Acls Drug Study

7/29/2019 Acls Drug Study

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Analgesics

Opiod analgesics alone or in combination with adjuvant agents such as non

steroidal anti inflammatory drugs have been conventionally used in pain

reliefAnti inflammatory drugs

Antibiotics

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


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


Class III: Not recommended

Not acceptable or useful and may be harmful

Evidence is absent or unsatisfactory, or based on poor studies


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Indeterminate

Continuing area of research; no recommendation until further data is

available

Oxygen

Indications

Any suspected cardiopulmonary emergency

Saturate hemoglobin with oxygen

Reduce anxiety & further damage

Note: Pulse oximetry should be monitoredOxygen

Dosing (How?)

Oxygen

Precautions (Watch Out!)

Pulse oximetry inaccurate in:

Low cardiac output

Vasoconstriction

Hypothermia

NEVER rely on pulse oximetry!

VF / Pulseless VT

Case 3

VF / Pulseless VT

Epinephrine

Indications (When & Why?)

Increases:

Heart rate

Force of contraction

Conduction velocity

Peripheral vasoconstriction


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Bronchial dilation

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 in10 mL normal saline

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

EpinephrinePrecautions (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

Vasopressin


Used to clampdown on vessels

Improves perfusion of heart, lungs, and brain

No direct effects on heart

Vasopressin

Dosing (How?)

One time dose of 40 units only


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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

Vasopressin


May result in an initial increase in blood pressure immediately following

return of pulseMay provoke cardiac ischemia

Amiodarone


Powerful antiarrhythmic with substantial toxicity, especially in the long term

Intravenous and oral behavior are quite different

Has effects on sodium & potassium

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

Amiodarone


May produce vasodilation & shock

May have negative inotropic effects

Terminal elimination

Half-life lasts up to 40 days

Lidocaine



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Depresses automaticity

Depresses excitability

Raises ventricular fibrillation threshold

Decreases ventricular irritability

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/kgA 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

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

Lidocaine


Reduce maintenance dose (not loading dose) in presence of impaired liver

function or left ventricular dysfunction

Discontinue infusion immediately if signs of toxicity develop

Magnesium Sulfate


Cardiac arrest associated with torsades de pointes or suspected

hypomagnesemic state


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Refractory VF

VF with history of ETOH abuse

Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic

overdose

Magnesium Sulfate

Dosing (How?)

1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push

Magnesium Sulfate

Precautions (Watch Out!)Occasional fall in blood pressure with rapid administration

Use with caution if renal failure is present

Procainamide


Recurrent VF





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

Procainamide

Dosing (How?)



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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

Procainamide


If cardiac or renal dysfunctionis present, reduce maximum total dose to 12 mg/kg and maintenance

infusion to 1 to 2 mg/min

Remember Endpoints of Administration

PEA

Case 4

PEA

Epinephrine


Increases:

Heart rate


Conduction velocity


Bronchial dilation

Epinephrine

Dosing (How?)



Endotracheal Route


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Epinephrine






dysfunction

Atropine Sulfate


Should only be used for bradycardia

Relative or Absolute

Used to increase heart rate

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: 0.04 mg/kg

Atropine Sulfate


Increases myocardial oxygen demand

May result in unwanted tachycardia or dysrhythmia

Asystole

Case 5

Asystole

Epinephrine



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Increases:

Heart rate


Conduction velocity


Bronchial dilation

Epinephrine

Dosing (How?)



Endotracheal Route


Epinephrine

Precautions (Watch Out!)Raising blood pressure and increasing heart rate may cause myocardial




dysfunction

Atropine Sulfate

Indications

Used to increase heart rate

Questionable absolute bradycardia

Atropine Sulfate

Dosing (How?)

1 mg IV push

Repeat every 3 to 5 minutes



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Atropine Sulfate

Precautions


Other Cardiac Arrest Drugs

Calcium Chloride

Indications

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

Calcium Chloride

Dosing

IV Slow Push8 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

Calcium Chloride

Precautions

Do not use routinely in cardiac arrest

Do not mix with sodium bicarbonate

Sodium Bicarbonate

Indications

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


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Class III (not useful or effective) in hypoxic lactic acidosis or hypercarbic

acidosis (eg, cardiac arrest and CPR without intubation)

Sodium Bicarbonate

Dosing

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)

Sodium Bicarbonate


Adequate ventilation and CPR, not bicarbonate, are the major "buffer

agents" in cardiac arrest

Not recommended for routine use in cardiac arrest patients

Acute Coronary Syndromes

Case 6


Aspirin

Indications

Administer to all patients with ACS, particularly reperfusion candidates

Give as soon as possible

Blocks formation of thromboxane A2, which causes platelets to aggregate

Aspirin

Dosing (How?)

160 to 325 mg tablets

Preferably chewed

May use suppository

Higher doses may be harmful

Aspirin

Precautions


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Relatively contraindicated in patients with active ulcer disease or asthma

Nitroglycerine

Indications

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

NitroglycerinIndications

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

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 g/min

Route of choice for emergencies

Titrate to effect

Nitroglycerine


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Use extreme caution if systolic BP


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ST Elevation

Recognition

of AMI

Know what to look for

ST elevation >1 mm

3 contiguous leads

Know where to look

Refer to 2000 ECCHandbook

ST ElevationBeta Blockers


To reduce myocardial ischemia and damage in AMI patients with elevated

heart rates, blood pressure, or both

Blocks catecholamines from binding to

-adrenergic receptors

Reduces HR, BP, myocardial contractility

Decreases AV nodal conduction

Decreases incidence of primary VF

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 (


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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

Beta Blockers


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

Heparin


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

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), roundto the nearest 50 IU

Heparin

Dosing (How?)


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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

Heparin


Same contraindications as for fibrinolytic therapy: active bleeding; recent

intracranial, intraspinal or eye surgery; severe hypertension; bleedingdisorders; gastroinintestinal bleeding

DO NOT use if platelet count is below 100 000

Glycoprotein IIb/IIIa Inhibitors


Inhibit the integrin glycoprotein IIb/IIIa receptor in the membrane of

platelets, inhibiting platelet aggregation

Indicated for Acute Coronary Syndromes without ST segment elevation



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


Indications

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


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Indications

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


Dosing

Abciximab (ReoPro)ACS with planned PCI within 24 hours

0.25 mg/kg bolus (10 to 60 minutes before procedure), then 0.125

mcg/kg/min infusion

PCI only

0.25 mg/kg bolus

Then 10 mcg/min infusion


Dosing

NOTE: Check package insert for current indications, doses, and

duration of therapy.

Optimal duration of therapy has NOT been established.


Dosing

Eptifibitide (Integrilin)


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



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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



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 > 150 000/mm3

PTCA

Fibrinolytics

IndicationsFor AMI in adults

ST elevation or new or presumably new LBBB; strongly suspicious for

injury

Time of onset of symptoms < 12 hours

Fibrinolytics

Indications

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

Fibrinolytics

Dosing

For fibrinolytic use, all patients should have 2 peripheral IV lines

1 line exclusively for fibrinolytic administration


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Fibrinolytics

Dosing for AMI Patients

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

Fibrinolytics

Dosing for AMI PatientsAnistreplase (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

Fibrinolytics

Adjunctive Therapy for AMI Patients (How?)

160 to 325 mg aspirin chewed as soon as possible


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Begin heparin immediately and continue for 48 hours if alteplase or

Retavase is used

Fibrinolytics

Dosing for Acute Ischemic Stroke

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 patientsFibrinolytics

Precautions

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

Fibrinolytics

Precautions

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

ACE Inhibitors



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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

ACE Inhibitors


Suspected MI & ST elevation in 2 or more anterior leads

Hypertension

Clinical signs of AMI with LV dysfunction

LV ejection fraction


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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

ACE InhibitorsPrecautions (Watch Out!)

Contraindicated in pregnancy

Contraindicated in angioedema

Reduce dose in renal failure

Avoid hypotension, especially following initial dose & in relative volume

depletion

Bradycardias

Case 7

Bradycardia

Bradycardia

Atropine Sulfate


First drug for symptomatic bradycardia

Increases heart rate by blocking the parasympathetic nervous system

Atropine Sulfate

Dosing (How?)

0.5 to 1.0 mg IV every 3 to 5 minutes as needed




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Atropine Sulfate


Use with caution in presence of myocardial ischemia and hypoxia


Seldom effective for:

Infranodal (type II) AV block

Third-degree block (Class IIb)

Dopamine


Second drug for symptomatic bradycardia (after atropine)

Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock

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

Dopamine

Dosing (How?)

IV Infusions (Titrate to Effect)

Low Dose RenalDose"

1 to 5 g/kg per minute

Moderate Dose Cardiac Dose"


High Dose Vasopressor Dose"


Dopamine


May use in patients with hypovolemia but only after volume replacement


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May cause tachyarrhythmias, excessive vasoconstriction

DO NOT mix with sodium bicarbonate

Epinephrine


Symptomatic bradycardia: After atropine, dopamine, and transcutaneous

pacing (Class IIb)

Epinephrine

Dosing (How?)

Profound Bradycardia2 to 10 g/min infusion (add 1 mg of 1:1000 to 500 mL normal saline;

infuse at 1 to 5 mL/min)

Epinephrine





Isoproterenol


Temporary control of bradycardia in heart transplant patients

Class IIb at low doses for symptomatic bradycardia

Heart Transplant Patients!

Isoproterenol

Dosing (How?)

Infuse at 2 to 10 g/min

Titrate to adequate heart rate

Isoproterenol


Increases myocardial oxygen requirements, which may increase

myocardial ischemia


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DO NOT administer with poison/drug-induced shock

Exception: Beta Blocker Poisoning

Stable Tachycardias

Case 9

Diltiazem


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 pressureAs an alternative, use verapamil

Diltiazem

Dosing (How?)

Acute Rate Control

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


5 to 15 mg/hour, titrated to heart rate

Diltiazem


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 -blockers can cause severe

hypotension

Verapamil



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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 pressureVerapamil

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

Verapamil


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

Verapamil


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 -blockers may produce severe

hypotension

Adenosine


First drug for narrow-complex PSVT

May be used diagnostically (after lidocaine) in wide-complex tachycardias

of uncertain type

Adenosine

Dose (How?)


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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

Adenosine


Transient side effects include:

Facial FlushingChest pain

Brief periods of asystole or bradycardia

Less effective in patients taking theophyllines

Beta Blockers


To convert to normal sinus rhythm or to slow ventricular response (or both)

in supraventricular tachyarrhythmias (PSVT, atrial fibrillation, or atrial

flutter)

-Blockers are second-line agents after adenosine, diltiazem, or digoxin

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 (


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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

Beta Blockers


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

Digoxin


To slow ventricular response in atrial fibrillation or atrial flutter

Third-line choice for PSVT

Digoxin

Dosing (How?)

IV Infusion

Loading doses of 10 to 15 g/kg provide therapeutic effect with minimum

risk of toxic effects

Maintenance dose is affected by body size and renal function

Digoxin



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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)

Amiodarone


Powerful antiarrhythmic with substantial toxicity, especially in the long term

Intravenous and oral behavior are quite different

AmiodaroneDosing (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)

Amiodarone

Dosing (How?)


540 mg IV over 18 hours (0.5 mg/min)

Amiodarone


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


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Half-life lasts up to 40 days

Amiodarone


Contraindicated in:

Second or third degree A-V block

Severe bradycardia

Pregnancy

CHF

Hypokalaemia

Liver dysfunction

Lidocaine

Indications


Depresses excitabilityRaises ventricular fibrillation threshold


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

Lidocaine

Dosing (How?)


2 to 4 mg/min

Lidocaine


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Reduce maintenance dose (not loading dose) in presence of impaired liver

function or left ventricular dysfunction

Discontinue infusion immediately if signs of toxicity develop

Magnesium Sulfate


Torsades de pointes with a pulse

Wide-complex tachycardia with history of ETOH abuse

Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclicoverdose

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

Magnesium Sulfate

Dosing (How?)


1 to 4 g/hour IV (titrate dose to control the torsades)

Magnesium Sulfate


Occasional fall in blood pressure with rapid administration

Use with caution if renal failure is present

Procainamide






Atrial fibrillation with rapid rate in Wolff-Parkinson-White syndrome


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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 areacceptable

Procainamide

Dosing (How?)


1 to 4 mg/min

Procainamide


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

Acute

Ischemic Stroke

Case 10

Acute

Ischemic Stroke

Nitroprusside


Hypertensive crisis

Nitroprusside


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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

Nitroprusside

Dosing Precautions (How?)

Use with an infusion pump; use hemodynamic monitoring for optimal safety

Cover drug reservoir with opaque materialNitroprusside


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

Drugs used in Overdoses

Calcium Chloride


As an antidote for toxic effects of calcium channel blocker overdose

Calcium Chloride

Dosing (How?)

8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel

blocker overdose

Calcium Chloride


Do not use routinely in cardiac arrest

Do not mix with sodium bicarbonate

Flumazenil


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Reduce respiratory depression and sedative effects from pure

benzodiazepine overdose

Flumazenil

Dosing (How?)

First Dose

0.2 mg IV over 15 seconds

Second Dose

0.3 mg IV over 30 secondsThird Dose

0.4 mg IV over 30 seconds

Maximum Dose

3 mg

Flumazenil


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 drugsknown to cause seizures

Naloxone Hydrochloride


Respiratory and neurologic depression due to opiate intoxication

unresponsive to oxygen and hyperventilation


Dosing (How?)

0.4 to 2 mg IVP every 2 minutes

Use higher doses for complete narcotic reversal


35/38

Can administer up to 10 mg in a short time (10 minutes)



May cause opiate withdrawal

Effects may not outlast effects of narcotics

Monitor for recurrent respiratory depression

Review of Infusions

Dobutamine

Indications

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

Dobutamine

Dosing (How?)

Usual infusion rate is 2 to 20 g/kg per minute

Titrate so heart rate does not increase by more than 10% of baseline

Hemodynamic monitoring is recommended for optimal use

Dobutamine


Avoid when systolic blood pressure


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Dosing

IV Infusions (Titrate to Effect)

Low Dose RenalDose"


Moderate Dose Cardiac Dose"


High Dose Vasopressor Dose"


Dopamine


May use in patients with hypovolemia but only after volume replacement

May cause tachyarrhythmias, excessive vasoconstriction

DO NOT mix with sodium bicarbonate

EpinephrineIndications

Symptomatic bradycardia: After atropine, dopamine, and transcutaneous

pacing (Class IIb)

Epinephrine

Dosing

Profound Bradycardia

2 to 10 g/min infusion (add 1 mg of 1:1000 to 500 mL normal saline;

infuse at 1 to 5 mL/min)

Epinephrine






dysfunction


37/38

Norepinephrine

Indications

For severe cardiogenic shock and hemodynamic significant hypotension

(systolic blood pressure < 70 mm/Hg) with low total peripheral resistance

This is an agent oflast resort for management of ischemic heart disease

and shock

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

Norepinephrine

Precautions

Increases myocardial oxygen requirements

May induce arrhythmias

Extravasation causes tissue necrosis

Calculating mg/min

dose X gtt factor

Solution Concentration

2 mg X 60 gtt/mL

4 mg

Using a 60 gtt set:

30 gtt/min = 30 cc/hr

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


38/38

Using a 60 gtt set:

18.75 cc/hr= 18.75 gtts/min

Furosemide

Indications

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

FurosemideDosing (How?)

20 to 40 mg slow IVP

If patient is taking at home, double their daily dose

Furosemide


Dehydration, hypovolemia, hypotension, hypokalemia, or other electrolyte

imbalance may occur

Questions?

Summary

To obtain a full understanding of ACLS pharmacology requires constant

review of:

Indications & Actions (When & Why?)

Dosing (How?)

Contraindications & Precautions (Watch Out!)

Acls Drug Study

Documents

Transcript of Acls Drug Study