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ACLS Pharmacotherapy Update ACLS Pharmacotherapy Update

ACLS Pharmacotherapy Update - PowerPoint Presentation

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ACLS Pharmacotherapy Update - PPT Presentation

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

adult algorithm dose medications algorithm adult medications dose pulse minutes administration acls tachycardia cardiac min epinephrine amiodarone blood arrest

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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) Slide5
Slide6

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 algorithmSlide11
Slide12
Slide13
Slide14
Slide15

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)Slide28
Slide29

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)Slide36
Slide37
Slide38

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

References

ACLS Provider Manual Supplementary Material (

2012).

American Heart Association Web site. Available at: http://www.hearttraining.com/media/documents/ACLS. Accessed August 13, 2013.

Barletta, JF. Cardiopulmonary resuscitation. In:

DiPiro

JT, Talbert RL, Yee GC,

Matzke

GR, Wells BG, Posey LM, editors. Pharmacotherapy. A

Pathophysiologic

Approach. 6th ed. New York (NY): McGraw Hill;2005:171-184.

Bauman JL, Schoen MD. Arrhythmias.

In

:

DiPiro

JT, Talbert RL, Yee GC,

Matzke

GR, Wells BG, Posey LM, editors. Pharmacotherapy.

A

Pathophysiologic

Approach.

6th

ed. New York (NY): McGraw Hill;2005:321-356.

DRUGDEX® System [Internet database].

Greenwood

Village,

Colo

: Thomson Healthcare.

Updated

periodically.

Hazinski

MF, Nolan JP,

Billi

JE, et al. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122:e1-330.

Lacy CF, Armstrong LL, Goldman MP, Lance LL.

Lexi

-Comp’s Drug Information Handbook. 17th ed. Hudson (OH): Lexi-Comp;2008.

Ponzer

CN, Advanced cardiac life support (ACLS) in adults. In: UpToDate,

Basow

, DS (Ed), UpToDate, Waltham, MA, 2013.