based on the guidelines 2000 emergency for...

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EMERGENCYPHARMACOLOGY I & II

Advanced Cardiac Life Support

Seminole Community CollegeSeminole Community College

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Based on the Guidelines 2000Based on the Guidelines 2000for Cardiopulmonaryfor Cardiopulmonary

Resuscitation & EmergencyResuscitation & EmergencyCardiovascular CareCardiovascular Care

International Consensus on ScienceInternational Consensus on Science

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Pharmacology IPharmacology I

AntiarrhythmicAntiarrhythmic Drugs Drugs

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ADENOSINE ADENOSINE ((AdenocardAdenocard))

• Mechanism of Action - Adenosine is aendogenous purine nucleoside thatdepresses AV node and sinus nodeactivity.

• Since most common forms of PSVTinvolve a reentry pathway including theAV node, Adenosine is effective interminating these arrhythmias.

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• Mechanism of Action cont.- if arrhythmiadoes not involve a reentry pathwayincluding Atrial Fibrillation or Flutter,Atrial or Ventricular Tachycardias,Adenosine will not be effective interminating these arrhythmias.

• If this is the case Adenosine may causeAV or Ventricular blocks.

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• INDICATIONS - Used in the treatmentof Paroxysmal SupraventricularTachycardia (PSVT) including PSVT inWPW syndrome.

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• PRECAUTIONS: Adenosine producesa short lived pharmacologic responsebecause it is rapidly metabolized byenzymatic degradation in the blood andtissues.

• The half-life is approximately 5 secondsor less.

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• PRECAUTIONS: Side effects arecommon but usually short lived;Flushing, dyspnea, chest pain andtransient sinus bradycardia andventricular ectopy after termination ofPSVT.

• Should not be used diagnostically forstable, wide complex tachycardias ofunknown type (this is a new guideline).

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• DOSAGE - 6 mg rapid bolus over 1-3seconds. Followed by 20 ml flush. A briefperiod of Asystole (up to 15 seconds) mayoccur after rapid administration.

• After 1-2 minutes give 12 mg, may repeata second 12 mg after 1 - 2 minutes. IVshould be in anticubital fossa. 92%conversion usually after the first 12 mgdose.

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AmiodaroneAmiodarone Hydrochloride Hydrochloride((CordaroneCordarone))

• Mechanisms of Action: effects on sodium,potassium, and calcium channels, alsowith alpha and beta blocking properties.

• Lengthens the cardiac action potential(antisympathetic action). Negativedromotropic effects on SA node and AVnode.

• It has vasodilatory affects that decreasecardiac workload and myocardial oxygenconsumption.

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• Indications: preferred treatment for atrial andventricular arrhythmias. Used prior toLidocaine.

• Treatment and prophylaxis of frequentlyrecurring ventricular fibrillation andhemodynamically unstable ventriculartachycardia in patients refractory to otheragents.

• Ventricular rate control of rapid atrialarrhythmias in patients with severely impairedleft ventricular function when digitalis isineffective. 12


• Indications: ventricular rate control dueto accessory pathway conduction inpreexcited atrial arrhythmias.

• Adjunct to electrical cardioversion ofrefractory PSVT’s and atrialtachycardia.

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• Effective for the control ofhemodynamically stable VT,polymorphic VT, and wide-complextachycardia of uncertain origin.

• Used after defibrillation and epinephrinein cardiac arrest due to persistent VF orVT.

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• Contraindications: hypersensitivity,cardiogenic shock, sinus bradycardia, 2nd

or 3rd degree block.• Hypotension most common side effect.• Treatment with fluid and temporary

pacing can correct hypotension due toAmiodarone in the field!

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• Dosage: in cardiac arrest due to pulseless VT orVF 300 mg rapid infusion diluted in 20 to 30 mlof saline or D5W. Followed by 150 mg every 3-5mins until arrhythmia is suppressed.

• Arrhythmias with a pulse: 150 mg over tenminutes followed by 1mg/min infusion for 6hours. Repeat 150 mg if necessary to amaximum daily (24 hrs)dose of 2.2 grams.

• Maintenance infusion: 0.5 mg/min maximumdaily dose of 2.2 grams.

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•• Administration difficulties:Administration difficulties:–– Contained in an Contained in an ampuleampule must use filtered needle to must use filtered needle to

draw up.draw up.–– Must be drawn up slowly because bubbles will occurMust be drawn up slowly because bubbles will occur

if drawn rapidly (soap-like solution).if drawn rapidly (soap-like solution).–– Must be given rapidly and only once.Must be given rapidly and only once.–– Many side effects.Many side effects.–– 150 mg/150 mg/ampuleampule, must draw up two , must draw up two ampulesampules..–– Expensive approximately $175.00 per 300 mg dose.Expensive approximately $175.00 per 300 mg dose.

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ATROPINE SULFATE

•• Mechanism of Action:Mechanism of Action: ParasympatholyticParasympatholyticdrug which enhances both sinus nodedrug which enhances both sinus nodeautomaticityautomaticity, and AV node conduction by, and AV node conduction byreversing cholinergic-mediated affects.reversing cholinergic-mediated affects.Inhibits the release of acetylcholine fromInhibits the release of acetylcholine fromthe the vagusvagus nerve. nerve.

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ATROPINE SULFATE

•• Indications:Indications: Ventricular Asystole, Ventricular Asystole,Conduction disturbances (SymptomaticConduction disturbances (Symptomatic11stst or 2 or 2ndnd degree type 1 AV blocks), degree type 1 AV blocks),Symptomatic bradycardia, slow Symptomatic bradycardia, slow pulselesspulselesselectrical activity.electrical activity.

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ATROPINE

• Precautions:– Tachydysrhythmias.– Increased myocardial oxygen consumption– Use with caution in the presence of acute

myocardial ischemia associated with acutemyocardial infarction.

– Do not push slowly as paradoxicalbradycardia may occur.

– Less than 0.5 mg can cause a further slowingof the rate.

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ATROPINE

• Precautions: do not use whenbradycardia from AV block at the His-Purkinje level Mobitz (type) II or 3rd

degree (complete) heart block with newwide-QRS complexes is suspected.

• Atropine can rarely accelerate sinus rateand AV node conduction.

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ATROPINE• Dosage:

– Asystole & Slow PEA 1 mg IVP and repeated every3-5 mins if asystole persists.

– Bradycardia & AV Blocks 0.5 mg - 1.0 mg every 3 -5 mins.

– ET administration: 2.0 - 2.5 mg diluted in 10 ml NS.– Maximum dose: 3 mg (0.04 mg/kg) complete

vagolytic dose.– Less than 0.5 mg causes paradoxical bradycardia.

•• Maximum dose should be reserved for Maximum dose should be reserved for asystolicasystoliccardiac arrest only, this is due to the increase incardiac arrest only, this is due to the increase inmyocardial oxygen demand!myocardial oxygen demand!

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PROPRANOLOL, METOPROLOL,PROPRANOLOL, METOPROLOL,ATENOLOL, ESMOLOLATENOLOL, ESMOLOL

• Mechanism of Action - Beta blockingagents attentuate the effects of circulatingcatecholamines by blocking their abilityto bind to beta receptors.

• Reduces heart rate, blood pressure,myocardial contractility and thereforemyocardial oxygen consumption.Decreases (depresses) the pumpingDecreases (depresses) the pumpingfunction of the heart.function of the heart.

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• Mechanism of Action – benefits inpatients with acute coronarysyndromes, including patients withnon-Q wave MI and unstable angina.

• Therefore beta blockers should beadministered in these patients underthese conditions!

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• Indications - Primary indication is tocontrol recurrent ventricular tachycardiaventricular fibrillation andsupraventricular arrhythmias.

• Precautions: Hypotension, Congestiveheart failure and bronchospasm.

• Dosage - Varies with desired effect.Currently not used in the field!

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BRETYLIUM TOSYLATEBRETYLIUM TOSYLATE((BretylolBretylol))

• Indications – no longer indicated fortreatment of ventricular arrhythmias,due to the decrease in availability and it’sdocumented ineffectiveness.

• Has been removed from all algorhythms.

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VERAPAMIL & DILTIAZEMVERAPAMIL & DILTIAZEM((CalanCalan - - IsoptinIsoptin, , CardizemCardizem))

• Mechanism of Action - Both are calciumchannel blocking agents that slowconduction and increase refractoriness inthe AV node. These actions terminatereentrant arrhythmias that require AVnodal conduction.

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• Verapamil is a negative inotropic agentthat causes a reduction in myocardialoxygen requirement. May also controlventricular response in A-Fib, A-Flutter,or multifocal Atrial Tachycardia.

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• Indications - Used in the treatment ofParoxysmal SupraventricularTachycardia (PSVT) narrow complexand ventricular rate control in AtrialFibrillation. However, Adenosine is thedrug of choice.

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• Precautions - Possible hemodynamiccompromise. Should not be used in WPWsyndrome or impaired heart function.

• Calcium is used for possible overdose ofVerapamil or other Calcium channelblocker.

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VERAPAMIL & DILTIAZEMVERAPAMIL & DILTIAZEM((CalanCalan, , IsoptinIsoptin, , CardizemCardizem))

• Dosage:Verapamil: 2.5 - 5.0 mg IV over 2minutes. Repeat doses of 5 - 10 mg every15 to 30 minutes to a maximum of 30 mg.Diltiazem: 0.25 mg/kg over 2 minutesfollowed by 0.35 mg/kg. Produces lessmyocardial depression than Verapamil.

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DISOPYRAMIDEDISOPYRAMIDE

•• Mechanism of Action: Mechanism of Action: antiarrhythmicantiarrhythmicagent that acts to slow conductionagent that acts to slow conductionvelocity, and prolongs the effectivevelocity, and prolongs the effectiverefractory period (similar torefractory period (similar toProcainamideProcainamide).).

•• Potent Potent anticholinergicanticholinergic, negative, negativeinotropicinotropic, and , and hypotensivehypotensive effects. effects.

•• Not used in the field!Not used in the field!

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FLECAINIDEFLECAINIDE

•• Mechanism of Action:Mechanism of Action: potent sodium channel potent sodium channelblocker with significant conduction-slowingblocker with significant conduction-slowingeffects.effects.

•• Indications:Indications: ventricular arrhythmias and for ventricular arrhythmias and forpatients in patients in supraventricularsupraventricular arrhythmias with arrhythmias withstructural heart disease. IV version (notstructural heart disease. IV version (notapproved in U.S.) has corrected A-fib, approved in U.S.) has corrected A-fib, EctopicEctopicA-tachycardia, A-flutter.A-tachycardia, A-flutter.

•• Precautions:Precautions: must be administered slowly, must be administered slowly,bradycardiabradycardia, hypotension, and neurological, hypotension, and neurologicalabnormalities.abnormalities.

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IBUTILIDEIBUTILIDE

•• Mechanism of Action:Mechanism of Action: short-acting short-actingantiarrhythmicantiarrhythmic drug. Effective by drug. Effective byprolonging the action potential durationprolonging the action potential durationand increasing the refractory period ofand increasing the refractory period ofcardiac tissue.cardiac tissue.

•• Indications:Indications: acute pharmacologic acute pharmacologicconversion of conversion of AtrialAtrial flutter or A-Fib flutter or A-Fibwhen electrical cardioversion has failed.when electrical cardioversion has failed.

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IBUTILIDEIBUTILIDE

•• Dosage:Dosage: Adults over 60 kg, IV 1 mg/10 ml Adults over 60 kg, IV 1 mg/10 mlover 10 minutes. Repeat if unsuccessfulover 10 minutes. Repeat if unsuccessful1mg/10ml over 10 minutes.1mg/10ml over 10 minutes.

•• If under 60 kg administer 0.01 mg/kg andIf under 60 kg administer 0.01 mg/kg andrepeat in second dose.repeat in second dose.

•• Precautions:Precautions: minimal effects on the heart minimal effects on the heartrate and BP. However. May causerate and BP. However. May causeventricular ventricular proarrhymiasproarrhymias especially especiallywhen there is an impaired LV.when there is an impaired LV.

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ISOPROTERENOL(ISOPROTERENOL(IsuprelIsuprel))

• Mechanism of Action - Isoproterenol is apure beta adrenergic agent. Potent

inotropic and chronotropic agent thatincreases cardiac output and myocardialoxygen demand.Isoproterenol can increase myocardialischemia and exacerbates arrhythmias.

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• Indications - Refractory torsades depointes (Chemical overdrive pacing) andimmediate control of hemodynamicallysignificant bradycardia especially in thedenervated hearts of heart transplantpatients. However, not the treatment ofchoice, used until a pacemaker, atropine,dobutamine is available and has failed.

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• Precautions - ventricular ectopy anddysrhythmias. Electronic pacingpreferred!

• Dosage - 2 to 10 mcq/min titrated toeffect. 1 mg/250 ml fluid infusion.

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LIDOCAINE (Xylocaine)

• Mechanism of Action - Suppressesventricular arrhythmias by decreasingthe automaticity of phase 4depolarization. Depresses conduction inreentrant pathways. Elevates fibrillationthreshold. Decreases excitability ofischemic tissue.

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LIDOCAINELIDOCAINE

• Indications: Used in the treatment of:– VF/ Pulseless VT that persists after

defibrillation and epinephrine (ClassIndeterminate).

– Control of hemodynamically compromisingPVC’s (Class Indeterminate).

– Hemodynamically stable VT (Class IIb)• Lidocaine is the second choice medication

behind other alternate agents:Amiodarone, Procainamide, Sotalol)

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LIDOCAINE

• Precautions - Routine prophylacticadministration is no longer recommendedin uncomplicated acute MI or ischemiawithout PVC's.

• Toxic - therapeutic balance is delicate.

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LIDOCAINE

• Dosage – In cardiac Arrest• Initial dose of 1.0 - 1.5 mg/Kg• Additional boluses of 0.5 - .75 mg/Kg

repeat in 3 - 5 minutes; maximumtotal dose of 3 mg/Kg.

• The more aggressive dosingapproach is recommended in cardiacarrest (1.5mg/kg).

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LIDOCAINE

• Dosage – In V-Tach with a pulse orother ventricular ectopic beats 0.5 –0.75 mg/Kg, 3 mg/Kg maximun dose.

• Infusion: 2-4 mg/min• Mix 1 Gm in 250 ml NS or 2 Gm in

500 ml.

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LIDOCAINE

• In Patients older than 70 years old, andin those with Hepatic dysfunction shouldreceive the initial normal loading dose.

• The maintenance infusion should bereduced by 50%.

• Infusion rate of 1 - 4 mg/minute (classindeterminate).

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LIDOCAINE

• Special Considerations:• Endotracheal Dose: 2 – 4 mg/kg• Reappearance of arrhythmias

during a constant infusion ofLidocaine should be treated with asmall bolus dose (0.5 mg/kg).

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LIDOCAINE

• Toxic reactions and Side effects:– Slurred speech– Altered consciousness– Muscle twitching– Seizures– Bradycardia

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MAGNESIUM SULFATEMAGNESIUM SULFATE

• Mechanism of Action - Magnesium deficiency is associated with

cardiac arrhythmias, symptoms ofcardiac insufficiency, and sudden cardiacarrest.

• Hypomagnesemia can precipitaterefractory V-Fib.

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• Indications - Used in the treatment ofVentricular Fibrillation / VentricularTachycardia after full doses ofAmiodarone and Lidocaine have failed toconvert rhythm. Treatment of choice forTorsades de pointes.

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• Should only be used when arrhythmiasmay be caused by Magnesium deficiencyor Torsades de Pointes.

• Dosage - 1 to 2 grams loading dosemixed in 10 ml of solution andadministered over 1 to 2 minutes.

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PROCAINAMIDE (Pronestyl)

• Mechanism of Action – supressesboth atrial and ventriculararrhythmias. Acceptable for thepharmacological conversion ofsupraventricular arrhythmias(particularly A Fib and A Flutter) tosinus rhythm (class IIa).

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• Supresses ventricular ectopy similarto Lidocaine. Recommended whenAmiodarone and Lidocaine iscontraindicated or it has failed tosuppress ventricular ectopy.

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• Increases ventricular fibrillationthreshold. Shortens effectiverefractory period of the AV node,lengthens refractory period inbundle of his.

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• Indications - Secondary toAmiodarone and Lidocaine in thefield. Used when both medicationshave failed to suppress the lifethreatening ventricular arrhythmias.Suppresses PVC's and recurrent V-tach, V-fib.

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• Precautions - Contraindicated inTorsades de Pointes, hypotensionafter rapid injection. Adverse ECGeffects. Use caution in acute MI.

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PROCAINAMIDE (PROCAINAMIDE (PronestylPronestyl))

• DOSAGE - Infusion of 30 mg/min untilone of the following is observed:– 1. Arrhythmia is suppressed– 2. Hypotension ensues– 3. QRS widens by 50%– 4. Total of 17 mg/kg administered (1.2

gm/70kg)•• Maintenance Infusion rate: 1 – 4Maintenance Infusion rate: 1 – 4

mg/minutemg/minute

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PROPAFENONEPROPAFENONE

•• Mechanism of Action:Mechanism of Action: AntiarrhythmicAntiarrhythmicagent with significant conduction-slowingagent with significant conduction-slowingand negative and negative inotropicinotropic effects with effects withadditional non-selective beta blockingadditional non-selective beta blockingproperties.properties.

•• Used in U.S. orallyUsed in U.S. orally only for treatment of only for treatment ofsupraventricularsupraventricular and ventricular and ventriculararrhythmias in patients withoutarrhythmias in patients withoutstructural heart disease.structural heart disease.

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PROPAFENONEPROPAFENONE

•• Indications:Indications: ventricular arrhythmias and ventricular arrhythmias andfor patients in for patients in supraventricularsupraventriculararrhythmias with structural heartarrhythmias with structural heartdisease. IV version (not approved in U.S.)disease. IV version (not approved in U.S.)has corrected A-fib, has corrected A-fib, EctopicEctopic A- A-tachycardia, A-flutter.tachycardia, A-flutter.

•• Dosage:Dosage: No field dose No field dose

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SOTALOLSOTALOL

•• Mechanism of Action:Mechanism of Action: prolongs action prolongs actionpotential duration like potential duration like AmiodaroneAmiodarone, and, andincreases cardiac tissue increases cardiac tissue refractorynessrefractoryness..

•• Used in U.S. orallyUsed in U.S. orally only for treatment of only for treatment ofsupraventricularsupraventricular and ventricular and ventriculararrhythmias in patients withoutarrhythmias in patients withoutstructural heart disease.structural heart disease.

•• Dosage:Dosage: No field dose No field dose

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Pharmacology IIPharmacology II

Agents to Optimize Cardiac OutputAgents to Optimize Cardiac Outputand Blood Pressureand Blood Pressure

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EPINEPHRINE (Adrenolin)

• Mechanisms of Action: Naturallyoccurring catecholamine with bothAlpha and Beta adrenergicproperties (Sympathomimeticagent).

• Greatest benefit from alphaadrenergic stimulating properties.

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EPINEPHRINE (Adrenolin)• Mechanisms of Action:

– Increases myocardial and cerebral bloodflow during CPR

– Increased systemic vascular resistance– Increased arterial blood pressure– Increased heart rate (Chronotropic effects)– Increased myocardial contraction (Inotropic

effect). Increased automaticity– Increased myocardial oxygen requirement

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EPINEPHRINE (Adrenolin)• Indications: “First Agent in All Forms of

Cardiac Arrest”– Improves V-Fib conversion, PEA, May

restore electrical activity in Asystole.– Vasopressor agent for symptomatic

bradycardia (not first line drug).• Vasopressin may be substituted in the V-fib algorhythm.

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• Precautions: May precipitate orexcerbate myocardial ischemia. Do notmix with alkaline solutions. Ventricularectopy in digitalized patients.

• Remember the increase in MyocardialOxygen Demand!

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• Dosage:– 1 mg of 1: 10,000 solution IVP every 3-5

minutes followed by 20 ml flush.– ET administration: 2 - 2.5 mg in 10 ml.– Infusion: 1 mg in 250 ml, dose 1 mcq/min.

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VASOPRESSINVASOPRESSIN

•• Mechanism of Action:Mechanism of Action: naturally naturallyoccurring occurring antidiureticantidiuretic hormone that acts hormone that actsas a non-adrenergic peripheralas a non-adrenergic peripheralvasoconstrictor.vasoconstrictor.

•• Indications:Indications: May be substituted for May be substituted forEpinephrine in the V-fib / V-Epinephrine in the V-fib / V-tachtach without withouta pulse algorithm (class a pulse algorithm (class IIbIIb).).

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•• Mechanism of Action: Mechanism of Action: during a shortduring a shortduration of V-Fib, during CPR increasedduration of V-Fib, during CPR increasedcoronary perfusion pressure, and vitalcoronary perfusion pressure, and vitalorgan blood flow.organ blood flow.

•• VasopressinVasopressin does not increase myocardial does not increase myocardialoxygen demand because of the lack ofoxygen demand because of the lack ofbeta adrenergic stimulation.beta adrenergic stimulation.

•• Vasopressin Vasopressin remains intact duringremains intact duringacidosis.acidosis.

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•• Half-life 10 – 20 minutesHalf-life 10 – 20 minutes•• Dosage: 40 U (units) IVPDosage: 40 U (units) IVP•• May follow up with Epinephrine after 10May follow up with Epinephrine after 10

– 20 minutes of initial administration.– 20 minutes of initial administration.•• May later be used for PEA and Asystole.May later be used for PEA and Asystole.•• Inexpensive to purchase and easy toInexpensive to purchase and easy to

administer.administer.

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NOREPINEPHRINENOREPINEPHRINE((LevophedLevophed))

• Mechanism of Action - Naturallyoccurring catecholamine that is a potentalpha receptor agonist andvasoconstrictor. Causes a great increasein myocardial oxygen demand and willexacerbate myocardial ischemia.

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NOREPINEPHRINENOREPINEPHRINE ( (LevophedLevophed))

• Indications – (None in the field)Treatment for hemodynamicallysignificant hypotension that is refractoryto other sympathomimetic amines.Should be considered as a last andtemporary measure.

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NOREPINEPHRINENOREPINEPHRINE ( (LevophedLevophed))

• Precautions - Increases myocardialoxygen requirement and will exacerbateischemia. If drug infiltrates 5 to 10 mg ofPhentolamine should also be infiltrated toprevent tissue necrosis and sloughing.

• Dosage - 0.5 - 1.0 mcq/minute titrated toeffect. 4 mg placed in 250 ml D5W.

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DOPAMINEDOPAMINE((IntropinIntropin))

• Mechanism of Action - A chemicalprecursor of norepinephrine that hasboth alpha and beta actions, andstimulates dopaminergic receptors in adose dependant fashion.

• Dopamine stimulates the heart throughbeta receptors.

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DOPAMINEDOPAMINE((IntropinIntropin))

• Indications: usually reserved forhypotension that occurs withsymptomatic bradycardia or post cardiacarrest. Goal BP 90 mm Hg.

• Precautions: dose dependant, higherdoses may have a profound negativeimpact on the heart. Do not use in thesame IV lines as Bicarbonate, mayinactivate. Extreme tissue destruction ifIV infiltrates.

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DOPAMINEDOPAMINE ( (IntropinIntropin))

• Other Precautions - SVT or ventriculararrhythmias. MAO inhibitors maypotentiate the effects of dopamine, use1/10th the normal dose. Alkalinesolutions inactivate dopamine. Must betapered off, use central line due to risk ofinfiltration causing severe damage.

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• Dosage: in low doses 1-2 mcq/Kg/minproduces vasodilation of renal,mesenteric, and cerebral arteries bystimulation dopaminergic receptors.

• At midrange doses 2 - 10 mcq/Kg/minproduces cardiovascular effects (Beta).

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• At higher doses 20 mcq/Kg/min producehemodynamic effects similar tonorepinephrine (peripheral arterialvasoconstriction).

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DOPAMINEDOPAMINE

• Field Dosage - 5 mcq/Kg/min titrated to effect. Final

recommended dose dosage range is 5 - 20mcq/kg/min.Dopaminergic effect: 1 – 2 mcq/kgBeta effect: 2 –10 mcq/kgAlpha effect: 10 – 20 mcq/kg

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DOBUTAMINE (DOBUTAMINE (DobutrexDobutrex))

• Mechanism of Action - syntheticsympathomimetic amine that exerts its potentinotropic effects by stimulating beta-1 andalpha adrenergic receptors in the myocardiumand blood vessels.

• Dobutamine has beneficial hemodynamiceffects and its lack of norepinephrine releaseminimize its effects on myocardial oxygendemand. DOES NOT PRODUCE RENALAND MESENTERIC VASODILATION LIKEDOPAMINE.

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DOBUTAMINE (DOBUTAMINE (DobutrexDobutrex))

• Indications - Treatment of pulmonarycongestion and severe systolic heartfailure.

• Precautions - High doses may causemyocardial ischemia, SVT and V-tach.

• Dosage - 2 to 20 mcq/Kg/min.

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AMRINONE (AMRINONE (InocorInocor)&)&MILRINONEMILRINONE

• Mechanism of Action - Rapid-actinginotropic agent who net effects aresimilar to dobutamine. Cardiac outputincreases and peripheral vascularresistance and preload are diminished.

• Indications - Severe congestive heartfailure refractory to diuretics orcardiogenic shock.

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AMRINONE (AMRINONE (InocorInocor)&)&MILRINONEMILRINONE

• Precautions - May induce or worsenmyocardial ischemia, and ventricularectopy.

• Dosage - 0.75 mg/Kg every 2 - 3 minutesfollowed by 5 to 15 mcq/Kg/min infusion.

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CALCIUM CHLORIDECALCIUM CHLORIDE

• Mechanism of Action - AlthoughCalcium ions play a critical role inmyocardial contractile performance andimpulse formation, however studies havenot shown benefit from the use of calciumand in fact may be detrimental.

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CALCIUM CHLORIDECALCIUM CHLORIDE

• Indications - Hyperkalemia,Hypocalcemia and channel blockertoxicity (verapamil) class IIb.

• Dosage - 2 mg - 4 mg/Kg repeat ifnecessary in 10 minute intervals.

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DIGITALISDIGITALIS

• Mechanism of Action - Rapid-actinginotropic agent who net effects aresimilar to dobutamine.

• Cardiac output increases and peripheralvascular resistance and preload arediminished.

• Extremely limited use in EmergencyCardiac Care.

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DIGITALISDIGITALIS• Indications – decreases ventricular rate

in Atrial flutter and Atrial fibrillation.No longer preferred method.

• Precautions - May induce or worsenmyocardial ischemia, and ventricularectopy (all lethal forms of dysrhythmiashave occurred).

• Dosage - 10 - 15 mcq/Kg every 2 - 3minutes followed by 5 to 15 mcq/Kg/mininfusion.

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NITROGLYCERINENITROGLYCERINE• Mechanism of Action - Organic nitrate

that relaxes vascular smooth muscle• Indications - Primary indication is to

relieve Angina Pectoris, initial treatmentof choice for ischemic-type pain or chestdiscomfort.

• Parenteral choice for the treatment ofcongestive heart failure, management ofuncomplicated MI.

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NITROGLYCERINENITROGLYCERINE

• Precautions: Hypotension, Headache.• Dosage - 0.3 mg - 0.4 mg every 3 - 5

minute intervals if discomfort is notrelieved.

• Infusion - 50 or 100 mg / 250 ml, rate 10to 20 mcg/min increased by 5 – 10 mcgevery 5 - 10 mins until desired clinicalresponse.

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SODIUM NITROPRUSSIDESODIUM NITROPRUSSIDE

• Mechanism of Action - SodiumNitroprusside is a potent peripheralvasodilator, effects are seen immediatelyand cease within minutes after infusionis discontinued.

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• Indications - Parenteral treatment ofchoice for severe heart failure andhypertensive emergencies whenimmediate reduction of peripheralresistance is necessary.

• Nitroglycerine is preferred because it isless likely to lower coronary perfusionpressure, and likely to increase perfusionto the myocardium.

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• Precautions - Hypotension is the mostcommon adverse reaction seen withnitroprusside. Hypotension mayprecipitate myocardial ischemia,infarction or stroke.

• Dosage - 0.1 to 5 mcq/Kg/min titrated toeffect. Mix 50 - 100 mg/250 ml D5W.

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SODIUM BICARBONATESODIUM BICARBONATE

• Mechanism of Action - SodiumBicarbonate reacts with the hydrogenions in the blood to form carbon dioxideand water to buffer metabolic acidosis.

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• Indications - Used during cardiacresuscitation only after defibrillation,effective CPR, Endotracheal intubation,hyperventilation with 100% oxygen andmore than one dose of epinephrine.

• May be used with the followingpreexisting conditions:metabolic acidosis,hyperkalemia, or tricyclic orphenobarbital overdose.

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• Precautions - The major problem is thatNaHCO3 has a high carbon dioxide content,the CO2 crosses rapidly into the cells causingan increase in intracellular hypercarbia andacidosis especially in myocardial and cerebralcells. Bicarbonate crosses much more slowly.

• Other problems include: Hypernatremia and ashift in the oxyhemoglobin saturation curvepreventing O2 release to the tissues. MetabolicAlkalosis. Do not mix with catecholamines.

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• Dosage - 1 mEq/Kg initially, 0.5 mEq/Kgdose every 10 minutes thereafter.

• Should be guided by blood gases ifpossible. Use after the first ten minutes incardiac arrest, however notrecommended by the AHA.

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DIURETICS (DIURETICS (FurosemideFurosemide))

• Mechanism of Action - Rapidly actingpotent diuretic that inhibits thereabsorption of sodium in the renal loopof henle. Has a direct venodilating effectin patients with pulmonary edema onsetapproximately 5 minutes. Diuresis occurslater.

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DIURETICS (DIURETICS (FurosemideFurosemide))

• Indications - Treatment of pulmonaryedema associated with left ventricularfailure.

• Precautions - Dehydration, hypotension,eletrolyte depletion in coronary heartdisease.

• Dosage: 0.5 - 1.0 mg/Kg initially IVslowly over 1 - 2 minutes.

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MORPHINEMORPHINE

• Mechanism of Action - Narcotic analgesic- manifests analgesic and hemodynamiceffects, increasing venous capacitanceand reduces systemic vascular resistance,reduces preload, relieving pulmonarycongestion. Reduces intramyocardial walltension, which decreases myocardialoxygen requirements. Reduces anxiety.

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MORPHINEMORPHINE

• Indications - Drug of choice in treatmentof pain and anxiety associated with AMIand in the Treatment of acute pulmonaryedema.

• Precautions - Respiratory depression,hypotension. Overdose can be correctedwith IV Naloxone (Narcan) 0.4 -0.8 mg.

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MORPHINEMORPHINE

• Dosage - 1 mg - 3 mg IV slowly over 1 to5 minutes until the desired effect isachieved.

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THROMBOLYTIC AGENTSTHROMBOLYTIC AGENTS((AnistreplaseAnistreplase, Streptokinase, , Streptokinase, AlteplaseAlteplase))

• Mechanism of Actions - Activate bothsoluble plasminogen and surface boundplasminogen to plasmin. Pharmacolgicthrombolysis occurs when surface-boundplasminogen is converted to surfacebound plasmin which digests fibrin anddissolves the clot.

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THROMBOLYTIC AGENTSTHROMBOLYTIC AGENTS((AnistreplaseAnistreplase, Streptokinase, , Streptokinase, AlteplaseAlteplase))

• Indications - Should be initiated immediateafter the onset of chest pain (within6-12 hours, ideally within 6 hours).

• Precautions - Bleeding is the majorcomplication as a result of thrombolytictherapy. Various contraindications for this typeof therapy.

• Dosage - Varies with type of drug used.• New Fibrolytic Agents now used: Ativase.

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SYMPTOMATICSYMPTOMATICBRADYCARDIABRADYCARDIA

• Remember the following sequence:

1st line - Atropine (except high block)2nd line - Pacemaker3rd line - Dopamine4th line - Epinephrine

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The EndThe End

•• This Microsoft PowerPoint presentationThis Microsoft PowerPoint presentationwas prepared bywas prepared by RobRob Holborn Holborn Ed.D, Ed.D,EMT-P, Seminole Community College.EMT-P, Seminole Community College.

•• The presentation was prepared by usingThe presentation was prepared by usingthe textbook:the textbook: Guidelines 2000 for Guidelines 2000 forCardiopulmonary Resuscitation andCardiopulmonary Resuscitation andEmergency Cardiovascular Care:Emergency Cardiovascular Care:International Consensus on Science andInternational Consensus on Science andthe 1998 National EMT-Paramedicthe 1998 National EMT-ParamedicCurriculumCurriculum

based on the guidelines 2000 emergency for...

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