PULSELESS ARREST TACHYCARDIA BRADYCARDIA Preform ABC’s UNSTABLE: Airway: is the airway open? Breathing: is air moving adequately? Circulation: is there a pulse? (altered mental status, ongoing chest pain, hypotension) **SYNCHRONIZE** cardiovert: Biphasic 120 and up with sedation ABC’s STABLE: Airway: is the airway open? Shockable rhythm? Breathing: is air moving adequately? 12-lead EKG / IV access / EXCLUDE sinus tachycardia Circulation: is there a pulse? NO YES May directly synchronize cardiovert Biphasic 120/150/200 J (except A. flutter) 12-Lead EKG / IV access NARROW QRS (<0.12 sec): WIDE QRS (≥ 0.12 sec): PEA / ASYSTOLE PULSELESS VF/VT *If asystole → confirm in two leads (if fine VT, REGULAR IRREGULAR REGULAR IRREGULAR Oxygen potential for Defib) RHYTHM: RHYTHM: RHYTHM: RHYTHM:

UNSTABLE: CPR until DEFIB ATRIAL FIBRILLATION OR VENTRICULAR OR ATRIAL FIBRILLATION (altered mental status, CPR x 2 minutes  Vagal stimulation as ADVANCED AIRWAY therapeutic ATRIAL FLUTTER UNCERTAIN RHYTHM WITH ABERRANCY ongoing chest pain, (minimize interruptions in CPR) SHOCK /diagnostic maneuver hypotension) IDENTIFY and TREAT POTENTIAL CAUSES Biphasic 200 J  Adenosine Control Rate:  Amiodarone  Follow Narrow QRS  Diltiazem irregular rhythm (see below)  SYNCHRONIZE First Line : Does rhythm convert?  Metoprolol cardiovert algorithm  Amiodarone  Atropine CPR IMMEDIATELY x 2 minutes YES WOLF PARKINSON WHITE DRUGS ADVANCED Probably reentry SVT Control Rhythm  Transcutaneous AIRWAY RHYTHM CHECK:  Observe  Amiodarone pacing  Adenosine if If <48 hrs: SVT WITH ABERRANCY  AVOID: Adenosine, shockable? use without delay in EPINEPHRINE 1 mg IVP q3-5 minutes recurrence  SYNCHRONIZE Beta-blockers, YES EPINEPHRINE or cardiovert Mobitz type II or 3 or  Follow Narrow QRS Digoxin, Calcium 1 mg IVP q3-5 min  Diltiazem (A. flutter = 50 J regular rhythm channel blockers AV block VASOPRESSIN 40 units IVP x1 to SHOCK or  Verapamil A. fib = up to 200 J) algorithm st nd replace the 1 or 2 dose of epinephrine VASOPRESSIN  Metoprolol  Amiodarone POLYMORPHIC  Call cardiology for 40 units IVP x1 to replace the 1st VENTRICULAR transvenous pacing nd NO If >48 hours: TACHYCARDIA CPR x 2 minutes or 2 dose of  Anticoagulation epinephrine Possibly atrial flutter, Second Line : ectopic atrial tachycardia, ^^NO CARDIOVERSION NOTE: If patient becomes RHYTHM CHECK: Organized rhythm? or junctional tachycardia (electrical or pharmacologic) UNSTABLE,  Dopamine drip* RHYTHM CHECK: without TEE first^^ SYNCHRONIZED shock: ^^NO CARDIOVERSION^^ Biphasic 200 J  Epinephrine drip* YES NO shockable? AMIODARONE

300 mg IVP, may MULTIFOCAL ATRIAL YES  Diltizem -NORMAL baseline QT: Third Line (drug induced; repeat 150 mg IVP in TACHYCARDIA ●Treat ischemia, e-lytes  Verapamil beta-blocker or calcium Pulse? Shockable? SHOCK 3-5 min for pulseless  Metoprolol ●Consider : arrest; 150 mg in 50 ^^NO CARDIOVERSION^^ Amiodarone, Beta- blockers, channel blocker)

YES NO YES (see VT/VF) ml D5W IV over 10 Lidocaine  Glucagon CPR x 2 minutes min for all other  Amiodarone ●If impaired cardiac  Diltiazem function, synchronize tachyarrhythmias; STABLE: Post- resuscitative care repeat as needed  Metoprolol cardiovert Observe and monitor or Lidocaine -INCREASED baseline QT:

(Torsades de Points): IDENTIFY and TREAT STOP? Consider magnesium sulfate for hypomagnesemia ● d/c offending agent POTENTIAL CAUSES ● Treat e-lytes & Torsades (see below) ●Consider: Magnesium sulfate

Consider quality of resuscitation IDENTIFY and TREAT POTENTIAL CAUSES IDENTIFY and (see below) IDENTIFY and IDENTIFY and IDENTIFY and TREAT **Minimize interruptions in chest compressions TREAT TREAT *See reverse side for **Pulse and rhythm checks are NOT recommended after shock delivery TREAT POTENTIAL POTENTIAL recommendations on **Rhythm checks should be brief POTENTIAL POTENTIAL CAUSES CAUSES CAUSES continuous infusion **Pulse checks should only be performed if there is an organized rhythm CAUSES (see below) **Resume CPR immediately (see below) (see below) (see below) **As the patient’s rhythm changes, follow the respective algorithm IDENTIFY and TREAT POTENTIAL CAUSES: DURING CPR: DRUG DOSING: Hypovolemia Toxins/tablets - Push hard and fast (100/min) Adenosine 6 mg rapid IVP followed immediately by rapid 20 ml saline flush; may repeat with 12 mg rapid IVP x2 (volume infusion) (digoxin, beta-blockers, CCB) - Minimize interruptions in chest Amiodarone* 300 mg IVP, may repeat 150 mg IVP in 3-5 min for pulseless arrest; 150 mg in 50 ml D5W IV over 10 min for all other tachyarrhythmias; Hypoxia Tamponade, cardiac compressions repeat as needed (oxygen, ventilation) (stat ECHO, pericardiocentesis) - One cycle of CPR: 30 0.5 mg IVP q3-5 min up to 3 mg for bradycardia Hyper- / Hypokalemia Tension PTX compressions then 2 breaths; 5 Atropine (see front page) (large bore angiocath in 2nd cycles = 2 minutes Digoxin 0.5 mg IV x1, 0.25 mg IV x1 in 6 hours, (optional) 0.25 mg IV x1 in 6 hours; (half the dose in patients with renal insufficiency and on amiodarone) Hydrogen ion (acidosis) intercostal space in - Avoid hyperventilation Diltiazem* 0.25 mg/kg IV push over 2 min (max: 20 mg); may repeat at 0.35 mg/kg (max: 25 mg) IV push over 2 min (buffer, ventilation) MIDCLAVICULAR line) - Secure airway and confirm Epinephrine 1 mg IVP q3-5 min (or per ETT @ 2x dose in 10 ml NS) Hyper- / Hypothermia Thrombosis-coronary placement Glucagon 3 mg IVP over 2 minutes, followed by 3 mg/hr if necessary Hypoglycemia (EKG, fibrinolytics) -** After an advanced airway is Lidocaine* 1-1.5 mg/kg IVP (or per ETT @ 2x dose) (max 3 mg/kg) Thrombosis-pulmonary placed, “cycles” of CPR are no Magnesium sulfate* 1-2 gms IVP over 1-3 minutes (fibrinolytics, surgical /IR evacuation) longer administered. Give Trauma continuous chest compressions Metoprolol 5mg IVP, may repeat q5min x3 if needed and tolerated (caution in patients with pulmonary disease and left ventricular dysfunction) without pauses for breaths. Give 8- Procainamide* 30 mg/min up to 17 mg/kg 10 breaths/minute. Check rhythm Vasopressin 40 units IVP x1 to replace the 1st or 2nd dose of epinephrine every 2 minutes. Verapamil 2.5-5 mg IVP over 2 min every 15-30 min (max: 20 mg) (caution in patients with left ventricular dysfunction) CUMC Medical Housestaff Adult Arrest Card July 2013

Important numbers: NYC Poison Control: 212-340-4494 Organ donation: 800-gift-4NY (800-443-8469)

Milstein: Allen: Arrest 5-3333 Arrest 4-5555 ICU Triage b. 86332 MAR b. 89000 AOD b. 82251 ICU 4-4124 Chief on Call (page operator) Chief on Call (page operator) CCU 5-8970 MICU A 5-6345 MICU B 5-4141 Lab Supervisor 5-6859 Medical examiner: 212-447-2030 Cath Lab: 2-4260 Pastoral care: 5-5817 b. 85547 NYP EMS: 5-9999 Transport: 5-6267

Anaphylaxis: (identify and eliminate the cause) Status Asthmaticus: 1) Airway and ventilation 1) O2 and nebulized bronchodilators (albuterol and 2) O2: early intubation if progressive stridor, lingual ipratropium) swelling, hypoxemia 2) Steroids: Methylprednisolone 40-60 mg IV q6h 3) Epinephrine: 0.3-0.5 mg SubQ/IM (0.3-0.5 ml of 3) Intubation with sedation (Ramsay Scale 5-6) 1:1,000 dilution) q15 to 20 min x3 doses  Permissive hypercapnea 4) Support circulation: fluids, vasopressors  Rate: 8-10 (if needed, sedate to respiratory 5) Steroids: Methylprednisolone 60 mg IV q6h rate of 8-10) 6) Antihistamines:  Volume: 5-7 ml/kg (based on ideal BW)  H1 blocker: Diphenhydramine 50 mg  Peak flow 80-120 L/min and PEEP of 5 IV/IM q6h  Tolerate high peak pressures but keep plateau  H2 blocker: Famotidine 20 mg IV/PO <30 q12h 4) Trouble with ventilation: 7) Nebulized beta-2 agonist (for bronchospasm):  check tube placement and patency albuterol 1 retic (3 ml) inhaled q2-4h  Tension pneumothorax? 8) Observation for 24 hours CAUTION: breath stacking, keep auto-PEEP ≤15 by increasing exhalation time (decrease rate, increase peak flow, square wave)

Hyperkalemic Arrest: Status Epilepticus: (Neuro emergency! 1) Calcium chloride: 1 g (10 ml of 10%) IVP over 30 Contact Neuro immediately.) seconds via central line; if impossible to obtain 1) Airway and ventilation (consider early intubation if central line and/or resuscitation is compromised in evidence of aspiration, hypoxemia, or pulmonary doing so, use peripheral line **for non-arrest use edema) calcium gluconate** 2) Check blood glucose 2) Sodium bicarbonate: 50 mEq (50 ml) IV push over 3) Pulse Ox, BP monitoring 5 minutes; may repeat every 5-10 min 4) Access – 2 wide bore IVs and IVF (to prevent ARF 3) Dextrose 50%: (50 ml of 50%) IVP over 5 minutes due to rhabdomyolysis) AND regular insulin 10 units IV push over 30 5) Lorazepam: 0.1 mg/kg IV push over 2-5 min (if no seconds IV access administer IM) 4) Nebulized albuterol: 1 (3ml) retic inhaled every 30 6) Phenytoin: 15-20 mg/kg IV no faster than 50 mg/min minutes or 25 mg/min in the elderly (If no IV access administer Fosphenytoin 20 mg/kg PE IM) 7) Thiamine: 100 mg IV push over 3 min and Dextrose 50%: (50 ml of 50%) IVP over 5 minutes 8) Labs: Tox screen, anticonvulsant drug levels, CBC, C7, ABG, LFT 9) Watch for hyperthermia 10) EEG monitoring

Medication Bolus Dose Maintenance Dose

AMIODARONE Pulseless VT / VF: 150-300 mg IVP over 450 mg in 250 ml D5W ONLY (Cordarone) 30 seconds (1.8 mg/ml) – mix in glass bottle Stable Tachyarrhythmia: 150 mg in 50 ml 1 mg/min (33 ml/hr) x6 hrs, then 0.5 mg/min (17 D5W IV over 10 min; may repeat ml/hr) x18 hrs; max 2.2 gms/24 hrs DILTIAZEM 0.25 mg/kg IV push over 2 min (max: 20 125 mg qs to 125 ml D5W (1 mg/ml)^ (Cardizem) mg); may repeat at 0.35 mg/kg (max: 25 Start at 5 mg/hr - titrate to blood pressure / heart mg) IV push over 2 minutes rate; max: 15 mg/hr DOBUTAMINE NOT RECOMMENDED 500 mg in 250 ml D5W (2 mg/ml) (Dobutrex) 2.5 - 20 micrograms/kg/min max: 40 micrograms/kg/min DOPAMINE NOT RECOMMENDED 400 mg in 250 ml D5W (1600 micrograms/ml) (Intropin) Start at 5 micrograms/kg/min (10.5 ml/hr for 70 kg pt) Dosing range: 0.5 - 20 micrograms/kg/min - titrate to blood pressure range (lower doses may be used for bradycardia) EPINEPHRINE** ACLS: 1 mg IV push every 3-5 minutes 2 mg in 250 ml D5W (8 micrograms/ml) (Adrenalin) 1 - 10 micrograms/min - titrate to blood pressure ^^Dose for anaphylaxis: 0.3 - 0.5 mg SubQ (0.3 - 0.5 ml of 1:1,000 dilution) ESMOLOL 500 micrograms/kg IV push over 30 2.5 g in 250 ml D5W (10 mg/ml) (Brevibloc) seconds (re-bolus prior to each increase Start 50 micrograms/kg/min, titrate rate by 25 in rate) micrograms/kg/min increments every 5 min - titrate to blood pressure/heart rate

FUROSEMIDE 20 - 80 mg IV push over 2 - 3 minutes 100 mg in 100 ml D5W (1 mg/ml) (Lasix) Start at 5 mg/hr - titrate to UOP; max 1000 mg/day rebolus when initiating infusion or prior to titration LABETALOL Initial dose: 10-20 mg IV push over 2 400 mg qs to 200 ml D5W (2 mg/ml)^ (Normodyne) minutes; may repeat or double the dose Start 1 - 2 mg/min - titrate to blood pressure/heart up to 50 mg/dose every 10 minutes rate

LIDOCAINE** 1-1.5 mg/kg (max: 100 mg) IV push over 1000 mg in 250 ml D5W (4 mg/ml) 3-5 minutes (not to exceed 50 mg/min); 1 - 4 mg/min (30 - 50 micrograms/kg/min) may repeat in 5 min with 0.5-0.75 mg/kg; max 3 mg/kg MAGNESIUM Torsades de pointes / symptomatic 4 g/100 mL infused over the next 2 - 3 hours; per SULFATE hypomagnesemia: 2 g IVP over 2 level consider continuous infusion totaling 10 g over minutes; recheck level 1 hour after 24 hours NOTE: if seizures persist, 2 - 4 g over 5 - 10 minutes may be repeated up to a total of 10 g over the next 6 hours

MILRINONE 50 micrograms/kg IV over 10 min 20 mg in 100 ml D5W (0.2 mg/ml) (Primacor) 0.375-0.75 micrograms/kg/min; adjust for renal impairment

NALOXONE 0.4-2 mg IV push over 30 seconds every 4 mg in 250 ml D5W (0.016 mg/ml) (Narcan) 2 min; max 10mg or response noted Start at 0.4 mg/h (25 ml/hr)-titrate to desired effect; may precipitate withdrawal symptoms, caution in patients on chronic narcotics; half-life 20 minutes NITROGLYCERINE NOT RECOMMENDED 50 mg in 250 ml D5W (0.2 mg/ml) Start at 5 micrograms/min- titrate to effect and blood pressure NITROPRUSSIDE NOT RECOMMENDED 50 mg in 250 ml D5W (0.2 mg/ml) (Nipride) Start at 0.2 micrograms/kg/min - titrate to blood pressure; max 10 micrograms/kg/min NOREPINEPHRINE NOT RECOMMENDED 4 mg in 250 ml D5W (16 micrograms/ml) (Levophed) Start at 5 micrograms/min(19 ml/hr) - titrate to blood pressure range Notify fellow or attending for doses > 40 micrograms/min

PHENYLEPHRINE NOT RECOMMENDED 20 mg in 250 ml D5W (80 micrograms/ml) (Neosynephrine) Start at 50 micrograms/min (38 ml/hr) - titrate to blood pressure range Notify fellow or attending for doses > 400 micrograms/min VASOPRESSIN ACLS: 40 units IV push over 30 seconds 100 units in 100 ml D5W (1 unit/ml) (Pitressin) Vasodilatory Shock: Start at 0.04 units/min, do NOT titrate up; may titrate DOWN as blood pressure tolerates **Medications that may be administered down the endotracheal tube at 2-2.5 times the dose (atropine, epinephrine, lidocaine, and naloxone)

^”qs" means to add to the quantity sufficient to equal the final volume stated