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Critical Medications

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ICU Medications

ICU Medications

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  • 1. CRITICAL MEDICATIONS Sherry L. Knowles, RN, CCRN, CRNI
  • 2. OBJECTIVES
    • Name common prescribed emergency medications.
    • List the indications of first line emergency medications.
    • Explain the use of frequently prescribed urgent medications.
    • Distinguish between multiple drug classifications.
    • Describe the actions and importance of common prescribed critical medications.
    • List the contraindications of commonly prescribed critical medications.
    • Discuss the general dosing ranges and administration of frequently prescribe emergency medications.
    At the end of this discussion, the viewer will be able to:
  • 3. EMERGENCY MEDICATIONS
  • 4. OXYGEN
    • Indications Oxygen is used in hypoxemia or suspected hypoxemia.
    • Has been proven to  the workload on the myocardium.
    • Uses Used as a first line treatments in all urgent situations.
    • Stable Start with Nasal Prongs at 2-4LPM.  May increase as needed to meet patient's requirements.
    • Unstable Start with Simple Mask at 6-8 LPM, or use non- rebreather mask as situation warrants at 12-15 LPM.
    • Dead Use Bag-valve-mask device with reservoir at 12- Patients:15 LPM. Intubation is the airway of choice. 
  • 5. OXYGEN
    • ALL PATIENTS
    • If patient's condition worsens, change to higher delivery device.
    • If at any time the patient's airway or ventilatory status worsens, support with the appropriate airway and Bag-valve-mask device with reservoir.
    • ADVERSE EFFECTS
    • Long term use of > 40%may damage lung tissue.
  • 6.
    • INDICATIONS
    • To restore electrical activity: Asystole, Ventricular Standstill, Pulseless Ventricular Tachycardia, Ventricular Fibrillation, PEA.
    • May also increase automaticity and make VF more susceptible to DC countershock.
    • Anaphylaxis, Acute Bronchospasm
    • Severe Hypotension
    • ACTIONS
    • Alpha Adrenergic (potent)
    • Beta 1 Adrenergic
    EPINEPHRINE (Adrenalin)
  • 7.
    • CARDIAC ARREST
    • 1 mg IV every 3-5 minutes (AHA guidelines)
    • RESPIRATORY DISTRESS
    • 0.3-0.5 mg (0.3-0.5 mL of 1:1,000 solution) IM or SC every 20 minutes to 4 hours
    • or
    • 0.5-1.5 mg (0.1-0.3 mL of 1:200 suspension) every 6 hours .
    • SHOCK
    • 1-4 mcg/minute by continuous IV infusion.
    EPINEPHRINE (Adrenalin)
  • 8. EPINEPHRINE (Adrenalin)
    • ROUTES
    • IV, ET, SC
    • STRENGTHS
    • IV Epinephrine strength  is 1:10000 (1mg = 10cc). If 1:1000 concentration is all that is available, it must be mixed with 10cc Normal Saline for a final product of 1:10000 solution.
    • ADVERSE EFFECTS
    • May cause worsening of myocardial ischemia and may cause PVC's or Ventricular Tachycardia. May result in undesired tachycardia.
  • 9. ATROPINE
    • INDICATIONS
    • Symptomatic Bradycardia
    • Asystole
    • DOSAGE
    • Give 0.5-1mg I.V. push every 3-5 minutes to a maximum dose of 3 mg/kg.
    • May be given down the endotracheal tube at twice the dose (Mix with 10cc normal saline when giving via ETT.
    • Doses smaller than 0.5mg may enhance bradycardia and should not be used.
  • 10. ATROPINE
    • ADVERSE EFFECTS
    • May cause supraventricular or ventricular tachycardia
    • May cause ventricular fibrillation
    • May cause worsening of myocardial ischemia, worsening of AV Blocks, and/or PVC's.
    • May result in undesired tachycardia
    • May cause blurred vision, dry eyes, dilated pupils
  • 11.
    • CLASSIFICATION
    • Adenosine is a naturally occurring nucleoside, a breakdown product of ATP
    • INDICATIONS
    • Adenosine is the drug of choice for paroxysmal supraventricular tachvcardia (PSVT)
    • Can also be used diagnostically for stable, wide complex tachyardias of unknown type after two doses of lidocaine
    • CONTRAINDICATIONS
    • Contraindicated in the following rhythms: Second- or third-degree AV block, sick-sinus syndrome, atrial flutter, atrial fibrillation, and ventricular tachycardia.
    ADENOSINE (Adenocard)
  • 12.
    • MODES OF ACTION
    • Adenosine has a negative chronotropic and dromotropic effect on sinus node and AV nodal conduction, without causing negative inotropic effects .
    • Acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and dromotropic activity.
    • Terminates paroxysmal SVT by blocking the slow antergrade pathway in patients with re-entrant tachycardia using an accessory pathway.
    • Causes a 6-10 arrest (this is expected).
    ADENOSINE (Adenocard)
  • 13. ADENOSINE (Adenocard)
    • CONSIDERATIONS
    • Caffeine and theophylline (methylxanthines) antagonize the action of adenosine.
    • Persantine (dipyridamole) potentates the effect of adenosine; reduction of adenosine dose may be required.
    • Tegretol (carbamazepine) may potentate the AV-nodal blocking effect of adenosine.
    • ADVERSE EFFECTS
    • Shortness of breath, lightheadedness, paresthesia, facial flushing, palpitations, chest pain, diaphoresis, hypotension, headache, nausea, metallic taste.
  • 14. ADENOSINE (Adenocard)
    • DOSAGE
    • Give 6mg rapid IV push over 1-3 seconds (as close to vein as possible) followed with a rapid IV NS flush
    • If no response after 1-2 min, give 12 mg rapid IV push over 1-3 seconds (as close to vein as possible) followed with a rapid IV NS flush.
    • The second 12 mg dose may be repeated once if needed (maximum 30 mg dose).
  • 15. AMIODARONE (Cordarone®)
    • CLASSIFICATION
    • Antiarrhythmic
    • ACTIONS
    • Alpha and Beta Blocker
    • Slows myocardial cell action potential
    • Prolongation of refractory period
    • Blocks the potassium and sodium channels
    • Reduces automaticity of SA Node
    • Reduces contractility and conduction velocity in the ventricles
    • Slows conduction of the AV Node, Bundle of His and Purkinjes
  • 16. AMIODARONE (Cordarone®)
    • INDICATIONS
    • Used to treat atrial and ventricular dysrhythmias
    • Refractory Ventricular Tachycardia
    • Wide Complex Tachycardia (With Pulse)
    • Pulseless Ventricular Fibrillation
    • Pulseless Ventricular Tachycardia
    • When used in patients who have CHF and arrhythmias, it has been shown to improve exercise tolerance, decrease hospitalizations, and improve pump function.
  • 17. AMIODARONE (Cordarone®)
    • CONTRAINDICATIONS
    • Cardiogenic Shock
    • 2 nd or 3 rd Degree HB (unless pacemaker readily available)
    • Hypersensitivity
    • ADVERSE EFFECTS
    • Hypotension & Bradycardia (usually responsive to pressor and fluid therapy)
    • Can cause fatal pulmonary toxicity
    • May cause pulmonary fibrosis
  • 18. AMIODARONE (Cordarone®)
    • HOW SUPPLIED
    • 150 mg/3ml Ampules
    • DOSAGE
    • VF/VT: 300mg IVP over 30 sec (follow with NS flush)
    • May repeat once at 150mg in 3-5 min
    • Max. cumulative dose: 2.2g IV/24hrs
    • Wide Complex Tachycardia (with pulse):
    • 150mg/100cc D 5 W over 10 min
        • May rebolus if necessary
    • IV Gtt:: Initially 1mg/min X 6 hours, then 0.5mg/min
  • 19. DOPAMINE
    • CLASSIFICATION
    • Positive Inotrope (catecholamine)
    • Alpha, Beta 1 and Dopa Adrenergic (dose dependent)
    • MODE OF ACTION
    • Dopamine is a precursor of Adrenaline and Noradrenaline (epinephrine and norepinenephrine).
  • 20. DOPAMINE
    • INDICATIONS
    • Cardiogenic and septic shock
    • Low doses may be useful in patients with low C.O or renal impairment.
    • Higher doses are used for inotropic support to increase HR and CO of patients in cardiogenic shock or severe cardiac failure.
    • USES
    • Primarily for the treatment of hypotension that is not secondary to hypovolemia.
  • 21. DOPAMINE
    • DOSAGE
    • Usual Mix 800mg Dopamine in 500cc NS or D 5 W.
    • Dopamine has different effects at precise dosage levels: At low dosage, 1-3mcg/kg/min it has dopaminergic properties that result in vasodilitation of renal, messenteric, and cerebral arteries. At dosages between 3-10mcg/kg/min it has beta-1 properties, similar to dobutamine. Greater than 10mcg/kg/min it has Alpha properties used to treat hypotension
    • Renal Perfusion: 1-3mcg/kg/min
    • Beta Range: 3-10mcg/kg/min
    • Alpha Range: 10-20mcg/kg/min
    • Greater than 20mcg/kg/min: May switch to norepinephrine .
  • 22. DOPAMINE
    • ADVERSE EFFECTS
    • Profound tachycardia may result in the presence of hypovolemia. Always treat the underlying hypovolemia before using Dopamine.
    • May increase both suprventricular and ventricular ectopy.
    • At higher doses myocardial blood flow may be reduced.
  • 23. LIDOCAINE
    • INDICATIONS
    • To suppress ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.
    • Lidocaine is a first line anti-arrhythmic drug used to treat PVC's, Ventricular Tachycardia, and Ventricular Fibrillation.
    • DOSAGE
    • Give 1-1.5mg/kg IV every 3-5 min. up to a maximum dose of 3mg/kg. (Lidocaine can be given down the endotracheal tube).
    • If Lidocaine is used to suppress a ventricular arrhythmia, always follow it with a lidocaine infusion.
    • Infusion rate: 1-4mg/min (usually 1 gram in 259cc NS).
  • 24. LIDOCAINE
    • ADVERSE EFFECTS
    • Lidocaine toxicity may cause CNS depression, seizures, hypotension, coma and death.
    • CONSIDERATIONS
    • In patients with impaired liver function or patients over 70 years old, give the recommended bolus, but may need to decrease the normal infusion rate by 50%.
  • 25.
    • CLASSIFICATION
    • Antiarrhythmic
    • MODES OF ACTION
    • Blocks (L-type) calcium channels, which are abundant in cardiac and smooth muscle.
    • Potent vasodilator of coronary vessels. This effect increases coronary blood flow, and reduces coronary vasospasm.
    • Vasodilator of peripheral vessels. Vasodilation occurs predominantly in arterioles; there is no significant effect on venous beds. This reduces peripheral resistance and afterload.
    DILTIAZEM (Cardizem)
  • 26.
    • ACTIONS
    • Negative chronotropic effect. Diltiazem causes a modest lowering of heart rate, and reduces myocardium oxygen consumption. This effect is used to depress the frequency of hyperactive tissue causing arrhythmias.
    • Negative inotropic effect. Diltiazem causes a modest decrease in contractility. This effect is due to slowing of the SA node. It results in reduced myocardium oxygen consumption.
    • Negative dromotropic effect. By slowing conduction through the AV node, diltiazem increases the time needed for each beat. This results in reduced myocardium oxygen consumption.
    DILTIAZEM (Cardizem)
  • 27. DILTIAZEM (Cardizem)
    • INDICATIONS
    • Supraventricular tachycardias
    • Atrial fibrillation or flutter
    • Hypertension
    • Unstable, variant and stable Angina.
    • CONTRAINDICATIONS
    • CHF
    • SA Node and AV Node Disturbances
    • Hypotension
    • WPW
  • 28. DILTIAZEM (Cardizem)
    • DOSAGE
    • 0.25 mg/kg IV push over 2 minutes. A second bolus dose of 0.35 mg/kg may be administered after 15 minutes if the response to the first bolus was not adequate.
    • The bolus dose(s) is followed by a continuous IV infusion at an initial rate of 5-10 mg/hour. The dosage may be increased by 5 mg/hour up to a maximum recommended infusion rate of 15 mg/hour.
    • ROUTE
    • IV
  • 29. DILTIAZEM (Cardizem)
    • INTERACTIONS
    • Beta blockers (may cause AV blocks)
    • Quinidine (may reduce drug clearance)
    • Hepatic enzymes (may inhibit metabolizing enzymes)
    • ADVERSE EFFECTS
    • Reflex sympathetic response
    • Hypotension.
    • Bradycardia.
    • Dizziness.
    • Flushing.
  • 30. PROCAINAMIDE (Pronestyl)
    • MODES OF ACTION
    • Suppresses phase-4 depolarization in normal ventricular muscle and purkinje fibers, reducing automaticity of ectopic pacemakers.
    • Suppresses reentry dysrhythmias by slowing intraventricular conduction.
    • May be effective in treating PVCs and recurrent ventricular tachycardia that cannot be controlled with lidocaine.
    • INDICATIONS
    • Ventricular dysrhythmias not controlled by Lidocaine.
    • Procainamide is not a first drug of choice for treatment of ventricular dysrhythmias.
  • 31. PROCAINAMIDE (Pronestyl)
    • CONTRAINTICATIONS
    • Contraindicated in second and third-degree AV block, digitalis toxicity, and torsades de pointes.
    • DOSAGE
    • 20 mg/min (30 mg/min for refractory VF): maximum dose is 17 mg/kg
    • Maintenance infusion is 1-4 mg/min. (1 gram/250cc NS).
    • END POINTS
    • End Points are: suppression of arrhythmia, hypotension, widening of the QRS greater than 50% of original width, and maximum dose reached.
  • 32.
    • CLASSIFICATION
    • Vasodilator (especially of the venous system) through relaxing the vascular smooth muscles.
    • MODE OF ACTION
    • Dilates the venous bed promoting peripheral pooling of blood, decreasing venous return to the heart and reducing left ventricular end diastolic pressure (preload)
    • Dilation of the arterial bed reducing systemic vascular resistance (SVR) and arterial pressure (afterload).
    NITROGLYCERINE (TRIDIL) ·
  • 33. NITROGLYCERINE (TRIDIL) ·
    • INDICATIONS
    • Acute episodes of angina.
    • Chest pain associated with acute coronary syndrome.
    • Management of angina associated with or resulting from coronary insufficiency, coronary artery disease, coronary occlusion, or sub acute myocardial infarction.
    • Hypertension
    • Cardiac failure
    • CHF
  • 34. MAGNESIUM SULFATE
    • INDICATIONS
    • Initial treatment in the management of torsades de pointes.
    • Dysrhythmias secondary to a tricyclic antidepressant overdose and digitalis toxicity.
    • Considered as a class Ila agent (probably helpful) for refractory ventricular fibrillation and ventricular tachycardia after administration of lidocaine.
    • USES
    • Used primarily for the treatment of Torsades de points.
  • 35.
    • DOSAGE
    • 1-2 grams IV diluted in 100cc of Normal Saline.
    • ADVERSE EFFECTS
    • Diaphoresis, facial flushing, hypotension, depressed reflexes, hypothermia, reduced heart rate, circulatory collapse, and respiratory depression.
    • CONSIDERATIONS
    • CNS depressant effects may be enhanced if the patient is taking other CNS depressants. Serious changes in cardiac function may occur with cardiac glycosides.
    MAGNESIUM SULFATE
  • 36. CALCIUM CHLORIDE
    • INDICATIONS
    • Hyperkalemia with secondary ECG changes ( cardiac toxicity )
    • Calcium channel blocker overdosage
    • Magnesium intoxication (overdose)
    • Digitalis Toxicity (with caution)
    • Hypocalcemic Tetany
    • Hypocalcemia
    • Adjunctive therapy in the treatment of insect bites and stings (especially black widow spider and scorpion)
  • 37. CALCIUM CHLORIDE
    • DOSAGE
    • Adult: 2-4 mEq/kg of 10% solution IV. May repeat as necessary at 10-min intervals.
    • Magnesium intoxication: 4.5-9 mEq via IV infusion at a rate not to exceed 200 mg/minute.
    • Hypocalcemic tetany: 4.5-16 mEq via IV infusion at a rate not to exceed 200 mg/minute.
    • Calcium channel blocker overdosage: 5-10 mL (6.8- 13.6 mEq) of 10% calcium chloride or 10-20 mL(4.65-9.3 mEq) of 10% calcium gluconate IV over 5 minutes.
    • Hyperkalemia with secondary cardiac toxicity: 2.25-14 mEq IV. Repeat after 1-2 minutes as necessary.
  • 38.
    • HOW SUPPLIED
    • 10% solution in 10 ml ampules, vials, and prefilled syringes (100 mg/ml)
    • ONSET & DURATION
    • Onset: 5-15 min Duration: Dose dependent (effects may persist for 4 hr after IV administration)
    CALCIUM CHLORIDE
  • 39. CALCIUM CHLORIDE
    • ADVERSE EFFECTS
    • Decreased heart rate (may cause asystole)
    • Decreased blood pressure
    • Peripheral vasodilatation
    • Calcium cause vasospasm in coronary and cerebral arteries.
    • Severe local necrosis and sloughing after IM use or infiltration
    • Metallic taste
    • INTERACTIONS
    • May worsen dysrhythmias secondary to digitalis.
    • May antagonize the effects of verapamil.
  • 40. ISOPROTERENOL (Isuprel)
    • CLASSIFICATION
    • Sympathomimetic
    • Beta Adrenergic
    • Potent inotropic and chronotropic effects)
    • INDICATIONS
    • Temporary control of hemodynamically significant bradycardia after trying other medications
    • CONSIDERATIONS
    • Watch for tachyarrhymithias and myocardial ischemia
  • 41.
    • INDICATIONS
    • Isoproterenol has lost favor with ACLS because of it's
    • potential to worsen myocardial ischemia.
    • In situations where Isoproterenol was used in the past, TCP
    • is the treatment of choice.
    • USES
    • Increases pacemaker SA automaticity and AV conduction.
    • DOSAGE
    • IV infusion: Titrate 0.5mcg to 5mcg minutes.
    ISOPROTERENOL (Isuprel)
  • 42. ISOPROTERENOL (Isuprel)
    • ADVERSE EFFECTS
    • May cause worsening of myocardial ischemia and may cause PVC's or Ventricular Tachycardia. May result in undesired tachycardia. May result in hypotension from vasodilitation.
    • CONSIDERATIONS
    • Transcutanous pacing is now the treatment of choice in place of Isoproterenol. There has been supportive evidence that Isoproterenol may be helpful in Torsades de Point.
  • 43. VASOPRESSIN ( Pitressin )
    • CLASSIFICATION
    • Vasoconstrictor
    • INDICATIONS
    • VT/VF
    • For bleeding esophageal varices
    • ROUTE
    • IV
  • 44. VASOPRESSIN ( Pitressin )
    • DOSAGE
    • VT/VF: Given as a one time 40 units IVP dose (it has a long half life). May start epinephrine 10-20 minutes after vasopressin dose (ACLS protocols).
    • For bleeding esophageal varices: 0.2 units/minute initially. The infusion rate may be increased by 0.2 units/minute every hour if bleeding continues and up to 1 unit/minute
    • ROUTE
    • IV
  • 45. URGENT MEDICATIONS
  • 46. TPA (Alteplase, Activase)
    • INDICATIONS
    • For acute myocardial infarction
    • Other types of thrombosis
    • DOSAGE
    • For patients weighing over 67 kg. 1. Administer 15 mg IV bolus. 2. Then administer 50 mg over next 30 minutes. 3. Then administer 35 mg over next 60 minutes. Total dose - 100mg in 90min.
  • 47. LABETALOL (Normodyne)
    • CLASSIFICATION
    • A lpha1-receptor blocker
    • Nonselective beta-receptor blocker
    • INDICATIONS
    • Hypertension
    • Used to lower blood pressure in a hypertensive crisis
  • 48. LABETALOL (Normodyne)
    • CONTRAINDICATIONS
    • Bradycardia
    • Bronchial Asthma
    • CHF
    • Second and third degree heart blocks
    • Cardiogenic Shock
  • 49. LABETALOL (Normodyne)
    • HOW SUPPLIED
    • 100 mg in 20 ml of solvent ampoule (5 mg/ml)
    • DOSAGE
    • Adult: 5-20 mg slow IV over 2 min; additional injections of 10-40 mg can be given at 1 0-min intervals prn.
    • Infusion: Mix 200 mg in 250 ml D5W (0.8 mg/ml); infuse at a rate of 2 mg/min, titrate to supine blood pressure.
  • 50. LABETALOL (Normodyne)
    • INTERACTIONS
    • Bronchodilator effects of beta-adrenergic agonists may be blunted by labetalol.
    • Nitroglycerin may augment hypotensive effects.
    • ADVERSE EFFECTS
    • Hypotension
    • Postural hypotension
    • Ventricular dysrhythmias
    • Bradycardia
    • Heart Failure
    • Diaphoresis
    • Dizziness
    • Bronchospasm
    • Dyspnea
    • Facial flushing
    • Headache
  • 51. NITROGLYCERIN (Nitro-Bid)
    • MODES OF ACTION
    • Increased venous pooling causing decreased preload. Dilation of the veins predominates over that of arterioles.
    • Decreased arterial resistance causing decreased afterload. Vasodilation decreases myocardial workload and oxygen demand.
    • Coronary vessel dilation. This, combined with the reduction in preload, contributes to increased subendocardial perfusion.
    • Reduced platelet aggregation. This may contribute to its effectiveness in treating unstable angina.
  • 52.
    • INDICATIONS
    • Angina
    • CHF
    • Useful as venous dilator in reducing filling pressures and the symptoms of pulmonary congestion, in chronic heart failure, and are in the management of acute heart failure.
    • CONTRAINDICATIONS
    • Increased Intracranial Pressure
    NITROGLYCERIN (Nitro-Bid)
  • 53. NITROGLYCERIN (Nitro-Bid)
    • CONSIDERATIONS
    • If patients are given the drug without a break in therapy for more than a day they can develop tolerance.
    • Severe myocardial ischemia leading to infarction or death may occur after abrupt withdrawal of long-term nitrate therapy.
    • Oral nitroglycerin undergoes significant first-pass metabolism and has less than 1% oral bioavailability. The sublingual route is effective for the treatment of acute attacks of angina, and is preferred in order to avoid first-pass metabolism.
  • 54. NITROPRUSSIDE (Nipride)
    • CLASSIFICATION
    • Potent Vasodilator (arterial and venous)
    • ACTIONS
    • Reduces Afterload and Preload
    • Decreases work of heart (  SVR and PVR)
    • INDICATIONS
    • Hypertensive Crisis
    • Pulmonary Hypertension
    • Postoperative BP Control (cardiac surgeries)
  • 55. NITROPRUSSIDE (Nipride)
    • CONSIDERATIONS
    • Compatible with D 5 W only
    • Solution is reddish brown and sensitive to light
    • Requires close BP monitoring
    • Prolonged use may cause thiocyanate toxicity
    • (delirium, blurred vision, tinnitus)
    • Monitor thiocyanate levels with prolonged use (>2 days)
  • 56. NOREPINEPHRINE (LEVOPHED)
    • CLASSIFICATION
    • A lpha, Beta1, and Beta2 Adrenergic
    • Positive Inotropic
    • Vasoconstrictor
    • INDICATIONS
    • Indicated for non volume related hypotension
    • U sed for the treatment of cardiogenic shock
  • 57. NOREPINEPHRINE (LEVOPHED)
    • DOSAGE
    • Mix 4mg of Norepinephrine in 250cc of Normal Saline
    • Start at 2mcg/min and titrate up for desired effect
    • ADVERSE EFFECTS
    • May cause worsening of myocardial ischemia
    • May result in undesired tachycardia
    • May cause PVC's or Ventricular Tachycardia
  • 58. SODIUM BICARBONATE
    • INDICATIONS
    • Routine administration of sodium bicarbonate is Not Recommended.
    • USES
    • Known preexisting bicarbonate-responsive acidosis.
    • Intubated patient with continued long arrest interval.
    • Upon return of spontaneous circulation after long arrest.
    • Tricyclic antidepressant overdose.
    • Alkalinization for treatment of specific intoxications. 
  • 59. SODIUM BICARBONATE
    • DOSAGE
    • Give 1 mEq/kg IV, may repeat with 0.5 mEq/kg every 10 min.
    • ADVERSE EFFECTS
    • Metabolic alkalosis, hypoxia, rise in intracellular PCO2 and increased tissue acidosis, electrolyte imbalance (tetany), seizures and tissue sloughing at injection site.
    • CONSIDERATIONS
    • Hyperventilation is the treatment of choice to correct both metabolic and respiratory acidosis in a Code Blue situation.
  • 60. VERAPAMIL
    • CLASSIFICATION
    • A ntiarrhythmic and Antianginal agent
    • MODE OF ACTION
    • Works by inhibiting the movement of calcium ions across cell membranes.
    • D ecreases atrial automaticity, reduces AV conduction velocity, and prolongs the AV nodal refractory period.
    • D epresses myocardial contractility, reduces vascular smooth muscle tone, and dilates coronary arteries in normal and ischemic tissues.
  • 61.
    • MODES OF ACTION
    • Negative inotropic effect.
    • Negative chronotropic effect.
    • Negative dromotropic effect.
    • Potent vasodilator of coronary vessels.
    • Vasodilator of peripheral vessels.
    • INDICATIONS
    • Primarily used in PSVT, Atrial flutter with a rapid
    • ventricular response and Atrial fibrillation with a rapid
    • ventricular response.
    VERAPAMIL
  • 62. VERAPAMIL
    • DOSAGE
    • Give 2.5-5.0 mg IV bolus over 2 min; repeat doses of 5-10 mg may be given every 15-30 min.
    • ADVERSE EFFECTS
    • Hypotension, especially in hypovolemic patients. Other reactions include myocardial depression, heart failure, dizziness, headache, nausea and vomiting, bradycardia, complete AV block, and peripheral (dependent) edema. 
    • CONSIDERATIONS
    • Give Calcium Chloride as reversal agent for Verapamil.
  • 63. VERAPAMIL (Calan, Isoptin)
    • CONTRAINDICATIONS
    • · CHF . Patients with reduced ventricular function may not be able to counteract the inotropic and chronotropic effects of verapamil, the result being an even higher compromise of function.
    • · SA node or AV conduction disturbances. Use of verapamil is contraindicated in patients with SA or AV nodal abnormalities, because of its negative chronotropic and dromotropic effects.
    • · Low blood pressure . Patients with systolic blood pressures below 90 mm Hg should not be treated with verapamil.
    • · Digitalis toxicity . Verapamil is contraindicated for atrial tachycardia caused by digitalis toxicity, because of pharmacokinetic interactions that may lead to increased blood digoxin levels.
    • · Wolff-Parkinson-White syndrome induced atrial fibrillation . Verapamil may paradoxically increase ventricular rate in some patients because of accessory conduction pathways.
  • 64. COMMON CLASSIFICATIONS
  • 65. ANTIARRHYTHMICS
    • ANTIARRHYTHMIC AGENTS
    • Sodium Channel Blockers (Class I)
    • Beta-Adrenergic Blockers (Class II)
    • Drugs that Prolong Repolarization (Class III)
    • Calcium Channel Blockers (Class IV)
    • Miscellaneous
  • 66. INOTROPIC AGENTS
    • INOTROPIC AGENTS
    • Cardiac Glycosides
    • Digoxin (Lanoxin)
    • Digitoxin (Crystodigin)
    • Beta-Adrenergic Agonists
    • Dobutamine (Dobutrex)
    • Dopamine (Intropin)
    • Phosphodiesterase Inhibitors (Primacor)
  • 67. THROMBOLYTIC AGENTS
    • THROMBOLYTIC AGENTS
    • Tissue Plasminogen Activator (Activase)
    • Urokinase (Abbokinase)
    • Streptokinase (Streptase)
    • Anistreplase/APSAC (Eminase)
    • THROMBOLYTIC AGENTS ANTAGONISTS
    • Amiocaproic Acid (Amicar)
    • Tranexamic Acid (Amstat)
  • 68. GPIIbIIIa INHIBITORS
    • Inhibits Platelet Activation
    • ReoPro
    • Integrilin
    • Aggrastat
    • Inhibits Platelet Receptor Sites
    • Stops clotting activity at the site of the clot
    • Can stop an MI
  • 69. ANTICOAGULANTS
    • ANTICOAGULANTS
    • Heparin
    • Warfarin (Coumadin)
    • ANTICOAGULANT ANTAGONISTS
    • Protamine
    • Vitamin K
  • 70. ANTIPLATELET AGENTS
    • ANTIPLATELET AGENTS
    • Aspirin
    • Dextrans
    • Dipryridamole (Persantine)
    • Sulfinpyrazone (Anturane)
    • Ticlopidine (Ticlid)
  • 71. ANTIHYPERTENSIVE AGENTS
    • Alpha Antagonists
    • Beta Antagonists
    • Combined Alpha/Beta Antagonists
    • Adrenergic Neuron Blocking Agents
    • CNS-Acting Antihypertensives
    • Anti-Angiotensin II Agents
    • Angiotensin Converting Enzyme (ACE) Inhibitors
    • Angiotensin-II Receptor Antagonists
    • Calcium Channel Blockers
    • Diuretics
      • Thiazides
      • High-Ceiling (Loop)
      • Potassium-Sparing
  • 72. ACE INHIBITORS & ANGIOTENSIN II ANTAGONISTS
    • ACE INHIBITORS
    • Enalapril (Vasotec)
    • Lisinopril (Zestril)
    • Captopril (Capoten)
    • ANGIOTENSIN II ANTAGONISTS
    • Losartan
    • Irbesartan
  • 73.
    • DIURETICS
    • High-Ceiling (Loop)
    • Furosemide (Lasix)
    • Thiazides
    • Chlorthalidone (Hygroton)
    • Hydrochlorothiazide (HydroDIURIL)
    • Aldosterone Antagonists
    • Spironolactone (Aldactone)
    • Potassium-Sparing Antagonists
    • Triamterene (Dyrenium)
    • Amiloride (Midamor)
    DIURETICS
  • 74. ANTI-LIPIDEMICS
    • ACTIONS
    • Inhibits HMG-CoA reductase, which mediates the first committed step in sterol biosynthesis, and induce an increase in high-affinity LDL receptors.
    • EFFECTS
    • Decreases LDL cholesterol levels by increasing the fractional catabolic rate of LDL and the liver's extraction of LDL precursors.
    • Modest decrease in triglycerides.
    • Modest increase in HDL cholesterol.
  • 75. COMMON MEDICATIONS
  • 76. ALBUTEROL  
    • CLASSIFICATION
    • Sympathomimetic, Bronchodilator
    • Beta 2 Adrenergic
    • USES
    • Relief of bronchospasm in patients with reversible obstructive airway disease
    • Prevention of exercise-induced bronchospasm
    • CONSIDERATIONS
    • Beta blockers may antagonize ALBUTEROL
    • May precipitate angina pectoris and dysrhythmias
  • 77. ARAMINE (METARAMINOL BITARTRATE)
    • CLASSIFICATION
    • Sympathomimetic
    • Alpha & Beta adrenergic
    • Positive Inotrope
    • MODE OF ACTION
    • It has direct and indirect sympathomimetic effects on both alpha and beta receptors, with mainly alpha effects.
    • CENTRALLY : Aramine has a positive Inotropic effect on the myocardium increasing cardiac output and systolic BP
    • PERIPHERALLY : Aramine causes peripheral vasoconstriction resulting in increased diastolic BP
  • 78.
    • INDICATIONS
    • Prevention and treatment of acute hypotension related to spinal anaesthesia.
    • Adjunct in treatment of hypotension related to shock anaphylaxis and sepsis.
    • CONTRAINDICATIONS
    • Pulmonary edema.
    • Hypersensitivity.
    ARAMINE (METARAMINOL BITARTRATE)
  • 79. ARAMINE (METARAMINOL BITARTRATE)
    • PRECAUTIONS
    • Aramine contains sulfite that may cause allergic reactions including anaphylaxis.
    • Monitor response carefully to prevent severe hypertension, prolonged use can have an cumulative effect.
    • Reduce rate gradually to reduce likelihood of rebound hypotension.
    • Aramine should be administered via a large central vein or a long line to prevent extravasation.
  • 80. ATENOLOL (TENORMIN)
    • CLASSIFICATION
    • Beta Blocker / Beta Antagonist
    • MODE OF ACTION
    • It has anti-anginal effect due to decreased left ventricular work and decreased oxygen utilization (by a decreased in the heart rate).
    • It has an anti-arrhythmic effect due to its anti-sympathetic effect of depressing sinus and atrioventricular node function and prolongation of atrial refractory period.
  • 81.
    • INDICATIONS
    • Hypertension
    • Atrial and ventricular arrhythmias
    • Angina
    • AMI
    • Overdose of certain drugs
    • Thyrotoxicosis
    • DOSAGE
    • 5 mg IV over 5 minutes every 10 minutes (IV total 10 mg).
    • Oral atenolol therapy should be initiated immediately after the second IV bolus with 50 mg, followed by another 50 mg oral dose 12 hours later. (maintenance dose usually 100 mg/day).
    ATENOLOL (TENORMIN)
  • 82. DDAVP (DESMOPRESSIN ACETATE, MINIRIN)
    • CLASSIFICATION
    • Antidiuretic Hormone Analogue.
    • MODES OF ACTION
    • Antidiuretic: DDAVP acts at a receptor site in the renal collecting tubule to increase permeability to water reabsorption.
    • Coagulation: High doses of DDAVP produce marked and sustained increases of factor VIII coagulant activity and Von Willebrand factor. Plasminogen activator is also released.
  • 83.
    • INDICATIONS
    • Diabetes Insipidus
    • As a diagnostic test to establish renal concentration capacity.
    • Bleeding in patients with platelet dysfunction.
    • Help to stop bleeding in haemophilia A patients with episodes of spontaneous or trauma induced injuries such as hemathroses, I M,. Haematomas or mucosal bleeding.
    DDAVP (DESMOPRESSIN ACETATE, MINIRIN)
  • 84. DOBUTAMINE (DOBUTREX)
    • CLASSIFICATION
    • Inotropic agent
    • MODE OF ACTION
    • Beta adrenergic
    • Vasodilator
    • INDICATIONS
    • Cardiac failure
    • Congestive heart failure.
    • Acute pulmonary edema
  • 85.
    • DOSAGE
    • The starting dose is 2-5mcg/kg/min I.V. then titrated up to 20mcg/kg/min.
    • ADVERSE EFFECTS
    • Dobutamine may cause hypotension secondary to it's beta-2 properties.
    • Tachycardia may result from Dobutamine's beta-1 properties, do not permit the heart rate to increase by 10% of it's original rate.
    • Dobutamine may cause an increase in ventricular ectopy.
    DOBUTAMINE (DOBUTREX)
  • 86. DIGOXIN
    • CLASSIFICATION
    • Cardiac glycoside
    • ACTIONS
    • Positive Inotrope (  contractility)
    • Negative Dromotrope (  conduction)
    • Negative Chronotrope (  heart rate)
    • Increases refractory period
    • USES
    • CHF
    • PAT
    • Atrial Fib/Flutter
    • CONSIDERATIONS
    • Monitor Levels
    • Can cause lethal rhythms
  • 87. FLECAINIDE ACETATE (TAMBOCOR)
    • CLASSIFICATION
    • Antiarrhythmic
    • MODE OF ACTION
    • Inhibits the fast sodium channel responsible for the rapid upstroke of the myocardial action potential.
    • Depresses conduction in all parts of the heart with its greatest effect on his Purkinje system.
    • INDICATIONS
    • SVT due to AV nodal pathways.
    • Paroxysmal AF /flutter
    • Life threatening ventricular arrhythmias not controlled by other drugs.
  • 88. FUROSEMIDE ( LASIX)
    • CLASSIFICATION
    • Diuretic
    • ACTIONS
    • Inhibits reabsorption of souium
    • INDICATIONS
    • CHF
    • Pulmonary Edema
    • CONTRAINDICATIONS
    • Anuria
    • States of severe electrolyte depletion
  • 89. HEPARIN
    • CLASSIFICATION
    • Anticoagulant
    • Anti-thrombin
    • CONTRAINDICATIONS
    • Recent surgery or stroke
    • Thrombocytopenia
    • Hemorrhage
    • USES
    • AMI
    • DIC
    • Venous thrombosis
    • DVT prophylaxis
  • 90.
    • CLASSIFICATIONS
    • Beta Blocker
    METOPROLOL (LOPRESSOR)
    • INDICATIONS
    • Hypertension
    • AMI Intervention
    • Angina
    • CONSIDERATIONS
    • Watch for hypotension
    • Contraindicated with sinus bradycardia, second and third degree heart block
    • May block cardiovascular signs of hypoglycemia
  • 91. REFLUDIN
    • CLASSIFICATION
    • Anticoagulant
    • Anti-thrombin
    • USES
    • AMI
    • Heparin Induced Throbocytopenia
    • Venous thrombosis
    • DVT prophylaxis
    • ADVERSE EFFECTS
    • Bleeding
    • Anemia
  • 92. CORLOPAM (FENOLDOPAM)
    • CLASSIFICATION
    • Vasodilator
    • Anti-thrombin
    • USES
    • Severe hypertension (high dose)
    • Second line agent (low dose) for low urine output
    • RESTRICTIONS
    • Treatment duration of 48 hours
  • 93. CORLOPAM (FENOLDOPAM)
    • CLASSIFICATION
    • Vasodilator
    • Anti-thrombin
    • DOSAGE
    • Low urine out put
      • 0.03mcg/kg/min (titration not required)
    • Hypertension
      • Starting 0.03 - 0.1mcg/kg/min.
      • NO bolus dose should be given.
      • Titrate to patient response
      • Increase no faster than 0.05-0.1mcg/kg/min every 15 minutes. Max 1.6 mcg/kg/min.
  • 94. CORLOPAM (FENOLDOPAM)
    • CONSIDERATIONS
    • Monitor BP frequently
    • Monitor serum potassium and sodium
    • When treating hypertension, oral agents should be instituted as soon as possible.
    • ADVERSE EFFECTS
    • Hypotension
    • Tachycardia
  • 95. MILIRONE (PRIMACOR)
    • CLASSIFICATION
    • Phosphodiesterase inhibitor
    • ACTION
    • Positive Inotrope
    • Vasodilator
    • USES
    • CHF
    • Heart Failure
  • 96. NADOLOL (CORGARD)
    • CLASSIFICATION
    • Beta Blocker
    • USES
    • Angina
    • Hypertension
    • ACTIONS
    • Negative inotropic effect.
    • Negative chronotropic effect.
    • Antihypertensive.
    • Decreased renin production.
  • 97. NALOXONE (NARCAN)
    • CLASSIFICATION
    • Opioid Antagonist
    • Narcotic antagonist
    • USES
    • To reverse the effects of opioids
    • Reverses the effects of morphine
  • 98. NOREPINEPHRINE (LEVOPHED)
    • CLASSIFICATION
    • Catecholamine
    • Alpha Adrenegic
    • Beta Adrenergic
    • CONSIDERATIONS
    • Increases myocardial oxygen demand
    • INDICATIONS
    • Acute Hypotension
    • Shock
  • 99. PHENYLEPHRINE (Neo-Synephrine)
    • CLASSIFICATION
    • Sympathomimetic
    • Alpha Adrenergic
    • INDICATIONS
    • Shock
    • Drug induced hypotension
    • Hypersensitivity Reactions
    • CONSIDERATIONS
    • Vasoconstrictor Only
  • 100. OXYTOCIN (PITOCIN)
    • CLASSIFICATION
    • Synthetic Hormone
    • INDICATIONS
    • Stimulate Birth
    • CONTRAINDICATIONS
    • Presence of a second fetus
  • 101. PHENYTOIN (DILANTIN)
    • CLASSIFICATION
    • Anticonvulsants
    • Antiarrhythmic
    • INDICATIONS
    • Grand mal/psychomotor seizures
    • Certain ventricular arrhythmias (ie: digoxin induced VT)
    • DOSAGES
    • Status epilepticus: (Adults) loading dose 10-15 mg/kg at a rate not to exceed 50 mg/min; then, 100 mg PO or IV q 6-8 hr.
    • Arrhythmias: ( Adults): 100 mg q 5 min up to maximum of 1 g.
  • 102. PROPOFOL (DIPRIVAN)
    • CLASSIFICATION
    • Sedative
    • Anesthetic
    • ADVERSE EFFECTS
    • Hypotension
    • Bradycardia
    • Apnea
    • Twitching
    • Seizures
    • Fever
    • INDICATIONS
    • ICU Sedation
  • 103. PROTAMINE (Protamine Sulphate)
    • CLASSIFICATION
    • Heparin Antagonist
    • INDICATIONS
    • Heparin Overdose
    • Bleeding while on heparin therapy
    • CONSIDERATIONS
    • Watch for heparin rebound
  • 104. SOTOLOL (BETAPASE)
    • CLASSIFICATION
    • Antiarrhythmic
    • ACTIONS
    • Blocks beta-adrenergic receptors.
    • Blocks potassium channels in cardiac muscle.
    • Negative inotropic effect.
    • Negative chronotropic effect.
    • Prolongs action potential duration and refractory period.
  • 105.
    • CLASSIFICATION
    • Neuromuscular Blocker
    VECURONIUM BROMIDE (NORCURON)
    • INDICATIIONS
    • Skeletal muscle relaxation during intubation/mechanical ventilation
    • Adjunct in general anesthesia
    • CONSIDERATIONS
    • Does not relieve pain, anxiety or affect consciousness
    • Will cause paralysis with apnea
  • 106. OTHER MEDICATIONS
  • 107. HALDOL
    • CLASSIFICATION
    • Butyrophrnone
    • Antipsychotic
    • INDICATIIONS
    • Psychosis
    • Nonpsychotic Behavior Disorders
    • Delirium
    • Tourette Syndrome
    • CONSIDERATIONS
    • Does not relieve pain, anxiety or affect consciousness
    • Will cause paralysis with apnea
  • 108. INTEGRILIN
    • CLASSIFICATION
    • GPIIb/IIIa Inhibitor
    • INDICATIONS
    • AMI
    • CONSIDERATIONS
    • Must screen patients
    • Need large bore IV’s
    • prior to administration
  • 109. MANNITOL
    • CLASSIFICATION
    • Osmotic Diuretic
    • INDICATIONS
    • Intracranial Swelling
    • Marked Oliguria
    • CONSIDERATIONS
    • Must warm solution to dissolve crystals
    • Watch for acute herniation
  • 110. MORPHINE
    • CONSIDERATIONS
    • Monitor for respiratory depression,
    • hypotension, bradycardia, and/or
    • decreased LOC.
    • Venous vasodilator: Decreases pulmonary
    • congestion and reduces work of heart.
    • Have Narcan available for reversal.
  • 111. MIDAZOLAM (VERSED)
    • CONSIDERATIONS
    • Monitor for respiratory depression,
    • hypotension, bradycardia, and/or
    • decreased LOC.
    • Induces amnesia.
    • Have Romazicon available for reversal.
  • 112. MUCAMYST (Aceteylcysteine)
    • CLASSIFICATION
    • Tylenol antidote
    • Mucolytic
    • CONSIDERATIONS
    • May cause bronchoconstriction
    • when used in aerosol
  • 113. PHENTOLAMINE (REGITINE)
    • CLASSIFICATION
    • Alpha Blocker
    • INDICATION & CONSIDERATIONS
    • Used for extravasation necrosis
    • such as infiltration of Dopamine.
    • Used to prevent hypertension with
    • test for pheochromocytoma.
    • Don’t give epinephrine to treat
    • phentolamine-induced hypotension
    • (give norepinephrine)
  • 114. THEOPHYLLINE (Aminophylline)
    • CLASSIFICATION
    • Bronchodilator
    • Spasmolytic
    • Beta Adrenergic
    • INDICATIONS
    • Bronchospasms
    • CHF
    • COPD
    • CONSIDERATIONS
    • Monitor Levels
    • Can cause seizures
  • 115. THE END
  • 116. References
    • Guidelines for Pacemakers and Defibrillators Updated. Journal Watch General Medicine 1998: 2-2.
    • Wood, D.A., Fox, K.F., Gibbs, S.R. (2001). Rapid cardiology--for chest pain, breathlessness and palpitations. QJ Med 94: 177-178.  
    • HAMMILL, S. C., HUBMAYR, R. D. (2000). The Rapidly Changing Management of Cardiac Arrhythmias. Am J Respir Crit Care Med 161: 1070-1073.
    • Bauersfeld, U., Nowak, B., Molinari, L., Malm, T., Kampmann, C., Schonbeck, M. H., Schuller, H. (1999). Low-energy epicardial pacing in children: the benefit of autocapture. Ann. Thorac. Surg. 68: 1380-1383.
    • KURBAAN, A S, SUTTON, R (1999). Pacing for vasovagal syncope. Heart 82: 649-650
    • Braunwall, e. (1992) Heart Disease : a textbook of cardiovascular disease, 4 th edition, WB Saunders
    • American Radio Relay League, Inc., Technical Information Service, 225 Main St., Newington, CT 06111 (860) 594-0214.
    • Thelan, Lynne A., Davie, Joseph K., Urden, Linda D., Lough, Mary E. (1994) Critical Care Nursing: Diagnosis and Management. Second Edition. Pg 313-322.
    • Graver, K (1998) A Practical Guide to EKG Interpretation, 2 nd edition
    • On-line: http://www.emedicine.com/emerg/topic699.htm
    • Dames' Clinical Nursing Education Webring