ACLS

New Points

EtCO2

BLS

ECG

V-fib, Pulseless VT

Asystole and PEA

Bradycardia

Tachycardia

New Points

• No ventilations for untrained lay persons
• Compression: a priority, push hard (2cm), push fast (100/min)
• No Atropine, no pacing on PEA/Asystole
• Supraglottic airway (eg. LMA) is upgraded
• Cricoid Pressure not routine
• Bedside Echo

EtCO2 is cool

• Tube confirmation
• Gauge of quality CPR
• Marker of futility of resus (<10mmHg)
• Marker of ROSC (increase of 10mmHg)

BLS

• Compressions: minimize interruptions, push hard/fast
• Ventilation: 30:2 (8-10 breaths if intubated)

ECG

• rate: fast or slow
• WRS: wide or narrow
• rhythm: regular or irregular

V-fib, Pulseless VT

• Shock + CPR - Adrenaline - Shock + CPR - Amiodarone - Causes
• Shock (Unsynchronized 200J biphasic, 360J monophasic) + CPR x 2 mins
• Adrenaline 1mg if Shock + CPR x 2 minute does not convert
• Shock + CPR
• Amiodarone 300mg IV push, repeat 150mg as indicated;
• or Lignocaine 1-1.5mg/kg then 0.5-0.75mg/kg q5-10 mins;
• or Magnesium 2g IV, then infusion (polymorphic VT)

Asytole, PEA

• Adrenaline 1mg q3-5 mins
• 6H: Hypovolemia, Hypoxia, Hypothermia, Hypoglycaemia, H ions (Acidosis), HypoK/HyperK
• 5T: Tox, cardiac Tamponade, Tension PTX, Thrombosis (AMI), Thrombosis (PE)

Bradycardia

• Significant if chest pain, hypotension, AMS, pulmonary oedema
• Profound bradycardia <40 bpm
• Temporize with Atropine 0.5mg 3-5 mins if QRS is not wide
• 1. Transcutaneous Pacing
• 2. Chronotropes:
• 2a. Dopamine 2-10mcg/kg/min
• 2b. Adrenaline 2-10mcg/min
• Transvenous pacing if above fails

Tachycardia

• 3 questions
• 1. Sinus?
• 2. QRS wide or narrow?
• 3. Regular or irregular?

Narrow regular

• Sinus Tachycardia: Tx underlying
• SVT: Vagal maneuver (converts 25%)
• Adenosine: 6mg IVP, then 12mg
• If fails, Diltiazem 15-20mg IV, then infusion of 5-15mg/h
• or Metoprolol 5mg IVP x 3 followed by 50mg PO
• Synchronized cardioversion 100J Biphasic

Narrow irregular

• MAT: Tx underlying HypoK, hypoMg
• Sinus Tachycardia with frequent PACs
• Afib, Aflutter with variable conduction
• Diltiazem
• MTP (good in setting of ACS)
• Amiodarone (good in hypotension, CHF)
• Digoxin (good in CHF)
• Synchronized Cardioversion: 120-200J

Wide regular

• VT unless proven otherwise
• If stable, antiarrhythmics
• 1. Procainamide 20-50mg/min till rhythm is suppressed, hypotensive or max (17mg/kg), avoid if prolonged QT
• 2. Amiodarone 150mg x 10 mins, repeat as necessary
• 3. Sotalol 100mg IV x 5 mins: avoid if prolonged QT
• Synchronized Cardioversion: 100J
• Adenosine is okay for Dx and Tx if rhythm is regular and monomorphic
• .
• SVT with aberrancy: Tx as SVT

Wide Irregular

• No AV nodal blockers (Adenosine, B blocker, Ca blockers, Dig), can trigger V-fib
• 1. Afib with preexcitation
• 1a. First line: Electric Cardioversion
• 2b. Second line: Procainamide, Amiodarone, Sotalol
• 2. Afib with aberrance
• 3. Polymorphic VT/Torsades
• 3a. Emergent Defib (NOT synchronized)
• 3b. Correct electrolytes
• 3b. Stop QT prolonging meds

Source: AHA ACLS 2010