ACLS Pharmacology

flushing

chest pain or tightness

brief periods of asystole or bradycardia

ventricular ectopy

Less effective in patients taking theophylline or caffeine

If administered for irregular, polymorohic wide-complex

tachycardia/VT, may cause deterioration

Transient periods of sinus bradycardia and ventricular

ectopy are common after termination of SVT

Safe and effective pregnancy

Adult Dosage:
IV Rapid Push

1. Adenosine
Class: Antidysrhythmics TACHY

Place patient in mild reverse Tredelenburg position

before administration of drug

Initial bolus of 6mg given rapidly over 1 to 3 seconds

followed by NS bolus of 20ml; then elevate the extremity

A second dose (12mg) can be given in 1 to 2 minutes if

needed

Indications:

stable narrow-complex SVT

unstable narrow complex re-entry tachycardia

Record rhythm strip during administration

Regular and monomorphic wide complex tachycardia

Draw up adenosine dose and flush in 2 separate

syringes

Attach both syringes to the IV injection port closest to

patient

Clamp IV tubing above injection port

Injection Technique:

Precautions / Contraindications:

Contraindicated in poison/ drug-induced tachycardia or

second-or third degree heart block.

Transient side effects

ACLS Pharmacology
Push IV adenosine as quickly as possible (1 to 3
Maximum cumulative dose:
seconds)
2.2g IV over 24hrs. May be administered as follows:
While maintaining pressure on adenosine plunger, push
Rapid infusion: 150 mg IV over first 10 minutes as
NS flush as rapidly as possible after adenosine
needed
Unclamp IV tubing
Slow infusion: 360 mg over 6hours (1mg per minute)

2. Amiodarone

Maintenance infusion :540mg IV over 18 hours (0.5mg

per minute)

Class: Antidysrhytmics, III

Indications:

VF/pulseless VT unresponsive to shock delivery, CPR,

and a vasopressor

Recurrent, hemodynamically unstable VT

May be used for treatment of some atrial and ventricular

arrhythmias

Precautions / Contraindications:

Rapid infusion may lead to hypotension

Do not administer with other drugs that prolong QT

interval (eg, procainamide)

Terminal elimination is extremely long.

Adult Dosage:
VF/VT Cardiac arrest Unresponsive to CPR, Shock,
and Vasopressor

First dose: 300 mg IV/IO

Second dose (if needed): 150mg IV/IO Push

Life-Threatening Arrhythmias

3. Atropine Sulfate
Class: Anticholinergic
Indications:

First drug for symptomatic sinus bradycardia

May be beneficial in presence of AV nodal block or

ventricular asystole.

Organophosphate poisoning (eg, nerve agent)

Precautions/Contraindications:

Use with caution in presence of myocardial ischemia and

hypoxia

Avoid in hypothermic bradycardia

Will not be effective for infranodal (type II) AV block and

new third-degree block with wide QRS complexes.

Doses of atropine <0.5mg may result in paradoxical

slowing of heart rate.

Adult Dosage:
Bradycardia (With or Without ACS)

ACLS Pharmacology
0.5mg IV every 3 to 5 minutes as needed, not to exceed
total dose of 0.04mg/kg (total 3mg)
Use shorter dosing interval (3minutes) and higher doses
in severe clinical conditions.

5. Epinephrine
Class: Alpha/Beta Adrenergic Agonists
Alpha/Beta Agonists

Organophosphate Poisoning

Extremely large doses (2-4 mg or higher) maybe needed

Indications:

Cardiac arrest: VF, pulseless VT, asystole, PEA

4. Dopamine

Symptomatic bradycardia

IV Infusion

Severe hypotension

Class: Inotropic Agents

Anaphylaxis, severe allergic reactions

Indications:

Second-line drug for symptomatic bradycardia

Use for hypotension (SBP 70 TO 100 mm Hg) with

signs and symptoms of shock.

Precautions/Contraindications:

Correct hypovolemia with volume replacement before

initiating dopamine
Use with caution in cardiogenic shock with accompanying
CHF

May cause tachyarrhythmia, excessive vasoconstrictions

Do not mix with sodium bicarbonate

Adult Dosage:
IV Administration

Usual infusion rate is 2 to 20 mcg/kg per minute

Titrate to patient response; taper slowly

Precautions/Contraindications:

Raising blood pressure and increasing heart rate may

cause myocardial ischemia, angina, and increased
myocardial oxygen demand

High doses do not improve survival or neurologic

outcome and may contribute to post resuscitation
myocardial dysfunction

Higher doses may be required to treat poison/druginduced shock

Adult Dosage:
Cardiac Arrest

IV/IO dose: 1mg (10ml of 1:10 000 solution)

administered every 3 to 5 minutes during resuscitation.
Follow each dose with 20ml flush, elevate arm for 10-20
seconds after dose

ACLS Pharmacology
Higher dose: Higher doses (up to 0.2mg/kg) may be used
Endotracheal route: 2 to 2.5mg diluted 10ml NS
for specific indications (-blocker or calcium channel
Profound Bradycardia or Hyotension
blocker overdose)
2 to 10 mcg per minute infusion; titrate to patient
Continuous infusion: Initial rate 0.1 to 0.5mcg per minute)
response
titrate to response

6. Lidocaine
Class: Antidysrythmic (Class 1-B)

Indications

Alternate to amiodarone in cardiac arrest VF/VT

Stable monomorphic VT with preserved ventricular

function

Stable polymorphic VT with normal baseline QT interval

and preserved LV function when ischemia is treated and
electrolyte balance is corrected.

Can be used for stable polymorphic VT with baseline QTinterval prolongation if torsades suspected

Precautions/Contraindications:

Prophylactic use in AMI is contraindicated

Reduce maintenance dose in presence of impaired liver

function or LV dysfunction.

Discontinue infusion immediately if signs of toxicity

develop

Adult Dosage:
Cardiac Arrest From VF/VT

Initial dose: 1 to 1.5 mg/kg IV/IO

For refractory VF may give additional 0.5 to 0.7mg/kg IV

push, repeat in 5 to 10 minutes; maximum 3 doses or
total of 3mg/kg

Perfusing Arrhythmia

For stable VT, wide-complex tachycardia of uncertain

type, significant ectopy:

Doses ranging from 0.5 to 0.75mg/kgand up to 1 to 1.5

mg/kg may be used

Repeat 0.5 to 0.75mg/kg every 5 to 10 minutes;

maximum total dose: 3mg/kg

Maintenance infusion

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

7. Magnesium Sulfate
Class: Antidysrhythmics
Indications:

Recommended for use in cardiac arrest only if torsades

de pointes or suspected hypomagnesia is present

Life-threatening ventricular arrhythmias due to digitalis

toxicity

Precautions/Contraindications:

ACLS Pharmacology
Adult Dosage:

Occasional fall in blood pressure with rapid

administration

IV administration

Cardiac arrest: One dose of 40 units IV/IO push may

replace either first or second dose of epinephrine.
Epinephrine can be administered every 3 to 5 minutes
during cardiac arrest

Vasodilatory shock: Continuous infusion of 0.02 to 0.04

units per unit

Use with caution if renal failure is present

Adult Dosage:
Cardiac Arrest (due to Hypomagnesia de Torsades de
Pointes)

1 to 2g (2 to 4ml of a 50% solution) diluted in 10ml of

D5W1 over 5 to 60 minutes IV

Torsades de Pointes With a Pulse or AMI With

Hypomagnesia

Loading dose of 1 to 2g mixed in 50 to 100ml

Follow with 0.5 to 1g per hour IV (titrate to control

torsades)

Drugs for ACS (Acute Coronary

Syndromes)
MONA
M = Morphine

8. Vasopressin
Indications

O = Oxygen (for oxygen saturation less than 94%)

N = Nitrates
A = Aspirin

May be used as an alternative pressor to epinephrine in

treatment of adult shock refractory VF

May be useful alternative to epinephrine in asystole, PEA

It is preferable to do a 12 Lead ECG, if available, prior to the

administration of nitroglycerin to verify your patients cardiac
rhythm status.

May be useful for hemodynamic support in vasodilatory

shock (eg, septic shock)

Morphine: Initial dose is 2 to 4 mg IV over 1 to 5 minutes,

administer slowly and only titrate to effect

Precautions/Contraindications:

Potent Peripheral vasoconstrictor.

Not recommended for responsive patients with coronary

artery disease

May administer to patients with suspected ischemic pain

unresponsive to oxygen and nitrates

ACLS Pharmacology
Before administering morphine, be sure that the patients
Before administering nitroglycerin, be sure that the
systolic blood pressure is >90 mm Hg and they are not
patients systolic blood pressure is >90 mmHg and they
hypovolemic
should not have bradycardia or tachycardia.
Remember to reassess and repeat vital signs between
Do not give nitroglycerin if the patient has had an erectile
doses
dysfunction drug within the past week.
At IU Health, Fentanyl may be an alternative pain
medication to morphine for the unstable patient (ie,
systolic blood pressure <90 mm Hg, hypovolemia,
Aspirin: 160 to 325 mg given as soon as possible, non-coated
bradycardia, etc.)
baby or adult aspirin may be used

Nitroglycerin: 1 spray sublingually every 3-5 minutes up to a

total of 3 sprays

Indications Standard therapy for all patients with new

pain/discomfort suggestive of ACS
Give within minutes of arrival
Nitroglycerin decreases pain in ischemia and is a
vasodilator.

Indications Standard therapy for all patients with new

pain/discomfort suggestive of ACS
Give within minutes of arrival
Aspirin irreversibly binds to platelets and partially inhibits
platelet function.
Before administering aspirin, make sure patient does not
have an aspirin allergy, or recent or active GI bleeding.