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ACLS Pharmacology

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  1. ACLS Pharmacology dr shabeel pn

  2. Objectives • To review and obtain a better understanding of medications used in ACLS • Indications & Actions (When & Why?) • Dosing (How?) • Contraindications & Precautions (Watch Out!)

  3. Drug Classifications • Class I: Recommendations • Excellent evidence provides support • Proven in both efficacy and safety • Class II: Recommendations • Level I studies are absent, inconsistent or lack power • Available evidence is positive but may lack efficacy • No evidence of harm

  4. Drug Classifications • Class IIa Vs IIb • Class IIa recommendations have • Higher level of available evidence • Better critical assessments • More consistency in results • Both are optional and acceptable, • IIa recommendations are probably useful • IIb recommendations are possibly helpful • Less compelling evidence for efficacy

  5. Drug Classifications • Class III: Not recommended • Not acceptable or useful and may be harmful • Evidence is absent or unsatisfactory, or based on poor studies • Indeterminate • Continuing area of research; no recommendation until further data is available

  6. Oxygen • Indications (When & Why?) • Any suspected cardiopulmonary emergency • Saturate hemoglobin with oxygen • Reduce anxiety & further damage • Note: Pulse oximetry should be monitored Universal Algorithm

  7. Oxygen • Dosing (How?) Universal Algorithm

  8. Oxygen • Precautions (Watch Out!) • Pulse oximetry inaccurate in: • Low cardiac output • Vasoconstriction • Hypothermia • NEVER rely on pulse oximetry! Universal Algorithm

  9. VF / Pulseless VT Case 3

  10. Epinephrine 1 mg IV push, repeat every 3 to 5 minutes • or • Vasopressin 40 U IV, single dose, 1 time only Resume attempts to defibrillate 1 x 360 J (or equivalent biphasic) within 30 to 60 seconds Consider antiarrhythmics: • Amiodarone (llb for persistent or recurrent VF/pulseless VT) • Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT) • Magnesium (llb if known hypomagnesemic state) • Procainamide (Indeterminate for persistent VF/pulseless VT; llb for recurrent VF/pulseless VT) Resume attempts to defibrillate VF / Pulseless VT

  11. Epinephrine • Indications (When & Why?) • Increases: • Heart rate • Force of contraction • Conduction velocity • Peripheral vasoconstriction • Bronchial dilation VF / Pulseless VT

  12. Epinephrine • Dosing (How?) • 1 mg IV push; may repeat every 3 to 5 minutes • May use higher doses (0.2 mg/kg) if lower dose is not effective • Endotracheal Route • 2.0 to 2.5 mg diluted in10 mL normal saline VF / Pulseless VT

  13. Epinephrine • Dosing (How?) • Alternative regimens for second dose (Class IIb) • Intermediate: 2 to 5 mg IV push, every 3 to 5 minutes • Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apart • High: 0.1 mg/kg IV push, every 3 to 5 minutes VF / Pulseless VT

  14. Epinephrine • Precautions (Watch Out!) • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand • Do not mix or give with alkaline solutions • Higher doses have not improved outcome & may cause myocardial dysfunction VF / Pulseless VT

  15. Vasopressin • Indications (When & Why?) • Used to “clamp” down on vessels • Improves perfusion of heart, lungs, and brain • No direct effects on heart VF / Pulseless VT

  16. Vasopressin • Dosing (How?) • One time dose of 40 units only • May be substituted for epinephrine • Not repeated at any time • May be given down the endotracheal tube • DO NOT double the dose • Dilute in 10 mL of NS VF / Pulseless VT

  17. Vasopressin • Precautions (Watch Out!) • May result in an initial increase in blood pressure immediately following return of pulse • May provoke cardiac ischemia VF / Pulseless VT

  18. Amiodarone • Indications (When & Why?) • Powerful antiarrhythmic with substantial toxicity, especially in the long term • Intravenous and oral behavior are quite different • Has effects on sodium & potassium VF / Pulseless VT

  19. Amiodarone • Dosing (How?) • Should be diluted in 20 to 30 mL of D5W • 300 mg bolus after first Epinephrine dose • Repeat doses at 150 mg VF / Pulseless VT

  20. Amiodarone • Precautions (Watch Out!) • May produce vasodilation & shock • May have negative inotropic effects • Terminal elimination • Half-life lasts up to 40 days VF / Pulseless VT

  21. Lidocaine • Indications (When & Why?) • Depresses automaticity • Depresses excitability • Raises ventricular fibrillation threshold • Decreases ventricular irritability VF / Pulseless VT

  22. Lidocaine • Dosing (How?) • Initial dose: 1.0 to 1.5 mg/kg IV • For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg • A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable • Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS VF / Pulseless VT

  23. Lidocaine • Dosing (How?) • Maintenance Infusion • 2 to 4 mg/min • 1000 mg / 250 mL D5W = 4 mg/mL • 15 mL/hr = 1 mg/min • 30 mL/hr = 2 mg/min • 45 mL/hr = 3 mg/min • 60 mL/hr = 4 mg/min VF / Pulseless VT

  24. Lidocaine • Precautions (Watch Out!) • Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction • Discontinue infusion immediately if signs of toxicity develop VF / Pulseless VT

  25. Magnesium Sulfate • Indications (When & Why?) • Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state • Refractory VF • VF with history of ETOH abuse • Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose VF / Pulseless VT

  26. Magnesium Sulfate • Dosing (How?) • 1 to 2 g  (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push VF / Pulseless VT

  27. Magnesium Sulfate • Precautions (Watch Out!) • Occasional fall in blood pressure with rapid administration • Use with caution if renal failure is present VF / Pulseless VT

  28. Procainamide • Indications (When & Why?) • Recurrent VF • Depresses automaticity • Depresses excitability • Raises ventricular fibrillation threshold • Decreases ventricular irritability VF / Pulseless VT

  29. Procainamide • Dosing (How?) • 30 mg/min IV infusion • May push at 50 mg/min in cardiac arrest • In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable • Maximum total dose: 17 mg/kg VF / Pulseless VT

  30. Procainamide • Dosing (How?) • Maintenance Infusion • 1 to 4 mg/min • 1000 mg / 250 mL of D5W = 4 mg/mL • 15 mL/hr = 1 mg/min • 30 mL/hr = 2 mg/min • 45 mL/hr = 3 mg/min • 60 mL/hr = 4 mg/min VF / Pulseless VT

  31. Procainamide • Precautions (Watch Out!) • If cardiac or renal dysfunctionis present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min • Remember Endpoints of Administration VF / Pulseless VT

  32. PEA Case 4

  33. PEA Review for most frequent causes • Hypovolemia • Hypoxia • Hydrogen ion—acidosis • Hyper-/hypokalemia • Hypothermia • Tablets (drug OD, accidents) • Tamponade, cardiac • Tension pneumothorax • Thrombosis, coronary (ACS) • Thrombosis, pulmonary (embolism) Epinephrine 1 mg IV push, repeat every 3 to 5 minutes Atropine 1 mg IV (if PEA rate is slow), repeat every 3 to 5 minutes as needed, to a totaldose of 0.04 mg/kg

  34. Epinephrine • Indications (When & Why?) • Increases: • Heart rate • Force of contraction • Conduction velocity • Peripheral vasoconstriction • Bronchial dilation Pulseless Electrical Activity

  35. Epinephrine • Dosing (How?) • 1 mg IV push; may repeat every 3 to 5 minutes • May use higher doses (0.2 mg/kg) if lower dose is not effective • Endotracheal Route • 2.0 to 2.5 mg diluted in10 mL normal saline Pulseless Electrical Activity

  36. Epinephrine • Precautions (Watch Out!) • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand • Do not mix or give with alkaline solutions • Higher doses have not improved outcome & may cause myocardial dysfunction Pulseless Electrical Activity

  37. Atropine Sulfate • Indications (When & Why?) • Should only be used for bradycardia • Relative or Absolute • Used to increase heart rate Pulseless Electrical Activity

  38. Atropine Sulfate • Dosing (How?) • 1 mg IV push • Repeat every 3 to 5 minutes • May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS • Maximum Dose: 0.04 mg/kg Pulseless Electrical Activity

  39. Atropine Sulfate • Precautions (Watch Out!) • Increases myocardial oxygen demand • May result in unwanted tachycardia or dysrhythmia Pulseless Electrical Activity

  40. Asystole Case 5

  41. Transcutaneous pacing: If considered, perform immediately Epinephrine1 mg IV push, repeat every 3 to 5 minutes Atropine 1 mg IV, repeat every 3 to 5 minutes up to a total of 0.04 mg/kg Asystole persistsWithhold or cease resuscitation efforts? • Consider quality of resuscitation? • Atypical clinical features present? • Support for cease-efforts protocols in place? Asystole

  42. Epinephrine • Indications (When & Why?) • Increases: • Heart rate • Force of contraction • Conduction velocity • Peripheral vasoconstriction • Bronchial dilation Asystole: The Silent Heart Algorithm

  43. Epinephrine • Dosing (How?) • 1 mg IV push; may repeat every 3 to 5 minutes • May use higher doses (0.2 mg/kg) if lower dose is not effective • Endotracheal Route • 2.0 to 2.5 mg diluted in10 mL normal saline Asystole: The Silent Heart Algorithm

  44. Epinephrine • Precautions (Watch Out!) • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand • Do not mix or give with alkaline solutions • Higher doses have not improved outcome & may cause myocardial dysfunction Asystole: The Silent Heart Algorithm

  45. Atropine Sulfate • Indications (When & Why?) • Used to increase heart rate • Questionable absolute bradycardia Asystole: The Silent Heart Algorithm

  46. Atropine Sulfate • Dosing (How?) • 1 mg IV push • Repeat every 3 to 5 minutes • May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS • Maximum Dose: 0.04 mg/kg Asystole: The Silent Heart Algorithm

  47. Atropine Sulfate • Precautions (Watch Out!) • Increases myocardial oxygen demand Asystole: The Silent Heart Algorithm

  48. Other Cardiac Arrest Drugs

  49. Calcium Chloride • Indications (When & Why?) • Known or suspected hyperkalemia (eg, renal failure) • Hypocalcemia (blood transfusions) • As an antidote for toxic effects of calcium channel blocker overdose • Prevent hypotension caused by calcium channel blockers administration Other Cardiac Arrest Drugs