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Drugs in ACLS

DRUG FOR CARDIAC ARRESTVasopressorThe routine use of any vasopressor during human cardiac arrest increases survival to hos-pital discharge, although improved short-term survival has been documented

The primary goal of CPR is to re-establishblood flow to vital organs until the restoration of spontaneous circulation Adrenaline (epinephrine) versus no adrenaline Standard-dose adrenaline was associated withsignificantly higher rates of prehospital ROSC (relative risk [RR]2.80 [95% CI 1.784.41], p < 0.00001) and survival to hospital admis-sion (RR 1.95 [95% CI 1.342.84], p = 0.0004) when compared toplaceboThere was no difference in survival to hospital discharge(RR 2.12 [95% CI 0.756.02], p = 0.16) or good neurological outcome, defined as Cerebral Performance Categories (CPC) 1 or 2 (RR 1.73,[95% CI 0.595.11], p = 0.32) Our current recommendation is to continue the use ofadrenaline during CPR as for Guidelines 2010. We have consid-ered the benefit in short-term outcomes (ROSC and admission to hospital) We have decided not tochange current practice until there is high-quality data on long-term outcomes Use. Adrenaline is available most commonly in two dilutions:1 in 10,000 (10 ml of this solution contains 1 mg of adrenaline)1 in 1000 (1 ml of this solution contains 1 mg of adrenaline). Both these dilutions are used routinely in Europe.IndicationsThe first drug used in cardiac arrest of any cause: it is included inthe ALS algorithm for use every 35 min of CPR.Preferred in the treatment of anaphylaxis A second-line treatment for cardiogenic shockAnti Arrhythmics DrugsAdenosine slows transmission across the AV node but has little effect on other myocardial cells or conduction pathways. It is highly effective for terminating paroxysmal SVT It has an extremely short half-life of 1015 s The smallest dose likely to be effective is 6 mg If unsuccessful this can be fol-lowed with up to two doses each of 12 mg every 12 min IndicationsRefractory VF/pVTHaemodynamically stable ventricular tachycardia (VT) and other resistant tachyarrhythmias We recommend that an initial intravenous dose of 300 mg amiodarone, diluted in 5% glucose to a volume of 20 ml LidocainLidocaine is recommended for use during ALS when amiodarone is unavailableIt decreases ventricular automaticity Suppresses ventricular ectopic activity It is effective in suppressing arrhythmias associated with depolarisation IndicationsLidocaine is indicated in refractory VF/pVT (when amiodarone is unavailable)When amiodarone is unavailable, consider an initial dose of 100 mg (11.5 mg kg1) of lidocaine for VF/pVT refractory. Give an additional bolus of 50 mg if necessary The total dose should not exceed 3 mg kgAmiodarone Has effects on sodium, potassium and calcium channels as well as alpha and beta adrenergic blocking properties IndicationsControl of haemodynamically stable monomorphic VT, polymor-phic VT and wide-complex tachycardia of uncertain origin.Paroxysmal SVT uncontrolled by adenosine, vagal manoeuvres or AV nodal blockade;Unsuccessful electrical cardioversionGive amiodarone, 300 mg intravenously, over 1060 min, depending on the circumstances and haemodynamic stability ofthe patient Followed by an infusion of 900 mg over 24 h Additional infusions of 150 mg can be repeated asnecessary for recurrent or resistant arrhythmias a maximum manufacturer-recommended total daily dose of 2 g Verapamil and Diltiazem Calcium channel blocking drug sthat slow conduction and increase refractoriness in the AV nodeThese actions may terminate re-entrant arrhythmias and control ventricular response rate in patients with a variety of atrial tachycardiasIndicationsStable regular narrow-complex tachycardias uncontrolled orunconverted by adenosine or vagal manoeuvresTo control ventricular rate in patients with AF or atrial flutter and preserved ventricular functionInitial dose of verapamil is 2.55 mg intravenously given over 2 min Give repeated doses of 510 mg every1530 min to a maximum of 20 mg.

Diltiazem at a dose of 250mcg/kg intravenously, followed by a second dose of 350mcg/kgDiltiazem may decrease myocardial contrac-tility and critically reduce cardiac output in patients with severe LV dysfunction

Beta-adrenergic blockersReduce the effects of circulating catecholamines and decrease heart rate and blood pressure They also have cardioprotective effects for patients with acutecoronary syndromes IndicationsNarrow-complex regular tachycardias uncontrolled by vagalmanoeuvres and adenosine in the patient with preserved ven-tricular functionTo control rate in AF and atrial flutter when ventricular functionis preservedThe intravenous dose of atenolol (beta1) is 5 mg given over 5 min, repeated if necessary after 10 min Metoprolol (beta1) isgiven in doses of 25 mg at 5-min intervals to a total of 15 mgPropranolol (beta1 and beta2 effects), 100mcg kg, is given slowly in three equal doses at 23min intervalsIntravenous esmolol is a short-acting (half-life of 29 min) beta1-selective beta-blocker. It is given as an intravenous loading dose of 500mcg kg over 1 min, followed by an infusion of 50200mcg kg/minSide effects of beta-blockade include bradycardia, AV con-duction delay and hypotension Contraindications to the use ofbeta-adrenergic blocking drugs include second- or third-degree heart block, hypotension, severe congestive heart failure and lung disease associated with bronchospasm.MagnesiumIs the first line treatment for polymorphic ven-tricular tachycardia (torsades de pointes) and ventricular orsupraventricular tachycardia associated with hypomagnesaemiaGive mag-nesium sulphate 2 g (8 mmol) over 10 min. This can be repeated once if necessary.Intravenous fluids Ensure normovolaemiaUse intravenous fluid to flush peripherally injected drugs into the central circulation