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Drugs in ACLS

Vent. Fib./Tach.

Asystole/PEA

Epinephrine
Vasopressin
Amiodarone
Lidocaine
Magnesium
Epinephrine
Vasopressin
(Atropine removed from
algorithm per 2010 ACLS
Guidelines)

Bradycardia

Tachycardia

Atropine
Epinephrine
Dopamine
adenosine
Diltiazem
Beta-blockers
amiodarone
Digoxin
Verapamil
Magnesium

Acute Coronary Syndromes

Oxygen
Aspirin
Nitroglycerin
Morphine
Fibrinolytic therapy
Heparin
Beta-Blockers

Acute Stroke

tPA-tissue plasminogen activator


Glucose (D50)
Labetalol
Nitroprusside
Nicardipine
Aspirin

Epinephrine
the primary drug used in the pulseless arrest algorithm. It is
used for its potent vasoconstrictive effects and also for its ability
to increase cardiac output. Epinephrine is considered a
vasopressor.
Indications for ACLS
1. Vasoconstriction effects: epinephrine binds directly to alpha-1 adrenergic
receptors of the blood vessels (arteries and veins) causing direct
vasoconstriction, thus, improving perfusion pressure to the brain and heart.
2. Cardiac Output: epinephrine also binds to beta-1-adrenergic receptors of the
heart. This indirectly improves cardiac output by:
o Increasing heart rate
o Increasing heart muscle contractility
o Increasing conductivity through the AV node
Epinephrine is used in the pulseless arrest algorithm as a direct IV
push and also in the bradycardia algorithm as an infusion. See the
respective algorithm pages for more information about their use in
each.

Routes
During ACLS, epinephrine can be given 3 ways: intravenous;
intraosseous, and endotracheal tube

Dosing

Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes.


IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or
D5W. The infusion should run at 2-10 micrograms/min (titrated to effect).
Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given
directly into the ET tube.

Epinephrine should be used with caution in patients suffering from


myocardial infarction since epinephrine increases heart rate and
raises blood pressure. This increase in HR and BP can increase
myocardial oxygen demand and worsen ischemia.
Note: There is no clinical evidence that the use of epinephrine, when
used during cardiac arrest, increases rates of survival to discharge
from the hospital. However, studies have shown that epinephrine
and vasopressin improve rates of ROSC (return of spontaneous
circulation).

Vasopressin
a primary drug used in the pulseless arrest algorithm. In high
concentrations, it raises blood pressure by inducing moderate
vasoconstriction, and it has been shown to be more effective than
epinephrine in asystolic cardiac arrest (Wenzel V, Krismer AC,
Arntz HR, Sitter H, Stadlbauer KH, Lindner KH (January 2004). A
comparison of vasopressin and epinephrine for out-of-hospital
cardiopulmonary resuscitation. N. Engl. J. Med. 350 (2): 10513.
doi:10.1056/NEJMoa025431. PMID 14711909.)
One major indication for vasopressin over epinephrine is its lower
risk for adverse side effects when compared with epinephrine.
With epinephrine, some studies have shown a risk of increased
myocardial oxygen consumption and post arrest arrhythmias
because of an increase in heart rate and contractility (beta 1
effects). Vasopressin also is thought too cause cerebral vessel
dilation and theoretically increase cerebral perfusion.
Trivia: Another name for vasopressin is antidiuretic hormone (ADH).

Routes
Vasopressin may be given IV/IO or by endotracheal tube.

Dosing
40 units of vasopressin IV/IO push may be given to replace the first
or second dose of epinephrine, and at this time, there is insufficient
evidence for recommendation of a specific dose per the
endotracheal tube.
In the ACLS pulseless arrest algorithm, vasopressin may replace the
first or second dose of epinephrine.

Amiodarone
considered a class III antiarrhythmic agent and is used for
various types tachyarrhythmias. Because of its associated toxicity
and serious side-effects it should be used cautiously and care should
be taken to ensure that cumulative doses are not exceeded.

Indications for ACLS


Amiodarone is an antiarrhythmic that is used to treat both
supraventricular arrhythmias and ventricular arrhythmias.
The mechanism of action of amiodarone remains unknown, but
within the framework of ACLS, amiodarone is used primarily to treat
ventricular fibrillation and ventricular tachycardia that occurs during
cardiac arrest and is unresponsive to shock delivery, CPR, and
vasopressors.
Amiodarone should not be used in individuals with polymorphic VT
as it associated with a prolonged QT interval which is made worse
with antiarrhythmic drugs.
Amiodarone should only be used after defibrillation/cardioversion
and first line drugs such as epinephrine and vasopressin have failed
to convert VT/VF.

Route
Amiodarone can be administered by intravenous or intraosseous
route.

Dosing
The maximum cumulative dose in a 24 hour period should not
exceed 2.2 grams.
Within the VT/VF pulseless arrest algorithm, the dosing is as follows:
300mg IV/IO push (if no conversion) 150 mg IV/IO push (after
conversion) Infusion #1 360 mg IV over 6 hours (1mg/min)
Infusion #2 540 mg IV over 18 hours (0.5mg/min)

For tachyarrhythmias other than life threatening, expert consultation


should be considered before use.
For Tachycardia other than pulseless VT/VF, Amiodarone dosing is as
follows: (see above note)
150 mg over 10 minutes repeat as needed if VT recurs
maintenance infusion of 1mg/min for 6 hours

Atropine
Atropine is the first drug used to treat bradycardia in the
bradycardia algorithm. It is classified as an anticholinergic drug and
increases firing of the SA Node by blocking the action of the vagas
nerve on the heart resulting in an increased heart rate.
Atropine should be used cautiously in the presence of myocardial
ischemia and hypoxia since it increases oxygen demand of heart
and can worsen ischemia.
The dosing for Atropine is 0.5 mg IV every 3-5 minutes as needed,
and the maximum total dosage that can be give is 3 mg.
Atropine should be avoided in hypothermic bradycardia and it will
not be effective for Mobitz type II/Second Degree Block Type 2.

Epinephrine and Dopamine


Epinephrine and dopamine are second-line drugs for symptomatic
bradycardia. They are both used as infusions in the bradycardia
algorithm if atropine is ineffective.
New 2010 ACLS guidelines state that if bradycardia is unresponsive
to atropine, an equally effective alternative to transcutaneous
pacing is the use of an IV infusion of the beta-adrenergic agonists
(dopamine or epinephrine).

Dosing:
Begin the epinephrine infusion at 2 to 10 mcg/min and titrate to
patients response.
The goal of therapy is to improve the patients clinical status rather
than target an exact heart rate.
Begin the dopamine infusion at 2 to 10 mcg/kg/min and titrate to
the patients response.

Precautions
Prior to use of ACLS drugs in the treatment of symptomatic
bradycardia, contributing factors of the bradycardia should be
explored then ruled out or corrected

Adenosine
used within the tachycardia algorithm when vagal maneuvers
fail to terminate stable narrow-complex SVT.
Adenosine is the primary drug used in the treatment of stable
narrow-complex SVT (supraventricular Tachycardia). It can now also
be used for regular monomorphic wide-complex tachycardia.
When given as a rapid IV bolus, adenosine slows cardiac conduction
particularly effecting conduction through the AV node. The rapid
bolus of adenosine also interrupts reentry (SVT causing) pathways
through the AV node and restores sinus rhythm in patients with SVT.
When injected into the body, adenosine is rapidly absorbed by red
blood cells and blood vessel endothelial cells and metabolized for
natural uses throughout the body. In light of this adenosine should
be administered by RAPID intravenous bolus so that a significant
bolus of adenosine reaches the heart before it is metabolized.
A change from the 2010 guidelines now has adenosine given up to
two times rather than three.

Dosing
The first dose of adenosine should be 6 mg administered rapidly
over 1-3 seconds followed by a 20 ml NS bolus. If the patients
rhythm does not convert out of SVT within 1 to 2 minutes, a second
12 mg dose may be given in similar fashion. All efforts should be
made to administer adenosine as quickly as possible.

Precautions
Some side effects of adenosine administration incude flushing, chest
pain/tightness, brief asystole or bradycardia.

Make sure that adenosine is not used for irregular, polymorphic


wide-complex tachycardia or VT. Use in these cases may cause
clinical deterioration.