ACLS pharmacology (2012)

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VF/ pulseless VT drugs
Epinephrine IV/IO (1mg q3-5min)
Vasopressin IV/IO (40u can replace first or second dose of EPI
Amiodarone IV/IO (First dose: 300mg bolus. 2nd dose: 150mg)

Asystole/PEA drugs
Epinephrine IV/IO (1mg q3-5min)
Vasopressin IV/IO (40u can replace first or second dose of EPI
Amiodarone IV/IO (First dose: 300mg bolus. 2nd dose: 150mg)

Refactory VF/VT drugs
Amiodarone

Biphasic joules
120-200J

Monophasic joules
360J

Hypothemia in a cardiac arrest pt who in VF/VT treatment
a single defibrillation attempt; if the patient fails to respond, additional defribrillation

Amiodarone indication
treatment of VF/ pulseless VT unresponsive to shock delivery, CPR, and a vasopressor

Amiodarone MOA
complext drug that affects sodium, potassium and calcium channels; it also has alpha adrenegic and beta andrenergic blocking properties

Lidocaine indication
alternative antiarrhytmic of long standing and widespread family. (however, no proven efficacy)
May consider when amiodarone is not available

Magnesium Sulfate indication
terminate or prevent recurrent torsades de pointes in patient who have a prolonged QT interval during sinus rhythm

Magniusm sulfate dosage
a loading dose of 1 to 2g IV/IO diluted in 10ml D5W given over 5 to 20mins; if ECG available, check QT prolongation

Lidocaine dosage
initial dose is 1 to 1.5mg/kg IV/IO. Repeat if indicated at 0.5 to 0.75mg/kg IV/IO over 5-10mins interval to max of 3mg/kg
If no IV/IO access, dose for endotracheal 2 to 4mg/kg

post cardiac arrest oxygen sat
94%

post cardiac ventilation rate
10-12 breath/mins

post cardiac treatment for hypotension (<90mmHg)
IV/IO bolus
vasopressor infusion
consider treatable cause
12 lead ECG

post cardiac IV bolus dose
1-2L normal saline or LR (if inducing hypotherma may use 4C fluid)

post cardiac Epinephrine dose
0.1-0.5mcg/kg per min (in 70kg adult: 7-35mcg per minutes

post cardiac dopamine dose
5-10cg/kg per min

post cardiac NE dose
0.1-0.5mcg/kg per min (in 70kg adult: 7-35mcg per minutes

dopamine
catecholamine like agent and a chemical precussor of NE that stimulates the heart through both alpha and beta adrenergic receptor

NE
naturally occuring postent vasoconstrictor and ionotropic agent.

Cause of PEA
Hs and Ts
Hs- hypovolemia, hypoxia, Hydrogen ion (acidosis), hyper/hypokalemia, Hypothermia
Ts
Tension pneumo, tamponade (cardiac), toxins, thrombosis (pulm), thrombosis (coronary)

hypovolemia (ECG and interventions)
narrow complex
rapid rate

hypoxia (ecg and intervention)
slow rate
oxygenation, ventilation, advanced airway

hyperkalemia (ecg and intervention)
T waves taller and peaked; P waves get smaller; QRS widens; sine wave PEA
tx- calcium chloride, sodium bicarb, glucose plus insulin, possibly albuterol

hypokalemia (ecg and intervention)
T waves flatten, prominent U waves, QRS widens, QT prolongs, wide-complex tach
tx- add magnesium if cardiac arrest

hypothemia (ecg and intervention)
J or Osborne waves
rewarming

PEA/ Asystole drugs
Epinephrine 1mg IV/IO q3-5min
or
Vasopressin 40U IV/IO

Reasons to stop resuscitative efforts
rigor mortis
indication of DNAR
threat to safety of providers

Acute coronary syndrome early treatment
Oxygen <94%, start at 4L Aspirin 160-325mg Nitroglycerin sublingual or spray Morphine if discomfort not relieved by nitroglycerin

Myocardial infarction/ injury
ST elevation or new or presumably new LBBB

MI treatment
start adjunctive therapy as needed (Nitro, beta blocker, heparin, clopidogrel, Glycoprotein IIb/IIa inhibitor)
Do not delay reperfusion

MI if >12hrs treatment
Consider early invasive strategy if: refractory ischemic chest discomfort, recurrent/persistent ST deviation, VT, signs of heart failure, hemodynamic instability

MI if <12hrs treatment
reperfusion goals
PCI goal of 90mins
Fibrinolysis goal of 30mins

myocardial ischemia (high risk UA/ NSTEMI)
ST depression or dynamic T wave inversion;

low/ intermittent risk ACS
normal or nondiagnostic changes in ST segment or T wave

Aspirin use and dosage
chew
use rectal ASA suppositories (300mg) for patients with nausea, vomitting, active PUD, or other disorders of upper GI tract

Nitro dosage
1 subligual tablet or spray q3-5min for ongoing symptoms; repeat dose total of 3 dose
sbp >90mg, hr 50-100/min

Morphine action
produces CNS analgesia, which reduces the adverse effects of neurohumoral activation, catechoalamine release, and heightened myocardial oxygen demand
produces venodilation,which reduces LV preload and O2 requirment
decrease systemic vascular resistances, thereby reducing lv afterload

streptokinase MOA
A fibrinolytic but not fibrin specific

Heparin use
routinely given as an adjunct for PCI and fibronlytic therapy with fibrin-specific agents (rtPA, reteplase, tenecteplase)

Bradycardia rhythm
Sinus bradycardia <50min HR, 1st degree AV blocks, 2nd degree AV block (Type 1(wencheback/Morbitz I) and Type 2 (morbitz II), 3rd degree AV

symptoms of bradycardia
chest discomfort or pain, sob, decrease loc, weakness, fatigue, lightheadedness, dizziness, and presyncope or syncope

sign of bradycardia
hypotension, orthostatic hypotension, diaphoresis, pulmonary congestion on PE or chest x ray, frank CHF or pulm edema, bradycardia-related (escape) frequent PVC or VT

Bradycardia first drug of choice (dose)
Atropine (First dose 0.5mg bolus. Repeat every 3-5minutes. Max 3g
***Do not rely on atropin in Mobitz type II or 3rd degree AV block or patients with 3rd degree AV block with a new wide QRS complex

Bradycardia second line of treatment
Transcuataneous pacing or
Dopamine 2 to 10mcg/kg per min/ Epinephrine 2 to 10mcg/min

Transcutaneous pacing indication
Hemodynamically unstable bradycardia (hypotension, AMS, signs of sok, ischemic chest discomfort, Acute HF hypotension); unstable clinical conditon likely due to the bradycardia; symptomatic sinus bradycardia, Mobitz type II, 3rd degree, new left, right, or alternating bundle block or bifascicular block

TCP precautions
severe hypothermia and asystole
conscious pt require analgesia for discomfort unless delay for sedation will cause/contribute to deterioration
Do not assess the carotid pulse to confirm mechanic capture; electrical stimulation cause muscular jerking that may mimic the carotid

pacing rate
60 t0 70/min if the symptmons due to bradycardia

symptoms and signs of unstable tachy
hypotension, actue AMS, signs of shock, ischemic chest discomfort, acute HF

tachycardia
rate >100/min; rate of clincal significance at its greater extremes and is more likely attribulatable to an arrhythmia rate of >150
unlikely that symptoms of instability at <150/mins

unstable tachy treatment
1. synchronized cardioversion
2. Adenosine IV dose: First dose- 6mg rapid IV push, follow with NS; second dose- 12mg if required

Stable tachy treatment
1. IV access and 12 lead ECG
2. Adenosine if regular and monomorphic
3. consider antiarrhythmic infusion
4. consider expert consultation

Synchronized Cardioversion initial doses
Narrow regular: 50-100J
Narrow irregular: 120-200J biphasic or 200J monophasic
Wide regular: 100J
Wide irregular: defibrilation dose (not synchronized)

Antiarrhythmic infusion for stable Wide-QRS tachycardia
procainamide: 20-50mg/min until arrthmia suppressed, hypotension ensues QRS duration increase >50% or max dose 17mg/kg given; maintenace infusion- 1-4mg/min. Avoid if prolonged QT or CHF
Amiodarone: First dose 150mg over 10min. Repeat as needed if VT recurs. Follow by maintenances infusion of 1mg/min for first 6hrs
Sotalol 100mg (1.5mg/kg) over 5mins. Avoid if prolonged QT

When to use synchronized shocks
Unstable SVT, unstable AFib, unstable A flutter, unstable regular monomorphic tach with pulses

when to use unsynchronized shocks
patient who is pulseless, pt demonstrating clinical deterioation such as those with sever shock or polymorphic VT and when you are unsure whether monomorphic or polymorphic VT

Stable tachy
no serious signs related to the tachy

Tachy classification
based on the appearance of the QRS complext, HR, and whether they are regular or irregular

Narrow QRS complex (SVT) tach- QRS<.12s) causes
Sinus tach
A-fib
A-flutter
AV nodal reentry

Wide QRS complex tach (QRS >0.12s) causes
Monomorphic VT
Polymorphic VT

Irregular narrow complex tach
A-fib

Stable Tachy drug
Adenosine

Sinus tach
>100/min but usually do not exceed 120 to 130/min; has gradual onset and gradual termination

Reentry SVT
has an abrupt onset and termination

Sinus tach cause
external influences on the heart, such as fever, anemia, hypotension, blood loss, or excercise; regular rhythm, although the rate my be slowed by vagal maneuver

sinus tach contraindication
cardioversion

Narrow QRS regular rhythm treatment
1. Attempt vagal maneuver
2. Adenosine 6mg as a rapid IV push in a large vein over 1second. Flush with 20ml saline and elevate the arm immediately
If SVT does not convert within 1 to 2 minutes, give a second dose of adenosine 12mg rapid IV with flush
***If conversion, probably reentry SVT; unconvertible, probably a-flutter, ectopic atrial tach, or junctional tach—> obtain expert consultation

Adenosine in pregancy
safe and effective

Adenosine interaction
larger doses may be required for patients with significant blood levels of theophylline, caffeine, or theobromine
Initial dose should be reduced to 3mg in patient taking dipyridamole or carbamazepine
May be bronchospasm in Asthma patients

Recurrent reentry SVT
adenosine or longer acting AV nodal blocking agent such as the non-dihydropyridine Ca2++ channel blocker (verapamil and diltazem) or beta blocker
***typically obtain expert consultation if they tachy recurs

Type of Strokes
Ischemic stroke (87%)
Hemorrhagic stroke (13%): Avoid anticoagulant

8 Ds of Stroke care
Detection, Dispatch, Delivery, Door, Data, Decision, Drug, Disposition

Critical time periods of stroke
immediate general assessment: 10mins
immediate neurologic assessment: 25mins
acquisition of CT of the head: 25mins
interpretation of the CT scan: 45mins

Time of fibrinolytic therapy (ED arrival)
60minutes

Time of fibrinolytic therapy (onset of symptoms)
3hrs, or 4.5 in selected patients

Signs and symptoms of possible stroke
sudden weakness or numbness of face, arm, or leg, especially on one side of the body
sudden confusion
trouble speaking or understanding
sudden trouble seeing in one or both eyes
sudden trouble walking
Dizziness or loss of balance or coordination
sudden severe headache with no known cause

Cincinnati Prehospital Stroke Scale
Facial droop
Arm drift
Abnormal speech
***presence of 1 finding on the CPPS has sensitivity of 59% and specificity of 89%

Image model to rule out hemorrhage
CT scan
**Do not give ASA, heparin, or tPA until the CT scan has ruled out intracranial hemorrhage

If Hemorrhage on CT…
patient is not a candidate for fibrinolytic; Consult a neurologist or neurosurgeon

If no abnormality on CT…
patient may be candidate for fibrinolytic therapy

Fibrinolytic inclusion criteria
Dx of ischemic stroke causing measurable neurologic deficit
onset of symptoms <3hrs before beginning treatment Age >18yrs

Fibrinolytic exclusion
head trauma or prior stroke in previous 3months
symptoms suggest subarachnoid hemorrhage
arterial puncture at noncompliance site in previous 7 days
hx of previous intracrania hemorrhage
Elevated BP (sbp >185mmHg or diastolic >110mg
Evidence of active bleeding on exam
acute bleeding diathesis, including but not limited to (plt <100,000; Heparin withn 48hrs, resulting in an aPTT greater than norma; current use of anticoagulant with INR >1.7 or PT>15se
blood glucose conc <50 mg/dl CT demo multilobar infarction

Treatment to Arterial HTN in patients with Acute Ischemic stroke (candidate for reperfusion)
>185/110mmHg
Labetolol 10-20mg IV over 1-2 min, may repeat x1 or
Nicardipine IV 5mg per hour, titrate up by 2.5mg per hr q5-15mins, max 15mg per hr; when desired BP reache, lower to 3mg per or
Other agent (hydraline, enalaprilat etc

Treatment for arterial HTN in patient with Acute Ischemic stroke (not candidate for reperfusion)
>220/120mmHg
In patient with concomitant organ system: acute MI, CHF, acute aortic dissection

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