CARDIAC DRUG REVIEW

WHAT DO YOU “SEE” WHEN YOU STIMULATE BETA

VASODILATEBRONCHODILATE+CHRONOTROPE+INOTROPE

EPI’S OTHER NAME?

ADRENALIN

WHAT DOES EPI DO THAT NOREPI AND DOPAMINE DO NOT DO?

BETA 2BRONCHODILATOR

1:1000 MEANS?

1 GRAM/1000 ML

1MG/1ML

WHO IS THIS 1:1 GIVEN TO?

ALIVE PATIENTSASTHMA/ALLERGIC

REACTIONSAFEST ROUTE

DOSE?How many mls is each dose?

HOW DO YOU MIX AN EPI INFUSION?

1 MG /250 ML

RUN AT ?

Epi is given first line to what pulseless rhythms?

V FibV TachAsystolePEA

How often?What dilution?

Why is Epi given during a resusucitation?

Alpha action-vasoconstriction throughout body

Perfuses the heart and brainCPR directs perfusion to the

above

Use ANS terms to describe Epinephrine.

Alpha stimulatingBeta stimulatingSympathomimeticAdrenergicCatecholamine

What are 4 generic rules for ANS pressor agents?

Don’t abruptly DC infusion/taper

BP must be monitoredin Trauma-never first lineTissue sloughing may

occur-watch site

What are 4 generic rules for Catecholamines?

Bicarb inactivates themAssess if currently on a Symp drugif on Beta Blocker may need to increase doseDo not work if pH to acid (below 7.2)

Other names for Dopamine?

Intropin

Dopastat

How is Dopamine different from the other alpha agents?

List FIVE

No IV bolusInfusion onlyDopaminergic-dilates

renal/mesentericCauses hypotensionGiven based on weight

Mix a Dopamine drip?

400 mg/250 ml

The Dopaminergic effects occur MAINLY at what rate?

1-4 mcg/kg/min

Describe what happens when Dopamine is infused at 5-10 mcg/kg/min.

primarily Betasome vasoconstriction, more closer to 10

10-20 mcg/kg/min of Dopamine results in

predominately alpha actions with substantial vasoconstriction

Finish this-at 10 mcg/kg/ min you run Dopamine at

20 or 30 or 40

Your patient is in cardiac arrest. What drugs could you administer via the ETT?

EpinephrineVasopressin

Don’t really give these anymore-but OK ETLidocaineAtropine

Indications for Vasopressin?

Cardiac arrest

don’t worry abouthemodynamic support in vasodilatory shock

Dose of Vasopressin?

40 units

How many times can you repeat the dose?

How is Vasopressin different from the other pressors?

List Four

Not alpha, ANS, sympathetic, Beta, etc

Bolus only“units”not as bad at irritating/stimulating

the heartlong half life-10-20 minutes

What are the S&S of Symptomatic Bradycardia?

List Five

hypotensionaltered LOCsigns of shockischemic chest discomfortacute heart failure

First line drug for the treatment of symptomatic bradycardia isWHY?

ATROPINEonly action is to increase

heart rate, no other demand on the heartWhat is the first line NON drug for

the rx of symptomatic brady?

Describe Atropine using ANS words.

List Four

Parasympatholytic+ chronotropeAnticholinergicParasympathetic blockingVagolytic

What is a non-cardiac use for Atropine?

Describe

Organophosphate poisoning

Organophosphates stimulate the Parasympathetic nervous system. Atropine blocks this.

What is the dose of Atropine?

0.5 mg IV bolus

What may happen if you give less than that?

Total dose of Atropine?

Two answers!

3 mg0.04 mg/kg

What side effect of Atropine interferes with your assessment?

Dilates pupils!

Atropine may not work in symptomatic brady if the patient is

WHY?

hypotensive or has myocardial hypoxiacan’t get to where it needs

to goORheart cannot respond

Another + chronotrope you could give AFTER Atropine, Dopamine, Epi and a TCP is

ISUPREL!

Using ANS terms, describe Isuprel

List Four

pure Beta+ chronotrope+ inotropeSympathomimeticCatecholamine

What would Isuprel do directly to BP?

lower it, cause hypotension

What would it do indirectly to the BP?

Your patient is in A Fib, HR of 220. You want to slow the rate with a medication.

List two that would be appropriate.

VerapamilDiltiazem

What are the other names for the above drugs?

What are the actions of these two drugs?

List MAIN three

Negative chronotrope (at AV)Negative inotropeCoronary and peripheral

vasodilation

Why might the CCB cause CHF or make it worse?

Which one is worse at the above?

They are both negative inotropes

Verapamil is the stronger inotrope, not a big worry in Diltiazem

You would administer Dilt/Verap to Narrow QRS tachy only in what situation?

if Adenosine had not worked

The CCB are contraindicated in what TACHY rhythms?

Name TWO, be specific.

WPW in A FibV tachAny wide QRS tachy of unknown

originAlso--

Sick Sinus SyndromeSecond/Third degree block

Your pt received ?? at the Urgent Care for her Tachy.You must not give the pt a CCB now.

What is the drug?

Beta Blocker IV

Describe the 1st AND 2nd dose of Diltiazem.

Be specific

0.25 mg/kg over 2 minutes15-20 is reasonable first dose

In 15 minutes repeat dose is 0.35 mg/kg over 2 minutes20-25 is a reasonable dose for

the average pt

Describe the first and second dose of Verapamil

Be Specific

Initial dose 5 mg IV bolusRepeat dose 5-10 mg in 15-30

minutes if dysrhythmia persists and no adverse response to first dose

What may be tried prior to the admin of CCB in a stable patient?

Vagal maneuvers

Your pt is in A fib, hypotensive and deteriorating rapidly you should…

Cardiovert

If patient is unstable in ANY tachycardia, cardioversion rules!

You have overdosed your patient with Verapamil.

What drug could you give to attempt to prevent toxic effects?

Calcium Chloride

What is the dose of Calcium?

500-1000 mg

10% solution

Administer with extreme caution IF AT ALL to patients on

Digoxin, Digitalis etc

May precipitate what?

What is a non-overdose indication of CA++?

How does Calcium help in this setting?

Known or suspected hyperkalemiahelps stabilize the myocardial cell

membrane

What does Bicarb do?

Talk Chemistry!

decreases acid by combining with H+ and then with ventilation eliminating CO2

What must the patient be “doing” when giving Bicarb?

Breathing!

on their own or via ETT

What is the dose of Bicarb?

1 mEq/kg

or ?

Never mix with…..

Name TWO

CalciumCatecholamines

What overdose would you use Bicarb for?

Cyclic Antidepressant

What are the indications for Mag Sulfate?

Name Three

Torsade de PointesEclampsiaAsthma

life threatening dysrhythmias due to dig toxicity

What is the dose of Mag when treating Torsade?

Both pulseless and with a pulse

1-2 grams diluted in 10 ml D5W

pulseless1-2 grams in 50-100 ml D5W

with a pulse

What are two actions of Mag that would help treat Eclampsia?

Smooth muscle relaxer

=vasodilationCNS depressant

What are the two main actions of Adenosine?

Negative chronotropeWeak bronchoconstrictor

so..cautious with what patients?

What are the top three side effects of Adenosine?

They occur commonly.

Facial FlushingDyspneaChest pressure/pain

Describe the dosing of Adenosine, including max.

6 mg IV bolus over 1-3 seconds

repeat in 1-2 minutes 12 mgmay repeat a second 12 mgtotal dose 30 mg

For Adenosine to be most effective…

List four steps for administration

Start IV proximal, close to central circ

Give as close to injection site as possible

Inject rapidlyAdminister a small bolus of fluid

(20ml) and elevate arm

Describe how Adenosine is beneficial in A Fib/Flutter

May help to diagnose but will not treat

What are the Sympathetic NS actions of Amiodarone?

Alpha blockerVasodilation

Beta blockernegative chronotropenegative inotropenegative dromotrope

What “channels” does it affect?

NaKCa

Thus

-slows conduction through vents

-slows heart rate and ↑ AV node conduction

-increases refractory period (atria/vent)

What two PNB rhythms may receive Amiodarone?

V TACHV FIB

Why would you never give this drug to PEA or Asystole?

What are the side effects of Amiodarone?

List two and describe why they are side effects.

Hypotensionalpha blocker

Bradybeta blocker

AV blockbeta block and calcium blocked

TDP increase QT

Amiodarone dose in PNB is

300 mg IV/IOsecond dose in 3-5 minutes

consider 150 mgin practice most do not dilute

10-15 mls/20-30 mls D5W

Amiodarone dose in Tachy WITH a pulse is

150 mg in 100 ml D5W over 10 minutes (15mg/min) no one uses this

May repeat every 10 minutes as needed

Rhythm is WPW with A fib

The two drugs used to treat this rhythm are?

Procainamide should be given until

List all 4

dysrythmia is suppressedQRS duration increases by

> 50%hypotension occurstotal dose of 17 mg/kg is

administered

Procainamide decreases excitability in what part of the heart?

AtriaPurkinje fibersVentricles

Do not use Procainamide in what ventricular rhythm?

Torsades

Why?Do not give with what drug…

because they both do the same as above?

A patient is in Ventricular escape at a rate of 40 with frequent PVCs. What would happen to the rhythm if Lidocaine was given?

Lidocaine (or Pronestyl or Cordarone) could eliminate all ventricular response and patient could go into Asystole.

What action does Lido have that Amiodarone nor Procainamide have?

It helps decrease an elevation in ICPit is an anesthetic

Lidocaine, because it is an anesthetic has CNS side effects.

List Four

Altered LOCSlurred speechVisual disturbancesMuscle twitchingSeizures

The end…are you exhausted?