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ACLS

MEDICATION
Routes of Administration

▪ Medications should be given IV or IO


▪ Avoid obtaining Central line access
▪ ET Tube administration ONLY if unable to gain IV or IO
Access
Medications for Cardiac
Arrest
Cardiac Arrest

Cardiac arrest algorithm is used for two pathways :


▪ A shockable rhythm : Ventricular Fibrillation (VF) or pulseless
Ventricular Tachycardia (VT)
▪ A nonshockable rhythm : asystole, Pulseless Electrical Activity (PEA)
Two Types of Agents

▪ “Pressor” Agents (increased blood flow)


▪ Epinephrine and Vasopressin

▪ Antidysrhythmics (suppression of dysrhythmia)


▪ Amiodarone, Lidocaine, Magnesium Sulfate
EPINEPHRINE

▪ Used during resuscitation primarily for its α-


adrenergic effects
▪ + inotrope, + chronotrope, SVR, BP
▪ automaticity
▪ force of contraction
▪  coronary and cerebral blood flow
▪ Bronchial dilation
Dosage IV/IO:
▪ Cardiac Arrest-1 mg q 3-5 min

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AMIODARONE

Dosage:
VF/pulseless VT = 300mg IVP/IO
may repeat one time at 150mg IVP/IO
LIDOCAINE

Indication:
 Consider using if amiodarone not available or allergy to
Amiodarone
LIDOCAINE

▪ Dosage:
1-1.5 mg/kg/dose x 1
then 0.5 – 0.75 mg/kg q 5-10 min (max. 3 doses or
3mg/kg)
MAGNESIUM SULFATE

▪ Indications: Torsades de pointes


(Hypomagnesaemia may lead to development of
Torsades)

Dosage:
 Pulseless arrest w/ Torsades,
= 1 – 2 grams
Administration in Cardiac Arrest

▪ Follow each medication with a 20 ml flush and elevate


arm 1-20 seconds
▪ Anticipate the next medication and have it ready to
administer
▪ If we administer medications at the beginning of the
cycle of CPR, we can circulate them for 2 minutes
Administer Medications at beginning of cycle
Medications for
Post Arrest Care
Post Arrest Hypotension Not
Responsive to Fluid Bolus

Vasopressor Infusions:
▪ Epinephrine 0.1-0.5 mcg/kg/min
▪ Dopamine 5-10 mcg/kg/min
▪ Norepinephrine 0.1-0.5 mcg/kg/min
BRADYCARDIA
Bradycardia

The drugs is given if bradyarrhythmia causing :

• Hypotension
• Acutely altered mental status
• Signs of shock
• Ischemic chest discomfort
• Acute heart failure

First-line treatment
Atropine 0.5 mg IV – may repeat to a total dose of 3 mg

Use atropine cautiously in the presence of acute coronary


ATROPINE ischemia or MI

Do not rely on atropine in Mobitz type II second or third


degree AV block or in patients with third – degree AV block
with a new wide QRS complex
If Atropine is ineffective, consider :

Transcutaneous
pacing

OR DOPAMINE
2 to 10 mcg/kg per minute
(chronotropic or heart rate dose)

OR 2 to 10 mcg/min
EPINEPHRINE
TACHYCARDIA
FOR
TACHYCARDIA
Tachycardia

CARDIOVERSION
Unstable Tachycardia
Sign & symptoms :
▪ Hypotension
▪ Acutely altered mental status Consider of giving
adenosine, if
▪ Signs of shock regular narrow
▪ Ischemic chest discomfort complex

▪ Acute heart failure First dose :


6 mg rapid IV push;
ADENOSINE follow with NS flush

Second dose :
12 mg if required
Tachycardia
Stable Tachycardia

If QRS ≥ 0.12 second (wide) If QRS is not wide

Consider : - Vagal maneuvers


- Adenosine only if regular & - Adenosine (if regular)
monomorphic - β–Blocker or calcium channel
First dose: 6 mg rapid IV push; follow blocker
with NS flush
Second dose: 12 mg if required

- Consider antiarrhytmic infusion


First dose: 150 mg over 10 minutes
Repeat as needed if VT recurs.
Follow by maintenance infusion of
1 mg/min for first 6 hours
Medications for
Acute Coronary
Syndromes
MONA

Oxygen
Start at 4 LPM and Titrate to maintain O2
saturation <94%
MONA
 Aspirin – 160mg – 325 mg (absorbed better if chewed)
- Aspirin (non-enteric coated) should be administered to ALL
patients suspected of acute coronary syndromes, unless
there is a true aspirin allergy or recent GI bleed.
MONA
Nitroglycerin
Dosage:

SL 0.4mg tab q5min x 3


Strong Cautions:
Right Ventricular infarct
Phosphodiestrace inhibitors in last 24-48 hours
MONA
Morphine –
Chest pain unresponsive to nitrates
Dosage:
2-4 mg repeat PRN
-
Side Effects: respiratory depression  BP
USE of PCI

▪ PCI is treatment of choice when it can be performed <


90 minutes door to balloon time
▪ PCI is treatment of choice If facility not capable of PCI,
but transfer to PCI facility can still accomplish door to
balloon time of < 90 minutes
Fibrinolytic Therapy

▪ Breaks up the fibrin network that binds clots together

Indications: ST elevation >1 mm in 2 or more contiguous leads or


new LBBB or new BBB that obscures ST
▪ Time of symptom onset must be <12 hours
▪ Caution: fibrinolytics can cause death from brain
hemorrhage
Adjunctive Treatments

▪ IV Nitroglycerin
▪ Heparin
▪ Clopidogrel (Plavix)
▪ Beta Blockers
▪ ACE Inhibitors
▪ Statin Therapies
Medications for
Stroke
Fibrinolytic Therapy
▪ Breaks up the fibrin network that binds clots together

Indications: Stroke symptoms > 1hour with normal CT Scan


▪ Time of symptom onset must be < 3 hours (now 4 ½)
▪ Caution: fibrinolytics can cause death from brain hemorrhage
▪ TPA is the only current approved medication
THANK YOU