ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Drug Name Indications Mechanism of Action Precautions Dose

Note: Follow IV push meds with fluid bolus
Oxygen ♦ Acute Chest Pain correct hypoxemia by ♦ O2 Toxicity with 2 –6 LPM by NC for CP/mild distress
♦ Suspected hypoxemia of O2 tension high FIO2s NRB Mask for mod. Distress/ CHF
any cause or c/o SOB Ï O2 content ♦ May cause ↑CO2 Bag/Mask Ventilation
♦ Cardiopulmonary Arrest Ï tissue oxygenation if a CO2 retainer Bag/ETT Ventilation or other advanced
airway

Epinephrine IVPush for ANY CARDIAC Ï SVR, BP, HR, CARDIAC ARREST:
ARREST: Contractility of heart, 1 mg IV Push (10 ml of 1:10,000 solution)
♦ Shock refractory VF & automaticity Repeat 1 mg q 3-5”
Pulseless VT Ïbloodflow to heart & Endotracheal dose = 2-2.5 times IV dose
♦ Asystole brain
♦ PEA Ï AV conduction SYMPTOMATIC BRADY:
IVDrip for Symp Brady velocity 2 – 10 mcg/min (note: OSU’s Guardian
pumps only do mcg/kg/min)

Vasopressin Alternative Pressor to EPI Non-adrenergic Peripheral ♦ Half life = 10 – Any pulseless patient:
for ANY CARDIAC Vasoconstrictor 20” 40 U IVsingle dose--1 time only
Pitressin® ARREST: Ïbloodflow to heart & ♦ Not To replace 1st or and dose of EPI
♦ VF/Pulseless VT brain recommended in
♦ Asystole CAD Can defibrillate every 2 minutes after
♦ PEA administration of Vasopressin
♦ Can replace 1st or 2nd
dose of EPI Endotracheal dose = 2-2.5 times IV dose
Also used for hemodynamic
support in Septic Shock

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Drug Name Indications Mechanism of Action Precautions Dose

Note: Follow IV push meds with fluid bolus
Atropine ♦ Symptomatic Bradycardia Parasympatholytic action: ♦ Ï myocardial O2 Asystole or PEA 1 mg IV every 3-5”
♦ Ventricular Asystole (2nd -accelerates rate of sinus demand: Bradycardia 0.5 mg every 3-5”
line) node discharge worsening Repeat to total dose of 0.04 mg/kg
♦ PEA if rate is brady (2nd -improves AV conduction ischemia Endotracheal dose = 2-2.5 times IV dose
line)

Amiodarone ♦ VF/Pulseless VT (2nd line) Anti arrhythmic ♦ Half life is long 300 mg IV Push in cardiac arrest (VF/VT)
♦ Vent. Arrhythmias –Sympt Possesses α- and β- ♦ May prolongs QT
Cordarone® PVCs adrenergic blocking 150 mg IV Push for tachys with pulse (give
♦ Preferred over Lido properties Monitor BP, HR, QT over 10 minutes)
Prolongs action potential interval
duration Can repeat ONE 150 mg in 5 mins.
Prolongs refractory period Contraindicated in:
Ð AV node conduction Cardiogenic shock, Draw 2 glass ampules through a large gauge
Ð sinus node function Marked Sinus Brady, needle diluted in 20-30 mL of D5W
2nd or 3rd block
Maintenance infusion:
1 mg/min over 6 hrs. then
0.5 mg/min over 18 hrs.
– max of 2.2 g over 24 hrs.

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Drug Name Indications Mechanism of Action Precautions Dose

Note: Follow IV push meds with fluid bolus
Lidocaine Alternative to Amiodarone in: Suppresses vent ectopy CNS Toxicity: For Vfib or Pulseless Vtach:
♦ Vtach (with pulse – stable) Ï VF threshold muscle twitching, 1 – 1.5 mg/kg repeat at 0.5 – 0.75 mg/kg in
♦ VF/Pulseless VT (2nd line) Ð Vent. Irritability slurred speech, resp. 3-5”
♦ Symptomatic PVCs Ð excitability arrest, altered for total dose of 3 mg/kg
helps prevent VTach consciousness,
seizures Vtach with pulse:
0.5 – 0.75 mg/kg repeat in 3-5”
Prophylactic use in for total dose of 3 mg/kg
MI no longer Infusion:
recommended. Infusion of 1-4 mg/min after
termination of vent arrhythm.

Ibutilide ♦ Rapid conversion of atrial Prolongs action potential Correct K & Mg > 60 kg: 1 mg over 10 min
fib or flutter of recent onset by delaying repolarization before initiating < 60 kg: 0.01 mg/kg over 10 min
Corvert® (< 48 hrs). Ibultilide
Can repeat with a 2nd dose

Procainamide ♦ Stable monomorphic Suppresses vent ectopy Monitor BP for 20 mg/min IV infusion
VTach with Normal QT Hypotension urgent situations up to 50 mg/min
and Normal LV function Monitor ECG for Ï (max 17 mg/kg)
♦ SVT uncontrolled by PR and QT Intervals, stop if arrhythmia suppressed, ÐBP, or QRS
Adenosine & vagal if QRS widening, & duration Ï by 50%
stable BP heart block Infusion: 1-4 mg/min
♦ Atrial Fib with rapid rate in Use with caution with
WPW Amiodarone
♦ Stable wide complex (prolongation QT)
Tachy of unknown origin

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Drug Name Indications Mechanism of Action Precautions Dose

Note: Follow IV push meds with fluid bolus
Magnesium ♦ Cardiac Arrest only if Antiarrhythmic Prophylactic use in
torsades is present or low Restores electrolyte MI no longer For Cardiac Arrest due to low MG or
Magnesium is suspected balance recommended Torsades: 1-2 g/10 ml D5W Over 1-2”
♦ Life threatening vent
arrhythmias due to dig tox. Ð dose with impaired
liver or LV
dysfunction

Adenosine ♦ Stable SVT Depresses SA & AV node ♦ Usually see brief 6 mg IV over 1 – 3 seconds followed by 20
♦ Undefined stable narrow activity of asystole after cc saline flush then elevate arm
complex tachycardia as a Slows AV conduction adm of drug (attach both syringes to same port)
diagnostic maneuver Half-life = 5 seconds ♦ Drug interactions wait 1-2”
Not effective in Afib, Aflutter, with
or VTach Theophylline, repeat 12 mg IV rapid push
Dipyridamole, & wait 1-2”
Carbamazepine
♦ Pts. feel flushing, repeat 12 mg IV rapid push
dyspnea, transient
CP

Verapamil ♦ Alternative Drug after Systemic vasodilation ♦ Expect ↓ BP – 2.5 – 5.0mg IV bolus over 2 minutes
Adenosine for SVT Negative Inotropic effect can counteract 2nd dose: 5 – 10 mg in 15-30”
Prolongs AV nodal with IV Ca
conduction time ♦ Do not use with
Ca++ channel blocker wide complex

Digoxin Slows ventricular response in Inotropic effect ♦ Toxic effects can 10 – 15 mcg/kg IV loading dose
♦ Afib or Aflutter Slows AV conduction cause serious
♦ CHF arrhythmias

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Drug Name Indications Mechanism of Action Precautions Dose

Note: Follow IV push meds with fluid bolus
Cardizem Controls vent rate in: Ca++ channel blocker ♦ BP may ↓ 15-20 mg (0.25 mg/kg) IV over 2”
(Diltiazem) ♦ Afib & Aflutter Prolongs effective ♦ DO NOT use for May repeat in 15” at 20-25 mg (0.35mg/kg)
♦ refractory period wide QRS Tachy, over 2”
Refractory SVT (after WPW with Afib,
Adenosine) sick sinus Infusion 5-15 mg/h titrate to HR.
syndrome, or β
blockers

Morphine ♦ CP with ACS unresponsive Ð Preload ♦ Administer 2-4 mg IV (over 1-5 mins) every 5 to 30
Sulfate to nitrates Ð Afterload slowly and titrate minutes
♦ Cardiogenic Pul. Edema to effect.
♦ Caution with RV
infarction
♦ May cause ↓BP
& Respiratory
compromise –
reverse with
Narcan

Aspirin ♦ All ACS Prevents platelet ♦ Contraindicated 160 mg to 325 mg tablet (chewing is
aggregation in acute ulcer preferable) – give immediately
disease, asthma,
or ASA
sensitivity.

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Drug Name Indications Mechanism of Action Precautions Dose

Note: Follow IV push meds with fluid bolus
Nitroglycerin ♦ Sublingual: Ð pain in ischemic tissue Contraindicated with Sublingual: 1 tablet (0.3-0.4 mg)
Suspected ischemic pain Ï venous dilation Hypotension BP < 90 – repeat Q5”
♦ IV Ðpreload & O2 or severe brady < 50.
Unstable Angina pectoris consumption ♦ Spray: oral mucosa 1 – 2 sprays
Acute MI Dilates Coronary Arteries – repeat Q5”
CHF Ï Collateral flow in MI
Hypertension Topical: 1-2” of 2% ointment
♦ Pre-existing hyperkalemia ♦ Adequate 1 mEq/kg IV bolus
Sodium ♦ Drug Overdose ventilation &
Bicarb ♦ Known ketoacidosis CPR are best
♦ Prolonged cardiac arrest “buffer agents”
with adequate ventilation

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Acute Coronary Syndromes:

ECG Findings Diagnostic Class Therapy

♦ ST elevation or new or presumably new ♦ Acute MI β Blockers
LBBB ♦ ST-elevation MI (STEMI) Clopidogrel (Plavix)
Heparin
If onset < 12 hours -- Reperfusion therapy
♦ PCI or
♦ Fibrinolysis
‰ Recominant Alteplase (Activase)
‰ Anistreplase (Eminase)
‰ Recombinant Reteplase (Retavase)
‰ Streptokinase (Streptase)
‰ Tenectaplase (TNKase)

♦ ST depression or T-wave inversion ♦ Acute MI Nitrates

♦ HIGH-RISK unstable angina (UA) β Blockers
♦ Non-ST-elevation AMI (NSTEMI) Clopidogrel (Plavix)
Heparin (antithrombin)
Glycoprotein IIb-IIIa inhibitors (antiplatelet)
‰ ReoPro
‰ Integrilin
‰ Aggrastat

♦ Nonspecific ECG findings ♦ Low– to intermediate- risk unstable angina ♦ Risk assessment
♦ Absence of changes in ST segment or T ♦ Serial cardiac markers
waves ♦ Serial ECGs/ST Segment monitoring
♦ Heparin
♦ Stress test

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 ACLS Emergency Cardiac Drug Therapy (bolded = changes based on 2005 AHA ACLS Guidelines) revised 01/18/07

Fibrinolytic Therapy for Stroke:

Inclusion Criteria: Exclusion Criteria:

‰ Age > 18 years ‰ History/Evidence of intracranial hemorrhage on CT

‰ Clinical diagnosis of ischemic stroke causing a measurable ‰ Active internal bleeding or acute trauma

neurologic deficit ‰ Uncontrolled HTN SBP > 185 or DBP > 110 at onset of

‰ Onset < 3 hours therapy

‰ Witnessed seizure at onset of symptoms

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