ACLS Workshop

DCH Regional Medical Center and Harrison School of Pharmacy, Auburn University

General Administration Concepts Follow each dose with 10-20 mL NS

Assists in drug distribution Prefilled 10 mL syringe available

Expiration times General times provided DCH policy for medication prepared at bedside – 8 hours

Administration must occur within 1 hour of preparation Infusions must be completed within 8 hours or be replaced by a pharmacy admixed

product Labeling of IV push doses not necessary if administered immediately after

preparation

Labeling of infusions Patient Identification Names/ amounts of all ingredients Names or initials of preparer Date and time prepared Expiration date and time

Alternative Routes of Administration Intraosseous

Into the bone Drug reaches heart in approximately 2 minutes

Endotracheal NAVEL

Naloxone, atropine, vasopressin, epinephrine, lidocaine Dose is 2 times the IV/IO dose Dilute in 10 mL fluid

NS – most common diluent Sterile water- may improve absorption of epinephrine or lidocaine

Drug reaches heart in approximately 2 minutes

Epinephrine Use – First line VF/VT, PEA, asystole Normal Dosing

1 mg via prefilled syringe (1:10,000 of 1mg/10mL) IVP Higher doses (up to 0.2 mg/kg) may be used if 1 mg dose fails

– rarely done Frequency – every 3-5 minutes

Every other defibrillation-drug administration sequence

Alternative Dosing Continuous Infusion

Epinephrine Preparation Infusion

Vial – 1:1,000 solution (30 mL) 1 mg/mL = 30 mg/vial

Step 1 – withdraw 1 mg (1mL) from vial Step 2 – add epinephrine to 250 mL D5W or NS Final concentration – 4 mcg/mL Alternative strengths

Double strength: add 2 mg (2 mL) epinephrine to 250 mL D5W or NS [Final concentration 8 mcg/mL]

Triple strength: add 3 mg (3 mL) epinephrine to 250 mL D5W or NS [Final concentration 12 mcg/mL]

Alternative (AHA dose): add 30 mg epinephrine to 250 mL D5W or NS [Final concentration 120 mcg/mL]

Protect from light Expires 24 hour after preparation

Usual starting dose – 0.05 mcg/kg/min (~ 200 mcg/min or 100 mL/hr)

Atropine Use – PEA and asystole Dosing

1 mg prefilled syringe Frequency – every 3-5 minutes

Alternate with epinephrine Maximum of 3 doses (i.e. 3 mg) Note: not for continuous infusion

Vasopressin Use – Alternative to 1st or 2nd dose of epinephrine in

VF/VT, PEA, or asystole (Only 1 dose is administered) Also used as adjunct to NE or DA in shock

Available – 20 unit vial (20 units/2 mL), 100 unit vial Dosing

Cardiac arrest - 40 units IVP Shock – 0.01-0.04 units/min IV continuous infusion

Preparation (for infusion) Step 1 – withdraw 250 units vasopressin Step 2 – add vasopressin to 250 mL D5W or NE Final concentration 1 unit/mL Expires 28 hours following preparation Refrigerate (not necessary in ACLS)

Amiodarone Use

Refractory cardiac arrest Wide-Complex Tachycardia (Stable)

i.e. tachycardia with pulses

Dosing dependent on use Max cumulative dose: 2.2 g IV/24 hours Note: ANY dose during a medical emergency should

be followed with a continuous infusion for at least 24 hours

Amiodarone Preparation and Administration Cardiac Arrest

Vial – 150 mg/ 3mL Step 1 - Withdraw 300 mg (2 vials) amiodarone (6mL)

Note – Filter needles no longer required Step 2 – Administer IVP undiluted Step 3 – Follow with 10-20 mL saline flush May repeat additional 150 mg (1 vial) IVP in 3-5 minutes

Amiodarone Preparation and Administration Wide-Complex Tachycardia

Vial – 150 mg/3mL Loading Dose

Step 1 – withdraw 150 mg amiodarone Step 2 – add amiodarone to 100 mL D5W Final concentration – 1.5 mg/mL Administer over 10 minutes Expires 2 hours after preparation

Amiodarone Preparation and Administration Maintenance Infusion

Step 1 – Transfer 250 mL D5W to glass bottle (if Baxter bag unavailable)

Step 2 – withdraw 450 mg amiodarone (3 vials) Alternative – withdraw 500 mg (3 vials) if able

Step 3 – add amiodarone to 250 mL D5W Final Concentration 1.8 mg/mL

Concentration with 500 mg : 2 mg/mL Administration

1 mg/min (360 mg) IV for six hours then 0.5 mg/min (540 mg) IV for 18 hours

Requires in-line filter for administration Expires 12 hours after preparation

Lidocaine Use – alternative to amiodarone in VT/VF, stable VT,

wide-complex tachycardia, wide complex PSVT May be given via ET tube Dosing

Initial Bolus – 1mg/kg – 1.5mg/kg IVP at 25-50 mg/min May repeat 50% original dose in 5-10 minutes Max 3 doses or 3 mg/kg

Infuse at 1-4 mg/min following bolus administration

Available Premixed solution (2 gm/500 mL D5W, 1 gm/250 mL D5W) Prefilled syringe (100 mg/5mL) 1 gm vial (20 mg/mL)

Lidocaine Preparation and Administration Preparation of infusion (if not using premixed bag)

Step 1 – withdraw 100 mL from 250 mL D5W bag Step 2 – withdraw 2 gm (2 vials) lidocaine

Note: Not in DCH ACLS carts Step 3 – inject into 150 mL D5W

Notes: Contraindicated in WPW Cannot administer through same IV line as epinephrine or

norepinephrine

Adenosine Use – First line narrow-complex PSVT

Do not use in VT Note – may cause transient asystole or bradycardia Available in 6 mg vial (3mg/2mL) Preparation

Withdraw appropriate dose from vial Is not diluted for infusion

Dosing and administration Place patient in mild reverse Trendelenburg position Initial dose – 6 mg IV push rapidly over 1-3 seconds Follow immediately with 20 mL NS bolus and elevate extremity May repeat 12 mg in 1-2 minutes if no response up to

2 additional doses

Norepinephrine Use – Hypotension and shock Available in 4 mg vial (4mg/4mL) Preparation

Step 1 – withdraw 4 mg (1 vial) Step 2 – add to 250 mL NS or D5W Final Concentration – 16 mcg/mL

Protect from light Expires 24 hours after preparation Initial infusion rate: 5 mcg/min

Phenylephrine Use: hypotension with tachycardia, paroxysmal SVT Preparation

Step 1 – withdraw 10 mg (1 vial) Note: DCH – withdraw 40 mg Not in DCH carts

Step 2 – add to 250 mL D5W or NS Final Concentration – 40 mcg/mL

Protect from light Expires 48 hours after preparation Initial infusion rate: 100-180 mcg/min Precautions – sulfite allergy

Dopamine Use – hypotension Premixed bag

400 mg/250 mL D5W Concentration – 1.6 mg/mL

Preparation Only if premixed bag unavailable Add 400 mg dopamine to 250 mL D5W or NS

May also add 800 mg if require concentrated infusion

Initial infusion rate: 5-10 mcg/kg/min Titrate to patient response

Usually to MAP ≥ 65 mmHg or SBP ≥ 90 mmHg

Precautions – tachycardia, arrhythmias Do not administer with sodium bicarbonate

Magnesium Sulfate Use – torsades de pointes or hypomagnesemia,

refractory VF (after lidocaine) Available – 1gm/2mL vial Preparation

Cardiac arrest Step 1 – withdraw 10 mL D5W into syringe Step 2 - withdraw 1-2 gm Mg (1-2 vials) into same syringe Final concentration 100-200 mg/mL Administer IVP over at least 5 minutes

Torsades de pointes when not in cardiac arrest Step 1 – withdraw 1-2 gm Mg (1-2 vials) Step 2 – add to 100 mL D5W Administer over 5-60 minutes IV

Calcium Chloride Use – CCB or BB overdose, hypocalcemia,

hyperkalemia, prophylactically before IV CCB to prevent hypotension

Not usually used in cardiac arrest Available

Prefilled syringe (1gm/10mL) Also available as Calcium Gluconate 1gm/10mL if only

peripheral access available) Dosing and administration

8-16 mg/kg (~ 5-10 mL or 0.5-1 prefilled syringe) slow IVP Repeat as needed

Do not administer with sodium bicarbonate

Naloxone Use – opiod overdose Available

1 mL vial (0.4 mg/mL) 10 mL vial (0.4 gm/mL)

Dosing 0.4-2 mg IVP every 2 minutes May give up to 10 mg in < 10 minutes

Sodium Bicarbonate Use – hyperkalemia, bicarbonate-responsive

acidosis (i.e. DKA), alkalinize urine (ASA or TCA overdose), prolonged resuscitation

Not recommended for routine use in cardiac arrest Available

50 mEq prefilled syringe (1 mEq/mL) Dosing

1 mEq/kg IV bolus May repeat 50% dose in 10 minutes