Pharmacology and Vascular Access in Resuscitation
Core arrest drugs
Epinephrine is the only drug shown to improve outcomes in arrest: 1 mg IV/IO of the 0.1 mg/mL (1:10,000) concentration, repeated every 3–5 minutes. For a non-shockable rhythm give it as soon as feasible; for VF/pulseless VT give it after the second shock. For refractory VF/pulseless VT, amiodarone 300 mg bolus then 150 mg, or lidocaine 1–1.5 mg/kg then 0.5–0.75 mg/kg, may be given after the second or third shock. For stable narrow-complex SVT, adenosine 6 mg rapid push then 12 mg. For symptomatic bradycardia, atropine 1 mg every 3–5 minutes to a maximum of 3 mg. Magnesium is used for torsades de pointes.
Access and administration
Establish IV access; if peripheral IV fails or cannot be obtained quickly, place an intraosseous line (proximal tibia is typical). Flush every drug with about 20 mL of saline and elevate the limb to speed delivery. Give drugs during compressions rather than pausing CPR, and keep the rhythm check pause short.
Traps
Questions test the concentration - giving 1 mg of 1:1000 instead of 1:10,000 is a classic error. Routine sodium bicarbonate and calcium are not recommended; reserve bicarbonate for hyperkalemia or tricyclic overdose and calcium for hyperkalemia, hypocalcemia, or calcium channel blocker toxicity. Do not give amiodarone before defibrillation attempts, and do not stop compressions to push a drug.
Rule of thumb
Epinephrine belongs to every arrest rhythm; defibrillation and CPR come first for shockable rhythms - the drug supports the shock, it does not replace it.