ACLS Pocket guide

ACLS Pocket Guide

Previous guidelines
VF/pulseless VT

Defibrillation x 3 (200J,200J-300J,360J) , then Secondary ABCD (Airway,

IV access)
Vasopressin 40 U iv x 1 only (preferred first agent, Class 2b) or
epinephrine1mg q3-5min (Class Indeterminant)
Defibrillate at 360J or biphasic shock
Amiodarone 300 mg iv push (diluted in 20 cc D5W). May rpt
150mg x 1 (Class 2b) May repeat 150 mg x 1 in 3-5
minutes
Lidocaine 1.0-1.5mg/kg ivp q3-5 min up to 3 mg/kg (Class
Inderterminate) Continuous infusion: 1 to 4 mg/min.
Add 1 gram/250 ml. Rate (ml/hr)= mg/min x 15.
Endotracheal tube: Give 2 to 2.5 x IV dose. Dilute up
to 10ml with normal saline.
Magnesium 1-2 g iv if polymorphic VT or hypomagnesiumic (Class
2b)
Procainamide 30 mg/min up to 17mg/kg "acceptable but not
recommended" in refractory VF (class 2b) Loading
regimen: 20-30 mg/min. Add 1 gram/250 ml D5W.
Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/
hr. or Add 1 gram/50ml: 20mg/min: 60 ml/hr. 30mg/
min: 90 ml/hr. Continuous infusion: 2 to 6 mg/min.
Add 1 gram/250 ml D5W. Rate (ml/hr)= mg/min x 15
bicarbonate prolonged arrest (Class 2b), high K
Defibrillate 360J or biphasic shock, repeat drug from above

Pulseless Electrical Activity/EMT

Basic CPR/ABCD // Secondary ABCD
Rule out most common etiology: Hypovolemia, Hypoxia, Hyper/
hypokalemia, Hypothermia …..
Consider bicarbonate
Epinephrine 1 mg q3-5 min iv . Epinephrine strengthens
myocardial contraction and increases cardiac output,
which will help improve myocardial and cerebral blood
flow. Continuous infusion: 1 to 4 mcg/min (range:
1-10 mcg/min). Add 1 mg/250 ml D5W or NS. Drip
rate (ml/hr)= mcg/min x 15. Endotracheal tube:
Give 2 to 2.5 x IV dose. (Dilute up to 10 ml with
normal saline)
Atropine If HR slow, 1 mg iv q3-5 min up to 0.04mg/kg

Asystole
BAsic CPR/ABCD // confirm asystole: check monitor,lead,power and
change leads

http://www.globalrph.com/acls_guide.htm (1 de 7)04/02/2009 14:28:57

ACLS Pocket guide

Consider bicarbonate: prolonged arrest (Class 2b), high K

Transcutaneous pacing, if used must be considered early, routine use not
necessary
Epinephrine 1mg iv q3-5min
Atropine 1 mg iv q3-5 min up to 0.04mg/kg. Endotracheal
tube: Give 2 to 2.5 x IV dose. (Dilute up to 10ml with
normal saline). Adverse reactions: CNS toxicity:
tremor, delirium. Hypo/hypertension.

Bradycardia
BAsic CPR/ABCD // Secondary ABCD: assess need for airway etc.
Serious signs or symptoms of bradycardia? if yes, then do the sequence:
Atropine 1 mg iv q3-5 min up to 0.04mg/kg. // Then
transcutaneous pacing, then Dopamine
Dopamine 5-20 mcg/kg/min
Epinephrine 2-10 mcg/min (Add 1 mg/250 ml )
Is Type 2 second degree AV block or third degree AV block present? If
yes: standby transcutaneous pacemaker, prepare for transvenous
pacemaker.

PSVT
EF normal: Priority: Ca-blocker> beta-blocker> digoxin> DC
Cardioversion. Consider procainamide, sotalol, amiodarone. If unstable
proceed to cardioversion
EF<40%, CHF: Priority: No Cardioversion. Digoxin or amiodarone or
diltiazem. If unstable proceed to cardioversion.

Atrial fibrillation/flutter:
Category 1. Normal EF
Rate control: Verapamil: 2.5 to 5 mg IV over 2 minutes. May repeat
dose of 5-10mg 15-30 minutes after 1st dose. Diltiazem: 0.25 mg/kg
over 2 minutes. If no response within 15 minutes, give second bolus of
0.35 mg/kg over 2 minutes. Subsequent doses should be individualized. If
effective start continuous infusion: 5-15 mg/hr. Esmolol: 500 mcg/kg IV
over 1 minute, followed by 50 mcg/kg/minute over 4 minutes. If
ineffective, repeat load of 500 mcg/kg, followed by 100 mcg/kg/min.

Cardiovert: If onset < 48 hours, consider DC cardioversion OR with one

of the following agents: Amiodarone, ibutilide, procainamide, (flecainide,
propafenone),sotalol.
If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone).
Either:
Delayed cardioversion: anticoagulate adequately x 3weeks then
Cardiovert then anticoagulate x 4 weeks .

Ibutilide: 1mg IV over 10min. May repeat x 1 in 10 minutes if needed.

Approved for acute termination. 1 mg/50 ml D5W or NS over 10 minutes.
If patient is < 60kg give 0.01 mg/kg over 10 minutes. Amiodarone:
(non-cardiac arrest) load 15 mg/min over 10 min (150 mg) (mix 150 mg
in 100cc D5W in PVC or Glass, infuse over 10 min) then 1 mg/min x 6
hrs (mix 900 mg in 500 cc D5W) then 0.5 mg/min x 18 hrs and beyond.

Anticoagulate if not contraindicated, if A fib > 48 hrs

Category 2. EF<40% or CHF (Avoid verapamil, beta-blockers, ibutilide,
procainamide (and propafenone/flecainide).
A. Rate control: digoxin, diltiazem, amiodarone (avoid if onset of AF > 48
hours)
B. Cardiovert: same as Category 1, except the only conversion agent
allowed is amiodarone.
C. Anticoagulate, if A fib > 49 hr.

http://www.globalrph.com/acls_guide.htm (2 de 7)04/02/2009 14:28:57

ACLS Pocket guide

Catepory 3. WPW A fib

Must not use adenosine, beta-blocker, Ca-blocker, Digoxin . If < 48 hour:
If EF normal: one of the following for both rate control and
cardioversion: amiodarone, procainamide, propafenone, sotalol,
flecainide If EF abnormal or CHF: amiodarone or cardioversion
If > 48 hour . Medication listed above may be associated with risk of
emboli. Anticoagulate and DC cardioversion as in Category 1.

Wide complex tachycardia, STABLE

If unable to make Dx: Note: no lidocaine and bretylium in protocol.
EF normal: DC cardioversion or procainamide or amiodarone
EF<40%,CHF: DC Cardioversion or amiodarone .

Procainamide dosing: Loading regimen: 20-30 mg/min. Add 1 gram/250

ml D5W. Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/hr.
Continuous infusion: 2 to 6 mg/min. Add 1 gram/250 ml D5W. Rate (ml/
hr)= mg/min x 15
Monomorphic VT (May proceed directly to cardioversion)
EF normal: one of the following procainamide (2a), sotalol (2a) OR
amiodarone (2b), lidocaine (2b)
EF poor: Step 1. Amiodarone 150 mg iv or 10 min OR lidocaine 0.5-0.75
mg/kg iv push . Step 2. Synchromized cardioversion

Intravenous Medications

Amiodarone:
I.V. DOSE RECOMMENDATIONS -- FIRST 24 HOURS -- Loading
infusions. The recommended starting dose of Cordarone I.V. is about
1000 mg over the first 24 hours of therapy, delivered by the following
infusion regimen.
First Rapid: 150 mg over the FIRST - 10 minutes (15 mg/min).
Add 3 mL of Cordarone I.V. (150 mg) to 100 mL D 5 W. Infuse 100 mL
over 10 minutes.
Followed by Slow: 360 mg over the NEXT 6 hours (1 mg/min).
Add 18 mL of Cordarone I.V. (900 mg) to 500 mL D 5 W (conc = 1.8
mg/mL).
Maint infusion: 540 mg over the REMAINING 18 hours (0.5
mg/min).

After first 24 hours, the maint infusion rate of 0.5 mg/min (720 mg/24
hours) should be continued utilizing a concentration of 1 to 6 mg/mL
(Cordarone I.V. concentrations greater than 2 mg/mL should be
administered via a central venous catheter). In the event of breakthrough
episodes of VF or hemodynamically unstable VT, Give 150-mg/100 ml
D5W over 10min to minimize potential for hypotension. The rate of the
maint inf may be inc to achieve effective arrhythmia suppression. // The
initial infusion rate should not exceed 30 mg/min. The maintenance
infusion of up to 0.5 mg/min can be cautiously continued for 2 to 3 weeks
regardless of the patient's age, renal function, or LV fcn. limited
experience in pts receiving Cordarone I.V. > 3 weeks.

Amrinone (Inocor): 0.75 mg/kg bolus IV over 2-3min, f/b infusion IV at

5-10 mcg/kg/min.

Cisatracium: Intermittent IV dosing: initial dose 0.15 - 0.2 mg/kg IV

bolus, followed by 0.03 mg/kg IV q40-60 minutes. Continuous infusion:
0.15-0.2 mg/kg bolus, followed by 1 to 3 mcg/kg/min. (range: 0.5 to 10
mcg/kg/min). Based on a standard dilution of 1 mg/ml (eg 100mg/100ml
or 200mg/200ml) and a weight of 70kg:

1 mcg/kg/min =4.2 ml/hr

3 mcg/kg/min =12.6 ml/hr
0.15 mg/kg =10.5 mg
0.2 mg/kg=14 mg

Digoxin: Loading dose: CHF: 8-12 mcg/kg in divided doses (q4-8h) over
12 to 24 hours. [Normally, give 50% of the total digitalizing dose in the

http://www.globalrph.com/acls_guide.htm (3 de 7)04/02/2009 14:28:57

ACLS Pocket guide

initial dose, then give 25% of the total dose in each of the two subsequent
doses at 8 to 12 hr intervals-Obtain EKG 6 hours after each dose to
assess potential toxicity (AV block, sinus bradycardia, atrial or nodal
ectopic beats, ventricular arrhythmias); Other: vision changes,
confusion.] If pt has renal insufficiency give 6 to 10 mcg/kg IBW. A-fib:
10 to 15 mcg/kg IBW given as above. (If given IVPush-admin over at
least 5 min)

Diltiazem 0.25 mg/kg over 2min. If no response c/in 15min, give 2nd
bolus of 0.35 mg/kg over 2min. Subsequent doses should be
individualized. If effective start continuous infusion: 5-15 mg/hr

Diprivan: ICU sedation: Usual initial dose 0.3 to 0.6 mg/kg/hr

(equivalent to 5-10 mcg/kg/min) over 5-10 minutes. Infusion rate can
then be increased by 0.3 to 0.6 mg/kg/hr at 3 to 5 minute intervals until
the desired level of sedation is achieved. Give by slow infusion only -
never bolus. Monitor for early signs of significant hypotension and/or
cardiac depression, which may be profound. Usual dose required for
maintenance: 1.5 to 4.5 mg/kg/hr. Based on the reported weight of 70kg,
here are the recommended pump settings:

Initial infusion rate: 0.3 mg/kg/hr (2.1 ml/hr) or 0.6 mg/kg/hr (4.2 ml/hr)
x 5-10 minutes, then increase by 2.1 to 4.2 ml/hr q3-5 minutes until
desired level of sedation. Usual maintenance rate: 1.5 mg/kg/hr (10.5 ml/
hr) to 4.5 mg/kg/hr (31.5 ml/hr).

Dobutamine: Drip rate (500mg/250 ml) ml /hr= wt(kg) x (mcg/min) x

0.03. Direct beta agonist that inc cardiac output with little direct effect on
BP. Uses: refractory CHF or hypotensive pts in whom vasodilators cannot
be used b/c of eff on BP. Usual range: 2-15 mcg/kg/min (up to 40). Little
effect on heart rate.

Dopamine: Calculation of drip rate (ml/hr) 400mg/250 ml: wt(kg) x mcg/

min x 0.0375. Refractory CHF: ini 0.5 to 2 mcg/kg/min Renal: 1 to 5 mcg/
kg/min. Severely ill pt: ini 5 mcg/kg/min, inc by 5 to 10 mcg/kg/min (q10
to 30 min) up to max of 50 mcg/kg/min. [0.5 to 2 mcg/kg/min-dopa; 2-
10-dopa/beta; >10-primarily alpha. Used to support BP, CO and renal
perfusion in shock.

Epinephrine: 1 to 4 mcg/min or 0.05 to 2 mcg/kg/min. Anaphylaxis

(adult): 0.1 to 0.5 SC / IM (1:1000) rpt q10 to 15 min prn or give 0.1 to
0.25 mg IV (1:10,000) over 5-10min rpt q5 to 15min prn or start cont
inf: 1 to 4 mcg/min

Eptifibatide (Integrilin): ACS: Bolus of 180 mcg/kg (maximum: 22.6

mg) over 1-2 minutes, begun ASAP following diagnosis, f/b a continuous
inf of 2 mcg/kg/min (maximum: 15 mg/hour) until hospital discharge or
initiation of CABG surgery, up to 72 hours. Concurrent aspirin (160-325
mg initially and daily thereafter) and heparin therapy (target aPTT 50-70
seconds) are recommended. Percutaneous coronary intervention
(PCI) with or without stenting: Bolus of 180 mcg/kg (maximum: 22.6
mg) administered immediately before the initiation of PCI, f/b a
continuous inf of 2 mcg/kg/min (maximum: 15 mg/hour). A second 180
mcg/kg bolus (maximum: 22.6 mg) should be administered 10 min after
the 1st bolus. Infusion should be continued until hospital discharge or for
up to 18-24 hours, whichever comes first; minimum of 12 hours of
infusion is recom. Concurrent aspirin (160-325 mg 1-24 hours before PCI
and daily thereafter) and heparin therapy (ACT 200-300 seconds during
PCI) are recommended. Heparin infusion after PCI is discouraged. In
patients who undergo coronary artery bypass graft surgery, discontinue
infusion prior to surgery. Dosing adjustment in renal impairment:
ACS: Scr >2 mg/dL and <4 mg/dL: Use 180 mcg/kg bolus (maximum:
22.6 mg) and 1 mcg/kg/mininfusion (maximum: 7.5 mg/hour) .
Percutaneous coronary intervention (PCI) with or without stenting:
Adults: Scr >2 mg/dL and <4 mg/dL: Use 180 mcg/kg bolus (maximum:
22.6 mg) administered immediately before the initiation of PCI and
followed by a cont inf of 1 mcg/kg/min (maximum: 7.5 mg/hour). A
second 180 mcg/kg (maximum: 22.6 mg) bolus should be admin 10 min
after the first bolus.

Esmolol: Dosing: PSVT: 500 mcg/kg over 1 min, then 50 mcg/kg/min x 4

to 5min. If heart rate not controlled, rpt load of 500 mcg/kg and increase

http://www.globalrph.com/acls_guide.htm (4 de 7)04/02/2009 14:28:57

ACLS Pocket guide

inf to 100 mcg/kg/min. Rpt load and increase infusion q5 to 10min as

needed to max of 200 (up to 300?) mcg/kg/min. Watch BP. Calculation of
drip rate (ml/hr): 2.5 grams/250 ml: wt (kg) x mcg/min x 0.006

Fenoldopam (Corlopam): severe HTN: Dosing: Usu initial rate: 0.1 mcg/
kg/min, increased by increments of 0.05 to 0.1 mcg/kg/min at 15-20min
intervals until target BP reached. Usual effective doses: 0.1 to 1.6 mcg/kg/
min. Generally, lower initial doses (0.03 to 0.1 mcg/kg/min) titrated
slowly, have been assoc c less reflex tachycardia. Never given by IV
bolus. 10mg/250 ml NS/D5W

Hydralazine: Parenteral (IV/IM) (Inject over 1 minute) Hypertension:

Initial: 10-20 mg/dose every 4-6h prn, may increase to 40 mg/dose;
change to oral therapy as soon as possible. Route is indicated only when
oral therapy is not feasible. HTN emergency: 10 to 40 milligrams,
repeated prn (q20-60 minutes), with frequent blood pressure monitoring.

Ibutalide: 1 mg over 10 min. May rpt x 1 after 10 min. Class III agent—
prolongs action potential (inc atrial and ventricular refractoriness.).

Isoproterenol: (B1/B2) agonist. IV infusion: 2 to 20 mcg/ min. Usual

initial rate: 5 mcg/min. Titrate to HR/BP. May give IVPush (must use
1:50,000 dilution). Calculation of drip rate 1 mg/250 ml (ml/hr) = 15 x
mcg/min. eg: 5 mcg/min = 75 ml/hr. Used to tx hemodynamically
significant bradycardia. Also indicated for tx of asthma

Labetalol: Dosing: ini 20 mg IVP over 2 min. May rpt 20 to 80 mg

q10min (up to 300 mg total dose) until desired BP is reached or start
continuous infusion: 2 mg/min (range: 1 to 3 mg/min)-titrate to BP.

Milrinone (Primacor): Load 50 mcg/kg IV over 10 min, then begin IV

infusion of 0.375 to 0.75 mcg/kg/min.

Natrecor: IV bolus of 2 mcg/kg (over 1 minute) followed by a continuous

infusion of 0.01 mcg/kg/min. Withdraw bolus dose from the infusion bag.
Higher initial dosages are not recommended. At intervals of 3 hours, the
dosage may be increased by 0.005 mcg/kg/minute (preceded by a bolus
of 1 mcg/kg), up to a maximum of 0.03 mcg/kg/minute. Indications: IV
treatment of patients with acutely decompensated CHF who have dyspnea
at rest or with minimal activity. Actions: venous and arterial vasodilation
(decreased PCWP etc), plus mild diuretic effect. Patients experiencing
hypotension during the infusion: Hold infusion. May attempt to restart at
a lower dose (reduce initial infusion dose by 30% and omit bolus). No
adjustment required in renal failure.

Nitroglycerin: (HTN/ CHF/ angina): ini inf rate 5 mcg/min. May inc by 5
mcg/min q3 to 5 min until response. If 20 mcg/min is inadequate, inc by
10 to 20 mcg/min q3 to 5min. Calculation of drip rate (50 mg/250 ml) ml/
hr = mcg/min x 0.3 (eg 5 mcg/min=@ 2ml/hr ; 20mcg/min = 6 ml/hr
etc.)

Nitroprusside: Onset: immediate Duration: 1 to 10min. Tx htn emer. IV

infusion rate: 0.5 to 10 mcg/ kg/ min-titrate to BP. Dosing: Initial: 0.3 to
0.5 mcg/kg/min—increase by 0.5 mcg/kg/min increments. (usual dose: 3
mcg/kg/min-rarely need > 4 mcg/kg/min). Note: when > 500 mcg/kg is
admin by continuous infusion at > 2 mcg/kg/min-cyanide is produced
faster than can be handled by endogenous mechanisms. Maximum
infusion rate: 10 mcg/kg/min. Calculation of drip rate 50 mg/250 ml (ml/
hr) = wt (kg) x mcg/min x 0.3

Norepinephrine: Used to maintain BP in hypotensive states. Most potent

vasoconstrictor (Norepi >>> phenylephrine). Dosage: ini 8 to 12 mcg/min
–titrate to BP(Usual target: SB:80-100 or MAP=80). Usual maint: 2 to 4
mcg/min. Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-10days
have been used in septic shock.) Calculation of drip rate 8 mg/ 250 ml
(ml/hr) = mcg/min x 1.875 Administer through a central line (large vein)

Phenylephrine: Alpha agonist). May be given IM,SC, Ivpush, or by cont

inf. TX mild/moderate hypotension, also PSVT. IV bolus tx: usu ini dose
0.5 mg [range: 0.1 to 1 mg (max)] rpt q10-15 min prn. IV infusion: usu
ini rate: 0.1 to 0.18 mg/min (titrate). Maximum rate: 10-15 mcg/kg/
min?. PSVT: 0.5 mg rapid Ivpush, subsequent doses may be inc in
increments of 0.1 to 0.2mg. Calculation of drip rate (40 mg/250) (ml/hr)

http://www.globalrph.com/acls_guide.htm (5 de 7)04/02/2009 14:28:57

ACLS Pocket guide

= (mg/min) x 375.

Procainamide: (Tx: PVC, VT, A-fib/flutter, PAT) Dosing: Loading: 100mg

q5min (max 25 to 50 mg/min) until arrhy disappears or adverse effects
up to (17 mg/kg max if nml renal fcn, otherwise max of 12 mg/kg). If
arrhy disappears, start IV infusion: 2 to 6 mg/min (Usual maint dose c
renal/cardiac failure: 1 to 2 mg/min) . If arrhy reappears, rpt bolus as
above. Side effects: Severe hypotension c rapid infusion; bradycardia, AV
block, V-fib. Alternate loading regimen: Add 1g/ 50 ml D5W-20 mg/min x
25 to 30 min, wait 10min for distribution, if no response continue c
loading. (Note: 20 mg/min= 60 ml/hr-1 g/50ml). If pt responds start
maint infusion: 2 to 6 mg/min. Stop infusion if QRS widens > 50%.
Steady state: 24hrs (IV) / 48 hrs (oral).
Calculation of drip rate (1 gram/250 ml) ml/hr: = (mg/min) x 15

Succinylcholine: Usual dosage: 0.6 mg/kg (range: 0.3 to 1.1 mg/kg)

over 10-30 seconds (up to total dose of 150mg). Maintainance: 0.04-0.07
mg/kg q5-10 minutes prn. Continuous infusion: 0.5 to 10 mg/min. Add
500mg/250ml D5W or NS. Based on the entered weight of 70kg:

0.6mg/kg =42mg, and the maintenance dose of 0.04 to 0.07mg/kg is:

(2.8 to 4.9 mg) q5-10 minutes.

Tirofiban (Aggrastat): initial rate of 0.4 mcg/kg/min for 30 minutes and

then continued at 0.1 mcg/kg/min. Patients with severe renal insufficiency
(creatinine clearance <30 mL/min) dec by 50%: (0.2 mcg/kg/min x
30min, f/b 0.05 mcg/kg/min)

Listed dosages are for - Adult patients ONLY. PLEASE READ THE
DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY
ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE
TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. GlobalRPH does
not directly or indirectly practice medicine or provide medical services and
therefore assumes no liability whatsoever of any kind for the information
and data accessed through the Service or for any diagnosis or treatment
made in reliance thereon.

David F. McAuley, Pharm.D., R.Ph.

GlobalRPh Inc.

[TOP]

http://www.globalrph.com/acls_guide.htm (6 de 7)04/02/2009 14:28:57

ACLS Pocket guide

Contact . Privacy Policy . Disclaimer

Copyright © 2005 GlobalRPh Inc.

http://www.globalrph.com/acls_guide.htm (7 de 7)04/02/2009 14:28:57