ACLS MEDICATIONS AND THEIR USE Garrett Thompson, Pharm.D. Wake Forest University Baptist Medical Center 11/28/2018

EPINEPHERINE alpha and beta agonist + inotrope, + chronotrope SVR, BP myocardial 02, requirements automaticity  coronary and cerebral blood flow 11/28/2018

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 11/28/2018

EPINEPHRINE Flush w/ 20cc saline when giving IV push to ensure delivery to central compartment PRECAUTIONS:  myocardial ischemia  myocardial irritability = VF 11/28/2018

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 11/28/2018

ATROPINE OR Treatment considerations are based on adequate perfusion S/S of poor perfusion caused by the bradycardia (Pacing, Atropine 0.5mg, Epi, Dopamine) 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

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**** 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

LIDOCAINE Side Effects: muscle twitching focal / grand mal seizures 11/28/2018

LIDOCAINE Reduce Dosage: use ½ recommended maintenance dose in patients with: -  CO, (CHF, cardiogenic shock) - hepatic dysfunction - age > 70 11/28/2018

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) 11/28/2018

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 11/28/2018

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 11/28/2018

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 11/28/2018

ADENOSINE Side Effects: - flushing - chest pain - brief asystole / bradycardia - malaise Recurrence of PSVT is 50%-60% 11/28/2018

Drug Administration Medications should be delivered DURING CPR ASAP after rhythm checks 11/28/2018

Oxygen – 1 - 6 L/min Aspirin – 160mg – 325 mg Oxygen and Aspirin - Aspirin (non-enteric coated) should be administered to ALL patients suspected of acute coronary syndromes, unless contraindicated 11/28/2018

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 11/28/2018

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) 11/28/2018

Morphine Morphine -  myocardial O2 requirements -  venous capacitance - treatment of pain -  SVR - chest pain w/ ACS unresponsive to nitrates Side Effects: respiratory depression  BP 11/28/2018

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) 11/28/2018

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 11/28/2018

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) 11/28/2018

Heparin Mechanism of action Indications 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 11/28/2018

Absolute Contraindications ß-Blockers Absolute Contraindications Cautions Mild/moderate CHF HR <60 bpm History of asthma IDDM Severe peripheral vascular disease Decompensated CHF/PE SBP <100 mm Hg Acute asthma (bronchospasm) 2nd- or 3rd-degree AV block 11/28/2018

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 11/28/2018

CRITICAL POINTS Know dosages, indications, contraindications, and side effects of drugs Know concentrations of drugs Know what drugs look like at your organization 11/28/2018