ACLS Meds

ADULT ACLS MEDICATIONS

CARDIAC ARREST

• Epinephrine
  • Indication: Cardiac arrest with VF, pulseless VT, PEA, or asystole.
  • Dose: 1 mg IV/IO every 3–5 minutes.
  • Key point: For PEA/asystole, give epinephrine as soon as possible. For VF/pulseless VT, prioritize defibrillation and CPR.

• Amiodarone
  • Indication: VF or pulseless VT that persists despite shocks.
  • First dose: 300 mg IV/IO bolus.
  • Second dose: 150 mg IV/IO.
  • Key point: Use amiodarone OR lidocaine for refractory VF/pulseless VT.

• Lidocaine
  • Indication: Alternative to amiodarone for refractory VF or pulseless VT.
  • First dose: 1–1.5 mg/kg IV/IO.
  • Second dose: 0.5–0.75 mg/kg IV/IO.

SYMPTOMATIC BRADYCARDIA WITH A PULSE

• Atropine
  • Indication: Bradycardia with signs of poor perfusion, such as hypotension, altered mental status, shock, ischemic chest discomfort, or acute heart failure.
  • Dose: 1 mg IV bolus. Repeat every 3–5 minutes.
  • Maximum total dose: 3 mg.
  • If ineffective: Consider transcutaneous pacing and/or a dopamine or epinephrine infusion.

• Dopamine infusion
  • Indication: Symptomatic bradycardia when atropine is ineffective.
  • Dose: 5–20 mcg/kg/min IV. Titrate to response.

• Epinephrine infusion
  • Indication: Symptomatic bradycardia when atropine is ineffective.
  • Dose: 2–10 mcg/min IV. Titrate to response.
  • Remember: This infusion dose is different from the 1 mg IV/IO cardiac-arrest dose.

TACHYCARDIA WITH A PULSE

• Adenosine
  • Indication: Regular narrow-complex tachycardia. It may also be considered for a regular, monomorphic wide-complex tachycardia.
  • First dose: 6 mg rapid IV push, immediately followed by a normal-saline flush.
  • Second dose: 12 mg rapid IV push if needed.
  • Key point: A tachycardia causing significant instability generally calls for synchronized cardioversion; sedation is given when feasible.

• Amiodarone infusion
  • Indication: Stable wide-QRS tachycardia.
  • Dose: 150 mg IV over 10 minutes. Repeat as needed if VT recurs.
  • Follow with: 1 mg/min infusion for the first 6 hours.
  • Remember: 150 mg over 10 minutes with a pulse versus 300 mg bolus for pulseless VF/VT.

• Procainamide infusion
  • Indication: Stable wide-QRS tachycardia.
  • Dose: 20–50 mg/min until the rhythm is suppressed, hypotension occurs, QRS duration increases by more than 50%, or a total of 17 mg/kg has been given.
  • Maintenance: 1–4 mg/min.
  • Avoid with prolonged QT or congestive heart failure.

ADULT ACLS: CARDIOVERSION, DEFIBRILLATION & PACING

SYNCHRONIZED CARDIOVERSION — unstable tachycardia with a pulse

• Turn SYNC on and confirm the markers appear on the QRS complexes.

• Atrial fibrillation: start at 200 J.

• Atrial flutter: start at 200 J.

• Narrow-complex tachycardia: start at 100 J.

• Monomorphic ventricular tachycardia (VT): start at 100 J.

Polymorphic VT: unsynchronized, high energy defibrillation

• Sedate if feasible, but do not delay treatment of a critically unstable patient.

DEFIBRILLATION — unsynchronized shock

• Use for VF, pulseless VT, or sustained polymorphic VT (including torsades), even if a pulse is present.

• Biphasic: use the manufacturer's recommended initial setting (commonly 120–200 J). If unknown, use the maximum available setting.

• Monophasic: 360 J.

• Do not use SYNC for polymorphic VT.

TRANSCUTANEOUS PACING — symptomatic bradycardia with a pulse

• Pacing is set in milliamps (mA), NOT joules.

• Set a pacing rate, commonly 60–80 beats/min.

• Increase the mA until electrical capture occurs: each pacing spike is followed by a QRS complex.

• Confirm mechanical capture with a corresponding pulse or blood pressure response.

• Provide pain control or sedation if the patient's condition allows