anti arrhythmic class teaching
TRANSCRIPT
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CLASS ROOM TEACHING ON
ANTI ARRHYTHMIC DRUGS
SUBMITTED TO SUBMITTED BY
MRS.MALATHI, MSC [N],PhD S.SURESH
LECTURER MSC [N] II YR
CHRI CHRI
SUBMITTED ON: 21.06.2011
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NAME OF THE STUDENT TEACHER : S.SURESH
SUBJECT : CLINICAL SPECIALITY-II
UNIT : UNIT XI [ PHARMACOLOGY]
TOPIC : ANTI ARRHYTHMIC DRUGS
PREVIOUS KNOWLEDGE
OF THE STUDENTS : THE STUDENTS HAVE PREVIOUS KNOWLEDGE ON ANTI ARRHYTHMIC DRUGS DURINGTHEIR BSC(N) PROGRAMME AND ALSO HAVE CLINICAL EXPOSURE.
METHODS OF TEACHING : LECTURE CUM DISCUSSION
COURSE & YEAR : MSC NURSING II YEAR
NO OF STUDENTS : 8
VENUE : LECTURE HALL
DATE & TIME : 21.6.2011 & 2.30 PM -3.00 PM
DURATION : 30 MINUTES
EVALUAT\OR : MRS. MALATHI, MSC [N], PhD, LECTURER, CHRI
A.V AIDS : LCD, OHP, BLACK BOARD,CHART
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CENTRAL OBJECTIVES:
The student gains adequate knowledge on Anti arrhythmic drugs and develops desirable attitude and skills in providing anti arrhythmic drugs to the
patients.
SPECIFIC OBJECTIVES:
At the end of the session the student will be able to
y define Anti arrhythmic drugs.y describe the purpose of Anti arrhythmic drugs.y discuss the classification of Anti arrhythmic drugs.y elaborate the mechanism of action, uses and adverse effects of the drugs of various classification.y discuss the nursing management during anti arrhythmic drugs administration.
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2
3.
2 mts
3mts
Define Anti
arrhythmic
drugs
describe the
purpose of
Anti
arrhythmic
drugs
DEFINITION
Antiarrhythmic drugs are medicines that correct irregular heartbeats and slow
down hearts that beat too fast.
PURPOSE:
Normally, the heart beats at a steady, even pace. The pace is controlled by
electrical signals that begin in one part of the heart and quickly spread through
the whole heart. If something goes wrong with this control system, the result
may be an irregular heartbeat, or an arrhythmia. Antiarrhythmic drugs correct
irregular heartbeats, restoring the normal rhythm. If the heart is beating too fast,
these drugs will slow it down. By correcting these problems, antiarrhythmic
drugs help the heart work more efficiently.
Teacher :
Defining by using LCD
Student :
Listening
Teacher :
Defining by using LCD
Student :
Listening
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4 3 mts Discuss the
classification
of anti
arrhythmic
drugs
CLASSIFICATION
Class I Membrane-stabilizing, inhibit fast sodium channel. Restrictionof sodium current
Class II Inhibition of sympathetic stimulation Class III Delayed repolarization Class IV Calcium antagonists. Inhibit slow calcium channel. Restriction
of calcium current
Class IA Quinidine Disopyramide Procainamide
Class IB Lidocaine Mexiletine Phenytoin ** Tocainide
Class IC Flecainide Encainide Propafenone
Teacher :
Explaining by using OHP
Student:
Listening
Taking down notes
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Class II Betablockers Class III
Amiodarone Sotalol
Class IV
Verapamil
Diltiazem
5 10 mts Describe the
mechanism of
action,dosage,
adverse
effects,uses.
CLASS IA DRUGS: also block potassium channel; thus prolong action
potential.
Teacher :
Explaining by using
CHART and OHP
Student:
Listening
Taking down notes
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Quinidine:
MECHANISM OF ACTION:
Inhibition of sodium channels, extending the effective refractory period
(ERP) of the myocardial cell membrane, thereby decreasing myocardial
conduction velocity, excitability and contractility.
Blockade of alpha adrenergic receptors, leading to a reflex increase in the
SA node rate and producing vasodilatation.
Blockade of Ikchannel, prolonging duration of action potential.
Blockade of muscarinic receptors, thereby enhancing conduction through
AV node.
DOSAGE:
Quinidine Sulfate tablets - 200 mg test dose, then 200 400 mg every 3hours X 3-4 doses then q6 hr
Quinidine Bisulfate 500 mg BID
USES:
Conversion to or maintenance of sinus rhythm in patients with atrial
fibrillation, flutter , or ventricular tachycardias.
Treatment of paroxysmal supraventricular tachycardia
Prevention of PSVT in patients with reentrant tachycardias including
wolff-parkinson white syndrome.
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ADVERSE EFFECTS:
Torsades de pointes.
ECG changes: prolonged QRS complex, giant U wave, ST segment
depression , flattened T wave.
Diarrhea.
Cinchonism.
Procainamide:
The local anesthetic is equivalent to quinidine as an anti arrhythmic agent
and has similar cardiac and toxic effects.
INDICATIONS
Useful for treatment of a wide variety of arrhythmias May use for treatment of PSVT uncontrolled by adenosine and
vagal maneuvers if blood pressure stable
Stable wide-complex tachycardia of unknown origin Atrial fibrillation with rapid rate in Wolff-Parkinson-White
syndrome
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DOSAGE
Cardiac Arrest 2 mg/min IV infusion (max dose 17 mg/kg); inrefractory VF/VT, 100 mg IV push doses given every 5 minutes
are acceptable
Other indications 20 mg/min IV infusion until one of thefollowing occurs:
Arrhythmia suppression Hypotension QRS widens by > 50% Total dose of 17 mg/kg given
Maintenance dose 1-4 mg/min (usually mixed 2 gms in 500ccD5W or NS)
Additional adverse effect induces systemic lupus erythematous.
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CLASS IB DRUGS:
Examples: lidocaine, tocainide and mesiletine
Class IB drugs decrease the duration of action potential.
Lidocaine:
PHARMACOKINETICS:
Short acting because of rapid hepatic metabolism. Loading dose should be followed by continuous intravenous
infusion.
MECHANISM OF ACTION:
Acts primarily on the purkinje fibres, depressing automaticity andshortening of the refractory period.
Has a higher affinity for ischemic tissue, suppressing spontaneousdepolarizations in the ventricles by inhibiting re entry mechanisms.
INDICATIONS:
Cardiac arrest from VF/VT Stable VT, wide-complex tachycardias of uncertain type, wide-complex
PSVT
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DOSAGE:
Cardiac arrest from VF/VT Initial dose: 1.0 to 1.5 mg/kg IV For refractory VF may give additional 0.5 to 0.75 mg/kg
IV push, repeat in 5 to 10 minutes; maximum total dose 3
mg/kg
A single dose of 1.5 mg/kg IV in cardiac arrest isacceptable
Tracheal administration 2-4 mg/kg
USE:
Suppression of ventricular tachycardia ; the 2000 guideline now
consider lidocaine a second choice behind other alternative agents for the
treatment of ventricular arrhythmias associated with CPR.
ADVERSE EFFECTS:
Seizures.
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Tocainide and mexiletine: orally effective congeners of lidocaine .
PHARMACOKINETICS:
Resistant to first pass hepatic metabolism. Half life : 8 to 20 hours.
USE:
Ventricular arrhythmias.
ADVERSE EFFECTS:
Dizziness, vertigo, nausea.
CLASS 1C:
Patients who can safely receive these medications are limited because ofthe pronounced effect on conduction
Encainide (Enkaid) and flecainide (Tambocor) PO Limited to life threatening dysrhythmias
Propafenone (Rhythmol) PO Has some mild beta blocking and Ca channel blocking effects
All meds should be started while in the hospital Minimal side effects
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Proponolol:
Total dose: 0.1 mg/kg by slow IV push divided into 3 equal doses at 2-3minute intervals. Do not exceed 1 mg/min
Repeat after 2 minutes if necessary Oldest of the beta blockers Can also be given PO. 10 30 mg tid or qid
USES:
Treatment and prophylaxis of PSVT and atrial fibrillation. Possible prevention of recurrent infarction in patients recovering from
MI.
ADVERSE EFFECTS:
Sedation, sleep disturbances,sexual dysfunction.
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Esmolol:
PHARMACOKINETICS:
Very short acting.(9 minutes). Administered by IV infusion.
DOSAGE:
0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05mg/kg/minute (max 0.3 mg/kg/minute)
Titrate to effect. Esmolol has a short half-life (2 to 9 minutes)
USES:
Short term control of SVT including ST and PSVT.
Emergency control of ventricular rate in patients with atrial fibrillation or
atrial flutter.
ADVERSE EFFECTS:
AV block, cardiac arrest.
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DOSAGE:
IV Loading dose: 1000 mg over 24 hours - 150mg in 100cc D5W,infuse over 10 minutes, then
Infuse 360 mg over the next 6 hours, then Infuse 540 mg over the next 18 hours, then Maintenance dose: 0.5 mg/min. May be continued up to 96 hours
or until rhythm is stable. Switch to oral form as soon as possible
PO Loading dose: 800 1600 mg/day in divided doses for 1-3weeks. Then reduce to 600-800 mg/day for 1 month. If rhythm
stable, decrease to 400 mg in 1-2 divided doses. Titrate to lowest
dose to limit side effects
ADVERSE EFFECT:
Cardiovascular effects: torsades de pointes, ECG changes( prolonged QTinterval
and QRS complex)
OTHER EFFECTS:
Pulmonary reactions such as pneumonitis, fibrosis.
Photo dermatitis, paresthesia, tremor.
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Sotalol:
This drug is an oral, non selective beta adrenergic receptor antagonist that
also blocks potassium channels.
DOSAGE:
Initial dose 80 mg PO bid. Adjust gradually (every 2-3 days) until appropriate
response occurs. May require 240 320 mg
USES:
Life threatening sustained VT, AF.
Adverse effects:
Prolonged QT interval
CLASS IV:
Calcium channel blockers:
EX: Verapamil, diltiazem.
Class IV drugs slow phase 4 depolarition in the SA node and decrease the heart
rate.
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MECHANISM OF ACTION:
Blockade of calcium uptake via a voltage sensitive channel,thereby reducing
inward flow of calcium into myocardium cells.
EFFECTS ON THE MYOCARDIUM:
Reduce the rate of SA node discharge. Slow conduction through the AV node. Prolong the AV node refractory period. Decrease the myocardial contractility. Vasodilation.
USES:
Treatment of PSVT.
Control of ventricular rate in atrial flutter or atrial fibrillation .
Adverse effects: Hypotension ,dizziness,constipation.
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6 7 mts Discuss the
nursing
management
NURSING CARE
nurse should monitor for
Heart block
Diarrhea, Hypotension, EKG changes, Cinchonism, Interacts with many commondrugs
Instruct licent to monitor pulse rate & rhythm; monitor EKG; monitor tinnitus andvisual disturbances
Ventricular dysrhythmias & Unlabelled Use: Digitalis-induced arrhythmias
Hypotension, CNS effects, GI distress, Bradycardia
Lidocaine given IV bolus and by infusion; give oral drugs with food & monitor EKG
confusion, drowsiness, slurred speech, seizures, with lidocaine
CLASS III:
Nurse Should monitor for
y Ventricular dysrhythmiasy Hypertensiony Muscle weaknessy Tremorsy Photophobiay Monitor vitals and ECG
Teacher :
Giving Hand out
Discussing
Student:
Listening
Participate in discussing
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7.
8.
2mt
1mt
summary and
conclusion
Reinforcement
of the topic
y Instructtheclienttakingamiodaroneto wear sunglass and sunscreens.
CLASS IV:
Nurses should monitorand assess for
Bradycardia Chest pain,urinary retentionand dry mouth. Heartrateand rhythm ;assess chest pain,urinary retention.
SUMMARY AND CONCLUSION:
so far we are discussed about anti arrhythmic drugs ,its purpose,dosage,
classification, mechanism of action, use ,adverse effects and nursing
management during administration of antiarrhythmic drugs.
I hope you all understand and will impart this theory while you are practicing.
ASSIGNMENT:Write an assignment on dysrhythmias
Submit on: 02.07.2011
Total marks: 10
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BIBLIOGRAPHY:
Books :
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1. K.D.Tripathi. Essentials Of Medical Pharmacology,5th Edition, Jaypee Publishers2. H.P.Rang et.al, Pharmacology,5th edition 2006,Elsevier publications.3. V N Sharma,Essentials of pharmacology,3rd edition, 2009,CBS publishers.4. Richard D.Howland etal, Pharmacology, 3rd edition, 2006, Lippincott Williams & Wilkins.5. Susan l. Woods et al,Cardiac Nursing, 5th ed, 2005, Lippincott Williams & Wilkins6. Debra k. Moser; Barbara Riegel, Cardiac Nursing: A Companion To Braunwald's Heart Disease, 2008, Saunders Elsevier7. Unless else specified in boxes, then ref is: Rang, H. P.. Pharmacology. Edinburgh: Churchill Livingstone
Journals :
1. Niessen, K.; Karsan, A. (2008). Circulation Research 102 (10): 1169.2. Lie K.I. et al, LIdocaine in the prevention of primary ventricular fibrillation, (Nov 2008) New Eng. J.Med 291: 1324-1326.3. Roden ,D.M. et al : current status of class III anti arrhythmic drug therapy.Am.J.cardiol,2009 72: 44-49.4. 4.Vaughan Williams ,E.M. et al : Classifying an anti arrhythmic action: J.Clin. Pharmacol,2010: 32: 964-977.5. Conti JB, Belardinelli L, Utterback DB, Curtis AB (March 1995). "Endogenous adenosine is an antiarrhythmic agent". Circulation91 (6): 17617.
Net references :
1. www.wikipedia.org2. www.medscape.com3. www.cvpharmacology.org