Adenosine (Adenocard)
First Line ACLS Drug
YES!
Indications and uses
Adenosine slows tachycardias associated with the AV node via modulation of the
autonomic nervous system without causing negative inotropic effects. It acts directly
on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and
dromotropic activity. Adenosine is the drug of choice for paroxysmal
supraventricular tachvcardia (PSVT) and can be used diagnostically for stable, wide
complex tachyardias of unknown type after two doses of lidocaine.
Dosage and Administration
Give 6mg IV push rapidly over 1-3 seconds as close to vein as possible. If no
response is observed after 1-2 min, administer 12 mg over 1-3 sec. The second 12 mg
dose may be repeated once if needed (maximum 30 mg dose).
Adverse Reactions
The following Side Effects have been documented: Facial flushing, lightheadedness,
paresthesia, headache, diaphoresis, palpitations, chest pain, hypotension, nausea,
metallic taste, and shortness of breath.
Special Considerations
Contraindicated in the following rhythms: Second- or third-degree AV block, or
sick-sinus syndrome. Atrial flutter, Atrial fibrillation, and Ventricular tachycardia.
Adenocard will cause a 6-10 arrest, this is expected. Methylxanthines (for example,
caffeine and theophylline) antagonize the action of adenosine. Dipyridamole
potentiates the effect of adenosine; reduction of adenosine dose may be required.
Carbamazepine may potentiate the AV-nodal blocking effect of adenosine.
Atropine
First Line ACLS Drug
YES!
Indications and uses
Indications: Increases the Heart Rate.
Uses: Used in bradycardia rhythms to increase the heart rate. (see special
considerations) Also used in Asystole.
Dosage and Administration
Give 0.5-1mg I.V. push every 3-5 minutes to a maximum dose of 3 mgs. May be
given down the endotracheal tube. Mix with 10cc normal saline when giving the
E.T. route.
Adverse Reactions
May cause worsening of myocardia ischemia, worsening of AV Blocks, and may
cause PVC's or Ventricular Tachycardia. May result in undesired tachycardia.
Special Considerations
Doses smaller than 0.5mg may enhance bradycardia and should not be used.
Atropine is no longer indicated in Second Degree Type II or Third Degree AV
Blocks!
Dobutamine
First Line ACLS Drug
NO!
Indications and uses
Indications: Dobutamine is a positive inotrophic drug, resulting in increased
myocardial contracture, thus improving cardiac output.
Uses: Dobutamine is used primarily in congestive heart failure associated with poor
cardiac output.
Dosage and Administration
The usual dose is 1 gram mixed in 250cc Normal Saline. The starting dose is
2.mcg/kg/min I.V. then titrated up to 20mcg/kg/min.
Adverse Reactions
Dobutamine may cause hypotension secondary to it's beta-2 properties. Tachycardia may
result from Dobutamine's beat-1 properties, do not permit the heart rate to increase by
10% of it's original rate. Dobutamine may cause an increase in ventricular ectopy.
Special Considerations
It is recommended that Dobutamine be titrated and controlled by a volumetric
infusion pump. Continuous cardiac monitoring is a necessity, and frequent blood
pressure measurement is recommended.
Dopamine
First Line ACLS Drug
YES!
Indications and uses
Indications: Dopamine is used primarily for the treatment of hypotension that is not
secondary to hypovolemia. Dopamine has different effects at precise dosage levels.
Greater than 10mcg/kg/min it has Alpha properties used to treat hypotension. At
low dosage, 1-3mcg/kg/min it has dopaminergic properties that result in
vasodilitation of renal, messenteric, and cerebral arteries. At dosages between 310mcg/kg/min it has beta-1 properties, similar to dobutamine.
Uses: For treatment of hypotension that is not volume related. First line drug for
hypotension starting at 10mcg/kg/min. If the systolic blood pressure is less than
70mmhg, use norepinephrine.
Dosage and Administration
Mix 800mgs of Dopamine in 250cc of Normal Saline. Titrate as follows.
Renal Perfusion: 1-3mcg/kg/min
Beta Range: 3-10mcg/kg/min
Alpha Range:10-20mcg/kg/min, greater than 20mcg/kg/min switch to
Norepinephrine.
Adverse Reactions
Profound tachycardia may result in the presence of hypovolemia. Always treat the
underlying hypovolemia before using Dopamine. May increase both suprventricular
and ventricular ectopy. At higher doses myocardial blood flow may be reduced.
Special Considerations
Use with a volumetric infusion device.
Epinephrine
First Line ACLS Drug
YES!
Indications and uses
Indications: Improved coronary and cerebral profusion is the primary beneficial
effect of epinephrine during cardiac arrest. May also increase automaticity and
make VF more susceptible to DC countershock.
Uses: Epinephrine is the first drug of choice of all ACLS situations where the
patient is pulseless, dead!
Dosage and Administration
Intermediate dose: Give 1mg IV push every 3-5 minutes, there is no maximum dose.
May be given down the endotracheal tube. Mix with 10cc normal saline when giving
the E.T. route.
Escalating dose: Give 2-5 mg IV every 3-5 min.
High dose: Give 0.1 mg/kg IV every 3-5 min.
Adverse Reactions
May cause worsening of myocardial ischemia and may cause PVC's or Ventricular
Tachycardia. May result in undesired tachycardia.
Special Considerations
ACLS Epinephrine strength is 1:10000 solution for IV. If 1:1000 is all that is
available, it must be mixed with 10cc Normal Saline for a final product of 1:10000
solution!
Isoproterenol
First Line ACLS Drug
NO!
Indications and uses
Indications: Isoproterenol has lost favor with ACLS because of it's potential to
worsen myocardial ischemia. In situations where Isoproterenol was used in the past,
TCP is the treatment of choice.
Uses: Increases pacemaker SA automaticity and AV conduction.
Dosage and Administration
IV infusion: Titrate 0.5mcg to 5mcg minutes.
Adverse Reactions
May cause worsening of myocardial ischemia and may cause PVC's or Ventricular
Tachycardia. May result in undesired tachycardia. Hypotension from vasodilitation.
Special Considerations
Transcutanous pacing is now the treatment of choice in place of Isoproterenol.
There has been supportive evidence that Isoproterenol may be helpful in Torsades
de Point.
Lidocaine
First Line ACLS Drug
YES!
Indications and uses
Indications: Suppression of Ventricular ectopy, Ventricular Tachycardia, and
Ventricular Fibrillation.
Uses: Lidocaine is the first line anti-arrhythmic drug of choice. Lidocaine is used to
treat PVC's, Ventricular Tachycardia, and Ventricular Fibrillation.
Dosage and Administration
Give 1-1.5mg/kg IV every 3-5 min. up to a maximum dose of 3mg/kg. In ACLS
situations if Lidocaine was used to suppress ventricular arrythmias, always follow
with an infusion. Lidocaine can be given down the endotracheal tube. For an
infusion mix 2 grams in 500cc Normal Saline Soultion. Infusion rate is 1-4mg/min.
Adverse Reactions
Lidocaine Toxcity may cause CNS depression, convulsions, coma, hypotension and
death.
Special Considerations
In patients with impaired liver function or patients over 70, give the recommended
bolus, but decrease the normal infusion rate by 50%
Magnesium Sulfate
First Line ACLS Drug
YES!
Indications and uses
Indications: Magnesium sulfate is gaining popularity as an initial treatment in the
management of various dysrhythmias, particularly torsades de pointes, and
dysrhythmias secondary to a tricyclic antidepressant overdose or digitalis toxicity.
The drug is also considered as a class Ila agent (probably helpful) for refractory
ventricular fibrillation and ventricular tachycardia after administration of lidocaine
or bretylium doses.
Uses: Used primarily for the treatment of Torsades de points.
Dosage and Administration
1-2 grams IV diluted in 100cc of Normal Saline.
Adverse Reactions
The following adverse reations have been documented: Diaphoresis, facial flushing,
hypotension, depressed reflexes, hypothermia, reduced heart rate, circulatory
collapse, and respiratory depression.
Special Considerations
CNS depressant effects may be enhanced if the patient is taking other CNS
depressants. Serious changes in cardiac function may occur with cardiac glycosides.
Norepinephrine
First Line ACLS Drug
YES!
Indications and uses
Indications: Norepinephrine stimulates alpha-, beta1-, and beta2-adrenergic
receptors in dose-related fashion. It is indicated for non volume related hypotension.
It is the first pressor of choice if the systolic BP is less than 70mmhg. Dopamine is
the first pressor of choice if the systolic BP is between 70 and 90mmhg.
Uses: Systolic blood pressure less than 70mmhg, in a non-volume depleted patient.
Also used for the treatment of cardiogenic shock.
Dosage and Administration
Mix 4mg of Norepinephrine in 250cc of Normal Saline. Start at 2mcg/min and
titrate up for desired effect.
Adverse Reactions
May cause worsening of myocardial ischemia and may cause PVC's or Ventricular
Tachycardia. May result in undesired tachycardia.
Special Considerations
Do not use Norepinephrine without correcting the underlying hypovolemia.
Norepinephrine should always be used with a volumetric pump.
Oxygen
First Line ACLS Drug
YES!
Indications and uses
Indications: Oxygen is used in hypoxemia or suspected hypoxemia. Supplemental
oxygen raises the blood oxygen saturation, providing better tissue oxygenation. Has
been proven to decrease the workload on the myocardium.
Uses: Used as one of the first line treatments in all ACLS Situations.
Dosage and Administration
Stable Patients: Start with Nasal Prongs at 2-4lpm. May increase as needed or
change device as needed to meet patient's requirements.
Unstable Patients: Start with Simple Mask at 6-8lpm, or situation warrants use nonrebreather mask at 12-15lpm.
Dead Patients: Use Bag-valve-mask device with reservoir at 12-15lpm. Use airway
adjunct to support ventilation. Intubation is the airway of choice in all dead
patients.
Adverse Reactions
Any time oxygen is initiated be aware of patient's condition. If patient's condition
worsens, change to higher delivery device. If at any time the patient's airway or
ventilatory status worsens, support with the appropriate airway and Bag-valvemask device with reservoir.
Special Considerations
Always evaluate your patient's ventilatory status on an on-going basis.
Procainamide
First Line ACLS Drug
NO!
Indications and uses
Indications: Procainamide suppresses phase-4 depolarization in normal ventricular
muscle and Purkinje fibers, reducing the automaticity of ectopic pacemakers. It also
suppresses reentry dyrhythmias by slowing intraventricular conduction.
Procainamide may be effective in treating PVCs and recurrent ventricular
tachycardia that cannot be controlled with lidocaine.
Uses: Procainamide is indicated for ventricular dysrhythmias not controlled by
Lidocaine. Procainamide is not a first drug of choice for treatment of ventricular
dysrhythmias.
Dosage and Administration
20 mg/min (30 mg/min for refractory VF): maximum dose is 17 mg/kg Maintenance
infusion (after resuscitation from cardiac arrest) is 1-4 mg/min. For infusion, mix 2
grams of Procainamide in 500cc Normal Saline.
Adverse Reactions
Contraindicated in the following, Second- and third-degree AV block, digitalis
toxicity, and Torsades de pointes.
Special Considerations
End Points to Procainamide administration are, suppression of arrhythmia,
hypotension, widening of the QRS greater than 50% of original width, and
maximum dose reached.
Sodium Bicarbonate
First Line ACLS Drug
NO!
Indications and uses
Indications: Routine administration of Sodium Bicarbonate is longer recommended.
Hyperventilation is the treatment of choice to correct both metabolic and
respiratory acidosis.
Uses: Known preexisting bicarbonate-responsive acidosis Intubated patient with
continued long arrest interval Upon return of spontaneous circulation after long
arrest interval Tricyclic antidepressant overdose Alkalinization for treatment of
specific intoxications.
Dosage and Administration
Give 1 mEq/kg IV, you may repeat with 0.5 mEq/kg q 10 min.
Adverse Reactions
Metabolic alkalosis, hypoxia, rise in intracellular Pco2 and increased tissue acidosis,
electrolyte imbalance (tetany), seizures and tissue sloughing at injection site.
Special Considerations
Hyperventilation is the treatment of choice to correct both metabolic and
respiratory acidosis in a Code Blue situation.
Verapamil
First Line ACLS Drug
YES!
Indications and uses
Indications: Verapamil is used as an antidysrhythmic and antianginal agent. It
works by inhibiting the movement of calcium ions across cell membranes. The slow
calcium ion current blocked by verapamil is more important for the activity of the
SA and AV nodes than for many other tissues in the heart. By interfering with this
current, calcium channel blockers achieve some selectivitv of action. Verapamil
decreases atrial automaticity, reduces AV conduction velocity, and prolongs the AV
nodal refractory period. In addition, verapamil depresses mvocardial contractility,
reduces vascular smooth muscle tone, and dilates coronary arteries in normal and
ischemic tissues.
Uses: Primarily used in PSVT, Atrial flutter with a rapid ventricular response and
Atrial fibrillation with a rapid ventricular response.
Dosage and Administration
Give 2.5-5.0 mg IV bolus over 2 min; repeat doses of 5-10 mg may be given every 1530 min.
Adverse Reactions
Hypotension, espcially in hypovolemic patients. Other reactions are, dizziness,
headache, nausea and vomiting, bradycardia, complete AV block, and peripheral
edema.
Special Considerations
Give Calcium Chloride as reversal agent for Verapamil.