drugs inresus06122011
TRANSCRIPT
ALS Subcommittee 2010
DRUGS IN CARDIOPULMONARY
RESUSCITATION
ALS Subcommittee 2010 ALS Subcommittee 2010
OBJECTIVES
Upon completion of this session, you will be able to:
• state the drugs commonly used in resuscitation
• outline the major actions of these drugs
• list 2 side effects related to the use of the drugs
ALS Subcommittee 2010 ALS Subcommittee 2010
DRUGS USED IN RESUSCITATION
• Adrenaline
• Vasopressin
• Atropine
• Amiodarone
• Lignocaine
• Adenosine
• Dopamine
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ACCESS TO DRUG ADMINISTRATION
• Intravenous
Peripheral or central
• Intra-osseous
• Intra-tracheal
– Larger dose
– Only if intravenous and intraosseous not available
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TECHNIQUE FOR IV DRUG ADMINISTRATION
• Use upper extremity veins
• Keep the access site elevated
• Each IV drug administration to be followed by 20-30mls bolus of normal saline
• The cannula should be as large as possible
• Use normal saline as the fluid of resuscitation
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TECHNIQUE FOR ENDOTRACHEAL DRUG ADMINISTRATION
• Dilute the drug in 10 ml saline
• Thread a long catheter through the ETT
• Stop chest compressions
• Inject the drug through the catheter
• Follow with 3-4 manual lung inflations
• Dosage: 2-2.5x the recommended IV dose
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INTRAOSSEOUS
• Available for adult usage
• Site: Iliac crest, sternum
• As effective as intravenous line for resuscitation
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ADRENALINE
1st drug in cardiac arrest
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ADRENALINE
• Indications:-
VF
Pulseless VT
Pulseless electrical activity (PEA)
Asystole
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ADRENALINE
• Routes of administration:-
› IV push OR Intraosseus 1 mg
Infusion (3mg in 50 mls N/S at 1ml/hr =1ug/min), titrate accordingly
› ETT (2-2.5X IV dose)
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ADRENALINE ---- ACTIONS
• increases contractile force of the heart thus increasing cardiac output
• increases conduction of SA node, AV node and ventricle thus increasing heart rate
• increases systemic vascular resistance through peripheral vasoconstriction thus increasing perfusion pressure
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ADRENALINE ---- SIDE-EFFECTS
• Ventricular irritability
– tachyarrthymias
• ↑ Myocardial Oxygen demand
- risk of ischaemia and MI
• Cerebrovascular event
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VASOPRESSIN
• A naturally occurring hormone
• At high doses of 40 units (recommended dosage during resuscitation)
– shunting of blood to heart and brain
– intense vasoconstriction
– may not increase myocardial oxygen demand
-- unlike adrenaline
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VASOPRESSIN
• Indications for use
– Considered as an alternative to adrenaline for shock due to refractory VF, asystole and PEA
– Used as a single bolus 40 units IV to replace 1st or 2nd dose of adrenaline
– As a hemodynamic support in septic shock
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ATROPINE
• Anticholinergic (parasympatholytic)
– inhibits effect of acetylcholine on SA and AV
node
– increases SA node and AV node conduction velocity
– decreases effective refractory period AV node
• Increases heart rate and cardiac output
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ATROPINE
Indication:
• Sinus, atrial or nodal bradycardia with
hemodynamic instability
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ATROPINE
Routes of administration:- • IV: 0.5mg for Acute symptomatic bradycardia Max 3mg
• ETT: 2-3 mg diluted in 10 mls saline
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ATROPINE ---- SIDE-EFFECTS
• Tachycardia
• Palpitations
• Paradoxical bradycardia (if dose < 0.5mg)
• Seizure (rare)
• Hypertension (rare)
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AMIODARONE
• Has characteristics of all 4 antiarrhythmic drug classes – affect sodium, potassium and calcium channel
– alpha and beta blocking properties
• Used in BOTH supraventricular and ventricular tachyarrthymias
– Refractory VT/VF
– Stable monomorphic or polymorphic VT
– PSVTs, atrial tachycardia, atrial fibrillation
– Wide complex tachycardia of uncertain origin
– Pre-excited atrial arrhythmia
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AMIODARONE
• VF, pulseless VT and refractory VT/VF
– Drug of Choice
• IV bolus dose 300 mg
• repeat IV bolus 150 mg in 3-5 mins followed by IV Infusion 900 mg over 24h
• Other arrhythmias
› IV Infusion 150 mg over 10 min
followed by IV infusion 900 mg over 24h
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LIGNOCAINE
Indication:
• Refractory VT/ VF (when amiodarone is not available)
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LIGNOCAINE ---- ACTIONS
• Raises fibrillatory threshold
• enhances the effect of DC shock
• Suppresses automaticity and shortens effective refractory period and action potential duration
• slows down heart rate
• Inhibits reentry mechanism – halts arrhythmias
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LIGNOCAINE
• Routes of administration:-
– IV push (1.0 to 1.5 mg/kg)
Additional 0.5-0.75 mg/kg
Max: 3 mg/kg
Infusion 1 gm Lignocaine in 500 ml N/S
30 to 120 ml/hr (1 – 4 mg/min)
– ETT (2-2.5X IV dose)
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LIGNOCAINE - SIDE-EFFECTS
• Seizures
• Respiratory depression / arrest
• Widening of QRS complexes
• Bradycardia - cardiac arrest
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ADENOSINE
• A short acting agent that depresses SA node and AV node function
• Used in narrow complex supraventricular tachycardia
• Half life : 5 seconds
• Initial dose of 6 mg rapid IV push (may be repeated at 12 mg )
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ADENOSINE - SIDE-EFFECTS
• Transient bradycardia or even ASYSTOLE • Hypotension • Chest pain • Dyspnoea • Bronchospasm (caution in asthma ) • Transient flushing
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DOPAMINE
Indications:
• cardiogenic shock
• septicaemic shock
• neurogenic shock
• anaphylactic shock
• hypovolaemic shock only after fluid resuscitation has failed to raise BP
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DOPAMINE
Route of administration:
• Infusion via central vein
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DOPAMINE - ACTIONS
Dose dependant effects
Usual dose: 5– 20ug/kg/min
• Increases myocardial contractility
– Increases cardiac output
• Causes peripheral vasoconstriction
– Increases blood pressure
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DOPAMINE - SIDE-EFFECTS
• Tachycardia
• Tachyarrhythmias
• Excessive peripheral vasoconstriction
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SODIUM BICARBONATE
• A significant sodium load
• 8.4% solution is hypertonic => arterial vasodilatation and hypotension
• Extravasation => tissue necrosis
• Not to be injected via same IV line as catecholamines and calcium
ALS Subcommittee 2010 ALS Subcommittee 2010
SODIUM BICARBONATE
• only beneficial in hyperkalaemia
• probably beneficial in
- bicarbonate responsive acidosis
• possibly beneficial in
- protracted cardiac arrest with effective ventilation
- postresuscitation acidosis with effective ventilation
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REVIEW OBJECTIVES
Are you be able to?
• State the drugs commonly used in resuscitation
• outline the major actions of these drugs
• list 2 side effects related to the use of the drugs
ALS Subcommittee 2010 ALS Subcommittee 2010
THANK YOU NATIONAL COMMITTEE ON RESUSCITATION TRAINING
SUBCOMMITEE FOR ADVANCED LIFE SUPPORT
Dr Tan Cheng Cheng
Dr Luah Lean Wah
Dr Ismail Tan
Dr Wan Nasrudin
Dr Chong Yoon Sin
Dr Priya Gill
Dr Ridzuan bin Dato’Mohd Isa
Dr Thohiroh Abdul Razak
Dr Adi Osman