Overview of acls pharmacology and update on new acls guidelines
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Overview of ACLS Pharmacology and Update on New ACLS Guidelines. Krista Piekos, Pharm.D. Clinical Pharmacy Specialist - Critical Care Harper University Hospital Adjunct Assistant Professor Wayne State University. Objectives. Pharmacists should be able to identify:

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Overview of acls pharmacology and update on new acls guidelines

Overview of ACLS Pharmacologyand Update on New ACLS Guidelines

Krista Piekos, Pharm.D.

Clinical Pharmacy Specialist - Critical Care

Harper University Hospital

Adjunct Assistant Professor

Wayne State University


Objectives

Objectives

  • Pharmacists should be able to identify:

    Why? …we use an agent

    When? …to use an agent

    How? …to use an agent

    What? ...to watch for

  • To familiarize the pharmacist with the ACLS algorithms

  • To help the pharmacist become comfortable with the crash cart

  • To introduce the needless delivery system


Outline

Outline

  • Present conclusions of the International Guidelines 2000 ACLS objectives with 2003 updates

  • Classification of recommendations

  • ACLS Algorithms

  • Pharmacology of agents used in algorithms

  • Overview of crash cart revisions

  • Overview of needless system


Background

Background

  • In Seattle 43% of patients in VF survived to hospital discharge if CPR w/in 4 min and defibrillation w/in 8 min

  • These figures are higher than national average - due to AED’s throughout public

  • Overall survival from CPR is poor 5-15%

  • Survival for in-patient CPR to discharge is <10%


Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care

Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

  • 1st international consensus on resuscitation guidelines

  • Experts from around the world

    • Identified issues

    • Gathered scientific evidence; level (quality) of evidence

    • Integrate into a class of recommendation

  • Revised guidelines


Classification of therapeutic interventions

Classification of Therapeutic Interventions

  • Class I: definitely helpful, excellent

  • Class II:

    Class II a -probably helpful; good to very good

    Class II b -possibly helpful; fair to good

  • Class Indeterminate: insufficient evidence; no harm, but no benefit

  • Class III: possibly harmful


New goals

New Goals

1.Early Defibrillation - Public Access Defibrillation (PAD)

Probability of successful defibrillation and survival is negatively related to the time from onset of VF to delivery of first shock

“PAD has the potential to be the single greatest advance in the treatment of prehospital sudden cardiac death since the invention of CPR” Circulation August 22, 2000

2.Establishing a specific diagnosis by ECG

3.Antiarrhythmic agents are just as likely to be proarrhythmic as they are antiarrhythmic.

One, and only one antiarrhythmic should be used.


Routes of administration

Routes of Administration

Intravenous

  • Preferred route

    Endotracheal

  • 2-2.5 X’s IV dose in 10ml volume

  • Each dose is followed by 10 ml NS flush down the ET tube

  • (Ex. epinephrine, atropine, lidocaine, diazepam, naloxone)

  • Absorption occurs at alveolar capillary interface

    Intraosseous (active bone marrow)

  • Pediatric patients without IV access

    Other: Sublingual, intracardiac, IM, SC (poor absorption)


Overview of acls pharmacology and update on new acls guidelines

ACLS Algorithm Approach


Universal algorithm

Universal Algorithm


Epinephrine

Epinephrine

WHY?

  • Natural catecholamine with  and ß-adrenergic agonist activity

    • Results in:

      •  flow to heart and brain

      •  SVR, SBP, DBP

      •  electrical activity in the myocardium & automaticity (success with defibrillation)

      • myocardial contraction (for refractory circulatory shock (CABG))

      • increases myocardial oxygen requirements

  • Primary benefit: -vasoconstriction

  • ß-adrenergic activity controversial b/c  myocardial work

    WHEN?

  • VF/VT, asystole, PEA, bradycardias


  • Epinephrine1

    Epinephrine

    HOW?

    • High dose versus standard dose?

    • Higher ROSC with high dose, but no change in survival

    • High doses may exacerbate postresuscitation myocardial dysfunction

      Recommendations:

      • Class I: 1 mg IV q 3 - 5 min

      • Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg

      • Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min

      • Infusion for  HR & BP (IIb)

        • 1mg in 250ml NS or D5W - infuse @ 1-10 mcg/min

      • ET Dose=2-2.5 times IV dose

        What to watch for?

  • Tachycardia, hypertension, myocardial ischemia, acidosis

    Incompatible with Ca, HCO3, aminophylline & PHY. Alkaline solutions cause auto-oxidation.


  • Vasopressin

    Vasopressin

    WHEN?

    • Alternative to epinephrine for shock-refractory VT/VF

      WHY?

    • Natural antidiuretic hormone

    • Potent vasoconstrictor by stimulation of SM -V1 receptors :

      •  BP & SVR;  CO, HR, myocardial O2 consumption and contractility

    • Does not  myocardial oxygen consumption

    • Not affected by severe acidosis

    • Class IIb for shock-refractory VF

    • Class Indeterminate for PEA, asystole

    • Half life = 10-20 minutes

      Dose?

    • 40 Units IVP - one time only!!!


    Why vasopressin

    Why Vasopressin?

    • During CPR, plasma ADH levels are higher in patients with return of spontaneous circulation (ROSC)

    • During CPR patients may be severely acidotic

    • Epinephrine compared to vasopressin pre-hospital CPR (20 patients/study group)

    • Multiple animal studies showing  ROSC

      EPI (n=20) VP (n=20)

      Survival to hospital35% 70% (p=0.06)

      24 hour survival 20% 60% (p=0.02)

      Discharge alive 15% 40% (p=0.16)


    Ilcor universal algorithm international liaison committee on resuscitation

    ILCOR Universal Algorithm(International Liaison Committee on Resuscitation)

    Medication changes in 2000:

    • Emphasis on identification of all possible stroke victims for IV fibrinolytics

    • Epinephrine has become Class Indeterminate

    • High-dose epinephrine no longer recommended

      • For shock-refractory VT/VF: Epinephrine 1 mg q 3-5 min

      • Vasopressin 40 Units IVP one time

    • Epinephrine alone for non-VT/VF


    Pulseless ventricular fibrillation or tachycardia

    Pulseless Ventricular Fibrillation or Tachycardia

    • In ACLS, always assume VF - most common

    • 85%-95% of survivors have VF

    • Survival dependant on early defibrillation

    • Medications indicated only after 3 failed shocks


    Vfib pulseless vt algorithm

    VFib/Pulseless VT Algorithm

    “Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better”

    Please -Precordial Thump If pulse-less with no defibrillator

    Shock 200J*

    Shock 200-300J*

    Shock 360J* (*only consecutive, if persistent)

    EVerybody - Epinephrine 1 mg IV q3-5 min or Vasopressin40 U IVP

    If VF/PVT persists, "CONSIDER" antiarrhythmics and sodium bicarb. NOTE: always "max out" one agent before proceeding to the next in order to limit pro-arrhythmic drug-drug interactions

    Shock 360J

    And - Amiodarone(First Choice) 300mg IV push. May repeat once at 150mg in 3-5 min. (max. cumulative dose: 2.2g IV/24hrs)


    Overview of acls pharmacology and update on new acls guidelines

    Drug-shock-drug-shock sequence (continued)

    “Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better”

    Let's - Lidocaine 1.0-1.5 mg/kg IV. May repeat in 3-5 min (max=3 mg/kg)

    Make -Magnesium Sulfate1-2 g slow IVP for suspected  Mg or TdP

    Patients- Procainamide30 mg/min, or 100 mg IV q 5 min. for refractory VF. (max. dose: 17 mg/kg)

    NOTE: Besides having a pro-arrhythmic drug-drug interaction with amiodarone, procainamide is of limited value in an arrest situation due to a lengthy administration time

    Better (consider buffers) - Bicarbonate 1 mEq/kg IV for:

    • preexisting  K+

    • bicarb-responsive acidosis

    • some drug overdoses

    • protracted code (intubated)

    • ROSC after long code with effective ventilation.


    Drugs for vf pvt

    Drugs for VF/PVT

    • Epinephrine - Why? How? What?

    • Vasopressin - Why? How? What?

    • Amiodarone

    • Magnesium

    • Procainamide

    • Lidocaine

    • Buffers


    Classification of antiarrhythmics

    Classification of Antiarrhythmics


    Drugs used for heart rhythm and rate amiodarone

    Drugs Used for Heart Rhythm and RateAmiodarone

    WHY?

    • Class III antiarrhythmic (characteristics of all classes)

    • Na, K and Ca channel blocker &  & -adrenergic blocker

    • Prolongs AP and RP

    • Decreases AV conduction velocity & SN function

      New Recommendations (WHEN?):

    • pulseless VT or VF (IIb)

    • hemodynamically stable VT (IIb), polymorphic VT (IIb), wide-complex tachycardia uncertain origin (IIb)

    • refractory PSVT (preserved function, IIa; impaired function IIb)

    • atrial tachycardia (IIb)

    • cardioversion of AF (IIa)


    Amiodarone

    Amiodarone

    HOW?

    • Cardiac arrest (PVT/VF) - 300mg IVP diluted in 20-30ml, may repeat with 150mg in 10 minutes, or start infusion (max=2..2 g/24h)

    • Atrial & ventricular arrhythmias in impaired hearts

      • 150mg IVP over 10 min

      • May repeat q10-15 min, or start gtt 1mg/min x 6 hours, then 0.5mg/min x 18 h

        WHAT?

    • Hypotension, bradycardia (slow rate, fluids)


    Why amiodarone arrest trial

    Why Amiodarone?ARREST Trial

    Objective:

    Efficacy of IV amiodarone in out-of-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia

    Endpoints:

    Hospital admission with perfusing rhythm

    Survival to discharge

    Functional neurologic status at discharge

    *Insufficiently powered to detect survival to discharge and functional neurologic status*


    Arrest trial amiodarone in the resuscitation of refractory sustained ventricular tachyarrhythmias

    ARREST Trial: Amiodarone in the Resuscitation of Refractory Sustained Ventricular Tachyarrhythmias

    • Prospective, randomized, DB, PC trial

    • 504 patients, who failed >/= 3 shocks

    • Randomized to placebo or 300mg IV amiodarone

    • Amiodarone Dosing:

      • 300mg diluted with 5% D5W to 20mL

      • Rapid IV bolus

    • Found a statistically significant increase in the number of patients who arrived to hospital alive (p=0.03)

    • Consistent results regardless of presenting rhythm

      This is the only antiarrhythmic agent which has shown definitive benefit in cardiac arrest!


    Arrest trial subgroup analysis

    ARREST Trial - Subgroup Analysis


    Drugs used for heart rhythm and rate magnesium sulfate

    Drugs Used for Heart Rhythm and RateMagnesium Sulfate

    WHY?Magnesium deficiency causes arrhythmias

    Facilitates ventricular repolarization by enhancing intracellular potassium flux, dilates coronary arteries

    WHEN?Suspected hypomagnesemia, pulseless VT/VF, torsade de pointes

    HOW?Class IIa in suspected hypomagnesemia, TdP, andClass IIb in VF/VT: 1 - 2gm slow IVP in 100ml

    WHAT?Hypotension at large doses


    Drugs used for heart rhythm and rate procainamide

    Drugs Used for Heart Rhythm and RateProcainamide

    WHY?

    • Suppresses both ventricular and atrial arrhythmias

    • Type Ia antiarrhythmic, affects fast Na+channels-slowing conduction velocity, prolongs RP, and decreases automaticity

    • Phase IV depolarization

      WHEN?

    • Refractory/recurrent VF/VT

    • Control of rapid ventricular response (IIb)

    • Conversion SVT (AF/Fl) (IIa)


    Drugs used for heart rhythm and rate procainamide1

    Drugs Used for Heart Rhythm and RateProcainamide

    HOW?VF: 20-30 mg/min slow infusion (max=17 mg/kg)

    AF with rapid vent. response: 100 mg over 5 min then infuse@ 1 - 4 mg/min

    1-2 gm/250ml D5W

    WHAT?Stop infusion if patient hypotensive, widened QRS >50%, arrhythmia suppression, or dose=17mg/kg

    Dose reduction in renal failure

    SLE syndrome

    Levels: PA=4-12 µg/ml

    NAPA=7-15 µg/ml (active metabolite-Class III)


    Drugs used for heart rhythm and rate lidocaine

    Drugs Used for Heart Rhythm and RateLidocaine

    WHY?

    • Type IB antiarrhythmic

    • Affects fast Na+ channels, shortens refractory period

    • Suppresses spontaneous depolarization

    • Local anesthetic, increases fibrillation threshold

    • Suppresses ventricular ectopy post-MI

    • Without effecting myocardial contractility, BP or AV nodal conduction

      WHEN?

    • SECOND-CHOICE agent

    • VT/VF refractory to electrical countershock and epinephrine

      (Indeterminate)

    • Control of PVC’s (Indeterminate)

    • Hemodynamically stable VT (IIb)

  • Not for routine prophylaxis post-MI, however, accepted in high-risk patients

    (hypokalemia, myocardial ishchemia, LV dysfunction)


  • Drugs used for heart rhythm and rate lidocaine1

    Drugs Used for Heart Rhythm and RateLidocaine

    HOW?Class IIa: 1 - 1.5 mg/kg IVP q5 - 10 min (max=3mg/kg)

    Infusion (with pulse): 1 - 4 mg/min (if pulse is regained)

    Therapeutic Levels: 1.5-6 µg/ml

    ET Dose: 2-2.5 times IV dose

    Preparation: 1-2 gm/250 ml D5W or NS

    WHAT?Hepatic metabolism, renal elimination

    Bradycardia, cardiac arrest, seizures

    Lidocaine toxicity/neurotoxicity - twitching, LOC, seizures, coma

    Lidocaine levels persist in low CO states


    Drugs used to improve cardiac output and blood pressure sodium bicarbonate

    Drugs Used to Improve Cardiac Output and Blood PressureSodium Bicarbonate

    WHY?Enhances sodium shift intracellularly, buffersacidosis, decreases toxicity of TCA’s, increasesclearance of acidic drugs

    WHEN?Class I - hyperkalemia

    Class IIa - bicarbonate-responsive acidosis metabolic acidosis secondary to loss of bicarb (renal/GI); overdoses (TCAs, phenobarbital, aspirin)

    Class IIb - protracted arrest in intubated patients

    Class III - hypoxic lactic acidosis

    HOW?1 mEq/kg IVP, 0.5mEq/kg q10 min prn

    WHAT?May worsen outcome if not intubated/ventilated. Metabolic alkalosis, decreased O2 delivery to tissues, hypokalemia, CNS acidosis, hypernatremia, hyperosmolarity

    Incompatible with calcium, epinephrine, atropine, norepinephrine, isoproterenol


    Summary v fib and pulseless v tach

    SummaryV.Fib and Pulseless V.Tach

    Changes:

    • Vasopressin added - Class IIb 40 U IVP x 1

    • Epinephrine - Class Indeterminate 1mg IVP q 3-5 min

    • Amiodarone added - Class IIb

      • 300mg IVP (cardiac arrest dose). May repeat 150mg x 1

    • Lidocaine - Class Indeterminate 1-1.5 mg/kg IVP q 3-5 min (Max = 3mg/kg)

    • Procainamide is acceptable but not recommended due to long administration times

    • Bretylium fell off algorithm due manufacturing problems


    The tachycardia algorithms

    The Tachycardia Algorithms

    Major New Concepts:

    • Make a specific rhythm diagnosis

    • Identify patients with significantly impaired cardiac function (EF<40%, overt HF)

    • Only use one antiarrhythmic, especially in damaged hearts

  • Resulted in 3 new algorithms


  • The tachycardia overview algorithm

    The Tachycardia Overview Algorithm

    Is the patient stable or unstable?

    StableUnstable

    Identify 1 of 4 types of tachycardia Cardioversion (premedicate)

    VT, PSVT, 100J, 200J, 300J, 360J

    AF/Aflutter

    Narrow-complex tachycardia

    Stable wide-complex tachycardia

    Stable monomorphic VT


    Tachycardia atrial fibrillation flutter

    Tachycardia - Atrial Fibrillation/Flutter

    4 Clinical Features:

    • Unstable?

    • Impaired cardiac function?

    • WPW?

    • Duration? <48h, or > 48h?

  • Focus - treat unstable patients urgently

  • Control ventricular response  convert  anticoagulate


  • Atrial fibrillation flutter

    Atrial Fibrillation/Flutter


    Drugs used in afib aflutter

    Drugs Used in Afib/AFlutter

    • Calcium channel blockers

    • Beta-blockers

    • Digoxin

    • Amiodarone

    • Procainamide

    • Flecainide (IV form in ACLS -not available in US)

    • Propafenone (IV form in ACLS -not available in US)

    • Sotalol (IV form in ACLS -not available in US)


    Drugs used for heart rhythm and rate calcium channel blockers

    Drugs Used for Heart Rhythm and RateCalcium Channel Blockers

    WHY?Blocks inward flow of Ca and Na, slows conduction, RP in AVN Terminate reentrant arrhythmias requiring AVN conductionControl ventricular response rate in AF/AFlCoronary vasodilation

    May exacerbate CHF

    Verapamil: Negative inotrope & chronotrope (good anti-ischemic)

    Class I for acute and preventative SVT

    Diltiazem: Direct negative chronotropic effect, mild negative inotrope

    Highly effective in controlling ventricular response in A Fib

    WHEN?Control ventricular response rate in patients with AF/Fl, or MAT

    Verapamil: PSVT not requiring cardioversion


    Drugs used for heart rhythm and rate calcium channel blockers1

    Drugs Used for Heart Rhythm and RateCalcium Channel Blockers

    HOW?Verapamil:2.5 - 5 mg IVP, over 2 min (max=30mg)

    Inf @ 5-10 mg/hr

    Diltiazem:0.25 mg/kg IVP, may repeat with 0.35mg/kg in 15 min

    Infuse @ 5-15 mg/hr

    WHAT?Contraindicated in wide QRS complex tachycardias and ventricular tachycardias, exacerbation of CHF inpatients with LV dysfunction

    Transient decrease in BP

    Avoid in sick sinus syndrome of AV block (w/out pacer)

    May potentiate digoxin toxicity.

    Incompatible with bicarbonate, epinephrine, furosemide


    Drugs used for heart rhythm and rate beta blockers

    Drugs Used for Heart Rhythm and RateBeta - Blockers

    WHY?B-adrenergic blockade, slows conduction and increases refractory period in AV node

    WHEN?AMI (reduces rate of reinfarction), reduces recurrent ischemia and incidence of VF in post-MI patients, USA

    HOW?Atenolol:2.5-5 mg IV over 5 min

    Metoprolol:5 - 10 mg IVP q 5 min

    Propranolol:0.1 mg/kg IV divided into 3

    doses @ 2 - 3 min intervals

    Esmolol:500 mcg/kg over 1 min

    Inf @ 50 mcg/kg/min

    WHAT?Hypotension, bradycardia, AV block, overt heart failure or severe bronchospasm/COPD


    Overview of acls pharmacology and update on new acls guidelines

    Stable Monomorphic Ventricular Tachycardia

    Impaired LV

    EF<40% or CHF

    Preserved

    Cardiac

    Function

    NOTE!

    May go directly to

    cardioversion

    • Amiodarone (IIB)

    • 150 mg IV bolus over 10 min

    • may repeat 150mg q10-15min or start infusion

    • OR

    • Lidocaine (IIB)

    • 0.5 to 0.75 mg/kg IV push

    • Then use

    • Synchronized cardioversion

    • Medications: any one

    • Procainamide (IIA)

    • Sotalol (IIA)*

    • Amiodarone (IIB)

    • Lidocaine (IIB)

    *Not yet available in the US.


    Narrow complex supraventricular tachycardia

    Narrow-Complex Supraventricular Tachycardia

    • Vagal stimulation

    • Adenosine

      • Junctional

        • 1. EF > 40% - Amiodarone, B-blocker, CCB

        • 2. EF <40%, CHF - Amiodarone

      • PSVT

        • EF>40% - CCB, BB, digoxin, DC cardioversion (procainamide, amiodarone, sotalol)

        • EF<40%, CHF - no DC cardioversion; digoxin, amiodarone, diltiazem

      • MAT

        • EF>40% -No DC cardioversion; CCB, BB, amiodarone

        • EF<40% -No DC cardioversion; amiodaonre, diltiazem


    Wide complex tachycardia

    Wide-Complex Tachycardia

    • “Wide” …. Prolonged QRS or QRST interval

    • HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter)

    • OLD - Lidocaine

    • NEW -

      • Establish diagnosis - 12-lead ECG

      • Adenosine if SVT- slows AV conduction. Short-lived hypotension

      • Amiodarone (IIa) normal LV function

      • Amiodarone (IIb) impaired LV function

      • Procainamide (IIa)- terminates SVT due to altering conduction across accessory pathways

      • Lidocaine if VT

      • Sotalol, propafenone, flecainide


    Drugs used for heart rhythm and rate adenosine

    Drugs Used for Heart Rhythm and RateAdenosine

    WHY?Endogenous nucleoside, slows conduction through the AV node and can interrupt AV nodal reentry pathways

    WHEN?PSVT (half-life=10 sec)

    If PSVT persists may want longer acting agent (verapamil or diltiazem)

    HOW?6 mg rapid IV over 1 - 3 sec, followed by 20 ml NS flush. May repeat in 1-2min with 12 mg dose.

    Max.=30 mg

    WHAT?Flushing, dyspnea, chest pain, post-conversion bradycardia

    Drug interaction with theophylline, dipyridamole


    Pulseless electrical activity

    Pulseless Electrical Activity

    • PEA… no pulse with + electrical activity (not VF/VT)

    • Reversible if underlying cause is reversed (5 H’s, 5 T’s)

      • Hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hyper/hypothermia

      • Tablets, tamponade, tension pneumothorax, thrombosis (ACS), thrombosis (PE)

        InterventionComments/Dose

        ProblemSearch for the probable cause and intervene (HCO3)

        Epinephrine1 mg IV q3-5 min.

        AtropineWith slow heart rate, 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)


    Atropine

    Atropine

    WHY?Anticholinergic/direct vagolytic

    Enhances sinus node automaticity and AVN conduction

    WHEN?PEA, symptomatic sinus bradycardia, asystole,

    HOW?Bradycardia: 0.5 -1 mg IV q3-5 min

    Asystole: 1 mg IV q 3-5 min

    Max = 0.04 mg/kg or 3 mg

    ET Dose=1-2mg diluted in 10mlParadoxical bradycardia with insufficient dose (<0.5mg)

    WHAT?Tachycardia; 2nd or 3rd degree AV block (paradoxical slowing may occur), MI (may worsen ischemia/HR)

    Incompatible with bicarbonate, epinephrine & norepinephrine


    Bradycardia

    Bradycardia

    “All Patients Deserve Empathy”

    (The sequence reflects interventions for increasingly severe bradycardia)

    • Absolute (< 60 BPM) or relative

    • Serious signs and symptoms (CP, SOB, hypotension, mental status changes)

      Mnemonic InterventionComments/Dose

      All Atropine 0.5-1.0 mg IVP q 3-5 min (max 0.03-0.04 mg/kg)

      PatientsPacing Use Transcutaneous Pacing if severe S/S

      Deserve Dopamine 5-20 µg/kg/min.

      Empathy Epinephrine 2-10 µg/min.


    Medications for bradycardia

    Medications for Bradycardia

    • Atropine - Why? How?

    • Dopamine

    • Epinephrine infusion

      • 1mg/250 ml @ 1-4 mcg/min

        Note: Lidocaine can be lethal if  HR is due to ventricular escape rhythm


    Dopamine

    Dopamine

    WHY?NE precursor

    Stimulates DA,  & -adrenergic receptors (dose-related)

    Want  -stimulation, for bradycardia-induced hypotension

    WHEN?Hypotension/shock

    HOW?renal: 2 - 5 mcg/kg/min

    cardiac: 5 - 10 mcg/kg/min (B1 & alpha)

    vascular: 10 - 20 mcg/kg/min (alpha)

    Preparation: 400 mg/250 ml D5W or NS

    WHAT?Tachycardia, tachyphylaxis, proarrhythmic

    If requiring > 20mcg/kg/min consider adding NE


    Acls algorithms asystole

    ACLS AlgorithmsAsystole

    • Consider possible causes and treat accordingly (ex.hypoxemia, hyper/hypokalemia, acidosis)

      Acronym “TEA”

      T Transcutaneous Pacing (TCP)(Class IIb) Only effective with early implementation along with appropriate interventions and medications

      E Epinephrine 1 mg IV q3-5 min.

      A Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)

    • Discourage shocking due to excess parasympathetic discharge

    • Consider Na Bicarbonate 1 mEq/kg


    Drugs used for myocardial ischemia pain

    Drugs Used for Myocardial Ischemia/Pain

    • Oxygen

    • Nitroglycerin

    • Morphine Sulfate

      • AMI - Aspirin, thrombolytics, heparin, lidocaine, beta-blockers

      • Glycoprotein IIb/IIIa receptor antagonists


    Acute myocardial infarction

    Acute Myocardial Infarction

    • “Call first, call fast, call 911”

    • Oxygen 4L/min

    • NTG SL, paste or spray; if BP > 90 mm Hg, IV NTG

    • Morphine IV

    • ASA PO (I)

    • Thrombolytics? (I) - within 6 hours of symptoms, (II) if > 6hr

    • IV heparin

    • B-blockers

    • Magnesium (if  Mg)


    Oxygen

    Oxygen

    Why?

    • increases hemoglobin saturation, improves tissue oxygenation

    •  supply to ischemic tissues

    • 16-17% oxygen from mouth-to-mouth

      When?

    • Must give supplemental oxygen in ACLS

    • Always for MI

      How?

    • NC 4 L/min, intubation, etc

    • Goal - Osat=97-98%

    • Confirm tube placement


    Drugs used for myocardial ischemia pain nitroglycerin

    Drugs Used for Myocardial Ischemia/PainNitroglycerin

    WHY?

    • binds to receptors on vascular smooth muscle - vasodilation (venous > arterial)

    •  venous BF to heart (preload) & O2 consumption

    • dilates coronary arteries -  myocardial blood supply

    • antagonizes vasospasm

    • increases collateral flow to ischemic myocardium

    • inhibits infarct expansion

    • decreases pain


    Drugs used for myocardial ischemia pain nitroglycerin1

    Drugs Used for Myocardial Ischemia/PainNitroglycerin

    WHEN?

    Ischemic CP; USA; pulmonary edema (when SBP>100); AMI

    SL NTG -drug of choice for angina

    IV NTG - drug of choice for unstable angina or AMI

    Congestive heart failure with ischemia

    HOW?

    IV: 10-20 mcg/min, increase by 5-10 mcg/min q5-10 min until desired

    effect or hemodynamic compromise

    SL: 1 tablet (0.4mg) SL q5min times 3

    Spray: 1 spray onto oral mucosa

    Ointment 2%: 1-2 inches over 2-4 inch area

    Patches: no role in acute therapy


    Drugs used for myocardial ischemia pain nitroglycerin2

    Drugs Used for Myocardial Ischemia/PainNitroglycerin

    Preparation:50 mg/250 ml D5W or NS

    Must be in glass bottle

    Cautions:

    • hypotension - treat with fluids, and rate reduction/elimination

    • bradycardia - vasovagal reflex to hypotension

      • treat with fluids, rate reduction, atropine

      • reflex tachycardia also a concern

    • headache, dizziness - may be diminished by laying down

    • patients develop tachyphylaxis to effects - promote nitrate-free periods, intermittent dosing and lowest-possible doses


    Drugs used for myocardial ischemia pain morphine sulfate

    Drugs Used for Myocardial Ischemia/PainMorphine Sulfate

    WHY?(Pain can  catecholamines - BP, HR, O2 demands)

    Opiate analgesic

     pain,  preload and afterload,  SVR,  anxiety

    Relieves pulmonary congestion,  myocardial oxygen demand

    WHEN?

    Pain, pulmonary edema, BP > 90 mm Hg

    HOW?

    1-3mg IVP (2-15 mg IVP q15-30 min prn)

    CAUTION?

    Respiratory & CNS depression, bradycardia, hypotension, N/V


    Drugs used for myocardial ischemia pain continued

    Drugs Used for Myocardial Ischemia/Pain(Continued)

    • Aspirin

    • Heparin

    • Thrombolytics - reteplase, alteplase, TNK

    • B Blockers

    • Magnesium

    • Lidocaine - not for prophylaxis


    Hypotension shock pulmonary edema

    Hypotension/Shock/Pulmonary Edema

    Identify Problem? Volume; Pump; Rate?

    • Volume:

      • fluids, blood, vasopressors

  • Pump:

    • s/s of shock - vasopressors; no s/s shock - dobutamine

    •  BP (>100 mm Hg) - NTG, Nitroprusside

    • pulmonary edema -furosemide 0.5-1mg/kg, morphine 1-3mg, NTG SL, oxygen/intubate

  • Rate: see algorithms


  • Drugs used to improve cardiac output and blood pressure norepinephrine

    Drugs Used to Improve Cardiac Output and Blood PressureNorepinephrine

    Action:Alpha & ß-adrenergic stimulation, increases contractility and HR, vasoconstriction, improves coronary blood flow

    Indication:Shock refractory to fluid replacement, severe hypotension

    Dose:0.5 - 1 mcg/min

    refractory shock = 8 - 30 mcg/min

    Preparation: 4-8mg/250 ml D5W or NS

    Caution:Hypertension, myocardial ischemia, cardiac arrest, palpitations


    Drugs used to improve cardiac output and blood pressure dobutamine

    Drugs Used to Improve Cardiac Output and Blood PressureDobutamine

    Action:B1- adrenergic activity

    Indication:Inotrope in heart failure/hypotension

    Dose:2 - 20 mcg/kg/min

    Preparation: 250 mg/250 ml D5W or NS

    Caution:tachyarrhythmias,worsens myocardial ischemia


    Drugs used to improve cardiac output and blood pressure inamrinone and milrinone

    Drugs Used to Improve Cardiac Output and Blood PressureInamrinone and Milrinone

    Action:Phosphodiesterase inhibitors, positive inotropes and vasodilator

    Indication:Refractory heart failure

    Dose:Inamrinone:750 mcg/kg over 2 - 3 min

    Inf @ 5 - 15 mcg/kg/min

    Milrinone:50 mcg/kg over 10 min

    Inf @ 0.375 - 0.75 mcg/kg/min

    Caution:Thrombocytopenia, worsens myocardial ischemia, SV and ventricular arrhythmias


    Drugs used for heart rhythm and rate isoproterenol

    Drugs Used for Heart Rhythm and RateIsoproterenol

    WHY? Synthetic sympathomimetic amine

    Pure B-adrenergic activity +inotropic& chronotrope

     HR/CO, contractility;  MAP secondary vasodilation

    WHEN? Symptomatic bradycardia

    Refractory torsades de pointes

    HOW? Class II - 2 - 10 mcg/min

    Class III - higher doses

    Preparation: 1 mg/ 250 ml D5W or NS

    WHAT? mycocardial O2 consumption & peripheral vasodilation

    Avoid in ischemic heart disease; arrhythmogenic


    Drugs used to improve cardiac output and blood pressure sodium nitroprusside

    Drugs Used to Improve Cardiac Output and Blood PressureSodium Nitroprusside

    Action:Antihypertensive, peripheral vasodilator, reduces afterload, increases CO and relieves pulmonary congestion

    Indication:Hypertension, AMI, CHF

    Dose:0.1 - 5 mcg/kg/min, and titrate up to 10mcg/kg/min

    Preparation:50 mg/250 ml D5W

    Caution:Cyanide and thiocyanate toxicity, hypotension


    Summary of 2000 changes

    Summary of 2000 Changes

    • NEW AGENTS - Amiodarone & Vasopressin

    • Amiodarone (Class IIb) & Procainamide (Class IIb) - hemodynamically stable wide-complex tachycardia (esp. in poor cardiac fxn)

    • VT - amiodarone & sotalol (Class IIa)

    • Vasopressin (Class IIb) - alternative to epinephrine

    • Bretylium acceptable, but not recommended

    • Lidocaine for VT/VF (Class Indeterminate) & Class III for prophylaxis of ventricular arrhythmias in AMI

    • Magnesium (Class IIb) -  Mg or TdP

    • High-dose epinephrine (Class Indeterminate)

    • Fibrinolytics for AMI & Stroke


    Crash cart revisions

    Crash Cart Revisions

    Summary of Changes:

    Additions: 5 amps of amiodarone 150mg/3ml (were 3)

    3 vials of vasopressin (20 Units/vial)

    1 bag of premixed dopamine 400mg in 250ml

    4 Na Bicarbonate syringes (were 3)

    5 filter needles

    20 blunt cannulas

    Deletions:1 dopamine vial (new total=1)

    Remove 5 epinephrine syringes (new total=10)

    Remove 1 lidocaine syringe (new total=2)

    Remove metoprolol


    Needless system cannulas

    Needless System/Cannulas


    Questions

    Questions ?


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