Introduction to Advanced Cardiac Life Support

When Cardio-Respiratory Arrest occurs, initiate Cadio-Pulmonary Resuscitation (CPR) then do defibrillation. Still, the chance for the patient to survive is nil and nothing will really work without administering emergency medications.

1. Cardiac/Cardiovascular Emergency Drugs categories :

• Cardiac stimulants or Adrenergic drugs
• Antidysrhythmics for abnormal rate or rhythm
• Blocker to slow down the heart
• Vasopressor to constrict and increases blood pressure
• Direct IV push or bolus. IV drips should apply to maintain the drug within the blood level serum.

2. Drugs use in Emergency or immediate situation
   1. Epinephrine
   2. Lidocaine
   3. Procainamide
   4. Amiodarone
   5. Vasopressin
   6. Atropine
   7. Dopamine
   8. Adenosine
   9. Propranolol
   10. Verapamil
3. Sympathetic and Parasympathetic Effects (See Autonomic Nervous System)
   
   
4. Discussion of the Emergency Drugs
   
   
   1. Epinephrine

• Better known as Adrenalin and stimulates alpha I, beta I and Beta II receptors. Causes positive tropic effects and constricts blood vessels to increase peripheral resistance leading to high blood pressure.
• Epinephrine is a naturally occurring hormone that is produced in the adrenal glands. It primarily increases the systolic BP, heart rate and cardiac output. It increases electrical activity in the myocardium or heart muscle to augment the automaticity of the heart to pump. But because it increases myocardial action, subsequently, high oxygen demand is needed.
• Indications: VF/ pulseless VT that are unresponsive to defibrillation, asystole/PEA, symptomatic bradycardia, severe hypotension and anaphylaxis.
• ADR: Tachycardia, hypertension, pulmonary edema
• Contraindications: Myocardial ischemia, angina pectoris (increased myocardial oxygen demand)
• Dosage: Initial administration of 1mg IV bolus that subsequently administration of 0.5mg which repeated at least every 3 to 5 minutes. Note: Flush line with 10ml of normal saline solution (NSS).
• If epinephrine is out in IV line, medications must be administered via intraossesous (IO) or via endotracheal tube(ET). Preferred route is IV/IO, but, if given via ET tube, double the dose except for vasopressin (insufficient evidence to recommend dose)
  N- arcan
  A- tropine
  V- asopressin
  E- epinephrine
  L- idocaine

2. Vasopressin

• It is the naturally produced andidiuretic hormone (ADH) in the body in the adrenal glands. It acts as non-adrenergic peripheral vasoconstrictor that promotes water reabsorption in the distal renal tubules and increasing muscle tone of the bladder, GI tract ureters and blood vessels. Alternative therapy to first or second dose of Epinephrine.
• Indications: VF/ pulseless VT that are unresponsive to defibrillation, Asystole/PEA, Vasodilatory shock especially in septic shock, may be helpful in prolonged arrest since it has a longer half-life than epinephrine.
• ADR: Hypertension (since it can increase peripheral vascular resistance), tremor, myocardial ischemia, angina pectoris
• Dosage: Dose is 40 units IV every administration (Provided as 20 units/ml ampule). If no response in 10-20 minutes, resume epinephrine, do not repeat dose of vasopressin. Some practitioners will redose vasopressin, but this is not supported by ACLS recommendations.

3. Lidocaine

• Indications: Indicated for rhythms that are “ventricular” in origin, ventricular tachycardia with pulse or venticular fibrillation
• Dosage: Cardiac arrest (VF/PVT) given as 1-1.5mg/kg IV initially usually 50 to 100mg. Repeat doses every 5 to 10 minutes for a total of 3 doses or 3mg/kg. May be given via ET tube which the dose must be double.

• Lidocaine drip: Mix 2 grams in 500ml (4mg/ml) of D5W. Start at 1-4mg/min to achieve levels of 1.5-6mcg/ml. Note: Monitor ECG constantly is necessity with infusions.
• ADR: Bradycardia, hypotension, heart block, sinus node depression, N/V, double vision, blurred vision, convulsion, seizure, anaphylaxis. Stop infusion immediately, draw blood specimen.

4. Procainamide

• For ventricular tachycardia with pulse especially if the patient is allergic to Lidocaine. It is rarely used to treat Ventricular Fibrillation (VF), because it takes too long to achieve adequate blood levels.
• Indications: Procainamide has a depressing effect on the heart and can decrease the heart rate, conduction, irritability and prolongs the refractory period. It decreses automaticity of the heart. Mild vagal effect on the AV node causing myocardial depression that can lead to heart block.
• Dosage: The IV dosage is slow injection of 100mg for 5 minutes or 20mg/min until total of 500mg has been given or adverse reactions occur such as hypotension development.
• Procainamide Drip: Same as to Lidocaine drip by mixing 2g in 500ml of D5W and infuse at 1 to 4mg/min for a maintenance dose. Maximum total dose is 17mg/kg.

5. Bretylium tosylate

• There is a very strong evidenced that Bretylium is useful to suppress both the ventricular tachycardia and ventricular fibrillation. It has an antiarrhythmic effect which increases the refractory period without increasing the heart rate. Bretylium is an adrenergic blocker and has antifibrillaroty effects in minutes (PNS). It is for recurrent VT and VF that fails to respond to lidocaine.
• Indications: Refractory VF and VT
• Dosage: 500mg undiluted. After 5 minutes, double the dose to 1000mg IV push or dilute in 50ml and infused over 10 minute period.
• Considerations: Decreased blood pressure (hypotension), rate decreases, enhances anginal pain, VT/VF, dopamine can be given to treat hypotension, increased potency of lanoxin, indicated when first line drug is ineffective, nephrotoxicity and liver toxicity, and monitor ECG.

6. Amiodarone / Cordarone

• Function to delays repolariztion (prolongs refractory time). Blocks alpha and beta receptors and affects sodium, potassium and calcium channels.
• Indications: Indicated for the treatmet and prophylaxis of frequently recurring VF/PVT, hemodynamically unstable VT, and also effective for atrial arrhythmias.
• Dosage: For VF/PVT give 300mg rapid IV infusion in 20 to 30 ml D5W. If still refractory VF/PVT give 150mg after 3 to 5 minutes. For VT with pulse give 150mg IV infusion in 100ml D5W every 10 minutes as needed.
• Continuous infusion (maximum dose is 2.2g/24hrs): Start 900mg in 500ml D5W with 360mg infused for the first 6 hours (1mg/min or 33.3ml/hr). Then followed by 540mg infused over 18hours (0.5mg/min or 16.6ml/hr).

7. Atropine

Acts on bradycardia and asystole

To give up to 3mg

Reduces effect of vagal stimulation

Opposes cholinergic effects

Parasympathetic blocking agent

Induces tachycardia

No to glaucoma

ECG monitoring

• It is a vagilytic, parasympathetic, blocker and parasympatholytic. Accelerates the rate of SA node discharge and enhances conduction through AV node. Despite all the efforts, electrical therapy, CPR and medications, nothing will work unless the patient has a viable blood pressure.
• Indications: Used for symptomatic sinus bradycardia with hypotension and asystole and for patients on asystole.
• Dosage and Administration: For asystole give 1mg IV push X3. For non-cardiac arrest patients (Symptomatic Sinus Bradycardia or heart blocks) give 0.5mg and repeat every 5 minutes with a maximum dose of up to 3mg.

8. Dopamine

• Dopamine is an alpha adrenergic agent that produces peripheral arterial vasoconstriction. It increases pulmonary vascular resistance and increases heart rate that may excerbate or induce SVT and pulmonary edema.
• Dosage: Dopamine must be administered only via IV drip. A 400mg mixed in 250ml D5W is administered. Initial rate of infusion must be 2.5 to 5 mcg/kg/min to keep systolic BP to at least 90. Dopamine in low doses will produce vasodilation of renal, mesenteric and cerebral arteries. If the dosage given is over 10mcg/kg/min, it will act as a vasoconstrictor. Only administered by IV infusion, NEVER as an IV PUSH or as a BOLUS. Do not discontinue abruptly. It must be tapered gradually to maintain within the blood level. Dosage is titrated according to patient's response.
• ADR: Dopamine can cause tissue necrosis or Extravasation.

9. Adenosine

• As as antitachyarrhythmic agent that depresses SA and AV node activity of the heart.
• Indications: SVT/PSVT only. It will not convert Atrial flutter, Atrial fibrillation and Ventricular tachycardia.
• Drug interaction: Patients taking theophylline or caffeine are less sensitive to adenosine and requires larger doses.
• Dosage and Administration: Give 6mg rapid IV push (1-2seconds). If “NO CONVERSION” after 1 to 2 minutes, may double the dose to 12mg X 2 rapid IV push within 1 to 2 seconds. Adenosine produces as short-lived response of less than 5 second. Make sure to flush the line with 10 to 20 ml NSS or IV solution after each administration. The patient should be supine during administration.

10. Beta Blockers / Propranolol

• Block sympathetic stimulation and controls hypertension, angina pectoris, SVT and contraindicated to Beta 2 agonist.
• Propranolol: Non-selective drug agent that acts on beta 1 and beta 2 receptors by reduction of heart rate, blood pressure, myocardial contractility, and oxygen demand of the heart.
• Indications: Atrial Fibrillation/ atrial flutter, PAT and SVT hypertension and tachycardia. Used for recurrent VT/VF and SVT's refractory to other therapies.
• ADR: Hypotension, CHF, bronchospasm and bradycardia
• Contraindications: Used with caution for diabetic patients, since it may mask symptoms of hypoglycemia or hyperglycemia. Do not give to patients with asthma and COPD.
• Dosage: Administer 0.5mg slow IV push (no faster that 1mg/min) and repeat in 2 minutes if needed. Additional dose should be given 4 hours after second dose.

11. Calcium Channel Blockers

• Slow conduction and prolong refractories in the AV node. It has negative inotropic and chronotropic actions. Suppress automaticity of the SA node. Depress conduction velocity and prolong the refractory period.
• Dosage and Administration: Give initial dose of 2.5mg to 5mg slow IV bolus over 2 to 3 minutes. Subsequently, 5 to 10mg every 15 to 30minutes until total dose of 30mg. Monitor for drop of blood pressure.

12. Verapamil

• It is a calcium-sodium flux blockers. Negative inotropic agent that reduces the myocadial oxygen consumption of the heart. Causes coronary vasodilation. It slows conduction in the AV node and prolong refractories making it useful in treating SVTs. Finally, slows down the VR in atrial flutter/fibrillation.

13. Diltiazem

• Acute rate control
• Dosage: By giving 15 to 20mg (0.25mg/kg)) in IV bolus over 2 minutes. Subsequent administration may be repeated in 15 minutes at 20 – 25mg (0.35mg/kg). Maintenance infusion must be 5 to 15 mg/hr that has been titrated to heart rate.