1) Adenosine

2) Amiodarone

3) Aspirin/ASA

4) Atropine

5) Beta-Adrenergic Blockers Atenolol, Metoprolol, Propranolol

6) Diltiazem, Verapamil, Calcium channel blockers

7) Dobutamine

8) Dopamine

9)   Epinephrine

10) Glycoprotein, IIb/IIIa Inhibitors, ReoPro, Integrilin, Aggrastat

11) Lidocaine

12) Magnesium Sulfate

13) Morphine Sulfate

14) Nitroglycerin

15) Nitro-prusside

16) Vasopressin

DOC for paroxysmal supraventricular tachycardia (PSVT) and can be used diagnostically for stable, narrow or wide complex tachycardias of unknown type

Decreases Tachycardias associated with the AV node:

--   no negative inotropic (strength of muscle contraction) effects

-- acts directly on sinus pacemaker cells & AV chronotropic and dromotropic (conduction speed) nodal conductivity

6mg IV push rapidly over 1-3 seconds in most proximal injection port

If no response after 1-2 min, administer 12mg over 1-3 seconds

Conversion rate after the second dose is 92%

Transient Asystole: facial flushing, lightheadedness, paresthesia, headache, diaphoresis, palpitations, chest pain, hypotension, nausea, metallic taste and shortness of breath.

Use two syringe technique

V-Fib

Pulseless V-Tach

Narrow and Wide Complex Tachycardias

Tachycardias associate with Wolff-Pakinson White Syndrome

beta-blocker like and potassime channel blocker like actions on the SA node and AV nodes

Increases the refractory period via sodium and potassium channel effects and slows intra-cardiac conduction of the cardiac action potential via sodium channel effects

Cardiact Arrest (vf/-vf):

First Dose: 300 mg iv/io push

Second Dose: 150mg iv/io push

Tachyarrhythmias:

Rapid infusion: 150mg over first 10 min. 15mg min, may repeat every 10 min as needed.

Slow infusion: 360mg iv over 6 hours, 1 mg min.

Maintenance infusion: 540 mg over 18 hours (0.5 mg per min).

Amiodarone comes in ____ ____ and therefore must be scored and a ______ needle used to aspirate the contents. Tubing must have ______. It is made in ______, a soap-like substance that easily bubbles if aspirated too quickly. It must then be mixed in ____ - _____ ML D5W for a rapid IVP. Do not adminster if prolonged ____.

glass ampules;

filtered;

filter;

"tween";

20 - 30;

QT

All patients with ACS, unless hypersensitive to ASA

Anticoagulant properties by blocking formation of thromboxane A₂

160 - 325mg non-enteric coated or baby aspirin or 2-4 p.o. tablets. May give rectally.

Relatively contraindicated in people with active ulcers or asthma and contraindicated for hypersensitivity to ASA

Bradycardia rhythms to increase heart rate

Increase the heart rate by blocking vagus nerve stimulation, allowing the heart to intrinsically increase in rate.

0.5mg/3mg max

Atropine: if greater thatn 3mg or less than 0.5mg is used, this is considered a _____ dose. May cause worsening of myocardial ischemia, worsening of AV blocks, and may cause PVC's or ventricular tachycardia. May result in undesired tachycardia.

Vagolytic

Indications for Beta-Adrenergic Blockers Atenolol, Metoprolol, Propranolol?

Post-infarction protection FROM incidence of VF and decrease myocardial ischemia. Refractory tachycardias.

Competitive antagonists at the adrenergic beta receptors. They slow the heart rate and lessen the force of contraction.

Bradyarrhythmias

Heart Block

Hypotension

CHF

Hx of bronchospasm

Wolff - Parkinson White

Indications of Calcium Channel blockers: Diltiazem, Verapamil.

Inhibiting the movement of calcium ions across cell membranes. It decreases atrial automaticity, reduces AV conduction velocity, and prolongs AV nodal refractory period.

Also, depresses myocardial contractility, reduces vascular smooth muscle tone, and dilates coronary arteries in normal and ischemic tissues.

Diltiazem: 0.25 mg /kg (over 2 min, e.g., 20 mg) then 0.35 mg/kg (over 2 min, e.g., 25 mg) in 15 min, infuse 5-15 mg per hour.

Verapamil: 2.5 to 5 mg IV over 2 minutes. 5 to 10mg

q 15 - 30 minutes to a max of 20mg.

Calcium Channel Blockers: watch for _____, espeically in hypovolemic patients. Other reactions are: dizziness, headache, nausea and vomitting, bradycardia, complete AV block. and peripheral edema.

Give ______ _______ as reversal agent for calcium channel blocker overdose.

hypotension

calcium chloride

Congestive Heart Failure associated with poor cardiac output, but no shock.

positive inotropic drug, resulting in increased myocardial contracture, thus improving cardiac output

1 gram mixed in 250 ML normal saline.

Starting dose: 2. mcg/kg/min IV/IO then titrated up to 20 mcg/kg/min.

Dobutamine may cause ______ secondary to its _____ properties.

____ may result from Dobutamine's ____ properties; do not permit the herat rate to increase by ____ of its original rate.

Dobutamine may cause an increase in _____ ______. It is recommended that Dobutamine be titrated and controlled by a volumetric infusion pump. Continuous cardiac monitoring is a necessity, and frequent blood pressure measurement is Recommended.

hypotension;

beta-2;

Tachycardia;

beta-1;

10 %;

ventricular ectopy

Treatment of hypotension that is not volume related

Alpha properties used to treat hypotension: greater than 10 mcg/kg/min

Dopaminergic properties result in vasodilation of renal, mesenteric, and cerebral arteries: 1-2 mcg/kg/min

Similar to dobutamine (beta-1 properties): 5-10 mcg/kg/min

Dopamine: profound _____ may result in the presence of ______. Always treat the underlying _______ before using Dopamine. May increase both supraventricular and ____ ____. At higher doses, myocardial blood flow may be reduced. Use with a volumetric infusion device.

tachycardia;

hypovolemia;

hypovolemia;

ventricular ectopy

Bradycardias refractory to other interventions as a drip.

First drug of choice in all ACLS situations where the patient is pulseless.

E-very P-ulseless I-ndividual Gets 1mg epi.

Improved coronary and cerebral perfusion is the primary beneficial effect of epinephrine during cardiac arrest.

May also increase automaticity and make VF more susceptible to DC counter shock.

Cardiac arrest: 1 mg q 3-5 min IV.

For bradycardias: 2-10 mcg/minute IV infusion. No end point to epinephrine IVP in an arrest.

Epinephrine: may cause worsening of myocardial ischemia and may cause ___ or ventricular tachycardia. May result in undersired _____. In the crash cart, a pre-mixed dose is available in a __:_______ concentration. This equals ____ mg/ML and therefore, the initial dose is ____ ML of ___:_____ IVP.

PVCs;

tachycardia;

1:10,000;

0.1;

10;

1:10,000

Indications of Glycoprotein, IIb/IIIa inhibitors, ReoPro, Integrilin, Aggrastat?

Acute coronary syndromes without ST-segment elevation

Inhibit platelet aggregation via inhibition of integrin glycoprotein IIb/IIIa receptor in the membrane of platelets.

Active internal bleeding or bleeding disorder in past 30 days, history of intracranial hemorrhage, or other bleeding, surgical procedure or trauma within 1 month, platelete count < 150,000/mm³ hypersensitivity and concomitant use of another GP IIb/IIIa inhibitor.

Stable wide complex tachycardias, V-Fib/pulseless V-Tach. Alternative to amiodarone

MOA of Lidocaine?

Suppresses ventricular ectopy. Elevates V-Fib threshold. Tachycardia: 0.5 - 0.75 mg/kg. Increase the dose if necessary.

Cardiac Arrest:

1-1.5 mg/kg/IVP 1st dose

0.5 - 0.75 mg/kg in V-Fib 2nd dose and any subsequent dose

2-4 mg/min continuous infusion after return of spontaneous circulation

Maximum dose of 3mg/kg

if the arrhythmia is wide, use lide!

management of arrhythmias, particularly torsades de pointes, and arrhythmias secondary to a tricyclic antidepressant overdose or digitalis toxicity.

The drug is also considered as a class IIA agent (probably helpful) for refractory ventricular fibrillation and ventricular tachycardia after administration of lidocaine.

Cardiac arrest: 1-2 grams in 10 mL over 5-20 min

Torsades (with pulse): 1-2 grams in 50 mL over 5-60 min

Analgesic and choice in acute coronary syndromes.

Used as an adjunct to lasix to aid reabsorption of fluids in pulmonary edema.

Relieves pulmonary congestion by increasing venous capacitance, allowing the client to tolerte a little more volume.

Also lowers myocardial oxygen demand by its effect of decreasing afterload via its vaso-dilatory properties.

2-4 mg q 5 minutes titrated to effect.

10 mg max

Morphine Sulfate: if nitroglycerin fails to relieve the chest pain, then morphine should be given. Morphine should be withheld if nitroglycerin relieves the pain. Monitor for hypotension and respiratory depression.

Potent vasodilatory properties. Reduces afterload by reducing sytemic vascular resistance.

0.3 - 0.4 mg SL Q5Min. 3 sprays max.

50 mg in 250 ML D5W per protocol.

Nitroglycerin & Nitro-prusside: potent vasodilator, important to monitor blood pressure. IF the systolic is less than 100, then there should be consideration for withholding the drug.

Blood pressure support and severe cardiogenic shock. Last resort for ischemic heart disease.

stimulates alpha-, beta 1-, and beta 2 - adrenergic receptors in dose-related fashion. It is indicated for non-volume related hypotension.

Mix: 4mg of Norephinephrine in 250 ML of normal saline.

Start at 2 mcg/min and titrate up for desired effect.

Norepinephrine/Levophed: may cause worsening of myocardial ischemia and may cuase PVC's or ventricular arrhythmias. May result in undesired tachycardia. Do not use Norepinephrine without correcting underlying hypovolemia. Norepinephrine should always be used with a volumetric pump.

Ischemia secondary to ACS. Respiratory distress or failure.

An increase in arterial oxygen tension, an increase in hemoglobin saturation and an increase in tissue oxygenation. Keep ROSC patients saturations ≥94%.

NC: 1- 6 LPM 21 - 44%

Vent: 4 - 12 LPM 24 - 50%

Partial: 6 - 10 LPM 35 - 60%

NRB: 6 - 15 LPM 60 - 100%

BVM: 95 - 100%

Oxygen: Baseline SaO₂ readings should be performed while the patient is breathing ____ air.

Indicated for ventricular arrhythmias not controlled by Lidocaine.

Not a first drug of choice for treatment of ventricular arrhythmias.

Suppresses phase - 4 depolarization in normal ventricular muscle and Purkinje Fibers, reducing the automaticity of ectopic pacemakers.

Also suppresses reentry dysrhythmias by slowing intraventricular conduction.

Procainamide may be effective in treating PVCs and recurrent ventricular tachycardia that cannot be controlled with lidocaine.

20 - 50 mg/min.

Maximum dose: 17 mg/kg.

Maintenence Infusion (after resuscitation from cardiac arrest) is 1-4 mg/min.

For infusion, mix 2 grams of Procainamide in 500 ML normal saline.

suppression of arrhythmia, hypotension, widening of the QRS greater than 50% of original width, and maximum dose reached.

If cardiac arrest persists, then a bolus of bicarb will not hurt and may potentially help.

Useful in ASA O.D., hyperkalemia, DKA, TCA O.D. ROSC after long arrest interval.

Give 1 mEq/kg IV; you may repeat iwth 0.5 mEq/kg q 10 min.

Sodium Bicarbonate: watch for metabolic alkalosis, hypoxia, rise in intracellular pCO₂ and increased tissue acidosis.

Potent peripheral vasoconstriction and shunting of blood while having no beta adrenergic effects.

Does not directly stimulate the heart.

40U IVP X 1: may be used as an alternative pressor in place of first or second dose of epi in cardiac arrest cases.

Epi can be adminstered every 3-5 min during the arrest.

Vasopressin may be used as an alternative to epinephrine in all pulseless arrests.