ACLS Medications – Study Notes

ACLS Overview

• ACLS = Advanced Cardiovascular Life Support (beyond BLS).

• Course is for nurses, physicians, respiratory therapists, pharmacists, and students.

• Medications/doses may vary by organization protocol. Always confirm with latest ACLS manual.

ACLS Drugs and Uses

1. Epinephrine

• First-line: Ventricular fibrillation (VF) & pulseless VT.

• Dose: 1 mg IV every 3–5 minutes during arrest.

• Increases coronary & cerebral perfusion.

• Rule of thumb: give every other cycle (≈4 minutes).

• Used in asystole & PEA (non-shockable rhythms).

• Moderate anaphylaxis: 0.3 mg IM (EpiPen).

2. Atropine

• First-line: Symptomatic bradycardia (HR < 50 with symptoms).

• Dose: 0.5 mg IV every 3–5 min, max 3 mg.

• Not recommended for asystole or PEA.

• Mechanism: inhibits vagus nerve → ↑ HR.

3. Adenosine

• For stable narrow-complex tachycardia (SVT) not responsive to vagal maneuvers.

• Mechanism: AV nodal blockade, interrupts reentrant pathways.

• Contraindicated in WPW with atrial fibrillation/flutter (may trigger VF).

4. Amiodarone

• For refractory VF/pulseless VT after shock + epinephrine.

• Initial dose (cardiac arrest): 300 mg IV push, second dose 150 mg.

• For stable wide-complex VT: 150 mg over 10 minutes, then maintenance infusion.

• First-line for stable monomorphic VT.

5. Lidocaine

• Alternative to amiodarone for ventricular arrhythmias.

• Max cumulative dose: 3 mg/kg.

6. Magnesium Sulfate

• First-line for Torsades de Pointes (TdP).

• Mechanism: stabilizes cardiac cell membranes.

7. Dopamine

• Indications:

  • Symptomatic bradycardia if atropine ineffective.

  • Severe hypotension when fluids fail.

  • Post-cardiac arrest for BP support.

• Infusion: 5–20 mcg/kg/min, titrate to effect.

8. Calcium Gluconate / Calcium Chloride

• Hyperkalemia: stabilizes cardiac membranes.

• Calcium channel blocker overdose: restores contractility.

9. Glucagon

• For beta-blocker overdose.

• Increases HR and contractility independent of beta-receptors.

10. Naloxone (Narcan)

• Adjunct in cardiac arrest due to opioid overdose.

• Given along with CPR & epinephrine.

11. Midazolam (Versed)

• Used to prevent shivering during therapeutic hypothermia after cardiac arrest.

Fluids in ACLS

• Normal saline (0.9% NaCl): preferred for initial resuscitation in hypovolemic arrest.

• Lactated Ringer’s: also isotonic but not compatible with many ACLS drugs during codes.

Special Cases

• WPW with atrial fibrillation/flutter: avoid AV nodal blockers (adenosine, verapamil, diltiazem, beta-blockers). Use amiodarone, procainamide, or lidocaine instead.

• Hyperkalemia-induced arrest: calcium gluconate (stabilizes cells), insulin + glucose, beta agonists, dialysis if severe.

Simplified Algorithm (Shockable rhythms – VF/pulseless VT)

1. CPR + Shock + IV/IO access.

2. Epinephrine 1 mg IV every 3–5 min.

3. Amiodarone 300 mg IV (or lidocaine).

4. Repeat cycles, continue shocks, reassess reversible causes (H’s & T’s).