Medications Used in Post-Cardiac Arrest Patients
In post-cardiac arrest patients, vasopressors (epinephrine or norepinephrine) and antiarrhythmic drugs (amiodarone or lidocaine) are the primary medications used to support circulation and prevent recurrent arrhythmias, though none have demonstrated improved long-term survival or neurological outcomes. 1
Vasopressors for Hemodynamic Support
Epinephrine (1 mg) is the primary vasopressor used during cardiac arrest resuscitation and may improve ROSC and short-term survival, but has not been shown to improve long-term survival or neurological outcomes 1
Norepinephrine (0.5-1.0 mcg/kg/min) may be preferred for post-ROSC hemodynamic support as it is associated with 63% lower odds of recurrent cardiac arrest compared to epinephrine 2
Dopamine (5-10 mcg/kg/min) can be used to treat hypotension, especially if associated with symptomatic bradycardia 1
Dobutamine (5-10 mcg/kg/min) is indicated for patients with low cardiac output after ROSC 1
Milrinone (loading dose 50 mcg/kg over 10 minutes, then 0.375 mcg/kg/min) may be used to treat low cardiac output with potentially less tachycardia than dobutamine 1
Antiarrhythmic Medications
Amiodarone may be considered for patients with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) during cardiac arrest, though it has not been shown to improve long-term survival 1
Lidocaine is an alternative to amiodarone for shock-refractory VF/pVT, with similar efficacy profiles 1
There is insufficient evidence to support or refute the routine prophylactic use of lidocaine early (within the first hour) after ROSC 1
In specific circumstances (such as during emergency medical services transport), prophylactic lidocaine may be considered to prevent recurrent arrhythmias 1
β-blockers have insufficient evidence to support their routine use early after ROSC, despite some observational data suggesting potential benefit 1
Sedatives and Analgesics
Propofol may be used for sedation in post-cardiac arrest patients, but requires careful dosing due to potential for hypotension, especially in hemodynamically unstable patients 3
Midazolam can be used for sedation but requires careful titration due to risk of respiratory depression, particularly when combined with opioids 4
Fluid Management
IV fluids are commonly used as part of post-cardiac arrest care, though there is insufficient evidence to support or refute their routine use 1
Rapid infusion of cold 0.9% saline or lactated Ringer's solution appears to be well-tolerated when used to induce therapeutic hypothermia 1
Important Clinical Considerations
Hemodynamic optimization should target a mean arterial pressure of approximately 65 mmHg and a central venous oxygen saturation (ScvO2) of 70% 1
Fluid administration and vasoactive/inotropic agents should be titrated to optimize blood pressure, cardiac output, and systemic perfusion 1
Hyperthermia after cardiac arrest is associated with worse outcomes and should be treated if it occurs 1
There is insufficient evidence to support routine use of mechanical circulatory support in post-cardiac arrest patients with cardiovascular dysfunction 1
Common Pitfalls to Avoid
Delaying epinephrine administration in non-shockable rhythms (PEA/asystole) - it should be administered as soon as feasible 5
Routine administration of calcium or sodium bicarbonate is not recommended in cardiac arrest patients unless specifically indicated for identified causes (e.g., hyperkalemia, tricyclic antidepressant overdose) 5, 6
Excessive fluid administration may worsen myocardial dysfunction in post-cardiac arrest patients 1
Overuse of sedatives without appropriate monitoring can lead to respiratory depression, especially when combined with opioids 4
Failure to monitor for and treat hyperthermia, which is associated with worse outcomes 1