Adenosine

Algorithm(s)

Ventricular tachycardia with a pulse

Dosing in ACLS

First dose: 6 mg IV push followed by saline bolus

Second dose: 12 mg IV push followed by saline bolus

Adverse effects

Headache, dizziness, metallic taste, dyspnea, hypotension, bradycardia or palpitations, nausea, flushing, sweating

Contraindications

Do not use in patients with second or third degree heart block

Clinical Pearls

Warn patients that they may feel strange when the medication is administered

It is best to place the patient in Trendelenburg position (head lowered respective to body/feet)

Administer only when the patient is on a cardiac monitor

Provide via a central line, if possible

The bolus should be given as rapidly as possible

Amiodarone

Algorithm(s)

Ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT)

Ventricular tachycardia with a pulse

Dosing in ACLS

First dose: 300 mg bolus IV

Second dose: 150 mg bolus IV

Maximum: 2.2 grams over 24 hours

Adverse effects

Headache, dizziness, tremors, ataxia; syncope, significant hypotension, bradycardia, CHF, Torsades de pointes, nausea, vomiting, diarrhea, rash, skin discoloration, hair loss, flushing, coagulation abnormalities

Contraindications

Do not use in patients with second or third degree heart block

Amiodarone interacts with many different drugs

When possible, do not give with other drugs that can prolong the QT interval

Clinical Pearls

Give as a bolus in cardiac arrest, but if drug is administered too rapidly, it can cause hypotension

Atropine

Algorithm(s)

Bradycardia

Dosing in ACLS

0.5 mg IV every 3-5 minutes

Maximum: 3 mg

Adverse effects

Headache, dizziness, confusion, anxiety, flushing, blurred vision, photophobia, pupil dilation, dry mouth, tachycardia, hypotension, hypertension, nausea, vomiting, constipation, urinary retention, painful urination, rash, dry skin

Contraindications

If bradycardia is due to hypothermia, do not give atropine

If you suspect cardiac ischemia, use atropine with caution, if at all

Clinical Pearls

Do not give dose less than 0.5 mg because it could paradoxically slow the heart rate

May give atropine more frequently than every three minutes in dire circumstances

Dopamine

Algorithm(s)

Bradycardia

Dosing in ACLS

IV infusion of 2 to 20 mcg/kg/minute titrated to response

Adverse effects

Headache, dyspnea, palpitations, PVCs, SVT, VT, nausea/ vomiting, acute renal failure

Contraindications

Use with caution in cardiogenic shock with congestive heart failure

Clinical Pearls

Do not mix in alkaline solutions or with sodium bicarbonate

May need to also give fluids if patient is hypovolemic

Should be on cardiac monitor with blood pressure and pulse oximetry

Epinephrine

Algorithm(s)

Asystole/Pulseless electrical activity (PEA)

Ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT)

Bradycardia

Dosing in ACLS

Cardiac arrest: 1 mg IV every 3 to 5 minutes, follow with 20 ml saline flush

Bradycardia: IV infusion of 2 to 10 mcg/minute titrated to response

Adverse effects

May worsen or cause cardiac ischemia

Tremors, anxiety, headaches, dizziness, confusion, SVT, VT, hallucinations, dyspnea, palpitations, chest pain, hypertension, nausea, vomiting, hyperglycemia, hypokalemia, vasoconstriction

Avoid VT caused by cocaine

Contraindications

There are no absolute contraindications to the use of injectable epinephrine when used properly during ACLS

Clinical Pearls

Can be given through endotracheal tube

Central line administration is preferred, it can cause local skin necrosis at injection site

Generally comes in two concentrations (1:10,000 and 1:1,000) so it is essential to know the proper volume to achieve desired dosage.

Should be on cardiac monitor with blood pressure and pulse oximetry

Lidocaine

Algorithm(s)

Ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT)

Ventricular tachycardia with a pulse

Dosing in ACLS

VF/pVT: 1 to 1.5 mg/kg IV bolus; may repeat X 2 every 5-10 minutes (half starting dose); maximum of 3 mg/kg; follow with 1 to 4 mg per minute infusion

Wide complex tachycardia with pulse: 0.5 to 0.75 mg/kg IV (up to 1.5 mg/kg); may repeat X 2 every 5-10 minutes (half starting dose); maximum of 3 mg/kg; follow with 1 to 4 mg per minute infusion

Adverse effects

Seizures, heart block, bradycardia, dyspnea, respiratory depression, nausea, vomiting, headache, dizziness, tremor, drowsiness, tinnitus, blurred vision, hypotension, rash

Contraindications

Do not use in wide complex bradycardia

Do not use prophylactically in acute myocardial infarction

Clinical Pearls

Should be on cardiac monitor with blood pressure and pulse oximetry

May cause seizures