1. CODE BLUE MANAGEMENT DRUG THERAPY

2. Bradycardia
Atropine
Dopamine infusion
Epinephrine infusion

3. Atropine Mechanism of Action
Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes)

4. Atropine Indications Precautions
First drug for symptomatic sinus bradycardia
May be beneficial in AV block or asystole
Second drug in asystole or slow PEA
Organophosphate poisoning; large dose may be needed
Precautions
MI and hypoxia – atropine increases oxygen demand
Avoid in hypothermia
Not effective for 2nd type II or new 3rd degree block (may slow the rhythm)
Doses < 0.5 mg may cause a paradoxical slowing

5. Don’t delay pacing for severely symptomatic (unstable) patients.
Atropine
Don’t delay pacing for severely symptomatic (unstable) patients.
Asystole or slow (<60)PEA
1 mg IV/IO push
Repeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg.
Bradycardia
0.5 mg IV every 3-5 minutes as needed; max. of 3 mg.
Use shorter dosing interval and higher doses in severe clinical situations
Endotracheal Administration
2-3 mg diluted in 10 mL water or NS
Organophosphate Poisoning
Large doses (2-4 mg or higher) may be necessary

6. Stimulates adrenergic receptors; dose dependent.
Dopamine
Mechanism of Action
Stimulates adrenergic receptors; dose dependent.

7. Dopamine Indications Precautions IV Administration
Second-line drug for symptomatic bradycardia
Hypotension with signs and symptoms of shock
Precautions
Correct hypovolemia with volume before initializing
Use caution with cardiogenic shock and associated CHF
May cause tachydysrhythmias; excessive vasoconstriction
Don’t mix with sodium bicarbonate
IV Administration
Infusion at 5-20 mcg/kg/min.
Titrate to patient response; taper slowly

8. Epinephrine
Mechanism of Action
Stimulates adrenergic receptors and is not dose dependent like dopamine.

9. Epinephrine Indications Cardiac arrest Symptomatic bradycardia
VF; VT; asystole; PEA
Symptomatic bradycardia
After atropine; alternative to dopamine
Severe hypotension
When atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitors
Anaphylaxis; severe allergic reactions
Combine with large fluid volume; corticosteroids; antihistamines

10. Tachycardia Adenosine Diltiazem Metoprolol Amiodarone Lidocaine
Magnesium Sulfate

11. Adenosine Mechanism of Action
Slows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.

12. Adenosine Indications 1st drug for stable, narrow complex, regular SVT
May consider for unstable SVT while preparing for cardioversion
Wide-complex tachycardia thought to be, or determined to be reentry SVT
Does not convert atrial fibrillation, atrial flutter, or VT
Diagnostic maneuver; stable narrow-complex SVT

13. Adenosine Place supine or mild reverse Trendelenburg
6 mg rapidly followed by 20 mL flush
May repeat at 12 mg every 1-2 minutes if unsuccessful

14. Diltiazem
Mechanism of Action
Inhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.

15. Diltiazem Indications Contraindications/Precautions
Controlling ventricular rate in a-fib or flutter
After adenosine to treat refractory reentry SVT if adequate blood pressure
Contraindications/Precautions
Do not use with wide-complex rhythms
Do not use with poison/drug induced tachycardia
Avoid in WPW
Avoid in AV nodal blocks
Blood pressure may drop from peripheral vasodilation

16. Metoprolol
Mechanism of Action
Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.

17. Metoprolol Indications
Administer to all patients with suspected MI or unstable angina, absent contraindications
Second-line agent for SVT refractory to adenosine
To reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressure
Emergency antihypertensive therapy for acute hemorrhagic or ischemic stroke

18. Metoprolol Contraindications/Precautions
Hemodynamically unstable patients should not receive
Signs of heart failure
Low cardiac output
Increased risk for cardiogenic shock
Relative contraindications: 1st, 2nd, 3rd degree blocks; active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHg
Concurrent administration of calcium channel blockers can cause serious hypotension
Monitor cardiac and pulmonary status throughout

19. Amiodarone Mechanism of Action
Prolongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.

20. Amiodarone Indications Contraindications/Precautions
Life threatening dysrhythmias
VF/pulseless VT unresponsive to shock, CPR, and vasopressor
Recurrent hemodynamically unstable VT
Seek expert opinion for other uses
Contraindications/Precautions
Bradycardia
2nd and 3rd degree block
Do not administer with meds that prolong QT interval (procainamide)

21. Amiodarone
VF/VT – 300 mg IV/IO in mL NS. Can follow with ONE dose of 150 mg in minutes, if needed.
Life threatening dysrhythmias
150 mg over 10 minutes. May repeat every 10 minutes as needed.

22. Lidocaine Mechanism of Action
Decreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.

23. Lidocaine Cardiac Arrest Perfusing Dysrhythmia Maintenance Infusion
Initial dose is mg/kg
Refractory VF mg/kg in 5-10 min. Max 3 mg/kg
Endotracheal dose 2-4 mg/kg
Perfusing Dysrhythmia
mg/kg up mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kg
Maintenance Infusion
1-4 mg/min

24. Magnesium Sulfate Mechanism of Action
Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.

25. Magnesium Sulfate Indications Precautions Dosing
Torsades is suspected in cardiac arrest
Lfe-threatening ventricular dysrhythmias in digitalis OD
Precautions
Fall in BP with rapid administration
Use caution in renal failure
Dosing
Arrest 1-2 g over 5-20 min.
Torsades w/ pulse 1-2 g over 5-60 min.

26. Vasopressin
Mechanism of Action
Causes vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.

27. Vasopressin Indications Contraindications/Precautions Dosing
Alternative to epinephrine in adult refractory VF/VT
Alternative to epinephrine in asystole or PEA
Contraindications/Precautions
Potent peripheral vasoconstrictor (increased demand upon resuscitation)
Dosing
Single dose of 40 u that replaces either the 1st or 2nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes after
Can be used endotracheally; no suggested dose