NEW 2010 ACLS PHARMACOLOGY I & II

DRUGS OXYGEN CLASSIFICATION Medicinal Gas ACTION Improves tissue oxygenation INDICATIONS 1. Chest Pain 2. Suspected hypoxia 3. Cardiac Arrest 1. 2. 3. 4. VF or Pulseless VT Asystole PEA SVR DOSAGE NC 1 6 L Mask 6-10 L NRB 10+L 100% in Code 1. 1 mg 1:10.000 IV MR q 3-5 min 2. 2-2.5 mg (1:1000) if via ETT MR q 3-5 min 3. Drip 1 mg/250 mL at 2-10 mcg/min & titrate (1:1000) 40 u IV USE INSTEAD OF 1 ND OR 2 DOSE OF EPI IN CODE SITUATION
ST

CONSIDERATIONS/PRECAUTIONS 0 toxicity, chronic CO retainers 2 BUT never withhold 0 in known or suspected hypoxia EVEN IF HAVE COPD Incompatible with NaHCO Tachydysrhythmias = workload of heart
3 2 2

EPINEPHRINE (Adrenalin, Epi)

Sympathomimetic

A1=Vasoconstriction B1= HR, contractility And conduction B2=Bronchodilation perfusion pressure with CPR cardiac & CNS blood flow Increases reabsorption by the renal tubules. Directly stimulates smooth muscle contraction = vasoconstriction Potent peripheral vasoconstrictor

VASOPRESSIN (Pitressin)

Antidiuretic Hormone

1 or 2 line drug for CARDIAC ARREST INSTEAD OF epinephrine May be useful for hemodynamic support in vasodilatory shock

st

nd

SVR may provoke cardiac ischemia Not recommended for responsive patients with CAD produces same positive effects of epinephrine, but does not have the negative effects Do not give with Procainamide Causes vasodilation May increase risk of Polymorphic VT HYPOTENSION May worsen existing arrhythmias or promote new ones

AMIODARONE (Cordarone)

Antiarrhythmic

Noncompetitive inhibitor of both alpha and beta adrenergic receptors. Inhibits outward potassium current, sodium channels which prolongs QT interval, QRS duration and slows ventricular conduction

1. 2. 3.

MAT, SVT, JT Pulsed VT PVT/V-fib

Perfusing Tachys: 150 mg IV push dilute in 100 mL and give over 810 mins MR q 10 min MAX dose: 2.2 gms/24 hr VT/VF: 300mg dilute in 20-30 mL MR 150 mg in 3-5 min If dysrhythmia clears: hang drip of 360 mg IV over 6 hours (1mg/min) and then 540 mg IV over 18 hours (0.5mg/min) 20 50 mg/min IV until: 1.Arrhythmia suppressed 2. Hypotension occurs 3.QRS widens 50% 4. Total 17 mg/Kg given Drip = 1-2 Gm /250-500 @ 1-4 mg/min

PROCAINAMIDE (Pronestyl)

Antiarrhythmic

1. Bi-directional block 2. Depresses atrial & ventricular automaticity 3. Ventricular depolarization time 4. Widens QRS

PREFERRED CHOICE FOR VT w/ Pulse STABLE

Monitor BP & EKG Hypotension with rapid injection = contractility. Caution with Acute MI. May reduce dose with renal failure or when on continuous infusion of > 3 mg/min in 24 hrs. May precipitate/worsen Torsades

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NEW 2010 ACLS PHARMACOLOGY I & II

DRUGS LIDOCAINE (Xylocaine) CLASSIFICATION Antiarrhythmic ACTION Depress automaticity. Blocks re-entry. No significant effect above HIS bundle INDICATIONS 1. VT STABLE 2. Polymorphic VT IF AMIODARONE NOT AVAILABLE USE FOR PVT AND V-FIB DOSAGE VT w/pulse - STABLE 0.5 0.75 mg/kg up to 1-1.5 mg/kg MR @ 0.5 - 0.75 mg/kg q 5-10 min to total 3 doses or 3 mg/kg VF/VT 1-1.5 mg/kg repeat dose in 3-5 min to total 3 mg/kg MAGNESIUM (Mag Sulfate) Electrolyte Deficiency is associated with cardiac arrhythmias, symptoms of cardiac insufficiency and sudden cardiac death. HR & AV conduction velocity 1. Suspected Hypomagnesemia - if present in recurrent and refractory VT/VF 2. Drug of choice for Torsades de Pointes Symptomatic bradys 1. Hypotension 2. Acutely altered mental 3. Ischemic chest discomfort 4. Signs of shock 5. Acute heart failure SVT/PSVT and AT/PAT involving re-entry pathway, including AV node Torsades/AMI 1-2 gm in 50 - 100 mL over 5-60 min THEN 0.5 to 1 gm/hr CONSIDERATIONS/PRECAUTIONS CNS Toxicity - if present then dose and monitor closely. Start maintenance drip at 1 mg/min higher than total bolus dose. i.e., gave 2.5 mg/kg = 4 mg/min drip 1 mg /kg = 2 mg/min drip = 30 gtts 1-2 mg/kg = 3 mg/min drip = 45 gtts 2-3 mg/kg = 4 mg/min drip = 60 gtts Can cause CNS depression and respiratory depression

ATROPINE

Parasympatholytic

Bradycardia: 0.5 mg q 3-5 min max = 3 mg ETT = 2-2.5 x IV dose

Tachydysrhythmias, VT, VF Caution with MI or myocardial ischemia Dose less than 0.5 mg may cause parasympathomimetic effect

ADENOSINE (Adenocard)

Endogenous purine nucleoside

Depresses AV node & sinus node activity

6 mg IV over 1-3 seconds with 20 mL/NS flush MR in 1-2 min 12 mg over 1-3 sec. rapid IV push X 1

Common but Transient: 1. Flushing 2. Dyspnea 3. AV block/Asystole 4. Chest pain 5. Sinus bradycardia 6. Ventricular ectopy Theophylline (& xanthine derivatives) block action Persantine & Tegretol potentiate action Monitor BP & EKG Hypotension - freq. can be reversed by CaCl 10% 2-4 mg/kg or 0.5 - 1 gm IV AV block, severe bradycardia May exacerbate CHF in patients with left ventricular dysfunction. Not given with beta blockers

VERAPAMIL (Calan) DILTIAZEM (Cardizem)

Slow Calcium Channel Blocker

1. (-) Inotropic 2. (-) Dromotropic 3. Vasodilator 4. Slows conduction & refractory state through the AV node

STABLE - A-flutter & A-fib with RVR STABLE- SVT, JT, MAT, PAT when vagal maneuvers and Adenosine unsuccessful

Verapamil 2.5-5 mg IV over 2 min. MR 5-10 mg q 15-30 min Diltiazem 0.25 mg/kg then 0.35 mg/kg in 15 minutes

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NEW 2010 ACLS PHARMACOLOGY I & II

DRUGS NITROGLYCERIN (Nitrostat, Nitrobid) CLASSIFICATION Coronary vasodilator ACTION 1. Preload reduction- with venodilation (30-40 mcg/min) 2. Afterload reduction (150-500 mcg/min) ARTERIAL dilation (as left ventricular filling pressure is decreased, arterial dilation effect is also Dilates coronary & cerebral arteries Inhibits platelet aggregation Preload reduction Mild afterload reduction Anti-anxiety, pain relief INDICATIONS Angina - Drug of choice 2 after 0 PO/SL - Angina, MI IV - Acute MI, unstable CHF (preferred over Nipride) HTN WITH ACS Chest pain sx/sx ACS 160-325 mg p.o. Allergic reaction Increased bleeding 1. MI 2. Pulmonary Edema 2-4 mg q 5 - 30 min titrate to symptoms Monitor for: 1. BP - hypotension 2. Respiratory depression 3. Pain relief Reverse with naloxone/nalmefene Monitor BP, EKG, I & O, and serum K Hypotension Hypovolemia leading to Shock Metabolic alkalosis Hypokalemia Dig Toxicity
+

DOSAGE SL: 0.3-0.4 mg q 3-5 min as needed to total of 3 tabs. IV 12.5 - 25 mcg Start at10-20 mcg/min Titrate to pain/BP

CONSIDERATIONS/PRECAUTIONS Monitor BP & EKG, pain relief Hypotension/tachycardia Bradycardia/syncope Reperfusion dysrhythmias Headache

ASPIRIN (ASA) MORPHINE (MSO4)

Anti-inflammatory

Narcotic analgesic CNS depressant

FUROSEMIDE (Lasix)

Loop Diuretic May have transient vasodilation effect with chronic CHF

1. Venodilation in 5 min 2. Diuresis

1. Pulmonary Edema 2. ICP 3. HTN emergency

0.5-1.0 mg/kg over 1-2 mins 20-40 mg IV usual dose double pts daily dose to 40-80 mg IV if no response, DOUBLE dose to 2 mg/kg over 1-2 mins

DOPAMINE (Intropin)

Sympathomimetic

Dopaminergic = 1-2 mcg/Kg/min. Beta = 2-10 mcg/Kg/min Beta & Alpha = >10-20 mcg/Kg/min Alpha = >20 mcg/Kg/min Buffering for metabolic acidosis

1. Hypotension not volume related 2. Cardiogenic shock 3. Bradycardia 4. ROSC

400 mg/250 mL 800 mg/500 mL (1600 mcg/mL) as listed

Monitor BP, EKG, UO, Sx of infiltration as for Norepinephrine Tachydysrhythmias = dose or D/C 3 Incompatible with NaHCO TAPER, don't stop abruptly MAO inhibitors potentiate Calcium, catecholamine incompatibility. Paradoxical cellular acidosis, hypernatremia, hyperosmolality. Metabolic alkalosis 1. Hypokalemia 2 2. 0 Hgb shift to left 2 3. C0 retention Central venous acidosis exacerbation

Sodium Bicarbonate 3 (NaHCO , Bicarb)

Alkaline

Metabolic acidosis when preexisting or has hyperkalemia, TCA OD, prolonged arrest state, alkalinization in ASA OD

Wait even in unwitnessed arrest 1 mEq/Kg initially, then 0.5 mEq/Kg q 10 min OR preferably according to ABG's Always with appropriate ventilation

LBW, LLC Jul 1994 rJune 2011

NEW 2010 ACLS PHARMACOLOGY I & II

DRUGS ATENOLOL (Tenormin) METOPROLOL (Lopressor) PROPRANOLOL CLASSIFICATION Beta blockers ACTION (-) Inotropic (-) Dromotropic (-) Chronotropic INDICATIONS Reduce incidence of VF in post MI patients. May reduce reinfarction in pts post-thrombolysis Convert SVT, A-fib, A-flutter Reduce myocardial ischemia in AMI Antihypertensive therapy for CVA DOSAGE Atenolol: 5 mg IV over 5 min WAIT 10 min then 5 mg over 5 min Metoprolol: 5 mg slow IV q 5 min up to 15 mg Propranolol: 0.1 mg/kg divided in 3 doses at 2-3 min intervals. Not to exceed 1 mg/min Esmolol: 0.5 mg/kg over 1 min THEN drip 0.05 mg/kg/min Labetalol: 10 mg IVP over 1-2 min. MR or double q 10 min MAX of 150 mg Enalapril: 1.25 mg IV over 2 min, then 1.25 to 5.0 mg every 6 hrs OR 2.5 mg PO & titrate to 20 mg PO BID Lisinopril: 5 mg w/in 24 hrs of sx/sx, then 5 mg after 24 hrs, then 10 mg after 48 hrs, then 10 mg q day for 6 weeks Captopril: 6.25 mg PO Advance to 25 mg TID then 50 mg TID as tolerated DIGITALIS (Digoxin, Lanoxin) Cardiotonic (+) Inotropic (-) Dromotropic (-) Chronotropic 1. Control RVR in A-fib/A-flutter 2. CHF 3. PSVT LOAD = 10 15 mcg/kg lean body weight Maintenance determined by body size and renal function Monitor EKG, Serum K+ toxicity: 1. GI 2. Visual 3. Dysrhythmias CONSIDERATIONS/PRECAUTIONS Bradycardias AV conduction delays Hypotension Caution with Reactive Airway Disease ++ Not given with Ca channel blockers

(Inderal) ESMOLOL
(Brevibloc) LABETALOL (Normodyne)

ACE INHIBITORS ENALAPRIL (Vasotec) LISINOPRIL (Zestril) CAPTOPRIL (Capoten)

Angiotensin converting enzyme inhibitors

Prevents conversion of angiotensin I to angiotensin II SVR cardiac output

Reduce mortality and improve LV function in AMI Use for AMI with ST , HTN, CHF w/o hypotension LV function 40%

CONTRAINDICATED IN PREGNANCY Reduce dose in renal failure Avoid hypotension Contraindicated in angioedema

LBW, LLC Jul 1994 rJune 2011

NEW 2010 ACLS PHARMACOLOGY I & II

DRUGS CLASSIFICATION Sympathomimetic Synthetic catecholamine ACTION Potent (+) inotropic Some HR Freq causes reflex peripheral vasodilation May use synergistically with Nipride A1- Vasoconstriction B1 - Contractility INDICATIONS 1. Refractory CHF 2. Cardiogenic shock Dopamine 1st if BP DOSAGE 250 mg/250 mL OR 15 x kg wt = mg of drug in 250 mL Rate = 2-20 mcg/Kg/min CONSIDERATIONS/PRECAUTIONS Monitor BP, EKG, UO Tachydysrhythmias Caution with CAD - May exacerbate ischemia with HR

DOBUTAMINE (Dobutrex)

NOREPINEPHRINE (Levophed)

Sympathomimetic

Cardiogenic shock Significant hypotension with < 70 mmHg systolic

4 mg/250 mL = (16 mcg/mL) 0.5-30 mcg/min

Invasive monitoring Monitor BP, EKG, UO, tachydysrhythmias. Caution with ischemic heart disease. Tissue necrosis & sloughing if infiltrates. Reinfiltrate area with Regitine (Phentolamine) 5-10 mg in 10-15 cc NS ASAP DO NOT GIVE WITH ALKALINES Invasive monitoring, BP, Thiocyanate toxicity 1. Tinnitus 2. Blurred vision 3. Delirium 4. ABD/chest pain Active internal bleeding or bleeding disorder in last 30 days Hx of ICB Surgical procedure or trauma within 1 month, platelet count <150,000 Hypersensitivity

NITROPRUSSIDE (Nipride)

Potent peripheral dilator Cyanide derivative

Acts directly on vasculature Preload & afterload reduction

1. Hypertensive Crisis 2. Heart failure

50 mg/250 mL initial dose: 0.1-5 mcg/kg/min TITRATE up q 3-5 mins Up to 5 mcg/kg/min may be required Abciximab: 0.25 mg/kg IV bolus 10-60 min before procedure THEN 0.125 mcg/kg/min drip Eptifibitide: 180 mcg/kg bolus THEN 2mcg/kg/min drip Tirofiban: 0.4mcg/kg/min IV for 30 min, THEN 0.1mcg/kg/min drip

GLYCOPROTEIN IIB/IIIA INHIBITORS Abciximab (Reopro) Eptifibitide (Integrilin) Tirofiban (Aggrastat)

Inhibits platelet aggregation

ACS w/o ST and no Q waves

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