FLORIDA HEART CPR*
Pharmacology for PALS
According to the American Heart Association, there are very few drugs that are
well supported when dealing with cardiac arrest and pre-arrest arrhythmias.
Because of this, priority is placed on high quality CPR, Defibrillation,
airway management and lastly the use of IV drugs.
:
The following interventions should be used for patients in cardiac arrest or
with severe arrhythmias.
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Establish IV or intraosseous (IO) access. Draw labs and flush line
IVP meds must be followed by 10cc of normal saline
Perform 2 min. of CPR before next intervention
Draw up next drug needed before next rhythm check
If no IV or IO site is available:
Deliver meds through ET tube only as a last resort!
Meds that can be delivered through ET:
 Lidocaine
 Epinephrine
 Atropine
 Narcan
All meds to be delivered at 2-2.5 times the recommended IV dose, except
epinephrine. The recommended endotracheal dose of epinephrine is 10
times the IV dose.
To deliver meds through ET:
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Remove needle from syringe if necessary
Pass catheter beyond tip of tracheal tube.
Spray drug quickly down catheter.
Deliver several breaths with BVM.
Resume CPR (to circulate drug)
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Pharmacology for PALS
The following are pharmacologic agents that may be relevant during resuscitation
of pediatric cardiac arrest. Be advised that your PALS textbook offers a more
detailed version of this list and you should refer to the text prior to your PALS
course for further information.
VASOPRESSORS
EPINEPHERINE
Classification:
Catecholamine, vasopressor, inotrope
Indications:
Cardiac Arrest, anaphylaxis, asthma, symptomatic bradycardia
Croup, hypotensive shock, toxins/overdose
Positive β effects (increased heart rate, contractility and
automaticity)
Positive α effects (peripheral vasoconstriction)
IVP IV every 3-5 minutes (see Broselow tape for exact weight
based doses)
IV/IO push
Tachycardia
Hypertension
PVC’s
Palpitations
Increased myocardial O2 demand
Actions:
Dosage:
Route:
Adverse
Effects:
The α-adrenergic-mediated vasoconstriction of epinephrine increases aortic
diastolic pressure and thus coronary perfusion pressure, a critical determinant of
successful resuscitation. Although epinephrine has been used universally in
resuscitation, there is little evidence to show that it improves survival in humans.
Both beneficial and toxic physiologic effects of epinephrine administration during
CPR have been shown in animal and human studies. Current studies show no
survival benefit from routine use of high dose epinephrine and it may be harmful,
particularly in asphyxia arrest. High dose epinephrine may be considered for
special resuscitation circumstances. (Chapter 9 PALS text)
**REFER TO THE BROSELOW TAPE FOR EXACT DOSES!**
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ANTIARRHYTHMICS
AMIODARONE
Indications:
Actions:
Dosage:
Route:
Adverse effects
SVT, Ventricular tachycardia with pulses, Pulseless arrest (VF
and Pulseless V-Tach.
Prolongs the action potential duration and effective refractory
period, slows sinus rate, prolongs PR and QT intervals and
noncompetitively inhibits α-adrenergic and β-adrenergic
receptors
VF/VT= Cardiac arrest: 5mg/kg IVP for first dose and up to
15mg/kg max dose (see Broselow tape for exact weight based
doses) For SVT and V-Tach with pulses 5mg/kg IV/IO over 2060 minutes (max dose 300mg) Upon ROSC: See JHACO
Guidelines for infusions
IV/IO
Hypotension, Bradycardia, SA node dysfunction, sinus arrest,
CHF, torsades, pulmonary fibrosis, ARDS
Amiodarone may be considered as part of the treatment of shock-refractory or
recurrent VF/VT. Amiodarone has α-adrenergic and β-adrenergic blocking
activity; affects sodium, potassium, and calcium channels; slows AV conduction;
prolongs the AV refractory period and QT interval; and slows ventricular
conduction (widens the QRS). Adult studies showed increased survival to
hospital admission but not to hospital discharge when amiodarone was used
compared to lidocaine. One study in children demonstrated the effectiveness of
amiodarone for life-threatening ventricular arrhythmias, but there have been no
published studies on the use of amiodarone for pediatric cardiac arrest.
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LIDOCAINE
Classification:
Indications:
Anti-arrhythmic
Ventricular Fibrillation, Pulseless Ventricular Tachycardia,
Rapid sequence intubation (RSI) i.e. ICP protection
Actions:
Depresses ventricular irritability and automaticity
Increases fibrillation threshold
Dosage:
V-Tach with a pulse or VF/Pulseless VT: see Broselow tape for
weight based doses. MAINTENANCE INFUSION upon ROSC:
see JHACO infusion protocol.
Route:
IVP, IO or IV Infusion
Adverse
Muscle tremors, heart block, myocardial depression,
Effects:
hypotension, seizures, cardiac arrest in bradycardias.
Lidocaine continues on next page.
Lidocaine has long been recommended for the treatment of ventricular
arrhythmias in infants and children because it decrease automaticity and
suppresses ventricular arrhythmias. Data from a study of shock-refractory VT in
adults showed that lidocaine was inferior to amiodarone, so lidocaine has been
recommended as a second line drug in shock-refractory cardiac arrest only when
amiodarone is not available. Its indications in the treatment of other ventricular
arrhythmias are uncertain. There have been no published studies on the use of
lidocaine in pediatric cardiac arrest.
MAGNESIUM SULFATE
Classification:
Indications:
Actions:
Dosage:
Adverse Effects:
Electrolyte, bronchodilator
Hypomagnesemia
Torsades de Pointes
Asthma (refractory status asthmaticus)
Smooth muscle relaxer
Exerts antiarrhythmic action
Cardiac arrest due to torsades: IV/IO route 25-50mg/kg; 25-50
mg/kg over 10-20 minutes for VT with pulses associated with
torsades or hypomagnesemia; 25-50mg/kg by slower infusion
(15-30 minutes) for treatment of status asthmaticus.
Mild bradycardia, hypotension, hypermagnesemia, respiratory
depression, weakness, heart block, and cardiac arrest may
develop with rapid administration. Contraindications: renal
failure
Magnesium Sulfate should be administered for the treatment of torsades de
pointes or hypomagnesemia. There is insufficient evidence to recommend for or
against the routine use of magnesium in pediatric cardiac arrest.
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OTHER AGENTS
ATROPINE
Classification:
Indications:
Actions:
Dosage:
Route:
Adverse
Effects:
Anticholinergic
Symptomatic bradycardia (usually secondary to vagal
stimulation; Toxins (organophosphate overdose, carbamate);
rapid sequence intubation (i.e. when using succinylcholine)
Increases heart rate and cardiac output by blocking vagal
stimulation; blocks acetylcholine and other muscarinic agonists
0.5 mg IVP in bradycardic patient. NOT TO EXCEED 3.0 mg
IV or IO
Tachycardia, dilated pupils, blurred vision, headache, dysuria,
weakness, bradycardia if used in smaller than recommended
doses. **Document clearly if used for patients with head injury,
because atropine will distort pupillary exam by causing pupil
dilation.
**Special considerations: Use drug in any child with bradycardia at time of
endotracheal intubation. Consider using drug to prevent bradycardia when
succinylcholine is used in an infant or young child, especially in the presence of
hypoxia and acidosis.
Atropine is indicated for the treatment of bradyarrythmias. There are no
published studies suggesting its efficacy for treatment of cardiac arrest in
pediatric patients. (See PALS text for complete discussion)
CALCIUM CHLORIDE
Classification:
Indications:
Actions:
Dosage:
Adverse
Effects:
Calcium ion (electrolyte)
Hypocalcaemia, hyperkalemia, consider for hypomagnesaemia
and treatment of calcium channel blocker overdose.
Needed for maintenance of nervous, muscular, skeletal
systems, enzyme reactions, normal cardiac contractility, and
blood coagulation.
20 mg/kg IO/IV slow push during cardiac arrest if hypocalcemia
is known or suspected; may repeat if documented or suspected
clinical indication persists. Infuse over 30-60 minutes for other
indications
Hypotension, bradycardia, asystole, heart block, cardiac arrest,
arrhythmias, venous thrombosis, necrosis upon infiltration,
hypercalcemia
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SODIUM BICARBONATE
Classification:
Indications:
Alkalinizing agent, electrolyte, buffer
Metabolic acidosis from an unknown cause or suspected
acidosis from confirmed prolonged down time, sodium channel
blocker overdose (e.g.Tricyclic antidepressant) Hyperkalemia
Actions:
Increases plasma bicarbonate, which buffers H+ ion (reversing
metabolic acidosis) forming carbon dioxide; elimination of
carbon dioxide via the respiratory tract increases pH.
Dosage:
1mEq/kg IV push, can be repeated as ordered by clinician in
cardiac arrest
Route:
IV/IO
**Special considerations: Do not administer via endotracheal route; Irrigate
IV/IO tubing with NS before and after infusions or use another line to administer.
Sodium bicarbonate is recommended for the treatment of symptomatic patients
with hyperkalemia, Tricyclic antidepressant overdose, or an overdose of other
sodium channel blocking agents. Routine use of sodium bicarbonate in cardiac
arrest is not recommended. After you have provided effective ventilation and
chest compressions and administered epinephrine, you may consider sodium
bicarbonate for prolonged cardiac arrest.
ADENOCARD/ADENOSINE
Classification:
Indications:
Dose:
Actions
Antiarrhythmic
SVT
IV/IO Rapidly: Exact weight based doses on Broselow tape
Briefly blocks conduction through AV node and interrupts
pathways through AV node. Allows return of NSR in patients
with SVT, including SVT associated with WPW. Depresses
sinus node automaticity.
******Note: This is NOT a complete list of drugs used in the PALS
course. Please consult your PALS textbook for a
complete list of drugs including classifications,
indications, doses and actions of each drug.
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