Drugs most commonly used in an ACLS course

ACLS Pharmacology Summary Table

This table provides information about common drugs used in ACLS.

DrugIndicationsPrecautions and contraindicationsAdult dosage
Adenosine-First drug for most forms of stable narrow-complex SVT; effective in terminating those due to reentry involving AV node or sinus node
-May consider for unstable narrow-complex reentry tachycardia while preparations are made for cardioversion
-Regular and monomorphic wide-complex tachycardia, thought to be or previously defined to be reentry SVT
-Does not convert atrial fibrillation, atrial flutter, or VT
-Diagnostic maneuver: stable narrow-complex SVT
Contraindicated in poison/ drug-induced tachycardia or second- or third-degree heart blockTransient side effects include flushing, chest pain or tightness, brief periods of asystole or bradycardia, ventricular ectopyLess effective (larger doses may be required) in patients taking theophylline or caffeineReduce initial dose to 3 mg in patients receiving dipyridamole or carbamazepine, in heart transplant patients, or if given by central venous accessIf administered for irregular, polymorphic wide-complex tachycardia/VT, may cause deterioration (including hypotension)Transient periods of sinus bradycardia and ventricular ectopy are common after termination of SVTSafe and effective in pregnancyIV Rapid Push
-Place the patient in mild reverse Trendelenburg position before administration of drugInitial bolus of 6 mg given rapidly over 1 to 3 seconds followed by NS bolus of 20 mL; then elevate the extremity
-A second dose (12 mg) can be given in 1 to 2 minutes if needed

Injection Technique
-Record rhythm strip during administration
-Draw up adenosine dose in one syringe and flush in another; attach both syringes to the same or immediately adjacent IV injection ports nearest patient, with adenosine closest to patient; clamp IV tubing above injection portPush IV adenosine as quickly as possible (1 to 3 seconds)
-While maintaining pressure on adenosine plunger, push NS flush as rapidly as possible after adenosineUnclamp IV tubing
AmiodaroneBecause its use is associated with toxicity, amiodarone is indicated for use in patients with life-threatening arrhythmias when administered with appropriate monitoring
1. VF/pVT unresponsive to shock delivery, CPR, and a vasopressor
2. Recurrent, hemodynamically unstable VT
With expert consultation, amiodarone may be used for treatment of some atrial and ventricular arrhythmias.
Caution: Multiple complex drug interactions
Rapid infusion may lead to hypotensionWith multiple dosing, cumulative doses >2.2 g over 24 hours are associated with significant hypotension in clinical trials
Do not administer with other drugs that prolong QT interval (eg, procainamide)Terminal elimination is extremely long (half-life lasts up to 40 days)
VF/pVT Cardiac Arrest Unresponsive to CPR, Shock, and Vasopressor
First dose: 300 mg IV/IO push
Second dose (if needed): 150 mg IV/IO push

Life-Threatening ArrhythmiasMaximum cumulative dose: 2.2 g IV over 24 hours.

May be administered as follows:
Rapid infusion: 150 mg IV over first 10 minutes (15 mg/min). May repeat rapid infusion (150 mg IV) every 10 minutes as needed
Slow infusion: 360 mg IV over 6 hours (1 mg/min)
Maintenance infusion: 540 mg IV over 18 hours (0.5 mg/min)
Atropine sulfate Can be given via endotracheal tubeFirst drug for symptomatic sinus bradycardiaMay be beneficial in presence of AV nodal block; not likely to be effective for type II second-degree or third-degree AV block or a block in non-nodal tissue
Routine use during PEA or asystole is unlikely to have a therapeutic benefit
Organophosphate (eg, nerve agent) poisoning: extremely large doses may be needed
Use with caution in presence of myocardial ischemia and hypoxia. Increases myocardial oxygen demandUnlikely to be effective for hypothermic bradycardiaMay not be effective for infranodal (type II) AV block and new third-degree block with wide QRS complexes (in these patients may cause paradoxical slowing; be prepared to pace or give catecholamines)Bradycardia (With or Without ACS) 1 mg IV every 3 to 5 minutes as needed, not to exceed total dose of 0.04 mg/kg (total 3 mg)

Organophosphate Poisoning Extremely large doses (2 to 4 mg or higher) may be needed
IV infusion
Second-line drug for symptomatic bradycardia (after atropine)Use for hypotension (systolic blood pressure ≤70-100 mm Hg) with signs and symptoms of shockCorrect hypovolemia with volume replacement before initiating dopamine
Use with caution in cardiogenic shock with accompanying CHF
May cause tachyarrhythmias, excessive vasoconstriction
Do not mix with sodium bicarbonate
IV Administration
Usual infusion rate is 5-20 mcg/kg per minute.Titrate to patient response; taper slowly
EpinephrineCan be given via endotracheal tubeAvailable in 1:10 000 and 1:1000 concentrationsCardiac arrest: VF, pulseless VT, asystole, PEA
Symptomatic bradycardia: Can be considered after atropine as an alternative infusion to dopamine
Severe hypotension: Can be used when pacing and atropine fail, when hypotension accompanies bradycardia, or with phosphodiesterase enzyme inhibitor
Anaphylaxis, severe allergic reactions: Combine with large fluid volume, corticosteroids, antihistamines
Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demandHigh doses do not improve survival or neurologic outcome and may contribute to postresuscitation myocardial dysfunctionHigher doses may be required to treat poison/drug-induced shockCardiac ArrestIV/IO dose: 
1 mg (10 mL of 0.1 mg/mL solution) administered every 3-5 minutes during resuscitation; follow each dose with 20 mL flush, elevate arm for 10-20 seconds after dose

Higher dose: Higher doses (up to 0.2 mg/kg) may be used for specific indications (β-blocker or calcium channel blocker overdose)

Continuous infusion: 
Initial rate: 0.1-0.5 mcg/kg per minute (for 70-kg patient: 7-35 mcg/min); titrate to response

Endotracheal route: 
2–2.5 mg diluted in 10 mL NS

Profound Bradycardia or Hypotension
2-10 mcg/min infusion; titrate to patient response
Can be given via endotracheal tube
-Alternative to amiodarone in cardiac arrest from VF/pVT
-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 QT-interval prolongation if torsades suspected
Contraindication: Prophylactic use in AMI is contraindicatedReduce maintenance dose (not loading dose) in presence of impaired liver function or LV dysfunctionDiscontinue infusion immediately if signs of toxicity developCardiac Arrest From VF/pVT Initial dose: 1-1.5 mg/kg IV/IOFor refractory VF, may give additional 0.5-0.75 mg/kg IV push and repeat in 5-10 minutes; maximum 3 doses or total of 3 mg/kg

Perfusing Arrhythmia
For stable VT, wide-complex tachycardia of uncertain type, significant ectopy:Doses ranging from 0.5-0.75 mg/kg and up to 1-1.5 mg/kg may be usedRepeat 0.5-0.75 mg/kg every 5-10 minutes; maximum total dose: 3 mg/kg

Maintenance Infusion
1-4 mg/min (30-50 mcg/kg per minute)
Magnesium sulfateRecommended for use in cardiac arrest only if torsades de pointes or suspected hypomagnesemia is present
-Life-threatening ventricular arrhythmias due to digitalis toxicity
-Routine administration in hospitalized patients with AMI is not recommended
Occasional fall in blood pressure with rapid administrationUse with caution if renal failure is presentCardiac Arrest (Due to Hypomagnesemia or Torsades de Pointes)
1-2 g (2-4 mL of a 50% solution diluted in 10 mL [eg, D5W, normal saline] given IV/IO)

Torsades de Pointes With a Pulse or AMI With Hypomagnesemia
Loading dose of 1-2 g mixed in 50-100 mL of diluent (eg, D5W, normal saline) over 5-60 minutes IVFollow with 0.5-1 g per hour IV (titrate to control torsades)
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