Download Brief ACLS - CC meds ref

21 Pages·2014·0.47 MB·English

Brief Critical Care Med Reference (Adult patients)
Adenosine

Indications:
 Narrow-complex PSVT
 Reentry tachycardia involving AV or SA node
 May use for unstable narrow-complex tachycardias (while preparing to cardiovert)
 Wide complex tachycardias thought to be rerentry SVT
 May use as a diagnostic tool for stable but undefined narrow-complex SVT (so that you can slow
it down enough to see the rhythm – best to have the patient on 12-lead (and recording) when
you push adenosine so that you can “capture” the slowed down rhythm.
Precautions/Contraindications:
 Drug or poison induced tachycardia
 2nd or 3rd degree heart blocks
 This drug may cause flushing, chest pain/tightness, asystole, bradycardia
 If patient is taking theophylline or caffeine the usual dose may be less effective (larger doses
may be required)
 In patients taking dipyridamole or carbamazepine reduce dose to 3 mg
 May cause deterioration (such as hypotension)if given to patients with wide-complex
tachycardia/VT
 Effective and safe for pregnant patients
Dosing and Administration:
 6 mg RAPID IV over 1 to 3 seconds for 1st dose
 If needed, 1-2 minutes later, give 2nd dose of 12 mg RAPID IV
 If needed, 1-2 minutes after the 2nd dose, a 3rd dose of 12 mg RAPID IV
 Sequence is 6 – 12 – 12
 Rapid flush technique:
o IV site as high on the arm as possible (AC)
o Attach adenosine syringe to port closest to the patient
o Attach flush syringe to next port up the IV line (closer to the IV bag)
o Clamp IV tubing above the flush site
o Push adenosine as quickly as possible and then push the flush as quickly as possible
(using 2 people for this might be the best)
Albuterol
Indications
 Acute bronchospasms
 Also used in the treatment of hyperkalemia.
Pharmacology and Actions
 Bronchodilator that relaxes bronchial smooth muscle by stimulating Beta 2 adrenergic
receptors.
Contraindications and Precautions
 Use with caution in patients with cardiac disease and hypertension, in patients with
hyperthyroidism or diabetes mellitus and in patients who are unusually responsive to Beta 2
adrenergics.
 Relative contraindication- Chest pain consistent with cardiac ischemia. Ischemic chest pain can
be exacerbated or caused by hypoxia which takes priority over increasing work load on the
heart.
Administration and Dosage
 2.5 mg mixed in 3 ml of normal saline administered via nebulizer.
Side Effects & Special Notes
1. Adverse effects of Albuterol include tremor nervousness, tachycardia, palpitations, and
hypertension.
2. Patients exhibiting little relief or rebound constriction may require continuous nebulizer
treatment. Consider adjunct treatments if this occurs.
3. Paradoxical bronchospasm may occur with excessive administration.
4. Hypokalemia may occur with continuous nebulizer treatments.
5. Stop treatment if pulse increases by greater than 20 beats per minute, frequent PVCs occur, any
tachyarrhythmias appear other than sinus tachycardia.
Amiodarone
Indications:
 Recurrent VF
 VT that is hemodynamically unstable
Precautions/Contraindications:
 Seek expert consultation for uses other than those listed above
 May cause multiple complex drug interactions
 Max cumulative dose over 24 hour period is 2.2 grams
 May prolong QT interval
 Extremely LONG half-life (up to 40 days)
Dosing and Administration:
 For CARDIAC ARREST unresponsive to CPR, Shock and vasopressor :
o Give 300 mg IV push
o May give additional 150 mg in 3 – 5 minutes
o If rhythm converts hang a drip (see below)
 For recurrent life threatening ventricular arrhythmias:
o 150 mg IV over 10 minutes (hang in a bag usually)
o May repeat 150 mg every 10 minutes as needed
 The continuous drip (slow infusion/maintenance infusion):
o 360 mg IV over 6 hours (1 mg/min)
o 540 mg IV over 18 hours (0.5 mg/min)
o Usually this is mixed – 900 mg in 500 ml and infuse at 33.3 ml for 1st 6 hours, then 17
ml/hr for next 18 hours.
o Don’t forget = max cumulative dose is 2.2 grams over 24 hours
Aspirin
Indications:
 ACS
 Symptoms of ischemic coronary event

Precautions/Contraindications:
 Hypersensitivity to asa
 Relatively contraindicated with asthma or active ulcer disease
Dosing and Administration:
 Give within minutes of arrival/symptom onset
 160mg-325mg NON-enteric coated (chewing is preferable)
 May give 300 mg PR if patient can’t take po

Atropine
Indications:
 Symptomatic sinus bradycardia
 May be useful in AV block or ventricular asystole
 Not effective for intranodal (Mobitz type II)
 Asystole or slow PEA (rate less than 60)
 Organophosphate poisoning (large doses usually needed for organophosphate tx)
Precautions/Contraindications:
 Will increase myocardial O2 demand – use cautiously with myocardial ischemia
 Not effective for infranodal AV or new 3rd degree block and may cause paradoxical slowing
 Avoid in hypothermia
Dosing and Administration:
 Asystole or Slow PEA
o 1 mg IV/IO
o May repeat as needed every 3 – 5 minutes to a MAX of 3 doses
 Bradycardia with a pulse
o 0.5 mg IV every 3 – 5 minutes as needed not to exceed a MAX of 3mg
Calcium Chloride
Indications:
 Suspected or known kyperkalemia (renal failure)
 Ionized hypocalcemia (multiple blood transfusion)
 Calcium channel blocker or beta blocker overdose with toxic effects
Precautions/Contraindications:
 Don’t use routinely in cardiac arrest
 Don’t mix with bicarb
Dosing and Administration:
 10% solution is 100 mg in 10 mL
 500-1000mg

Dextrose

Indications:
 Suspected hypoglycemia
 Also used with insulin in the treatment of hyperkalemia.
Contraindications and Precautions:
 Hyperglycemia, diabetic coma, intracranial or intraspinal hemorrhage and delirium tremens.
 Use cautiously in cardiac or pulmonary disease, hypertension, renal insufficiency, or urinary
obstruction.
Administration and Dosage
 Adults: 50cc of 50% dextrose (25 grams) IV
 Repeat as necessary.

Side Effects & Special Notes
 Dextrose is extremely hypertonic. It should be administered into a rapid-running IV established
in a large vein. Inadvertent extravasation will lead to tissue sloughing and necrosis.
 Indiscriminate use of D50 should be avoided in the unconscious patient – check blood glucose
before administering.
Diltiazem
Indications:
 To slow ventricular response in A-fib/A-flutter
 Reentry SVT with narrow QRS and adequate blood pressure
Precautions/Contraindications:
 Don’t use for wide complex tachycardia of uncertain origin
 Don’t use for tachycardias caused by poisoning or overdose
 Avoid in patients with WPW, oral beta blocker therapy, sick sinus syndrome, or AV block without
a pacer
 BP may drop as a result of vasodilation – this can be compounded with beta blocker use
Dosing and Administration:
 For Acute rate control
o 15 – 20 mg (0.25 mg/kg) IV
o May repeat in 15 minutes at 20 – 25 mg (0.35 mg/kg) over 2 minutes
 Maintenance infusion
o 5-15 mg/hour
o Generally this is mixed as a 1:1 drip (125 mg in 25 mL is added to a 100 mL bag resulting
in 125 mg in 125 mL of D5W or NS)
Dopamine
Indications:
 2nd line for symptomatic bradycardia (following atropine)
 Hypotension with signs of shock
Precautions/Contraindications:
 Use caution in cardiogenic shock with CHF
 May cause tachycardia
 Do NOT mix with bicarb
 Correct volume problems before using dopamine
Dosing and Administration:
 2-20 mcg/kg/min
 Titrate for effect
 May be mixed a number of ways (check the bag). Commonly 400 mg in 250 mL D5W or NS.
Epinephrine
Indications:
 Cardiac arrest: VF, pulseless VT, asystole, PEA
 Symptomatic bradycardia : possible alternate after atropine
 Severe hypotension with bradycardia or with phosphodiesterase inhibitor: may use when pacing
and atropine fail
 Anaphylaxis or severe allergic reaction
Precautions/Contraindications:
 May cause myocardial ischemia and/or increase myocardial oxygen demand
Dosing and Administration:
 Epi is available in 2 concentrations
o 1:10,000 bristoject is 1 mg in 10 mL
o 1:1,000 bottle or ampule is 1 mg in 1 mL
 Cardiac Arrest
o 1mg IV/IO every 3 – 5 minutes during resuscitation (no max)
 Via ETT
o 2 to 2.5 mg in 10 mL of NS (use the 1:1000 bottle)
 Continuous Infusion
o Add 1 mg to 500 mL D5W or NS
o Infusion rate is 2 – 10 mcg/min (not weight based)
o Titrate for effect
Etomidate
Pharmacology and Actions:
 Ultra-short acting, nonbarbiturate, hypnotic with a favorable hemodynamic and respiratory
profile.
 Provides no analgesic effect.
 Peak response within 1 minute.
 Duration is usually 4-8 minutes.
 Rapidly penetrates the brain.
 Minimal to no cardiovascular effects.
Indications:
 Sedative used with Rapid Sequence Induction/Intubation of medical or trauma patients
Administration and Dosage
 0.3 mg/kg IV push

Side Effects & Special Notes
 Myoclonus or involuntary muscle movement (most common side effect), resolves quickly when
Succinylcholine added or spontaneously with mild support such as jaw thrust & oxygen.
 Isolated case reports of seizure and epileptiform activity; use with caution in epileptic patients.
 Adrenal suppression - Usually no clinical effects and returns to baseline in 24 hours.
 Can be used in pregnant and pediatric patients as long as you understand its restrictions
Flumazenil (Romazicon)
Pharmacology and Actions:
 Antagonizes effects of benzodiazepines
Indications:
 Flumazenil is indicated for the reversal of benzodiazepines.
Administration and Dosage:
 Adults: 0.2 mg IV, an additional dose of 0.3 mg may be given 30 seconds later. Subsequent doses
of 0.5mg may be given at 1 minute intervals if needed to a total of 3 mg

Contraindications and Precautions:
 Flumazenil is contraindicated in patients with hypersensitivity to flumazenil or benzodiazepines.
 Do not give Flumazenil to patients who are receiving benzodiazepines for life-threatening
medical problems such as status epilepticus or increased intracranial pressure.
 Use cautiously in overdoses of mixed CNS depressants as the effects of other agents may
emerge when the effects of benzodiazepines are removed.
 It should be used cautiously in patients with a history of seizures, head injuries, severe hepatic
impairment, pregnancy, lactation and children less than 2 years of age
Side Effects & Special Notes:
 Side effects of flumazenil may include: seizures, dizziness, agitiation, drowsiness, emotional
lability, fatigue, headache, abnormal vision and hearing, arrhythmia, chest pain, hypertension,
nausea, vomiting, flushed skin, diaphoresis, shivers, or parasthesia.
Ipratropium Bromide (Atrovent)
Pharmacology and Actions:
 Anticholinergic which inhibits the interaction of acetylcholine at receptor sites on the bronchial
smooth muscle, resulting in decreased cGMP and bronchodilation.
 Atrovent blocks the actions of acetylcholine, which inhibits parasympathetic stimulation. This
action causes bronchodilation and dries bronchial secretions
Indications:
 For bronchodilation during bronchospasm
 For treatment of COPD and asthma
Contraindications:
 Known hypersensitivity to Atrovent
Dosage and Administration
 One unit dose (0.5mg/2.5ml) via aerosol nebulizer.
 Usually administer with first dose of Albuterol.

Side Effects and Special Notes
 Dry mouth, blurred vision, rash, palpitations