ACLS Pharmacotherapy Update
Jessica Schwenk, Pharm.D.
September 14, 2013
Introduction
Objectives
ACLS Guideline Overview
Access for Medications in ACLS
Objectives
• Identify and describe medications used in
Advanced Cardiovascular Life Support (ACLS)
• Understand indications, mechanism of action,
dose, administration, and precautions for
ACLS medications
• Recognize place in therapy for medications in
updated ACLS algorithms
ACLS Guidelines
• Developed by American Heart Association
– Released every 5 years
– Published in Circulation
• Most Recent
– 2010 Guidelines for advanced cardiac life support
• Used comprehensive review of resuscitation literature
performed by the International Liaison Committee on
Resuscitation (ILCOR)
ACLS Guidelines
• First priority
– High quality CPR
– Early defibrillation
• Second priority
– Medication administration
– Advanced airway
• For drug administration or ventilation
Access for Medications in ACLS
• Intravenous (IV) Route
– Preferred route
• Central line not required; can interrupt CPR
– Medications take 1-2 minutes to reach central
circulation
• Give medications as IV bolus, flush with 20 mL fluid
Access for Medications in ACLS
• Intraosseous (IO) Route
– Secondary method
– Safe and effective for administering medications,
fluids, and blood as well as drawing blood
– ALL medications that can be given IV can be given
IO
• Administer medications and flush with at least 20 mL
fluid (as with IV administration)
Access for Medications in ACLS
• Endotracheal (ET) Route
– Not preferred; last resort
– Medication doses are 2-2.5 times IV/IO doses
• Optimal dosing not known
– Medications that can be given ET: epinephrine,
vasopressin, lidocaine (atropine, naloxone)
• Dilute with 5-10 mL SW/NS, administer into ET tube,
follow with several positive pressure breaths
ACLS Medications
Adult cardiac arrest algorithm
Adult cardiac arrest algorithm
• Medications:
– Ventricular fibrillation or ventricular tachycardia
(VF/VT)
• Vasopressors: epinephrine, vasopressin
• Antiarrhythmics: amiodarone
– Not on algorithm: lidocaine, magnesium
– Asystole/Pulseless electrical activity (PEA)
• Vasopressors: epinephrine, vasopressin
Adult cardiac arrest algorithm
• Vasopressor medications
– Include: epinephrine, norepinephrine, vasopressin
– Goal: increase coronary and cerebral perfusion
– Effects:
• Increase systemic arteriolar vasoconstriction
• Maintain vascular tone
• Shunt blood to heart and brain
– ONLY medications shown to improve ROSC and
short term survival
Adult cardiac arrest algorithm
• Epinephrine (Adrenaline)
– MOA: ɑ- and β-receptor agonist
• ɑ-receptor stimulation restores circulation
• β-receptor stimulation
– May lower defibrillation threshold
– Increases myocardial oxygen demand
Adult cardiac arrest algorithm
• Epinephrine
– Dose and Administration
– VF, PVT, asystole, PEA
• IV/IO: 1 mg every 3-5 minutes
– Concentration 0.1mg/ml (1:10,000 or 1 mg/10ml)
– Flush with 20 ml NS (central line preferred)
• ET: 2-2.5 mg every 3-5 minutes
– Dilute in 5-10 ml SW or NS (use epi 1 mg/ml or 1:1,000)
Vasopressors
• Vasopressin (antidiuretic hormone)
– MOA: acts on V1 receptor (among others) to
cause vasoconstriction
• Increases blood pressure and systemic vascular
resistance
– Benefits over epinephrine
• Not inhibited by metabolic acidosis
• No β-receptor activity
– Vasopressin vs. epinephrine for cardiac arrest?
• No significant difference in ROSC when given 2 doses
Vasopressors
• Vasopressin
– Dose and Administration
– VF, PVT, asystole, PEA
• IV/IO: 40 units one time (to replace 1st or 2nd dose of
epinephrine every 3-5 minutes)
– 40 Units/2 ml (2 vials of 20 units/ml)
– Flush with 20 ml NS
• ET: 80-100 units one time (to replace 1st or 2nd dose of
epinephrine every 3-5 minutes)
– Dilute in 5-10 ml SW or NS
Adult cardiac arrest algorithm
• Antiarrhythmic medications for cardiac arrest
(pulseless VF/VT) include:
– Amiodarone
• Not on algorithm: lidocaine, magnesium
– Goal: increase the fibrillation threshold
• Prevent development or recurrence of VF and PVT
Adult cardiac arrest algorithm
• Amiodarone (Cordarone, Pacerone)
– MOA: Class III antiarrhythmic (potassium channel
blocker)
• Acutely: inhibits α- and β-adrenergic stimulation, blocks
calcium channels
– Side effects (acute):
• Hypotension, fever, elevated LFTs, confusion, nausea,
thrombocytopenia
Adult cardiac arrest algorithm
• Amiodarone
– Dose and administration
– Pulseless VF/VT
• 300 mg bolus IV/IO, follow with 150 mg in 3-5 minutes
• Give IV/IO push. If possible dilute in 20-30 ml D5W
– Amiodarone vial concentration is 50 mg/ml
– Flush with 20 ml
• Central line preferred
• Incompatible with sodium bicarbonate
Other antiarrhythmics
• Lidocaine (NOT on algorithm for VF/PVT)
– MOA: Class Ib antiarrhythmic, sodium channel
blocker
– 2010 Guidelines: “There is inadequate evidence to
support or refute the use of lidocaine…” in
refractory VF/VT
• Amiodarone beneficial over lidocaine for survival-toadmission
• May be considered if amiodarone is not available
Other Antiarrhythmics
• Lidocaine (NOT on algorithm for VF/PVT)
– Dose and Administration
• IV/IO: 1-1.5 mg/kg, then 0.5-0.75 mg/kg every 5 to 10
minutes
– Lidocaine 100 mg/5 ml syringe (20 mg/ml)
• ET: 2-3 mg/kg in 10 ml NS
– Dose and Administration
• Monitoring: discontinue if signs of toxicity
– Sedations, seizures, confusion
Other Antiarrhythmics
• Magnesium (NOT on algorithm for VF/PVT)
– Use: suspected hypomagnesemia, Torsades de
Pointes
– Dose and Administration (cardiac arrest)
• Magnesium 1-2 g IV/IO
– Magnesium sulfate 50% vials (1 g/2 mL or 0.5 g/ml)
• Dilute to 10 ml (NS)
• Administer over 5-20 minutes
– Monitor:
• Hypotension, respiratory and CNS depression
ACLS Medications
Adult bradycardia algorithm
(with pulse)
Adult bradycardia algorithm
(with pulse)
Adult bradycardia algorithm
(with pulse)
Adult bradycardia algorithm
(with pulse)
• Medications
– Atropine
– Dopamine
– Epinephrine
Adult bradycardia algorithm
(with pulse)
• Atropine
– MOA: anticholinergic agent, blocks acetylcholine
at M2-receptors of heart
– Dose and administration
• 0.5 mg IV/IO bolus, repeat every 3-5 minutes
• Max 3 mg total dose
• Atropine syringe 1 mg/10 ml (0.1 mg/ml)
– Contraindications/Precautions
• Evidence of a high degree (second degree [Mobitz] type
II or third degree) atrioventricular (AV) block
• May be harmful in cardiac ischemia
Adult bradycardia algorithm
(with pulse)
• Dopamine
– MOA: adrenergic and dopaminergic receptor
agonist, stimulation of β1-recptors increases HR
– Dose and Administration
• 2-10 mcg/kg/min IV/IO infusion (up to 20 mcg/kg/min)
• Titrate to response, increase by 5 mcg/kg/min every
10-30 minutes as needed
• Premade bags are 200 mg/250 ml D5W (800 mcg/ml)
• Central line preferred
• Incompatible with sodium bicarbonate
Adult bradycardia algorithm
(with pulse)
• Epinephrine
– MOA: adrenergic agonist, stimulation of β1recptors increases HR
– Dose and Administration
•
•
•
•
•
2-10 mcg/min IV/IO infusion
Titrate to response
Standard drip 4 mg/250 ml NS or D5W (16 mcg/ml)
Central line preferred
Incompatible with sodium bicarbonate
ACLS Medications
Adult tachycardia algorithm
(with pulse)
Adult tachycardia algorithm
(with pulse)
• Medications
– Regular narrow complex
• Adenosine
• Calcium channel blockers or beta blocker
– Irregular narrow complex
• Calcium channel blocker or beta blocker
• Amiodarone
Adult tachycardia algorithm
(with pulse)
• Medications
– Regular wide complex
• Adenosine
• Calcium channel blockers or beta blocker
• Antiarrhythmics: procainamide, amiodarone, sotolol
– Irregular wide complex
• Antiarrhythmics: procainamide, amiodarone, sotolol
• Polymorphic VT, Torsades de Pointes: magnesium
Adult tachycardia algorithm
(with pulse)
• Adenosine
– Dose and Administration
• 6-12 mg IV into large proximal vein—fast
• Flush with 20 mL immediately, elevate limb
– Extremely short half life
• May repeat 2nd and 3rd dose of 12 mg
• Larger doses (18 mg IV)
– Theophylline or theobromine, caffeine;
• Smaller doses (3mg IV)
– Dipyridamole or carbamazepine, transplanted hearts, or into a
central vein.
Adult tachycardia algorithm
(with pulse)
• Adenosine
– Side effects
• Chest discomfort, dyspnea, and flushing
• Warn patient!
– Monitoring
• Continuous ECG recording during administration
• If adenosine fails to convert SVT, watch for atrial flutter
or a non-reentrant SVT
Adult tachycardia algorithm
(with pulse)
• Diltiazem
– First choice for acute a-fib with RVR
– Dose and administration
• Bolus 15-20 mg IV push over 2 minutes (0.25 mg/kg)
• Repeat with 20-25 mg IV push over 2 minutes after 15
minutes (0.35 mg/kg)
– Diltiazem vials 5 mg/ml
• IV infusion 5-10 mg/hour, titrate up by 5 mg/hour as
needed
– Diltiazem infusion 1 mg/ml
– Monitor: ECG, blood pressure
Adult tachycardia algorithm
(with pulse)
• Verapamil
– Dose and administration
• 2.5-5 mg IV push over 2 minutes
• Repeat with 5-10 mg over 2 minutes after 15-30
minutes
– Maximum total dose 20 mg
– Monitor: ECG, blood pressure
Adult tachycardia algorithm
(with pulse)
• Metoprolol
– Dose and administration
• 5 mg IV push over 1 minute for 3 doses every 2-5
minutes
– Monitor: ECG, blood pressure
Adult tachycardia algorithm
(with pulse)
• Atenolol
– Dose and administration
• 5 mg slow IV push over 5 minutes
• Repeat in 10 minutes
– Monitor: ECG, blood pressure
Adult tachycardia algorithm
(with pulse)
• Esmolol
– Dose and administration
• 500 mcg/kg IV push over 1 minute (may repeat)
– 10 mg/ml
• IV infusion 50 mcg/kg/minute for 4 minutes
• Titrate by 50 mcg/kg/minute at least every 4 minutes
– Max 200 mcg/kg/min
• Repeat in 10 minutes
– Monitor: ECG, blood pressure
Adult tachycardia algorithm
(with pulse)
• Procainamide
– Class 1a antiarrhythmic (sodium channel blocker)
– Dose and administration
• IV infusion 20 mg/min (20 mg/ml in D5W)
– Alternate dosing: 100 mg IV push over 2 min every 5 min
• Continue until the arrhythmia is suppressed, or:
– Hypotension
– QRS widens 50% beyond baseline
– Max dose of 17 mg/kg
• Maintenance infusion 1-3 mg/min (2 mg/ml in D5W)
– Monitor: ECG, QT interval, pulse, blood pressure
• ADR: dysrhythmia, systemic lupus erythematosus (up to 30%),
hematologic effects, hepatotoxicity
Adult tachycardia algorithm
(with pulse)
• Amiodarone
– Dose and administration
• 150 mg IV over 10 min, repeat for recurrence
– Mix in 100 ml D5W (1.5 mg/ml)
• Follow IV infusion 1 mg/min for 6 hours, then 0.5 mg/min 0.5
mg/min IV for 18 hours
– Infusion 1.5 mg/ml
•
•
•
•
Max 2.2 g/24 hr
Central line preferred
Use in-line filter
Incompatible with sodium bicarbonate
– Monitor: ECG, pulse, blood pressure
• ADR: hyper/hypthyroidism, lupus, vision impairment,
renal/liver impairment, pulmonary fibrosis
Adult tachycardia algorithm
(with pulse)
• Magnesium
– Torsades de Pointes
– Dose and Administration
• Magnesium 1-2 g IV
– Magnesium sulfate 50% vials (1 g/2 mL or 0.5 g/ml)
• Dilute to 10 ml (NS)
• Administer over 5-20 minutes
• Maintenance infusion 0.5-1 g/hour
– To correct deficiency
– Monitor:
• hypotension, respiratory and CNS depression
Extravasation
• Hyaluronidase (150 units/ml)
– Inject 0.2 ml subq around the area of the
extravasation (5 injections)
• Amiodarone (hot compress)
• Calcium (cold compress)
• Phentolamine (5 mg with 9 ml NS)
– Inject small amount into blanched area, additional
as needed
• Epineprine (norepinephrine, phenylephrine)
• Dopamine
• Vasopressin
What else is in the crash cart?
References
•
•
•
•
•
•
•
ACLS Provider Manual Supplementary Material (2012). American Heart
Association Web site. Available at:
http://www.hearttraining.com/media/documents/ACLS. Accessed August 13,
2013.
Barletta, JF. Cardiopulmonary resuscitation. In: DiPiro JT, Talbert RL, Yee GC,
Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic
Approach. 6th ed. New York (NY): McGraw Hill;2005:171-184.
Bauman JL, Schoen MD. Arrhythmias. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR,
Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 6th
ed. New York (NY): McGraw Hill;2005:321-356.
DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson
Healthcare. Updated periodically.
Hazinski MF, Nolan JP, Billi JE, et al. 2010 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation 2010;122:e1-330.
Lacy CF, Armstrong LL, Goldman MP, Lance LL. Lexi-Comp’s Drug Information
Handbook. 17th ed. Hudson (OH): Lexi-Comp;2008.
Ponzer CN, Advanced cardiac life support (ACLS) in adults. In: UpToDate, Basow,
DS (Ed), UpToDate, Waltham, MA, 2013.