6 Cardiac Drugs Revised 11-01-15

8/11/2019 6 Cardiac Drugs Revised 11-01-15

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Cardiovascular Drugs in Advanced

Cardiac Life Support

A Member of the

The Asian Representative of


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ACLS Guidelines

during cardiac arrest

drug intervention is

secondary only

to other interventions


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Central Line

Subclavian vein

Internal jugular vein

Needs interruption

Higher peak concentration

central circulation time

Complications

Peripheral Line

Antecubital vein

External jugular vein

No interruption

Lower peak concentration

central circulation time

Complications

Intravenous Access


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Peripheral IV site

Administer drugs by Bolus

20 cc of saline or distilled water

Elevate the extremity for 10 to 20 seconds


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NAVEL (Naloxone, Atropine,Vasopressin, Epinephrine, Lidocaine)

Administer 2 to 2.5 times the

recommended IV dose diluted in 10 mlNSS or distilled water

Tracheal Drug Administration


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ACLS Drugs

Agents used to Op t imize

Cardiac Output and Blood

Pressure

Agents used to t reat

Arrhy thmias

Tachycardia BradycardiCardiac Arrest Shock

Heart fai lur e/

Pulmonary

edema

Misc; buffers


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3 Dimensions of the Cardiovascular System Peripheral vascular tone

Inotropic state of the heart

Chronotropic state of the heart

Clinically used in:

Acute ischemic heart disease

Acute and chronic heart failure

ShockCardiac arrest

Agents used to Optimize Cardiac Output and

Blood Pressure


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EpinephrineMOA- Increases SVR, BP, HR, Contractility, automaticity

- Increases blood flow to heart & brain, AV conduction veloci

- Alpha-adrenergic effects can increase coronary & cerebral

perfusion pressure during CPR

- Beta-adrenergic effects may increase myocardial work &reduce subendocardial perfusion

No evidence to show that it improves survival

Dose: 1 mg IV bolus every 3-5 mins

Medications for Cardiac Arrest


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Vasopressin MOA - Non-adrenergic peripheral vasoconstrictor that causes

coronary & renal vasoconstriction

- Increases blood flow to heart & brain

Indications:

1. Alternative to epinephrine for treatment of adult shock-refractory VF/pulseless VT, PEA and asystole

2. Hemodynamic support in vasodilatory shock

Dose: - 40U IV single dose to replace one dose of epinephrine(for cardiac arrest)

- 0.020.04 U/min (for vasodilatory shock)

Medications for Cardiac Arrest


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Norepinephrine MOA - Naturally occurring potent vasoconstrictor and inotropic

agent

- Usually induces renal and splanchnic vasoconstriction

Indications:1. Severe hypotension (SBP < 70mmHg)

2. Low total peripheral resistance

Dose: - 0.10.5 mcg/kg/min infusion

Note: Not used for cardiac arrest

Do not administer is same IV line as Na Bicarb

Agents used for shock


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Dopamine MOA - Catecholamine, alpha and beta-adrenergic receptor

agonist and peripheral dopamine receptor agonist

Indications:

1. Hypotension (SBP 70-100mmHg)2. Symptomatic significant bradycardia

3. After ROSC (Return of Spontaneous Circulation)

Dose: - 220 mcg/kg/min infusion, titrate to patient response

Note: Do not administer is same IV line as Na Bicarb

Agents used for shock


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Dobutamine:

MOA- synthetic sympathomimetic amine with positiveinotropic action and minimal positive chronotropic

activity at low doses (2.5 ug/kg per min), but

moderate chronotropic activity at higher doses

Indication:

Severe systolic heart failure (SBP 70-100mmHg)

Dose :2-20 ug/kg/min

Note: vasodilating activity precludes its use when a

vasoconstrictor effect is requiredDo not administer in same IV line as Na Bicarbonate

Agents used for Shock


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Little data indicates that therapy with buffers improves outcome

1. Does not improve ability to defibrillate or improve survival rates

animals

2. Can compromise coronary perfusion pressure

3. May cause adverse effects due to extracellular alkalosis,including shifting the oxyhemoglobin saturation curve

4. May induce hyperosmolality and hypernatremia

5. Produce carbon dioxide

6. May inactivate simultaneously administered catecholamine

Agents used for Shock

Buffers: Sodium Bicarbonate


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MOA :Reverses acidosis caused by global

hypoperfusion

Indications:

HyperkalemiaTricyclic or phenobarbital overdose

Patients with pre-existing metabolic acidosis

?After a protracted arrest or long resuscitative efforts

Dose:1 mEq/kg

Agents used for Shock/Arrest

Buffers: Sodium Bicarbonate

A t d f H t F il /P l


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Diuretics: FurosemideMOA :Potent diuretic

- Direct venodilating effect in patients with acute pulmonary

edema

- Transient vasoconstrictor effect when heart failure is chron

- Onset of vascular effect is within 5 minutes

Dose:0.51 mg/kg IV injected slowly

Agents used for Heart Failure/Pulmonary

Edema


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Question

Drug of first choice for SVT is:

A. Atropine

B. Adenosine C. Lidocaine

D. Amiodarone


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Antiarrhythmic Drugs for tachycardia

Adenosine

MOA :Depresses AV node & sinus node activityHalf-life is < 5 seconds (degraded in the blood & periphery)

Indications:Should be used if SVT is suspected

*Note : 2010 CPR GuidelineRecommended in the initial diagnosis & treatment of stable,undifferentiated regular, monomorphic wide-complex tachycardia

Dose: 6 mgrapid IV push in 2-3 seconds, followed by 20ml saline flus

If no response may give 2nddose: 12 mg after 1-2 minutes.

May give a 3rddose: 12 mgif still no response


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Calcium Channel Blockers

MOA :Slow conduction & increase refractorinessin the AV node

- May also control ventricular response rate in

patients with AF, Flutter, or MAT- Systemic vasodilation

- Negative Inotropic effect

Antiarrhythmic Drugs for Tachycardia


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Calcium Channel Blockers

Verapamil

Indication:

- Effective in stable narrow complex PSVT

- Alternative drug after Adenosine

- Should not be given in patients with impaired ventricular functior heart failure

- Should not be given if hypotensive

Dose:2.55 mg IV given in 2 minutes.

Administered every 1530 mins to a max of 20 mg



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B-Adrenergic Blockers

Indications:- Class I in acute coronary syndromes

- to convert to sinus or to slow ventricular response or both (AF/ flutt

MFAT, re-entry SVT)

- Second line after adenosine

- *Labetalol recommended for emergency anti-hypertensive therapy hemorrhagic and acute ischemic stroke

Contraindication

-Hemodynamic instability

- 2o and 3oAV block

- Asthma- Cocaine-induced ACS



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B-Adrenergic BlockersLabetalol Dose:10 mg IV push (1-2mins), maybe repeated or

doubled every 10 mins; max dose 150mg

OR same initial bolus then infusion at 2-8mg/min

Esmolol Dose:0.5 mg/ kg loading dose50 mcg/ kg per minute maintenance infusion

2ndbolus of 0.5 mg/ kg infused in 1minute

repeated every 4 minutes for a total maximum

of 300 mcg/ kg per minute


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Amiodarone

Class III anti-arrhythmic

MOA - Affects Na, K and Ca channels as well as alpha and betaadrenergic blocking properties

- Prolongs action potential duration, refractory period,

decreases AV node conduction and sinus node function

Indications:

1. After defibrillation and epinephrine in cardiac arrest with

persistent pulseless VT or VF, stable/unstable VT

2. Ventricular rate control of rapid atrial arrhythmias in severely

impaired LV function

3. Adjunct to electrical cardioversion in refractory PSVTs, atrialtachycardia & pharmacologic cardioversion of AF

Anti-arrhythmic Drugs for Tachycardia


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Amiodarone

Side effects are hypotension and bradycardia

Dose:

1. VT with pulse 150mg IV over 10mins followed by

1mg/kg/min infusion for 6 hours,then 0.5mg/kg/min

2. Pulseless VT/VF 300mg IV push

then 150mg IV - 2nddose if needed

after another cycle of CPR

Anti-arrhythmic Drugs for Tachycardia

A ti h th i D f T h di


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Lidocaine Indications:

- VF/ pulseless VTthat persist after defibrillation and

administration of epinephrine

- Control of hemodynamically compromising PVCs- Hemodynamically stable VT

Alternative if Amiodarone unavailable

Dose:Initial bolus of 11.5 mg/ kg IV. Additional bolus of0.5 to 0.75mg/ kg can be given over 35 minutes for

refractory VT/ VF.



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Anti-Arrhythmic for VF

Amiodarone administration to patients with refractoryVF and pulseless VT in the out of hospital settingimproved survival to hospital admission

ARREST trial randomized double-blinded study patients with ventricular fibrillation

(VF) or pulseless VT refractory todefibrillation received eitheramiodarone (300 mg IV bolus) orplacebo

Survival to hospital admission better

in amiodarone arm (44%) versusplacebo (34 %)Kudenchuk, PJ, Cobb, LA, Copass, MK, et al. N Engl J Med 1999; 341:871

ALIVE trial randomized double-blinded study patients with VF or VT refractory to

defibrillation, CPR, and vasopressortreatment received either amiodarone mg/kg) and placebo lidocaine (n = 180or lidocaine (1.5 mg/kg) and placeboamiodarone (n = 167)

Survival to hospital admission was bettwith amiodarone (22.8 %) compared tlidocaine (12 %)

Dorian, P, Cass, D, Schwartz, B, et al. N Engl J Med 2002; 34

A ti h th i D f T h di


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Lidocaine Delicate toxic-to-therapeutic balance

Routine use in AMI is not recommended

No proven short-term or long-term efficacy in cardiacarrest

CNS Toxicity: muscle twitching, slurred speech, resp.

arrest, altered consciousness, seizures



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Antiarrhythmic Drugs

Magnesium Effectively terminates torsades de pointes

Not effective in irregular/ polymorphic VT in patients with

normal QT

Not recommended in cardiac arrest except when arrhythm

are suspected to be caused by magnesium deficiency

Dose: 12 gm (8-16meqs) mixed in 50100 ml D5W given over 5 t60 mins. Followed by 0.5 to 1gm IV infusion

1 to 2 gm diluted in 100 ml D5W administered over 12 mins

emergency situations

A ti h th i D f B d di


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Atropine MOA : Parasympatholytic action:- accelerates rate of sinus node discharge- improves AV conduction

- Reverses cholinergic-mediated decreases in heart rate,

systemic vascular resistance, & blood pressure

Indication: Symptomatic sinus bradycardia (Class I)

- AV block Nodal level

- use with caution in AMI

Antiarrhythmic Drugs for Bradycardia



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Atropine

Should not be relied fully in Mobitz type II block Dose: 0.5 mg every 35 mins

A total dose of 3 mg (0.04 mg/kg) results in full

vagal blockade in humans

*Note: 2010 CPR guideline changes1. Asystole & PEA indications have been deleted2. If atropine is not effective, may give epinephrine infusion for

symptomatic bradycardia as an alternative to pacing

Epinephrine Dose : 2-10 mcg/min (1mg in 500cc of D5 W or normalsaline by continuous infusion)

- titrate to patients response




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Epinephrine

MOA- Increases SVR, BP, HR, Contractility, automaticity- Increases blood flow to heart & brain, AV conduction velocity- Alpha-adrenergic effects can increase coronary & cerebral

perfusion pressure during CPR

Dose

:2-10 mcg/min (1mg in 500cc of D5 W or normal saline bycontinuous infusion)

- titrate to patients response

*Note: 2010 CPR guideline changes

If atropine is not effective, may give epinephrine infusion forsymptomatic bradycardia as an alternative to pacing




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Isoproterenol

MOA : Pure B-adrenergic agonist with potent inotropic and

chronotropic effects

Limited evidence

Indications: Temporizing measure for torsades de

pointes before pacing & in significant bradycardiawhen atropine and dobutamine has failed and

pacing is not available

- Not indicated in patients with cardiac arrest or

hypotension

Dose:210 mcg/ min titrated according to the heart rate

and rhythm response


Mi ll D


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Miscellaneous Drugs

Digoxin

MOA:enhances central and peripheral vagal tone, slows SA node

discharge rate, shortens atrial refractoriness, and prolongs AV

nodal refractoriness through ANS effect

Indication:supraventricular arrhythmias (AF/flutter)

Peak effect - after 1.5 - 3 hours Less effective than adenosine, verapamil, or beta blockers.

Dose: Acute loading dose 0.5 to 1.0 mg IV or PO

0.004 to 0.006mg/kg initially over 5 min.

Then 0.002 to 0.003mg/kg at 4-8hr interval.Total of 0.008 to 0.012mg/kg divided to 8 to 16hrs

Mi ll D


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Nitroglycerine

Decreases chest pain in ACS

Indication:ACS, CHF, Hypertensive urgency w/ ACS

MOA

Increases venous dilation Decreases preload & O2 consumption

Dilates Coronary Arteries

Increases Collateral flow in MI

Tolerance may develop

Miscellaneous Drugs

Mi ll D


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Nitroglycerine

IV bolus12.5 to 25 mcg (if no SL or spray given)

Infusion10mcg/min titrate to effect

Increase by 10 mcg /min every 3-5min until desired effect Max dose 200mcg/min

Sublingual Tablet (0.3-0.4mg) 1 tab every 5min

Spray1-2 sprays for 0.51sec every 5min

Max of 3 doses

Miscellaneous Drugs


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ANTIARRHYTHMICS IN PREGNANCY

No antiarrhythmic drug is completely safe during

pregnancy, but most are well tolerated and can be give

with relatively low risk.

Close monitoring of serum concentration and patient

response

Drug therapy should be avoided during the first trimeste

of pregnancy if possible

Drugs with the longest record of safety should be used

first-line therapy

A ti A h th i i P


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Anti-Arrhythmics in Pregnancy Lidocainegenerally well tolerated

Flecainidehas been shown to be very effective in treating fetal supraventricular

tachycardia

Beta-Blockersare generally well tolerated and can be used with relative safety i

pregnancy

recent data - may cause intrauterine growth retardation if they are administere

during the first trimester

Amiodaronereported to cause congenital abnormalities avoided during the first trimester and used only to treat life-threatening

arrhythmias that fail to respond to other therapies

Adenosineis generally safe to use in pregnancy

drug of choice for acute termination of maternal SVT

Digoxinhas a long track record of treating both maternal and fetal arrhythmias,and is one of the safest antiarrhythmics to use during pregnancy.


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The PHA Council on Cardiopulmonary Resuscitation


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BILL


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Epinephrine 1mg (41.75) x 5 = 208.7Atropine 0.5 mg (20.75) x 6 = 124.5Amiodarone 150 mg (378) x 2 = 756Dopamine drip 400mg = 940

Levophed drip = 1,62IVF Plain NSS 1 L = 111.7Intubation set = 440ET tube = 505O2 tank = 2,00O2 regulator = 135

Use of defibrillator 705 + 360 = 1,0IV insertion = 195IV cannula = 110Suction tube = 330Tegaderm = 60ECG leads x 5 = 200

TOTAL = PhP 8,800.9

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6 Cardiac Drugs Revised 11-01-15