Jessica Schwenk PharmD 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 ID: 275852
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Slide1
ACLS Pharmacotherapy Update
Jessica Schwenk, Pharm.D.
September 14, 2013Slide2
Introduction
Objectives
ACLS Guideline Overview
Access for Medications in ACLSSlide3
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 algorithmsSlide4
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) Slide5Slide6
ACLS Guidelines
First priority
High quality CPR
Early defibrillation
Second priority
Medication administration
Advanced airway
For drug
administration or
ventilationSlide7
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 fluidSlide8
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)Slide9
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 breathsSlide10
ACLS Medications
Adult cardiac arrest algorithmSlide11Slide12Slide13Slide14Slide15
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, vasopressinSlide16
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 survivalSlide17
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 demandSlide18
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)Slide19
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 dosesSlide20
Vasopressors
Vasopressin
Dose and Administration
VF, PVT,
asystole
, PEA
IV/IO: 40 units one time (to replace 1
st
or 2
nd
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 1
st
or 2
nd
dose of epinephrine every 3-5 minutes)
Dilute in 5-10 ml SW or NSSlide21
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 PVTSlide22
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, thrombocytopeniaSlide23
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 bicarbonateSlide24
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-to-admission
May be considered if amiodarone is not availableSlide25
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, confusionSlide26
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 depressionSlide27
ACLS Medications
Adult bradycardia algorithm
(with pulse)Slide28Slide29
Adult bradycardia algorithm
(with pulse)Slide30
Adult bradycardia algorithm
(with pulse)Slide31
Adult bradycardia algorithm
(with pulse)
Medications
Atropine
Dopamine
EpinephrineSlide32
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 ischemiaSlide33
Adult bradycardia algorithm
(with pulse)
Dopamine
MOA: adrenergic and dopaminergic receptor agonist, stimulation of
β
1-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 bicarbonateSlide34
Adult
bradycardia
algorithm
(with pulse)
Epinephrine
MOA: adrenergic agonist, stimulation of
β
1-recptors 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 bicarbonateSlide35
ACLS Medications
Adult tachycardia algorithm
(with pulse)Slide36Slide37Slide38
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
AmiodaroneSlide39
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: magnesiumSlide40
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 2
nd
and 3
rd
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.Slide41
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 SVTSlide42
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 pressureSlide43
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 pressureSlide44
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 pressureSlide45
Adult tachycardia algorithm
(with pulse)
Atenolol
Dose and administration
5 mg slow IV push over 5 minutes
Repeat in 10 minutes
Monitor: ECG, blood pressureSlide46
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 pressureSlide47
Adult tachycardia algorithm
(with pulse)
Procainamide
Class
1
a
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,
hepatotoxicitySlide48
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)
F
ollow 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 fibrosisSlide49
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 depressionSlide50
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)
I
nject
small amount into blanched area, additional as
needed
Epineprine
(
norepinephrine
,
phenylephrine
)
Dopamine
VasopressinSlide51
What else is in the crash cart?Slide52
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