Medications of Advanced Cardiovascular Life Support

ACLS Class Recommendations

Class I Always do this! Class IIa Intervention of choice. Class IIb Give careful consideration. Class Indeterminate Clinical judgment Class III Not recommended!

Last Revision: July 2006

Drugs Given Via ET Tube Narcan Atropine Vasopressin Epinephrine Lidocaine

Preferred route is IV/IO If given via ET Tube, double the dose except Vasopressin (insufficient evidence to recommend a dose)

Epinephrine (Adrenaline)
Mechanism of Action
- and -adrenergic activity

Indication(s)
VF / pulseless VT unresponsive to defibrillation
ACLS Class IIb Recommendation ACLS Class Indeterminate Recommendation

Asystole / PEA Symptomatic bradycardia, severe hypotension, & anaphylaxis

Epinephrine (Adrenaline)
Standard dose = 1 mg every 3-5 minutes
Follow each dose with saline flush May be given via ET tube (double the dose)

Epinephrine (Adrenaline)
Precautions
Tachycardia, Hypertension, Pulmonary edema Myocardial Ischemia, Angina
Increased myocardial oxygen demand

High dose / Escalating dose

No longer recommended No improvement of survival or neurological outcomes May contribute to post-tx myocardial dysfunction

Overdose treatment is supportive

Misc
Provided as 1:10,000 prefilled syringe 10 mL = 1 mg Also available as 1:1,000 vial (more concentrated) 1 mL = 1 mg

Epinephrine Drip
Initiate at 1 mcg/min, titrate to hemodynamic endpoint (2-10 mcg/min)

Vasopressin
Mechanism of Action
Naturally occurring antidiuretic hormone Acts as non-adrenergic peripheral vasoconstrictor Direct stimulation of smooth muscle V1 receptors Does not increase myocardial O2 consumption
No beta effects

Vasopressin
Indication(s)
VF / pulseless VT unresponsive to defibrillation
ACLS Class IIb Recommendation ACLS Class Indeterminate Recommendation

Asystole / PEA Vasodilatory shock (i.e. septic shock) May be helpful in prolonged arrest
Longer half-life than epinephrine

Levels higher in patients who survive CPR

Vasopressin
Dose is 40 units IV x1 dose
alternative to 1st or 2nd dose of epinephrine

Vasopressin
Precautions
Hypertension, Tremor Myocardial Ischemia, Angina
Increased peripheral vascular resistance

Re-dosing (Class Indeterminate)

If no response in 10-20 minutes, resume epinephrine, do not repeat doses of vasopressin Re-dosing vasopressin seems rational, but is not supported by human-data. Some practitioners will re-dose vasopressin, this is not supported by ACLS recommendations.

Overdose treatment is supportive

Consider osmotic diuretics if severe overdose

Misc
Provided as 20 unit/mL ampule

Atropine
Mechanism of Action
Enhances sinus node automaticity & AV conduction Parasympatholytic (direct vagolytic action)

Atropine
Symptomatic Bradycardia: 0.5 mg IV
Doses less than 0.5 mg may cause paradoxical bradycardia Do not delay pacing for symptomatic patients

Indication(s)
Symptomatic bradycardia
ACLS Class I Recommendation ACLS Class IIa Recommendation ACLS Class IIb Recommendation ACLS Class Indeterminate Recommendation

1st degree AV block Mobitz type 1 AV block Slow PEA/Asystole

Cardiac Arrest: 1 mg IV Repeat doses every 5 minutes to total of 3 mg

Fully vagolytic at 3 mg ACLS Guideline for max is 0.04 mg/kg

May give via ET tube (double the dose)

Atropine
Precautions
Existing tachycardia Avoid in hypothermic bradycardia Increases myocardial O2 demand

Classification of VF/VT
Persistent (shock resistant): persists after multiple shocks Refractory: persists after shocks, CPR, airway, AND drugs Recurrent: returns after a successful intervention

Misc
May be used for organophosphate poisoning (i.e. nerve agent)
Extremely large doses may be needed in this case (2-4 mg or higher with exposure to nerve agents)

Amiodarone (Cordarone)
Mechanism of Action
Delays repolarization (prolongs refractory period) Blocks - and -adrenergic receptors Affects sodium, potassium, and calcium channels

Amiodarone (Cordarone)
Cardiac Arrest (VF/pulseless VT) given as 300 mg rapid IV infusion in 20-30 mL D5W
One supplemental dose of 150 mg may be given in 3-5 min if refractory VF/pulseless VT

Indication(s)
Persistent or recurrent VF / pulseless VT
ACLS Class IIb Recommendation

VT (with pulse), dose is 150 mg IV every 10 min as needed Continuous Infusion (max of 2.2 grams/24 hr)
900 mg in 500 mL D5W (1.8 mg/mL) 1 mg/min (33.3 mL/hr) for 6 hr, then 0.5 mg/min (16.6 mL/hr) for remainder of infusion

Effective in atrial & ventricular arrhythmias

Amiodarone (Cordarone)
Precautions
Hypotension, dizziness, fatigue, N/V Significant bradycardia & heart block Pulmonary & hepatic toxicities

Lidocaine
Mechanism of Action
Depresses diastolic depolarization & automaticity in the ventricles

Indication(s)
Persistent or recurrent VF / pulseless VT
ACLS Class Indeterminate Recommendation Most useful in sustained VF / pulseless VT or wide-complex tachycardia of unknown origin

Misc
Provided as 150 mg ampule Multiple drug interactions Should be administered via central line if possible Infusions > 2 hr must be in glass or PVC-free

Perfusing arrhythmias

Lidocaine
Cardiac Arrest (VF/pulseless VT) given as 1 1.5 mg/kg IV initially
Repeat doses of 0.5 0.75 mg/kg ( of initial dose) IV every 5-10 min for a total of 3 doses (or) 3 mg/kg May give via ET tube (double the dose)

Lidocaine
Precautions
Bradycardia, hypotension, heart block, sinus node depression, N/V, double vision, dyspnea Excessive drowsiness is a sign of high blood levels leading to seizures, loss of consciousness, coma
Stop infusion immediately, draw levels

Lidocaine Drip
Start at 1-4 mg/min to achieve levels of 1.5 6 mcg/mL Reduce maintenance infusion if hepatic impairment Constant ECG monitoring is necessary w/ infusions

Procainamide (Pronestyl)
Mechanism of Action
Depresses the excitability of cardiac muscle to electrical stimulation and slows conduction in the atrium, the bundle of HIS and the ventricle

Procainamide (Pronestyl)
PVCs and Recurrent VT: 20 mg/min
Titrate to suppression of arrhythmia 17 mg/kg max (or) limited by adverse events (i.e.) hypotension, QRS widened by 50% Follow with 1-4 mg/min drip

Indication(s)
Recurrent VF / pulseless VT
ACLS Class Indeterminate Recommendation Most appropriate if return of circulation at least twice & has perfusing rhythm

Precautions
May precipitate or exacerbate CHF Correct hypokalemia before use Can further depress AV conduction in digoxin-induced toxicity Hypotension, rash, and diarrhea are major side effects

Assist with conversion of A.fib/flutter, PSVT

Other Antiarrhythmics
(Not on Exam)

Magnesium Sulfate
Indication(s):
Torsades de pointes
ACLS Class IIb Recommendation if known or suspected hypomagnesaemia (chronic malnutrition, etc.)

Ibutilide (short-acting antiarrhythmic)

10 min IV infusion of 1 mg (if >60 kg) Rhythm conversion or rate control of A.fib/flutter when Ca++Channel or -blockers ineffective Conversion of atrial fib/flutter in WPW
Intervention of choice is DC Cardioversion

Note: Vent arrhythmias (polymorphic VT, torsades)

Dose based on patient stability: 1 2 gm

In 10 mL NS over 1 2 minutes in cardiac arrest In 50 mL over 5 60 minutes in Torsades w/ pulse Follow with infusion of 0.5 to 1 gm/hr for up to 24 hr

Sotalol ( -blocker w/ antiarrythmic properties)

0.2-1.5 mg/kg IV over 5 minutes Life-threatening VT, stable/unstable angina, & HTN Conversion of atrial fib/flutter in WPW
Intervention of choice is DC Cardioversion

Sodium Bicarbonate
Indication(s)
Hyperkalemia
ACLS Class I Recommendation ACLS Class IIa Recommendation

Calcium Chloride
Hypercalcaemia & Cardiac resuscitation
Hyperkalemia & Ca++Channel Blocker Overdose
0.5-1 gram IV (~5-10 mL of 10% solution)

Tricyclic Antidepressant Overdose Phenobarbital overdose, Preexisting acidosis, Prolonged arrest

Precautions
Do not routinely use in cardiac arrest Do not mix with sodium bicarbonate Flush line after infusion to prevent precipitation May cause a decrease in HR or BP Questionable value unless documented hypocalcaemia

1 mEq / kg initial, then dose every 10 min Precautions

Monitor ABGs, paradoxical acidosis due to CO2 diffusion & deleterious shift in oxygen dissociation curve ACLS Class III Recommendation if not intubated & hypercarbic acidosis (excess CO2)

Vasopressors
Is the tank full?
Without enough fluid in the system, the blood pressure will not correct

Dopamine (Intropin)
Mechanism of Action
-, -, and DA receptor agonist

Is there a pump problem?

Is the heart actually contracting or just quivering?

Indication(s)
Refractory symptomatic bradycardia Failed atropine & pacing (or while awaiting pacing)

Is there a rate problem?

Bradycardia or tachycardia? Both will lead to ineffective circulation

2-10 mcg/kg/min infusion

Considered an inotropic dose

Precaution: Watch for Extravasation!

Norepinephrine (Levophed)
Mechanism of Action
Powerful -receptors agonist (arterial/venous) 1-receptor agonist ( myocardial contractions)

Dobutamine (Dobutrex)
Mechanism of Action
Primarily affects -receptors

Indication(s)
Severe & hemodynamically significant hypotension plus low total peripheral vascular resistance

Indication(s)
Severe systolic heart failure and cannot tolerate vasopressors Treatment of choice if hemodynamically significant right-ventricular infarction

2-12 mcg/min infusion

May need up to 30 mcg/min if refractory shock

2-20 mcg/kg/min infusion

Increases renal & mesenteric blood flow by CO2

Precaution: Watch for Extravasation!

Adenosine (Adenocard)
Mechanism of Action
Slows conduction through AV node Interrupts AV nodal reentry pathways

Adenosine (Adenocard)
Diagnostic
Undefined, stable narrow-complex SVT Will not convert atrial tachycardias or VT as reentry not involving the AV or sinus node

Indication(s)
Defined, stable, narrow-complex AV or sinus nodal reentry tachycardia (reentry SVT)
ACLS Class I Recommendation ACLS Class IIb Recommendation

6 mg rapid IV push (over 1-3 seconds) followed by immediate saline flush push
May repeat with 12 mg bolus (x1-2) if no conversion

Unstable, reentry SVT

Adenosine (Adenocard)
Precautions
Transient bradycardia (asystole!), ventricular ectopy, flushing, dyspnea, and chest pain Caution in patients prone to bradycardia or conduction defects without pacemaker

Calcium Channel Blockers

Mechanism of Action
Ca++ channel blockade in cardiac pacemaker cells, reduces AV node conductivity

Rate control, Reduce MI damage/mortality

Class IIa ACLS Recommendation Diltiazem: 0.25-0.35 mg/kg (20-25 mg) over 2 min Repeat in 15 min if needed Verapamil: 2.5-5 mg IV bolus over 2-3 min Repeat in 15-30 min if needed with 5-10 mg
May be dosed at 5 mg q15 min to total of 30 mg Agent of choice if PSVT with narrow QRS

Misc (drug interactions)

Reduce dose to 3 mg Dispyridamole, Carbamazepine, Cardiac Transplant, CVL Admin Dose at 12 mg Theophylline, Caffeine

Calcium Channel Blockers

Precautions
Considered harmful ( Class III) if A.fib/flutter associated with known pre-excitation syndrome (i.e. Wolff-Parkinson-White syndrome) Causes edema, 1st degree heart block, hypotension, bradycardia, vasodilation Causes 2nd & 3rd degree heart block to lesser extent Overdose management
Repeated calcium may reverse cardiac contractility Repeated epinephrine, glucagon may help with BP/HR

Beta Blockers
Mechanism of Action
Block beta-adrenergic receptors

Rate control, Reduce MI damage/mortality

Class IIa ACLS Recommendation Atenolol: 5 mg/5 min, repeat in 10 min Metoprolol: 5 mg/5 min, up to 15 mg max Propranolol: 1-3 mg (1 mg/min max) repeat in 2 min if needed Esmolol: 0.5 mg/kg over 1 min (loading dose) 0.05 mg/kg/min infusion (0.3 mg/kg/min max)

Beta Blockers
Precautions
Expert consultation needed with Wolff-ParkinsonWhite syndrome Causes hypotension, difficulty breathing, severe bradycardia Contraindicated in patients with asthma or reactive airway disease Overdose management
Fluids are most useful for hypotension Repeated epinephrine, glucagon may help with BP/HR

Milrinone (Primacor)
Mechanism of Action
Phosphodiesterase III inhibitor vasodilator

Indication(s)
Severe CHF or Refractory cardiogenic shock
Ideal because increases cardiac output without increasing myocardial oxygen demand

50 mcg/kg load over 10 min, then 0.375 0.75 mcg/kg/min maintenance infusion Precautions
Increased heart rate, ventricular irritability, sulfa allergy

Digoxin (Lanoxin)
Mechanism of Action
Cardiac Glycoside Slows ventricular response

M.O.N.A. for ACS

Morphine: 2-4 mg
Repeat dose of 2-8 mg every 5-15 min as needed Do not use if patient hypovolemic

Indication(s)
Atrial fibrillation / flutter PSVT

Oxygen: 100%
Assist with myocardial oxygen demands

10 15 mcg/kg load
Negative chronotropic effects
Initially seen at 5-30 min Peak effect at 1.5-3 hr

Nitroglycerin: 0.4 mg tablet SL every 5 min x3

Reduces preload

Aspirin: 325 mg tablet (chewable) Remember: MONA greets all patients

Nitroglycerin
Mechanism of Action
Reduces cardiac oxygen demand by decreasing left ventricular pressure and systemic vascular resistance Dilates coronary arteries and improves collateral flow to ischemic regions

Nitroglycerin
Precautions
Hypotensive patients RV infarction ED treatment Causes hypotension, syncope, headache, nausea, tachycardia & paradoxical bradycardia, hypoxemia

Indication(s)
Stable Angina: 0.4 mg tablet every 5 min x3 Unstable Angina (& other ACS): 12.5 25 mcg IV bolus followed by 10-20 mcg/min continuous infusion (titrate to effect)

Nitroprusside (Nipride)
Mechanism of Action
Potent, rapid-acting vasodilator that reduces both preload and afterload

Nitroprusside (Nipride)
Precautions
Monitor closely in elderly & hypovolemic patients Hypotension, CO2 retention, headache, nausea, abdominal cramping

Indications
Hypertensive Emergencies Acute Pulmonary Edema & Heart Failure

Cyanide & Thiocyanate Toxicity

Metabolized by RBC to hydrocyanic acid & cyanide Liver metabolizes hydrocyanic acid & cyanide to thiocyanate Monitor for tinnitus, visual blurring, mental status changes, confusion, hyperreflexia, convulsions treatment with sodium thiosulphate (consult Rx)

Initiate at 0.1 mcg/kg/min, titrate every 3-5 min to 5 mcg/kg/min (max of 10 mcg/kg/min)
Be sure to protect bag from light!

Fibrinolytics
Absolute Contraindications
Any prior intracranial hemorrhage Known structural cerebral vascular lesion (i.e. AVM) Known malignant intracranial neoplasm Ischemic stroke within 3 months (except acute ischemic stroke within 3 hours) Suspected aortic dissection Active bleeding or bleeding diathesis (except menses) Significant closed head/facial trauma within 3 months

Fibrinolytics
Relative Contraindications
Hx of chronic, severe, poorly controlled HTN Hx prior ischemic stroke >3 months, dementia, or other intracranial pathology Traumatic or prolonged CPR or major surg (<3 wks) Recent internal bleeding (within 2-4 weeks) Noncompressible vascular punctures Pregnancy Active Peptic Ulcer Disease Allergy on prior exposure to fibrinolytic Current use of anticoagulants (higher dose = higher risk)

tPA
Indication(s)
Acute, ischemic stroke
Total Dose: 0.9 mg/kg (max of 90 mg) Give 10% of total dose as initial IV bolus over 1 minute Give remaining 90% as IV infusion over 60 minutes

tPA
Precautions
Do not use if neurological signs are spontaneously clearing and are near baseline Physician should discuss risks/benefits with patient Check against absolute & relative contraindications for fibrinolytic therapy

AMI with ST segment elevation

Accelerated infusion (1.5 hr total therapy) 15 mg IV bolus 0.75 mg/kg (max of 50 mg) over next 30 minutes 0.5 mg/kg (max of 35 mg) over next 60 minutes

Glycoprotein IIb/IIIa Inhibitors

Mechanism
Inhibit platelet glycoprotein receptors, thereby inhibiting platelet aggregation Clot-Busters

Glycoprotein IIb/IIIa Inhibitors

Abciximab (Reopro)
0.25 mg/kg bolus, then 0.125 mcg/kg/min for 12-24 hr (up to 10 mcg/min max) Must use with heparin Platelet function recovers in ~48 hours

Indication
ACS without ST-segment elevation

Precautions
Active/Recent hx of abnormal bleeding, CVA within 30 days, Severe hypertension (SBP >200, DBP >110), Thrombocytopenia, SCr Bleeding, hypotension, GI hemorrhage, pulmonary hemorrhage

Eptifibatide (Integrilin)
180 mcg/kg bolus, then 2 mcg/kg/min Platelet function recovers in 4 to 8 hours

Tirofiban (Aggrastat)
0.4 mcg/kg/min bolus (over 30 min), then 0.1 mcg/kg/min infusion for 48-96 hr Platelet function recovers in 4 to 8 hours

Heparin (unfractionated)
Mechanism
Inactivates thrombin & activated coagulation factors IX, X, XI, XII

Low-Molecular Weight Heparin

Mechanism
Inactivates thrombin & selective inhibition of factors Xa

Indication(s)
Adjuvant therapy in AMI (STEMI & NSTEMI)

Indication(s)
Adjuvant therapy in AMI (STEMI & NSTEMI)

60 unit/kg load (max of 4,000 units) 12 units/kg/hr infusion (max of 1,000 units/hr)
Keep aPTT in target range of 1.5 2x control for 48 hours (or) until after angioplasty Follow institutional protocol Begin with fibrin-specific lytics (alteplase, etc.)

NSTEMI & Unstable angina

Enoxaparin (Lovenox) 1 mg/kg SQ q12h Reduce interval or dose in renal failure (CrCl <30 mL/min)

STEMI
As adjunct with fibrinolytic
In patients, ages <75 yr with SCr <2.5 in males, <2 in females

Clopidogrel (Plavix)
Mechanism of Action
Irreversibly inhibits platelet adenosine diphosphate receptor resulting in reduction of platelet aggregation

Medication Overdose
Naloxone (Narcan)
Reverses opiate activities, including respiratory depression from natural & synthetic opioids 0.4 2 mg every 2-3 min up to 10 mg Duration of 20-60 min, typically shorter than most opioids so will need repeat doses May be given via the ET tube (double the dose)

Indication(s) 300 mg single oral dose, 75 mg daily

STEMI, up to 75 years of age, in E.R. patients who receive aspirin, heparin, and fibrinolytics ACS with elevated cardiac markers (or) ECG changes consistent with ischemia (excluding STEMI) if PCI is planned Suspected ACS & unable to take ASA (allergy, etc)

Flumazenil (Romazicon)
Reverses sedative effects of benzodiazepines Does not reverse respiratory depression with BZD 0.2 mg over 15 sec, repeat in 1 min intervals up to 1 mg Duration of ~60 minutes, repeat as needed

Current Guidelines
Circulation, Volume 112, Issue 24 Supplement; December 13, 2005
Freely available at http://circ.ahajournals.org

Currents in Emergency Cardiovascular Care, Volume 16, Number 4; Winter 2005-2006

Freely available at http://www.americanheart.org

Handbook of Emergency Cardiovascular Care. American Heart Association, Guidelines CPR/ECC 2005.
Available for purchase through AHA

10