Beruflich Dokumente
Kultur Dokumente
Pharmacology
and
Update on New ACLS
Guidelines
Krista Piekos, Pharm.D.
Clinical Pharmacy Specialist - Critical Care
Harper University Hospital
Adjunct Assistant Professor
Wayne State University
Objectives
Outline
Background
evidence
Integrate into a class of recommendation
Revised guidelines
Classification of
Therapeutic Interventions
New Goals
1. Early Defibrillation - Public Access Defibrillation (PAD)
Probability of successful defibrillation and survival is negatively
related to the time from onset of VF to delivery of first shock
PAD has the potential to be the single greatest advance in the
treatment of prehospital sudden cardiac death since the invention
of CPR
Circulation August 22, 2000
Routes of
Administration
Intravenous
Preferred route
Endotracheal
ACLS
Algorithm
Approach
Universal Algorithm
Epinephrine
WHY?
(CABG))
increases myocardial oxygen requirements
WHEN?
VF/VT, asystole, PEA, bradycardias
Epinephrine
HOW?
High dose versus standard dose?
Higher ROSC with high dose, but no change in survival
High doses may exacerbate postresuscitation myocardial dysfunction
Recommendations:
Class I: 1 mg IV q 3 - 5 min
Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg
Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min
Infusion for HR & BP (IIb)
1mg in 250ml NS or D5W - infuse @ 1-10 mcg/min
Vasopressin
WHEN?
Alternative to epinephrine for shock-refractory VT/VF
WHY?
Natural antidiuretic hormone
Potent vasoconstrictor by stimulation of SM -V 1 receptors :
Why Vasopressin?
(n=20)
VP
35%
(p=0.06)
20%
60%
15%
(p=0.16)
(n=20)
70%
(p=0.02)
40%
Pulseless Ventricular
Fibrillation
or Tachycardia
VFib/Pulseless VT Algorithm
Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients
Better
Please -
Shock 200J*
Shock 200-300J*
Shock 360J*
Shock 360J
And - Amiodarone (First Choice) 300mg IV push. May repeat once at
150mg in 3-5 min. (max. cumulative dose: 2.2g IV/24hrs)
Drug-shock-drug-shock sequence
(continued)
preexisting K+
bicarb-responsive acidosis
some drug overdoses
protracted code (intubated)
ROSC after long code with effective ventilation.
Class
Drug
Ia
Quinidine
Procainamide
Disopyramide
Ib
Lidocaine
Mexiletine
Tocainide
Ic
Classification of
Antiarrhythmics
Conduction Velocity Refractory Period
Automaticity
Ion Block
Sodium
Sodium
(fast on-off)
0/
Flecainide
Propafenone
Moricizine
Sodium
(slow on-off)
II
Beta-Blockers
Calcium
III
Amiodarone
Bretylium
Sotalol
Potassium
IV
Verapamil
Diltiazem
0
Calcium
WHY?
Class III antiarrhythmic (characteristics of all classes)
Na, K and Ca channel blocker & & -adrenergic blocker
Prolongs AP and RP
Decreases AV conduction velocity & SN function
New Recommendations (WHEN?):
pulseless VT or VF (IIb)
hemodynamically stable VT (IIb), polymorphic VT (IIb),
wide-complex tachycardia uncertain origin (IIb)
refractory PSVT (preserved function, IIa; impaired function
IIb)
atrial tachycardia (IIb)
cardioversion of AF (IIa)
Amiodarone
HOW?
Cardiac arrest (PVT/VF) - 300mg IVP diluted
in 20-30ml, may repeat with 150mg in 10
minutes, or start infusion (max=2..2 g/24h)
Atrial & ventricular arrhythmias in impaired
hearts
WHAT?
Hypotension, bradycardia (slow rate, fluids)
Why Amiodarone?
ARREST Trial
Objective:
Efficacy of IV amiodarone in out-of-hospital
cardiac arrest due to ventricular fibrillation or
pulseless ventricular tachycardia
Endpoints:
Hospital admission with perfusing rhythm
Survival to discharge
Functional neurologic status at discharge
*Insufficiently powered to detect survival to discharge and
functional neurologic status*
Amiodarone
70
60
50
40
30
20
10
0
Placebo
WHY?
WHEN?
Refractory/recurrent VF/VT
Control of rapid ventricular response (IIb)
Conversion SVT (AF/Fl) (IIa)
mg/kg)
min
WHAT?
Stop infusion if patient hypotensive, widened QRS
>50%,
arrhythmia suppression, or dose=17mg/kg
Dose reduction in renal failure
SLE syndrome
Levels:
PA=4-12 g/ml
NAPA=7-15 g/ml (active metabolite-Class III)
WHY?
Type IB antiarrhythmic
Affects fast Na+ channels, shortens refractory period
Suppresses spontaneous depolarization
Local anesthetic, increases fibrillation threshold
Suppresses ventricular ectopy post-MI
WHEN?
SECOND-CHOICE agent
VT/VF refractory to electrical countershock and epinephrine
(Indeterminate)
Control of PVCs (Indeterminate)
Hemodynamically stable VT (IIb)
acidosis,
decreases toxicity of TCAs, increases clearance of acidic drugs
WHEN?
Class I - hyperkalemia
Class IIa - bicarbonate-responsive acidosis metabolic
acidosis secondary to loss of bicarb (renal/GI);
overdoses (TCAs, phenobarbital, aspirin)
Class IIb - protracted arrest in intubated patients
Class III - hypoxic lactic acidosis
Summary
V.Fib and Pulseless V.Tach
Changes:
Vasopressin added - Class IIb 40 U IVP x 1
Epinephrine - Class Indeterminate 1mg IVP q 3-5
min
Amiodarone added - Class IIb
300mg IVP (cardiac arrest dose). May repeat 150mg x 1
The Tachycardia
Algorithms
Major New Concepts:
Make a specific rhythm diagnosis
Identify patients with significantly
impaired cardiac function (EF<40%,
overt HF)
Only use one antiarrhythmic, especially
in damaged hearts
Stable
Unstable
Cardioversion
(premedicate)
AF/Aflutter
Narrow-complex VT, PSVT,
tachycardia
Stable wide-complex
tachycardia
Stable monomorphic VT
100J, 200J,
360J
300J,
Tachycardia - Atrial
Fibrillation/Flutter
4 Clinical Features:
Unstable?
Impaired cardiac function?
WPW?
Duration? <48h, or > 48h?
Focus - treat unstable patients urgently
Control ventricular response convert
anticoagulate
Condition
Atrial
Fibrillation/Flutter
Rate Control
EF > 40%
CCB (I)
-Blocker (I)
EF < 40%
Digoxin (IIb)
Diltiazem (IIb)
Amiodarone (IIb)
WPW
Preserved heart
fxn:
DC Cardioversion
Amiodarone(IIb)
Flecainide (IIb)
Procainamide (IIb)
Propafenone (IIb)
Sotalol (IIb)
Impaired
EF<40%:
DC Cardioversion
Amiodarone(IIb)
Conversion
> 48h
DC Cardioversion
Amiodarone (IIa)
Ibutilide (IIa)
Flecainide (IIa)
Propafenone (IIa)
Procainamide (IIa)
DC Cardioversion
OR
Amiodarone (IIb)
Conversion
< 48h
No DC Cardioversion
Anticoagulation x 3
weeks, then CV, then
anticoagulation x 4 wk
OR r/o clot by TEE,
CV, then AC x 4 wk
(See above)
DC Cardioversion
Amiodarone (IIb)
Flecainide (IIb)
Propafenone (IIb)
Procainamide (IIb)
Sotalol (IIb)
(See above)
HOW? Atenolol:
2.5-5 mg IV over 5 min
Metoprolol:
5 - 10 mg IVP q 5 min
Propranolol:
0.1 mg/kg IV divided into 3
doses @ 2 - 3 min intervals
Esmolol: 500 mcg/kg over 1 min
Inf @ 50 mcg/kg/min
WHAT?
heart
Preserved
Cardiac
Function
NOTE!
May go directly to
cardioversion
Impaired LV
EF<40% or
CHF
Amiodarone (IIB)
150 mg IV bolus over 10 min
may repeat 150mg q10-15min or
start infusion
OR
Lidocaine (IIB)
0.5 to 0.75 mg/kg IV push
Then use
Synchronized cardioversion
Narrow-Complex Supraventricular
Tachycardia
Vagal stimulation
Adenosine
Junctional
PSVT
EF>40% - CCB, BB, digoxin, DC cardioversion
(procainamide, amiodarone, sotalol)
EF<40%, CHF - no DC cardioversion; digoxin,
amiodarone, diltiazem
MAT
EF>40% -No DC cardioversion; CCB, BB, amiodarone
EF<40% -No DC cardioversion; amiodaonre, diltiazem
Wide-Complex Tachycardia
Wide . Prolonged QRS or QRST interval
HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter)
OLD - Lidocaine
NEW Establish diagnosis - 12-lead ECG
Adenosine if SVT- slows AV conduction. Short-lived
hypotension
Amiodarone (IIa) normal LV function
Amiodarone (IIb) impaired LV function
Procainamide (IIa)- terminates SVT due to altering
conduction across accessory pathways
Lidocaine if VT
Sotalol, propafenone, flecainide
WHEN?
PSVT (half-life=10 sec)
If PSVT persists may want longer acting agent
diltiazem)
AV
(verapamil or
NS flush.
WHAT?
Flushing, dyspnea, chest pain, post-conversion
bradycardia
Drug interaction with theophylline, dipyridamole
Ts)
hyper/hypokalemia, hyper/hypothermia
thrombosis (PE)
Intervention Comments/Dose
Problem
(HCO3)
(max.
Atropine
WHY? Anticholinergic/direct vagolytic
Enhances sinus node automaticity and AVN conduction
WHEN?
WHAT?
Tachycardia; 2nd or 3rd degree AV block
(paradoxical
slowing may occur), MI (may worsen
ischemia/HR)
Incompatible with bicarbonate, epinephrine & norepinephrine
Bradycardia
All Patients Deserve Empathy
(The sequence reflects interventions for increasingly severe bradycardia)
Absolute (< 60 BPM) or relative
Serious signs and symptoms (CP, SOB, hypotension, mental
status changes)
Mnemonic
Intervention
All
mg/kg)
Atropine
Comments/Dose
0.5-1.0 mg IVP q 3-5 min (max 0.03-0.04
Patients
Pacing
severe S/S
Deserve
Dopamine
Empathy
Epinephrine
Dopamine
WHY? NE precursor
Stimulates DA, & -adrenergic receptors (dose-related)
Want -stimulation, for bradycardia-induced
hypotension
WHEN?
Hypotension/shock
WHAT?
Tachycardia, tachyphylaxis, proarrhythmic
If requiring > 20mcg/kg/min consider adding NE
ACLS Algorithms
Asystole
Consider possible causes and treat accordingly
discharge
Consider Na Bicarbonate 1 mEq/kg
Oxygen
Nitroglycerin
Morphine Sulfate
AMI - Aspirin, thrombolytics, heparin,
lidocaine, beta-blockers
Glycoprotein IIb/IIIa receptor antagonists
Oxygen
Why?
increases hemoglobin saturation,
improves tissue oxygenation
supply to ischemic tissues
16-17% oxygen from mouth-to-mouth
When?
Must give supplemental oxygen in ACLS
Always for MI
How?
NC 4 L/min, intubation, etc
Goal - Osat=97-98%
Confirm tube placement
Nitroglycerin
WHEN?
Ischemic CP; USA; pulmonary edema (when SBP>100); AMI
SL NTG -drug of choice for angina
IV NTG - drug of choice for unstable angina or AMI
Congestive heart failure with ischemia
HOW?
IV: 10-20 mcg/min, increase by 5-10 mcg/min q5-10 min until desired
effect or hemodynamic compromise
SL: 1 tablet (0.4mg) SL q5min times 3
Spray: 1 spray onto oral mucosa
Ointment 2%: 1-2 inches over 2-4 inch area
Patches: no role in acute therapy
Aspirin
Heparin
Thrombolytics - reteplase,
alteplase, TNK
B Blockers
Magnesium
Lidocaine - not for prophylaxis
Hypotension/Shock/Pulmona
ry Edema
Identify Problem? Volume; Pump; Rate?
Volume:
fluids, blood, vasopressors
Pump:
s/s of shock - vasopressors; no s/s shock dobutamine
BP (>100 mm Hg) - NTG, Nitroprusside
pulmonary edema -furosemide 0.51mg/kg, morphine 1-3mg, NTG SL,
oxygen/intubate
Action:
Alpha & -adrenergic
stimulation, increases
contractility
and HR, vasoconstriction, improves
coronary blood flow
Indication:
severe
Dose:
0.5 - 1 mcg/min
refractory shock = 8 - 30 mcg/min
Preparation:
4-8mg/250 ml D5W or NS
Caution:
Hypertension, myocardial ischemia,
cardiac arrest,
palpitations
Action:
Indication:
Dose:
2 - 20 mcg/kg/min
Preparation:
Caution:
tachyarrhythmias,worsens myocardial
ischemia
Action:
Phosphodiesterase inhibitors, positive
inotropes and
vasodilator
Indication:
Action:
Antihypertensive, peripheral vasodilator,
reduces afterload, increases CO and relieves
pulmonary
congestion
Indication:
Summary of 2000
Changes
Amiodarone (Class IIb) & Procainamide (Class IIb) hemodynamically stable wide-complex tachycardia (esp. in
poor cardiac fxn)
VT - amiodarone & sotalol (Class IIa)
Vasopressin (Class IIb) - alternative to epinephrine
Bretylium acceptable, but not recommended
Lidocaine for VT/VF (Class Indeterminate) & Class III for
prophylaxis of ventricular arrhythmias in AMI
Magnesium (Class IIb) - Mg or TdP
High-dose epinephrine (Class Indeterminate)
Fibrinolytics for AMI & Stroke
Needless System/Cannulas
Questions ?