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Overview of ACLS Pharmacology and Update on New ACLS Guidelines

Krista Piekos, Pharm.D. Clinical Pharmacy Specialist - Critical Care Harper University Hospital Adjunct Assistant Professor Wayne State University

Objectives
Pharmacists should be able to identify: Why? we use an agent When? to use an agent How? to use an agent What? ...to watch for To familiarize the pharmacist with the ACLS algorithms To help the pharmacist become comfortable with the crash cart To introduce the needless delivery system

Outline
Present conclusions of the International Guidelines 2000 ACLS objectives with 2003 updates Classification of recommendations ACLS Algorithms Pharmacology of agents used in algorithms Overview of crash cart revisions Overview of needless system

Background
In Seattle 43% of patients in VF survived to hospital discharge if CPR w/in 4 min and defibrillation w/in 8 min These figures are higher than national average - due to AEDs throughout public Overall survival from CPR is poor 5-15% Survival for in-patient CPR to discharge is <10%

Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care


1st international consensus on resuscitation guidelines Experts from around the world
Identified issues Gathered scientific evidence; level (quality) of evidence Integrate into a class of recommendation

Revised guidelines

Classification of Therapeutic Interventions


Class I: definitely helpful, excellent Class II: Class II a -probably helpful; good to very good Class II b -possibly helpful; fair to good Class Indeterminate: insufficient evidence; no harm, but no benefit Class III: possibly harmful

New Goals
1. Early Defibrillation - Public Access Defibrillation (PAD)
Probability of successful defibrillation and survival is negatively related to the time from onset of VF to delivery of first shock PAD has the potential to be the single greatest advance in the treatment of prehospital sudden cardiac death since the invention of CPR
Circulation August 22, 2000

2. Establishing a specific diagnosis by ECG 3. Antiarrhythmic agents are just as likely to be proarrhythmic as they are antiarrhythmic. One, and only one antiarrhythmic should be used.

Routes of Administration
Intravenous Preferred route Endotracheal

2-2.5 Xs IV dose in 10ml volume Each dose is followed by 10 ml NS flush down the ET tube (Ex. epinephrine, atropine, lidocaine, diazepam, naloxone) Absorption occurs at alveolar capillary interface

Intraosseous (active bone marrow) Pediatric patients without IV access Other: Sublingual, intracardiac, IM, SC (poor absorption)

ACLS Algorithm Approach

Universal Algorithm

Epinephrine
WHY?
Natural catecholamine with and -adrenergic agonist activity

Results in:
flow to heart and brain SVR, SBP, DBP electrical activity in the myocardium & automaticity ( success with defibrillation) myocardial contraction (for refractory circulatory shock (CABG)) increases myocardial oxygen requirements

Primary benefit: -vasoconstriction -adrenergic activity controversial b/c myocardial work WHEN? VF/VT, asystole, PEA, bradycardias

Epinephrine
HOW? High dose versus standard dose? Higher ROSC with high dose, but no change in survival High doses may exacerbate postresuscitation myocardial dysfunction Recommendations:

Class I: 1 mg IV q 3 - 5 min Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min Infusion for HR & BP (IIb)
1mg in 250ml NS or D5W - infuse @ 1-10 mcg/min

ET Dose=2-2.5 times IV dose

What to watch for?

Tachycardia, hypertension, myocardial ischemia, acidosis


Incompatible with Ca, HCO3, aminophylline & PHY. Alkaline solutions cause auto-oxidation.

Vasopressin
WHEN? Alternative to epinephrine for shock-refractory VT/VF WHY? Natural antidiuretic hormone Potent vasoconstrictor by stimulation of SM -V1 receptors :
BP & SVR; CO, HR, myocardial O2 consumption and contractility

Does not myocardial oxygen consumption Not affected by severe acidosis Class IIb for shock-refractory VF Class Indeterminate for PEA, asystole Half life = 10-20 minutes Dose? 40 Units IVP - one time only!!!

Why Vasopressin?

During CPR, plasma ADH levels are higher in patients with return of spontaneous circulation (ROSC) During CPR patients may be severely acidotic Epinephrine compared to vasopressin pre-hospital CPR (20 patients/study group) Multiple animal studies showing ROSC EPI (n=20) VP (n=20)

Survival to hospital 24 hour survival Discharge alive

35% 20% 15%

70% 60% 40%

(p=0.06) (p=0.02) (p=0.16)

ILCOR Universal Algorithm


(International Liaison Committee on Resuscitation)

Medication changes in 2000:


Emphasis on identification of all possible stroke
victims for IV fibrinolytics Epinephrine has become Class Indeterminate High-dose epinephrine no longer recommended

For shock-refractory VT/VF: Epinephrine 1 mg q 3-5 min

Vasopressin 40 Units IVP one time


Epinephrine alone for non-VT/VF

Pulseless Ventricular Fibrillation or Tachycardia

In ACLS, always assume VF - most common

85%-95% of survivors have VF Survival dependant on early defibrillation Medications indicated only after 3 failed shocks

VFib/Pulseless VT Algorithm
Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better Please - Precordial Thump If pulse-less with no defibrillator Shock 200J* Shock 200-300J* Shock 360J* (*only consecutive, if persistent)

EVerybody - Epinephrine 1 mg IV q3-5 min or Vasopressin 40 U IVP


If VF/PVT persists, "CONSIDER" antiarrhythmics and sodium bicarb. NOTE: always "max out" one agent before proceeding to the next in order to limit pro-arrhythmic drug-drug interactions

Shock 360J
And - Amiodarone (First Choice) 300mg IV push. May repeat once at 150mg in 3-5 min. (max. cumulative dose: 2.2g IV/24hrs)

Drug-shock-drug-shock sequence

(continued)

Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better Let's - Lidocaine 1.0-1.5 mg/kg IV. May repeat in 3-5 min (max=3 mg/kg) Make - Magnesium Sulfate 1-2 g slow IVP for suspected Mg or TdP Patients- Procainamide 30 mg/min, or 100 mg IV q 5 min. for refractory VF. (max. dose: 17 mg/kg)
NOTE: Besides having a pro-arrhythmic drug-drug interaction with amiodarone, procainamide is of limited value in an arrest situation due to a lengthy administration time

Better (consider buffers) - Bicarbonate 1 mEq/kg IV for:


preexisting K+ bicarb-responsive acidosis some drug overdoses protracted code (intubated) ROSC after long code with effective ventilation.

Drugs for VF/PVT


Epinephrine - Why? How? What? Vasopressin - Why? How? What?

Amiodarone
Magnesium Procainamide Lidocaine Buffers

Classification of Antiarrhythmics
Class Ia Drug Quinidine Procainamide Disopyramide Lidocaine Mexiletine Tocainide Flecainide Propafenone Moricizine Beta-Blockers Amiodarone Bretylium Sotalol Verapamil Diltiazem Conduction Velocity Refractory Period Automaticity Ion Block Sodium

Ib

0/ 0

Sodium (fast on-off) Sodium (slow on-off) Calcium Potassium

Ic

II III

0
Calcium

IV

Drugs Used for Heart Rhythm and Rate Amiodarone


WHY? Class III antiarrhythmic (characteristics of all classes) Na, K and Ca channel blocker & & -adrenergic blocker Prolongs AP and RP Decreases AV conduction velocity & SN function

New Recommendations (WHEN?): pulseless VT or VF (IIb) hemodynamically stable VT (IIb), polymorphic VT (IIb), wide-complex tachycardia uncertain origin (IIb) refractory PSVT (preserved function, IIa; impaired function IIb) atrial tachycardia (IIb) cardioversion of AF (IIa)

Amiodarone
HOW? Cardiac arrest (PVT/VF) - 300mg IVP diluted in 2030ml, may repeat with 150mg in 10 minutes, or start infusion (max=2..2 g/24h) Atrial & ventricular arrhythmias in impaired hearts

150mg IVP over 10 min May repeat q10-15 min, or start gtt 1mg/min x 6 hours, then 0.5mg/min x 18 h

WHAT? Hypotension, bradycardia (slow rate, fluids)

Why Amiodarone?
ARREST Trial
Objective: Efficacy of IV amiodarone in out-of-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia Endpoints: Hospital admission with perfusing rhythm Survival to discharge Functional neurologic status at discharge
*Insufficiently powered to detect survival to discharge and functional neurologic status*

ARREST Trial: Amiodarone in the Resuscitation of Refractory Sustained Ventricular Tachyarrhythmias


Prospective, randomized, DB, PC trial

504 patients, who failed >/= 3 shocks


Randomized to placebo or 300mg IV amiodarone Amiodarone Dosing:
300mg diluted with 5% D5W to 20mL

Rapid IV bolus

Found a statistically significant increase in the number of

patients who arrived to hospital alive (p=0.03) Consistent results regardless of presenting rhythm
This is the only antiarrhythmic agent which has shown definitive benefit in cardiac arrest!

ARREST Trial - Subgroup Analysis


Amiodarone 70 Placebo

% Surviving to Admission

60 50 40 30 20 10 0
All Patients VF Asystol e or PEA ROSC No ROSC

Drugs Used for Heart Rhythm and Rate


Magnesium Sulfate
WHY? Magnesium deficiency causes arrhythmias Facilitates ventricular repolarization by enhancing intracellular potassium flux, dilates coronary arteries Suspected hypomagnesemia, pulseless VT/VF, torsade de pointes

WHEN?

HOW?

Class IIa in suspected hypomagnesemia, TdP, and Class IIb in VF/VT: 1 - 2gm slow IVP in 100ml Hypotension at large doses

WHAT?

Drugs Used for Heart Rhythm and Rate


Procainamide
WHY?

Suppresses both ventricular and atrial arrhythmias Type Ia antiarrhythmic, affects fast Na+channels-slowing conduction velocity, prolongs RP, and decreases automaticity Phase IV depolarization
Refractory/recurrent VF/VT Control of rapid ventricular response (IIb) Conversion SVT (AF/Fl) (IIa)

WHEN?

Drugs Used for Heart Rhythm and Rate


Procainamide
HOW? VF: 20-30 mg/min slow infusion (max=17 mg/kg) AF with rapid vent. response: 100 mg over 5 min then infuse@ 1 - 4 mg/min 1-2 gm/250ml D5W

WHAT?

Stop infusion if patient hypotensive, widened QRS >50%, arrhythmia suppression, or dose=17mg/kg Dose reduction in renal failure SLE syndrome Levels: PA=4-12 g/ml NAPA=7-15 g/ml (active metabolite-Class III)

Drugs Used for Heart Rhythm and Rate


Lidocaine
WHY?

Type IB antiarrhythmic Affects fast Na+ channels, shortens refractory period Suppresses spontaneous depolarization Local anesthetic, increases fibrillation threshold Suppresses ventricular ectopy post-MI
Without effecting myocardial contractility, BP or AV nodal conduction

WHEN?
SECOND-CHOICE agent VT/VF refractory to electrical countershock and epinephrine

(Indeterminate) Control of PVCs (Indeterminate) Hemodynamically stable VT (IIb)

Not for routine prophylaxis post-MI, however, accepted in high-risk patients (hypokalemia, myocardial ishchemia, LV dysfunction)

Drugs Used for Heart Rhythm and Rate


Lidocaine
HOW? Class IIa: 1 - 1.5 mg/kg IVP q5 - 10 min (max=3mg/kg) Infusion (with pulse): 1 - 4 mg/min (if pulse is regained) Therapeutic Levels: 1.5-6 g/ml ET Dose: 2-2.5 times IV dose Preparation: 1-2 gm/250 ml D5W or NS Hepatic metabolism, renal elimination Bradycardia, cardiac arrest, seizures Lidocaine toxicity/neurotoxicity - twitching, LOC, seizures, coma Lidocaine levels persist in low CO states

WHAT?

Drugs Used to Improve Cardiac Output and Blood Pressure Sodium Bicarbonate
WHY?
Enhances sodium shift intracellularly, buffers acidosis, decreases toxicity of TCAs, increases clearance of acidic drugs Class I - hyperkalemia Class IIa - bicarbonate-responsive acidosis metabolic acidosis secondary to loss of bicarb (renal/GI); overdoses (TCAs, phenobarbital, aspirin) Class IIb - protracted arrest in intubated patients Class III - hypoxic lactic acidosis 1 mEq/kg IVP, 0.5mEq/kg q10 min prn

WHEN?

HOW?

WHAT?

May worsen outcome if not intubated/ventilated. Metabolic alkalosis, decreased O2 delivery to tissues, hypokalemia, CNS acidosis, hypernatremia, hyperosmolarity
Incompatible with calcium, epinephrine, atropine, norepinephrine, isoproterenol

Summary V.Fib and Pulseless V.Tach


Changes: Vasopressin added - Class IIb 40 U IVP x 1 Epinephrine - Class Indeterminate 1mg IVP q 3-5 min Amiodarone added - Class IIb
300mg IVP (cardiac arrest dose). May repeat 150mg x 1

Lidocaine - Class Indeterminate 1-1.5 mg/kg IVP q 3-5 min (Max = 3mg/kg) Procainamide is acceptable but not recommended due to long administration times Bretylium fell off algorithm due manufacturing problems

The Tachycardia Algorithms


Major New Concepts:
Make a specific rhythm diagnosis Identify patients with significantly impaired
cardiac function (EF<40%, overt HF) Only use one antiarrhythmic, especially in damaged hearts

Resulted in 3 new algorithms

The Tachycardia Overview Algorithm


Is the patient stable or unstable?

Stable
Identify 1 of 4 types of tachycardia

Unstable
Cardioversion
(premedicate)

AF/Aflutter Narrow-complex tachycardia Stable wide-complex tachycardia Stable monomorphic VT VT, PSVT, 100J, 200J, 300J, 360J

Tachycardia - Atrial Fibrillation/Flutter


4 Clinical Features: Unstable? Impaired cardiac function? WPW? Duration? <48h, or > 48h? Focus - treat unstable patients urgently Control ventricular response convert anticoagulate

Atrial Fibrillation/Flutter
Condition EF > 40% Rate Control CCB (I) -Blocker (I) Conversion > 48h DC Cardioversion Amiodarone (IIa) Ibutilide (IIa) Flecainide (IIa) Propafenone (IIa) Procainamide (IIa) DC Cardioversion OR Amiodarone (IIb) Impaired EF<40%: DC Cardioversion Amiodarone(IIb) DC Cardioversion Amiodarone (IIb) Flecainide (IIb) Propafenone (IIb) Procainamide (IIb) Sotalol (IIb) Conversion < 48h No DC Cardioversion Anticoagulation x 3 weeks, then CV, then anticoagulation x 4 wk OR r/o clot by TEE, CV, then AC x 4 wk (See above)

EF < 40%

Digoxin (IIb) Diltiazem (IIb) Amiodarone (IIb) Preserved heart fxn: DC Cardioversion Amiodarone(IIb) Flecainide (IIb) Procainamide (IIb) Propafenone (IIb) Sotalol (IIb)

WPW

(See above)

Drugs Used in Afib/AFlutter


Calcium channel blockers Beta-blockers Digoxin Amiodarone Procainamide Flecainide (IV form in ACLS -not available in US) Propafenone (IV form in ACLS -not available in
US)

Sotalol (IV form in ACLS -not available in US)

Drugs Used for Heart Rhythm and Rate


Calcium Channel Blockers
WHY? Blocks inward flow of Ca and Na, slows conduction, RP in AVN Terminate reentrant arrhythmias requiring AVN conduction Control ventricular response rate in AF/AFl Coronary vasodilation May exacerbate CHF Negative inotrope & chronotrope (good anti-ischemic) Class I for acute and preventative SVT Direct negative chronotropic effect, mild negative inotrope Highly effective in controlling ventricular response in A Fib Control ventricular response rate in patients with AF/Fl, or MAT Verapamil: PSVT not requiring cardioversion

Verapamil:

Diltiazem:

WHEN?

Drugs Used for Heart Rhythm and Rate


Calcium Channel Blockers
HOW? Verapamil: 2.5 - 5 mg IVP, over 2 min (max=30mg) Inf @ 5-10 mg/hr 0.25 mg/kg IVP, may repeat with 0.35mg/kg in 15 min Infuse @ 5-15 mg/hr

Diltiazem:

WHAT?

Contraindicated in wide QRS complex tachycardias and ventricular tachycardias, exacerbation of CHF in patients with LV dysfunction Transient decrease in BP Avoid in sick sinus syndrome of AV block (w/out pacer)
May potentiate digoxin toxicity.

Incompatible with bicarbonate, epinephrine, furosemide

Drugs Used for Heart Rhythm and Rate


Beta - Blockers
WHY? WHEN? B-adrenergic blockade, slows conduction and increases refractory period in AV node AMI (reduces rate of reinfarction), reduces recurrent ischemia and incidence of VF in postMI patients, USA Atenolol: Metoprolol: Propranolol: Esmolol: WHAT? 2.5-5 mg IV over 5 min 5 - 10 mg IVP q 5 min 0.1 mg/kg IV divided into 3 doses @ 2 - 3 min intervals 500 mcg/kg over 1 min Inf @ 50 mcg/kg/min

HOW?

Hypotension, bradycardia, AV block, overt heart failure or severe bronchospasm/COPD

Stable Monomorphic Ventricular Tachycardia

Preserved Cardiac Function

NOTE! May go directly to cardioversion

Impaired LV EF<40% or CHF

Medications: any one Procainamide (IIA) Sotalol (IIA)* Amiodarone (IIB) Lidocaine (IIB)
*Not yet available in the US.

Amiodarone (IIB) 150 mg IV bolus over 10 min may repeat 150mg q10-15min or start infusion OR Lidocaine (IIB) 0.5 to 0.75 mg/kg IV push Then use Synchronized cardioversion

Narrow-Complex Supraventricular Tachycardia


Vagal stimulation Adenosine
Junctional

1. EF > 40% - Amiodarone, B-blocker, CCB 2. EF <40%, CHF - Amiodarone

PSVT
EF>40% - CCB, BB, digoxin, DC cardioversion (procainamide, amiodarone, sotalol) EF<40%, CHF - no DC cardioversion; digoxin, amiodarone, diltiazem

MAT
EF>40% -No DC cardioversion; CCB, BB, amiodarone EF<40% -No DC cardioversion; amiodaonre, diltiazem

Wide-Complex Tachycardia
Wide . Prolonged QRS or QRST interval
HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter) OLD - Lidocaine NEW Establish diagnosis - 12-lead ECG Adenosine if SVT- slows AV conduction. Short-lived hypotension Amiodarone (IIa) normal LV function Amiodarone (IIb) impaired LV function Procainamide (IIa)- terminates SVT due to altering conduction across accessory pathways Lidocaine if VT Sotalol, propafenone, flecainide

Drugs Used for Heart Rhythm and Rate Adenosine


WHY? Endogenous nucleoside, slows conduction through the AV node and can interrupt AV nodal reentry pathways PSVT (half-life=10 sec) If PSVT persists may want longer acting agent (verapamil or diltiazem) 6 mg rapid IV over 1 - 3 sec, followed by 20 ml NS flush. May repeat in 1-2min with 12 mg dose. Max.=30 mg Flushing, dyspnea, chest pain, post-conversion bradycardia Drug interaction with theophylline, dipyridamole

WHEN?

HOW?

WHAT?

Pulseless Electrical Activity


PEA no pulse with + electrical activity (not VF/VT) Reversible if underlying cause is reversed (5 Hs, 5 Ts)
Hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hyper/hypothermia Tablets, tamponade, tension pneumothorax, thrombosis (ACS), thrombosis (PE)

Intervention
Problem Epinephrine

Comments/Dose
Search for the probable cause and intervene (HCO3) 1 mg IV q3-5 min.

Atropine

With slow heart rate, 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)

Atropine
WHY? Anticholinergic/direct vagolytic Enhances sinus node automaticity and AVN conduction PEA, symptomatic sinus bradycardia, asystole, Bradycardia: 0.5 -1 mg IV q3-5 min Asystole: 1 mg IV q 3-5 min Max = 0.04 mg/kg or 3 mg ET Dose=1-2mg diluted in 10ml
Paradoxical bradycardia with insufficient dose (<0.5mg)

WHEN? HOW?

WHAT?

Tachycardia; 2nd or 3rd degree AV block (paradoxical slowing may occur), MI (may worsen ischemia/HR)
Incompatible with bicarbonate, epinephrine & norepinephrine

Bradycardia
All Patients Deserve Empathy
(The sequence reflects interventions for increasingly severe bradycardia)

Absolute (< 60 BPM) or relative Serious signs and symptoms (CP, SOB, hypotension, mental status changes)
Intervention Comments/Dose

Mnemonic

All mg/kg)
Patients

Atropine
Pacing

0.5-1.0 mg IVP q 3-5 min (max 0.03-0.04


Use Transcutaneous Pacing if severe S/S

Deserve
Empathy

Dopamine
Epinephrine

5-20 g/kg/min.
2-10 g/min.

Medications for Bradycardia


Atropine - Why? How? Dopamine Epinephrine infusion 1mg/250 ml @ 1-4 mcg/min

Note: Lidocaine can be lethal if HR is due to ventricular escape rhythm

Dopamine
WHY? related) hypotension WHEN? NE precursor Stimulates DA, & -adrenergic receptors (doseWant -stimulation, for bradycardia-induced Hypotension/shock

HOW?

renal: 2 - 5 mcg/kg/min cardiac: 5 - 10 mcg/kg/min (B1 & alpha) vascular: 10 - 20 mcg/kg/min (alpha)
400 mg/250 ml D5W or NS Tachycardia, tachyphylaxis, proarrhythmic If requiring > 20mcg/kg/min consider adding NE

Preparation: WHAT?

ACLS Algorithms Asystole


Consider possible causes and treat accordingly (ex.hypoxemia,

hyper/hypokalemia, acidosis) Acronym TEA


T Transcutaneous Pacing (TCP) (Class IIb) Only effective with early implementation along with appropriate interventions and medications E Epinephrine 1 mg IV q3-5 min.

A mg/kg)

Atropine 1 mg IV q3-5 min. (max. dose 0.04

Discourage shocking due to excess parasympathetic discharge Consider Na Bicarbonate 1 mEq/kg

Drugs Used for Myocardial Ischemia/Pain

Oxygen Nitroglycerin Morphine Sulfate

AMI - Aspirin, thrombolytics, heparin, lidocaine, beta-blockers Glycoprotein IIb/IIIa receptor antagonists

Acute Myocardial Infarction


Call first, call fast, call 911 Oxygen 4L/min NTG SL, paste or spray; if BP > 90 mm Hg, IV NTG Morphine IV ASA PO (I) Thrombolytics? (I) - within 6 hours of symptoms, (II) if > 6hr IV heparin B-blockers Magnesium (if Mg)

Oxygen
Why? increases hemoglobin saturation, improves tissue oxygenation supply to ischemic tissues 16-17% oxygen from mouth-to-mouth When? Must give supplemental oxygen in ACLS Always for MI How? NC 4 L/min, intubation, etc Goal - Osat=97-98% Confirm tube placement

Drugs Used for Myocardial Ischemia/Pain


Nitroglycerin
WHY?

binds to receptors on vascular smooth muscle vasodilation (venous > arterial) venous BF to heart (preload) & O2 consumption dilates coronary arteries - myocardial blood supply antagonizes vasospasm increases collateral flow to ischemic myocardium inhibits infarct expansion decreases pain

Drugs Used for Myocardial Ischemia/Pain


Nitroglycerin
WHEN?
Ischemic CP; USA; pulmonary edema (when SBP>100); AMI SL NTG -drug of choice for angina IV NTG - drug of choice for unstable angina or AMI Congestive heart failure with ischemia

HOW?
IV: 10-20 mcg/min, increase by 5-10 mcg/min q5-10 min until desired effect or hemodynamic compromise SL: 1 tablet (0.4mg) SL q5min times 3 Spray: 1 spray onto oral mucosa Ointment 2%: 1-2 inches over 2-4 inch area Patches: no role in acute therapy

Drugs Used for Myocardial Ischemia/Pain


Nitroglycerin
Preparation: 50 mg/250 ml D5W or NS Must be in glass bottle

Cautions:

hypotension - treat with fluids, and rate reduction/elimination bradycardia - vasovagal reflex to hypotension treat with fluids, rate reduction, atropine reflex tachycardia also a concern headache, dizziness - may be diminished by laying down patients develop tachyphylaxis to effects - promote nitrate-free periods, intermittent dosing and lowest-possible doses

Drugs Used for Myocardial Ischemia/Pain


Morphine Sulfate
WHY? (Pain can catecholamines - BP, HR, O2 demands) Opiate analgesic pain, preload and afterload, SVR, anxiety Relieves pulmonary congestion, myocardial oxygen demand WHEN? Pain, pulmonary edema, BP > 90 mm Hg HOW? 1-3mg IVP (2-15 mg IVP q15-30 min prn) CAUTION? Respiratory & CNS depression, bradycardia, hypotension, N/V

Drugs Used for Myocardial Ischemia/Pain (Continued)


Aspirin
Heparin Thrombolytics - reteplase, alteplase, TNK

B Blockers
Magnesium Lidocaine - not for prophylaxis

Hypotension/Shock/Pulmonary Edema
Identify Problem? Volume; Pump; Rate? Volume:
fluids, blood, vasopressors

Pump:
s/s of shock - vasopressors; no s/s shock -

dobutamine BP (>100 mm Hg) - NTG, Nitroprusside pulmonary edema -furosemide 0.5-1mg/kg, morphine 1-3mg, NTG SL, oxygen/intubate

Rate: see algorithms

Drugs Used to Improve Cardiac Output and Blood Pressure


Norepinephrine
Action: Alpha & -adrenergic stimulation, increases contractility and HR, vasoconstriction, improves coronary blood flow Shock refractory to fluid replacement, severe hypotension

Indication:

Dose:
Preparation: Caution:

0.5 - 1 mcg/min refractory shock = 8 - 30 mcg/min


4-8mg/250 ml D5W or NS Hypertension, myocardial ischemia, cardiac arrest, palpitations

Drugs Used to Improve Cardiac Output and Blood Pressure


Dobutamine
Action: Indication: Dose: Preparation: Caution: B1- adrenergic activity Inotrope in heart failure/hypotension 2 - 20 mcg/kg/min 250 mg/250 ml D5W or NS tachyarrhythmias,worsens myocardial ischemia

Drugs Used to Improve Cardiac Output and Blood Pressure


Inamrinone and Milrinone
Action: Phosphodiesterase inhibitors, positive inotropes and vasodilator
Refractory heart failure

Indication:

Dose:

Inamrinone:
Milrinone:

750 mcg/kg over 2 - 3 min Inf @ 5 - 15 mcg/kg/min 50 mcg/kg over 10 min Inf @ 0.375 - 0.75 mcg/kg/min

Caution:

Thrombocytopenia, worsens myocardial ischemia, SV and ventricular arrhythmias

Drugs Used for Heart Rhythm and Rate Isoproterenol


WHY? Synthetic sympathomimetic amine Pure B-adrenergic activity +inotropic& chronotrope HR/CO, contractility; MAP secondary vasodilation

WHEN? Symptomatic bradycardia Refractory torsades de pointes HOW? Class II - 2 - 10 mcg/min


Class III - higher doses Preparation: 1 mg/ 250 ml D5W or NS WHAT? mycocardial O2 consumption & peripheral vasodilation Avoid in ischemic heart disease; arrhythmogenic

Drugs Used to Improve Cardiac Output and Blood Pressure


Sodium Nitroprusside
Action: Antihypertensive, peripheral vasodilator, reduces afterload, increases CO and relieves pulmonary congestion Hypertension, AMI, CHF 0.1 - 5 mcg/kg/min, and titrate up to 10mcg/kg/min 50 mg/250 ml D5W Cyanide and thiocyanate toxicity, hypotension

Indication: Dose: Preparation: Caution:

Summary of 2000 Changes

NEW AGENTS - Amiodarone & Vasopressin


Amiodarone (Class IIb) & Procainamide (Class IIb) hemodynamically stable wide-complex tachycardia (esp. in poor cardiac fxn) VT - amiodarone & sotalol (Class IIa) Vasopressin (Class IIb) - alternative to epinephrine Bretylium acceptable, but not recommended Lidocaine for VT/VF (Class Indeterminate) & Class III for prophylaxis of ventricular arrhythmias in AMI Magnesium (Class IIb) - Mg or TdP High-dose epinephrine (Class Indeterminate) Fibrinolytics for AMI & Stroke

Crash Cart Revisions


Summary of Changes: Additions: 5 amps of amiodarone 150mg/3ml (were 3) 3 vials of vasopressin (20 Units/vial) 1 bag of premixed dopamine 400mg in 250ml 4 Na Bicarbonate syringes (were 3) 5 filter needles 20 blunt cannulas Deletions: 1 dopamine vial (new total=1) Remove 5 epinephrine syringes (new total=10) Remove 1 lidocaine syringe (new total=2) Remove metoprolol

Needless System/Cannulas

Questions ?