Transcript ACLS Medications and Their Use

ACLS
MEDICATIONS
AND THEIR USE
Garrett Thompson, Pharm.D.
Wake Forest University Baptist Medical Center
4/8/2017
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EPINEPHERINE
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alpha and beta agonist
+ inotrope, + chronotrope
SVR, BP
myocardial 02, requirements
automaticity
 coronary and cerebral blood flow
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EPINEPHERINE
 Dose: 1 mg q 3-5 min (1:10,000)
(doses>1mg are not beneficial and do not improve
survival or neurological outcomes and may contribute to
post resuscitation myocardial dysfunction)
 Continuous infusion rate: 0.1-0.5mcg/kg/min post
resuscitation care in hypotensive pt who receive ROSC
 Up to 0.2mg/kg may be considered
(eg. Beta blocker/Calcium Channel Blocker overdose) but
not recommended and may be harmful
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EPINEPHRINE
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Flush w/ 20cc saline when giving IV push
to ensure delivery to central compartment
PRECAUTIONS:
 myocardial ischemia
 myocardial irritability = VF
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ATROPINE
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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
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Indications:
- symptomatic bradycardia
- HR< 60 bpm and inadequate for clinical
condition
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ATROPINE
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Treatment considerations are based on
adequate perfusion
OR
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S/S of poor perfusion caused by the bradycardia
(Pacing, Atropine 0.5mg, Epi, Dopamine)
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ATROPINE
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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
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MAGNESIUM SULFATE
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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 D5W IV/IO over 5 – 20 min.
Torsades w/ pulse or AMI w/ hypomagnesemia - 1 – 2 grams
in 50 – 100 ml D5W over 5 – 60 min IV/IO
then 0.5gm – 1 gm / hr
 Side Effects: flushing, sweating, mild
 HR/BP
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SODIUM BICARBONATE
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MOA:
H+ + HCO3-  H2CO3  H20 + CO2
 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 q10 min. thereafter
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SODIUM BICARBONATE
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Side Effects:  Na+, alkalemia, plasma
hyperosmolality, worsening intracellular acidosis
Contraindicated: hypoxic lactic acidosis i.e.
prolonged cardiopulmonary arrest
NaHCO3- not shown to improve defibrillation
success to increase survival rate after brief
cardiac arrest
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DOPAMINE
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MOA: precursor of norepinephrine that stimulates
dopaminergic, , and  receptors in a dose- dependent
fashion
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Dose: 1-5 mcg/kg/min  cerebral, renal, mesenteric
vasodilatation
5-10 mcg/kg/min  stimulates , 1 receptors
resulting in CO, HR, BP, cardiac contractility
10-20 mcg/kg/min  BP ( receptors
predominate)
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Starting dose 2-20 mcg/kg/min
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DOPAMINE
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Indications: severe symptomatic bradycardia (after
atropine), hemodynamically significant hypotension in
absence of hypovolemia
After : pacing, atropine,
- start dopamine or epinephrine drip (2-10ug/min)
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Side Effects:  HR, induce
/exacerbate arrhythmias, exacerbate pulmonary
congestion and compromise CO, tissue sloughing if
extravasation occurs
****Do not administer w/ sodium bicarbonate****
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AMIODARONE
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1ST line antiarrhythmic for:
- wide complex tachycardias (Ok to use in pts.
w/impaired heart function EF < 40%)
- good for SVT and VT tachyarrythmias
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AMIODARONE
Dose: VF/pulseless VT = 300mg IVP diluted
in 20-30 ml D5W
MR 150mg in 20-30ml D5W
in 3-5 min x 1 if needed
Max. 2.2 g / 24 hr
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AMIODARONE
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Dose (cont’d):
Wide Complex Stable Tachycardias
- 150mg IV in 100 ml D5W given over 10 min.
- MR q10 min. prn, then 1mg/min over 6 hrs,
then 0.5mg/min x 18 hrs, then
maintenance 0.5mg/min
t ½  40 days
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AMIODARONE
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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
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LIDOCAINE
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MOA: - only use for ventricular arrhythmias
-  automaticity
-  ventricular ectopy
-  VF threshold directionally proportionate to
plasma concentration
eg. 6mcg/ml-antifibrillatory
eg. 2-5 mcg/ml-controls ventricular ectopy
 Indication: persistent/refractory VF / pulseless VT
wide complex tachycardias
stable VT
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LIDOCAINE
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Dose:
1-1.5 mg/kg/dose x 1, then 0.5 – 0.75 mg/kg q 510 min (max. 3mg/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
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LIDOCAINE
Side Effects: muscle twitching
focal / grand mal seizures
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LIDOCAINE
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Reduce Dosage:
use ½ recommended maintenance dose in
patients with:
-  CO, (CHF, cardiogenic shock)
- hepatic dysfunction
- age > 70
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PROCAINAMIDE
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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)
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PROCAINAMIDE
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Dose: 20 mg/min up to 50 mg/min in urgent
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Stop infusion of bolus when:
situations to max. dose of 17 mg/kg, OR…
1.
2.
3.
4.
Arrhythmia suppressed
 BP
QRS complex widened by 50% of original width
17 mg/kg has been administered
Maintenance infusion 1-4 mg/min
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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
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ADENOSINE
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Dose: 6mg  12 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 3mg, ..
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 3mg)
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 3mg
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ADENOSINE
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Side Effects: - flushing
- chest pain
- brief asystole / bradycardia
- malaise
Recurrence of PSVT is 50%-60%
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Drug Administration
Medications should be delivered
DURING CPR
ASAP after rhythm checks
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Oxygen and Aspirin
 Oxygen – 1 - 6 L/min
Aspirin – 160mg – 325 mg
- Aspirin (non-enteric coated) should be administered
to ALL patients suspected of acute coronary
syndromes, unless contraindicated
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Nitroglycerin
 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
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Nitroglycerin
Nitroglycerin (cont’d)
Dose: SL 0.4mg tab q5min x 3
IV Bolus 12.5-25 mcg if no SL given,
then 10-20mcg/min titrated to effect
(range 50-200 mcg/min)
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Morphine
 Morphine
-  myocardial O2 requirements
-  venous capacitance
- treatment of pain
-  SVR
- chest pain w/ ACS unresponsive to nitrates
Side Effects: respiratory depression
 BP
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Antiplatelet Agents:
Glycoprotein IIB/IIIa agents
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Blocks glycoprotein IIb/IIIa receptors on platelets
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Blocked receptors cannot attach to fibrinogen
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Fibrinogen cannot aggregate platelets to platelets
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Indications: Acute Coronary Syndrome
-STEMI or nonSTEMI /UA undergoing PCI
-NONSTEMI/Unstable angina managed medically
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Examples: abciximab (ReoPro), eptifibitide (Integrilin),
tirofiban (Aggrastat)
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ACE Inhibitors
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Mechanism of action
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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
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Fibrinolytic Therapy
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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
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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 (tPA, Activase),
anistreplase (Eminase), reteplase (Retavase), streptokinase
(Streptase), tenecteplase (TNKase)
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Heparin
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Mechanism of action
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Indirect thrombin inhibitor (with AT III)
Indications
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PTCA or CABG
With fibrin-specific lytics
High risk for systemic emboli
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Conditions with high risk for systemic emboli,
such as large anterior MI, atrial
fibrillation, or LV thrombus
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ß-Blockers
Absolute
Contraindications
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Decompensated
CHF/PE
SBP <100 mm Hg
Acute asthma
(bronchospasm)
2nd- or 3rd-degree
AV block
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Cautions
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Mild/moderate CHF
HR <60 bpm
History of asthma
IDDM
Severe peripheral
vascular disease
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ENDOTRACHEAL TUBE
MEDICATIONS
**ET tube meds not recommended
unless IV/IO access is not available
L idocaine
Epinephrine
Atropine
N arcan
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2- 2.5 x normal dose
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CRITICAL POINTS
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Know dosages, indications, contraindications,
and side effects of drugs
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Know concentrations of drugs
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Know what drugs look like at your organization
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