1. ACLS Workshop
DCH Regional Medical Center and Harrison School of Pharmacy, Auburn University

2. General Administration Concepts
Follow each dose with mL NS
Assists in drug distribution
Prefilled 10 mL syringe available
Expiration times
General times provided
DCH policy for medication prepared at bedside – 8 hours
Administration must occur within 1 hour of preparation
Infusions must be completed within 8 hours or be replaced by a pharmacy admixed product
Labeling of IV push doses not necessary if administered immediately after preparation
Labeling of infusions
Patient Identification
Names/ amounts of all ingredients
Names or initials of preparer
Date and time prepared
Expiration date and time

3. Alternative Routes of Administration
Intraosseous
Into the bone
Drug reaches heart in approximately 2 minutes
Endotracheal
NAVEL
Naloxone, atropine, vasopressin, epinephrine, lidocaine
Dose is 2 times the IV/IO dose
Dilute in 10 mL fluid
NS – most common diluent
Sterile water- may improve absorption of epinephrine or lidocaine

4. Epinephrine Use – First line VF/VT, PEA, asystole Normal Dosing
1 mg via prefilled syringe (1:10,000 of 1mg/10mL) IVP
Higher doses (up to 0.2 mg/kg) may be used if 1 mg dose fails – rarely done
Frequency – every 3-5 minutes
Every other defibrillation-drug administration sequence
Alternative Dosing
Continuous Infusion

5. Epinephrine Preparation
Infusion
Vial – 1:1,000 solution (30 mL)
1 mg/mL = 30 mg/vial
Step 1 – withdraw 1 mg (1mL) from vial
Step 2 – add epinephrine to 250 mL D5W or NS
Final concentration – 4 mcg/mL
Alternative strengths
Double strength: add 2 mg (2 mL) epinephrine to 250 mL D5W or NS [Final concentration 8 mcg/mL]
Triple strength: add 3 mg (3 mL) epinephrine to 250 mL D5W or NS [Final concentration 12 mcg/mL]
Alternative (AHA dose): add 30 mg epinephrine to 250 mL D5W or NS [Final concentration 120 mcg/mL]
Protect from light
Expires 24 hour after preparation
Usual starting dose – 0.05 mcg/kg/min (~ 200 mcg/min or 100 mL/hr)

6. Atropine Use – PEA and asystole Dosing 1 mg prefilled syringe
Frequency – every 3-5 minutes
Alternate with epinephrine
Maximum of 3 doses (i.e. 3 mg)
Note: not for continuous infusion

7. Vasopressin
Use – Alternative to 1st or 2nd dose of epinephrine in VF/VT, PEA, or asystole (Only 1 dose is administered)
Also used as adjunct to NE or DA in shock
Available – 20 unit vial (20 units/2 mL), 100 unit vial
Dosing
Cardiac arrest - 40 units IVP
Shock – units/min IV continuous infusion
Preparation (for infusion)
Step 1 – withdraw 250 units vasopressin
Step 2 – add vasopressin to 250 mL D5W or NE
Final concentration 1 unit/mL
Expires 28 hours following preparation
Refrigerate (not necessary in ACLS)

8. Amiodarone Use Dosing dependent on use
Refractory cardiac arrest
Wide-Complex Tachycardia (Stable)
i.e. tachycardia with pulses
Dosing dependent on use
Max cumulative dose: 2.2 g IV/24 hours
Note: ANY dose during a medical emergency should be followed with a continuous infusion for at least 24 hours

9. Amiodarone Preparation and Administration
Cardiac Arrest
Vial – 150 mg/ 3mL
Step 1 - Withdraw 300 mg (2 vials) amiodarone (6mL)
Note – Filter needles no longer required
Step 2 – Administer IVP undiluted
Step 3 – Follow with mL saline flush
May repeat additional 150 mg (1 vial) IVP in 3-5 minutes

10. Amiodarone Preparation and Administration
Wide-Complex Tachycardia
Vial – 150 mg/3mL
Loading Dose
Step 1 – withdraw 150 mg amiodarone
Step 2 – add amiodarone to 100 mL D5W
Final concentration – 1.5 mg/mL
Administer over 10 minutes
Expires 2 hours after preparation

11. Amiodarone Preparation and Administration
Maintenance Infusion
Step 1 – Transfer 250 mL D5W to glass bottle (if Baxter bag unavailable)
Step 2 – withdraw 450 mg amiodarone (3 vials)
Alternative – withdraw 500 mg (3 vials) if able
Step 3 – add amiodarone to 250 mL D5W
Final Concentration 1.8 mg/mL
Concentration with 500 mg : 2 mg/mL
Administration
1 mg/min (360 mg) IV for six hours then
0.5 mg/min (540 mg) IV for 18 hours
Requires in-line filter for administration
Expires 12 hours after preparation

12. Lidocaine
Use – alternative to amiodarone in VT/VF, stable VT, wide-complex tachycardia, wide complex PSVT
May be given via ET tube
Dosing
Initial Bolus – 1mg/kg – 1.5mg/kg IVP at mg/min
May repeat 50% original dose in 5-10 minutes
Max 3 doses or 3 mg/kg
Infuse at 1-4 mg/min following bolus administration
Available
Premixed solution (2 gm/500 mL D5W, 1 gm/250 mL D5W)
Prefilled syringe (100 mg/5mL)
1 gm vial (20 mg/mL)

13. Lidocaine Preparation and Administration
Preparation of infusion (if not using premixed bag)
Step 1 – withdraw 100 mL from 250 mL D5W bag
Step 2 – withdraw 2 gm (2 vials) lidocaine
Note: Not in DCH ACLS carts
Step 3 – inject into 150 mL D5W
Notes:
Contraindicated in WPW
Cannot administer through same IV line as epinephrine or norepinephrine

14. Adenosine Use – First line narrow-complex PSVT
Do not use in VT
Note – may cause transient asystole or bradycardia
Available in 6 mg vial (3mg/2mL)
Preparation
Withdraw appropriate dose from vial
Is not diluted for infusion
Dosing and administration
Place patient in mild reverse Trendelenburg position
Initial dose – 6 mg IV push rapidly over 1-3 seconds
Follow immediately with 20 mL NS bolus and elevate extremity
May repeat 12 mg in 1-2 minutes if no response up to 2 additional doses

15. Norepinephrine Use – Hypotension and shock
Available in 4 mg vial (4mg/4mL)
Preparation
Step 1 – withdraw 4 mg (1 vial)
Step 2 – add to 250 mL NS or D5W
Final Concentration – 16 mcg/mL
Protect from light
Expires 24 hours after preparation
Initial infusion rate: 5 mcg/min

16. Phenylephrine Use: hypotension with tachycardia, paroxysmal SVT
Preparation
Step 1 – withdraw 10 mg (1 vial)
Note: DCH – withdraw 40 mg
Not in DCH carts
Step 2 – add to 250 mL D5W or NS
Final Concentration – 40 mcg/mL
Protect from light
Expires 48 hours after preparation
Initial infusion rate: mcg/min
Precautions – sulfite allergy

17. Dopamine Use – hypotension Premixed bag Preparation
400 mg/250 mL D5W
Concentration – 1.6 mg/mL
Preparation
Only if premixed bag unavailable
Add 400 mg dopamine to 250 mL D5W or NS
May also add 800 mg if require concentrated infusion
Initial infusion rate: 5-10 mcg/kg/min
Titrate to patient response
Usually to MAP ≥ 65 mmHg or SBP ≥ 90 mmHg
Precautions – tachycardia, arrhythmias
Do not administer with sodium bicarbonate

18. Magnesium Sulfate
Use – torsades de pointes or hypomagnesemia, refractory VF (after lidocaine)
Available – 1gm/2mL vial
Preparation
Cardiac arrest
Step 1 – withdraw 10 mL D5W into syringe
Step 2 - withdraw 1-2 gm Mg (1-2 vials) into same syringe
Final concentration mg/mL
Administer IVP over at least 5 minutes
Torsades de pointes when not in cardiac arrest
Step 1 – withdraw 1-2 gm Mg (1-2 vials)
Step 2 – add to 100 mL D5W
Administer over 5-60 minutes IV

19. Calcium Chloride
Use – CCB or BB overdose, hypocalcemia, hyperkalemia, prophylactically before IV CCB to prevent hypotension
Not usually used in cardiac arrest
Available
Prefilled syringe (1gm/10mL)
Also available as Calcium Gluconate 1gm/10mL if only peripheral access available)
Dosing and administration
8-16 mg/kg (~ 5-10 mL or prefilled syringe) slow IVP
Repeat as needed
Do not administer with sodium bicarbonate

20. Naloxone Use – opiod overdose Available Dosing 1 mL vial (0.4 mg/mL)
10 mL vial (0.4 gm/mL)
Dosing
0.4-2 mg IVP every 2 minutes
May give up to 10 mg in < 10 minutes

21. Sodium Bicarbonate
Use – hyperkalemia, bicarbonate-responsive acidosis (i.e. DKA), alkalinize urine (ASA or TCA overdose), prolonged resuscitation
Not recommended for routine use in cardiac arrest
Available
50 mEq prefilled syringe (1 mEq/mL)
Dosing
1 mEq/kg IV bolus
May repeat 50% dose in 10 minutes