ACLS Pharmacology

Question 1

This drug is the first used for most forms of stable narrow-complex SVT and is effective in terminating those due to reentry involving AV node or sinus node.

Answer 1

Adenosine

Question 2

is Adenosine safe and effective in pregnancy?

Answer 2

Yes

Question 3

when is adenosine contraindicated?

Answer 3

in poison or drug induced tachycardia or second- or third-degree heart block

Question 4

what are the side effects of adenosine?

Answer 4

flushing, chest pain or tightness, brief periods of asystole or bradycardia, ventricular ectopy

Question 5

what is a common thing to see after giving adenosine?

Answer 5

transient periods of sinus bradycardia and ventricular ectopy are common after termination of SVT

Question 6

what are the steps taken when pushing adenosine?

Answer 6

• place the patient in mild Trendelenburg
• initial bolus of 6 mg given rapidly over 1 to 3 seconds followed by NS bolus of 20 ml, then elevate the extremity
• a second dose can be given in 1 to 2 minutes if needed

Question 7

what should you be doing as you are giving adenosine?

Answer 7

record a rhythm strip

Question 8

what is the half life of amiodarone?

Answer 8

40 days

Question 9

when is amiodarone indicated?

Answer 9

VF/ pulseless VT unresponsive to shock delivery, CPR, and a vasopressor
- recurrent, hemodynamically unstable VT

Question 10

amiodarone used for VF/ pVT cardiac arrest unresponsive to shock, CPR, and Vasopressor, what would be the first dose?

Answer 10

300 mg IV/IO push for the first dose

- if a second dose is needed, 150 mg IV/IO push

Question 11

amiodarone used for life threatening arrhythmias, what is the maximum dose?
Rapid
Slow
Maintenance

Answer 11

2.2 g IV over 24 hours.
Rapid - 150 mg IV over 10 minutes (150 mg Q 10 min)
Slow - 360 mg IV over 6 hours (1 mg per minute)
Maintenance - 540 mg IV over 18 hours (0.5 mg per minute)

Question 12

How can some drugs be given if you don’t have IV access

Answer 12

The endotracheal (ET) route for drug delivery may be used when a life-threatening or serious condition requires immediate drug intervention, but intravenous or intraosseous access is not readily available

Question 13

what are the two acronyms for drugs that can be given via ET tube
adults and peds

Answer 13

adults - NAVEL
Peds - LEAN
Naloxone, atropine, Vasopressin (adults only), epinephrine, Lidocaine

Question 14

what is the first line drug for symptomatic sinus bradycardia?

Answer 14

atropine

Question 15

when is atropine unlikely to be effective?

Answer 15

Type II second degree or third degree AV block in nonmodal tissue

Question 16

what is something to consider when using atropine in the presence of myocardial ischemia and hypoxia?

Answer 16

it increases myocardial O2 demand

Question 17

what may be the effect of using a dose of atropine that is less than 0.5 mg?

Answer 17

may cause paradoxical slowing of the heart

Question 18

what is the recommended dose of atropine for bradycardia?

Answer 18

0.5 mg IV Q 3 to 5 minutes PRN, not to exceed a total dose of 0.04 mg per kg (total 3 mg)

Question 19

when would you use a lager dose of atropine (2 to 4 mg or higher)

Answer 19

in a case of Organophosphate Poisoning, or nerve agent

Question 20

what is the second line drug for symptomatic bradycardia?

Answer 20

Dopamine

after atropine

Question 21

aside from being the second line drug after atropine, when would you use Dopamine?

Answer 21

for hypotension with SBP >70 - 100 mmHg with signs and symptoms of shock

Question 22

what are 4 contraindications/ considerations when administering Dopamine?

Answer 22

• correct hypovolemia with volume replacement before using
• use with caution with cardiogenic shock with CHF
• May cause tachyarrhythmias, excessive vasoconstriction
• do not mix with sodium Bicarb

Question 23

what is the typical IV administration of Dopamine?

Answer 23

2 to 20 mcg/kg per minute, titrate to patient response and taper slowly

Question 24

what are the 4 indications for epinephrine listed in the ACLS book?

Answer 24

cardiac arrest with VF, pulseless VT, asystole, PEA

• Symptomatic bradycardia can be considered after atropine as an alternative infusion to dopamine
• Severe hypotension; can be used when pacing and atropine fail, when hypotension accompanies bradycardia, or with phosphodiesterase enzyme inhibitor
• Anaphylaxis, severe allergic reactions; combine with large fluid volume, corticosteroids, and antihistamines

Question 25

what are some contraindications/ precautions for epinephrine?

Answer 25

raising BP and HR may increase O2 demand on myocardium

• higher doses do not improve survival outcomes and may contribute to post resuscitation myocardial dysfunction
• higher doses may be required to treat poison/ drug induced shock

Question 26

epinephrine used for cardiac arrest, what is the dose?

Answer 26

IV/IO dose; 1 mg (10 ml 0f 1:10,000 solution) administered Q 3 to 5 minutes during resuscitation. Follow each dose with 20 ml flush, elevate arm for 10 to 20 seconds after dose

Question 27

when would a higher dose of epinephrine be warranted?

Answer 27

higher doses (up to 0.2 mg/kg) may be used for specific indications such as B-blocker or calcium channel blocker overdose)

Question 28

what would the dose for epinephrine be for continuous infusion?

Answer 28

Initially 0.1 to 0.5 mcg/kg per minute (for 70 kg patient; 7 - 35 mcg per minute) titrate response

Question 29

what would the dose be for epinephrine given the endotracheal route?

Answer 29

2 to 2.5 mg diluted in 10 ml NS

Question 30

what drug can be used as an alternative to amiodarone in cardiac arrest from VF/pVT?

Answer 30

Lidocaine

Question 31

what are the 4 indications for using Lidocaine as per the ACLS manual?

Answer 31

• stable monomorphic VT with preserved ventricular function
• stable polymorphic VT with preserved LV function when ischemia is treated and electrolyte balance is corrected
• can be used for polymorphic VT with baseline
• QT interval prolongation if torsades suspected

Question 32

what are the doses used for Lidocaine in cardiac arrest from VF/pVT

Answer 32

initial dose; 1 to 1.5 mg/kg IV/IO
- for refractory VF, may give an additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; max dose 3 doses or total 3mg/kg

Question 33

what would the dose be for a maintenance infusion of Lidocaine?

Answer 33

1 to 4 mg per minute (30 to 50 mcg/kg per minute)

Question 34

when is magnesium used in cardiac arrest

Answer 34

torsades or suspected hypomagnesemia

Question 35

aside from cardiac arrest, what are the indications for using magnesium sulfate as stated in the ACLS manual

Answer 35

life - threatening ventricular arrhythmia due to digitalis toxicity

Question 36

what are some contraindications/ considerations for using magnesium sulfate?

Answer 36

occasional fall in blood pressure with rapid administrations

- Use with caution if renal failure if present.

Question 37

what are the doses for administering Magnesium sulfate in cardiac arrest (due to hypomagnesemia or Torsades de Pointes)?

Answer 37

1 to 2 g (2 to 4 ml of a 50% solution diluted in 10 ml (eg D5W or NSS) given IV/IO)

Question 38

what are the doses for magnesium sulfate used to treat Torsades de Pointes with a pulse or AMI with hypomagnesemia?
what is the loading dose and what do you follow with?

Answer 38

loading dose of 1 to 2 g mixed in 50 to 100 ml of dilutent over 5 to 60 minutes IV
- follow with 0.5 to 1 g per hour IV (titrate to control TdP)