Medications
The medications recommended by the American Heart Association for CPR change every time new guidelines are published, but this is not because the AHA can’t make up its mind as much as that the use of the ACLS medication protocol is based on experience, theory, and very thin research. As new evidence for and against certain medications surfaces, the protocols will continue to change. For now, the most recent recommended changes for each drug are below.
Atropine:
NO LONGER IN THE PEA/ASYSTOLE ALGORITHM.
In previous guidelines, atropine was partnered with epinephrine as the medications administered during CPR for asystolic patients and patients with electrical activity but no cardiac function. However, the B-agonist effects of atropine are already being provided by epinephrine, so there is no added benefit of giving another medication.
For Asystole/PEA, it's now just epinephrine 1 mg every 3-5 minutes and CPR, that’s it.
Atropine remains the drug of choice for temporizing bradycardic patients as a bridge to definitive treatment (trans-cutaneous, then trans-venous pacing). The dose of atropine in bradycardia is 0.5 mg (5ml) IVP every 3-5 minutes with a maximum dose of 3 mg (30 ml, 3 boxes). After the maximum dose of atropine has been given, all of the drug receptors in the body have been saturated, and there is no therapeutic benefit to giving any more atropine. Resist the urge to give more.
Adenosine:
Adenosine was already the first-line medication for supra-ventricular tachycardia, designed to be used to reset an uncontrolled tachycardia originating from above the ventricles. New guidelines place adenosine as the first-line drug of choice for all tachycardias with the idea being that differentiating a wide-complex tachycardia from a narrow-complex tachycardia is incredibly difficult. If the tachycardia is originating from below the AV node (within the ventricle), then adenosine won’t have an effect but it also won’t hurt the patient.
The dosing for adenosine hasn’t changed; the first dose is 6 mg (2 ml), the second and third doses are 12mg (4 ml). Adenosine must be given IV push in the port closest to the patient, and must immediately be followed by a 20 ml bolus of normal saline given as an IV push.
