ACLS and Anaphylaxis Quick Reference

Code-blue drug doses, push-dose pressors, post-ROSC checklist, and anaphylaxis management.

Cardiac Arrest Drug Doses

Drug	Indication	Adult Dose	Peds Dose	Notes
Epinephrine	VF/pVT, PEA, asystole	1 mg IV/IO q3-5 min	0.01 mg/kg IV/IO q3-5 min (max 1 mg)	First drug for all rhythms. Give immediately.
Amiodarone	Refractory VF/pVT after 2nd shock	300 mg IV/IO push; may repeat 150 mg once	5 mg/kg IV/IO (max 300 mg); may repeat once	First-line antiarrhythmic.
Lidocaine	Refractory VF/pVT (alternative to amiodarone)	1-1.5 mg/kg IV/IO; may repeat 0.5-0.75 mg/kg q5-10 min (max 3 mg/kg)	1 mg/kg IV/IO; may repeat once	Alternative when amiodarone is unavailable or contraindicated.
Magnesium	Torsades de pointes, hypomagnesemia	1-2 g IV/IO over 5-20 min	25-50 mg/kg IV/IO (max 2 g)	Give for torsades regardless of Mg level.
Calcium (gluconate 10%)	Hyperkalemia, hypocalcemia, calcium channel blocker overdose	1 g IV/IO over 5-10 min	20 mg/kg (0.2 mL/kg) IV/IO	Not routine in arrest — use only for specific indications.
Sodium bicarbonate	Severe metabolic acidosis, TCA overdose, hyperkalemia	1 mEq/kg IV/IO (50 mEq per amp)	1 mEq/kg IV/IO	Not routine. Use only for specific indications. Give after adequate ventilation.
Vasopressin	No longer recommended as routine	—	—	Removed from AHA algorithm. Use epinephrine alone.

See AHA Algorithm PDFs for full decision trees.

Push-Dose Pressor Recipes

Used for transient hypotension (e.g., intubation, sedation, sepsis resuscitation) while preparing a continuous infusion.

Epinephrine 10 mcg/mL

Step	Action
Draw up	1 mL of epinephrine 1 mg/mL (standard cardiac amp)
Add to	9 mL of NS (total 10 mL)
Final concentration	10 mcg/mL (0.01 mg/mL)
Dose	0.5-2 mL (5-20 mcg) IV push q2-5 min PRN
Onset	1-2 min; duration 5-10 min

Phenylephrine 100 mcg/mL

Step	Action
Draw up	1 mL of phenylephrine 10 mg/mL (standard vial)
Add to	99 mL of NS (total 100 mL)
Final concentration	100 mcg/mL (0.1 mg/mL)
Dose	0.5-2 mL (50-200 mcg) IV push q2-5 min PRN
Onset	1-2 min; duration 10-15 min

For continuous vasopressor infusion protocols see Vasopressors.

Post-ROSC Checklist

Domain	Target / Action	Notes
MAP	at least 65 mmHg	Use push-dose pressors or infusion to maintain. Three negative RCTs (Jakkula 2018, Ameloot 2019, Kjaergaard 2022) showed no benefit from aggressive augmentation above 65. IBCC Post-Arrest
ECG	12-lead within 10 min	Compare to prior. ST elevation or new LBBB triggers cath lab activation.
PCI	Emergent angiography for OMI, shockable rhythm, or hemodynamic instability	Do not delay for neurologic prognostication.
TTM	Target 36-37.5 deg C for at least 36 h	Avoid fever. Active temperature management.
Sedation	Propofol or dexmedetomidine preferred	Avoid benzodiazepines (associated with worse outcomes).
Ventilation	Normocapnia (pCO2 35-45 mmHg)	Avoid hyperventilation and hypercapnia.
Oxygenation	SpO2 92-98%	Avoid hyperoxia (excess O2 worsens neurologic injury).
Glucose	140-180 mg/dL	Avoid hypoglycemia and severe hyperglycemia.
Seizures	EEG monitoring if available; treat with levetiracetam or propofol	Nonconvulsive status is common post-arrest.
Neuroprognostication	Defer at least 72 h after return of normothermia	Multimodal: EEG, SSEP, MRI, NSE. Do not use clinical exam alone.

H’s and T’s (Reversible Causes of Arrest)

H’s	T’s
Hypovolemia	Tension pneumothorax
Hypoxia	Tamponade (cardiac)
Hydrogen ion (acidosis)	Toxins (overdose)
Hypo-/hyperkalemia	Thrombosis (pulmonary embolism)
Hypothermia	Thrombosis (coronary — ACS)

Anaphylaxis

Acute Recognition

Anaphylaxis is a clinical diagnosis. Key features: acute onset (minutes to hours) of skin/mucosal involvement (urticaria, flushing, angioedema) plus respiratory compromise (dyspnea, wheeze, stridor) or hypotension, or both. Isolated skin findings without respiratory or hemodynamic involvement are not anaphylaxis.

IM Epinephrine — First-Line

Population	Dose	Concentration	Route	Repeat
Adult	0.3-0.5 mg	1 mg/mL (1:1000)	IM vastus lateralis	q5-15 min PRN
Pediatric	0.01 mg/kg (max 0.3 mg)	1 mg/mL (1:1000)	IM vastus lateralis	q5-15 min PRN

IM vastus lateralis is preferred over deltoid (faster absorption). Auto-injectors (EpiPen) deliver 0.3 mg (adult) or 0.15 mg (peds 15-30 kg).

IV Epinephrine Infusion — Refractory Anaphylaxis

For patients who do not respond to IM epinephrine or are in shock.

Step	Action
Preparation	1 mg epinephrine in 250 mL NS (4 mcg/mL)
Starting rate	0.1-0.5 mcg/kg/min IV infusion
Titrate	To effect. Use standard vasopressor infusion protocol.
Monitoring	Continuous telemetry, noninvasive BP q2-5 min

Beta-Blocker Note

Patients on beta-blockers may have refractory anaphylaxis. If inadequate response to epinephrine:

Intervention	Dose	Notes
Glucagon	1-5 mg IV over 5 min, then 5-15 mcg/min infusion	Bypasses beta-receptor; has positive inotropic and chronotropic effects.
Consider	IV fluids, vasopressor infusion	Epinephrine may be less effective — do not withhold it, but anticipate need for additional support.

Steroids and Antihistamines — Controversy

There is a UK-vs-US split on the routine use of steroids and antihistamines in acute anaphylaxis:

Position	Recommendation	Source
UK (RCUK 2021)	Steroids and antihistamines are NOT routinely recommended in acute anaphylaxis. Evidence review found no high-quality data supporting their use.	Dodd 2021
US (AAAAI/ACAAI 2020)	H1 and H2 antihistamines (diphenhydramine, famotidine) and corticosteroids remain listed as adjunctive therapies.	IBCC Anaphylaxis

Bottom line: Epinephrine is the only life-saving drug in anaphylaxis. Steroids and antihistamines have not been shown to reduce mortality or prevent biphasic reactions. If used, they are adjunctive only and must never delay or replace epinephrine. WikEM Anaphylaxis