⚡ ACLS Deep Dive: Rhythms with a Pulse (Brady & Tachy) ⚡

1️⃣ Core Concepts — When to Shock, When to Chill 💥 Synchronized Cardioversion: For unstable rhythms with a pulse — unstable SVT, AFib, flutter, or monomorphic VT. Sedate if possible. ⚡ Unsynchronized (Defibrillation): For pulseless VT/VF or unstable polymorphic VT (if rhythm can’t be timed safely). 🧠 Rule: If they have a pulse but are tanking → cardiovert. No pulse → shock.

2️⃣ Bradycardia Algorithm 🫀 (HR < 50 + symptoms) 1️⃣ Atropine 1 mg IV bolus, repeat q3–5 min (max 3 mg). 2️⃣ If ineffective → TCP (Transcutaneous Pacing) or Epinephrine 2–10 mcg/min / Dopamine 5–20 mcg/kg/min. 3️⃣ Don’t delay pacing for ECG — treat first. 🚫 Atropine traps: – Doesn’t work in Mobitz II or 3° AV block w/ wide QRS — pace instead. – Ineffective in heart transplant pts. – <0.5 mg may paradoxically slow HR.

3️⃣ Tachycardia Algorithm 🔥 (HR > 150) 💣 If Unstable (shock, hypotension, chest pain, AMS, HF): → Immediate synchronized cardioversion (follow device energy levels). 💤 Sedate if conscious unless rapidly deteriorating. 📈 If Stable:

• Narrow QRS, Regular (SVT): Vagal maneuvers → Adenosine 6 mg rapid IV push, then 12 mg if needed.
• Wide QRS, Regular/Monomorphic: Expert consult → Amiodarone 150 mg IV over 10 min, or Procainamide/Sotalol if available. ⚠️ Avoid AV nodal blockers (Adenosine, CCBs, β-blockers) in irregular wide-complex rhythms (e.g., pre-excited AFib/WPW) — can cause VF!

4️⃣ High-Yield Meds 💊 • Atropine: 1 mg IV q3–5 min (max 3 mg). Avoid in advanced blocks/transplants. • Epinephrine (infusion): 2–10 mcg/min for bradycardia after atropine fails. • Dopamine: 5–20 mcg/kg/min if epi unavailable. • Adenosine: 6 mg → 12 mg IV push for regular narrow tachycardia. 🚫 Never for irregular wide-complex rhythms. • Amiodarone: 150 mg IV over 10 min for stable wide monomorphic VT → 1 mg/min x 6 hr → 0.5 mg/min.

5️⃣ Airway & Oxygen 🫁 Maintain patent airway; assist ventilation if needed. Give O₂ only if hypoxemic. Monitor continuously.

6️⃣ Nursing Priorities & Real-World Moves 🩺 ✅ If unstable → act fast: Atropine, pacing, or cardioversion. Don’t wait for 12-lead. ✅ Confirm mechanical capture with TCP (check femoral pulse — not carotid). ✅ Sedate before cardioversion if conscious. ✅ Get expert consult for stable wide-complex tachycardias. 📞 Call for help early if instability persists or rhythm unclear.

7️⃣ Exam Traps & Common Mistakes ⚠️ 🚫 Giving Atropine in 3° block w/ wide QRS — it won’t work. Go straight to pacing or Epi/Dopa. 🚫 Using AV nodal blockers (Adenosine, β-blockers, CCBs) in pre-excited AFib → can cause VF. 🚫 Delaying cardioversion for an unstable tachycardia — act first. 🚫 Forgetting sedation for conscious cardiovert patients. 🚫 Mistaking electrical twitch for a pulse during pacing — always confirm mechanical capture.

8️⃣ 2-Min Quick Recall 🔥 1️⃣ Brady: Atropine 1 mg → TCP → Epi 2–10 mcg/min / Dopa 5–20 mcg/kg/min. 2️⃣ Don’t rely on Atropine for Mobitz II, 3° AV block, or transplant pts. 3️⃣ Unstable tachy = cardiovert NOW. 4️⃣ Stable SVT = vagal → Adenosine 6 → 12 mg. 5️⃣ Stable monomorphic VT = Amio 150 mg/10 min. 6️⃣ Never Adenosine or AV blockers in irregular wide-complex. 7️⃣ Always confirm mechanical capture after pacing.