ACLS Pharmacology dr shabeel pn.

ACLS Pharmacology dr shabeel pn

Objectives To review and obtain a better understanding of medications used in ACLS Indications & Actions (When & Why?) Dosing (How?) Contraindications & Precautions (Watch Out!)

Drug Classifications Class I: Recommendations
Excellent evidence provides support Proven in both efficacy and safety Class II: Recommendations Level I studies are absent, inconsistent or lack power Available evidence is positive but may lack efficacy No evidence of harm

Drug Classifications Class IIa Vs IIb Class IIa recommendations have
Higher level of available evidence Better critical assessments More consistency in results Both are optional and acceptable, IIa recommendations are probably useful IIb recommendations are possibly helpful Less compelling evidence for efficacy

Drug Classifications Class III: Not recommended Indeterminate
Not acceptable or useful and may be harmful Evidence is absent or unsatisfactory, or based on poor studies Indeterminate Continuing area of research; no recommendation until further data is available

Oxygen Indications (When & Why?)
Any suspected cardiopulmonary emergency Saturate hemoglobin with oxygen Reduce anxiety & further damage Note: Pulse oximetry should be monitored Universal Algorithm

Oxygen Dosing (How?) Device Flow Rate Oxygen % Universal Algorithm
Nasal Prongs 1 to 6 lpm 24 to 44% Venturi Mask 4 to 8 lpm 24 to 40% Partial Rebreather Mask 6 to 10 lpm 35 to 60% Bag Mask 15 lpm up to 100% Universal Algorithm

Oxygen Precautions (Watch Out!) Pulse oximetry inaccurate in:
Low cardiac output Vasoconstriction Hypothermia NEVER rely on pulse oximetry! Universal Algorithm

VF / Pulseless VT Case 3

1 x 360 J (or equivalent biphasic) within 30 to 60 seconds
VF / Pulseless VT Epinephrine 1 mg IV push, repeat every 3 to 5 minutes or Vasopressin 40 U IV, single dose, 1 time only Resume attempts to defibrillate 1 x 360 J (or equivalent biphasic) within 30 to 60 seconds Consider antiarrhythmics: Amiodarone (llb for persistent or recurrent VF/pulseless VT) Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT) Magnesium (llb if known hypomagnesemic state) Procainamide (Indeterminate for persistent VF/pulseless VT; llb for recurrent VF/pulseless VT) Epinephrine (Class Indeterminate) 1 mg IV push every 3 to 5 minutes. If this fails, higher doses of epinephrine (up to 0.2 mg/kg) are acceptable but not recommended (there is growing evidence that it may be harmful). Vasopressin is recommended only for VF/VT; there is no evidence to support its use in asystole or PEA. There is no evidence about The value of repeated vasopressin doses or The best approach after the first single bolus of vasopressin As a Class Indeterminate action, it is acceptable to resume epinephrine 1 mg IV push every 3 to 5 minutes if there was no response in 5 to 10 minutes to a single IV dose of vasopressin. The evidence for this approach is based on rational conjecture. Suggestion to instructors Resist the requests to tell the learners whether you prefer epinephrine or vasopressin. The evidence, as of 2001, makes them equivalent, with vasopressin, as a nonadrenergic agent, associated with fewer adverse side effects. The supply chain from production to widespread distribution throughout all hospitals and the EMS system has been slow to develop.

Epinephrine Indications (When & Why?) Increases:
Heart rate Force of contraction Conduction velocity Peripheral vasoconstriction Bronchial dilation VF / Pulseless VT

Epinephrine Dosing (How?)
1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route 2.0 to 2.5 mg diluted in 10 mL normal saline VF / Pulseless VT

Epinephrine Dosing (How?)
Alternative regimens for second dose (Class IIb) Intermediate: 2 to 5 mg IV push, every 3 to 5 minutes Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apart High: 0.1 mg/kg IV push, every 3 to 5 minutes VF / Pulseless VT

Epinephrine Precautions (Watch Out!)
Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction VF / Pulseless VT

Vasopressin Indications (When & Why?) Used to “clamp” down on vessels
Improves perfusion of heart, lungs, and brain No direct effects on heart VF / Pulseless VT

Vasopressin Dosing (How?) One time dose of 40 units only
May be substituted for epinephrine Not repeated at any time May be given down the endotracheal tube DO NOT double the dose Dilute in 10 mL of NS VF / Pulseless VT

Vasopressin Precautions (Watch Out!)
May result in an initial increase in blood pressure immediately following return of pulse May provoke cardiac ischemia VF / Pulseless VT

Amiodarone Indications (When & Why?)
Powerful antiarrhythmic with substantial toxicity, especially in the long term Intravenous and oral behavior are quite different Has effects on sodium & potassium VF / Pulseless VT

Amiodarone Dosing (How?) Should be diluted in 20 to 30 mL of D5W
300 mg bolus after first Epinephrine dose Repeat doses at 150 mg VF / Pulseless VT

Amiodarone Precautions (Watch Out!) May produce vasodilation & shock
May have negative inotropic effects Terminal elimination Half-life lasts up to 40 days VF / Pulseless VT

Lidocaine Indications (When & Why?) Depresses automaticity
Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability VF / Pulseless VT

Lidocaine Dosing (How?) Initial dose: 1.0 to 1.5 mg/kg IV
For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS VF / Pulseless VT

Lidocaine Dosing (How?) Maintenance Infusion 2 to 4 mg/min
1000 mg / 250 mL D5W = 4 mg/mL 15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min VF / Pulseless VT

Lidocaine Precautions (Watch Out!)
Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction Discontinue infusion immediately if signs of toxicity develop VF / Pulseless VT

Magnesium Sulfate Indications (When & Why?)
Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state Refractory VF VF with history of ETOH abuse Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose VF / Pulseless VT

Magnesium Sulfate Dosing (How?)
1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push VF / Pulseless VT

Magnesium Sulfate Precautions (Watch Out!)
Occasional fall in blood pressure with rapid administration Use with caution if renal failure is present VF / Pulseless VT

Procainamide Indications (When & Why?) Recurrent VF
Depresses automaticity Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability VF / Pulseless VT

Procainamide Dosing (How?) 30 mg/min IV infusion
May push at 50 mg/min in cardiac arrest In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable Maximum total dose: 17 mg/kg VF / Pulseless VT

Procainamide Dosing (How?) Maintenance Infusion 1 to 4 mg/min
1000 mg / 250 mL of D5W = 4 mg/mL 15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min VF / Pulseless VT

Procainamide Precautions (Watch Out!)
If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min Remember Endpoints of Administration VF / Pulseless VT

PEA Case 4

Review for most frequent causes
PEA Review for most frequent causes Hypovolemia Hypoxia Hydrogen ion—acidosis Hyper-/hypokalemia Hypothermia Tablets (drug OD, accidents) Tamponade, cardiac Tension pneumothorax Thrombosis, coronary (ACS) Thrombosis, pulmonary (embolism) Epinephrine 1 mg IV push, repeat every 3 to 5 minutes Atropine 1 mg IV (if PEA rate is slow), repeat every 3 to 5 minutes as needed, to a total dose of 0.04 mg/kg

Pulseless Electrical Activity
Epinephrine Indications (When & Why?) Increases: Heart rate Force of contraction Conduction velocity Peripheral vasoconstriction Bronchial dilation Pulseless Electrical Activity

Epinephrine Dosing (How?) 1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route 2.0 to 2.5 mg diluted in 10 mL normal saline Pulseless Electrical Activity

Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Pulseless Electrical Activity

Atropine Sulfate Indications (When & Why?) Should only be used for bradycardia Relative or Absolute Used to increase heart rate Pulseless Electrical Activity

Atropine Sulfate Dosing (How?) 1 mg IV push Repeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS Maximum Dose: mg/kg Pulseless Electrical Activity

Atropine Sulfate Precautions (Watch Out!) Increases myocardial oxygen demand May result in unwanted tachycardia or dysrhythmia Pulseless Electrical Activity

Asystole Case 5

If considered, perform immediately repeat every 3 to 5 minutes
Asystole Transcutaneous pacing: If considered, perform immediately Epinephrine 1 mg IV push, repeat every 3 to 5 minutes Atropine 1 mg IV, up to a total of 0.04 mg/kg Asystole persists Withhold or cease resuscitation efforts? Consider quality of resuscitation? Atypical clinical features present? Support for cease-efforts protocols in place?

Asystole: The Silent Heart Algorithm
Epinephrine Indications (When & Why?) Increases: Heart rate Force of contraction Conduction velocity Peripheral vasoconstriction Bronchial dilation Asystole: The Silent Heart Algorithm

Epinephrine Dosing (How?) 1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route 2.0 to 2.5 mg diluted in 10 mL normal saline Asystole: The Silent Heart Algorithm

Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Asystole: The Silent Heart Algorithm

Atropine Sulfate Indications (When & Why?) Used to increase heart rate Questionable absolute bradycardia Asystole: The Silent Heart Algorithm

Atropine Sulfate Dosing (How?) 1 mg IV push Repeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS Maximum Dose: mg/kg Asystole: The Silent Heart Algorithm

Atropine Sulfate Precautions (Watch Out!) Increases myocardial oxygen demand Asystole: The Silent Heart Algorithm

Other Cardiac Arrest Drugs

Calcium Chloride Indications (When & Why?) Known or suspected hyperkalemia (eg, renal failure) Hypocalcemia (blood transfusions) As an antidote for toxic effects of calcium channel blocker overdose Prevent hypotension caused by calcium channel blockers administration Other Cardiac Arrest Drugs

Calcium Chloride Dosing (How?) IV Slow Push 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers Other Cardiac Arrest Drugs

Calcium Chloride Precautions (Watch Out!) Do not use routinely in cardiac arrest Do not mix with sodium bicarbonate Other Cardiac Arrest Drugs

Sodium Bicarbonate Indications (When & Why?) Class I if known preexisting hyperkalemia Class IIa if known preexisting bicarbonate-responsive acidosis Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation Class III (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation) Other Cardiac Arrest Drugs

Sodium Bicarbonate Dosing (How?) 1 mEq/kg IV bolus Repeat half this dose every 10 minutes thereafter If rapidly available, use arterial blood gas analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration) Other Cardiac Arrest Drugs

Sodium Bicarbonate Precautions (Watch Out!) Adequate ventilation and CPR, not bicarbonate, are the major "buffer agents" in cardiac arrest Not recommended for routine use in cardiac arrest patients Other Cardiac Arrest Drugs

Acute Coronary Syndromes
Case 6

Immediate assessment (<10 minutes) Measure vital signs (automatic/standard BP cuff) Measure oxygen saturation Obtain IV access Obtain 12-lead ECG (physician reviews) Perform brief, targeted history and physical exam; focus on eligibility for fibrinolytic therapy Obtain initial serum cardiac marker levels Evaluate initial electrolyte and coagulation studies Request, review portable chest x-ray (<30 minutes) Chest pain suggestive of ischemia Immediate general treatment Oxygen at 4 L/min Aspirin 160 to 325 mg Nitroglycerin SL or spray Morphine IV (if pain not relieved with nitroglycerin) Memory aid: “MONA” greets all patients (Morphine, Oxygen, Nitroglycerin, Aspirin) EMS personnel can perform immediate assessment and treatment (“MONA”), including initial 12-lead ECG and review for fibrinolytic therapy indications and contraindications. Assess initial 12-lead ECG

Aspirin Indications (When & Why?) Administer to all patients with ACS, particularly reperfusion candidates Give as soon as possible Blocks formation of thromboxane A2, which causes platelets to aggregate Acute Coronary Syndromes

Aspirin Dosing (How?) 160 to 325 mg tablets Preferably chewed May use suppository Higher doses may be harmful Acute Coronary Syndromes

Aspirin Precautions (Watch Out!) Relatively contraindicated in patients with active ulcer disease or asthma Acute Coronary Syndromes

Nitroglycerine Indications (When & Why?) Chest pain of suspected cardiac origin Unstable angina Complications of AMI, including congestive heart failure, left ventricular failure Hypertensive crisis or urgency with chest pain Acute Coronary Syndromes

Nitroglycerin Indications (When & Why?) Decreases pain of ischemia Increases venous dilation Decreases venous blood return to heart Decreases preload and cardiac oxygen consumption Dilates coronary arteries Increases cardiac collateral flow Acute Coronary Syndromes

Nitroglycerine Dosing (How?) Sublingual Route 0.3 to 0.4 mg; repeat every 5 minutes Aerosol Spray Spray for 0.5 to 1.0 second at 5 minute intervals IV Infusion Infuse at 10 to 20 µg/min Route of choice for emergencies Titrate to effect Acute Coronary Syndromes

Nitroglycerine Precautions (Watch Out!) Use extreme caution if systolic BP <90 mm Hg Use extreme caution in RV infarction Suspect RV infarction with inferior ST changes Limit BP drop to 10% if patient is normotensive Limit BP drop to 30% if patient is hypertensive Watch for headache, drop in BP, syncope, tachycardia Tell patient to sit or lie down during administration Acute Coronary Syndromes

Morphine Sulfate Indications (When & Why?) Chest pain and anxiety associated with AMI or cardiac ischemia Acute cardiogenic pulmonary edema (if blood pressure is adequate) Acute Coronary Syndromes

Morphine Sulfate Indications (When & Why?) To reduce pain of ischemia To reduce anxiety To reduce extension of ischemia by reducing oxygen demands Acute Coronary Syndromes

Morphine Sulfate Dosing (How?) 1 to 3 mg IV (over 1 to 5 minutes) every 5 to 10 minutes as needed Acute Coronary Syndromes

Morphine Sulfate Precautions (Watch Out!) Administer slowly and titrate to effect May compromise respiration; therefore use with caution in acute pulmonary edema Causes hypotension in volume-depleted patients Acute Coronary Syndromes

ST elevation or new or presumably new LBBB: strongly suspicious for injury ST-elevation AMI ST depression or dynamic T-wave inversion: strongly suspicious for ischemia High-risk unstable angina/ non–ST-elevation AMI Nondiagnostic ECG: absence of changes in ST segment or T waves Intermediate/low-risk unstable angina

ST Elevation

Recognition of AMI Know what to look for— Know where to look
ST elevation >1 mm 3 contiguous leads Know where to look Refer to 2000 ECC Handbook J point plus 0.04 second PR baseline ST-segment deviation = 4.5 mm

ST Elevation Baseline Ischemia—tall or inverted T wave (infarct), ST segment may be depressed (angina) Injury—elevated ST segment, T wave may invert Infarction (Acute)—abnormal Q wave, ST segment may be elevated and T wave may be inverted Infarction (Age Unknown)—abnormal Q wave, ST segment and T wave returned to normal

Beta Blockers Indications (When & Why?) To reduce myocardial ischemia and damage in AMI patients with elevated heart rates, blood pressure, or both Blocks catecholamines from binding to ß-adrenergic receptors Reduces HR, BP, myocardial contractility Decreases AV nodal conduction Decreases incidence of primary VF Acute Coronary Syndromes

Beta Blockers Dosing (How?) Esmolol 0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min Titrate to effect, Esmolol has a short half-life (<10 minutes) Labetalol 10 mg labetalol IV push over 1 to 2 minutes May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min Acute Coronary Syndromes

Beta Blockers Dosing (How?) Metoprolol 5 mg slow IV at 5-minute intervals to a total of 15 mg Atenolol 5 mg slow IV (over 5 minutes) Wait 10 minutes, then give second dose of 5 mg slow IV (over 5 minutes) Propranolol 1 to 3 mg slow IV. Do not exceed 1 mg/min Repeat after 2 minutes if necessary Acute Coronary Syndromes

Beta Blockers Precautions (Watch Out!) Concurrent IV administration with IV calcium channel blocking agents like verapamil or diltiazem can cause severe hypotension Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction Monitor cardiac and pulmonary status during administration May cause myocardial depression Acute Coronary Syndromes

Heparin Indications (When & Why?) For use in ACS patients with Non Q wave MI or unstable angina Inhibits thrombin generation by factor Xa inhibition and also inhibit thrombin indirectly by formation of a complex with antithrombin III Acute Coronary Syndromes

Heparin Dosing (How?) Initial bolus 60 IU/kg Maximum bolus: 4000 IU Continue at 12 IU/kg/hr (maximum 1000 IU/hr for patients < 70 kg), round to the nearest 50 IU Acute Coronary Syndromes

Heparin Dosing (How?) Adjust to maintain activated partial thromboplastin time (aPTT) 1.5 to 2.0 times the control values for 48 hours or angiography Target range for aPTT after first 24 hours is between 50 & 70 seconds (may vary with laboratory) Check aPTT at 6, 12, 18, and 24 hours Follow Institutional Heparin Protocol Acute Coronary Syndromes

Heparin Precautions (Watch Out!) Same contraindications as for fibrinolytic therapy: active bleeding; recent intracranial, intraspinal or eye surgery; severe hypertension; bleeding disorders; gastroinintestinal bleeding DO NOT use if platelet count is below Acute Coronary Syndromes

Glycoprotein IIb/IIIa Inhibitors
Indications (When & Why?) Inhibit the integrin glycoprotein IIb/IIIa receptor in the membrane of platelets, inhibiting platelet aggregation Indicated for Acute Coronary Syndromes without ST segment elevation Acute Coronary Syndromes

Indications (When & Why?) Abciximab (ReoPro) Non Q wave MI or unstable angina with planned PCI within 24 hours Must use with heparin Binds irreversibly with platelets Platelet function recovery requires 48 hours Acute Coronary Syndromes

Indications (When & Why?) Eptifibitide (Integrilin) Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI Platelet function recovers within 4 to 8 hours after discontinuation Acute Coronary Syndromes

Indications (When & Why?) Tirofiban (Aggrastat) Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI Platelet function recovers within 4 to 8 hours after discontinuation Acute Coronary Syndromes

Dosing (How?) NOTE: Check package insert for current indications, doses, and duration of therapy. Optimal duration of therapy has NOT been established. Acute Coronary Syndromes

Dosing (How?) Abciximab (ReoPro) ACS with planned PCI within 24 hours 0.25 mg/kg bolus (10 to 60 minutes before procedure), then mcg/kg/min infusion PCI only 0.25 mg/kg bolus Then 10 mcg/min infusion Acute Coronary Syndromes

Dosing (How?) Eptifibitide (Integrilin) Acute Coronary Syndromes 180 mcg/kg IV bolus, then 2 mcg/kg/min infusion PCI 135 mcg/kg IV bolus, then begin 0.5 mcg/kg/min infusion, then repeat bolus in 10 minutes Acute Coronary Syndromes

Dosing (How?) Tirofiban (Aggrastat) Acute Coronary Syndromes or PCI 0.4 mcg/kg/min infusion IV for 30 minutes Then 0.1 mcg/kg/min infusion Acute Coronary Syndromes

Precautions (Watch Out!) Active internal bleeding or bleeding disorder within 30 days History of intracranial hemorrhage or other bleeding Surgical procedure or trauma within 1 month Platelet count > /mm3 Acute Coronary Syndromes

Fibrinolytics Indications (When & Why?) For AMI in adults ST elevation or new or presumably new LBBB; strongly suspicious for injury Time of onset of symptoms < 12 hours Acute Coronary Syndromes

Fibrinolytics Indications (When & Why?) For Acute Ischemic Stroke Sudden onset of focal neurologic deficits or alterations in consciousness Absence of subarachnoid or intracerebral hemorrhage Alteplase can be started in less than 3 hours of symptom onset Acute Coronary Syndromes

Fibrinolytics Dosing (How?) For fibrinolytic use, all patients should have 2 peripheral IV lines 1 line exclusively for fibrinolytic administration Acute Coronary Syndromes

Fibrinolytics Dosing for AMI Patients (How?) Alteplase, recombinant (tPA) Accelerated Infusion 15 mg IV bolus Then 0.75 mg/kg over the next 30 minutes Not to exceed 50 mg Then 0.5 mg/kg over the next 60 minutes Not to exceed 35 mg 3 hour Infusion Give 60 mg in the first hour (initial 6 to 10 mg is given as a bolus) Then 20 mg/hour for 2 additional hours Acute Coronary Syndromes

Fibrinolytics Dosing for AMI Patients (How?) Anistreplase (APSAC) Reconstitute 30 units in 50 mL of sterile water 30 units IV over 2 to 5 minutes Reteplase, recombinant Give first 10 unit IV bolus over 2 minutes 30 minutes later give second 10 unit IV bolus over 2 minutes Streptokinase 1.5 million IU in a 1 hour infusion Tenecteplase (TNKase) Bolus 30 to 50 mg Acute Coronary Syndromes

Fibrinolytics Adjunctive Therapy for AMI Patients (How?) 160 to 325 mg aspirin chewed as soon as possible Begin heparin immediately and continue for 48 hours if alteplase or Retavase is used Acute Coronary Syndromes

Fibrinolytics Dosing for Acute Ischemic Stroke (How?) Alteplase, recombinant (tPA) Give 0.9 mg/kg (maximum 90 mg) infused over 60 minutes Give 10% of total dose as an initial IV bolus over 1 minute Give the remaining 90% over the next 60 minutes Alteplase is the only agent approved for use in Ischemic Stroke patients Acute Coronary Syndromes

Fibrinolytics Precautions (Watch Out!) Specific Exclusion Criteria Active internal bleeding (except mensus) within 21 days History of CVA, intracranial, or intraspinal within 3 months Major trauma or serious injury within 14 days Aortic dissection Severe uncontrolled hypertension Acute Coronary Syndromes

Fibrinolytics Precautions (Watch Out!) Specific Exclusion Criteria Known bleeding disorders Prolonged CPR with evidence of thoracic trauma Lumbar puncture within 7 days Recent arterial puncture at noncompressible site During the first 24 hours of fibrinolytic therapy for ischemic stroke, do not give aspirin or heparin Acute Coronary Syndromes

ACE Inhibitors Indications (When & Why?) Reduce mortality & improve LV dysfunction in post AMI patients Help prevent adverse LV remodeling, delay progression of heart failure, and decrease sudden death & recurrent MI Acute Coronary Syndromes

ACE Inhibitors Indications (When & Why?) Suspected MI & ST elevation in 2 or more anterior leads Hypertension Clinical signs of AMI with LV dysfunction LV ejection fraction <40% Acute Coronary Syndromes

ACE Inhibitors Indications (When & Why?) Generally not started in the ED but within first 24 hours after: Fibrinolytic therapy has been completed Blood pressure has stabilized Acute Coronary Syndromes

ACE Inhibitors Dosing (How?) Should start with low-dose oral administration (with possible IV doses for some preparations) and increase steadily to achieve a full dose within 24 to 48 hours Acute Coronary Syndromes

ACE Inhibitors Dosing (How?) Enalapril 2.5 mg PO titrated to 20 mg BID IV dosing of 1.25 mg IV over 5 minutes, then 1.25 to 5 mg IV every six hours Captopril Start with 6.25 mg PO Advance to 25 mg TID, then to 50 mg TID as tolerated Acute Coronary Syndromes

ACE Inhibitors Dosing (How?) Lisinopril (AMI dose) 5 mg within 24 hours onset of symptoms 10 mg after 24 hours, then 10 mg after 48 hours, then 10 mg PO daily for six weeks Ramipril Start with single dose of 2.5 mg PO Titrate to 5 mg PO BID as tolerated Acute Coronary Syndromes

ACE Inhibitors Precautions (Watch Out!) Contraindicated in pregnancy Contraindicated in angioedema Reduce dose in renal failure Avoid hypotension, especially following initial dose & in relative volume depletion Acute Coronary Syndromes

Bradycardias Case 7

Bradycardia Primary ABCD Survey Secondary ABCD Survey Bradycardia
Slow (absolute bradycardia = rate <60 bpm) or Relatively slow (rate less than expected relative to underlying condition or cause) Assess ABCs Secure airway noninvasively Ensure monitor/defibrillator is available Primary ABCD Survey Secondary ABCD Survey Assess secondary ABCs (invasive airway management needed?) Oxygen–IV access–monitor–fluids Vital signs, pulse oximeter, monitor BP Obtain and review 12-lead ECG Obtain and review portable chest x-ray Problem-focused history Problem-focused physical examination Consider causes (differential diagnoses)

Serious signs or symptoms? Type II second-degree AV block
Bradycardia Intervention sequence Atropine 0.5 to 1.0 mg Transcutaneous pacing if available Dopamine 5 to 20 µg/kg per minute Epinephrine 2 to 10 µg/min Isoproterenol 2 to 10 µg/min Serious signs or symptoms? Due to bradycardia? Type II second-degree AV block or Third-degree AV block? Observe Prepare for transvenous pacer If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed No Yes

Atropine Sulfate Indications (When & Why?)
First drug for symptomatic bradycardia Increases heart rate by blocking the parasympathetic nervous system Bradycardias

Atropine Sulfate Dosing (How?)
0.5 to 1.0 mg IV every 3 to 5 minutes as needed May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS Maximum Dose: mg/kg Bradycardias

Atropine Sulfate Precautions (Watch Out!)
Use with caution in presence of myocardial ischemia and hypoxia Increases myocardial oxygen demand Seldom effective for: Infranodal (type II) AV block Third-degree block (Class IIb) Bradycardias

Dopamine Indications (When & Why?)
Second drug for symptomatic bradycardia (after atropine) Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock Bradycardias

Dopamine Dosing (How?) IV Infusions (Titrate to Effect)
400 mg / 250 mL of D5W = 1600 mcg/mL 800 mg/ 250 mL of D5W = 3200 mcg/mL Bradycardias

Low Dose “Renal Dose" 1 to 5 µg/kg per minute Moderate Dose “Cardiac Dose" 5 to 10 µg/kg per minute High Dose “Vasopressor Dose" 10 to 20 µg/kg per minute Bradycardias

Dopamine Precautions (Watch Out!)
May use in patients with hypovolemia but only after volume replacement May cause tachyarrhythmias, excessive vasoconstriction DO NOT mix with sodium bicarbonate Bradycardias

Epinephrine Indications (When & Why?)
Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb) Bradycardias

Epinephrine Dosing (How?) Profound Bradycardia
2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min) Bradycardias

Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Bradycardias

Isoproterenol Indications (When & Why?)
Temporary control of bradycardia in heart transplant patients Class IIb at low doses for symptomatic bradycardia Heart Transplant Patients! Bradycardias

Isoproterenol Dosing (How?) Infuse at 2 to 10 µg/min
Titrate to adequate heart rate Bradycardias

Isoproterenol Precautions (Watch Out!)
Increases myocardial oxygen requirements, which may increase myocardial ischemia DO NOT administer with poison/drug-induced shock Exception: Beta Blocker Poisoning Bradycardias

Stable Tachycardias Case 9

Diltiazem Indications (When & Why?)
To control ventricular rate in atrial fibrillation and atrial flutter Use after adenosine to treat refractory PSVT in patients with narrow QRS complex and adequate blood pressure As an alternative, use verapamil Stable Tachycardias

Diltiazem Dosing (How?) Acute Rate Control Maintenance Infusion
15 to 20 mg (0.25 mg/kg) IV over 2 minutes May repeat in 15 minutes at 20 to 25 mg (0.35 mg/kg) over 2 minutes Maintenance Infusion 5 to 15 mg/hour, titrated to heart rate Stable Tachycardias

Diltiazem Precautions (Watch Out!)
Do not use calcium channel blockers for tachycardias of uncertain origin Avoid calcium channel blockers in patients with Wolff-Parkinson-White syndrome, in patients with sick sinus syndrome, or in patients with AV block without a pacemaker Expect blood pressure drop resulting from peripheral vasodilation Concurrent IV administration with IV ß-blockers can cause severe hypotension Stable Tachycardias

Verapamil Indications (When & Why?)
Used as an alternative to diltiazem for ventricular rate control in atrial fibrillation and atrial flutter Drug of second choice (after adenosine) to terminate PSVT with narrow QRS complex and adequate blood pressure Stable Tachycardias

Verapamil Dosing (How?) 2.5 to 5.0 mg IV bolus over 1to 2 minutes
Second dose: 5 to 10 mg, if needed, in 15 to 30 minutes. Maximum dose: 30 mg Older patients: Administer over 3 minutes Stable Tachycardias

Verapamil Precautions (Watch Out!)
Do not use calcium channel blockers for wide-QRS tachycardias of uncertain origin Avoid calcium channel blockers in patients with Wolff-Parkinson-White syndrome and atrial fibrillation, sick sinus syndrome, or second- or third-degree AV block without pacemaker Stable Tachycardias

Verapamil Precautions (Watch Out!)
Expect blood pressure drop caused by peripheral vasodilation IV calcium can restore blood pressure, and some experts recommend prophylactic calcium before giving calcium channel blockers Concurrent IV administration with IV ß-blockers may produce severe hypotension Stable Tachycardias

Adenosine Indications (When & Why?) First drug for narrow-complex PSVT
May be used diagnostically (after lidocaine) in wide-complex tachycardias of uncertain type Stable Tachycardias

Adenosine Dose (How?) IV Rapid Push
Initial bolus of 6 mg given rapidly over 1 to 3 seconds followed by normal saline bolus of 20 mL; then elevate the extremity Repeat dose of 12 mg in 1 to 2 minutes if needed A third dose of 12 mg may be given in 1 to 2 minutes if needed Stable Tachycardias

Adenosine Precautions (Watch Out!) Transient side effects include:
Facial Flushing Chest pain Brief periods of asystole or bradycardia Less effective in patients taking theophyllines Stable Tachycardias

Beta Blockers Indications (When & Why?)
To convert to normal sinus rhythm or to slow ventricular response (or both) in supraventricular tachyarrhythmias (PSVT, atrial fibrillation, or atrial flutter) ß-Blockers are second-line agents after adenosine, diltiazem, or digoxin Stable Tachycardias

Beta Blockers Dosing (How?) Esmolol Labetalol Stable Tachycardias
0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min Titrate to effect, Esmolol has a short half-life (<10 minutes) Labetalol 10 mg labetalol IV push over 1 to 2 minutes May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min Stable Tachycardias

Beta Blockers Dosing (How?) Metoprolol Atenolol Propranolol
5 mg slow IV at 5-minute intervals to a total of 15 mg Atenolol 5 mg slow IV (over 5 minutes) Wait 10 minutes, then give second dose of 5 mg slow IV (over 5 minutes) Propranolol 1 to 3 mg slow IV. Do not exceed 1 mg/min Repeat after 2 minutes if necessary Stable Tachycardias

Beta Blockers Precautions (Watch Out!)
Concurrent IV administration with IV calcium channel blocking agents like verapamil or diltiazem can cause severe hypotension Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction Monitor cardiac and pulmonary status during administration May cause myocardial depression Stable Tachycardias

Digoxin Indications (When & Why?)
To slow ventricular response in atrial fibrillation or atrial flutter Third-line choice for PSVT Stable Tachycardias

Digoxin Dosing (How?) IV Infusion
Loading doses of 10 to 15 µg/kg provide therapeutic effect with minimum risk of toxic effects Maintenance dose is affected by body size and renal function Stable Tachycardias

Digoxin Precautions (Watch Out!)
Toxic effects are common and are frequently associated with serious arrhythmias Avoid electrical cardioversion unless condition is life threatening Use lower current settings (10 to 20 Joules) Stable Tachycardias

Amiodarone Indications (When & Why?)
Powerful antiarrhythmic with substantial toxicity, especially in the long term Intravenous and oral behavior are quite different Stable Tachycardias

Amiodarone Dosing (How?) Stable Wide-Complex Tachycardias
Rapid Infusion 150 mg IV over 10 minutes (15 mg/min) May repeat Slow Infusion 360 mg IV over 6 hours (1 mg/min) Stable Tachycardias

Amiodarone Dosing (How?) Maintenance Infusion
540 mg IV over 18 hours (0.5 mg/min) Stable Tachycardias

Amiodarone Precautions (Watch Out!) May produce vasodilation & shock
May have negative inotropic effects May prolong QT Interval DO NOT administer with other drugs that may prolong QT Interval (Procainamide) Terminal elimination Half-life lasts up to 40 days Stable Tachycardias

Amiodarone Precautions (Watch Out!) Contraindicated in:
Second or third degree A-V block Severe bradycardia Pregnancy CHF Hypokalaemia Liver dysfunction Stable Tachycardias

Lidocaine Indications (When & Why?) Depresses automaticity
Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability Stable Tachycardias

Lidocaine Dosing (How?)
For stable VT, wide-complex tachycardia of uncertain type, significant ectopy, use as follows: 1.0 to 1.5 mg/kg IV push Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes; maximum total dose, 3 mg/kg Stable Tachycardias

Lidocaine Dosing (How?) Maintenance Infusion 2 to 4 mg/min
Stable Tachycardias

Lidocaine Precautions (Watch Out!)
Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction Discontinue infusion immediately if signs of toxicity develop Stable Tachycardias

Magnesium Sulfate Indications (When & Why?)
Torsades de pointes with a pulse Wide-complex tachycardia with history of ETOH abuse Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose Stable Tachycardias

Magnesium Sulfate Dosing (How?)
Loading dose of 1 to 2 grams mixed in 50 to 100 mL of D5W IV push over 5 to 60 minutes Stable Tachycardias

Magnesium Sulfate Dosing (How?) Maintenance Infusion
1 to 4 g/hour IV (titrate dose to control the torsades) Stable Tachycardias

Magnesium Sulfate Precautions (Watch Out!)
Occasional fall in blood pressure with rapid administration Use with caution if renal failure is present Stable Tachycardias

Procainamide Indications (When & Why?) Depresses automaticity
Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability Atrial fibrillation with rapid rate in Wolff-Parkinson-White syndrome Stable Tachycardias

Procainamide Dosing (How?) Perfusing Arrhythmia
20 mg/min IV infusion until: Hypotension develops Arrhythmia is suppressed QRS widens by >50% Maximum dose of 17 mg/kg is reached In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable Stable Tachycardias

Procainamide Dosing (How?) Maintenance Infusion 1 to 4 mg/min
Stable Tachycardias

Procainamide Precautions (Watch Out!)
If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min Remember Endpoints of Administration Stable Tachycardias

Acute Ischemic Stroke Case 10

Acute Ischemic Stroke Suspected Stroke EMS assessments and actions
Immediate assessment: <10 minutes from arrival Assess ABCs, vital signs Provide oxygen by nasal cannula Obtain IV access; obtain blood samples (CBC, electolytes, coagulation studies) Check blood sugar; treat if indicated Obtain 12-lead ECG, check for arrhythmias Perform general neurological screening assessment Alert Stroke Team: neurologist, radiologist, CT technician Immediate neurological assessment: <25 minutes from arrival Review patient history Establish onset (<3 hours required for fibrinolytics) Perform physical examination Perform neurological examination: Determine level of consciousness (Glasgow Coma Scale) Determine level of stroke severity (NIH Stroke Scale or Hunt and Hess Scale) Order urgent noncontrast CT scan (door-to–CT scan performed: goal <25 minutes from arrival) Read CT scan (door-to–CT read: goal <45 minutes from arrival) Perform lateral cervical spine x-ray (if patient comatose/history of trauma) EMS assessments and actions Immediate assessments performed by EMS personnel include Cincinnati Prehospital Stroke Scale (includes difficulty speaking, arm weakness, facial droop) Los Angeles Prehospital Stroke Screen Alert hospital to possible stroke patient Rapid transport to hospital Suspected Stroke Detection Dispatch Delivery Door

Nitroprusside Indications (When & Why?) Hypertensive crisis
Acute Ischemic Stroke

Nitroprusside Dosing (How?)
Begin at 0.1 mcg/kg/min and titrate upward every 3 to 5 minutes to desired effect Up to 0.5 mcg/kg/min Action occurs within 1 to 2 minutes Acute Ischemic Stroke

Nitroprusside Dosing Precautions (How?)
Use with an infusion pump; use hemodynamic monitoring for optimal safety Cover drug reservoir with opaque material Acute Ischemic Stroke

Nitroprusside Precautions (Watch Out!)
Light-sensitive; therefore, wrap drug reservoir in aluminum foil May cause hypotension and CO2 retention May exacerbate intrapulmonary shunting Other side effects include headaches, nausea, vomiting, and abdominal cramps Acute Ischemic Stroke

Drugs used in Overdoses

Drugs Used in Overdoses
Calcium Chloride Indications (When & Why?) As an antidote for toxic effects of calcium channel blocker overdose Drugs Used in Overdoses

Calcium Chloride Dosing (How?) 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose Drugs Used in Overdoses

Calcium Chloride Precautions (Watch Out!) Do not use routinely in cardiac arrest Do not mix with sodium bicarbonate Drugs Used in Overdoses

Flumazenil Indications (When & Why?) Reduce respiratory depression and sedative effects from pure benzodiazepine overdose Drugs Used in Overdoses

Flumazenil Dosing (How?) First Dose 0.2 mg IV over 15 seconds Second Dose 0.3 mg IV over 30 seconds Third Dose 0.4 mg IV over 30 seconds Maximum Dose 3 mg Drugs Used in Overdoses

Flumazenil Precautions (Watch Out!) Effects may not outlast effects of benzodiazepines Monitor for recurrent respiratory depression DO NOT use in suspected tricyclic overdose DO NOT use in seizure-prone patients DO NOT use if unknown type overdose or mixed drug overdose with drugs known to cause seizures Drugs Used in Overdoses

Naloxone Hydrochloride
Indications (When & Why?) Respiratory and neurologic depression due to opiate intoxication unresponsive to oxygen and hyperventilation Drugs Used in Overdoses

Dosing (How?) 0.4 to 2 mg IVP every 2 minutes Use higher doses for complete narcotic reversal Can administer up to 10 mg in a short time (10 minutes) Drugs Used in Overdoses

Precautions (Watch Out!) May cause opiate withdrawal Effects may not outlast effects of narcotics Monitor for recurrent respiratory depression Drugs Used in Overdoses

Review of Infusions

Dobutamine Indications (When & Why?)
Consider for pump problems (congestive heart failure, pulmonary congestion) with systolic blood pressure of 70 to 100 mm Hg and no signs of shock Increases Inotropy Review of Infusions

Dobutamine Dosing (How?)
Usual infusion rate is 2 to 20 µg/kg per minute Titrate so heart rate does not increase by more than 10% of baseline Hemodynamic monitoring is recommended for optimal use Review of Infusions

Dobutamine Precautions (Watch Out!)
Avoid when systolic blood pressure <100 mm Hg with signs of shock May cause tachyarrhythmias, fluctuations in blood pressure, headache, and nausea DO NOT mix with sodium bicarbonate Review of Infusions

Dopamine Indications (When & Why?)
Second drug for symptomatic bradycardia (after atropine) Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock Review of Infusions

Low Dose “Renal Dose" 1 to 5 µg/kg per minute Moderate Dose “Cardiac Dose" 5 to 10 µg/kg per minute High Dose “Vasopressor Dose" 10 to 20 µg/kg per minute Review of Infusions

Dopamine Precautions (Watch Out!)
May use in patients with hypovolemia but only after volume replacement May cause tachyarrhythmias, excessive vasoconstriction DO NOT mix with sodium bicarbonate Review of Infusions

Epinephrine Indications (When & Why?)
Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb) Review of Infusions

Epinephrine Dosing (How?) Profound Bradycardia
2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min) Review of Infusions

Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Review of Infusions

Norepinephrine Indications (When & Why?)
For severe cardiogenic shock and hemodynamic significant hypotension (systolic blood pressure < 70 mm/Hg) with low total peripheral resistance This is an agent of last resort for management of ischemic heart disease and shock Review of Infusions

Norepinephrine Dosing (How?)
0.5 to 1 mcg/min titrated to improve blood pressure (up to 30 mcg/min) DO NOT administer is same IV line as alkaline infusions Poison/drug-induced hypotension may higher doses to achieve adequate perfusion Review of Infusions

Norepinephrine Precautions (Watch Out!)
Increases myocardial oxygen requirements May induce arrhythmias Extravasation causes tissue necrosis Review of Infusions

Calculating mg/min dose X gtt factor Solution Concentration = gtts/min
2 mg X 60 gtt/mL 4 mg Using a 60 gtt set: 30 gtt/min = 30 cc/hr = gtts/min = 30 gtts/min

Calculating mcg/kg/min
dose X kg X gtt factor solution concentration 5 mcg/min X 75 kg X 60 gtt/mL 1600 mcg/cc Using a 60 gtt set: 18.75 cc/hr = gtts/min = cc/hr = cc/hr

Furosemide Indications (When & Why?)
For adjuvant therapy of acute pulmonary edema in patients with systolic blood pressure >90 to 100 mm Hg (without S/S of shock) Hypertensive emergencies Increased intracranial pressure

Furosemide Dosing (How?) 20 to 40 mg slow IVP
If patient is taking at home, double their daily dose

Furosemide Precautions (Watch Out!)
Dehydration, hypovolemia, hypotension, hypokalemia, or other electrolyte imbalance may occur

Jeremy Maddux ncmedix@msn.com
Questions? Jeremy Maddux

Summary To obtain a full understanding of ACLS pharmacology requires constant review of: Indications & Actions (When & Why?) Dosing (How?) Contraindications & Precautions (Watch Out!)

Thank You!

ACLS Pharmacology dr shabeel pn.

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