ACLS Pharmacology

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ACLS Pharmacology

• Jeremy Maddux
• NREMTP

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Objectives

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

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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

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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

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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

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Oxygen

• Indications (When Why?)
• Any suspected cardiopulmonary emergency
• Saturate hemoglobin with oxygen
• Reduce anxiety further damage
• Note Pulse oximetry should be monitored

Universal Algorithm
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Oxygen

• Dosing (How?)

Device Flow Rate Oxygen
Nasal Prongs 1 to 6 lpm 24 to 44
Venturi Mask 4 to 8 lpm 24 to 40
Partial Rebreather Mask 6 to 10 lpm 35 to 60
Bag Mask 15 lpm up to 100
Universal Algorithm
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Oxygen

• Precautions (Watch Out!)
• Pulse oximetry inaccurate in
• Low cardiac output
• Vasoconstriction
• Hypothermia
• NEVER rely on pulse oximetry!

Universal Algorithm
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VF / Pulseless VT

• Case 3

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VF / Pulseless VT
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Epinephrine

• Indications (When Why?)
• Increases
• Heart rate
• Force of contraction
• Conduction velocity
• Peripheral vasoconstriction
• Bronchial dilation

VF / Pulseless VT
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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 in 10 mL normal saline

VF / Pulseless VT
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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
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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
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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
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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
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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
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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
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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
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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
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Lidocaine

• Indications (When Why?)
• Depresses automaticity
• Depresses excitability
• Raises ventricular fibrillation threshold
• Decreases ventricular irritability

VF / Pulseless VT
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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
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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
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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
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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
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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
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Magnesium Sulfate

• Precautions (Watch Out!)
• Occasional fall in blood pressure with rapid
  administration
• Use with caution if renal failure is present

VF / Pulseless VT
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Procainamide

• Indications (When Why?)
• Recurrent VF
• Depresses automaticity
• Depresses excitability
• Raises ventricular fibrillation threshold
• Decreases ventricular irritability

VF / Pulseless VT
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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
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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
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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
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PEA

• Case 4

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PEA
Review for most frequent causes

• Hypovolemia
• Hypoxia
• Hydrogen ionacidosis
• 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
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Epinephrine

• Indications (When Why?)
• Increases
• Heart rate
• Force of contraction
• Conduction velocity
• Peripheral vasoconstriction
• Bronchial dilation

Pulseless Electrical Activity
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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 in 10 mL normal saline

Pulseless Electrical Activity
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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
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Atropine Sulfate

• Indications (When Why?)
• Should only be used for bradycardia
• Relative or Absolute
• Used to increase heart rate

Pulseless Electrical Activity
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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
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Atropine Sulfate

• Precautions (Watch Out!)
• Increases myocardial oxygen demand
• May result in unwanted tachycardia or dysrhythmia

Pulseless Electrical Activity
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Asystole

• Case 5

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Asystole
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Epinephrine

• Indications (When Why?)
• Increases
• Heart rate
• Force of contraction
• Conduction velocity
• Peripheral vasoconstriction
• Bronchial dilation

Asystole The Silent Heart Algorithm
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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 in 10 mL normal saline

Asystole The Silent Heart Algorithm
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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
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Atropine Sulfate

• Indications (When Why?)
• Used to increase heart rate
• Questionable absolute bradycardia

Asystole The Silent Heart Algorithm
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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
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Atropine Sulfate

• Precautions (Watch Out!)
• Increases myocardial oxygen demand

Asystole The Silent Heart Algorithm
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Other Cardiac Arrest Drugs
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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
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Calcium Chloride

• Dosing (How?)
• IV Slow Push
• 8 to 16 mg/kg (usually 5 to 10 mL) IV for
  hyperkalemia and calcium channel blocker overdose
• 2 to 4 mg/kg (usually 2 mL) IV for prophylactic
  pretreatment before IV calcium channel blockers

Other Cardiac Arrest Drugs
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Calcium Chloride

• Precautions (Watch Out!)
• Do not use routinely in cardiac arrest
• Do not mix with sodium bicarbonate

Other Cardiac Arrest Drugs
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Sodium Bicarbonate

• Indications (When Why?)
• Class I if known preexisting hyperkalemia
• Class IIa if known preexisting bicarbonate-respons
  ive acidosis
• Class IIb if prolonged resuscitation with
  effective ventilation upon return of spontaneous
  circulation
• Class III  (not useful or effective) in hypoxic
  lactic acidosis or hypercarbic acidosis (eg,
  cardiac arrest and CPR without intubation)

Other Cardiac Arrest Drugs
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Sodium Bicarbonate

• Dosing (How?)
• 1 mEq/kg IV bolus
• Repeat half this dose every 10 minutes thereafter
• If rapidly available, use arterial blood gas
  analysis to guide bicarbonate therapy (calculated
  base deficits or bicarbonate concentration)

Other Cardiac Arrest Drugs
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Sodium Bicarbonate

• Precautions (Watch Out!)
• Adequate ventilation and CPR, not bicarbonate,
  are the major "buffer agents" in cardiac arrest
• Not recommended for routine use in cardiac arrest
  patients

Other Cardiac Arrest Drugs
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Acute Coronary Syndromes

• Case 6

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Acute Coronary Syndromes
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Aspirin

• Indications (When Why?)
• Administer to all patients with ACS, particularly
  reperfusion candidates
• Give as soon as possible
• Blocks formation of thromboxane A2, which causes
  platelets to aggregate

Acute Coronary Syndromes
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Aspirin

• Dosing (How?)
• 160 to 325 mg tablets
• Preferably chewed
• May use suppository
• Higher doses may be harmful

Acute Coronary Syndromes
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Aspirin

• Precautions (Watch Out!)
• Relatively contraindicated in patients with
  active ulcer disease or asthma

Acute Coronary Syndromes
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Nitroglycerine

• Indications (When Why?)
• Chest pain of suspected cardiac origin
• Unstable angina
• Complications of AMI, including congestive heart
  failure, left ventricular failure
• Hypertensive crisis or urgency with chest pain

Acute Coronary Syndromes
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Nitroglycerin

• Indications (When Why?)
• Decreases pain of ischemia
• Increases venous dilation
• Decreases venous blood return to heart
• Decreases preload and cardiac oxygen consumption
• Dilates coronary arteries
• Increases cardiac collateral flow

Acute Coronary Syndromes
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Nitroglycerine

• Dosing (How?)
• Sublingual Route
• 0.3 to 0.4 mg repeat every 5 minutes
• Aerosol Spray
• Spray for 0.5 to 1.0 second at 5 minute intervals
• IV Infusion
• Infuse at 10 to 20 µg/min
• Route of choice for emergencies
• Titrate to effect

Acute Coronary Syndromes
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Nitroglycerine

• Precautions (Watch Out!)
• Use extreme caution if systolic BP lt90 mm Hg
• Use extreme caution in RV infarction
• Suspect RV infarction with inferior ST changes
• Limit BP drop to 10 if patient is normotensive
• Limit BP drop to 30 if patient is hypertensive
• Watch for headache, drop in BP, syncope,
  tachycardia
• Tell patient to sit or lie down during
  administration

Acute Coronary Syndromes
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Morphine Sulfate

• Indications (When Why?)
• Chest pain and anxiety associated with AMI or
  cardiac ischemia
• Acute cardiogenic pulmonary edema (if blood
  pressure is adequate)

Acute Coronary Syndromes
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Morphine Sulfate

• Indications (When Why?)
• To reduce pain of ischemia
• To reduce anxiety
• To reduce extension of ischemia by reducing
  oxygen demands

Acute Coronary Syndromes
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Morphine Sulfate

• Dosing (How?)
• 1 to 3 mg IV (over 1 to 5 minutes) every 5 to 10
  minutes as needed

Acute Coronary Syndromes
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Morphine Sulfate

• Precautions (Watch Out!)
• Administer slowly and titrate to effect
• May compromise respiration therefore use with
  caution in acute pulmonary edema
• Causes hypotension in volume-depleted patients

Acute Coronary Syndromes
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Acute Coronary Syndromes
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ST Elevation
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Recognition of AMI

• Know what to look for
• ST elevation gt1 mm
• 3 contiguous leads
• Know where to look
• Refer to 2000 ECC Handbook

J point plus 0.04 second
PR baseline
ST-segment deviation 4.5 mm
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ST Elevation
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Beta Blockers

• Indications (When Why?)
• To reduce myocardial ischemia and damage in AMI
  patients with elevated heart rates, blood
  pressure, or both
• Blocks catecholamines from binding to
  ß-adrenergic receptors
• Reduces HR, BP, myocardial contractility
• Decreases AV nodal conduction
• Decreases incidence of primary VF

Acute Coronary Syndromes
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Beta Blockers

• Dosing (How?)
• Esmolol
• 0.5 mg/kg over 1 minute, followed by continuous
  infusion at 0.05 mg/kg/min
• Titrate to effect, Esmolol has a short half-life
  (lt10 minutes)
• Labetalol
• 10 mg labetalol IV push over 1 to 2 minutes
• May repeat or double labetalol every 10 minutes
  to a maximum dose of 150 mg, or give initial dose
  as a bolus, then start labetalol infusion 2 to 8
  µg/min

Acute Coronary Syndromes
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Beta Blockers

• Dosing (How?)
• Metoprolol
• 5 mg slow IV at 5-minute intervals to a total of
  15 mg
• Atenolol
• 5 mg slow IV (over 5 minutes)
• Wait 10 minutes, then give second dose of 5 mg
  slow IV (over 5 minutes)
• Propranolol
• 1 to 3 mg slow IV. Do not exceed 1 mg/min
• Repeat after 2 minutes if necessary

Acute Coronary Syndromes
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Beta Blockers

• Precautions (Watch Out!)
• Concurrent IV administration with IV calcium
  channel blocking agents like verapamil or
  diltiazem can cause severe hypotension
• Avoid in bronchospastic diseases, cardiac
  failure, or severe abnormalities in cardiac
  conduction
• Monitor cardiac and pulmonary status during
  administration
• May cause myocardial depression

Acute Coronary Syndromes
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Heparin

• Indications (When Why?)
• For use in ACS patients with Non Q wave MI or
  unstable angina
• Inhibits thrombin generation by factor Xa
  inhibition and also inhibit thrombin indirectly
  by formation of a complex with antithrombin III

Acute Coronary Syndromes
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Heparin

• Dosing (How?)
• Initial bolus 60 IU/kg
• Maximum bolus 4000 IU
• Continue at 12 IU/kg/hr (maximum 1000 IU/hr for
  patients lt 70 kg), round to the nearest 50 IU

Acute Coronary Syndromes
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Heparin

• Dosing (How?)
• Adjust to maintain activated partial
  thromboplastin time (aPTT) 1.5 to 2.0 times the
  control values for 48 hours or angiography
• Target range for aPTT after first 24 hours is
  between 50 70 seconds (may vary with
  laboratory)
• Check aPTT at 6, 12, 18, and 24 hours
• Follow Institutional Heparin Protocol

Acute Coronary Syndromes
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Heparin

• Precautions (Watch Out!)
• Same contraindications as for fibrinolytic
  therapy active bleeding recent intracranial,
  intraspinal or eye surgery severe hypertension
  bleeding disorders gastroinintestinal bleeding
• DO NOT use if platelet count is below 100 000

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Indications (When Why?)
• Inhibit the integrin glycoprotein IIb/IIIa
  receptor in the membrane of platelets, inhibiting
  platelet aggregation
• Indicated for Acute Coronary Syndromes without ST
  segment elevation

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Indications (When Why?)
• Abciximab (ReoPro)
• Non Q wave MI or unstable angina with planned PCI
  within 24 hours
• Must use with heparin
• Binds irreversibly with platelets
• Platelet function recovery requires 48 hours

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Indications (When Why?)
• Eptifibitide (Integrilin)
• Non Q wave MI, unstable angina managed medically,
  and unstable angina / Non Q wave MI patients
  undergoing PCI
• Platelet function recovers within 4 to 8 hours
  after discontinuation

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Indications (When Why?)
• Tirofiban (Aggrastat)
• Non Q wave MI, unstable angina managed medically,
  and unstable angina / Non Q wave MI patients
  undergoing PCI
• Platelet function recovers within 4 to 8 hours
  after discontinuation

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Dosing (How?)
• NOTE Check package insert for current
  indications, doses, and duration of therapy.
• Optimal duration of therapy has NOT been
  established.

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Dosing (How?)
• Abciximab (ReoPro)
• ACS with planned PCI within 24 hours
• 0.25 mg/kg bolus (10 to 60 minutes before
  procedure), then 0.125 mcg/kg/min infusion
• PCI only
• 0.25 mg/kg bolus
• Then 10 mcg/min infusion

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Dosing (How?)
• Eptifibitide (Integrilin)
• Acute Coronary Syndromes
• 180 mcg/kg IV bolus, then 2 mcg/kg/min infusion
• PCI
• 135 mcg/kg IV bolus, then begin 0.5 mcg/kg/min
  infusion, then repeat bolus in 10 minutes

Acute Coronary Syndromes
89
Glycoprotein IIb/IIIa Inhibitors

• Dosing (How?)
• Tirofiban (Aggrastat)
• Acute Coronary Syndromes or PCI
• 0.4 mcg/kg/min infusion IV for 30 minutes
• Then 0.1 mcg/kg/min infusion

Acute Coronary Syndromes
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Glycoprotein IIb/IIIa Inhibitors

• Precautions (Watch Out!)
• Active internal bleeding or bleeding disorder
  within 30 days
• History of intracranial hemorrhage or other
  bleeding
• Surgical procedure or trauma within 1 month
• Platelet count gt 150 000/mm3

Acute Coronary Syndromes
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PTCA
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Fibrinolytics

• Indications (When Why?)
• For AMI in adults
• ST elevation or new or presumably new LBBB
  strongly suspicious for injury
• Time of onset of symptoms lt 12 hours

Acute Coronary Syndromes
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Fibrinolytics

• Indications (When Why?)
• For Acute Ischemic Stroke
• Sudden onset of focal neurologic deficits or
  alterations in consciousness
• Absence of subarachnoid or intracerebral
  hemorrhage
• Alteplase can be started in less than 3 hours of
  symptom onset

Acute Coronary Syndromes
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Fibrinolytics

• Dosing (How?)
• For fibrinolytic use, all patients should have 2
  peripheral IV lines
• 1 line exclusively for fibrinolytic administration

Acute Coronary Syndromes
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Fibrinolytics

• Dosing for AMI Patients (How?)
• Alteplase, recombinant (tPA)
• Accelerated Infusion
• 15 mg IV bolus
• Then 0.75 mg/kg over the next 30 minutes
• Not to exceed 50 mg
• Then 0.5 mg/kg over the next 60 minutes
• Not to exceed 35 mg
• 3 hour Infusion
• Give 60 mg in the first hour (initial 6 to 10 mg
  is given as a bolus)
• Then 20 mg/hour for 2 additional hours

Acute Coronary Syndromes
96
Fibrinolytics

• Dosing for AMI Patients (How?)
• Anistreplase (APSAC)
• Reconstitute 30 units in 50 mL of sterile water
• 30 units IV over 2 to 5 minutes
• Reteplase, recombinant
• Give first 10 unit IV bolus over 2 minutes
• 30 minutes later give second 10 unit IV bolus
  over 2 minutes
• Streptokinase
• 1.5 million IU in a 1 hour infusion
• Tenecteplase (TNKase)
• Bolus 30 to 50 mg

Acute Coronary Syndromes
97
Fibrinolytics

• Adjunctive Therapy for AMI Patients (How?)
• 160 to 325 mg aspirin chewed as soon as possible
• Begin heparin immediately and continue for 48
  hours if alteplase or Retavase is used

Acute Coronary Syndromes
98
Fibrinolytics

• Dosing for Acute Ischemic Stroke (How?)
• Alteplase, recombinant (tPA)
• Give 0.9 mg/kg (maximum 90 mg) infused over 60
  minutes
• Give 10 of total dose as an initial IV bolus
  over 1 minute
• Give the remaining 90 over the next 60 minutes
• Alteplase is the only agent approved for use in
  Ischemic Stroke patients

Acute Coronary Syndromes
99
Fibrinolytics

• Precautions (Watch Out!)
• Specific Exclusion Criteria
• Active internal bleeding (except mensus) within
  21 days
• History of CVA, intracranial, or intraspinal
  within 3 months
• Major trauma or serious injury within 14 days
• Aortic dissection
• Severe uncontrolled hypertension

Acute Coronary Syndromes
100
Fibrinolytics

• Precautions (Watch Out!)
• Specific Exclusion Criteria
• Known bleeding disorders
• Prolonged CPR with evidence of thoracic trauma
• Lumbar puncture within 7 days
• Recent arterial puncture at noncompressible site
• During the first 24 hours of fibrinolytic therapy
  for ischemic stroke, do not give aspirin or
  heparin

Acute Coronary Syndromes
101
ACE Inhibitors

• Indications (When Why?)
• Reduce mortality improve LV dysfunction in post
  AMI patients
• Help prevent adverse LV remodeling, delay
  progression of heart failure, and decrease sudden
  death recurrent MI

Acute Coronary Syndromes
102
ACE Inhibitors

• Indications (When Why?)
• Suspected MI ST elevation in 2 or more anterior
  leads
• Hypertension
• Clinical signs of AMI with LV dysfunction
• LV ejection fraction lt40

Acute Coronary Syndromes
103
ACE Inhibitors

• Indications (When Why?)
• Generally not started in the ED but within first
  24 hours after
• Fibrinolytic therapy has been completed
• Blood pressure has stabilized

Acute Coronary Syndromes
104
ACE Inhibitors

• Dosing (How?)
• Should start with low-dose oral administration
  (with possible IV doses for some preparations)
  and increase steadily to achieve a full dose
  within 24 to 48 hours

Acute Coronary Syndromes
105
ACE Inhibitors

• Dosing (How?)
• Enalapril
• 2.5 mg PO titrated to 20 mg BID
• IV dosing of 1.25 mg IV over 5 minutes, then 1.25
  to 5 mg IV every six hours
• Captopril
• Start with 6.25 mg PO
• Advance to 25 mg TID, then to 50 mg TID as
  tolerated

Acute Coronary Syndromes
106
ACE Inhibitors

• Dosing (How?)
• Lisinopril (AMI dose)
• 5 mg within 24 hours onset of symptoms
• 10 mg after 24 hours, then 10 mg after 48 hours,
  then 10 mg PO daily for six weeks
• Ramipril
• Start with single dose of 2.5 mg PO
• Titrate to 5 mg PO BID as tolerated

Acute Coronary Syndromes
107
ACE Inhibitors

• Precautions (Watch Out!)
• Contraindicated in pregnancy
• Contraindicated in angioedema
• Reduce dose in renal failure
• Avoid hypotension, especially following initial
  dose in relative volume depletion

Acute Coronary Syndromes
108
Bradycardias

• Case 7

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Bradycardia
110
Bradycardia
111
Atropine Sulfate

• Indications (When Why?)
• First drug for symptomatic bradycardia
• Increases heart rate by blocking the
  parasympathetic nervous system

Bradycardias
112
Atropine Sulfate

• Dosing (How?)
• 0.5 to 1.0 mg IV every 3 to 5 minutes as needed
• May give via ET tube (2 to 2.5 mg) diluted in 10
  mL of NS
• Maximum Dose 0.04 mg/kg

Bradycardias
113
Atropine Sulfate

• Precautions (Watch Out!)
• Use with caution in presence of myocardial
  ischemia and hypoxia
• Increases myocardial oxygen demand
• Seldom effective for
• Infranodal (type II) AV block
• Third-degree block (Class IIb)

Bradycardias
114
Dopamine

• Indications (When Why?)
• Second drug for symptomatic bradycardia (after
  atropine)
• Use for hypotension (systolic BP 70 to 100 mm Hg)
  with S/S of shock

Bradycardias
115
Dopamine

• Dosing (How?)
• IV Infusions (Titrate to Effect)
• 400 mg / 250 mL of D5W 1600 mcg/mL
• 800 mg/ 250 mL of D5W 3200 mcg/mL

Bradycardias
116
Dopamine

• Dosing (How?)
• IV Infusions (Titrate to Effect)
• Low Dose Renal Dose"
• 1 to 5 µg/kg per minute
• Moderate Dose Cardiac Dose"
• 5 to 10 µg/kg per minute
• High Dose Vasopressor Dose"
• 10 to 20 µg/kg per minute

Bradycardias
117
Dopamine

• Precautions (Watch Out!)
• May use in patients with hypovolemia but only
  after volume replacement
• May cause tachyarrhythmias, excessive
  vasoconstriction
• DO NOT mix with sodium bicarbonate

Bradycardias
118
Epinephrine

• Indications (When Why?)
• Symptomatic bradycardia After atropine,
  dopamine, and transcutaneous pacing (Class IIb)

Bradycardias
119
Epinephrine

• Dosing (How?)
• Profound Bradycardia
• 2 to 10 µg/min infusion (add 1 mg of 11000 to
  500 mL normal saline infuse at 1 to 5 mL/min)

Bradycardias
120
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

Bradycardias
121
Isoproterenol

• Indications (When Why?)
• Temporary control of bradycardia in heart
  transplant patients
• Class IIb at low doses for symptomatic
  bradycardia
• Heart Transplant Patients!

Bradycardias
122
Isoproterenol

• Dosing (How?)
• Infuse at 2 to 10 µg/min
• Titrate to adequate heart rate

Bradycardias
123
Isoproterenol

• Precautions (Watch Out!)
• Increases myocardial oxygen requirements, which
  may increase myocardial ischemia
• DO NOT administer with poison/drug-induced shock
• Exception Beta Blocker Poisoning

Bradycardias
124
Stable Tachycardias

• Case 9

125
Diltiazem

• Indications (When Why?)
• To control ventricular rate in atrial
  fibrillation and atrial flutter
• Use after adenosine to treat refractory PSVT in
  patients with narrow QRS complex and adequate
  blood pressure
• As an alternative, use verapamil

Stable Tachycardias
126
Diltiazem

• Dosing (How?)
• Acute Rate Control
• 15 to 20 mg (0.25 mg/kg) IV over 2 minutes
• May repeat in 15 minutes at 20 to 25 mg (0.35
  mg/kg) over 2 minutes
• Maintenance Infusion
• 5 to 15 mg/hour, titrated to heart rate

Stable Tachycardias
127
Diltiazem

• Precautions (Watch Out!)
• Do not use calcium channel blockers for
  tachycardias of uncertain origin
• Avoid calcium channel blockers in patients with
  Wolff-Parkinson-White syndrome, in patients with
  sick sinus syndrome, or in patients with AV block
  without a pacemaker
• Expect blood pressure drop resulting from
  peripheral vasodilation
• Concurrent IV administration with IV ß-blockers
  can cause severe hypotension

Stable Tachycardias
128
Verapamil

• Indications (When Why?)
• Used as an alternative to diltiazem for
  ventricular rate control in atrial fibrillation
  and atrial flutter
• Drug of second choice (after adenosine) to
  terminate PSVT with narrow QRS complex and
  adequate blood pressure

Stable Tachycardias
129
Verapamil

• Dosing (How?)
• 2.5 to 5.0 mg IV bolus over 1to 2 minutes
• Second dose 5 to 10 mg, if needed, in 15 to 30
  minutes. Maximum dose 30 mg
• Older patients Administer over 3 minutes

Stable Tachycardias
130
Verapamil

• Precautions (Watch Out!)
• Do not use calcium channel blockers for wide-QRS
  tachycardias of uncertain origin
• Avoid calcium channel blockers in patients with
  Wolff-Parkinson-White syndrome and atrial
  fibrillation, sick sinus syndrome, or second- or
  third-degree AV block without pacemaker

Stable Tachycardias
131
Verapamil

• Precautions (Watch Out!)
• Expect blood pressure drop caused by peripheral
  vasodilation
• IV calcium can restore blood pressure, and some
  experts recommend prophylactic calcium before
  giving calcium channel blockers
• Concurrent IV administration with IV ß-blockers
  may produce severe hypotension

Stable Tachycardias
132
Adenosine

• Indications (When Why?)
• First drug for narrow-complex PSVT
• May be used diagnostically (after lidocaine) in
  wide-complex tachycardias of uncertain type

Stable Tachycardias
133
Adenosine

• Dose (How?)
• IV Rapid Push
• Initial bolus of 6 mg given rapidly over 1 to 3
  seconds followed by normal saline bolus of 20
  mL then elevate the extremity
• Repeat dose of 12 mg in 1 to 2 minutes if needed
• A third dose of 12 mg may be given in 1 to 2
  minutes if needed

Stable Tachycardias
134
Adenosine

• Precautions (Watch Out!)
• Transient side effects include
• Facial Flushing
• Chest pain
• Brief periods of asystole or bradycardia
• Less effective in patients taking theophyllines

Stable Tachycardias
135
Beta Blockers

• Indications (When Why?)
• To convert to normal sinus rhythm or to slow
  ventricular response (or both) in
  supraventricular tachyarrhythmias (PSVT, atrial
  fibrillation, or atrial flutter)
• ß-Blockers are second-line agents after
  adenosine, diltiazem, or digoxin

Stable Tachycardias
136
Beta Blockers

• Dosing (How?)
• Esmolol
• 0.5 mg/kg over 1 minute, followed by continuous
  infusion at 0.05 mg/kg/min
• Titrate to effect, Esmolol has a short half-life
  (lt10 minutes)
• Labetalol
• 10 mg labetalol IV push over 1 to 2 minutes
• May repeat or double labetalol every 10 minutes
  to a maximum dose of 150 mg, or give initial dose
  as a bolus, then start labetalol infusion 2 to 8
  µg/min

Stable Tachycardias
137
Beta Blockers

• Dosing (How?)
• Metoprolol
• 5 mg slow IV at 5-minute intervals to a total of
  15 mg
• Atenolol
• 5 mg slow IV (over 5 minutes)
• Wait 10 minutes, then give second dose of 5 mg
  slow IV (over 5 minutes)
• Propranolol
• 1 to 3 mg slow IV. Do not exceed 1 mg/min
• Repeat after 2 minutes if necessary

Stable Tachycardias
138
Beta Blockers

• Precautions (Watch Out!)
• Concurrent IV administration with IV calcium
  channel blocking agents like verapamil or
  diltiazem can cause severe hypotension
• Avoid in bronchospastic diseases, cardiac
  failure, or severe abnormalities in cardiac
  conduction
• Monitor cardiac and pulmonary status during
  administration
• May cause myocardial depression

Stable Tachycardias
139
Digoxin

• Indications (When Why?)
• To slow ventricular response in atrial
  fibrillation or atrial flutter
• Third-line choice for PSVT

Stable Tachycardias
140
Digoxin

• Dosing (How?)
• IV Infusion
• Loading doses of 10 to 15 µg/kg provide
  therapeutic effect with minimum risk of toxic
  effects
• Maintenance dose is affected by body size and
  renal function

Stable Tachycardias
141
Digoxin

• Precautions (Watch Out!)
• Toxic effects are common and are frequently
  associated with serious arrhythmias
• Avoid electrical cardioversion unless condition
  is life threatening
• Use lower current settings (10 to 20 Joules)

Stable Tachycardias
142
Amiodarone

• Indications (When Why?)
• Powerful antiarrhythmic with substantial
  toxicity, especially in the long term
• Intravenous and oral behavior are quite different

Stable Tachycardias
143
Amiodarone

• Dosing (How?)
• Stable Wide-Complex Tachycardias
• Rapid Infusion
• 150 mg IV over 10 minutes (15 mg/min)
• May repeat
• Slow Infusion
• 360 mg IV over 6 hours (1 mg/min)

Stable Tachycardias
144
Amiodarone

• Dosing (How?)
• Maintenance Infusion
• 540 mg IV over 18 hours (0.5 mg/min)

Stable Tachycardias
145
Amiodarone

• Precautions (Watch Out!)
• May produce vasodilation shock
• May have negative inotropic effects
• May prolong QT Interval
• DO NOT administer with other drugs that may
  prolong QT Interval (Procainamide)
• Terminal elimination
• Half-life lasts up to 40 days

Stable Tachycardias
146
Amiodarone

• Precautions (Watch Out!)
• Contraindicated in
• Second or third degree A-V block
• Severe bradycardia
• Pregnancy
• CHF
• Hypokalaemia
• Liver dysfunction

Stable Tachycardias
147
Lidocaine

• Indications (When Why?)
• Depresses automaticity
• Depresses excitability
• Raises ventricular fibrillation threshold
• Decreases ventricular irritability

Stable Tachycardias
148
Lidocaine

• Dosing (How?)
• For stable VT, wide-complex tachycardia of
  uncertain type, significant ectopy, use as
  follows
• 1.0 to 1.5 mg/kg IV push
• Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes
  maximum total dose, 3 mg/kg

Stable Tachycardias
149
Lidocaine

• Dosing (How?)
• Maintenance Infusion
• 2 to 4 mg/min

Stable Tachycardias
150
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

Stable Tachycardias
151
Magnesium Sulfate

• Indications (When Why?)
• Torsades de pointes with a pulse
• Wide-complex tachycardia with history of ETOH
  abuse
• Life-threatening ventricular arrhythmias due to
  digitalis toxicity, tricyclic overdose

Stable Tachycardias
152
Magnesium Sulfate

• Dosing (How?)
• Loading dose of 1 to 2 grams mixed in 50 to 100
  mL of D5W IV push over 5 to 60 minutes

Stable Tachycardias
153
Magnesium Sulfate

• Dosing (How?)
• Maintenance Infusion
• 1 to 4 g/hour IV (titrate dose to control the
  torsades)

Stable Tachycardias
154
Magnesium Sulfate

• Precautions (Watch Out!)
• Occasional fall in blood pressure with rapid
  administration
• Use with caution if renal failure is present

Stable Tachycardias
155
Procainamide

• Indications (When Why?)
• Depresses automaticity
• Depresses excitability
• Raises ventricular fibrillation threshold
• Decreases ventricular irritability
• Atrial fibrillation with rapid rate in
  Wolff-Parkinson-White syndrome

Stable Tachycardias
156
Procainamide

• Dosing (How?)
• Perfusing Arrhythmia
• 20 mg/min IV infusion until
• Hypotension develops
• Arrhythmia is suppressed
• QRS widens by gt50
• Maximum dose of 17 mg/kg is reached
• In refractory VF/VT, 100 mg IV push doses given
  every 5 minutes are acceptable

Stable Tachycardias
157
Procainamide

• Dosing (How?)
• Maintenance Infusion
• 1 to 4 mg/min

Stable Tachycardias
158
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

Stable Tachycardias
159
Acute Ischemic Stroke

• Case 10

160
Acute Ischemic Stroke
161
Nitroprusside

• Indications (When Why?)
• Hypertensive crisis

Acute Ischemic Stroke
162
Nitroprusside

• Dosing (How?)
• Begin at 0.1 mcg/kg/min and titrate upward every
  3 to 5 minutes to desired effect
• Up to 0.5 mcg/kg/min
• Action occurs within 1 to 2 minutes

Acute Ischemic Stroke
163
Nitroprusside

• Dosing Precautions (How?)
• Use with an infusion pump use hemodynamic
  monitoring for optimal safety
• Cover drug reservoir with opaque material

Acute Ischemic Stroke
164
Nitroprusside

• Precautions (Watch Out!)
• Light-sensitive therefore, wrap drug reservoir
  in aluminum foil
• May cause hypotension and CO2 retention
• May exacerbate intrapulmonary shunting
• Other side effects include headaches, nausea,
  vomiting, and abdominal cramps

Acute Ischemic Stroke
165
Drugs used in Overdoses
166
Calcium Chloride

• Indications (When Why?)
• As an antidote for toxic effects of calcium
  channel blocker overdose

Drugs Used in Overdoses
167
Calcium Chloride

• Dosing (How?)
• 8 to 16 mg/kg (usually 5 to 10 mL) IV for
  hyperkalemia and calcium channel blocker overdose

Drugs Used in Overdoses
168
Calcium Chloride

• Precautions (Watch Out!)
• Do not use routinely in cardiac arrest
• Do not mix with sodium bicarbonate

Drugs Used in Overdoses
169
Flumazenil

• Indications (When Why?)
• Reduce respiratory depression and sedative
  effects from pure benzodiazepine overdose

Drugs Used in Overdoses
170
Flumazenil

• Dosing (How?)
• First Dose
• 0.2 mg IV over 15 seconds
• Second Dose
• 0.3 mg IV over 30 seconds
• Third Dose
• 0.4 mg IV over 30 seconds
• Maximum Dose
• 3 mg

Drugs Used in Overdoses
171
Flumazenil

• Precautions (Watch Out!)
• Effects may not outlast effects of
  benzodiazepines
• Monitor for recurrent respiratory depression
• DO NOT use in suspected tricyclic overdose
• DO NOT use in seizure-prone patients
• DO NOT use if unknown type overdose or mixed drug
  overdose with drugs known to cause seizures

Drugs Used in Overdoses
172
Naloxone Hydrochloride

• Indications (When Why?)
• Respiratory and neurologic depression due to
  opiate intoxication unresponsive to oxygen and
  hyperventilation

Drugs Used in Overdoses
173
Naloxone Hydrochloride

• Dosing (How?)
• 0.4 to 2 mg IVP every 2 minutes
• Use higher doses for complete narcotic reversal
• Can administer up to 10 mg in a short time (10
  minutes)

Drugs Used in Overdoses
174
Naloxone Hydrochloride

• Precautions (Watch Out!)
• May cause opiate withdrawal
• Effects may not outlast effects of narcotics
• Monitor for recurrent respiratory depression

Drugs Used in Overdoses
175
Review of Infusions
176
Dobutamine

• Indications (When Why?)
• Consider for pump problems (congestive heart
  failure, pulmonary congestion) with systolic
  blood pressure of 70 to 100 mm Hg and no signs of
  shock
• Increases Inotropy

Review of Infusions
177
Dobutamine

• Dosing (How?)
• Usual infusion rate is 2 to 20 µg/kg per minute
• Titrate so heart rate does not increase by more
  than 10 of baseline
• Hemodynamic monitoring is recommended for optimal
  use

Review of Infusions
178
Dobutamine

• Precautions (Watch Out!)
• Avoid when systolic blood pressure lt100 mm Hg
  with signs of shock
• May cause tachyarrhythmias, fluctuations in blood
  pressure, headache, and nausea
• DO NOT mix with sodium bicarbonate

Review of Infusions
179
Dopamine

• Indications (When Why?)
• Second drug for symptomatic bradycardia (after
  atropine)
• Use for hypotension (systolic BP 70 to 100 mm Hg)
  with S/S of shock

Review of Infusions
180
Dopamine

• Dosing (How?)
• IV Infusions (Titrate to Effect)
• Low Dose Renal Dose"
• 1 to 5 µg/kg per minute
• Moderate Dose Cardiac Dose"
• 5 to 10 µg/kg per minute
• High Dose Vasopressor Dose"
• 10 to 20 µg/kg per minute

Review of Infusions
181
Dopamine

• Precautions (Watch Out!)
• May use in patients with hypovolemia but only
  after volume replacement
• May cause tachyarrhythmias, excessive
  vasoconstriction
• DO NOT mix with sodium bicarbonate

Review of Infusions
182
Epinephrine

• Indications (When Why?)
• Symptomatic bradycardia After atropine,
  dopamine, and transcutaneous pacing (Class IIb)

Review of Infusions
183
Epinephrine

• Dosing (How?)
• Profound Bradycardia
• 2 to 10 µg/min infusion (add 1 mg of 11000 to
  500 mL normal saline infuse at 1 to 5 mL/min)

Review of Infusions
184
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

Review of Infusions
185
Norepinephrine

• Indications (When Why?)
• For severe cardiogenic shock and hemodynamic
  significant hypotension (systolic blood pressure
  lt 70 mm/Hg) with low total peripheral resistance
• This is an agent of last resort for management of
  ischemic heart disease and shock

Review of Infusions
186
Norepinephrine

• Dosing (How?)
• 0.5 to 1 mcg/min titrated to improve blood
  pressure (up to 30 mcg/min)
• DO NOT administer is same IV line as alkaline
  infusions
• Poison/drug-induced hypotension may higher doses
  to achieve adequate perfusion

Review of Infusions
187
Norepinephrine

• Precautions (Watch Out!)
• Increases myocardial oxygen requirements
• May induce arrhythmias
• Extravasation causes tissue necrosis

Review of Infusions
188
Calculating mg/min

• dose X gtt factor
• Solution Concentration
• 2 mg X 60 gtt/mL
• 4 mg
• Using a 60 gtt set
• 30 gtt/min 30 cc/hr

gtts/min
30 gtts/min
189
Calculating mcg/kg/min

• dose X kg X gtt factor
• solution concentration
• 5 mcg/min X 75 kg X 60 gtt/mL
• 1600 mcg/cc
• Using a 60 gtt set
• 18.75 cc/hr 18.75 gtts/min

cc/hr
18.75 cc/hr
190
Furosemide

• Indications (When Why?)
• For adjuvant therapy of acute pulmonary edema in
  patients with systolic blood pressure gt90 to 100
  mm Hg (without S/S of shock)
• Hypertensive emergencies
• Increased intracranial pressure

191
Furosemide

• Dosing (How?)
• 20 to 40 mg slow IVP
• If patient is taking at home, double their daily
  dose

192
Furosemide

• Precautions (Watch Out!)
• Dehydration, hypovolemia, hypotension,
  hypokalemia, or other electrolyte imbalance may
  occur

193
Questions?

• Jeremy Maddux
• ncmedix_at_msn.com

194
Summary

• To obtain a full understanding of ACLS
  pharmacology requires constant review of
• Indications Actions (When Why?)
• Dosing (How?)
• Contraindications Precautions (Watch Out!)

195
Thank You!