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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


  • 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


  • 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


  • 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 Emergency Cardiovascular Care

  • 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 Emergency Cardiovascular Care

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 Emergency Cardiovascular Care


  • Preferred route


  • 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)

ACLS Algorithm Approach Emergency Cardiovascular Care

Universal algorithm
Universal Algorithm Emergency Cardiovascular Care

Epinephrine Emergency Cardiovascular Care


  • 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


  • VF/VT, asystole, PEA, bradycardias

  • Epinephrine1
    Epinephrine Emergency Cardiovascular Care


    • High dose versus standard dose?

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

    • High doses may exacerbate postresuscitation myocardial dysfunction


      • 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 Emergency Cardiovascular Care


    • Alternative to epinephrine for shock-refractory VT/VF


    • 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


    • 40 Units IVP - one time only!!!

    Why vasopressin
    Why Vasopressin? Emergency Cardiovascular Care

    • 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 hospital 35% 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 Emergency Cardiovascular Care(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 Emergency Cardiovascular Careor 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 Emergency Cardiovascular Care

    “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)

    Drug-shock-drug-shock sequence Emergency Cardiovascular Care (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- Procainamide 30 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 Emergency Cardiovascular Care

    • Epinephrine - Why? How? What?

    • Vasopressin - Why? How? What?

    • Amiodarone

    • Magnesium

    • Procainamide

    • Lidocaine

    • Buffers

    Classification of antiarrhythmics
    Classification of Antiarrhythmics Emergency Cardiovascular Care

    Drugs used for heart rhythm and rate amiodarone
    Drugs Used for Heart Rhythm and Rate Emergency Cardiovascular CareAmiodarone


    • 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 Emergency Cardiovascular Care


    • 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


    • Hypotension, bradycardia (slow rate, fluids)

    Why amiodarone arrest trial
    Why Amiodarone? Emergency Cardiovascular CareARREST Trial


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


    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 Sustained Ventricular Tachyarrhythmias

    Drugs used for heart rhythm and rate magnesium sulfate
    Drugs Used for Heart Rhythm and Rate Sustained Ventricular TachyarrhythmiasMagnesium 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, and Class 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 Rate Sustained Ventricular TachyarrhythmiasProcainamide


    • Suppresses both ventricular and atrial arrhythmias

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

    • Phase IV depolarization


    • 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 Rate Sustained Ventricular TachyarrhythmiasProcainamide

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

    AF with rapid vent. response: 100 mg over 5 min then [email protected] 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 Rate Sustained Ventricular TachyarrhythmiasLidocaine


    • 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


    • SECOND-CHOICE agent

    • VT/VF refractory to electrical countershock and epinephrine


    • 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 Rate Sustained Ventricular TachyarrhythmiasLidocaine

    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 Pressure Sustained Ventricular TachyarrhythmiasSodium Bicarbonate

    WHY?Enhances sodium shift intracellularly, buffers acidosis, decreases toxicity of TCA’s, increases clearance 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
    Summary Sustained Ventricular TachyarrhythmiasV.Fib and Pulseless V.Tach


    • 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 Sustained Ventricular Tachyarrhythmias

    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 Sustained Ventricular Tachyarrhythmias

    Is the patient stable or unstable?


    Identify 1 of 4 types of tachycardia Cardioversion (premedicate)

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


    Narrow-complex tachycardia

    Stable wide-complex tachycardia

    Stable monomorphic VT

    Tachycardia atrial fibrillation flutter
    Tachycardia - Atrial Fibrillation/Flutter Sustained Ventricular Tachyarrhythmias

    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 Sustained Ventricular Tachyarrhythmias

    Drugs used in afib aflutter
    Drugs Used in Afib/AFlutter Sustained Ventricular Tachyarrhythmias

    • 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 Rate Sustained Ventricular TachyarrhythmiasCalcium Channel Blockers

    WHY? Blocks inward flow of Ca and Na, slows conduction, RP in AVN Terminate reentrant arrhythmias requiring AVN conduction Control ventricular response rate in AF/AFl Coronary 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 Rate Sustained Ventricular TachyarrhythmiasCalcium 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 in patients 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 Rate Sustained Ventricular TachyarrhythmiasBeta - 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

    Stable Monomorphic Ventricular Tachycardia Sustained Ventricular Tachyarrhythmias

    Impaired LV

    EF<40% or CHF





    May go directly to


    • 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 Sustained Ventricular Tachyarrhythmias

    • 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 Sustained Ventricular Tachyarrhythmias

    • “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 Rate Sustained Ventricular TachyarrhythmiasAdenosine

    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 Sustained Ventricular Tachyarrhythmias

    • 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)

        Intervention Comments/Dose

        Problem Search for the probable cause and intervene (HCO3)

        Epinephrine 1 mg IV q3-5 min.

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

    Atropine Sustained Ventricular Tachyarrhythmias

    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 10ml Paradoxical 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 Sustained Ventricular Tachyarrhythmias

    “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 Intervention Comments/Dose

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

      Patients Pacing 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 Sustained Ventricular Tachyarrhythmias

    • 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 Sustained Ventricular Tachyarrhythmias

    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 Algorithms Sustained Ventricular TachyarrhythmiasAsystole

    • 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 Sustained Ventricular Tachyarrhythmias

    • Oxygen

    • Nitroglycerin

    • Morphine Sulfate

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

      • Glycoprotein IIb/IIIa receptor antagonists

    Acute myocardial infarction
    Acute Myocardial Infarction Sustained Ventricular Tachyarrhythmias

    • “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 Sustained Ventricular Tachyarrhythmias


    • increases hemoglobin saturation, improves tissue oxygenation

    •  supply to ischemic tissues

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


    • Must give supplemental oxygen in ACLS

    • Always for MI


    • 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/Pain Sustained Ventricular TachyarrhythmiasNitroglycerin


    • 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/Pain Sustained Ventricular TachyarrhythmiasNitroglycerin


    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


    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/Pain Sustained Ventricular TachyarrhythmiasNitroglycerin

    Preparation: 50 mg/250 ml D5W or NS

    Must be in glass bottle


    • 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/Pain Sustained Ventricular TachyarrhythmiasMorphine Sulfate

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

    Opiate analgesic

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

    Relieves pulmonary congestion,  myocardial oxygen demand


    Pain, pulmonary edema, BP > 90 mm Hg


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


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

    Drugs used for myocardial ischemia pain continued
    Drugs Used for Myocardial Ischemia/Pain Sustained Ventricular Tachyarrhythmias(Continued)

    • Aspirin

    • Heparin

    • Thrombolytics - reteplase, alteplase, TNK

    • B Blockers

    • Magnesium

    • Lidocaine - not for prophylaxis

    Hypotension shock pulmonary edema
    Hypotension/Shock/Pulmonary Edema Sustained Ventricular Tachyarrhythmias

    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 Pressure Sustained Ventricular TachyarrhythmiasNorepinephrine

    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 Pressure Sustained Ventricular TachyarrhythmiasDobutamine

    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 Pressure Sustained Ventricular TachyarrhythmiasInamrinone 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 Rate Sustained Ventricular TachyarrhythmiasIsoproterenol

    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 Pressure Sustained Ventricular TachyarrhythmiasSodium 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 Sustained Ventricular Tachyarrhythmias

    • 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 Sustained Ventricular Tachyarrhythmias

    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 Sustained Ventricular Tachyarrhythmias


    Questions ? Sustained Ventricular Tachyarrhythmias