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ACLS Pharmacotherapy Update

ACLS Pharmacotherapy Update. Jessica Schwenk, Pharm.D. September 14, 2013. Introduction. Objectives ACLS Guideline Overview Access for Medications in ACLS. Objectives. Identify and describe medications used in Advanced Cardiovascular Life Support (ACLS)

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ACLS Pharmacotherapy Update

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  1. ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013

  2. Introduction Objectives ACLS Guideline Overview Access for Medications in ACLS

  3. Objectives • Identify and describe medications used in Advanced Cardiovascular Life Support (ACLS) • Understand indications, mechanism of action, dose, administration, and precautions for ACLS medications • Recognize place in therapy for medications in updated ACLS algorithms

  4. ACLS Guidelines • Developed by American Heart Association • Released every 5 years • Published in Circulation • Most Recent • 2010 Guidelines for advanced cardiac life support • Used comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation (ILCOR)

  5. ACLS Guidelines • First priority • High quality CPR • Early defibrillation • Second priority • Medication administration • Advanced airway • For drug administration or ventilation

  6. Access for Medications in ACLS • Intravenous (IV) Route • Preferred route • Central line not required; can interrupt CPR • Medications take 1-2 minutes to reach central circulation • Give medications as IV bolus, flush with 20 mL fluid

  7. Access for Medications in ACLS • Intraosseous (IO) Route • Secondary method • Safe and effective for administering medications, fluids, and blood as well as drawing blood • ALL medications that can be given IV can be given IO • Administer medications and flush with at least 20 mL fluid (as with IV administration)

  8. Access for Medications in ACLS • Endotracheal (ET) Route • Not preferred; last resort • Medication doses are 2-2.5 times IV/IO doses • Optimal dosing not known • Medications that can be given ET: epinephrine, vasopressin, lidocaine (atropine, naloxone) • Dilute with 5-10 mL SW/NS, administer into ET tube, follow with several positive pressure breaths

  9. ACLS Medications Adult cardiac arrest algorithm

  10. Adult cardiac arrest algorithm • Medications: • Ventricular fibrillation or ventricular tachycardia (VF/VT) • Vasopressors: epinephrine, vasopressin • Antiarrhythmics: amiodarone • Not on algorithm: lidocaine, magnesium • Asystole/Pulseless electrical activity (PEA) • Vasopressors: epinephrine, vasopressin

  11. Adult cardiac arrest algorithm • Vasopressor medications • Include: epinephrine, norepinephrine, vasopressin • Goal: increase coronary and cerebral perfusion • Effects: • Increase systemic arteriolar vasoconstriction • Maintain vascular tone • Shunt blood to heart and brain • ONLY medications shown to improve ROSC and short term survival

  12. Adult cardiac arrest algorithm • Epinephrine (Adrenaline) • MOA: ɑ- and β-receptor agonist • ɑ-receptor stimulation restores circulation • β-receptor stimulation • May lower defibrillation threshold • Increases myocardial oxygen demand

  13. Adult cardiac arrest algorithm • Epinephrine • Dose and Administration • VF, PVT, asystole, PEA • IV/IO: 1 mg every 3-5 minutes • Concentration 0.1mg/ml (1:10,000 or 1 mg/10ml) • Flush with 20 ml NS (central line preferred) • ET: 2-2.5 mg every 3-5 minutes • Dilute in 5-10 ml SW or NS (use epi 1 mg/ml or 1:1,000)

  14. Vasopressors • Vasopressin (antidiuretic hormone) • MOA: acts on V1 receptor (among others) to cause vasoconstriction • Increases blood pressure and systemic vascular resistance • Benefits over epinephrine • Not inhibited by metabolic acidosis • No β-receptor activity • Vasopressin vs. epinephrine for cardiac arrest? • No significant difference in ROSC when given 2 doses

  15. Vasopressors • Vasopressin • Dose and Administration • VF, PVT, asystole, PEA • IV/IO: 40 units one time (to replace 1st or 2nd dose of epinephrine every 3-5 minutes) • 40 Units/2 ml (2 vials of 20 units/ml) • Flush with 20 ml NS • ET: 80-100 units one time (to replace 1st or 2nd dose of epinephrine every 3-5 minutes) • Dilute in 5-10 ml SW or NS

  16. Adult cardiac arrest algorithm • Antiarrhythmic medications for cardiac arrest (pulseless VF/VT) include: • Amiodarone • Not on algorithm: lidocaine, magnesium • Goal: increase the fibrillation threshold • Prevent development or recurrence of VF and PVT

  17. Adult cardiac arrest algorithm • Amiodarone (Cordarone, Pacerone) • MOA: Class III antiarrhythmic (potassium channel blocker) • Acutely: inhibits α- and β-adrenergic stimulation, blocks calcium channels • Side effects (acute): • Hypotension, fever, elevated LFTs, confusion, nausea, thrombocytopenia

  18. Adult cardiac arrest algorithm • Amiodarone • Dose and administration • Pulseless VF/VT • 300 mg bolus IV/IO, follow with 150 mg in 3-5 minutes • Give IV/IO push. If possible dilute in 20-30 ml D5W • Amiodarone vial concentration is 50 mg/ml • Flush with 20 ml • Central line preferred • Incompatible with sodium bicarbonate

  19. Other antiarrhythmics • Lidocaine (NOT on algorithm for VF/PVT) • MOA: Class Ib antiarrhythmic, sodium channel blocker • 2010 Guidelines: “There is inadequate evidence to support or refute the use of lidocaine…” in refractory VF/VT • Amiodarone beneficial over lidocaine for survival-to-admission • May be considered if amiodarone is not available

  20. Other Antiarrhythmics • Lidocaine (NOT on algorithm for VF/PVT) • Dose and Administration • IV/IO: 1-1.5 mg/kg, then 0.5-0.75 mg/kg every 5 to 10 minutes • Lidocaine 100 mg/5 ml syringe (20 mg/ml) • ET: 2-3 mg/kg in 10 ml NS • Dose and Administration • Monitoring: discontinue if signs of toxicity • Sedations, seizures, confusion

  21. Other Antiarrhythmics • Magnesium (NOT on algorithm for VF/PVT) • Use: suspected hypomagnesemia, Torsades de Pointes • Dose and Administration (cardiac arrest) • Magnesium 1-2 g IV/IO • Magnesium sulfate 50% vials (1 g/2 mL or 0.5 g/ml) • Dilute to 10 ml (NS) • Administer over 5-20 minutes • Monitor: • Hypotension, respiratory and CNS depression

  22. ACLS Medications Adult bradycardia algorithm (with pulse)

  23. Adult bradycardia algorithm (with pulse)

  24. Adult bradycardia algorithm (with pulse)

  25. Adult bradycardia algorithm (with pulse) • Medications • Atropine • Dopamine • Epinephrine

  26. Adult bradycardia algorithm (with pulse) • Atropine • MOA: anticholinergic agent, blocks acetylcholine at M2-receptors of heart • Dose and administration • 0.5 mg IV/IO bolus, repeat every 3-5 minutes • Max 3 mg total dose • Atropine syringe 1 mg/10 ml (0.1 mg/ml) • Contraindications/Precautions • Evidence of a high degree (second degree [Mobitz] type II or third degree) atrioventricular (AV) block • May be harmful in cardiac ischemia

  27. Adult bradycardia algorithm (with pulse) • Dopamine • MOA: adrenergic and dopaminergic receptor agonist, stimulation of β1-recptors increases HR • Dose and Administration • 2-10 mcg/kg/min IV/IO infusion (up to 20 mcg/kg/min) • Titrate to response, increase by 5 mcg/kg/min every 10-30 minutes as needed • Premade bags are 200 mg/250 ml D5W (800 mcg/ml) • Central line preferred • Incompatible with sodium bicarbonate

  28. Adult bradycardiaalgorithm (with pulse) • Epinephrine • MOA: adrenergic agonist, stimulation of β1-recptors increases HR • Dose and Administration • 2-10 mcg/min IV/IO infusion • Titrate to response • Standard drip 4 mg/250 ml NS or D5W (16 mcg/ml) • Central line preferred • Incompatible with sodium bicarbonate

  29. ACLS Medications Adult tachycardia algorithm (with pulse)

  30. Adult tachycardia algorithm (with pulse) • Medications • Regular narrow complex • Adenosine • Calcium channel blockers or beta blocker • Irregular narrow complex • Calcium channel blocker or beta blocker • Amiodarone

  31. Adult tachycardia algorithm (with pulse) • Medications • Regular wide complex • Adenosine • Calcium channel blockers or beta blocker • Antiarrhythmics: procainamide, amiodarone, sotolol • Irregular wide complex • Antiarrhythmics: procainamide, amiodarone, sotolol • Polymorphic VT, Torsades de Pointes: magnesium

  32. Adult tachycardia algorithm (with pulse) • Adenosine • Dose and Administration • 6-12 mg IV into large proximal vein—fast • Flush with 20 mL immediately, elevate limb • Extremely short half life • May repeat 2nd and 3rd dose of 12 mg • Larger doses (18 mg IV) • Theophylline or theobromine, caffeine; • Smaller doses (3mg IV) • Dipyridamole or carbamazepine, transplanted hearts, or into a central vein.

  33. Adult tachycardia algorithm (with pulse) • Adenosine • Side effects • Chest discomfort, dyspnea, and flushing • Warn patient! • Monitoring • Continuous ECG recording during administration • If adenosine fails to convert SVT, watch for atrial flutter or a non-reentrant SVT

  34. Adult tachycardia algorithm (with pulse) • Diltiazem • First choice for acute a-fib with RVR • Dose and administration • Bolus 15-20 mg IV push over 2 minutes (0.25 mg/kg) • Repeat with 20-25 mg IV push over 2 minutes after 15 minutes (0.35 mg/kg) • Diltiazem vials 5 mg/ml • IV infusion 5-10 mg/hour, titrate up by 5 mg/hour as needed • Diltiazem infusion 1 mg/ml • Monitor: ECG, blood pressure

  35. Adult tachycardia algorithm (with pulse) • Verapamil • Dose and administration • 2.5-5 mg IV push over 2 minutes • Repeat with 5-10 mg over 2 minutes after 15-30 minutes • Maximum total dose 20 mg • Monitor: ECG, blood pressure

  36. Adult tachycardia algorithm (with pulse) • Metoprolol • Dose and administration • 5 mg IV push over 1 minute for 3 doses every 2-5 minutes • Monitor: ECG, blood pressure

  37. Adult tachycardia algorithm (with pulse) • Atenolol • Dose and administration • 5 mg slow IV push over 5 minutes • Repeat in 10 minutes • Monitor: ECG, blood pressure

  38. Adult tachycardia algorithm (with pulse) • Esmolol • Dose and administration • 500 mcg/kg IV push over 1 minute (may repeat) • 10 mg/ml • IV infusion 50 mcg/kg/minute for 4 minutes • Titrate by 50 mcg/kg/minute at least every 4 minutes • Max 200 mcg/kg/min • Repeat in 10 minutes • Monitor: ECG, blood pressure

  39. Adult tachycardia algorithm (with pulse) • Procainamide • Class 1a antiarrhythmic (sodium channel blocker) • Dose and administration • IV infusion 20 mg/min (20 mg/ml in D5W) • Alternate dosing: 100 mg IV push over 2 min every 5 min • Continue until the arrhythmia is suppressed, or: • Hypotension • QRS widens 50% beyond baseline • Max dose of 17 mg/kg • Maintenance infusion 1-3 mg/min (2 mg/ml in D5W) • Monitor: ECG, QT interval, pulse, blood pressure • ADR: dysrhythmia, systemic lupus erythematosus (up to 30%), hematologic effects, hepatotoxicity

  40. Adult tachycardia algorithm (with pulse) • Amiodarone • Dose and administration • 150 mg IV over 10 min, repeat for recurrence • Mix in 100 ml D5W (1.5 mg/ml) • Follow IV infusion 1 mg/min for 6 hours, then 0.5 mg/min 0.5 mg/min IV for 18 hours • Infusion 1.5 mg/ml • Max 2.2 g/24 hr • Central line preferred • Use in-line filter • Incompatible with sodium bicarbonate • Monitor: ECG, pulse, blood pressure • ADR: hyper/hypthyroidism, lupus, vision impairment, renal/liver impairment, pulmonary fibrosis

  41. Adult tachycardia algorithm (with pulse) • Magnesium • Torsadesde Pointes • Dose and Administration • Magnesium 1-2 g IV • Magnesium sulfate 50% vials (1 g/2 mL or 0.5 g/ml) • Dilute to 10 ml (NS) • Administer over 5-20 minutes • Maintenance infusion 0.5-1 g/hour • To correct deficiency • Monitor: • hypotension, respiratory and CNS depression

  42. Extravasation • Hyaluronidase(150 units/ml) • Inject 0.2 ml subq around the area of the extravasation (5 injections) • Amiodarone (hot compress) • Calcium (cold compress) • Phentolamine(5 mg with 9 ml NS) • Inject small amount into blanched area, additional as needed • Epineprine (norepinephrine, phenylephrine) • Dopamine • Vasopressin

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