ACLS Medications

Younas inayat

BradycardiaAtropineDopamine infusionEpinephrine infusion

AtropineMechanism of ActionInhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes)

AtropineIndicationsFirst drug for symptomatic sinus bradycardiaMay be beneficial in AV block or asystoleSecond drug in asystole or slow PEAOrganophosphate poisoning; large dose may be neededPrecautionsMI and hypoxia atropine increases oxygen demandAvoid in hypothermiaNot effective for 2nd type II or new 3rd degree block (may slow the rhythm)Doses < 0.5 mg may cause a paradoxical slowing

DopamineMechanism of ActionStimulates adrenergic receptors; dose dependent.

DopamineIndicationsSecond-line drug for symptomatic bradycardiaHypotension with signs and symptoms of shockPrecautionsCorrect hypovolemia with volume before initializingUse caution with cardiogenic shock and associated CHFMay cause tachydysrhythmias; excessive vasoconstrictionDont mix with sodium bicarbonateIV AdministrationInfusion at 5-20 mcg/kg/min.Titrate to patient response; taper slowly

EpinephrineMechanism of ActionStimulates adrenergic receptors and is not dose dependent like dopamine.

EpinephrineIndicationsCardiac arrestVF; VT; asystole; PEASymptomatic bradycardiaAfter atropine; alternative to dopamineSevere hypotensionWhen atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitorsAnaphylaxis; severe allergic reactionsCombine with large fluid volume; corticosteroids; antihistamines

EpinephrinePrecautionsMay increase myocardial ischemia, angina, and oxygen demandHigh doses do not improve survival; may be detrimentalHigher doses may be needed for poison/drug induced shockDosingCardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min.High dose up to 0.2 mg/kg for specific drug ODsInfusion of 2-10 mcg/min.Endotracheal of 2-2.5 times normal doseSQ/IM 0.3-0.5 mg

TachycardiaAdenosineDiltiazemMetoprololAmiodaroneLidocaineMagnesium Sulfate

AdenosineMechanism of ActionSlows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.

AdenosineIndications1st drug for stable, narrow complex, regular SVTMay consider for unstable SVT while preparing for cardioversionWide-complex tachycardia thought to be, or determined to be reentry SVTDoes not convert atrial fibrillation, atrial flutter, or VTDiagnostic maneuver; stable narrow-complex SVT

AdenosineContraindications/PrecautionsPoison/drug induced tachycardia is contraindicated2nd and 3rd degree block is contraindicatedTransient side effects; flushing, CP, asystole, brady, ectopyLess effective with theophylline or caffeineIf used for VT may cause worsening of clinical conditionTransient periods of sinus brady or ventricular ectopy common after termination of SVTSafe in pregnancy

AdenosinePlace supine or mild reverse Trendelenburg6 mg rapidly followed by 20 mL flushMay repeat at 12 mg every 1-2 minutes if unsuccessful

DiltiazemMechanism of ActionInhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.

DiltiazemIndicationsControlling ventricular rate in a-fib or flutterAfter adenosine to treat refractory reentry SVT if adequate blood pressureContraindications/PrecautionsDo not use with wide-complex rhythmsDo not use with poison/drug induced tachycardiaAvoid in WPWAvoid in AV nodal blocksBlood pressure may drop from peripheral vasodilation

DiltiazemRate control15-20 mg (0.25 mg/kg) IV over 2 minutesAfter 15 min. another 20-25 mg (0.35 mg/kg) IV over 2 minutes, if neededMaintenance Infusion5-15 mg/hour; titrated to physiologically appropriate heart rate

MetoprololMechanism of ActionSelectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.

MetoprololIndicationsAdminister to all patients with suspected MI or unstable angina, absent contraindicationsSecond-line agent for SVT refractory to adenosineTo reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressureEmergency antihypertensive therapy for acute hemorrhagic or ischemic stroke

MetoprololContraindications/PrecautionsHemodynamically unstable patients should not receiveSigns of heart failureLow cardiac outputIncreased risk for cardiogenic shockRelative contraindications: 1st, 2nd, 3rd degree blocks; active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHgConcurrent administration of calcium channel blockers can cause serious hypotensionMonitor cardiac and pulmonary status throughout

AmiodaroneMechanism of ActionProlongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.

AmiodaroneIndicationsLife threatening dysrhythmiasVF/pulseless VT unresponsive to shock, CPR, and vasopressorRecurrent hemodynamically unstable VTSeek expert opinion for other usesContraindications/PrecautionsBradycardia2nd and 3rd degree blockDo not administer with meds that prolong QT interval (procainamide)

AmiodaroneVF/VT 300 mg IV/IO in 20-30 mL NS. Can follow with ONE dose of 150 mg in 3-5 minutes, if needed.Life threatening dysrhythmias150 mg over 10 minutes. May repeat every 10 minutes as needed.

LidocaineMechanism of ActionDecreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.

LidocaineIndicationsAlternative to amiodarone in VF/VT arrestStable monomorphic VTMalignant PVCsCan be used if Torsades is suspectedContraindications/PrecautionsProphylactic use in AMI is contraindicatedReduce maintenance dose in liver impaired patientsDiscontinue infusion if toxicity develops

LidocaineCardiac ArrestInitial dose is 1-1.5 mg/kgRefractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3 mg/kgEndotracheal dose 2-4 mg/kgPerfusing Dysrhythmia0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kgMaintenance Infusion1-4 mg/min

Magnesium SulfateMechanism of ActionIncreases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.

Magnesium SulfateIndicationsTorsades is suspected in cardiac arrestLfe-threatening ventricular dysrhythmias in digitalis ODPrecautionsFall in BP with rapid administrationUse caution in renal failureDosingArrest 1-2 g over 5-20 min.Torsades w/ pulse 1-2 g over 5-60 min.

VasopressinMechanism of ActionCauses vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.

VasopressinIndicationsAlternative to epinephrine in adult refractory VF/VTAlternative to epinephrine in asystole or PEAContraindications/PrecautionsPotent peripheral vasoconstrictor (increased demand upon resuscitation)DosingSingle dose of 40 u that replaces either the 1st or 2nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes afterCan be used endotracheally; no suggested dose