1. Establish IV access
2. Identify rhythm monitor
3. Administer drugs
4. “appropriate for rhythm and
Simultaneous recording of aortic diastolic (red) and right atrial (yellow) pressures during CPR in
which 2 ventilations are delivered within 4-second time period
Ewy, G. A. Circulation 2005;111:2134-2142
How to give the medication
• I.V. • E.T.T
– Fast I.V. Bolus.
– 2-3 times the I.V. dose
– 10 cc N.S. flush.
– Raise the arm. – Diluted 10cc N.S.
– Use central venous – 3-4 ambo-bag “to
access if it available. diffuse the medication”
Which Meds can be given
Naloxon Atropine Vasopressin Epinephrine Lidocaine
• Action : α & β – adrenergic agonist activity
• Indication: all Pulseless rhythms.
• initial dose 1mg ( 10mL of 1:10 000 solution )
• Additional doses of 1mg every 3- 5 min
• No maximum dose.
• PVC with digitalis.
• Myocardial ischemia
• Survival higher in patients who had higher endogenous
• Action :
• Vasoconstriction by direct stimulation of the smooth
muscle V1 receptor.
• Combination with epinephrine resulted in decreased
cerebral perfusion 3
• increase coronary perfusion and cerebral oxygen
delivery during CPR 4
• Has no β – adrenergic activity.
• Indication: all Pulseless rhythms.
– Start with 40 units I.V. once.
– Don’t combine with epinephrine
Vasopressin & Epinephrine
no statistically significant differences between
vasopressin and epinephrine
for death within 24 hrs or death before hospital discharge after a
• There is thus insufficient evidence to support or refute the
use of vasopressin as an alternative to or in combination
with epinephrine in any cardiac arrest rhythm.
– Action : vagolytic action “SA and AV node”
– Indication: asystole & PEA with rhythm < 60/min .
– initial dose 1 mg
– Additional doses every 3-5 min
– max dose 3 mg/Kg
– Myocardial ischemia
– Action : Na+, K+, Ca++ channel blocker and α & β Blocker.
– Indication: shock refractory VF/ Pulseless VT.
– initial dose 300 mg bolus
– Additional doses of 150 mg/kg
– Infusion dose of
– 1 mg/min for 6 Hr ( 360 mg ) then
– 0.5 mg/min for 18 Hr ( 540 mg )
– Maximum dose of 2.2 Gram / 24 Hr
– Prolonged QT.
– Negative Inotrope
Medication 2005 changes
Epinephrine •No change
Vasopressin •All pulseless rhythms
•Can be used in E.T.T
Atropine •Maximum dose 3 mg
Amiodarone •No changes
Lidocaine •No changes
• Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and
meta-analysis. Arch Intern Med 2005:17-24
• 2005 International Consensus Conference.Circulation 2005;112:III-29
• Linder KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW,
Georgieff M, Stress hormone response during and after cardiopulmonary
resuscitation. Anesthesiology 1992;77:662-668
• Linder KH, Haak T, Keller A, Bothner U, Lurie KG, Release of
endogenous vasopressors during and after cardiopulmonary
resuscitation. Heart 1996;75:145-150
• Wenzel V, Linder KH, Augenstein S, Prengel AW, Strohmenger HU,
Vasopressin combined with epinephrine decreases cerebral perfusion
compared with vasopressin alone during cardiopulmonary resuscitation in
pigs. Stroke. 1998;29:1462-1467: discussion 1467-1468.
• Babar SI, Berg RA, Hilwig RW, Kern KB, Ewy GA Vasopressin versus
epinephrine during CPR: a randomized swine outcome study.
Resuscitation 1999; 185-192
• Linder KH, Dricks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie
KG, Randomized comparison of epinephrine and vasopressin in patients
with out of hospital VF. Lancet. 1997; 349: 535-537
• Kudenchuk PJet al. Amiodarone for resuscitation after out-of-hospital
cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999:871-878
• Dorian P et al. Amiodarone as compared with lidocaine for shock-resistant
ventricular fibrillation. N Engl J Med 2002:884-90
• 2005 International Consensus Conference.Circulation 2005;112:III-17
• Paul Dorian, et al. NEJM 2002 Amiodarone as Compared with Lidocaine for
Shock-Resistant Ventricular Fibrillation