ACLS Arrhythmias and Treatment Modalities

Presented by CMR CPR (a division of CMR Medical Supply, LLC)

An American Heart Association Affiliated Training Site

DISCLAIMER

• The following information is provided by the American Heart Association.

• Monies collected do not represent income for the American Heart

Association. • Please review and study your American

Heart Association ACLS Manual before attempting to complete the AHA ACLS

Course.

QRS Complex

P wave indicates Atrial depolarization. QRS complex indicates Ventricular depolarization

T wave indicates re-polarization

Normal Sinus Rhythm

1st Degree Heart Block

• Usually benign, very common

• Not treatable in ACLS

• Progressively gets worse over time

• Not actually a block- just a delay in conduction

• PRI- >20 (4 small boxes)

• Normally regular

2nd Degree Heart Block, type 1 aka “Wenckebach”

• Usually Irregular

• Not treatable in ACLS

• PRI- Long, long, longer, DROP- must be a Wenckebach!

2nd Degree, Type 2 Heart Block

• Blocked P waves/dropped QRS Complexes

• Usually 1 or 2 additional P waves

• This is getting worse…

3rd Degree Heart Block (Complete Heart Block)

• Malignant

• Usually Bradycardic, Irregular

• Won’t take long…NEED TO TREAT!

• P waves regular, not associated w/ QRS complexes

Supra Ventricular Tachycardia (SVT)

• Firing somewhere above the Ventricles

• Treatable over 150 BPM per ACLS

• Regular and FAST!

Ventricular Tachycardia (V- tach with or w/o Pulses)

• Extremely dangerous arrhythmia

• Patient wont last long

• Wide and Bizarre pattern, but regular

• Shock-able rhythm (if no pulse present)

Torsades de Pointes

• Translates to: “Twisted of the Spikes”

• Described as Polymorphic Tachycardia

• May degenerate to V-Fib if persistent

• Caused by HYPOkalemia/HYPOmagnasemia

Ventricular Fibrillation (V-Fib)

• Won’t have a pulse

• Fine or coarse

• Shock-able rhythm

• Patient is in CARDIAC ARREST at this point

Pulseless Electrical Activity (PEA)

• ANY rhythm can be PEA as long as it doesn’t have a PULSE!

• YOU MUST CHECK A PULSE WITH EVERY RHYTHM- In a Cardiac Arrest!

Asystole (Flat line)

• Heart not producing ANY electrical activity

• NON-Shock-able Rhythm

• Patient is DEAD

Acute M.I. (Leads 2,3 & aVF)

ACLS DRUGS

Atropine

• Derived from the Nightshade Plant (deadly)

• Dilates pupils, increases heart rate

• Used to treat symptomatic bradycardia

• No longer used for PEA

DOSE: 0.5 mg with a maximum of 3.0 mg

ACLS DRUGS

Adenosine

• Inhibits neurotransmitters

• “Resets” heart

• Asystole for 3-5 seconds

• Causes a transient heart block in the AV node

• Used to treat Asymptomatic SVT over 150bpm

• NOT for wide complex IRREGULAR V -Tach

DOSE: 6.0 mg then 12.0 mg

ACLS DRUGS

Amiodarone Bolus

• Anti-arrythmic

• Works on the Atria and the Ventricles

DOSE: 300 mg then 150 mg. MAX: 450 mg

ACLS DRUGS Epinephrine (Bolus)

• Hormone naturally occurring in the body

• Affects the Sympathetic Nervous System

• Constricts blood vessels, increases peripheral resistance

• Increases Heart Rate (Inotropic effects and Chronotropic effects) (electricity and rate)

DOSE: 1.0 mg NO MAX DOSE!

ACLS DRUGS Vasopressin

• Anti-diuretic hormone

• Retains water in the body and constricts blood vessels

• May be used in cardiac arrest in place of 1st or second dose of epinephrine

• Half life is 10-20 minutes

DOSE: 40 units

ACLS DRUGS

Dopamine

• Second-line drug for symptomatic bradycardia when atropine is not effective

• Used for cardiogenic shock in the absence of hypovolemia

Dose: 2-10 micrograms/kg/min infusion

ACLS DRUGS

Epinephrine (Infusion)

• Second-line drug for symptomatic bradycardia when atropine is not effective. Choose EPI or Dopamine

Dose: 2-10 micrograms/kg/min infusion

ACLS DRUGS

Magnesium Sulfate

• For the treatment of Torsades with pulses present

Dose: 1-2 Grams

H’s and T’s

• Hypovolemia

• Hypoxia

• Hydrogen Ions (acidosis)

• Hyper/Hypo kalemia

• Hypothermia

• Toxins

• Tamponade (cardiac)

• Tension Pneumothorax

• Thrombosis (coronary)

Circular Algorithm

Treatment Modalities per ACLS

• V-FIB or (V-TACH w/o pulses) are the only shock-able rhythms.

• Start at 360J, and continue at 360J* (With a MONO-phasic Defibrillator)

• High Quality CPR

• EPI or (Vasopressin, 1st or 2nd dose)

• Amiodarone- 300mg, then 150mg (450mg MAX)

SVT

• Treatable at 150 BPM

• Use Valsalva Maneuver First (Think BLS)

• Stable= Drugs. Adenosine 6mg, 12mg, done

• Unstable= Electricity. Synchronized Cardioversion. (sedate first) 100 J,200J, 300J 360J* (discussed in class)

• MAKE SURE YOU PUSH SYNCH BUTTON!

• Be careful w/ rapid A fib- throw a clot…BAD

V-TACH w/PULSES (Regular)

• Dangerous arrhythmia- PT. wont last long

• Valsalva maneuver first (Think BLS)

• Stable= Use Adenosine

• Unstable= Electricity (Monophasic)

• 100J,200J, 300J 360J

• Try to sedate first. Don’t delay treatment.

• PT. will usually be UNSTABLE!

V-Tach (Irregular, Torsades)

• Dangerous arrhythmia- PT. wont last long

• Valsalva maneuver first (Think BLS)

• Stable= Adenosine- not indicated.

• Magnesium Sulfate

• Electricity. 100J,200J, 300J 360J (Monophasic)

Bradycardias

• Less than 60 BPM

• Stable= DO NOT TREAT- watch patient

• Unstable= (1) Atropine (2) Dopamine or EPI Drip (3)Pacing…

Pacing

• Apply D-Fib Pads on Pt

• Set Pacer at 80 bpm

• Increase mA until 1 pacer spike precedes QRS

• Check Femoral Artery for pulse that matches monitor

• If is doesn’t, increase mA until it does

PEA (Pulsless Electrical Activity)

• A rhythm that appears on a monitor to have a pulse, but does not when the pulse is checked

• High quality CPR

• Epinephrine, 1.0 mg

• NON- SHOCKABLE!

Complete Heart Block (3rd degree)

• The use of Atropine is not indicated

• Transcutaneous pacing

• Fluids

• Oxygen

• Cardiology consult