Adult Advanced
Life Support
ALS
2021
Bradycardia
Bradycardia
Definition
Bradycardia is defined as a heart rate of <60 beats/ min. However, when
bradycardia is the cause of symptoms, the rate is generally <50 beats per minute .
Approach
1. Attach a monitor to the patient
2. Establish IV access
3. Evaluate BP
4. If possible, obtain a 12-lead ECG to better define the rhythm
Remember that signs and symptoms of bradycardia may be mild; asymptomatic
or minimally symptomatic patients do not necessarily require treatment .
If the bradycardia is suspected to be the cause of acute altered mental status,
ischemic chest discomfort, acute heart failure, hypotension, or other signs of
shock, the patient should receive immediate treatment.
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Treatment
Atropine
1.First-line drug for acute symptomatic bradycardia
2.Temporizing RX while awaiting a TC or TV pacemaker for symptomatic sinus
bradycardia, conduction block at the level of theAV node, or sinus arrest.
The recommended atropine dose for bradycardia is 0.5 mg IV every 3 to 5
minutes to a maximum total dose of 3 mg.
Atropine administration should not delay external pacing for patients with poor
perfusion.
Use atropine cautiously in the presence of acute coronary ischemia or MI;
increased heart rate may worsen ischemia or increase infarction size.
Atropine will likely to be ineffective inpatients who have undergone cardiac
transplantation because the transplanted heart lacks vagal innervation.
Avoid relying on atropine in type II 2nd AVB or 3rd AV block where the location of
block is infranodal(such as in His bundle).
These bradyarrhythmias are not likely to respond to atropine and are preferably
treated with TCP or Alpha-adrenergic support as temporizing measures while the
patient is prepared for TVP .
Pacing
1.Initiate TCP in unstable patients who do not respond to atropine .
2.Immediate pacing might be considered in unstable patients with high-degree AV
block when IV access is not available .
TCP is a temporizing measure.
TCP is painful in conscious patients, and, whether effective or not (achieving
inconsistent capture), the patient should be prepared for transvenous pacing .
Alternative Drugs
1.Dopamine, epinephrine, and glycopyrrolate are alternatives when a
bradyarrhythmia is unresponsive to atropine, or as a temporizing measure while
awaiting the availability of a pacemaker.
2.Glucagon May be appropriate in overdose of B -blocker or calcium
channel blocker.
Dopamine.infusion may be used for symptomatic bradycardia, particularly if
associated with hypotension, in whom atropine may be inappropriate or after
atropine fails Begin dopamine infusion at 2 to 10 mcg/kg /min. and titrate to
response.
Epinephrine
may be used for patients with symptomatic bradycardia, particularly if associated
with hypotension, for whom atropine may be inappropriate or after atropine fails
Begin the infusion at 2 to 10 mcg/min and titrate to effect.
Tachycardia
Definition
Tachycardia is defined as an arrhythmia with a rate of >100 beats
per minute.
Classification of Tachyarrhythmias
Narrow–QRS-complex (SVT) tachycardias (QRS <0.12sec)
In order of frequency
● Sinus tachycardia-regular
● Atrial fibrillation-irregular
● Atrial flutter-irregular
● AV nodal reentry(SVT)-regular
● Multifocal atrial tachycardia (MAT)-may be irregular
Wide–QRS-complex tachycardias (QRS >=0.12 second)
● VT and VF
● SVT with aberrancy
● Pre-excited tachycardia (Wolff-Parkinson-White[WPW] syndrome)
Approach
1. Attach a monitor to the patient
2. Establish IV access
3. Evaluate BP
4. If possible, obtain a 12-lead ECG to better define the rhythm, but this should not
delay immediate cardioversion if the patient is unstable.
If the patient demonstrates rate-related cardiovascular compromise with S/S such
as acute altered mental status, ischemic chest discomfort, acute heart failure,
hypotension, or other signs of shock suspected to be due to a tachyarrhythmia,
proceed to immediate synchronized cardioversion
Cardioversion
If possible, establish IV access before cardioversion and administer sedation if the
patient is conscious.
Synchronized cardioversion
is shock delivery that is timed (synchronized) with the QRS complex. This
synchronization avoids shock delivery during the refractory period of the cardiac
cycle when a shock could produce VF.
Synchronized cardioversion is recommended to treat (1)unstable SVT, (2) unstable
AF, (3) unstable atrial flutter, and (4)unstable VT.
Cardioversion Waveform and Energy
1. Biphasic cardioversion of AF is 120 to 200 J.If the initial shock fails, providers
should increase in a stepwise fashion.
2. Biphasic Cardioversion of atrial flutter and other SVTs is 50 to 100 J
3. Cardioversion with monophasic waveforms should begin at 200 J and increase in
stepwise fashion if not successful .
4. Monomorphic VT (regular form and rate) with a pulse responds well to
monophasic or biphasic synchronized cardioversion at initial energies of 100 J.
5. if a patient has polymorphic VT, treat the rhythm as VF and deliver high-energy
unsynchronized shocks (ie,DC) .
6. If there is any doubt whether mono-or polymorphic VT is present in the unstable
patient, do not delay shock to perform rhythm analysis:provide high-energy
unsynchronized shocks (ie,DC).
Regular Narrow-Complex Tachycardia
A-Sinus Tachycardia
Usually results from a physiologic stimulus, such as fever, anemia, or
hypotension/shock.
Sinus tachycardia is defined as a heart rate more than 100 beats per minute.
If judged to be sinus tachycardia, no specific treatment is required.
Instead, therapy is directed toward identification and treatment of the
underlying cause.
B-Supraventricular Tachycardia (AV nodal reentrant tachycardia)
Regular, narrow complex tachycardia(QRS<0.12 sec.)
Treatment for SVT
1.Non pharmacological
Vagal maneuvers such as: Valsalva maneuver or carotid sinus
massage.
This will terminate up to 25% of SVTs
2. Pharmacological
Adenosine
If SVT does not respond to vagal maneuvers, give 6 mg of IV
adenosine as a rapid IV push through a large vein followed by
a 20 mL saline flush .
If the rhythm does not convert within 1 to 2 min., give a 12 mg
rapid IV push using the method above.
Adenosine is safe and effective in pregnancy.
Side effects ; flushing, dyspnea, and chest discomfort are the most
frequently observed.
Adenosine should not be given to patients with asthma.
Amiodarone
can be useful in RX of SVT, but the onset of action of is slower than
that of adenosine.
Give 300mg in 250ml 5% G/W over 10-60 minutes
Followed by 900mg in 500-1000 ml 5% G/W.
Verapamil
2.5 mg to 5 mg IV bolus over 2-5 minutes. If no response, repeated doses of 5 mg
to 10 mg may be administered every 15 to 30 minutes to a total dose of 20 mg.
An alternative dosing regimen is to give a 5 mg bolus every 15 minutes to a total
dose of 30 mg.
Verapamil should not be given to==
1. Patients with wide-complex tachycardias.
2. Impaired ventricular function or heart failure
Metoprolol, Atenolol, Propranolol, Esmolol, and Labetolol
Like calcium channel blockers, they also have –ve inotropic effects and further
reduce cardiac output in patients with heart failure.
Side effects of B-blockers can include bradycardias, AV Block, and hypotension.
B-blockers should be used with caution in patients with COPD, Asthma,DM
Wide-Complex Tachycardia
Wide-complex tachycardias are defined as those with a QRS >=0.12
second.
Causes
● VT or VF
● SVT with aberrancy
● Pre-excited tachycardias (associated with or mediated by
an accessory pathway)
● Ventricular paced rhythms
Treatment for Regular Wide-Complex Tachycardias
For patients who are stable with likely VT :
IV antiarrhythmic Procainamide,amiodarone , or sotalol can be considered.
If one of these agents is given, a second agent should not be given without expert
consultation.
If antiarrhythmic RX is unsuccessful, cardioversion or expert consultation should
be considered
Procainamide
Administered at a rate of 20 to 50 mg/min until the arrhythmia is
suppressed, hypotension ensues, QRS duration increases 50%, or the
maximum dose of 17 mg/kg is given.
Procainamide should be avoided in patients with prolonged QT and
congestive heart failure.
IV sotalol (100 mg IV over 5 minutes) was found to be more effective
than lidocaine when administered to patients with stable
monomorphic VT Sotalol should be avoided in patients with a
prolonged QT
Irregular Tachycardias
Atrial Fibrillation and Flutter
An irregular narrow-complex or wide-complex tachycardia is most
likely atrial fibrillation with an uncontrolled ventricular response.
Treatment
General MX of AF should focus on
1.Control of the rapid ventricular rate (rate control) .
2.conversion of hemodynamically unstable AF to sinus
rhythm(rhythm control), or both.
Patients with an AF duration of>= 48 hours are at increased risk
for cardio embolic events.
Electric or pharmacologic cardioversion (conversion to normal
sinus rhythm) should not be attempted in these patients unless
the patient is unstable.
An alternative strategy is to perform cardioversion (mech. or
chemical) following anticoagulation with heparin and performance of
trans esophageal echocardiography to ensure the absence of a left
atrial thrombus .
Rate Control (AF with HR>120bpm)
Patients who are hemodynamically unstable should receive prompt
electric cardioversion.
Stable patients require ventricular rate control.
IV B-blockers and calcium channel blockers such as diltiazem are the
drugs of choice for acute rate control in most individuals with AF
and rapid ventricular response
Rhythm Control
Polymorphic (Irregular) VT
Polymorphic (irregular) VT requires immediate defibrillation with the same
strategy used for VF.
-If a long QT interval is observed during sinus rhythm (ie, the VT is torsades de
pointes), the first step is to stop medications known to prolong the QT interval,
correct electrolyte imbalance Magnesium is commonly used to treat torsades de
pointes VT (polymorphic VT associated with long QT interval) .
-In the absence of a prolonged QT , the most common cause of polymorphic VT is
myocardial ischemia.
In this situation IV amiodarone may reduce the frequency of arrhythmia
recurrence
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