ACLS Pharmacology

1
ACLS Pharmacology

• Drugs used in
• cardiac arrest
• management.

2
Antidysrhythmics

• Those medications used to control or suppress
  cardiac dysrhythmias.

3
Antidysrhythmics

• Atropine Sulfate
• Parasympathetic Blocking Agent
• Blocks acetylcholine liberated from the
  parasympathetic nerve endings
• Cardiac Effects
• Accelerates heart rate
• Enhances conduction velocity
• Increases force of contraction (slightly)

4
Atropine Continued

• Lung Effects
• Relaxes smooth muscle in the bronchial tree
• GI Tract Effects
• Inhibits gastrointestinal secretions
• Decreases gut motility
• Genitourinary Tract Effects
• Decrease normal bladder tone

5
Atropine Continued

• Used to treat symptomatic bradycardia
• Absolute bradycardia lt 60 bpm
• Relative bradycardia may be gt 60 bpm
• Dose
• IV 0.5 to 1.0 mg to a total of 0.04 mg/kg
• ET 1.0 to 2.5 mg in 10 ml of NS
• ET dose is 2 to 2.5 times IV dose

6
Atropine Continued

• WATCH OUT!!!
• May increase myocardial O2 demand
• Possible V-fib or V-tach (Very unlikely)
• Less effective in infranodal blocks
• Should be used with caution in 2nd degree heart
  blocks
• Should be used simultaneously with TCP

7
Lidocaine

• Lidocaine Effects
• Depresses automaticity
• Depresses excitability
• Raises ventricular fibrilation threshold
• Decreases ventricular irritability

8
Lidocaine Continued

• Lidocaine Indications
• Diminish ventricular irritability in ischemic
  myocardium
• Wide QRS tachycardia
• Ventricular fibrillation and pulseless
  Ventricular tachycardia
• Suppress ventricular ectopy

9
Lidocaine Continued

• Lidocaine Dosing
• Suppression of ventricular ectopy
• 1.0 to 1.5 mg/kg may repeat every 5 minutes at
  half dose to a max of 3.0 mg/kg
• V-fib pulseless V-Tach
• 1.5 mg/kg may Q 3-5 min to a max of 3.0 mg/kg
• Drip dose
• 2 to 4 mg/minute

10
Lidocaine Continued

• WATCH OUT!!!!
• Double the dose down the tube
• May cause seizures or apresthesias
• Half the drip dose for patients over 70 or that
  have liver problems
• 2 Gram Lidocaine fits in the Epi and Atropine
  injectors BE CAREFUL!

11
Procainamide - Pronestyl

• Procainamide Effects
• Depresses automaticity
• Depresses excitability
• Raises ventricular fibrilation threshold
• Decreases ventricular irritability

12
Procainamide Continued

• Procainamide Indications
• Ventricular ectopy refractory to Lidocaine
• Refractor or recurrent V-fib or V-Tach

13
Procainamide Continued

• Procainamide Dose
• 20-30 mg/minute until one of four (1 of 4)
  conditions are met
• It works
• QRS widens by 50
• Hypotension develops
• A total dose of 17mg/kg is given
• Drip 1 to 4 mg/min

14
Procainamide Continued

• WATCH OUT!!!!
• Use Lidocaine first
• Reduce maintenance dose for renal failure
  patients
• Do not administer with QT prolongation or
  torsades de pointes

15
Amiodarone am-ee-OH-da-rone

• Amiodarone effects
• Powerful antiarrhythmic with substantial
  toxicity, especially in the long term
• Intravenous and oral behavior are quite different
  
• Volume of distribution is large, half-life is
  long.
• Suppresses V-Fib and V-Tach

16
Amiodarone Continued

• Amiodarone dose
• Primary V-Fib
• 300 mg bolus after first Epi dose
• V-Tach
• Loading dose 300 mg in 100 ml D5W over 20-30
  minutes
• Maintenance 600 mg in 200 ml D5W at 17ml/hr
• SVT
• Long term oral dose only

17
Amiodarone Continued

• WATCH OUT !!!!
• Contraindicated in
• Second or third degree A-V block
• Severe bradycardia
• Pregnancy
• CHF
• Hypokalaemia
• Liver dysfunction

18
Amiodarone Continued

• Contraindications Continued
• Patients taking
• Beta Blockers Diltiazem
• Digoxin Diuretics
• Patients may sunburn for up to 3 months after
  amiodarone administration even through window
  glass
• Must be given in glass bottles

19
Bretylium - Bretylol

• Bretylium Effects
• Increase the effective refractory period
• Prolongs the action potential duration
• Decreases adrenergic tone
• Bretylium Indications
• Refractory or recurrent V-fib or pulseless
  V-tach
• Stable ventricular tachycardia

20
Bretylium Continued

• Bretylium Dose
• Refractory or recurrent V-fib
• 5 to 10 mg/kg IV bolus repeated every 5 minutes
  to a total of no more than 35 mg/kg followed by a
  drip of 1-4 mg/min
• Stable V-Tach
• 5 to 10 mg/kg IV bolus over 8-10 minutes repeated
  every 5 minutes to a total of no more than 30
  mg/kg followed by a drip of 1-4 mg/min

21
Bretylium Continued

• WATCH OUT!!!!
• Hypotension especially orthostatic hypotension
• Beware of projectile vomiting (Ever see the
  exorcist?)

22
Adenosine - Adenocard

• Adenosine Effects
• Decrease conduction through the AV node
• Adenosine Indications
• SVT
• After initial trial of Lidocaine in wide complex
  tachycardia of unknown origin

23
Adenosine Continued

• Adenosine Dose
• 6 mg IV SLAMMED!!
• 12 mg IV SLAMMED!!
• 12 mg IV SLAMMED!!
• All followed by 20 ml NS Flush
• Watchout!!!!
• Arrhythmias, chest pain, dyspnea

24
Verapamil

• Verapamil Effects
• Slow calcium channel blocker slows conduction
  through the AV node
• Decreases myocardial contractility
• Verapamil Indications
• SVT
• Decrease the ventricular response in A-fib or
  A-flutter

25
Verapamil Continued

• Verapamil Dose
• 5 mg IV push no faster than 1 mg/min
• If no effect in 30 minutes may repeat the dose at
  10 mg IV push
• WATCH OUT!!!!
• Hypotension, Bradyarrhythmias, CHF
• DO NOT USE WITH WPW

26
Sympathomimetic Agents

• Epinephrine Effects
• Increases
• Heart rate
• Force of contraction
• Conduction velocity
• Peripheral vasoconstriction
• Bronchial dilation

27
Epinephrine Continued

• Epinephrine Indications
• Asystole
• Fine ventricular fibrillation
• Pulseless electrical activity
• Symptomatic bradycardia
• Anaphylaxis
• Bronchospastic conditions

28
Epinephrine Continued

• Epinephrine Dosage
• 1 mg of 110,000 solution IV repeated every 3
  to 5 minutes
• 2.0 to 2.5 mg in 10 ml NS given ET
• Can be given in alternate dosing schemes
• escalating 1-3-5 mg IV
• intermediate 2-5 mg IV
• high dose 0.1 mg/kg IV

29
Epinephrine Continued

• WATCH OUT!!!!
• Tachyarrhythmias
• Precipitation of angina
• Increases myocardial Oxygen demand
• Anxiety and muscle tremors

30
Norepinephrine

• Norepinephrine Effects
• Preipheral vasoconstriction
• Norepinephrine Indications
• Cardiogenic shock
• Norepinephrine Dosage
• 8 mg in 500 ml D5W titrate to BP of 90

31
Norepinephrine Continued

• WATCH OUT!!!!
• Severe hypertension
• Perception of angina, infarction or dysrrhythmias
• Intracerebral hemorrhage
• Tissue sloughing

32
Dopamine

• Dopamine Effects
• Dose Dependent
• 0.5 go 2.0 mcg\kg\min produces renal and
  mesenteric vessel dilation
• 2 to 10 mcg\kg\min produces mostly beta 1 effects
• 10 to 20 mcg\kg\min produce beta 1 and
  dopaminergic effects
• gt than 20 mcg\kg\min produces alpha effects

33
Dopamine Continued

• Dopamine Indications
• Cardiogenic shock
• Vasogenic shock
• Symptomatic bradyarrhythmias
• Dopamine Dosages
• 0.5 to 20 mcg\kg\min

34
Dopamine Continued

• WATCH OUT!!!!
• Tachyarrhythmias
• Increased myocardial oxygen demand
• Hypertension
• Tissue necrosis
• Hypotension (low dose only)

35
Other drugs

• Oxygen
• Well duh!
• Morphine sulfate
• Narcotic analgesic which can cause peripheral
  vasodilatation used to treat CP and CHF
• Given 2-10 mg IV push

36
Other Drugs Continued

• Lasix
• Loop diuretic used to treat pulmonary edema
• 40 to 80 mg IV push
• Nitroglycerin
• Potent vasodilator that decreases myocardial
  workload, used to treat CP
• 0.04 mg sublingually or IV infusion

37
Other Drugs Continued

• Valium
• Benzdiazapine used to sedate prior to
  cardioversion
• 2 to 10 mg IV push
• Versed
• Benzdiazapine used to sedate prior to
  cardioversion
• 2 to 10 mg IV push

38
Other Drugs Continued

• Digitalis
• Cardiac glycoside used to control ventricular
  rate in A-fib
• VERY narrow therapeutic range
• VERY weird dysrythmias and yellow vision with
  overdose

39
Other Drugs Continued

• Beta Blockers
• Used to treat dysrhythmias, high blood pressure
  and angina
• Calcium Channel Blockers
• Used to treat angina, hypertension and dysrythmias