AHA Mega (and not so Mega) Code Meds

My brother was visiting the other day and found me studying in the morning.  He sat down across the table from me and asked, bemusedly, "Are you ever going to be done with school?"

Nah.  Nope.  Wrong career for that.  I decided to go into medicine, which means being in school for all perpetuity.  Also, do you not know me?  I'm the kid that just wants to know why.

In this case, I was studying for the AHA ACLS exam based off their 2015 Handbook of ER Cardiovascular Care.  This will be a series of posts where I vomit up everything I can remember from my crash course.

The main challenges:

1) A medications mixed up: atropine, adenosine, amiodarone.  I'll try to create little reminders for you, but I haven't really figured out a way to remember these except for repetition (literally, I took PALS, then TNCC, and now ACLS all within 6 months, so, seriously, repetition is all I've got).

2) How to remember which medications go with which EKG/scenario.  The flowcharts are very confusing.  It'll be easier to understand when I (re)break down EKGs in a different post that I'll link here later.  This is my cheat sheet just for medications.

3) When to use expert consult, when to use meds, when to use electricity?

Tachycardia with atrial involvement

Here are the main medications you need for tachycardia with a pulse and nonsymptomat (stable-nonsymptomatic): examples of this are a-fib or a-flutter <150bpm ventricular response.

Expert consultation and most likely Ca2+ blockers, B-Blockers, and anticoagulants.

Oftentimes this situation can deteriorate into tachy with a pulse and symptoms...

Here are the main medications you need for tachycardia with a pulse and symptoms (stable-symptomatic):

First give Adenosine 6 mg, then 12 mg if v-tach is refractory (refractory means it refuses to slow down).  Adenosine must be pushed fast, as in you don't have time to mess around with unscrewing a flush, etc.  Adenosine has to be given fast enough to cause a brief asystole.  You need to choose an IV site close to the heart, and use a stopcock mechanism.  Memory trick: I remember to use Adenosine to stop the heart because I must stop before I go into a lion's den.

(So, adenosine is given for symptomatic tachycardia involving the atria.)

Refractory after 12 mg adenosine?  Cardiovert.
Cardioversion joules:
Narrow and regular QRS (=SVT)? start at 50J, then work your way up to 100J.
Narrow irregular QRS (a-fib w/ RVR)? start with 120, then work your way up to 200J
If your QRS is wide and Irregular, you are in V-fib--immediately DFIB 120J and follow your algorithm for cardiac arrest with a shockable rhythm. Give epi 1 mg q 3-5 minutes alternating with 2 doses of amiodarone while continuing CPR and rescue breaths (300mg bolus first dose, then 150mg second dose--note: if you already started using amiodarone to slow down ventricular tachycardia, you will have to trade out these doses of amiodarone because of reasons and other reasons -- all of which I find unsatisfactory for my curiosity, but I don't have a better answer at this time).

I made the distinction of tachy with a pulse (sbp>=90mmhg) w/ or w/o symptoms b/c the test will make that distinction.  Stable, w/o symptoms=expert consultation.  Stable, w/ symptoms=medications.  Unstable= sedation, pain medication, cardioversion.

Tachycardia originating from the ventricles w/ a pulse and SBP>90 (stable)

If the QRS complexes are wide and you don't see p-waves, it's v-tachy originating from the ventricles.  The patient is, as my instructor jokingly said, "only half dead," so you only give 1/2 the amiodarone you would normally give for a totally dead (v-fib, pulseless v-tach) patient.  That is to say, give 150 mg amiodarone over 10 minutes by IV drip, and then synchronize cardiovert if the v-tach is refractory.

(So, amiodarone is used for tachycardias originating from/associated with ventricles.)

Here are the main medications you need for brady with a pulse:

Atropine: 0.5 mg q 3-5 min for a max total dose of 3mg (=6 doses)
Epi 2-10mcg/min infusion
Dopamine 2-20mcg/kg/min infusion

(I specifically placed epi and dopamine in this order b/c it helps me remember: 2-10 mcg/min first, then 2-20 mcg/kg/min, but in reality, you'd ask your doctor which medication they would like you to infuse.)

If refractory/severe bradycardia (like 3rd degree block), get consent if the patient is conscious, then give sedation and pain medication (fentanyl, morphine) and begin pacing @ 70ppm.  You may begin pacing before the patient is started on drips.

PEA/Asystole: Epi, epi, epi, epi, epi... with a lot of CPR, diagnose the underlying problem.