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ACLS begins with BLS, and an assessment of a patient's airway, breathing, and circulation. At each step, it is important to act before continuing. Shocks are provided according to montior and vital signs, not in in response to an AED's evaluation.
A secondary survey should be quickly done to identify possible causes of cardiac arrest (e.g., a heart attack, drug overdose, or trauma).
Throughout ACLS, it is critical to continue chest compression with minimal interruptions.
ACLS survey is often done by many team members, and should be on an ongoing basis throughout ACLS response.
AirwayIs the airway open? Does the patient need an advanced airway?
BreathingIs oxygenation and ventilation sufficient? If used, is the airway device properly placed and monitored? Are CO2 and O2 sats being monitored?
CirculationWhat is the current cardiac rhythm? Is IV/IO access obtained? Does the patient need fluids or medications?
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Differential DiagnosisWhy did arrest occur? Are there any other factors? Can we reverse the cause(s)? 7 H's and 5 T's: pnemonic for mechanisms
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What is the child's weight?
ECG is initially required to identify rhythm disturbance. Examine width of QRS complex, as well as presence or absence of P waves.
A sinus tachycardia will normally be <220 bpm in an infant and <180 bpm in a child.
If tachycardia is sinus, treat the underlying condition. These include hypoxia, hypovolemia, hyperthermia, fever, toxins, therapeutics, pain, and anxiety.
If supraventricular tachycardia is suspected, identify and treat possible causes. Consider vagal maneuvers, establish IV/IO access. Consider adenosine 0.1 mg/kg, max 6 mg. Use as rapidly as possible.
Consider cardioversion with 0.5-1 J/kg.
If patient is unstable, or ventricular tachycardia is present, consider amiodarone 5mg/kg IV drip, or lidocaine 1 mg/kg.
Bradycardias are often caused by hypoxia. Support airway and ventilation with oxygenation.
Begin chest compressions if HR is less than 60/min.
Consider epinephrine IV/IO at 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) or ET at 0.1 mg/kg.
If vagal stimulation or cholinergic poisoning is suspected, use atropine at 0.02 mg/kg (min = 0.1 mg, max = 0.5 mg in a child, 1 mg in an adolescent). Atropine may be given q5 minutes, to a total dose of 1 mg in a child (2 mg in an adolescent).
Cardiac pacing may be considered in bradycardia caused by congenital or acquired heart disease if there is third degree heart block.
Defibrillation 2-4 J/kg
Epinephrine 0.01 mg/kg IV/IO every 3-5 minutes
Shock after 30-60 seconds of medication
Amiodarone 5mg/kg bolus IV/IO, or lidocaine 1 mg/kg IV/IO/TT bolus, or magnesium 25-50 mg/kg IV/IO for Torsades de pointes