ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013.

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Transcript of ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013.

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ACLS Pharmacotherapy Update Jessica Schwenk, Pharm.D. September 14, 2013 Slide 2 Introduction Objectives ACLS Guideline Overview Access for Medications in ACLS Slide 3 Objectives Identify and describe medications used in Advanced Cardiovascular Life Support (ACLS) Understand indications, mechanism of action, dose, administration, and precautions for ACLS medications Recognize place in therapy for medications in updated ACLS algorithms Slide 4 ACLS Guidelines Developed by American Heart Association Released every 5 years Published in Circulation Most Recent 2010 Guidelines for advanced cardiac life support Used comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation (ILCOR) Slide 5 Slide 6 ACLS Guidelines First priority High quality CPR Early defibrillation Second priority Medication administration Advanced airway For drug administration or ventilation Slide 7 Access for Medications in ACLS Intravenous (IV) Route Preferred route Central line not required; can interrupt CPR Medications take 1-2 minutes to reach central circulation Give medications as IV bolus, flush with 20 mL fluid Slide 8 Access for Medications in ACLS Intraosseous (IO) Route Secondary method Safe and effective for administering medications, fluids, and blood as well as drawing blood ALL medications that can be given IV can be given IO Administer medications and flush with at least 20 mL fluid (as with IV administration) Slide 9 Access for Medications in ACLS Endotracheal (ET) Route Not preferred; last resort Medication doses are 2-2.5 times IV/IO doses Optimal dosing not known Medications that can be given ET: epinephrine, vasopressin, lidocaine (atropine, naloxone) Dilute with 5-10 mL SW/NS, administer into ET tube, follow with several positive pressure breaths Slide 10 ACLS Medications Adult cardiac arrest algorithm Slide 11 Slide 12 Slide 13 Slide 14 Slide 15 Medications: Ventricular fibrillation or ventricular tachycardia (VF/VT) Vasopressors: epinephrine, vasopressin Antiarrhythmics: amiodarone Not on algorithm: lidocaine, magnesium Asystole/Pulseless electrical activity (PEA) Vasopressors: epinephrine, vasopressin Slide 16 Adult cardiac arrest algorithm Vasopressor medications Include: epinephrine, norepinephrine, vasopressin Goal: increase coronary and cerebral perfusion Effects: Increase systemic arteriolar vasoconstriction Maintain vascular tone Shunt blood to heart and brain ONLY medications shown to improve ROSC and short term survival Slide 17 Adult cardiac arrest algorithm Epinephrine (Adrenaline) MOA: - and -receptor agonist -receptor stimulation restores circulation -receptor stimulation May lower defibrillation threshold Increases myocardial oxygen demand Slide 18 Adult cardiac arrest algorithm Epinephrine Dose and Administration VF, PVT, asystole, PEA IV/IO: 1 mg every 3-5 minutes Concentration 0.1mg/ml (1:10,000 or 1 mg/10ml) Flush with 20 ml NS (central line preferred) ET: 2-2.5 mg every 3-5 minutes Dilute in 5-10 ml SW or NS (use epi 1 mg/ml or 1:1,000) Slide 19 Vasopressors Vasopressin (antidiuretic hormone) MOA: acts on V1 receptor (among others) to cause vasoconstriction Increases blood pressure and systemic vascular resistance Benefits over epinephrine Not inhibited by metabolic acidosis No -receptor activity Vasopressin vs. epinephrine for cardiac arrest? No significant difference in ROSC when given 2 doses Slide 20 Vasopressors Vasopressin Dose and Administration VF, PVT, asystole, PEA IV/IO: 40 units one time (to replace 1 st or 2 nd dose of epinephrine every 3-5 minutes) 40 Units/2 ml (2 vials of 20 units/ml) Flush with 20 ml NS ET: 80-100 units one time (to replace 1 st or 2 nd dose of epinephrine every 3-5 minutes) Dilute in 5-10 ml SW or NS Slide 21 Adult cardiac arrest algorithm Antiarrhythmic medications for cardiac arrest (pulseless VF/VT) include: Amiodarone Not on algorithm: lidocaine, magnesium Goal: increase the fibrillation threshold Prevent development or recurrence of VF and PVT Slide 22 Adult cardiac arrest algorithm Amiodarone (Cordarone, Pacerone) MOA: Class III antiarrhythmic (potassium channel blocker) Acutely: inhibits - and -adrenergic stimulation, blocks calcium channels Side effects (acute): Hypotension, fever, elevated LFTs, confusion, nausea, thrombocytopenia Slide 23 Adult cardiac arrest algorithm Amiodarone Dose and administration Pulseless VF/VT 300 mg bolus IV/IO, follow with 150 mg in 3-5 minutes Give IV/IO push. If possible dilute in 20-30 ml D5W Amiodarone vial concentration is 50 mg/ml Flush with 20 ml Central line preferred Incompatible with sodium bicarbonate Slide 24 Other antiarrhythmics Lidocaine (NOT on algorithm for VF/PVT) MOA: Class Ib antiarrhythmic, sodium channel blocker 2010 Guidelines: There is inadequate evidence to support or refute the use of lidocaine in refractory VF/VT Amiodarone beneficial over lidocaine for survival-to- admission May be considered if amiodarone is not available Slide 25 Other Antiarrhythmics Lidocaine (NOT on algorithm for VF/PVT) Dose and Administration IV/IO: 1-1.5 mg/kg, then 0.5-0.75 mg/kg every 5 to 10 minutes Lidocaine 100 mg/5 ml syringe (20 mg/ml) ET: 2-3 mg/kg in 10 ml NS Dose and Administration Monitoring: discontinue if signs of toxicity Sedations, seizures, confusion Slide 26 Other Antiarrhythmics Magnesium (NOT on algorithm for VF/PVT) Use: suspected hypomagnesemia, Torsades de Pointes Dose and Administration (cardiac arrest) Magnesium 1-2 g IV/IO Magnesium sulfate 50% vials (1 g/2 mL or 0.5 g/ml) Dilute to 10 ml (NS) Administer over 5-20 minutes Monitor: Hypotension, respiratory and CNS depression Slide 27 ACLS Medications Adult bradycardia algorithm (with pulse) Slide 28 Slide 29 Adult bradycardia algorithm (with pulse) Slide 30 Slide 31 Medications Atropine Dopamine Epinephrine Slide 32 Adult bradycardia algorithm (with pulse) Atropine MOA: anticholinergic agent, blocks acetylcholine at M2-receptors of heart Dose and administration 0.5 mg IV/IO bolus, repeat every 3-5 minutes Max 3 mg total dose Atropine syringe 1 mg/10 ml (0.1 mg/ml) Contraindications/Precautions Evidence of a high degree (second degree [Mobitz] type II or third degree) atrioventricular (AV) block May be harmful in cardiac ischemia Slide 33 Adult bradycardia algorithm (with pulse) Dopamine MOA: adrenergic and dopaminergic receptor agonist, stimulation of 1-recptors increases HR Dose and Administration 2-10 mcg/kg/min IV/IO infusion (up to 20 mcg/kg/min) Titrate to response, increase by 5 mcg/kg/min every 10-30 minutes as needed Premade bags are 200 mg/250 ml D5W (800 mcg/ml) Central line preferred Incompatible with sodium bicarbonate Slide 34 Adult bradycardia algorithm (with pulse) Epinephrine MOA: adrenergic agonist, stimulation of 1- recptors increases HR Dose and Administration 2-10 mcg/min IV/IO infusion Titrate to response Standard drip 4 mg/250 ml NS or D5W (16 mcg/ml) Central line preferred Incompatible with sodium bicarbonate Slide 35 ACLS Medications Adult tachycardia algorithm (with pulse) Slide 36 Slide 37 Slide 38 Adult tachycardia algorithm (with pulse) Medications Regular narrow complex Adenosine Calcium channel blockers or beta blocker Irregular narrow complex Calcium channel blocker or beta blocker Amiodarone Slide 39 Adult tachycardia algorithm (with pulse) Medications Regular wide complex Adenosine Calcium channel blockers or beta blocker Antiarrhythmics: procainamide, amiodarone, sotolol Irregular wide complex Antiarrhythmics: procainamide, amiodarone, sotolol Polymorphic VT, Torsades de Pointes: magnesium Slide 40 Adult tachycardia algorithm (with pulse) Adenosine Dose and Administration 6-12 mg IV into large proximal veinfast Flush with 20 mL immediately, elevate limb Extremely short half life May repeat 2 nd and 3 rd dose of 12 mg Larger doses (18 mg IV) Theophylline or theobromine, caffeine; Smaller doses (3mg IV) Dipyridamole or carbamazepine, transplanted hearts, or into a central vein. Slide 41 Adult tachycardia algorithm (with pulse) Adenosine Side effects Chest discomfort, dyspnea, and flushing Warn patient! Monitoring Continuous ECG recording during administration If adenosine fails to convert SVT, watch for atrial flutter or a non-reentrant SVT Slide 42 Adult tachycardia algorithm (with pulse) Diltiazem First choice for acute a-fib with RVR Dose and administration Bolus 15-20 mg IV push over 2 minutes (0.25 mg/kg) Repeat with 20-25 mg IV push over 2 minutes after 15 minutes (0.35 mg/kg) Diltiazem vials 5 mg/ml IV infusion 5-10 mg/hour, titrate up by 5 mg/hour as needed Diltiazem infusion 1 mg/ml Monitor: ECG, blood pressure Slide 43 Adult tachycardia algorithm (with pulse) Verapamil Dose and administration 2.5-5 mg IV push over 2 minutes Repeat with 5-10 mg over 2 minutes after 15-30 minutes Maximum total dose 20 mg Monitor: ECG, blood pressure Slide 44 Adult tachycardia algorithm (with pulse) Metoprolol Dose and administration 5 mg IV push over 1 minute for 3 doses every 2-5 minutes Monitor: ECG, blood pressure Slide 45 Adult tachycardia algorithm (with pulse) Atenolol Dose and administration 5 mg slow IV push over 5 minutes Repeat in 10 minutes Monitor: ECG, blood pressure Slide 46 Adult tachycardia algorithm (with pulse) Esmolol Dose and administration 500 mcg/kg IV push over 1 minute (may repeat) 10 mg/ml IV infusion 50 mcg/kg/minute for 4 minutes Titrate by 50 mcg/kg/minute at least every 4 minutes Max 200 mcg/kg/min Repeat in 10 minutes Monitor: ECG, blood pressure Slide 47 Adult tachycardia algorithm (with pulse) Procainamide Class 1a antiarrhythmic (sodium channel blocker) Dose and administration IV infusion 20 mg/min (20 mg/ml in D5W) Alternate dosing: 100 mg IV push over 2 min every 5 min Continue until the arrhythmia is suppressed, or: Hypotension QRS widens 50% beyond baseline Ma