acls pharmacology 2010v2

7/28/2019 ACLS Pharmacology 2010v2

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ACLS PHARMACOLOGY


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GOAL

To increase vascular tone

To improve automaticity and cardiac output

To treat arrhythmias

To improve oxygenation to the critical

organs


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OXYGEN

Yes, it is a drug!

Expired air contains 16% oxygen

Decreased paO2


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OXYGEN

Indication:

cardiorespiratory arrest

chest pain

hypoxia regardless of origin

Always use 100%

Precautions


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DRUGS AFFECTING

VASCULAR TONE


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EPINEPHRINE

Non-specific adrenergic agonist

Effects on the heart:

increases S-A node discharge rate

improves A-V conduction

Effects on the vasculature:

constricts

Net effect: tachycardia, increased blood

pressure


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EPINEPHRINE Indications:

cardiac arrest

symptomatic bradycardia

severe hypotension

anaphylaxis

Dose:

1 mg IV/IO every 3-5 minutes. Flush line.

ET no longer recommended

Higher doses?


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EPINEPHRINE

Precautions:

Increased work on the heart

Ischemia


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VASOPRESSIN

Pressor and antidiuretic

Indications:

alternative to epinephrine in the treatment ofshock-refractory VF

Dose: 40 units IV, IO, ET once only

Precautions: not recommended for patients with CAD

Caution in patients with CHF


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OTHER VASOACTIVE

DRUGS Dopamine

precursor of norepinephrine

adrenergic and dopaminergic effects

Norepinephrine

non-specific adrenergic agonist

Phenylephrine

alpha 1 agonist

Continuous infusion


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OTHER VASOACTIVE

DRUGS Titrate to response

Precautions:

excessive vasoconstriction

decreased cardiac output

extravasation


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DRUGS THAT INCREASE

CARDIAC OUTPUT


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ATROPINE Parasympatholytic (decreases effect of acetylcholine

at muscarinic receptors)

Decreases cholinergic effects at the SA and AV nodes.

Indications: Symptomatic sinus bradycardia

Heart block

No longer for PEA or asystole

Dose: 1 mg IV every 3-5 minutes to a maximum of

0.04 mg/kg or 3 mg

For symptomaticbradycardia 0.5 mg


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ATROPINE

Precautions:

Increased workload on the heart

Paradoxical bradycardia with doses lower than0.5 mg


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DOBUTAMINE

Beta-1 specific agonist

Increased contractility with small increase

in heart rate

Dose: continuous infusion at 2-20

mcg/kg/min.


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DOBUTAMINE

Precautions:

Tachyarrhythmias

Headache, nausea

Use with caution in severe CAD


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INAMRINONE AND

MILRINONE Phosphodiesterase inhibitors

Independent of the adrenergic system

Dose:

bolus

continuous infusion

Precautions:

hypotension, thrombocytopenia


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ANTIARRHYTHMICS


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ADENOSINE

Naturally occurring nucleoside

Indication:

narrow complex PSVT

Dose: 6 mg fast IV push, repeat 12 mg once

after 2 minutes

Precautions

flushing, chest pain, brief asystole


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AMIODARONE

Class III antiarrhythmic

Indications:

VF, pulseless VT (now drug of choice)

VT and wide complex tachycardia

adjunct to electrical cardioversion in SVT,

PSVT


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AMIODARONE

Dose:

Cardiac arrest: 300 mg IV push. May repeat

150 mg in 3-5 minutes

Stable wide complex tachycardia: rapid and

slow infusion regimens

Precautions:

vasodilatation and hypotension

negative inotropic effects

long half-life


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LIDOCAINE

Indications:

cardiac arrest from VF/VT

stable VT

Dose:

1-1.5 mg/kg bolus

continuous infusion 1-4 mg/min


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LIDOCAINE

Precautions:

reduce dose with hepatic impairment

CNS side effects


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PROCAINAMIDE

Indications:

PSVT, VT, VF

Dose: 20-30 mg/min (max rate 50 mg/min) IVuntil:

arrhythmia is suppressed

hypotension

QRS widens by >50% total dose of 17 mg/kg given

Maintenance infusion at 1-4 mg/min


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PROCAINAMIDE

Precautions

Active metabolite

Reduce dose in renal failure

QT segment prolongation

proarrhythmic


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MAGNESIUM SULFATE

Indication:

cardiac arrest iftorsades de pointes present

Refractory VF

ventricular arrhythmia secondary to digoxin

toxicity

Dose: 1-2 g IV Precautions:

hypotension, renal dysfunction


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VERAPAMIL AND

DILTIAZEM Indications:

PSVT, A-fib, A-flutter

Dosing

IV bolus

continuous infusion (diltiazem only)

Precautions:

WPW

negative inotropy, hypotension


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DIGOXIN

Indications

A-fib, A-flutter, PSVT

Dose:

10-15 mcg/kg

Precautions:

arrhythmias

effect of low K, Mg, high Ca


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BETA-BLOCKERS

Indications:

PSVT

AMI

Hypertension

Drugs used:

Atenolol, metoprolol, esmolol, labetalol


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BETA-BLOCKERS

Precautions:

additive A-V block

hypotension

negative inotropy


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MISCELLANEOUS AGENTS


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CALCIUM CHLORIDE

Indications:

Arrhythmias secondary to hyperkalemia

Hypocalcemia

Dose:

1 gram (10% solution) slow IV push

Precautions:

bradycardia

hypotension


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SODIUM BICARBONATE

Indication:

Metabolic acidosis

Dose:

1 mEq/kg IV push

Precautions:

hypokalemia, alkalosis

hypernatremia


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LOOP DIURETICS

Furosemide

Ethacrynic acid (not a sulfonamide)

Bumetanide

Torsemide


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LOOP DIURETICS

Indication:

Pulmonary edema

Dose:

Furosemide 40 mg (starting)

Precautions:

Electrolyte disturbances (K, Mg)

Hypovolemia


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MORPHINE SULFATE

Analgesic action

Vasodilator

Indications: Acute MI, Pulmonary edema

Dose: 2-5 mg IV

Precautions: Sedation, respiratory

depression, hypotension

Naloxone does not reverse hypotension


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THROMBOLYTIC THERAPY


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What are thrombolytics?

Proteins

Act on plasminogen to form plasmin

Plasmin cleaves fibrin

Clots dissolved


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Why thrombolytics?

Remarkable improvement in outcomes of

MI patients

Must be started as soon as diagnosis ismade


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THROMBOLYTICS

Streptokinase (Streptase)

Anistreplase (Eminase)

Alteplase (Activase, t-PA)

Reteplase (Retavase)

Tenecteplase (TNKase)


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CONTRAINDICATIONS

Recent hemorrhagic stroke

Recent surgery

Active internal bleeding

Cerebral neoplasm

Severe uncontrolled hypertension


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SUMMARY

Know your algorithms. Refer to the cards.

Know WHY you are giving the drug

Flush the line after each drug

CIRCULATE

You are not alone!

acls pharmacology 2010v2

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