2020 ACLS Guidelines on Vasopressors and Non-Vasopressors During Cardiac Arrest

The 2020 ACLS Guidelines were published in October 2020 [1]. This first of 3 blog posts will focus on vasopressor and non-vasopressor medications during cardiac arrest. Part 2 will focus on specific arrhythmia management and Part 3 will focus on toxicologic interventions.


There were no major updates for vasopressors and non-vasopressors used during cardiac arrest. The American Heart Association (AHA) published Highlights of the 2020 Guidelines [PDF] as a clear and concise summary. Now that the AHA is releasing focused updates in the 5-year period between guidelines (like this one on lidocaine), fewer major changes likely will be needed when the full guidelines are published.




  • Recommended for patients in cardiac arrest (COR 1, LOE B-R)
  • Reasonable to administer 1 mg every 3-5 minute (COR 2a, LOE B-R)
  • Reasonable to administer as soon as feasible in non-shockable rhythm (COR 2a, LOE C-LD)
  • May be reasonable to administer after initial defibrillation attempts have failed in shockable rhythm (COR 2b, LOE C-LD)

Amiodarone or lidocaine

  • May be considered for VF/pVT unresponsive to defibrillation (COR 2b, LOE B-R)





  • Offers no advantage over epinephrine (COR 2b, LOE C-LD)


  • During CPR, are of uncertain benefit in OHCA (COR 2b, LOE C-LD)


  • Routine use NOT recommended (COR 3, LOE B-NR)

Sodium bicarbonate

  • Routine use NOT recommended (COR 3)


  • Routine use NOT recommended (LOE B-R)

Table: Vasopressors and non-vasopressors used during cardiac arrest (VF: ventricular fibrillation, pVT: pulseless ventricular tachycardia)



Panchal AR, Bartos JA, Cabañas JG, et al; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.

Buprenorphine prescribing: The Get Waivered Initiative makes it easier to get your DEA-X Waiver

A major development in curbing the opioid epidemic is the introduction of the medication buprenorphine to address opioid addiction. Being able to prescribe this medication, however, requires a special DEA-X Waiver in the United States. Dr. Alister Martin, the Founder of the Get Waivered initiative, is working to reduce the barriers for clinicians to obtain the training and paperwork necessary to obtain this waiver. Dr. Michelle Lin talks with Dr. Martin on this podcast about the backstory of the Get Waivered program, the lowered barriers to obtaining training, and some sneak peaks on what is new on the launching pad for his program.

Interesting fact: Medical students can participate in the free DEA-X waiver training now. The certificate of completion has no expiration date and can be submitted, when eligible for this waiver license.

Podcast with Dr. Alister Martin on the Get Waivered program

Visit the Get Waivered site to learn of their upcoming online training events and hot off the press news.

Additional Reading

  • A Tale of Two Epidemics: COVID-19 and the Opioid Crisis

ACEP E-QUAL podcasts on the opioid epidemic

  1. Opioid Use Disorder (OUD) Access in the Time of COVID
  2. Transitioning to Outpatient Care in OUD
  3. Substance Use Disorder Chat
  4. Pain Management for Patients with Opioid Use Disorder
  5. Opioid Overdose Prevention & Naloxone Distribution
  6. Opioid Withdrawals & Buprenorphine in the ED
  7. Buprenorphine after Opiate Overdose Part 1
  8. Buprenorphine After Opiate Overdose Part 2
  9. Supercharging Medication Assisted Therapy (MAT) with PAs and APRNs


buprenorphine suboxone OUD get waivered

Disclosure: ALiEM is proud to be a collaborator with the Get Waivered Initiative. This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for Foundation purposes notwithstanding any copyright notation hereon.

By |2020-11-30T14:11:47-08:00Dec 2, 2020|Podcasts, Tox & Medications|

SAEM Clinical Image Series: Surfing Sting


A 38-year-old male presents 8 days after being stung in the left foot while surfing. He reports the sudden onset of sharp pain while walking in the ocean. He was seen initially in the emergency department. The puncture wound on his left foot was anesthetized, explored, and irrigated. No X-ray was obtained, no foreign body was discovered, and he was discharged home.

Two days ago, he noticed worsening heat, itchiness, swelling, and skin changes (red bumps and patches extending from the foot up to the lower calf) in his left foot. His current pain is rated 3/10 and localized to the left foot. The patient is able to walk and bear weight. He has been taking ibuprofen for pain control and is not taking antibiotics. He denies fevers, but reports fatigue and feels more cold than usual.


ACMT Toxicology Visual Pearls: Case of a Toxic Tea


The plant pictured is used as a tea, powder, or capsule by individuals looking to self-treat pain or opioid use disorder.  Patients may develop nausea, vomiting, hallucinations, or other serious clinical effects after ingestion.  What compound is contained in this plant?

  1. Arecoline from Areca catechu
  2. Kava lactone from Piper methysticum
  3. Mitragynine from Mitragyna speciosa
  4. Salvinorin from Salvia divinorum


3 – Mitragynine from Mitragyna speciosa also known as Kratom

What is Kratom? [1-6]

  • Kratom is an herbal product that derives from the tree Mitragyna speciosa, native to Southeast Asia, where it has been historically used as a stimulant.
  • Recently it has grown in popularity in western countries for its opioid activity, primarily used to self-treat opioid withdrawal and chronic pain.
  • It is sold in several forms including leaves, powder, capsules, gum, and extract.
  • The active compound, mitragynine, may cause nausea, vomiting, hallucinations, and opioid-like Deaths have been reported.
  • There are currently no FDA-approved uses for kratom and its legal status is evolving, most recently classified by the DEA as a Drug and Chemical of Concern. The FDA continues to warn consumers not to use any products labeled as containing the botanical substance kratom or its psychoactive compounds, mitragynine, and 7-hydroxymitragynine.

What is the clinical presentation of kratom toxicity? [1,3,5,7]

  • Kratom contains over 40 alkaloids, including mitragynine. Mitragynine is primarily a mu-opioid receptor agonist but also has activity at postsynaptic α-2, serotonin, dopamine, adenosine, and additional opioid receptors.
  • Kratom’s neuropsychiatric effects occur rapidly after ingestion and may last 4-6 hours after the exposure.
  • At lower ingestions (approximately 2-6 grams) kratom acts as a stimulant, while larger ingestions predominantly result in sedation and other opioid effects.
  • The dose-dependent effects of kratom are thought to be due to the dual binding of α adrenergic receptors leading to stimulation and μ opioid receptors causing sedation.
  • Gastrointestinal symptoms including nausea, vomiting, and constipation
  • Cardiovascular symptoms such as tachycardia and hypertension
  • Neurologic symptoms including seizures, hallucinations, agitation, psychosis, and coma
  • Respiratory depression can occur
  • Substance use disorder and withdrawal are reported with symptoms similar to other opioids.

How do you manage kratom toxicity? [1, 3]

  • Minor symptoms generally require only supportive care
  • Naloxone can reverse opioid effects
  • Benzodiazepines can be used to treat patients with seizures, tachycardia, hypertension, and agitation.
  • Withdrawal and substance use disorder may be managed similarly to other opioids.

Bedside pearls

  • Kratom use is increasingly popular in the United States, often for self-treatment of chronic pain or opioid use disorder.
  • Kratom acts on many different receptors, including the μ, κ, and δ opioid receptors, which contributes to potential withdrawal symptoms and substance use disorders
  • Toxicity can lead to life-threatening symptoms such as respiratory depression, seizure, and coma
  • Withdrawal presents similarly to opioid withdrawal and should be managed similarly

This post has been peer-reviewed on behalf of ACMT by William Eggleston, Bryan Judge, and Louise Kao


  1. Rech MA, Donahey E, Cappiello Dziedzic JM, Oh L, Greenhalgh E. New drugs of abuse. Pharmacotherapy. 2015;35(2):189-197. doi:10.1002/phar.1522 PMID: 25471045
  2. Stolt AC, Schröder H, Neurath H, et al. Behavioral and neurochemical characterization of kratom (Mitragyna speciosa) extract. Psychopharmacology (Berl). 2014;231(1):13-25. doi:10.1007/s00213-013-3201-y  PMID: 23846544
  3. Fox LM. Plant- and Animal-Derived Dietary Supplements. In: Goldfrank’s Toxicologic Emergencies. Nelson LW Howland MA Lewin NA eds; 11th edition 2019; McGraw Hill,
  4. Boyer EW, Babu KM, Adkins JE, McCurdy CR, Halpern JH. Self-treatment of opioid withdrawal using kratom (Mitragynia speciosa korth). Addiction. 2008;103(6):1048-1050. doi:10.1111/j.1360-0443.2008.02209.x PMID: 18482427
  5. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom Use and Toxicities in the United States. Pharmacotherapy. 2019;39(7):775-777. doi:10.1002/phar.2280 PMID: 31099038
  6. Department of Justice/Drug Enforcement Administration Drug Fact Sheet:  Kratom.  Available at: https://www.dea.gov/factsheets/kratom, accessed August 24, 2020
  7. Swogger MT, Walsh Z. Kratom use and mental health: A systematic review. Drug Alcohol Depend. 2018;183:134-140. doi:10.1016/j.drugalcdep.2017.10.012  PMID: 29248691

SAEM Clinical Image Series: Red, White, & Blue


A 29-year-old female presented to the emergency department for a rash on her right calf. 5 days prior, at her home in Alabama, the patient developed pain and swelling of her right calf following a spider bite while putting on her pants. The patient felt a “burning pain” and found a spider which she then killed. She went to a hospital and received cephalexin, trimethoprim/sulfamethoxazole, and oxycodone. Despite taking these medications she continued having aching pain rated 10/10 in her right calf along with generalized pruritus. The patient stated that the bite evolved from an initial generalized redness into a blue/black lesion with blistering and extensive redness along her leg and torso. She denied fever, chills, lightheadedness, abdominal pain, nausea, vomiting, and hematuria.


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