The timer at the bottom flashes and gives a brief audio alert every 2 minutes (120 seconds) if started. You may also scroll the time forward / backward to adjust. Algorithms below are simplifications of ACLS / PALS for VT / VF / PEA / asystole.
Every 2 minutes:
- Pulses? → see ROSC pathway below
- Rhythm check
- Epinephrine 1:10,000 0.01 mg/kg, max 1 mg, IV / IO every other cycle*
- If VF / VT,
- Defibrillate 2 J/kg x1, then 4 J/kg, max 10 J/kg or 200 J (or machine max)
- ± Amiodarone 5 mg/kg, max 300 mg bolus IV / IO, may repeat x2 for 1st dose, then 150 mg/kg for 2nd dose (given on alternate cycles from epinephrine)
*Vasopressin removed from 2015 update to ACLS.
Dosing calculator (kg):
Estimate weight by using a Broselow tape or the formula 3*Age + 7 for 1-15 years.
Basics:
- Compression rate 100-120 bpm
- Compression depth: 5-6cm
- Breath rate: 10 / min
- Use end-tidal CO2 monitoring
Adjunctive Treatments:
- IV fluids: pressure bag 2L
- Naloxone 0.4mg (for suspected opioid overdose)
- Calcium gluconate 30mEq or chloride 10mEq
- Sodium bicarbonate 1-3 amps
- Magnesium 2g
- Max-dose vasopressor infusion(s)
Reversible causes: (H's and T's)
|
|
Electrical storm:
- Def: Pulseless VT or VF refractory to epi / shocks x 3
- ± Defibrillate at max energy from 2 separate defibrillators (one set ant-post, one set R upper chest - L lower chest), simultaneously
- ± β-blocker: Esmolol 0.5mg/kg bolus then 0.1mg/kg/hr or propranolol 0.15mg/kg
ROSC (Return of Spontaneous Circulation):
- Full set of vitals (Goals: SaO2 ≥ 94%, SBP ≥ 90 mmHg)
- IV fluid bolus
- EKG
- ± CXR
- ± Cath lab
- ± Central venous access and arterial line for continued BP monitoring and vasopressors
- If not following commands → ± therapeutic hypothermia / normothermia
References:
- ACLS, PALS, 2015
- Nademanee, K et al. Treating Electrical Storm: Sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation. 2000; 102: 742-7.
- Eifling, M et al. The evaluation and management of electrical storm. Tex Heart Inst J. 2011; 32(8): 111-21.
- Cabanas, JG et al. Double sequential external defibrillation in out-of-hospital refractory ventricular fibrillation: a report of 10 cases. Prehosp Emerg Care. 2015; 19(1): 126-30.