NEW
2010 ACLS PHARMACOLOGY I & II
LBW, LLC
Jul 1994 – rJune 2011
1
DRUGS
CLASSIFICATION ACTION
INDICATIONS DOSAGE
CONS
IDERATIONS/PRECAUTIONS
OXYGEN
Medicinal Gas
Improves tissue
oxygenation
1. Chest Pain
2. Suspected hypoxia
3. Cardiac Arrest
NC 1 – 6 L
Mask 6-10 L
NRB 10+L
100% in Code
0
2
toxicity, chronic CO
2
retainers
BUT never withhold 0
2
in known or
suspected hypoxia – EVEN IF HAVE
COPD
EPINEPHRINE
(Adrenalin, Epi)
Sympathomimetic A1=Vasoconstriction
B1=
↑
HR, contractility
And conduction
B2=Bronchodilation
↑
perfusion pressure
with CPR
↑
cardiac & CNS blood
flow
1. VF or Pulseless VT
2. Asystole
3. PEA
4.
↓
SVR
1. 1 mg 1:10.000 IV
MR q 3-5 min
2. 2-2.5 mg (1:1000) if
via ETT MR q 3-5 min
3. Drip 1 mg/250 mL at
2-10 mcg/min & titrate
(1:1000)
Incompatible with NaHCO
3
Tachydysrhythmias =
↑
workload of
heart
VASOPRESSIN
(Pitressin)
Antidiuretic Hormone Increases reabsorption by
the renal tubules.
Directly stimulates smooth
muscle contraction =
vasoconstriction
Potent peripheral
vasoconstrictor
1
st
or 2
nd
line drug for
CARDIAC ARREST
INSTEAD OF epinephrine
May be useful for
hemodynamic support in
vasodilatory shock
40 u IV -
USE INSTEAD OF 1
ST
OR 2
ND
DOSE OF EPI IN
CODE SITUATION
⇑
⇑⇑
⇑
SVR may
provoke cardiac ischemia
Not recommended for responsive
patients with CAD
“produces same positive effects of
epinephrine, but does not have the
negative effects”
AMIODARONE
(Cordarone)
Antiarrhythmic
Noncompetitive inhibitor
of both alpha and beta
adrenergic receptors.
Inhibits outward
potassium current, sodium
channels which prolongs
QT interval, QRS duration
and slows ventricular
conduction
1. MAT, SVT, JT
2. Pulsed VT
3. PVT/V-fib
Perfusing Tachys:
150 mg IV push dilute in
100 mL and give over 8-
10 mins MR q 10 min
MAX dose: 2.2 gms/24 hr
VT/VF:
300mg dilute in 20-30 mL
MR 150 mg in 3-5 min
If dysrhythmia clears
:
hang drip of 360 mg IV
over 6 hours (1mg/min)
and then 540 mg IV over
18 hours (0.5mg/min)
Do not give with Procainamide
Causes vasodilation
May increase risk of Polymorphic VT
HYPOTENSION
May worsen existing arrhythmias or
promote new ones
PROCAINAMIDE
(Pronestyl)
Antiarrhythmic 1. Bi-directional block
2. Depresses atrial
& ventricular automaticity
3.
↑
Ventricular
depolarization time
4. Widens QRS
PREFERRED CHOICE
FOR
VT w/ Pulse – STABLE
20 – 50 mg/min IV until:
1.Arrhythmia suppressed
2. Hypotension occurs
3.QRS widens
↑
50%
4. Total 17 mg/Kg given
Drip
= 1-2 Gm /250-500
@ 1-4 mg/min
Monitor BP & EKG
Hypotension with rapid injection =
↓
contractility. Caution with Acute MI.
May reduce dose with renal failure or
when on continuous infusion of > 3
mg/min in 24 hrs.
May precipitate/worsen Torsades
NEW
2010 ACLS PHARMACOLOGY I & II
LBW, LLC
Jul 1994 – rJune 2011
2
DRUGS
CLASSIFICATION ACTION
INDICATIONS DOSAGE
CONS
IDERATIONS/PRECAUTIONS
LIDOCAINE
(Xylocaine)
Antiarrhythmic Depress automaticity.
Blocks re-entry. No
significant effect above
HIS bundle
1. VT STABLE
2. Polymorphic VT
IF AMIODARONE NOT
AVAILABLE USE FOR
PVT AND V-FIB
VT w/pulse
-
STABLE
0.5 – 0.75 mg/kg up to
1-1.5 mg/kg
MR @ 0.5 - 0.75 mg/kg
q 5-10 min to total
3 doses or 3 mg/kg
VF/VT
1-1.5 mg/kg –
repeat ½ dose in 3-5 min
to total
3 mg/kg
CNS Toxicity - if present then
↓
dose
and monitor closely.
Start maintenance drip at 1 mg/min
higher than total bolus dose.
i.e., gave 2.5 mg/kg = 4 mg/min drip
1 mg /kg = 2 mg/min drip = 30 gtts
1-2 mg/kg = 3 mg/min drip = 45 gtts
2-3 mg/kg = 4 mg/min drip = 60 gtts
MAGNESIUM
(Mag Sulfate)
Electrolyte Deficiency is associated
with cardiac arrhythmias,
symptoms of cardiac
insufficiency and sudden
cardiac death.
1. Suspected
Hypomagnesemia - if
present in recurrent
and refractory VT/VF
2. Drug of choice for
Torsades de Pointes
Torsades/AMI 1-2 gm in
50 - 100 mL over 5-60
min THEN 0.5 to 1 gm/hr
Can cause CNS depression and
respiratory depression
ATROPINE
Parasympatholytic
↑
HR & AV conduction
velocity
Symptomatic bradys
1. Hypotension
2. Acutely altered mental
3. Ischemic chest
discomfort
4. Signs of shock
5. Acute heart failure
Bradycardia:
0.5 mg q 3-5 min
max = 3 mg
ETT
= 2-2.5 x IV dose
Tachydysrhythmias, VT, VF
Caution with MI or myocardial
ischemia
Dose less than 0.5 mg may cause
parasympathomimetic effect
ADENOSINE
(Adenocard)
Endogenous purine
nucleoside
Depresses AV node &
sinus node activity
SVT/PSVT and AT/PAT
involving re-entry pathway,
including AV node
6 mg IV over 1-3 seconds
with 20 mL/NS flush
MR
in 1-2 min
12 mg over 1-3 sec. rapid
IV push X 1
Common but Transient:
1. Flushing
2. Dyspnea
3. AV block/
Asystole
4. Chest pain
5. Sinus bradycardia
6. Ventricular ectopy
Theophylline (& xanthine derivatives)
block action
Persantine & Tegretol potentiate
action
VERAPAMIL
(Calan)
DILTIAZEM
(Cardizem)
Slow Calcium
Channel Blocker
1. (-) Inotropic
2. (-) Dromotropic
3. Vasodilator
4. Slows conduction &
↑
refractory state through
the AV node
STABLE - A-flutter & A-fib
with RVR
STABLE- SVT, JT, MAT,
PAT when vagal
maneuvers and Adenosine
unsuccessful
Verapamil
2.5-5 mg IV
over 2 min. MR 5-10 mg
q 15-30 min
Diltiazem
0.25 mg/kg
then 0.35 mg/kg in 15
minutes
Monitor BP & EKG
Hypotension - freq. can be reversed
by CaCl 10% 2-4 mg/kg
or 0.5 - 1 gm IV
AV block, severe bradycardia
May exacerbate CHF in patients with
left ventricular dysfunction.
Not given with beta blockers
NEW
2010 ACLS PHARMACOLOGY I & II
LBW, LLC
Jul 1994 – rJune 2011
3
DRUGS
CLASSIFICATION ACTION
INDICATIONS DOSAGE
CONS
IDERATIONS/PRECAUTIONS
NITROGLYCERIN
(Nitrostat, Nitrobid)
Coronary vasodilator 1. Preload reduction- with
venodilation
(30-40 mcg/min)
2. Afterload reduction -
(150-500 mcg/min)
ARTERIAL dilation (as left
ventricular filling pressure
is decreased, arterial
dilation effect is also
⇓
Dilates coronary &
cerebral arteries
Angina - Drug of choice
after 0
2
PO/SL - Angina, MI
IV - Acute MI, unstable CHF
(preferred over Nipride)
HTN WITH ACS
SL:
0.3-0.4 mg q 3-5 min
as needed to total of 3
tabs.
IV
– 12.5 - 25 mcg
Start at10-20 mcg/min
Titrate to pain/BP
Monitor BP & EKG, pain relief
Hypotension/tachycardia
Bradycardia/syncope
Reperfusion dysrhythmias
Headache
ASPIRIN
(ASA)
Anti-inflammatory Inhibits platelet
aggregation
Chest pain – sx/sx ACS 160-325 mg p.o. Allergic rea
ction
Increased bleeding
MORPHINE
(MSO
4
)
Narcotic analgesic
CNS depressant
Preload reduction
Mild afterload reduction
Anti-anxiety, pain relief
1. MI
2. Pulmonary Edema
2-4 mg q 5 - 30 min
titrate to symptoms
Monitor for:
1. BP - hypotension
2. Respiratory depression
3. Pain relief
Reverse with naloxone/nalmefene
FUROSEMIDE
(Lasix)
Loop Diuretic
May have transient
vasodilation effect
with chronic CHF
1. Venodilation in 5 min
2. Diuresis
1. Pulmonary Edema
2.
⇑
ICP
3. HTN emergency
0.5-1.0 mg/kg over 1-2
mins
20-40 mg IV usual dose
double pts daily dose to
40-80 mg IV
if no response, DOUBLE
dose to 2 mg/kg over 1-2
mins
Monitor BP, EKG, I & O, and serum K
+
Hypotension
Hypovolemia leading to Shock
Metabolic alkalosis
Hypokalemia
Dig Toxicity
DOPAMINE
(Intropin)
Sympathomimetic Dopaminergic
=
1-2 mcg/Kg/min.
Beta
= 2-10 mcg/Kg/min
Beta & Alpha
=
>10-20 mcg/Kg/min
Alpha
=
>
20 mcg/Kg/min
1. Hypotension not
volume related
2. Cardiogenic shock
3. Bradycardia
4. ROSC
400 mg/250 mL
800 mg/500 mL
(1600 mcg/mL) as listed
Monitor BP, EKG, UO, Sx of infiltration
as for Norepinephrine
Tachydysrhythmias =
↓
dose or D/C
Incompatible with NaHCO
3
TAPER, don't stop abruptly
MAO inhibitors potentiate
Sodium
Bicarbonate
(NaHCO
3
, Bicarb)
Alkaline Buffering for metabolic
acidosis
Metabolic acidosis when
preexisting or has
hyperkalemia,
TCA OD, prolonged arrest
state, alkalinization in ASA
OD
Wait even in unwitnessed
arrest
1 mEq/Kg initially, then
0.5 mEq/Kg q 10 min OR
preferably according to
ABG's
Always
with
appropriate ventilation
Calcium, catecholamine
incompatibility. Paradoxical cellular
acidosis, hypernatremia,
hyperosmolality. Metabolic alkalosis
1. Hypokalemia
2. 0
2
Hgb shift to left
3. C0
2
retention
Central venous acidosis exacerbation
NEW
2010 ACLS PHARMACOLOGY I & II
LBW, LLC
Jul 1994 – rJune 2011
4
DRUGS
CLASSIFICATION ACTION
INDICATIONS DOSAGE
CONS
IDERATIONS/PRECAUTIONS
ATENOLOL
(Tenormin)
METOPROLOL
(Lopressor)
PROPRANOLOL
(Inderal)
ESMOLOL
(Brevibloc)
LABETALOL
(Normodyne)
Beta blockers (-) Inotropic
(-) Dromotropic
(-) Chronotropic
Reduce incidence of VF in
post MI patients.
May reduce reinfarction in
pts post-thrombolysis
Convert SVT, A-fib, A-flutter
Reduce myocardial
ischemia in AMI
Antihypertensive therapy for
CVA
Atenolol
: 5 mg IV over 5
min WAIT 10 min then 5
mg over 5 min
Metoprolol
: 5 mg slow IV
q 5 min up to 15 mg
Propranolol
: 0.1 mg/kg
divided in 3 doses at 2-3
min intervals. Not to
exceed 1 mg/min
Esmolol:
0.5 mg/kg over
1 min THEN drip 0.05
mg/kg/min
Labetalol:
10 mg IVP
over 1-2 min. MR or
double q 10 min MAX of
150 mg
Bradycardias
AV conduction delays
Hypotension
Caution with Reactive Airway Disease
Not given with Ca
++
channel blockers
ACE INHIBITORS
ENALAPRIL
(Vasotec)
LISINOPRIL
(Zestril)
CAPTOPRIL
(Capoten)
Angiotensin
converting enzyme
inhibitors
Prevents conversion of
angiotensin I to
angiotensin II
⇓
SVR
⇑
cardiac output
Reduce mortality and
improve LV function in AMI
Use for AMI with ST
⇑
,
HTN, CHF w/o hypotension
LV function
⇓
40%
Enalapril:
1.25 mg IV
over 2 min, then 1.25 to
5.0 mg every 6 hrs OR
2.5 mg PO & titrate to 20
mg PO BID
Lisinopril:
5 mg w/in 24
hrs of sx/sx, then 5 mg
after 24 hrs, then 10 mg
after 48 hrs, then 10 mg q
day for 6 weeks
Captopril:
6.25 mg PO
Advance to 25 mg TID
then 50 mg TID as
tolerated
CONTRAINDICATED IN
PREGNANCY
Reduce dose in renal failure
Avoid hypotension
Contraindicated in angioedema
DIGITALIS
(Digoxin, Lanoxin)
Cardiotonic (+) Inotropic
(-) Dromotropic
(-) Chronotropic
1. Control RVR in
A-fib/A-flutter
2. CHF
3. PSVT
LOAD = 10 – 15 mcg/kg
lean body weight
Maintenance determined
by body size and renal
function
Monitor EKG, Serum K+ toxicity:
1. GI
2. Visual
3. Dysrhythmias
NEW
2010 ACLS PHARMACOLOGY I & II
LBW, LLC
Jul 1994 – rJune 2011
5
DRUGS
CLASSIFICATION ACTION
INDICATIONS DOSAGE
CONS
IDERATIONS/PRECAUTIONS
DOBUTAMINE
(Dobutrex)
Sympathomimetic
Synthetic
catecholamine
Potent (
+)
inotropic
Some
↑
HR
Freq causes reflex
peripheral vasodilation
May use synergistically
with Nipride
1. Refractory CHF
2. Cardiogenic shock
Dopamine 1st if
⇓
BP
250 mg/250 mL OR
15 x kg wt = mg of drug
in 250 mL
Rate = 2-20 mcg/Kg/min
Monitor BP, EKG, UO
Tachydysrhythmias
Caution with CAD - May exacerbate
ischemia with
↑
HR
NOREPINEPHRINE
(Levophed)
Sympathomimetic A1- Vasoconstriction
B1 -
↑
Contractility
Cardiogenic shock
Significant hypotension with
< 70 mmHg systolic
4 mg/250 mL =
(16 mcg/mL)
0.5-30 mcg/min
Invasive monitoring
Monitor BP, EKG,
UO, tachydysrhythmias. Caution with
ischemic heart disease. Tissue
necrosis & sloughing if infiltrates.
Reinfiltrate area with Regitine
(Phentolamine) 5-10 mg in
10-15 cc NS ASAP
DO NOT GIVE WITH ALKALINES
NITROPRUSSIDE
(Nipride)
Potent peripheral
dilator Cyanide
derivative
Acts directly on
vasculature Preload &
afterload reduction
1. Hypertensive Crisis
2. Heart failure
50 mg/250 mL
initial dose:
0.1-5 mcg/kg/min
TITRATE up q 3-5 mins
Up to 5 mcg/kg/min may
be required
Invasive monitoring
, BP, Thiocyanate
toxicity
1. Tinnitus
2. Blurred vision
3. Delirium
4. ABD/chest pain
GLYCOPROTEIN
IIB/IIIA INHIBITORS
Abciximab
(Reopro)
Eptifibitide
(Integrilin)
Tirofiban
(Aggrastat)
Inhibits platelet
aggregation
ACS w/o ST
⇑
and no Q
waves
Abciximab:
0.25 mg/kg
IV bolus 10-60 min
before procedure THEN
0.125 mcg/kg/min drip
Eptifibitide:
180 mcg/kg
bolus THEN 2mcg/kg/min
drip
Tirofiban:
0.4mcg/kg/min
IV for 30 min, THEN
0.1mcg/kg/min drip
Active internal bleeding or bleeding
disorder in last 30 days
Hx of ICB
Surgical procedure or trauma
within 1 month, platelet count
<150,000
Hypersensitivity