Acls pharmacology

Pharmacology is an important part of ACLS program. In ACLS Program,we are using many essential drugs for surviving cardiac arrest cases in Emergency department. We are introducing ACLS which is locally called ARC ( Advanced Resuscitation Course) started in Square Hospitals Ltd,Dhaka,Bangladesh. Hope it will help many health care provider to know the useful medication in case of CPR.

1. ACLS PHARMACOLOGY BY DR.ZAHID,EMERGENCY DEPT SQUARE HOSPITALS LTD,BANGLADESH

2. ACLS Medication

3. Medication using during cardiac arrest: Objectives of drug Treatment : To correct hypoxia. To correct metabolic acidosis. Increase cardiac perfusion during CPR. Stimulate cardiac contraction. Accelerate heart rate. Relieve pain & Treat pulmonary edema.

4. EMERGENCY MEDICATION General Principles: All drugs must be given as bolus dose. No chance to give wrong dose. No time wasted. Always flush with 20 ml NS and raising the arm.

5. EMERGENCY MEDICATION Routes of administration: Intravenous: Peripheral or Central line. Oral route: Via ET tube: Dose is 2.5 times the IV dose. Intracardiac : Cardiocenthesis technique. Intra osseous route: For the children usually.

6. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Concentration Dose Remarks Adenosine Narrow complex SVT 3mg/ml in 2 ml vial (Total: 6 mg) 6 mg rapid bolus ( 1-3 seconds). Repeat dose: 12 mg if no response with in 1-2 min. Half life: < 5 s Side Effect: Flushing, Chest pain, tightness, Sinus bradycardia . Preg C. Amiodarone Recurrent VF AF, Flutter, Stable VT Unstable VT refractory to other medication. 50 mg/ml in 3 ml ampules. Total: 150 mg. For VT/VF with Cardiac arrest: 300 mg rapid infusion. Repeat 150 mg over 3-5 min. Side Effect: H ypotension, Prodysrhythmic , Preg D

7. Adenosine Adenosine is the primary drug used in the treatment of stable narrow-complex SVT (Supraventricular Tachycardia ). Dosing: The first dos e of adenosine should be 6 mg administered rapidly over 1-3 seconds followed by a 20 ml NS bolus. If the patient’s rhythm does not convert out of SVT within 1 to 2 minutes, a second 12 mg dose may be given in similar fashion. Child: 100mcg/kg 1 st dose. 2 nd : 200mcg/kg.

8. Adenosine Caution: Prodysrhythmic , do not give in preexisting 2nd or 3 rd degree block, Preg C.

9. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Concentration Dose Remarks Adenosine Narrow complex SVT 3mg/ml in 2 ml vial (Total: 6 mg) 6 mg rapid bolus ( 1-3 seconds). Repeat dose: 12 mg if no response with in 1-2 min. Half life: < 5 s Side Effect: Flushing, Chest pain, tightness, Sinus bradycardia . Preg C. Amiodarone Recurrent VF AF, Flutter, Stable VT Unstable VT refractory to other medication. 50 mg/ml in 3 ml ampules. Total: 150 mg. For VT/VF with Cardiac arrest: 300 mg rapid infusion. Repeat 150 mg over 3-5 min. Child: 5mg/kg over 3 min. Side Effect: H ypotension, Prodysrhythmic , Preg D

10. Amiodarone MOA: Blocks K efflux (Class III antidysrhythmic ); also has Na channel blocking (class I ),beta blocking (class II), and Ca channel blocking (class IV) properties. Dose : Pulseless VF/VT: 300mg IV rapid push followed by 150mg IV rapid push if necessary at next pulse check Stable wide complex tachycardias : 150mg IV over 10 minutes , followed by infusion of 1mg/min x 6hours, then 0.5 mg/min thereafter. Child: 5mg/kg ( Max:300mg) Indications : P ulseless VF/VT, Wide complex tachydysrhythmias . Caution: Causes hypotension, prodysrhythmic , Preg D

11. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Concentration Dose Remarks Epinephrine Cardiac arrest VT/VF, Asystole , PEA, Symptomatic bradycardia after Atropine. 0.1 mg/ml in 10 ml syringe. (1: 10,000 Soln ) 1 mg IV every 3-5 mins . Child: 0.01-0.03mg/kg Each 1 mg bolus IV dose should be flush of 20 ml fluid. Dopamine 2 nd drug for symptomatic bradycardia . Significant hypotention SPB <70 mm of Hg. 40 mg/ ml in 5 ml ampoule. Total: 200 mg. 5-10 mcg/kg/min IV beta effects 10-20 mcg/kg/min IV alpha effects Don’t mix with NaHco3: Excessive vasoconstriction.

12. EPINEPHRINE MOA: Epinephrine, more commonly known as adrenaline, is a hormone secreted by the medulla of the adrenal glands. Indication: Cardiac arrest VT/VF, Asystole , PEA, Symptomatic bradycardia after Atropine. Dose: 0.1 mg/ml in 10 ml syringe. (1: 10,000 Soln ), Adult: 1 mg IV every 3-5 mins . Child: 0.01-0.03mg/kg Caution: Each 1 mg bolus IV dose should be flush of 20 ml fluid, Hotness in site, SOB, Irregular pulse.

13. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Concentration Dose Remarks Epinephrine Cardiac arrest VT/VF, Asystole , PEA, Symptomatic bradycardia after Atropine. 0.1 mg/ml in 10 ml syringe. (1: 10,000 Soln ) 1 mg IV every 3-5 mins . Child: 0.01-0.03mg/kg Each 1 mg bolus IV dose should be flush of 20 ml fluid. Dopamine 3rd nd drug for symptomatic bradycardia . Significant hypotention SPB <70 mm of Hg. 40 mg/ ml in 5 ml ampoule. Total: 200 mg. 5-10 mcg/kg/min IV beta effects 10-20 mcg/kg/min IV alpha effects Don’t mix with NaHco3: Excessive vasoconstriction.

14. Dopamine MOA: alpha1, beta1, and dopaminergic agonist Dose : < 5 mcg/kg/min IV dopaminergic effects (not recommended ). 5-10 mcg/kg/min IV primarily beta effects ( Positive inotropic & Vasodilation.) 10-20 mcg/kg/min IV primarily alpha effects (Vasoconstriction) Indications : D ecompensated heart failure, hypotension. Caution: T achydysrhythmias , tissue necrosis if extravasation or arterial administration therefore needs to be given through central venous line , Preg C.

15. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Conc Dose Remarks Dobutamine CHF with SBP>100 & DBP Normal. 12.5 mg/ml in 20 ml vials. 2-20microgm/ kg/min Avoid when SBP <100 . Tachyarrhythmia. Preg B Magnesium sulphate Cardiac arrest associated with Torsades de Pointes. Suspected hypomagnesemia 10 ml ampoules 50% MgSo4=5 gm mg. AMI: Loading dose 1.2 gm. Helpful for refractory VT/VF after Lidocaine or Amiodarone Preg A Lidocaine Cardiac arrest: VF/VT. Wide complex Tachycardia. Venicular ectopy . 5 ml syringe: 100 mg/5 ml Cardiac arrest: 1-1.5 mg/kg initial bolus. Refactory VF: 0.5-0.75mg/kg.

16. Dobutamine MOA: Synthetic catecholamine: Beta1 agonist > beta2 agonist. Dose: 2-20mcg/kg/min IV Indications : D ecompensated heart failure, refractory hypotension. Caution: T achycardia , hypotension if not euvolemic , PVCs. Preg B

17. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Conc Dose Remarks Dobutamine CHF with SBP>100 & DBP Normal. 12.5 mg/ml in 20 ml vials. 2-20microgm/ kg/min Avoid when SBP <100 . Tachyarrhythmia. Preg B Magnesium sulphate Cardiac arrest associated with Torsades de Pointes. Suspected hypomagnesemia Eclampsia,BA . 10 ml ampoules 50% MgSo4=5 gm mg. Infusion: 1g/100mL 2g/100mL AMI: Loading dose 2 gm. Child: 25-50 mg/kg. Helpful for refractory VT/VF after Lidocaine or Amiodarone Preg A Lidocaine Cardiac arrest: VF/VT. Wide complex Tachycardia. Venicular ectopy . 5 ml syringe: 100 mg/5 ml Cardiac arrest: 1-1.5 mg/kg initial bolus. Refactory VF: 0.5-0.75mg/kg.

18. Magnesium Sulfate MOA: P articipates in physiologic processes. Dose: Eclampsia : 2-4 grams IV over 5 minutes Pulseless torsades : 2 grams IV push. Asthma exacerbation: 2 grams over 15 minutes. Indications : T orsades , ventricular dysrhythmias, eclampsia , status asthmaticus . Caution: R espiratory depression, hypotension, Preg A

19. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Conc Dose Remarks Dobutamine CHF with SBP>100 & DBP Normal. 12.5 mg/ml in 20 ml vials. 2-20microgm/ kg/min Avoid when SBP <100 . Tachyarrhythmia. Preg B Magnesium sulphate Cardiac arrest associated with Torsades de Pointes. Suspected hypomagnesemia 10 ml ampoules 50% MgSo4=5 gm mg. AMI: Loading dose 1.2 gm. Helpful for refractory VT/VF after Lidocaine or Amiodarone Preg A Lidocaine Cardiac arrest: VF/VT. Wide complex Tachycardia. Venicular ectopy . 5 ml syringe: 100 mg/5 ml Cardiac arrest: 1-1.5 mg/kg initial bolus. Refactory VF: 0.5-0.75mg/kg.

20. Lidocaine MOA: Blocking Na Channel. Indication: VT/VF refectory to other medication. Dose: 1mg to 1.5 mg/kg IV bolus once; may repeat if necessary at a dose of 0.5 to 0.75 mg/kg IV every 5 to 10 minutes up to a maximum cumulative dose of 3 mg/kg. Caution: S leepiness , muscle twitching, confusion, Decrease BP.

21. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Conc Dose Remarks Nor epinephrine Cardiogenic shock Hypotention refractory to IVF 2mcg/ml in 2 ml vials. Begin:0.1-0.5mcg/ kg/min. Increase myocardial o2 requirement. Induce arrythmias . Tissue necrosis if extravasation . Preg C . Atropine Symptomatic bradycardia . Organophosphate poisoning. 600mcg/ml. 0.5-0.6mg IV push repeat up to total dose of 3mg if needed. Hyperthermic patients tachydysrhythmias . Preg C

22. Norepinephrine MOA: Alpha1 agonist > beta1 agonist Dose: 1-30 mcg/min IV. AHA: 0.1-0.5mcg/kg/min. Indications : H ypotension refractory to IVF Caution: T achydysrhythmias , tissue necrosis if catheter infltrates or administered through an arterial line therefore needs to be given via a central venous line, Preg C

23. ACLS MEDICATION DRUG USED IN CARDIAC ARREST Drug Indication Conc Dose Remarks Nor epinephrine Cardiogenic shock Hypotention refractory to IVF 2mcg/ml in 2 ml vials. Begin:0.5-1mgm/ kg/min. Increase myocardial o2 requirement. Induce arrythmias . Tissue necrosis if extravasation . Preg C . Atropine Symptomatic bradycardia . Organophosphate poisoning. 600mcg/ml. 0.5-0.6mg IV push repeat up to total dose of 3mg if needed. Hyperthermic patients tachydysrhythmias . Preg C

24. Atropine MOA: D irect anticholinergic. Dose : Organophosphate/ carbamate toxicity: 1-6 mg IV q 3-5 minutes PRN, until dry secretions (can double dose each time until adequate response achieved) Pedia : Bradycardia : 0.02 mg/kg IVx1; 0.5 mg max single dose; 1 mg max. Adult: Bradycardia : 0.5 mg IV, 3 mg max. Indications : Organophosphate/ carbamate toxicity, bradycardia . Caution: H yperthermic patients, tachydysrhythmias , Preg C . Physostagmin antidot .

25. Sodium Bicarbonate MOA: I ncreases serum bicarbonate (increases buffer stores) Dose: Hyperkalemia or metabolic acidosis: 50 mEq IV x 1 (1 amp = 50 mEq ). TCA toxicity: 1-2 mEq /kg IV bolus to achieve a serum pH of 7.45-7.55 and QRS narrowing; effective serum alkalinization unlikely with continuous infusion. Salicylate toxicity: 3 amps (150mEq) in 1 liter D5W given as 10-20 ml/kg bolus,then 2-3ml/kg/hr; goal urine pH 7.5-8.0 Indications : hyperkalemia, TCA toxicity, salicylate toxicity, metabolic acidosis. Caution: C aution in CHF, overshooting into metabolic alkalosis, hypernatremia , Preg C

26. BRADYCARDIA

27. RSI Medication

28. RSI RSI is the preferred method of endotracheal tube intubation (ETTI) in the emergency department (ED). Steps of RSI: (6 Ps); Plan. Position. Pre-Oxygenate & Pre treatment. Preparation. Paralyze. Post intubation.

29. DRUG USED IN RSI PRETREATMENT MEDICATIONS Drug Indication Conc Dose Remarks Fentanyl To provide sedation & analgesia; 50 mcg/ml in 2 ml ampoules. 1-2 mcg/kg slow IV push (over 1-2 min) Duration of action: 0.5-1 h. Preg C Lidocaine Useful with asthma/COPD Decrease hypertensive response 20mg/ml in 50 ml vials. 1.5 mg/kg IV push Duration of action: 10-20 min

30. Fentanyl MOA: O pioid agonist producing analgesia with adjunctive sedative effects. Dose: 25-100 mcg IV q 1-2 hours; Recommended dose 1 mcg/kg. Indications : P ain control, sedation adjunct Caution: R espiratory depression, vasodilation (hypotension ),laryngospasm , Preg C

31. DRUG USED IN RSI PRETREATMENT MEDICATIONS Drug Indication Conc Dose Remarks Fentanyl To provide sedation & analgesia; 50 mcg/ml in 2 ml ampoules. 1-2 mcg/kg slow IV push (over 1-2 min) Duration of action: 0.5-1 h. Preg C Lidocaine Useful with asthma/COPD Decrease hypertensive response 20mg/ml in 50 ml vials. 1.5 mg/kg IV push Duration of action: 10-20 min Vecuronium ( Norcuron ) Decreases fasciculation & potassium release from cells; 10mg/vial mix with 10 ml DW. Defasciculating dose: 0.01 mg/kg IV push (typically about 1 mg, Avoid higher doses to produce paralytic effect. Preg B

32. Lidocaine MOA: Blocking Na Channel. Indication : Head injury to decrease ICP. Decrease cough reflex in COPD,Asthma . Dose: 1mg to 1.5 mg/kg IV bolus once; may repeat if necessary at a dose of 0.5 to 0.75 mg/kg IV every 5 to 10 minutes up to a maximum cumulative dose of 3 mg/kg. Caution: S leepiness , muscle twitching, confusion, Decrease BP.

33. DRUG USED IN RSI DRUG USING INDUCTION Drug Indication Concentration Dose Remarks Etomidate Ultrashort -acting nonbarbiturate hypnotic agent. 2mg/ml in 10 ml vials. RSI is 0.3 mg/kg IV, or a typical adult dose of 20 mg. No analgesic proparies . Does not depress the cardiovascular system . Ketamine Ideal induction agent for RSI because it produces rapid sedation. Both analgesic and amnesic properties 50mg/ml in 10 ml vials. 2 mg/kg IV with clinical recovery in 10-15 minutes. Ketamine is highly lipid soluble. Agent of choice with bronchospasm. Half-life : 7-11 minutes. Preg D

34. Etomidate MOA: GABA-like effects on brain stem reticular formation causing hypnosis Dose: 0.3 mg/kg IV Indications : RSI induction Caution: C ortisol depression, lowers seizure threshold, Preg C

35. DRUG USED IN RSI DRUG USING INDUCTION Drug Indication Concentration Dose Remarks Etomidate Ultrashort -acting nonbarbiturate hypnotic agent. 2mg/ml in 10 ml vials. RSI is 0.3 mg/kg IV, or a typical adult dose of 20 mg. No analgesic proparies . Does not depress the cardiovascular system . Ketamine Ideal induction agent for RSI because it produces rapid sedation. Both analgesic and amnesic properties 50mg/ml in 10 ml vials. 2 mg/kg IV with clinical recovery in 10-15 minutes. Ketamine is highly lipid soluble. Agent of choice with bronchospasm. Half-life : 7-11 minutes. Preg D

36. Ketamine MOA: Acts on cortex and limbic system . Dose: Subdissociative : 0.1-0.5 mg/kg IV Procedural sedation: 0.5-1 mg/kg IV RSI induction: 2 mg/kg IV Indications : A nalgesia , sedation, RSI induction Caution: E mergence reactions (treat with benzos or barbs ),laryngospasm , IOP increase, ICP increase, tachycardia, hypertension, Preg D

37. DRUG USED IN RSI DRUG USING INDUCTION Drug Indication Conc Dose Remarks Propofol Sedative hypnotic. 10mg/ml in 20ml ampoules. Induction dose is 2 mg/kg, Short duration of action of 10-15 min. Myocardial depressant, Decrease in MAP. Decreases cerebral metabolism & ICP. Preg B Midazolam Seizure, RSI Procedural sedation, Ventilator sedation. 5mg/ml in 3 ml vials. RSI is 0.1 mg/kg, Infusion: 1-10 mg/hour. Respiratory depression, Hypotensive effects, Preg D.

38. Propofol MOA: GABAa agonist, Na channel blocker Dose: Procedural Sedation: 1 mg/kg IV bolus then 0.5 mg/kg q 3 minutes to effect RSI induction: 1.5-2.5 mg/kg IV x 1 Ventilator Sedation: 5-50 mcg/kg/min) Indications : P rocedural sedation, RSI induction, ventilator sedation. Caution: H ypotension , anaphylaxis, bradycardia , apnea, Preg B

39. DRUG USED IN RSI DRUG USING INDUCTION Drug Indication Conc Dose Remarks Propofol Sedative hypnotic. 10mg/ml in 20ml ampoules. Induction dose is 2 mg/kg, Short duration of action of 10-15 min. Myocardial depressant, Decrease in MAP. Decreases cerebral metabolism & ICP. Preg B Midazolam Seizure, RSI Procedural sedation, Ventilator sedation. 5mg/ml in 3 ml vials. RSI is 0.1 mg/kg, Infusion: 1-10 mg/hour. Respiratory depression, Hypotensive effects, Preg D.

40. Midazolam MOA: E nhances inhibitory effects of GABA Dose: RSI induction: 0.1 mg/kg IV Usual continuous infusion: 1-10 mg/hour Procedural Sedation: 0.02 - 0.04 mg/kg IV Indications : S eizure abortion, procedural sedation, ventilator sedation, RSI. Caution: R espiratory depression, hypotensive effects, Preg D

41. DRUG USED IN RSI Drug using as Paralytic agent Drug Indication Concentration Dose Remarks Succinylcholine Depolarizing agent used for rapid sequence induction. Available as a 20-mg/mL solution. Dose is 1.5 mg/kg in adults and 2 mg/kg in children younger than 5 years. Rapid onset, Ultrashort duration and safety. Muscle relaxation with in 30 sec. T otal paralysis in 45 sec, lasting 7-10 minutes. Increase serum potassium. Preg C .

42. Succinylcholine MOA: D epolarizing neuromuscular agent Dose: 1.5 mg/kg (or 3-4 mg/kg IM ) Rapid onset (45-60 seconds) Short half-life (6-8 minutes of paralysis) Indications : RSI paralysis. Caution: H yperkalemia , subacute burn/crush with hyperkalemia, glaucoma (increases IOP), increases ICP, Preg C

43. NORCURIUM Vecuronium ( Norcuron ) Decreases fasciculation & potassium release from cells; 10mg/vial mix with 10 ml DW. Defasciculating dose: 0.01 mg/kg IV push (typically about 1 mg, Avoid higher doses to produce paralytic effect. Preg B

44. N ocuronium MOA: N on-depolarizing neuromuscular agent Dose: 1mg/kg IV Indications : RSI paralysis. Can give hyperkaleamia pt. Caution: P rolonged paralysis, Preg B

45. ACS Medication

46. ACLS MEDICATION DRUG USING ACS Drug Indication Concentration Dose Remarks Nitroglycerin Chest pain suspected to be cardiac origin. Unstable angina HTN crisis Tab SL: 0.3-0.4 mg. Spray: 200 dose: 0.4 mg/dose. Ampoule: 8mg/10 ml. Sublingual: 0.2-0.4 mg repeated every 5 min. Spray: 0.4-0.8 SL. Infusion: 10-20 microgm /min With AMI SBP drop 10%. HTN emergency: 30% drop. Morphine Sulphate Analgesic of choice for AMI. Acute pulmonary oedema . 2-4 mg/ml in Syringe. 2-5 mg IV slowly over 1-5 min. Repeat every 5-30 min. May respiratory depression. Naloxone: 0.4-0.8 mg IV for reverse.

47. Nitroglycerin MOA: V enodilator , stimulates cGMP production Dose: 5-200mcg/min , increase 10 mcg q 3-5 min until desired effect; higher doses are usually required for pulmonary edema therefore recommend starting at a dose > 5 mcg/min Indications : CHF, angina Caution: H ypotension , methemoglobinemia , Preg C

48. ACLS MEDICATION DRUG USING ACS Drug Indication Concentration Dose Remarks Nitroglycerin Chest pain suspected to be cardiac origin. Unstable angina HTN crisis Tab SL: 0.3-0.4 mg. Spray: 200 dose: 0.4 mg/dose. Ampoule: 8mg/10 ml. Sublingual: 0.2-0.4 mg repeated every 5 min. Spray: 0.4-0.8 SL. Infusion: 10-20 microgm /min With AMI SBP drop 10%. HTN emergency: 30% drop. Morphine Sulphate Analgesic of choice for AMI. Acute pulmonary oedema . 2-4 mg/ml in Syringe. 2-5 mg IV slowly over 1-5 min. Repeat every 5-30 min. May respiratory depression. Naloxone: 0.4-0.8 mg IV for reverse.

49. Morphine sulfate MOA: O pioid agonist producing analgesia with adjunctive sedative effects Dose: 2-10 mg IV q 2-6 hours. Recommended dose 0.1 mg/kg IV Indications : P ain control Caution: R espiratory depression, vasodilation (hypotension), Preg C Antidot : Nalaxone : 0.4-2 mg IV stat.

50. SUMMERY Know dosages, indications, contraindications, and side effects of drugs. Know concentrations of drugs. Know what drugs using in our organization.

51. Thanks! Prevent Cardiac Arrest!!