Adenosine. poison/drug induced. flushing, chest pain, transient asystole. Precautions: tachycardia. fibrillation, atrial flutter. Indications: or VT

Transcription

1 Adenosine Indications: 1. Narrow complex PSVT 2. Does not convert atrial fibrillation, atrial flutter or VT 1. Side effects include flushing, chest pain, transient asystole 2. May deteriorate widecomplex tachycardia 3. Contraindicated in poison/drug induced tachycardia

2 Adenosine - dosage 1. Initial bolus of 6 mg rapidly over 1 ~ 3 seconds followed by NS bolus of 20 ml; elevate the extremity 2. Repeated dose of 12 mg in 1 ~ 2 minutes if needed 3. A third dose of 12 mg in 1 ~ 2 minutes if needed

3 Amiodarone Indications: 1. Wide variety of atrial and ventricular tachyarrhythmias 2. Rate control of rapid atrial arrhythmias in patients with impaired LV function when digoxin has proven ineffective 1. May produce vasodilation and hypotension 2. May have negative inotropic effects 3. May prolong QT interval Amiodarone - dosage 1. Cardiac arrest 300 mg IV push, repeated dose of 150 mg IV push in 3 ~ 5 minutes if needed 2. Wide-complex tachycardia * rapid infusion: 150 mg IV over 10 minutes, may repeat rapid infusion (150 mg) every 10 minutes as needed * slow infusion: 360 mg IV over 6 hours (1 mg/min) then + maintenance infusion: 540 mg IV over 18 hours (0.5 mg/min)

4 Indications: 1. All patients with ACS(symptoms as pressure, heavy weight, squeezing, crushing) 2. Aspirin blocks formation of thromboxane A2 which causes platelets to aggregate, arteries to constrict. This reduces overall AMI mortality, reinfarction, nonfatal stroke. Aspirin 1. Relatively contraindicated in patients with active ulcer disease or asthma 2. Contraindicated in known hypersensitivity Aspirin - dosage 160 ~ 325 mg tablet taken as soon as possible (chewing is preferable to swallowing) and then daily

5 Atropine sulfate Indications: 1. Symptomatic sinus bradycardia 2. May be beneficial in AV block at the nodal level (1 & 2 type I AV block) 3. Second drug (after epinephrine) for asystole or PEA 1. Caution in presence of myocardial ischemia 2. Avoid in hypothermic bradycardia 3. No effect for infranodal (2 type II) AV block and 3 AV block with wide QRS complex

6 Atropine - dosage 1. Asystole or PEA: 1mg IV push, repeat every 3~5 minutes to a maximum dose of 3 mg 2. Symptomatic bradycardia: 0.5 mg IV every 3~5 minutes, maximum total dose of 3mg 3. Tracheal administration: 2~3 mg diluted in 10 ml NS

7 Indications: 1. To slow ventricular response in atrial fibrillation or atrial flutter 2. Alternative for PSVT Digoxin 1. Toxic effects are common and frequently associated with serious arrhythmias 2. Avoid cardioversion if patient is receiving digoxin unless condition is lifethreatening Digoxin - dosage Loading doses of 10~15 ug/kg lean body weight, maintenance dose is affected by body size and renal function

8 Diltiazem Indications: 1. Control ventricular rate in atrial fibrillation and atrial flutter 2. Use after adenosine to treat refractory PSVT with narrow-qrs complex 1. Do not use CCB in wide- QRS tachycardias 2. Avoid CCB in patients with WPW syndrome plus rapid atrial fibrillation or flutter 3. Avoid in patients with SSS or with AV block 4. Avoid in patients receiving β-blockers 5. BP drop may happen

9 Dobutamine Indications: Pump problems (CHF, pulmonary congestion or pulmonary edema) with systolic BP of 70~100 mmhg and no signs of shock 1. Avoid with systolic pressure <100 mmhg and signs of shock 2. May cause tachyarrhythmias, fluctuations in BP, headache and nausea 3. Contraindicated in poison/drug induced shock 4. Do not mix with NaHCO3 Dobutamine - dosage IV infusion only--- * infusion rate is 2~20 ug/kg/min * titrate so heart rate does not increase by >10% baseline

10 Dopamine Indications: 1. Second drug for symptomatic bradycardia (after atropine) 2. Use for hypotension (systolic BP with 70~100 mmhg) with symptoms/ signs of shock 1. Use in patients with hypovolemia only after volume replacement 2. May cause tachyarrhythmias 3. Taper slowly 4. Do not mix with NaHCO3

11 Dopamine - dosage Continuous infusions (ug/kg/min) Low dose: 1~5 (dopaminergic doses) Moderate dose: 5~10 (β-cardiac doses) High doses: 10~20 (α-vasopressor doses)

12 Indications: 1. Cardiac arrest VF/ pulseless VT, asystole, PEA 2. Symptomatic bradycardia after atropine, dopamine and TCP 3. Severe hypotension 4. Anaphylaxis, severe allergic reactions combine with large fluid volumes, steroids, antihistamines Epinephrine 1. May cause myocardial oxygen demand and angina 2. High doses do not improve survival or neurologic outcome Epinephrine - dosage 1. Cardiac arrest - IV doses: 1 mg every 3~5 minutes followed with 20 ml IV flush - Continuous infusion: 30 mg in 250 ml NS; run at 100 ml/h and titrate to response - Tracheal route: 2 mg in 10 ml NS 2. Profound bradycardia or hypotension - 2~10 ug/min (add 1 mg to 500 ml NS; infuse at 1~5 ml/min) 3. Anaphylaxis - IM dose of 0.3~0.5 mg, may be repeated after 5~10minutes - IV dose of 0.1~0.5 mg, should be used only for profound, lifethreatening manifestations

13 Furosemide Indications: 1. Acute pulmonary edema with systolic BP>90 mmhg 2. Hypertensive emergencies 3. Increased intracranial pressure Dehydration, hypovolemia, hypotension, hypokalemia

14 Furosemide - dosage IV infusion - 0.5~1.0 mg/kg over 1~2 minutes - If no response, double dose to 2.0 mg/kg over 1~2 minutes

15 Heparin Indications: 1. Adjuvant therapy in AMI 2. Begin heparin with fibrinolytics 1. Contraindications: active bleeding; recent intracranial, intraspinal, or eye surgery; severe hypertension; bleeding disorders; GI bleeding 2. Do not use if Plt count <100,000 or with history of heparin-induced thrombocytopenia Heparin - dosage IV infusion - Initial bolus 60 IU/kg (maximum 4000 IU) - Continue 12 IU/kg/hour (maximum 1000 IU/hour) - Adjust to maintain aptt 1.5~2.0 times the control values for 48 hours or until angiography - Target range for aptt after first 24 hours is 50~70 seconds - Check aptt at 6, 12, 18 and 24 hours

16 Lidocaine Indications: Monomorphic VT with preserved ventricular function (Class Indeterminate) Polymorphic VTwith normal baseline QT interval with ischemia is treated and electrolyte is corrected. Polymorphic VT with a prolonged baseline QT interval that suggests torsades de points Precautions If ventricular function is i,mpaired: use amiodarone as an antiarrhythmic agent. If unsuccessful, perform DC cardioversion.

17 Lidocaine-- Dosage Initail doses ranging from 0.5to 0.75mg/kg and up to 1 to 1.5mg/kg may be used. Repeat 0.5 to 0.75 mg/kg every 5 to 10 mins. To a max. total dose of 3 mg/kg. Maintenance infusion of 1 to 4 mg/min ( 30 to 50 ug/kg per min) Magnesium sulfate Indications 1. Use in cardiac arrest only if torsades de pointes or suspected hypomagnesemia 2. Refractory Vf (after lidocaine) 3. Torsades de pointes 4. Life threatening ventrucular arrhythmias due to digoxin toxicity Precaution: 1. Occasional fall in BP with rapid administration 2. Use with caution if renal failure is present

18 MgSO4 - dosage 1. Cardiac arrest (hypo-mg or TDP) - 1~2 g diluted in 10 ml of D5W IV push 2. Torsades de Pointes - loading dose of 1~2 g mixed in 50~100 ml of D5W, over 5~60 minutes - Follow with 0.5~1.0 g/h IV

19 Morphine sulfate Indications: 1. Chest pain with ACS unresponsive to nitrates 2. Acute cardiogenic pulmonary edema 1. Administer slowly and titrate to effect 2. May compromise respiration 3. Causes hypotension in volume-depleted patients Morphine - dosage 2 ~ 4 mg IV (over 1 ~ 5 minutes) every 5 ~ 30 minutes

20 Indications 1. Ischemic chest pain 2. For initial 24~48 hours in patients with AMI and CHF, persistent or recurrent ischemia, or hypertension 3. Continued use (beyond 48 hours) for patients with recurrent angina or persistent pulmonary congestion 4. Hypertensive urgency with ACS Nitroglycerin 1. Avoid BP drop - 10% if normotensive - 30% if hypertensive - < 90 mmhg 2. Do not mix with other drugs 3. Contraindications - Hypotension - Severe bradycardia or tachycardia - RV infarction - Viagra within 24hours

21 Nitroglycerin - dosage 1. IV infusion - IV bolus: 12.5 ~ 25 ug - Infuse at 10 ~ 20 ug/min - Titrate to effects 2. Sublingual - 1 tablet (0.4 mg); repeat every 5 minutes

22 Norepinephrine Indications: 1. Severe cardiogenic shock and hemodynamically significant hypotension (SBP < 70mmHg) 2. Last line of drug for ischemic heart disease and shock 1. Increase myocardial oxygen demands 2. May induce arrhythmias 3. Extravasation causes tissue necrosis Norepinephrine - dosage IV infusion only ~ 1.0 ug/min titrated to improve BP (up to 30 ug/min) - Do not administer in same IV line as alkaline solutions

23 Sodium bicarbonate Indications - Class I: hyperkalemia - Class IIa: metabolic acidosis or overdose (TCA, cocaine, aspirin) - Class IIb: prolonged resuscitation; upon return of spontaneous circulation after long arrest interval - Class III: hypercarbic acidosis Not recommended for routine use in cardiac arrest patients

24 NaHCO3 - dosage - 1 meq/kg IV bolus - Repeat half this dose every 10 minutes thereafter

25 Verapamil Indications: 1. Alternative (after adenosine) to terminate PSVT with narrow complex 2. May control ventricular response in patients with atrial fibrillation, flutter, or multifocal atrial tachycardia 1. Do not use CCB for wide-qrs tachycardias of uncertain origin 2. Avoid CCB in patients with WPW syndrome plus rapid atrial fibrillation or flutter 3. Avoid in patients with SSS or with AV block 4. Avoid in patients receiving β-blockers 5. BP drop IV infusion Verapamil - dosage ~ 5.0 mg IV bolus over 2 minutes - 5~10 mg in 15 ~30 minutes if needed, maximum dose: 20 mg - Alternative: 5 mg bolus every 15 minutes to total dose of 30 mg - Older patients: administer over 3 minutes