ACLS: Crash Course in Crash Carts

ACLS: Crash course in crash carts

By Andrew Herman, MS, RN

How proficient would you really be if a code situa- the setting at 2 mA above that capture point. The tion occurred? Even while keeping your skills up to patient should now be ready for immediate transfer date with advanced cardiovascular life support for more definitive care, such as internal pacing. (ACLS) recertification, it’s possible for nurses to find themselves out-of-practice. This article outlines Tachycardia the magic numbers associated with ACLS, the tools At the other extreme, tachycardia can cause the and medications you’ll find in the crash cart, and patient’s cardiac perfusion to drop because the treatment guidelines to follow in a code situation. heart is beating faster than it’s designed to do. This brings us to our next ACLS magic number: Bradycardia 150. A heart rate above 150 beats/minute is the Let’s begin with a bradycardia situation. Here, we point at which electrical therapy should be consid- encounter one of our ACLS magic numbers: 90. As ered. Supraventricular tachycardia, rapid atrial a rule, a patient with a dysrhythmia who still flutter, or rapid atrial fibrillation will show a maintains a systolic BP of 90 mm Hg or higher can narrow QRS complex on the ECG of less than receive treatment with medications. But, if the sys- 0.12 seconds, which equals three of the small tolic BP decreases to below 90, we have to set up 0.04-second squares on the ECG graph. Ventricular for electrical therapy. tachycardia will have a very wide QRS complex of Ideally, crash carts are standardized. The top greater than 0.12 seconds. drawer of the cart has three boxes of atropine; the It’s important to distinguish regular (evenly prepackaged injection in each box contains 1 mg. spaced), narrow tachycardia from irregular, narrow Give these patients 0.5 mg—or half—of the injection tachycardia because the treatment differs regarding to speed up the heart. This same dose can be repeated, medications and the amount of electricity used. It can if necessary, every 3 to 5 minutes for a maximum be difficult to tell the difference because the QRS com- dose of 3 mg. plexes appear very close to each other on the ECG. Atropine isn’t effective against advanced heart Conditions permitting, a 12-lead ECG should be per- blocks. However, if the patient is conducting few or formed to help determine the exact dysrhythmia. no P waves with a ventricular rate in the 30s, his or A quick treatment that can be attempted right her BP is likely so low that pacing is indicated. The away is having the patient perform a vagal maneu- pacer pads are placed on the patient’s chest and ver to lower his or her heart rate. A variety of vagal back, ideally with the heart sandwiched in between. maneuvers exist; the type I used in my ICU career Set the defibrillator to the pace function, which was to have the patient forcefully cough once. defaults to a rate of 70 beats/minute. Next, gradu- ally increase the milliamp (mA) setting on the out- Regular put control until the patient shows a ventricular If the physician decides to treat the dysrhythmia capture after each pacer spike on the ECG. Leave as a regular tachycardia with a systolic BP greater

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. than 90, the first drug of choice is adenosine 6 mg 10 minutes. If using an infusion pump, your infu- via rapid I.V. push, immediately followed by 20 sion rate will be 600 mL/hr. The idea here is to mL 0.9% sodium chloride solution. The patient’s reduce the rate of ventricular response to the atrial ECG tracing may display a flat line for a few sec- fibrillation. The physician may not want to convert onds before reappearing at a reduced rate. There the atrial fibrillation to sinus rhythm at this time are three 6 mg vials of adenosine in the cart medi- because it may put the patient at risk for stroke. cation drawer. After the initial dose is adminis- However, if this patient’s BP drops below 90, then tered, a second dose of 12 mg can be given in the synchronized cardioversion must be considered same manner. (200 joules biphasic). Other drugs that can be tried after adenosine are Wide-QRS ventricular tachycardia can also be verapamil 5 mg I.V. over 2 to 5 minutes or diltiazem regular or irregular. In either case, the patient is at 0.25 mg/kg I.V. The second dose of diltiazem is 0.35 risk for a sudden drop in BP. If the patient is still mg/kg. These medications aren’t in the cart, even maintaining a systolic BP of greater than 90, he or though they’re drugs needed on very short notice. she can still benefit from amiodarone 150 mg in 100 The medication drawer contains vials of vasopres- mL D5 infused over 10 minutes. Consider putting sin, which is no longer recommended in ACLS. defibrillation pads in place because a regular, wide Health systems should consider removing these tachycardia with systolic BP of less than 90 needs vials from that spot and replacing them with vera- 100 joules synchronized. A patient with an irregular, pamil vials. Why verapamil? It’s more useful in an wide tachycardia needs 200 joules unsynchronized. emergency because there’s no drug calculation This is because the monitor will have difficulty involved. placing hash marks over erratic ventricular If the patient’s systolic BP drops below 90 at any complexes. point, then place defibrillator pads front-to-back and prepare for cardioversion. A regular, narrow- Enter epinephrine QRS tachycardia receives 50 to 100 joules biphasic One ACLS rule of thumb is to do a carotid pulse (meaning that the unit delivers electricity in two check each time the patient has an ECG rhythm directions), with the monitor set in SYNCH mode change. A patient can show a normal sinus rhythm so that the shock is delivered in the proper phase of on the ECG and have no pulse or BP, which is polarization-repolarization. In this mode, the word called pulseless electrical activity (PEA). The first SYNCH will appear on the monitor and hash marks action here is to immediately start chest compres- will appear over each QRS complex. The physician, sions over the bottom half of the patient’s sternum time permitting, may elect to give the patient I.V. at one-third the depth of the chest at a rate of at sedation before the shock. Be sure no one touches least 100 compressions/minute. This is necessary the patient during the shock. because chest compressions only deliver a small percentage of the body’s natural cardiac output. Irregular During a code, you’ll need a second person to take If the physician decides that the patient is experi- over chest compressions after 2 minutes. In a encing an irregular, narrow tachycardia, as in rapid 2-minute period, the patient should receive five atrial fibrillation, then use of adenosine isn’t indi- cycles of 30 compressions with two ventilations in cated. The first-line medications for this patient between. Compressions shouldn’t be interrupted with a systolic BP of greater than 90 are verapamil for more than 10 seconds. or diltiazem; but again, these aren’t readily avail- Six boxes of 1:10,000 strength epinephrine, 1 mg able in crash carts. The medication that we do have each, are located along the left side of the cart medi- on hand to treat rapid atrial fibrillation is a 150 mg cation drawer. The dose of epinephrine is the same vial of amiodarone. in PEA, asystole, pulseless ventricular tachycardia, In the second drawer, the I.V. fluids drawer of or ventricular fibrillation: 1 mg via I.V. push every 3 the cart, you’ll note a 100 mL bag of dextrose 5% to 5 minutes. PEA and asystole aren’t shockable solution (D5). You can mix the amiodarone 150 mg rhythms; they’re treated with epinephrine and qual- in this bag and infuse it slowly by gravity over ity CPR while the physician considers why the

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. patient is in this rhythm. Common causes are tray and assorted endotracheal (ET) tubes. Some dehydration, hypoxia, hypothermia, swings in medications, such as lidocaine, epinephrine, and potassium, acidosis, cardiac tamponade, and ten- atropine, as well as naloxone, can also be given sion pneumothorax. If the monitor suddenly shows through the ET tube if the patient’s I.V. access is a flat line, check the ECG wire attachments to the challenging or lost. However, the I.V. doses must be patient and check a couple of other leads (ll, lll, doubled if given via the airway and followed by 10 and avF), if necessary, to make sure that the patient mL of 0.9% sodium chloride solution. isn’t in a fine ventricular fibrillation rhythm, which is shockable. Closing thoughts Both ventricular tachycardia without a pulse and To sum up, in ACLS the magic numbers are 90 and coarse ventricular fibrillation are defibrillated with 150. A systolic BP of less than 90 mm Hg or a heart 200 joules biphasic. CPR then resumes immediately rate greater than 150 beats/minute should make us for another 2 minutes while medications are given. think about applying defibrillation pads to the pa- After epinephrine 1 mg I.V. is administered, the tient and delivering electrical therapy. If we have next medication to try is amiodarone 300 mg via I.V. QRS complexes on the ECG, we need to know if push. There are three 450 mg vials of amiodarone in they’re narrow or wide, and regular or irregular. the medication drawer. So, your dose is two-thirds Two rescuers are needed to perform chest com- the content of one of these vials. Your follow-up pressions. ACLS recertification is important, and dose of amiodarone is 150 mg I.V., which is the this guide to crash carts is another tool that you remainder of the vial. can familiarize yourself with to be prepared in the In the medication drawer are also four 100 mg event of a code situation. ■ boxes of lidocaine. Some sources indicate that lidocaine is still a good option in the treatment of ven- REFERENCES tricular tachycardia and ventricular fibrillation, Craig-Brangan KJ, Day MP. Update: 2015 AHA BLS and ACLS guidelines. Nursing. 2016;46(2):40-45. whereas others note that it should play less of a Herrmann C. Cardiac advanced life support-surgical guideline: over- role. The initial dose of lidocaine is 1 to 1.5 mg/kg view and implementation. AACN Adv Crit Care. 2014;25(2):123-129. via I.V. push, which is roughly equivalent to one Sinz E, Navarro K, Soderberg ES, Callaway CW, American Heart Association. Advanced Cardiovascular Life Support: Provider Manual. 100 mg prepackaged injection for an adult patient. Dallas, TX: American Heart Association; 2011. A second dose of lidocaine is one-half of the first. Wagner BJ, Yunker NS. A pharmacologic review of cardiac arrest. Plast Surg Nurs. 2014;34(3):133-137.

Intubation Andrew Herman is a Clinical Nurse at VA Puget Sound Health Care System’s If a patient doesn’t respond right away to defibrilla- American Lake Division in Tacoma, Wash. tion, then we have to consider intubation. The bot- The author has disclosed no financial relationships related to this article. tom drawer of the crash cart contains an intubation DOI-10.1097/01.NME.0000520145.38552.bd