• Class: Electrolyte replacement /Alkalizing Agent
• MOA: Counteracts existing acidosis
• Indications: Acidosis, Drug intoxications (barbiturates, salicylates, methyl alcohol)
• Contraindications:  Metabolic alkalosis, hypocalcemia
• Side effects: metabolic alkalosis, hypernatremia, injection site reaction, sodium and fluid retention, peripheral edema.

• Dosing 

Metabolic acidosis during cardiac arrest 

Adult:1 mEq/kg slow IV/IO may repeat at 0.5 mEq/kg in 10 mins

Pedi:SAA

• Trade- Xylocaine
• Class – Antiarrhythmic / NA+ blocker
• MOA – blocks sodium channels increasing the recovery period after repolarization. Suppresses automaticity in the His-Purkinje system and depolarization in the ventricles.
• Indication – Ventricular arrhythmias
• Contraindications - AV block, Bleeding, thrombocytopenia, Use caution in bradycardia, hypovolemia, cardiogenic shock, adams stokes syndrome, WPW
• Side effects – Toxicity ( signs may include anxiety, apprehension, euphoria, nervousness, disorientation, dizziness, blurred vision, facial paresthesias, tremors, hearing disturbances, slurred speech, seizures, sinus bradycardia.) Seizures without warning, cardiac arrhythmias, hypotension, cardiac arrest, pain at injection site. 
• Dosing 

Pulseless v- tach and v-fib

Adult: – 1-1.5mg/kg IV/IO may repeat at half the original dose (0.5 to 0.75mg/kg) every 5-10 mins to a max dose of 3mg/kg. 

Maintenance drip 1-4mg/min

Pedi:  1mg/kg IV/IO (max 100mg) 

Maintenance

20-50 mcg/kg/min

Perfusing ventricular rhythms 

Adult: 0.5-0.75mg/kg IV/IO repeat every 5-10mins to a max dose of 3mg/kg

Pedi: 1mg/kg IV/IO may repeat every 5-10 mins to a max of 3mg/kg

• •Trade – Cordarone
• •Class – Antiarrhythmic
• •MOA - Acts directly on the myocardium to delay repolarization and increase the duration of action potential 
• •Indications – Ventricular arrhythmias, second line for atrial rhythms.
• •Contraindications – Sick sinus syndrome, second and third degree heart block, cardiogenic shock, when episodes of bradycardia have cause syncope, sensitivity to benzyl alcohol and iodine.
• •Side effects – Burning at the IV site, hypotension, bradycardia. 
• •Dosing

Ventricular Fibrillation, and Pulseless Ventricular Tachycardia 

Adult: 300mg IV/IO followed by 150mg in 3-5 mins 

        1mg/min maintenance infusion after ROSC

Pedi: 5mg/kg max dose 300mg may repeat 5mg/kg up to 15mg/kg

Stable Wide Complex Tachycardia

Adult: 150mg over 10 mins. 

Pedi: 5mg/kg IV/IO over 20-60 mins

• Class- Antidote 
• Description- Calcium chloride increases myocardial contractile force and increases ventricular automaticity.
• Indications-Hyperkalemia, hypocalcemia, hypermagnesemia, and calcium channel blocker toxicity.
• Contraindications-Ventricular fibrillation, hypercalcemia, and possible digitalis toxicity.
• Precautions- It may precipitate toxicity in patients taking digoxin. Ensure the IV line is in a large vein and flushed before using and after calcium
• Dosing Adult 

Bradycardia of Suspected Hyperkalemia  

Adult: 1G IV, IO over 5-10mins

Cardiac Arrest of Suspected Hyperkalemia

Adult: 1G IV IO

Hyperkalemia

 Adult: 1G IV/IO may repeat after 5 mins

• Trade – Adenocard 
• Classification – Antiarrhythmic 
• MOA– Slows the conduction of electrical impulses at the AV node
• Indication – SVT
• Contraindications – Sick sinus syndrome, second or 3rd degree heart block, Poison/drug induced tachycardia, asthma, or bronchospasm 
• Side Effects– Sense of impending doom, complaints of flushing, chest pressure, throat tightness, numbness, brief period of asystole after administration. 
• Dosing 

Adult:  6mg rapid IV/IO followed by a rapid saline flush; If rhythm doesn’t break in 1-2 minutes 2nd dose of 12mg RAPID IV/IO followed by saline flush

Pediatric:

Greater than 110 pounds SAA

Less than 110 pounds initial dose 0.1mg/kg IV/IO (max 6mg)  Followed by a rapid saline flush second dose if rhythm persists or reoccurs 0.2mg/kg (max 12mg) followed by a rapid saline flush.

• Trade – Calcium Gluconate 
• Class – Electrolyte solution 
• MOA – Counteracts the toxicity of hyperkalemia by stabilizing the membrane of the cardiac cells, reducing the likelihood of fibrillation 
• Indication – Hyperkalemia, hypocalcemia, hypermagnesemia 
• Contraindications - VF, Dig toxicity, hypercalcemia 
• Side effects – soft tissue necrosis, hypotension, bradycardia ( if administered rapidly)
• Dosing 

Adult: 500 to 1000mg IV/IO (packaged as 100mg/ml) administer 1-1.5 ml/min max dose 3G IV/IO 

Pedi: 60-100ml/kg IV/IO slowly over a 5-10 minute period maximum dose 3G IV/IO

• Trade– Lopressor, Toprol XL
• Class– Beta Blocker ( Class II antiarrhythmic) 
• MOA– Inhibits the strength of the hearts contraction as well as the heart rate
• Indication– ACS, HTN, SVT, atrial flutter, Afib, thyrotoxicosis 
• Contraindications– Cardiogenic Shock, AV Block, Bradycardia
• Side effects – Tiredness, dizziness, diarrhea, heart block, bradycardia, bronchospasm, drop in blood pressure.
• Dosing 

Adult: 5mg slow IV/IO over 2 minute period, Repeat at 5 minute intervals as necessary up to 15mg

Pediatric: Not Recommended 

• Trade – Cardizem 
• Class – Calcium channel Blocker ( class IV antiarrhythmic) 
• MOA – Blocks Calcium from moving into the heart muscle cell, which prolongs the conduction of electrical impulses through the AV node 
• Indication – Rapid atrial fibrillation 
• Contraindications – Hypotension, Heart block, heart failure 
• Side effects – Flushing, headache, bradycardia, hypotension, heart block, myocardial depression, severe AV block, at high doses cardiac arrest 
• Dosing 

Adult: 0.25mg/kg IV/IO 2nd dose of 0.35mg/kg IV/IO

Pediatric: Not recommended 

• Class – Anticholinergic 
• MOA – Competes reversibly with ACH at the site of the muscarinic receptor. 
• Indication – Symptomatic Bradycardia, asystole or PEA, Nerve agent exposure or organophosphate poisoning.
• Contraindications – Acute MI, Myasthenia Gravis, GI obstruction, closed angle glaucoma, known sensitivity to atropine, belladonna alkaloids, or sulfites. Atropine may not be effective on second degree type 2 and 3rd degree heart blocks.
• Side effects – decreased secretions resulting in dry mouth and hot skin, intense facial flushing, blurred vision or dilation of the pupils with photophobia, tachycardia and restlessness. Atropine may cause paradoxical bradycardia if the dose administered is too low or if it is administered too slowly. 
• Dosing 

Symptomatic Bradycardia 

Adult: 0.5mg IV/IO every 3-5 minutes to a maximum dose of 3mg

Pediatric: 0.02mg/kg  IV/IO up to a total dose of 2mg  

Nerve Agent or Organophosphate Poisoning 

Adult: 1-6mg IV/IM repeat every 5 minutes until symptoms dissipate 

Pediatric: 0.05mg/kg IV/IM every 10 – 30 minutes until symptoms dissipate