ACLS MEDICATIONS AND THEIR USE Garrett Thompson Pharm

ACLS MEDICATIONS AND THEIR USE Garrett Thompson, Pharm. D. Wake Forest University Baptist Medical Center 11/25/2020 1

EPINEPHERINE n n n alpha and beta agonist + inotrope, + chronotrope SVR, BP myocardial 02, requirements automaticity coronary and cerebral blood flow 11/25/2020 2

EPINEPHERINE Dose: 1 mg q 3 -5 min (1: 10, 000) (doses>1 mg are not beneficial and do not improve survival or neurological outcomes and may contribute to post resuscitation myocardial dysfunction) Continuous infusion rate: 0. 1 -0. 5 mcg/kg/min post resuscitation care in hypotensive pt who receive ROSC Up to 0. 2 mg/kg may be considered (eg. Beta blocker/Calcium Channel Blocker overdose) but not recommended and may be harmful 11/25/2020 3

EPINEPHRINE n n Flush w/ 20 cc saline when giving IV push to ensure delivery to central compartment PRECAUTIONS: myocardial ischemia myocardial irritability = VF 11/25/2020 4

ATROPINE n MOA: blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the central nervous system HR, CO Not likely to be effective for type II second-degree or third degree block OR block in non-nodal tissue § Indications: - symptomatic bradycardia - HR< 60 bpm and inadequate for clinical condition 11/25/2020 5

ATROPINE n Treatment considerations are based on adequate perfusion OR n S/S of poor perfusion caused by the bradycardia (Pacing, Atropine 0. 5 mg, Epi, Dopamine) 11/25/2020 6

ATROPINE n § DOSE: 0. 5 mg q 3 -5 min for symptomatic bradycardia Max. = 3 mg (usually 2 -3 mg is a full vagolytic dose in most patients) Side Effects: HR, coma, flushed hot skin, ataxia, blurred vision, myocardial ischemia 11/25/2020 7

MAGNESIUM SULFATE n n § MOA: physiological calcium channel blocker Indications: Torsades de pointes Hypomagnesemic states that may lead to arrhythmias Cardiac Arrest Dose: VT, Torsades = 1 – 2 grams § mix in 10 ml D 5 W IV/IO over 5 – 20 min. Torsades w/ pulse or AMI w/ hypomagnesemia - 1 – 2 grams in 50 – 100 ml D 5 W over 5 – 60 min IV/IO then 0. 5 gm – 1 gm / hr § Side Effects: flushing, sweating, mild HR/BP 11/25/2020 8

SODIUM BICARBONATE n MOA: H+ + HCO 3 - H 2 CO 3 H 20 + CO 2 § Indications: hyperkalemia pre-existing metabolic acidosis eg. DKA phenobarbital / TCA / aspirin overdose Adequate ventilation and CPR, not bicarbonate, are the major “buffer agents” in cardiac arrest. § Dose: 1 meq/kg, then ½ dose q 10 min. thereafter 11/25/2020 9

SODIUM BICARBONATE n n n Side Effects: Na+, alkalemia, plasma hyperosmolality, worsening intracellular acidosis Contraindicated: hypoxic lactic acidosis i. e. prolonged cardiopulmonary arrest Na. HCO 3 - not shown to improve defibrillation success to increase survival rate after brief cardiac arrest 11/25/2020 10

DOPAMINE n MOA: precursor of norepinephrine that stimulates n Dose: 1 -5 mcg/kg/min cerebral, renal, mesenteric n dopaminergic, , and receptors in a dose- dependent fashion vasodilatation 5 -10 mcg/kg/min stimulates , 1 receptors resulting in CO, HR, BP, cardiac contractility 10 -20 mcg/kg/min BP ( receptors predominate) Starting dose 2 -20 mcg/kg/min 11/25/2020 11

DOPAMINE n Indications: severe symptomatic bradycardia (after atropine), hemodynamically significant hypotension in absence of hypovolemia After : pacing, atropine, - start dopamine or epinephrine drip (2 -10 ug/min) n Side Effects: HR, induce /exacerbate arrhythmias, exacerbate pulmonary congestion and compromise CO, tissue sloughing if extravasation occurs ****Do not administer w/ sodium bicarbonate**** 11/25/2020 12

AMIODARONE n 1 ST line antiarrhythmic for: - wide complex tachycardias (Ok to use in pts. w/impaired heart function EF < 40%) - good for SVT and VT tachyarrythmias 11/25/2020 13

AMIODARONE Dose: VF/pulseless VT = 300 mg IVP diluted in 20 -30 ml D 5 W MR 150 mg in 20 -30 ml D 5 W in 3 -5 min x 1 if needed Max. 2. 2 g / 24 hr 11/25/2020 14

AMIODARONE n Dose (cont’d): Wide Complex Stable Tachycardias - 150 mg IV in 100 ml D 5 W given over 10 min. - MR q 10 min. prn, then 1 mg/min over 6 hrs, then 0. 5 mg/min x 18 hrs, then maintenance 0. 5 mg/min t ½ 40 days 11/25/2020 15

AMIODARONE § n § Side Effects: BP ( rate of infusion) sinus bradycardia EKG Effects: - prolongation of PR, QRS, and QT intervals Concerns of administration - must use large bore angiocath - must be diluted 11/25/2020 16

LIDOCAINE n MOA: - only use for ventricular arrhythmias - automaticity - ventricular ectopy - VF threshold directionally proportionate to plasma concentration eg. 6 mcg/ml-antifibrillatory eg. 2 -5 mcg/ml-controls ventricular ectopy § Indication: persistent/refractory VF / pulseless VT 11/25/2020 wide complex tachycardias stable VT 17

LIDOCAINE n Dose: 1 -1. 5 mg/kg/dose x 1, then 0. 5 – 0. 75 mg/kg q 5 -10 min (max. 3 mg/kg) – refractory VF, pulseless VT 0. 5 -0. 75 mg/kg up to 1. 0 -1. 5 mg/kg for pts. w/ pulse i. e. stable ventricular tachycardias - Maintenance infusion at 1 -4 mg/min 11/25/2020 18

LIDOCAINE Side Effects: muscle twitching focal / grand mal seizures 11/25/2020 19

LIDOCAINE n Reduce Dosage: use ½ recommended maintenance dose in patients with: - CO, (CHF, cardiogenic shock) - hepatic dysfunction - age > 70 11/25/2020 20

PROCAINAMIDE n n MOA: supraventricular and ventricular ectopy use caution in pts. w/ EF < 40% Indications: - afib w/ WPW, refractory reentry SVT - persistent cardiac arrest due to VF/VT - wide complex tachycardias - stable VT (rarely use to treat VT due to prolonged time required to administer effective doses i. e. rapid administration= BP) 11/25/2020 21

PROCAINAMIDE n Dose: 20 mg/min up to 50 mg/min in urgent n Stop infusion of bolus when: situations to max. dose of 17 mg/kg, OR… 1. Arrhythmia suppressed 2. BP 3. QRS complex widened by 50% of original width 4. 17 mg/kg has been administered Maintenance infusion 1 -4 mg/min 11/25/2020 22

ADENOSINE § MOA: chemically converts the AV node interrupts AV nodal reentry § Indications: - PSVT - DOC for diagnosing supraventricular tachycardias (if arrhythmia is not due to reentry involving AV/SA node, i. e. a. fib/flutter, atrial/ventricular tachycardias, adenosine will not terminate arrhythmia) § Do not use with ventricular tachycardias 11/25/2020 23

ADENOSINE n Dose: 6 mg 12 mg (q ~ 1 -2 min. ) (dose given over 1 -3 sec) -follow each dose w/ 20 ml flush (given over 1 -3 sec) -if using already established central line - dose to 3 mg, . . Note: Patients taking theophylline/caffeine are less sensitive to adenosine and may require greater doses Dipyridamole blocks adenosine uptake and potentiates its effects (consider dose to 3 mg) Heart transplant patients are more sensitive to adenosine and may require smaller doses Tegretol may increase the degree of heart block produced by adenosine = higher doses of heart block therefore, the dose to 3 mg 11/25/2020 24

ADENOSINE n Side Effects: - flushing - chest pain - brief asystole / bradycardia - malaise Recurrence of PSVT is 50%-60% 11/25/2020 25

Drug Administration Medications should be delivered DURING CPR ASAP after rhythm checks 11/25/2020 26

Oxygen and Aspirin n Oxygen – 1 - 6 L/min §Aspirin – 160 mg – 325 mg - Aspirin (non-enteric coated) should be administered to ALL patients suspected of acute coronary syndromes, unless contraindicated 11/25/2020 27

Nitroglycerin n Nitroglycerin – MOA: - initial antianginal for suspected ischemic pain - preload at lower doses - afterload at higher doses - dilates large coronary arteries - coronary collateral blood flow to ischemic myocardium - antagonizes vasospasms 11/25/2020 28

Nitroglycerin (cont’d) Dose: SL 0. 4 mg tab q 5 min x 3 IV Bolus 12. 5 -25 mcg if no SL given, then 10 -20 mcg/min titrated to effect (range 50 -200 mcg/min) 11/25/2020 29

Morphine n Morphine - myocardial O 2 requirements - venous capacitance - treatment of pain - SVR - chest pain w/ ACS unresponsive to nitrates Side Effects: respiratory depression BP 11/25/2020 30

Antiplatelet Agents: Glycoprotein IIB/IIIa agents n Blocks glycoprotein IIb/IIIa receptors on platelets n Blocked receptors cannot attach to fibrinogen n Fibrinogen cannot aggregate platelets to platelets n Indications: Acute Coronary Syndrome -STEMI or non. STEMI /UA undergoing PCI -NONSTEMI/Unstable angina managed medically n Examples: abciximab (Reo. Pro), eptifibitide (Integrilin), tirofiban (Aggrastat) 11/25/2020 31

ACE Inhibitors n Mechanism of action n n Reduces BP by inhibiting angiotensin-converting enzyme (ACE) Alters post-AMI LV remodeling by inhibiting tissue ACE Lowers peripheral vascular resistance by vasodilatation Reduces mortality and CHF from AMI 11/25/2020 32

Fibrinolytic Therapy n n Breaks up the fibrin network that binds clots together Indications: ST elevation >1 mm in 2 or more contiguous leads or new LBBB or new BBB that obscures ST n n Time of symptom onset must be <12 hours Caution: fibrinolytics can cause death from brain hemorrhage Agents differ in their site of action, ease of preparation and administration; cost; need for heparin 5 agents currently available: alteplase (t. PA, Activase), anistreplase (Eminase), reteplase (Retavase), streptokinase (Streptase), tenecteplase (TNKase) 11/25/2020 33

Heparin n Mechanism of action n n Indirect thrombin inhibitor (with AT III) Indications n n n PTCA or CABG With fibrin-specific lytics High risk for systemic emboli n 11/25/2020 Conditions with high risk for systemic emboli, such as large anterior MI, atrial fibrillation, or LV thrombus 34

ß-Blockers Absolute Contraindications n n Decompensated CHF/PE SBP <100 mm Hg Acute asthma (bronchospasm) 2 nd- or 3 rd-degree AV block 11/25/2020 Cautions n n n Mild/moderate CHF HR <60 bpm History of asthma IDDM Severe peripheral vascular disease 35

ENDOTRACHEAL TUBE MEDICATIONS **ET tube meds not recommended unless IV/IO access is not available L idocaine Epinephrine Atropine N arcan 11/25/2020 2 - 2. 5 x normal dose 36

CRITICAL POINTS n Know dosages, indications, contraindications, and side effects of drugs n Know concentrations of drugs n Know what drugs look like at your organization 11/25/2020 37