acls medications.ppt
TRANSCRIPT
BradycardiaAtropineDopamine infusionEpinephrine infusion
AtropineMechanism of Action
Inhibits the actions of acetycholine on structures
innervated by postganglionic sites
(smooth/cardiac muscle, SA/AV nodes)
AtropineIndications
First drug for symptomatic sinus bradycardiaMay be beneficial in AV block or asystoleSecond drug in asystole or slow PEAOrganophosphate poisoning; large dose may be
neededPrecautions
MI 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
AtropineAsystole or slow (<60)PEA
1 mg IV/IO pushRepeat 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 Administration2-3 mg diluted in 10 mL water or NS
Organophosphate PoisoningLarge doses (2-4 mg or higher) may be necessary
Don’t delay pacing for severely symptomatic (unstable) patients.
Don’t delay pacing for severely symptomatic (unstable) patients.
DopamineMechanism of Action
Stimulates adrenergic receptors; dose
dependent.
DopamineIndications
Second-line drug for symptomatic bradycardiaHypotension with signs and symptoms of shock
PrecautionsCorrect hypovolemia with volume before initializingUse caution with cardiogenic shock and associated CHFMay cause tachydysrhythmias; excessive
vasoconstrictionDon’t mix with sodium bicarbonate
IV AdministrationInfusion at 5-20 mcg/kg/min.Titrate to patient response; taper slowly
EpinephrineMechanism of Action
Stimulates adrenergic receptors and is not dose dependent like dopamine.
EpinephrineIndications
Cardiac arrest 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
EpinephrinePrecautions
May increase myocardial ischemia, angina, and oxygen demand
High doses do not improve survival; may be detrimental
Higher doses may be needed for poison/drug induced shock
DosingCardiac 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 2-2.5 times normal doseSQ/IM 0.3-0.5 mg
TachycardiaAdenosineDiltiazemMetoprololAmiodaroneLidocaineMagnesium Sulfate
AdenosineMechanism of Action
Slows impulse formation in the SA node; slows
conduction time through AV node; depresses left ventricular function and
restores NSR.
AdenosineIndications
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
AdenosineContraindications/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
AdenosinePlace supine or mild reverse Trendelenburg6 mg rapidly followed by 20 mL flushMay repeat at 12 mg every 1-2 minutes if
unsuccessful
DiltiazemMechanism 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.
DiltiazemIndications
Controlling ventricular rate in a-fib or flutterAfter adenosine to treat refractory reentry SVT if
adequate blood pressureContraindications/Precautions
Do 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
DiltiazemRate control
15-20 mg (0.25 mg/kg) IV over 2 minutesAfter 15 min. another 20-25 mg (0.35 mg/kg)
IV over 2 minutes, if neededMaintenance Infusion
5-15 mg/hour; titrated to physiologically appropriate heart rate
MetoprololMechanism of Action
Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing
cardiac output, and decreasing BP.
MetoprololIndications
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
MetoprololContraindications/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
AmiodaroneMechanism of Action
Prolongs myocardial cell action potential duration and refractory period by
direct action on all cardiac tissue; decreases AV and SA
conduction rates.
AmiodaroneIndications
Life threatening dysrhythmias VF/pulseless VT unresponsive to shock, CPR, and
vasopressor Recurrent hemodynamically unstable VT Seek expert opinion for other uses
Contraindications/PrecautionsBradycardia2nd and 3rd degree blockDo not administer with meds that prolong QT
interval (procainamide)
AmiodaroneVF/VT – 300 mg IV/IO in 20-30 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.
LidocaineMechanism of Action
Decreases depolarization, automaticity, and
excitability of ventricle during diastole by direct
action, reversing ventricular dysrhythmias.
LidocaineIndications
Alternative to amiodarone in VF/VT arrestStable monomorphic VTMalignant PVC’sCan be used if Torsades is suspected
Contraindications/PrecautionsProphylactic use in AMI is contraindicatedReduce maintenance dose in liver impaired
patientsDiscontinue infusion if toxicity develops
LidocaineCardiac Arrest
Initial dose is 1-1.5 mg/kgRefractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3
mg/kgEndotracheal dose 2-4 mg/kg
Perfusing Dysrhythmia0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range.
Repeat if necessary at lower range to total dose of 3 mg/kg
Maintenance Infusion1-4 mg/min
Magnesium SulfateMechanism of Action
Increases magnesium levels in cases where prolonged
QT interval is thought to be secondary to
hypomagnesemia.
Magnesium SulfateIndications
Torsades is suspected in cardiac arrestLfe-threatening ventricular dysrhythmias in
digitalis ODPrecautions
Fall in BP with rapid administrationUse caution in renal failure
DosingArrest 1-2 g over 5-20 min.Torsades w/ pulse 1-2 g over 5-60 min.
VasopressinMechanism of Action
Causes vasoconstriction with reduced blood flow, increasing core perfusion
during cardiac arrest.
VasopressinIndications
Alternative to epinephrine in adult refractory VF/VT
Alternative to epinephrine in asystole or PEAContraindications/Precautions
Potent 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 after
Can be used endotracheally; no suggested dose