ACLS update 2010, and Acute Resusitation and ACLS Medications

Drug Dosage Indications/Comments Antiarrhythmic Agents Adenosine Bolus: 6 mg (initial) If no response, bolus with 12 mg after 1 “2 min For conversion of PSVT unresponsive to vagal maneuvers May repeat 12 mg once Give as rapid IV bolus over 1 “3 s followed by rapid 10 ml fluid bolus May use lower bolus dose of 3 mg if central line available Be cautious of interactions with theophylline (inhibits adenosine), dipyridamole (potentiates adenosine), other drugs that prolong QT interval Amiodarone 300 mg bolus IV 150 mg bolus IV followed by 1 mg/min for 6 h and then 0.5 mg/min for 18 h For VF or pulseless VT refractory to shock ; may repeat 150 mg bolus IV in 3 “5 min For stable wide-complex tachycardia up to a total dose 2.2 g IV per 24 h May use for narrow complex atrial arrhythmias, as adjunct to cardioversion Monitor for bradycardia and hypotension Atropine Bolus: 0.5 mg IV (maximum dose 3 mg) For either absolute (<60 beats/min) or relative symptomatic bradycardia Bolus: 1 mg IV For bradycardia manifesting with lack of pulse, PEA or for asystole unresponsive to epinephrine May repeat dose every 3 “5 min up to maximum dose 0.04 mg/kg or 3 mg ETT bolus: 2 “3 mg Dilute up to 10 ml in NS or sterile water (IV preferred) Diltiazem 0.25 mg/kg IV bolus over 2 min (typically 15 “20 mg) For control of ventricular response rate in A fib or A flutter, or other narrow complex tachycardia May repeat once Do not use in wide-complex tachycardia 0.35 mg/kg IV bolus over 2 min (typically 25 mg) Negative inotrope, so use cautiously if reduced LV function Maintenance infusion 5 “15 mg/h Epinephrine Bolus: 1 mg IV (10 ml of 1:10,000 solution) Therapy for refractory VF or pulseless VT; dose should be followed by CPR and defibrillation; may be repeated every 3 “5 min Initial therapy for PEA; may repeat every 3 “5 min Initial therapy for asystole; may repeat every 3 “5 min ETT bolus: 2 “2.5 mg Dilute up to 10 ml NS or sterile water (IV preferred) Infusion: 2 “10 µg/min For treatment of symptomatic bradycardia unresponsive to atropine and transcutaneous pacing; alternative to dopamine Ibutilide 1 mg IV infused over 10 min; may be repeated after 10 min Use 0.01 mg/kg if <60 kg For treatment of atrial arrhythmias Monitor electrolytes and EKG Increased risk for torsade de pointes if elderly, abnormal LV function (EF <35%), or electrolyte abnormalities Monitor for 4 “24 h Isoproterenol Infusion: 2 “10 µg/min May be used in torsade de pointes unresponsive to magnesium Use with extreme caution; at higher doses is considered harmful Not indicated for cardiac arrest, hypotension, or bradycardia Lidocaine Bolus: 1 “1.5 mg/kg For wide-complex tachycardia of uncertain type, stable VT, and control of PVCs May be followed by boluses of 0.5 “0.75 mg/kg every 5 “10 min up to a total of 3 mg/kg Only bolus therapy should be used in cardiac arrest Bolus: 1.5 mg/kg Initial bolus dose suggested when VF is present and defibrillation and epinephrine have failed ETT bolus: 2 “4 mg/kg Diluted in 5 “10 ml NS or sterile water (IV preferred) Infusion: 2 “4 mg/min Continuous infusion used after bolus dosing and following return of perfusion to prevent recurrent ventricular arrhythmias Because half-life of lidocaine increases after 24 “48 h, the dose should be reduced after 24 h, or levels should be monitored Therapeutic levels 1 “4 mg/L Full-loading dose but reduced infusion rate in patients with low cardiac output, hepatic dysfunction, or age over 70 years Magnesium sulfate Bolus: 1 “2 g (8 “16 mEq) Drug of choice in patients with torsade de pointes For recurrent/refractory VT or VF For hypomagnesemia For ventricular dysrhythmias, administer over 1 “2 min For magnesium deficiency, administer over 60 min Infusion: 0.5 “1 g/h (4 “8 mEq/h) Rate and duration of infusion determine clinically or by magnitude of magnesium deficiency Naloxone 0.4 mg IV is typical Onset of action 2 min IV and <5 min IM/SC May give 0.4 “2 mg IV every 2 “3 min (maximum dose is 10 mg) Duration of action ~45 min Give 0.4 mg diluted in 10 ml NS or sterile water slowly to avoid abrupt narcotic withdrawal 0.8 mg IM/SC Hypertension/hypotension, cardiac arrhythmias, pulmonary edema may occur Monitor for reoccurring respiratory depression because narcotics typically last longer than naloxone ETT: 2 mg diluted in 5 “10 ml NS or sterile water (IV preferred) Procainamide 12 “17 mg/kg; administer at rate of 20 “30 mg/min (maximum 50 mg/min) Infrequently used Recommended when lidocaine is contraindicated or has failed to suppress ventricular ectopy Use higher dose for more urgent situations (VF or pulseless VT) Maximum total dose of 17 mg/kg Continue bolus dosing until arrhythmia suppressed, hypotension, QRS complex widens by 50% of original width, or maximum total dose given Rapid infusion may cause precipitous hypotension Avoid in patients with QT prolongation (>30% above baseline) or torsade de pointes Infusion: 1 “4 mg/min Continuous maintenance infusion, after return of perfusion, to prevent recurrent arrhythmias Reduce dosage in renal failure Monitor blood levels in patients with renal failure or with >24-h infusion Therapeutic levels: procainamide 4 “10 mg/L, N-acetyl-procainamide (NAPA) 10 “20 mg/L Vasopressin 40 U IV push, one dose only As an alternative to 1st or 2nd dose epinephrine in refractory VF, asystole, or PEA resume epinephrine after 3 “5 min Verapamil Bolus: 2.5 “10 mg over 2 “3 min Only give to patients with narrow complex PSVT unresponsive to adenosine May repeat in 15 “30 min prn Max. cumulative = 20 mg Diltiazem (0.25 mg/kg) is an alternative to verapamil because it has less negative inotropy Vasopressor Agents Dopamine (For other vasopressors, Table 3.8 ) Infusion: 2 “20 µg/kg/min For treatment of symptomatic bradycardia unresponsive to atropine and transcutaneous pacing For treatment of hypotension that is unresponsive to volume Electrolyte Agents Sodium bicarbonate Bolus: 1 mEq/kg Helpful in limited clinical conditions: hyperkalemia, bicarbonate responsive acidosis, tricyclic antidepressant overdose Not recommended in the majority of arrest cases (hypoxic lactic acidosis) Guide therapy by blood gas analyses and calculated base deficit to minimize iatrogenic alkalosis A fib, atrial fibrillation; A flutter, atrial flutter; CPR, cardiopulmonary resuscitation; EF, ejection fraction; EKG, electrocardiogram; ETT, endotracheal tube; IM, intramuscular; IV, intravenous; LV, left ventricular; MI, myocardial infarction; NS, normal saline; PEA, pulseless electrical activity; PSVT, paroxysmal supraventricular tachycardia; PVC, premature ventricular contraction; SC, subcutaneous ; VF, ventricular fibrillation; VT, ventricular tachycardia

Shock General Management

Type of Shock Initial Therapy Subsequent Therapy Cardiogenic Shock Massive myocardial infarction Supplemental oxygen , aspirin, pain relief, venous access Therapy for ACS (see Table 3.1 ) Optimize volume status and ensure adequate preload Treat arrhythmias Consider RHC Determine need for inotropic agents; diuretics; vasodilators; vasopressors (see Tables 3.3 and 3.8 ) Consider mechanical ventilation Early IAB, coronary arteriography, and revascularization by PCI or bypass grafting Consider thrombolytic agent if cardiac catheterization not possible Nonischemic cardiomyopathy Therapy as above, but omit therapy for ACS Consider IAB or assist devices as bridge to transplantation Consider reversible causes (e.g., acute valvular regurgitation requiring emergent valve replacement, thyrotoxicosis ) Oligemic Shock Massive hemorrhage, severe dehydration, etc. For hemorrhage, large bore peripheral or central venous access Volume resuscitation with packed RBCs and 0.9% NaCl Consider use of blood warmer If large bleed , consider platelets, fresh frozen plasma, and supplemental calcium For dehydration, volume resuscitation with 0.9% NaCl or Ringer's lactate Monitor electrolytes and coagulation If hypotension persists despite volume resuscitation, consider: possibility of coexisting sepsis, tamponade, or ACS; RHC; inotropic and/or vasopressor agents Consult GI and surgery for massive gastrointestinal hemorrhage (see Table 7.1 ) Extracardiac Obstructive Shock Tamponade Confirm suspected diagnosis with echocardiography and/or RHC, temporize by increasing filling pressures with bolus 0.9% NaCl IV; support BP Urgent percutaneous pericardiocentesis, surgical pericardiotomy, or pericardial window Massive pulmonary embolism Correct hypoxemia; administer heparin or LMWH; thrombolytic therapy (alteplase 100 mg IV over 2 h); give inotropic support such as dobutamine for right heart strain and failure Consider percutaneous catheter suction thrombectomy or thoracotomy with embolectomy Consider IVC filter long term See Table 4.11 Tension pneumothorax Emergent needle or tube thoracostomy Tube thoracostomy Distributive Shock Septic shock Emergent broad-spectrum antibiotics IV after blood cultures; IV crystalloid; if shock persists, consider RHC If shock persists despite adequate preload, add dopamine 2 “20 µg/kg/min; or norepinephrine 2 µg/min Consider vasopressin in refractory shock Stress dose steroids hydrocortisone 100 mg IV q8h; optional fludrocortisone 50 µg po qd Consider baseline cortisol level prior to glucocorticosteroid therapy and corticotropin stimulation test Role of drotrecogin alfa is not established a Anaphylaxis Epinephrine 0.3 “0.5 mg for severe symptoms of hypotension, bronchospasm, or laryngeal edema; given as 0.3 “0.5 ml of 1:1,000 SC or 0.5 “1.0 ml of 1:10,000 solution IV; also give diphenhydramine 50 mg IV; repeat 25 “50 mg IV q4h prn; abnormal permeability causes intravascular depletion, which should be corrected with volume Cautious administration prn of additional epinephrine; give corticosteroids (Methylprednisolone 60 mg IV or equivalent) and cimetidine 300 mg IV q12; these will have delayed rather than immediate effect For persistent symptoms and patient on ²-blockers, give glucagon 1 mg IV Hypoadren-alism Administer dexamethasone 4 mg IV q6h together with fluids To confirm diagnosis, perform corticotropin stimulation test (dexamethasone will not interfere); draw baseline cortisol level, give 250 µg IV cosyntropin, and repeat cortisol level 30 min later Neurogenic Trendelenburg position; fluids If hypotension persists, consider vasopressors (e.g., phenylephrine or metaraminol) ACS, acute coronary syndrome; BP, blood pressure; GI, gastroenterology; IAB, intra- aortic balloon; IV, intravenous; IVC, inferior vena cava; LMWH, low molecular weight heparin; PCI, percutaneous coronary intervention; RBCs, red blood cells ; RHC, right heart catheterization a While some authors recommend drotrecogin alfa (recombinant activated protein C) in highly selected patients with a high risk of death (Apache score of ‰25) and a low risk of bleeding, the role of drotrecogin alfa in septic patients has not been clearly established. It has no effect or is harmful in septic patients with Apache score of <25, in surgical patients with single organ dysfunction, and in pediatric sepsis. The risk of serious bleeding including intracerebral hemorrhage is increased in patients receiving drotrecogin alfa.

Hypovolemic Shock

Mild Moderate Severe Life- threatening % loss of intravascular volume ‰10 “15% 15 “30% 30 “40% >40% Loss of intravascular volume (cc) <700 “800 800 “1500 1500 “2000 >2000 Mean arterial pressure WNL WNL Reduced Reduced Heart rate 80 “100 101 “119 120 “140 >140 Pulse pressure WNL/increased 101 “119 Reduced 120 “140 Reduced >140 Reduced Respirations (breaths/min) 15 “20 21 “29 30 “35 >35 Capillary refill test a ‰2 s >3 s >3 s >3 s Urine output (cc/h) ‰30 20 “30 5 “15 Oliguria Mental status Uneasy Mild anxiety Anxiety or confusion Confusion or lethargy Volume replacement Crystalloid Crystalloid Crystalloid or blood if indicated Crystalloid or blood if indicated a The capillary refill test is performed by pressing on the fingernail or the hypothenar eminence. The test is not valid in hypothermic patients. WNL = within normal limits.

Crystalloids and Colloids

Fluid Dosage Comments 0.9% NaCl ‰500 ml a Hyperchloremic metabolic acidosis secondary to vigorous NaCl replacement may occur Lactated Ringer's ‰500 ml a Balanced electrolyte composition (mEq/L): Na + 130, K + 4, Ca ++ 3, Cl - 110, lactate 28 Not compatible with blood products 5% albumin 0.25 “1 g/kg b Each 250 ml contains 12.5 g albumin 25% albumin 0.25 “1 g/kg b Each 100 ml contains 25 g albumin 6% hetastarch ‰500 ml a Chemically modified glucose polymer Large doses, especially >1500 ml, can lead to coagulopathies (factor VIII deficiency) and platelet abnormalities Can cause artifactual hyperamylasemia Anaphylactoid reactions have occurred Total amount should not exceed 1,500 ml/d (20 ml/kg) Cautious use in cardiac bypass and septic patients 6% hetastarch in lactated electrolyte injection 500 “1,000 ml Chemically modified glucose polymer Balanced electrolyte composition (mEq/L): Na + 143, K + 3, Ca ++ 5, Cl - 124, Mg ++ 0.9, lactate 28, dextrose 0.99 g/L A volume expander used to support oncotic pressure and provide electrolytes Doses >1,500 ml are rarely required Can cause artifactual hyperamylasemia Use with caution in anticoagulated patients a Most crystalloids are given in 500 ml aliquots as quickly as possible (i.e., over 10 “15 minutes) to increase blood pressure or perfusion. If initial aliquot is not successful in increasing blood pressure, then repeat until hemodynamic stability or the addition of a vasopressor agent occur. b Colloid has no proven outcome benefit in general ICU patients; it may have a role in hypotensive patients. Dextrans and gelatins are rarely used plasma expanders.

Universal Algorithm for Adult Emergency Cardiac Care AED, automatic external defibrillator; CPR, cardiopulmonary resuscitation; ECG, electro-cardiogram; EMS Emergency Management Service; IV, intravenous; MI, myocardial infarction

Algorithm for Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT) ABC, airway breathing circulation; CPR, cardiopulmonary resuscitation; IV, intravenous; PEA, pulseless electrical activity Give drugs typically at 3 “5 minute intervals: Vasopressin 40 U IV single dose (wait 10 minutes before giving epinephrine)

Algorithm for Pulseless Electrical Activity (PEA) CPR, cardiopulmonary resuscitation; EMD, electromechanical dissociation; IV, intravenous Class I: definitely helpful. Class IIa: acceptable, probably helpful. Class IIb: acceptable, possibly helpful. Class III: not indicated, may be harmful. *Sodium bicarbonate 1 mEq/kg: is Class I: if patient has known pre-existing hyperkalemia. Sodium bicarbonate 1 mEq/kg: Class IIa: if known pre-existing bicarbonate-responsive acidosis; if overdose with tricyclic antidepressants; to alkalinize the urine in drug overdoses. Class IIb: if intubated and long arrest interval; upon return to spontaneous circulation after long arrest interval. Class III: hypoxic lactic acidosis. (

Asystole Treatment Algorithm CPR, cardiopulmonary resuscitation; IV, intravenous; TCP, transcutaneous pacing (

Bradycardia Algorithm (Patient not in Cardiac Arrest) ABC, airway breathing circulation; AV, atrioventricular; BP, blood pressure; ECG, electrocardiogram; HF, heart failure; IV, intravenous; MI, myocardial infarction; TCP, transcutaneous pacemaker *Serious signs or symptoms must be related to the slow rate. Clinical manifestations include: symptoms (chest pain, shortness of breath , decreased level of consciousness) and signs (low BP, shock, pulmonary congestion, HF, acute MI). Do not delay TCP while awaiting IV access or for atropine to take effect if patient is symptomatic. §Atropine should be given in repeat doses in 3 “5 minutes up to total of 0.04 mg/kg. Never treat third-degree heart block plus ventricular escape beats with lidocaine. #Verify patient tolerance and mechanical capture. Use analgesia and sedation as needed. (

Tachycardia Algorithm ABC, airway breathing circulation; AV, atrioventricular; BP, blood pressure; DC, direct current; ECG, electrocardiogram; LV, left ventricular; PSVT, paroxysmal supraventricular tachycardia; VT, ventricular tachycardia

Electrical Cardioversion Algorithm (Patient not in Cardiac Arrest) IV, intravenous; VT, ventricular tachycardia *PSVT (paroxysmal supraventricular tachycardia) and atrial flutter often respond to lower energy levels (start with 50 J) Source Link can be found here- http://www.aclspro.com/links.htm