Drugs Used in ACLS

Routes of access for drugs

• Intravenous Route (IV)
• Drug as bolus push followed by 20ml IV Saline Flush
• Elevate for 10-20 seconds, if possible, to help the drug reach central
circulation

• Intraosseous Route (IO)

• All drugs and IV Fluids can be given

• Endotracheal Route (ETT)

• Dosage 2.0-2.5 x the IV Dose
Adenosine
• Stable Narrow Complex SVT
• Monomorphic VT – if thought to be reentry SVT

• Does not convert Atrial fibrillation, Atrial Flutter or VT

• Causes flushing, chest pain or tightness, brief asystole

• Contraindicated:
• Poison/Drug induced tachycardia
• 2nd or 3rd degree heart block
Adenosine
• Initial Dosage 6mg followed by 12mg if required in 1-2 minutes

• Reduce initial dose to 3mg if giving through CV Line, Heart Transplant and Patients
on Dipyridamole & carbamazepine

• Rapid IV Push followed by Rapid Flush of 20ml Saline followed by Raising

Extremity for 10-20 Sec.

• Record rhythm strip during administration

• Safe in pregnancy
Amiodarone
• Refractory Ventricular Arrythmias
• Unresponsive to Defibrillation
• Atrial Arrythmias – with expert advice

• Don’t give with other QT prolonging Drugs

• Rapid push causes hypotension

• First does 300mg, Second dose 150mg

• Slow Infusion – 1mg/min for 6 hours followed by 0.5mg/min
• Fast Infusion – 150mg over 10 min, repeat every 10 min, if needed
Atropine
• Symptomatic Bradycardia – 1st Line

• IV/IO Dose:
• 1 mg every 3-5 min; max dose 3mg total (0.04mg/kg),followed by Rapid Flush
of 20ml Saline followed by Raising Extremity for 10-20 Sec.

• Can be given via ETT – 2-2.5mg diluted in 10ml Saline

• Not likely to be effective in 2nd degree Type-II and 3rd degree Blocks

• May even cause paradoxical slowing in infra-nodal Type 2 Blocks and 3 rd degree
block with wide QRS
Atropine
• Unlikely to effect Hypothermic bradycardia

• Very high doses for Organophosphate poisoning

• 2-4mg or Higher

• Use with caution in Myocardial Ischemia and Hypoxia

• Increase myocardial oxygen demand
Dopamine
• Symptomatic Bradycardia – 2nd Line
• Hypotension

• Can cause tachyarrhythmias

• 5-20mcg/kg/min (don’t Mix with Sodium Bicarbonate)

Epinephrine
• Cardiac arrest (PEA, Pulseless VT/VF, Asystole)

• Symptomatic bradycardia – 2nd Line, Alternative to Dopamine

• Hypotension

• Anaphylaxis – with IV Fluids, Antihistamines & Steroids

Epinephrine
• IV/IO Dose:
• 1 mg every 3-5 minutes, followed by Rapid Flush of 20ml Saline followed
by Raising Extremity for 10-20 Sec.

• Can be given via ETT – Dose 2.0-2.5mg diluted in 10ml Saline

• Infusion for hypotension – 0.01-0.5 mcg/kg/min

• Profound Bradycardia – 2-10 mcg/min

• May need Higher Doses Up to 0.2mg/kg

Lignocaine
• Cardiac Arrest with Refractory VT/VF – alternate to Amiodarone
• Torsade

• Reduce maintenance dose in patients with poor LV Function and Impaired

Liver Function (Loading Dose Remain Same)

• Stable Monomorphic VT with Normal LV Function

• Stable Polymorphic VT with Normal QT and Normal LV Function
Lignocaine
• IV/IO Dose:
• 1-1.5mg/kg, followed by Rapid Flush of 20ml Saline followed by
Raising Extremity for 10-20 Sec.
• Repeat 0.5-0.75mg/kg every 5-10 min (Total 3mg/kg)

• Can be given via ETT: 2-3mg/kg diluted in 10ml Saline

• Infusion 1-4mg/min (30-50mcg/kg/min)

Magnesium Sulphate
• Cardiac Arrest, Only if suspecting it due to Torsade or
Hypomagnesemia

• Ventricular Arrythmias due to Digitalis Toxicity

• Dosage: 1-2gm IV over 5-60 minutes

• Hypotension with Rapid Infusion

• Infusion 0.5-1.0gm/hour
Naloxone
• Opioids overdose

• IV/IO Dose:
• 0.4 mg – 2mg, followed by Rapid Flush of 20ml Saline followed by
Raising Extremity for 10-20 Sec
• May repeat the doses after 4 minutes.

• Can be given via ETT: 0.8-2mg, diluted in 10ml Saline

The current recommended volumes for ETT instillation of each medication are
dilution to a total volume of 10 mL in adults, 5 mL for children, and 1 mL for
neonates.