DRUGS USED IN EMERGENCIES
 The higher coronary blood flow increases the
frequency of the VF waveform and should im-
DRUGS USED IN CARDIAC ARREST
prove the chance of restoring a circulation
Drugs delivery in the treatment
when defibrillation is attempted
of cardiac arrest
 Peripheral venous drug delivery.
Drugs injected peripherally must be followed by
 Bronchodilation
 Increases myocardial contractility
 The alpha-adrenergic actions of adrenaline
a flush of at least 20 ml of fluid and elevation of
cause vasoconstriction, which increases myo-
the extremity for 10—20 s to facilitate drug deliv-
cardial and cerebral perfusion pressure.
ery to the central circulation.
 Tracheal route.
Is not further recommended
 Intraosseous route.
Amiodarone
If VF/VT persists after three shocks,
give 300 mg amiodarone by bolus injection.
If intravenous access is difficult or impossible.
A further dose of 150 mg may be given for recur-
Although normally considered as an alternative
rent or refractory VF/VT, followed by an infusion
route for vascular access in children, it can also be
of 900 mg over24.
effective in adults.
Membrane-stabilising anti-arrhythmic drug
Intraosseous injection of drugs achieves adequate
increases the duration of the action potential
plasma concentrations in a time comparable with
and refractory period in atrial and ventricular my-
injection through a central venous catheter.
ocardium.
Atrioventricular conduction is slowed, and a simi-
Shockable rhythms
lar effect is seen with accessory pathways.
Ventricular fibrillation/pulseless ventricular tach-
Amiodarone has a mild negative inotropic action
ycardia)
and causes peripheral vasodilation through non-
 adrenaline is the first drug used in cardiac ar-
competitive alpha-blocking effects.
rest
 1 mg is given the first time after 3 first electrical shocks
 and than 1 mg every 3—5 min of CPR (every
second loop of CPR)
Lidocaine
1mg/kg - may be used as an alternative
if amiodarone is not available.
Do not give lidocaine if amiodarone has been given already
Epinephrine
Lidocaine is indicated in refractory
 Alfa, beta-mimetic
VF/VT
 The alpha-adrenergic actions of adrenaline
cause vasoconstriction, which increases myocardial and cerebral perfusion pressure.
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Non-shockable rhythms (PEA and asystole)
hospital cardiac arrests) or after return of sponta-
Severe bradyarrhythmias, asystole
neous circulation is not recommended.
Pulseless Electrical Activity (PEA)
Give sodium bicarbonate (50 mmol) if cardiac
 absence of a palpable pulse or other signs
arrest is associated with hyperkalaemia or tricyclic
of circulation despite the presence on the
antidepressant overdose;
ECG monitor of recognisable complexes
repeat the dose according to the clinical condition
which normally produce a pulse.
and result of repeated blood gas analysis.
 mechanical myocardial contractions are to
Bicarbonate causes generation of carbon
weak to produce a detectable pulse or
dioxide, which diffuses rapidly into cells.
blood pressure.
This has the following effects.
• It exacerbates intracellular acidosis.
Management:
• It produces a negative inotropic effect on
causes elimination
ischaemic myocardium.
start CPR 30:2 and give adrenaline 1mg as soon as
• It presents a large, osmotically active, sodium
intravascular access is achieved
load to an already compromised circulation and
Atropine is not further recomennded for therapy
brain.
of non-shockable rythms in cardiac arrest
• It produces a shift to the left in the oxygen dissociation
In cardiac arrest – if possible –
curve, further inhibiting release of oxygen
ventilation with 100% concentrated oxygen
to the tissues.
Other drugs
Calcium salts- only when indicated specifically,
Magnesium (8mmol=4ml 50% magnesium sul-
i.e. in pulseless electrical activity
phate or 2 g) - initial intravenous dose of 2 g pe-
caused by
ripherally over 1—2 min; it may be repeated after
• hyperkalaemia
10—15 min.
• hypocalcaemia
 for refractory VF/VT if there is any suspi-
• overdose of calcium channel-blocking drugs
cion of hypomagnesaemia (e.g., patients
The initial dose of 10 ml 10% calcium chloride
on potassium-losing diuretics)
(6.8 mmol Ca2+) may be repeated if necessary.
 torsades de pointes
 digoxin toxicity
HYPERVENTILATION
 Treatment of the underlying cause
Bicarbonates
 Low concentration of CO2 can be beneficial
Administering sodium bicarbonate routinely dur-
 For patients with psychogenic hyperventila-
ing cardiac arrest and CPR (especially in out-of-
tion careful explanation of the basis of their
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symptoms can be reassuring and is often sufficient
 Others have benefited from beta-blockers or
anxiolytics
 hydrocortisone 100-500 mg i.v. or prednisolone 50-100 mg i.v. or methyloprednisolone 1,0-2,0 mg i.v.
 Inhibit anaphylactic/inflammatory reaction
 Inhibit phospholipase A2 (PG, TXA, PI),
ANAPHYLACTIC SHOCK
stablize membranes-inhibit release of his-
 Oxygen
tamine and its congeniers, decrease mem-
 Horizontal position
branes permeability, decrease leukocytes
 Cuff on the arm
migration and antibodies production, in-
 Fluids – 0.9% saline or 5% glucose i.v.
creases sensitivity of adrenergic receptors
to epinephrine
Epinephrine
 0.5-1.0 mg given s.c. or i.m. (rarely i.v.)
 Increases blood pressure – constricts small
blood vessels in the skin and mucosa and
renal arteries
 Stimulates beta1 –receptors: causes increased cardiac output (ino- and chronotropic positive effects)
Antihistaminics
 Clemastine 2 mg i.v. or antazoline 100 mg
i.v.
 Block histamine receptors H1 in tissues
and protect them against histamine released in anaphylactic reaction
 Ranitidine 50 mg i.v.
 Relaxes bronchi and decreases edema in
mucosa
ASTHMA
 Increases blood flow in the liver, skeletal
muscles, coronary arteries
 Beta2-mimetics – inhalation/nebulization
 Decreases blood volume
 Prednisone – 10-20 mg orally
 Increases oxygen demand
 Oxygen
 Is arrhytmogenic
 Hydrocortisone – 500 mg, followed by infusion 200-400 mg in 500 ml of glucose
Beta2-mimetics
 Dilate bronchi
 Ipratropium
 Theophyline - 5 mg/kg in slow injection
 Albuterol or fenoterol
i.v. within 10-15 min, followed with infu-
 In mild to moderate bronchospasm in inha-
sion of 0,5-0,6 mg/kg/h.
lation/nebulization – albuterol 2,5 – 5 mg
 In severe bronchospasm – albuterol 0.5 mg
s.c
HYPERTENSIVE EMERGENCY
Drugs given s.l. or orally
 Captopril 12.5-25 mg s.l.
Glucocorticosteroids
 Nifendypine – 10 mg s.l.
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 Nitroglycerine/isosorbide dinitrate – 0.5
mg s.l./10 mg s.l.
 Clonidine 0.2 orally
 Prazosine 1 mg orally
Drugs given parenterally
 Labetalol
PULMONARY EDEMA
 Nitroglycerine 0.5 mg s.l. repeated every
10 min
 Furosemide 40-60 mg i.v.
 Morphine 5 mg i.v.
 Nitroglycerine 0.5-1 mg/h in infusion
 Diazoxide
 Furosemide
EPILEPTIC SEIZURES
 Nitroprusside sodium
 Diazepam 10 mg i.v.
 Phentolamine
 Barbiturates: phenobarbithal, thopental
 Hydralazine
 Phenytoin
 Trimetaphan
ANGINAL PAIN/MI
 Nitroglycerine 0.5 mg s.l. repeated 3 times
(every 15 min) under blood pressure and
heart rate control
 Morphine 5 mg i.v.
 ASA 150 mg (300 mg) or ticlopidine 250
mg
 Oxygen
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