ACLS PHARMACOLOGY

GOAL
To increase vascular tone To improve automaticity and cardiac output To treat arrhythmias To improve oxygenation to the critical organs

OXYGEN
Yes, it is a drug! Expired air contains 16% oxygen Decreased paO2

OXYGEN
Indication:
cardiorespiratory arrest chest pain hypoxia regardless of origin

Always use 100% Precautions

DRUGS AFFECTING VASCULAR TONE

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

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?

EPINEPHRINE
Precautions:
Increased work on the heart Ischemia

VASOPRESSIN
Pressor and antidiuretic Indications:
alternative to epinephrine in the treatment of shock-refractory VF

Dose: 40 units IV, IO, ET once only Precautions:

not recommended for patients with CAD Caution in patients with CHF

OTHER VASOACTIVE DRUGS

Dopamine
precursor of norepinephrine adrenergic and dopaminergic effects

Norepinephrine
non-specific adrenergic agonist

Phenylephrine
alpha 1 agonist

Continuous infusion

OTHER VASOACTIVE DRUGS

Titrate to response Precautions:
excessive vasoconstriction decreased cardiac output extravasation

DRUGS THAT INCREASE CARDIAC OUTPUT

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 symptomatic bradycardia 0.5 mg

ATROPINE
Precautions:
Increased workload on the heart Paradoxical bradycardia with doses lower than 0.5 mg

DOBUTAMINE
Beta-1 specific agonist Increased contractility with small increase in heart rate Dose: continuous infusion at 2-20 mcg/kg/min.

DOBUTAMINE
Precautions:
Tachyarrhythmias Headache, nausea Use with caution in severe CAD

INAMRINONE AND MILRINONE

Phosphodiesterase inhibitors Independent of the adrenergic system Dose:
bolus continuous infusion

Precautions:
hypotension, thrombocytopenia

ANTIARRHYTHMICS

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

AMIODARONE
Class III antiarrhythmic Indications:
VF, pulseless VT (now drug of choice) VT and wide complex tachycardia adjunct to electrical cardioversion in SVT, PSVT

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

LIDOCAINE
Indications:
cardiac arrest from VF/VT stable VT

Dose:
1-1.5 mg/kg bolus continuous infusion 1-4 mg/min

LIDOCAINE
Precautions:
reduce dose with hepatic impairment CNS side effects

PROCAINAMIDE
Indications:
PSVT, VT, VF

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

arrhythmia is suppressed hypotension QRS widens by >50% total dose of 17 mg/kg given

Maintenance infusion at 1-4 mg/min

PROCAINAMIDE
Precautions
Active metabolite Reduce dose in renal failure QT segment prolongation proarrhythmic

MAGNESIUM SULFATE
Indication:
cardiac arrest if torsades de pointes present Refractory VF ventricular arrhythmia secondary to digoxin toxicity

Dose: 1-2 g IV Precautions:

hypotension, renal dysfunction

VERAPAMIL AND DILTIAZEM

Indications:
PSVT, A-fib, A-flutter

Dosing
IV bolus continuous infusion (diltiazem only)

Precautions:
WPW negative inotropy, hypotension

DIGOXIN
Indications
A-fib, A-flutter, PSVT

Dose:
10-15 mcg/kg

Precautions:
arrhythmias effect of low K, Mg, high Ca

BETA-BLOCKERS
Indications:
PSVT AMI Hypertension

Drugs used:
Atenolol, metoprolol, esmolol, labetalol

BETA-BLOCKERS
Precautions:
additive A-V block hypotension negative inotropy

MISCELLANEOUS AGENTS

CALCIUM CHLORIDE
Indications:
Arrhythmias secondary to hyperkalemia Hypocalcemia

Dose:
1 gram (10% solution) slow IV push

Precautions:
bradycardia hypotension

SODIUM BICARBONATE
Indication:
Metabolic acidosis

Dose:
1 mEq/kg IV push

Precautions:
hypokalemia, alkalosis hypernatremia

LOOP DIURETICS
Furosemide Ethacrynic acid (not a sulfonamide) Bumetanide Torsemide

LOOP DIURETICS
Indication:
Pulmonary edema

Dose:
Furosemide 40 mg (starting)

Precautions:
Electrolyte disturbances (K, Mg) Hypovolemia

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

THROMBOLYTIC THERAPY

What are thrombolytics?

Proteins Act on plasminogen to form plasmin Plasmin cleaves fibrin Clots dissolved

Why thrombolytics?
Remarkable improvement in outcomes of MI patients Must be started as soon as diagnosis is made

THROMBOLYTICS
Streptokinase (Streptase) Anistreplase (Eminase) Alteplase (Activase, t-PA) Reteplase (Retavase) Tenecteplase (TNKase)

CONTRAINDICATIONS
Recent hemorrhagic stroke Recent surgery Active internal bleeding Cerebral neoplasm Severe uncontrolled hypertension

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!