Cardioversion

The following guidelines are per ACLS 2010 guidelines

VF/pulseless VT

Defibrillation x 3 (200J,200J-300J,360J) , then Secondary ABCD (Airway, IV access)
Vasopressin 40 U iv x 1 only (preferred first agent, Class 2b) orepinephrine1mg q3-5min (Class Indeterminant)
Defibrillate at 360J or biphasic shock
Amiodarone 300 mg iv push (diluted in 20 cc D5W). May rpt 150mg x 1 (Class 2b) May repeat 150 mg x 1 in 3-5 minutes
Lidocaine 1.0-1.5mg/kg ivp q3-5 min up to 3 mg/kg (Class Inderterminate) Continuous infusion: 1 to 4 mg/min. Add 1 gram/250 ml. Rate (ml/hr)= mg/min x 15. Endotracheal tube: Give 2 to 2.5 x IV dose. Dilute up to 10ml with normal saline.
Magnesium 1-2 g iv if polymorphic VT or hypomagnesiumic (Class 2b)
Procainamide 30 mg/min up to 17mg/kg “acceptable but not recommended” in refractory VF (class 2b) Loading regimen: 20-30 mg/min. Add 1 gram/250 ml D5W. Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/hr. or Add 1 gram/50ml: 20mg/min: 60 ml/hr. 30mg/min: 90 ml/hr. Continuous infusion: 2 to 6 mg/min. Add 1 gram/250 ml D5W. Rate (ml/hr)= mg/min x 15
bicarbonate prolonged arrest (Class 2b), high K
Defibrillate 360J or biphasic shock, repeat drug from above

 

 

Pulseless Electrical Activity/EMT

Basic CPR/ABCD  //    Secondary ABCD
Rule out most common etiology: Hypovolemia, Hypoxia, Hyper/hypokalemia, Hypothermia …..
Consider bicarbonate
Epinephrine 1 mg q3-5 min iv . Epinephrine strengthens myocardial contraction and increases cardiac output, which will help improve myocardial and cerebral blood flow. Continuous infusion: 1 to 4 mcg/min (range: 1-10 mcg/min). Add 1 mg/250 ml D5W or NS. Drip rate (ml/hr)= mcg/min x 15.Endotracheal tube: Give 2 to 2.5 x IV dose. (Dilute up to 10 ml with normal saline)
Atropine If HR slow, 1 mg iv q3-5 min up to 0.04mg/kg

 

Asystole

BAsic CPR/ABCD // confirm asystole: check monitor,lead,power and change leads
Consider bicarbonate: prolonged arrest (Class 2b), high K
Transcutaneous pacing, if used must be considered early, routine use not necessary
Epinephrine 1mg iv q3-5min
Atropine 1 mg iv q3-5 min up to 0.04mg/kg.   Endotracheal tube: Give 2 to 2.5 x IV dose. (Dilute up to 10ml with normal saline). Adverse reactions: CNS toxicity: tremor, delirium. Hypo/hypertension.

 

Bradycardia

BAsic CPR/ABCD  // Secondary ABCD: assess need for airway etc.
Serious signs or symptoms of bradycardia? if yes, then do the sequence:
Atropine 0.5 mg iv q3-5 min up to 0.04mg/kg.  //     Then transcutaneous pacing, then Dopamine
Dopamine 5-20 mcg/kg/min
Epinephrine 2-10 mcg/min   (Add 1 mg/250 ml )
Is Type 2 second degree AV block or third degree AV block present? If yes: standby transcutaneous pacemaker, prepare for transvenous pacemaker.

 

 

PSVT

EF normal: Priority: Ca-blocker> beta-blocker> digoxin> DC Cardioversion. Consider procainamide, sotalol, amiodarone. If unstable proceed to cardioversion
EF<40%, CHF: Priority: No Cardioversion. Digoxin or amiodarone or diltiazem. If unstable proceed to cardioversion.

 

Atrial fibrillation/flutter:

Category 1. Normal EF
Rate control
Verapamil: 2.5 to 5 mg IV over 2 minutes. May repeat dose of 5-10mg 15-30 minutes after 1st dose.  Diltiazem: 0.25 mg/kg over 2 minutes. If no response within 15 minutes, give second bolus of 0.35 mg/kg over 2 minutes. Subsequent doses should be individualized. If effective start continuous infusion: 5-15 mg/hr.  Esmolol: 500 mcg/kg IV over 1 minute, followed by 50 mcg/kg/minute over 4 minutes. If ineffective, repeat load of 500 mcg/kg, followed by 100 mcg/kg/min.

Cardiovert: If onset < 48 hours, consider DC cardioversion OR with one of the following agents: Amiodarone, ibutilide, procainamide, (flecainide,propafenone),sotalol.
If onset > 48 hours: avoid drugs that may cardiovert (e.g. amiodarone). Either:
Delayed cardioversion: anticoagulate adequately x 3weeks then Cardiovert then anticoagulate x 4 weeks . 

Ibutilide: 1mg IV over 10min. May repeat x 1 in 10 minutes if needed. Approved for acute termination. 1 mg/50 ml D5W or NS over 10 minutes. If patient is < 60kg give 0.01 mg/kg over 10 minutes. Amiodarone:(non-cardiac arrest) load 15 mg/min over 10 min (150 mg) (mix 150 mg in 100cc D5W in PVC or Glass, infuse over 10 min)  then 1 mg/min x 6 hrs (mix 900 mg in 500 cc D5W) then 0.5 mg/min x 18 hrs and beyond.

Anticoagulate if not contraindicated, if A fib > 48 hrs

Category 2. EF<40% or CHF  (Avoid verapamil, beta-blockers, ibutilide, procainamide (and propafenone/flecainide).
A. Rate control: digoxin, diltiazem, amiodarone (avoid if onset of AF > 48 hours)
B. Cardiovert: same as Category 1, except the only conversion agent allowed is amiodarone.
C. Anticoagulate, if A fib > 49 hr.
Catepory 3. WPW A fib
Must not use adenosine, beta-blocker, Ca-blocker, Digoxin . If < 48 hour:  If EF normal: one of the following for both rate control and cardioversion: amiodarone, procainamide, propafenone, sotalol, flecainide  If EF abnormal or CHF: amiodarone or cardioversion
If > 48 hour . Medication listed above may be associated with risk of emboli. Anticoagulate and DC cardioversion as in Category 1.

 

Wide complex tachycardia,  STABLE

If unable to make Dx: Note: no lidocaine and bretylium in protocol.
EF normal: DC cardioversion or procainamide or amiodarone
EF<40%,CHF: DC Cardioversion or amiodarone .

Procainamide dosing: Loading regimen: 20-30 mg/min. Add 1 gram/250 ml D5W. Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/hr. Continuous infusion: 2 to 6 mg/min. Add 1 gram/250 ml D5W. Rate (ml/hr)= mg/min x 15

Monomorphic VT (May proceed directly to cardioversion)
EF normal: one of the following procainamide (2a), sotalol (2a) OR amiodarone (2b), lidocaine (2b)
EF poor: Step 1. Amiodarone 150 mg iv or 10 min OR lidocaine 0.5-0.75 mg/kg iv push .   Step 2. Synchromized cardioversion
Intravenous Medications

Amiodarone:
I.V. DOSE RECOMMENDATIONS  — FIRST 24 HOURS —  Loading infusions.   
 The recommended starting dose of Cordarone I.V. is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen.
First Rapid: 150 mg over the FIRST – 10 minutes (15 mg/min).  Add 3 mL of Cordarone I.V.  (150 mg) to 100 mL D W. Infuse 100 mL over 10 minutes.
Followed by Slow: 360 mg over the NEXT  6 hours (1 mg/min).  Add 18 mL of Cordarone I.V.  (900 mg) to 500 mL D W  (conc = 1.8 mg/mL).
Maint  infusion540 mg over the REMAINING  18 hours (0.5 mg/min).  

After  first 24 hours, the maint infusion rate of 0.5 mg/min (720 mg/24 hours) should be continued utilizing a concentration of 1 to 6 mg/mL (Cordarone I.V. concentrations greater than 2 mg/mL should be administered via a central venous catheter). In the event of breakthrough episodes of VF or hemodynamically unstable VT, Give 150-mg/100 ml D5W  over 10min to minimize  potential for hypotension. The rate of the maint inf may be inc to achieve effective arrhythmia suppression. //  The initial infusion rate should not exceed 30 mg/min. The maintenance infusion of up to 0.5 mg/min can be cautiously continued for 2 to 3 weeks regardless of the patient’s age, renal function, or LV fcn.  limited experience in pts receiving Cordarone I.V. > 3 weeks.  


Amrinone (Inocor):  0.75 mg/kg bolus IV over 2-3min, f/b infusion IV at 5-10 mcg/kg/min.

Cisatracium: Intermittent IV dosing: initial dose 0.15 – 0.2 mg/kg IV bolus, followed by 0.03 mg/kg IV q40-60 minutes. Continuous infusion: 0.15-0.2 mg/kg bolus, followed by 1 to 3 mcg/kg/min. (range: 0.5 to 10 mcg/kg/min). Based on a standard dilution of 1 mg/ml (eg 100mg/100ml or 200mg/200ml) and a weight of 70kg:

1 mcg/kg/min =4.2 ml/hr
3 mcg/kg/min =12.6 ml/hr
0.15 mg/kg =10.5 mg
0.2 mg/kg=14 mg

Digoxin: Loading dose: CHF: 8-12 mcg/kg in divided doses (q4-8h) over 12 to 24 hours. [Normally, give 50% of the total digitalizing dose in the initial dose, then give 25% of the total dose in each of the two subsequent doses at 8 to 12 hr intervals-Obtain EKG 6 hours after each dose to assess potential toxicity (AV block, sinus bradycardia, atrial or nodal ectopic beats, ventricular arrhythmias); Other: vision changes, confusion.] If pt has renal insufficiency give 6 to 10 mcg/kg IBW. A-fib:10 to 15 mcg/kg IBW given as above. (If given IVPush-admin over at least 5 min)

Diltiazem  0.25 mg/kg over 2min. If no response c/in 15min, give 2ndbolus of 0.35 mg/kg over 2min. Subsequent doses should be individualized. If effective start continuous infusion: 5-15 mg/hr

Diprivan: ICU sedation: Usual initial dose 0.3 to 0.6 mg/kg/hr (equivalent to 5-10 mcg/kg/min) over 5-10 minutes. Infusion rate can then be increased by 0.3 to 0.6 mg/kg/hr at 3 to 5 minute intervals until the desired level of sedation is achieved. Give by slow infusion only – never bolus. Monitor for early signs of significant hypotension and/or cardiac depression, which may be profound. Usual dose required for maintenance: 1.5 to 4.5 mg/kg/hr. Based on the reported weight of 70kg, here are the recommended pump settings:

Initial infusion rate: 0.3 mg/kg/hr (2.1 ml/hr) or 0.6 mg/kg/hr (4.2 ml/hr) x 5-10 minutes, then increase by 2.1 to 4.2 ml/hr q3-5 minutes until desired level of sedation. Usual maintenance rate: 1.5 mg/kg/hr (10.5 ml/hr) to 4.5 mg/kg/hr (31.5 ml/hr).

Dobutamine: Drip rate (500mg/250 ml) ml /hr= wt(kg) x (mcg/min) x 0.03. Direct beta agonist that inc cardiac output with little direct effect on BP. Uses: refractory CHF or hypotensive pts in whom vasodilators cannot be used b/c of eff on BP. Usual range: 2-15 mcg/kg/min (up to 40). Little effect on heart rate.

Dopamine: Calculation of drip rate (ml/hr) 400mg/250 ml: wt(kg) x mcg/min x 0.0375. Refractory CHF: ini 0.5 to 2 mcg/kg/min Renal: 1 to 5 mcg/kg/min. Severely ill pt: ini 5 mcg/kg/min, inc by 5 to 10 mcg/kg/min (q10 to 30 min) up to max of 50 mcg/kg/min. [0.5 to 2 mcg/kg/min-dopa; 2-10-dopa/beta; >10-primarily alpha. Used to support BP, CO and renal perfusion in shock.

Epinephrine: 1 to 4 mcg/min or 0.05 to 2 mcg/kg/min. Anaphylaxis (adult): 0.1 to 0.5 SC / IM (1:1000) rpt q10 to 15 min prn or give 0.1 to 0.25 mg IV (1:10,000) over 5-10min rpt q5 to 15min prn or start cont inf: 1 to 4 mcg/min

Eptifibatide (Integrilin)ACS: Bolus of 180 mcg/kg (maximum: 22.6 mg) over 1-2 minutes, begun ASAP following diagnosis, f/b a continuous inf of 2 mcg/kg/min (maximum: 15 mg/hour) until hospital discharge or initiation of CABG surgery, up to 72 hours. Concurrent aspirin (160-325 mg initially and daily thereafter) and heparin therapy (target aPTT 50-70 seconds) are recommended.     Percutaneous coronary intervention (PCI) with or without stenting: Bolus of 180 mcg/kg (maximum: 22.6 mg) administered immediately before the initiation of PCI, f/b a continuous inf of 2 mcg/kg/min (maximum: 15 mg/hour). A second 180 mcg/kg bolus (maximum: 22.6 mg) should be administered 10 min after the 1st bolus. Infusion should be continued until hospital discharge or for up to 18-24 hours, whichever comes first; minimum of 12 hours of infusion is recom. Concurrent aspirin (160-325 mg 1-24 hours before PCI and daily thereafter) and heparin therapy (ACT 200-300 seconds during PCI) are recommended. Heparin infusion after PCI is discouraged. In patients who undergo coronary artery bypass graft surgery, discontinue infusion prior to surgery.     Dosing adjustment in renal impairment: ACS: Scr >2 mg/dL and <4 mg/dL: Use 180 mcg/kg bolus (maximum: 22.6 mg) and 1 mcg/kg/mininfusion (maximum: 7.5 mg/hour) . Percutaneous coronary intervention (PCI) with or without stenting: Adults: Scr >2 mg/dL and <4 mg/dL: Use 180 mcg/kg bolus (maximum: 22.6 mg) administered immediately before the initiation of PCI and followed by a cont inf of 1 mcg/kg/min (maximum: 7.5 mg/hour). A second 180 mcg/kg (maximum: 22.6 mg) bolus should be admin 10 min after the first bolus.

 

Esmolol: Dosing: PSVT: 500 mcg/kg over 1 min, then 50 mcg/kg/min x 4 to 5min. If heart rate not controlled, rpt load of 500 mcg/kg and increase inf to 100 mcg/kg/min. Rpt load and increase infusion q5 to 10min as needed to max of 200 (up to 300?) mcg/kg/min. Watch BP. Calculation of drip rate (ml/hr): 2.5 grams/250 ml: wt (kg) x mcg/min x 0.006

Fenoldopam (Corlopam): severe HTN:  Dosing: Usu initial rate: 0.1 mcg/kg/min, increased by increments of 0.05 to 0.1 mcg/kg/min at 15-20min intervals until target BP reached. Usual effective doses: 0.1 to 1.6 mcg/kg/min.  Generally, lower initial doses (0.03 to 0.1 mcg/kg/min) titrated slowly, have been assoc c less reflex tachycardia. Never given by IV bolus.    10mg/250 ml NS/D5W

Hydralazine: Parenteral (IV/IM) (Inject over 1 minute) Hypertension: Initial: 10-20 mg/dose every 4-6h prn, may increase to 40 mg/dose; change to oral therapy as soon as possible. Route is indicated only when oral therapy is not feasible.  HTN emergency: 10 to 40 milligrams, repeated prn (q20-60 minutes), with frequent blood pressure monitoring. 

Ibutalide: 1 mg over 10 min.  May rpt x 1 after 10 min.  Class III agent—prolongs action potential (inc atrial and ventricular refractoriness.).

Isoproterenol: (B1/B2) agonist. IV infusion: 2 to 20 mcg/ min. Usual initial rate: 5 mcg/min. Titrate to HR/BP. May give IVPush (must use 1:50,000 dilution). Calculation of drip rate 1 mg/250 ml (ml/hr) = 15 x mcg/min. eg: 5 mcg/min = 75 ml/hr.   Used to tx hemodynamically significant bradycardia. Also indicated for tx of asthma

Labetalol: Dosing: ini 20 mg IVP over 2 min. May rpt 20 to 80 mg q10min (up to 300 mg total dose) until desired BP is reached or start continuous infusion: 2 mg/min (range: 1 to 3 mg/min)-titrate to BP.

Milrinone (Primacor):  Load 50 mcg/kg IV over 10 min, then begin IV infusion of 0.375 to 0.75 mcg/kg/min.

Natrecor: IV bolus of 2 mcg/kg (over 1 minute) followed by a continuous infusion of 0.01 mcg/kg/min. Withdraw bolus dose from the infusion bag. Higher initial dosages are not recommended.  At intervals of 3 hours, the dosage may be increased by 0.005 mcg/kg/minute (preceded by a bolus of 1 mcg/kg), up to a maximum of 0.03 mcg/kg/minute.   Indications: IV treatment of patients with acutely decompensated CHF who have dyspnea at rest or with minimal activity. Actions: venous and arterial vasodilation (decreased PCWP etc), plus mild diuretic effect.   Patients experiencing hypotension during the infusion: Hold infusion. May attempt to restart at a lower dose (reduce initial infusion dose by 30% and omit bolus).  No adjustment required in renal failure.

Nitroglycerin: (HTN/ CHF/ angina): ini inf rate 5 mcg/min. May inc by 5 mcg/min q3 to 5 min until response. If 20 mcg/min is inadequate, inc by 10 to 20 mcg/min q3 to 5min. Calculation of drip rate (50 mg/250 ml) ml/hr = mcg/min x 0.3 (eg 5 mcg/min=@ 2ml/hr ; 20mcg/min = 6 ml/hr etc.)

Nitroprusside: Onset: immediate Duration: 1 to 10min. Tx htn emer. IV infusion rate: 0.5 to 10 mcg/ kg/ min-titrate to BP. Dosing: Initial: 0.3 to 0.5 mcg/kg/min—increase by 0.5 mcg/kg/min increments. (usual dose: 3 mcg/kg/min-rarely need > 4 mcg/kg/min). Note: when > 500 mcg/kg is admin by continuous infusion at > 2 mcg/kg/min-cyanide is produced faster than can be handled by endogenous mechanisms. Maximum infusion rate: 10 mcg/kg/min. Calculation of drip rate 50 mg/250 ml (ml/hr) = wt (kg) x mcg/min x 0.3

Norepinephrine: Used to maintain BP in hypotensive states. Most potent vasoconstrictor (Norepi >>> phenylephrine). Dosage: ini 8 to 12 mcg/min –titrate to BP(Usual target: SB:80-100 or MAP=80). Usual maint: 2 to 4 mcg/min. Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-10days have been used in septic shock.) Calculation of drip rate 8 mg/ 250 ml (ml/hr) = mcg/min x 1.875 Administer through a central line (large vein)

Phenylephrine: Alpha agonist). May be given IM,SC, Ivpush, or by cont inf. TX mild/moderate hypotension, also PSVT. IV bolus tx: usu ini dose 0.5 mg [range: 0.1 to 1 mg (max)] rpt q10-15 min prn. IV infusion: usu ini rate: 0.1 to 0.18 mg/min (titrate). Maximum rate: 10-15 mcg/kg/min?.   PSVT: 0.5 mg rapid Ivpush, subsequent doses may be inc in increments of 0.1 to 0.2mg. Calculation of drip rate (40 mg/250) (ml/hr) = (mg/min) x 375.

Procainamide: (Tx: PVC, VT, A-fib/flutter, PAT) Dosing: Loading: 100mg q5min (max 25 to 50 mg/min) until arrhy disappears or adverse effects up to (17 mg/kg max if nml renal fcn, otherwise max of 12 mg/kg). If arrhy disappears, start IV infusion: 2 to 6 mg/min (Usual maint dose c renal/cardiac failure: 1 to 2 mg/min) . If arrhy reappears, rpt bolus as above. Side effects: Severe hypotension c rapid infusion; bradycardia, AV block, V-fib. Alternate loading regimen: Add 1g/ 50 ml D5W-20 mg/min x 25 to 30 min, wait 10min for distribution, if no response continue c loading. (Note: 20 mg/min= 60 ml/hr-1 g/50ml). If pt responds start maint infusion: 2 to 6 mg/min. Stop infusion if QRS widens > 50%. Steady state: 24hrs (IV) / 48 hrs (oral).
Calculation of drip rate (1 gram/250 ml) ml/hr: = (mg/min) x 15

Succinylcholine: Usual dosage: 0.6 mg/kg (range: 0.3 to 1.1 mg/kg) over 10-30 seconds (up to total dose of 150mg). Maintainance: 0.04-0.07 mg/kg q5-10 minutes prn. Continuous infusion: 0.5 to 10 mg/min. Add 500mg/250ml D5W or NS. Based on the entered weight of 70kg:

0.6mg/kg =42mg, and the maintenance dose of 0.04 to 0.07mg/kg is:(2.8 to 4.9 mg) q5-10 minutes.

Tirofiban (Aggrastat): initial rate of 0.4 mcg/kg/min for 30 minutes and then continued at 0.1 mcg/kg/min. Patients with severe renal insufficiency (creatinine clearance <30 mL/min) dec by 50%: (0.2 mcg/kg/min x 30min, f/b 0.05 mcg/kg/min)

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