ACLS Provider: Course

Medications in ACLS

Medications play a crucial role in Advanced Cardiac Life Support (ACLS), supporting the restoration of normal cardiac rhythms, improving circulation and perfusion, and managing underlying causes of cardiac arrest and arrhythmias. This lesson reviews the key medications used in ACLS and their specific indications and administration guidelines.

Key ACLS Medications:

  • Epinephrine: Epinephrine is a potent vasopressor and positive inotrope, meaning it increases blood vessel constriction and strengthens heart muscle contractions. In cardiac arrest, epinephrine is used to increase coronary and cerebral perfusion pressure, improving the chances of successful defibrillation and ROSC.
    • Indications: Ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT), asystole, and pulseless electrical activity (PEA).
    • Administration: 1 mg IV/IO (intravenous/intraosseous) every 3–5 minutes during CPR.
  • Amiodarone: Amiodarone is an antiarrhythmic medication used to treat refractory (unresponsive to initial shocks) VF and pVT. It works by prolonging the action potential duration and refractory period of cardiac cells, helping to stabilize the heart's electrical activity.
    • Indications: Shock-refractory VF and pVT.
    • Administration: 300 mg IV/IO bolus initially, followed by a second dose of 150 mg IV/IO if needed.
  • Atropine: Atropine is an anticholinergic medication that blocks the effects of the vagus nerve, which can slow the heart rate. It is used to treat symptomatic bradycardia.
    • Indications: Symptomatic bradycardia (e.g., bradycardia with hypotension, altered mental status, or chest pain).
    • Administration: 0.5 mg IV every 3–5 minutes, with a maximum total dose of 3 mg.
  • Lidocaine: Lidocaine is another antiarrhythmic medication that can be used as an alternative to amiodarone in the treatment of VF/pVT.
    • Indications: VF/pVT, especially when amiodarone is unavailable.
    • Administration: Initial dose of 1–1.5 mg/kg IV/IO, followed by additional doses of 0.5–0.75 mg/kg IV/IO every 5–10 minutes, up to a maximum total dose of 3 mg/kg.
  • Dopamine: Dopamine is a vasopressor and inotrope that can be used to treat hypotension and symptomatic bradycardia that is unresponsive to atropine.
    • Indications: Symptomatic bradycardia unresponsive to atropine, hypotension (especially in the setting of bradycardia).
    • Administration: Continuous IV infusion at a rate of 2–20 mcg/kg/min, titrated to effect.
  • Adenosine: Adenosine is an antiarrhythmic medication used to treat stable narrow-complex supraventricular tachycardia (SVT). It works by slowing conduction through the AV node, which can terminate re-entry circuits that cause SVT.
    • Indications: Stable narrow-complex SVT.
    • Administration: Rapid IV push of 6 mg initially, followed by 12 mg if the first dose is ineffective. It is crucial to administer adenosine rapidly followed by a saline flush.

General Principles of Medication Administration in ACLS:

  • Fastest Available Route (IV/IO): Medications should be administered via the fastest available route, which is typically intravenous (IV) or intraosseous (IO) access. IO access is a rapid and reliable alternative when IV access is difficult to obtain.
  • Flush with Saline: After administering any medication, it is essential to flush the IV/IO line with 20 mL of normal saline to ensure that the entire dose reaches the central circulation.
  • Monitor for Side Effects and Effectiveness: Closely monitor the patient for any adverse effects of the medications and assess their effectiveness in achieving the desired clinical outcome (e.g., restoration of a normal heart rhythm, improvement in blood pressure).