Running ACLS

A 23-year-old college student collapses suddenly while playing basketball. Teammates call 911. EMS arrives within 4 minutes.

• Initial assessment: Patient unresponsive, not breathing, no pulse.

• Suspected cause: arrhythmogenic sudden cardiac arrest (possible hypertrophic cardiomyopathy, Brugada, WPW, or long QT).

Step 1 – Basic Life Support (BLS Survey)

• Check responsiveness: None.

• Activate EMS/code team and get AED/defibrillator.

• Check breathing/pulse: Absent.

• Start CPR immediately (30:2 if no advanced airway).

Step 2 – Rhythm Check #1

• Monitor shows ventricular fibrillation (VF).

Actions:

1. Shock #1 (biphasic 200 J).

2. Resume CPR for 2 minutes (no pulse check).

3. Establish IV/IO access.

Step 3 – Rhythm Check #2

• Still VF.

Actions:

1. Shock #2.

2. Resume CPR immediately.

3. Give epinephrine 1 mg IV/IO (repeat q3–5 min).

4. Place advanced airway, confirm with waveform capnography (EtCO₂ target ≥10 mmHg during CPR).

Step 4 – Rhythm Check #3

• Still VF.

Actions:

1. Shock #3.

2. Resume CPR.

3. Give amiodarone 300 mg IV/IO bolus.

4. Continue compressions + oxygenation.

Step 5 – Rhythm Check #4

• Rhythm changes to pulseless VT.

Actions:

1. Shock #4.

2. Resume CPR immediately.

3. Continue meds: repeat epinephrine and consider amiodarone 150 mg if recurrent VF/VT.

Step 6 – ROSC Achieved

After next cycle:

• Rhythm: sinus tachycardia.

• Pulse present.

• BP: 82/50 mmHg.

• Patient comatose.

Step 7 – Post-ROSC Care

Airway & Oxygenation

• Maintain advanced airway.

• SpO₂ 94–99%, avoid hyperoxia.

• Monitor EtCO₂ 35–40 mmHg.

Circulation

• IV fluids (30 mL/kg bolus).

• Start norepinephrine infusion for MAP ≥65.

• Obtain 12-lead ECG.

Findings:

• ECG shows long QT interval, suggesting congenital long QT syndrome → likely trigger of arrest.

Targeted Therapy

• Correct electrolytes (Mg, K, Ca).

• Stop QT-prolonging drugs if present.

• Consider IV magnesium if torsades risk.

• Admit to ICU, consult electrophysiology for ICD evaluation.

Neuro Protection

• If patient remains comatose: start targeted temperature management (32–36°C for ≥24 hrs).

Step 8 – Identify & Treat Reversible Causes (Hs & Ts)

• Hs: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/hyperkalemia, Hypothermia.

• Ts: Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE/MI), Trauma.

• In this case → likely arrhythmic cause (long QT).

Step 9 – Disposition

• ICU admission with continuous telemetry.

• Neurologic evaluation post-rewarming.

• Cardiology/EP referral for genetic testing, ICD placement, and family screening.

Key Learning Points

1. High-quality CPR and early defibrillation are the most critical interventions in shockable rhythms.

2. Medications support CPR, but do not replace shocks and compressions.

3. Post-ROSC care determines long-term survival and neurologic outcome.

4. Young patients often have structural or electrical cardiac disease (HCM, Brugada, WPW, long QT). Identifying this prevents recurrence.

Great layered questions-- you’re asking about three key things:

1. Managing Hs & Ts (reversible causes of arrest)

2. QT-prolonging agents to watch for

3. Electrolyte correction in cardiac arrest/arrhythmias

1. Management of Hs & Ts

Hs (hypovolemia, hypoxia, H+, hypo/hyper-K+, hypothermia):

• Hypovolemia → Rapid IV fluids, blood products if hemorrhage.

• Hypoxia → Ensure airway, oxygen, ventilate with 100% O₂ until ROSC, then titrate.

• Hydrogen ion (acidosis) → CPR/ventilation first, consider sodium bicarbonate if severe metabolic acidosis or TCA/other tox.

• Hypo-/hyperkalemia → See electrolyte correction section below.

• Hypothermia → Active rewarming (warm IV fluids, blankets, external devices).

Ts (tension pneumothorax, tamponade, toxins, thrombosis-PE, thrombosis-MI, trauma):

• Tension pneumothorax → Needle decompression → chest tube.

• Tamponade (cardiac) → Pericardiocentesis.

• Toxins → Antidotes (naloxone, calcium for CCB, high-dose insulin, lipid therapy, etc.), decontaminate/supportive care.

• Thrombosis (PE) → Thrombolysis or surgical embolectomy.

• Thrombosis (MI) → Emergent PCI.

• Trauma → Address bleeding/airway/circulation surgically.

2. QT-Prolonging Agents (risk of torsades → syncope, arrest)

Antiarrhythmics

• Class Ia: Quinidine, Procainamide, Disopyramide

• Class III: Sotalol, Amiodarone, Dofetilide, Ibutilide

Antibiotics

• Macrolides: Erythromycin, Clarithromycin, Azithromycin

• Fluoroquinolones: Levofloxacin, Ciprofloxacin, Moxifloxacin

Psychotropics

• Antipsychotics: Haloperidol, Ziprasidone, Quetiapine, Risperidone

• Antidepressants: Tricyclics (amitriptyline), SSRIs (citalopram, escitalopram)

Others

• Methadone

• Chloroquine, Hydroxychloroquine

• Ondansetron (especially IV, high doses)

3. Electrolyte Correction in Arrest/Arrhythmias

Hypokalemia (K⁺ <3.5 mmol/L)

• IV potassium chloride:

  • Severe/unstable: 10–20 mEq/hr IV (central line preferred).

  • Avoid glucose-containing solutions (worsens hypokalemia).

• Goal: Keep K⁺ >4.0 mmol/L in cardiac patients.

Hyperkalemia (K⁺ >5.5 mmol/L, risk of arrest)

• Cardiac stabilization: IV calcium chloride or gluconate.

• Shift K⁺ into cells:

  • Insulin (10 units IV) + glucose (25–50 g IV D50).

  • Albuterol nebulized (10–20 mg).

  • Sodium bicarbonate if acidosis.

• Remove K⁺: Loop diuretics, dialysis, potassium binders.

Hypomagnesemia

• Risk: torsades de pointes.

• IV magnesium sulfate 1–2 g over 15 min (can repeat).

Hypocalcemia

• Treat with IV calcium gluconate or chloride if symptomatic (QT prolongation, tetany, arrhythmias).