3 AtropineMechanism of ActionInhibits 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 bradycardiaMay be beneficial in AV block or asystoleSecond drug in asystole or slow PEAOrganophosphate poisoning; large dose may be neededPrecautionsMI and hypoxia – atropine increases oxygen demandAvoid in hypothermiaNot 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. AtropineDon’t delay pacing for severely symptomatic (unstable) patients.Asystole or slow (<60)PEA1 mg IV/IO pushRepeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg.Bradycardia0.5 mg IV every 3-5 minutes as needed; max. of 3 mg.Use shorter dosing interval and higher doses in severe clinical situationsEndotracheal Administration2-3 mg diluted in 10 mL water or NSOrganophosphate PoisoningLarge doses (2-4 mg or higher) may be necessary
7 Dopamine Indications Precautions IV Administration Second-line drug for symptomatic bradycardiaHypotension with signs and symptoms of shockPrecautionsCorrect hypovolemia with volume before initializingUse caution with cardiogenic shock and associated CHFMay cause tachydysrhythmias; excessive vasoconstrictionDon’t mix with sodium bicarbonateIV AdministrationInfusion at 5-20 mcg/kg/min.Titrate to patient response; taper slowly
8 EpinephrineMechanism of ActionStimulates adrenergic receptors and is not dose dependent like dopamine.
9 Epinephrine Indications Cardiac arrest Symptomatic bradycardia VF; VT; asystole; PEASymptomatic bradycardiaAfter atropine; alternative to dopamineSevere hypotensionWhen atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitorsAnaphylaxis; severe allergic reactionsCombine with large fluid volume; corticosteroids; antihistamines
10 Epinephrine Precautions Dosing May increase myocardial ischemia, angina, and oxygen demandHigh doses do not improve survival; may be detrimentalHigher doses may be needed for poison/drug induced shockDosingCardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min.High dose up to 0.2 mg/kg for specific drug OD’sInfusion of 2-10 mcg/min.Endotracheal of times normal doseSQ/IM mg
12 AdenosineMechanism of ActionSlows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.
13 Adenosine Indications 1st drug for stable, narrow complex, regular SVT May consider for unstable SVT while preparing for cardioversionWide-complex tachycardia thought to be, or determined to be reentry SVTDoes not convert atrial fibrillation, atrial flutter, or VTDiagnostic maneuver; stable narrow-complex SVT
14 Adenosine Contraindications/Precautions Poison/drug induced tachycardia is contraindicated2nd and 3rd degree block is contraindicatedTransient side effects; flushing, CP, asystole, brady, ectopyLess effective with theophylline or caffeineIf used for VT may cause worsening of clinical conditionTransient periods of sinus brady or ventricular ectopy common after termination of SVTSafe in pregnancy
15 Adenosine Place supine or mild reverse Trendelenburg 6 mg rapidly followed by 20 mL flushMay repeat at 12 mg every 1-2 minutes if unsuccessful
16 DiltiazemMechanism of ActionInhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.
17 Diltiazem Indications Contraindications/Precautions Controlling ventricular rate in a-fib or flutterAfter adenosine to treat refractory reentry SVT if adequate blood pressureContraindications/PrecautionsDo not use with wide-complex rhythmsDo not use with poison/drug induced tachycardiaAvoid in WPWAvoid in AV nodal blocksBlood pressure may drop from peripheral vasodilation
18 Diltiazem Rate control Maintenance Infusion 15-20 mg (0.25 mg/kg) IV over 2 minutesAfter 15 min. another mg (0.35 mg/kg) IV over 2 minutes, if neededMaintenance Infusion5-15 mg/hour; titrated to physiologically appropriate heart rate
19 MetoprololMechanism of ActionSelectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.
20 Metoprolol Indications Administer to all patients with suspected MI or unstable angina, absent contraindicationsSecond-line agent for SVT refractory to adenosineTo reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressureEmergency antihypertensive therapy for acute hemorrhagic or ischemic stroke
21 Metoprolol Contraindications/Precautions Hemodynamically unstable patients should not receiveSigns of heart failureLow cardiac outputIncreased risk for cardiogenic shockRelative contraindications: 1st, 2nd, 3rd degree blocks; active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHgConcurrent administration of calcium channel blockers can cause serious hypotensionMonitor cardiac and pulmonary status throughout
22 AmiodaroneMechanism of ActionProlongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.
23 Amiodarone Indications Contraindications/Precautions Life threatening dysrhythmiasVF/pulseless VT unresponsive to shock, CPR, and vasopressorRecurrent hemodynamically unstable VTSeek expert opinion for other usesContraindications/PrecautionsBradycardia2nd and 3rd degree blockDo not administer with meds that prolong QT interval (procainamide)
24 AmiodaroneVF/VT – 300 mg IV/IO in mL NS. Can follow with ONE dose of 150 mg in 3-5 minutes, if needed.Life threatening dysrhythmias150 mg over 10 minutes. May repeat every 10 minutes as needed.
25 LidocaineMechanism of ActionDecreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.
26 Lidocaine Indications Contraindications/Precautions Alternative to amiodarone in VF/VT arrestStable monomorphic VTMalignant PVC’sCan be used if Torsades is suspectedContraindications/PrecautionsProphylactic use in AMI is contraindicatedReduce maintenance dose in liver impaired patientsDiscontinue infusion if toxicity develops
27 Lidocaine Cardiac Arrest Perfusing Dysrhythmia Maintenance Infusion Initial dose is mg/kgRefractory VF mg/kg in 5-10 min. Max 3 mg/kgEndotracheal dose 2-4 mg/kgPerfusing Dysrhythmiamg/kg up mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kgMaintenance Infusion1-4 mg/min
28 Magnesium SulfateMechanism of ActionIncreases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.
29 Magnesium Sulfate Indications Precautions Dosing Torsades is suspected in cardiac arrestLfe-threatening ventricular dysrhythmias in digitalis ODPrecautionsFall in BP with rapid administrationUse caution in renal failureDosingArrest 1-2 g over 5-20 min.Torsades w/ pulse 1-2 g over 5-60 min.
30 VasopressinMechanism of ActionCauses vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.
31 Vasopressin Indications Contraindications/Precautions Dosing Alternative to epinephrine in adult refractory VF/VTAlternative to epinephrine in asystole or PEAContraindications/PrecautionsPotent peripheral vasoconstrictor (increased demand upon resuscitation)DosingSingle dose of 40 u that replaces either the 1st or 2nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes afterCan be used endotracheally; no suggested dose