Adult advanced cardiovascular life support

This chapter will review the current recommendations from the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Asystole/pulseless electrical activity

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Algorithm ( Fig. 3.1 )

Figure 3.1

Algorithm for asystole and PEA.

Data from Panchal AR, Berg KM, Kudenchuk PJ, et al. 2018 American Heart Association focused update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest. Circulation. 2018;138:e740–e749 . CPR , Cardiopulmonary resuscitation; PEA , Pulseless electrical activity; ROSC, Return of spontaneous circulation. ^a5 H’s , h ypovolemia, h ypoxia, h ydrogen ion (acidosis), h ypo-/hyperkalemia, and h ypothermia. 5 T’s , t ension pneumothorax, t amponade (cardiac), t oxins, t hrombosis (pulmonary), and t hrombosis (coronary).

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Pharmacologic management ( Table 3.1 )

Table 3.1

Antiarrhythmic Drugs for ACLS

Adapted from Panchal AR, Berg KM, Kudenchuk PJ, et al. 2018 American Heart Association focused update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest. Circulation . 2018;138:e740–e749 and Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation . 2010;122(suppl 3):S729–S767.

DRUG	STANDARD DOSING	MOA	COMMENTS
Asystole/PEA and VF/pVT (see Fig. 3.1 and 3.2 )
Epinephrine	IV/IO: 1 mg q3–5min ET: 2–2.5 mg q3–5min (dilute with 5–10 mL of NS or sterile water)	α-Adrenergic agonist vasoconstriction	↑ Coronary and cerebral perfusion pressure during CPR ↑ ROSC; ↑ survival to hospital admission in out-of-hospital arrests
VF/pVT (see Fig. 3.2 )
Amiodarone	IV/IO: First dose: 300 mg Second dose: 150 mg	Na/K/Ca channel and β-receptor antagonist; Class III antiarrhythmic	Administer as push if pulseless For VF/pVT refractory to defibrillation
Lidocaine	IV/IO: First dose: 1–1.5 mg/kg Second dose: 0.5–0.75 mg/kg	Na channel antagonist; Class Ib antiarrhythmic	For VF/pVT refractory to defibrillation Increased risk of toxicities in hepatic dysfunction, HF, and elderly
Magnesium	IV/IO: 1–2 g over 5 min (diluted in 10 mL of 5% dextrose or sterile water)	Stops EAD by inhibiting Ca channel influx	Optimal dosing not established Indicated in Torsades de pointes
Bradycardia With Pulse (see Fig. 3.3 )
Atropine	IV: 0.5 mg q3–5min Maximum: 3 mg	Blocks acetylcholine at parasympathetic sites in smooth muscle; ↑ cardiac output	First-line for acute symptomatic bradycardia
Dopamine	IV: 2–10 mcg/kg/min	β-Adrenergic agonist with rate-accelerating effect	For bradycardia unresponsive to atropine
Epinephrine	IV: 2–10 mcg/min	β-Adrenergic agonist with rate-accelerating effect	For bradycardia unresponsive to atropine
Tachycardia With Pulse (see Fig. 3.4 )
Adenosine	First dose: 6 mg IV Second dose: 12 mg IV Administer rapidly over 1–2 s Follow each dose with 20 mL NS flush	Slows conduction time and interrupts reentry pathways through the AV node	Drug of choice for re-entrant tachycardias involving the AV node Reduce initial dose to 3 mg if concurrent carbamazepine or dipyridamole, transplanted heart, or central line administration
Amiodarone	IV: 150 mg over 10 min (may repeat) then 1 mg/min ×6 h, followed by 0.5 mg/min ×18 h Max dose: 2.2 g/24 h	Na/K/Ca channel and β-receptor antagonist; Class III antiarrhythmic	Administer as slow infusion if pulse obtained Preferred in AF with HF Can convert AF to sinus rhythm: embolic risk ADR: hypotension, bradycardia, elevated liver enzymes, phlebitis DDI: inhibits digoxin and warfarin metabolism via cytochrome P450
Procainamide	IV: 20–50 mg/min until arrhythmia resolved Maximum: 17 mg/kg Maintenance: 1–4 mg/min	↓ Myocardial excitability and conduction velocity; Class Ia antiarrhythmic	Avoid if prolonged QT or HF
Sotalol	IV: 100 mg over 5 min	β ₁and β ₂receptor antagonist; Class II and III antiarrhythmic	Avoid if prolonged QT
Metoprolol	2.5–5 mg IV over 2 min; repeat q5–10min up to three doses	Cardioselective β ₁receptor antagonists	Preferred in AF associated with hyperadrenergic states (e.g., acute MI, post-cardiac surgery)
Esmolol	IV: 500 mcg/kg then 50 mcg/kg/min; titrate by 25 mcg/kg/min q5min Max: 200 mcg/kg/min	Cardioselective β ₁receptor antagonists	Ultra-short-acting; rapid dose titration Preferred in AF associated with hyperadrenergic states
Diltiazem	IV: 0.25 mg/kg over 2 min (may repeat bolus with 0.35 mg/kg), then 5–15 mg/h	Ca channel blocker	Possess negative inotropic effects; however, safely used in HF ADR: hypotension, cardiac depression
Verapamil	IV: 0.25–5 mg over 2 min; may repeat q15–30min up to 20 mg	Ca channel blocker	Potent negative inotropic effects and hypotension; avoid in HF
Notes: • Vasopressin was removed from current guidelines to simplify given no advantage over epinephrine • Adding methylprednisolone and vasopressin to epinephrine during ACLS plus stress dose hydrocortisone for post-ROSC shock may be considered to promote ROSC during cardiac arrest and improve discharge neurologic function in patients who survive; however further confirmatory data needed • When IV/IO access is unavailable, epinephrine, vasopressin, and lidocaine can be administered via endotracheal tube at 2–2.5 times the IV dose.