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ACLS recommendation for procainamide in tachycardic rhythms is:
Loading dose 20 mg/minute (up to 50 mg/minute for more urgent situations) until:
- Arrhythmia is controlled
- Hypotension occurs
- QRS complex widens by 50% of its original width
- or total of 17 mg/kg is given
Maintenance infusion is 1 to 4 mg/min.
An easier method for dosing acute onset atrial fibrillation in stable patients was used in the Ottawa Aggressive Protocol, in which they administered 1 gm over 60 min, which was interrupted if BP < 100 mmHg; if corrected by a 250 ml IV bolus, the infusion was resumed. This was not used, however if the patient was to be admitted.
A strategy for treating stable monomorphic VT with procainamide used:
100 mg IV over 1-2 minutes, repeat as necessary until an endpoint of
- Termination of tachycardia
- Drug induced hemodynamic deterioration
- Completion of 800 mg maximal dose
If no slowing of the tachycardia occurred with a dose of 400 mg, the administration was ceased.
References
1. Steil IG, Clement CM, Perry JJ et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010;12(3):181-91.
2. Komura S, Chinushi M, Furushima H. et al. Efficacy of Procainamide and Lidocaine in Terminating Sustained Monomorphic Ventricular Tachycardia. Circulation May 2010 Vol 72