Adrenaline and amiodarone dosages in resuscitation: Rectifying misinformation
M Botha, M Wells and L
Dickerson are from the Division of Emergency Medicine,
University of the Witwatersrand, Johannesburg, South Africa.
L Wallis and M Stander are from the Divisions of
Emergency Medicine, University of Cape Town and University of
Stellenbosch, South Africa. The authors are members of the
Advocacy for Resuscitation Research Education Science and
Training (ARREST) Special Interest Group of the Emergency
Medicine Society of South Africa (EMSSA).
Despite the recognition of specialists in emergency medicine
and the professionalisation of prehospital emergency care,
international guidelines and consensus are often ignored, and
the lag between guideline publication and translation into
clinical practice is protracted. South African literature should
reflect the latest evidence to guide resuscitation and safe
patient care. This article addresses erroneous details regarding
life-saving interventions in the South
African Medicines Formulary, 10th edition.
S Afr Med J 2013;103(10):713-714.
Until recently, training and education in resuscitation have
received little attention in South Africa (SA). Despite the
recognition of specialists in emergency medicine and the
professionalisation of prehospital emergency care, international
guidelines and consensus are often ignored and the lag between
guideline publication and translation into clinical practice is
protracted. South African literature should reflect the latest
evidence to guide resuscitation and safe patient care. However,
in the current South African Medicines
detail regarding these life-saving interventions is missing and
erroneous, and incongruent with current international consensus.
Most drugs that are commonly used during the management of
cardiac arrest are reported incorrectly.
Adrenaline in cardiac arrest
The SAMF advocates ‘IV injection, 1 mg (10 ml 1:10 000) every 5 cycles of CPR’ in an adult patient. This statement is incorrect. Five cycles of cardiopulmonary resuscitation (CPR) implies five cycles of 30 compressions followed by 2 ventilations. If performed at the required rate and efficiency, these 5 cycles would be complete in 2 minutes. Giving adrenaline every 2 minutes is double the dose recommended by the international guidelines; the use of ‘mega-dose’ adrenaline is potentially harmful and should not be used. The administration of 1 mg intravenous (IV)/intraosseous (IO) adrenaline is reasonable every 3 - 5 minutes during adult cardiac arrest.2 , 3]
For paediatric cardiac arrest, the SAMF correctly recommends adrenaline at 0.1 ml/kg/dose of a 1:10 000 solution; however, this should be given every 3 - 5 minutes rather than the 5 - 15 minutes cited.1 , 4 Furthermore, the SAMF prescribes an IV infusion of 0.1 - 1 mcg/kg/minute as an alternative in cardiac arrest. IV bolus administration is the preferred practice.4
Adrenaline for asthma and anaphylaxis
According to the SAMF, adrenaline
can be administered slowly via the IV route using 3 - 5 ml of a 1:10 000 solution (1 mg/10 ml) in asthma and
acute anaphylaxis. This is extremely unsafe. For patients not in
cardiac arrest, an IV adrenaline bolus dose of no more than 0.05
-0.1 mg is recommended;5 the SAMF suggests a much larger dosage
which is not supported by any international guideline.
Amiodarone in cardiac arrest
The SAMF states that ‘in acute
resuscitation, slow IV boluses of 150 mg
may be given.’ This statement is not in accord with the
International Liaison Committee on Resuscitation (ILCOR) and
American Heart Association (AHA) treatment recommendations. If
amiodarone is administered for refractory ventricular
fibrillation or pulseless ventricular tachycardia, then a 300 mg bolus should be given 2
minutes after the first adrenaline dose. Should the patient
remain in a shockable rhythm following a further 2 minutes of
CPR, a defibrillation shock, another adrenaline dose, and
another 2 minutes of CPR (5 cycles of 30:2), then a further 150 mg IV amiodarone may be
Atropine in asystole
The SAMF states that atropine may
be administered to patients in asystole. This has not been part
of the ILCOR recommendations since 2010. It should not be used.
The SAMF is a well-respected
benchmark and vade mecum for the
SA healthcare provider. It is vital that the text is correct,
contemporary and follows international clinical guidelines to
ensure consistent and safe patient care, particularly in the
management of patients in extremis.
Response from the editors of the SAMF
Dawn Rossiter, Editor of the SAMF, and Marc Blockman, the Managing Editor, note the statement from the ARREST Special Interest Group of EMSSA.
Recommendations from the 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care2 will be reflected in the next edition due for publication in January 2014.
The aim of the SAMF is to promote
safe and rational drug therapy, and we welcome all comments and
1. Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town. South African Medicines Formulary. 10th ed. Rossiter D, ed. Cape Town: Health and Medical Publishing Group, 2012:132-135.
2. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S729-S767. [http://dx.doi.org/10.1161/CIRCULATIONAHA.110.970988]
3. Deakin CD, Morrison LJ, Morley PT, et al. Part 8: Advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81(Suppl 1):e93-e174. [http://dx.doi.org/10.1016/j.resuscitation.2010.08.027]
4. de Caen AR, Kleinman MER, Chameides L, et al. Part 10: Paediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81:e213-e259. [http://dx.doi.org/10.1016/j.resuscitation.2010.08.028]
5. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: Cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S829-S861. [http://dx.doi.org/10.1161/CIRCULATIONAHA.110.971069]
Accepted 11 August 2013.
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