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Overview of ACLS Pharmacology and Update on New ACLS Guidelines

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Title: Overview of ACLS Pharmacology and Update on New ACLS Guidelines


1
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

2
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

3
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

4
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 AEDs throughout public
  • Overall survival from CPR is poor 5-15
  • Survival for in-patient CPR to discharge is lt10

5
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

6
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

7
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.

8
Routes of Administration
  • Intravenous
  • Preferred route
  • Endotracheal
  • 2-2.5 Xs 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)

9
  • ACLS Algorithm Approach

10
Universal Algorithm
11
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

12
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 _at_ 1-10 mcg/min
  • ET Dose2-2.5 times IV dose
  • What to watch for?
  • Tachycardia, hypertension, myocardial ischemia,
    acidosis
  • Incompatible with Ca, HCO3, aminophylline PHY.
    Alkaline solutions cause auto-oxidation.

13
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!!!

14
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 (n20) VP (n20)
  • Survival to hospital 35 70
    (p0.06)
  • 24 hour survival 20 60
    (p0.02)
  • Discharge alive 15 40
    (p0.16)

15
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

16
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

17
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
    Vasopressin 40 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)

18
  • 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 (max3 mg/kg)
  • Make - Magnesium Sulfate 1-2 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.

19
Drugs for VF/PVT
  • Epinephrine - Why? How? What?
  • Vasopressin - Why? How? What?
  • Amiodarone
  • Magnesium
  • Procainamide
  • Lidocaine
  • Buffers

20
Classification of Antiarrhythmics
21
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)

22
Amiodarone
  • HOW?
  • Cardiac arrest (PVT/VF) - 300mg IVP diluted in
    20-30ml, may repeat with 150mg in 10 minutes, or
    start infusion (max2..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)

23
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

24
ARREST Trial Amiodarone in the Resuscitation
of Refractory Sustained Ventricular
Tachyarrhythmias
  • Prospective, randomized, DB, PC trial
  • 504 patients, who failed gt/ 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
    (p0.03)
  • Consistent results regardless of presenting
    rhythm
  • This is the only antiarrhythmic agent which has
    shown definitive benefit in cardiac arrest!

25
ARREST Trial - Subgroup Analysis
26
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

27
Drugs Used for Heart Rhythm and RateProcainamide
  • WHY?
  • Suppresses both ventricular and atrial
    arrhythmias
  • Type Ia antiarrhythmic, affects fast
    Nachannels-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)

28
Drugs Used for Heart Rhythm and RateProcainamide
  • HOW? VF 20-30 mg/min slow infusion (max17
    mg/kg)
  • AF with rapid vent. response 100 mg over 5
    min then infuse_at_ 1 - 4
    mg/min
  • 1-2 gm/250ml D5W
  • WHAT? Stop infusion if patient hypotensive,
    widened QRS gt50, arrhythmia suppression, or
    dose17mg/kg
  • Dose reduction in renal failure
  • SLE syndrome
  • Levels PA4-12 µg/ml
  • NAPA7-15 µg/ml (active metabolite-Class III)

29
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 PVCs (Indeterminate)
  • Hemodynamically stable VT (IIb)
  • Not for routine prophylaxis post-MI, however,
    accepted in high-risk patients
  • (hypokalemia, myocardial ishchemia, LV
    dysfunction)

30
Drugs Used for Heart Rhythm and RateLidocaine
  • HOW? Class IIa 1 - 1.5 mg/kg IVP q5 - 10 min
    (max3mg/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

31
Drugs Used to Improve Cardiac Output and Blood
PressureSodium Bicarbonate
  • WHY? Enhances sodium shift intracellularly,
    buffers acidosis, decreases toxicity of TCAs,
    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

32
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

33
The Tachycardia Algorithms
  • Major New Concepts
  • Make a specific rhythm diagnosis
  • Identify patients with significantly impaired
    cardiac function (EFlt40, overt HF)
  • Only use one antiarrhythmic, especially in
    damaged hearts
  • Resulted in 3 new algorithms

34
The Tachycardia Overview Algorithm
  • Is the patient stable or unstable?
  • Stable Unstable
  • 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
35
Tachycardia - Atrial Fibrillation/Flutter
  • 4 Clinical Features
  • Unstable?
  • Impaired cardiac function?
  • WPW?
  • Duration? lt48h, or gt 48h?
  • Focus - treat unstable patients urgently
  • Control ventricular response ? convert ?
    anticoagulate

36
Atrial Fibrillation/Flutter
37
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)

38
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

39
Drugs Used for Heart Rhythm and RateCalcium
Channel Blockers
  • HOW? Verapamil 2.5 - 5 mg IVP, over 2 min
    (max30mg)
  • Inf _at_ 5-10 mg/hr
  • Diltiazem 0.25 mg/kg IVP, may repeat with
    0.35mg/kg in 15 min
  • Infuse _at_ 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

40
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 _at_ 2 - 3 min intervals
  • Esmolol 500 mcg/kg over 1 min
  • Inf _at_ 50 mcg/kg/min
  • WHAT? Hypotension, bradycardia, AV block, overt
    heart failure or severe bronchospasm/COPD

41
Stable Monomorphic Ventricular Tachycardia
Impaired LV EFlt40 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.
42
Narrow-Complex Supraventricular Tachycardia
  • Vagal stimulation
  • Adenosine
  • Junctional
  • 1. EF gt 40 - Amiodarone, B-blocker, CCB
  • 2. EF lt40, CHF - Amiodarone
  • PSVT
  • EFgt40 - CCB, BB, digoxin, DC cardioversion
    (procainamide, amiodarone, sotalol)
  • EFlt40, CHF - no DC cardioversion digoxin,
    amiodarone, diltiazem
  • MAT
  • EFgt40 -No DC cardioversion CCB, BB, amiodarone
  • EFlt40 -No DC cardioversion amiodaonre, diltiazem

43
Wide-Complex Tachycardia
  • Wide . Prolonged QRS or QRST interval
  • HR gt 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

44
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-life10 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

45
Pulseless Electrical Activity
  • PEA no pulse with electrical activity (not
    VF/VT)
  • Reversible if underlying cause is reversed (5
    Hs, 5 Ts)
  • 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)

46
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 Dose1-2mg diluted in 10ml Paradoxical
    bradycardia with insufficient dose (lt0.5mg)
  • WHAT? Tachycardia 2nd or 3rd degree AV block
    (paradoxical slowing may occur), MI (may
    worsen ischemia/HR)
  • Incompatible with bicarbonate, epinephrine
    norepinephrine

47
Bradycardia
  • All Patients Deserve Empathy
  • (The sequence reflects interventions for
    increasingly severe bradycardia)
  • Absolute (lt 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.

48
Medications for Bradycardia
  • Atropine - Why? How?
  • Dopamine
  • Epinephrine infusion
  • 1mg/250 ml _at_ 1-4 mcg/min
  • Note Lidocaine can be lethal if ? HR is due to
    ventricular escape rhythm

49
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 gt 20mcg/kg/min consider adding NE

50
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

51
Drugs Used for Myocardial Ischemia/Pain
  • Oxygen
  • Nitroglycerin
  • Morphine Sulfate
  • AMI - Aspirin, thrombolytics, heparin, lidocaine,
    beta-blockers
  • Glycoprotein IIb/IIIa receptor antagonists

52
Acute Myocardial Infarction
  • Call first, call fast, call 911
  • Oxygen 4L/min
  • NTG SL, paste or spray if BP gt 90 mm Hg, IV NTG
  • Morphine IV
  • ASA PO (I)
  • Thrombolytics? (I) - within 6 hours of symptoms,
    (II) if gt 6hr
  • IV heparin
  • B-blockers
  • Magnesium (if ? Mg)

53
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 - Osat97-98
  • Confirm tube placement

54
Drugs Used for Myocardial Ischemia/PainNitroglyce
rin
  • WHY?
  • binds to receptors on vascular smooth muscle -
    vasodilation (venous gt 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

55
Drugs Used for Myocardial Ischemia/PainNitroglyce
rin
  • WHEN?
  • Ischemic CP USA pulmonary edema (when
    SBPgt100) 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

56
Drugs Used for Myocardial Ischemia/PainNitroglyce
rin
  • 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

57
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 gt 90 mm Hg
  • HOW?
  • 1-3mg IVP (2-15 mg IVP q15-30 min prn)
  • CAUTION?
  • Respiratory CNS depression, bradycardia,
    hypotension, N/V

58
Drugs Used for Myocardial Ischemia/Pain(Continued
)
  • Aspirin
  • Heparin
  • Thrombolytics - reteplase, alteplase, TNK
  • B Blockers
  • Magnesium
  • Lidocaine - not for prophylaxis

59
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 (gt100 mm Hg) - NTG, Nitroprusside
  • pulmonary edema -furosemide 0.5-1mg/kg, morphine
    1-3mg, NTG SL, oxygen/intubate
  • Rate see algorithms

60
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

61
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

62
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 _at_ 5 - 15 mcg/kg/min
  • Milrinone 50 mcg/kg over 10 min
  • Inf _at_ 0.375 - 0.75 mcg/kg/min
  • Caution Thrombocytopenia, worsens myocardial
    ischemia, SV and ventricular arrhythmias

63
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

64
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

65
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

66
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 total1)
  • Remove 5 epinephrine syringes (new total10)
  • Remove 1 lidocaine syringe (new total2)
  • Remove metoprolol

67
Needless System/Cannulas
68
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