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 2
nd
type II or new 3
rd
degree block (may slow
the rhythm)
Doses < 0.5 mg may cause a paradoxical slowing

5. Atropine
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
Don’t delay pacing for severely
symptomatic (unstable)
patients.

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
1
st
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
2
nd
and 3
rd
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: 1
st
, 2
nd
, 3
rd
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
2
nd
and 3
rd
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 1
st
or 2
nd
dose
of epinephrine. Epinephrine can be resumed 3-5
minutes after
Can be used endotracheally; no suggested dose