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Adrenaline (epinephrine)is the main drug used during resuscitation from cardiac arrest. A 1mg dose should be given at least every
three minutes during the arrest. Intravenous adrenaline enhances cerebral and myocardial blood flow by increasing peripheral vascular
resistance and raising aortic diastolic pressure. These peripheral vascular actions are primarily alpha1 (α 1), and alpha2 (α 2),
receptor-mediated. Beta1(β 1) and Beta2 (β 2) receptor actions also occur though a beta effect has not been shown to be beneficial in
restoring spontaneous circulation in VF, asystole or EMD. Indeed, β 1 effects may increase myocardial oxygen demand and increase
the risk of arrhythmias in a beating heart. Recently, high dose adrenaline (5mg) has been tried during resuscitation in an attempt to
improve the survival of cardiac arrest but there was no improvement in outcome.
The ALS algorithm suggests the use of antiarrhythmics, buffers, atropine and pacing. Antiarrhythmic drugs are considered in figure 7.
Atropine as a single dose of 3mg is sufficient to block vagal tone completely and should be used once in cases of asystole. It is also
indicated for symptomatic bradycardia in a dose of 0.5mg - 1mg.
Sodium bicarbonate In prolonged arrests, the effects of acidosis become significant. The use of sodium bicarbonate as a buffer has
been controversial; it is associated with hyperosmolarity and carbon dioxide production, and may worsen intra-cellular acidosis.
Carbon dioxide-consuming buffers, such as Carbicarb and THAM have been developed, but no buffer has been shown to improve
outcome. Nevertheless, sodium bicarbonate continues to be recommended (50mls of 8.4% solution) after 15 minutes of cardiac arrest
or when the arterial pH is less than 7.1, or the base deficit is more negative than -10. It should be used early in arrests caused by
acidosis, hyperkalaemia or tricyclic overdosage, but must not be given by the tracheal route or mixed with calcium or adrenaline
solutions.
Drug Delivery
Despite widespread and long-standing use, no drug has definitively been shown to increase survival to hospital discharge
in patients with cardiac arrest. Some drugs do appear to improve the return of spontaneous circulation and thus may
reasonably be given (for dosing, including pediatric, see Table 3: Respiratory and Cardiac Arrest: Drugs for
Resuscitation* ).
Table 3
In a patient with a peripheral IV line, drug administration is followed by a fluid bolus (“wide open” IV in adults; 3 to 5 mL in
young children) to flush the agent into the central circulation. In a patient without IV or intraosseous access, atropine
andepinephrine
, when indicated, may be given via the endotracheal tube at 2 to 2.5 times the IV dose.
First-line drugs: Epinephrine
is the main drug used in cardiac arrest although its benefit is increasingly challenged. It is given q 3 to 5 min. Epinephrine
has combined α- and β-adrenergic effects. The α-adrenergic effects may augment coronary diastolic pressure, thereby
also increases the likelihood of successful defibrillation. However, β-adrenergic effects may be detrimental because they
increase O2 requirements (especially of the heart) and cause vasodilation. Intracardiac injection of epinephrine
is not recommended because pneumothorax, coronary artery laceration, and cardiac tamponade may occur.
Atropine
sulfate is a parasympatholytic drug that increases heart rate and conduction through the atrioventricular node. It is given
for asystole (except in children), bradyarrhythmias, and high-degree atrioventricular nodal block, although no survival
Amiodarone
rvasopressin
. It is also of potential value if VT or VF recurs following successful defibrillation; a lower dose is given over 10 min
Other drugs: Ca chloride is recommended for patients with hyperkalemia, hypermagnesemia, hypocalcemia, or Ca
channel blocker toxicity. In others, because intracellular Ca is already higher than normal, additional Ca is likely to be
detrimental. Because cardiac arrest in patients on renal dialysis is often a result of or accompanied by hyperkalemia,
these patients may benefit from a trial of Ca if bedside K determination is unavailable. Caution is necessary because Ca
Mg sulfate has not been shown to improve outcome in randomized clinical studies. However, it may be helpful in patients
with torsades de pointes or known or suspected Mg deficiency (ie, alcoholics, protracted diarrhea).
Procainamide
Phenytoin
may rarely be used to treat VF or VT, but only when it is due to digitalis toxicity and is refractory to other drugs. Dose is 50
NaHCO3 is no longer recommended unless cardiac arrest is caused by hyperkalemia, hypermagnesemia, or tricyclic
antidepressant overdose with complex ventricular arrhythmias. In pediatric patients, NaHCO3 should be considered when
cardiac arrest is prolonged (> 10 min); it is administered only if there is good ventilation. When NaHCO3 is used, arterial
pH should be monitored before infusion and after each 50-mEq dose (1 to 2 mEq/kg in children).
Lidocaine
Only a small number of drugs are indicated during cardiac arrest and there is little in the way of scientific evidence for their
use. However many drugs have also been disgarded because of lack of evidence for efficiency. One must always
remember that although drugs can be very useful during a cardiac arrest, good chest compressions and adequate
Adrenaline
Indications
Dose
3mg (diluted to 10-20mls with sterile water endotracheally every 3-5 mins if IV / IO access is unavailable)
Actions
Adrenaline is a naturally occurring sympathomimetic that possesses both alpha (α) and beta
(β) adrenergic agonist activity. α1 and α2stimulation leads to marked peripheral vasoconstriction and a subsequent
increase in systemic vascular resistance. This, in turn, leads to an increase in both cerebral and coronary perfusion. In the
beating heart, stimulation of β1 receptors leads to increased force and rate of contraction of the heart which can have a
negative impact on the situation by increasing myocardial oxygen demand, thus increasing the risk of
myocardial ischaemia. However, β-adrenergic stimulation may enhance cerebral blood flow.
Adrenaline is arrhythmogenic. After successful resuscitation, adrenaline can induce ventricular fibrillation (VF).
Amiodarone
Indications
300mg IV
Use
The major, acute, side effects of amiodarone are bradycardia and hypotension. Use of amiodarone should be considered
Actions
Amiodarone is a Vaughan-Williams class III anti-arrhythmic agent that has many actions, many of which are not fully
understood. It acts as a membrane stabilising drug and it increases the duration of both the action potential and the
refractory period in both atrial and ventricular myocardium. Amiodarone is also mildly inotropic and and causes peripheral
Adenosine
Atropine
Glucagon
Indications
Beta-blocker overdose
Magnesium
Indications
Dose
2g IV over 10 minutes
Use