Pharmacology and Electrical Therapy
Arrest and periarrest drugs
- Epinephrine: 1 mg IV/IO of the 1:10,000 (0.1 mg/mL) concentration every 3–5 minutes in arrest; 2–10 mcg/min infusion for bradycardia or shock. The 1:1000 concentration is for IM anaphylaxis, not arrest.
- Amiodarone: 300 mg bolus in refractory VF/pVT, then 150 mg; 150 mg over 10 minutes for stable VT.
- Lidocaine: 1–1.5 mg/kg, then 0.5–0.75 mg/kg.
- Magnesium sulfate: 1–2 g for torsades de pointes.
- Atropine: 1 mg, up to 3 mg total, for symptomatic bradycardia.
- Adenosine: 6 mg then 12 mg, rapid push with immediate flush.
- Dopamine: 5–20 mcg/kg/min. Naloxone for suspected opioid toxicity. Calcium and sodium bicarbonate have narrow indications (hyperkalemia, calcium-channel-blocker overdose, tricyclic overdose) - not routine in arrest.
Electrical therapy
Defibrillation is unsynchronized: biphasic 120–200 J per manufacturer recommendation, or 360 J monophasic, for VF/pVT. Synchronized cardioversion uses lower energy: 50–100 J for narrow regular rhythms such as SVT and flutter, 120–200 J for atrial fibrillation, and 100 J for monomorphic VT with a pulse. Safety for every shock: announce and confirm "clear," stop compressions, remove oxygen sources and transdermal patches, dry the chest, and ensure no one is touching the patient or bed.
Traps
Mix-ups between 1:10,000 and 1:1000 epinephrine. Shock energy answers that ignore the rhythm. Delivering a synchronized shock to VF. Pacing without confirming mechanical capture.
Rule of thumb
Shock the dead (unsynchronized), sync the living. Escalate energy if the first shock fails.