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ACLS Medications

ACLS Medications. Bradycardia. Atropine Dopamine infusion Epinephrine infusion. Atropine. Mechanism of Action Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes). Atropine. Indications

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ACLS Medications

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  1. ACLS Medications

  2. Bradycardia • Atropine • Dopamine infusion • Epinephrine infusion

  3. Atropine • Mechanism of Action Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes)

  4. Atropine • Indications • First drug for symptomatic sinus bradycardia • May be beneficial in AV block or asystole • Second drug in asystole or slow PEA • Organophosphate poisoning; large dose may be needed • Precautions • MI and hypoxia – atropine increases oxygen demand • Avoid in hypothermia • Not effective for 2nd type II or new 3rd degree block (may slow the rhythm) • Doses < 0.5 mg may cause a paradoxical slowing

  5. Atropine Don’t delay pacing for severely symptomatic (unstable) patients. • Asystole or slow (<60)PEA • 1 mg IV/IO push • Repeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg. • Bradycardia • 0.5 mg IV every 3-5 minutes as needed; max. of 3 mg. • Use shorter dosing interval and higher doses in severe clinical situations • Endotracheal Administration • 2-3 mg diluted in 10 mL water or NS • Organophosphate Poisoning • Large doses (2-4 mg or higher) may be necessary

  6. Dopamine • Mechanism of Action Stimulates adrenergic receptors; dose dependent.

  7. Dopamine • Indications • Second-line drug for symptomatic bradycardia • Hypotension with signs and symptoms of shock • Precautions • Correct hypovolemia with volume before initializing • Use caution with cardiogenic shock and associated CHF • May cause tachydysrhythmias; excessive vasoconstriction • Don’t mix with sodium bicarbonate • IV Administration • Infusion at 5-20 mcg/kg/min. • Titrate to patient response; taper slowly

  8. Epinephrine • Mechanism of Action Stimulates adrenergic receptors and is not dose dependent like dopamine.

  9. Epinephrine • Indications • Cardiac arrest • VF; VT; asystole; PEA • Symptomatic bradycardia • After atropine; alternative to dopamine • Severe hypotension • When atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitors • Anaphylaxis; severe allergic reactions • Combine with large fluid volume; corticosteroids; antihistamines

  10. Epinephrine • Precautions • May increase myocardial ischemia, angina, and oxygen demand • High doses do not improve survival; may be detrimental • Higher doses may be needed for poison/drug induced shock • Dosing • Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min. • High dose up to 0.2 mg/kg for specific drug OD’s • Infusion of 2-10 mcg/min. • Endotracheal of 2-2.5 times normal dose • SQ/IM 0.3-0.5 mg

  11. Tachycardia • Adenosine • Diltiazem • Metoprolol • Amiodarone • Lidocaine • Magnesium Sulfate

  12. Adenosine • Mechanism of Action Slows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.

  13. Adenosine • Indications • 1st drug for stable, narrow complex, regular SVT • May consider for unstable SVT while preparing for cardioversion • Wide-complex tachycardia thought to be, or determined to be reentry SVT • Does not convert atrial fibrillation, atrial flutter, or VT • Diagnostic maneuver; stable narrow-complex SVT

  14. Adenosine • Contraindications/Precautions • Poison/drug induced tachycardia is contraindicated • 2nd and 3rd degree block is contraindicated • Transient side effects; flushing, CP, asystole, brady, ectopy • Less effective with theophylline or caffeine • If used for VT may cause worsening of clinical condition • Transient periods of sinus brady or ventricular ectopy common after termination of SVT • Safe in pregnancy

  15. Adenosine • Place supine or mild reverse Trendelenburg • 6 mg rapidly followed by 20 mL flush • May repeat at 12 mg every 1-2 minutes if unsuccessful

  16. Diltiazem • Mechanism of Action Inhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.

  17. Diltiazem • Indications • Controlling ventricular rate in a-fib or flutter • After adenosine to treat refractory reentry SVT if adequate blood pressure • Contraindications/Precautions • Do not use with wide-complex rhythms • Do not use with poison/drug induced tachycardia • Avoid in WPW • Avoid in AV nodal blocks • Blood pressure may drop from peripheral vasodilation

  18. Diltiazem • Rate control • 15-20 mg (0.25 mg/kg) IV over 2 minutes • After 15 min. another 20-25 mg (0.35 mg/kg) IV over 2 minutes, if needed • Maintenance Infusion • 5-15 mg/hour; titrated to physiologically appropriate heart rate

  19. Metoprolol • Mechanism of Action Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.

  20. Metoprolol • Indications • Administer to all patients with suspected MI or unstable angina, absent contraindications • Second-line agent for SVT refractory to adenosine • To reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressure • Emergency antihypertensive therapy for acute hemorrhagic or ischemic stroke

  21. Metoprolol • Contraindications/Precautions • Hemodynamically unstable patients should not receive • Signs of heart failure • Low cardiac output • Increased risk for cardiogenic shock • Relative contraindications: 1st, 2nd, 3rd degree blocks; active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHg • Concurrent administration of calcium channel blockers can cause serious hypotension • Monitor cardiac and pulmonary status throughout

  22. Amiodarone • Mechanism of Action Prolongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.

  23. Amiodarone • Indications • Life threatening dysrhythmias • VF/pulseless VT unresponsive to shock, CPR, and vasopressor • Recurrent hemodynamically unstable VT • Seek expert opinion for other uses • Contraindications/Precautions • Bradycardia • 2nd and 3rd degree block • Do not administer with meds that prolong QT interval (procainamide)

  24. Amiodarone • 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. • Life threatening dysrhythmias • 150 mg over 10 minutes. May repeat every 10 minutes as needed.

  25. Lidocaine • Mechanism of Action Decreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.

  26. Lidocaine • Indications • Alternative to amiodarone in VF/VT arrest • Stable monomorphic VT • Malignant PVC’s • Can be used if Torsades is suspected • Contraindications/Precautions • Prophylactic use in AMI is contraindicated • Reduce maintenance dose in liver impaired patients • Discontinue infusion if toxicity develops

  27. Lidocaine • Cardiac Arrest • Initial dose is 1-1.5 mg/kg • Refractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3 mg/kg • Endotracheal dose 2-4 mg/kg • Perfusing Dysrhythmia • 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 • Maintenance Infusion • 1-4 mg/min

  28. Magnesium Sulfate • Mechanism of Action Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.

  29. Magnesium Sulfate • Indications • Torsades is suspected in cardiac arrest • Lfe-threatening ventricular dysrhythmias in digitalis OD • Precautions • Fall in BP with rapid administration • Use caution in renal failure • Dosing • Arrest 1-2 g over 5-20 min. • Torsades w/ pulse 1-2 g over 5-60 min.

  30. Vasopressin • Mechanism of Action Causes vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.

  31. Vasopressin • Indications • Alternative to epinephrine in adult refractory VF/VT • Alternative to epinephrine in asystole or PEA • Contraindications/Precautions • Potent peripheral vasoconstrictor (increased demand upon resuscitation) • Dosing • Single dose of 40 u that replaces either the 1st or 2nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes after • Can be used endotracheally; no suggested dose

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