1. Keep up to date with advanced cardiac life support (ACLS) recommendations (i.e., maintain your knowledge base).

  2. Promptly defibrillate a patient with ventricular fibrillation (V fib), or pulseless or symptomatic ventricular tachycardia (V tach).

  3. Diagnose serious arrhythmias (V tach, V fib, supraventricular tachycardia, atrial fibrillation, or second- or third-degree heart block), and treat according to ACLS protocols.

  4. Suspect and promptly treat reversible causes of arrhythmias (e.g., hyperkalemia, digoxin toxicity, cocaine intoxication) before confirmation of the diagnosis.

  5. Ensure adequate ventilation (i.e., with a bag valve mask), and secure the airway in a timely manner.

  6. In patients requiring resuscitation, assess their circumstances (e.g., asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation.)

  7. In patients with serious medical problems or end-stage disease, discuss code status and end-of-life decisions (e.g., resuscitation, feeding tubes, levels of treatment), and readdress these issues periodically. See Palliative.

  8. Attend to family members (e.g., with counselling, presence in the code room) during and after resuscitating a patient.

  9. In a pediatric resuscitation, use appropriate resources ( e.g., Braeslow tape, the patient’s weight) to determine the correct drug doses and tube sizes. See PALS and NRP.

Note: Shock is not dealt with in this topic. See Trauma.

PEA Quick Management

  • QRS Narrow (RV Problem)

    • FLUIDS + Consider causes

      • Cardiac tamponade

      • Tension pneumothorax

      • Mechanical hyperinflation (ventilation managment)

      • Pulmonary embolism

      • Severe hypovolemia/hemorrhage

      • Acute MI (myocardial rupture)

  • QRS Wide (LV Problem)

    • IV Calcium + IV Bicarbonate boluses + Consider causes

      • Severe hyperK

      • Sodium-channel blocker (eg. TCA) toxicity

      • Acute MI (pump failure)

Symptomatic Bradycardia Quick Management

  • Atropine 1mg, repeat q5 mins to max 3mg

  • Epinephrine 2-10mcg/min infusion, titrate

  • Consider Calcium Chloride 1g or Calcium Gluconate 3g

    • Cover possible hyperkalemia, hypocalcemia, hypermagnesemia, medication (CCB, BB)

  • Transcutaneous pacing (or Transvenous pacing if available)

    • Consider Fentanyl/Ketamine for sedation

    • Confirm capture (avoid pseudo-pacing)

      • Use bedside ultrasound, pulse oximetry, palpable distal pulse


Digoxin toxicity

  • EKG: Many arrhythmias (eg. PVCs, ventricrular bigeminy/trigeminy, slow Afib, sinus brady, AV block, regularized AF, VT)

  • Suspect in bradycardia and GI symptoms

  • Consider activated charcoal if <2h, alert and protected airway

  • Treat arrhythmia, end organ dysfunction or hyperkalemia with antidote digoxin-specific antibody (Fab) fragments (Digibind)

    • If antidote not available, can use atropine 0.5mg IV for bradycardia

Cocaine intoxication

  • EKG: Tachycardia +/- ischemic changes

  • ABC, vitals

    • Airway management (avoid succinylcholine, consider rocuronium or other nondepolarizing agent)

    • Manage hypothermia/hyperthermia

  • Diazepam 5mg IV q3-5 mins for agitation (and hypertension)

  • Phentolamine 1-5mg IV for hypertension

    • Avoid beta-blockers

  • Sodium bicarbonate 1-2mEq/kg IV push for QRS widening

  • Look for emergencies (eg. arrythmias, seizures, ICH, ACS, dissection, arterial thromboembolism)