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

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

3. 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: mcg/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

4. 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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5. 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

6. ATROPINE OR Treatment considerations are based on adequate perfusion
S/S of poor perfusion caused by the bradycardia (Pacing, Atropine 0.5mg, Epi, Dopamine)
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7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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
mg/kg up to mg/kg for pts. w/ pulse
i.e. stable ventricular tachycardias
- Maintenance infusion at 1-4 mg/min
11/28/2018

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

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

21. 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

22. 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

23. 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

24. 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

25. ADENOSINE Side Effects: - flushing - chest pain
- brief asystole / bradycardia
- malaise
Recurrence of PSVT is 50%-60%
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26. Drug Administration Medications should be delivered DURING CPR
ASAP after rhythm checks
11/28/2018

27. 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

28. 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

29. Nitroglycerin (cont’d)
Dose: SL 0.4mg tab q5min x 3
IV Bolus mcg if no SL given, then 10-20mcg/min titrated to effect
(range mcg/min)
11/28/2018

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. ENDOTRACHEAL TUBE MEDICATIONS
**ET tube meds not recommended
unless IV/IO access is not available
L idocaine
Epinephrine
Atropine
N arcan
x normal dose
11/28/2018

37. 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