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ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013.

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Presentation on theme: "ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013."— Presentation transcript:

1 ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013

2 Introduction Objectives ACLS Guideline Overview Access for Medications in ACLS

3 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 algorithms

4 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)

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6 ACLS Guidelines First priority – High quality CPR – Early defibrillation Second priority – Medication administration – Advanced airway For drug administration or ventilation

7 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 fluid

8 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)

9 Access for Medications in ACLS Endotracheal (ET) Route – Not preferred; last resort – Medication doses are 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 breaths

10 ACLS Medications Adult cardiac arrest algorithm

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15 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, vasopressin

16 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 survival

17 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 demand

18 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: mg every 3-5 minutes – Dilute in 5-10 ml SW or NS (use epi 1 mg/ml or 1:1,000)

19 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 doses

20 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: units one time (to replace 1 st or 2 nd dose of epinephrine every 3-5 minutes) – Dilute in 5-10 ml SW or NS

21 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 PVT

22 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, thrombocytopenia

23 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 ml D5W – Amiodarone vial concentration is 50 mg/ml – Flush with 20 ml Central line preferred Incompatible with sodium bicarbonate

24 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 available

25 Other Antiarrhythmics Lidocaine (NOT on algorithm for VF/PVT) – Dose and Administration IV/IO: mg/kg, then 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, confusion

26 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 depression

27 ACLS Medications Adult bradycardia algorithm (with pulse)

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29 Adult bradycardia algorithm (with pulse)

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31 Medications – Atropine – Dopamine – Epinephrine

32 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 ischemia

33 Adult bradycardia algorithm (with pulse) Dopamine – MOA: adrenergic and dopaminergic receptor agonist, stimulation of β1-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 minutes as needed Premade bags are 200 mg/250 ml D5W (800 mcg/ml) Central line preferred Incompatible with sodium bicarbonate

34 Adult bradycardia algorithm (with pulse) Epinephrine – MOA: adrenergic agonist, stimulation of β1- 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 bicarbonate

35 ACLS Medications Adult tachycardia algorithm (with pulse)

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38 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 Amiodarone

39 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: magnesium

40 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.

41 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 SVT

42 Adult tachycardia algorithm (with pulse) Diltiazem – First choice for acute a-fib with RVR – Dose and administration Bolus mg IV push over 2 minutes (0.25 mg/kg) Repeat with 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 pressure

43 Adult tachycardia algorithm (with pulse) Verapamil – Dose and administration mg IV push over 2 minutes Repeat with 5-10 mg over 2 minutes after minutes – Maximum total dose 20 mg – Monitor: ECG, blood pressure

44 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 pressure

45 Adult tachycardia algorithm (with pulse) Atenolol – Dose and administration 5 mg slow IV push over 5 minutes Repeat in 10 minutes – Monitor: ECG, blood pressure

46 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 pressure

47 Adult tachycardia algorithm (with pulse) Procainamide – Class 1a 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, hepatotoxicity

48 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) Follow 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 fibrosis

49 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 g/hour – To correct deficiency – Monitor: hypotension, respiratory and CNS depression

50 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) – Inject small amount into blanched area, additional as needed Epineprine (norepinephrine, phenylephrine) Dopamine Vasopressin

51 What else is in the crash cart?

52 References ACLS Provider Manual Supplementary Material (2012). American Heart Association Web site. Available at: Accessed August 13, 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: 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: DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Hazinski MF, Nolan JP, Billi JE, et al International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122:e 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.


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