ACLS Notes

Bradycardia: Atropine, Dopamine, Epinephrine, TCP

Heart rate, fluid, and dopamine help to get a low BP up

3 ways to deliver electricity to the heart:
o defibrillation, cardioversion, TCP (transcutaneous pacing)
Defibrillation for vfib and vtac
Asystole has no electricity flowing through the heart; no need to shock
Vtac
o With pulse or without a pulse; 2 types
o Defib ONLY with NO PULSE
3 things make patient unstable (according to AHA); consideration medication, but
TREAT with electricity
o Altered mental status (Whats your name? Where are you? Whos the president?
NOT do you know your name? do you know where you are)
o Chest pain
o Hypotension (systolic less than 90)
Radial pulse needs at least a systolic of 90 (most distal pulse)
SA node fires 60-100 (normal heart rate)
AV node fires at 40-60 (potential for bradycardia if only AV node is firing)
Heart rate X stroke volume = Cardiac Output
20-gauge needle to start IV on cardiac patient; needed for bolus; L AC preferable (look at
hand first in case it blows)
EPI = every pulseless individual
Amiodarone (anti-dysrhythmic)
Atropine blocks out the vagus nerve and speed up the heart; vagal maneuver stimulates
the vagus nerve to slow the heart; start with 0.5 mg IV => total MAX dose is 3 mg
Always put pads on patient first, even if you dont use them
Opiate use would show respiratory depression
Transcutaneous pacing (use milliamps) is using with the pads to pace the heart rate to
70 bpm; pacer spike needs to be in front of a QRS complex, taking over the P wave;
milliamps are used and increased until the desired HR is achieved
o Next check for a pulse
o Next check BP (increased HR [up to 100] until BP is at desired location)
o Versed given for pain or Ativan
Bradycardia, symptomatic or non-symptomatic, use ATROPINE
Fluids started at 250cc with lung-sound checks to prevent fluid overload; max dose of
1000cc
o Stop fluids and other treatments at 90 systolic
Epinephrine can be considered in bradycardia if nothing else is working

Tachycardia: Adenosine, Amiodarone (vfib), Lidocaine (vfib)

SVT has NO P wave (rate above 150)

o SVT cant be treated; find and treat the underlying cause
Ventricular tachycardia
Sinus Tachycardia
Ex: SVT pt with no P wave, BP 80/40, altered mental status, heart palpitations
(symptomatic pt)
o Synchronized cardioversion will deliver shock at the top of every R wave; syncs
the R waves
o Start joules at 50, clear, and shock
o Hold the button to deliver shock across all R waves
o Goal is to restart the heart
o Increase joules if first doesnt work (50, 100, 120); different literature shows
different stopping points
(For stable pt) Adenosine 6 mg first dose into IV at left AC; follow with a 20cc flush
(saline; used to move the med out of the tube and into the heart); print strip after each
adenosine dose
o Adenosine stops the heart to be able to restart it
o If first dose doesnt work, double the dose (12 mg)
o After second dose, must move on to cardioversion
There is not tx for SVT; just treat underlying cause

Give medication after shock because chest compressions continue and help circulate the
medication

Bradycardia:
Dopamine increases contractility of the heart
o Comes in 400mg/250 mL
o Weight in pounds, drop the last number, subtract 2 (street rule for dopamine;
only works for 5 micrograms/kilogram)
Targeted temperature management effective in better outcomes in acute MI situations
Epi, Amiodarone, lidocaine = vfib and vtac
Amiodarone = with pulse given over time; 150 mg in a 100 mg bag over 10 minutes
Amiodarone = without pulse, IV push 300 mg for first dose
Lidocaine (SM relaxer) has very short half-life; Amiodarone (NOT a SM relaxer) halflife is 18-24 days
Example: Vfib/vtac no pulse
o CPR (2 min)
o Pads (vf/vt no pulse)

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Defib 200J
IV/IO
Epi 1 mg (1: 10,000)
CPR (2 min)
Check pulse, monitor
Still vf/vt
Defib 300J
Ami 300 mg IV push
Check pulse, monitor
Vf/vt, no pulse
Defib 360J
Epi 1 mg (1:10,000)
CPR (2 min)
Check pulse, monitor
Vf/vt, no pulse
Defib 360J
Ami 450 mg IV push
CPR 2 min
Check pulse, monitor
Vf/vt
Defib 360J
Epi 1mg (1:10,000)
Keep using Epi from here on out; Amiodarone maxed out and Joules
maxed out