Acls medications


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Acls medications

  1. 2. Bradycardia <ul><li>Atropine </li></ul><ul><li>Dopamine infusion </li></ul><ul><li>Epinephrine infusion </li></ul>
  2. 3. Atropine <ul><li>Mechanism of Action </li></ul><ul><ul><li>Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes) </li></ul></ul>
  3. 4. Atropine <ul><li>Indications </li></ul><ul><ul><li>First drug for symptomatic sinus bradycardia </li></ul></ul><ul><ul><li>May be beneficial in AV block or asystole </li></ul></ul><ul><ul><li>Second drug in asystole or slow PEA </li></ul></ul><ul><ul><li>Organophosphate poisoning; large dose may be needed </li></ul></ul><ul><li>Precautions </li></ul><ul><ul><li>MI and hypoxia – atropine increases oxygen demand </li></ul></ul><ul><ul><li>Avoid in hypothermia </li></ul></ul><ul><ul><li>Not effective for 2 nd type II or new 3 rd degree block (may slow the rhythm) </li></ul></ul><ul><ul><li>Doses < 0.5 mg may cause a paradoxical slowing </li></ul></ul>
  4. 5. Atropine <ul><li>Asystole or slow (<60)PEA </li></ul><ul><ul><li>1 mg IV/IO push </li></ul></ul><ul><ul><li>Repeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg. </li></ul></ul><ul><li>Bradycardia </li></ul><ul><ul><li>0.5 mg IV every 3-5 minutes as needed; max. of 3 mg. </li></ul></ul><ul><ul><li>Use shorter dosing interval and higher doses in severe clinical situations </li></ul></ul><ul><li>Endotracheal Administration </li></ul><ul><ul><li>2-3 mg diluted in 10 mL water or NS </li></ul></ul><ul><li>Organophosphate Poisoning </li></ul><ul><ul><li>Large doses (2-4 mg or higher) may be necessary </li></ul></ul>Don’t delay pacing for severely symptomatic (unstable) patients.
  5. 6. Dopamine <ul><li>Mechanism of Action </li></ul><ul><ul><li>Stimulates adrenergic receptors; dose dependent. </li></ul></ul>
  6. 7. Dopamine <ul><li>Indications </li></ul><ul><ul><li>Second-line drug for symptomatic bradycardia </li></ul></ul><ul><ul><li>Hypotension with signs and symptoms of shock </li></ul></ul><ul><li>Precautions </li></ul><ul><ul><li>Correct hypovolemia with volume before initializing </li></ul></ul><ul><ul><li>Use caution with cardiogenic shock and associated CHF </li></ul></ul><ul><ul><li>May cause tachydysrhythmias; excessive vasoconstriction </li></ul></ul><ul><ul><li>Don’t mix with sodium bicarbonate </li></ul></ul><ul><li>IV Administration </li></ul><ul><ul><li>Infusion at 5-20 mcg/kg/min. </li></ul></ul><ul><ul><li>Titrate to patient response; taper slowly </li></ul></ul>
  7. 8. Epinephrine <ul><li>Mechanism of Action </li></ul><ul><ul><li>Stimulates adrenergic receptors and is not dose dependent like dopamine. </li></ul></ul>
  8. 9. Epinephrine <ul><li>Indications </li></ul><ul><ul><li>Cardiac arrest </li></ul></ul><ul><ul><ul><li>VF; VT; asystole; PEA </li></ul></ul></ul><ul><ul><li>Symptomatic bradycardia </li></ul></ul><ul><ul><ul><li>After atropine; alternative to dopamine </li></ul></ul></ul><ul><ul><li>Severe hypotension </li></ul></ul><ul><ul><ul><li>When atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitors </li></ul></ul></ul><ul><ul><li>Anaphylaxis; severe allergic reactions </li></ul></ul><ul><ul><ul><li>Combine with large fluid volume; corticosteroids; antihistamines </li></ul></ul></ul>
  9. 10. Epinephrine <ul><li>Precautions </li></ul><ul><ul><li>May increase myocardial ischemia, angina, and oxygen demand </li></ul></ul><ul><ul><li>High doses do not improve survival; may be detrimental </li></ul></ul><ul><ul><li>Higher doses may be needed for poison/drug induced shock </li></ul></ul><ul><li>Dosing </li></ul><ul><ul><li>Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min. </li></ul></ul><ul><ul><li>High dose up to 0.2 mg/kg for specific drug OD’s </li></ul></ul><ul><ul><li>Infusion of 2-10 mcg/min. </li></ul></ul><ul><ul><li>Endotracheal of 2-2.5 times normal dose </li></ul></ul><ul><ul><li>SQ/IM 0.3-0.5 mg </li></ul></ul>
  10. 11. Tachycardia <ul><li>Adenosine </li></ul><ul><li>Diltiazem </li></ul><ul><li>Metoprolol </li></ul><ul><li>Amiodarone </li></ul><ul><li>Lidocaine </li></ul><ul><li>Magnesium Sulfate </li></ul>
  11. 12. Adenosine <ul><li>Mechanism of Action </li></ul><ul><ul><li>Slows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR. </li></ul></ul>
  12. 13. Adenosine <ul><li>Indications </li></ul><ul><ul><li>1 st drug for stable, narrow complex, regular SVT </li></ul></ul><ul><ul><li>May consider for unstable SVT while preparing for cardioversion </li></ul></ul><ul><ul><li>Wide-complex tachycardia thought to be, or determined to be reentry SVT </li></ul></ul><ul><ul><li>Does not convert atrial fibrillation, atrial flutter, or VT </li></ul></ul><ul><ul><li>Diagnostic maneuver; stable narrow-complex SVT </li></ul></ul>
  13. 14. Adenosine <ul><li>Contraindications/Precautions </li></ul><ul><ul><li>Poison/drug induced tachycardia is contraindicated </li></ul></ul><ul><ul><li>2 nd and 3 rd degree block is contraindicated </li></ul></ul><ul><ul><li>Transient side effects; flushing, CP, asystole, brady, ectopy </li></ul></ul><ul><ul><li>Less effective with theophylline or caffeine </li></ul></ul><ul><ul><li>If used for VT may cause worsening of clinical condition </li></ul></ul><ul><ul><li>Transient periods of sinus brady or ventricular ectopy common after termination of SVT </li></ul></ul><ul><ul><li>Safe in pregnancy </li></ul></ul>
  14. 15. Adenosine <ul><li>Place supine or mild reverse Trendelenburg </li></ul><ul><li>6 mg rapidly followed by 20 mL flush </li></ul><ul><li>May repeat at 12 mg every 1-2 minutes if unsuccessful </li></ul>
  15. 16. Diltiazem <ul><li>Mechanism of Action </li></ul><ul><ul><li>Inhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction. </li></ul></ul>
  16. 17. Diltiazem <ul><li>Indications </li></ul><ul><ul><li>Controlling ventricular rate in a-fib or flutter </li></ul></ul><ul><ul><li>After adenosine to treat refractory reentry SVT if adequate blood pressure </li></ul></ul><ul><li>Contraindications/Precautions </li></ul><ul><ul><li>Do not use with wide-complex rhythms </li></ul></ul><ul><ul><li>Do not use with poison/drug induced tachycardia </li></ul></ul><ul><ul><li>Avoid in WPW </li></ul></ul><ul><ul><li>Avoid in AV nodal blocks </li></ul></ul><ul><ul><li>Blood pressure may drop from peripheral vasodilation </li></ul></ul>
  17. 18. Diltiazem <ul><li>Rate control </li></ul><ul><ul><li>15-20 mg (0.25 mg/kg) IV over 2 minutes </li></ul></ul><ul><ul><li>After 15 min. another 20-25 mg (0.35 mg/kg) IV over 2 minutes, if needed </li></ul></ul><ul><li>Maintenance Infusion </li></ul><ul><ul><li>5-15 mg/hour; titrated to physiologically appropriate heart rate </li></ul></ul>
  18. 19. Metoprolol <ul><li>Mechanism of Action </li></ul><ul><ul><li>Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP. </li></ul></ul>
  19. 20. Metoprolol <ul><li>Indications </li></ul><ul><ul><li>Administer to all patients with suspected MI or unstable angina, absent contraindications </li></ul></ul><ul><ul><li>Second-line agent for SVT refractory to adenosine </li></ul></ul><ul><ul><li>To reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressure </li></ul></ul><ul><ul><li>Emergency antihypertensive therapy for acute hemorrhagic or ischemic stroke </li></ul></ul>
  20. 21. Metoprolol <ul><li>Contraindications/Precautions </li></ul><ul><ul><li>Hemodynamically unstable patients should not receive </li></ul></ul><ul><ul><ul><li>Signs of heart failure </li></ul></ul></ul><ul><ul><ul><li>Low cardiac output </li></ul></ul></ul><ul><ul><ul><li>Increased risk for cardiogenic shock </li></ul></ul></ul><ul><ul><li>Relative contraindications: 1 st , 2 nd , 3 rd degree blocks; active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHg </li></ul></ul><ul><ul><li>Concurrent administration of calcium channel blockers can cause serious hypotension </li></ul></ul><ul><ul><li>Monitor cardiac and pulmonary status throughout </li></ul></ul>
  21. 22. Amiodarone <ul><li>Mechanism of Action </li></ul><ul><ul><li>Prolongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates. </li></ul></ul>
  22. 23. Amiodarone <ul><li>Indications </li></ul><ul><ul><li>Life threatening dysrhythmias </li></ul></ul><ul><ul><ul><li>VF/pulseless VT unresponsive to shock, CPR, and vasopressor </li></ul></ul></ul><ul><ul><ul><li>Recurrent hemodynamically unstable VT </li></ul></ul></ul><ul><ul><ul><li>Seek expert opinion for other uses </li></ul></ul></ul><ul><li>Contraindications/Precautions </li></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>2 nd and 3 rd degree block </li></ul></ul><ul><ul><li>Do not administer with meds that prolong QT interval (procainamide) </li></ul></ul>
  23. 24. Amiodarone <ul><li>VF/VT – 300 mg IV/IO in 20-30 mL NS. Can follow with ONE dose of 150 mg in 3-5 minutes, if needed. </li></ul><ul><li>Life threatening dysrhythmias </li></ul><ul><ul><li>150 mg over 10 minutes. May repeat every 10 minutes as needed. </li></ul></ul>
  24. 25. Lidocaine <ul><li>Mechanism of Action </li></ul><ul><ul><li>Decreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias. </li></ul></ul>
  25. 26. Lidocaine <ul><li>Indications </li></ul><ul><ul><li>Alternative to amiodarone in VF/VT arrest </li></ul></ul><ul><ul><li>Stable monomorphic VT </li></ul></ul><ul><ul><li>Malignant PVC’s </li></ul></ul><ul><ul><li>Can be used if Torsades is suspected </li></ul></ul><ul><li>Contraindications/Precautions </li></ul><ul><ul><li>Prophylactic use in AMI is contraindicated </li></ul></ul><ul><ul><li>Reduce maintenance dose in liver impaired patients </li></ul></ul><ul><ul><li>Discontinue infusion if toxicity develops </li></ul></ul>
  26. 27. Lidocaine <ul><li>Cardiac Arrest </li></ul><ul><ul><li>Initial dose is 1-1.5 mg/kg </li></ul></ul><ul><ul><li>Refractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3 mg/kg </li></ul></ul><ul><ul><li>Endotracheal dose 2-4 mg/kg </li></ul></ul><ul><li>Perfusing Dysrhythmia </li></ul><ul><ul><li>0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kg </li></ul></ul><ul><li>Maintenance Infusion </li></ul><ul><ul><li>1-4 mg/min </li></ul></ul>
  27. 28. Magnesium Sulfate <ul><li>Mechanism of Action </li></ul><ul><ul><li>Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia. </li></ul></ul>
  28. 29. Magnesium Sulfate <ul><li>Indications </li></ul><ul><ul><li>Torsades is suspected in cardiac arrest </li></ul></ul><ul><ul><li>Lfe-threatening ventricular dysrhythmias in digitalis OD </li></ul></ul><ul><li>Precautions </li></ul><ul><ul><li>Fall in BP with rapid administration </li></ul></ul><ul><ul><li>Use caution in renal failure </li></ul></ul><ul><li>Dosing </li></ul><ul><ul><li>Arrest 1-2 g over 5-20 min. </li></ul></ul><ul><ul><li>Torsades w/ pulse 1-2 g over 5-60 min. </li></ul></ul>
  29. 30. Vasopressin <ul><li>Mechanism of Action </li></ul><ul><ul><li>Causes vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest. </li></ul></ul>
  30. 31. Vasopressin <ul><li>Indications </li></ul><ul><ul><li>Alternative to epinephrine in adult refractory VF/VT </li></ul></ul><ul><ul><li>Alternative to epinephrine in asystole or PEA </li></ul></ul><ul><li>Contraindications/Precautions </li></ul><ul><ul><li>Potent peripheral vasoconstrictor (increased demand upon resuscitation) </li></ul></ul><ul><li>Dosing </li></ul><ul><ul><li>Single dose of 40 u that replaces either the 1 st or 2 nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes after </li></ul></ul><ul><ul><li>Can be used endotracheally; no suggested dose </li></ul></ul>