Presentation is loading. Please wait.

Presentation is loading. Please wait.

Overview of ACLS Pharmacology and Update on New ACLS Guidelines Krista Piekos, Pharm.D. Clinical Pharmacy Specialist - Critical Care Harper University.

Similar presentations


Presentation on theme: "Overview of ACLS Pharmacology and Update on New ACLS Guidelines Krista Piekos, Pharm.D. Clinical Pharmacy Specialist - Critical Care Harper University."— Presentation transcript:

1 Overview of ACLS 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

2 Objectives Pharmacists should be able to identify: Pharmacists should be able to identify: Why? …we use an agent When? …to use an agent How? …to use an agent What?...to watch for To familiarize the pharmacist with the ACLS algorithms To familiarize the pharmacist with the ACLS algorithms To help the pharmacist become comfortable with the crash cart To help the pharmacist become comfortable with the crash cart To introduce the needless delivery system To introduce the needless delivery system

3 Outline Present conclusions of the International Guidelines 2000 ACLS objectives with 2003 updates Present conclusions of the International Guidelines 2000 ACLS objectives with 2003 updates Classification of recommendations Classification of recommendations ACLS Algorithms ACLS Algorithms Pharmacology of agents used in algorithms Pharmacology of agents used in algorithms Overview of crash cart revisions Overview of crash cart revisions Overview of needless system Overview of needless system

4 Background In Seattle 43% of patients in VF survived to hospital discharge if CPR w/in 4 min and defibrillation w/in 8 min In Seattle 43% of patients in VF survived to hospital discharge if CPR w/in 4 min and defibrillation w/in 8 min These figures are higher than national average - due to AEDs throughout public These figures are higher than national average - due to AEDs throughout public Overall survival from CPR is poor 5-15% Overall survival from CPR is poor 5-15% Survival for in-patient CPR to discharge is <10% Survival for in-patient CPR to discharge is <10%

5 Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 1st international consensus on resuscitation guidelines 1st international consensus on resuscitation guidelines Experts from around the world Experts from around the world Identified issues Identified issues Gathered scientific evidence; level (quality) of evidence Gathered scientific evidence; level (quality) of evidence Integrate into a class of recommendation Integrate into a class of recommendation Revised guidelines Revised guidelines

6 Classification of Therapeutic Interventions Class I: definitely helpful, excellent Class I: definitely helpful, excellent Class II: Class II: Class II a -probably helpful; good to very good Class II b -possibly helpful; fair to good Class Indeterminate: insufficient evidence; no harm, but no benefit Class Indeterminate: insufficient evidence; no harm, but no benefit Class III: possibly harmful Class III: possibly harmful

7 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, Establishing a specific diagnosis by ECG 3. Antiarrhythmic agents are just as likely to be proarrhythmic as they are antiarrhythmic. One, and only one antiarrhythmic should be used.

8 Routes of Administration Intravenous Preferred route Preferred routeEndotracheal · Xs IV dose in 10ml volume · Each dose is followed by 10 ml NS flush down the ET tube · (Ex. epinephrine, atropine, lidocaine, diazepam, naloxone) · Absorption occurs at alveolar capillary interface Intraosseous (active bone marrow) · Pediatric patients without IV access Other: Sublingual, intracardiac, IM, SC (poor absorption)

9 ACLS Algorithm Approach

10 Universal Algorithm

11 Epinephrine WHY? Natural catecholamine with and ß-adrenergic agonist activityNatural catecholamine with and ß-adrenergic agonist activity Results in: Results in: flow to heart and brain flow to heart and brain SVR, SBP, DBP SVR, SBP, DBP electrical activity in the myocardium & automaticity ( success with defibrillation) electrical activity in the myocardium & automaticity ( success with defibrillation) myocardial contraction (for refractory circulatory shock (CABG)) myocardial contraction (for refractory circulatory shock (CABG)) increases myocardial oxygen requirements increases myocardial oxygen requirements Primary benefit: -vasoconstrictionPrimary benefit: -vasoconstriction ß-adrenergic activity controversial b/c myocardial workß-adrenergic activity controversial b/c myocardial workWHEN? VF/VT, asystole, PEA, bradycardiasVF/VT, asystole, PEA, bradycardias

12 Epinephrine HOW? High dose versus standard dose?High dose versus standard dose? Higher ROSC with high dose, but no change in survivalHigher ROSC with high dose, but no change in survival High doses may exacerbate postresuscitation myocardial dysfunctionHigh doses may exacerbate postresuscitation myocardial dysfunctionRecommendations: Class I: 1 mg IV q min Class I: 1 mg IV q min Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min Infusion for HR & BP (IIb) Infusion for HR & BP (IIb) 1mg in 250ml NS or D5W mcg/min 1mg in 250ml NS or D5W mcg/min ET Dose=2-2.5 times IV dose ET Dose=2-2.5 times IV dose What to watch for? Tachycardia, hypertension, myocardial ischemia, acidosis Tachycardia, hypertension, myocardial ischemia, acidosis Incompatible with Ca, HCO3, aminophylline & PHY. Alkaline solutions cause auto-oxidation.

13 Vasopressin WHEN? Alternative to epinephrine for shock-refractory VT/VF Alternative to epinephrine for shock-refractory VT/VFWHY? Natural antidiuretic hormone Natural antidiuretic hormone Potent vasoconstrictor by stimulation of SM -V 1 receptors : Potent vasoconstrictor by stimulation of SM -V 1 receptors : BP & SVR; CO, HR, myocardial O2 consumption and contractility BP & SVR; CO, HR, myocardial O2 consumption and contractility Does not myocardial oxygen consumption Does not myocardial oxygen consumption Not affected by severe acidosis Not affected by severe acidosis Class IIb for shock-refractory VF Class IIb for shock-refractory VF Class Indeterminate for PEA, asystole Class Indeterminate for PEA, asystole Half life = minutes Half life = minutesDose? 40 Units IVP - one time only!!! 40 Units IVP - one time only!!!

14 Why Vasopressin? During CPR, plasma ADH levels are higher in patients with return of spontaneous circulation (ROSC) During CPR, plasma ADH levels are higher in patients with return of spontaneous circulation (ROSC) During CPR patients may be severely acidotic During CPR patients may be severely acidotic Epinephrine compared to vasopressin pre-hospital CPR (20 patients/study group) Epinephrine compared to vasopressin pre-hospital CPR (20 patients/study group) Multiple animal studies showing ROSC Multiple animal studies showing ROSC EPI (n=20) VP (n=20) EPI (n=20) VP (n=20) Survival to hospital35% 70% (p=0.06) 24 hour survival 20% 60% (p=0.02) Discharge alive 15% 40% (p=0.16)

15 ILCOR Universal Algorithm (International Liaison Committee on Resuscitation) Medication changes in 2000: Emphasis on identification of all possible stroke victims for IV fibrinolytics Emphasis on identification of all possible stroke victims for IV fibrinolytics Epinephrine has become Class Indeterminate Epinephrine has become Class Indeterminate High-dose epinephrine no longer recommended High-dose epinephrine no longer recommended For shock-refractory VT/VF: Epinephrine 1 mg q 3-5 min For shock-refractory VT/VF: Epinephrine 1 mg q 3-5 min Vasopressin 40 Units IVP one time Vasopressin 40 Units IVP one time Epinephrine alone for non-VT/VF Epinephrine alone for non-VT/VF

16 Pulseless Ventricular Fibrillation or Tachycardia In ACLS, always assume VF - most common In ACLS, always assume VF - most common 85%-95% of survivors have VF 85%-95% of survivors have VF Survival dependant on early defibrillation Survival dependant on early defibrillation Medications indicated only after 3 failed shocks Medications indicated only after 3 failed shocks

17 VFib/Pulseless VT Algorithm Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients BetterPlease Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better Please -Precordial Thump If pulse-less with no defibrillator Shock 200J* Shock J* Shock 360J* (*only consecutive, if persistent) EVerybody - Epinephrine 1 mg IV q3-5 min or Vasopressin 40 U IVP If VF/PVT persists, "CONSIDER" antiarrhythmics and sodium bicarb. NOTE: always "max out" one agent before proceeding to the next in order to limit pro-arrhythmic drug-drug interactions 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)

18 Drug-shock-drug-shock sequence (continued) Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients BetterPlease Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better Let's - Lidocaine mg/kg IV. May repeat in 3-5 min (max=3 mg/kg) Make -Magnesium Sulfate 1-2 g slow IVP for suspected Mg or TdP Patients- Procainamide30 mg/min, or 100 mg IV q 5 min. for refractory VF. (max. dose: 17 mg/kg) NOTE: Besides having a pro-arrhythmic drug-drug interaction with amiodarone, procainamide is of limited value in an arrest situation due to a lengthy administration time Better (consider buffers) - Bicarbonate 1 mEq/kg IV for: preexisting K+ preexisting K+ bicarb-responsive acidosis bicarb-responsive acidosis some drug overdoses some drug overdoses protracted code (intubated) protracted code (intubated) ROSC after long code with effective ventilation. ROSC after long code with effective ventilation.

19 Drugs for VF/PVT Epinephrine - Why? How? What? Epinephrine - Why? How? What? Vasopressin - Why? How? What? Vasopressin - Why? How? What? Amiodarone Amiodarone Magnesium Magnesium Procainamide Procainamide Lidocaine Lidocaine Buffers Buffers

20 Classification of Antiarrhythmics

21 Drugs Used for Heart Rhythm and Rate Amiodarone WHY? Class III antiarrhythmic (characteristics of all classes) Class III antiarrhythmic (characteristics of all classes) Na, K and Ca channel blocker & & -adrenergic blocker Na, K and Ca channel blocker & & -adrenergic blocker Prolongs AP and RP Prolongs AP and RP Decreases AV conduction velocity & SN function Decreases AV conduction velocity & SN function New Recommendations (WHEN?): pulseless VT or VF (IIb) pulseless VT or VF (IIb) hemodynamically stable VT (IIb), polymorphic VT (IIb), wide-complex tachycardia uncertain origin (IIb) hemodynamically stable VT (IIb), polymorphic VT (IIb), wide-complex tachycardia uncertain origin (IIb) refractory PSVT (preserved function, IIa; impaired function IIb) refractory PSVT (preserved function, IIa; impaired function IIb) atrial tachycardia (IIb) atrial tachycardia (IIb) cardioversion of AF (IIa) cardioversion of AF (IIa)

22 Amiodarone HOW? Cardiac arrest (PVT/VF) - 300mg IVP diluted in ml, may repeat with 150mg in 10 minutes, or start infusion (max=2..2 g/24h) Cardiac arrest (PVT/VF) - 300mg IVP diluted in ml, may repeat with 150mg in 10 minutes, or start infusion (max=2..2 g/24h) Atrial & ventricular arrhythmias in impaired hearts Atrial & ventricular arrhythmias in impaired hearts 150mg IVP over 10 min 150mg IVP over 10 min May repeat q10-15 min, or start gtt 1mg/min x 6 hours, then 0.5mg/min x 18 h May repeat q10-15 min, or start gtt 1mg/min x 6 hours, then 0.5mg/min x 18 hWHAT? Hypotension, bradycardia (slow rate, fluids) Hypotension, bradycardia (slow rate, fluids)

23 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*

24 ARREST Trial: Amiodarone in the Resuscitation of Refractory Sustained Ventricular Tachyarrhythmias Prospective, randomized, DB, PC trial Prospective, randomized, DB, PC trial 504 patients, who failed >/= 3 shocks 504 patients, who failed >/= 3 shocks Randomized to placebo or 300mg IV amiodarone Randomized to placebo or 300mg IV amiodarone Amiodarone Dosing: Amiodarone Dosing: 300mg diluted with 5% D5W to 20mL 300mg diluted with 5% D5W to 20mL Rapid IV bolus Rapid IV bolus Found a statistically significant increase in the number of patients who arrived to hospital alive ( p =0.03) Found a statistically significant increase in the number of patients who arrived to hospital alive ( p =0.03) Consistent results regardless of presenting rhythm Consistent results regardless of presenting rhythm This is the only antiarrhythmic agent which has shown definitive benefit in cardiac arrest!

25 ARREST Trial - Subgroup Analysis

26 Drugs Used for Heart Rhythm and Rate Magnesium Sulfate WHY?Magnesium deficiency causes arrhythmias Facilitates ventricular repolarization by enhancing intracellular potassium flux, dilates coronary arteries WHEN?Suspected hypomagnesemia, pulseless VT/VF, torsade de pointes HOW?Class IIa in suspected hypomagnesemia, TdP, and Class IIb in VF/VT: 1 - 2gm slow IVP in 100ml WHAT?Hypotension at large doses

27 Drugs Used for Heart Rhythm and Rate Procainamide WHY? Suppresses both ventricular and atrial arrhythmias Suppresses both ventricular and atrial arrhythmias Type Ia antiarrhythmic, affects fast Na+channels-slowing conduction velocity, prolongs RP, and decreases automaticity Type Ia antiarrhythmic, affects fast Na+channels-slowing conduction velocity, prolongs RP, and decreases automaticity Phase IV depolarization Phase IV depolarizationWHEN? Refractory/recurrent VF/VT Refractory/recurrent VF/VT Control of rapid ventricular response (IIb) Control of rapid ventricular response (IIb) Conversion SVT (AF/Fl) (IIa) Conversion SVT (AF/Fl) (IIa)

28 Drugs Used for Heart Rhythm and Rate Procainamide HOW?VF: mg/min slow infusion (max=17 mg/kg) AF with rapid vent. response: 100 mg over 5 min then mg/min 1-2 gm/250ml D5W 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 µg/ml NAPA=7-15 µg/ml (active metabolite-Class III)

29 Drugs Used for Heart Rhythm and Rate Lidocaine WHY? Type IB antiarrhythmic Type IB antiarrhythmic Affects fast Na+ channels, shortens refractory period Affects fast Na+ channels, shortens refractory period Suppresses spontaneous depolarization Suppresses spontaneous depolarization Local anesthetic, increases fibrillation threshold Local anesthetic, increases fibrillation threshold Suppresses ventricular ectopy post-MI Suppresses ventricular ectopy post-MI Without effecting myocardial contractility, BP or AV nodal conduction Without effecting myocardial contractility, BP or AV nodal conductionWHEN? SECOND-CHOICE agent SECOND-CHOICE agent VT/VF refractory to electrical countershock and epinephrine VT/VF refractory to electrical countershock and epinephrine (Indeterminate) (Indeterminate) Control of PVCs (Indeterminate) Control of PVCs (Indeterminate) Hemodynamically stable VT (IIb) Hemodynamically stable VT (IIb) Not for routine prophylaxis post-MI, however, accepted in high-risk patients Not for routine prophylaxis post-MI, however, accepted in high-risk patients (hypokalemia, myocardial ishchemia, LV dysfunction)

30 Drugs Used for Heart Rhythm and Rate Lidocaine HOW?Class IIa: mg/kg IVP q min (max=3mg/kg) Infusion (with pulse): mg/min (if pulse is regained) Therapeutic Levels: µg/ml ET Dose: times IV dose Preparation: 1-2 gm/250 ml D5W or NS WHAT?Hepatic metabolism, renal elimination Bradycardia, cardiac arrest, seizures Lidocaine toxicity/neurotoxicity - twitching, LOC, seizures, coma Lidocaine levels persist in low CO states

31 Drugs Used to Improve Cardiac Output and Blood Pressure Drugs Used to Improve Cardiac Output and Blood Pressure Sodium Bicarbonate WHY? Enhances sodium shift intracellularly, buffersacidosis, decreases toxicity of TCAs, increasesclearance 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 HOW?1 mEq/kg IVP, 0.5mEq/kg q10 min prn WHAT?May worsen outcome if not intubated/ventilated. Metabolic alkalosis, decreased O2 delivery to tissues, hypokalemia, CNS acidosis, hypernatremia, hyperosmolarity Incompatible with calcium, epinephrine, atropine, norepinephrine, isoproterenol

32 Summary V.Fib and Pulseless V.Tach Changes: Vasopressin added - Class IIb 40 U IVP x 1 Vasopressin added - Class IIb 40 U IVP x 1 Epinephrine - Class Indeterminate 1mg IVP q 3-5 min Epinephrine - Class Indeterminate 1mg IVP q 3-5 min Amiodarone added - Class IIb Amiodarone added - Class IIb 300mg IVP (cardiac arrest dose). May repeat 150mg x 1 300mg IVP (cardiac arrest dose). May repeat 150mg x 1 Lidocaine - Class Indeterminate mg/kg IVP q 3-5 min (Max = 3mg/kg) Lidocaine - Class Indeterminate mg/kg IVP q 3-5 min (Max = 3mg/kg) Procainamide is acceptable but not recommended due to long administration times Procainamide is acceptable but not recommended due to long administration times Bretylium fell off algorithm due manufacturing problems Bretylium fell off algorithm due manufacturing problems

33 The Tachycardia Algorithms Major New Concepts: Make a specific rhythm diagnosis Make a specific rhythm diagnosis Identify patients with significantly impaired cardiac function (EF<40%, overt HF) Identify patients with significantly impaired cardiac function (EF<40%, overt HF) Only use one antiarrhythmic, especially in damaged hearts Only use one antiarrhythmic, especially in damaged hearts Resulted in 3 new algorithms Resulted in 3 new algorithms

34 The Tachycardia Overview Algorithm Is the patient stable or unstable? Stable Unstable Identify 1 of 4 types of tachycardia Cardioversion (premedicate) VT, PSVT, 100J, 200J, 300J, 360J VT, PSVT, 100J, 200J, 300J, 360J AF/Aflutter Narrow-complex tachycardia Stable wide-complex tachycardia Stable monomorphic VT

35 Tachycardia - Atrial Fibrillation/Flutter 4 Clinical Features: Unstable? Unstable? Impaired cardiac function? Impaired cardiac function? WPW? WPW? Duration? 48h? Duration? 48h? Focus - treat unstable patients urgently Focus - treat unstable patients urgently Control ventricular response convert anticoagulate Control ventricular response convert anticoagulate

36 Atrial Fibrillation/Flutter

37 Drugs Used in Afib/AFlutter Calcium channel blockers Calcium channel blockers Beta-blockers Beta-blockers Digoxin Digoxin Amiodarone Amiodarone Procainamide Procainamide Flecainide (IV form in ACLS -not available in US) Flecainide (IV form in ACLS -not available in US) Propafenone (IV form in ACLS -not available in US) Propafenone (IV form in ACLS -not available in US) Sotalol (IV form in ACLS -not available in US) Sotalol (IV form in ACLS -not available in US)

38 Drugs Used for Heart Rhythm and Rate Calcium Channel Blockers WHY?Blocks inward flow of Ca and Na, slows conduction, RP in AVN Terminate reentrant arrhythmias requiring AVN conduction Control ventricular response rate in AF/AFl Coronary vasodilation May exacerbate CHF Verapamil: Negative inotrope & chronotrope (good anti-ischemic) Class I for acute and preventative SVT Diltiazem: Direct negative chronotropic effect, mild negative inotrope Highly effective in controlling ventricular response in A Fib WHEN?Control ventricular response rate in patients with AF/Fl, or MAT Verapamil: PSVT not requiring cardioversion

39 Drugs Used for Heart Rhythm and Rate Calcium Channel Blockers HOW?Verapamil: mg IVP, over 2 min (max=30mg) 5-10 mg/hr Diltiazem:0.25 mg/kg IVP, may repeat with 0.35mg/kg in 15 min 5-15 mg/hr WHAT?Contraindicated in wide QRS complex tachycardias and ventricular tachycardias, exacerbation of CHF inpatients with LV dysfunction Transient decrease in BP Avoid in sick sinus syndrome of AV block (w/out pacer) May potentiate digoxin toxicity. Incompatible with bicarbonate, epinephrine, furosemide

40 Drugs Used for Heart Rhythm and Rate Beta - Blockers WHY?B-adrenergic blockade, slows conduction and increases refractory period in AV node WHEN?AMI (reduces rate of reinfarction), reduces recurrent ischemia and incidence of VF in post- MI patients, USA HOW?Atenolol:2.5-5 mg IV over 5 min Metoprolol: mg IVP q 5 min Propranolol:0.1 mg/kg IV divided into min intervals Esmolol:500 mcg/kg over 1 min 50 mcg/kg/min WHAT?Hypotension, bradycardia, AV block, overt heart failure or severe bronchospasm/COPD

41 Stable Monomorphic Ventricular Tachycardia Medications: any one Procainamide (IIA) Sotalol (IIA)* Amiodarone (IIB) Lidocaine (IIB) 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 NOTE! May go directly to cardioversion Impaired LV EF<40% or CHF PreservedCardiacFunction *Not yet available in the US.

42 Narrow-Complex Supraventricular Tachycardia Vagal stimulation Vagal stimulation Adenosine Adenosine Junctional Junctional 1. EF > 40% - Amiodarone, B-blocker, CCB 1. EF > 40% - Amiodarone, B-blocker, CCB 2. EF <40%, CHF - Amiodarone 2. EF <40%, CHF - Amiodarone PSVT PSVT EF>40% - CCB, BB, digoxin, DC cardioversion (procainamide, amiodarone, sotalol) EF>40% - CCB, BB, digoxin, DC cardioversion (procainamide, amiodarone, sotalol) EF<40%, CHF - no DC cardioversion; digoxin, amiodarone, diltiazem EF<40%, CHF - no DC cardioversion; digoxin, amiodarone, diltiazem MAT MAT EF>40% -No DC cardioversion; CCB, BB, amiodarone EF>40% -No DC cardioversion; CCB, BB, amiodarone EF<40% -No DC cardioversion; amiodaonre, diltiazem EF<40% -No DC cardioversion; amiodaonre, diltiazem

43 Wide-Complex Tachycardia Wide …. Prolonged QRS or QRST interval Wide …. Prolonged QRS or QRST interval HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter) HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter) OLD - Lidocaine OLD - Lidocaine NEW - NEW - Establish diagnosis - 12-lead ECG Establish diagnosis - 12-lead ECG Adenosine if SVT- slows AV conduction. Short-lived hypotension Adenosine if SVT- slows AV conduction. Short-lived hypotension Amiodarone (IIa) normal LV function Amiodarone (IIa) normal LV function Amiodarone (IIb) impaired LV function Amiodarone (IIb) impaired LV function Procainamide (IIa)- terminates SVT due to altering conduction across accessory pathways Procainamide (IIa)- terminates SVT due to altering conduction across accessory pathways Lidocaine if VT Lidocaine if VT Sotalol, propafenone, flecainide Sotalol, propafenone, flecainide

44 Drugs Used for Heart Rhythm and Rate Adenosine WHY?Endogenous nucleoside, slows conduction through the AV node and can interrupt AV nodal reentry pathways WHEN?PSVT (half-life=10 sec) If PSVT persists may want longer acting agent (verapamil or diltiazem) HOW?6 mg rapid IV over sec, followed by 20 ml NS flush. May repeat in 1-2min with 12 mg dose. Max.=30 mg WHAT?Flushing, dyspnea, chest pain, post-conversion bradycardia Drug interaction with theophylline, dipyridamole

45 Pulseless Electrical Activity PEA… no pulse with + electrical activity (not VF/VT) PEA… no pulse with + electrical activity (not VF/VT) Reversible if underlying cause is reversed (5 Hs, 5 Ts) Reversible if underlying cause is reversed (5 Hs, 5 Ts) Hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hyper/hypothermia Hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hyper/hypothermia Tablets, tamponade, tension pneumothorax, thrombosis (ACS), thrombosis (PE) Tablets, tamponade, tension pneumothorax, thrombosis (ACS), thrombosis (PE) InterventionComments/Dose ProblemSearch for the probable cause and intervene (HCO3) Epinephrine1 mg IV q3-5 min. AtropineWith slow heart rate, 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)

46 Atropine WHY?Anticholinergic/direct vagolytic Enhances sinus node automaticity and AVN conduction WHEN?PEA, symptomatic sinus bradycardia, asystole, HOW?Bradycardia: mg IV q3-5 min Asystole: 1 mg IV q 3-5 min Max = 0.04 mg/kg or 3 mg ET Dose=1-2mg diluted in 10ml Paradoxical bradycardia with insufficient dose (<0.5mg) WHAT?Tachycardia; 2nd or 3rd degree AV block (paradoxical slowing may occur), MI (may worsen ischemia/HR) Incompatible with bicarbonate, epinephrine & norepinephrine

47 Bradycardia All Patients Deserve Empathy (The sequence reflects interventions for increasingly severe bradycardia) Absolute (< 60 BPM) or relative Absolute (< 60 BPM) or relative Serious signs and symptoms (CP, SOB, hypotension, mental status changes) Serious signs and symptoms (CP, SOB, hypotension, mental status changes) Mnemonic InterventionComments/Dose All Atropine mg IVP q 3-5 min (max mg/kg) PatientsPacing Use Transcutaneous Pacing if severe S/S Deserve Dopamine 5-20 µg/kg/min. Empathy Epinephrine 2-10 µg/min.

48 Medications for Bradycardia Atropine - Why? How? Atropine - Why? How? Dopamine Dopamine Epinephrine infusion Epinephrine infusion 1mg/ mcg/min 1mg/ mcg/min Note: Lidocaine can be lethal if HR is due to ventricular escape rhythm

49 Dopamine WHY?NE precursor Stimulates DA, & -adrenergic receptors (dose- related) Want -stimulation, for bradycardia-induced hypotension WHEN?Hypotension/shock HOW?renal: mcg/kg/min cardiac: mcg/kg/min ( B 1 & alpha ) vascular: mcg/kg/min ( alpha ) Preparation: 400 mg/250 ml D5W or NS WHAT?Tachycardia, tachyphylaxis, proarrhythmic If requiring > 20mcg/kg/min consider adding NE

50 ACLS Algorithms Asystole Consider possible causes and treat accordingly (ex.hypoxemia, hyper/hypokalemia, acidosis) Consider possible causes and treat accordingly (ex.hypoxemia, hyper/hypokalemia, acidosis) Acronym TEA T Transcutaneous Pacing (TCP) (Class IIb) Only effective with early implementation along with appropriate interventions and medications E Epinephrine 1 mg IV q3-5 min. A Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg) A Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg) Discourage shocking due to excess parasympathetic discharge Discourage shocking due to excess parasympathetic discharge Consider Na Bicarbonate 1 mEq/kg Consider Na Bicarbonate 1 mEq/kg

51 Drugs Used for Myocardial Ischemia/Pain Oxygen Oxygen Nitroglycerin Nitroglycerin Morphine Sulfate Morphine Sulfate AMI - Aspirin, thrombolytics, heparin, lidocaine, beta-blockers AMI - Aspirin, thrombolytics, heparin, lidocaine, beta-blockers Glycoprotein IIb/IIIa receptor antagonists Glycoprotein IIb/IIIa receptor antagonists

52 Acute Myocardial Infarction Call first, call fast, call 911 Call first, call fast, call 911 Oxygen 4L/min Oxygen 4L/min NTG SL, paste or spray; if BP > 90 mm Hg, IV NTG NTG SL, paste or spray; if BP > 90 mm Hg, IV NTG Morphine IV Morphine IV ASA PO (I) ASA PO (I) Thrombolytics? (I) - within 6 hours of symptoms, (II) if > 6hr Thrombolytics? (I) - within 6 hours of symptoms, (II) if > 6hr IV heparin IV heparin B- blockers B- blockers Magnesium (if Mg) Magnesium (if Mg)

53 Oxygen Why? increases hemoglobin saturation, improves tissue oxygenation increases hemoglobin saturation, improves tissue oxygenation supply to ischemic tissues supply to ischemic tissues 16-17% oxygen from mouth-to-mouth 16-17% oxygen from mouth-to-mouthWhen? Must give supplemental oxygen in ACLS Must give supplemental oxygen in ACLS Always for MI Always for MIHow? NC 4 L/min, intubation, etc NC 4 L/min, intubation, etc Goal - Osat=97-98% Goal - Osat=97-98% Confirm tube placement Confirm tube placement

54 Drugs Used for Myocardial Ischemia/Pain Nitroglycerin WHY? binds to receptors on vascular smooth muscle - vasodilation (venous > arterial) binds to receptors on vascular smooth muscle - vasodilation (venous > arterial) venous BF to heart (preload) & O2 consumption venous BF to heart (preload) & O2 consumption dilates coronary arteries - myocardial blood supply dilates coronary arteries - myocardial blood supply antagonizes vasospasm antagonizes vasospasm increases collateral flow to ischemic myocardium increases collateral flow to ischemic myocardium inhibits infarct expansion inhibits infarct expansion decreases pain decreases pain

55 Drugs Used for Myocardial Ischemia/Pain 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: 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

56 Drugs Used for Myocardial Ischemia/Pain Nitroglycerin Preparation:50 mg/250 ml D5W or NS Must be in glass bottle Cautions: hypotension - treat with fluids, and rate reduction/elimination hypotension - treat with fluids, and rate reduction/elimination bradycardia - vasovagal reflex to hypotension bradycardia - vasovagal reflex to hypotension treat with fluids, rate reduction, atropine treat with fluids, rate reduction, atropine reflex tachycardia also a concern reflex tachycardia also a concern headache, dizziness - may be diminished by laying down headache, dizziness - may be diminished by laying down patients develop tachyphylaxis to effects - promote nitrate-free periods, intermittent dosing and lowest-possible doses patients develop tachyphylaxis to effects - promote nitrate-free periods, intermittent dosing and lowest-possible doses

57 Drugs Used for Myocardial Ischemia/Pain Morphine Sulfate WHY? (Pain can catecholamines - BP, HR, O2 demands) Opiate analgesic pain, preload and afterload, SVR, anxiety pain, preload and afterload, SVR, anxiety Relieves pulmonary congestion, myocardial oxygen demand WHEN? Pain, pulmonary edema, BP > 90 mm Hg HOW? 1-3mg IVP (2-15 mg IVP q15-30 min prn) CAUTION? Respiratory & CNS depression, bradycardia, hypotension, N/V

58 Drugs Used for Myocardial Ischemia/Pain (Continued) Aspirin Aspirin Heparin Heparin Thrombolytics - reteplase, alteplase, TNK Thrombolytics - reteplase, alteplase, TNK B Blockers B Blockers Magnesium Magnesium Lidocaine - not for prophylaxis Lidocaine - not for prophylaxis

59 Hypotension/Shock/Pulmonary Edema Identify Problem? Volume; Pump; Rate? Volume: Volume: fluids, blood, vasopressors fluids, blood, vasopressors Pump: Pump: s/s of shock - vasopressors; no s/s shock - dobutamine s/s of shock - vasopressors; no s/s shock - dobutamine BP (>100 mm Hg) - NTG, Nitroprusside BP (>100 mm Hg) - NTG, Nitroprusside pulmonary edema -furosemide 0.5-1mg/kg, morphine 1-3mg, NTG SL, oxygen/intubate pulmonary edema -furosemide 0.5-1mg/kg, morphine 1-3mg, NTG SL, oxygen/intubate Rate: see algorithms Rate: see algorithms

60 Drugs Used to Improve Cardiac Output and Blood Pressure Norepinephrine Action:Alpha & ß-adrenergic stimulation, increases contractility and HR, vasoconstriction, improves coronary blood flow Indication:Shock refractory to fluid replacement, severe hypotension Dose: mcg/min refractory shock = mcg/min Preparation: 4-8mg/250 ml D5W or NS Caution:Hypertension, myocardial ischemia, cardiac arrest, palpitations

61 Drugs Used to Improve Cardiac Output and Blood Pressure Dobutamine Action:B1- adrenergic activity Indication:Inotrope in heart failure/hypotension Dose: mcg/kg/min Preparation: 250 mg/250 ml D5W or NS Caution:tachyarrhythmias,worsens myocardial ischemia

62 Drugs Used to Improve Cardiac Output and Blood Pressure Inamrinone and Milrinone Action:Phosphodiesterase inhibitors, positive inotropes and vasodilator Indication:Refractory heart failure Dose:Inamrinone:750 mcg/kg over min mcg/kg/min Milrinone:50 mcg/kg over 10 min mcg/kg/min Caution:Thrombocytopenia, worsens myocardial ischemia, SV and ventricular arrhythmias

63 Drugs Used for Heart Rhythm and Rate Isoproterenol WHY? Synthetic sympathomimetic amine Pure B-adrenergic activity +inotropic& chronotrope Pure B-adrenergic activity +inotropic& chronotrope HR/CO, contractility; MAP secondary vasodilation HR/CO, contractility; MAP secondary vasodilation WHEN? Symptomatic bradycardia Refractory torsades de pointes Refractory torsades de pointes HOW? Class II mcg/min Class III - higher doses Class III - higher doses Preparation: 1 mg/ 250 ml D5W or NS Preparation: 1 mg/ 250 ml D5W or NS WHAT? mycocardial O2 consumption & peripheral vasodilation Avoid in ischemic heart disease; arrhythmogenic Avoid in ischemic heart disease; arrhythmogenic

64 Drugs Used to Improve Cardiac Output and Blood Pressure Sodium Nitroprusside Action:Antihypertensive, peripheral vasodilator, reduces afterload, increases CO and relieves pulmonary congestion Indication:Hypertension, AMI, CHF Dose: mcg/kg/min, and titrate up to 10mcg/kg/min Preparation:50 mg/250 ml D5W Caution:Cyanide and thiocyanate toxicity, hypotension

65 Summary of 2000 Changes NEW AGENTS - Amiodarone & Vasopressin NEW AGENTS - Amiodarone & Vasopressin Amiodarone (Class IIb) & Procainamide (Class IIb) - hemodynamically stable wide-complex tachycardia (esp. in poor cardiac fxn) Amiodarone (Class IIb) & Procainamide (Class IIb) - hemodynamically stable wide-complex tachycardia (esp. in poor cardiac fxn) VT - amiodarone & sotalol (Class IIa) VT - amiodarone & sotalol (Class IIa) Vasopressin (Class IIb) - alternative to epinephrine Vasopressin (Class IIb) - alternative to epinephrine Bretylium acceptable, but not recommended Bretylium acceptable, but not recommended Lidocaine for VT/VF (Class Indeterminate) & Class III for prophylaxis of ventricular arrhythmias in AMI Lidocaine for VT/VF (Class Indeterminate) & Class III for prophylaxis of ventricular arrhythmias in AMI Magnesium (Class IIb) - Mg or TdP Magnesium (Class IIb) - Mg or TdP High-dose epinephrine (Class Indeterminate) High-dose epinephrine (Class Indeterminate) Fibrinolytics for AMI & Stroke Fibrinolytics for AMI & Stroke

66 Crash Cart Revisions Summary of Changes: Additions: 5 amps of amiodarone 150mg/3ml (were 3) 3 vials of vasopressin (20 Units/vial) 1 bag of premixed dopamine 400mg in 250ml 4 Na Bicarbonate syringes (were 3) 5 filter needles 20 blunt cannulas Deletions: 1 dopamine vial (new total=1) Remove 5 epinephrine syringes (new total=10) Remove 1 lidocaine syringe (new total=2) Remove metoprolol

67 Needless System/Cannulas

68 Questions ?


Download ppt "Overview of ACLS Pharmacology and Update on New ACLS Guidelines Krista Piekos, Pharm.D. Clinical Pharmacy Specialist - Critical Care Harper University."

Similar presentations


Ads by Google