CARDIAC DRUG REVIEW

WHAT DO YOU “SEE” WHEN YOU STIMULATE BETA

VASODILATE BRONCHODILATE +CHRONOTROPE +INOTROPE

EPI’S OTHER NAME?

ADRENALIN

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

BETA 2 BRONCHODILATOR

1:1000 MEANS?

1 GRAM/1000 ML 1MG/1ML

WHO IS THIS 1:1 GIVEN TO?

ALIVE PATIENTS ASTHMA/ALLERGIC REACTION SAFEST 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 Fib V Tach Asystole PEA How often? What dilution?

Why is Epi given during a resusucitation?

Alpha action-vasoconstriction throughout body Perfuses the heart and brain CPR directs perfusion to the above

Use ANS terms to describe Epinephrine.

Alpha stimulating Beta stimulating Sympathomimetic Adrenergic Catecholamine

What are 4 generic rules for ANS pressor agents?

Don’t abruptly DC infusion/taper BP must be monitored in Trauma-never first line Tissue sloughing may occur-watch site

What are 4 generic rules for Catecholamines?

Bicarb inactivates them Assess if currently on a Symp drug if on Beta Blocker may need to increase dose Do 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 bolus Infusion only Dopaminergic-dilates renal/mesenteric Causes hypotension Given 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 Beta some 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?

Epinephrine Vasopressin Don’t really give these anymore-but OK ET Lidocaine Atropine

Indications for Vasopressin?

Cardiac arrest don’t worry about hemodynamic 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 heart long half life minutes

What are the S&S of Symptomatic Bradycardia? List Five

hypotension altered LOC signs of shock ischemic chest discomfort acute heart failure

First line drug for the treatment of symptomatic bradycardia is WHY?

ATROPINE only action is to increase heart rate, no other demand on the heart What is the first line NON drug for the rx of symptomatic brady?

Describe Atropine using ANS words. List Four

Parasympatholytic + chronotrope Anticholinergic Parasympathetic blocking Vagolytic

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 mg 0.04 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 hypoxia can’t get to where it needs to go OR heart 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 + inotrope Sympathomimetic Catecholamine

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.

Verapamil Diltiazem 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 inotrope Coronary 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 Fib V tach Any wide QRS tachy of unknown origin Also-- Sick Sinus Syndrome Second/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 1 st AND 2 nd dose of Diltiazem. Be specific

0.25 mg/kg over 2 minutes is reasonable first dose In 15 minutes repeat dose is 0.35 mg/kg over 2 minutes is a reasonable dose for the average pt

Describe the first and second dose of Verapamil Be Specific

Initial dose 5 mg IV bolus Repeat dose 5-10 mg in 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?

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 hyperkalemia helps 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

Calcium Catecholamines

What overdose would you use Bicarb for?

Cyclic Antidepressant

What are the indications for Mag Sulfate? Name Three

Torsade de Pointes Eclampsia Asthma 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 pulseless 1-2 grams in ml D5W with a pulse

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

Smooth muscle relaxer =vasodilation CNS depressant

What are the two main actions of Adenosine?

Negative chronotrope Weak bronchoconstrictor so..cautious with what patients?

What are the top three side effects of Adenosine? They occur commonly.

Facial Flushing Dyspnea Chest pressure/pain

Describe the dosing of Adenosine, including max.

6 mg IV bolus over 1-3 seconds repeat in 1-2 minutes 12 mg may repeat a second 12 mg total 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 rapidly Administer 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 blocker Vasodilation Beta blocker negative chronotrope negative inotrope negative dromotrope

What “channels” does it affect?

Na K Ca 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 TACH V 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.

Hypotension alpha blocker Brady beta blocker AV block beta block and calcium blocked TDP increase QT

Amiodarone dose in PNB is

300 mg IV/IO second dose in 3-5 minutes consider 150 mg in practice most do not dilute 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 suppressed QRS duration increases by > 50% hypotension occurs total dose of 17 mg/kg is administered

Procainamide decreases excitability in what part of the heart?

Atria Purkinje fibers Ventricles

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 ICP it is an anesthetic

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

Altered LOC Slurred speech Visual disturbances Muscle twitching Seizures

The end…are you exhausted?