Cardiac Emergency Drugs
Adenosine
Why? an endogenous purine nucleoside used to slow conduction through the AV node;
to interrupt AV nodal reentry pathways and to restore normal sinus rhythm from PSVT
When? administered for the conversion of PSVT
How? Give 6mg IVP over 1 - 3 seconds; then if indicated, give12mg IVP. May repeat
a second 12 mg dose. All doses should be at least 3 minutes apart, though when
administered, done quickly.
Precautions! Persons taking theophylline may need a larger dose; heart transplants
need less.
Amrinone
Why? an inotropic medication used to increase cardiac output, decrease pre and
afterload at doses between two and 15 mcg/min. Greater than 15mcg/min causes
tachycardia.
When? administered for the treatment of congestive heart failure (CHF) refractory to
diuretics, vasodilators and conventional inotropes
How? give a loading dose of .75mg/kg, then start infusion at 2-5mcg/kg/min and
titrate up to 10-15mcg/kg/min. For infusion: mix 300mg Amrinone (ampules provide
5mg/ml) with 60cc normal saline for a total volume of 120ml, so that 2.5mg = 1ml.
With this concentration, use the following calculation: First divide 41.66 by the
patient's weight in kilograms, then multiply the result by the cc per hour to obtain the
mcg/kg/min (the amount of micrograms per one kilogram per one minute).
Precautions! don’t mix with dextrose or lasix; the clear yellow color is normal;
ensure no hypovolemia before administration
Atropine
Why? a parasympatholytic used to enhance sinus node automaticity and AV
conduction
When? administered to the patient with symptomatic bradycardia
How? 0.5 to 1.0 mg every five minutes until desired results or a total dose of .04/kg
is achieved
Precautions! May cause VF, tachycardia, and exacerbation of MI. Doses less than
0.5 may cause bradycardia.
Beta-blockers: Propranolol, Metoprolol, Atenolol, and Esmolol
Why? to reduce heart rate, blood pressure, myocardial contractility, and myocardial
oxygen consumption
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When? for control of recurrent VT/VF, or rapid supraventricular arrhythmias
refractory to other meds
How? Atenolol - 5mg over 5minutes, then repeat in ten minutes. Metoprolol - 5mg
over 5 minutes, repeat q 5 minutes to a total of 15 mg.
Propranolol - 2mg over 2 minutes, q 2 minutes, to a total of 0.1mg/kg.
Precautions! may cause hypotension, CHF and bronchospasm
Calcium Chloride
Why? an element used to increase the force of myocardial contraction
When? administered for treatment of hypocalcemia, hyperkalemia, or calcium channel
blocker toxicity
How? Calcium Chloride 10% solution contains 13.6 mEqs (1ml=100mg) of calcium give 2 to 4mg/kg and repeat as necessary at ten minute intervals
Precautions! may precipitate digitalis toxicity; precipitates with sodium bicarbonate
Digitalis
Why? a cardiac glycoside used to slow and strengthen myocardial contraction
When? administered for treatment of CHF, PSVT, atrial fibrillation and flutter.
How? a loading dose of 1 mg is divided into several doses and given over a 24 hour
period
Precautions! Hypokalemia, hypomagnesemia, and hypercalcemia potentiate digoxin.
Diltiazem
Why? a calcium channel blocker used to slow conduction and prolong refractoriness in
AV node; and to slow the ventricular response to atrial fibrillation and flutter
When? administered to patients with PSVT and supraventricular arrhythmias
How? give initial IV push loading dose of 25mg/kg over 2minutes.
IV infusion: mix 125 mg diltiazem (25 ml) into 100cc to yield 1mg/ml, and infuse at 5
- 15mg/hr.
Precautions! Avoid concurrent IV usage with IV betablocker; incompatible with lasix
Dobutamine
Why? to increase myocardial contractility and stroke volume; to decrease peripheral
vascular resistance and reduce ventricular filling pressure.
When? administered for treatment of low cardiac output and hypotension with
pulmonary congestion, and left ventricular dysfunction that can't tolerate vasodilators;
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for treatment of right ventricular infarction, in addition to moderate volume loading, to
lower preload and afterload.
How? Always dilute before infusion. Mix 500mg into 250cc D5W; with this
concentration, calculate using this formula: First divide 33.3 by the patient’s weight in
kilograms, then multiply the result by the cc per hour to obtain the mcg/kg/min.
Dosage range is 2.5 to 10 mcg/kg/min.
Precautions! may cause tachycardias; contains sulfites; greater than 10mcg may
cause vasodilation; don’t mix with heparin, antibiotics, or sodium bicarbonate.
Dopamine
Why? Dopamine is a dose dependent adrenergic (sympathomimetic). Dopaminergic
effects: 1-2 mcg/kg/min produce cerebral, renal and mesoteric vasodilation, increased
urine output and no change in heart rate and blood pressure. Inotropic effects: 210mcg/kg/min increases cardiac output and vasoconstriction. Adrenergic effects: more
than 10mcg/kg/min increases systemic vascular resistance, heart rate, blood pressure
and generalized vasoconstriction.
When? administered for treatment of significant hypotension in the absence of
hypovolemia; for treatment of significant hypotension accompanied with bradycardia;
to improve cerebral perfusion immediately post resuscitation; may be administered in
dopaminergic dosages to treat acute renal failure
How? Use the lowest dose which produces adequate perfusion. Always dilute before
infusion. Mix 400mg into 250cc D5W; with this concentration, calculate using this
formula: First divide 26.6 by the patient’s weight in kilograms, then multiply the result
by the cc per hour to obtain the mcg/kg/min. Dosage range is 5 - 20 mcg/kg/min.
Precautions! increases heart rate; can exacerbate pulmonary congestion; may
induce arrhythmias, nausea/vomiting, extravasation; is inactivated in alkaline
solutions; correct hypovolemia before use
Electricity
Why? Defibrillate to produce temporary asystole, in order to completely depolarize the
myocardium, to provide an opportunity for the natural pacemaker to kick in.
When? administered as soon as possible for pulseless VT and VF; synchronized
cardioversion for SVT (supraventricular tachycardia), atrial fibrillation and flutter
How? Defibrillate up to three times if needed for persistent VT/VF (200J, 200-300J,
360J) with the paddles placed over the anterior-apex, or anterior-posterior position.
Fifty to one hundred joules are administered for synchronized cardioversion of atrial
fib/flutter. Don’t lean on the paddles (they may slide)--apply 25 pounds of pressure.
Use the appropriate conductive material between paddles and person to maximize
current flow, and to reduce the potential for burns and sparking.
Precautions! Ensure all coworkers are clear, or you may have a second patient. Use
the chant, "I am going to shock on three; One, I am clear; Two, you are clear; Three,
everybody is clear," to avoid shocking the code team.
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Epinephrine
Why? a catecholamine (sympathomimetic) given to increase heart rate, blood
pressure, coronary and cerebral blood flow, and myocardial electrical activity
When? administered to patients with cardiac arrest from VF, pulseless VT, asystole,
PEA (pulseless electrical activity), and profoundly symptomatic bradycardia
How? IV push : 1mg (10ml of a 1:10,000 solution) every 3-5 minutes during
resuscitation.
IV infusion (for symptomatic bradycardia or septic shock) : 1mg (1mL of a 1:1000
solution) in 500cc D5W, so that 1cc = 2mcg, and 1mcg/min is 30cc/hour. Start
infusion at 1mcg/minute; titrate from 2 to 10 mcg/minute per hemodynamic needs.
Precautions! Epinephrine may cause exacerbation of MI (myocardial infarction),
ventricular ectopy, hypertension, altered LOC (level of consciousness) and
nausea/vomiting. This drug will cause sloughing of skin and necrosis if infiltrated.
Don’t mix with alkaline solutions.
Furosemide
Why? a potent diuretic that inhibits reabsorption of sodium chloride
When? for treatment of pulmonary congestion associated with left ventricular
dysfunction
How? may give 20 to 40 mg IV push over 1 to 2 minutes, up to 2mg/kg total dosage
Precautions! dehydration, deplete calcium, potassium, magnesium, sodium.
Isoproterenol
Why? Synthetic sympathomimetic amine with potent inotropic (pump) and
chronotropic (rate) properties; used to increase cardiac output, despite its tendency to
cause a reduction in mean blood pressure due to venous pooling and peripheral
vasodilation; used to relax bronchial smooth muscle
When? administered for treatment of bradycardia in the denervated heart
How? Always dilute before infusion. Mix 1 mg in 250 cc D5W; so that 4mcg = 1 cc.
Dosage: 2 to 10mcg/minute
Precautions! markedly increases myocardial O2 consumption
Lidocaine
Why? an antiarrhythmic agent used to decrease automaticity; to suppress ventricular
arrhythmias
When? administered as the first antiarrhythmic choice for VT and VF
How? First IV push load with 1 to 1.5 mg/kg. If lidocaine successfully stops the
arrhythmia, then start an IV infusion of 2 to 4mg/minute Mix 2 Gms Lidocaine in
250cc, so that 2mg/min = 15cc hour.
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Precautions! May cause neurological changes, myocardial and circulatory
depression.
Magnesium
Why? an element required for multiple enzymatic reactions
When? administered in the treatment of torsades de pointes; and to reduce
postinfarction ventricular arrhythmias
How? for treatment of VT mix 1 to 2 Gms (2-4ml of 50% sol.) in 10cc D5W to run
over 1 to 2 minutes; for treatment of VF give 1 to 2 Gms IV push.
Precautions! Flushing, sweating, hypotension, mild bradycardia may result from
rapid administration. Hypermagnesemia may produce depressed reflexes, and
respiratory paralysis.
Morphine
Why? a narcotic analgesic used to reduce pain and anxiety, to increase venous
capacitance and to decrease SVR (systemic vascular resistance)
When? administered for treatment of pain and anxiety; for treatment of pulmonary
edema and MI pain
How? Give 1 to 3mg slow IV push over 1 to 5 minutes
Precautions! Morphine is a respiratory depressant. It may cause hypotension,
particularly in hypovolemic persons. Effects can be reversed with IV naloxone (0.4 to
0.8mg).
Nitroglycerine
Why? a potent vasodilator used to increase blood flow to the myocardium
When? for treatment of unstable angina, myocardial infarction, or CHF.
How? Always dilute before infusion. Mix 50mg NTG in 250cc D5W; with this
concentration, use the following formula: { 3.3 multiplied by the cc per hour =
mcg/minute}; may titrate by 3.3 mcg (or 1cc) every five minutes, or as indicated by
hemodynamic needs.
Precautions! headache, hypotension
Nitroprusside
Why? a potent peripheral vasodilator used to relax both arterial and venous smooth
muscle in order to quickly reduce blood pressure; decreases both pre and afterload
When? administered for treatment of hypertensive emergencies; during left
ventricular failure and pulmonary congestion
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How? Always dilute before infusion. Mix 50mg nitroprusside in 250cc; with this
concentration, use this calculation: First divide 3.3 by the patient's weight in
kilograms, then multiply the result by the cc per hour to obtain the mcg/kg/min. Wrap
in aluminum foil to reduce light exposure. May be a faint brown color
Precautions! may cause hypotension, myocardial ischemia, infarction, or stroke.
Monitor for toxicity with compromised renal or hepatic functions.
Norepinephrine
Why? a catecholamine used to exert potently positive inotropic and vasopressor
control
When? administered for treatment of significant hypotension, and for septic and
neurogenic shock
How? Dilute before infusion. IV infusion: Mix 2mg in 250cc to yield 8mcg/ml; so that
2mcg/min = 15cc/hr. The dosage range is 2 to 80 mcg/minute.
Precautions! may cause severe vasoconstriction, extravasation, arrhythmias,
increased myocardial O2 requirements
Oxygen
Why? a drug used to prevent hypoxia/hypoxemia
When? administered to patients with chest pain, hypoxemia and during CPR
How? 100% FIO2 (fraction inspired oxygen) is administered during CPR.
4L/min is given for O2 sat. (oxygen saturation) > 97% during chest pain.
Switch to venturi mask for low O2 sat. Utilize pulse oximetry to monitor adequate
delivery.
Precautions! Always ensure oxygen is adequately delivered (mask fits, oxygen
connected and turned on, etc).
Procainamide
Why? an antiarrhythmic used to suppress ventricular ectopy, and to convert
supraventricular arrhythmias or to prevent their reoccurrence
When? administered to the patient with recurrent VT when lidocaine is ineffective;
also administered for conversion and prevention of SVT
How? The initial bolus is 20-30mg/minute until a total of 17mg/kg is achieved. If
indicated, start an IV infusion at 2-4mg/minute. Mix 2 Gms in 250cc, to yield:
2mg/minute = 15cc/hour
Precautions! Rapid push causes hypotension; watch for widened QRS and seizures.
Sodium Bicarbonate
Why? an alkalinizer used as a buffering agent to neutralize excess acid
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When? administered in the treatment of hyperkalemia, tricyclic or phenobarbital
overdose, preexisting metabolic acidosis
How? IV push: initial dose 1mg/kg, then half this dosage q 10 minute as indicated;
or IV infusion: mix 297.5meq in 500cc and titrate per ABGs.
Precautions! provokes potent negative inotropic activity; hyperosmolality, and
hypernatremia
Thrombolytics
Why? to activate the formation of plasmin, which digests fibrin and dissolves the clot
When? as soon as possible after onset of pain. Indicated for persons with 2
contiguous EKG leads that have ST segment elevation of at least 0.1mV.
How? Anistreplase - gently mix 5cc sterile water into 30 Unit vial, administer over five
minutes and within 30 minutes of diluting. Streptokinase - gently dilute the 750
thousand or 1,500 thousand Units with 45ml of D5W or NS and infuse over 30 - 60
minutes.
Alteplase - give 10 mg over 2 minutes, then 50 mg over 1 hour, then 20 mg over the
second hour, and 20 mg over the third hour for a total dose of 100 mg over three
hours.
Precautions! bleeding from punctures; chest pain, reperfusion arrhythmias
Verapamil
Why? a calcium channel blocker; slow conduction and prolong refractoriness in the
AV node; also slow ventricular response to atrial fibrillation and flutter
When? administered to patient with PSVT and supraventricular arrhythmias
How? Give 2.5 to 5mg IV push over 1 to 2 minutes. If inadequate, give 5 mg every
fifteen minutes until desired response is achieved or a total of 30 mg is administered.
Precautions! may cause hypotension; avoid usage with patients demonstrating a
wide QRS tachycardia, unless known to be supraventricular.
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