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Overview of ACLS Pharmacology and Update on New ACLS Guidelines. Krista Piekos, Pharm.D. Clinical Pharmacy Specialist - Critical Care Harper University Hospital Adjunct Assistant Professor Wayne State University. Objectives. Pharmacists should be able to identify:

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overview of acls pharmacology and update on new acls guidelines

Overview of ACLS Pharmacologyand Update on New ACLS Guidelines

Krista Piekos, Pharm.D.

Clinical Pharmacy Specialist - Critical Care

Harper University Hospital

Adjunct Assistant Professor

Wayne State University

objectives
Objectives
  • Pharmacists should be able to identify:

Why? …we use an agent

When? …to use an agent

How? …to use an agent

What? ...to watch for

  • To familiarize the pharmacist with the ACLS algorithms
  • To help the pharmacist become comfortable with the crash cart
  • To introduce the needless delivery system
outline
Outline
  • Present conclusions of the International Guidelines 2000 ACLS objectives with 2003 updates
  • Classification of recommendations
  • ACLS Algorithms
  • Pharmacology of agents used in algorithms
  • Overview of crash cart revisions
  • Overview of needless system
background
Background
  • In Seattle 43% of patients in VF survived to hospital discharge if CPR w/in 4 min and defibrillation w/in 8 min
  • These figures are higher than national average - due to AED’s throughout public
  • Overall survival from CPR is poor 5-15%
  • Survival for in-patient CPR to discharge is <10%
guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care
Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
  • 1st international consensus on resuscitation guidelines
  • Experts from around the world
    • Identified issues
    • Gathered scientific evidence; level (quality) of evidence
    • Integrate into a class of recommendation
  • Revised guidelines
classification of therapeutic interventions
Classification of Therapeutic Interventions
  • Class I: definitely helpful, excellent
  • Class II:

Class II a -probably helpful; good to very good

Class II b -possibly helpful; fair to good

  • Class Indeterminate: insufficient evidence; no harm, but no benefit
  • Class III: possibly harmful
new goals
New Goals

1. Early Defibrillation - Public Access Defibrillation (PAD)

Probability of successful defibrillation and survival is negatively related to the time from onset of VF to delivery of first shock

“PAD has the potential to be the single greatest advance in the treatment of prehospital sudden cardiac death since the invention of CPR” Circulation August 22, 2000

2.Establishing a specific diagnosis by ECG

3.Antiarrhythmic agents are just as likely to be proarrhythmic as they are antiarrhythmic.

One, and only one antiarrhythmic should be used.

routes of administration
Routes of Administration

Intravenous

  • Preferred route

Endotracheal

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

Intraosseous (active bone marrow)

  • Pediatric patients without IV access

Other: Sublingual, intracardiac, IM, SC (poor absorption)

epinephrine
Epinephrine

WHY?

  • Natural catecholamine with  and ß-adrenergic agonist activity
    • Results in:
        •  flow to heart and brain
        •  SVR, SBP, DBP
        •  electrical activity in the myocardium & automaticity (success with defibrillation)
        • myocardial contraction (for refractory circulatory shock (CABG))
        • increases myocardial oxygen requirements
  • Primary benefit: -vasoconstriction
  • ß-adrenergic activity controversial b/c  myocardial work

WHEN?

  • VF/VT, asystole, PEA, bradycardias
epinephrine1
Epinephrine

HOW?

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

Recommendations:

      • Class I: 1 mg IV q 3 - 5 min
      • Class IIb: 2-5mg IVP q3-5min, or 1mg-3mg-5mg
      • Class Indeterminate: high-dose 0.1mg/kg IVP q3-5min
      • Infusion for  HR & BP (IIb)
        • 1mg in 250ml NS or D5W - infuse @ 1-10 mcg/min
      • ET Dose=2-2.5 times IV dose

What to watch for?

  • Tachycardia, hypertension, myocardial ischemia, acidosis

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

vasopressin
Vasopressin

WHEN?

  • Alternative to epinephrine for shock-refractory VT/VF

WHY?

  • Natural antidiuretic hormone
  • Potent vasoconstrictor by stimulation of SM -V1 receptors :
    •  BP & SVR;  CO, HR, myocardial O2 consumption and contractility
  • Does not  myocardial oxygen consumption
  • Not affected by severe acidosis
  • Class IIb for shock-refractory VF
  • Class Indeterminate for PEA, asystole
  • Half life = 10-20 minutes

Dose?

  • 40 Units IVP - one time only!!!
why vasopressin
Why Vasopressin?
  • During CPR, plasma ADH levels are higher in patients with return of spontaneous circulation (ROSC)
  • During CPR patients may be severely acidotic
  • Epinephrine compared to vasopressin pre-hospital CPR (20 patients/study group)
  • Multiple animal studies showing  ROSC

EPI (n=20) VP (n=20)

Survival to hospital 35% 70% (p=0.06)

24 hour survival 20% 60% (p=0.02)

Discharge alive 15% 40% (p=0.16)

ilcor universal algorithm international liaison committee on resuscitation
ILCOR Universal Algorithm(International Liaison Committee on Resuscitation)

Medication changes in 2000:

  • Emphasis on identification of all possible stroke victims for IV fibrinolytics
  • Epinephrine has become Class Indeterminate
  • High-dose epinephrine no longer recommended
    • For shock-refractory VT/VF: Epinephrine 1 mg q 3-5 min
    • Vasopressin 40 Units IVP one time
  • Epinephrine alone for non-VT/VF
pulseless ventricular fibrillation or tachycardia
Pulseless Ventricular Fibrillation or Tachycardia
  • In ACLS, always assume VF - most common
  • 85%-95% of survivors have VF
  • Survival dependant on early defibrillation
  • Medications indicated only after 3 failed shocks
vfib pulseless vt algorithm
VFib/Pulseless VT Algorithm

“Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better”

Please - Precordial Thump If pulse-less with no defibrillator

Shock 200J*

Shock 200-300J*

Shock 360J* (*only consecutive, if persistent)

EVerybody - Epinephrine 1 mg IV q3-5 min or Vasopressin40 U IVP

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

Shock 360J

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

slide18
Drug-shock-drug-shock sequence (continued)

“Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better”

Let's - Lidocaine 1.0-1.5 mg/kg IV. May repeat in 3-5 min (max=3 mg/kg)

Make - Magnesium Sulfate1-2 g slow IVP for suspected  Mg or TdP

Patients- Procainamide 30 mg/min, or 100 mg IV q 5 min. for refractory VF. (max. dose: 17 mg/kg)

NOTE: Besides having a pro-arrhythmic drug-drug interaction with amiodarone, procainamide is of limited value in an arrest situation due to a lengthy administration time

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

  • preexisting  K+
  • bicarb-responsive acidosis
  • some drug overdoses
  • protracted code (intubated)
  • ROSC after long code with effective ventilation.
drugs for vf pvt
Drugs for VF/PVT
  • Epinephrine - Why? How? What?
  • Vasopressin - Why? How? What?
  • Amiodarone
  • Magnesium
  • Procainamide
  • Lidocaine
  • Buffers
drugs used for heart rhythm and rate amiodarone
Drugs Used for Heart Rhythm and RateAmiodarone

WHY?

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

New Recommendations (WHEN?):

  • pulseless VT or VF (IIb)
  • hemodynamically stable VT (IIb), polymorphic VT (IIb), wide-complex tachycardia uncertain origin (IIb)
  • refractory PSVT (preserved function, IIa; impaired function IIb)
  • atrial tachycardia (IIb)
  • cardioversion of AF (IIa)
amiodarone
Amiodarone

HOW?

  • Cardiac arrest (PVT/VF) - 300mg IVP diluted in 20-30ml, may repeat with 150mg in 10 minutes, or start infusion (max=2..2 g/24h)
  • Atrial & ventricular arrhythmias in impaired hearts
    • 150mg IVP over 10 min
    • May repeat q10-15 min, or start gtt 1mg/min x 6 hours, then 0.5mg/min x 18 h

WHAT?

  • Hypotension, bradycardia (slow rate, fluids)
why amiodarone arrest trial
Why Amiodarone?ARREST Trial

Objective:

Efficacy of IV amiodarone in out-of-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia

Endpoints:

Hospital admission with perfusing rhythm

Survival to discharge

Functional neurologic status at discharge

*Insufficiently powered to detect survival to discharge and functional neurologic status*

arrest trial amiodarone in the resuscitation of refractory sustained ventricular tachyarrhythmias
ARREST Trial: Amiodarone in the Resuscitation of Refractory Sustained Ventricular Tachyarrhythmias
  • Prospective, randomized, DB, PC trial
  • 504 patients, who failed >/= 3 shocks
  • Randomized to placebo or 300mg IV amiodarone
  • Amiodarone Dosing:
    • 300mg diluted with 5% D5W to 20mL
    • Rapid IV bolus
  • Found a statistically significant increase in the number of patients who arrived to hospital alive (p=0.03)
  • Consistent results regardless of presenting rhythm

This is the only antiarrhythmic agent which has shown definitive benefit in cardiac arrest!

drugs used for heart rhythm and rate magnesium sulfate
Drugs Used for Heart Rhythm and RateMagnesium Sulfate

WHY? Magnesium deficiency causes arrhythmias

Facilitates ventricular repolarization by enhancing intracellular potassium flux, dilates coronary arteries

WHEN? Suspected hypomagnesemia, pulseless VT/VF, torsade de pointes

HOW? Class IIa in suspected hypomagnesemia, TdP, and Class IIb in VF/VT: 1 - 2gm slow IVP in 100ml

WHAT? Hypotension at large doses

drugs used for heart rhythm and rate procainamide
Drugs Used for Heart Rhythm and RateProcainamide

WHY?

  • Suppresses both ventricular and atrial arrhythmias
  • Type Ia antiarrhythmic, affects fast Na+channels-slowing conduction velocity, prolongs RP, and decreases automaticity
  • Phase IV depolarization

WHEN?

  • Refractory/recurrent VF/VT
  • Control of rapid ventricular response (IIb)
  • Conversion SVT (AF/Fl) (IIa)
drugs used for heart rhythm and rate procainamide1
Drugs Used for Heart Rhythm and RateProcainamide

HOW?VF: 20-30 mg/min slow infusion (max=17 mg/kg)

AF with rapid vent. response: 100 mg over 5 min then infuse@ 1 - 4 mg/min

1-2 gm/250ml D5W

WHAT? Stop infusion if patient hypotensive, widened QRS >50%, arrhythmia suppression, or dose=17mg/kg

Dose reduction in renal failure

SLE syndrome

Levels: PA=4-12 µg/ml

NAPA=7-15 µg/ml (active metabolite-Class III)

drugs used for heart rhythm and rate lidocaine
Drugs Used for Heart Rhythm and RateLidocaine

WHY?

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

WHEN?

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

(Indeterminate)

      • Control of PVC’s (Indeterminate)
      • Hemodynamically stable VT (IIb)
  • Not for routine prophylaxis post-MI, however, accepted in high-risk patients

(hypokalemia, myocardial ishchemia, LV dysfunction)

drugs used for heart rhythm and rate lidocaine1
Drugs Used for Heart Rhythm and RateLidocaine

HOW? Class IIa: 1 - 1.5 mg/kg IVP q5 - 10 min (max=3mg/kg)

Infusion (with pulse): 1 - 4 mg/min (if pulse is regained)

Therapeutic Levels: 1.5-6 µg/ml

ET Dose: 2-2.5 times IV dose

Preparation: 1-2 gm/250 ml D5W or NS

WHAT? Hepatic metabolism, renal elimination

Bradycardia, cardiac arrest, seizures

Lidocaine toxicity/neurotoxicity - twitching, LOC, seizures, coma

Lidocaine levels persist in low CO states

drugs used to improve cardiac output and blood pressure sodium bicarbonate
Drugs Used to Improve Cardiac Output and Blood PressureSodium Bicarbonate

WHY?Enhances sodium shift intracellularly, buffers acidosis, decreases toxicity of TCA’s, increases clearance of acidic drugs

WHEN?Class I - hyperkalemia

Class IIa - bicarbonate-responsive acidosis metabolic acidosis secondary to loss of bicarb (renal/GI); overdoses (TCAs, phenobarbital, aspirin)

Class IIb - protracted arrest in intubated patients

Class III - hypoxic lactic acidosis

HOW? 1 mEq/kg IVP, 0.5mEq/kg q10 min prn

WHAT? May worsen outcome if not intubated/ventilated. Metabolic alkalosis, decreased O2 delivery to tissues, hypokalemia, CNS acidosis, hypernatremia, hyperosmolarity

Incompatible with calcium, epinephrine, atropine, norepinephrine, isoproterenol

summary v fib and pulseless v tach
SummaryV.Fib and Pulseless V.Tach

Changes:

  • Vasopressin added - Class IIb 40 U IVP x 1
  • Epinephrine - Class Indeterminate 1mg IVP q 3-5 min
  • Amiodarone added - Class IIb
    • 300mg IVP (cardiac arrest dose). May repeat 150mg x 1
  • Lidocaine - Class Indeterminate 1-1.5 mg/kg IVP q 3-5 min (Max = 3mg/kg)
  • Procainamide is acceptable but not recommended due to long administration times
  • Bretylium fell off algorithm due manufacturing problems
the tachycardia algorithms
The Tachycardia Algorithms

Major New Concepts:

    • Make a specific rhythm diagnosis
    • Identify patients with significantly impaired cardiac function (EF<40%, overt HF)
    • Only use one antiarrhythmic, especially in damaged hearts
  • Resulted in 3 new algorithms
the tachycardia overview algorithm
The Tachycardia Overview Algorithm

Is the patient stable or unstable?

StableUnstable

Identify 1 of 4 types of tachycardia Cardioversion (premedicate)

VT, PSVT, 100J, 200J, 300J, 360J

AF/Aflutter

Narrow-complex tachycardia

Stable wide-complex tachycardia

Stable monomorphic VT

tachycardia atrial fibrillation flutter
Tachycardia - Atrial Fibrillation/Flutter

4 Clinical Features:

    • Unstable?
    • Impaired cardiac function?
    • WPW?
    • Duration? <48h, or > 48h?
  • Focus - treat unstable patients urgently
  • Control ventricular response  convert  anticoagulate
drugs used in afib aflutter
Drugs Used in Afib/AFlutter
  • Calcium channel blockers
  • Beta-blockers
  • Digoxin
  • Amiodarone
  • Procainamide
  • Flecainide (IV form in ACLS -not available in US)
  • Propafenone (IV form in ACLS -not available in US)
  • Sotalol (IV form in ACLS -not available in US)
drugs used for heart rhythm and rate calcium channel blockers
Drugs Used for Heart Rhythm and RateCalcium Channel Blockers

WHY? Blocks inward flow of Ca and Na, slows conduction, RP in AVN Terminate reentrant arrhythmias requiring AVN conduction Control ventricular response rate in AF/AFl Coronary vasodilation

May exacerbate CHF

Verapamil: Negative inotrope & chronotrope (good anti-ischemic)

Class I for acute and preventative SVT

Diltiazem: Direct negative chronotropic effect, mild negative inotrope

Highly effective in controlling ventricular response in A Fib

WHEN? Control ventricular response rate in patients with AF/Fl, or MAT

Verapamil: PSVT not requiring cardioversion

drugs used for heart rhythm and rate calcium channel blockers1
Drugs Used for Heart Rhythm and RateCalcium Channel Blockers

HOW? Verapamil: 2.5 - 5 mg IVP, over 2 min (max=30mg)

Inf @ 5-10 mg/hr

Diltiazem: 0.25 mg/kg IVP, may repeat with 0.35mg/kg in 15 min

Infuse @ 5-15 mg/hr

WHAT? Contraindicated in wide QRS complex tachycardias and ventricular tachycardias, exacerbation of CHF in patients with LV dysfunction

Transient decrease in BP

Avoid in sick sinus syndrome of AV block (w/out pacer)

May potentiate digoxin toxicity.

Incompatible with bicarbonate, epinephrine, furosemide

drugs used for heart rhythm and rate beta blockers
Drugs Used for Heart Rhythm and RateBeta - Blockers

WHY? B-adrenergic blockade, slows conduction and increases refractory period in AV node

WHEN? AMI (reduces rate of reinfarction), reduces recurrent ischemia and incidence of VF in post- MI patients, USA

HOW? Atenolol: 2.5-5 mg IV over 5 min

Metoprolol: 5 - 10 mg IVP q 5 min

Propranolol: 0.1 mg/kg IV divided into 3

doses @ 2 - 3 min intervals

Esmolol: 500 mcg/kg over 1 min

Inf @ 50 mcg/kg/min

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

slide41

Stable Monomorphic Ventricular Tachycardia

Impaired LV

EF<40% or CHF

Preserved

Cardiac

Function

NOTE!

May go directly to

cardioversion

  • Amiodarone (IIB)
  • 150 mg IV bolus over 10 min
  • may repeat 150mg q10-15min or start infusion
  • OR
  • Lidocaine (IIB)
  • 0.5 to 0.75 mg/kg IV push
  • Then use
  • Synchronized cardioversion
  • Medications: any one
  • Procainamide (IIA)
  • Sotalol (IIA)*
  • Amiodarone (IIB)
  • Lidocaine (IIB)

*Not yet available in the US.

narrow complex supraventricular tachycardia
Narrow-Complex Supraventricular Tachycardia
  • Vagal stimulation
  • Adenosine
    • Junctional
      • 1. EF > 40% - Amiodarone, B-blocker, CCB
      • 2. EF <40%, CHF - Amiodarone
    • PSVT
      • EF>40% - CCB, BB, digoxin, DC cardioversion (procainamide, amiodarone, sotalol)
      • EF<40%, CHF - no DC cardioversion; digoxin, amiodarone, diltiazem
    • MAT
      • EF>40% -No DC cardioversion; CCB, BB, amiodarone
      • EF<40% -No DC cardioversion; amiodaonre, diltiazem
wide complex tachycardia
Wide-Complex Tachycardia
  • “Wide” …. Prolonged QRS or QRST interval
  • HR > 120 bpm (ex. VT, sinus tachycardia, A.flutter)
  • OLD - Lidocaine
  • NEW -
      • Establish diagnosis - 12-lead ECG
      • Adenosine if SVT- slows AV conduction. Short-lived hypotension
      • Amiodarone (IIa) normal LV function
      • Amiodarone (IIb) impaired LV function
      • Procainamide (IIa)- terminates SVT due to altering conduction across accessory pathways
      • Lidocaine if VT
      • Sotalol, propafenone, flecainide
drugs used for heart rhythm and rate adenosine
Drugs Used for Heart Rhythm and RateAdenosine

WHY? Endogenous nucleoside, slows conduction through the AV node and can interrupt AV nodal reentry pathways

WHEN? PSVT (half-life=10 sec)

If PSVT persists may want longer acting agent (verapamil or diltiazem)

HOW? 6 mg rapid IV over 1 - 3 sec, followed by 20 ml NS flush. May repeat in 1-2min with 12 mg dose.

Max.=30 mg

WHAT? Flushing, dyspnea, chest pain, post-conversion bradycardia

Drug interaction with theophylline, dipyridamole

pulseless electrical activity
Pulseless Electrical Activity
  • PEA… no pulse with + electrical activity (not VF/VT)
  • Reversible if underlying cause is reversed (5 H’s, 5 T’s)
    • Hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, hyper/hypothermia
    • Tablets, tamponade, tension pneumothorax, thrombosis (ACS), thrombosis (PE)

Intervention Comments/Dose

Problem Search for the probable cause and intervene (HCO3)

Epinephrine 1 mg IV q3-5 min.

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

atropine
Atropine

WHY? Anticholinergic/direct vagolytic

Enhances sinus node automaticity and AVN conduction

WHEN? PEA, symptomatic sinus bradycardia, asystole,

HOW? Bradycardia: 0.5 -1 mg IV q3-5 min

Asystole: 1 mg IV q 3-5 min

Max = 0.04 mg/kg or 3 mg

ET Dose=1-2mg diluted in 10ml Paradoxical bradycardia with insufficient dose (<0.5mg)

WHAT? Tachycardia; 2nd or 3rd degree AV block (paradoxical slowing may occur), MI (may worsen ischemia/HR)

Incompatible with bicarbonate, epinephrine & norepinephrine

bradycardia
Bradycardia

“All Patients Deserve Empathy”

(The sequence reflects interventions for increasingly severe bradycardia)

  • Absolute (< 60 BPM) or relative
  • Serious signs and symptoms (CP, SOB, hypotension, mental status changes)

Mnemonic Intervention Comments/Dose

All Atropine 0.5-1.0 mg IVP q 3-5 min (max 0.03-0.04 mg/kg)

Patients Pacing Use Transcutaneous Pacing if severe S/S

Deserve Dopamine 5-20 µg/kg/min.

Empathy Epinephrine 2-10 µg/min.

medications for bradycardia
Medications for Bradycardia
  • Atropine - Why? How?
  • Dopamine
  • Epinephrine infusion
    • 1mg/250 ml @ 1-4 mcg/min

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

dopamine
Dopamine

WHY? NE precursor

Stimulates DA,  & -adrenergic receptors (dose-related)

Want  -stimulation, for bradycardia-induced hypotension

WHEN? Hypotension/shock

HOW? renal: 2 - 5 mcg/kg/min

cardiac: 5 - 10 mcg/kg/min (B1 & alpha)

vascular: 10 - 20 mcg/kg/min (alpha)

Preparation: 400 mg/250 ml D5W or NS

WHAT? Tachycardia, tachyphylaxis, proarrhythmic

If requiring > 20mcg/kg/min consider adding NE

acls algorithms asystole
ACLS AlgorithmsAsystole
  • Consider possible causes and treat accordingly (ex.hypoxemia, hyper/hypokalemia, acidosis)

Acronym “TEA”

T Transcutaneous Pacing (TCP)(Class IIb) Only effective with early implementation along with appropriate interventions and medications

E Epinephrine 1 mg IV q3-5 min.

A Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)

  • Discourage shocking due to excess parasympathetic discharge
  • Consider Na Bicarbonate 1 mEq/kg
drugs used for myocardial ischemia pain
Drugs Used for Myocardial Ischemia/Pain
  • Oxygen
  • Nitroglycerin
  • Morphine Sulfate
    • AMI - Aspirin, thrombolytics, heparin, lidocaine, beta-blockers
    • Glycoprotein IIb/IIIa receptor antagonists
acute myocardial infarction
Acute Myocardial Infarction
  • “Call first, call fast, call 911”
  • Oxygen 4L/min
  • NTG SL, paste or spray; if BP > 90 mm Hg, IV NTG
  • Morphine IV
  • ASA PO (I)
  • Thrombolytics? (I) - within 6 hours of symptoms, (II) if > 6hr
  • IV heparin
  • B-blockers
  • Magnesium (if  Mg)
oxygen
Oxygen

Why?

  • increases hemoglobin saturation, improves tissue oxygenation
  •  supply to ischemic tissues
  • 16-17% oxygen from mouth-to-mouth

When?

  • Must give supplemental oxygen in ACLS
  • Always for MI

How?

  • NC 4 L/min, intubation, etc
  • Goal - Osat=97-98%
  • Confirm tube placement
drugs used for myocardial ischemia pain nitroglycerin
Drugs Used for Myocardial Ischemia/PainNitroglycerin

WHY?

  • binds to receptors on vascular smooth muscle - vasodilation (venous > arterial)
  •  venous BF to heart (preload) & O2 consumption
  • dilates coronary arteries -  myocardial blood supply
  • antagonizes vasospasm
  • increases collateral flow to ischemic myocardium
  • inhibits infarct expansion
  • decreases pain
drugs used for myocardial ischemia pain nitroglycerin1
Drugs Used for Myocardial Ischemia/PainNitroglycerin

WHEN?

Ischemic CP; USA; pulmonary edema (when SBP>100); AMI

SL NTG -drug of choice for angina

IV NTG - drug of choice for unstable angina or AMI

Congestive heart failure with ischemia

HOW?

IV: 10-20 mcg/min, increase by 5-10 mcg/min q5-10 min until desired

effect or hemodynamic compromise

SL: 1 tablet (0.4mg) SL q5min times 3

Spray: 1 spray onto oral mucosa

Ointment 2%: 1-2 inches over 2-4 inch area

Patches: no role in acute therapy

drugs used for myocardial ischemia pain nitroglycerin2
Drugs Used for Myocardial Ischemia/PainNitroglycerin

Preparation: 50 mg/250 ml D5W or NS

Must be in glass bottle

Cautions:

  • hypotension - treat with fluids, and rate reduction/elimination
  • bradycardia - vasovagal reflex to hypotension
    • treat with fluids, rate reduction, atropine
    • reflex tachycardia also a concern
  • headache, dizziness - may be diminished by laying down
  • patients develop tachyphylaxis to effects - promote nitrate-free periods, intermittent dosing and lowest-possible doses
drugs used for myocardial ischemia pain morphine sulfate
Drugs Used for Myocardial Ischemia/PainMorphine Sulfate

WHY?(Pain can  catecholamines - BP, HR, O2 demands)

Opiate analgesic

 pain,  preload and afterload,  SVR,  anxiety

Relieves pulmonary congestion,  myocardial oxygen demand

WHEN?

Pain, pulmonary edema, BP > 90 mm Hg

HOW?

1-3mg IVP (2-15 mg IVP q15-30 min prn)

CAUTION?

Respiratory & CNS depression, bradycardia, hypotension, N/V

drugs used for myocardial ischemia pain continued
Drugs Used for Myocardial Ischemia/Pain(Continued)
  • Aspirin
  • Heparin
  • Thrombolytics - reteplase, alteplase, TNK
  • B Blockers
  • Magnesium
  • Lidocaine - not for prophylaxis
hypotension shock pulmonary edema
Hypotension/Shock/Pulmonary Edema

Identify Problem? Volume; Pump; Rate?

  • Volume:
      • fluids, blood, vasopressors
  • Pump:
      • s/s of shock - vasopressors; no s/s shock - dobutamine
      •  BP (>100 mm Hg) - NTG, Nitroprusside
      • pulmonary edema -furosemide 0.5-1mg/kg, morphine 1-3mg, NTG SL, oxygen/intubate
  • Rate: see algorithms
drugs used to improve cardiac output and blood pressure norepinephrine
Drugs Used to Improve Cardiac Output and Blood PressureNorepinephrine

Action: Alpha & ß-adrenergic stimulation, increases contractility and HR, vasoconstriction, improves coronary blood flow

Indication: Shock refractory to fluid replacement, severe hypotension

Dose: 0.5 - 1 mcg/min

refractory shock = 8 - 30 mcg/min

Preparation: 4-8mg/250 ml D5W or NS

Caution: Hypertension, myocardial ischemia, cardiac arrest, palpitations

drugs used to improve cardiac output and blood pressure dobutamine
Drugs Used to Improve Cardiac Output and Blood PressureDobutamine

Action: B1- adrenergic activity

Indication: Inotrope in heart failure/hypotension

Dose: 2 - 20 mcg/kg/min

Preparation: 250 mg/250 ml D5W or NS

Caution: tachyarrhythmias,worsens myocardial ischemia

drugs used to improve cardiac output and blood pressure inamrinone and milrinone
Drugs Used to Improve Cardiac Output and Blood PressureInamrinone and Milrinone

Action: Phosphodiesterase inhibitors, positive inotropes and vasodilator

Indication: Refractory heart failure

Dose: Inamrinone: 750 mcg/kg over 2 - 3 min

Inf @ 5 - 15 mcg/kg/min

Milrinone: 50 mcg/kg over 10 min

Inf @ 0.375 - 0.75 mcg/kg/min

Caution: Thrombocytopenia, worsens myocardial ischemia, SV and ventricular arrhythmias

drugs used for heart rhythm and rate isoproterenol
Drugs Used for Heart Rhythm and RateIsoproterenol

WHY? Synthetic sympathomimetic amine

Pure B-adrenergic activity +inotropic& chronotrope

 HR/CO, contractility;  MAP secondary vasodilation

WHEN? Symptomatic bradycardia

Refractory torsades de pointes

HOW? Class II - 2 - 10 mcg/min

Class III - higher doses

Preparation: 1 mg/ 250 ml D5W or NS

WHAT? mycocardial O2 consumption & peripheral vasodilation

Avoid in ischemic heart disease; arrhythmogenic

drugs used to improve cardiac output and blood pressure sodium nitroprusside
Drugs Used to Improve Cardiac Output and Blood PressureSodium Nitroprusside

Action: Antihypertensive, peripheral vasodilator, reduces afterload, increases CO and relieves pulmonary congestion

Indication: Hypertension, AMI, CHF

Dose: 0.1 - 5 mcg/kg/min, and titrate up to 10mcg/kg/min

Preparation: 50 mg/250 ml D5W

Caution: Cyanide and thiocyanate toxicity, hypotension

summary of 2000 changes
Summary of 2000 Changes
  • NEW AGENTS - Amiodarone & Vasopressin
  • Amiodarone (Class IIb) & Procainamide (Class IIb) - hemodynamically stable wide-complex tachycardia (esp. in poor cardiac fxn)
  • VT - amiodarone & sotalol (Class IIa)
  • Vasopressin (Class IIb) - alternative to epinephrine
  • Bretylium acceptable, but not recommended
  • Lidocaine for VT/VF (Class Indeterminate) & Class III for prophylaxis of ventricular arrhythmias in AMI
  • Magnesium (Class IIb) -  Mg or TdP
  • High-dose epinephrine (Class Indeterminate)
  • Fibrinolytics for AMI & Stroke
crash cart revisions
Crash Cart Revisions

Summary of Changes:

Additions: 5 amps of amiodarone 150mg/3ml (were 3)

3 vials of vasopressin (20 Units/vial)

1 bag of premixed dopamine 400mg in 250ml

4 Na Bicarbonate syringes (were 3)

5 filter needles

20 blunt cannulas

Deletions: 1 dopamine vial (new total=1)

Remove 5 epinephrine syringes (new total=10)

Remove 1 lidocaine syringe (new total=2)

Remove metoprolol