Drugs in ACLS

DRUG FOR CARDIAC ARREST

Vasopressor
The 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

Adrenaline (epinephrine) versus no

adrenaline
Standard-dose adrenaline was associated

withsignificantly higher rates of prehospital

ROSC (relative risk [RR]2.80 [95% CI 1.78
4.41], p < 0.00001) and survival to hospital
admis-sion (RR 1.95 [95% CI 1.342.84], p =
0.0004) when compared toplacebo
There 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 shortterm 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.

Indications
The 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 shock

Anti Arrhythmics Drugs

Adenosine 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

Indications
Refractory VF/pVT
Haemodynamically 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

Lidocain
Lidocaine is recommended for use

during ALS when amiodarone is

unavailable
It decreases ventricular
automaticity
Suppresses ventricular ectopic
activity
It is effective in suppressing
arrhythmias associated with

Indications
Lidocaine 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 kg

Amiodarone
Has effects on sodium,
potassium and calcium channels
as well as alpha and beta
adrenergic blocking properties

Indications
Control 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 cardioversion

Give 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 node
These actions may terminate reentrant arrhythmias and control
ventricular response rate in
patients with a variety of atrial
tachycardias

Indications
Stable regular narrow-complex

tachycardias uncontrolled orunconverted

by adenosine or vagal manoeuvres
To control ventricular rate in patients with
AF or atrial flutter and preserved
ventricular function
Initial dose of verapamil is 2.55 mg
intravenously given over 2 min
Give repeated doses of 510 mg every15
30 min to a maximum of 20 mg.

Diltiazem at a dose of 250mcg/kg

intravenously, followed by a second

dose of 350mcg/kg
Diltiazem may decrease myocardial
contrac-tility and critically reduce
cardiac output in patients with severe
LV dysfunction

Beta-adrenergic blockers
Reduce the effects of circulating

catecholamines and decrease heart

rate and blood pressure
They also have cardioprotective
effects for patients with
acutecoronary syndromes

Indications
Narrow-complex regular

tachycardias uncontrolled by
vagalmanoeuvres and adenosine in
the patient with preserved ventricular function
To control rate in AF and atrial
flutter when ventricular functionis
preserved

The 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 mg
Propranolol (beta1 and beta2 effects),
100mcg kg, is given slowly in three equal
doses at
23min intervals
Intravenous esmolol is a short-acting (halflife 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/min

Side effects of beta-blockade

include bradycardia, AV conduction 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.

Magnesium
Is the first line treatment for

polymorphic ven-tricular
tachycardia (torsades de pointes)
and ventricular orsupraventricular
tachycardia associated with
hypomagnesaemia
Give mag-nesium sulphate 2 g (8
mmol) over 10 min. This can be
repeated once if necessary.

Intravenous fluids
Ensure normovolaemia
Use intravenous fluid to flush

peripherally injected drugs into the

central circulation