ACLS Question here

[palmer1121]

Ok so I finished ACLS tuesday and have a question....

Hypothetical Scenario:

Working a V-FIb arrest. You have good CPR in place, Airway is controlled, Shocks per ACLS, EPI every 3-5m. You have given your 300 mg first dose and 150 mg second dose of Amio, and you get ROSC.

My question is: You should hang a Amio maintenance drip per ACLS @ 1 mg/min. The recommended drip is 900mg Amio in 500ml D5W for a conc. of 1.8 mg/ml, administered through a 60 gtt set @ 33.3 drops per min. First off, my service does not carry enough Amio to mix this drip, and secondly 33.3 drops per min is gonna be hard to calculate. So would it be acceptable to mix 100 mg Amio in 100 ml for a conc of 1 mg/ml and give through a 10 gtt set @ 10gtts/min? This given drip would give you 100 mins of maintenance, which is more than enough to get you to the hospital in my area. Thoughts?

 

[usalsfyre]

If you must, yes. I'd rather see it run through a pump (how all medicated infusions should be run) or, baring that hung on a microdrip set run @ 60gtts/min. Reason being a macro drip is a very blunt instrument to be delivering meds with.

It's really time states started requiring IV pumps if infusions are in protocols.

 

[Veneficus]

Personally,

If a 10gtts made the math easier for me, I would go with it.

Is it as accurate as a 60? who knows? But most emergency medications have a margin of error built into the dosing.

There are a couple of things wrong I find with mandating pumps.

The first is, once providers replace a skill with technology, they lose the skill. Then if they are required to function without it, they are useless.

To preserve the ability of working in austere environments and conditions, we were required to learn all kinds of "old school" ways of performing various tests and physical exams. I very much agree with that and think that EMS providers of all people should be required also as "out of hospital" experts.

That is one of the reasons I always go off the deep end everytime some cretin thinks in order to function as a physician it requires all kinds of technology driven gadgets in a hospital. A case of providers really not knowing what they don't know.

The second reason is that I have found preset dosing on the pumps to often fall into the minimm dose. Call me pessimistic, But I am willing to bet that many providers would fall into the trap of going with the preset dosing, rather than calculate the dose and then set the pump because it removes the math component entirely.

 

[palmer1121]

That is exactly my thinking in using the 10 gtt set. At 0300, running on 2 hours sleep it will be a lot easier to set up/calculate than the formula given in the ACLS book

 

[Farmer2DO]

Also remember amiodarone's half life. From an article in American Family Physician, the half life is 58 DAYS. Here's the link to an article:

http://www.aafp.org/afp/2003/1201/p2189.html

Also remember that amiodarone is cleared by the liver. In these patients, especially in the immediate post arrest period, I doubt the liver is going to be functioning 100%, after being underperfused.

In our protocols, we only worry if transport after ROSC is greater than 20 minutes, and then we load an addtional 150 mg over 10 minutes. The big question is, how long are your transport times? We have been told not to worry about the maintainance infusion, as the half life is so long, it's something the hospital can worry about after you get there.