ACLS CORE MEDICATIONS

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Algorithms

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Bradycardia
y Atropine y Dopamine infusion y Epinephrine infusion

Atropine
y Mechanism of Action

Inhibits the actions of acetylcholine on structures innervated by parasympathetic nervous system (smooth muscle, SA/AV nodes)

Atropine
y Indications y First drug for symptomatic sinus bradycardia y May be beneficial in AV block or asystole y Second drug in asystole or slow PEA y Organophosphate poisoning; large dose may be needed y Precautions y MI and hypoxia atropine increases oxygen demand y Avoid in hypothermia y Not effective for 2nd type II or new 3rd degree block (may slow the rhythm) y Doses < 0.5 mg may cause a paradoxical slowing

Atropine

Don t delay pacing for severely symptomatic (unstable) patients.

y Asystole or slow (<60)PEA y 1 mg IV/IO push y Repeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg. y Bradycardia y 0.5 mg IV every 3-5 minutes as needed; max. of 3 mg. y Use shorter dosing interval and higher doses in severe clinical situations y Endotracheal Administration y 2-3 mg diluted in 10 mL water or NS y Organophosphate Poisoning y Large doses (2-4 mg or higher) may be necessary

Dopamine
y Mechanism of Action

Stimulates sympathetic adrenergic receptors; dose dependent.

Dopamine
y Indications y Second-line drug for symptomatic bradycardia y Hypotension with signs and symptoms of shock y Precautions y Correct hypovolemia with volume before initializing y Use caution with cardiogenic shock and associated CHF y May cause tachydysrhythmias; excessive vasoconstriction y Don t mix with sodium bicarbonate y IV Administration 2-10 ug/kg/min y Infusion at 5-20 mcg/kg/min. y Titrate to patient response; taper slowly

Epinephrine
y Mechanism of Action

Stimulates adrenergic receptors and is not dose dependent like dopamine.

Epinephrine
y Indications y Cardiac arrest pulseless
y

VF; VT; asystole; PEA

y Symptomatic bradycardia y After atropine; alternative to dopamine y Severe hypotension y When atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitors y Anaphylaxis; severe allergic reactions y Combine with large fluid volume; corticosteroids; antihistamines

Epinephrine
y Precautions y May increase myocardial ischemia, angina, and oxygen demand y High doses do not improve survival; may be detrimental y Higher doses may be needed for poison/drug induced shock y Dosing y Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min. y Infusion of 2-10 mcg/min. y Endotracheal of 2-2.5 times normal dose

Tachycardia

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Tachycardia
y Adenosine y Diltiazem y Metoprolol y Amiodarone y Lidocaine y Magnesium Sulfate

Adenosine
y Mechanism of Action

Slows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.

Adenosine
y Indications y 1st drug for stable, narrow complex, regular SVT y May consider for unstable SVT while preparing for cardioversion y Wide-complex tachycardia thought to be, or determined to be reentry SVT y Does not convert atrial fibrillation, atrial flutter, or VT y Diagnostic maneuver; stable narrow-complex SVT

Adenosine
y Contraindications/Precautions y Poison/drug induced tachycardia is contraindicated y 2nd and 3rd degree block is contraindicated y Transient side effects; flushing, asystole, brady, ectopic beats ,asthma. y Less effective with theophylline or caffeine. y If used for VT may cause worsening of clinical condition y Transient periods of sinus brady or ventricular ectopy common after termination of SVT y Safe in pregnancy

Adenosine
y Place supine or mild reverse Trendelenburg y 6 mg rapidly followed by 20 mL flush y May repeat at 12 mg every 1-2 minutes if unsuccessful.

Twice.

Diltiazem
y Mechanism of Action

Inhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.

Diltiazem
y Indications y Controlling ventricular rate in a-fib or flutter y After adenosine to treat refractory reentry SVT if adequate blood pressure y Contraindications/Precautions y Do not use with wide-complex rhythms y Do not use with poison/drug induced tachycardia y Avoid in WPW y Avoid in AV nodal blocks y Blood pressure may drop from peripheral vasodilation

Diltiazem
y Rate control y 15-20 mg (0.25 mg/kg) IV over 2 minutes y After 15 min. another 20-25 mg (0.35 mg/kg) IV over 2 minutes, if needed y Maintenance Infusion y 5-15 mg/hour; titrated to physiologically appropriate heart rate

Metoprolol
y Mechanism of Action

Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.

Metoprolol
y Indications y Administer to all patients with suspected MI or unstable angina, absent contraindications y Second-line agent for SVT refractory to adenosine y To reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressure y Emergency antihypertensive therapy for acute hemorrhagic or ischemic stroke

Metoprolol
y Contraindications/Precautions y Hemodynamically unstable patients should not receive
y y y

Signs of heart failure Low cardiac output Increased risk for cardiogenic shock

y Relative contraindications: 1st, 2nd, 3rd degree blocks;

active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHg y Concurrent administration of calcium channel blockers can cause serious hypotension y Monitor cardiac and pulmonary status throughout

Anti-Arrhythmias

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Amiodarone
y Mechanism of Action

Prolongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.

Amiodarone
y Indications y Life threatening dysrhythmias
y y y

VF/pulseless VT unresponsive to shock, CPR, and vasopressor Recurrent hemodynamically unstable VT Seek expert opinion for other uses

y Contraindications/Precautions y Bradycardia y 2nd and 3rd degree block y Do not administer with meds that prolong QT interval (procainamide)

Amiodarone
y VF/VT

300 mg IV/IO in 20-30 mL NS. Can follow with ONE dose of 150 mg in 3-5 minutes, if needed. y Life threatening dysrhythmias
y 150 mg over 10 minutes. May repeat every 10 minutes as

needed. y Maximum 2.2 g./24hr results in hypotension

Lidocaine
y Mechanism of Action

Decreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.

Lidocaine
y Indications y Alternative to amiodarone in VF/VT arrest y Stable monomorphic VT y Malignant PVC s y Can be used if Torsades is suspected y Contraindications/Precautions y Prophylactic use in AMI is contraindicated y Reduce maintenance dose in liver impaired patients y Discontinue infusion if toxicity develops

Lidocaine
y Cardiac Arrest y Initial dose is 1-1.5 mg/kg y Refractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3 mg/kg y Endotracheal dose 2-4 mg/kg y Perfusing Dysrhythmia y 0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kg y Maintenance Infusion y 1-4 mg/min

Magnesium Sulfate
y Mechanism of Action

Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.

Magnesium Sulfate
y Indications y Torsades is suspected in cardiac arrest y Life-threatening ventricular dysrhythmias in digitalis . y Precautions y Fall in BP with rapid administration y Use caution in renal failure y Dosing y Arrest 1-2 g over 5-20 min. y Torsades w/ pulse 1-2 g over 5-60 min.

Vasopressin
y Mechanism of Action

Causes vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.

Vasopressin
y Indications y Alternative to epinephrine in adult refractory VF/VT y Alternative to epinephrine in asystole or PEA y Contraindications/Precautions y Potent peripheral vasoconstrictor (increased demand upon resuscitation) y Dosing y Single dose of 40 u that replaces either the 1st or 2nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes after y Can be used endotracheally; no suggested dose

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