ACLS Pharmacotherapy Update Jessica Schwenk Pharm D September

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

Introduction Objectives ACLS Guideline Overview Access for Medications in ACLS

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

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)

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

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 m. L fluid

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 m. L fluid (as with IV administration)

Access for Medications in ACLS • Endotracheal (ET) Route – Not preferred; last resort – Medication doses are 2 -2. 5 times IV/IO doses • Optimal dosing not known – Medications that can be given ET: epinephrine, vasopressin, lidocaine (atropine, naloxone) • Dilute with 5 -10 m. L SW/NS, administer into ET tube, follow with several positive pressure breaths

ACLS Medications Adult cardiac arrest algorithm

Adult cardiac arrest algorithm • 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

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

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

Adult cardiac arrest algorithm • Epinephrine – Dose and Administration – VF, PVT, asystole, PEA • IV/IO: 1 mg every 3 -5 minutes – Concentration 0. 1 mg/ml (1: 10, 000 or 1 mg/10 ml) – Flush with 20 ml NS (central line preferred) • ET: 2 -2. 5 mg every 3 -5 minutes – Dilute in 5 -10 ml SW or NS (use epi 1 mg/ml or 1: 1, 000)

Vasopressors • Vasopressin (antidiuretic hormone) – MOA: acts on V 1 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

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: 80 -100 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

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

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

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 20 -30 ml D 5 W – Amiodarone vial concentration is 50 mg/ml – Flush with 20 ml • Central line preferred • Incompatible with sodium bicarbonate

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-toadmission • May be considered if amiodarone is not available

Other Antiarrhythmics • Lidocaine (NOT on algorithm for VF/PVT) – Dose and Administration • IV/IO: 1 -1. 5 mg/kg, then 0. 5 -0. 75 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

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 m. L or 0. 5 g/ml) • Dilute to 10 ml (NS) • Administer over 5 -20 minutes – Monitor: • Hypotension, respiratory and CNS depression

ACLS Medications Adult bradycardia algorithm (with pulse)

Adult bradycardia algorithm (with pulse)

Adult bradycardia algorithm (with pulse)

Adult bradycardia algorithm (with pulse) • Medications – Atropine – Dopamine – Epinephrine

Adult bradycardia algorithm (with pulse) • Atropine – MOA: anticholinergic agent, blocks acetylcholine at M 2 -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

Adult bradycardia algorithm (with pulse) • Dopamine – MOA: adrenergic and dopaminergic receptor agonist, stimulation of β 1 -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 1030 minutes as needed • Premade bags are 200 mg/250 ml D 5 W (800 mcg/ml) • Central line preferred • Incompatible with sodium bicarbonate

Adult bradycardia algorithm (with pulse) • Epinephrine – MOA: adrenergic agonist, stimulation of β 1 recptors increases HR – Dose and Administration • • • 2 -10 mcg/min IV/IO infusion Titrate to response Standard drip 4 mg/250 ml NS or D 5 W (16 mcg/ml) Central line preferred Incompatible with sodium bicarbonate

ACLS Medications Adult tachycardia algorithm (with pulse)

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

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

Adult tachycardia algorithm (with pulse) • Adenosine – Dose and Administration • 6 -12 mg IV into large proximal vein—fast • Flush with 20 m. L 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 (3 mg IV) – Dipyridamole or carbamazepine, transplanted hearts, or into a central vein.

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

Adult tachycardia algorithm (with pulse) • Diltiazem – First choice for acute a-fib with RVR – Dose and administration • Bolus 15 -20 mg IV push over 2 minutes (0. 25 mg/kg) • Repeat with 20 -25 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

Adult tachycardia algorithm (with pulse) • Verapamil – Dose and administration • 2. 5 -5 mg IV push over 2 minutes • Repeat with 5 -10 mg over 2 minutes after 15 -30 minutes – Maximum total dose 20 mg – Monitor: ECG, blood pressure

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

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

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

Adult tachycardia algorithm (with pulse) • Procainamide – Class 1 a antiarrhythmic (sodium channel blocker) – Dose and administration • IV infusion 20 mg/min (20 mg/ml in D 5 W) – 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 D 5 W) – Monitor: ECG, QT interval, pulse, blood pressure • ADR: dysrhythmia, systemic lupus erythematosus (up to 30%), hematologic effects, hepatotoxicity

Adult tachycardia algorithm (with pulse) • Amiodarone – Dose and administration • 150 mg IV over 10 min, repeat for recurrence – Mix in 100 ml D 5 W (1. 5 mg/ml) • Follow IV infusion 1 mg/min for 6 hours, then 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

Adult tachycardia algorithm (with pulse) • Magnesium – Torsades de Pointes – Dose and Administration • Magnesium 1 -2 g IV – Magnesium sulfate 50% vials (1 g/2 m. L or 0. 5 g/ml) • Dilute to 10 ml (NS) • Administer over 5 -20 minutes • Maintenance infusion 0. 5 -1 g/hour – To correct deficiency – Monitor: • hypotension, respiratory and CNS depression

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

What else is in the crash cart?

References • • ACLS Provider Manual Supplementary Material (2012). American Heart Association Web site. Available at: http: //www. hearttraining. com/media/documents/ACLS. Accessed August 13, 2013. Barletta, JF. Cardiopulmonary resuscitation. In: Di. Piro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 6 th ed. New York (NY): Mc. Graw Hill; 2005: 171 -184. Bauman JL, Schoen MD. Arrhythmias. In: Di. Piro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 6 th ed. New York (NY): Mc. Graw Hill; 2005: 321 -356. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Hazinski MF, Nolan JP, Billi JE, et al. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122: e 1 -330. Lacy CF, Armstrong LL, Goldman MP, Lance LL. Lexi-Comp’s Drug Information Handbook. 17 th ed. Hudson (OH): Lexi-Comp; 2008. Ponzer CN, Advanced cardiac life support (ACLS) in adults. In: Up. To. Date, Basow, DS (Ed), Up. To. Date, Waltham, MA, 2013.