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RESUSCITATION PHARMACOLOGY
RESUSCITATION PHARMACOLOGY
• Correct hypoxia• Establish spontaneous circulation
at an adequate blood pressure• Promote optimal cardiac function• Prevent or suppress arrhythmias• Relieve pain• Correct acidosis• Treat congestive heart failure
IMPORTANT DRUGS FOR ACLS
• Oxygen BP
Epinephrine/adrenaline Vasopressin Dopamine
HR Atropine
Ventricular arrhythmia Amiodarone Lidocaine / lignocaine Procainamide Magnesium sulphate
Supraventricular arrhythmia Adenosine Diltiazem Amiodarone
• AMI Morphine Nitroglycerine Aspirin Fibrinolytics
• Misc Sodium bicarbonate Calcium chloride
SCHEME FOR STUDY
• Mechanism of action (why ?)
• Indication (when ?)
• Dosage (how ?) correct dose for the correct indication through the correct route
• Precautions (watch out !)
OXYGEN
• Mechanism of action O2 tension hemoglobin saturation tissue oxygenation
• Indication All patients in ACLS
OXYGEN
• Dosage Spontaneous breathing
1 – 6 L/min via nasal cannula 4 L/min for AMI 6 – 10 L/min via non-breathing face mask
Cardiac arrest 15 L/min using bag mask
• Precaution ?? COAD
Epinephrine / Adrenaline
• Mechanism of Action & adrenergic stimulation SVR, SBP, DBP coronary and cerebral blood flow electrical & strength of myocardium
myocardial O2 requirement automaticity
Epinephrine / Adrenaline
• Indication All patient in cardiac arrest
Severe hypotension Symptomatic bradycardia Anaphylaxis
• Dosage Cardiac arrest
1 mg (10ml 1:10000) IV push Q3-5 min Flush with NS + arm elevation for 10-20s 2 – 2.5x IV dose through ETT
Non-Cardiac arrest 2 - 20g/min
• Precautions Precipitate in alkaline solutions
Epinephrine / Adrenaline
Vasopressin
• Mechanism of action Potent vasoconstrictor SVR, SBP, DBP coronary and cerebral blood flow
• Indication Alternative to 1st and 2nd dose of
epinephrine for VF/ pulseless VT
Vasopressin
• Dosage 40 U IV push 1x
• Precautions May provoke cardiac ischemia
Dopamine
• Mechanism of action Stimulation of dopaminergic, &
adrenergic receptor
• Indication Hypotension (70 – 100mmHg) Second drug for hypotensive
bradycardia
Dopamine
• Dosage 5 - 20g/kg/min Titrate to response
• Precautions Taper gradually Start after volume replacement Do not mix with sodium bicarbonate Monitor IV site
Atropine• Mechanism of action
Block parasympathetic receptor of heart SA node automaticity AV node conduction Not to stimulate the heart
• Indication Symptomatic sinus bradycardia While waiting for pacing (don’t delay) Second drug in asystole / PEA Organophosphate poisoning
Atropine• Dosage
Arrest1mg IV/IO push Q3 – 5min2 – 3mg ETT
Bradycardia0.5mg IV/IO Q3 – 5min
Max. 3mg Extremely large dose may be need for
organophosphate poisoning
Atropine
• Precautions Paradoxical bradycardia with < 0.5mg Worsen myocardial ischaemia Avoid in hypothermic bradycardia Not useful in AV block of
2nd degree Type II3rd degree
Anti-arrhythmics
• Pro-arrhythmics
• Negative inotrope ( force) (+) for Ca channel blocker, -blocker,
procainamide, lignocaine (+) for amiodarone (-) for digoxin
Anti-arrhythmics
• Slow the heart (-ve chronotrope) AV node vs. accessory pathway AV node only
Adenosine, digoxin AV node > accessory pathway
Ca channel blocker, -blockerLidocaine
AV node = accessory pathwayAmiodarone, procainamide
Amiodarone• Mechanism of action
Block Na, K and Ca channels & blocking properties
• Indication VT/VF cardiac arrest refractory to shock
+ epinephrine Recurrent life-threatening VT Other arrhythmias (need expert)
Amiodarone
• Dosage Cardiac Arrest
300mg IV push (in 20-30ml D5)+ 150mg IV push in 3-5 min 1x
Ventricular Tachyarrhythmias150mg IV over 10min
Maintenance1mg/min IV for 6 hours then0.5mg/min IV for 18 hours
Max dose 2.2g/day
Amiodarone
• Precautions Multiple drug interaction Long half-life (up to 40 days) Hypotension with rapid/repeated dose Prolong QT interval
Lidocaine / lignocaine
• Mechanism of Action Block Na channel ventricular ectopy excitability in ischemic tissue
• Indication Alternative to amiodarone in cardiac
arrest from VT/VF Stable VT with good LV
Lidocaine / Lignocaine• Dosage
Loading1-1.5mg/kg IV push (arrest)0.5-0.75mg/kg IV push (stable VT)+ 0.5-0.75mg/kg IV Q3 - 5minUp to 3mg/kgETT: 2-4mg/kg 1x
Maintenance1-4mg/min IV
Lidocaine / Lignocaine• Precautions
Not recommended as prophylaxis in MI
Reduce dose Impaired liver functionPoor LV
Stop infusion if signs of toxicity occurs
Procainamide
• Mechanism of Action Block Na channel ventricular ectopy conduction
• Indication Suppression of recurrent VF/VT Other tachy-arrhythmias
Procainamide• Dosage
Recurrent VF/VT 20mg/min (up to 50mg/min) infusion until
o Arrhythmias suppressiono Hypotensiono QRS widen by 50%o 17mg/kg given (60mins for 70kg
patient)
Maintenanceo 1 – 4mg/min
Procainamide
• Precautions Hypotension Reduce to 12mg/kg max in patient
with heart / renal failure Prolong QT interval Pro-arrhythmic, esp. in AMI, K, Mg
Magnesium Sulphate
• Drug of choice for Torsades de Pointes
• Dosage 1-2g IV over 5-20min Then infusion 0.5 – 1g/hr Titrate to control torsades
Adenosine / ATP
• MECHANISM OF ACTION SA node and AV node Short half-life < 5s
• INDICATION Termination of PSVT Diagnostic maneuver for stable
narrow complex SVT
Adenosine / ATP
• DOSAGE 6mg adenosine / 10mg ATP, follow by
20ml NS 12mg adenosine / 20mg ATP in 1-2min if
no response A third dose of 12mg / 20mg ATP in 1-
2min
• PRECAUTIONS Flushing, dyspnoea, chest pain
Diltiazem
• MECHANISM OF ACTIONCa channel blocker automaticity conduction
• INDICATIONRate control for AFTerminate stable re-entry SVT if
adenosine fails
Diltiazem• DOSAGE
15-20mg IV over 2 min Repeat in 15 min at 20-25mg IV PRN Then 5-15mg/hr Titrate to effect
• PRECAUTIONS Not to be used in
Wide complex tachycardia of uncertain origin
Drug induced tachycardia WPW syndrome with AF
DRUGS for AMI
• “MONA greets all MI patients”
M = MorphineO = OxygenN = NitrateA = Aspirin
Morphine
• MECHANISM OF ACTIONRelieve pain myocardial oxygen demand
• INDICATIONChest pain no responding to nitratePulmonary edema
Morphine
• DOSAGE2-4mg IV Q5-30minTitrate to effect
• PRECAUTIONSHypotensionCNS / respiratory depression
Nitroglycerin
• MECHANISM OF ACTION Vasodilation
preload, afterloadCoronary artery vasodilation
• INDICATION Ischemic chest pain Ongoing or recurrent ischaemia in MI Pulmonary edema, hypertensive urgency
Nitroglycerin
• DOSAGESL : 0.5mg Q 5minIV : start with 10-20g/min
• PRECAUTIONSPhosphodiesterase inhibitor for
erectile dysfunctionHypotensionHeadache
Aspirin• MECHANISM OF ACTION
Inhibit platelet action
• INDICATION All patient with ACS
• DOSAGE 162-325mg PO (300mg) Chewing
• PRECAUTIONS Peptic ulcer, asthma
Fibrinolytics• MECHANISM OF ACTION
Reperfusion of myocardium
• INDICATION ST elevation MI or new LBBB <12hr from onset
• CHOICE Streptokinase Alteplase
• PRECAUTIONS Screen for contraindications
Calcium Chloride• INDICATION
Hyper KHypo CaCa channel blocker / -blocker
overdose
• DOSAGE5-10ml 10% CaCI2
Sodium Bicarbonate• INDICATION
Hyper K Bicarbonate responsive acidosis (DKA) Tricyclic antidepressant overdose
• DOSAGE 1mmol/kg IV bolus Monitor ABG
• PRECAUTIONS Not routine for cardiac arrest
THANK YOU