acls pharmacology
Download
Skip this Video
Download Presentation
ACLS Pharmacology

Loading in 2 Seconds...

play fullscreen
1 / 195

ACLS Pharmacology - PowerPoint PPT Presentation


  • 1071 Views
  • Uploaded on

ACLS Pharmacology. Jeremy Maddux NREMTP. Objectives. To review and obtain a better understanding of medications used in ACLS Indications & Actions (When & Why?) Dosing (How?) Contraindications & Precautions (Watch Out!). Drug Classifications. Class I: Recommendations

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'ACLS Pharmacology' - MartaAdara


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
acls pharmacology

ACLS Pharmacology

Jeremy Maddux

NREMTP

objectives
Objectives
  • To review and obtain a better understanding of medications used in ACLS
    • Indications & Actions (When & Why?)
    • Dosing (How?)
    • Contraindications & Precautions (Watch Out!)
drug classifications
Drug Classifications
  • Class I: Recommendations
    • Excellent evidence provides support
    • Proven in both efficacy and safety
  • Class II: Recommendations
    • Level I studies are absent, inconsistent or lack power
    • Available evidence is positive but may lack efficacy
    • No evidence of harm
drug classifications5
Drug Classifications
  • Class IIa Vs IIb
    • Class IIa recommendations have
      • Higher level of available evidence
      • Better critical assessments
      • More consistency in results
    • Both are optional and acceptable,
    • IIa recommendations are probably useful
    • IIb recommendations are possibly helpful
      • Less compelling evidence for efficacy
drug classifications6
Drug Classifications
  • Class III: Not recommended
    • Not acceptable or useful and may be harmful
    • Evidence is absent or unsatisfactory, or based on poor studies
  • Indeterminate
    • Continuing area of research; no recommendation until further data is available
oxygen
Oxygen
  • Indications (When & Why?)
    • Any suspected cardiopulmonary emergency
    • Saturate hemoglobin with oxygen
    • Reduce anxiety & further damage
    • Note: Pulse oximetry should be monitored

Universal Algorithm

oxygen8
Oxygen
  • Dosing (How?)

Universal Algorithm

oxygen9
Oxygen
  • Precautions (Watch Out!)
    • Pulse oximetry inaccurate in:
      • Low cardiac output
      • Vasoconstriction
      • Hypothermia
    • NEVER rely on pulse oximetry!

Universal Algorithm

vf pulseless vt11

Epinephrine 1 mg IV push, repeat every 3 to 5 minutes

  • or
  • Vasopressin 40 U IV, single dose, 1 time only

Resume attempts to defibrillate

1 x 360 J (or equivalent biphasic) within 30 to 60 seconds

Consider antiarrhythmics:

  • Amiodarone (llb for persistent or recurrent VF/pulseless VT)
  • Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT)
  • Magnesium (llb if known hypomagnesemic state)
  • Procainamide (Indeterminate for persistent VF/pulseless VT; llb for recurrent VF/pulseless VT)

Resume attempts to defibrillate

VF / Pulseless VT
epinephrine
Epinephrine
  • Indications (When & Why?)
    • Increases:
      • Heart rate
      • Force of contraction
      • Conduction velocity
    • Peripheral vasoconstriction
    • Bronchial dilation

VF / Pulseless VT

epinephrine13
Epinephrine
  • Dosing (How?)
    • 1 mg IV push; may repeat every 3 to 5 minutes
    • May use higher doses (0.2 mg/kg) if lower dose is not effective
    • Endotracheal Route
      • 2.0 to 2.5 mg diluted in10 mL normal saline

VF / Pulseless VT

epinephrine14
Epinephrine
  • Dosing (How?)
    • Alternative regimens for second dose (Class IIb)
      • Intermediate: 2 to 5 mg IV push, every 3 to 5 minutes
      • Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apart
      • High: 0.1 mg/kg IV push, every 3 to 5 minutes

VF / Pulseless VT

epinephrine15
Epinephrine
  • Precautions (Watch Out!)
    • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand
    • Do not mix or give with alkaline solutions
    • Higher doses have not improved outcome & may cause myocardial dysfunction

VF / Pulseless VT

vasopressin
Vasopressin
  • Indications (When & Why?)
    • Used to “clamp” down on vessels
    • Improves perfusion of heart, lungs, and brain
    • No direct effects on heart

VF / Pulseless VT

vasopressin17
Vasopressin
  • Dosing (How?)
    • One time dose of 40 units only
    • May be substituted for epinephrine
    • Not repeated at any time
    • May be given down the endotracheal tube
      • DO NOT double the dose
      • Dilute in 10 mL of NS

VF / Pulseless VT

vasopressin18
Vasopressin
  • Precautions (Watch Out!)
    • May result in an initial increase in blood pressure immediately following return of pulse
    • May provoke cardiac ischemia

VF / Pulseless VT

amiodarone
Amiodarone
  • Indications (When & Why?)
    • Powerful antiarrhythmic with substantial toxicity, especially in the long term
    • Intravenous and oral behavior are quite different
    • Has effects on sodium & potassium

VF / Pulseless VT

amiodarone20
Amiodarone
  • Dosing (How?)
    • Should be diluted in 20 to 30 mL of D5W
      • 300 mg bolus after first Epinephrine dose
      • Repeat doses at 150 mg

VF / Pulseless VT

amiodarone21
Amiodarone
  • Precautions (Watch Out!)
    • May produce vasodilation & shock
    • May have negative inotropic effects
    • Terminal elimination
      • Half-life lasts up to 40 days

VF / Pulseless VT

lidocaine
Lidocaine
  • Indications (When & Why?)
    • Depresses automaticity
    • Depresses excitability
    • Raises ventricular fibrillation threshold
    • Decreases ventricular irritability

VF / Pulseless VT

lidocaine23
Lidocaine
  • Dosing (How?)
    • Initial dose: 1.0 to 1.5 mg/kg IV
    • For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg
    • A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable
    • Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS

VF / Pulseless VT

lidocaine24
Lidocaine
  • Dosing (How?)
    • Maintenance Infusion
      • 2 to 4 mg/min
      • 1000 mg / 250 mL D5W = 4 mg/mL
        • 15 mL/hr = 1 mg/min
        • 30 mL/hr = 2 mg/min
        • 45 mL/hr = 3 mg/min
        • 60 mL/hr = 4 mg/min

VF / Pulseless VT

lidocaine25
Lidocaine
  • Precautions (Watch Out!)
    • Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction
    • Discontinue infusion immediately if signs of toxicity develop

VF / Pulseless VT

magnesium sulfate
Magnesium Sulfate
  • Indications (When & Why?)
    • Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state
    • Refractory VF
    • VF with history of ETOH abuse
    • Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose

VF / Pulseless VT

magnesium sulfate27
Magnesium Sulfate
  • Dosing (How?)
    • 1 to 2 g  (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push

VF / Pulseless VT

magnesium sulfate28
Magnesium Sulfate
  • Precautions (Watch Out!)
    • Occasional fall in blood pressure with rapid administration
    • Use with caution if renal failure is present

VF / Pulseless VT

procainamide
Procainamide
  • Indications (When & Why?)
    • Recurrent VF
    • Depresses automaticity
    • Depresses excitability
    • Raises ventricular fibrillation threshold
    • Decreases ventricular irritability

VF / Pulseless VT

procainamide30
Procainamide
  • Dosing (How?)
    • 30 mg/min IV infusion
    • May push at 50 mg/min in cardiac arrest
    • In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable
    • Maximum total dose: 17 mg/kg

VF / Pulseless VT

procainamide31
Procainamide
  • Dosing (How?)
    • Maintenance Infusion
      • 1 to 4 mg/min
      • 1000 mg / 250 mL of D5W = 4 mg/mL
        • 15 mL/hr = 1 mg/min
        • 30 mL/hr = 2 mg/min
        • 45 mL/hr = 3 mg/min
        • 60 mL/hr = 4 mg/min

VF / Pulseless VT

procainamide32
Procainamide
  • Precautions (Watch Out!)
    • If cardiac or renal dysfunctionis present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min
    • Remember Endpoints of Administration

VF / Pulseless VT

slide33

PEA

Case 4

slide34
PEA

Review for most frequent causes

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion—acidosis
  • Hyper-/hypokalemia
  • Hypothermia
  • Tablets (drug OD, accidents)
  • Tamponade, cardiac
  • Tension pneumothorax
  • Thrombosis, coronary (ACS)
  • Thrombosis, pulmonary (embolism)

Epinephrine 1 mg IV push,

repeat every 3 to 5 minutes

Atropine 1 mg IV (if PEA rate is slow),

repeat every 3 to 5 minutes as needed, to a totaldose of 0.04 mg/kg

epinephrine35
Epinephrine
  • Indications (When & Why?)
    • Increases:
      • Heart rate
      • Force of contraction
      • Conduction velocity
    • Peripheral vasoconstriction
    • Bronchial dilation

Pulseless Electrical Activity

epinephrine36
Epinephrine
  • Dosing (How?)
    • 1 mg IV push; may repeat every 3 to 5 minutes
    • May use higher doses (0.2 mg/kg) if lower dose is not effective
    • Endotracheal Route
      • 2.0 to 2.5 mg diluted in10 mL normal saline

Pulseless Electrical Activity

epinephrine37
Epinephrine
  • Precautions (Watch Out!)
    • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand
    • Do not mix or give with alkaline solutions
    • Higher doses have not improved outcome & may cause myocardial dysfunction

Pulseless Electrical Activity

atropine sulfate
Atropine Sulfate
  • Indications (When & Why?)
    • Should only be used for bradycardia
      • Relative or Absolute
    • Used to increase heart rate

Pulseless Electrical Activity

atropine sulfate39
Atropine Sulfate
  • Dosing (How?)
    • 1 mg IV push
    • Repeat every 3 to 5 minutes
    • May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS
    • Maximum Dose: 0.04 mg/kg

Pulseless Electrical Activity

atropine sulfate40
Atropine Sulfate
  • Precautions (Watch Out!)
    • Increases myocardial oxygen demand
    • May result in unwanted tachycardia or dysrhythmia

Pulseless Electrical Activity

asystole

Asystole

Case 5

asystole42

Transcutaneous pacing:

If considered, perform immediately

Epinephrine1 mg IV push,

repeat every 3 to 5 minutes

Atropine 1 mg IV,

repeat every 3 to 5 minutes

up to a total of 0.04 mg/kg

Asystole persistsWithhold or cease resuscitation efforts?

  • Consider quality of resuscitation?
  • Atypical clinical features present?
  • Support for cease-efforts protocols in place?
Asystole
epinephrine43
Epinephrine
  • Indications (When & Why?)
    • Increases:
      • Heart rate
      • Force of contraction
      • Conduction velocity
    • Peripheral vasoconstriction
    • Bronchial dilation

Asystole: The Silent Heart Algorithm

epinephrine44
Epinephrine
  • Dosing (How?)
    • 1 mg IV push; may repeat every 3 to 5 minutes
    • May use higher doses (0.2 mg/kg) if lower dose is not effective
    • Endotracheal Route
      • 2.0 to 2.5 mg diluted in10 mL normal saline

Asystole: The Silent Heart Algorithm

epinephrine45
Epinephrine
  • Precautions (Watch Out!)
    • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand
    • Do not mix or give with alkaline solutions
    • Higher doses have not improved outcome & may cause myocardial dysfunction

Asystole: The Silent Heart Algorithm

atropine sulfate46
Atropine Sulfate
  • Indications (When & Why?)
    • Used to increase heart rate
      • Questionable absolute bradycardia

Asystole: The Silent Heart Algorithm

atropine sulfate47
Atropine Sulfate
  • Dosing (How?)
    • 1 mg IV push
    • Repeat every 3 to 5 minutes
    • May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS
    • Maximum Dose: 0.04 mg/kg

Asystole: The Silent Heart Algorithm

atropine sulfate48
Atropine Sulfate
  • Precautions (Watch Out!)
    • Increases myocardial oxygen demand

Asystole: The Silent Heart Algorithm

calcium chloride
Calcium Chloride
  • Indications (When & Why?)
    • Known or suspected hyperkalemia (eg, renal failure)
    • Hypocalcemia (blood transfusions)
    • As an antidote for toxic effects of calcium channel blocker overdose
    • Prevent hypotension caused by calcium channel blockers administration

Other Cardiac Arrest Drugs

calcium chloride51
Calcium Chloride
  • Dosing (How?)
    • IV Slow Push
      • 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose
      • 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers

Other Cardiac Arrest Drugs

calcium chloride52
Calcium Chloride
  • Precautions (Watch Out!)
    • Do not use routinely in cardiac arrest
    • Do not mix with sodium bicarbonate

Other Cardiac Arrest Drugs

sodium bicarbonate
Sodium Bicarbonate
  • Indications (When & Why?)
    • Class I if known preexisting hyperkalemia
    • Class IIa if known preexisting bicarbonate-responsive acidosis
    • Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation
    • Class III  (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation)

Other Cardiac Arrest Drugs

sodium bicarbonate54
Sodium Bicarbonate
  • Dosing (How?)
    • 1 mEq/kg IV bolus
    • Repeat half this dose every 10 minutes thereafter
    • If rapidly available, use arterial blood gas analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration)

Other Cardiac Arrest Drugs

sodium bicarbonate55
Sodium Bicarbonate
  • Precautions (Watch Out!)
    • Adequate ventilation and CPR, not bicarbonate, are the major "buffer agents" in cardiac arrest
    • Not recommended for routine use in cardiac arrest patients

Other Cardiac Arrest Drugs

acute coronary syndromes58

Chest painsuggestive of ischemia

  • Immediate assessment (<10 minutes)
  • Measure vital signs (automatic/standard BP cuff)
  • Measure oxygen saturation
  • Obtain IV access
  • Obtain 12-lead ECG (physician reviews)
  • Perform brief, targeted history and physical exam;focus on eligibility for fibrinolytic therapy
  • Obtain initial serum cardiac marker levels
  • Evaluate initial electrolyte and coagulation studies
  • Request, review portable chest x-ray (<30 minutes)
  • Immediate general treatment
  • Oxygen at 4 L/min
  • Aspirin 160 to 325 mg
  • Nitroglycerin SL or spray
  • Morphine IV (if pain not relieved withnitroglycerin)

EMS personnel canperform immediateassessment and treat-ment (“MONA”),including initial 12-lead ECG and review forfibrinolytic therapyindications andcontraindications.

Memory aid: “MONA” greetsall patients (Morphine, Oxygen, Nitroglycerin, Aspirin)

Assess initial 12-lead ECG

Acute Coronary Syndromes
aspirin
Aspirin
  • Indications (When & Why?)
    • Administer to all patients with ACS, particularly reperfusion candidates
      • Give as soon as possible
    • Blocks formation of thromboxane A2, which causes platelets to aggregate

Acute Coronary Syndromes

aspirin60
Aspirin
  • Dosing (How?)
    • 160 to 325 mg tablets
      • Preferably chewed
      • May use suppository
    • Higher doses may be harmful

Acute Coronary Syndromes

aspirin61
Aspirin
  • Precautions (Watch Out!)
    • Relatively contraindicated in patients with active ulcer disease or asthma

Acute Coronary Syndromes

nitroglycerine
Nitroglycerine
  • Indications (When & Why?)
    • Chest pain of suspected cardiac origin
    • Unstable angina
    • Complications of AMI, including congestive heart failure, left ventricular failure
    • Hypertensive crisis or urgency with chest pain

Acute Coronary Syndromes

nitroglycerin
Nitroglycerin
  • Indications (When & Why?)
    • Decreases pain of ischemia
    • Increases venous dilation
    • Decreases venous blood return to heart
    • Decreases preload and cardiac oxygen consumption
    • Dilates coronary arteries
    • Increases cardiac collateral flow

Acute Coronary Syndromes

nitroglycerine64
Nitroglycerine
  • Dosing (How?)
    • Sublingual Route
      • 0.3 to 0.4 mg; repeat every 5 minutes
    • Aerosol Spray
      • Spray for 0.5 to 1.0 second at 5 minute intervals
    • IV Infusion
      • Infuse at 10 to 20 µg/min
      • Route of choice for emergencies
      • Titrate to effect

Acute Coronary Syndromes

nitroglycerine65
Nitroglycerine
  • Precautions (Watch Out!)
    • Use extreme caution if systolic BP <90 mm Hg
    • Use extreme caution in RV infarction
      • Suspect RV infarction with inferior ST changes
    • Limit BP drop to 10% if patient is normotensive
    • Limit BP drop to 30% if patient is hypertensive
    • Watch for headache, drop in BP, syncope, tachycardia
    • Tell patient to sit or lie down during administration

Acute Coronary Syndromes

morphine sulfate
Morphine Sulfate
  • Indications (When & Why?)
    • Chest pain and anxiety associated with AMI or cardiac ischemia
    • Acute cardiogenic pulmonary edema (if blood pressure is adequate)

Acute Coronary Syndromes

morphine sulfate67
Morphine Sulfate
  • Indications (When & Why?)
    • To reduce pain of ischemia
    • To reduce anxiety
    • To reduce extension of ischemia by reducing oxygen demands

Acute Coronary Syndromes

morphine sulfate68
Morphine Sulfate
  • Dosing (How?)
    • 1 to 3 mg IV (over 1 to 5 minutes) every 5 to 10 minutes as needed

Acute Coronary Syndromes

morphine sulfate69
Morphine Sulfate
  • Precautions (Watch Out!)
    • Administer slowly and titrate to effect
    • May compromise respiration; therefore use with caution in acute pulmonary edema
    • Causes hypotension in volume-depleted patients

Acute Coronary Syndromes

acute coronary syndromes70

ST elevation or new or presumably new LBBB:

    • strongly suspicious for injury
  • ST-elevation AMI
  • ST depression or dynamicT-wave inversion:
    • strongly suspicious for ischemia
  • High-risk unstable angina/non–ST-elevation AMI
  • Nondiagnostic ECG:
    • absence of changes in ST segment or T waves
  • Intermediate/low-riskunstable angina
Acute Coronary Syndromes
recognition of ami
Recognition of AMI
  • Know what to look for—
    • ST elevation >1 mm
    • 3 contiguous leads
  • Know where to look
    • Refer to 2000 ECCHandbook

J point plus

0.04 second

PR baseline

ST-segment deviation= 4.5 mm

st elevation73

Baseline

Ischemia—tall or inverted T wave (infarct),ST segment may be depressed (angina)

Injury—elevated ST segment, T wave may invert

Infarction (Acute)—abnormal Q wave,ST segment may be elevated and T wavemay be inverted

Infarction (Age Unknown)—abnormal Q wave,ST segment and T wave returned to normal

ST Elevation
beta blockers
Beta Blockers
  • Indications (When & Why?)
    • To reduce myocardial ischemia and damage in AMI patients with elevated heart rates, blood pressure, or both
    • Blocks catecholamines from binding to ß-adrenergic receptors
    • Reduces HR, BP, myocardial contractility
    • Decreases AV nodal conduction
    • Decreases incidence of primary VF

Acute Coronary Syndromes

beta blockers75
Beta Blockers
  • Dosing (How?)
    • Esmolol
      • 0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min
      • Titrate to effect, Esmolol has a short half-life (<10 minutes)
    • Labetalol
      • 10 mg labetalol IV push over 1 to 2 minutes
      • May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min

Acute Coronary Syndromes

beta blockers76
Beta Blockers
  • Dosing (How?)
    • Metoprolol
      • 5 mg slow IV at 5-minute intervals to a total of 15 mg
    • Atenolol
      • 5 mg slow IV (over 5 minutes)
      • Wait 10 minutes, then give second dose of 5 mg slow IV (over 5 minutes)
    • Propranolol
      • 1 to 3 mg slow IV. Do not exceed 1 mg/min
      • Repeat after 2 minutes if necessary

Acute Coronary Syndromes

beta blockers77
Beta Blockers
  • Precautions (Watch Out!)
    • Concurrent IV administration with IV calcium channel blocking agents like verapamil or diltiazem can cause severe hypotension
    • Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction
    • Monitor cardiac and pulmonary status during administration
    • May cause myocardial depression

Acute Coronary Syndromes

heparin
Heparin
  • Indications (When & Why?)
    • For use in ACS patients with Non Q wave MI or unstable angina
    • Inhibits thrombin generation by factor Xa inhibition and also inhibit thrombin indirectly by formation of a complex with antithrombin III

Acute Coronary Syndromes

heparin79
Heparin
  • Dosing (How?)
    • Initial bolus 60 IU/kg
      • Maximum bolus: 4000 IU
    • Continue at 12 IU/kg/hr (maximum 1000 IU/hr for patients < 70 kg), round to the nearest 50 IU

Acute Coronary Syndromes

heparin80
Heparin
  • Dosing (How?)
    • Adjust to maintain activated partial thromboplastin time (aPTT) 1.5 to 2.0 times the control values for 48 hours or angiography
    • Target range for aPTT after first 24 hours is between 50 & 70 seconds (may vary with laboratory)
    • Check aPTT at 6, 12, 18, and 24 hours
    • Follow Institutional Heparin Protocol

Acute Coronary Syndromes

heparin81
Heparin
  • Precautions (Watch Out!)
    • Same contraindications as for fibrinolytic therapy: active bleeding; recent intracranial, intraspinal or eye surgery; severe hypertension; bleeding disorders; gastroinintestinal bleeding
    • DO NOT use if platelet count is below 100 000

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors
Glycoprotein IIb/IIIa Inhibitors
  • Indications (When & Why?)
    • Inhibit the integrin glycoprotein IIb/IIIa receptor in the membrane of platelets, inhibiting platelet aggregation
    • Indicated for Acute Coronary Syndromes without ST segment elevation

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors83
Glycoprotein IIb/IIIa Inhibitors
  • Indications (When & Why?)
    • Abciximab (ReoPro)
      • Non Q wave MI or unstable angina with planned PCI within 24 hours
      • Must use with heparin
        • Binds irreversibly with platelets
        • Platelet function recovery requires 48 hours

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors84
Glycoprotein IIb/IIIa Inhibitors
  • Indications (When & Why?)
    • Eptifibitide (Integrilin)
      • Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI
      • Platelet function recovers within 4 to 8 hours after discontinuation

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors85
Glycoprotein IIb/IIIa Inhibitors
  • Indications (When & Why?)
    • Tirofiban (Aggrastat)
      • Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI
      • Platelet function recovers within 4 to 8 hours after discontinuation

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors86
Glycoprotein IIb/IIIa Inhibitors
  • Dosing (How?)
    • NOTE: Check package insert for current indications, doses, and duration of therapy.
      • Optimal duration of therapy has NOT been established.

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors87
Glycoprotein IIb/IIIa Inhibitors
  • Dosing (How?)
    • Abciximab (ReoPro)
      • ACS with planned PCI within 24 hours
        • 0.25 mg/kg bolus (10 to 60 minutes before procedure), then 0.125 mcg/kg/min infusion
      • PCI only
        • 0.25 mg/kg bolus
        • Then 10 mcg/min infusion

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors88
Glycoprotein IIb/IIIa Inhibitors
  • Dosing (How?)
    • Eptifibitide (Integrilin)
      • Acute Coronary Syndromes
        • 180 mcg/kg IV bolus, then 2 mcg/kg/min infusion
      • PCI
        • 135 mcg/kg IV bolus, then begin 0.5 mcg/kg/min infusion, then repeat bolus in 10 minutes

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors89
Glycoprotein IIb/IIIa Inhibitors
  • Dosing (How?)
    • Tirofiban (Aggrastat)
      • Acute Coronary Syndromes or PCI
        • 0.4 mcg/kg/min infusion IV for 30 minutes
        • Then 0.1 mcg/kg/min infusion

Acute Coronary Syndromes

glycoprotein iib iiia inhibitors90
Glycoprotein IIb/IIIa Inhibitors
  • Precautions (Watch Out!)
    • Active internal bleeding or bleeding disorder within 30 days
    • History of intracranial hemorrhage or other bleeding
    • Surgical procedure or trauma within 1 month
    • Platelet count > 150 000/mm3

Acute Coronary Syndromes

fibrinolytics
Fibrinolytics
  • Indications (When & Why?)
    • For AMI in adults
      • ST elevation or new or presumably new LBBB; strongly suspicious for injury
      • Time of onset of symptoms < 12 hours

Acute Coronary Syndromes

fibrinolytics93
Fibrinolytics
  • Indications (When & Why?)
    • For Acute Ischemic Stroke
      • Sudden onset of focal neurologic deficits or alterations in consciousness
      • Absence of subarachnoid or intracerebral hemorrhage
      • Alteplase can be started in less than 3 hours of symptom onset

Acute Coronary Syndromes

fibrinolytics94
Fibrinolytics
  • Dosing (How?)
    • For fibrinolytic use, all patients should have 2 peripheral IV lines
      • 1 line exclusively for fibrinolytic administration

Acute Coronary Syndromes

fibrinolytics95
Fibrinolytics
  • Dosing for AMI Patients (How?)
    • Alteplase, recombinant (tPA)
      • Accelerated Infusion
        • 15 mg IV bolus
        • Then 0.75 mg/kg over the next 30 minutes
          • Not to exceed 50 mg
        • Then 0.5 mg/kg over the next 60 minutes
          • Not to exceed 35 mg
      • 3 hour Infusion
        • Give 60 mg in the first hour (initial 6 to 10 mg is given as a bolus)
        • Then 20 mg/hour for 2 additional hours

Acute Coronary Syndromes

fibrinolytics96
Fibrinolytics
  • Dosing for AMI Patients (How?)
    • Anistreplase (APSAC)
      • Reconstitute 30 units in 50 mL of sterile water
      • 30 units IV over 2 to 5 minutes
    • Reteplase, recombinant
      • Give first 10 unit IV bolus over 2 minutes
      • 30 minutes later give second 10 unit IV bolus over 2 minutes
    • Streptokinase
      • 1.5 million IU in a 1 hour infusion
    • Tenecteplase (TNKase)
      • Bolus 30 to 50 mg

Acute Coronary Syndromes

fibrinolytics97
Fibrinolytics
  • Adjunctive Therapy for AMI Patients (How?)
    • 160 to 325 mg aspirin chewed as soon as possible
    • Begin heparin immediately and continue for 48 hours if alteplase or Retavase is used

Acute Coronary Syndromes

fibrinolytics98
Fibrinolytics
  • Dosing for Acute Ischemic Stroke (How?)
    • Alteplase, recombinant (tPA)
      • Give 0.9 mg/kg (maximum 90 mg) infused over 60 minutes
        • Give 10% of total dose as an initial IV bolus over 1 minute
        • Give the remaining 90% over the next 60 minutes
    • Alteplase is the only agent approved for use in Ischemic Stroke patients

Acute Coronary Syndromes

fibrinolytics99
Fibrinolytics
  • Precautions (Watch Out!)
    • Specific Exclusion Criteria
      • Active internal bleeding (except mensus) within 21 days
      • History of CVA, intracranial, or intraspinal within 3 months
      • Major trauma or serious injury within 14 days
      • Aortic dissection
      • Severe uncontrolled hypertension

Acute Coronary Syndromes

fibrinolytics100
Fibrinolytics
  • Precautions (Watch Out!)
    • Specific Exclusion Criteria
      • Known bleeding disorders
      • Prolonged CPR with evidence of thoracic trauma
      • Lumbar puncture within 7 days
      • Recent arterial puncture at noncompressible site
      • During the first 24 hours of fibrinolytic therapy for ischemic stroke, do not give aspirin or heparin

Acute Coronary Syndromes

ace inhibitors
ACE Inhibitors
  • Indications (When & Why?)
    • Reduce mortality & improve LV dysfunction in post AMI patients
    • Help prevent adverse LV remodeling, delay progression of heart failure, and decrease sudden death & recurrent MI

Acute Coronary Syndromes

ace inhibitors102
ACE Inhibitors
  • Indications (When & Why?)
    • Suspected MI & ST elevation in 2 or more anterior leads
    • Hypertension
    • Clinical signs of AMI with LV dysfunction
    • LV ejection fraction <40%

Acute Coronary Syndromes

ace inhibitors103
ACE Inhibitors
  • Indications (When & Why?)
    • Generally not started in the ED but within first 24 hours after:
      • Fibrinolytic therapy has been completed
      • Blood pressure has stabilized

Acute Coronary Syndromes

ace inhibitors104
ACE Inhibitors
  • Dosing (How?)
    • Should start with low-dose oral administration (with possible IV doses for some preparations) and increase steadily to achieve a full dose within 24 to 48 hours

Acute Coronary Syndromes

ace inhibitors105
ACE Inhibitors
  • Dosing (How?)
    • Enalapril
      • 2.5 mg PO titrated to 20 mg BID
      • IV dosing of 1.25 mg IV over 5 minutes, then 1.25 to 5 mg IV every six hours
    • Captopril
      • Start with 6.25 mg PO
      • Advance to 25 mg TID, then to 50 mg TID as tolerated

Acute Coronary Syndromes

ace inhibitors106
ACE Inhibitors
  • Dosing (How?)
    • Lisinopril (AMI dose)
      • 5 mg within 24 hours onset of symptoms
      • 10 mg after 24 hours, then 10 mg after 48 hours, then 10 mg PO daily for six weeks
    • Ramipril
      • Start with single dose of 2.5 mg PO
      • Titrate to 5 mg PO BID as tolerated

Acute Coronary Syndromes

ace inhibitors107
ACE Inhibitors
  • Precautions (Watch Out!)
    • Contraindicated in pregnancy
    • Contraindicated in angioedema
    • Reduce dose in renal failure
    • Avoid hypotension, especially following initial dose & in relative volume depletion

Acute Coronary Syndromes

bradycardia

Bradycardia

  • Slow (absolute bradycardia = rate <60 bpm)
  • or
  • Relatively slow (rate less than expected relative to underlying condition or cause)

Primary ABCD Survey

  • Assess ABCs
  • Secure airway noninvasively
  • Ensure monitor/defibrillator is available

Secondary ABCD Survey

  • Assess secondary ABCs (invasive airway management needed?)
  • Oxygen–IV access–monitor–fluids
  • Vital signs, pulse oximeter, monitor BP
  • Obtain and review 12-lead ECG
  • Obtain and review portable chest x-ray
  • Problem-focused history
  • Problem-focused physical examination
  • Consider causes (differential diagnoses)
Bradycardia
bradycardia110

Serious signs or symptoms?

Due to bradycardia?

No

Yes

Type II second-degree AV block

or

Third-degree AV block?

  • Intervention sequence
  • Atropine0.5 to 1.0 mg
  • Transcutaneous pacingif available
  • Dopamine 5 to 20 µg/kg per minute
  • Epinephrine 2 to 10 µg/min
  • Isoproterenol 2 to 10 µg/min

No

Yes

  • Prepare for transvenous pacer
  • If symptoms develop, use transcutaneous pacemaker until transvenous pacer placed

Observe

Bradycardia
atropine sulfate111
Atropine Sulfate
  • Indications (When & Why?)
    • First drug for symptomatic bradycardia
      • Increases heart rate by blocking the parasympathetic nervous system

Bradycardias

atropine sulfate112
Atropine Sulfate
  • Dosing (How?)
    • 0.5 to 1.0 mg IV every 3 to 5 minutes as needed
    • May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS
    • Maximum Dose: 0.04 mg/kg

Bradycardias

atropine sulfate113
Atropine Sulfate
  • Precautions (Watch Out!)
    • Use with caution in presence of myocardial ischemia and hypoxia
    • Increases myocardial oxygen demand
    • Seldom effective for:
      • Infranodal (type II) AV block
      • Third-degree block (Class IIb)

Bradycardias

dopamine
Dopamine
  • Indications (When & Why?)
    • Second drug for symptomatic bradycardia (after atropine)
    • Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock

Bradycardias

dopamine115
Dopamine
  • Dosing (How?)
    • IV Infusions (Titrate to Effect)
    • 400 mg / 250 mL of D5W = 1600 mcg/mL
    • 800 mg/ 250 mL of D5W = 3200 mcg/mL

Bradycardias

dopamine116
Dopamine
  • Dosing (How?)
    • IV Infusions (Titrate to Effect)
      • Low Dose “Renal Dose"
        • 1 to 5 µg/kg per minute
      • Moderate Dose “Cardiac Dose"
        • 5 to 10 µg/kg per minute
      • High Dose “Vasopressor Dose"
        • 10 to 20 µg/kg per minute

Bradycardias

dopamine117
Dopamine
  • Precautions (Watch Out!)
    • May use in patients with hypovolemia but only after volume replacement
    • May cause tachyarrhythmias, excessive vasoconstriction
    • DO NOT mix with sodium bicarbonate

Bradycardias

epinephrine118
Epinephrine
  • Indications (When & Why?)
    • Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb)

Bradycardias

epinephrine119
Epinephrine
  • Dosing (How?)
    • Profound Bradycardia
      • 2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min)

Bradycardias

epinephrine120
Epinephrine
  • Precautions (Watch Out!)
    • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand
    • Do not mix or give with alkaline solutions

Bradycardias

isoproterenol
Isoproterenol
  • Indications (When & Why?)
    • Temporary control of bradycardia in heart transplant patients
    • Class IIb at low doses for symptomatic bradycardia
    • Heart Transplant Patients!

Bradycardias

isoproterenol122
Isoproterenol
  • Dosing (How?)
    • Infuse at 2 to 10 µg/min
    • Titrate to adequate heart rate

Bradycardias

isoproterenol123
Isoproterenol
  • Precautions (Watch Out!)
    • Increases myocardial oxygen requirements, which may increase myocardial ischemia
    • DO NOT administer with poison/drug-induced shock
      • Exception: Beta Blocker Poisoning

Bradycardias

diltiazem
Diltiazem
  • Indications (When & Why?)
    • To control ventricular rate in atrial fibrillation and atrial flutter
    • Use after adenosine to treat refractory PSVT in patients with narrow QRS complex and adequate blood pressure
    • As an alternative, use verapamil

Stable Tachycardias

diltiazem126
Diltiazem
  • Dosing (How?)
    • Acute Rate Control
      • 15 to 20 mg (0.25 mg/kg) IV over 2 minutes
      • May repeat in 15 minutes at 20 to 25 mg (0.35 mg/kg) over 2 minutes
    • Maintenance Infusion
      • 5 to 15 mg/hour, titrated to heart rate

Stable Tachycardias

diltiazem127
Diltiazem
  • Precautions (Watch Out!)
    • Do not use calcium channel blockers for tachycardias of uncertain origin
    • Avoid calcium channel blockers in patients with Wolff-Parkinson-White syndrome, in patients with sick sinus syndrome, or in patients with AV block without a pacemaker
    • Expect blood pressure drop resulting from peripheral vasodilation
    • Concurrent IV administration with IV ß-blockers can cause severe hypotension

Stable Tachycardias

verapamil
Verapamil
  • Indications (When & Why?)
    • Used as an alternative to diltiazem for ventricular rate control in atrial fibrillation and atrial flutter
    • Drug of second choice (after adenosine) to terminate PSVT with narrow QRS complex and adequate blood pressure

Stable Tachycardias

verapamil129
Verapamil
  • Dosing (How?)
    • 2.5 to 5.0 mg IV bolus over 1to 2 minutes
    • Second dose: 5 to 10 mg, if needed, in 15 to 30 minutes. Maximum dose: 30 mg
    • Older patients: Administer over 3 minutes

Stable Tachycardias

verapamil130
Verapamil
  • Precautions (Watch Out!)
    • Do not use calcium channel blockers for wide-QRS tachycardias of uncertain origin
    • Avoid calcium channel blockers in patients with Wolff-Parkinson-White syndrome and atrial fibrillation, sick sinus syndrome, or second- or third-degree AV block without pacemaker

Stable Tachycardias

verapamil131
Verapamil
  • Precautions (Watch Out!)
    • Expect blood pressure drop caused by peripheral vasodilation
    • IV calcium can restore blood pressure, and some experts recommend prophylactic calcium before giving calcium channel blockers
    • Concurrent IV administration with IV ß-blockers may produce severe hypotension

Stable Tachycardias

adenosine
Adenosine
  • Indications (When & Why?)
    • First drug for narrow-complex PSVT
    • May be used diagnostically (after lidocaine) in wide-complex tachycardias of uncertain type

Stable Tachycardias

adenosine133
Adenosine
  • Dose (How?)
    • IV Rapid Push
    • Initial bolus of 6 mg given rapidly over 1 to 3 seconds followed by normal saline bolus of 20 mL; then elevate the extremity
    • Repeat dose of 12 mg in 1 to 2 minutes if needed
    • A third dose of 12 mg may be given in 1 to 2 minutes if needed

Stable Tachycardias

adenosine134
Adenosine
  • Precautions (Watch Out!)
    • Transient side effects include:
      • Facial Flushing
      • Chest pain
      • Brief periods of asystole or bradycardia
    • Less effective in patients taking theophyllines

Stable Tachycardias

beta blockers135
Beta Blockers
  • Indications (When & Why?)
    • To convert to normal sinus rhythm or to slow ventricular response (or both) in supraventricular tachyarrhythmias (PSVT, atrial fibrillation, or atrial flutter)
    • ß-Blockers are second-line agents after adenosine, diltiazem, or digoxin

Stable Tachycardias

beta blockers136
Beta Blockers
  • Dosing (How?)
    • Esmolol
      • 0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min
      • Titrate to effect, Esmolol has a short half-life (<10 minutes)
    • Labetalol
      • 10 mg labetalol IV push over 1 to 2 minutes
      • May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min

Stable Tachycardias

beta blockers137
Beta Blockers
  • Dosing (How?)
    • Metoprolol
      • 5 mg slow IV at 5-minute intervals to a total of 15 mg
    • Atenolol
      • 5 mg slow IV (over 5 minutes)
      • Wait 10 minutes, then give second dose of 5 mg slow IV (over 5 minutes)
    • Propranolol
      • 1 to 3 mg slow IV. Do not exceed 1 mg/min
      • Repeat after 2 minutes if necessary

Stable Tachycardias

beta blockers138
Beta Blockers
  • Precautions (Watch Out!)
    • Concurrent IV administration with IV calcium channel blocking agents like verapamil or diltiazem can cause severe hypotension
    • Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction
    • Monitor cardiac and pulmonary status during administration
    • May cause myocardial depression

Stable Tachycardias

digoxin
Digoxin
  • Indications (When & Why?)
    • To slow ventricular response in atrial fibrillation or atrial flutter
    • Third-line choice for PSVT

Stable Tachycardias

digoxin140
Digoxin
  • Dosing (How?)
    • IV Infusion
      • Loading doses of 10 to 15 µg/kg provide therapeutic effect with minimum risk of toxic effects
      • Maintenance dose is affected by body size and renal function

Stable Tachycardias

digoxin141
Digoxin
  • Precautions (Watch Out!)
    • Toxic effects are common and are frequently associated with serious arrhythmias
    • Avoid electrical cardioversion unless condition is life threatening
      • Use lower current settings (10 to 20 Joules)

Stable Tachycardias

amiodarone142
Amiodarone
  • Indications (When & Why?)
    • Powerful antiarrhythmic with substantial toxicity, especially in the long term
    • Intravenous and oral behavior are quite different

Stable Tachycardias

amiodarone143
Amiodarone
  • Dosing (How?)
    • Stable Wide-Complex Tachycardias
      • Rapid Infusion
        • 150 mg IV over 10 minutes (15 mg/min)
        • May repeat
      • Slow Infusion
        • 360 mg IV over 6 hours (1 mg/min)

Stable Tachycardias

amiodarone144
Amiodarone
  • Dosing (How?)
    • Maintenance Infusion
      • 540 mg IV over 18 hours (0.5 mg/min)

Stable Tachycardias

amiodarone145
Amiodarone
  • Precautions (Watch Out!)
    • May produce vasodilation & shock
    • May have negative inotropic effects
    • May prolong QT Interval
      • DO NOT administer with other drugs that may prolong QT Interval (Procainamide)
    • Terminal elimination
      • Half-life lasts up to 40 days

Stable Tachycardias

amiodarone146
Amiodarone
  • Precautions (Watch Out!)
    • Contraindicated in:
      • Second or third degree A-V block
      • Severe bradycardia
      • Pregnancy
      • CHF
      • Hypokalaemia
      • Liver dysfunction

Stable Tachycardias

lidocaine147
Lidocaine
  • Indications (When & Why?)
    • Depresses automaticity
    • Depresses excitability
    • Raises ventricular fibrillation threshold
    • Decreases ventricular irritability

Stable Tachycardias

lidocaine148
Lidocaine
  • Dosing (How?)
    • For stable VT, wide-complex tachycardia of uncertain type, significant ectopy, use as follows:
      • 1.0 to 1.5 mg/kg IV push
      • Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes; maximum total dose, 3 mg/kg

Stable Tachycardias

lidocaine149
Lidocaine
  • Dosing (How?)
    • Maintenance Infusion
      • 2 to 4 mg/min

Stable Tachycardias

lidocaine150
Lidocaine
  • Precautions (Watch Out!)
    • Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction
    • Discontinue infusion immediately if signs of toxicity develop

Stable Tachycardias

magnesium sulfate151
Magnesium Sulfate
  • Indications (When & Why?)
    • Torsades de pointes with a pulse
    • Wide-complex tachycardia with history of ETOH abuse
    • Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose

Stable Tachycardias

magnesium sulfate152
Magnesium Sulfate
  • Dosing (How?)
    • Loading dose of 1 to 2 grams mixed in 50 to 100 mL of D5W IV push over 5 to 60 minutes

Stable Tachycardias

magnesium sulfate153
Magnesium Sulfate
  • Dosing (How?)
    • Maintenance Infusion
      • 1 to 4 g/hour IV (titrate dose to control the torsades)

Stable Tachycardias

magnesium sulfate154
Magnesium Sulfate
  • Precautions (Watch Out!)
    • Occasional fall in blood pressure with rapid administration
    • Use with caution if renal failure is present

Stable Tachycardias

procainamide155
Procainamide
  • Indications (When & Why?)
    • Depresses automaticity
    • Depresses excitability
    • Raises ventricular fibrillation threshold
    • Decreases ventricular irritability
    • Atrial fibrillation with rapid rate in Wolff-Parkinson-White syndrome

Stable Tachycardias

procainamide156
Procainamide
  • Dosing (How?)
    • Perfusing Arrhythmia
      • 20 mg/min IV infusion until:
        • Hypotension develops
        • Arrhythmia is suppressed
        • QRS widens by >50%
        • Maximum dose of 17 mg/kg is reached
      • In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable

Stable Tachycardias

procainamide157
Procainamide
  • Dosing (How?)
    • Maintenance Infusion
      • 1 to 4 mg/min

Stable Tachycardias

procainamide158
Procainamide
  • Precautions (Watch Out!)
    • If cardiac or renal dysfunctionis present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min
    • Remember Endpoints of Administration

Stable Tachycardias

acute ischemic stroke160

Immediate assessment:

  • <10 minutes from arrival
  • Assess ABCs, vital signs
  • Provide oxygen by nasal cannula
  • Obtain IV access; obtain blood samples (CBC, electolytes, coagulation studies)
  • Check blood sugar; treat if indicated
  • Obtain 12-lead ECG, check for arrhythmias
  • Perform general neurological screening assessment
  • Alert Stroke Team: neurologist, radiologist, CT technician
  • Immediate neurological assessment:
  • <25 minutes from arrival
  • Review patient history
  • Establish onset (<3 hours required for fibrinolytics)
  • Perform physical examination
  • Perform neurological examination:
    • Determine level of consciousness (Glasgow Coma Scale)
    • Determine level of stroke severity (NIH Stroke Scale orHunt and Hess Scale)
  • Order urgent noncontrast CT scan(door-to–CT scan performed: goal <25 minutes from arrival)
  • Read CT scan (door-to–CT read: goal <45 minutes from arrival)
  • Perform lateral cervical spine x-ray (if patient comatose/history of trauma)

Suspected Stroke

  • Detection
  • Dispatch
  • Delivery
  • Door
  • EMS assessments and actions
  • Immediate assessments performed by EMS
  • personnel include
  • Cincinnati Prehospital Stroke Scale (includes difficulty speaking, arm weakness, facial droop)
  • Los Angeles Prehospital Stroke Screen
  • Alert hospital to possible stroke patient
  • Rapid transport to hospital
Acute Ischemic Stroke
nitroprusside
Nitroprusside
  • Indications (When & Why?)
    • Hypertensive crisis

Acute Ischemic Stroke

nitroprusside162
Nitroprusside
  • Dosing (How?)
    • Begin at 0.1 mcg/kg/min and titrate upward every 3 to 5 minutes to desired effect
      • Up to 0.5 mcg/kg/min
    • Action occurs within 1 to 2 minutes

Acute Ischemic Stroke

nitroprusside163
Nitroprusside
  • Dosing Precautions (How?)
    • Use with an infusion pump; use hemodynamic monitoring for optimal safety
    • Cover drug reservoir with opaque material

Acute Ischemic Stroke

nitroprusside164
Nitroprusside
  • Precautions (Watch Out!)
    • Light-sensitive; therefore, wrap drug reservoir in aluminum foil
    • May cause hypotension and CO2 retention
    • May exacerbate intrapulmonary shunting
    • Other side effects include headaches, nausea, vomiting, and abdominal cramps

Acute Ischemic Stroke

calcium chloride166
Calcium Chloride
  • Indications (When & Why?)
    • As an antidote for toxic effects of calcium channel blocker overdose

Drugs Used in Overdoses

calcium chloride167
Calcium Chloride
  • Dosing (How?)
    • 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose

Drugs Used in Overdoses

calcium chloride168
Calcium Chloride
  • Precautions (Watch Out!)
    • Do not use routinely in cardiac arrest
    • Do not mix with sodium bicarbonate

Drugs Used in Overdoses

flumazenil
Flumazenil
  • Indications (When & Why?)
    • Reduce respiratory depression and sedative effects from pure benzodiazepine overdose

Drugs Used in Overdoses

flumazenil170
Flumazenil
  • Dosing (How?)
    • First Dose
      • 0.2 mg IV over 15 seconds
    • Second Dose
      • 0.3 mg IV over 30 seconds
    • Third Dose
      • 0.4 mg IV over 30 seconds
    • Maximum Dose
      • 3 mg

Drugs Used in Overdoses

flumazenil171
Flumazenil
  • Precautions (Watch Out!)
    • Effects may not outlast effects of benzodiazepines
    • Monitor for recurrent respiratory depression
    • DO NOT use in suspected tricyclic overdose
    • DO NOT use in seizure-prone patients
    • DO NOT use if unknown type overdose or mixed drug overdose with drugs known to cause seizures

Drugs Used in Overdoses

naloxone hydrochloride
Naloxone Hydrochloride
  • Indications (When & Why?)
    • Respiratory and neurologic depression due to opiate intoxication unresponsive to oxygen and hyperventilation

Drugs Used in Overdoses

naloxone hydrochloride173
Naloxone Hydrochloride
  • Dosing (How?)
    • 0.4 to 2 mg IVP every 2 minutes
    • Use higher doses for complete narcotic reversal
    • Can administer up to 10 mg in a short time (10 minutes)

Drugs Used in Overdoses

naloxone hydrochloride174
Naloxone Hydrochloride
  • Precautions (Watch Out!)
    • May cause opiate withdrawal
    • Effects may not outlast effects of narcotics
    • Monitor for recurrent respiratory depression

Drugs Used in Overdoses

dobutamine
Dobutamine
  • Indications (When & Why?)
    • Consider for pump problems (congestive heart failure, pulmonary congestion) with systolic blood pressure of 70 to 100 mm Hg and no signs of shock
    • Increases Inotropy

Review of Infusions

dobutamine177
Dobutamine
  • Dosing (How?)
    • Usual infusion rate is 2 to 20 µg/kg per minute
    • Titrate so heart rate does not increase by more than 10% of baseline
    • Hemodynamic monitoring is recommended for optimal use

Review of Infusions

dobutamine178
Dobutamine
  • Precautions (Watch Out!)
    • Avoid when systolic blood pressure <100 mm Hg with signs of shock
    • May cause tachyarrhythmias, fluctuations in blood pressure, headache, and nausea
    • DO NOT mix with sodium bicarbonate

Review of Infusions

dopamine179
Dopamine
  • Indications (When & Why?)
    • Second drug for symptomatic bradycardia (after atropine)
    • Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock

Review of Infusions

dopamine180
Dopamine
  • Dosing (How?)
    • IV Infusions (Titrate to Effect)
      • Low Dose “Renal Dose"
        • 1 to 5 µg/kg per minute
      • Moderate Dose “Cardiac Dose"
        • 5 to 10 µg/kg per minute
      • High Dose “Vasopressor Dose"
        • 10 to 20 µg/kg per minute

Review of Infusions

dopamine181
Dopamine
  • Precautions (Watch Out!)
    • May use in patients with hypovolemia but only after volume replacement
    • May cause tachyarrhythmias, excessive vasoconstriction
    • DO NOT mix with sodium bicarbonate

Review of Infusions

epinephrine182
Epinephrine
  • Indications (When & Why?)
    • Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb)

Review of Infusions

epinephrine183
Epinephrine
  • Dosing (How?)
    • Profound Bradycardia
      • 2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min)

Review of Infusions

epinephrine184
Epinephrine
  • Precautions (Watch Out!)
    • Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand
    • Do not mix or give with alkaline solutions
    • Higher doses have not improved outcome & may cause myocardial dysfunction

Review of Infusions

norepinephrine
Norepinephrine
  • Indications (When & Why?)
    • For severe cardiogenic shock and hemodynamic significant hypotension (systolic blood pressure < 70 mm/Hg) with low total peripheral resistance
    • This is an agent of last resort for management of ischemic heart disease and shock

Review of Infusions

norepinephrine186
Norepinephrine
  • Dosing (How?)
    • 0.5 to 1 mcg/min titrated to improve blood pressure (up to 30 mcg/min)
    • DO NOT administer is same IV line as alkaline infusions
    • Poison/drug-induced hypotension may higher doses to achieve adequate perfusion

Review of Infusions

norepinephrine187
Norepinephrine
  • Precautions (Watch Out!)
    • Increases myocardial oxygen requirements
    • May induce arrhythmias
    • Extravasation causes tissue necrosis

Review of Infusions

calculating mg min
Calculating mg/min

dose X gtt factor

Solution Concentration

2 mg X 60 gtt/mL

4 mg

Using a 60 gtt set:

  • 30 gtt/min = 30 cc/hr

= gtts/min

= 30 gtts/min

calculating mcg kg min
Calculating mcg/kg/min

doseX kg X gtt factor

solution concentration

5 mcg/min X75 kg X 60 gtt/mL

1600 mcg/cc

Using a 60 gtt set:

  • 18.75 cc/hr = 18.75 gtts/min

= cc/hr

= 18.75 cc/hr

furosemide
Furosemide
  • Indications (When & Why?)
    • For adjuvant therapy of acute pulmonary edema in patients with systolic blood pressure >90 to 100 mm Hg (without S/S of shock)
    • Hypertensive emergencies
    • Increased intracranial pressure
furosemide191
Furosemide
  • Dosing (How?)
    • 20 to 40 mg slow IVP
    • If patient is taking at home, double their daily dose
furosemide192
Furosemide
  • Precautions (Watch Out!)
    • Dehydration, hypovolemia, hypotension, hypokalemia, or other electrolyte imbalance may occur
summary
Summary
  • To obtain a full understanding of ACLS pharmacology requires constant review of:
    • Indications & Actions (When & Why?)
    • Dosing (How?)
    • Contraindications & Precautions (Watch Out!)
ad