Drugs for Cardiac Arrest

OVERVIEW

This page is a collection of the Australian Resuscitation Council recommended medications in Cardiac Arrest (see ANZCOR Guidelines 11.5, 12.2, 13.7) with some additional medications, dosing advice, and administration advice, using the best available evidence or professional guidelines.

While the listed drugs have theoretical benefits in selected situations, no medication has been shown to improve long-term survival in humans after cardiac arrest. Priorities are defibrillation, oxygenation and ventilation together with external cardiac compression.

ANZCOR

DISCLAIMER

• It is the clinician’s responsibility to check that the right medication and the right dose for the right patient is given at the right time
• Click on the drug name to be taken to LITFL page with further information about that drug and evidence (or lack thereof) regarding its use

ROUTES OF ADMINISTRATION

• Intravenous (IV)
  • Preferred route
  • Avoid (where possible) the use of lower limb veins due to impairment of venous return below the diaphragm in cardiac arrest
  • Follow drug administration with at least 20-30 mL of fluid (in adults) and ongoing cardiac compressions
  • If a central line is present, it should be used
  • In newborns an umbilical vein catheter is the suggested route
• Intraosseous (IO)
  • Preferred if IV not available
  • Suitable for fluid resuscitation, drug delivery (at the same doses), and laboratory evaluation (do yourself a favour, and don’t try to run a blood gas from the IO through your analyser)
• Endotracheal (ET)
  • If IV/IO cannot be attained, and an ETT is present, administration of SOME medications is possible, with variable absorption
  • Give 3-10x the dose diluted in 10 mL of water to aid in absorption
  • The only drugs recommended are: Adrenaline, lignocaine, and atropine
  • Other drugs may cause mucosal and alveolar damage
  • This is NOT recommended if a laryngeal mask airway (LMA) is present
• Intracardiac
  • Just don’t do it. John Travolta might have done it, but it doesn’t mean you should “Pulp Fiction” the patient!

Drugs used in cardiac arrest

For antidotes please see: https://litfl.com/antidotes-summary/ and https://litfl.com/tox-library/antidotes/

ADRENALINE

• Indication: Patients in cardiac arrest
• Dose:
  • Adults: 1 mg (1 mL of 1:1000, or 10 mL of 1:10 000) via IV or IO / ETT consider doses 3-10x of IV (i.e. 3 – 10 mg)
  • Paeds: 10 μg/kg IV or IO [max 1mg] // ETT consider doses 3-10x of IV (i.e. 30-100 μg/kg)
  • Newborn: 10-30 μg/kg (0.1 to 0.3 mL/kg of a 1:10 000 solution) IV / 50-100 μg/kg (0.5-1 mL/kg of a 1:10 000 solution) via ETT [max 1mg]
• Frequency:
  • VF/VT after 2^nd shock, then every 2^nd loop
  • PEA/Asystole in initial loop, then every 2^nd loop
• MoA: Naturally occurring catecholamine with alpha and beta effects
• Adverse effects: Tachyarrhythmias, severe hypertension, tissue necrosis in extravasation
• Contraindications: Care should be used in CALS (Cardiac Surgery Advanced Life Support), administer on senior clinician advice only, with smaller aliquots such as 50 μg (adults). Please refer to your local CALS protocols.
• Administration advice:
  • 1 mL of 1:1000 = 1 mg / 1000 μg
  • 1 mL of 1:10 000 = 100 μg
  • 1 mL of 1:100 000 = 10 μg
  • Consider drawing up infusion for post-arrest care, a quick way is to add 1mL of 1:1000 (1 mg) to a 100 mL bag of 0.9% saline which would make 1:100 000 concentration or 1 mL = 10 μg (also useful for small bolus administration)

ALTEPLASE

• Indication: Suspected or confirmed massive pulmonary embolus as cause of cardiac arrest
• Dose:
  • Adults: 50 mg IV/IO and strap in for 60-90 mins of CPR after administration. Could consider further bolus of 50 mg.
• Frequency: Bolus initial dose, consider second dose
• MoA: Recombinant tissue plasminogen activator (rt-PA), thrombolytic
• Adverse effects: Bleeding, anaphylaxis, intracranial haemorrhage
• Contraindications: Prehospital use in cardiac arrest, trauma and active bleeding. Relative contraindications: recent surgery, prolonged CPR etc.
• Administration advice: White powder for reconstitution with sterile water, also compatible with 0.9% saline, it will precipitate in 5% dextrose. Don’t shake while mixing.

AMIODARONE

• Indication: Shock-resistant VF and pulseless VT
• Dose:
  • Adults: 300 mg IV/IO for initial dose, consider 150 mg as repeat dose, and then infusion of 15 mg/kg over 24 hours
  • Paeds: 5 mg/kg IV/IO [max 300mg]
• Frequency: Between the 3^rd and 4^th shock,consider further dose
• MoA: Class III antiarrhythmic with effects on sodium, potassium and calcium channels
• Adverse effects: Hypotension, bradycardia, heart block, tissue necrosis in extravasation
• Contraindications: Rare to have contraindications in cardiac arrest, however caution with WPW (case report of spontaneous VF, however if using for VF or VT, may as well crack on) or patients with 2^nd or 3^rd degree heart block (get ready to pace)
• Administration advice: Must be administered in 5% dextrose, otherwise will precipitate in saline, remember to also administer flush with 5% dextrose

CALCIUM

• Indication: Hyperkalaemia, hypocalcaemia, hypermagnesaemia, overdose of calcium channel blockers
• Dose:
  • Adults:
    • Bolus dose of 5-10 mL of 10% calcium chloride for hyperkalaemia / hypocalcaemia
    • In calcium channel blocker overdose give 20 mL of 10% calcium chloride IV/IO
  • Paeds:
    • Bolus dose of 0.2 mL/kg of 10% calcium chloride (=0.136 mmol/kg) for hyperkalaemia / hypocalcaemia / calcium channel blocker overdose (OR 0.7mL/kg of calcium gluconate)
• Frequency: Every 10-15 mins as required guided by blood gases or QT interval on ECG, or up to 3x in calcium channel blocker toxicity
• MoA: Is an essential cation for normal muscle and nerve activity
• Adverse effects: Possible increase in myocardial and cerebral injury by mediating cell death, tissue necrosis with extravasation
• Administration advice:
  • Administer over 5-10 mins if ROSC, otherwise bolus if in cardiac arrest
  • Calcium chloride 10 mL of 10% = 6.8 mmol or 0.68 mmol/mL
  • Calcium gluconate 10 mL of 10% = 2.2 mmol or 0.22 mmol/mL

FLUIDS

• 10-20 mL/kg (Paeds and Adults) of isotonic crystalloid 0.9% saline or Hartmann’s solution, replace blood loss with blood (and other blood products)

LIGNOCAINE (LIDOCAINE)

• Indication: For shock refractory and/or amiodarone refractory VT/VF
• Dose:
  • Adults:
    • 1 mg/kg bolus IV/IO, addition bolus of 0.5 mg/kg may be administered IV/IO, 2-3x dose via ETT.
    • Infusion: 1-4 mg/min do not commence prior to ROSC.
  • Paeds:
    • 1 mg/kg IV/IO. 2-3x the dose via ETT.
• Frequency: Bolus initial dose, consider second dose after 5minutes, and can consider infusion in refractory VT
• MoA: Class IB antiarrhythmic, sodium channel blocker
• Adverse effects: Neurological effects such as slurred speech, altered consciousness, muscle twitching and seizures; cardiovascular such as hypotension, bradycardia, heart block, asystole
• Contraindications: Relative in heart failure and liver failure
• Administration advice:
  • Most commonly recommended infusion: 1-4 mg/min after ROSC for up to 24 hours (use the lowest possible rate that controls the arrhythmia)
  • One way to administer such an infusion:
    • 4 mg/min for 1 hour, then 2 mg/min for 1 hour, then 1 mg/min for 22 hours
    • If using 1% lignocaine: 24 mL/hour (240 mg/h) for 1 hour, then 12mL/h (120mg/h), then 6 mL/h (60 mg/h)
  • Lignocaine 1% = 10 mg/mL
    • Commonly presented in 5 mL ampoules = 50 mg in 5 mL
  • Lignocaine 2% = 20 mg/mL
    • Commonly presented in 5 mL ampoules = 100 mg in 5 mL
  • Avoid administration in the same cannula with sodium bicarbonate

MAGNESIUM

• Indication: Torsades de pointes, digoxin toxicity, VF/pulseless VT, documented hypokalaemia or hypomagnesaemia
• Dose:
  • Adults: Boluses of 5 mmol IV/IO (5mmol = 1.2g of Magnesium sulphate)
  • Paeds: Boluses of 0.1-0.2 mmol/kg IV/IO
• Frequency: May repeat bolus once. Adults: followed by infusion of 20 mmol over 1-4 hours. Paeds: followed by infusion of 0.3 mmol/kg over 4 hours.
• MoA: Essential electrolyte for membrane stability, and essential cofactor in enzyme systems
• Adverse effects: Muscle weakness and respiratory failure
• Administration advice:
  • Administer boluses over 1-2 mins
  • 2.47 g = 10 mmol of magnesium sulphate heptahydrate
    • 1 mmol = 0.247 g
    • 1 g = 4 mmol / 2 g = 8 mmol / 4g = 16 mmol / 6 g = 24 mmol
  • Incompatible with: Calcium chloride, sodium bicarbonate, potassium phosphate

OXYGEN

• Administer 100% FiO2 during cardiac arrest
• Hyperoxaemia can be harmful after ROSC
• Titrate to SpO2 94-98%

SODIUM BICARBONATE

• Indication: Hyperkalaemia, metabolic acidosis, TCA overdose, protracted cardiac arrest
• Dose:
  • Adults: 1 mmol/kg IV/IO
  • Paeds: 0.5-1 mmol/kg IV/IO
• Frequency: As guided by blood gases.
• MoA: It is an alkalising solution that combines with hydrogen ions to form a weak carbonic acid -> breaks down to CO₂ and H₂O
• Adverse effects: Metabolic alkalosis, hypokalaemia, hyperosmolality (secondary to sodium load), intracellular acidosis may develop (as CO2 shifts intracellularly)
• Contraindications: Hypokalaemia
• Administration advice:
  • Give over 1-2 mins
  • ANZCOR recommends NOT to give routine sodium bicarbonate in paediatric arrests unless for hyperkalaemia or TCA overdose
  • Requires good ventilation to blow off CO2 produced from same (as able)
  • May inactivate adrenaline or calcium if administered in the same IV line, may also precipitate and result in loss of a precious IV line during the arrest.
  • The 8.4% bottles of sodium bicarbonate provide 1 mmol/mL of sodium and bicarbonate
  • To quickly prepare an isotonic preparation; dilute 150 mmol of sodium bicarbonate (150 mL of the 8.4% stuff) into 850 mL of 5% dextrose (remove 150 mL prior, otherwise you won’t fit the 150 mL in)
  • Sodium bicarbonate is not compatible with a number of medications nor Hartmann’s fluid (anything that contains calcium or magnesium salts)

NOT CURRENTLY RECOMMENDED BY ANZCOR IN ALS

• Aminophylline (for brady-asystolic cardiac arrest)
• Atropine
• Vasopressin
• Corticosteroids

EVIDENCE

Norwegian RCT (Olasveengen, JAMA 2009)

• IV drug administration vs no drug administration -> increases short-term survival but no difference in hospital discharge, quality of CPR or long-term survival (1 year)

See ILCOR CoSTR via: http://ilcor.org [Free webpage access here]

References and Links

• British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. (2003). Thorax, 58(6), 470-483. doi: 10.1136/thorax.58.6.470 [Free Full Text]
• Collinsworth, K., Kalman, S., & Harrison, D. (1974). The Clinical Pharmacology of Lidocaine as an Antiarrhythymic Drug. Circulation, 50(6), 1217-1230. doi: 10.1161/01.cir.50.6.1217 [Free Full Text]
• Kirmani, B., 2012. The cardiac surgery advanced life support course. 3rd ed. [Raleigh, N.C.]: [Lulu.com].
• Lidocaine CV, Lidopen (lidocaine) dosing, indications, interactions, adverse effects, and more. (2022). Retrieved 13 August 2022, from https://reference.medscape.com/drug/lidocaine-cv-lidopen-342302
• Manisterski, Y., Vaknin, Z., Ben-Abraham, R., Efrati, O., Lotan, D., & Berkovitch, M. et al. (2002). Endotracheal Epinephrine: A Call for Larger Doses. Anesthesia & Analgesia, 95(4), 1037-1041. doi: 10.1097/00000539-200210000-00045
• Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009 Nov 25;302(20):2222-9. doi: 10.1001/jama.2009.1729. PubMed PMID: 19934423.
• Resus.org.au. 2016. ANZCOR Guideline 11.5 – Medications in Adult Cardiac Arrest. [online] Available at: <https://resus.org.au/download/section_11/anzcor-guideline-11-5-medications-august-16.pdf> [Accessed 13 August 2022].
• Resus.org.au. 2021. ANZCOR Guideline 12.2 – Paediatric Advanced Life. [online] Available at: <https://resus.org.au/download/section_12/anzcor-guideline-12-2-paediatric-advanced-life-support-pals-nov-2021.pdf> [Accessed 13 August 2022].
• Resus.org.au. 2021. ANZCOR Guideline 13.7 – Medications or Fluids for the Resuscitation of the Newborn. [online] Available at: <https://resus.org.au/download/section_13/anzcor-guideline-13_7-april-2021.pdf> [Accessed 13 August 2022].
• Soar J, Donnino MW, Andersen LW, Berg KM, Böttiger BW, Callaway CW, Deakin CD, Drennan I, Neumar RW, Nicholson TC, O’Neil BJ, Paiva EF, Parr MJ, Reynolds JC, Ristagno G, Sandroni C, Wang TL, Welsford M, Nolan JP, Morley PT. Antiarrhythmic Drugs for Cardiac Arrest in Adults and Children Consensus on Science and Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2018 May 30. Available from: http://ilcor.org [Free webpage access here]

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