Resus - Drugs for Resus and Peri-Arrest (adult) 2015

Question 1

Adrenaline

Answer 1

Arrest

• Shockable: 1mg (10ml, 1:10,000) IV after 3rd shock (count 3 stacked shocks as 1), repeat every 3-5 min (alternate cycles)
• Non-shockable: 1mg (10ml, 1:10,000) IV as soon as IV access, repeat every 3-5 min (alternate cycles)

Peri-arrest

• 2nd line for cardiogenic shock: 0.05-1mcg/kg/min
• Bradycardia: 2-10mcg/min
• Anaphylaxis: 500mcg (0.5ml, 1:1,000) IM every 5min

Question 2

Amiodarone

Answer 2

Arrest
- Shockable only: 300mg IV diluted in 5% dextrose to 20ml after 3rd shock (count 3 stacked shocks as 3), further 150mg if VF/pVT persists after 5 shocks

Peri-arrest

• Haemodynamically stable monomorphic VT, polymorphic VT and wide-complex tachycardia of uncertain origin
• To control rapid ventricular rate due to accessory pathway in pre-excited atrial arrhythmias (e.g. AF)
• To achieve chemical cardioversion
• After unsuccessful electrical cardioversion to increase likelihood of subsequent electrical cardioversion succeeding
• 300mg IV 10-60min, then 900mg over 24h

Question 3

Calcium

Answer 3

Arrest

- PEA caused by high K+, low Ca2+ or Ca-channel blocker overdose: 6.8mmol (10ml, 10%) CaCl2 IV

Question 4

Sodium bicarbonate

Answer 4

Arrest
- If high K+ or tricyclic overdose: 50mmol (50ml, 8.4%) IV, repeat as necessary guided by acid-base balance. Do not give via same route as calcium solutions

Question 5

Fluids

Answer 5

Arrest

- Fast crystalloids IV

Question 6

Fibrinolytics

Answer 6

Arrest
- If likely 2° to PE: Alteplase (r-tPA) 10mg IV bolus then further doses to total 50mg at 15min and 100mg by 2h. Alternatively, tenecteplase 500-600mcg/kg

Question 7

Adenosine

Answer 7

Peri-arrest
- Paroxysmal SVT with re-entrant circuits including AV node: 6mg bolus, if unsuccessful the 12mg bolus after 1-2min, then further 12mg bolus after further 1-2min. Warn patient of possible nausea, flushing, chest discomfort

Question 8

Aspirin

Answer 8

Peri-arrest

- Acute coronary syndromes: 300mg PO crushed/chewed

Question 9

Atropine

Answer 9

Peri-arrest
- Sinus, atrial or nodal bradycardia or AV block in unstable patient (adverse features present): 500mcg IV, repeated to total 3mg if required

Question 10

Beta-blockers

atenolol, metoprolol, proranolol, esmolol

Answer 10

Peri-arrest

• Narrow complex regular tachycardia uncontrolled and unconverted by vagal manoeuvres or adenosine
• To control rate in atrial AF and atrial flutter when ventricular function preserved

Question 11

Verapamil

Answer 11

Peri-arrest

• Stable regular narrow-complex tachycardias uncontrolled and unconverted by vagal manoeuvres or adenosine
• Control ventricular rate in AF or atrial flutter with preserved ventricular function when duration less than 48h
• 2.5-5mg IV over 2min, if no therapeutic response, repeated doses of 5-10mg every 15-30min to total 20mg

Question 12

Digoxin

Answer 12

Peri-arrest

- AF with fast ventricular response: 500mcg IV over 30min

Question 13

Positive inotropes
(dobutamine, dopamine, noradrenaline)

Answer 13

Peri-arrest

• Low BP in absence of hypovolaemia
• Cardiogenic shock

Question 14

Magnesium

Answer 14

Peri-arrest

• Polymorphic ventricular tachycardia (torsade de pointes)
• Digoxin toxicity
• 2g IV over 10min, repeat once if necessary

Question 15

Nitrates

Answer 15

Peri-arrest

• Prophylaxis/relief of angina, MI, acute and chronic LVF
• GTN 1-2 sprays (400mcg/spray) SL
• GTN 1-2 tablets (300mg) SL
• GTN infusion 10-200mcg/min IV
• Isosorbide dinitrate infusion 2-10mg/h IV