ACLS

MEDICATIONS
AND THEIR USE

Garrett Thompson, Pharm.D.

Wake Forest University Baptist Medical Center

1/21/2018 1
 EPINEPHERINE

 alpha and beta agonist

 + inotrope, + chronotrope
 SVR, BP
 myocardial 02, requirements
 automaticity
  coronary and cerebral blood flow

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 EPINEPHERINE
 Dose: 1 mg q 3-5 min (1:10,000)
(doses>1mg are not beneficial and do not improve
survival or neurological outcomes and may contribute to
post resuscitation myocardial dysfunction)

 Continuous infusion rate: 0.1-0.5mcg/kg/min post

resuscitation care in hypotensive pt who receive ROSC

 Up to 0.2mg/kg may be considered

(eg. Beta blocker/Calcium Channel Blocker overdose) but
not recommended and may be harmful
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 EPINEPHRINE

 Flush w/ 20cc saline when giving IV push

to ensure delivery to central compartment

 PRECAUTIONS:

 myocardial ischemia
 myocardial irritability = VF

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 ATROPINE
 MOA: blocks action of acetylcholine at parasympathetic
sites in smooth muscle, secretory glands, and the
central nervous system
 HR,  CO

 Not likely to be effective for type II second-degree or

third degree block OR block in non-nodal tissue

 Indications:
- symptomatic bradycardia
- HR< 60 bpm and inadequate for clinical
condition

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 ATROPINE
 Treatment considerations are based on
adequate perfusion

OR

 S/S of poor perfusion caused by the bradycardia

(Pacing, Atropine 0.5mg, Epi, Dopamine)

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 ATROPINE
 DOSE: 0.5 mg q 3-5 min for symptomatic bradycardia
Max. = 3 mg
(usually 2-3 mg is a full vagolytic dose in most patients)

 Side Effects:  HR, coma, flushed hot skin, ataxia,

blurred vision,  myocardial ischemia

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 MAGNESIUM SULFATE
 MOA: physiological calcium channel blocker

 Indications: Torsades de pointes

Hypomagnesemic states that may lead to
arrhythmias
 Cardiac Arrest Dose: VT, Torsades = 1 – 2 grams
 mix in 10 ml D5W IV/IO over 5 – 20 min.

Torsades w/ pulse or AMI w/ hypomagnesemia - 1 – 2 grams

in 50 – 100 ml D5W over 5 – 60 min IV/IO
then 0.5gm – 1 gm / hr
 Side Effects: flushing, sweating, mild
 HR/BP

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 SODIUM BICARBONATE
 MOA: H+ + HCO3-  H2CO3  H20 + CO2

 Indications: hyperkalemia
pre-existing metabolic acidosis
eg. DKA
phenobarbital / TCA / aspirin overdose

 Adequate ventilation and CPR, not bicarbonate, are the

major “buffer agents” in cardiac arrest.

 Dose: 1 meq/kg, then ½ dose q10 min. thereafter

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 SODIUM BICARBONATE
 Side Effects:  Na+, alkalemia, plasma
hyperosmolality, worsening intracellular acidosis

 Contraindicated: hypoxic lactic acidosis i.e.

prolonged cardiopulmonary arrest

 NaHCO3- not shown to improve defibrillation

success to increase survival rate after brief
cardiac arrest

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 DOPAMINE
 MOA: precursor of norepinephrine that stimulates
dopaminergic, , and  receptors in a dose- dependent
fashion
 Dose: 1-5 mcg/kg/min  cerebral, renal, mesenteric
vasodilatation
5-10 mcg/kg/min  stimulates , 1 receptors
resulting in CO, HR, BP, cardiac contractility
10-20 mcg/kg/min  BP ( receptors
predominate)

 Starting dose 2-20 mcg/kg/min

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 DOPAMINE
 Indications: severe symptomatic bradycardia (after
atropine), hemodynamically significant hypotension in
absence of hypovolemia

After : pacing, atropine,

- start dopamine or epinephrine drip (2-10ug/min)

 Side Effects:  HR, induce

/exacerbate arrhythmias, exacerbate pulmonary
congestion and compromise CO, tissue sloughing if
extravasation occurs

****Do not administer w/ sodium bicarbonate****

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 AMIODARONE

 1ST line antiarrhythmic for:

- wide complex tachycardias (Ok to use in pts.

w/impaired heart function EF < 40%)

- good for SVT and VT tachyarrythmias

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 AMIODARONE

Dose: VF/pulseless VT = 300mg IVP diluted

in 20-30 ml D5W

MR 150mg in 20-30ml D5W

in 3-5 min x 1 if needed

Max. 2.2 g / 24 hr

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 AMIODARONE
 Dose (cont’d):
Wide Complex Stable Tachycardias
- 150mg IV in 100 ml D5W given over 10 min.
- MR q10 min. prn, then 1mg/min over 6 hrs,
then 0.5mg/min x 18 hrs, then
maintenance 0.5mg/min

t ½  40 days

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 AMIODARONE
 Side Effects:  BP ( rate of infusion)
sinus bradycardia

 EKG Effects:
- prolongation of PR, QRS, and QT intervals

 Concerns of administration
- must use large bore angiocath
- must be diluted

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 LIDOCAINE
 MOA: - only use for ventricular arrhythmias
-  automaticity
-  ventricular ectopy
-  VF threshold directionally proportionate to
plasma concentration
eg. 6mcg/ml-antifibrillatory
eg. 2-5 mcg/ml-controls ventricular ectopy

 Indication: persistent/refractory VF / pulseless VT

wide complex tachycardias
stable VT
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 LIDOCAINE

 Dose:
1-1.5 mg/kg/dose x 1, then 0.5 – 0.75 mg/kg q 5-
10 min (max. 3mg/kg) – refractory VF, pulseless VT

0.5-0.75 mg/kg up to 1.0-1.5 mg/kg for pts. w/ pulse

i.e. stable ventricular tachycardias

- Maintenance infusion at 1-4 mg/min

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 LIDOCAINE

Side Effects: muscle twitching

focal / grand mal seizures

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 LIDOCAINE

 Reduce Dosage:
use ½ recommended maintenance dose in
patients with:

-  CO, (CHF, cardiogenic shock)

- hepatic dysfunction
- age > 70

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 PROCAINAMIDE
 MOA:  supraventricular and ventricular ectopy
use caution in pts. w/ EF < 40%
 Indications:
- afib w/ WPW, refractory reentry SVT
- persistent cardiac arrest due to VF/VT
- wide complex tachycardias
- stable VT
(rarely use to treat VT due to prolonged time
required to administer effective doses i.e. rapid
administration=  BP)
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 PROCAINAMIDE
 Dose: 20 mg/min up to 50 mg/min in urgent
situations to max. dose of 17 mg/kg, OR…

 Stop infusion of bolus when:

1. Arrhythmia suppressed
2.  BP
3. QRS complex widened by 50% of original width
4. 17 mg/kg has been administered

Maintenance infusion 1-4 mg/min

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 ADENOSINE
 MOA: chemically converts the AV node
interrupts AV nodal reentry
 Indications:
- PSVT
- DOC for diagnosing supraventricular
tachycardias

(if arrhythmia is not due to reentry involving AV/SA

node, i.e. a.fib/flutter, atrial/ventricular tachycardias,
adenosine will not terminate arrhythmia)

 Do not use with ventricular tachycardias

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 ADENOSINE
 Dose: 6mg  12 mg  12 mg (q ~ 1-2 min.) (dose given over 1-3 sec)
-follow each dose w/ 20 ml flush (given over 1-3 sec)
-if using already established central line -  dose to 3mg, ..

Note: Patients taking theophylline/caffeine are less sensitive to adenosine

and may require greater doses

Dipyridamole blocks adenosine uptake and potentiates its effects

(consider  dose to 3mg)

Heart transplant patients are more sensitive to adenosine and may

require smaller doses

Tegretol may increase the degree of heart block produced by adenosine

= higher doses of heart block therefore,  the dose to 3mg

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 ADENOSINE

 Side Effects: - flushing

- chest pain
- brief asystole / bradycardia
- malaise

Recurrence of PSVT is 50%-60%

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 Drug Administration

Medications should be delivered

DURING CPR
ASAP after rhythm checks

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 Oxygen and Aspirin

 Oxygen – 1 - 6 L/min

Aspirin – 160mg – 325 mg

- Aspirin (non-enteric coated) should be administered
to ALL patients suspected of acute coronary
syndromes, unless contraindicated

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 Nitroglycerin
 Nitroglycerin –
MOA: - initial antianginal for suspected ischemic pain
-  preload at lower doses
-  afterload at higher doses
- dilates large coronary arteries
-  coronary collateral blood
flow to ischemic myocardium
- antagonizes vasospasms

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 Nitroglycerin

Nitroglycerin (cont’d)
Dose: SL 0.4mg tab q5min x 3
IV Bolus 12.5-25 mcg if no SL given,
then 10-20mcg/min titrated to effect
(range 50-200 mcg/min)

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 Morphine

 Morphine
-  myocardial O2 requirements
-  venous capacitance
- treatment of pain
-  SVR
- chest pain w/ ACS unresponsive to nitrates

Side Effects: respiratory depression

 BP

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 Antiplatelet Agents:
Glycoprotein IIB/IIIa agents
 Blocks glycoprotein IIb/IIIa receptors on platelets
 Blocked receptors cannot attach to fibrinogen
 Fibrinogen cannot aggregate platelets to platelets
 Indications: Acute Coronary Syndrome
-STEMI or nonSTEMI /UA undergoing PCI
-NONSTEMI/Unstable angina managed medically

 Examples: abciximab (ReoPro), eptifibitide (Integrilin),

tirofiban (Aggrastat)

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 ACE Inhibitors
 Mechanism of action
 Reduces BP by inhibiting angiotensin-converting
enzyme (ACE)
 Alters post-AMI LV remodeling by inhibiting
tissue ACE
 Lowers peripheral vascular resistance
by vasodilatation
 Reduces mortality and CHF from AMI

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 Fibrinolytic Therapy
 Breaks up the fibrin network that binds clots together

 Indications: ST elevation >1 mm in 2 or more contiguous

leads or new LBBB or new BBB that obscures ST
 Time of symptom onset must be <12 hours
 Caution: fibrinolytics can cause death from brain
hemorrhage

 Agents differ in their site of action, ease of preparation and

administration; cost; need for heparin

 5 agents currently available: alteplase (tPA, Activase),

anistreplase (Eminase), reteplase (Retavase), streptokinase
(Streptase), tenecteplase (TNKase)
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 Heparin

 Mechanism of action
 Indirect thrombin inhibitor (with AT III)
 Indications
 PTCA or CABG
 With fibrin-specific lytics
 High risk for systemic emboli
 Conditions with high risk for systemic emboli,
such as large anterior MI, atrial
fibrillation, or LV thrombus

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 ß-Blockers
Absolute
Cautions
Contraindications

 Decompensated  Mild/moderate CHF

CHF/PE  HR <60 bpm
 SBP <100 mm Hg  History of asthma
 Acute asthma  IDDM
(bronchospasm)  Severe peripheral
vascular disease
 2nd- or 3rd-degree
AV block

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 ENDOTRACHEAL TUBE
MEDICATIONS
**ET tube meds not recommended
unless IV/IO access is not available

L idocaine
Epinephrine
Atropine
N arcan
2- 2.5 x normal dose

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 CRITICAL POINTS

 Know dosages, indications, contraindications,

and side effects of drugs

 Know concentrations of drugs

 Know what drugs look like at your organization

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