Cardiac Arrest

• Epinephrine    

  • Cardiac Arrest (Asystole, PEA, Vfib, Vtach without a pulse)

  • Given during cardiac arrest to improve coronary and cerebral perfusion. As a vasoconstrictor and inotropic agent, it helps improve the chances of obtain ROSC (Return of Spontaneous Circulation)

  • Dose: 1 mg every 3-5 minutes IV/IO

• Calcium Chloride

  • Calcium plays an important role in myocardial cell membrane stability and contractility. 

  • It is given during cardiac arrest when certain issues are suspected such as Hyperkalemia, Hypocalcemia, and calcium channel blocker overdose. 

    • Hyperkalemia: High levels of potassium irritate the heart which can lead to deadly arrhythmias. Calcium stabilizes cardiac cell membranes. 

    • Hypocalcemia: Given to replace the needed calcium.

    • Calcium Channel Blocker OD: Calcium chloride helps counteract the effects on cardiac and smooth muscle cells by helping restore cardiac conduction, cardiac contractility, and prevent the vasodilation effects.

  • Adult Dose: 1g IV/IO (10ml of a 10% calcium chloride solution) 

• Sodium Bicarbonate

  • During cardiac arrest it is given to help treat the severe metabolic acidosis since acidosis impairs cardiac function and cellular metabolism. By counteracting the acidosis, we are helping improve the chances of obtaining ROSC (Return of Spontaneous Circulation)

  • Adult Dose: 50mEq (50 ml of an 8.4% Sodium Bicarb)

• Amiodarone

  • An antiarrhythmic used during cardiac arrest for ventricular fibrillation and ventricular tachycardia without a pulse. 

  • Prolongs the action potential and refractory period of cardiac cells. Vfib and Vtach without a pulse are essentially rhythms where the ventricles are very excitable and irritable, by prolonging the action potential and the refractory period, it helps calm down cardiac cells (less irritable and less excitable). 

  • Adult Dose: 300mg IV, then if needed, a repeat 150mg. 

  • Note that if ROSC is obtain, an infusion of amiodarone should be initiated. 

• Lidocaine

  • An antiarrhythmic used during cardiac arrest for ventricular fibrillation and ventricular tachycardia without a pulse. 

  • It blocks sodium channels in cardiac cells which help slow down conduction and ultimately stabilize cardiac cell membranes as a result. 

    • Remember that during the action potential, there is depolarization and repolarization. Depolarization is started by the influx of sodium, and the faster this occurs, the more excitable or irritable the cell can be. By slowing it down, you are essentially calming it down. 

  • Adult Dose: 1 to 1.5 mg/kg IV/IO then if needed a repeat of 0.5 to 0.75 mg/kg IV/IO

• Magnesium Sulfate

  • Used in cardiac arrest to help treat torsades de pointes (Polymorphic ventricular tachycardia)

  • Magnesium is essential in helping cell membrane ion channels work well and when there is an imbalance, Polymorphic ventricular tachycardia results

  • Adult Dose: 2 g

  • If successful, an infusion/drip of magnesium should be started. 

• Narcan

  • Reversal of suspected opioid overdose

    • Opioid overdose will result in respiratory depression and ultimate arrest if left untreated

  • Adult Dose: 0.4 to 2 mg IV/IO/IN/IM (If there is no pulse, you will be doing 2mg IVP)

  • If successful, an infusion/drip should be started. 

  • High doses often lead to flash pulmonary edema and as a result a poor outcome. 

• Dextrose

  • Treatment of hypoglycemia 

  • Adult Dose: 25g (50 ml of a 50% dextrose solution) IV

  • If successful, continue to monitor glucose levels closely and if needed an infusion/drip should be started of D5 or D10

• IV Fluids

  • Normal Saline or Lactated Ringers

  • Used during cardiac arrest when needed to replenish intravascular volume. This can help improve perfusion and as a result increase the chances of obtaining ROSC. 

Other Medications

• Atropine 

  • Used in Symptomatic Bradycardia. It blocks parasympathetic stimulation of the heart (blocks the vagus nerve) and as a result improves conduction through the AV node. 

  • Adult Dose: 1mg every 3-5 minutes, max of 3mg

  • Note that atropine may not be effective in 3rd degree AV blocks. May still be ordered to give it by the provider, however, you should be preparing more adequate treatments like Transcutaneous Pacing 

• Adenosine 

  • Used in Supraventricular Tachycardia (SVT)

  • It has a very short half life of 10 seconds and works by blocking conduction through the AV node. This helps stop the rapid rhythm and allows the SA node to take over (as it should).

  • Given as a rapid IV push followed by a 20ml NS rapid flush to ensure it reaches the heart as again it has a very short half life of 10 seconds. 

  • Adult Dose: 6mg IVP, if not successful followed by 12mg IVP.