ACLS Lecture

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ACLS Lecture

  1. 1. 2005 AHA Guideline Changes BLS for Healthcare Providers ACLS Updates
  2. 3. Purpose of BLS Changes <ul><li>To improve survival from cardiac arrest by increasing the number of victims of cardiac arrest who receive early, high-quality CPR </li></ul><ul><ul><li>Planned, practiced response with CPR/AEDs yields survival rates of 49-74% </li></ul></ul>
  3. 4. What Have We Learned About CPR? <ul><li>330,000 die annually from coronary heart disease CDC </li></ul><ul><li>60% from Sudden cardiac event @ home or en route </li></ul><ul><li>85-90% in VF/VT arrest </li></ul><ul><li>2-3 x greater survival if CPR is immediate, with defib <5 min. </li></ul><ul><li>EMS relies on trained, willing, equipped public </li></ul>
  4. 5. Less than 1/3 get bystander CPR Even pros don’t do good CPR! <ul><li>Too slow </li></ul><ul><li>Too shallow </li></ul><ul><li>No CPR x 24-49% of the arrest! </li></ul>
  5. 6. Most significant changes 2005 <ul><li>IT’S ALL ABOUT BLOOD FLOW! </li></ul><ul><li>Emphasis on effective CPR </li></ul><ul><ul><li>Fast; deep; 50/50; minimal interruption </li></ul></ul><ul><li>Single compression-to-ventilation ratio </li></ul><ul><ul><li>30:2 single rescuer adult, child, infant, excluding newborns </li></ul></ul>
  6. 7. Most significant changes (cont.) <ul><li>Each shock from an AED should be followed by 2 minutes of CPR (5 cycles of 30:2) starting with compressions </li></ul><ul><li>Each rescue breath should take one second and produce visible chest rise </li></ul><ul><li>Reaffirmation that AEDs should be used for kids 1-8 y.o. </li></ul>
  7. 8. Why change compressions? <ul><li>When compressions stop, blood flow stops! </li></ul><ul><li>Universal compression ratio easier to learn/retain </li></ul><ul><li>Higher ratio yields more blood flow; keeps pump “primed” </li></ul>
  8. 9. Why shorten breaths? <ul><li>Large volume breaths increase ITP; decrease venous return to heart </li></ul><ul><li>Long breaths interrupt compressions </li></ul><ul><li>Hyperventilation decreases coronary and cerebral perfusion pressures </li></ul><ul><li>Over-ventilation increases air in stomach; regurgitation/aspiration </li></ul>
  9. 10. Why from 3 shocks to 1? <ul><li>Biphasic defibrillators eliminate VF 85% on first shock </li></ul><ul><li>Current AED sequence can delay CPR 37 seconds </li></ul><ul><li>Long CPR interruptions decrease likelihood of subsequent successful shocks </li></ul><ul><li>Myocardial “stunning” (O2, ATP depletion) </li></ul>
  10. 11. Chest Compressions <ul><li>2005 (New): </li></ul><ul><ul><li>Push hard, fast, rate of 100 per minute </li></ul></ul><ul><ul><li>Allow full chest recoil after each compression </li></ul></ul><ul><ul><li>Minimize interruptions (no more than 10 seconds at a time) except for specific interventions (advanced airway/AED) </li></ul></ul>
  11. 12. Chest Compressions cont’d <ul><li>2000 (Old): </li></ul><ul><ul><li>Less emphasis was given to need for adequate depth, complete chest recoil, and minimizing interruptions </li></ul></ul>
  12. 13. Chest Compressions cont’d <ul><li>Why: </li></ul><ul><ul><li>If chest not allowed to recoil: </li></ul></ul><ul><ul><ul><li>less venous return to heart </li></ul></ul></ul><ul><ul><ul><li>reduced filling of heart </li></ul></ul></ul><ul><ul><ul><li>Decreased cardiac output for subsequent chest compressions </li></ul></ul></ul><ul><ul><li>When chest compressions are interrupted, blood flow stops and coronary artery perfusion pressure falls </li></ul></ul>
  13. 14. Chest Compressions cont’d <ul><li>Why: </li></ul><ul><ul><li>Study of CPR performed by healthcare providers found that: </li></ul></ul><ul><ul><ul><li>½ of chest compressions too shallow </li></ul></ul></ul><ul><ul><ul><li>No compressions provided during 24% to 49% of CPR time </li></ul></ul></ul>
  14. 15. Changing Compressors Every 2 Minutes <ul><li>2005 (New): </li></ul><ul><ul><li>If more than 1 rescuer present, change “compressor” roles every 2 minutes </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Rescuers changed when fatigued-usually did not report feeling fatigued until 5min. or more </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>In manikin studies, rescuer fatigue developed in as little as 1-2minutes(as demonstrated by inadequate chest compressions) </li></ul></ul>
  15. 16. Rescue Breathing without Compressions <ul><li>2005 (New): </li></ul><ul><ul><li>10-12 breaths per minute (adults) 1 every 5-6 seconds </li></ul></ul><ul><ul><li>12-20 breaths per minute for infant or child 1 every 3-5 seconds </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>10-12 breaths for adults </li></ul></ul><ul><ul><li>20 breaths for infant or child </li></ul></ul>
  16. 17. Rescue Breathing without Compressions cont’d <ul><li>Why: </li></ul><ul><ul><li>Wider range of acceptable breaths for infant and child will allow the provider to tailor support to patient </li></ul></ul><ul><ul><li>Note: If you are assisting lay rescuer-they are not taught to deliver rescue breaths without chest compression </li></ul></ul>
  17. 18. Rescue Breaths with Compressions <ul><li>2005 (New): </li></ul><ul><ul><li>Each rescue breath should be given over 1 second and produce visible chest rise </li></ul></ul><ul><ul><li>Avoid breaths that are too large or too forceful </li></ul></ul><ul><ul><li>Manikins configured so that visible chest rise occurs at 500-600ml </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Rescue breaths over 1-2 seconds </li></ul></ul><ul><ul><li>Recommended tidal volume for adult rescue breaths was 700ml-1000ml </li></ul></ul>
  18. 19. Rescue Breaths with Compressions cont’d <ul><li>Why: </li></ul><ul><ul><li>Oxygen Delivery </li></ul></ul><ul><ul><ul><li>Oxygen delivery is product of oxygen content in the arterial blood and cardiac output (blood flow) </li></ul></ul></ul><ul><ul><ul><li>During first minutes of CPR for VF SCA, initial oxygen content in blood adequate/ cardiac output is reduced </li></ul></ul></ul><ul><ul><ul><li>Effective chest compressions more important than rescue breaths immediately after VF SCA </li></ul></ul></ul>
  19. 20. Rescue Breaths with Compressions cont’d <ul><li>Why: </li></ul><ul><ul><li>Ventilation-Perfusion Ratio </li></ul></ul><ul><ul><ul><li>The best oxygenation of blood and elimination of CO2 occur when ventilation (volume of breaths x rate) closely matches perfusion </li></ul></ul></ul><ul><ul><ul><li>During CPR , blood flow to lungs is about 25-33% of normal </li></ul></ul></ul><ul><ul><ul><li>Less ventilations needed during cardiac arrest than when patient has perfusing rhythm </li></ul></ul></ul>
  20. 21. Rescue Breaths with Compressions cont’d <ul><li>Why: </li></ul><ul><ul><li>Hyperventilation leads to: </li></ul></ul><ul><ul><ul><li>Increased positive pressure in the chest </li></ul></ul></ul><ul><ul><ul><li>Decreased venous return to the heart </li></ul></ul></ul><ul><ul><ul><li>Limited refilling of heart </li></ul></ul></ul><ul><ul><ul><li>Decreased cardiac output during subsequent compressions </li></ul></ul></ul><ul><ul><ul><li>Gastric distention/vomiting </li></ul></ul></ul>
  21. 23. 2 Rescuer CPR with Advanced Airway <ul><li>2005 (New): </li></ul><ul><ul><li>No pause for ventilation when there is an advanced airway in place </li></ul></ul><ul><ul><li>8-10 breaths per minute </li></ul></ul>
  22. 24. 2 Rescuer CPR with Advanced Airway cont’d <ul><li>2000 (Old): </li></ul><ul><ul><li>Recommended “asynchronous” compressions and ventilations </li></ul></ul><ul><ul><li>Ventilation rate of 12-15 per minute </li></ul></ul><ul><ul><li>Rescuers taught to re-check for signs of circulation “every few minutes” </li></ul></ul>
  23. 25. 2 Rescuer CPR with Advanced Airway cont’d <ul><li>Why: </li></ul><ul><ul><li>Ventilations can be delivered during compressions </li></ul></ul><ul><ul><li>Avoid excessive number of breaths </li></ul></ul><ul><ul><li>During CPR, blood flow to lungs decreased, so lower than normal respiratory rate will maintain adequate oxygenation </li></ul></ul>
  24. 26. Airway/Trauma Victims <ul><li>2005 (New): </li></ul><ul><ul><li>In patients with suspected cervical spine injuries-if unable to open airway using the jaw thrust, use the head-tilt chin lift </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Jaw thrust without head tilt taught to both lay rescuers and healthcare providers </li></ul></ul>
  25. 27. Airway/Trauma Victims cont’d <ul><li>Why: </li></ul><ul><ul><li>Jaw thrust difficult maneuver to learn,may not effectively open airway and it can cause spinal movement </li></ul></ul><ul><ul><li>Opening the airway is a priority in an unresponsive trauma victim </li></ul></ul><ul><ul><li>Manual stabilization preferred over immobilization devices during CPR </li></ul></ul>
  26. 28. “ Adequate” vs.Presence or Absence of Breathing <ul><li>2005 (New): </li></ul><ul><li>BLS healthcare provider checks for: </li></ul><ul><ul><li>adequate breathing in adult victims </li></ul></ul><ul><ul><li>presence or absence of breathing in children and infants </li></ul></ul><ul><li>Advanced healthcare provider (with ACLS and PALS/PEPP) will assess for adequate breathing in victims of all ages </li></ul>
  27. 29. Adequate vs. Presence or Absence of Breathing cont’d <ul><li>2000 (Old): </li></ul><ul><ul><li>Healthcare provider checked for adequate breathing for victims of all ages </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>Children may demonstrate breathing patterns (rapid, grunting) which are adequate but not normal </li></ul></ul><ul><ul><li>Assessment for adequate breathing is more consistent with advanced provider skill </li></ul></ul>
  28. 30. Infant/Child: Give 2 Effective Breaths <ul><li>2005 (New): </li></ul><ul><ul><li>Attempt “a couple of times” to deliver 2 effective breaths (that cause visible chest rise) </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Healthcare providers were taught to move head through a variety of positions to obtain optimal airway opening </li></ul></ul>
  29. 31. Infant/Child: Give 2 Effective Breaths cont’d <ul><li>Why: </li></ul><ul><ul><li>Most common mechanism of cardiac arrest in infants and children is asphyxial </li></ul></ul><ul><ul><li>Rescuer must be able to provide effective breaths </li></ul></ul>
  30. 32. Lone Healthcare Provider-”phone first” vs. “CPR first” <ul><li>2005 (New): </li></ul><ul><ul><li>Tailor sequence to most likely cause of cardiac arrest </li></ul></ul><ul><ul><ul><li>“ Phone First” Sudden witnessed collapse (adult or child)-likely to be cardiac in origin. Call 9-1-1 and get the AED </li></ul></ul></ul><ul><ul><ul><li>“ CPR First” Hypoxic Arrest (adult or child)- give 5 cycles or about 2 minutes of CPR before leaving victim to call 9-1-1 and get the AED </li></ul></ul></ul>
  31. 33. Lone Healthcare Provider cont’d <ul><li>2000 (Old): Tailoring response to likely cause of arrest was not emphasized in training </li></ul><ul><li>Why: </li></ul><ul><ul><li>Sudden collapse-likely cardiac and early CPR and defibrillation needed </li></ul></ul><ul><ul><li>Victims of hypoxic arrest need immediate CPR </li></ul></ul>
  32. 34. “ Child” BLS Guidelines <ul><li>2005 (New): </li></ul><ul><ul><li>Child CPR guidelines for healthcare providers apply to victims from 1 year of age to onset puberty (about 12-14 years old) </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Child CPR age 1-8 </li></ul></ul>
  33. 35. “ Child” BLS cont’d <ul><li>Why: </li></ul><ul><ul><li>No single anatomic or physiologic characteristic that distinguishes a “child” victim from an “adult” victim </li></ul></ul><ul><ul><li>No scientific evidence that identifies a precise age to begin adult techniques </li></ul></ul>
  34. 36. Symptomatic Bradycardia Infants/Children <ul><li>2005 (New): </li></ul><ul><ul><li>Chest compressions indicated if HR <60 and signs of poor perfusion, despite adequate ventilation </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Same recommendation in 2000 guidelines but it was not incorporated into the BLS training </li></ul></ul>
  35. 37. Symptomatic Bradycardia Infants/Children cont’d <ul><li>Why: </li></ul><ul><ul><li>Bradycardia is common terminal rhythm in infants and children </li></ul></ul><ul><ul><li>Do not want to wait for development of pulseless arrest to begin chest compressions if there are signs of poor perfusion and no improvement with 02 and ventilatory support </li></ul></ul>
  36. 38. Child Chest Compressions <ul><li>2005 (New): </li></ul><ul><ul><li>Use heel of 1 or 2 hands </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Use heel of 1 hand </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>Child manikin study showed that rescuers performed better chest compressions using the “adult” technique </li></ul></ul>
  37. 39. Infant Chest Compressions <ul><li>2005 (New): </li></ul><ul><ul><li>Use the 2 thumb-encircling technique-sternum compressed with thumbs and use fingers to squeeze thorax </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Use of fingers to compress chest wall was not described </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>This technique results in higher coronary artery perfusion pressure </li></ul></ul>
  38. 40. Compression to Ventilation Ratios Infants/Children <ul><li>2005 (New): </li></ul><ul><ul><li>Lone rescuer :Compression to ventilation ratio 30:2 for infants, children and adults for </li></ul></ul><ul><ul><li>2 Rescuer CPR : 15:2 ratio for infants and children </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>15:2 adults 5:1 infants/children </li></ul></ul>
  39. 41. Compression to Ventilation Ratios Infants/Children cont’d <ul><li>Why: </li></ul><ul><ul><li>Simplify training </li></ul></ul><ul><ul><li>Reduce interruptions in chest compressions </li></ul></ul><ul><ul><li>15:2 ratio for 2 rescuer CPR for infants/children will provide additional ventilations </li></ul></ul>
  40. 43. Foreign Body Airway Obstruction <ul><li>2005 (New): </li></ul><ul><ul><li>Airway obstructions classified as mild or severe </li></ul></ul><ul><ul><li>Rescuers should act only if signs of severe obstruction present </li></ul></ul><ul><ul><ul><li>poor air exchange </li></ul></ul></ul><ul><ul><ul><li>Increased respiratory distress </li></ul></ul></ul><ul><ul><ul><li>Silent cough </li></ul></ul></ul><ul><ul><ul><li>Cyanosis </li></ul></ul></ul><ul><ul><ul><li>Inability to speak or breath </li></ul></ul></ul>
  41. 44. Foreign Body Airway Obstruction cont’d <ul><li>2005 (New) cont’d </li></ul><ul><ul><li>If victim becomes unresponsive </li></ul></ul><ul><ul><ul><li>ACTIVATE 9-1-1 and begin CPR </li></ul></ul></ul><ul><ul><ul><li>When airway opened during CPR, look in mouth and remove object if seen </li></ul></ul></ul><ul><ul><ul><li>No blind finger sweeps </li></ul></ul></ul>
  42. 45. Foreign Body Airway Obstruction cont’d <ul><li>2000 (Old): </li></ul><ul><ul><li>Rescuers taught to recognize </li></ul></ul><ul><ul><ul><li>Partial obstruction with good air exchange </li></ul></ul></ul><ul><ul><ul><li>Partial obstruction with poor air exchange </li></ul></ul></ul><ul><ul><ul><li>Complete airway obstruction </li></ul></ul></ul><ul><ul><li>Rescuers taught to ask 2 questions </li></ul></ul><ul><ul><ul><li>Are you choking? </li></ul></ul></ul><ul><ul><ul><li>Can you speak? </li></ul></ul></ul><ul><ul><li>Sequence for unresponsive choking victim was a complicated sequence/included abdominal thrusts </li></ul></ul>
  43. 46. Foreign Body Airway Obstruction cont’d <ul><li>Why: </li></ul><ul><ul><li>Simplification </li></ul></ul><ul><ul><li>Compressions during CPR may increase intrathoracic pressure more than abdominal thrusts </li></ul></ul><ul><ul><li>Blind finger sweeps may injure victims mouth/throat or rescuers finger </li></ul></ul>
  44. 47. Shock /Immediate CPR <ul><li>2005 (New): </li></ul><ul><ul><li>Delivery of single shock for VF and pulseless VT followed by immediate CPR </li></ul></ul><ul><ul><li>Perform 2 minutes of CPR before checking for signs of circulation </li></ul></ul>
  45. 48. Shock /Immediate CPR cont’d <ul><li>2000 (Old): </li></ul><ul><ul><li>3 stacked shocks recommended </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>3 shocks were based on use of monophasic waveforms </li></ul></ul><ul><ul><li>New biphasic defibrillators have a higher first-shock success rate </li></ul></ul><ul><ul><li>3-shock sequence can result in delays up to 37 seconds or longer from delivery of shock and delivery of first post-shock compression </li></ul></ul>
  46. 49. Monophasic Defibrillation dose <ul><li>2005 (New): </li></ul><ul><ul><li>Initial and subsequent shocks for VF/pulseless VT in adults 360J </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>200, 200-300J, 360J </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>One dose to simplify training </li></ul></ul>
  47. 50. Biphasic Defibrillation Dose <ul><li>2005 (New): </li></ul><ul><ul><li>Initial shock for adults:150-200J for biphasic truncated exponential waveform </li></ul></ul><ul><ul><li>120J for rectilinear biphasic waveform </li></ul></ul><ul><ul><li>The second dose should be the same or higher </li></ul></ul><ul><ul><li>Rescuers should use the device-specific defibrillation dose. If rescuer unfamiliar with device-specific dose-use default dose of 200J </li></ul></ul>
  48. 51. Biphasic Defibrillation Dose cont’d <ul><li>2000 (Old): </li></ul><ul><ul><li>200J, 200-300J, 360J </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>Simplify defibrillation </li></ul></ul><ul><ul><li>Support use of device-specific doses </li></ul></ul>
  49. 52. Use of AED’s in Children <ul><li>2005 (New): </li></ul><ul><ul><li>Recommended use of AED’s in children 1-8 years old </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Insufficient evidence to recommend for or against use of AED’s in children under 8 years old </li></ul></ul><ul><li>Why: </li></ul><ul><ul><li>Evidence published since 2000 shows AED’s safe and effective for use in infants and children </li></ul></ul>
  50. 53. Community/Lay Rescuer AED Programs <ul><li>2005 (New): </li></ul><ul><ul><li>CPR/AED use by public safety first responders recommended to increase SCA survival rates </li></ul></ul><ul><ul><li>Insufficient evidence to recommend for or against AED’s in homes </li></ul></ul><ul><li>2000 (Old): </li></ul><ul><ul><li>Key elements of an AED program included: </li></ul></ul><ul><ul><ul><li>Physician oversight </li></ul></ul></ul><ul><ul><ul><li>Training of rescuers </li></ul></ul></ul><ul><ul><ul><li>Integration with EMS </li></ul></ul></ul><ul><ul><ul><li>Process of CQI </li></ul></ul></ul>
  51. 54. Community/Lay Rescuer AED Programs cont’d <ul><li>2005 (Why): </li></ul><ul><ul><li>The North American PAD trial reinforced the importance of planned and practiced response. </li></ul></ul><ul><ul><ul><li>Even at sites with AED’s in place- the AED’s were deployed for less than half the of the cardiac arrests at those sites indicating the need for frequent CPR </li></ul></ul></ul>
  52. 56. Tx of Arrhythmias AHA 2005 Guidelines
  53. 57. CPR Algorithm
  54. 58. Pulseless Algorithm
  55. 59. Brady- Arryhthmias
  56. 60. Tachy- Arryhthymias
  57. 61. Pulseless Arrest 4 Basic Rhythms <ul><li>Shockable </li></ul><ul><li>V-fib </li></ul><ul><li>V-Tach </li></ul><ul><li>Non-Shockable </li></ul><ul><li>Asystole </li></ul><ul><li>PEA </li></ul>
  58. 62. Shockable Rhthyms <ul><li>Ventricular Tachycardia </li></ul><ul><li>V-Fib </li></ul><ul><ul><li>Shock early </li></ul></ul><ul><ul><li>ABC’s </li></ul></ul><ul><li>Tx of VT/VF </li></ul><ul><ul><li>Shock- biphashic 200j, monophasic 360j (one x) </li></ul></ul><ul><ul><li>CPR-IV, ETT </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>CPR-epi/vasopressin </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>CPR-Lido/amiodarone </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>CPR-epi </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>CPR- lido/amio </li></ul></ul>
  59. 63. NON-Shockable <ul><li>PEA </li></ul><ul><li>Asystole </li></ul><ul><li>Tx of Asystole & PEA </li></ul><ul><ul><li>CPR-IV,airway </li></ul></ul><ul><ul><li>Meds-vasopressin/epi </li></ul></ul><ul><ul><li>CPR-2 min </li></ul></ul><ul><ul><li>Meds-epi,atropine* </li></ul></ul><ul><ul><li>CPR </li></ul></ul><ul><ul><li>Meds-epi,atro </li></ul></ul><ul><ul><li>CPR </li></ul></ul><ul><ul><li>*Atropine used in PEA, only for HR < 60 </li></ul></ul>
  60. 64. Contributing Factors H’s and T’s <ul><li>Hypovolemia </li></ul><ul><li>Hypoxia </li></ul><ul><li>Hydrogen ion (acidosis) </li></ul><ul><li>Hypo/hyperkalemia </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Hypothermia </li></ul><ul><li>Toxins (drugs) </li></ul><ul><li>Tamponade (cardiac) </li></ul><ul><li>Tension PTX </li></ul><ul><li>Thrombosis (coronary or pulmonary) </li></ul><ul><li>Trauma </li></ul>
  61. 65. Tachycardia’s Stable vs. Unstable <ul><li>Stable </li></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>12 lead </li></ul></ul><ul><ul><li>Narrow complex </li></ul></ul><ul><ul><li>Wide complex </li></ul></ul><ul><ul><li>Treat causes </li></ul></ul><ul><ul><ul><li>H’s and T’s </li></ul></ul></ul><ul><li>Unstable </li></ul><ul><ul><li>Altered MS </li></ul></ul><ul><ul><li>CP </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Signs of shock </li></ul></ul>
  62. 66. Tx of Stable Tachycardias <ul><li>A-fib/flutter </li></ul><ul><ul><li>Vagal maneuvers </li></ul></ul><ul><ul><li>Diltiazem (Ca++ channel blocker) </li></ul></ul><ul><li>SVT </li></ul><ul><ul><li>Adenosine </li></ul></ul><ul><li>V-Tach (WITH PULSE) </li></ul><ul><ul><li>Antiarrhythmic: Lido, Amio, (Mg+ for torsades) </li></ul></ul>
  63. 67. Tx of Unstable Tachycardias <ul><li>Perform immediate synchronized cardioversion </li></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>Sedate if conscious </li></ul></ul><ul><ul><li>DO NOT DELAY CARDIOVERSION </li></ul></ul>
  64. 68. Bradycardias Tx of Bradycardias <ul><li>Stable </li></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>Adequate perfusion? </li></ul></ul><ul><ul><li>Monitor BP!! </li></ul></ul><ul><li>Unstable </li></ul><ul><ul><li>Poor perfusion </li></ul></ul><ul><ul><li>Immediate transcutaneous pacing </li></ul></ul><ul><ul><li>Consider atropine while awaiting pacer </li></ul></ul><ul><ul><li>Consider epi or dopamine if pacing ineffective </li></ul></ul>
  65. 69. <ul><li>ACLS Class Recommendations </li></ul><ul><li>Class I – Always do this! </li></ul><ul><li>Class IIa – Intervention of choice. </li></ul><ul><li>Class IIb – Give careful consideration. </li></ul><ul><li>Class Indeterminate – Clinical judgment </li></ul><ul><li>Class III – Not recommended! </li></ul>

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