Transcript CARDIAC DRUG REVIEW

CARDIAC DRUG REVIEW
WHAT DO YOU “SEE” WHEN
YOU STIMULATE BETA
VASODILATE
BRONCHODILATE
+CHRONOTROPE
+INOTROPE
EPI’S OTHER NAME?
ADRENALIN
WHAT DOES EPI DO THAT
NOREPI AND DOPAMINE DO
NOT DO?
BETA 2
BRONCHODILATOR
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
RUN AT
?
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?
1-4
mcg/kg/min
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
 What
it, cause hypotension
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
of Diltiazem.
Be specific
st
1
AND
nd
2
dose
 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,
 May
Digitalis etc
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
patients?
with what
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


Brady


beta blocker
AV block


alpha blocker
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?