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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

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Acls pharmacology l.jpg

ACLS Pharmacology

Jeremy Maddux

NREMTP


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Objectives

  • To review and obtain a better understanding of medications used in ACLS

    • Indications & Actions (When & Why?)

    • Dosing (How?)

    • Contraindications & Precautions (Watch Out!)


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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


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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


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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


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Oxygen

  • Indications (When & Why?)

    • Any suspected cardiopulmonary emergency

    • Saturate hemoglobin with oxygen

    • Reduce anxiety & further damage

    • Note: Pulse oximetry should be monitored

Universal Algorithm


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Oxygen

  • Dosing (How?)

Universal Algorithm


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Oxygen

  • Precautions (Watch Out!)

    • Pulse oximetry inaccurate in:

      • Low cardiac output

      • Vasoconstriction

      • Hypothermia

    • NEVER rely on pulse oximetry!

Universal Algorithm



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  • 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


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Epinephrine

  • Indications (When & Why?)

    • Increases:

      • Heart rate

      • Force of contraction

      • Conduction velocity

    • Peripheral vasoconstriction

    • Bronchial dilation

VF / Pulseless VT


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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


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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


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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


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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


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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


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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


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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


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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


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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


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Lidocaine

  • Indications (When & Why?)

    • Depresses automaticity

    • Depresses excitability

    • Raises ventricular fibrillation threshold

    • Decreases ventricular irritability

VF / Pulseless VT


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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


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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


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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


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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


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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


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Magnesium Sulfate

  • Precautions (Watch Out!)

    • Occasional fall in blood pressure with rapid administration

    • Use with caution if renal failure is present

VF / Pulseless VT


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Procainamide

  • Indications (When & Why?)

    • Recurrent VF

    • Depresses automaticity

    • Depresses excitability

    • Raises ventricular fibrillation threshold

    • Decreases ventricular irritability

VF / Pulseless VT


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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


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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


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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


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PEA

Case 4


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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


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Epinephrine

  • Indications (When & Why?)

    • Increases:

      • Heart rate

      • Force of contraction

      • Conduction velocity

    • Peripheral vasoconstriction

    • Bronchial dilation

Pulseless Electrical Activity


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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


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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


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Atropine Sulfate

  • Indications (When & Why?)

    • Should only be used for bradycardia

      • Relative or Absolute

    • Used to increase heart rate

Pulseless Electrical Activity


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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


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Atropine Sulfate

  • Precautions (Watch Out!)

    • Increases myocardial oxygen demand

    • May result in unwanted tachycardia or dysrhythmia

Pulseless Electrical Activity


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Asystole

Case 5


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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


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Epinephrine

  • Indications (When & Why?)

    • Increases:

      • Heart rate

      • Force of contraction

      • Conduction velocity

    • Peripheral vasoconstriction

    • Bronchial dilation

Asystole: The Silent Heart Algorithm


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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


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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


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Atropine Sulfate

  • Indications (When & Why?)

    • Used to increase heart rate

      • Questionable absolute bradycardia

Asystole: The Silent Heart Algorithm


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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


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Atropine Sulfate

  • Precautions (Watch Out!)

    • Increases myocardial oxygen demand

Asystole: The Silent Heart Algorithm



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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


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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


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Calcium Chloride

  • Precautions (Watch Out!)

    • Do not use routinely in cardiac arrest

    • Do not mix with sodium bicarbonate

Other Cardiac Arrest Drugs


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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


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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


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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



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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


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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


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Aspirin

  • Dosing (How?)

    • 160 to 325 mg tablets

      • Preferably chewed

      • May use suppository

    • Higher doses may be harmful

Acute Coronary Syndromes


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Aspirin

  • Precautions (Watch Out!)

    • Relatively contraindicated in patients with active ulcer disease or asthma

Acute Coronary Syndromes


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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


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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


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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


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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


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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


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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


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Morphine Sulfate

  • Dosing (How?)

    • 1 to 3 mg IV (over 1 to 5 minutes) every 5 to 10 minutes as needed

Acute Coronary Syndromes


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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


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  • 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



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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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



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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


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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


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Fibrinolytics

  • Dosing (How?)

    • For fibrinolytic use, all patients should have 2 peripheral IV lines

      • 1 line exclusively for fibrinolytic administration

Acute Coronary Syndromes


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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Bradycardias

Case 7


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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


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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


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Atropine Sulfate

  • Indications (When & Why?)

    • First drug for symptomatic bradycardia

      • Increases heart rate by blocking the parasympathetic nervous system

Bradycardias


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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


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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


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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


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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


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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


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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


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Epinephrine

  • Indications (When & Why?)

    • Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb)

Bradycardias


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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


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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


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Isoproterenol

  • Indications (When & Why?)

    • Temporary control of bradycardia in heart transplant patients

    • Class IIb at low doses for symptomatic bradycardia

    • Heart Transplant Patients!

Bradycardias


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Isoproterenol

  • Dosing (How?)

    • Infuse at 2 to 10 µg/min

    • Titrate to adequate heart rate

Bradycardias


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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



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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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Digoxin

  • Indications (When & Why?)

    • To slow ventricular response in atrial fibrillation or atrial flutter

    • Third-line choice for PSVT

Stable Tachycardias


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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


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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


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Amiodarone

  • Indications (When & Why?)

    • Powerful antiarrhythmic with substantial toxicity, especially in the long term

    • Intravenous and oral behavior are quite different

Stable Tachycardias


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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


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Amiodarone

  • Dosing (How?)

    • Maintenance Infusion

      • 540 mg IV over 18 hours (0.5 mg/min)

Stable Tachycardias


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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


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Amiodarone

  • Precautions (Watch Out!)

    • Contraindicated in:

      • Second or third degree A-V block

      • Severe bradycardia

      • Pregnancy

      • CHF

      • Hypokalaemia

      • Liver dysfunction

Stable Tachycardias


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Lidocaine

  • Indications (When & Why?)

    • Depresses automaticity

    • Depresses excitability

    • Raises ventricular fibrillation threshold

    • Decreases ventricular irritability

Stable Tachycardias


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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


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Lidocaine

  • Dosing (How?)

    • Maintenance Infusion

      • 2 to 4 mg/min

Stable Tachycardias


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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


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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


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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


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Magnesium Sulfate

  • Dosing (How?)

    • Maintenance Infusion

      • 1 to 4 g/hour IV (titrate dose to control the torsades)

Stable Tachycardias


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Magnesium Sulfate

  • Precautions (Watch Out!)

    • Occasional fall in blood pressure with rapid administration

    • Use with caution if renal failure is present

Stable Tachycardias


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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


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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


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Procainamide

  • Dosing (How?)

    • Maintenance Infusion

      • 1 to 4 mg/min

Stable Tachycardias


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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


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Acute Ischemic Stroke

Case 10


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  • 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


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Nitroprusside

  • Indications (When & Why?)

    • Hypertensive crisis

Acute Ischemic Stroke


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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


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Nitroprusside

  • Dosing Precautions (How?)

    • Use with an infusion pump; use hemodynamic monitoring for optimal safety

    • Cover drug reservoir with opaque material

Acute Ischemic Stroke


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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



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Calcium Chloride

  • Indications (When & Why?)

    • As an antidote for toxic effects of calcium channel blocker overdose

Drugs Used in Overdoses


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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


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Calcium Chloride

  • Precautions (Watch Out!)

    • Do not use routinely in cardiac arrest

    • Do not mix with sodium bicarbonate

Drugs Used in Overdoses


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Flumazenil

  • Indications (When & Why?)

    • Reduce respiratory depression and sedative effects from pure benzodiazepine overdose

Drugs Used in Overdoses


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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


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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


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Naloxone Hydrochloride

  • Indications (When & Why?)

    • Respiratory and neurologic depression due to opiate intoxication unresponsive to oxygen and hyperventilation

Drugs Used in Overdoses


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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


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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



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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


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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


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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


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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


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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


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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


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Epinephrine

  • Indications (When & Why?)

    • Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb)

Review of Infusions


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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


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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


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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


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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


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Norepinephrine

  • Precautions (Watch Out!)

    • Increases myocardial oxygen requirements

    • May induce arrhythmias

    • Extravasation causes tissue necrosis

Review of Infusions


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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


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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


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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


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Furosemide

  • Dosing (How?)

    • 20 to 40 mg slow IVP

    • If patient is taking at home, double their daily dose


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Furosemide

  • Precautions (Watch Out!)

    • Dehydration, hypovolemia, hypotension, hypokalemia, or other electrolyte imbalance may occur


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Questions?

Jeremy Maddux

[email protected]


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Summary

  • To obtain a full understanding of ACLS pharmacology requires constant review of:

    • Indications & Actions (When & Why?)

    • Dosing (How?)

    • Contraindications & Precautions (Watch Out!)



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