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Drugs that affect the Cardiovascular system
Chemeketa Community College F ’08 P. Andrews, Instructor
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What about ‘em?
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LEAD Drugs Lidocaine Epinephrine Atropine Dopamine
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 Amiodarone Prolongs action potential and refractory period
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Let’s Review First Most drugs treat dysrhythmias Most prevalent
Tachycardia Bradycardia Generated through abnormal impulse formation (automaticity) OR abnormal conductivity
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Dysrhythmias - Most often caused by imbalance between sympathetic and parasympathetic nervous systems
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Bradycardia Excessive parasympathetic stimulation through muscarinic receptors
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Tachycardia Variety of causes
Ischemia, mycoardial infarction, excessive sympathetic stimulation
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Develop phase 4 depolarization, generate abnormal impulse
Ectopic foci Abnormal conduction; One-way valve
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Antidysrhythmics SODIUM CHANNEL BLOCKERS
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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
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Lidocaine Class Indications Action Antidysrhythmic
VT, Vf, malignant PVC’s Action Decreases ventricular automaticity & excitability Raises fibrillation threshold Decreases conduction in ischemic cardiac tissue without affecting normal conduction
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Contraindications Precaution:
Advanced AV block (Mobitz II , 3rd 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%
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Side effects Drowsiness Dizziness Confusion Hypotension
Nausea, vomiting Dysrhythmias Respiratory depression Cardiac arrest
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Route & Dosage: How supplied
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
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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
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Antidysrhythmics Potassium Channel Blockers
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amiodarone (Amrinone, Cordarone)
Class antiarrhythmic Indications recurrent VF, unstable VT When other therapies are ineffective
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Action Contraindications Precautions
Prolongs action potential and refractory period Slows sinus rate, increases PR, QT intervals Contraindications Severe sinus node dysfunction 2nd and 3rd degree AV block Precautions CHF, severe pulmonary or liver disease
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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
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Route & dosage Requires large initial loading dose (IV route) to prevent delay in onset action Must use filter needle Draw up slowly – Foams!
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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
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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
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How supplied 50mg/ml in 3-ml ampules
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Bretylium Tosylate (Bretylol)
Class; antiadysrhythmic Different from all other antidysrhythmics Does not suppress automaticity Has no effect on conduction velocity
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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
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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
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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
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Dosage How supplied 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
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Antidysrhythmics Calcium Channel Blockers
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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
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Contraindications Precautions Adverse reactions, SE Hypersensitivity
Severe hepatic impairment Adverse reactions, SE Arrhythmias, CHF
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Dosage and route How supplied 5 – 10 mg, IV
2.5 mg/ml in 2 & 4 ml vials, ampules and syringes
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diltiazem (Cardizem) Class Indication Action
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
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Contraindications Precautions Hypersensitivity Sick sinus syndrome
2nd or 3rd degree AV block Precautions Severe hepatic impairment
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Adverse reactions, SE Dosage & route How supplied 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
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Antidysrhythmics Miscellaneous
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Adenosine (Adenocard)
Class Antiarrhythmic agent Indication Conversion of PSVT As a diagnostic tool to assess myocardial perfusion
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Action Contraindications Precautions
Restores normal sinus rhythm by interrupting re-entry pathways in AV node Slows conduction through AV node Contraindications 2nd or 3rd degree block Precautions Asthma Unstable angina
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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
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How supplied Onset is immediate Duration is 1 – 2 min
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!!
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digoxin (Lanoxin) Class Indications Antiarrhythmic agent
Cardiotonic and inotropic agent Indications CHF Tachyarrhythmias Af & AF PAT
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Action Contraindications 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
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Precautions Adverse reactions, SE Electrolyte abnormalities
Dysrhythmias Fatigue Blurred, yellow vision Anorexia, N/V
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Dosage & route How supplied 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
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Magnesium Sulfate Class: CNS depressant, anticonvulsant. Indications
Refractory Vf/pulseless VT Torsades de Pointes Digoxin-induced VT/Vf Seizures 2ndary to eclampsia
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Contraindications and precautions
None in refractory Vf, VT, Torsades Renal disease Heart block Hypermagnesemia
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Side effects Hypotension Asystole Cardiac arrest
Respiratory and CNS depression Flushing Sweating
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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
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Anticholingergics
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Atropine Sulfate Class Indications Anticholinergic (parasympatholytic)
Muscarinic antagonist Indications Symptomatic bradycardia Asystole PEA if bradycardia Insecticide poisoning
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Contraindications and precautions
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
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Side effects Dry mouth Blurred vision Urinary retention Constipation
Tachycardia; possibly VT, Vf
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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.
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Antihypertensives Diuretics
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Furosemide (Lasix) Class Indication Loop diuretic agent
Antihypertensive agent Indication Edema 2ndary to CHF hypertension
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Action Contraindictions Precautions
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
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Adverse reactions, SE Dosage & route How supplied
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
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Other Vasodilators and Antianginals
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Nitroglycerin Class: Antianginal agent; Nitrate Indications: Action:
Relief of acute anginal pain Hypertension CHF with APE Action: Relaxes vascular smooth muscle; decreases myocardial workload and oxygen demand
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Contraindications Hypotension Hypovolemia Intracranial bleed
Aortic stenosis Recent Viagra use
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Side effects H/A 2ndary to vasodilation Hypotension N/V Tachycardia
Flushing
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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
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Hemostatic Agents Antiplatelets
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Aspirin (Salicylate) Class Indication Antiplatelet agent
Inflammatory disorders Fever TIA MI
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Action Produces analgesia
Reduces inflammation and fever by inhibiting the production of prostoglandins Decreases platelet aggregation
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Contraindications Precautions Hypersensitivity
Bleeding disorders or thrombocytopenia Precautions GI bleeds or ulcers Chronic alcohol use/abuse Severe renal disease Viral infections Pregnancy
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Adverse reactions, SE GI bleeding Anaphylaxis Laryngeal edema
Dyspepsia, epigastric distress Heartburn, nausea
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Childrens aspirin, 81 mg tablets Aspirin 325 - 500 mg tablets
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
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Thrombolytics
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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.
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Contraindications Active internal bleeding Hx of CVA
Recent CNS trauma or surgery Severe uncontrolled hypertension Known bleeding tendencies
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Precautions Adverse reactions, SE Recent (10 days) major surgery
GI or GU bleeding Adverse reactions, SE Intracranial hemorrhage GI bleeding, retroperitoneal bleeding GU tract bleeding Anaphylaxis Reperfusion arrhythmias
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Dosage & route MI 60 mg over first hour, 20 mg over 2nd hour, 20 mg over 3rd 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
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Other Cardiac Medications
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Calcium Chloride & Calcium Gluconate
Class Mineral, electrolyte Indications Hyperkalemia Hypermagnesemia Cardiac arrest
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Action Contraindications
Acts as an activator in transmission of nerve impulses and contraction of cardiac, skeletal, smooth muscles Contraindications Hypercalcemia Vf
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Route & dosage: cardiac arrest
Adverse reactions,SE Cardiac arrest Arrhythmias Constipation, nausea Phlebitis Route & dosage: cardiac arrest 7 – 14 mEq IVP
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How supplied Calcium chloride 10% Calcium gluconate 10%
1.36 mEq/ml in 20 ml preloads Calcium gluconate 10% 0.45 mEq/ml in 20 ml preloads
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Dopamine (intropin) Class Indications Cardiotonic and inotropic agent
Vasopressor Indications Improve BP Improve cardiac output
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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
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Sodium Bicarbonate Class: Alkalinizing agent Indications: Action:
Metabolic acidosis 2ndary to cardiac arrest Cyclic antidepressants Action: Neutralizes excess acid
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Contraindications Precautions Tachyarrhythmias Pheochromoctoma
Hypersensitivity to bisulfites Precautions Hypovolemia MI
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Adverse reactions, SE Route & dosage Arrhythmias, hypotension
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
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How supplied 40 mg/ml or 80 mg/ml in preload or vial
Premixed injection: 1600 mcg/ml in 250 and 500 ml D5W
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Epinephrine 1:10,000 Class Direct-acting catecholamine secreted by the adrenal medulla in response to sympathetic stimulation.
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Indications Asystole Vf Pulseless VT PEA
Acute bronchospasm associated with asthma or COPD Anaphylaxis
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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
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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.
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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
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Dosage How supplied 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
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Propranolol (Inderal)
Class Antianginal agent Arrhythmic agent Antihypertensive agent Indication VT, Vf, Af, AF, PSVT Hypertension Angina Anterior MI w/ HTN, tachycardia
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Action Contraindication
Blocks stimulation of beta1 and beta2 adrenergic receptor sites Contraindication Uncompensated CHF Pulmonary edema Cardiogenic shock Bradycardia or heart block
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Adverse reaction, SE Dosage & route How supplied
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
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Contraindications and precautions
None in confirmed metabolic acidosis Precaution: Tissue necrosis if infiltrates Side effects: Metabolic alkalosis Decreased potassium Fluid overload
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Dosage: How supplied 1 mEq/kg IVP followed by 0.5 mEq/kg q 10 min.
1 mEq/ml in 50 ml preload
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Vasopressin Class Indications Antidiuretic hormone
Non-adrenergic peripheral vasoconstrictor Indications Alternative to Epinephrine in refractory Vf May be effective with asystole, PEA
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Contraindications, precautions Adverse reactions, SE
Directly stimulates smooth muscle receptors Increases coronary perfusion pressure Contraindications, precautions None in cardiac arrest Adverse reactions, SE unknown
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Dosage & route 40 units, IVP, one time only How supplied unknown
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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
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You arrive to find the pt
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
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DDX? TX? Why? Anything else?
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