ACLS Pharmacology Review

ACLS

Pharmacology

1

Objectives

 To review and obtain a better understanding of medications used in

ACLS

– Indications & Actions

(When & Why?)

– Dosing

(How?)

– Contraindications & Precautions

(Watch

Out!)

2

3

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

4

Drug


 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

5

Drug


 Class III: Not recommended

– Not acceptable or useful and may be harmful

– Evidence is absent or unsatisfactory, or based on poor studies

 Indeterminate

– Continuing area of research; no recommendation until further data is available

6

Oxygen

 Indications (When & Why?)

– Any suspected cardiopulmonary emergency

– Saturate hemoglobin with oxygen

– Reduce anxiety & further damage

– Note: Pulse oximetry should be monitored

Universal Algorithm

7

Oxygen

 Dosing (How?)

Device

Nasal Prongs

Venturi Mask

Partial Rebreather

Mask

Bag Mask

Flow Rate

1 to 6 lpm

4 to 8 lpm

6 to 10 lpm

15 lpm

Oxygen %

24 to 44%

24 to 40%

35 to 60% up to 100%


8

Oxygen

 Precautions (Watch Out!)

– Pulse oximetry inaccurate in:

 Low cardiac output

 Vasoconstriction

 Hypothermia

– NEVER rely on pulse oximetry!


9

VF / Pulseless

VT

Case 3

10

VF / Pulseless VT

•

•

Epinephrine 1 mg IV push, repeat every 3 to 5 minutes or

Vasopressin 40 U IV, single dose , 1 time only

Resume attempts to defibrillate

1 x 360 J (or equivalent biphasic) within 30 to 60 seconds

•

•

•

•

Consider antiarrhythmics:

Amiodarone (llb for persistent or recurrent VF/pulseless VT)

Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT)

Magnesium (llb if known hypomagnesemic state)

Procainamide (Indeterminate for persistent VF/pulseless VT; llb for recurrent VF/pulseless VT)

Resume attempts to defibrillate

11

Epinephrine


– Increases:

 Heart rate

 Force of contraction

 Conduction velocity

– Peripheral vasoconstriction

– Bronchial dilation


12

Epinephrine


– 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 in 10 mL normal saline


13

Epinephrine


– 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


14

Epinephrine


– 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


15

Vasopressin


– Used to “clamp” down on vessels

– Improves perfusion of heart, lungs, and brain

– No direct effects on heart


16

Vasopressin


– One time dose of 40 units only

– 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


17

Vasopressin


– May result in an initial increase in blood pressure immediately following return of pulse

– May provoke cardiac ischemia


18

Amiodarone


– Powerful antiarrhythmic with substantial toxicity, especially in the long term

– Intravenous and oral behavior are quite different

– Has effects on sodium & potassium


19

Amiodarone


– Should be diluted in 20 to 30 mL of D5W

 300 mg bolus after first Epinephrine dose

 Repeat doses at 150 mg


20

Amiodarone


– May produce vasodilation & shock

– May have negative inotropic effects

– Terminal elimination

 Half-life lasts up to 40 days


21

Lidocaine


– Depresses automaticity

– Depresses excitability

– Raises ventricular fibrillation threshold

– Decreases ventricular irritability


22

Lidocaine


– 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/kg

– A 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


23

Lidocaine


– Maintenance Infusion

 2 to 4 mg/min

 1000 mg / 250 mL D5W = 4 mg/mL

– 15 mL/hr = 1 mg/min





24

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


25

Magnesium

Sulfate


– Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state

– Refractory VF

– VF with history of ETOH abuse

– Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose


26

Magnesium

Sulfate


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


27

Magnesium

Sulfate


– Occasional fall in blood pressure with rapid administration

– Use with caution if renal failure is present


28

Procainamide


– Recurrent VF






29

Procainamide


– 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


30

Procainamide



 1 to 4 mg/min

 1000 mg / 250 mL of D5W = 4 mg/mL






31

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


32

PEA

Case 4

33

PEA

Review for most frequent causes

• H ypovolemia

• H ypoxia

• H ydrogen ion —acidosis

•

H yper-/hypokalemia

• H ypothermia

•

•

•

•

•

T

T

T

T

T ablets (drug OD, accidents) amponade, cardiac ension pneumothorax hrombosis, coronary (ACS) hrombosis, pulmonary (embolism)

Epinephrine 1 mg IV push, repeat every 3 to 5 minutes

Atropine 1 mg IV (if PEA rate is slow ), repeat every 3 to 5 minutes as needed, to a total dose of 0.04 mg/kg

34

Epinephrine


– Increases:

 Heart rate





Pulseless Electrical Activity

35

Epinephrine







36

Epinephrine






37

Atropine Sulfate


– Should only be used for bradycardia

 Relative or Absolute

– Used to increase heart rate


38



– 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


39



– Increases myocardial oxygen demand

– May result in unwanted tachycardia or dysrhythmia


40

Asystole

Case 5

41

Asystole

Transcutaneous pacing:

If considered, perform immediately

Epinephrine 1 mg IV push, repeat every 3 to 5 minutes

Atropine 1 mg IV, repeat every 3 to 5 minutes up to a total of 0.04 mg/kg

Asystole persists

Withhold or cease resuscitation efforts?

• Consider quality of resuscitation?

• Atypical clinical features present?

• Support for cease-efforts protocols in place?

42

Epinephrine


– Increases:

 Heart rate





Asystole: The Silent Heart Algorithm

43

Epinephrine







44

Epinephrine






45



– Used to increase heart rate

 Questionable absolute bradycardia


46



– 1 mg IV push

– Repeat every 3 to 5 minutes




47





48

Other Cardiac

Arrest Drugs

49

Calcium Chloride


– 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

Other Cardiac Arrest Drugs

50



– IV Slow Push

 8 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


51



– Do not use routinely in cardiac arrest

– Do not mix with sodium bicarbonate


52

Sodium

Bicarbonate


– Class I if known preexisting hyperkalemia

– Class IIa if known preexisting bicarbonateresponsive acidosis

– Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation

– Class III (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation)


53

Sodium

Bicarbonate


– 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)


54

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


55

Acute Coronary

Syndromes

Case 6

56

57


Syndromes

Chest pain suggestive of ischemia

Immediate assessment (<10 minutes)

• Measure vital signs (automatic/standard BP cuff)

• Measure oxygen saturation

• Obtain IV access

• Obtain 12-lead ECG (physician reviews)

• Perform brief, targeted history and physical exam; focus on eligibility for fibrinolytic therapy

• Obtain initial serum cardiac marker levels

• Evaluate initial electrolyte and coagulation studies

• Request, review portable chest x-ray (<30 minutes)

Immediate general treatment

• Oxygen at 4 L/min

• Aspirin 160 to 325 mg

• Nitroglycerin SL or spray

• Morphine IV (if pain not relieved with nitroglycerin)

Memory aid: “MONA” greets all patients (Morphine, Oxygen,

Nitroglycerin, Aspirin)

Assess initial 12-lead ECG

EMS personnel can perform immediate assessment and treatment (“MONA”), including initial 12-lead

ECG and review for fibrinolytic therapy indications and contraindications.

58

Aspirin


– Administer to all patients with ACS, particularly reperfusion candidates

 Give as soon as possible

– Blocks formation of thromboxane A2, which causes platelets to aggregate

Acute Coronary Syndromes

59

Aspirin


– 160 to 325 mg tablets

 Preferably chewed

 May use suppository

– Higher doses may be harmful


60

Aspirin


– Relatively contraindicated in patients with active ulcer disease or asthma


61

Nitroglycerine


– 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


62

Nitroglycerin


– 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


63



– 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 µg/min

 Route of choice for emergencies

 Titrate to effect


64



– Use extreme caution if systolic BP <90 mm Hg

– Use extreme caution in RV infarction

– Suspect RV infarction with inferior ST changes

– Limit BP drop to 10% if patient is normotensive

– Limit BP drop to 30% if patient is hypertensive

– Watch for headache, drop in BP, syncope, tachycardia

– Tell patient to sit or lie down during administration


65

Morphine Sulfate


– Chest pain and anxiety associated with AMI or cardiac ischemia

– Acute cardiogenic pulmonary edema (if blood pressure is adequate)


66



– To reduce pain of ischemia

– To reduce anxiety

– To reduce extension of ischemia by reducing oxygen demands


67



– 1 to 3 mg IV (over 1 to 5 minutes) every 5 to

10 minutes as needed


68



– Administer slowly and titrate to effect

– May compromise respiration; therefore use with caution in acute pulmonary edema

– Causes hypotension in volume-depleted patients


69


Syndromes

• ST elevation or new or presumably new LBBB: strongly suspicious for injury

• ST-elevation AMI

• ST depression or dynamic

T-wave inversion: strongly suspicious for ischemia

• High-risk unstable angina/ non–ST-elevation AMI

• Nondiagnostic ECG: absence of changes in ST segment or

T waves

• Intermediate/low-risk unstable angina

70

ST Elevation

71

Recognition of AMI





Know what to look for —

– ST elevation

>

1 mm

– 3 contiguous leads

Know where to look

– Refer to 2000 ECC

Handbook

J point plus

0.04 second

PR baseline

ST-segment deviation

= 4.5 mm

72

ST Elevation

Baseline

Ischemia—tall or inverted T wave (infarct),

ST segment may be depressed (angina)

Injury—elevated ST segment, T wave may invert

Infarction (Acute)—abnormal Q wave,

ST segment may be elevated and T wave may be inverted

Infarction (Age Unknown)—abnormal Q wave,

ST segment and T wave returned to normal

73

Beta Blockers


– To reduce myocardial ischemia and damage in AMI patients with elevated heart rates, blood pressure, or both

– Blocks catecholamines from binding to

ß-adrenergic receptors

– Reduces HR, BP, myocardial contractility

– Decreases AV nodal conduction

– Decreases incidence of primary VF


74

Beta Blockers


– 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 (<10 minutes)

– Labetalol

 10 mg labetalol IV push over 1 to 2 minutes

 May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min


75

Beta Blockers


– 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


76

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


77

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


78

Heparin


– Initial bolus 60 IU/kg

 Maximum bolus: 4000 IU

– Continue at 12 IU/kg/hr (maximum 1000

IU/hr for patients < 70 kg), round to the nearest 50 IU


79

Heparin


– 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


80

Heparin


– Same contraindications as for fibrinolytic therapy: active bleeding; recent intracranial, intraspinal or eye surgery; severe hypertension; bleeding disorders; gastroinintestinal bleeding

– DO NOT use if platelet count is below 100

000


81

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


82

Glycoprotein



– 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


83

Glycoprotein



– 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


84

Glycoprotein



– 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


85

Glycoprotein



– NOTE: Check package insert for current indications, doses, and duration of therapy.

 Optimal duration of therapy has NOT been established.


86

Glycoprotein



– 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


87

Glycoprotein



– Eptifibitide (Integrilin)

 Acute Coronary Syndromes

– 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


88

Glycoprotein



– Tirofiban (Aggrastat)

 Acute Coronary Syndromes or PCI

– 0.4 mcg/kg/min infusion IV for 30 minutes

– Then 0.1 mcg/kg/min infusion


89

Glycoprotein



– 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


90

PTCA

91

Fibrinolytics


– For AMI in adults

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

 Time of onset of symptoms < 12 hours


92

Fibrinolytics


– 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


93

Fibrinolytics


– For fibrinolytic use, all patients should have

2 peripheral IV lines

 1 line exclusively for fibrinolytic administration


94

Fibrinolytics

 Dosing for AMI Patients (How?)

– 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


95

Fibrinolytics

 Dosing for AMI Patients (How?)

– Anistreplase (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


96

Fibrinolytics

 Adjunctive Therapy for AMI Patients

(How?)

– 160 to 325 mg aspirin chewed as soon as possible

– Begin heparin immediately and continue for

48 hours if alteplase or Retavase is used


97

Fibrinolytics

 Dosing for Acute Ischemic Stroke (How?)

– 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 patients


98

Fibrinolytics


– 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


99

Fibrinolytics


– 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


100

ACE Inhibitors


– 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


101



– Suspected MI & ST elevation in 2 or more anterior leads

– Hypertension

– Clinical signs of AMI with LV dysfunction

– LV ejection fraction <40%


102



– Generally not started in the ED but within first 24 hours after:

 Fibrinolytic therapy has been completed

 Blood pressure has stabilized


103



– Should start with low-dose oral administration (with possible IV doses for some preparations) and increase steadily to achieve a full dose within 24 to 48 hours


104



– Enalapril

 2.5 mg PO titrated to 20 mg BID

 IV dosing of 1.25 mg IV over 5 minutes, then

1.25 to 5 mg IV every six hours

– Captopril

 Start with 6.25 mg PO

 Advance to 25 mg TID, then to 50 mg TID as tolerated


105



– 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


106



– Contraindicated in pregnancy

– Contraindicated in angioedema

– Reduce dose in renal failure

– Avoid hypotension, especially following initial dose & in relative volume depletion


107

Bradycardias

Case 7

108

Bradycardia

•

•

Bradycardia

Slow (absolute bradycardia = rate <60 bpm) or

Relatively slow (rate less than expected relative to underlying condition or cause)

Primary ABCD Survey

• Assess ABCs

• Secure airway noninvasively

• Ensure monitor/defibrillator is available

Secondary ABCD Survey

• Assess secondary ABCs (invasive airway management needed?)

• Oxygen–IV access–monitor–fluids

• Vital signs, pulse oximeter, monitor BP

• Obtain and review 12-lead ECG

• Obtain and review portable chest x-ray

• Problem-focused history

• Problem-focused physical examination

• Consider causes (differential diagnoses)

109

Bradycardia

No

Type II second-degree AV block or

Third-degree AV block?

Serious signs or symptoms?

Due to bradycardia?

No

Yes

Intervention sequence

• Atropine 0.5 to 1.0 mg

• Transcutaneous pacing if available

• Dopamine 5 to 20 µg/kg per minute

• Epinephrine 2 to 10 µg/min

• Isoproterenol 2 to 10 µg/min

Yes

Observe

• Prepare for transvenous pacer

• If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed

110



– First drug for symptomatic bradycardia

 Increases heart rate by blocking the parasympathetic nervous system

Bradycardias

111



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



Bradycardias

112



– Use with caution in presence of myocardial ischemia and hypoxia


– Seldom effective for:

 Infranodal (type II) AV block

 Third-degree block (Class IIb)

Bradycardias

113

Dopamine


– Second drug for symptomatic bradycardia

(after atropine)

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

Bradycardias

114

Dopamine


– IV Infusions (Titrate to Effect)

– 400 mg / 250 mL of D5W = 1600 mcg/mL

– 800 mg/ 250 mL of D5W = 3200 mcg/mL

Bradycardias

115

Dopamine



 Low Dose “Renal Dose"

– 1 to 5 µg/kg per minute

 Moderate Dose “Cardiac Dose"


 High Dose “Vasopressor Dose"


Bradycardias

116

Dopamine


– May use in patients with hypovolemia but only after volume replacement

– May cause tachyarrhythmias, excessive vasoconstriction

– DO NOT mix with sodium bicarbonate

Bradycardias

117

Epinephrine


– Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing

(Class IIb)

Bradycardias

118

Epinephrine


– Profound Bradycardia



2 to 10 µg/min infusion (add 1 mg of 1:1000 to

500 mL normal saline; infuse at 1 to 5 mL/min)

Bradycardias

119

Epinephrine




Bradycardias

120

Isoproterenol


– Temporary control of bradycardia in heart transplant patients

– Class IIb at low doses for symptomatic bradycardia

– Heart Transplant Patients!

Bradycardias

121

Isoproterenol


– Infuse at 2 to 10 µg/min

– Titrate to adequate heart rate

Bradycardias

122

Isoproterenol


– Increases myocardial oxygen requirements, which may increase myocardial ischemia

– DO NOT administer with poison/druginduced shock

 Exception: Beta Blocker Poisoning

Bradycardias

123

Stable

Tachycardias

Case 9

124

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 pressure

– As an alternative, use verapamil

Stable Tachycardias

125

Diltiazem


– 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


126

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 ß-blockers can cause severe hypotension


127

Verapamil


– 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 pressure


128

Verapamil


– 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


129

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


130

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 ßblockers may produce severe hypotension


131

Adenosine


– First drug for narrow-complex PSVT

– May be used diagnostically (after lidocaine) in wide-complex tachycardias of uncertain type


132

Adenosine

 Dose (How?)

– 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


133

Adenosine


– Transient side effects include:

 Facial Flushing

 Chest pain

 Brief periods of asystole or bradycardia

– Less effective in patients taking theophyllines


134

Beta Blockers


– To convert to normal sinus rhythm or to slow ventricular response (or both) in supraventricular tachyarrhythmias (PSVT, atrial fibrillation, or atrial flutter)

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


135

Beta Blockers


– 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 (<10 minutes)

– Labetalol

 10 mg labetalol IV push over 1 to 2 minutes

 May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min


136

Beta Blockers


– 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


137

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


138

Digoxin


– To slow ventricular response in atrial fibrillation or atrial flutter

– Third-line choice for PSVT


139

Digoxin


– IV Infusion



Loading doses of 10 to 15 µg/kg provide therapeutic effect with minimum risk of toxic effects

 Maintenance dose is affected by body size and renal function


140

Digoxin


– 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)


141

Amiodarone


– Powerful antiarrhythmic with substantial toxicity, especially in the long term

– Intravenous and oral behavior are quite different


142

Amiodarone


– 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)


143

Amiodarone



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


144

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

 Half-life lasts up to 40 days


145

Amiodarone


– Contraindicated in:

 Second or third degree A-V block

 Severe bradycardia

 Pregnancy

 CHF

 Hypokalaemia

 Liver dysfunction


146

Lidocaine







147

Lidocaine


– 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


148

Lidocaine



 2 to 4 mg/min


149

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


150

Magnesium

Sulfate


– Torsades de pointes with a pulse

– Wide-complex tachycardia with history of

ETOH abuse

– Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose


151

Magnesium

Sulfate


– Loading dose of 1 to 2 grams mixed in 50 to

100 mL of D5W IV push over 5 to 60 minutes


152

Magnesium

Sulfate



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


153

Magnesium

Sulfate


– Occasional fall in blood pressure with rapid administration

– Use with caution if renal failure is present


154

Procainamide






– Atrial fibrillation with rapid rate in Wolff-

Parkinson-White syndrome


155

Procainamide


– 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 are acceptable


156

Procainamide



 1 to 4 mg/min


157

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


158

Acute

Ischemic Stroke

Case 10

159

Acute

Ischemic Stroke









Detection

Dispatch

Delivery

Door

Immediate assessment:

<10 minutes from arrival

• Assess ABCs, vital signs

• Provide oxygen by nasal cannula

• Obtain IV access; obtain blood samples (CBC, electolytes, coagulation studies)

• Check blood sugar; treat if indicated

• Obtain 12-lead ECG, check for arrhythmias

• Perform general neurological screening assessment

• Alert Stroke Team: neurologist, radiologist,

CT technician

Suspected Stroke EMS assessments and actions

Immediate assessments performed by EMS personnel include

• Cincinnati Prehospital Stroke Scale

(includes difficulty speaking, arm weakness, facial droop)

• Los Angeles Prehospital Stroke Screen

• Alert hospital to possible stroke patient

• Rapid transport to hospital

Immediate neurological assessment:

<25 minutes from arrival

• Review patient history

• Establish onset (<3 hours required for fibrinolytics)

• Perform physical examination

• Perform neurological examination:

 Determine level of consciousness (Glasgow Coma Scale)

 Determine level of stroke severity (NIH Stroke Scale or

Hunt and Hess Scale)

• Order urgent noncontrast CT scan

(door-to–CT scan performed: goal <25 minutes from arrival)

• Read CT scan (door-to–CT read: goal <45 minutes from arrival)

• Perform lateral cervical spine x-ray (if patient comatose/history of trauma)

160

Nitroprusside


– Hypertensive crisis

Acute Ischemic Stroke

161

Nitroprusside


– 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


162

Nitroprusside

 Dosing Precautions (How?)

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

– Cover drug reservoir with opaque material


163

Nitroprusside


– 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


164

Drugs used in

Overdoses

165



– As an antidote for toxic effects of calcium channel blocker overdose

Drugs Used in Overdoses

166



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


167



– Do not use routinely in cardiac arrest

– Do not mix with sodium bicarbonate


168

Flumazenil


– Reduce respiratory depression and sedative effects from pure benzodiazepine overdose


169

Flumazenil


– First Dose

 0.2 mg IV over 15 seconds

– Second Dose


– Third Dose


– Maximum Dose

 3 mg


170

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 drugs known to cause seizures


171

Naloxone

Hydrochloride


– Respiratory and neurologic depression due to opiate intoxication unresponsive to oxygen and hyperventilation


172

Naloxone

Hydrochloride


– 0.4 to 2 mg IVP every 2 minutes

– Use higher doses for complete narcotic reversal

– Can administer up to 10 mg in a short time

(10 minutes)


173

Naloxone

Hydrochloride


– May cause opiate withdrawal

– Effects may not outlast effects of narcotics

– Monitor for recurrent respiratory depression


174

Review of

Infusions

175

Dobutamine


– 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

Review of Infusions

176

Dobutamine


– Usual infusion rate is 2 to 20 µg/kg per minute

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

– Hemodynamic monitoring is recommended for optimal use


177

Dobutamine


– Avoid when systolic blood pressure <100 mm Hg with signs of shock

– May cause tachyarrhythmias, fluctuations in blood pressure, headache, and nausea



178

Dopamine


– Second drug for symptomatic bradycardia

(after atropine)

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


179

Dopamine



 Low Dose “Renal Dose"


 Moderate Dose “Cardiac Dose"


 High Dose “Vasopressor Dose"



180

Dopamine


– May use in patients with hypovolemia but only after volume replacement

– May cause tachyarrhythmias, excessive vasoconstriction



181

Epinephrine


– Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing

(Class IIb)


182

Epinephrine


– Profound Bradycardia



2 to 10 µg/min infusion (add 1 mg of 1:1000 to

500 mL normal saline; infuse at 1 to 5 mL/min)


183

Epinephrine






184

Norepinephrine


– For severe cardiogenic shock and hemodynamic significant hypotension

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

– This is an agent of last resort for management of ischemic heart disease and shock


185



– 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


186



– Increases myocardial oxygen requirements

– May induce arrhythmias

– Extravasation causes tissue necrosis


187

Calculating mg/min dose X gtt factor

Solution Concentration

= gtts/min

2 mg X 60 gtt/mL

4 mg

= 30 gtts/min

Using a 60 gtt set:

 30 gtt/min = 30 cc/hr

188

Calculating mcg/kg/min dose X kg X gtt factor solution concentration

= cc/hr

5 mcg/min X 75 kg X 60 gtt/mL

1600 mcg/cc

= 18.75 cc/hr

Using a 60 gtt set:

 18.75 cc/hr = 18.75 gtts/min

189

Furosemide


– 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

190

Furosemide


– 20 to 40 mg slow IVP

– If patient is taking at home, double their daily dose

191

Furosemide


– Dehydration, hypovolemia, hypotension, hypokalemia, or other electrolyte imbalance may occur

192

Questions?

Jeremy Maddux

ncmedix@msn.com

193

Summary

 To obtain a full understanding of ACLS pharmacology requires constant review of:

– Indications & Actions

(When & Why?)

– Dosing

(How?)

– Contraindications & Precautions

(Watch

Out!)

194

Thank You!

195

ACLS Pharmacology Review

PEA

Asystole

Bradycardias

= gtts/min

= cc/hr

Questions?

Jeremy Maddux

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ACLS Pharmacology Review

PEA

Asystole

Bradycardias

= gtts/min

= cc/hr

Questions?

Jeremy Maddux

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