ACLS 2010 Guidelines AHA

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stephkidwell
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259687
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ACLS 2010 Guidelines AHA
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2014-02-04 22:23:55
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ACLS
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Initial ACLS certification
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  1. BLS Survey
    • 1. Responsive? Breathing (5-10 sec chest scan)
    • 2. Emergency response, AED
    • 3. Pulse (5-10 sec, carotid adult/child, brachial infant)
    • 4. AED upon arrival (compress while charging)
    • 5. No shock - recheck q2min, resume CPR
  2. High quality CPR (6)
    • 1. 100/min
    • 2. at least 2" in adult, at least 1/3 AP diameter in kids (about 2" in children or about 1.5" in infants)
    • 3. complete chest recoil
    • 4. min interruptions < 10 s
    • 5. switch q2min (5 cycles)
    • 6. Avoid excessive ventilation
  3. Ventilation rates:
    bag mask
    advanced cardiac arrest
    advanced respiratory arrest
    • 30:2 bag maks
    • advanced cardiac arrest - q6-8s (8-10/min)
    • advanced resp arrest - q 5-6 s(10-12/min)
  4. BLS compression: breath

    adult lone, adult 2 rescuer
    child long, child 2 rescuer
    infant long, infant 2 rescuer
    • adult lone - 30:2, 2 rescuer - 30:2
    • child lone - 30:2, 2 rescuer - 15:2
    • infant lone - 30:2 (2 finger)
    • infant 2 rescuer - 15:2 (encircling)
  5. BLS child exceptions:

    witnessed collapse (lone)
    suspected drowning/other hypoxia (lone)
    collapse: emergency resp/AED 1st, then CPR (child is in cardiac arrest!)

    hypoxia: 5 cycles CPR then emergency resp/AED
  6. Which survey/order to use?

    conscious pt?
    unconscious pt?
    conscious - ACLS first

    unconscious - BLS, then ACLS
  7. ACLS Survey (4 steps)
    • 1. Airway
    • 2. Breathing 
    • 3. Circulation
    • 4. Differential Dx
  8. ACLS Survey, Breathing (4)
    • 1. Patent in unconscious pt? - head tilt/chin lift (or jaw thrust), OPA, NPA
    • 2. Advanced airway? - laryngeal mask, laryngeal tube, esophageal-tracheal tube (placed w/o interrupting compressions)
    • 3. Placement? - phys exam, QWC
    • 4. Secure device, monitor placement - QWC
  9. BLS Choking 

    Adult/child (1 yr to puberty)
    • 1. Are you OK?
    • 2. abdominal thrusts (chest thrusts if large)
    • 3. unresponsive - witness activate emerg resp/AED, if no breathing begin CPR (no pulse check)
    • 4. Before breaths check for foreign body, remove if visible only
    • 5. Lone - activate emerg resp/AED after 5 cycles
  10. BLS Choking infant
    • 1. Confirm obstruction (difficulty breathing, silent/weak cry/cough)
    • 2. 5 back slaps/chest thrusts (support head)
    • 3. unresponsive - witness activate emerg resp/AED, if no breathing begin CPR (no pulse check)4. Before breaths check for foreign body, remove if visible only
    • 5. Lone - activate emerg resp/AED after 5 cycles
  11. ACLS Survey - Breathing (3)
    • 1. Suppl ox - a) 100% CA, b) non CA - titrate to at least 94% SaO2
    • 2. ventilation/oxygenation adequate? - chest rise, cyanosis, QWC, SaO2
    • 3. Avoid excessive ventilation
  12. ACLS Survey - Circulation (5)
    • 1. effective compr? QWC PETCO2 at least 10, IAP at least 20 mm Hg
    • 2. CA rhythms - VF, pulseless VT, PEA, asystole
    • 3. Defib/cardioversion
    • 4. IV/IO access, vasopressors, antiarrhythmics
    • 5. ROSC? pt with pulse stable? give fluids/drugs
  13. ACLS Survey - Differential DX
    - what caused arrest?

    - is cause reversible
  14. ACLS Team (8)
    • 1. Know your role and those of others (leader, observer, comp, airway, IV/IO, defib/monitor) 
    • 2. Closed-loop communication, eye contact, confirm actions
    • 3. Clear messages/repeat orders/question orders
    • 4. Know limitations, ask for help
    • 5. Share knowledge
    • 6. Constructive intervention
    • 7. Re-evaluation/Summary
    • 8. Mutual respect
  15. Adult Chain of Survival (5)
    • 1. Recognition of CA, emerg resp
    • 2. Early high quality CPR, emphasize comp
    • 3. Defib
    • 4. ACLS
    • 5. Post CA care
  16. ACLS - Improve care (3)
    • 1. Evaluate resusc/outcome (Ulstein, CPR rate, time to defib, survival to hosp DC), info sharing of dispatch, EMS, hosp
    • 2. Benchmarking (CARES CA Registry to Enhance Survival out of hosp, Get With the Guidelines in hosp)
    • 3. Address deficiencies
  17. Post CA Care (5 basics)
    • 1. Therapeutic hypothermia
    • 2. Hemodynamic and ventilation optimization
    • 3. Immediate coronary reperfusion with PCI
    • 4. Glycemic control
    • 5. Neuro care/prognostication
  18. Post CA care - therapeutic hypothermia

    when? how much? how?
    • - Comatose adult pt w/o meaningful response to commands 
    • - ROSC achieved after out of hospl initial VF rhythm
    • - 32-34 C (89.6-93.2 F) for 12-24 hours
    • - (Consider for other rhythms in and out of hosp too)
  19. Post CA care - Hemodynamic/Ventilation Optimization (3)
    • 1. In resucs - 100% Ox, in Post CA care titrate to arterial ox sat at least 94%
    • 2. Start vent 10-12 br/min, titrate to PETCO2 35-40 or PaCO2 40-45 mm Hg
    • 3. Titrate fluid, vasoactive/inotropics to optimize BP, CO, systemic perfusion (MAP at least 65%)
  20. Post CA care - Coronary Reperfusion
    PCI center, can be concurrent with hypothermia

    Within 3 hours from onset of symptoms (4.5 hrs for some pts)
  21. Post CA care - glycemic control do and don't
    Do aim fr 144-180 mg/dL

    Don't go lower (80-100 mg/dL) - increased risk of hypoglycemia
  22. Post CA care - neuro/prognostication
    Reliable early prognostication of neuro outcome is essential
  23. ACLS case 1 - respiratory arrest BLS
    • 1. Responsiveness/breathing (5-10 s chest scan)
    • 2. Activate ERS/AED
    • 3. Carotid pulse 5-10s (YES in this case)
    • 4. 1 breath q5-6s or 10-12/min if bag/mask or advanced airway
    • 5. Check pulse q2min (if not, CPR/AED)
  24. ACLS  - Respiratory Arrest, Airway
    • 1.Patent? Use head tilt-chin lift, OPA, or NPA
    • 2.Advanced? laryngeal mask tube, laryngeal tube, esophageal-tracheal tube
    • 3. Placement? QWC + phys exam
    • 4. Secure/Monitor placement?
  25. ACLS - Resp Arrest, Breathing
    • 1. Vent/ox adequate? (100% CA), Resp arrest - titrate to achieve at least 94% pulse ox; chest rise, cyanosis? 
    • 2. QWC/oxyhemoglobin sat
    • 3. Avoid excessive vent -  Ventilate q5-6 s or 10-12/min, 1 s per breath, visible chest rise
  26. Basic Airways (4)
    • 1. head tilt-chin lift (jaw thrust w/o head extension if head trauma)
    • 2. Bag mask - 600 ml tidal vol over 1s
    • 3. OPA
    • 4. NPA
  27. OPA
    • 1. pts at risk for obstruction
    • 2. UNconscious pts (otherwise stimulates gag)
    • 3. OK during bag-mask vent
    • 4. OK to use during suctioning of intubated pt (prevents biting/occluding ET)
  28. Using OPA
    • 1. Clear mouth/throat of secretions
    • 2. Size - tip OPA at mouth corner, flange at angle of mandible
    • 3. Insert curve up (or side), rotate to curve down
    • 4. Alt - hold tongue down with depressor, insert straight in
    • 5. monitor head/jaw position, suction prn (-80 to -120 mm Hg)
    • 6. Check fro spontaneous resp, pos pressure vent if not
  29. NPA insertion
    • 1. OK conscious or unconscious pts
    • 2. Size - should not blanch nostrils (diam smallest pt finger); length tip of nose to earlobe
    • 3. lubricate
    • 4. insert along floor of noasopharynx
    • 5. If resistance rotate and/or try other nostril (may be bigger)
    • 6. Maintain head position, suction prn (-80 to -120 mm Hg)
    • 7. Check for spontaneous resp, pos pressure vent if not
    • 7. CAUTION if facial trauma - may go into brain
  30. ACLS case - VF treated with CPR/AED
    (lone rescuer out of hospital)
    • 1. Responsive? Breathing?
    • 2. Activate ERS/get AED
    • 3. Check pulse (compress while charging?), none in this case
    • 4. If shockable deliver shock, resume CPR 2 min
    • 5. If not shockable, resume CPR 2 min
    • 6. If ROSC, 1 breath q5-6s, check pulse q2min
    • 7. If starts breathing recovery position, recheck
  31. AED steps (7)
    • 1. On
    • 2. Attach pads to bare chest (wipe if covered with water/sweat)
    • 3. Attach pad cables to AED
    • 4. Analyze rhythm, be clear
    • 5. Compress while charging
    • 6. Shock if advised, everyone clear
    • 7. Resume CPR immediately
  32. AED troubleshooting
    • 1. Wipe water/sweat from chest
    • 2. "wax" with pads, get new pads, or shave
    • 3. pull pt out of water
    • 4. OK to use on ice/small puddle
    • 5. Not on top of pacemaker, shock 30-60 s after implanted defib shocks pt
    • 6. Not on top of med patch, remove patch and wipe, if necessary
  33. ACLS case - VF/Pulseless VT - witnessed CA, manual defib
    • USE ADULT CA ALGORITHM:
    • 1. CPR, give O2, attach monitor/defib
    • 2. Shockable? (do not interrupt comp > 10 s) If VF/pulseless VT then shock, obtain access and give drugs in 2 min between rhythm checks, consider advanced airway, breaths q6-8s, confirm with QWC
    • 3. If not shockable, and rhythm organized (regular and narrow) check pulse
    •  a) if no pulse resume CPR, obtain access, give drugs btwn rhythm checks q2min, consider advanced airway, breaths q6-8s, confirm with QWC
    •  b) if pulse, proceed with post CA care
    • 4. Repeat until ROSC
    • 5. Post CA care after ROSC
    • 6. Shocks: Biphasic - 120-200 J, Monophasic - 360 J
  34. ROSC
    • Return of spontaneous circulation
    • - CHeck pulse and BP
    • - shown by abrupt sustained increase in PETCO2, usually greater than 40 mmHg
    • - spontaneous arterial pressure waves
  35. Adult CA drugs
    1. Vasopressors - a) Epinephrine IV/IO - 1 mg q 3-5 min, b) Vasopressin IV/IO 40 mg can replace 1st or 2nd dose epi

    2. Amiodarone - 1st 300mg bolus, second 150 mg bolus, NO MORE

    3. If no amiodarone, lidocaine 1st 1-1.5 mg/kg IV/IO (then 0.5-0.75 mg/kg IV/IO q5-10 min) to max of 3 mg/kg

    4. Mag sulfate for torsades de pointes, loading 1-2 g IV/IO diluted in 10 mL D5W as IV/IO bolus over 5-20 min
  36. Reversible causes of CA
    • Hypovolemia
    • Hypoxia
    • Hypothermia
    • Hydrogen ion (acidosis)
    • Hypo/hyperkalemia
    • Tension pneumothorax
    • Tamponade, cardiac
    • Toxins
    • Thrombosis, coronary or pulmonary
  37. Pulse check during ACLS
    • - ONLY if nonshockable rhythm AND organized (regular and narrow)
    • - done during rhythm analysis
    • - if pulse, proceed to post CA care
    • - if nonshockable and no pulse or any doubt, proceed to PEA/asystole pathway
  38. PETCO2
    • - normal 35-40 mm Hg
    • - indicates ROSC when abruptly increases
    • - indicates ET placement
    • - if <10 mm Hg, need to improve compressions
  39. IAP
    • - surrogate for CPP (coronary perfusion pressure)
    • - if <20 mm Hg need to improve compressions
  40. SCVO2
    • - Central venous O2 Sat
    • - normal 60-80%
    • - if <30% need to improve compressions
  41. VF/VT + Hypothermia (severe vs moderate)
    • - severe hypothermia = <30 C (86 F)
    •   - shock while engaged in active core rewarming
    •   - pt has dec. drug metabolism, need to lower dose
    •   - do NOT give antiarrhythmics, give vasopressors and warm up pt!
    • - moderate hypothermia - 30-34 C (86-93.2 F)
    •   - space meds at longer intervals, core rewardming
  42. CA drugs - Peripheral IV basics
    • - 1-2 mins to reach central circulation
    • - several CPR cycles to take effect
    • - give by IV bolus unless otherwise specified
    • - follow with 20 ml IV fluid
    • - elevate above heart 10-20 s
  43. ET drugs basics
    • - only done if cannot establish IV or IO access
    • - exact dosages unknown, variable by pt
    • - usually dosed 2-2.5x IV/IO dose
    • - must dilute in 5-10 ml NS or sterile water
    • - inject directly into trachea
  44. Epinephrine during CA
    - 1mg IV/IO q3-5 mins

    - vasoconstriction, increases HR/BP, increases perfusion to heart/brain
  45. Vasopressin during CA
    - 40 Units IV/IO can replace 1st or 2nd dose epinephrine

    - same effect as epinephrine
  46. Amiodarone during CA
    - antiarrhythmic

    - given after vasopressors

    • - 1st dose 300 mg IV/IO push
    • - 2nd dose 150 mg IV/IO push given 3-5 mins after 1st dose, if needed - NO MORE!
  47. Lidocaine during CA
    - given if Amiodarone not available

    - 1st dose 1.0- 1.5 mg/kg IV/IO 

    - then 0.5 - 0.75 mg/kg IV/IO q5-10 mins

    - max dose 3mg

    - if given ET route dose is 2-4 mg/kg
  48. Mg SO4 during CA
    • - only given for torades de pointes with prolonged QT in NSR (or Mg depletion, hypokalemia, etc)
    • - 1-2 g IV/IO diluted in 10ml D5W over 5-20 mins
  49. Post CA care - ventilation/oxygenation
    • - If unconscious/unresponsive need advanced airway:
    •    - vent 10-12 br/min (q8-10s) and titrate to:
    •        - PETCO2 35-40, PaCO 40-45 mm Hg
    •        - titrate FiO2 to achieve SaO2 94% or >
    •        (if unable to titrate give 100% O2)
  50. Post CA care IV (volume/temp)
    • - maintain SBP > 90
    • - bolus 1-2 L NS or LR
    • - if inducing hypothermia give fluid 4 deg C
  51. Post CA care IV drug infusions
    Epinephrine 0.1-0.5 mcg/kg/min (7-35 mcg/min in 70 kg adult)

    Dopamine 5-10 mcg/kh/min

    • Norepinephrine same dose as epi
    • - use if severe hypotension with SBP <70 and epi ineffective
  52. Post CA care, Induced hypothermia
    • - ONLY intervention to improve neurologic recovery
    • - consider if comatose (pt does not give meaningful responses to commands)
    • - target temp 32-34 C for 12-24 hrs
    • - use any combo of: rapid infusion of ice cold isotonic non-glucose fluid, endovascular catheter, surface cooling devices
    • - if comatose pt spontaneously develops mild hypothermia, do not rewarm for 12-24 hrs >ROSC
    • - monitor with esophageal thermometer, bladder cath (in nonanuric pt), pulm art cath if already in place
    • - PCI and hypothermia OK togther
  53. PEA management basics
    • - TREAT THE CAUSE
    • - IV/IO access priority over advanced airway unless:
    •    - bag-mask ineffective
    •    - arrest caused by hypoxia
  54. When to check for pulse (and what to do if you do/don't find one!)
    • - check only if you see ORGANIZED rhythm (regular, narrow complexes)
    • - if no pulse, back to CPR/drugs
    • - if pulse, go to post CA care
  55. PEA/Arrest causes (list)
    • Hypoxia**
    • Hypovolemia**
    • Toxicity*
    • Hypothermia
    • Hydrogen ion (acidosis)
    • Hypo/hyperkalemia

    • Tension pneumothorax
    • Tamponade
    • Thrombosis, coronary
    • Thrombosis, pulmonary

    - If narrow QRS, probably NOT cardiac in origin!
  56. ID/treat PEA/arrest causes: Hypovolemia
    • - narrow complex, rapid rate
    • - flat neck veins
    • - increasing DBP, decreasing SBP until BP not detectable
    • - TR with volume infusion (consider occult internal hemorrhage, severe dehydration)
  57. ID/treat PEA/arrest causes: Hypoxia
    • - slow rate
    • - cyanosis, Bl gases, airway problems
    • - TR: O2 via advanced airway
  58. ID/treat PEA/arrest causes: Toxicity
    • - slow rate, often prolonged QT
    • - neuro exam, pupils, may be hypotensive
    • - bottles/drugs at scene
    • - TR: drug specific antidotes, intubate, prolonged CPR, CP bypass, dialysis, TCP, correct electrolytes, Narcan
  59. ID/treat PEA/arrest causes: Hydrogen ion (acidosis)
    • - low amplitude QRS
    • - hx DM, acidosis (responsive to bicarb), renal failure
    • -TR; Na bicarb, O2
  60. ID/treat PEA/arrest causes: Hyperkalemia
    • - tall, peaked T waves, P's get smaller, QRS widens
    • - sine wave PEA
    • - hx renal failure, recent dialysis, fistulas, DM, meds
    • - TR: CaCl, Na bicarb, glucose + insulin, maybe albuterol
  61. ID/treat PEA/arrest causes: Hypokalemia
    • - T's flatten, prominent U's, QRS widens, QT prolonged, wide complex tachycardia
    • - hx diuretics
    • - TR: Mg if in CA
  62. ID/treat PEA/arrest causes: Hypothermia
    • - J/Osborne waves (pos wave btwn QRS and T)
    • - hx cold exposure, low temp
    • -TR: hypothermia algorithm
  63. ID/treat PEA/arrest causes: Tension pneumothorax
    • - hypoxia (slow rate) - VS tamponade (rapid)
    • - narrow
    • - no pulse with CPR, neck vein distension
    • - trachael deviation
    • - unequal breath sounds
    • - difficult to ventilate
    • - TR if US confirmation: needle decompression, chest tube thoracostemy
  64. ID/treat PEA/arrest causes: Cardiac Tamponade
    • - rapid rate (vs. tension pneumothorax)
    • - narrow
    • - no pulse with CPR
    • - neck vein distention
    • - TR if confirmed with US: pericardiocentesis, give volume while initiating treatment
  65. ID/treat PEA/arrest causes: Thrombosis PE
    • - rapid, narrow
    • - prior pos test for DVT or PE (vs. tamponade)
    • - no pulse with CPR
    • - distended neck veins
    • - TR: fibrinolytics, surgical embolectomy
  66. ID/treat PEA/arrest causes: Thrombosis, coronary/MI
    • - ECG data, Q, ST changes, T inversions
    • - cardiac markers
    • - good pulse with CPR
    • - TR: ACS algorithm (fibrinolytics, PCI)
  67. Asystole
    • - IV/IO access priority over advanced airway unless asystole caused by hypoxia
    • - TREAT UNDERLYING CAUSE (H/T)
    • - STOP: - rigor mortis, DNAR, unsafe for providers
    • - consider longer resusc. effort if:
    •    - hypothermia, drug OD, other reversible causes
    •    - ROSC of any duration achieved
    •    - possibility of fine VF, not asystole (if in doubt treat as VF)
  68. ACS basics
    • - rapidly deteriorates to VF or hypotensive bradyarrythmia - be prepared to tr these (drug/defib)
    • - focus on ECG, rapid reperfusion (fibrinolytics, PCI), relief of ischemic pain, tr early life threatening complications
    • - drugs: O2, ASA, nitroglycerin, morphine, fibrinolytics, heparin, adjuncts (B-blockers, ADP antagonists, ACE-inh, statins)
    • - **chest discomf suggests ischemia, tr as MI**
  69. ACS s/s
    • chest discomfort: pain, pressure, tightness for more than a few minutes
    • - radiates to back, btwn shoulder blades, neck, jaw, arms
    • - light headedness, fainting, sweating, NV with chest discomfort
    • - unexplained SOB w or w/o chest discomfort
    • - symptoms may also suggest MI mimics (aortic dissection, PE, tamponade, pneumothorax)
  70. ACS drugs for chest discomfort
    • - ASA 160-325 mg chewed or 300 mg PR if N/V, peptic ulcer, other UGI disease; X if allergy, active or recent GI bleeding
    • - O2 4L/min (100% in CA) if dyspneic, hypoxic, HF, SaO2 <94% (or unknown); not given routinely
    • - nitroglycerin 1 tab/spray q 3-5 min up to 3 doses
    •   - must have SBP >90, no lower than 30 mm Hg below baseline if known, HR 50-100
    •    - caution/contraindicated:
    •        - inferior wall MI
    •        - acute RV infarct (also no morphine, diuretics, other vol depleters)
    •       - SB <90, HR <50 or >100
    •       - recent phosphodiesterase inh (sildenafil, vardenafil in 24 hrs, tadalafil in 48 hrs)
    • - morphine: use if chest discomfort not relieved by nitro
    •     - caution: UA/NSTEMI, acute RV infarction (give fluid if hypotension develops)
  71. ACS reperfusion goal times
    • - ED evaluation - 10 mins
    • - fibrinolytics- 30 mins to needle
    • - PCI - 90 mins to balloon inflation (limited to 12 hours form onset of symptoms, usually)
    • - consult should not delay tr unless very tricky case
    • - 4Ds of tr delay: door-data-decision-drug
  72. Classifying ACS: STEMI
    • 1)STEMI - ST elevation  on 2 or more contiguous leads or LBBB (V1 neg R, V6 double R)
    •  - 2mm (0.2 mV) on V2 or V3,  1mm in all other leads
    •  - 2.5 mm (0.25 mV in men < 40), 1 .5 mm (0.15 in women) on V2/V3
  73. Classifying ACS: NSTEMI/High risk UA
    • - ST depression at least 0.5mm (0.05mV), OR
    • - dynamic T wave inversion + chest discomfort, OR
    • - transient ST elevation at least 0.5mm (0.05 mV) fro < 20 minutes
  74. Classifying ACS: Intermediate or low risk UA
    • - need serial cardiac markers, functional testing for further risk stratification (new data may change risk category)
    • - normal ECG
    • - ST deviation either direction < 0.5mm (0.05 mV)
    • - T inversion 2mm or less (0.2 mV)
  75. Fibrinolytic therapy drugs/indication
    • - fibrin specific: rtPA, reteplase, tenecteplase
    • - non-fibrin specific: streptokinase (most common)
    •  1) STEMI, onset of symptoms <12 hrs, qualifying ECG, PCI unavailable in 90 min of 1st med contact
    • 2) "STEMI" on posterior wall (ST elevation in early precordial leads V1-V6), < 12hrs, qualifying ECG
    • 3)>12 hrs IF persistent chest discomfort + STE
  76. Absolute X fibrinolytics
    • - any prior intracranial bleed
    • - cerebral vascular lesion
    • - malignant intracranial neoplasm
    • - ischemic stroke within 3 mo (unless within 3 hrs)
    • - aortic dissection
    • - active bleeding
    • - major closed head/face traums w/in 3 mo
    • - >24 hrs from onset of symptoms
    • - ST depression (unless true posterior wall MI)
  77. Fibrinolytics with caution
    • - chronic severe HTN (hx or current) >180/110
    • - dementia or other intracranial pathology
    • - traumatic.prolonged CPR/major surgery last 3 wks
    • - recent int bleeding (2-4 w)
    • - noncompressible vascular puncture
    • - prior fibrinolytics with poor allergic response
    • - pregnancy
    • - current anticoags with elevated INR
  78. PCI - what, when
    • Percutaneous coronary intervention - balloon inflation and stent placement
    • - Primary - preferred over fibrinolytics if <3hrs from onset of symptoms or contraindications to fibrinolytics
    • - Rescue PCI - fibrinolytics fail
  79. ACS: IV nitroglycerin
    • - not routinely used
    • - used if chest discomfort persist after SL/spray nitro
    • - used in STEMI complicated by pulm edema or HTN
    • - management: titrate to effect, keep SB >90, limit drop in SBP to 30 mm Hg below BL in hypertensives, 10% drop in normotensives
  80. ACS: IV heparin
    • - routinely given as adjunct for PCI and fibrinolytics
    • - be careful!!! incorrect dosing/monitoring leads to hemorrhage!
  81. Bradycardia basics
    • - true symptomatic brady if: rate < 50, pt syptomatic, symptoms due to brady
    • - if HR <50 then symptoms probably related to brady
    • - 1st line drug = atropine
    • - may use TCP, epinephrine, or dopamine
    • - may need expert consult
    • - recognition of brady due to VA block takes priority over ID type of AV block
    • - HURRY - if symptomatic may rapidly progress to CA
  82. Bradycardia s/s
    • - symptoms: chest discomfort, SOB, dec LOC, weakness, fatigue, light headedness, presyncope/syncope
    • - signs: hypotension, orthostatic hypo, diaphoresis, pulmonary congestion, CHF, pulm edema
    • - may have bradycardia related (escape) ventricular rhythms (PVC, VT)
  83. Bradycardia management
    • - Adequate perfusion? BP WNL, OK mental status, warm extensions, cap refill < 3s, no pallor/cyanosis, periph pulses, urine output >30 ml/hr, no edema
    • - if yes, observe and monitor
    • - if no, ATROPINE 1st dose 0.5 mg bolus, repeat 3-5 min to 3 mg total, but do not delay TCP fr atropine if unstable/poor perfusion
    • - atropine effective? If not, TCP or epi or Dop 2-10 mcg/kg/min
    • - use caution w atropine in acute coronary ischemia or MI
    • - do NOT rely on atropine in 2 deg type ii or 3 deg AV block with new wide QRS
  84. TCP basics
    • - give analgesics/sedatives if possible
    • - IMMEDIATELY in unstable pts with higher degree heart block, if IV unavailable, if atropine ineffective
    • - after TCP confirm capture
    • - reassess for improvement/hemodynamic stability
    • - if both atropine and TCP ineffective, need consult, consider epi pr dop 2-10 mcg/kg/min and titrate to effect, prepare for transvenous pacing
  85. TCP indications
    • - hemodynamically unstable bradycardia
    • (hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure)
    • - AMI with symptomatic brady
    • - 2nd deg type 2
    • - 3rd deg AV block
    • - new BBB
    • - brady with V escape rhythms (PVC)
  86. TCP precautions
    • X severe hypothermia, asystole
    • - requires analgesia/sedatives if possible
    • - carotid pulse inadequate to confirm capture
    • - if ACS, pace with lowest HR for stability of high O2 demand!
  87. Performing TCP
    • - electrodes on
    • - pacer on
    • - rate 60/min (adjust) - if symptoms are due to brady, should see improvement at rate 60-70/min
    • - set to 2mA> dose at which capture occurs
    • - don't target HR, look fr improvement in clinical status
  88. Bradycardia-dependnet V rhythms
    • - fail to respond to drugs
    • - can deteriorate to VT or VF
    • - TCP may eliminate them

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