Muhammad Yusuf Muharam,

MBBS (UM), MMed. Emergency (USM)

Emergency & Trauma Department,
Hospital Queen Elizabeth
Kota Kinabalu, Sabah
23rd September 2014

 Introduction
Resuscitative

drugs

Pharmacology

Summary

 Severe,

often lifethreatening consequences

can occur if paramedics
make a mistake.

???

Pharmacology

scientific study of how various

substances interact with or
alter the function of living
organisms.

Chemicals

have been used

for centuries.

 Formal

scientific study began in the 17th and

18th centuries.

Some

ancient remedies are still used today.

Atropa belladonna, poppy seed Papaver

somniferum etc

EBM

guidelines assist clinicians using

pharmacologic interventions.

Medications undergo extensive testing and

clinical trials.

 Medications

for desired effect in the body.

Pharmacodynamics:

as a medication is
administered, it alters a function or process
of the body.

Any medication can cause toxic effects.

 Pharmacokinetics:

action of the body on a

medication
Process

of medication administration (ADME):

Absorption
Distribution
Metabolism/Biotransformation
Elimination

 Cardiac

Output = HR X SV

Heart Rate x Stroke Volume

SV

stroke volume cardiac output

stroke volume cardiac output
heart rate
cardiac output
heart rate
cardiac output

= EDV ESV

 Mean

(average) Arterial Pressure (MAP)

(Diastolic Pressure + Pulse Pressure) / 3

DBP + 1/3 (SBP-DBP)

Blood

Flow (vascular system) = Cardiac

Output

relatively constant but will vary in the individual

organs.
At rest:

brain 13%
internal organs 24%
heart 4%
skeletal muscle 20%

kidneys 20%

 Blood

pressure is affected
by cardiac output and
resistance.

Cardiac

output is affected
by blood volume.

So

blood volume also

affects blood pressure.

 Adrenaline

/
epinephrine

Magnesium

sulphate

Amiodarone

Dopamine

Atropine

Dobutamine

Adenosine

Sodium

Bicarbonate

- and -agonist, it increases

blood pressure (BP),
coronary perfusion pressure (CPP),
cerebral blood flow (CBF).

mainstay Rx in the pulseless patient

regardless of the underlying rhythm.

Route: iv, im, io, ETT

High-dose epinephrine ?? no longer recommended.

Indications

Cardiac arrest
VF; Pulseless VT; asystole; PEA

Anaphylaxis; severe allergic reactions

Combine with large fluid volume; corticosteroids;
antihistamines

Severe hypotension

Systemic vascular resistance

Systemic arterial pressure
Heart rate

Contractile state
Myocardial oxygen requirement
Improved cerebral and myocardial
blood flow from vasoconstriction and
increased perfusion pressure

Precautions

Standard preparation

May increase myocardial ischemia, angina, and

oxygen demand
High doses do not improve survival; may be
detrimental

1 mg/ml ampoule

S/E:

tachy, HPT, arrhythmias

CPR all
pulseless
conditions

1 mg every 3 5 min

Undiluted

IV: 0.1 mg every 10 mins

+ 9 ml NS
as required
ADRENALINE Anaphylaxis
(0.1 mg/ml)
I.M: 0.2 0.5 mg (1:1000)
every 5 15 mins

(1 mg/ml)
Strength
1:1000)

Start 2 20 mcg/min
Or 2 20 ml/hr
Hypotension
/ Shock

3mg in 47ml of D5%

(0.06mg/ml) or

Amiodarone useful in treating both supra- and

ventricular tachydysrhythmias.

Increase the rate of survival from cardiac arrest,

BUT has not been shown to increase survival to
hospital discharge.

In PSVT, Amiodarone is a second-line agent, and

can be used when adenosine fails.

 The

maximum dose in 24 hour: not exceed 2.2

grams.
Cardiac arrest
Pulseless VT or
VF

Initial 300 mg, may repeat

dose at 150 mg
Loading dose:
Step 1: 150 mg stat

AMIODARONE
(150 mg/3ml)

Non-cardiac arrest
Stable VT/ SVT Maintenance dose:
Step 2: 360 mg over 6 hrs (run
Atrial
33.3 ml/hr)
fibrillation
Step 3: 540 mg over 18 hrs (run
16.7 ml/hr)

 hyper/hypothyroidism,
bradycardia,
proarrhythmia,
nausea,
anorexia,
photosensitivity,
corneal

microdeposits.
Pulmonary toxicity
(pneumonitis)

Atropine

For symptomatic bradycardia that are due to

increased parasympathetic tone.

Atropine should not be used when infranodal

pathology is suspected such as with seconddegree AV blocks.

Heart transplant???

Atropine is ineffective in the setting of previous heart

transplant and may worsen ischemia during a
myocardial infarction.

 Mechanism

of Action

Inhibits the actions of acetycholine on structures

innervated by postganglionic sites
(smooth/cardiac muscle, SA/AV nodes)

Indications

First line drug for symptomatic sinus bradycardia

Organophosphate poisoning; large dose may be

needed

Precautions

Not effective for type II 2nd or 3rd degree block (may

slow the rhythm)

Doses < 0.5 mg may cause a paradoxical slowing

Dont delay pacing for

severely symptomatic
(unstable) patients.

ATROPINE
(1 mg/ml)

CPR Asystole,
PEA

1 mg every 3 5 mins
(Max: 0.04 mg/kg)

Symptomatic
bradycardia

0.5 mg every 3 5 mins

(Max : 3 mg total dose)

1 2 mg and with doubling of

Organo-phosphate each subsequent dose every 3-5
poisoning
minutes until full atropinisation
effect.

 HA,
convulsion,
VT,
paradoxical

bradycardia,
eye dryness,
dry mouth,
constipation,
flushed skin

 Mechanism

of Action

Slows impulse formation in the SA node;

Slows conduction time through AV node;
Depress LV function and restores NSR.

 Indications

1st drug for stable, narrow complex, regular SVT

May consider for unstable SVT while preparing for

cardioversion

 Place

supine or mild reverse Trendelenburg,

IV nearest to the heart

Ampoule:

6mg / 2 ml

Half-life???

ADENOSINE
(6 mg/2ml)

Supraventricular
tachycardia (SVT)

6 12 mg - 12 mg
(Max. single dose:
12 mg)
f/by 20 ml NS
bolus

 Contraindications/Precautions

2nd and 3rd degree block is contraindicated

Transient side effects; flushing, CP, asystole, brady,

ectopy, bronchospasm

Transient periods of sinus brady or ventricular

ectopy common after termination of SVT

Safe in pregnancy

 Transcient

brady,
Complete HB
Ventricular standstill
Dyspnoea
Nausea
Angina like chest pain
Bronchospasm
Raised ICP

 Mechanism

of Action

Increases magnesium levels in cases where

prolonged QT interval is thought to be
secondary to hypomagnesemia.

 Indications

Torsades is suspected in cardiac arrest

Life-threatening ventricular dysrhythmias in
digitalis OD

Precautions

Fall in BP with rapid administration

Dosing

Arrest 1-2 g over 5-20 min.

Torsades w/ pulse 1-2 g over 5-60 min.

MAGNESIUM
SULPHATE

AEBA

2 g (4 ml) over 20 min

Torsade de pointes

1 2 g over 15 mins

Treatment for
hypomagnesemia

1 2 g over 5 to 60 mins

(2.47 g/5ml)
Pre-eclampsia/
Eclampsia

4 5 g over 20 mins, followed

by 1 2 g/hr
(Max: 40 g/24 hr)
20gm (40ml) in 450NS
(40mg/ml)

 Bradycardia
Diplopia
HA
Hypotension
Nausea,

SOB
Vomiting
Weakness
Reduce reflex

 Mechanism

of Action

Stimulates adrenergic receptors

(dose dependent)

Indications

Second-line drug for symptomatic bradycardia

Hypotension with signs and symptoms of shock

Precautions

Correct hypovolemia with volume before initializing

May cause tachydysrhythmias; excessive vasoconstriction
Dont mix with sodium bicarbonate

1 20 mcg/kg/min
(Max: 20 mcg/kg/min)
DOPAMINE Hypotension
(200 mg/5 ml)
/ shock

(200mg in 45 ml of NS:
4mg/ml)

 chest
fast,

pain;

slow, or pounding heartbeats; arrythmia

weakness,
swelling
N,V

confusion,

in your feet or ankles,

 Mechanism

of action
Direct beta-adrenergic stimulator
Potent

inotropic effect but less chronotropic

Renal and mesenteric flow follows cardiac
output
Myocardial work is balanced by increases in
coronary flow at clinical doses

 Indications

Congestive heart failure

Cardiogenic shock

Hemodynamically significant hypotension

DOBUTAMINE
(250 mg/20 ml)

Hypotension/
shock

2.5 20 mcg/kg/min
(Max: 20 mcg/kg/min)
(250mg in 30 ml: 5mg/ml)

 Generally

dose related, uncommon

if < 10mcg/kg/min
Tachycardia
Arrhythmias
Tremors
HPT
Angina like chest pain
Nausea
Vomiting

 Mechanism

of action

Reacts with H+ ion, as in metabolic acidosis

HCO3- + H+
H2CO3
CO2 + H20

No definite evidence of benefit in arrest

Indication

Consider in severe metabolic acidosis eg.

Cardiac arrest

 Dose

1 mmol/kg initially, OR 50-100 ml of 8.4%

NaHCO3 over 30-60 mins

Precautions

Worsened intracellular acidosis from CO2

formation and retention

Hyperosmolality and hypernatremia

Metabolic alkalosis

Acute hypokalemia

 Indication

PEA d/t; HyperK, hypoCa, CCB overdose

Dose:

10 ml of 10% calcium gluconate (6.8 mmol/L Ca)

S/E:

Brady,
Arrythmias, tissue irrtation (local)

 MUST

KNOW DRUGS in Emergency

Department

Local

protocol of drug

Always

re-confirm before giving ANY drugs to

patient
Report

any drug reaction