MT 27-29 ACLS 07.17.

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Table 1. Medications Used for Adults in Pulseless Arrest

Drugs are de-emphasized in the new guidelines for resuscitation, but below are some facts you need to know.

Classification Out of Favor Recommendations Dosage Comments

Vasopressors High-dose Epinephrine for VF/pulseless 1 mg IV/IO every 3 to 5 minutes (higher doses The Committee considered removing
epinephrine VT may be used in the vasopressors from the pulseless arrest algorithm;
and asystole/PEA case of overdose from beta- or however, because of the
calcium-channel blockers.) possible benefits for short-term survival and the
lack of a placebo versus vasopressor trial, they
One dose of vasopressin 40 U IV or IO may be were kept in.
substituted for either the first or second dose of
epinephrine but has not been shown to improve
survival.

Antiarrhythmics Antiarrhythmics other Amiodarone for VF/pulseless Amiodarone 300 mg IV or IO, once, then con- Amiodarone is the only antiarrhythmic that has
than amiodarone, such VT sider additional 150 mg. been shown to improve
as procainamide, for (lidocaine remains accept- short-term outcome, but even it did not improve
VF and pulseless VT able to use.) A new aqueous formulation has reduced the survival to hospital discharge.
incidence of hypotension associated with this
drug.

Atropine for asystole/slow 1 mg IV or IO, repeat every 3 to 5 minutes up

PEA to three doses.

Magnesium for 1 to 2 g diluted in 10 mL D5W IV

torsades de pointes or IO push over 5 to 20 minutes

KEY
VF = ventricular fibrillation VT = ventricular tachycardia PEA = pulseless electrical activity IO = intraosseous

PULSELESS ARREST
• BLS Algorithm: Call for help, give CPR
• Give oxygen when available
• Attach monitor/defibrillator when available

2
Shockable Check rhythm Not Shockable
3 Shockable rhythm? 9
VF/VT Asystole/PEA

4
Give 1 shock
• Manual biphasic: device specific
(typically 120 to 200 J)
10
Note: If unknown, use 200 J
Resume CPR immediately for 5 cycles
• AED: device specific When IV/IO available, give vasopressor
• Monophasic: 360 J • Epinephrine 1 mg IV/IO
Resume CPR immediately Repeat every 3 to 5 min
or
• May give 1 dose of vasopressin 40 U IV/IO to
5 Give 5 cycles of CPR*
replace first or second dose of epinephrine
Check rhythm No Consider atropine 1 mg IV/IO
Shockable rhythm? for asystole or slow PEA rate
Repeat every 3 to 5 min (up to 3 doses)

6 Shockable

Continue CPR while defibrillator is charging

Give 1 shock Give 5 cycles
• Manual biphasic: device specific of CPR*
(same as first shock or higher dose)
Note: If unknown, use 200 J 11
• AED: device specific
• Monophasic: 360 J Check rhythm
Resume CPR immediately after the shock Shockable rhythm?
When IV/IO available, give vasopressor during CPR
(before or after the shock)
• Epinephrine 1 mg IV/IO
Repeat every 3 to 5 min
or
• May give 1 dose of vasopressin 40 U IV/IO to
12
replace first or second dose of epinephrine
Not
13
• If asystole, go to Box 10
• If electrical activity, check Shockable Shockable Go to
Give 5 cycles of CPR* pulse. If no pulse, go to
7 Box 4
Box 10
Check rhythm No • If pulse present, begin
Shockable rhythm? postresuscitation care

Shockable
8 During CPR
Continue CPR while defibrillator is charging • Push hard and fast (100/min) • Rotate compressors every
Give 1 shock • Ensure full chest recoil 2 minutes with rhythm checks
• Manual biphasic: device specific • Search for and treat possible
(same as first shock or higher dose) • Minimize interruptions in chest
compressions contributing factors:
Note: If unknown, use 200 J – Hypovolemia
• AED: device specific • One cycle of CPR: 30 compressions – Hypoxia
• Monophasic: 360 J then 2 breaths; 5 cycles ≈2 min – Hydrogen ion (acidosis)
Resume CPR immediately after the shock • Avoid hyperventilation – Hypo-/hyperkalemia
Consider antiarrhythmics; give during CPR – Hypoglycemia
• Secure airway and confirm placement – Hypothermia
(before or after the shock)
amiodarone (300 mg IV/IO once, then – Toxins
– Tamponade, cardiac
consider additional 150 mg IV/IO once) or
lidocaine (1 to 1.5 mg/kg first dose, then 0.5 to
* After an advanced airway is placed,
rescuers no longer deliver “cycles” – Tension pneumothorax
0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg) of CPR. Give continous chest com- – Thrombosis (coronary or
Consider magnesium, loading dose pressions without pauses for breaths. pulmonary)
Give 8 to 10 breaths/minute. Check – Trauma
1 to 2 g IV/IO for torsades de pointes
After 5 cycles of CPR,* got to Box 5 above rhythm every 2 minutes

© 2005 American Heart Association

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