not be a concern during
ACLS
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IV Fluids
Volume Expanders – crystalloids , eg
Ringer’s lactate, N/S, or colloids, eg
Albumin or Hetastarch
 TKO – D5W, N/S
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Morphine Sulfate
Drug of choice for pain
 Also decreases pre-load
 IV dose – 2-4 mg as often as every 5
minutes
 Precautions
 May cause respiratory depression
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The Following Drugs Help to
Control Heart Rate & Rhythm
Lidocaine
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Indications:
 PVCs, Vtach, Vfib
 Can be toxic so no longer given
prophylactically
IV dose :
 1-1.5 mg/kg bolus then continuous infusion of
2-4 mg/min
 Can be given down ET tube
Signs of toxicity:
 slurred speech, seizures, altered consciousness
Amiodarone (Cordarone)
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Indications:
 Like Lidocaine – Vtach, Vfib
IV Dose:
 300 mg in 20-30 ml of N/S or D5W
 Supplemental dose of 150 mg in 20-30 ml of
N/S or D5W
 Followed with continuous infusion of 1
mg/min for 6 hours than .5mg/min to a
maximum daily dose of 2 grams
Contraindications:
 Cardiogenic shock, profound Sinus
Bradycardia, and 2nd and 3rd degree blocks that
do not have a pacemaker
Procainamide (Pronestyl)
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Indications:
 Like lidocaine (is usually a second choice)
 Uncontrolled Afib or Atrial flutter if no signs of
heart failure
Dose :
 continuous IV infusion. Initially 20mg/min
then titrated down to 1-4 mg/min
Side effects
 Hypotension
 Widening of the QRS
Atropine
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Indications:
 Symptomatic sinus bradycardia
 Second Degree Heart Block Mobitz I
 May be tried in asystole
 Organophosphate poisoning
IV Dose:
 .5 – 1 mg every 3-5 minutes
 Max dose is .04mg/kg
 Can be given down ET tube
Side Effects:
 May worsen ischemia
Isoproterenol (Isuprel)
Indications:
 Temporary stimulant prior to pacemaker
 Bradycardia refractory to atropine
 Torsades de Pointes refractory to
magnesium sulfate
 IV dose:
 Continuous infusion of 2-10
micrograms/ml of infusion fluid
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Adenosine
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Indication:
 PSVT
IV Dose:
 6 mg bolus followed by 12 mg in 1-2 minutes if
needed
Side Effects:
 Flushing
 Dyspnea
 Chest Pain
 Sinus Brady
 PVCs
Verapamil
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Indications:
 Is a calcium channel blocker that may terminate
PSVT (is a backup to Adenosine) as well as
atrial flutter and uncontrolled atrial fib
IV Dose:
 2.5-5 mg over 2 minutes up to 20 mg
Side Effects:
 Hypotension
N &V
Magnesium
Used for refractory Vfib or Vtach caused by
hypomagnesemia and Torsades de Pointes
 Dose:
 1-2 grams over 2 minutes
 Side Effects
 Hypotension
 Asystole!
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Propranolol
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Beta blocker that may be useful for Vfib
and Vtach that has not responded to other
therapies
 Very useful for patients whose cardiac
emergency was precipitated by
hypertension
 Also used for Afib, Aflutter, & PSVT
The Following Drugs Improve
Cardiac Output &Blood Pressure
Epinephrine
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Because of alpha, beta-1, and beta-2 stimulation, it
increases heart rate,stroke volume and blood
pressure
 Helps convert fine vfib to coarse Vfib
 May help in asystole
 Also PEA and symptomatic bradycardia
IV Dose:
 1 mg every 3-5 minutes
 Can be given down the ET tube
 Can also be given intracardiac
 May increase ischemia because of increased O2
demand by the heart
Vasopressin (ADH)
Similar effects to Epinephrine without as
much cardiovascular side effects!
 IV dose = 40 IU
 Can be given down ET tube
 May be better for asystole
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Norepinephrine (Levarterenol)
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Similar in effect to epinephrine
Used for severe hypotension that is NOT due to
hypovolemia
Cardiogenic shock
Administered as a continuous infusion
 Adult rate is usually 2-12 micrograms/min
 Range is .5-1 microgram up to 30!
Side effects:
 Like epinephrine, it may worsen ischemia
 Extravasation causes tissue necrosis
Dopamine
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Used for hypotension (not due to hypovolemia)
 Usually tried before norepinephrine
 Has alpha, beta, and dopaminergic properties
 Dopaminergic dilates renal and mesenteric
arteries
Second choice for bradycardia (after Atropine)
IV Dose:
 1-20 micrograms/kg
Side effects:
 Ectopic beats
Dobutamine
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Actions similar to Dopamine
Used for CHF with hypotension
IV Dose:
 2-20 micrograms/minute
Side effects:
 Tachycardia
N &V
 Headache
 Tremors
Digitalis (Digoxin)
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Slows conduction through A-V node and increases
force of contraction
Used in CHF and chronic atrial fib/flutter
Can be given orally or IV
Side effects:
 Arrhythmias
 N & V, diarrhea
 Agitation
Nitroglycerin
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Vasodilator that helps relieve pain from angina
pectoris
Can be given IV, sublingually, as an ointment or a
slow release patch
Side effects:
 Headache
 Hypotension
 Syncope
 V/Q mismatch
Sodium Nitroprusside (Nipride)
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Vasodilator used for hypertensive crisis
IV dose:
 Loading dose of 50 –100 mg followed by
infusion of .5-8 micrograms/kg/min
 Is light sensitive so IV bag must be wrapped in
tin foil
Side effects:
 Hypotension so patient must have continuous
hemodynamic monitoring
Sodium Bicarbonate
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Used for METABOLIC acidosis hyperkalemia
 H + HCO3 >H2CO3>H2O and CO2
 Airway and ventilation have to be functional!
IV Dose:
 1 mEq/kg
 If ABGs, [BE] x wt in kg/6
Side effects:
 Metabolic alkalosis
 Increased CO2 production
Thrombolytics
Used to improve coronary blood flow by
lysing clots, ie coronary thrombosis
 Best if given within six hours of onset of
chest pain
 Examples: TPA/Alteplase(Activase),
Streptokinase
 Side effects:
 Bleeding
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ACLS Scenario
You Run the Code!
A 62 year old female is admitted
to the ER with chest pain,
dyspnea, and moist, gurgling
crackles. She appears in acute
distress and is cyanotic. Vital
signs are: P =110, R = 20, BP =
80/40.
Cardiac monitoring is initiated
and the following EKG is
observed:
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What is the patients arrhythmia and probable
medical problem?
What therapies should be done? Explain each one.
The EKG began to show:
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What is occurring in the heart to cause this
arrhythmia?
How is this treated?
What other arrhythmias may occur now?
The patient suddenly becomes
lifeless and the EKG shows:
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Uh oh! What now?
The treatment(s) are unsuccessful
and the following EKG appears:
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What should be done now and why?
Finally, the following EKG is
obtained. However, BP is 40/0
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What needs to be done now?
You saved her! The course is complete!
Bretylium Tosylate (Bretylol)
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Indications:
 Same as lidocaine and procainamide (usually
when condition doesn’t respond to these two)
IV dose:
 5-10mg/kg bolus followed by continuous
infusion of 1-2 kg/min
Side Effects:
N &V
 Hypotension
Amrinone
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Similar to dobutamine
Used for refractory CHF
IV Dose:
 2-15 micrograms/kg/min
Side effects:
 May worsen ischemia
N &V
 Thrombocytopenia