Drugs that affect the Cardiovascular system

Chemeketa Community College

What

abou

t ‘em

?

LEAD Drugs

• Lidocaine– Interferes with sodium channels to block conduction abnormalities

• Epinephrine– Increases heart rate, blood pressure and stimulates liver

• Atropine– Blocks acetylcholine, speeds heart

• Dopamine- Increases contractile force

• Amioderone– Prolongs action potential and refractory period

Let’s Review First

• Most drugs treat dysrhythmias• Most prevalent

– Tachycardia

– Bradycardia

• Generated through abnormal impulse formation (automaticity)

• OR abnormal conductivity

• Dysrhythmias - Most often caused by imbalance between sympathetic and parasympathetic nervous systems

Bradycardia

• Excessive parasympathetic stimulation through muscarinic receptors

Tachycardia

• Variety of causes

• Ischemia, mycoardial infarction, excessive sympathetic stimulation

• Develop phase 4 depolarization, generate abnormal impulse– Ectopic foci

• Abnormal conduction;– One-way valve

Antidysrhythmics

• SODIUM CHANNEL BLOCKERS

What do they do, anyway?

• -amide, ester forms of local anesthetics elevate the threshold of electric excitation of the nerve– Enter open, inactive sodium channels– Anesthetic closes the channel, blocking sodium

influx• Delays impulse• Decreases action potential• Blocks conduction

Procainamide

• Class: antiarrhythmic

• Indications

• Treatment of ventricular and arial arrhythmias– PACs, PVCs, VT, PAT, post conversion from

Af or AF

• Action– Decreases myocardial excitability– Slows conduction velocity– Suppresses arrhythmias

• Contraindications– Hypersensitivity– Poisonings from tricyclic antidepressants

• Caution– MI– CHF– geriatrics

• Adverse reactions– Seizures– Asystole– Heart block– Ventricular arrhythmias– Diarrhea

• Route & dose– IV, 20-30 mg/min IV until

• Dysrhythmia converted• Hypotension• QRS widens > 50%• 17 mg/kg administered

– Cardiac Arrest: 100 mg IVP q 5 min.– Infusion: 1 – 4 mg/min (1 gm in 250

ml NS)

• How supplied• 10 mg/ml in 100 mg preload

Lidocaine

• Class– Antidysrhythmic

• Indications– VT, Vf, malignant PVC’s

• Action– Decreases ventricular automaticity & excitability

– Raises fibrillation threshold

– Decreases conduction in ischemic cardiac tissue without affecting normal conduction

• Contraindications– Advanced AV block (Mobitz II , 3rd degree

blocks– Torsades de pointes– Stokes-Adams syndrome

• Precaution: – Heart rate less than 60– Hepatic disease - reduce by 50%– >70 y/o – reduce by 50%

• Side effects– Drowsiness– Dizziness– Confusion– Hypotension– Nausea, vomiting– Dysrhythmias– Respiratory depression– Cardiac arrest

• Route & Dosage:– Loading dose of 1 – 1.5 mg/kg

IVP q 5 min. Max dose of 3 mg/kg– After perfusion is reestablished,

admin. Lidocaine gtt at 2-4 mg/min (start gtt at 1 mg/min if pt > 70 y/o

• How supplied– 10 mg/ml in 100 mg preload

Lidocaine is drug of choice for

• Most types of drug-induced monomorphic VT or Vf, and for VT, Vf associated with cocaine-induced myocardial ischemia

Antidysrhythmics

• Potassium Channel Blockers

Bretylium Tosylate (Bretylol)

• Class; antiadysrhythmic– Different from all other antidysrhythmics– Does not suppress automaticity– Has no effect on conduction velocity

• Indications– VT, Vf refractory to lidocaine and defibrillation– Recurrent Vf – VT with a pulse that fails to respond to

lidocaine or procainamide– Wide complex tachycardias not controlled by

lidocaine and adenosine

• Action– Causes an initial but transient release of

norepinephrine; effect lasts ~ 20 min. – Then inhibits release of norepinephrine and

blocks reuptake of norepinehprine, resulting in depletion of norepinephrine. Results in:

• Increased fibrillation threshold

• Prolonged effective refractory period

• Suppression of reentry dysrhythmias

• Contraindication and precautions– No contraindications when used for Tx of life-threatening

dysrhythmias– Contraindicated in Torsades– Can result in prolonged hypotension in postresuscitation

phase

• Side effects– Initial transient elevated BP followed by hypotension– Dizziness, syncope– Angina– Bradycardia– If administered by rapid IVP, N/V

• Dosage– Vf, pulseless VT: 5 mg/kg IVP

• Repeat with 10 mg/kg q 15 min to max dose of 30-35 mg/kg

– If conversion, administer bretylium drip at 1-2 mg/min.

• How supplied– 50 mg/ml in 10 ml preload

amiodarone (Amrinone, Cordarone)

• Class– antiarrhythmic

• Indications– recurrent VF, unstable VT– When other therapies are ineffective

• Action– Prolongs action potential and refractory period

– Slows sinus rate, increases PR, QT intervals

• Contraindications– Severe sinus node dysfunction

– 2nd and 3rd degree AV block

• Precautions– CHF, severe pulmonary or liver disease

• Adverse reactions– ARDS, pulmonary fibrosis, CHF, worsening

of arrhythmias– Liver function abnormalities– Anorexia, constipation, N/V, ataxia,

involuntary movement, paresthesia, periphreal neuropathy, tremors

– Bradycardia, hypotension– Dizziness, fatigue, malaise, corneal

microdeposits

• Route & dosage– Requires large initial loading dose

(IV route) to prevent delay in onset action

– Must use filter needle

– Draw up slowly – Foams!

• For VT hemodynamically stable (SBP> 85)– 150 mg IV over 10-30 minutes– 900 mg IV over 24 hrs by infusion– Repeat 150 mg IV bolus for VT

• For VT/VF unstable or no BP– 150-300 mg IV bolus– IV infusion (1mg/min)– May repeat bolus

• Not water soluble – must use solventPolysorbate 80

• Polysorbate 80 clinical effects:– Decrease heart rate – Depress AV node conduction– Increase atria and ventricular

refractory periods– Available only in glass ampules

• How supplied– 50mg/ml in 3-ml ampules

Antidysrhythmics

• Calcium Channel Blockers

Verapamil (Isoptin, Calan)

• Class– Antianginal, Antiarrhythmic, antihypertensive agent

• Indications– Hypertension, angina, Prinzmetal’s angina, Af or AF

with rapid ventricular response

• Action– Inhibits transport of calcium into myocardial and

vascular smooth muscle

– Decreases SA and AV conduction

• Contraindications– Hypersensitivity

• Precautions– Severe hepatic impairment

• Adverse reactions, SE– Arrhythmias, CHF

• Dosage and route– 5 – 10 mg, IV

• How supplied– 2.5 mg/ml in 2 & 4 ml vials, ampules and

syringes

diltiazem (Cardizem)

• Class– Antianginal, antiarrhythmic, antihypertensive

• Indication– Hypertension, angina, SVTs and Af & AF with rapid

ventricular response– NEW ONSET Af/AF (onset 48 hours or less)

• Diltiazem OR cardioversion

• Action– Inhibits the transport of calcium into myocardial and

vascular smooth muscle

• Contraindications– Hypersensitivity– Sick sinus syndrome – 2nd or 3rd degree AV block

• Precautions– Severe hepatic impairment

• Adverse reactions, SE– Arrhythmias

– CHF

– Peripheral edema

• Dosage & route– 0.25 mg/kg

– May repeat in 15 minutes with dose of 0.35 mg/kg

– Follow with gtt at 10 mg/hr

• How supplied– 5 mg/ml in 10 ml vials

– 25 mg preloads

Antidysrhythmics

• Miscellaneous

Adenosine (Adenocard)

• Class– Antiarrhythmic agent

• Indication– Conversion of PSVT– As a diagnostic tool to assess myocardial

perfusion

• Action– Restores normal sinus rhythm by interrupting

re-entry pathways in AV node– Slows conduction through AV node

• Contraindications– 2nd or 3rd degree block

• Precautions– Asthma– Unstable angina

• Adverse reactions & side effects– SOB– Facial flushing– Transient arrhythmias

• Dosage & route– 6 mg rapid IVP– Repeat in 1 – 2 min. prn at 12 mg rapid IVP– Repeat in 1 – 2 min. prn at 12 mg rapid IVP

• How supplied– 6 mg and 12 mg preload syringes or vials

• Onset is immediate

• Duration is 1 – 2 min

• Note: Proximal IV, RAPID bolus, 20 ml flush with arm raised is critical!!

digoxin (Lanoxin)

• Class– Antiarrhythmic agent– Cardiotonic and inotropic agent

• Indications– CHF– Tachyarrhythmias– Af & AF– PAT

• Action– Increases force of myocardial contractility– Prolongs refractory period of AV node– Decreases conductiion through SA and AV

nodes

• Contraindications– Hypersensitivity– Uncontrolled ventricular arrhythmias– AV block– IHSS

• Precautions– Electrolyte abnormalities

• Adverse reactions, SE– Dysrhythmias – Fatigue– Blurred, yellow vision– Anorexia, N/V

• Dosage & route– 0.6 – 1.0 mg (10-15 mcg/kg) initially– Give additional fractions at 4 – 8 h intervals– Total dose 200 mg

• How supplied– 0.25 mg/ml in 1 ml preload

Magnesium Sulfate

• Class: CNS depressant, anticonvulsant.

• Indications– Refractory Vf/pulseless VT– Torsades de Pointes– Digoxin-induced VT/Vf– Seizures 2ndary to eclampsia

• Contraindications and precautions– None in refractory Vf, VT, Torsades– Renal disease– Heart block– Hypermagnesemia

• Side effects– Hypotension– Asystole– Cardiac arrest– Respiratory and CNS depression– Flushing– Sweating

• Dosage & Route– Refractory VT: 1-2 gm IVP over 1-2 min.– Refractory Vf: 1-2 gm IVP over 1-2 min.– Digoxin-induced VT/Vf: 2 gm IVP– Seizures 2ndary to eclampsia: 1-4 gm slow IVP

Anticholingergics

Atropine Sulfate

• Class– Anticholinergic (parasympatholytic)– Muscarinic antagonist

• Indications– Symptomatic bradycardia– Asystole– PEA if bradycardia– Insecticide poisoning

• Action– Blocks the effects of acetylcholine at

muscarinic receptors which would cause a decrease in heart rate.

• Contraindications and precautions– Glaucoma or myasthenia gravis– Can cause tachycardia– Administer cautiously in pt. With MI or

myocardial ischemia

• Side effects– Dry mouth– Blurred vision– Urinary retention– Constipation– Tachycardia; possibly VT, Vf

• Dosage & Route– Symptomatic bradycardia; 0.5 mg IVP q 5 min.

Max dose 0.04 mg/kg– Asystole; 1.0 mg IVP q 5 min. Max dose 0.04

mg/kg– PEA; 1.0 mg IVP q 5 min. Max dose 0.04

mg/kg– Pesticide poisoning; 2-5 mg IV q 15-30 min.

Antihypertensives

• Diuretics

Furosemide (Lasix)

• Class– Loop diuretic agent– Antihypertensive agent

• Indication– Edema 2ndary to CHF– hypertension

• Action– Inhibits reabsorption of sodium and chloride

from the loop of Henle and distal renal tubule

• Contraindictions– Hypersensitivity; cross-sensitivity with

thiazides and sulfonamides may occur

• Precautions– Severe liver disease with cirrhosis or ascites

• Adverse reactions, SE– Dehydration, hypochloremia, hypokalemia,

hypomagnesemia, hyponatremia, hypovolemia, metabolic acidosis

• Dosage & route– 20 – 80 mg/day (prehospital setting: generally

double the patient’s home dose up to 80 mg IVP)

• How supplied– 10 mg/ml in 4 or 8 ml preloads

Bumetanide (Bumex)

• Class– Loop diuretic agent– Antihypertensive agent

• Indication– Edema 2ndary to CHF– Hepatic or renal disease– Hypertension

• Action– Inhibits reabsorption of sodium and chloride

from the loop of Henle and distal renal tubule– Increases renal excretion of water, sodium,

chloride, magnesium, hydrogen, calcium

• Contraindication– Hypersensitivity; cross sensitivity with

thiazides and sulfonamides

• Precautions, – Pre-existing liver disease with cirrhosis or

ascites

• Adverse reactions, SE– Dehydration, hypochloremia, hypokalemia,

hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis

• Dosage & Route– 0.5 – 1.0 mg/day IV– May be repeated q 2-3 h prn up to 10 mg/day

• How supplied– 0.25 mg/ml in 10 ml syringes or preloads

Aldactone (spironolactone)

• Class– Potassium sparing diuretic

• Indications– Counteract potassium loss caused by other

diuretics– Commonly used with other agents ( diazides) to

treat edema or hypertension

• Action– Causes loss of sodium bicarbonate and calcium

while saving potassium and hydrogen ions.– Weak diuretic and antihypertensive agent when

compared with other diuretics

• Contraindication– Hypersensitivity– hyperkalemia

• Precautions– Hepatic dysfunction– Geriatrics– Diabetics

• Adverse reactions & SE– Hyperkalemia– Dizziness

• Route & dosage– PO 25 – 400 mg/d as a single dose or 2-4

divided doses. CHF – 12.5 – 25 mg day

• How supplied– 25, 50 or 100 mg tablets

Antihypertensives

• ACE Inhibitors - Angiotension converting enzyme

enalapril (Enalaprilat, Vasotec)• Class

– Antihypertensive

• Indication– Hypertension– CHF

• Action– ACE inhibitors block conversion of

angiotension I to vasoconstrictor angiotension II.

– Causes systemic vasodilation

• Contraindications– Hypersensitivity

• Precautions– Renal impairment– Hepatic impairment– Hypovolemia– Geriatrics– Concurrent diuretic therapy

• Adverse reactions, SE– Angioedema– Cough– Hypotension– Taste disturbances– Proteinuria

• Dosage & route– 0.625 – 1.25 mg q 6 h IV

• How supplied– 1.25 mg in 1 mg preload or vial

Antihypertensives

• Calcium Channel Blocking Agents

Nifedipine (Procardia)

• Class– Antianginal agent– Antihypertensive agent– Calcium channel blocker

• Indication– Hypertension– Angina– Prinzmetal’s angina

• Action– Inhibits transport of calcium into myocardial

and vascular smooth muscle cells– Systemic vasodilation, resulting in decreased

BP

• Contraindication– Hypersensitivity– Sick sinus syndrome– 2nd or 3rd degree block

• Precautions– Severe hepatic impairment

• Adverse reactions, SE– Arrhythmias, CHF – Headache– Peripheral edema– flushing

• Dosage & route– 10 mg SL – May be repeated in 10 minutes

• How supplied– 10 mg capsules

Antihypertensive

• Beta Blocking agent

Labetalol

• Class– Antianginal agent– Antihypertensive agent– Nonselective beta-adrenergic blocking agent

• Indication– Management of hypertension

• Action– Blocks stimulation of beta1 and beta2 adrenergic

receptor sites

• Contraindications– Uncompensated CHF– Pulmonary edema– Cardiogenic shock– Bradycardia or heart block

• Precautions– Renal impairment

– Hepatic impairment

– Geriatrics

• Adverse reactions, SE– Arrhythmias

– Bradycardias

– CHF

– Pulmonary edema

– Orthostatic hypotension

– Fatigue, weakness

– impotence

• Dosage & route– 20 mg (0.25 mg/kg) initially– Additional doses of 40-80 mg q 10 min prn– Max dose 300 mg– Gtt 2 mg/min

• How supplied– 5 mg/ml in 4 mg preload syringe

• Direct Vasodilators

Sodium Nitroprusside (Nitroprusside, Nitropress

• Class– Antihypertensive agent

• Indications– Hypertensive crisis– Cardiogenic shock

• Action– Produces peripheral vasodilation by direct

action on venous and arteriolar smooth muscle

• Contraindications– Hypersensitivity– Decreased cerebral perfusion

• Precautions– Renal disease– Hepatic disease– Geriatrics

• Adverse reactions, SE– Cyanide toxicity– Dizziness, H/A– Abdominal pain, N/V

• Route & dosage– 0.3 mcg/kg/min initially– May be increased prn up to 10 mcg/kg/min not

to exceed 10 min. of therapy

• How supplied– Powder for injection: 50 mg/vial– Reconstitute in 500 cc D5W– Concentration is 100 mcg/ml

Other Vasodilators and Antianginals

Nitroglycerin

• Class: Antianginal agent; Nitrate• Indications:

– Relief of acute anginal pain– Hypertension– CHF with APE

• Action:– Relaxes vascular smooth muscle; decreases

myocardial workload and oxygen demand

• Contraindications– Hypotension– Hypovolemia– Intracranial bleed – Aortic stenosis– Recent Viagra use

• Side effects– H/A 2ndary to vasodilation– Hypotension– N/V– Tachycardia– Flushing

• Dosage & Route– Tablets

• 0.3 - 0.4 mg SL q 3-5 min. • Max 3 doses

– Paste• 1 – 2 cm (6-12 mg) topically

– Spray• 1 - 2 sprays (0.4 - 0.8 mg) SL

– IV• Mix 25 mg in 250 ml D5W (100 mcg/ml);

infuse at 5 mcg/min, titrated to effect

Atenolol (Tenormin)

• Class– Antianginal agent– Antihypertensive agent– Selective beta-adrenergic blocking agent

• Indication– Hypertension– Angina

• Action– Blocks stimulation of beta1 receptors. Does not

usually affect beta2 receptors.

– Decreases BP and heart rate

• Contraindications – Uncompensated CHF– Pulmonary edema– Cardiogenic shock – Bradycardia or heart block

• Precautions– Renal impairment– Hepatic impairment– Geriatrics– Pulmonary disease (beta selectivity may be

lost)– Diabetes (may mask signs of hypoglycemia)

• Adverse reactions, SE– Bradycardia, CHF, pulmonary edema– Fatigue, weakness– Impotence

• Dosage & route– 5 mg IV – Repeat in 10 min

• How supplied– 0.5 mg/ml in 10 ml preload or vial

Hemostatic Agents

Antiplatelets

Aspirin (Salicylate)

• Class– Antiplatelet agent

• Indication– Inflammatory disorders– Fever– TIA– MI

• Action– Produces analgesia – Reduces inflammation and fever by inhibiting

the production of prostoglandins– Decreases platelet aggregation

• Contraindications– Hypersensitivity – Bleeding disorders or thrombocytopenia

• Precautions– GI bleeds or ulcers– Chronic alcohol use/abuse– Severe renal disease– Viral infections – Pregnancy

• Adverse reactions, SE– GI bleeding– Anaphylaxis– Laryngeal edema– Dyspepsia, epigastric distress– Heartburn, nausea

• Dosage & route• Pain, Fever

– PO, Rectal• 325 – 500 mg q 3 h OR• 325 – 650 mg q 4 h• Not to exceed 4 g/day

• Cardiac chest pain– PO– 81 mg x 3 chewable childrens aspirin (243 mg)

• (UNLESS TAKING COUMADIN)

• How supplied• Childrens aspirin, 81 mg tablets• Aspirin 325 - 500 mg tablets

• Anticoagulants

Heparin

• Class – Anticoagulant

• Indication– Venous thromboembolism– Pulmonary emboli– Af with embolization

• Action– Potentiates inhibitory effect of antithrombin on

factor Xa and thrombin– Prevents conversion of fibrinogen to fibrin

• Contraindications– Hypesensitivity– Uncontrolled bleeding– Severe thrombocytopenia

• Precautions– Severe liver or kidney disease– Untreated hypertension– Ulcers– Spinal cord or brain injury– Women > 60 y/o

• Adverse reactions, SE– Bleeding– Anemia– Thrombocytopenia

• Route & dosage– 10,000 units, followed by 5,000 – 10,000 units

q 4-6 h IV– Gtt: 15 – 18 units/kg/hr

• How supplied– 1,000 – 5,000 units/ml in 10 ml tubex or

preload syringes

• Thrombolytics

Alteplase (Activase, t-PA)

• Class– Thrombolytic agents (plasminogen activators)

• Indications– Coronary thrombosis– Acute ischemic stroke

• Action– Converts plasminogen to plasmin, which is then

able to degrade fibrin in clots.

• Contraindications– Active internal bleeding– Hx of CVA– Recent CNS trauma or surgery– Severe uncontrolled hypertension– Known bleeding tendencies

• Precautions– Recent (10 days) major surgery

– GI or GU bleeding

• Adverse reactions, SE– Intracranial hemorrhage

– GI bleeding, retroperitoneal bleeding

– GU tract bleeding

– Anaphylaxis

– Reperfusion arrhythmias

• Dosage & route– MI

• 60 mg over first hour, 20 mg over 2nd hour, 20 mg over 3rd hour for total dose of 100 mg.

• How suppliedpowder for injection, packaged with sterile water for injection20 mg vial or 50 mg vial

Reconstitute with 20 mg or 50 mg using 18-ga needle

Avoid excess agitation; solution may foam• Start two IV lines first

Other Cardiac Medications

Calcium Chloride & Calcium Gluconate

• Class– Mineral, electrolyte

• Indications– Hyperkalemia– Hypermagnesemia– Cardiac arrest

• Action– Acts as an activator in transmission of nerve

impulses and contraction of cardiac, skeletal, smooth muscles

• Contraindications– Hypercalcemia– Vf

• Adverse reactions,SE– Cardiac arrest– Arrhythmias– Constipation, nausea– Phlebitis

• Route & dosage: cardiac arrest– 7 – 14 mEq IVP

• How supplied

• Calcium chloride 10%– 1.36 mEq/ml in 20 ml preloads

• Calcium gluconate 10%– 0.45 mEq/ml in 20 ml preloads

Dopamine (intropin)

• Class– Cardiotonic and inotropic agent– Vasopressor

• Indications– Improve BP– Improve cardiac output

• Action– Small doses stimulate dopaminergic receptors,

producing renal vasodilation– Large doses stimulate dopaminergic and beta-

adrenergic receptors, producing cardiac stimulation and renal vasodilation

– Larger doses stimulate alpha-adrenergic receptors and may cause renal vasoconstriction

• Contraindications– Tachyarrhythmias– Pheochromoctoma– Hypersensitivity to bisulfites

• Precautions– Hypovolemia– MI

• Adverse reactions, SE– Arrhythmias, hypotension

• Route & dosage– Renal vasodilation – 0.5 – 3 mcg/kg/min IV– Cardiac stimulation – 2.0 – 10.0 mcg/kg/min IV– Increased peripheral vascular resistance – 10

mcg/kg/min; titrate to effect

• How supplied– 40 mg/ml or 80 mg/ml in preload or vial– Premixed injection: 1600 mcg/ml in 250 and

500 ml D5W

Dobutamine

• Class– Cardiotonic and inotropic agent

• Indications– Short-term management of heart failure caused

by depressed contractility

• Action– Stimulates beta1 receptors with minor effect on

heart rate or peripheral vessels

• Contraindications– Hypersensitivity– IHSS

• Precautions– History of hypertension– MI– Af– Ventricular ectopic beats– hypovolemia

• Adverse reactions, SE– Hypertension, increased heart rate– PVCs

• Route & dosage– 0.5 – 1.0 mcg/kg/min, titrated to effect (range 2

- 20 mcg/kg/min

• How supplied– 12.5 mg/ml in 20 ml vial

Epinephrine 1:10,000

• Class– Direct-acting catecholamine secreted by the

adrenal medulla in response to sympathetic stimulation.

• Indications– Asystole– Vf– Pulseless VT– PEA– Acute bronchospasm associated with asthma or

COPD– Anaphylaxis

• Action– Stimulates beta1, beta2 and alpha1 receptors. – Effect on beta receptors significantly more profound

than on alpha receptors.– Beta1 stimulation results in increased contractility,

increased heart rate, increased AV conduction– Can cause spontaneous myocardial contraction in

asystole.– Increases likelihood of successful defibrillation– Beta2 stimulation results in bronchodilation,

vasodilation in skeletal muscle– Stimulation of alpha1 receptors causes vasoconstriction

• Note: Vascular effects are dose-related.– At low doses, beta2 receptors predominate with

decreased total peripheral resistance and decreased BP

– With larger doses, alpha effects predominate with increased peripheral vascular resistance and increased BP.

• Contraindications and precautions– No contraindications in cardiac arrest

– Protect Epi from light

– Unstable in alkaline solutions I.e., Sodium Bicarbonate

• Side effects– CNS stimulation

– H/A, dizziness, pallor

– N/V

– Palpitations

• Dosage– Cardiac Arrest: 1 mg IVP q 3-5 min.– Endotracheal admin. 2 – 2.5 x IV dose– Acute bronchospasm assoc. with asthma,

COPD: 0.3 mg – 0.5 mg 1:1,000 solution SC q 5-20 min.

• How supplied– 1 mg/ml in 10 ml preload

Isoproterenol (Isuprel)

• Class– Beta-adrenergic agonist

• Indications– Refractory torsade de pointes– Immediate temporary control of

hemodynamically significant bradycardia of heart transplant patients

• Action– Causes an increase in rate and force of heart

contractions

• Contraindications– Ischemic heart disease– Hypotension– Cardiac arrest

• Adverse reactions, SE– Arrhythmias– VT, Vf– NOTE: increases cardiac oxygen demand

• Dosage & route– 2 – 10 mcg/min IV; titrate to HR and rhythm– Mix 1 mg in 250 ml of D5W; gtt at 2 mcg/min

• How supplied– 1 mg in 1 ml preload

Metaprolol (Lopressor)

• Class– Antianginal agent– Antiarrhythmic

• Indications– Hypertension– angina

• Action– Blocks stimulation of beta1 adrenergic

receptors.

• Contraindications– Uncompensated CHF– Pulmonary edema– Cardiogenic shock– Bradycardia or heartblock

• Precautions– Renal impairment– Hepatic impairment– Geriatrics

• Adverse reactions, SE– Bradycardia, CHF, pulmonary edema– Fatigue, weakness

• Dosage & route– MI: 5 mg q 2 min for for total of 15 mg. Then

50 mg orally bid for at least 24 hours; then increase to 100 mg bid

• How supplied– 1 mg/ml in 5 mg preload or vial

Propranolol (Inderal)• Class

– Antianginal agent– Arrhythmic agent– Antihypertensive agent

• Indication– VT, Vf, Af, AF, PSVT– Hypertension– Angina– Anterior MI w/ HTN, tachycardia

• Action– Blocks stimulation of beta1 and beta2 adrenergic

receptor sites

• Contraindication– Uncompensated CHF– Pulmonary edema– Cardiogenic shock– Bradycardia or heart block

• Adverse reaction, SE– Arrhythmias, bradycardia, CHF, pulmonary edema

– Fatigue, weakness

• Dosage & route– 1 – 3 mg; repeat after 2 min and again in 4 hours prn

• How supplied– 1 mg/ml in 3 ml preload

Norepinephrine (Levophed)• Class

– Adrenergic

– Vasopressor

• Indications– Hemodynamically significant hypotension

– Septic or neurogenic shock

• Action– Beta1 adrenergic effect increases myocardial

contractility and potent alpha adrenergic effect causes arterial and venous vasoconstriction

• Contraindications– Hypotension 2ndary to hypovolemia– Myocardial ischemia or infarction

• Precautions– Hypertension– Cardiac disease– Increases cardiac oxygen demand but does not

increase coronary blood flow

• Adverse reactions, SE– Bradycardia, hypertension, arrhythmias,

chest pain– Dyspnea– Necrosis at IV site

• Route & dosage– 0.5 – 30 mcg/min titrate to effect– Mix 4 mg in 250 ml D5W (16 mcg/ml)

Sodium Bicarbonate

• Class: Alkalinizing agent

• Indications:– Metabolic acidosis 2ndary to cardiac arrest– Cyclic antidepressants

• Action:– Neutralizes excess acid

• Contraindications and precautions– None in confirmed metabolic acidosis– Precaution: Tissue necrosis if infiltrates

• Side effects:– Metabolic alkalosis– Decreased potassium– Fluid overload

• Dosage:– 1 mEq/kg IVP followed by 0.5 mEq/kg q 10

min.

• How supplied– 1 mEq/ml in 50 ml preload

Vasopressin

• Class – Antidiuretic hormone– Non-adrenergic peripheral vasoconstrictor

• Indications– Alternative to Epinephrine in refractory Vf– May be effective with asystole, PEA

• Action– Directly stimulates smooth muscle receptors– Increases coronary perfusion pressure

• Contraindications, precautions– None in cardiac arrest

• Adverse reactions, SE– unknown

• Dosage & route– 40 units, IVP, one time only

• How supplied– unknown

Off you go….

• A 78 y/o female, found unconscious and unresponsive by her daughter. Down time unknown. Unsure if the pt. Is breathing or has a pulse.

• PMH: HTN, AMI (2003), CVA (1998) with left-sided deficits

• You arrive to find the pt. Supine on the living room floor, unconscious, unresponsive. Weak carotid pulse is present.

• B/P 82/40, RR 8

• ECG; Mobitz II with frequent multifocal PVCs

• DDX?

• TX?

• Why?

• Anything else?