ACLS Pharmacotherapy Update

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ACLS Pharmacotherapy Update. Jessica Schwenk, Pharm.D. September 14, 2013. Introduction. Objectives ACLS Guideline Overview Access for Medications in ACLS. Objectives. Identify and describe medications used in Advanced Cardiovascular Life Support (ACLS) - PowerPoint PPT Presentation

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ACLS Pharmacotherapy Update

ACLS Pharmacotherapy UpdateJessica Schwenk, Pharm.D.September 14, 2013IntroductionObjectivesACLS Guideline OverviewAccess for Medications in ACLSObjectivesIdentify and describe medications used in Advanced Cardiovascular Life Support (ACLS)Understand indications, mechanism of action, dose, administration, and precautions for ACLS medicationsRecognize place in therapy for medications in updated ACLS algorithmsACLS GuidelinesDeveloped by American Heart AssociationReleased every 5 yearsPublished in CirculationMost Recent2010 Guidelines for advanced cardiac life support Used comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation (ILCOR) Reviewed continually4

Universal cardiac arrest algorithm5ACLS GuidelinesFirst priorityHigh quality CPREarly defibrillationSecond priorityMedication administrationAdvanced airwayFor drug administration or ventilation

Do not interrupt chest compressionsUnless bag-mask ventilation is ineffectiveNO MEDICATION HAS BEEN PROVEN TO INCREASE CHANCES OF SURVIVAL TO HOSPITAL DISCHARGE (human, placebo-controlled study)6Access for Medications in ACLSIntravenous (IV) RoutePreferred routeCentral line not required; can interrupt CPRMedications take 1-2 minutes to reach central circulationGive medications as IV bolus, flush with 20 mL fluidIV preferred unless central line in placePlacing central line can interrupt and cause complicationsvascular laceration, hematomas, bleedingcan be relative contraindication to fibrinolytic therapy (insertion into non-compressable area of a vein)IVflush, wait to reach circulation w/ CPR. Possible elevate limb (not studied)7Access for Medications in ACLSIntraosseous (IO) RouteSecondary methodSafe and effective for administering medications, fluids, and blood as well as drawing bloodALL medications that can be given IV can be given IOAdminister medications and flush with at least 20 mL fluid (as with IV administration)IO cannulation provides access to noncollapsible venous plexus in the bone marrow.Time to effectiveness similar to IVNeed to apply more pressure with IO administration.Helpful for pediatric codes8Access for Medications in ACLSEndotracheal (ET) RouteNot preferred; last resortMedication doses are 2-2.5 times IV/IO dosesOptimal dosing not knownMedications 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

ACLS MedicationsAdult cardiac arrest algorithm

Adult cardiac arrest algorithmMedications:Ventricular fibrillation or ventricular tachycardia (VF/VT)Vasopressors: epinephrine, vasopressinAntiarrhythmics: amiodarone Not on algorithm: lidocaine, magnesiumAsystole/Pulseless electrical activity (PEA)Vasopressors: epinephrine, vasopressin

There is insufficient evidence to support or refute the use ofatropine in cardiac arrest to improve survival to hospital discharge.15Adult cardiac arrest algorithmVasopressor medicationsInclude: epinephrine, norepinephrine, vasopressinGoal: increase coronary and cerebral perfusionEffects: Increase systemic arteriolar vasoconstrictionMaintain vascular toneShunt blood to heart and brainONLY medications shown to improve ROSC and short term survival

Vasoconstriction -> improve perfusion pressureMaintain vascular tone -> decreases arteriolar collapseGuidelines: use may be considered in adult cardiac arrest16Adult cardiac arrest algorithmEpinephrine (Adrenaline)MOA: - and -receptor agonist-receptor stimulation restores circulation-receptor stimulation May lower defibrillation thresholdIncreases myocardial oxygen demandAdrenergic, non-selectiveEfficacy due to stimulation of alpha receptors, (a2a1-agonists such as phenylphrine and methoxamine no advantage over epi/norepi. Probably because a2 receptors more accessible. Also a1 receptors decrease in ischemia)Effect of beta stimulation: unclear beneficial or harmful beta stimulation possibly lowers defibrillation threshold, but increases hearts 02 demand, may increase severity of post-resuscitation myocardial dysfunction17Adult cardiac arrest algorithmEpinephrine Dose and AdministrationVF, PVT, asystole, PEAIV/IO: 1 mg every 3-5 minutesConcentration 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 minutesDilute in 5-10 ml SW or NS (use epi 1 mg/ml or 1:1,000)

18VasopressorsVasopressin (antidiuretic hormone)MOA: acts on V1 receptor (among others) to cause vasoconstrictionIncreases blood pressure and systemic vascular resistanceBenefits over epinephrineNot inhibited by metabolic acidosisNo -receptor activityVasopressin vs. epinephrine for cardiac arrest?No significant difference in ROSC when given 2 doses

VasopressorsVasopressinDose and AdministrationVF, PVT, asystole, PEAIV/IO: 40 units one time (to replace 1st or 2nd dose of epinephrine every 3-5 minutes)40 Units/2 ml (2 vials of 20 units/ml)Flush with 20 ml NSET: 80-100 units one time (to replace 1st or 2nd dose of epinephrine every 3-5 minutes)Dilute in 5-10 ml SW or NS

Adult cardiac arrest algorithmAntiarrhythmic medications for cardiac arrest (pulseless VF/VT) include:AmiodaroneNot on algorithm: lidocaine, magnesiumGoal: increase the fibrillation thresholdPrevent development or recurrence of VF and PVT

We suggest that antiarrhythmic drugs be considered after a second unsuccessful defibrillation attempt in anticipation of a third shockPreviously, also procainamide and bretylium

21Adult cardiac arrest algorithmAmiodarone (Cordarone, Pacerone)MOA: Class III antiarrhythmic (potassium channel blocker)Acutely: inhibits - and -adrenergic stimulation, blocks calcium channelsSide effects (acute):Hypotension, fever, elevated LFTs, confusion, nausea, thrombocytopenia

K channel blockers: Prolongs repolarizationprolongs action potential and refractory period in myocardial tissue, decreases AV conduction and sinus node function22Adult cardiac arrest algorithmAmiodaroneDose and administrationPulseless VF/VT300 mg bolus IV/IO, follow with 150 mg in 3-5 minutesGive IV/IO push. If possible dilute in 20-30 ml D5WAmiodarone vial concentration is 50 mg/mlFlush with 20 mlCentral line preferredIncompatible with sodium bicarbonate

Other antiarrhythmicsLidocaine (NOT on algorithm for VF/PVT)MOA: Class Ib antiarrhythmic, sodium channel blocker2010 Guidelines: There is inadequate evidence to support or refute the use of lidocaine in refractory VF/VTAmiodarone beneficial over lidocaine for survival-to-admissionMay be considered if amiodarone is not availableOther AntiarrhythmicsLidocaine (NOT on algorithm for VF/PVT)Dose and AdministrationIV/IO: 1-1.5 mg/kg, then 0.5-0.75 mg/kg every 5 to 10 minutesLidocaine 100 mg/5 ml syringe (20 mg/ml)ET: 2-3 mg/kg in 10 ml NSDose and AdministrationMonitoring: discontinue if signs of toxicity Sedations, seizures, confusion

Other AntiarrhythmicsMagnesium (NOT on algorithm for VF/PVT)Use: suspected hypomagnesemia, Torsades de PointesDose 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 minutesMonitor: Hypotension, respiratory and CNS depression

15 minutes26ACLS MedicationsAdult bradycardia algorithm (with pulse)

Adult bradycardia algorithm (with pulse)Adult bradycardia algorithm (with pulse)

Bradycardia is defined conservatively as a heart rate below 60 beats per minute, but symptomatic bradycardia generally entails rates below 50 beats per minute. The 2010 ACLS Guidelines recommend that clinicians not intervene unless the patient exhibits evidence of inadequate tissue perfusion thought to result from the slow heart rate 30Adult bradycardia algorithm (with pulse)MedicationsAtropineDopamineEpinephrineAdult bradycardia algorithm (with pulse)AtropineMOA: anticholinergic agent, blocks acetylcholine at M2-receptors of heart Dose and administration0.5 mg IV/IO bolus, repeat every 3-5 minutesMax 3 mg total doseAtropine syringe 1 mg/10 ml (0.1 mg/ml) Contraindications/PrecautionsEvidence of a high degree (second degree [Mobitz] type II or third degree) atrioventricular (AV) block May be harmful in cardiac ischemia

blocks action of acetylcholine at parasympathetic receptors 32Adult bradycardia algorithm (with pulse)DopamineMOA: adrenergic and dopaminergic receptor agonist, stimulation of 1-recptors increases HRDose and Administration2-10 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 neededPremade bags are 200 mg/250 ml D5W (800 mcg/ml)Central line preferredIncompatible with sodium bicarbonateAdult bradycardia algorithm (with pulse)EpinephrineMOA: adrenergic agonist, stimulation of 1-recptors increases HRDose and Administration2-10 mcg/min IV/IO infusionTitrate to responseStandard drip 4 mg/250 ml NS or D5W (16 mcg/ml)Central line preferredIncompatible with sodium bicarbonateACLS MedicationsAdult tachycardia algorithm (with pulse)

Adult tachycardia algorithm (with pulse)MedicationsRegular narrow complexAdenosineCalcium channel blockers or beta blockerIrregular narrow complexCalcium channel blocker or beta blockerAmiodarone

Adult tachycardia algorithm (with pulse)MedicationsRegular wide complexAdenosineCalcium channel blockers or beta blockerAntiarrhythmics: procainamide, amiodarone, sotololIrregular wide complexAntiarrhythmics: procainamide, amiodarone, sotololPolymorphic VT, Torsades de Pointes: magnesium

Adult tachycardia algorithm (with pulse)AdenosineDose and Administration6-12 mg IV into large proximal veinfastFlush with 20 mL immediately, elevate limbExtremely short half lifeMay repeat 2nd and 3rd dose of 12 mgLarger doses (18 mg IV) Theophylline or theobromine, caffeine; Smaller doses (3mg IV) Dipyridamole or carba