Advance Cardiac Life Support I (ACLS)
Clement Arthur S. Torio, MD Bradycardia Symptoms: chest pain, SOB, decreased level of consciousness, weakness, fatigue, exercise intolerance, lightheadedness, dizziness, “spells” Signs: hypotension (orthostatic), diaphoresis, pulmonary congestion on PE or CXR, frank CHF or pulmonary edema, chest pain, ACS, PVCs Treat the patient, not the monitor If AMI is the cause, and the bradycardia is symptomatic, treat the AMI or the bradycardia Cardinal Rule: treat the original pathology rather than the sequelae of the pathology Treat only symptomatic bradycardia The bradycardia must cause the symptoms Recognize the red flag bradycardias that are likely to deteriorate (even if asymptomatic) nd 2 degree AV block type II rd 3 degree AV heart block (Complete Heart Block The overall treatment approach: Atropine Transcutaneous pacing Dopamine Epinephrine
Notes: Atropine Used in narrow QRS complex rd Never in 3 degree AV block Epinephrine / Dopamine Used in wide QRS complex
Drugs for Tachyarrythmias Supraventricular • Adenosine • B – adrenergic blockers • Calcium Channel Blockers Supraventricular / Ventricular • Amiodarone Ventricular • Lidocaine • Magnesium Sulfate
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Tachycardia Stable or Unstable? With serious signs and symptoms due to tachycardia ECG question: Is the QRS complex WIDE or NARROW? (Normal 0.10 – 0.12 seconds) 5 principles to keep in mind Antiarrythmics are also proarrythmics One antiarrythmic may help, more than one may harm Antiarrhythmics can make an impaired heart worse Electrical cardioversion can be the intervention of choice or a “second antiarrhythmic” First diagnose – then treat
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Unstable Tachycardia Criteria The patient displays serious symptoms (SOB, chest pain, dyspnea on exertion, altered mental status) Signs (pulmonary edema, rales, rhonchi, hypotension, orthostasis, jugular vein distention, peripheral edema, ichemic ECG changes, PLUS Tachycardia is the immediate cause of the signs and symptoms The tachycardia requires immediate treatment with synchronized cardioversion to prevent further hemodynamic deterioration. Energy selection PSVT: 50J, 100J, 200J, 300J, 360J VT: 100J, 200J, 300J, 360J Polymorphic VT (treat like VF): 200J, 200J to 300J, 360J Atrial fibrillation: 100J, 200J, 300J, 360J Atrial flutter: 50J, 100J, 200J, 300J, 360J
Synchronized Cardioversion Algorithm
Pulseless Electrical Activity (PEA) Refers to any semiorganized electrical activity that can be seen on the monitor screen although the patient lacks palpable pulse Exclusions: VF/ Vtach Points to Remember Search for the reversible causes (5Hs and 5 Ts) Epinephrine is the initial treatment Atropine used only for relative and absolute bradycardia Summary Always assess your patient Determine if STABLE or UNSTABLE Know your rhythm If Stable: Give appropriate medications If Unstable: Synchronize Cardioversion
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