Treatment Guide

For significant changes in rhythms, especially tachyarrhythmias or any rhythm causing hemodynamic
compromise, obtain 12-lead ECG and consider expert consultation. Always assess and treat the patient, not
the rhythm. Patient symptoms will determine treatment.
Sinus Rhythms
NSR None; Normal
Sinus Bradycardia (SB) Symptomatic only: (All Trained Dogs Eat acronym)
 Atropine 1 mg IVP (preferred)
 Transcutaneous Pacing
 Dopamine 5-10 mcg/kg/min (if unresponsive to atropine & pacing)
 Epinephrine 2-10 mcg/min (if unresponsive to atropine & pacing)
Sinus Tachycardia (ST) Treat underlying cause (fever, anxiety, pain, hyperthyroidism, CHF,
hypovolemia, etc.); AMI – β blocker
Sinus Arrhythmia None, normal variant
Sinus Pause Depends on frequency, length of pause and cause – if severe or due to
sinus node dysfunction (SND), pacemaker is indicated
Atrial Arrhythmias
Wandering Atrial Pacemaker None
PACs None usually unless very frequent and worried that patient may go into a
faster atrial rhythm; eliminate cause (e.g. caffeine, tobacco, electrolyte
imbalances, etc.)
Atrial Tachycardia (AT)  Check electrolytes, for underlying causes, stimulant drugs
Paroxysmal if see it start or  Attempt vagal maneuvers (if stable)
stop (PAT)  Adenosine 6 mg rapid IV push. If no conversion, give 12 mg. (ACLS
recommendation but can give two doses of 12 mg.)
 Elective cardioversion if unable to convert and symptomatic. (If
unstable, go directly to synchronized cardioversion.)
Atrial Flutter  Check electrolytes (K+, Mg++)
 Attempt vagal maneuver
 Calcium channel blockers, β blockers, amiodarone
 Acute vs. chronic or time in arrhythmia before considering cardioversion
and only for unstable
Atrial Fibrillation (rapid  Control rate with Diltiazem or β-blockers.
response)  If acute (< 48 hours) and hemodynamically unstable, elective
cardioversion.
Multifocal Atrial Tachycardia  Same as AT
(MAT)
Junctional Arrhythmias
PJCs  Check electrolytes (K+, Mg++)
Junctional Rhythm  None, usually an escape rhythm.
 If unstable,  vagal tone on SA node with Atropine 0.5 mg IVP – repeat
every 3-5 min. (max. 3 mg)
 Treat underlying causes (e.g. hypoxia)
 Follow ACLS Bradycardia algorithm.
Accelerated Junctional Usually none; assess hemodynamic status and treat as needed;
Rhythm
Junctional Tachycardia (JT)  Treat underlying cause
 If rapid, attempt vagal maneuvers.
 Adenosine 6 mg rapid IV push. If no conversion, give 12 mg. (ACLS
recommendation but can give two doses of 12 mg.)
Junctional Escape Beat None - Friendly beat (junction paces because SA did not)
Supraventricular Tachycardia  Treat underlying cause (question if drug-related cause)
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 Treatment Guide
(SVT)  Attempt vagal maneuvers.
 Adenosine 6 mg rapid IV push. If no conversion, give 12 mg. (ACLS
recommendation but can give two doses of 12 mg.)
 Elective cardioversion. (If unstable, synchronized cardioversion.)
Ventricular Arrhythmias
PVCs (unifocal, multifocal, Amiodarone
couplets, runs of VT, bigeminy,  Rapid Infusion = 150 mg IV over 10 minutes (15 mg/min);
trigeminy, quadrigeminy)  Slow infusion = 1mg/min over 6 hours (33.3 cc/hr) [360 mg total]
 Maintenance infusion = 0.5 mg/min over 18 hours (16.5 cc/hr) [540 mg
total]
 Max cumulative dose: 2.2 g IV over 24 hours
Lidocaine
 Doses ranging from 0.5-0.75 mg/kg every 5-10 min for perfusing
arrhythmia; up to 1-1.5 mg/kg may be used
 Max total dose: 3 mg/kg.
Ventricular Tachycardia (VT)  Convert rhythm using Amiodarone – 150 mg over 10 minutes, consider
with pulse drip (see above)
 Elective cardioversion. (If unstable, go directly to synchronized
cardioversion.)
Ventricular Tachycardia (VT) –  CPR – start immediately. Push hard and push fast (rate 100-120/min).
pulseless  Defibrillate – analyze rhythm, and shock if in VF/pulseless VT.
 CPR – resume CPR immediately after shock delivery. Continue for 5
cycles / 2 minutes.
 Vasopressor – Epinephrine 1 mg q 3-5 min – give as soon as possible
after resuming CPR, circulate with chest compressions.
 Defibrillate – analyze rhythm, and shock if in VF/pulseless VT.
 CPR – resume CPR immediately after shock delivery. Continue for 5
cycles / 2 minutes.
 Antiarrhythmic – Amiodarone first dose 300 mg bolus IV/IO or Lidocaine
1-1.5 mg/kg up to 3 mg/kg. Give as soon as possible after resuming
CPR, circulate with chest compressions. (Amiodarone 2nd dose, if
needed = 150 mg).
 Defibrillate – analyze rhythm, and shock if in VF/pulseless VT.
 CPR – resume CPR immediately after shock delivery. Continue for 5
cycles / 2 minutes.
Torsade de pointes Magnesium Sulfate – 1 to 2 g over 5-10 minutes
(polymorphic VT)
Ventricular Fibrillation (VF) Same at Pulseless VT
Idioventricular Use DEAD acronym
 Determine whether to initiate resuscitation.
 Epinephrine 1 mg every 3-5 minutes (can replace 1st or 2nd dose of Epi
with 40 units Vasopressin)
 Atropine 1 mg IVP every 3-5 minutes to max of 3 mg
 Differential Diagnosis or Discontinue Resuscitation
Accelerated Idioventricular Usually none, self-limited – goes away when sinus rate becomes faster.
(AIVR)
Asystole Use DED acronym (DEAD without Atropine)
 Determine whether to initiate resuscitation - CPR
 Epinephrine 1 mg every 3-5 minutes
 Differential Diagnosis or Discontinue Resuscitation
Ventricular Standstill Same as Asystole
Ventricular Escape Beat None – friendly beat (ventricle paces because SA and AV did not)
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 Treatment Guide
AV Blocks
1st Degree AVB Symptomatic only (rare unless rate also slow):
 Atropine 0.5 mg IVP every 3-5 min PRN, not to exceed total dose of
0.04 mg/kg (or 3 mg)
Mobitz I (2nd Degree AVB) Symptomatic only:
(Wenckebach)  Atropine 0.5 mg IVP as above
Mobitz II (2nd Degree AVB) Symptomatic only:
 Transcutaneous Pacing
 Atropine not indicated - only consider if pacing delayed
2nd Degree AVB 2:1 Symptomatic only:
3rd Degree AVB (Complete  Transcutaneous Pacing
Heart Block)  Treat hypotension
 Permanent pacemaker
Bundle Branch Block (BBB)  Monitor for further block in bundle branches, which would result in
bifasicular block or complete (3rd o) AVB
 Consider expert consultation
Pacemakers
Cause Treatment
Failure to Sense  Sensitivity turned off–  Sensitivity measured in milliamperes (mV),
makes it an the lower the value, the higher the sensitivity;
asynchronous (fixed ranges from 0.5mV (most sensitive) to 20mV
rate) pacemaker (least sensitive)
Failure to Pace  Oversensing  Change pacemaker to asynchronous mode.
If failure to fire persists, then oversensing is
not the cause.
 Lead dislodged from  Repositioning patient on side may reconnect
heart lead to heart tissue
 Lead dislodge from  Reattach lead wires
pacemaker generator
 Lead fracture  Reattach wires below fracture site if external.
If suspect internal fracture site, apply
transcutaneous pacemaker.
 Low or dead battery  Replace battery
 Any  If above techniques are unsuccessful, begin
transcutaneous pacing or CPR if indicated.
Failure to Capture  Lead dislodged from  Repositioning patient on side may reconnect
heart lead to heart tissue
 Lead dislodge from  Reattach lead wires
pacemaker generator
 Scar tissue (inhibits  Increase pacemaker output or try switching
signal transmission) positive and negative electrodes in pulse
generator
 Chemical  Hold medication or correct electrolyte
imbalances. Increase output temporarily
 Low battery  Replace battery
 Any  If above techniques are unsuccessful, begin
transcutaneous pacing or CPR if indicated.

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 BRIEF ACLS DRUG REVIEW
ADENOSINE
Class: Indicated for: IV Bolus Dosage (no IO):
Endogenous nucleoside PSVT / Regular Narrow complex 6 mg rapid IV push – 1st dose;
Tachycardia 12 mg rapid IV push – 2nd dose
Notes: Doses are followed by a saline flush. One subsequent dose of 12 mg is recommended per ACLS
protocol at 1 – 2 minute intervals, but a 2nd 12 mg dose may be considered. Use the port closest to
cannulation. The AHA recommends that the dose be cut by half if administering through a central line, or
in the presence of Dipyridamole or Carbamazepine. Larger doses may be required in the presence of
caffeine or Theophylline.

AMIODARONE
Class: Indicated for: IV Bolus Dosage (no IO):
Antiarrhythmic V-Fib / Pulseless V-Tach 300 mg – 1st dose; 150 mg –
2nd dose
Arrhythmias 360 mg (1.0mg/min) over 6 hours
(slow)
Infusion dose 150 mg (0.5mg/min) over 10
minutes (rapid)
540 mg IV/IO over 18 hours (.5
mg/min)
Notes: Cumulative doses >2.2 g/24 hours are associated with significant hypotension. Do not administer
with other drugs that prolong QT interval (i.e., Procainimide). Terminal elimination is extremely long – half
life lasts up to 40 days. During arrest, IV bolus should be delivered slowly, over 1 – 3 minutes.

ASPIRIN
Class: Indicated for: Dosage (no IV/IO):
NSAID (Non-Steroidal Anti- Chest pain / ACS 160 mg – 325 mg
Inflammatory Drug) Suppository Dose: 300 mg
Notes: In suspected ACS, Aspirin can block platelet aggregation and arterial constriction. Also helps with
pain control. May cause or exacerbate GI bleeding.

ATROPINE
Class: Indicated for: IV/IO Bolus Dosage:
Parasympathetic Blocker Bradycardia 0.5 mg every 3-5 minutes as
needed
Asystole, slow PEA 1 mg every 3-5 minutes (up to 3
mg)
Notes: Used only in symptomatic bradycardia or in PEA with heart rate < 60. (Not indicated in 2 nd Degree
Type II or 3rd Degree heart block.) Doses < 0.5 mg may result in paradoxical slowing of the heart. ET
route discouraged, but can be used if IV/IO access not available.

DEXTROSE/GLUCOSE
Class: Indicated for: IV/IO Bolus Dosage:
Carbohydrate Hypoglycemia 25 g (50 ml) of D50W
Notes: Used to reverse documented hypoglycemia in patients with symptomatic bradycardia or during
cardiac arrest. Should not be used routinely during cardiac arrest.

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DILTIAZEM
Class: Indicated for: IV Bolus Dosage:
Calcium Channel Blocker A-Fib / A-Flutter 15-20 mg over 2 minutes
Notes: May cause hypotension. Do not use in wide-QRS tachycardias of uncertain origin.

DOPAMINE
Class: Indicated for: IV Infusion Dosage:
Catecholamine Symptomatic Bradycardia 2-10 μg/kg/min – cardiac dose
Hypotension 10-20 μg/kg/min – vasopressor
dose
Notes: Titrate to patient response. Correct hypovolemia with volume replacement before initiating
Dopamine. May cause tachyarrhythmias. Do not mix with Sodium Bicarbonate.

EPINEPHRINE
Class: Indicated for: IV/IO Bolus Dosage:
Catecholamine Pulseless Arrest 1 mg (1:10,000) every 3-5
minutes
Symptomatic Bradycardia Infusion: 1 mg in 500ml of D5W
or NaCl at 1 μg/min titrated to
effect.
Notes: First line drug in all pulseless rhythms. Increases myocardial oxygen demand, and may cause
myocardial ischemia or angina. ET route is discouraged, but if used give 2-2.5 mg of a 1:1000 solution
diluted in 10 ml normal saline.

FLUID ADMINISTRATION (e.g., Normal Saline / NaCl)

Class: Indicated for: IV/IO Bolus Dosage:
Fluid Volume Hypovolemia 250 – 500 cc bolus (repeat as
needed)
Notes: Use to treat specific reversible causes, such as hypovolemia. Routine administration of fluids
during a resuscitation is not indicated, as it can reduce coronary perfusion pressure.

HEPARIN (Unfractionated)
Class: Indicated for: IV/IO Bolus Dosage:
Anticoagulant STEMI (AMI) Initial Dose: 60 IU/kg (max. 4000
IU)
Infusion: 12 IU/kg/hr (max. 1000
IU/hr)
Notes: Do not use in patients with active bleeding or bleeding disorders; severe hypertension; or recent
surgery. Monitor aPTT and platelet count while administering.

LIDOCAINE
Class: Indicated for: IV/IO Bolus Dosage:
Antiarrhythmic V-Fib/Pulseless V-Tach 1-1.5 mg/kg (1st dose)
Stable V-Tach Infusion: 1-4 mg/min (30-50
μg/kg/min)
Notes: May repeat at 0.5-0.75 mg/kg every 5-10 minutes to a max. dose of 3 mg/kg. Use with caution in
presence of impaired liver; discontinue if signs of toxicity develop. Prophylactic use in AMI is
contraindicated. ET route discouraged, but can be used if IV/IO access not available.

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MAGNESIUM SULFATE
Class: Indicated for: IV/IO Bolus Dosage:
Electrolyte Torsades de pointes or 1-2 g in 10 ml D5W over 5-20
Hypomagnesemia minutes
Notes: A fall in blood pressure may be noted with rapid administration. Dose is given over 5-20 minutes
during cardiac arrest, 5-60 minutes in living patients. Use with caution in renal failure.

MORPHINE SULFATE
Class: Indicated for: IV/IO Bolus Dosage:
Opiate / Analgesic Chest pain 2-4 mg every 5-30 minutes
Pulmonary edema
Notes: Administer slowly and titrate to effect; may cause hypotension. May cause respiratory depression – be
prepared to support ventilations. Naloxone (Narcon) is the reversal agent.

METOPROLOL TARTATE
Class: Indicated for: IV/IO Bolus Dosage:
Beta-blocker Slows ventricular response 5mg at 5 min intervals up to a
SVT, Atrial Fibrillation, Atrial total of 15 mg
Flutter
Notes: Caution with asthma.

NALOXONE HYDROCHLORIDE (NARCAN)

Class: Indicated for: IV/IO Bolus Dosage:
Opiate Antagonist Narcotic overdose 0.4-2.0 mg (up to 10 mg in 10
min.)
Notes: Monitor for recurrence of respiratory depression. May cause opiate withdrawal. ET route discouraged,
but can be used if IV/IO access not available.

NITROGLYCERIN
Class: Indicated for: IV Bolus Dosage:
Vasodilator Chest pain/ACS 12.5-25 μg in D5W or NaCl
Sublingual Dose: 0.3 – 0.4 mg
Notes: Most commonly given sublingually as tablet or spray – repeat up to 3 doses at 5 minute intervals.
Hypotension may occur. Do not use with Viagra or other phosphodiasterase inhibitors; with severe
bradycardia or tachycardia; or in presence of RV infarction or inferior MI. Do not mix with other drugs.

NOREPINEPHRINE
Class: Indicated for: IV Bolus Dosage:
Vasoconstrictor Hypotension 0.1-0.5 mcg/kg/min adjust to
achieve desire blood pressure
and systemic perfusion (7-35
mcg per min in 70kg adult)
MUST be given via central line. Titrate to patient response. Correct hypovolemia with volume replacement
before initiating.

OXYGEN
Class: Indicated for: IV Bolus Dosage (no IO):
Atmospheric Gas Any cardiopulmonary emergency Stable Patient: 2-6 lpm via NC
Suspected stroke Unstable Patient: 10-15 lpm via
NRB
Notes: Pulse oximetry is a useful method of titrating oxygen administration; however, it may be inaccurate in
low cardiac output states or in patients with specific toxicities (such as Carbon Monoxide exposure).
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SODIUM BICARBONATE
Class: Indicated for: IV Bolus Dosage:
Buffer Acidosis, hyperkalemia 1 mEq/kg
Notes: Not recommended for routine use in cardiac arrest patients. If available, use arterial blood gas analysis
to guide bicarbonate therapy.