Cardiac Arrest Management Pharmacology

Question 1

Epinephrine dosage in cardiac arrest

Answer 1

• 1 mg IV/IO for cardiac arrest. Repeat q 3-5 minutes (current literature suggests maximum dose of 3-4 mg)

Question 2

What is the preferred, second-line, and third-line route of drug administration in cardiac arrest

Answer 2

• Preferred: Intravenous
• 2nd: Intraosseous (humeral strongly preferred)
• 3rd: External Jugular IV

Question 3

Sodium Bicarbonate dosage in cardiac arrest

Answer 3

• 1 mEq/kg slow IV push - repeat 0.5 mEq/kg q 10-15 min. prn

Question 4

Lidocaine dosage in cardiac arrest

Answer 4

• 1.0 - 1.5 mg/kg IV bolus or 2.0 mg/kg via ETT if IV not available in the arrested patient

Followed by 0.5 - 1.0 mg/kg bolus repeat prn to max of 3 mg/kg

Question 5

Describe ECG findings suggestive of a hyperkalemic cause of cardiac arrest and suggest pharmacological interventions

Answer 5

• PEA with bizarre, extremely wide complex rhythm (Sine-wave appearance)
• RRWCT (Regular REALLY Wide Complex Tachycardia)
• VF or asystole with Hx suggestive of hyperK
• Calcium Chloride
  
  • 1 g over 3 minutes repeat x1 in 10 minutes if indications still present
• Sodium Bicarbonate
  
  • 1 mEq/kg slow IV push - repeat 0.5 mEq/kg q 10-15 min. prn

Question 6

Naloxone dosage in cardiac arrest with suspected opioid overdose etiology

Answer 6

• May consider 2 mg IM or IV (IV preferable) with the possibility that the patient is not in cardiac arrest

Question 7

What is the most beneficial effect of epinephrine in cardiac arrest?

Answer 7

it increases systemic vascular resistance thus improving blood flow to vital organs with chest compressions

Question 8

Calcium Chloride (CaCl₂) dosage in cardiac arrest

Answer 8

• 1 g over 3 minutes repeat x1 in 10 minutes if indications still present

Question 9

What is best practice for administration of epinephrine in cardiac arrest?

Answer 9

• use a 1:10,000 diluted dose of epinephrine (1 mg in 10 mLs)
  
  • e.g. use a preload to reduce dosing errors

Question 10

Which ACLS drugs have been definitively shown to improve patient-centred outcomes (neurologically-intact survival to hospital discharge) in adult cardiac arrest patients?

Answer 10

none of them!

Question 11

Describe situations where Magnesium Sulfate may be of benefit in cardiac arrest

Answer 11

• Either refractory VF / pVT with the following
  
  • Suspected hypo-magnesemic states such as alcoholism, anorexia and prescribed diuretic treatment
  • Patients receiving prescribed anti arrhythmic medication, particularly sotalol hydrochloride
• The dysrhythmia is identified as Torsades de Pointes

Question 12

Describe dosing differences for amiodarone between cardiac arrest vs. unstable refractory or recurrent VT

Answer 12

• Cardiac arrest
  
  • Bolus!
  • 300 mg IV bolus; may repeat 150 mg bolus in 10 min
• Refractory/recurrent VT
  
  • Infusion!
  • 150 mg IV over 10 min

Question 13

List common TCAs and Salicylates and identify drugs used in TCA/Salicylate poisoning

Answer 13

• TCAs
  
  • Amitriptyline (Elavil)
  • Doxepin (Sinequan)
  • Nortryptyline (Pamelor)
  • Imipramine (Tofranil)
• Salicylates
  
  • ASA (Aspirin)
• Treatment: Sodium Bicarbonate
  
  • 1 mEq/kg slow IV push - repeat 0.5 mEq/kg q 10-15 min. prn

Question 14

Describe situations where Sodium Bicarbonate may be beneficial in cardiac arrest

Answer 14

• Known or suspected hyperkalemia
• Suspected TCA or salicylate overdose

Question 15

Is Amiodarone or Lidocaine preferred for treatment of refractory VF / pVT?

Answer 15

amiodarone

300mg IV bolus with 150mg IV bolus repeat after 10 minutes

Question 16

Amiodarone dosage in cardiac arrest

Answer 16

• 300 mg IV bolus; may repeat 150 mg bolus in 10 min for ventricular fibrillation/pulseless VT.

Question 17

A patient in cardiac arrest presents with the following rhythm strip. Discuss pharmacology to be considered in their management

Answer 17

• Pt is in VF
• Epinephrine
  
  • 1mg q. 3-5minutes
• Amiodarone if refractory to defibrillation
  
  • 300mg IV bolus after 3rd shock, 150mg IV bolus in 10 minutes
• Magnesium Sulfate if refractory to defibrillation
  
  • 4g IV bolus if hypomagnesemia or antiarrhythmic cause suspected
• Further pharmacology targeted to specfic causes

Question 18

Which drugs are given to correct hyperkalemia in cardiac arrest, and in what dosages?

Answer 18

• Calcium Chloride
  
  • 1 g over 3 minutes repeat x1 in 10 minutes
• Sodium Bicarbonate
  
  • 1 mEq/kg slow IV push - repeat 0.5 mEq/kg q 10-15 min. prn
• Note! Use extreme caution with co-administration of CaCl₂ and bicarb to either use independent sites or fully flush the line between administrations. Ensure PIV patency as extravasation causes tissue necrosis.

Question 19

Is amiodarone given as an infusion or bolus in cardiac arrest?

Answer 19

Bolus!

Question 20

Magnesium sulfate dosage in cardiac arrest

Answer 20

• 4 g IV bolus in cardiac arrest with VF or pVT
• Note discrepancy from unstable or refractory TdP

Question 21

When is the first dose of amiodarone given in cardiac arrest, and at what dose?

Answer 21

• after the 3rd attempt at defibrillation of a shockable rhythm (VF / pVT)
• The first dose is 300mg IV/IO push followed by 150mg IV/IO push in 10 minutes