BASIC ACLS Pharmacology

Adenosine Amiodarone Atropine Epinephrine Vasopressin

Adenosine

NON-ARREST DOSE 6 mg given rapidly over 1 to 3 seconds followed by 20 mL NS bolus; second dose (12 mg) may be given in 1 to 2 minutes if needed; third dose (12 mg) may be given in 1 to 2 minutes if needed INDICATIONS/PRECAUTIONS ADDITIONAL INFORMATION Indications Injection Technique st drug for most forms of stable 1 Place patient in mild reverse narrow-complex tachycardia (SVT). Trendelenburg position before Effective in terminating those due administration of drug to reentry involving AV or sinus Record rhythm strip during node. administration May consider for unstable narrow Draw up adenosine dose and complex tachy while preparations flush in 2 separate syringes are made for cardioversion. Attach both syringes to the Wide-complex regular tachycardia injection port closest to the thought to be or previously defined patient to be reentry SVT. Clamp IV tubing above injection Undefined, stable narrow-complex port SVT as a diagnostic maneuver. Push adenosine as quickly as possible (over 1-3 seconds) Precautions/Contraindications While maintaining pressure on Contraindication: poison/drugadenosine syringe plunger, push induced tachy or second- or thirdNS flush as quickly as possible degree AV block. after adenosine administration Does NOT convert atrial Unclamp IV tubing fibrillation, atrial flutter or ventricular tachycardia (VT). Transient side effects include flushing, chest pain or tightness, brief periods of aystole or bradycardia, ventricular ectopy. Less effective (larger doses may be required) in patients taking theophylline or caffeine Reduce dose to 3 mg in patients receiving dipyridamole or carbamazepine Consider using 3 mg dose in patients with central IV access If administered for wide-complex tachy/VT, may cause deterioration including hypotension. Safe and effective in pregnancy.

ARREST DOSE n/a

Amiodarone

ARREST DOSE NON-ARREST DOSE 300 mg IV/IO push (recommended 150 mg IV rapidly infused over 10 mins dilution in 20-30 mL D5W); may re- (15mg/min); may repeat rapid infusion every 10 dose ONCE with 150 mg (also mins as needed; do not exceed 2.2 grams/24 diluted) after 3 to 5 mins hours INDICATIONS/PRECAUTIONS ADDITIONAL INFORMATION Indications Patients must be hospitalized Cardiac arrest unresponsive to while the loading doses of CPR, shock and vasopressors amiodarone are administered. Because of its potentially lifeAmiodarone should be threatening side effects and the prescribed only by physicians difficulties associated with experienced in the tx of lifemanaging its use, amiodarone threatening dysrhythmias, should be prescribed for the tx of thoroughly familiar with only recurrent VF or recurrent amiodarones benefits and risks, hemodynamically unstable VT and have access to labs capable of when they have not responded to monitoring the effectiveness and other antiarrhythmic agents or side effects of amiodarone tx. when alternative agents have not been tolerated. Precautions/Contraindications With multiple dosings, cumulative doses >2.2 grams in 24 hours were associated with significant hypotension in clinical trials. Do not administer with other drugs that prolong QT interval. Terminal elimination is EXTREMELY long (half-life of up to 40 days).

Atropine Sulfate

ARREST DOSE No longer recommended

NON-ARREST DOSE 0.5 mg IV every 3 to 5 minus as needed, not to exceed total dose of 0.04 mg/kg (total 3 mg) ADDITIONAL INFORMATION May be given via endotracheal tube; dose is 2 to 3 mg diluted in 10 mL sterile water or NS Use shorter dosing interval (3 mins) and higher doses in severe clinical conditions Administration should not delay pacing for severely symptomatic patients

INDICATIONS/PRECAUTIONS Indications 1st drug for symptomatic sinus bradycardia May be beneficial for nodal block or ventricular asystole. Will not be effective for type II blocks. Organophosphate (eg, nerve agent) poisoning: extremely large doses (2 to 4 mg or higher) may be needed Precautions/Contraindications Increases myocardial oxygen demand---use with caution in presence of myocardial ischemia and hypoxia Avoid in hypothermic bradycardia Will not be effective for type II blocks and new 3rd degree blocks with wide QRS complexes: may cause paradoxical slowing in these pts---be prepared to pace or give catecholamines Doses <0.5 mg may result in paradoxical slowing of HR

Epinephrine

ARREST DOSE 1 mg IV/IO push; may repeat every 3 to 5 mins

NON-ARREST DOSE Profound bradycardia or hypotension: 2-10 g/min infusion; titrate to patient response

INDICATIONS/PRECAUTIONS Indications 1st drug for cardiac arrest Infusion can be used in bradycardia when pacing and atropine fail, when hypotension accompanies bradycardia, as an alternative infusion to dopamine, or with phosphodiesterase enzyme inhibitor-induced hypotension Precautions/Contraindications Raising BP and increasing HR may cause myocardial ischemia, angina and increased myocardial oxygen demand High doses do not improve survival or neurological outcome and may contribute to postresuscitation myocardial dysfunction Higher doses may be required to treat poison/drug-induced shock

ADDITIONAL INFORMATION May also be administered via endotracheal tube; dose is 2 to 2.5 mg diluted in 10 mL NS Available in 1:10,000 and 1:1000 concentrations Cardiac arrest = 1 mg (10 mL of 1:10,000) Infusion = 1 mg (1 mL of 1:1000) to 500 mL NS or D5W

Vasopressin

ARREST DOSE 40 units IV/IO push

NON-ARREST DOSE n/a ADDITIONAL INFORMATION Delivered as a single, one-time dose that may replace either 1st or 2nd dose of epinephrine; epinephrine may be administered every 3 to 5 mins during cardiac arrest May be administered via endotracheal tube, but insufficient evidence currently exists to recommend specific dose

INDICATIONS/PRECAUTIONS Indications May be used as an alternative pressor to epinephrine in adult cardiac arrest May be useful for hemodynamic support in vasodilatory shock (eg, septic shock) Precautions/Contraindications Potent peripheral vasoconstrictor; increased PVR may provoke cardiac ischemia and angina Not recommended for responsive patients with CAD