ACLS CE

Part III of III

Defibrillation and ACLS Drug Therapy

http://en.wikipedia.org/wiki/Defibrillation

Prepared and presented by

Marc Imhotep Cray, M.D.

Defibrillation
Defibrillation is a common treatment for life-threatening
cardiac dysrhythmias, ventricular fibrillation and pulseless
ventricular tachycardia
Defibrillation consists of delivering a therapeutic dose of
electrical energy to the heart with a device called a defibrillator
External depolarization of the heart to stop Vfib or Vtach that
has not responded to other maneuvers

Defibrillation

Know your AED*

Universal steps:
1. Power ON
2. Attach electrode
pads
3. Analyze the rhythm
4. Shock (if advised)

*Automated External Defibrillator

3

Automated External Defibrillator

Defibrillation
Most frequent initial rhythm in witnessed sudden
cardiac arrest is ventricular fibrillation (VF) or
pulseless ventricular tachycardia (VT) which rapidly
deteriorates into VF
The only effective treatment for VF is electrical
defibrillation
Probability of successful defibrillation diminishes
rapidly over time
VF rapidly converts to asystole if not treated
5

Early Defibrillation = Increased Survival

Do AEDs work?
Example of deploying AEDs in a highly populated and
monitored environmentStill debates about cost effectiveness
Outcomes of Rapid Defibrillation by
Security Officers after Cardiac Arrest in
Casinos
NEJM Vol 343 (17) October 26, 2000
Used AEDs on 105 patients with
Ventricular Fibrillation
53% survived to discharge (back to casino)
Previously, less than 5% survive

Also see: Use of Automated External

Defibrillators by a U.S. Airline
Page LA et al. N Engl J Med 2000;
343:1210-1216

An AED at a railway station in Japan. The

AED box has information on how to use it
in Japanese, English, Chinese and Korean,
and station staff are trained to use it.
http://en.wikipedia.org/wiki/File:AED_Oim
7
achi_06z1399sv.jpg

Public-Access Defibrillation and Survival after

Out-of-Hospital Cardiac Arrest
http://www.nejm.org/doi/full/10.1056/NEJMoa040566

Community based trial of AED deployment and

layperson training.
30 in AED group versus 15 survivors in CPR only
group to hospital discharge
Average age of survivor - 69.8 years
Study cost - $9.5 million
Study Conclusions
Training and equipping volunteers to attempt early defibrillation within a
structured response system can increase the number of survivors to hospital
discharge after out-of-hospital cardiac arrest in public locations. Trained
laypersons can use AEDs safely and effectively.
8

Defibrillation Procedure
Position paddles
Clear the patient
Shock and then resume CPR
for 5 cycles then re-analyze
after each shock
Prepare drug therapy
Next slides

ACLS Drug Therapy

N.B. Following is only a outlined capsule ACLS drugs,

for a details see
ACLS Core Drugs American Heart Association 2006, pdf

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

Oxygen
FIO2 100%
Assist Ventilation
O2 Toxicity should not be a concern during
ACLS

IV Fluids
Volume Expanders
crystalloids , e.g. Ringers lactate, N/S, or
colloids, e.g. Albumin or Hetastarch
TKO D5W, N/S

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

Drugs that help to

Control Heart Rate & Rhythm

Lidocaine
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)
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)
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

Bretylium Tosylate (Bretylol)

Indications:
Same as lidocaine and procainamide (usually
when condition doesnt respond to these two)
IV dose:
5-10mg/kg bolus followed by continuous infusion
of 1-2 kg/min
Side Effects:
N&V
Hypotension

Atropine
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

Adenosine

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
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!

Propranolol
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

Drugs use to Improve

Cardiac Output & Blood Pressure

Epinephrine
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

Norepinephrine (Levarterenol)
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
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
N&V

Dobutamine
Actions similar to Dopamine
Used for CHF with hypotension
IV Dose:
2-20 micrograms/minute
Side effects:
Tachycardia
N&V
Headache
Tremors

Amrinone
Similar to dobutamine
Used for refractory CHF
IV Dose:
2-15 micrograms/kg/min
Side effects:
May worsen ischemia
N&V
Thrombocytopenia

Digitalis (Digoxin)
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
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)

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
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

End of ACLS CE Part III

THANK YOU FOR YOUR ATTENTION

Further study:
http://www.uptodate.com/contents/advanced-cardiaclife-support-acls-in-adults