critical medications

CRITICAL MEDICATIONS

Sherry L. Knowles, RN, CCRN, CRNI

OBJECTIVES

1. Name common prescribed emergency medications.

2. List the indications of first line emergency medications.

3. Explain the use of frequently prescribed urgent medications.

4. Distinguish between multiple drug classifications.

5. Describe the actions and importance of common prescribed critical medications.

6. List the contraindications of commonly prescribed critical medications.

7. Discuss the general dosing ranges and administration of frequently prescribe emergency medications.

At the end of this discussion, the viewer will be able to:

EMERGENCY MEDICATIONS

OXYGENIndications Oxygen is used in hypoxemia or suspected hypoxemia.

Has been proven to the workload on the myocardium.

Uses Used as a first line treatments in all urgent situations.

Stable Start with Nasal Prongs at 2-4LPM.  May increase as needed to meet patient's requirements.

Unstable Start with Simple Mask at 6-8 LPM, or use non-rebreather mask as situation warrants at 12-15 LPM.

Dead Use Bag-valve-mask device with reservoir at 12-Patients:15 LPM. Intubation is the airway of choice. 

OXYGEN

ALL PATIENTS• If patient's condition worsens, change to higher delivery

device.

• If at any time the patient's airway or ventilatory status worsens, support with the appropriate airway and Bag-valve-mask device with reservoir.

ADVERSE EFFECTS• Long term use of > 40%may damage lung tissue.

INDICATIONS

• To restore electrical activity: Asystole, Ventricular Standstill, Pulseless Ventricular Tachycardia, Ventricular Fibrillation, PEA.

• May also increase automaticity and make VF more susceptible to DC countershock.

• Anaphylaxis, Acute Bronchospasm

• Severe Hypotension

ACTIONS

• Alpha Adrenergic (potent)

• Beta1 Adrenergic

EPINEPHRINE (Adrenalin)

CARDIAC ARREST

• 1 mg IV every 3-5 minutes (AHA guidelines)

RESPIRATORY DISTRESS

• 0.3-0.5 mg (0.3-0.5 mL of 1:1,000 solution) IM or SC every 20 minutes to 4 hours

or

• 0.5-1.5 mg (0.1-0.3 mL of 1:200 suspension) every 6 hours.

SHOCK• 1-4 mcg/minute by continuous IV infusion.

EPINEPHRINE (Adrenalin)

EPINEPHRINE (Adrenalin)

ROUTES• IV, ET, SC

STRENGTHS• IV Epinephrine strength  is 1:10000 (1mg = 10cc). If 1:1000

concentration is all that is available, it must be mixed with 10cc Normal Saline for a final product of 1:10000 solution.

ADVERSE EFFECTS• May cause worsening of myocardial ischemia and may cause

PVC's or Ventricular Tachycardia. May result in undesired tachycardia.

ATROPINE INDICATIONS• Symptomatic Bradycardia

• Asystole

DOSAGE• Give 0.5-1mg I.V. push every 3-5 minutes to a maximum dose

of 3 mg/kg.

• May be given down the endotracheal tube at twice the dose (Mix with 10cc normal saline when giving via ETT.

• Doses smaller than 0.5mg may enhance bradycardia and should not be used.

ATROPINE

ADVERSE EFFECTS

• May cause supraventricular or ventricular tachycardia

• May cause ventricular fibrillation

• May cause worsening of myocardial ischemia, worsening of AV Blocks, and/or PVC's.

• May result in undesired tachycardia

• May cause blurred vision, dry eyes, dilated pupils

CLASSIFICATION • Adenosine is a naturally occurring nucleoside, a breakdown

product of ATP

INDICATIONS• Adenosine is the drug of choice for paroxysmal

supraventricular tachvcardia (PSVT)

• Can also be used diagnostically for stable, wide complex tachyardias of unknown type after two doses of lidocaine

CONTRAINDICATIONS• Contraindicated in the following rhythms: Second- or third-

degree AV block, sick-sinus syndrome, atrial flutter, atrial fibrillation, and ventricular tachycardia.

ADENOSINE (Adenocard)

MODES OF ACTION

• Adenosine has a negative chronotropic and dromotropic effect on sinus node and AV nodal conduction, without causing negative inotropic effects.

• Acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and dromotropic activity.

• Terminates paroxysmal SVT by blocking the slow antergrade pathway in patients with re-entrant tachycardia using an accessory pathway.

• Causes a 6-10 arrest (this is expected).

ADENOSINE (Adenocard)

ADENOSINE (Adenocard)CONSIDERATIONS

• Caffeine and theophylline (methylxanthines) antagonize the action of adenosine.

• Persantine (dipyridamole) potentates the effect of adenosine; reduction of adenosine dose may be required.

• Tegretol (carbamazepine) may potentate the AV-nodal blocking effect of adenosine.

ADVERSE EFFECTS

• Shortness of breath, lightheadedness, paresthesia, facial flushing, palpitations, chest pain, diaphoresis, hypotension, headache, nausea, metallic taste.

ADENOSINE (Adenocard)

DOSAGE

• Give 6mg rapid IV push over 1-3 seconds (as close to vein as possible) followed with a rapid IV NS flush

• If no response after 1-2 min, give 12 mg rapid IV push over 1-3

seconds (as close to vein as possible) followed with a rapid IV NS flush.

• The second 12 mg dose may be repeated once if needed (maximum 30 mg dose).

AMIODARONE (Cordarone®)

CLASSIFICATION • Antiarrhythmic

ACTIONS

• Alpha and Beta Blocker

• Slows myocardial cell action potential

• Prolongation of refractory period

• Blocks the potassium and sodium channels

• Reduces automaticity of SA Node

• Reduces contractility and conduction velocity in the ventricles

• Slows conduction of the AV Node, Bundle of His and Purkinjes

AMIODARONE (Cordarone®)INDICATIONS

• Used to treat atrial and ventricular dysrhythmias

• Refractory Ventricular Tachycardia

• Wide Complex Tachycardia (With Pulse)

• Pulseless Ventricular Fibrillation

• Pulseless Ventricular Tachycardia

• When used in patients who have CHF and arrhythmias, it has been shown to improve exercise tolerance, decrease hospitalizations, and improve pump function.

AMIODARONE (Cordarone®)

CONTRAINDICATIONS

• Cardiogenic Shock

• 2nd or 3rd Degree HB (unless pacemaker readily available)

• Hypersensitivity

ADVERSE EFFECTS

• Hypotension & Bradycardia (usually responsive to pressor and fluid therapy)

• Can cause fatal pulmonary toxicity

• May cause pulmonary fibrosis

AMIODARONE (Cordarone®)HOW SUPPLIED

• 150 mg/3ml Ampules

DOSAGE• VF/VT: 300mg IVP over 30 sec (follow with NS flush)

May repeat once at 150mg in 3-5 min

Max. cumulative dose: 2.2g IV/24hrs

• Wide Complex Tachycardia (with pulse):

150mg/100cc D5W over 10 min

May rebolus if necessary

• IV Gtt:: Initially 1mg/min X 6 hours, then 0.5mg/min

DOPAMINE

CLASSIFICATION

• Positive Inotrope (catecholamine)

• Alpha, Beta1 and Dopa Adrenergic (dose dependent)

MODE OF ACTION

• Dopamine is a precursor of Adrenaline and Noradrenaline (epinephrine and norepinenephrine).

DOPAMINEINDICATIONS

• Cardiogenic and septic shock

• Low doses may be useful in patients with low C.O or renal impairment.

• Higher doses are used for inotropic support to increase HR and CO of patients in cardiogenic shock or severe cardiac failure.

USES

• Primarily for the treatment of hypotension that is not secondary to hypovolemia.

DOPAMINEDOSAGE

• Usual Mix 800mg Dopamine in 500cc NS or D5W.

• Dopamine has different effects at precise dosage levels: At low dosage, 1-3mcg/kg/min it has dopaminergic properties that result in vasodilitation of renal, messenteric, and cerebral arteries. At dosages between 3-10mcg/kg/min it has beta-1 properties, similar to dobutamine. Greater than 10mcg/kg/min it has Alpha properties used to treat hypotension

Renal Perfusion: 1-3mcg/kg/min

Beta Range: 3-10mcg/kg/min

Alpha Range: 10-20mcg/kg/min

Greater than 20mcg/kg/min: May switch to norepinephrine.

DOPAMINE

ADVERSE EFFECTS

• Profound tachycardia may result in the presence of hypovolemia. Always treat the underlying hypovolemia before using Dopamine.

• May increase both suprventricular and ventricular ectopy.

• At higher doses myocardial blood flow may be reduced.

LIDOCAINEINDICATIONS• To suppress ventricular ectopy, ventricular tachycardia, and

ventricular fibrillation.

• Lidocaine is a first line anti-arrhythmic drug used to treat PVC's, Ventricular Tachycardia, and Ventricular Fibrillation.

DOSAGE• Give 1-1.5mg/kg IV every 3-5 min. up to a maximum dose of

3mg/kg. (Lidocaine can be given down the endotracheal tube).

• If Lidocaine is used to suppress a ventricular arrhythmia, always follow it with a lidocaine infusion.

• Infusion rate: 1-4mg/min (usually 1 gram in 259cc NS).

LIDOCAINE

ADVERSE EFFECTS

• Lidocaine toxicity may cause CNS depression, seizures, hypotension, coma and death.

CONSIDERATIONS

• In patients with impaired liver function or patients over 70 years old, give the recommended bolus, but may need to decrease the normal infusion rate by 50%.

CLASSIFICATION

• Antiarrhythmic

MODES OF ACTION

• Blocks (L-type) calcium channels, which are abundant in cardiac and smooth muscle.

• Potent vasodilator of coronary vessels. This effect increases coronary blood flow, and reduces coronary vasospasm.

• Vasodilator of peripheral vessels. Vasodilation occurs predominantly in arterioles; there is no significant effect on venous beds. This reduces peripheral resistance and afterload.

DILTIAZEM (Cardizem)

ACTIONS

• Negative chronotropic effect. Diltiazem causes a modest lowering of heart rate, and reduces myocardium oxygen consumption. This effect is used to depress the frequency of hyperactive tissue causing arrhythmias.

• Negative inotropic effect. Diltiazem causes a modest decrease in contractility. This effect is due to slowing of the SA node. It results in reduced myocardium oxygen consumption.

• Negative dromotropic effect. By slowing conduction through the AV node, diltiazem increases the time needed for each beat. This results in reduced myocardium oxygen consumption.

DILTIAZEM (Cardizem)

DILTIAZEM (Cardizem)INDICATIONS• Supraventricular tachycardias

• Atrial fibrillation or flutter

• Hypertension

• Unstable, variant and stable Angina.

CONTRAINDICATIONS• CHF

• SA Node and AV Node Disturbances

• Hypotension

• WPW

DILTIAZEM (Cardizem)

DOSAGE

• 0.25 mg/kg IV push over 2 minutes. A second bolus dose of 0.35 mg/kg may be administered after 15 minutes if the response to the first bolus was not adequate.

• The bolus dose(s) is followed by a continuous IV infusion at an initial rate of 5-10 mg/hour. The dosage may be increased by 5 mg/hour up to a maximum recommended infusion rate of 15 mg/hour.

ROUTE

• IV

DILTIAZEM (Cardizem)INTERACTIONS

• Beta blockers (may cause AV blocks)

• Quinidine (may reduce drug clearance)

• Hepatic enzymes (may inhibit metabolizing enzymes)

ADVERSE EFFECTS

• Reflex sympathetic response

• Hypotension.

• Bradycardia.

• Dizziness.

• Flushing.

PROCAINAMIDE (Pronestyl)MODES OF ACTION • Suppresses phase-4 depolarization in normal ventricular

muscle and purkinje fibers, reducing automaticity of ectopic pacemakers.

• Suppresses reentry dysrhythmias by slowing intraventricular conduction.

• May be effective in treating PVCs and recurrent ventricular tachycardia that cannot be controlled with lidocaine.

INDICATIONS• Ventricular dysrhythmias not controlled by Lidocaine.

• Procainamide is not a first drug of choice for treatment of ventricular dysrhythmias.

PROCAINAMIDE (Pronestyl)CONTRAINTICATIONS• Contraindicated in second and third-degree AV block, digitalis

toxicity, and torsades de pointes.

DOSAGE• 20 mg/min (30 mg/min for refractory VF): maximum dose is

17 mg/kg

• Maintenance infusion is 1-4 mg/min. (1 gram/250cc NS).

END POINTS• End Points are: suppression of arrhythmia, hypotension,

widening of the QRS greater than 50% of original width, and maximum dose reached.

CLASSIFICATION • Vasodilator (especially of the venous system) through

relaxing the vascular smooth muscles.

MODE OF ACTION • Dilates the venous bed promoting peripheral pooling of blood,

decreasing venous return to the heart and reducing left ventricular end diastolic pressure (preload)

• Dilation of the arterial bed reducing systemic vascular resistance (SVR) and arterial pressure (afterload).

NITROGLYCERINE (TRIDIL) ·

NITROGLYCERINE (TRIDIL) ·

INDICATIONS

• Acute episodes of angina.

• Chest pain associated with acute coronary syndrome.

• Management of angina associated with or resulting from coronary insufficiency, coronary artery disease, coronary occlusion, or sub acute myocardial infarction.

• Hypertension

• Cardiac failure

• CHF

MAGNESIUM SULFATE

INDICATIONS• Initial treatment in the management of torsades de pointes.

• Dysrhythmias secondary to a tricyclic antidepressant overdose and digitalis toxicity.

• Considered as a class Ila agent (probably helpful) for refractory ventricular fibrillation and ventricular tachycardia after administration of lidocaine.

USES• Used primarily for the treatment of Torsades de points.

DOSAGE• 1-2 grams IV diluted in 100cc of Normal Saline.

ADVERSE EFFECTS• Diaphoresis, facial flushing, hypotension, depressed reflexes,

hypothermia, reduced heart rate, circulatory collapse, and respiratory depression.

CONSIDERATIONS• CNS depressant effects may be enhanced if the patient is

taking other CNS depressants. Serious changes in cardiac function may occur with cardiac glycosides.

MAGNESIUM SULFATE

CALCIUM CHLORIDE

INDICATIONS

• Hyperkalemia with secondary ECG changes (cardiac toxicity)

• Calcium channel blocker overdosage

• Magnesium intoxication (overdose)

• Digitalis Toxicity (with caution)

• Hypocalcemic Tetany

• Hypocalcemia

• Adjunctive therapy in the treatment of insect bites and stings (especially black widow spider and scorpion)

CALCIUM CHLORIDE

DOSAGE• Adult: 2-4 mEq/kg of 10% solution IV. May repeat as necessary

at 10-min intervals.

• Magnesium intoxication: 4.5-9 mEq via IV infusion at a rate not to exceed 200 mg/minute.

• Hypocalcemic tetany: 4.5-16 mEq via IV infusion at a rate not to exceed 200 mg/minute.

• Calcium channel blocker overdosage: 5-10 mL (6.8- 13.6 mEq) of 10% calcium chloride or 10-20 mL(4.65-9.3 mEq) of 10% calcium gluconate IV over 5 minutes.

• Hyperkalemia with secondary cardiac toxicity: 2.25-14 mEq IV. Repeat after 1-2 minutes as necessary.

HOW SUPPLIED

• 10% solution in 10 ml ampules, vials, and prefilled syringes (100 mg/ml)

ONSET & DURATION

• Onset: 5-15 min Duration: Dose dependent (effects may persist for 4 hr after IV administration)

CALCIUM CHLORIDE

CALCIUM CHLORIDE

ADVERSE EFFECTS• Decreased heart rate (may cause asystole) • Decreased blood pressure• Peripheral vasodilatation

• Calcium cause vasospasm in coronary and cerebral arteries.• Severe local necrosis and sloughing after IM use or infiltration• Metallic taste

INTERACTIONS• May worsen dysrhythmias secondary to digitalis. • May antagonize the effects of verapamil.

ISOPROTERENOL (Isuprel)

CLASSIFICATION• Sympathomimetic • Beta Adrenergic• Potent inotropic and chronotropic effects)

INDICATIONS• Temporary control of hemodynamically significant

bradycardia after trying other medications

CONSIDERATIONS• Watch for tachyarrhymithias and myocardial ischemia

INDICATIONS

• Isoproterenol has lost favor with ACLS because of it's potential to worsen myocardial ischemia.

• In situations where Isoproterenol was used in the past, TCP is the treatment of choice.

USES• Increases pacemaker SA automaticity and AV conduction.

DOSAGE• IV infusion: Titrate 0.5mcg to 5mcg minutes.

ISOPROTERENOL (Isuprel)

ISOPROTERENOL (Isuprel)

ADVERSE EFFECTS• May cause worsening of myocardial ischemia and may

cause PVC's or Ventricular Tachycardia. May result in undesired tachycardia. May result in hypotension from vasodilitation.

CONSIDERATIONS• Transcutanous pacing is now the treatment of choice in

place of Isoproterenol. There has been supportive evidence that Isoproterenol may be helpful in Torsades de Point.

VASOPRESSIN (Pitressin)

CLASSIFICATION• Vasoconstrictor

INDICATIONS• VT/VF• For bleeding esophageal varices

ROUTE• IV

VASOPRESSIN (Pitressin)

DOSAGE

• VT/VF: Given as a one time 40 units IVP dose (it has a long half life). May start epinephrine 10-20 minutes after vasopressin dose (ACLS protocols).

• For bleeding esophageal varices: 0.2 units/minute initially. The infusion rate may be increased by 0.2 units/minute every hour if bleeding continues and up to 1 unit/minute

ROUTE

• IV

URGENT MEDICATIONS

TPA (Alteplase, Activase)

INDICATIONS• For acute myocardial infarction• Other types of thrombosis

DOSAGE

• For patients weighing over 67 kg.1. Administer 15 mg IV bolus.2. Then administer 50 mg over next 30 minutes.3. Then administer 35 mg over next 60 minutes.Total dose - 100mg in 90min.

LABETALOL (Normodyne)

CLASSIFICATION

• Alpha1-receptor blocker

• Nonselective beta-receptor blocker

INDICATIONS

• Hypertension

• Used to lower blood pressure in a hypertensive crisis

LABETALOL (Normodyne)

CONTRAINDICATIONS

• Bradycardia

• Bronchial Asthma

• CHF

• Second and third degree heart blocks

• Cardiogenic Shock

LABETALOL (Normodyne)

HOW SUPPLIED • 100 mg in 20 ml of solvent ampoule (5 mg/ml)

DOSAGE• Adult: 5-20 mg slow IV over 2 min; additional injections of 10-40

mg can be given at 1 0-min intervals prn.

• Infusion: Mix 200 mg in 250 ml D5W (0.8 mg/ml); infuse at a rate of 2 mg/min, titrate to supine blood pressure.

LABETALOL (Normodyne)INTERACTIONS

• Bronchodilator effects of beta-adrenergic agonists may be blunted by labetalol.

• Nitroglycerin may augment hypotensive effects.

ADVERSE EFFECTS • Hypotension

• Postural hypotension

• Ventricular dysrhythmias

• Bradycardia

• Heart Failure• Diaphoresis

• Dizziness • Bronchospasm

• Dyspnea• Facial flushing • Headache

NITROGLYCERIN (Nitro-Bid)

MODES OF ACTION

• Increased venous pooling causing decreased preload. Dilation of the veins predominates over that of arterioles.

• Decreased arterial resistance causing decreased afterload. Vasodilation decreases myocardial workload and oxygen demand.

• Coronary vessel dilation. This, combined with the reduction in preload, contributes to increased subendocardial perfusion.

• Reduced platelet aggregation. This may contribute to its effectiveness in treating unstable angina.

INDICATIONS • Angina • CHF • Useful as venous dilator in reducing filling pressures and the

symptoms of pulmonary congestion, in chronic heart failure, and are in the management of acute heart failure.

CONTRAINDICATIONS • Increased Intracranial Pressure

NITROGLYCERIN (Nitro-Bid)

NITROGLYCERIN (Nitro-Bid)

CONSIDERATIONS

• If patients are given the drug without a break in therapy for more than a day they can develop tolerance.

• Severe myocardial ischemia leading to infarction or death may occur after abrupt withdrawal of long-term nitrate therapy.

• Oral nitroglycerin undergoes significant first-pass metabolism and has less than 1% oral bioavailability. The sublingual route is effective for the treatment of acute attacks of angina, and is preferred in order to avoid first-pass metabolism.

NITROPRUSSIDE (Nipride)

CLASSIFICATION

• Potent Vasodilator (arterial and venous)

ACTIONS

• Reduces Afterload and Preload• Decreases work of heart ( SVR and PVR)

INDICATIONS

• Hypertensive Crisis• Pulmonary Hypertension• Postoperative BP Control (cardiac surgeries)

NITROPRUSSIDE (Nipride)

CONSIDERATIONS

• Compatible with D5W only

• Solution is reddish brown and sensitive to light

• Requires close BP monitoring

• Prolonged use may cause thiocyanate toxicity

(delirium, blurred vision, tinnitus)

• Monitor thiocyanate levels with prolonged use (>2 days)

NOREPINEPHRINE (LEVOPHED)

CLASSIFICATION

• Alpha, Beta1, and Beta2 Adrenergic

• Positive Inotropic

• Vasoconstrictor

INDICATIONS

• Indicated for non volume related hypotension

• Used for the treatment of cardiogenic shock

NOREPINEPHRINE (LEVOPHED)

DOSAGE

• Mix 4mg of Norepinephrine in 250cc of Normal Saline

• Start at 2mcg/min and titrate up for desired effect

ADVERSE EFFECTS

• May cause worsening of myocardial ischemia

• May result in undesired tachycardia

• May cause PVC's or Ventricular Tachycardia

SODIUM BICARBONATE

INDICATIONS• Routine administration of sodium bicarbonate is Not

Recommended.

USES

• Known preexisting bicarbonate-responsive acidosis.

• Intubated patient with continued long arrest interval.

• Upon return of spontaneous circulation after long arrest.

• Tricyclic antidepressant overdose.

• Alkalinization for treatment of specific intoxications. 

SODIUM BICARBONATE

DOSAGE

• Give 1 mEq/kg IV, may repeat with 0.5 mEq/kg every 10 min.

ADVERSE EFFECTS

• Metabolic alkalosis, hypoxia, rise in intracellular PCO2 and increased tissue acidosis, electrolyte imbalance (tetany), seizures and tissue sloughing at injection site.

CONSIDERATIONS

• Hyperventilation is the treatment of choice to correct both metabolic and respiratory acidosis in a Code Blue situation.

VERAPAMIL

CLASSIFICATION• Antiarrhythmic and Antianginal agent

MODE OF ACTION• Works by inhibiting the movement of calcium ions across cell

membranes. • Decreases atrial automaticity, reduces AV conduction velocity,

and prolongs the AV nodal refractory period. • Depresses myocardial contractility, reduces vascular smooth

muscle tone, and dilates coronary arteries in normal and ischemic tissues.

MODES OF ACTION

• Negative inotropic effect.

• Negative chronotropic effect.

• Negative dromotropic effect.

• Potent vasodilator of coronary vessels.

• Vasodilator of peripheral vessels.

INDICATIONS• Primarily used in PSVT, Atrial flutter with a rapid ventricular response and Atrial fibrillation with a rapid ventricular response.

VERAPAMIL

VERAPAMILDOSAGE• Give 2.5-5.0 mg IV bolus over 2 min; repeat doses of 5-10

mg may be given every 15-30 min.

ADVERSE EFFECTS• Hypotension, especially in hypovolemic patients. Other

reactions include myocardial depression, heart failure, dizziness, headache, nausea and vomiting, bradycardia, complete AV block, and peripheral (dependent) edema. 

CONSIDERATIONS• Give Calcium Chloride as reversal agent for Verapamil.

VERAPAMIL (Calan, Isoptin)CONTRAINDICATIONS· CHF. Patients with reduced ventricular function may not be able to counteract

the inotropic and chronotropic effects of verapamil, the result being an even higher compromise of function.

· SA node or AV conduction disturbances. Use of verapamil is contraindicated in patients with SA or AV nodal abnormalities, because of its negative chronotropic and dromotropic effects.

· Low blood pressure. Patients with systolic blood pressures below 90 mm Hg should not be treated with verapamil.

· Digitalis toxicity. Verapamil is contraindicated for atrial tachycardia caused by digitalis toxicity, because of pharmacokinetic interactions that may lead to increased blood digoxin levels.

· Wolff-Parkinson-White syndrome induced atrial fibrillation. Verapamil may paradoxically increase ventricular rate in some patients because of accessory conduction pathways.

COMMON CLASSIFICATIONS

ANTIARRHYTHMICS

ANTIARRHYTHMIC AGENTS

• Sodium Channel Blockers (Class I)

• Beta-Adrenergic Blockers (Class II)

• Drugs that Prolong Repolarization (Class III)

• Calcium Channel Blockers (Class IV)

• Miscellaneous

INOTROPIC AGENTSINOTROPIC AGENTS

• Cardiac Glycosides

• Digoxin (Lanoxin)

• Digitoxin (Crystodigin)

• Beta-Adrenergic Agonists

• Dobutamine (Dobutrex)

• Dopamine (Intropin)

• Phosphodiesterase Inhibitors (Primacor)

THROMBOLYTIC AGENTS

THROMBOLYTIC AGENTS

• Tissue Plasminogen Activator (Activase)

• Urokinase (Abbokinase)

• Streptokinase (Streptase)

• Anistreplase/APSAC (Eminase)

• THROMBOLYTIC AGENTS ANTAGONISTS

• Amiocaproic Acid (Amicar)

• Tranexamic Acid (Amstat)

GPIIbIIIa INHIBITORS

Inhibits Platelet Activation• ReoPro

• Integrilin

• Aggrastat

Inhibits Platelet Receptor Sites• Stops clotting activity at the site of the clot

• Can stop an MI

ANTICOAGULANTS

ANTICOAGULANTS

• Heparin

• Warfarin (Coumadin)

ANTICOAGULANT ANTAGONISTS

• Protamine

• Vitamin K

ANTIPLATELET AGENTS

ANTIPLATELET AGENTS

• Aspirin

• Dextrans

• Dipryridamole (Persantine)

• Sulfinpyrazone (Anturane)

• Ticlopidine (Ticlid)

ANTIHYPERTENSIVE AGENTS• Alpha Antagonists• Beta Antagonists • Combined Alpha/Beta Antagonists • Adrenergic Neuron Blocking Agents• CNS-Acting Antihypertensives• Anti-Angiotensin II Agents• Angiotensin Converting Enzyme (ACE) Inhibitors• Angiotensin-II Receptor Antagonists• Calcium Channel Blockers• Diuretics

– Thiazides– High-Ceiling (Loop)– Potassium-Sparing

ACE INHIBITORS & ANGIOTENSIN II ANTAGONISTS

ACE INHIBITORS• Enalapril (Vasotec) • Lisinopril (Zestril)• Captopril (Capoten)

ANGIOTENSIN II ANTAGONISTS• Losartan • Irbesartan

DIURETICS• High-Ceiling (Loop) • Furosemide (Lasix) • Thiazides • Chlorthalidone (Hygroton) • Hydrochlorothiazide (HydroDIURIL) • Aldosterone Antagonists • Spironolactone (Aldactone) • Potassium-Sparing Antagonists • Triamterene (Dyrenium) • Amiloride (Midamor)

DIURETICS

ANTI-LIPIDEMICS

ACTIONS• Inhibits HMG-CoA reductase, which mediates the first

committed step in sterol biosynthesis, and induce an increase in high-affinity LDL receptors.

EFFECTS• Decreases LDL cholesterol levels by increasing the fractional

catabolic rate of LDL and the liver's extraction of LDL precursors.

• Modest decrease in triglycerides.

• Modest increase in HDL cholesterol.

COMMON MEDICATIONS

ALBUTEROL  CLASSIFICATION• Sympathomimetic, Bronchodilator• Beta2 Adrenergic

USES• Relief of bronchospasm in patients with reversible

obstructive airway disease• Prevention of exercise-induced bronchospasm

CONSIDERATIONS• Beta blockers may antagonize ALBUTEROL• May precipitate angina pectoris and dysrhythmias

ARAMINE (METARAMINOL BITARTRATE)

CLASSIFICATION • Sympathomimetic• Alpha & Beta adrenergic• Positive Inotrope

MODE OF ACTION • It has direct and indirect sympathomimetic effects on both

alpha and beta receptors, with mainly alpha effects.

• CENTRALLY: Aramine has a positive Inotropic effect on the myocardium increasing cardiac output and systolic BP

• PERIPHERALLY: Aramine causes peripheral vasoconstriction resulting in increased diastolic BP

INDICATIONS • Prevention and treatment of acute hypotension related to

spinal anaesthesia.

• Adjunct in treatment of hypotension related to shock anaphylaxis and sepsis.

CONTRAINDICATIONS • Pulmonary edema.

• Hypersensitivity.

ARAMINE (METARAMINOL BITARTRATE)

ARAMINE (METARAMINOL BITARTRATE)

PRECAUTIONS • Aramine contains sulfite that may cause allergic reactions

including anaphylaxis.

• Monitor response carefully to prevent severe hypertension, prolonged use can have an cumulative effect.

• Reduce rate gradually to reduce likelihood of rebound hypotension.

• Aramine should be administered via a large central vein or a long line to prevent extravasation.

ATENOLOL (TENORMIN)

CLASSIFICATION

• Beta Blocker / Beta Antagonist

MODE OF ACTION

• It has anti-anginal effect due to decreased left ventricular work and decreased oxygen utilization (by a decreased in the heart rate).

• It has an anti-arrhythmic effect due to its anti-sympathetic effect of depressing sinus and atrioventricular node function and prolongation of atrial refractory period.

INDICATIONS • Hypertension • Atrial and ventricular arrhythmias • Angina • AMI • Overdose of certain drugs • Thyrotoxicosis

DOSAGE• 5 mg IV over 5 minutes every 10 minutes (IV total 10 mg). • Oral atenolol therapy should be initiated immediately after the

second IV bolus with 50 mg, followed by another 50 mg oral dose 12 hours later. (maintenance dose usually 100 mg/day).

ATENOLOL (TENORMIN)

DDAVP (DESMOPRESSIN ACETATE, MINIRIN)

CLASSIFICATION • Antidiuretic Hormone Analogue.

MODES OF ACTION • Antidiuretic: DDAVP acts at a receptor site in the renal

collecting tubule to increase permeability to water reabsorption.

• Coagulation: High doses of DDAVP produce marked and sustained increases of factor VIII coagulant activity and Von Willebrand factor. Plasminogen activator is also released.

INDICATIONS

• Diabetes Insipidus

• As a diagnostic test to establish renal concentration capacity.

• Bleeding in patients with platelet dysfunction.

• Help to stop bleeding in haemophilia A patients with episodes of spontaneous or trauma induced injuries such as hemathroses, I M,. Haematomas or mucosal bleeding.

DDAVP (DESMOPRESSIN ACETATE, MINIRIN)

DOBUTAMINE (DOBUTREX) CLASSIFICATION • Inotropic agent

MODE OF ACTION • Beta adrenergic• Vasodilator

INDICATIONS • Cardiac failure • Congestive heart failure.• Acute pulmonary edema

DOSAGE• The starting dose is 2-5mcg/kg/min I.V. then titrated up to

20mcg/kg/min.

ADVERSE EFFECTS• Dobutamine may cause hypotension secondary to it's beta-2

properties.

• Tachycardia may result from Dobutamine's beta-1 properties, do not permit the heart rate to increase by 10% of it's original rate.

• Dobutamine may cause an increase in ventricular ectopy.

DOBUTAMINE (DOBUTREX)

DIGOXINCLASSIFICATION• Cardiac glycoside

ACTIONS• Positive Inotrope ( contractility)• Negative Dromotrope ( conduction)• Negative Chronotrope ( heart rate)• Increases refractory period

USES• CHF• PAT• Atrial Fib/Flutter

CONSIDERATIONS• Monitor Levels• Can cause lethal rhythms

FLECAINIDE ACETATE (TAMBOCOR) CLASSIFICATION • Antiarrhythmic

MODE OF ACTION • Inhibits the fast sodium channel responsible for the rapid

upstroke of the myocardial action potential.

• Depresses conduction in all parts of the heart with its greatest effect on his Purkinje system.

INDICATIONS • SVT due to AV nodal pathways. • Paroxysmal AF /flutter • Life threatening ventricular arrhythmias not controlled by

other drugs.

FUROSEMIDE (LASIX)CLASSIFICATION• Diuretic

ACTIONS• Inhibits reabsorption of souium

INDICATIONS• CHF• Pulmonary Edema

CONTRAINDICATIONS• Anuria• States of severe electrolyte depletion

HEPARIN CLASSIFICATION• Anticoagulant• Anti-thrombin

CONTRAINDICATIONS• Recent surgery or

stroke• Thrombocytopenia• Hemorrhage

USES• AMI• DIC• Venous thrombosis• DVT prophylaxis

CLASSIFICATIONS• Beta Blocker

METOPROLOL (LOPRESSOR)

INDICATIONS• Hypertension• AMI Intervention• Angina

CONSIDERATIONS• Watch for hypotension• Contraindicated with sinus bradycardia, second and third

degree heart block• May block cardiovascular signs of hypoglycemia

REFLUDIN

CLASSIFICATION• Anticoagulant• Anti-thrombin

USES• AMI• Heparin Induced Throbocytopenia• Venous thrombosis• DVT prophylaxis

ADVERSE EFFECTS• Bleeding• Anemia

CORLOPAM (FENOLDOPAM)

CLASSIFICATION

• Vasodilator• Anti-thrombin

USES

• Severe hypertension (high dose)• Second line agent (low dose) for

low urine output

RESTRICTIONS • Treatment duration of

48 hours

CORLOPAM (FENOLDOPAM)

CLASSIFICATION• Vasodilator• Anti-thrombin

DOSAGE • Low urine out put

• 0.03mcg/kg/min (titration not required)• Hypertension

• Starting 0.03 - 0.1mcg/kg/min.

• NO bolus dose should be given.

• Titrate to patient response

• Increase no faster than 0.05-0.1mcg/kg/min every 15 minutes. Max 1.6 mcg/kg/min.

CORLOPAM (FENOLDOPAM)

CONSIDERATIONS

• Monitor BP frequently• Monitor serum potassium and sodium• When treating hypertension, oral agents should be

instituted as soon as possible.

ADVERSE EFFECTS

• Hypotension• Tachycardia

MILIRONE (PRIMACOR)

CLASSIFICATION• Phosphodiesterase inhibitor

ACTION• Positive Inotrope• Vasodilator

USES• CHF• Heart Failure

NADOLOL (CORGARD)

CLASSIFICATION• Beta Blocker

USES• Angina• Hypertension

ACTIONS• Negative inotropic effect. • Negative chronotropic effect. • Antihypertensive. • Decreased renin production.

NALOXONE (NARCAN)

CLASSIFICATION

• Opioid Antagonist

• Narcotic antagonist

USES

• To reverse the effects of opioids

• Reverses the effects of morphine

NOREPINEPHRINE (LEVOPHED)

CLASSIFICATION • Catecholamine• Alpha Adrenegic• Beta Adrenergic

CONSIDERATIONS• Increases myocardial

oxygen demand

INDICATIONS • Acute Hypotension • Shock

PHENYLEPHRINE (Neo-Synephrine)

CLASSIFICATION • Sympathomimetic• Alpha Adrenergic

INDICATIONS • Shock• Drug induced

hypotension• Hypersensitivity

Reactions

CONSIDERATIONS• Vasoconstrictor Only

OXYTOCIN (PITOCIN)

CLASSIFICATION• Synthetic Hormone

INDICATIONS• Stimulate Birth

CONTRAINDICATIONS• Presence of a second fetus

PHENYTOIN (DILANTIN) CLASSIFICATION • Anticonvulsants • Antiarrhythmic

INDICATIONS • Grand mal/psychomotor seizures • Certain ventricular arrhythmias (ie: digoxin induced VT)

DOSAGES• Status epilepticus: (Adults) loading dose 10-15 mg/kg at a rate

not to exceed 50 mg/min; then, 100 mg PO or IV q 6-8 hr.

• Arrhythmias: (Adults): 100 mg q 5 min up to maximum of 1 g.

PROPOFOL (DIPRIVAN)

CLASSIFICATION• Sedative• Anesthetic

ADVERSE EFFECTS• Hypotension• Bradycardia• Apnea• Twitching• Seizures• Fever

INDICATIONS• ICU Sedation

PROTAMINE (Protamine Sulphate)

CLASSIFICATION• Heparin Antagonist

INDICATIONS• Heparin Overdose• Bleeding while on

heparin therapy

CONSIDERATIONS• Watch for heparin rebound

SOTOLOL (BETAPASE)

CLASSIFICATION• Antiarrhythmic

ACTIONS• Blocks beta-adrenergic receptors. • Blocks potassium channels in cardiac muscle. • Negative inotropic effect. • Negative chronotropic effect. • Prolongs action potential duration and refractory period.

CLASSIFICATION• Neuromuscular Blocker

VECURONIUM BROMIDE (NORCURON)

INDICATIIONS• Skeletal muscle relaxation during

intubation/mechanical ventilation • Adjunct in general anesthesia

CONSIDERATIONS• Does not relieve pain, anxiety or

affect consciousness • Will cause paralysis with apnea

OTHER MEDICATIONS

HALDOL

CLASSIFICATION• Butyrophrnone• Antipsychotic

INDICATIIONS• Psychosis • Nonpsychotic Behavior

Disorders• Delirium• Tourette Syndrome

CONSIDERATIONS• Does not relieve pain, anxiety or

affect consciousness • Will cause paralysis with apnea

INTEGRILIN

CLASSIFICATION• GPIIb/IIIa Inhibitor

INDICATIONS• AMI

CONSIDERATIONS• Must screen patients• Need large bore IV’s prior to administration

MANNITOL

CLASSIFICATION• Osmotic Diuretic

INDICATIONS• Intracranial Swelling• Marked Oliguria

CONSIDERATIONS• Must warm solution to dissolve crystals• Watch for acute herniation

CONSIDERATIONS

• Monitor for respiratory depression, hypotension, bradycardia, and/or decreased LOC.

• Venous vasodilator: Decreases pulmonary congestion and reduces work of heart.

• Have Narcan available for reversal.

MORPHINE

MIDAZOLAM (VERSED)

CONSIDERATIONS

• Monitor for respiratory depression, hypotension, bradycardia, and/or decreased LOC.

• Induces amnesia.

• Have Romazicon available for reversal.

CLASSIFICATION

• Tylenol antidote• Mucolytic

MUCAMYST (Aceteylcysteine)

CONSIDERATIONS

• May cause bronchoconstriction when used in aerosol

PHENTOLAMINE (REGITINE)

CLASSIFICATION

• Alpha BlockerINDICATION & CONSIDERATIONS

• Used for extravasation necrosis such as infiltration of Dopamine.

• Used to prevent hypertension with test for pheochromocytoma.

• Don’t give epinephrine to treat phentolamine-induced hypotension (give norepinephrine)

CLASSIFICATION• Bronchodilator• Spasmolytic• Beta Adrenergic

THEOPHYLLINE (Aminophylline)

INDICATIONS• Bronchospasms• CHF• COPD

CONSIDERATIONS• Monitor Levels• Can cause seizures

THE END

References• Guidelines for Pacemakers and Defibrillators Updated. Journal Watch General Medicine

1998: 2-2.

• Wood, D.A., Fox, K.F., Gibbs, S.R. (2001). Rapid cardiology--for chest pain, breathlessness and palpitations. QJ Med 94: 177-178.  

• HAMMILL, S. C., HUBMAYR, R. D. (2000). The Rapidly Changing Management of Cardiac Arrhythmias. Am J Respir Crit Care Med 161: 1070-1073.

• Bauersfeld, U., Nowak, B., Molinari, L., Malm, T., Kampmann, C., Schonbeck, M. H., Schuller, H. (1999). Low-energy epicardial pacing in children: the benefit of autocapture. Ann. Thorac. Surg. 68: 1380-1383.

• KURBAAN, A S, SUTTON, R (1999). Pacing for vasovagal syncope. Heart 82: 649-650

• Braunwall, e. (1992) Heart Disease : a textbook of cardiovascular disease, 4 th edition, WB Saunders

• American Radio Relay League, Inc., Technical Information Service, 225 Main St., Newington, CT 06111 (860) 594-0214.

• Thelan, Lynne A., Davie, Joseph K., Urden, Linda D., Lough, Mary E. (1994) Critical Care Nursing: Diagnosis and Management. Second Edition. Pg 313-322.

• Graver, K (1998) A Practical Guide to EKG Interpretation, 2nd edition

• On-line: http://www.emedicine.com/emerg/topic699.htm

• Dames' Clinical Nursing Education Webring