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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) or
epinephrine1mg 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
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 1 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.
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 5 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 5 W (conc = 1.8 mg/mL).
Maint infusion: 540 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.
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 2nd bolus 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).
Ibutalide: 1 mg over 10 min. May rpt x 1 after 10 min. Class III agent—
prolongs action potential (inc atrial and ventricular refractoriness.).
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.
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.)
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)