Acute Resuscitation

TABLE 1.1. Advanced Cardiac Life Support (ACLS) Drugs

Drug	Dosage	Indications/Comments
Antiarrhythmic Agents
Adenosine	Bolus: 6 mg (initial) If no response, bolus with 12 mg after 1–2 min	For conversion of PSVT unresponsive to vagal maneuvers
	May repeat 12 mg once	Give as rapid IV bolus over 1–3 s followed by rapid 10 ml fluid bolus May use lower bolus dose of 3 mg if central line available Be cautious of interactions with theophylline (inhibits adenosine), dipyridamole (potentiates adenosine), other drugs that prolong QT interval
Amiodarone	300 mg bolus IV 150 mg bolus IV followed by 1 mg/min for 6 h and then 0.5 mg/min for 18 h	For VF or pulseless VT refractory to shock; may repeat 150 mg bolus IV in 3–5 min For stable wide-complex tachycardia up to a total dose 2.2 g IV per 24 h May use for narrow complex atrial arrhythmias, as adjunct to cardioversion Monitor for bradycardia and hypotension
Atropine	Bolus: 0.5 mg IV (maximum dose 3 mg)	For either absolute (<60 beats/min) or “relative” symptomatic bradycardia
	Bolus: 1 mg IV	For bradycardia manifesting with lack of pulse, PEA or for asystole unresponsive to epinephrine May repeat dose every 3–5 min up to maximum dose 0.04 mg/kg or 3 mg
	ETT bolus: 2–3 mg	Dilute up to 10 ml in NS or sterile water (IV preferred)
Diltiazem	0.25 mg/kg IV bolus over 2 min (typically 15–20 mg)	For control of ventricular response rate in A fib or A flutter, or other narrow complex tachycardia
	May repeat once	Do not use in wide-complex tachycardia
	0.35 mg/kg IV bolus over 2 min (typically 25 mg)	Negative inotrope, so use cautiously if reduced LV function
	Maintenance infusion 5–15 mg/h
Epinephrine	Bolus: 1 mg IV (10 ml of 1:10,000 solution)	Therapy for refractory VF or pulseless VT; dose should be followed by CPR and defibrillation; may be repeated every 3–5 min
		Initial therapy for PEA; may repeat every 3–5 min
		Initial therapy for asystole; may repeat every 3–5 min
	ETT bolus: 2–2.5 mg	Dilute up to 10 ml NS or sterile water (IV preferred)
	Infusion: 2–10 μg/min	For treatment of symptomatic bradycardia unresponsive to atropine and transcutaneous pacing; alternative to dopamine
Ibutilide	1 mg IV infused over 10 min; may be repeated after 10 min Use 0.01 mg/kg if <60 kg	For treatment of atrial arrhythmias Monitor electrolytes and EKG Increased risk for torsade de pointes if elderly, abnormal LV function (EF <35%), or electrolyte abnormalities Monitor for 4–24 h
Isoproterenol	Infusion: 2–10 μg/min	May be used in torsade de pointes unresponsive to magnesium
		Use with extreme caution; at higher doses is considered harmful
		Not indicated for cardiac arrest, hypotension, or bradycardia
Lidocaine	Bolus: 1–1.5 mg/kg	For wide-complex tachycardia of uncertain type, stable VT, and control of PVCs May be followed by boluses of 0.5–0.75 mg/kg every 5–10 min up to a total of 3 mg/kg Only bolus therapy should be used in cardiac arrest
	Bolus: 1.5 mg/kg	Initial bolus dose suggested when VF is present and defibrillation and epinephrine have failed
	ETT bolus: 2–4 mg/kg	Diluted in 5–10 ml NS or sterile water (IV preferred)
	Infusion: 2–4 mg/min	Continuous infusion used after bolus dosing and following return of perfusion to prevent recurrent ventricular arrhythmias Because half-life of lidocaine increases after 24–48 h, the dose should be reduced after 24 h, or levels should be monitored Therapeutic levels 1–4 mg/L Full-loading dose but reduced infusion rate in patients with low cardiac output, hepatic dysfunction, or age over 70 years
Magnesium sulfate	Bolus: 1–2 g (8–16 mEq)	Drug of choice in patients with torsade de pointes For recurrent/refractory VT or VF For hypomagnesemia For ventricular dysrhythmias, administer over 1–2 min For magnesium deficiency, administer over 60 min
	Infusion: 0.5–1 g/h (4–8 mEq/h)	Rate and duration of infusion determine clinically or by magnitude of magnesium deficiency
Naloxone	0.4 mg IV is typical	Onset of action 2 min IV and <5 min IM/SC
	May give 0.4–2 mg IV every 2–3 min (maximum dose is 10 mg)	Duration of action ∼45 min Give 0.4 mg diluted in 10 ml NS or sterile water slowly to avoid abrupt narcotic withdrawal
	0.8 mg IM/SC	Hypertension/hypotension, cardiac arrhythmias, pulmonary edema may occur Monitor for reoccurring respiratory depression because narcotics typically last longer than naloxone
	ETT: 2 mg diluted in 5–10 ml NS or sterile water	(IV preferred)
Procainamide	12–17 mg/kg; administer at rate of 20–30 mg/min (maximum 50 mg/min)	Infrequently used Recommended when lidocaine is contraindicated or has failed to suppress ventricular ectopy Use higher dose for more urgent situations (VF or pulseless VT) Maximum total dose of 17 mg/kg Continue bolus dosing until arrhythmia suppressed, hypotension, QRS complex widens by 50% of original width, or maximum total dose given Rapid infusion may cause precipitous hypotension Avoid in patients with QT prolongation (>30% above baseline) or torsade de pointes
	Infusion: 1–4 mg/min	Continuous maintenance infusion, after return of perfusion, to prevent recurrent arrhythmias Reduce dosage in renal failure Monitor blood levels in patients with renal failure or with >24-h infusion Therapeutic levels: procainamide 4–10 mg/L, N-acetyl-procainamide (NAPA) 10–20 mg/L
Vasopressin	40 U IV push, one dose only	As an alternative to 1st or 2nd dose epinephrine in refractory VF, asystole, or PEA resume epinephrine after 3–5 min
Verapamil	Bolus: 2.5–10 mg over 2–3 min	Only give to patients with narrow complex PSVT unresponsive to adenosine
	May repeat in 15–30 min prn Max. cumulative = 20 mg	Diltiazem (0.25 mg/kg) is an alternative to verapamil because it has less negative inotropy
Vasopressor Agents
Dopamine (For other vasopressors, Table 3.8)	Infusion: 2–20 μg/kg/min	For treatment of symptomatic bradycardia unresponsive to atropine and transcutaneous pacing For treatment of hypotension that is unresponsive to volume
Electrolyte Agents
Sodium bicarbonate	Bolus: 1 mEq/kg	Helpful in limited clinical conditions: hyperkalemia, bicarbonate responsive acidosis, tricyclic antidepressant overdose Not recommended in the majority of arrest cases (hypoxic lactic acidosis) Guide therapy by blood gas analyses and calculated base deficit to minimize iatrogenic alkalosis
A fib, atrial fibrillation; A flutter, atrial flutter; CPR, cardiopulmonary resuscitation; EF, ejection fraction; EKG, electrocardiogram; ETT, endotracheal tube; IM, intramuscular; IV, intravenous; LV, left ventricular; MI, myocardial infarction; NS, normal saline; PEA, pulseless electrical activity; PSVT, paroxysmal supraventricular tachycardia; PVC, premature ventricular contraction; SC, subcutaneous; VF, ventricular fibrillation; VT, ventricular tachycardia