The presentation covers basics of pharmacotherapy involves in advanced life support scenario including peri-arrest situations which have been updated 2019

1. Practice principles in
Advanced life support
pharmacotherapy
Dr. P.P.Venugopalan , DA,DNB,
MNAMS, MEM-Gw
Director and Lead Consultant
,Emergency Medicine
Aster DM Healthcare -India Lead
Updated on 29.03.2019

2. A 54-year-old man brought
to casualty
❏ Collapsed
❏ Shake & Shout :no response
❏ No Carotid pulse
❏ Call for help-defibrillator
❏ Start CPR
❏ Open airway
❏ Two rescue breaths
❏ Attach defibrillator
200
joules
DC shock
Biphasic

4. Shockable rhythms
Non-shockable
rhythms
Cardiacarrestrhythms

5. Shockable
Rhythm
❏ VF
❏ VT
Non
Shockable
Rhythm
❏ PEA
❏ Asystole
1. Shock
2. CPR
3. Drug
1. CPR
2. Drug

6. Rhythm not changing
What drug you want to give now?
Epinephrine

8. EPINEPHRINE - When??
Cardiac arrest
❏ VF
❏ Pulseless
VT
❏ Asystole
❏ PEA
Non Cardiac
arrest situations
❏ Symptomatic
bradycardia
❏ Severe
Hypotension
❏ Anaphylaxis

9. EPINEPHRINE-IN CARDIAC
ARREST : How??
1. Alpha stimulation –
peripheral vasoconstriction
and improved coronary and
cerebral circulation
2. Beta stimulation- ?
Detrimental
3. ? Convert fine fibrillation to
coarse fibrillation

10. ???
Better
response
to shock

11. EPINEPHRINE: How much??
●1: 1000 Solution (1 mg / ml)
●Dilute to 10 cc by Normal
Saline
●Administered as bolus
●20 cc chaser
●Dose 1 mg every 3 to 5
minutes.

12. EPINEPHRINE: What route ?
1. Intravenous bolus
2. Intraosseous
3. Transtracheal – 2 to 3mg diluted to
10ml, give 5 ventilation to disperse the
drug into bronchial tree
4. Intracardiac- least preferred route

13. 1 mg Epi
(1 in 1000 dil)
9 ml
Normal
Saline
(1 in
10,000
dilution )
IV push
20 ml Saline
Chaser
Elevate limb
above heart
level
Epi h e n ti Car
ar t

14. INTRACARDIAC ROUTE:
When?
Open cardiac massage.
Class III

15. INTRACARDIAC ROUTE :
what are the problems?
1. Coronary artery
laceration.
2. Cardiac tamponade.
3. Pneumothorax.

16. If Epinephrine is not effective…
Alternative ?
VASOPRESSIN
Removed from 2015 AHA
guideline

17. VASOPRESSIN: What is it?
❏Antidiuretic hormone
❏??? Alternative to
Epinephrine in VF/VT
refractory to three shocks
❏Half life vasopressin 10-20
minutes, (Epinephrine 3 to 5
minutes)

18. VASOPRESSIN
❏ Non adrenergic
vasoconstriction by
stimulation of V1
receptors of smooth
muscles
❏ Dose 40 unit IV single dose

19. CPR- Shock-Drug Sequence Contd..
●Refractory rhythm even after
fourth shock
●What are the other drugs to
be considered at this stage
Vasopressin
was removed
form guideline

20. Shock refractory cardiac arrest :
what are the other options??
1. Amiodarone
2. Lignocaine.
3. Magnesium.
4. Buffer.

21. AMIODARONE: How?
❏ Effects on sodium,
Potassium, and
calcium channels
❏ Alpha & Beta
adrenergic blocking
properties

22. AMIODARONE : When ?
Recommended after
defibrillation and
epinephrine
in cardiac arrest with
persistent
VF/VT.

23. AMIODARONE : How much?
❏ Dose- 300 mg (Diluted to 20
ml with D5W) Slow IV
❏ Another 150 mg IV for
Recurrent VF/VT
❏ Then infusion of 1 mg/minute
for 6 hours→ 0.5 mg /minute
( maximum dose 2.2g/day)

24. AMIODARONE- Non-cardiac
arrest indications
❏ Polymorphic VT & wide complex
tachycardia
❏ Stable VT (not responding to
cardioversion, poor LV function)
❏ SVT, PSVT (adjuvant to
cardioversion)
❏ Multifocal atrial tachycardia
❏ Atrial fibrillation or Flutter

25. AMIODARONE- How much
in Noncardiac arrest scenario?
Maximum doses 2.2gm IV per 24 hours.
❏ Rapid infusion:150 mg IV over first 10
minutes (15mg/min) repeat dose 150 mg
IV every 10 minutes
❏ Slow infusion: 360 mg IV over 6 hours
(1mg/min)
❏ Maintenance: 540 mg IV over 18 hours
(0.5mg/ min)

26. AMIODARONE- Problems
●Vasodilation and hypotension
●Multiple dose (more than 2.2 gm/24 hour
significant hypotension).
●Negative inotropic effects.
●Prolonged QT interval (don’t use with
procainamide or Lignocaine)
●Extremely long half life (upto 40 days)

27. LIGNOCAINE
●Local Anaesthetic agent
●Sodium channel blocker
●2% solution.
●Used preservative free
Xylocard for IV use.
●Class indeterminate

28. LIGNOCAINE- When?
❏Cardiac arrest from VF/VT,
(Class indeterminate)
❏Non cardiac arrest condition
(Class IIB)
❏Stable VT
❏Wide complex tachycardias
❏Wide complex PSVT

29. LIGNOCAINE- How much?
Cardiac arrest
■Initial dose : 1 to 1.5mg/Kg IV
■Refractory VF: Repeat 0.5 to
0.75 mg IV push (in 5 to 10
minutes)
■Max. total dose 3 mg /Kg)
■Tracheal route: 2 to 4 mg /Kg

30. LIGNOCAINE- How much?
Non Cardiac arrest conditions
■1 to 1.5 mg /Kg IV push.
■Repeat dose 0.5 to 0.75 mg every 5 to
10 minutes
■Max. total dose 3 mg/Kg
■Maintenance infusion: 1 to 4 mg /Min
(30 to 50 Mcg/Kg/min

31. LIGNOCAINE- Precautions
●Don’t give if patient is already on
Amiodarone.
●Prophylactic use in AMI (not
recommended)
●Reduce maintenance dose in liver
dysfunction and LV dysfunction.
●Stop infusion if toxicity
develops.

32. LIGNOCAINE- Toxicity
❏ Circumoral
paresthesia
❏ Convulsion
❏ Respiratory arrest
❏ Cardiac arrest

33. PROCAINAMIDE
●Local anaesthetic agent
●Alternative to lignocaine

34. PROCAINAMIDE -How much?
●Cardiac arrest-20 mg/min IV
infusion
Bolus dose: 100 mg IV push
repeat every 5 min
(max Dose 17mg/Kg)
●Non Cardiac arrest-20 mg/min IV
infusion
Maintenance infusion 1 to 4
mg / min

35. Endpoint:
1.Arrhythmia
suppression
2.Hypotension
3.QRS widens >50 %
4.Total dose of 17
mg/Kg
PROCAINAMIDE

36. PROCAINAMIDE- Precautions
1. Renal dysfunction
2. Proarrhythmic situations
(AMI, Hypokalemia,
Hypomagnesemia)
3. LV dysfunction
4. Drugs prolongs QT
interval(Amiodarone)

37. MgSO4
- Indication
●Cardiac arrest
❏ Suspected hypomagnesemia
❏ Refractory VF after Lignocaine
●Non cardiac arrest
❏ Torsade point with pulse
❏ Ventricular arrhythmia in digitalis toxicity.

38. MgSO4
: How much??
●Cardiac arrest
❏ 1-2 gm (2-4 ml 50% solution),
diluted in 10 ml of D5
W- IV push
●Non cardiac arrest
❏ Loading dose 1-2 gm 50 – 100 ml
of D5
W- IV over 5- 60 min
❏ Infusion 0.5 – 1 gm / hr IV

40. BICARBONATE
Indication:
Class I (Acceptable, supported by
definite evidence)
1. Known pre-existing hyperkalemia.

41. BICARBONATE - Indication
Class II a (acceptable, good evidence
support)
1. Known bicarbonate response
acidosis.
2. Tricyclic overdose.
3. To alkalinize Urine.

42. BICARBONATE - Indication
Class II b (acceptable fair evidence
support)
1. Intubated and ventilated patient with
long arrest interval.
2. ROSC –After long arrest interval.

43. BICARBONATE - Indication
Class III (harmful not
recommended)
1. Hypercarbic acidosis.

44. BICARBONATE - Dose
1 meq/kg – give half dose
every 10 to 20 minutes.
Get ABG and
Calculate (mmol
-IV)
Wt x BE x 0.2
2

45. NaHCO3Na
load
Intracellular
Acidosis
Hyper
osmolarity
1. Intracranial bleed
2. Umbilical vein
thrombosis
3. Hepatic necrosis
Thrombophlebitis
Alkalinity
❏ Inactivate
Catecholamines
❏ Phlebitis
❏ Lt shift of
ODC
❏ Tissue
Hypoxia
Problems

46. Calcium
❏ Indications are
➢ Hypocalcemia
➢ Hyperkalemia
➢ Calcium antagonist overdose
❏ 10% CaCl2
at 2-4 mg/kg repeated as
necessary at 10-minute intervals
❏ Worries regarding the role of
Ca++
in ischaemic cell damage
during reperfusion to the heart
and the brain

47. Drugs used in
Peri-arrest situations

48. ❏ Symptomatic Bradycardia
❏ Symptomatic Tachycardia
❏ Acute Coronary syndrome
❏ Hypotension & Shock

51. ATROPINE
SULPHATE-When?
●Symptomatic bradycardia (Class I)
●AV block at nodal level (Class IIa)

52. CHB
Mobitz
Type 2
ATROPINE IS NOT useful ??

53. ATROPINE SULPHATE- How
much?
❖ Cardiac arrest (PEA, Asystole) :
No role
Non cardiac arrest situation
❏ 0.5 – 1 mg IV Push repeat 3-5 min as
needed
❏ Can be administer through trachea

54. ADENOSINE

55. ADENOSINE : When?
●First drug for most forms of narrow complex
PSVT
❏ Not useful in atrial fibrillation,
flutter, or VF

56. Tachy is
more
dangerous :
Why ?

57. Oxygen
Supply
Oxygen
Demand
Myocardial
Oxygen Balance
Tachycardi
a

58. ADENOSINE- How much?
●Rapid IV push
❏ Mild reverse trendelenburg
position
❏ Initial bolus- 6 mg rapidly
over 1-3 seconds followed
by normal saline bolus of 20
ml
❏ Elevate extremity
❏ Repeat dose 12 mg in
1–2 min

59. ADENOSINE- Injection
technique
●Record rhythm strip.
●Use different syringes for adenosine
and flush.
●Attach both syringes to injection port.
●Push IV adenosine as quickly as
possible.
●Maintaining pressure on adenosine
plunger

62. ADENOSINE- Precautions
❏ Side effects:
Flushing
Chest pain
Transient asystole
Bradycardia
VPC
❏ Less effective in patient on
Theophylline

63. ❏ Wide complex
tachycardias or VT.
❏ Drug induced
tachycardias
Adenosine : No use

64. HYPOTENSION , SHOCK
Search for
●Volume problem
●Pump problem
●Rate problem
Shock : Mismatch in Oxygen
Demand vs Supply at tissue level

65. Shock & Hypotension :Which
DRUG ? When?
Systolic BP
❏ < 70 mmHg +
signs/symptom of
shock
NOREPINEPHRINE
0.5 to 30 mcg/min IV

66. Systolic BP
❏ 70-100 mmHg +
signs/symptoms of
shock
DOPAMINE
5-15 mcg/Kg/min IV
Shock & Hypotension :Which
DRUG ? When?

67. Dose Dependant
Receptor
Responsiveness
Dopamine
❏ D receptor stimulation
❏ Renal vasodilation
❏ 2-5 mcg/kg/mt
❏ Beta receptor stimulation
❏ +ve Inotropic
❏ 5-10 mcg/kg/mt
❏ Alpha Receptor
stimulation
❏ Vasoconstriction
❏ 10-20 mcg/kg/mt

68. Shock & Hypotension :Which
DRUG ? When?
Systolic BP
❏ 70-100 + No
signs/symptoms of
shock
DOBUTAMINE
2-20 mcg/Kg/Min IV

69. Shock & Hypotension :Which
DRUG ? When?
Systolic BP
❏ >100 mmHg
NITROGLYCERINE
10-20 mcg/min IV
OR
NITROPRUSSIDE
0.1 – 0.5 mcg/Kg/min IV

70. Some Memory Aids
❏LEAN
❏MONA
❏MEAL

71. LEAN
LEAN “4”
transtracheal
administration.
❏Lignocaine
❏Epinephrine
❏Atropine
❏Naloxone

72. Transtracheal Drug Administration

73. MONA
“Greets all patients”
“4” Immediate
treatment of ACS
●Morphine
●Oxygen
●Nitroglycerin
●Aspirin

74. ONAM
It could be this way also !!!

75. MEAL
MEAL “4” Beta Blockers
family
●Metoprolol
●Esmolol
●Atenolol
●Labetalol (Alpha &
Beta)

76. Intraosseous route of administration
Second most preferred route when IV is not available