Drugs that affect the Cardiovascular system Chemeketa Community College

What about ‘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, 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, 3 rd 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 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 –2 nd and 3 rd 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 minutes –900 mg IV over 24 hrs by infusion –Repeat 150 mg IV bolus for VT For VT/VF unstable or no BP – mg IV bolus –IV infusion (1mg/min) –May repeat bolus

Not water soluble – must use solvent Polysorbate 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 –2 nd or 3 rd 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 –2 nd or 3 rd 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

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 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 –2 nd or 3 rd 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 beta 1 and beta 2 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 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 mg SL q 3-5 min. Max 3 doses –Paste 1 – 2 cm (6-12 mg) topically –Spray sprays ( 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 beta 1 receptors. Does not usually affect beta 2 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 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 2 nd hour, 20 mg over 3 rd hour for total dose of 100 mg. How supplied powder for injection, packaged with sterile water for injection 20 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 beta 1 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 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 beta 1 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 beta 1 and beta 2 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 –Beta 1 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?