Overview of ACLS

Pharmacology
and
Update on New ACLS
Guidelines
Krista Piekos, Pharm.D.
Clinical Pharmacy Specialist - Critical Care
Harper University Hospital
Adjunct Assistant Professor
Wayne State University

Objectives

Pharmacists should be able to identify:

Why?
we use an agent
When?
to use an agent
How?
to use an agent
What?
...to watch for
To familiarize the pharmacist with the ACLS
algorithms
To help the pharmacist become comfortable
with the crash cart
To introduce the needless delivery system

Outline

Present conclusions of the International

Guidelines 2000 ACLS objectives with
2003 updates
Classification of recommendations
ACLS Algorithms
Pharmacology of agents used in
algorithms
Overview of crash cart revisions
Overview of needless system

Background

In Seattle 43% of patients in VF survived

to hospital discharge if CPR w/in 4 min
and defibrillation w/in 8 min
These figures are higher than national
average - due to AEDs throughout public
Overall survival from CPR is poor 5-15%
Survival for in-patient CPR to discharge
is <10%

Guidelines 2000 for

Cardiopulmonary
Resuscitation and
Emergency Cardiovascular
Care

1st international consensus on

resuscitation guidelines
Experts from around the world
Identified issues

Gathered scientific evidence; level (quality) of

evidence
Integrate into a class of recommendation

Revised guidelines

Classification of
Therapeutic Interventions

Class I: definitely helpful, excellent

Class II:
Class II a -probably helpful;
good to very good
Class II b -possibly helpful; fair to
good
Class Indeterminate: insufficient
evidence; no harm, but no benefit
Class III: possibly harmful

New Goals
1. Early Defibrillation - Public Access Defibrillation (PAD)
Probability of successful defibrillation and survival is negatively
related to the time from onset of VF to delivery of first shock
PAD has the potential to be the single greatest advance in the
treatment of prehospital sudden cardiac death since the invention
of CPR
Circulation August 22, 2000

2. Establishing a specific diagnosis by ECG

3. Antiarrhythmic agents are just as likely to be
proarrhythmic as they are antiarrhythmic.
One, and only one antiarrhythmic should be used.

Routes of
Administration
Intravenous
Preferred route
Endotracheal

2-2.5 Xs IV dose in 10ml volume

Each dose is followed by 10 ml NS flush down the ET tube
(Ex. epinephrine, atropine, lidocaine, diazepam, naloxone)
Absorption occurs at alveolar capillary interface

Intraosseous (active bone marrow)

Pediatric patients without IV access
Other: Sublingual, intracardiac, IM, SC (poor absorption)

ACLS
Algorithm
Approach

Universal Algorithm

Epinephrine
WHY?

Natural catecholamine with and -adrenergic agonist

activity
Results in:
flow to heart and brain
SVR, SBP, DBP
electrical activity in the myocardium & automaticity (
success with defibrillation)
myocardial contraction (for refractory circulatory shock

(CABG))
increases myocardial oxygen requirements

Primary benefit: -vasoconstriction

-adrenergic activity controversial b/c myocardial work

WHEN?
VF/VT, asystole, PEA, bradycardias

Epinephrine
HOW?
High dose versus standard dose?
Higher ROSC with high dose, but no change in survival
High doses may exacerbate postresuscitation myocardial dysfunction
Recommendations:

Class I: 1 mg IV q 3 - 5 min
Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg
Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min
Infusion for HR & BP (IIb)
1mg in 250ml NS or D5W - infuse @ 1-10 mcg/min

ET Dose=2-2.5 times IV dose

What to watch for?

Tachycardia, hypertension, myocardial ischemia, acidosis
Incompatible with Ca, HCO3, aminophylline & PHY. Alkaline solutions cause autooxidation.

Vasopressin
WHEN?
Alternative to epinephrine for shock-refractory VT/VF
WHY?
Natural antidiuretic hormone
Potent vasoconstrictor by stimulation of SM -V 1 receptors :

BP & SVR; CO, HR, myocardial O2 consumption and

contractility

Does not myocardial oxygen consumption

Not affected by severe acidosis
Class IIb for shock-refractory VF
Class Indeterminate for PEA, asystole
Half life = 10-20 minutes
Dose?
40 Units IVP - one time only!!!

Why Vasopressin?

During CPR, plasma ADH levels are higher in patients

with return of spontaneous circulation (ROSC)
During CPR patients may be severely acidotic
Epinephrine compared to vasopressin pre-hospital
CPR (20 patients/study group)
Multiple animal studies showing ROSC
EPI
Survival to hospital
24 hour survival
Discharge alive

(n=20)

VP

35%
(p=0.06)
20%
60%
15%
(p=0.16)

(n=20)

70%
(p=0.02)
40%

ILCOR Universal Algorithm

(International Liaison Committee on Resuscitation)

Medication changes in 2000:

Emphasis on identification of all possible

stroke victims for IV fibrinolytics

Epinephrine has become Class Indeterminate
High-dose epinephrine no longer
recommended
For shock-refractory VT/VF: Epinephrine 1 mg q 3-5
min

Vasopressin 40 Units IVP one time

Epinephrine alone for non-VT/VF

Pulseless Ventricular
Fibrillation
or Tachycardia

In ACLS, always assume VF - most common

85%-95% of survivors have VF

Survival dependant on early defibrillation
Medications indicated only after 3 failed shocks

VFib/Pulseless VT Algorithm
Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients
Better
Please -

Precordial Thump If pulse-less with no defibrillator

Shock 200J*
Shock 200-300J*
Shock 360J*

(*only consecutive, if persistent)

EVerybody - Epinephrine 1 mg IV q3-5 min or Vasopressin 40 U IVP

If VF/PVT persists, "CONSIDER" antiarrhythmics and sodium bicarb. NOTE: always "max
out" one agent before proceeding to the next in order to limit pro-arrhythmic drug-drug
interactions

Shock 360J
And - Amiodarone (First Choice) 300mg IV push. May repeat once at
150mg in 3-5 min. (max. cumulative dose: 2.2g IV/24hrs)

Drug-shock-drug-shock sequence

(continued)

Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients

Better
Let's - Lidocaine 1.0-1.5 mg/kg IV. May repeat in 3-5 min (max=3
mg/kg)
Make Magnesium Sulfate 1-2 g slow IVP for suspected Mg or
TdP
Patients- Procainamide 30 mg/min, or 100 mg IV q 5 min. for refractory
VF. (max. dose: 17 mg/kg)
NOTE: Besides having a pro-arrhythmic drug-drug interaction with amiodarone, procainamide is of
limited value in an arrest situation due to a lengthy administration time

Better (consider buffers) - Bicarbonate 1 mEq/kg IV for:

preexisting K+
bicarb-responsive acidosis
some drug overdoses
protracted code (intubated)
ROSC after long code with effective ventilation.

Drugs for VF/PVT

Epinephrine - Why? How? What?

Vasopressin - Why? How? What?
Amiodarone
Magnesium
Procainamide
Lidocaine
Buffers

Class

Drug

Ia

Quinidine
Procainamide
Disopyramide

Ib

Lidocaine
Mexiletine
Tocainide

Ic

Classification of
Antiarrhythmics
Conduction Velocity Refractory Period
Automaticity

Ion Block
Sodium

Sodium
(fast on-off)

0/

Flecainide
Propafenone
Moricizine

Sodium
(slow on-off)

II

Beta-Blockers

Calcium

III

Amiodarone
Bretylium
Sotalol

Potassium

IV

Verapamil
Diltiazem

0
Calcium

Drugs Used for Heart Rhythm

and Rate
Amiodarone

WHY?
Class III antiarrhythmic (characteristics of all classes)
Na, K and Ca channel blocker & & -adrenergic blocker
Prolongs AP and RP
Decreases AV conduction velocity & SN function
New Recommendations (WHEN?):
pulseless VT or VF (IIb)
hemodynamically stable VT (IIb), polymorphic VT (IIb),
wide-complex tachycardia uncertain origin (IIb)
refractory PSVT (preserved function, IIa; impaired function
IIb)
atrial tachycardia (IIb)
cardioversion of AF (IIa)

Amiodarone
HOW?
Cardiac arrest (PVT/VF) - 300mg IVP diluted
in 20-30ml, may repeat with 150mg in 10
minutes, or start infusion (max=2..2 g/24h)
Atrial & ventricular arrhythmias in impaired
hearts

150mg IVP over 10 min

May repeat q10-15 min, or start gtt 1mg/min x 6
hours, then 0.5mg/min x 18 h

WHAT?
Hypotension, bradycardia (slow rate, fluids)

Why Amiodarone?
ARREST Trial

Objective:
Efficacy of IV amiodarone in out-of-hospital
cardiac arrest due to ventricular fibrillation or
pulseless ventricular tachycardia
Endpoints:
Hospital admission with perfusing rhythm
Survival to discharge
Functional neurologic status at discharge
*Insufficiently powered to detect survival to discharge and
functional neurologic status*

ARREST Trial: Amiodarone in the

Resuscitation of Refractory
Sustained Ventricular
Tachyarrhythmias

Prospective, randomized, DB, PC trial

504 patients, who failed >/= 3 shocks

Randomized to placebo or 300mg IV amiodarone
Amiodarone Dosing:
300mg diluted with 5% D5W to 20mL
Rapid IV bolus

Found a statistically significant increase in the

number of patients who arrived to hospital alive

(p=0.03)
Consistent results regardless of presenting rhythm
This is the only antiarrhythmic agent which has shown definitive benefit in
cardiac arrest!

ARREST Trial - Subgroup

Analysis
% Surviving to
Admission

Amiodarone
70
60
50
40
30
20
10
0

Placebo

Drugs Used for Heart Rhythm

and Rate
Magnesium Sulfate

WHY? Magnesium deficiency causes arrhythmias

Facilitates ventricular repolarization by enhancing
intracellular potassium flux, dilates coronary
arteries
WHEN?
VT/VF,

Suspected hypomagnesemia, pulseless

torsade de pointes

HOW? Class IIa in suspected hypomagnesemia, TdP,

and Class IIb in VF/VT: 1 - 2gm slow IVP in 100ml
WHAT?

Hypotension at large doses

Drugs Used for Heart Rhythm

and Rate
Procainamide

WHY?

Suppresses both ventricular and atrial

arrhythmias
Type Ia antiarrhythmic, affects fast Na+channelsslowing conduction velocity, prolongs RP, and
decreases automaticity
Phase IV depolarization

WHEN?

Refractory/recurrent VF/VT
Control of rapid ventricular response (IIb)
Conversion SVT (AF/Fl) (IIa)

Drugs Used for Heart Rhythm

and Rate
Procainamide

HOW? VF: 20-30 mg/min slow infusion (max=17

AF with rapid vent. response: 100 mg over 5
then infuse@ 1 - 4 mg/min
1-2 gm/250ml D5W

mg/kg)
min

WHAT?
Stop infusion if patient hypotensive, widened QRS
>50%,
arrhythmia suppression, or dose=17mg/kg
Dose reduction in renal failure
SLE syndrome
Levels:
PA=4-12 g/ml
NAPA=7-15 g/ml (active metabolite-Class III)

Drugs Used for Heart Rhythm

and Rate
Lidocaine

WHY?

Type IB antiarrhythmic
Affects fast Na+ channels, shortens refractory period
Suppresses spontaneous depolarization
Local anesthetic, increases fibrillation threshold
Suppresses ventricular ectopy post-MI

Without effecting myocardial contractility, BP or AV nodal conduction

WHEN?
SECOND-CHOICE agent
VT/VF refractory to electrical countershock and epinephrine

(Indeterminate)
Control of PVCs (Indeterminate)
Hemodynamically stable VT (IIb)

Not for routine prophylaxis post-MI, however, accepted in high-risk

patients
(hypokalemia, myocardial ishchemia, LV dysfunction)

Drugs Used for Heart Rhythm

and Rate
Lidocaine

HOW? Class IIa: 1 - 1.5 mg/kg IVP q5 - 10 min (max=3mg/kg)

Infusion (with pulse): 1 - 4 mg/min (if pulse is regained)
Therapeutic Levels: 1.5-6 g/ml
ET Dose: 2-2.5 times IV dose
Preparation: 1-2 gm/250 ml D5W or NS
WHAT?
Hepatic metabolism, renal elimination
Bradycardia, cardiac arrest, seizures
Lidocaine toxicity/neurotoxicity - twitching, LOC,
seizures, coma
Lidocaine levels persist in low CO states

Drugs Used to Improve Cardiac Output and

Blood Pressure
Sodium Bicarbonate

WHY? Enhances sodium shift intracellularly, buffers

acidosis,
decreases toxicity of TCAs, increases clearance of acidic drugs

WHEN?

Class I - hyperkalemia
Class IIa - bicarbonate-responsive acidosis metabolic
acidosis secondary to loss of bicarb (renal/GI);
overdoses (TCAs, phenobarbital, aspirin)
Class IIb - protracted arrest in intubated patients
Class III - hypoxic lactic acidosis

HOW? 1 mEq/kg IVP, 0.5mEq/kg q10 min prn

WHAT? May worsen outcome if not intubated/ventilated.
Metabolic alkalosis, decreased O2 delivery to tissues, hypokalemia,
CNS acidosis, hypernatremia, hyperosmolarity
Incompatible with calcium, epinephrine, atropine, norepinephrine, isoproterenol

Summary
V.Fib and Pulseless V.Tach
Changes:
Vasopressin added - Class IIb 40 U IVP x 1
Epinephrine - Class Indeterminate 1mg IVP q 3-5
min
Amiodarone added - Class IIb
300mg IVP (cardiac arrest dose). May repeat 150mg x 1

Lidocaine - Class Indeterminate 1-1.5 mg/kg IVP q 35 min (Max = 3mg/kg)

Procainamide is acceptable but not recommended
due to long administration times
Bretylium fell off algorithm due manufacturing
problems

The Tachycardia
Algorithms
Major New Concepts:
Make a specific rhythm diagnosis
Identify patients with significantly
impaired cardiac function (EF<40%,
overt HF)
Only use one antiarrhythmic, especially
in damaged hearts

Resulted in 3 new algorithms

The Tachycardia Overview Algorithm

Is the patient stable or unstable?

Stable

Unstable

Identify 1 of 4 types of tachycardia

Cardioversion

(premedicate)

AF/Aflutter
Narrow-complex VT, PSVT,
tachycardia
Stable wide-complex
tachycardia
Stable monomorphic VT

100J, 200J,
360J

300J,

Tachycardia - Atrial
Fibrillation/Flutter
4 Clinical Features:
Unstable?
Impaired cardiac function?
WPW?
Duration? <48h, or > 48h?
Focus - treat unstable patients urgently
Control ventricular response convert
anticoagulate

Condition

Atrial
Fibrillation/Flutter
Rate Control

EF > 40%

CCB (I)
-Blocker (I)

EF < 40%

Digoxin (IIb)
Diltiazem (IIb)
Amiodarone (IIb)

WPW

Preserved heart
fxn:
DC Cardioversion
Amiodarone(IIb)
Flecainide (IIb)
Procainamide (IIb)
Propafenone (IIb)
Sotalol (IIb)

Impaired
EF<40%:
DC Cardioversion
Amiodarone(IIb)

Conversion
> 48h
DC Cardioversion
Amiodarone (IIa)
Ibutilide (IIa)
Flecainide (IIa)
Propafenone (IIa)
Procainamide (IIa)
DC Cardioversion
OR
Amiodarone (IIb)

Conversion
< 48h
No DC Cardioversion
Anticoagulation x 3
weeks, then CV, then
anticoagulation x 4 wk
OR r/o clot by TEE,
CV, then AC x 4 wk
(See above)

DC Cardioversion
Amiodarone (IIb)
Flecainide (IIb)
Propafenone (IIb)
Procainamide (IIb)
Sotalol (IIb)

(See above)

Drugs Used in Afib/AFlutter

Calcium channel blockers

Beta-blockers
Digoxin
Amiodarone
Procainamide
Flecainide (IV form in ACLS -not available in US)
Propafenone (IV form in ACLS -not available in
US)

Sotalol (IV form in ACLS -not available in US)

Drugs Used for Heart Rhythm

and Rate
Calcium Channel Blockers

WHY? Blocks inward flow of Ca and Na, slows conduction, RP in

AVN
Terminate reentrant arrhythmias requiring AVN
conduction
Control ventricular response rate in AF/AFl
Coronary vasodilation
May exacerbate CHF
Verapamil: Negative inotrope & chronotrope (good anti-ischemic)
Class I for acute and preventative SVT
Diltiazem: Direct negative chronotropic effect, mild negative
inotrope
Highly effective in controlling ventricular response in A Fib
WHEN?
Control ventricular response rate in patients with
AF/Fl, or MAT
Verapamil: PSVT not requiring cardioversion

Drugs Used for Heart Rhythm

and Rate
Calcium Channel Blockers

HOW? Verapamil: 2.5 - 5 mg IVP, over 2 min (max=30mg)

Inf @ 5-10 mg/hr
Diltiazem: 0.25 mg/kg IVP, may repeat with
0.35mg/kg in 15 min
Infuse @ 5-15 mg/hr
WHAT?
Contraindicated in wide QRS complex
tachycardias and
ventricular tachycardias,
exacerbation of CHF in patients
with LV dysfunction
Transient decrease in BP
Avoid in sick sinus syndrome of AV block (w/out pacer)
May potentiate digoxin toxicity.

Incompatible with bicarbonate, epinephrine, furosemide

Drugs Used for Heart Rhythm

and Rate
Beta - Blockers

WHY? B-adrenergic blockade, slows conduction and

increases refractory period in AV node
WHEN?
reduces
post-

AMI (reduces rate of reinfarction),

recurrent ischemia and incidence of VF in
MI patients, USA

HOW? Atenolol:
2.5-5 mg IV over 5 min
Metoprolol:
5 - 10 mg IVP q 5 min
Propranolol:
0.1 mg/kg IV divided into 3
doses @ 2 - 3 min intervals
Esmolol: 500 mcg/kg over 1 min
Inf @ 50 mcg/kg/min
WHAT?
heart

Hypotension, bradycardia, AV block, overt

failure or severe bronchospasm/COPD

Stable Monomorphic Ventricular Tachycardia

Preserved
Cardiac
Function

NOTE!
May go directly to
cardioversion

Medications: any one

Procainamide (IIA)
Sotalol (IIA)*
Amiodarone (IIB)
Lidocaine (IIB)
*Not yet available in the US.

Impaired LV
EF<40% or
CHF

Amiodarone (IIB)
150 mg IV bolus over 10 min
may repeat 150mg q10-15min or
start infusion
OR
Lidocaine (IIB)
0.5 to 0.75 mg/kg IV push
Then use
Synchronized cardioversion

Narrow-Complex Supraventricular
Tachycardia
Vagal stimulation
Adenosine
Junctional

1. EF > 40% - Amiodarone, B-blocker, CCB

2. EF <40%, CHF - Amiodarone

PSVT
EF>40% - CCB, BB, digoxin, DC cardioversion
(procainamide, amiodarone, sotalol)
EF<40%, CHF - no DC cardioversion; digoxin,
amiodarone, diltiazem

MAT
EF>40% -No DC cardioversion; CCB, BB, amiodarone
EF<40% -No DC cardioversion; amiodaonre, diltiazem

Wide-Complex Tachycardia
Wide . Prolonged QRS or QRST interval
HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter)
OLD - Lidocaine
NEW Establish diagnosis - 12-lead ECG
Adenosine if SVT- slows AV conduction. Short-lived
hypotension
Amiodarone (IIa) normal LV function
Amiodarone (IIb) impaired LV function
Procainamide (IIa)- terminates SVT due to altering
conduction across accessory pathways
Lidocaine if VT
Sotalol, propafenone, flecainide

Drugs Used for Heart Rhythm

and Rate
Adenosine
WHY? Endogenous nucleoside, slows conduction through the
node and can interrupt AV nodal reentry pathways

WHEN?
PSVT (half-life=10 sec)
If PSVT persists may want longer acting agent
diltiazem)

AV

(verapamil or

HOW? 6 mg rapid IV over 1 - 3 sec, followed by 20 ml

May repeat in 1-2min with 12 mg dose.
Max.=30 mg

NS flush.

WHAT?
Flushing, dyspnea, chest pain, post-conversion
bradycardia
Drug interaction with theophylline, dipyridamole

Pulseless Electrical Activity

PEA no pulse with + electrical activity (not VF/VT)
Reversible if underlying cause is reversed (5 Hs, 5

Ts)

Hypovolemia, hypoxia, hydrogen ion (acidosis),

hyper/hypokalemia, hyper/hypothermia

Tablets, tamponade, tension pneumothorax, thrombosis (ACS),

thrombosis (PE)

Intervention Comments/Dose
Problem
(HCO3)

Search for the probable cause and intervene

Epinephrine 1 mg IV q3-5 min.

Atropine
With slow heart rate, 1 mg IV q3-5 min.
dose 0.04 mg/kg)

(max.

Atropine
WHY? Anticholinergic/direct vagolytic
Enhances sinus node automaticity and AVN conduction
WHEN?

PEA, symptomatic sinus bradycardia, asystole,

HOW? Bradycardia: 0.5 -1 mg IV q3-5 min

Asystole: 1 mg IV q 3-5 min
Max = 0.04 mg/kg or 3 mg
ET Dose=1-2mg diluted in 10ml
Paradoxical bradycardia with
insufficient dose (<0.5mg)

WHAT?
Tachycardia; 2nd or 3rd degree AV block
(paradoxical
slowing may occur), MI (may worsen
ischemia/HR)
Incompatible with bicarbonate, epinephrine & norepinephrine

Bradycardia
All Patients Deserve Empathy
(The sequence reflects interventions for increasingly severe bradycardia)
Absolute (< 60 BPM) or relative
Serious signs and symptoms (CP, SOB, hypotension, mental

status changes)

Mnemonic

Intervention

All
mg/kg)

Atropine

Comments/Dose
0.5-1.0 mg IVP q 3-5 min (max 0.03-0.04

Patients
Pacing
severe S/S
Deserve

Dopamine

Empathy

Epinephrine

Use Transcutaneous Pacing if

5-20 g/kg/min.
2-10 g/min.

Medications for Bradycardia

Atropine - Why? How?

Dopamine
Epinephrine infusion
1mg/250 ml @ 1-4 mcg/min

Note: Lidocaine can be lethal if HR is due to

ventricular escape rhythm

Dopamine
WHY? NE precursor
Stimulates DA, & -adrenergic receptors (dose-related)
Want -stimulation, for bradycardia-induced
hypotension
WHEN?

Hypotension/shock

HOW? renal: 2 - 5 mcg/kg/min

cardiac:
5 - 10 mcg/kg/min (B1 & alpha)
vascular: 10 - 20 mcg/kg/min ( alpha)
Preparation:

400 mg/250 ml D5W or NS

WHAT?
Tachycardia, tachyphylaxis, proarrhythmic
If requiring > 20mcg/kg/min consider adding NE

ACLS Algorithms
Asystole
Consider possible causes and treat accordingly

(ex.hypoxemia, hyper/hypokalemia, acidosis)

Acronym TEA

T Transcutaneous Pacing (TCP) (Class IIb) Only

effective with early implementation along with
appropriate interventions and medications
E

Epinephrine 1 mg IV q3-5 min.

Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)

Discourage shocking due to excess parasympathetic

discharge
Consider Na Bicarbonate 1 mEq/kg

Drugs Used for

Myocardial Ischemia/Pain

Oxygen
Nitroglycerin
Morphine Sulfate
AMI - Aspirin, thrombolytics, heparin,
lidocaine, beta-blockers
Glycoprotein IIb/IIIa receptor antagonists

Acute Myocardial Infarction

Call first, call fast, call 911

Oxygen 4L/min
NTG SL, paste or spray; if BP > 90 mm Hg, IV
NTG
Morphine IV
ASA PO (I)
Thrombolytics? (I) - within 6 hours of
symptoms, (II) if > 6hr
IV heparin
B-blockers
Magnesium (if Mg)

Oxygen
Why?
increases hemoglobin saturation,
improves tissue oxygenation
supply to ischemic tissues
16-17% oxygen from mouth-to-mouth
When?
Must give supplemental oxygen in ACLS
Always for MI
How?
NC 4 L/min, intubation, etc
Goal - Osat=97-98%
Confirm tube placement

Drugs Used for Myocardial

Ischemia/Pain
WHY?

Nitroglycerin

binds to receptors on vascular smooth muscle vasodilation (venous > arterial)

venous BF to heart (preload) & O2
consumption
dilates coronary arteries - myocardial blood
supply
antagonizes vasospasm
increases collateral flow to ischemic
myocardium
inhibits infarct expansion
decreases pain

Drugs Used for Myocardial

Ischemia/Pain
Nitroglycerin

WHEN?
Ischemic CP; USA; pulmonary edema (when SBP>100); AMI
SL NTG -drug of choice for angina
IV NTG - drug of choice for unstable angina or AMI
Congestive heart failure with ischemia

HOW?
IV: 10-20 mcg/min, increase by 5-10 mcg/min q5-10 min until desired
effect or hemodynamic compromise
SL: 1 tablet (0.4mg) SL q5min times 3
Spray: 1 spray onto oral mucosa
Ointment 2%: 1-2 inches over 2-4 inch area
Patches: no role in acute therapy

Drugs Used for Myocardial

Ischemia/Pain
Nitroglycerin

Preparation: 50 mg/250 ml D5W or NS

Must be in glass bottle
Cautions:
hypotension - treat with fluids, and rate
reduction/elimination
bradycardia - vasovagal reflex to hypotension
treat with fluids, rate reduction, atropine
reflex tachycardia also a concern
headache, dizziness - may be diminished by laying
down
patients develop tachyphylaxis to effects - promote
nitrate-free periods, intermittent dosing and
lowest-possible doses

Drugs Used for Myocardial

Ischemia/Pain
Morphine Sulfate

WHY? (Pain can catecholamines - BP, HR, O2 demands)

Opiate analgesic
pain, preload and afterload, SVR, anxiety
Relieves pulmonary congestion, myocardial oxygen demand
WHEN?
Pain, pulmonary edema, BP > 90 mm Hg
HOW?
1-3mg IVP (2-15 mg IVP q15-30 min prn)
CAUTION?
Respiratory & CNS depression, bradycardia, hypotension, N/V

Drugs Used for Myocardial

Ischemia/Pain
(Continued)

Aspirin
Heparin
Thrombolytics - reteplase,
alteplase, TNK
B Blockers
Magnesium
Lidocaine - not for prophylaxis

Hypotension/Shock/Pulmona
ry Edema
Identify Problem? Volume; Pump; Rate?
Volume:
fluids, blood, vasopressors

Pump:
s/s of shock - vasopressors; no s/s shock dobutamine
BP (>100 mm Hg) - NTG, Nitroprusside
pulmonary edema -furosemide 0.51mg/kg, morphine 1-3mg, NTG SL,
oxygen/intubate

Rate: see algorithms

Drugs Used to Improve Cardiac

Output and Blood Pressure
Norepinephrine

Action:
Alpha & -adrenergic
stimulation, increases
contractility
and HR, vasoconstriction, improves
coronary blood flow
Indication:
severe

Shock refractory to fluid replacement,

hypotension

Dose:

0.5 - 1 mcg/min
refractory shock = 8 - 30 mcg/min

Preparation:

4-8mg/250 ml D5W or NS

Caution:
Hypertension, myocardial ischemia,
cardiac arrest,
palpitations

Drugs Used to Improve Cardiac

Output and Blood Pressure
Dobutamine

Action:

B1- adrenergic activity

Indication:

Inotrope in heart failure/hypotension

Dose:

2 - 20 mcg/kg/min

Preparation:

250 mg/250 ml D5W or NS

Caution:
tachyarrhythmias,worsens myocardial
ischemia

Drugs Used to Improve Cardiac

Output and Blood Pressure
Inamrinone and Milrinone

Action:
Phosphodiesterase inhibitors, positive
inotropes and
vasodilator
Indication:

Refractory heart failure

Dose: Inamrinone: 750 mcg/kg over 2 - 3 min

Inf @ 5 - 15 mcg/kg/min
Milrinone: 50 mcg/kg over 10 min
Inf @ 0.375 - 0.75 mcg/kg/min
Caution:
Thrombocytopenia, worsens myocardial
ischemia, SV and ventricular arrhythmias

Drugs Used for Heart Rhythm

and Rate
Isoproterenol
WHY? Synthetic sympathomimetic amine
Pure B-adrenergic activity +inotropic& chronotrope
HR/CO, contractility; MAP secondary vasodilation
WHEN? Symptomatic bradycardia
Refractory torsades de pointes
HOW?
Class II - 2 - 10 mcg/min
Class III - higher doses
Preparation: 1 mg/ 250 ml D5W or NS
WHAT?

mycocardial O2 consumption & peripheral vasodilation

Avoid in ischemic heart disease; arrhythmogenic

Drugs Used to Improve Cardiac

Output and Blood Pressure
Sodium Nitroprusside

Action:
Antihypertensive, peripheral vasodilator,
reduces afterload, increases CO and relieves
pulmonary
congestion
Indication:

Hypertension, AMI, CHF

Dose: 0.1 - 5 mcg/kg/min, and titrate up to 10mcg/kg/min

Preparation: 50 mg/250 ml D5W
Caution:
Cyanide and thiocyanate toxicity,
hypotension

Summary of 2000
Changes

NEW AGENTS - Amiodarone & Vasopressin

Amiodarone (Class IIb) & Procainamide (Class IIb) hemodynamically stable wide-complex tachycardia (esp. in
poor cardiac fxn)
VT - amiodarone & sotalol (Class IIa)
Vasopressin (Class IIb) - alternative to epinephrine
Bretylium acceptable, but not recommended
Lidocaine for VT/VF (Class Indeterminate) & Class III for
prophylaxis of ventricular arrhythmias in AMI
Magnesium (Class IIb) - Mg or TdP
High-dose epinephrine (Class Indeterminate)
Fibrinolytics for AMI & Stroke

Crash Cart Revisions

Summary of Changes:
Additions: 5 amps of amiodarone 150mg/3ml (were
3)
3 vials of vasopressin (20 Units/vial)
1 bag of premixed dopamine 400mg in 250ml
4 Na Bicarbonate syringes (were 3)
5 filter needles
20 blunt cannulas
Deletions:
Remove
Remove
Remove

1 dopamine vial (new total=1)

5 epinephrine syringes (new total=10)
1 lidocaine syringe (new total=2)
metoprolol

Needless System/Cannulas

Questions ?