Transcript ACLS Pharmacology Review

ACLS
Pharmacology
1
Objectives

To review and obtain a better
understanding of medications used in
ACLS
– Indications & Actions (When & Why?)
– Dosing (How?)
– Contraindications & Precautions (Watch
Out!)
2
3
Drug
Classifications

Class I: Recommendations
– Excellent evidence provides support
– Proven in both efficacy and safety

Class II: Recommendations
– Level I studies are absent, inconsistent or lack
power
– Available evidence is positive but may lack efficacy
– No evidence of harm
4
Drug
Classifications

Class IIa Vs IIb
– Class IIa recommendations have
 Higher
level of available evidence
 Better critical assessments
 More consistency in results
– Both are optional and acceptable,
– IIa recommendations are probably useful
– IIb recommendations are possibly helpful
 Less
compelling evidence for efficacy
5
Drug
Classifications

Class III: Not recommended
– Not acceptable or useful and may be
harmful
– Evidence is absent or unsatisfactory, or
based on poor studies

Indeterminate
– Continuing area of research; no
recommendation until further data is
available
6
Oxygen

Indications (When & Why?)
– Any suspected cardiopulmonary emergency
– Saturate hemoglobin with oxygen
– Reduce anxiety & further damage
– Note: Pulse oximetry should be monitored
Universal Algorithm
7
Oxygen

Dosing (How?)
Device
Flow Rate
Oxygen %
Nasal Prongs
1 to 6 lpm
24 to 44%
Venturi Mask
4 to 8 lpm
24 to 40%
Partial Rebreather
Mask
6 to 10 lpm
35 to 60%
15 lpm
up to 100%
Bag Mask
Universal Algorithm
8
Oxygen

Precautions (Watch Out!)
– Pulse oximetry inaccurate in:
 Low
cardiac output
 Vasoconstriction
 Hypothermia
– NEVER rely on pulse oximetry!
Universal Algorithm
9
VF / Pulseless
VT
Case 3
10
VF / Pulseless VT
• Epinephrine 1 mg IV push, repeat every 3 to 5 minutes
or
• Vasopressin 40 U IV, single dose, 1 time only
Resume attempts to defibrillate
1 x 360 J (or equivalent biphasic) within 30 to 60 seconds
Consider antiarrhythmics:
• Amiodarone (llb for persistent or recurrent VF/pulseless VT)
• Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT)
• Magnesium (llb if known hypomagnesemic state)
• Procainamide (Indeterminate for persistent VF/pulseless VT;
llb for recurrent VF/pulseless VT)
Resume attempts to defibrillate
11
Epinephrine

Indications (When & Why?)
– Increases:
 Heart
rate
 Force of contraction
 Conduction velocity
– Peripheral vasoconstriction
– Bronchial dilation
VF / Pulseless VT
12
Epinephrine

Dosing (How?)
– 1 mg IV push; may repeat every 3 to 5
minutes
– May use higher doses (0.2 mg/kg) if lower
dose is not effective
– Endotracheal Route
 2.0
to 2.5 mg diluted in 10 mL normal saline
VF / Pulseless VT
13
Epinephrine

Dosing (How?)
– Alternative regimens for second dose (Class
IIb)
 Intermediate:
2 to 5 mg IV push, every 3 to 5
minutes
 Escalating: 1 mg, 3 mg, 5 mg IV push, each
dose 3 minutes apart
 High: 0.1 mg/kg IV push, every 3 to 5 minutes
VF / Pulseless VT
14
Epinephrine

Precautions (Watch Out!)
– Raising blood pressure and increasing heart
rate may cause myocardial ischemia,
angina, and increased myocardial oxygen
demand
– Do not mix or give with alkaline solutions
– Higher doses have not improved outcome &
may cause myocardial dysfunction
VF / Pulseless VT
15
Vasopressin

Indications (When & Why?)
– Used to “clamp” down on vessels
– Improves perfusion of heart, lungs, and brain
– No direct effects on heart
VF / Pulseless VT
16
Vasopressin

Dosing (How?)
– One time dose of 40 units only
– May be substituted for epinephrine
– Not repeated at any time
– May be given down the endotracheal tube
 DO
NOT double the dose
 Dilute in 10 mL of NS
VF / Pulseless VT
17
Vasopressin

Precautions (Watch Out!)
– May result in an initial increase in blood
pressure immediately following return of
pulse
– May provoke cardiac ischemia
VF / Pulseless VT
18
Amiodarone

Indications (When & Why?)
– Powerful antiarrhythmic with substantial
toxicity, especially in the long term
– Intravenous and oral behavior are quite
different
– Has effects on sodium & potassium
VF / Pulseless VT
19
Amiodarone

Dosing (How?)
– Should be diluted in 20 to 30 mL of D5W
 300
mg bolus after first Epinephrine dose
 Repeat doses at 150 mg
VF / Pulseless VT
20
Amiodarone

Precautions (Watch Out!)
– May produce vasodilation & shock
– May have negative inotropic effects
– Terminal elimination
 Half-life
lasts up to 40 days
VF / Pulseless VT
21
Lidocaine

Indications (When & Why?)
– Depresses automaticity
– Depresses excitability
– Raises ventricular fibrillation threshold
– Decreases ventricular irritability
VF / Pulseless VT
22
Lidocaine

Dosing (How?)
– Initial dose: 1.0 to 1.5 mg/kg IV
– For refractory VF may repeat 1.0 to 1.5
mg/kg IV in 3 to 5 minutes; maximum total
dose, 3 mg/kg
– A single dose of 1.5 mg/kg IV in cardiac
arrest is acceptable
– Endotracheal administration: 2 to 2.5 mg/kg
diluted in 10 mL of NS
VF / Pulseless VT
23
Lidocaine

Dosing (How?)
– Maintenance Infusion
2
to 4 mg/min
 1000
mg / 250 mL D5W = 4 mg/mL
– 15 mL/hr = 1 mg/min
– 30 mL/hr = 2 mg/min
– 45 mL/hr = 3 mg/min
– 60 mL/hr = 4 mg/min
VF / Pulseless VT
24
Lidocaine

Precautions (Watch Out!)
– Reduce maintenance dose (not loading
dose) in presence of impaired liver function
or left ventricular dysfunction
– Discontinue infusion immediately if signs of
toxicity develop
VF / Pulseless VT
25
Magnesium
Sulfate

Indications (When & Why?)
– Cardiac arrest associated with torsades de
pointes or suspected hypomagnesemic state
– Refractory VF
– VF with history of ETOH abuse
– Life-threatening ventricular arrhythmias due
to digitalis toxicity, tricyclic overdose
VF / Pulseless VT
26
Magnesium
Sulfate

Dosing (How?)
– 1 to 2 g (2 to 4 mL of a 50% solution) diluted
in 10 mL of D5W IV push
VF / Pulseless VT
27
Magnesium
Sulfate

Precautions (Watch Out!)
– Occasional fall in blood pressure with rapid
administration
– Use with caution if renal failure is present
VF / Pulseless VT
28
Procainamide

Indications (When & Why?)
– Recurrent VF
– Depresses automaticity
– Depresses excitability
– Raises ventricular fibrillation threshold
– Decreases ventricular irritability
VF / Pulseless VT
29
Procainamide

Dosing (How?)
– 30 mg/min IV infusion
– May push at 50 mg/min in cardiac arrest
– In refractory VF/VT, 100 mg IV push doses
given every 5 minutes are acceptable
– Maximum total dose: 17 mg/kg
VF / Pulseless VT
30
Procainamide

Dosing (How?)
– Maintenance Infusion
1
to 4 mg/min
 1000
mg / 250 mL of D5W = 4 mg/mL
– 15 mL/hr = 1 mg/min
– 30 mL/hr = 2 mg/min
– 45 mL/hr = 3 mg/min
– 60 mL/hr = 4 mg/min
VF / Pulseless VT
31
Procainamide

Precautions (Watch Out!)
– If cardiac or renal dysfunction
is present, reduce maximum total dose to 12
mg/kg and maintenance infusion to 1 to 2
mg/min
– Remember Endpoints of Administration
VF / Pulseless VT
32
PEA
Case 4
33
PEA
Review for most frequent causes
•
•
•
•
•
Hypovolemia
Hypoxia
Hydrogen ion—acidosis
Hyper-/hypokalemia
Hypothermia
•
•
•
•
•
Tablets (drug OD, accidents)
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary (ACS)
Thrombosis, pulmonary (embolism)
Epinephrine 1 mg IV push,
repeat every 3 to 5 minutes
Atropine 1 mg IV (if PEA rate is slow),
repeat every 3 to 5 minutes as needed, to a total
dose of 0.04 mg/kg
34
Epinephrine

Indications (When & Why?)
– Increases:
 Heart
rate
 Force of contraction
 Conduction velocity
– Peripheral vasoconstriction
– Bronchial dilation
Pulseless Electrical Activity
35
Epinephrine

Dosing (How?)
– 1 mg IV push; may repeat every 3 to 5
minutes
– May use higher doses (0.2 mg/kg) if lower
dose is not effective
– Endotracheal Route
 2.0
to 2.5 mg diluted in 10 mL normal saline
Pulseless Electrical Activity
36
Epinephrine

Precautions (Watch Out!)
– Raising blood pressure and increasing heart
rate may cause myocardial ischemia,
angina, and increased myocardial oxygen
demand
– Do not mix or give with alkaline solutions
– Higher doses have not improved outcome &
may cause myocardial dysfunction
Pulseless Electrical Activity
37
Atropine Sulfate

Indications (When & Why?)
– Should only be used for bradycardia
 Relative
or Absolute
– Used to increase heart rate
Pulseless Electrical Activity
38
Atropine Sulfate

Dosing (How?)
– 1 mg IV push
– Repeat every 3 to 5 minutes
– May give via ET tube (2 to 2.5 mg) diluted
in 10 mL of NS
– Maximum Dose: 0.04 mg/kg
Pulseless Electrical Activity
39
Atropine Sulfate

Precautions (Watch Out!)
– Increases myocardial oxygen demand
– May result in unwanted tachycardia or
dysrhythmia
Pulseless Electrical Activity
40
Asystole
Case 5
41
Asystole
Transcutaneous pacing:
If considered, perform immediately
Epinephrine 1 mg IV push,
repeat every 3 to 5 minutes
Atropine 1 mg IV,
repeat every 3 to 5 minutes
up to a total of 0.04 mg/kg
Asystole persists
Withhold or cease resuscitation efforts?
• Consider quality of resuscitation?
• Atypical clinical features present?
• Support for cease-efforts protocols in place?
42
Epinephrine

Indications (When & Why?)
– Increases:
 Heart
rate
 Force of contraction
 Conduction velocity
– Peripheral vasoconstriction
– Bronchial dilation
Asystole: The Silent Heart Algorithm
43
Epinephrine

Dosing (How?)
– 1 mg IV push; may repeat every 3 to 5
minutes
– May use higher doses (0.2 mg/kg) if lower
dose is not effective
– Endotracheal Route
 2.0
to 2.5 mg diluted in 10 mL normal saline
Asystole: The Silent Heart Algorithm
44
Epinephrine

Precautions (Watch Out!)
– Raising blood pressure and increasing heart
rate may cause myocardial ischemia,
angina, and increased myocardial oxygen
demand
– Do not mix or give with alkaline solutions
– Higher doses have not improved outcome &
may cause myocardial dysfunction
Asystole: The Silent Heart Algorithm
45
Atropine Sulfate

Indications (When & Why?)
– Used to increase heart rate
 Questionable
absolute bradycardia
Asystole: The Silent Heart Algorithm
46
Atropine Sulfate

Dosing (How?)
– 1 mg IV push
– Repeat every 3 to 5 minutes
– May give via ET tube (2 to 2.5 mg) diluted
in 10 mL of NS
– Maximum Dose: 0.04 mg/kg
Asystole: The Silent Heart Algorithm
47
Atropine Sulfate

Precautions (Watch Out!)
– Increases myocardial oxygen demand
Asystole: The Silent Heart Algorithm
48
Other Cardiac
Arrest Drugs
49
Calcium Chloride

Indications (When & Why?)
– Known or suspected hyperkalemia (eg, renal
failure)
– Hypocalcemia (blood transfusions)
– As an antidote for toxic effects of calcium
channel blocker overdose
– Prevent hypotension caused by calcium
channel blockers administration
Other Cardiac Arrest Drugs
50
Calcium Chloride

Dosing (How?)
– IV Slow Push
8
to 16 mg/kg (usually 5 to 10 mL) IV for
hyperkalemia and calcium channel blocker
overdose
 2 to 4 mg/kg (usually 2 mL) IV for prophylactic
pretreatment before IV calcium channel blockers
Other Cardiac Arrest Drugs
51
Calcium Chloride

Precautions (Watch Out!)
– Do not use routinely in cardiac arrest
– Do not mix with sodium bicarbonate
Other Cardiac Arrest Drugs
52
Sodium
Bicarbonate

Indications (When & Why?)
– Class I if known preexisting hyperkalemia
– Class IIa if known preexisting bicarbonateresponsive acidosis
– Class IIb if prolonged resuscitation with effective
ventilation; upon return of spontaneous circulation
– Class III (not useful or effective) in hypoxic lactic
acidosis or hypercarbic acidosis (eg, cardiac arrest
and CPR without intubation)
Other Cardiac Arrest Drugs
53
Sodium
Bicarbonate

Dosing (How?)
– 1 mEq/kg IV bolus
– Repeat half this dose every 10 minutes
thereafter
– If rapidly available, use arterial blood gas
analysis to guide bicarbonate therapy
(calculated base deficits or bicarbonate
concentration)
Other Cardiac Arrest Drugs
54
Sodium
Bicarbonate

Precautions (Watch Out!)
– Adequate ventilation and CPR, not
bicarbonate, are the major "buffer agents" in
cardiac arrest
– Not recommended for routine use in cardiac
arrest patients
Other Cardiac Arrest Drugs
55
Acute Coronary
Syndromes
Case 6
56
57
Acute Coronary
Syndromes
Chest pain
suggestive of ischemia
Immediate assessment (<10 minutes)
• Measure vital signs (automatic/standard BP cuff)
• Measure oxygen saturation
• Obtain IV access
• Obtain 12-lead ECG (physician reviews)
• Perform brief, targeted history and physical exam;
focus on eligibility for fibrinolytic therapy
• Obtain initial serum cardiac marker levels
• Evaluate initial electrolyte and coagulation studies
• Request, review portable chest x-ray (<30 minutes)
Immediate general treatment
• Oxygen at 4 L/min
• Aspirin 160 to 325 mg
• Nitroglycerin SL or spray
• Morphine IV (if pain not relieved with
nitroglycerin)
Memory aid: “MONA” greets
all patients (Morphine, Oxygen,
Nitroglycerin, Aspirin)
EMS personnel can
perform immediate
assessment and treatment (“MONA”),
including initial 12-lead
ECG and review for
fibrinolytic therapy
indications and
contraindications.
Assess initial 12-lead ECG
58
Aspirin

Indications (When & Why?)
– Administer to all patients with ACS,
particularly reperfusion candidates
 Give
as soon as possible
– Blocks formation of thromboxane A2, which
causes platelets to aggregate
Acute Coronary Syndromes
59
Aspirin

Dosing (How?)
– 160 to 325 mg tablets
 Preferably
chewed
 May use suppository
– Higher doses may be harmful
Acute Coronary Syndromes
60
Aspirin

Precautions (Watch Out!)
– Relatively contraindicated in patients with
active ulcer disease or asthma
Acute Coronary Syndromes
61
Nitroglycerine

Indications (When & Why?)
– Chest pain of suspected cardiac origin
– Unstable angina
– Complications of AMI, including congestive
heart failure, left ventricular failure
– Hypertensive crisis or urgency with chest
pain
Acute Coronary Syndromes
62
Nitroglycerin

Indications (When & Why?)
– Decreases pain of ischemia
– Increases venous dilation
– Decreases venous blood return to heart
– Decreases preload and cardiac
oxygen consumption
– Dilates coronary arteries
– Increases cardiac collateral flow
Acute Coronary Syndromes
63
Nitroglycerine

Dosing (How?)
– Sublingual Route
 0.3
to 0.4 mg; repeat every 5 minutes
– Aerosol Spray
 Spray
for 0.5 to 1.0 second at 5 minute intervals
– IV Infusion
 Infuse
at 10 to 20 µg/min
 Route of choice for emergencies
 Titrate to effect
Acute Coronary Syndromes
64
Nitroglycerine

Precautions (Watch Out!)
– Use extreme caution if systolic BP <90 mm Hg
– Use extreme caution in RV infarction
–
Suspect RV infarction with inferior ST changes
– Limit BP drop to 10% if patient is normotensive
– Limit BP drop to 30% if patient is hypertensive
– Watch for headache, drop in BP, syncope,
tachycardia
– Tell patient to sit or lie down during administration
Acute Coronary Syndromes
65
Morphine Sulfate

Indications (When & Why?)
– Chest pain and anxiety associated with AMI
or cardiac ischemia
– Acute cardiogenic pulmonary edema (if
blood pressure is adequate)
Acute Coronary Syndromes
66
Morphine Sulfate

Indications (When & Why?)
– To reduce pain of ischemia
– To reduce anxiety
– To reduce extension of ischemia by reducing
oxygen demands
Acute Coronary Syndromes
67
Morphine Sulfate

Dosing (How?)
– 1 to 3 mg IV (over 1 to 5 minutes) every 5 to
10 minutes as needed
Acute Coronary Syndromes
68
Morphine Sulfate

Precautions (Watch Out!)
– Administer slowly and titrate to effect
– May compromise respiration; therefore use
with caution in acute pulmonary edema
– Causes hypotension in volume-depleted
patients
Acute Coronary Syndromes
69
Acute Coronary
Syndromes
• ST elevation or new or
presumably new LBBB:
strongly suspicious for
injury
• ST-elevation AMI
• ST depression or dynamic
T-wave inversion:
strongly suspicious
for ischemia
• High-risk unstable angina/
non–ST-elevation AMI
• Nondiagnostic ECG:
absence of changes
in ST segment or
T waves
• Intermediate/low-risk
unstable angina
70
ST Elevation
71
Recognition
of AMI

Know what to look
for—
– ST elevation >1 mm
– 3 contiguous leads

J point plus
0.04 second
Know where to look
– Refer to 2000 ECC
Handbook
PR baseline
ST-segment deviation
= 4.5 mm
72
ST Elevation
Baseline
Ischemia—tall or inverted T wave (infarct),
ST segment may be depressed (angina)
Injury—elevated ST segment, T wave may invert
Infarction (Acute)—abnormal Q wave,
ST segment may be elevated and T wave
may be inverted
Infarction (Age Unknown)—abnormal Q wave,
ST segment and T wave returned to normal
73
Beta Blockers

Indications (When & Why?)
– To reduce myocardial ischemia and damage
in AMI patients with elevated heart rates,
blood pressure, or both
– Blocks catecholamines from binding to
ß-adrenergic receptors
– Reduces HR, BP, myocardial contractility
– Decreases AV nodal conduction
– Decreases incidence of primary VF
Acute Coronary Syndromes
74
Beta Blockers

Dosing (How?)
– Esmolol


0.5 mg/kg over 1 minute, followed by continuous infusion at
0.05 mg/kg/min
Titrate to effect, Esmolol has a short half-life (<10 minutes)
– Labetalol


10 mg labetalol IV push over 1 to 2 minutes
May repeat or double labetalol every 10 minutes to a
maximum dose of 150 mg, or give initial dose as a bolus,
then start labetalol infusion 2 to 8 µg/min
Acute Coronary Syndromes
75
Beta Blockers

Dosing (How?)
– Metoprolol

5 mg slow IV at 5-minute intervals to a total of 15 mg
– Atenolol


5 mg slow IV (over 5 minutes)
Wait 10 minutes, then give second dose of 5 mg slow IV
(over 5 minutes)
– Propranolol


1 to 3 mg slow IV. Do not exceed 1 mg/min
Repeat after 2 minutes if necessary
Acute Coronary Syndromes
76
Beta Blockers

Precautions (Watch Out!)
– Concurrent IV administration with IV calcium
channel blocking agents like verapamil or diltiazem
can cause severe hypotension
– Avoid in bronchospastic diseases, cardiac failure, or
severe abnormalities in cardiac conduction
– Monitor cardiac and pulmonary status during
administration
– May cause myocardial depression
Acute Coronary Syndromes
77
Heparin

Indications (When & Why?)
– For use in ACS patients with Non Q wave MI
or unstable angina
– Inhibits thrombin generation by factor Xa
inhibition and also inhibit thrombin indirectly
by formation of a complex with antithrombin
III
Acute Coronary Syndromes
78
Heparin

Dosing (How?)
– Initial bolus 60 IU/kg
 Maximum
bolus: 4000 IU
– Continue at 12 IU/kg/hr (maximum 1000
IU/hr for patients < 70 kg), round to the
nearest 50 IU
Acute Coronary Syndromes
79
Heparin

Dosing (How?)
– Adjust to maintain activated partial thromboplastin
time (aPTT) 1.5 to 2.0 times the control values for
48 hours or angiography
– Target range for aPTT after first 24 hours is between
50 & 70 seconds (may vary with laboratory)
– Check aPTT at 6, 12, 18, and 24 hours
– Follow Institutional Heparin Protocol
Acute Coronary Syndromes
80
Heparin

Precautions (Watch Out!)
– Same contraindications as for fibrinolytic
therapy: active bleeding; recent intracranial,
intraspinal or eye surgery; severe
hypertension; bleeding disorders;
gastroinintestinal bleeding
– DO NOT use if platelet count is below 100
000
Acute Coronary Syndromes
81
Glycoprotein
IIb/IIIa Inhibitors

Indications (When & Why?)
– Inhibit the integrin glycoprotein IIb/IIIa
receptor in the membrane of platelets,
inhibiting platelet aggregation
– Indicated for Acute Coronary Syndromes
without ST segment elevation
Acute Coronary Syndromes
82
Glycoprotein
IIb/IIIa Inhibitors

Indications (When & Why?)
– Abciximab (ReoPro)
 Non
Q wave MI or unstable angina with planned
PCI within 24 hours
 Must use with heparin
– Binds irreversibly with platelets
– Platelet function recovery requires 48 hours
Acute Coronary Syndromes
83
Glycoprotein
IIb/IIIa Inhibitors

Indications (When & Why?)
– Eptifibitide (Integrilin)
 Non
Q wave MI, unstable angina managed
medically, and unstable angina / Non Q wave MI
patients undergoing PCI
 Platelet function recovers within 4 to 8 hours
after discontinuation
Acute Coronary Syndromes
84
Glycoprotein
IIb/IIIa Inhibitors

Indications (When & Why?)
– Tirofiban (Aggrastat)
 Non
Q wave MI, unstable angina managed
medically, and unstable angina / Non Q wave MI
patients undergoing PCI
 Platelet function recovers within 4 to 8 hours
after discontinuation
Acute Coronary Syndromes
85
Glycoprotein
IIb/IIIa Inhibitors

Dosing (How?)
– NOTE: Check package insert for current
indications, doses, and duration of
therapy.
 Optimal
duration of therapy has NOT been
established.
Acute Coronary Syndromes
86
Glycoprotein
IIb/IIIa Inhibitors

Dosing (How?)
– Abciximab (ReoPro)
 ACS
with planned PCI within 24 hours
– 0.25 mg/kg bolus (10 to 60 minutes before
procedure), then 0.125 mcg/kg/min infusion
 PCI only
– 0.25 mg/kg bolus
– Then 10 mcg/min infusion
Acute Coronary Syndromes
87
Glycoprotein
IIb/IIIa Inhibitors

Dosing (How?)
– Eptifibitide (Integrilin)
 Acute
Coronary Syndromes
– 180 mcg/kg IV bolus, then 2 mcg/kg/min
infusion
 PCI
– 135 mcg/kg IV bolus, then begin 0.5
mcg/kg/min infusion, then repeat bolus in 10
minutes
Acute Coronary Syndromes
88
Glycoprotein
IIb/IIIa Inhibitors

Dosing (How?)
– Tirofiban (Aggrastat)
 Acute
Coronary Syndromes or PCI
– 0.4 mcg/kg/min infusion IV for 30 minutes
– Then 0.1 mcg/kg/min infusion
Acute Coronary Syndromes
89
Glycoprotein
IIb/IIIa Inhibitors

Precautions (Watch Out!)
– Active internal bleeding or bleeding disorder
within 30 days
– History of intracranial hemorrhage or other
bleeding
– Surgical procedure or trauma within 1 month
– Platelet count > 150 000/mm3
Acute Coronary Syndromes
90
PTCA
91
Fibrinolytics

Indications (When & Why?)
– For AMI in adults
 ST
elevation or new or presumably new LBBB;
strongly suspicious for injury
 Time of onset of symptoms < 12 hours
Acute Coronary Syndromes
92
Fibrinolytics

Indications (When & Why?)
– For Acute Ischemic Stroke
 Sudden
onset of focal neurologic deficits or
alterations in consciousness
 Absence of subarachnoid or intracerebral
hemorrhage
 Alteplase can be started in less than 3 hours of
symptom onset
Acute Coronary Syndromes
93
Fibrinolytics

Dosing (How?)
– For fibrinolytic use, all patients should have
2 peripheral IV lines
1
line exclusively for fibrinolytic administration
Acute Coronary Syndromes
94
Fibrinolytics

Dosing for AMI Patients (How?)
– Alteplase, recombinant (tPA)


Accelerated Infusion
– 15 mg IV bolus
– Then 0.75 mg/kg over the next 30 minutes
 Not to exceed 50 mg
– Then 0.5 mg/kg over the next 60 minutes
 Not to exceed 35 mg
3 hour Infusion
– Give 60 mg in the first hour (initial 6 to 10 mg is given
as a bolus)
– Then 20 mg/hour for 2 additional hours
Acute Coronary Syndromes
95
Fibrinolytics

Dosing for AMI Patients (How?)
– Anistreplase (APSAC)


Reconstitute 30 units in 50 mL of sterile water
30 units IV over 2 to 5 minutes
– Reteplase, recombinant


Give first 10 unit IV bolus over 2 minutes
30 minutes later give second 10 unit IV bolus over 2
minutes
– Streptokinase

1.5 million IU in a 1 hour infusion
– Tenecteplase (TNKase)

Bolus 30 to 50 mg
Acute Coronary Syndromes
96
Fibrinolytics

Adjunctive Therapy for AMI Patients
(How?)
– 160 to 325 mg aspirin chewed as soon as
possible
– Begin heparin immediately and continue for
48 hours if alteplase or Retavase is used
Acute Coronary Syndromes
97
Fibrinolytics

Dosing for Acute Ischemic Stroke (How?)
– Alteplase, recombinant (tPA)
 Give
0.9 mg/kg (maximum 90 mg) infused over
60 minutes
– Give 10% of total dose as an initial IV bolus
over 1 minute
– Give the remaining 90% over the next 60
minutes
– Alteplase is the only agent approved for use
in Ischemic Stroke patients
Acute Coronary Syndromes
98
Fibrinolytics

Precautions (Watch Out!)
– Specific Exclusion Criteria
 Active
internal bleeding (except mensus) within
21 days
 History of CVA, intracranial, or intraspinal within 3
months
 Major trauma or serious injury within 14 days
 Aortic dissection
 Severe uncontrolled hypertension
Acute Coronary Syndromes
99
Fibrinolytics

Precautions (Watch Out!)
– Specific Exclusion Criteria
 Known
bleeding disorders
 Prolonged CPR with evidence of thoracic trauma
 Lumbar puncture within 7 days
 Recent arterial puncture at noncompressible site
 During the first 24 hours of fibrinolytic therapy for
ischemic stroke, do not give aspirin or heparin
Acute Coronary Syndromes
100
ACE Inhibitors

Indications (When & Why?)
– Reduce mortality & improve LV dysfunction
in post AMI patients
– Help prevent adverse LV remodeling, delay
progression of heart failure, and decrease
sudden death & recurrent MI
Acute Coronary Syndromes
101
ACE Inhibitors

Indications (When & Why?)
– Suspected MI & ST elevation in 2 or more
anterior leads
– Hypertension
– Clinical signs of AMI with LV dysfunction
– LV ejection fraction <40%
Acute Coronary Syndromes
102
ACE Inhibitors

Indications (When & Why?)
– Generally not started in the ED but within
first 24 hours after:
 Fibrinolytic
therapy has been completed
 Blood pressure has stabilized
Acute Coronary Syndromes
103
ACE Inhibitors

Dosing (How?)
– Should start with low-dose oral
administration (with possible IV doses for
some preparations) and increase steadily to
achieve a full dose within 24 to 48 hours
Acute Coronary Syndromes
104
ACE Inhibitors

Dosing (How?)
– Enalapril
 2.5
mg PO titrated to 20 mg BID
 IV dosing of 1.25 mg IV over 5 minutes, then
1.25 to 5 mg IV every six hours
– Captopril
 Start
with 6.25 mg PO
 Advance to 25 mg TID, then to 50 mg TID as
tolerated
Acute Coronary Syndromes
105
ACE Inhibitors

Dosing (How?)
– Lisinopril (AMI dose)
5
mg within 24 hours onset of symptoms
 10 mg after 24 hours, then 10 mg after 48 hours,
then 10 mg PO daily for six weeks
– Ramipril
 Start
with single dose of 2.5 mg PO
 Titrate to 5 mg PO BID as tolerated
Acute Coronary Syndromes
106
ACE Inhibitors

Precautions (Watch Out!)
– Contraindicated in pregnancy
– Contraindicated in angioedema
– Reduce dose in renal failure
– Avoid hypotension, especially following initial
dose & in relative volume depletion
Acute Coronary Syndromes
107
Bradycardias
Case 7
108
Bradycardia
Bradycardia
• Slow (absolute bradycardia = rate <60 bpm)
or
• Relatively slow (rate less than expected
relative to underlying condition or cause)
Primary ABCD Survey
• Assess ABCs
• Secure airway noninvasively
• Ensure monitor/defibrillator is available
•
•
•
•
•
•
•
•
Secondary ABCD Survey
Assess secondary ABCs (invasive airway management needed?)
Oxygen–IV access–monitor–fluids
Vital signs, pulse oximeter, monitor BP
Obtain and review 12-lead ECG
Obtain and review portable chest x-ray
Problem-focused history
Problem-focused physical examination
Consider causes (differential diagnoses)
109
Bradycardia
Serious signs or symptoms?
Due to bradycardia?
No
Type II second-degree AV block
or
Third-degree AV block?
No
Observe
Yes
Intervention sequence
• Atropine 0.5 to 1.0 mg
• Transcutaneous pacing if available
• Dopamine 5 to 20 µg/kg per minute
• Epinephrine 2 to 10 µg/min
• Isoproterenol 2 to 10 µg/min
Yes
• Prepare for transvenous pacer
• If symptoms develop, use
transcutaneous pacemaker until
transvenous pacer placed
110
Atropine Sulfate

Indications (When & Why?)
– First drug for symptomatic bradycardia
 Increases
heart rate by blocking the
parasympathetic nervous system
Bradycardias
111
Atropine Sulfate

Dosing (How?)
– 0.5 to 1.0 mg IV every 3 to 5 minutes as
needed
– May give via ET tube (2 to 2.5 mg) diluted
in 10 mL of NS
– Maximum Dose: 0.04 mg/kg
Bradycardias
112
Atropine Sulfate

Precautions (Watch Out!)
– Use with caution in presence of myocardial
ischemia and hypoxia
– Increases myocardial oxygen demand
– Seldom effective for:
 Infranodal
(type II) AV block
 Third-degree block (Class IIb)
Bradycardias
113
Dopamine

Indications (When & Why?)
– Second drug for symptomatic bradycardia
(after atropine)
– Use for hypotension (systolic BP 70 to 100
mm Hg) with S/S of shock
Bradycardias
114
Dopamine

Dosing (How?)
– IV Infusions (Titrate to Effect)
– 400 mg / 250 mL of D5W = 1600 mcg/mL
– 800 mg/ 250 mL of D5W = 3200 mcg/mL
Bradycardias
115
Dopamine

Dosing (How?)
– IV Infusions (Titrate to Effect)
Dose “Renal Dose"
– 1 to 5 µg/kg per minute
 Moderate Dose “Cardiac Dose"
– 5 to 10 µg/kg per minute
 High Dose “Vasopressor Dose"
– 10 to 20 µg/kg per minute
 Low
Bradycardias
116
Dopamine

Precautions (Watch Out!)
– May use in patients with hypovolemia but only after
volume replacement
– May cause tachyarrhythmias, excessive
vasoconstriction
– DO NOT mix with sodium bicarbonate
Bradycardias
117
Epinephrine

Indications (When & Why?)
– Symptomatic bradycardia: After atropine,
dopamine, and transcutaneous pacing
(Class IIb)
Bradycardias
118
Epinephrine

Dosing (How?)
– Profound Bradycardia
2
to 10 µg/min infusion (add 1 mg of 1:1000 to
500 mL normal saline; infuse at 1 to 5 mL/min)
Bradycardias
119
Epinephrine

Precautions (Watch Out!)
– Raising blood pressure and increasing heart
rate may cause myocardial ischemia,
angina, and increased myocardial oxygen
demand
– Do not mix or give with alkaline solutions
Bradycardias
120
Isoproterenol

Indications (When & Why?)
– Temporary control of bradycardia in heart
transplant patients
– Class IIb at low doses for symptomatic
bradycardia
– Heart Transplant Patients!
Bradycardias
121
Isoproterenol

Dosing (How?)
– Infuse at 2 to 10 µg/min
– Titrate to adequate heart rate
Bradycardias
122
Isoproterenol

Precautions (Watch Out!)
– Increases myocardial oxygen requirements,
which may increase myocardial ischemia
– DO NOT administer with poison/druginduced shock
 Exception:
Beta Blocker Poisoning
Bradycardias
123
Stable
Tachycardias
Case 9
124
Diltiazem

Indications (When & Why?)
– To control ventricular rate in atrial fibrillation
and atrial flutter
– Use after adenosine to treat refractory PSVT
in patients with narrow QRS complex and
adequate blood pressure
– As an alternative, use verapamil
Stable Tachycardias
125
Diltiazem

Dosing (How?)
– Acute Rate Control
 15
to 20 mg (0.25 mg/kg) IV over 2 minutes
 May repeat in 15 minutes at 20 to 25 mg (0.35
mg/kg) over 2 minutes
– Maintenance Infusion
5
to 15 mg/hour, titrated to heart rate
Stable Tachycardias
126
Diltiazem

Precautions (Watch Out!)
– Do not use calcium channel blockers for
tachycardias of uncertain origin
– Avoid calcium channel blockers in patients with
Wolff-Parkinson-White syndrome, in patients with
sick sinus syndrome, or in patients with AV block
without a pacemaker
– Expect blood pressure drop resulting from
peripheral vasodilation
– Concurrent IV administration with IV ß-blockers can
cause severe hypotension
Stable Tachycardias
127
Verapamil

Indications (When & Why?)
– Used as an alternative to diltiazem for
ventricular rate control in atrial fibrillation and
atrial flutter
– Drug of second choice (after adenosine) to
terminate PSVT with narrow QRS complex
and adequate blood pressure
Stable Tachycardias
128
Verapamil

Dosing (How?)
– 2.5 to 5.0 mg IV bolus over 1to 2 minutes
– Second dose: 5 to 10 mg, if needed, in 15 to
30 minutes. Maximum dose: 30 mg
– Older patients: Administer over 3 minutes
Stable Tachycardias
129
Verapamil

Precautions (Watch Out!)
– Do not use calcium channel blockers for
wide-QRS tachycardias of uncertain origin
– Avoid calcium channel blockers in patients
with Wolff-Parkinson-White syndrome and
atrial fibrillation, sick sinus syndrome, or
second- or third-degree AV block without
pacemaker
Stable Tachycardias
130
Verapamil

Precautions (Watch Out!)
– Expect blood pressure drop caused by
peripheral vasodilation
– IV calcium can restore blood pressure, and
some experts recommend prophylactic
calcium before giving calcium channel
blockers
– Concurrent IV administration with IV ßblockers may produce severe hypotension
Stable Tachycardias
131
Adenosine

Indications (When & Why?)
– First drug for narrow-complex PSVT
– May be used diagnostically (after lidocaine)
in wide-complex tachycardias of uncertain
type
Stable Tachycardias
132
Adenosine

Dose (How?)
– IV Rapid Push
– Initial bolus of 6 mg given rapidly over 1 to 3
seconds followed by normal saline bolus of
20 mL; then elevate the extremity
– Repeat dose of 12 mg in 1 to 2 minutes if
needed
– A third dose of 12 mg may be given in 1 to 2
minutes if needed
Stable Tachycardias
133
Adenosine

Precautions (Watch Out!)
– Transient side effects include:
 Facial
Flushing
 Chest pain
 Brief periods of asystole or bradycardia
– Less effective in patients taking
theophyllines
Stable Tachycardias
134
Beta Blockers

Indications (When & Why?)
– To convert to normal sinus rhythm or to slow
ventricular response (or both) in
supraventricular tachyarrhythmias (PSVT,
atrial fibrillation, or atrial flutter)
– ß-Blockers are second-line agents after
adenosine, diltiazem, or digoxin
Stable Tachycardias
135
Beta Blockers

Dosing (How?)
– Esmolol


0.5 mg/kg over 1 minute, followed by continuous infusion at
0.05 mg/kg/min
Titrate to effect, Esmolol has a short half-life (<10 minutes)
– Labetalol


10 mg labetalol IV push over 1 to 2 minutes
May repeat or double labetalol every 10 minutes to a
maximum dose of 150 mg, or give initial dose as a bolus,
then start labetalol infusion 2 to 8 µg/min
Stable Tachycardias
136
Beta Blockers

Dosing (How?)
– Metoprolol

5 mg slow IV at 5-minute intervals to a total of 15 mg
– Atenolol


5 mg slow IV (over 5 minutes)
Wait 10 minutes, then give second dose of 5 mg slow IV
(over 5 minutes)
– Propranolol


1 to 3 mg slow IV. Do not exceed 1 mg/min
Repeat after 2 minutes if necessary
Stable Tachycardias
137
Beta Blockers

Precautions (Watch Out!)
– Concurrent IV administration with IV calcium
channel blocking agents like verapamil or diltiazem
can cause severe hypotension
– Avoid in bronchospastic diseases, cardiac failure, or
severe abnormalities in cardiac conduction
– Monitor cardiac and pulmonary status during
administration
– May cause myocardial depression
Stable Tachycardias
138
Digoxin

Indications (When & Why?)
– To slow ventricular response in atrial
fibrillation or atrial flutter
– Third-line choice for PSVT
Stable Tachycardias
139
Digoxin

Dosing (How?)
– IV Infusion
 Loading
doses of 10 to 15 µg/kg provide
therapeutic effect with minimum risk of toxic
effects
 Maintenance dose is affected by body size and
renal function
Stable Tachycardias
140
Digoxin

Precautions (Watch Out!)
– Toxic effects are common and are frequently
associated with serious arrhythmias
– Avoid electrical cardioversion unless
condition is life threatening
 Use
lower current settings (10 to 20 Joules)
Stable Tachycardias
141
Amiodarone

Indications (When & Why?)
– Powerful antiarrhythmic with substantial
toxicity, especially in the long term
– Intravenous and oral behavior are quite
different
Stable Tachycardias
142
Amiodarone

Dosing (How?)
– Stable Wide-Complex Tachycardias
 Rapid
Infusion
– 150 mg IV over 10 minutes (15 mg/min)
– May repeat
 Slow Infusion
– 360 mg IV over 6 hours (1 mg/min)
Stable Tachycardias
143
Amiodarone

Dosing (How?)
– Maintenance Infusion
 540
mg IV over 18 hours (0.5 mg/min)
Stable Tachycardias
144
Amiodarone

Precautions (Watch Out!)
– May produce vasodilation & shock
– May have negative inotropic effects
– May prolong QT Interval
 DO
NOT administer with other drugs that may
prolong QT Interval (Procainamide)
– Terminal elimination
 Half-life
lasts up to 40 days
Stable Tachycardias
145
Amiodarone

Precautions (Watch Out!)
– Contraindicated in:
 Second
or third degree A-V block
 Severe bradycardia
 Pregnancy
 CHF
 Hypokalaemia
 Liver dysfunction
Stable Tachycardias
146
Lidocaine

Indications (When & Why?)
– Depresses automaticity
– Depresses excitability
– Raises ventricular fibrillation threshold
– Decreases ventricular irritability
Stable Tachycardias
147
Lidocaine

Dosing (How?)
– For stable VT, wide-complex tachycardia of
uncertain type, significant ectopy, use as
follows:
 1.0
to 1.5 mg/kg IV push
 Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes;
maximum total dose, 3 mg/kg
Stable Tachycardias
148
Lidocaine

Dosing (How?)
– Maintenance Infusion
2
to 4 mg/min
Stable Tachycardias
149
Lidocaine

Precautions (Watch Out!)
– Reduce maintenance dose (not loading
dose) in presence of impaired liver function
or left ventricular dysfunction
– Discontinue infusion immediately if signs of
toxicity develop
Stable Tachycardias
150
Magnesium
Sulfate

Indications (When & Why?)
– Torsades de pointes with a pulse
– Wide-complex tachycardia with history of
ETOH abuse
– Life-threatening ventricular arrhythmias due
to digitalis toxicity, tricyclic overdose
Stable Tachycardias
151
Magnesium
Sulfate

Dosing (How?)
– Loading dose of 1 to 2 grams mixed in 50 to
100 mL of D5W IV push over 5 to 60
minutes
Stable Tachycardias
152
Magnesium
Sulfate

Dosing (How?)
– Maintenance Infusion
1
to 4 g/hour IV (titrate dose to control the
torsades)
Stable Tachycardias
153
Magnesium
Sulfate

Precautions (Watch Out!)
– Occasional fall in blood pressure with rapid
administration
– Use with caution if renal failure is present
Stable Tachycardias
154
Procainamide

Indications (When & Why?)
– Depresses automaticity
– Depresses excitability
– Raises ventricular fibrillation threshold
– Decreases ventricular irritability
– Atrial fibrillation with rapid rate in WolffParkinson-White syndrome
Stable Tachycardias
155
Procainamide

Dosing (How?)
– Perfusing Arrhythmia
 20
mg/min IV infusion until:
– Hypotension develops
– Arrhythmia is suppressed
– QRS widens by >50%
– Maximum dose of 17 mg/kg is reached
 In refractory VF/VT, 100 mg IV push doses given
every 5 minutes are acceptable
Stable Tachycardias
156
Procainamide

Dosing (How?)
– Maintenance Infusion
1
to 4 mg/min
Stable Tachycardias
157
Procainamide

Precautions (Watch Out!)
– If cardiac or renal dysfunction
is present, reduce maximum total dose to 12
mg/kg and maintenance infusion to 1 to 2
mg/min
– Remember Endpoints of Administration
Stable Tachycardias
158
Acute
Ischemic Stroke
Case 10
159
Acute
Ischemic Stroke
Suspected Stroke
 Detection
 Dispatch
 Delivery
 Door
Immediate assessment:
<10 minutes from arrival
• Assess ABCs, vital signs
• Provide oxygen by nasal cannula
• Obtain IV access; obtain blood samples (CBC,
electolytes, coagulation studies)
• Check blood sugar; treat if indicated
• Obtain 12-lead ECG, check for arrhythmias
• Perform general neurological screening assessment
• Alert Stroke Team: neurologist, radiologist,
CT technician
EMS assessments and actions
Immediate assessments performed by EMS
personnel include
• Cincinnati Prehospital Stroke Scale
(includes difficulty speaking, arm
weakness, facial droop)
• Los Angeles Prehospital Stroke Screen
• Alert hospital to possible stroke patient
• Rapid transport to hospital
Immediate neurological assessment:
<25 minutes from arrival
• Review patient history
• Establish onset (<3 hours required for fibrinolytics)
• Perform physical examination
• Perform neurological examination:
 Determine level of consciousness (Glasgow Coma Scale)
 Determine level of stroke severity (NIH Stroke Scale or
Hunt and Hess Scale)
• Order urgent noncontrast CT scan
(door-to–CT scan performed: goal <25 minutes from arrival)
• Read CT scan (door-to–CT read: goal <45 minutes from arrival)
• Perform lateral cervical spine x-ray (if patient comatose/history
of trauma)
160
Nitroprusside

Indications (When & Why?)
– Hypertensive crisis
Acute Ischemic Stroke
161
Nitroprusside

Dosing (How?)
– Begin at 0.1 mcg/kg/min and titrate upward
every 3 to 5 minutes to desired effect
 Up
to 0.5 mcg/kg/min
– Action occurs within 1 to 2 minutes
Acute Ischemic Stroke
162
Nitroprusside

Dosing Precautions (How?)
– Use with an infusion pump; use
hemodynamic monitoring for optimal safety
– Cover drug reservoir with opaque material
Acute Ischemic Stroke
163
Nitroprusside

Precautions (Watch Out!)
– Light-sensitive; therefore, wrap drug
reservoir in aluminum foil
– May cause hypotension and CO2 retention
– May exacerbate intrapulmonary shunting
– Other side effects include headaches,
nausea, vomiting, and abdominal cramps
Acute Ischemic Stroke
164
Drugs used in
Overdoses
165
Calcium Chloride

Indications (When & Why?)
– As an antidote for toxic effects of calcium
channel blocker overdose
Drugs Used in Overdoses
166
Calcium Chloride

Dosing (How?)
– 8 to 16 mg/kg (usually 5 to 10 mL) IV for
hyperkalemia and calcium channel blocker
overdose
Drugs Used in Overdoses
167
Calcium Chloride

Precautions (Watch Out!)
– Do not use routinely in cardiac arrest
– Do not mix with sodium bicarbonate
Drugs Used in Overdoses
168
Flumazenil

Indications (When & Why?)
– Reduce respiratory depression and sedative
effects from pure benzodiazepine overdose
Drugs Used in Overdoses
169
Flumazenil

Dosing (How?)
– First Dose
 0.2
mg IV over 15 seconds
– Second Dose
 0.3
mg IV over 30 seconds
– Third Dose
 0.4
mg IV over 30 seconds
– Maximum Dose
3
mg
Drugs Used in Overdoses
170
Flumazenil

Precautions (Watch Out!)
– Effects may not outlast effects of
benzodiazepines
– Monitor for recurrent respiratory depression
– DO NOT use in suspected tricyclic overdose
– DO NOT use in seizure-prone patients
– DO NOT use if unknown type overdose or
mixed drug overdose with drugs known to
cause seizures
Drugs Used in Overdoses
171
Naloxone
Hydrochloride

Indications (When & Why?)
– Respiratory and neurologic depression due
to opiate intoxication unresponsive to
oxygen and hyperventilation
Drugs Used in Overdoses
172
Naloxone
Hydrochloride

Dosing (How?)
– 0.4 to 2 mg IVP every 2 minutes
– Use higher doses for complete narcotic
reversal
– Can administer up to 10 mg in a short time
(10 minutes)
Drugs Used in Overdoses
173
Naloxone
Hydrochloride

Precautions (Watch Out!)
– May cause opiate withdrawal
– Effects may not outlast effects of narcotics
– Monitor for recurrent respiratory depression
Drugs Used in Overdoses
174
Review of
Infusions
175
Dobutamine

Indications (When & Why?)
– Consider for pump problems (congestive
heart failure, pulmonary congestion) with
systolic blood pressure of 70 to 100 mm Hg
and no signs of shock
– Increases Inotropy
Review of Infusions
176
Dobutamine

Dosing (How?)
– Usual infusion rate is 2 to 20 µg/kg per
minute
– Titrate so heart rate does not increase by
more than 10% of baseline
– Hemodynamic monitoring is recommended
for optimal use
Review of Infusions
177
Dobutamine

Precautions (Watch Out!)
– Avoid when systolic blood pressure <100
mm Hg with signs of shock
– May cause tachyarrhythmias, fluctuations in
blood pressure, headache, and nausea
– DO NOT mix with sodium bicarbonate
Review of Infusions
178
Dopamine

Indications (When & Why?)
– Second drug for symptomatic bradycardia
(after atropine)
– Use for hypotension (systolic BP 70 to 100
mm Hg) with S/S of shock
Review of Infusions
179
Dopamine

Dosing (How?)
– IV Infusions (Titrate to Effect)
Dose “Renal Dose"
– 1 to 5 µg/kg per minute
 Moderate Dose “Cardiac Dose"
– 5 to 10 µg/kg per minute
 High Dose “Vasopressor Dose"
– 10 to 20 µg/kg per minute
 Low
Review of Infusions
180
Dopamine

Precautions (Watch Out!)
– May use in patients with hypovolemia but only after
volume replacement
– May cause tachyarrhythmias, excessive
vasoconstriction
– DO NOT mix with sodium bicarbonate
Review of Infusions
181
Epinephrine

Indications (When & Why?)
– Symptomatic bradycardia: After atropine,
dopamine, and transcutaneous pacing
(Class IIb)
Review of Infusions
182
Epinephrine

Dosing (How?)
– Profound Bradycardia
2
to 10 µg/min infusion (add 1 mg of 1:1000 to
500 mL normal saline; infuse at 1 to 5 mL/min)
Review of Infusions
183
Epinephrine

Precautions (Watch Out!)
– Raising blood pressure and increasing heart
rate may cause myocardial ischemia,
angina, and increased myocardial oxygen
demand
– Do not mix or give with alkaline solutions
– Higher doses have not improved outcome &
may cause myocardial dysfunction
Review of Infusions
184
Norepinephrine

Indications (When & Why?)
– For severe cardiogenic shock and
hemodynamic significant hypotension
(systolic blood pressure < 70 mm/Hg) with
low total peripheral resistance
– This is an agent of last resort for
management of ischemic heart disease and
shock
Review of Infusions
185
Norepinephrine

Dosing (How?)
– 0.5 to 1 mcg/min titrated to improve blood
pressure (up to 30 mcg/min)
– DO NOT administer is same IV line as
alkaline infusions
– Poison/drug-induced hypotension may
higher doses to achieve adequate perfusion
Review of Infusions
186
Norepinephrine

Precautions (Watch Out!)
– Increases myocardial oxygen requirements
– May induce arrhythmias
– Extravasation causes tissue necrosis
Review of Infusions
187
Calculating
mg/min
dose X gtt factor
= gtts/min
Solution Concentration
2 mg X 60 gtt/mL
4 mg
= 30 gtts/min
Using a 60 gtt set:
 30 gtt/min = 30 cc/hr
188
Calculating
mcg/kg/min
dose X kg X gtt factor
= cc/hr
solution concentration
5 mcg/min X 75 kg X 60 gtt/mL
= 18.75 cc/hr
1600 mcg/cc
Using a 60 gtt set:
 18.75 cc/hr = 18.75 gtts/min
189
Furosemide

Indications (When & Why?)
– For adjuvant therapy of acute pulmonary
edema in patients with systolic blood
pressure >90 to 100 mm Hg (without S/S of
shock)
– Hypertensive emergencies
– Increased intracranial pressure
190
Furosemide

Dosing (How?)
– 20 to 40 mg slow IVP
– If patient is taking at home, double their daily
dose
191
Furosemide

Precautions (Watch Out!)
– Dehydration, hypovolemia, hypotension,
hypokalemia, or other electrolyte imbalance
may occur
192
Questions?
Jeremy Maddux
[email protected]
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Summary

To obtain a full understanding of ACLS
pharmacology requires constant review
of:
– Indications & Actions (When & Why?)
– Dosing (How?)
– Contraindications & Precautions (Watch
Out!)
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Thank You!
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