CARDIAC DRUG REVIEW

WHAT DO YOU “SEE” WHEN
YOU STIMULATE BETA

 VASODILATE
 BRONCHODILATE
 +CHRONOTROPE
 +INOTROPE

EPI’S OTHER NAME?



WHAT DOES EPI DO THAT
NOREPI AND DOPAMINE DO
NOT DO?




1:1000 MEANS?

 1 GRAM/1000 ML
 1MG/1ML

WHO IS THIS 1:1 GIVEN TO?

 ALIVE PATIENTS
 ASTHMA/ALLERGIC
REACTION
 SAFEST ROUTE
 DOSE?
 How many mls is each dose?

HOW DO YOU MIX AN EPI
INFUSION?

 1 MG /250 ML


Epi is given first line to what pulseless rhythms?

 V Fib
 V Tach
 Asystole
 PEA
 How often?
 What dilution?

Why is Epi given during a resusucitation?

 Alpha action-vasoconstriction throughout body
 Perfuses the heart and brain
 CPR directs perfusion to the above

Use ANS terms to describe
Epinephrine.

 Alpha stimulating
 Beta stimulating
 Sympathomimetic
 Adrenergic
 Catecholamine

What are 4 generic rules for
ANS pressor agents?

 Don’t abruptly DC infusion/taper
 BP must be monitored
 in Trauma-never first line
 Tissue sloughing may occur-watch site

What are 4 generic rules for
Catecholamines?

 Bicarb inactivates them
 Assess if currently on a Symp drug
 if on Beta Blocker may need to increase dose
 Do not work if pH to acid (below
7.2)

Other names for Dopamine?

 Intropin
 Dopastat

How is Dopamine different from the other alpha agents?
List FIVE

 No IV bolus
 Infusion only
 Dopaminergic-dilates renal/mesenteric
 Causes hypotension
 Given based on weight

Mix a Dopamine drip?

 400 mg/250 ml

The Dopaminergic effects occur MAINLY at what rate?



Describe what happens when
Dopamine is infused at 5-10 mcg/kg/min.

 primarily Beta
 some vasoconstriction, more closer to 10

10-20 mcg/kg/min of
Dopamine results in

 predominately alpha actions with substantial vasoconstriction

Finish thisat 10 mcg/kg/ min you run
Dopamine at

 20 or 30 or 40

Your patient is in cardiac arrest.
What drugs could you administer via the ETT?

 Epinephrine
 Vasopressin
Don’t really give these anymore-but OK ET
 Lidocaine
 Atropine

Indications for Vasopressin?

 Cardiac arrest
 don’t worry about
 hemodynamic support in vasodilatory shock

Dose of Vasopressin?

 40 units
 How many times can you repeat the dose?

How is Vasopressin different from the other pressors?
List Four

 Not alpha, ANS, sympathetic,
Beta, etc
 Bolus only
 “units”
 not as bad at irritating/stimulating the heart
 long half life-10-20 minutes

What are the S&S of
Symptomatic Bradycardia?
List Five

 hypotension
 altered LOC
 signs of shock
 ischemic chest discomfort
 acute heart failure

First line drug for the treatment of symptomatic bradycardia is
WHY?

 ATROPINE
 only action is to increase heart rate, no other demand on the heart
 What is the first line NON drug for the rx of symptomatic brady?

Describe Atropine using ANS words.
List Four

 Parasympatholytic
 + chronotrope
 Anticholinergic
 Parasympathetic blocking
 Vagolytic

What is a non-cardiac use for
Atropine?
Describe

 Organophosphate poisoning
 Organophosphates stimulate the
Parasympathetic nervous system.
Atropine blocks this.

What is the dose of Atropine?

 0.5 mg IV bolus
 What may happen if you give less than that?

Total dose of Atropine?
Two answers!

 3 mg
 0.04 mg/kg

What side effect of Atropine interferes with your assessment?

 Dilates pupils!

Atropine may not work in symptomatic brady if the patient is
WHY?

 hypotensive or has myocardial hypoxia
 can’t get to where it needs to go
 OR
 heart cannot respond

Another + chronotrope you could give AFTER Atropine, Dopamine,
Epi and a TCP is

 ISUPREL!

Using ANS terms, describe
Isuprel
List Four

 pure Beta
 + chronotrope
 + inotrope
 Sympathomimetic
 Catecholamine

What would Isuprel do directly to BP?

 lower it, cause hypotension
 What would it do indirectly to the BP?

Your patient is in A Fib, HR of
220. You want to slow the rate with a medication.
List two that would be appropriate.

 Verapamil
 Diltiazem
 What are the other names for the above drugs?

What are the actions of these two drugs?
List MAIN three

 Negative chronotrope (at AV)
 Negative inotrope
 Coronary and peripheral vasodilation

Why might the CCB cause
CHF or make it worse?
Which one is worse at the above?

 They are both negative inotropes
 Verapamil is the stronger inotrope, not a big worry in Diltiazem

You would administer Dilt/Verap to Narrow QRS tachy only in what situation?

 if Adenosine had not worked

The CCB are contraindicated in what TACHY rhythms?
Name TWO, be specific.

 WPW in A Fib
 V tach
 Any wide QRS tachy of unknown origin
Also--
 Sick Sinus Syndrome
 Second/Third degree block

Your pt received ?? at the Urgent Care for her Tachy.
You must not give the pt a CCB now.
What is the drug?

 Beta Blocker IV

Describe the 1 st AND 2 nd dose of Diltiazem.
Be specific

 0.25 mg/kg over 2 minutes
 15-20 is reasonable first dose
 In 15 minutes repeat dose is 0.35 mg/kg over 2 minutes
 20-25 is a reasonable dose for the average pt

Describe the first and second dose of Verapamil
Be Specific

 Initial dose 5 mg IV bolus
 Repeat dose 5-10 mg in 15-30 minutes if dysrhythmia persists and no adverse response to first dose

What may be tried prior to the admin of CCB in a stable patient?

 Vagal maneuvers

Your pt is in A fib, hypotensive and deteriorating rapidly you should…

 Cardiovert
 If patient is unstable in ANY tachycardia, cardioversion rules!

You have overdosed your patient with Verapamil.
What drug could you give to attempt to prevent toxic effects?

 Calcium Chloride

What is the dose of Calcium?

 500-1000 mg
10% solution

Administer with extreme caution
IF AT ALL to patients on

 Digoxin, Digitalis etc
 May precipitate what?

What is a non-overdose indication of CA++?
How does Calcium help in this setting?

 Known or suspected hyperkalemia
 helps stabilize the myocardial cell membrane

What does Bicarb do?
Talk Chemistry!

 decreases acid by combining with H+ and then with ventilation eliminating CO2

What must the patient be
“doing” when giving Bicarb?

 Breathing!
 on their own or via ETT

What is the dose of Bicarb?

 1 mEq/kg
 or ?

Never mix with…..
Name TWO

 Calcium
 Catecholamines

What overdose would you use
Bicarb for?

 Cyclic Antidepressant

What are the indications for
Mag Sulfate?
Name Three

 Torsade de Pointes
 Eclampsia
 Asthma
 life threatening dysrhythmias due to dig toxicity

What is the dose of Mag when treating Torsade?
Both pulseless and with a pulse

 1-2 grams diluted in 10 ml
D5W
 pulseless
 1-2 grams in 50-100 ml D5W
 with a pulse

What are two actions of Mag that would help treat Eclampsia?

 Smooth muscle relaxer
=vasodilation
 CNS depressant

What are the two main actions of Adenosine?

 Negative chronotrope
 Weak bronchoconstrictor
 so..cautious with what patients?

What are the top three side effects of Adenosine?
They occur commonly.

 Facial Flushing
 Dyspnea
 Chest pressure/pain

Describe the dosing of
Adenosine, including max.

 6 mg IV bolus over 1-3 seconds
 repeat in 1-2 minutes 12 mg
 may repeat a second 12 mg
 total dose 30 mg

For Adenosine to be most effective…
List four steps for administration

 Start IV proximal, close to central circ
 Give as close to injection site as possible
 Inject rapidly
 Administer a small bolus of fluid
(20ml) and elevate arm

Describe how Adenosine is beneficial in A Fib/Flutter

 May help to diagnose but will not treat

What are the Sympathetic NS actions of Amiodarone?

 Alpha blocker
 Vasodilation
 Beta blocker
 negative chronotrope
 negative inotrope
 negative dromotrope

What “channels” does it affect?

 Na
 K
 Ca
 Thus
-slows conduction through vents
-slows heart rate and ↑ AV node conduction
-increases refractory period (atria/vent)

What two PNB rhythms may receive Amiodarone?

 V TACH
 V FIB
 Why would you never give this drug to PEA or Asystole?

What are the side effects of
Amiodarone?
List two and describe why they are side effects.

 Hypotension
 alpha blocker
 Brady
 beta blocker
 AV block
 beta block and calcium blocked
 TDP
 increase QT

Amiodarone dose in PNB is

 300 mg IV/IO
 second dose in 3-5 minutes consider 150 mg
 in practice most do not dilute
 10-15 mls/20-30 mls D5W

Amiodarone dose in Tachy
WITH a pulse is

 150 mg in 100 ml D5W over 10 minutes (15mg/min) no one uses this
 May repeat every 10 minutes as needed

 Rhythm is WPW with A fib
 The two drugs used to treat this rhythm are?

Procainamide should be given until
List all 4

 dysrythmia is suppressed
 QRS duration increases by
> 50%
 hypotension occurs
 total dose of 17 mg/kg is administered

Procainamide decreases excitability in what part of the heart?

 Atria
 Purkinje fibers
 Ventricles

Do not use Procainamide in what ventricular rhythm?

 Torsades
 Why?
 Do not give with what drug…because they both do the same as above?

A patient is in Ventricular escape at a rate of 40 with frequent PVCs. What would happen to the rhythm if Lidocaine was given?

 Lidocaine (or Pronestyl or
Cordarone) could eliminate all ventricular response and patient could go into Asystole.

What action does Lido have that
Amiodarone nor Procainamide have?

 It helps decrease an elevation in
ICP
 it is an anesthetic

Lidocaine, because it is an anesthetic has CNS side effects.
List Four

 Altered LOC
 Slurred speech
 Visual disturbances
 Muscle twitching
 Seizures

The end…are you exhausted?