Younas inayat

Bradycardia
Atropine
Dopamine infusion
Epinephrine infusion

Atropine
Mechanism of Action

Inhibits the actions of

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

Atropine
Indications
First drug for symptomatic sinus bradycardia
May be beneficial in AV block or asystole
Second drug in asystole or slow PEA
Organophosphate poisoning; large dose may be
needed
Precautions
MI and hypoxia atropine increases oxygen demand
Avoid in hypothermia
Not effective for 2nd type II or new 3rd degree block
(may slow the rhythm)
Doses < 0.5 mg may cause a paradoxical slowing

Atropine

Dont delay pacing for

severely symptomatic
(unstable) patients.

Asystole or slow (<60)PEA

1 mg IV/IO push
Repeat every 3 to 5 minutes (if rhythm persists) to
max. of 3 mg.
Bradycardia
0.5 mg IV every 3-5 minutes as needed; max. of 3
mg.
Use shorter dosing interval and higher doses in
severe clinical situations
Endotracheal Administration
2-3 mg diluted in 10 mL water or NS
Organophosphate Poisoning
Large doses (2-4 mg or higher) may be necessary

Dopamine
Mechanism of Action

Stimulates adrenergic
receptors; dose
dependent.

Dopamine
Indications
Second-line drug for symptomatic bradycardia
Hypotension with signs and symptoms of shock
Precautions
Correct hypovolemia with volume before initializing
Use caution with cardiogenic shock and associated CHF
May cause tachydysrhythmias; excessive
vasoconstriction
Dont mix with sodium bicarbonate
IV Administration
Infusion at 5-20 mcg/kg/min.
Titrate to patient response; taper slowly

Epinephrine
Mechanism of Action

Stimulates adrenergic
receptors and is not dose
dependent like dopamine.

Epinephrine
Indications
Cardiac arrest

VF; VT; asystole; PEA

Symptomatic bradycardia
After atropine; alternative to dopamine
Severe hypotension

When atropine and pacing fail; hypotension

accompanying bradycardia; phosphodiesterase
enzyme inhibitors

Anaphylaxis; severe allergic reactions

Combine with large fluid volume; corticosteroids;
antihistamines

Epinephrine
Precautions
May increase myocardial ischemia, angina, and oxygen
demand
High doses do not improve survival; may be detrimental
Higher doses may be needed for poison/drug induced
shock
Dosing
Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min.
High dose up to 0.2 mg/kg for specific drug ODs
Infusion of 2-10 mcg/min.
Endotracheal of 2-2.5 times normal dose
SQ/IM 0.3-0.5 mg

Tachycardia
Adenosine
Diltiazem
Metoprolol
Amiodarone
Lidocaine
Magnesium Sulfate

Adenosine
Mechanism of Action

Slows impulse formation in

the SA node; slows
conduction time through AV
node; depresses left
ventricular function and
restores NSR.

Adenosine
Indications
1st drug for stable, narrow complex, regular SVT
May consider for unstable SVT while preparing

for cardioversion
Wide-complex tachycardia thought to be, or
determined to be reentry SVT
Does not convert atrial fibrillation, atrial flutter,
or VT
Diagnostic maneuver; stable narrow-complex
SVT

Adenosine
Contraindications/Precautions
Poison/drug induced tachycardia is contraindicated
2nd and 3rd degree block is contraindicated
Transient side effects; flushing, CP, asystole, brady,

ectopy
Less effective with theophylline or caffeine
If used for VT may cause worsening of clinical
condition
Transient periods of sinus brady or ventricular
ectopy common after termination of SVT
Safe in pregnancy

Adenosine
Place supine or mild reverse Trendelenburg
6 mg rapidly followed by 20 mL flush
May repeat at 12 mg every 1-2 minutes if

unsuccessful

Diltiazem
Mechanism of Action

Inhibits calcium movement

across cell membranes of
cardiac and smooth muscle.
Causes vasodilation, decreses
heart rate and contractility,
slows SA and AV conduction.

Diltiazem
Indications
Controlling ventricular rate in a-fib or flutter
After adenosine to treat refractory reentry SVT if
adequate blood pressure
Contraindications/Precautions
Do not use with wide-complex rhythms
Do not use with poison/drug induced tachycardia
Avoid in WPW
Avoid in AV nodal blocks
Blood pressure may drop from peripheral
vasodilation

Diltiazem
Rate control
15-20 mg (0.25 mg/kg) IV over 2 minutes
After 15 min. another 20-25 mg (0.35 mg/kg) IV
over 2 minutes, if needed
Maintenance Infusion
5-15 mg/hour; titrated to physiologically

appropriate heart rate

Metoprolol
Mechanism of Action

Selectively blocks beta-1

receptors, slowing sinus
heart rate, decreasing
cardiac output, and
decreasing BP.

Metoprolol
Indications
Administer to all patients with suspected MI or

unstable angina, absent contraindications

Second-line agent for SVT refractory to
adenosine
To reduce myocardial ischemia in MI patients
with elevated heart rate and/or blood pressure
Emergency antihypertensive therapy for acute
hemorrhagic or ischemic stroke

Metoprolol
Contraindications/Precautions
Hemodynamically unstable patients should not
receive
Signs of heart failure
Low cardiac output
Increased risk for cardiogenic shock

Relative contraindications: 1 st, 2nd, 3rd degree

blocks; active asthma; reactive airway disease;

severe bradycardia; hypotension < 100 mmHg
Concurrent administration of calcium channel
blockers can cause serious hypotension
Monitor cardiac and pulmonary status throughout

Amiodarone
Mechanism of Action

Prolongs myocardial cell

action potential duration and
refractory period by direct
action on all cardiac tissue;
decreases AV and SA
conduction rates.

Amiodarone
Indications
Life threatening dysrhythmias

VF/pulseless VT unresponsive to shock, CPR, and

vasopressor
Recurrent hemodynamically unstable VT
Seek expert opinion for other uses

Contraindications/Precautions
Bradycardia
2nd and 3rd degree block
Do not administer with meds that prolong QT

interval (procainamide)

Amiodarone
VF/VT 300 mg IV/IO in 20-30 mL NS. Can

follow with ONE dose of 150 mg in 3-5

minutes, if needed.
Life threatening dysrhythmias
150 mg over 10 minutes. May repeat every 10

minutes as needed.

Lidocaine
Mechanism of Action

Decreases depolarization,
automaticity, and
excitability of ventricle
during diastole by direct
action, reversing ventricular
dysrhythmias.

Lidocaine
Indications
Alternative to amiodarone in VF/VT arrest
Stable monomorphic VT
Malignant PVCs
Can be used if Torsades is suspected

Contraindications/Precautions
Prophylactic use in AMI is contraindicated
Reduce maintenance dose in liver impaired

patients
Discontinue infusion if toxicity develops

Lidocaine
Cardiac Arrest
Initial dose is 1-1.5 mg/kg
Refractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3
mg/kg
Endotracheal dose 2-4 mg/kg
Perfusing Dysrhythmia
0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range. Repeat

if necessary at lower range to total dose of 3 mg/kg

Maintenance Infusion
1-4 mg/min

Magnesium Sulfate
Mechanism of Action

Increases magnesium levels

in cases where prolonged QT
interval is thought to be
secondary to
hypomagnesemia.

Magnesium Sulfate
Indications
Torsades is suspected in cardiac arrest
Lfe-threatening ventricular dysrhythmias in

digitalis OD

Precautions
Fall in BP with rapid administration
Use caution in renal failure

Dosing
Arrest 1-2 g over 5-20 min.
Torsades w/ pulse 1-2 g over 5-60 min.

Vasopressin
Mechanism of Action

Causes vasoconstriction
with reduced blood flow,
increasing core perfusion
during cardiac arrest.

Vasopressin
Indications
Alternative to epinephrine in adult refractory VF/VT
Alternative to epinephrine in asystole or PEA
Contraindications/Precautions
Potent peripheral vasoconstrictor (increased
demand upon resuscitation)
Dosing
Single dose of 40 u that replaces either the 1 st or
2nd dose of epinephrine. Epinephrine can be
resumed 3-5 minutes after
Can be used endotracheally; no suggested dose