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  • 1.  
  • 2. Bradycardia
    • Atropine
    • Dopamine infusion
    • Epinephrine infusion
  • 3. Atropine
    • Mechanism of Action
      • Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes)
  • 4. Atropine
    • Indications
      • First drug for symptomatic sinus bradycardia
      • May be beneficial in AV block or asystole
      • Second drug in asystole or slow PEA
      • Organophosphate poisoning; large dose may be needed
    • Precautions
      • MI and hypoxia – atropine increases oxygen demand
      • Avoid in hypothermia
      • Not effective for 2 nd type II or new 3 rd degree block (may slow the rhythm)
      • Doses < 0.5 mg may cause a paradoxical slowing
  • 5. Atropine
    • Asystole or slow (<60)PEA
      • 1 mg IV/IO push
      • Repeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg.
    • Bradycardia
      • 0.5 mg IV every 3-5 minutes as needed; max. of 3 mg.
      • Use shorter dosing interval and higher doses in severe clinical situations
    • Endotracheal Administration
      • 2-3 mg diluted in 10 mL water or NS
    • Organophosphate Poisoning
      • Large doses (2-4 mg or higher) may be necessary
    Don’t delay pacing for severely symptomatic (unstable) patients.
  • 6. Dopamine
    • Mechanism of Action
      • Stimulates adrenergic receptors; dose dependent.
  • 7. Dopamine
    • Indications
      • Second-line drug for symptomatic bradycardia
      • Hypotension with signs and symptoms of shock
    • Precautions
      • Correct hypovolemia with volume before initializing
      • Use caution with cardiogenic shock and associated CHF
      • May cause tachydysrhythmias; excessive vasoconstriction
      • Don’t mix with sodium bicarbonate
    • IV Administration
      • Infusion at 5-20 mcg/kg/min.
      • Titrate to patient response; taper slowly
  • 8. Epinephrine
    • Mechanism of Action
      • Stimulates adrenergic receptors and is not dose dependent like dopamine.
  • 9. Epinephrine
    • Indications
      • Cardiac arrest
        • VF; VT; asystole; PEA
      • Symptomatic bradycardia
        • After atropine; alternative to dopamine
      • Severe hypotension
        • When atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitors
      • Anaphylaxis; severe allergic reactions
        • Combine with large fluid volume; corticosteroids; antihistamines
  • 10. Epinephrine
    • Precautions
      • May increase myocardial ischemia, angina, and oxygen demand
      • High doses do not improve survival; may be detrimental
      • Higher doses may be needed for poison/drug induced shock
    • Dosing
      • Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min.
      • High dose up to 0.2 mg/kg for specific drug OD’s
      • Infusion of 2-10 mcg/min.
      • Endotracheal of 2-2.5 times normal dose
      • SQ/IM 0.3-0.5 mg
  • 11. Tachycardia
    • Adenosine
    • Diltiazem
    • Metoprolol
    • Amiodarone
    • Lidocaine
    • Magnesium Sulfate
  • 12. Adenosine
    • Mechanism of Action
      • Slows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.
  • 13. Adenosine
    • Indications
      • 1 st drug for stable, narrow complex, regular SVT
      • May consider for unstable SVT while preparing for cardioversion
      • Wide-complex tachycardia thought to be, or determined to be reentry SVT
      • Does not convert atrial fibrillation, atrial flutter, or VT
      • Diagnostic maneuver; stable narrow-complex SVT
  • 14. Adenosine
    • Contraindications/Precautions
      • Poison/drug induced tachycardia is contraindicated
      • 2 nd and 3 rd degree block is contraindicated
      • Transient side effects; flushing, CP, asystole, brady, ectopy
      • Less effective with theophylline or caffeine
      • If used for VT may cause worsening of clinical condition
      • Transient periods of sinus brady or ventricular ectopy common after termination of SVT
      • Safe in pregnancy
  • 15. Adenosine
    • Place supine or mild reverse Trendelenburg
    • 6 mg rapidly followed by 20 mL flush
    • May repeat at 12 mg every 1-2 minutes if unsuccessful
  • 16. Diltiazem
    • Mechanism of Action
      • Inhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.
  • 17. Diltiazem
    • Indications
      • Controlling ventricular rate in a-fib or flutter
      • After adenosine to treat refractory reentry SVT if adequate blood pressure
    • Contraindications/Precautions
      • Do not use with wide-complex rhythms
      • Do not use with poison/drug induced tachycardia
      • Avoid in WPW
      • Avoid in AV nodal blocks
      • Blood pressure may drop from peripheral vasodilation
  • 18. Diltiazem
    • Rate control
      • 15-20 mg (0.25 mg/kg) IV over 2 minutes
      • After 15 min. another 20-25 mg (0.35 mg/kg) IV over 2 minutes, if needed
    • Maintenance Infusion
      • 5-15 mg/hour; titrated to physiologically appropriate heart rate
  • 19. Metoprolol
    • Mechanism of Action
      • Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.
  • 20. Metoprolol
    • Indications
      • Administer to all patients with suspected MI or unstable angina, absent contraindications
      • Second-line agent for SVT refractory to adenosine
      • To reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressure
      • Emergency antihypertensive therapy for acute hemorrhagic or ischemic stroke
  • 21. Metoprolol
    • Contraindications/Precautions
      • Hemodynamically unstable patients should not receive
        • Signs of heart failure
        • Low cardiac output
        • Increased risk for cardiogenic shock
      • Relative contraindications: 1 st , 2 nd , 3 rd degree blocks; active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHg
      • Concurrent administration of calcium channel blockers can cause serious hypotension
      • Monitor cardiac and pulmonary status throughout
  • 22. Amiodarone
    • Mechanism of Action
      • Prolongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.
  • 23. Amiodarone
    • Indications
      • Life threatening dysrhythmias
        • VF/pulseless VT unresponsive to shock, CPR, and vasopressor
        • Recurrent hemodynamically unstable VT
        • Seek expert opinion for other uses
    • Contraindications/Precautions
      • Bradycardia
      • 2 nd and 3 rd degree block
      • Do not administer with meds that prolong QT interval (procainamide)
  • 24. Amiodarone
    • VF/VT – 300 mg IV/IO in 20-30 mL NS. Can follow with ONE dose of 150 mg in 3-5 minutes, if needed.
    • Life threatening dysrhythmias
      • 150 mg over 10 minutes. May repeat every 10 minutes as needed.
  • 25. Lidocaine
    • Mechanism of Action
      • Decreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.
  • 26. Lidocaine
    • Indications
      • Alternative to amiodarone in VF/VT arrest
      • Stable monomorphic VT
      • Malignant PVC’s
      • Can be used if Torsades is suspected
    • Contraindications/Precautions
      • Prophylactic use in AMI is contraindicated
      • Reduce maintenance dose in liver impaired patients
      • Discontinue infusion if toxicity develops
  • 27. Lidocaine
    • Cardiac Arrest
      • Initial dose is 1-1.5 mg/kg
      • Refractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3 mg/kg
      • Endotracheal dose 2-4 mg/kg
    • Perfusing Dysrhythmia
      • 0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kg
    • Maintenance Infusion
      • 1-4 mg/min
  • 28. Magnesium Sulfate
    • Mechanism of Action
      • Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.
  • 29. Magnesium Sulfate
    • Indications
      • Torsades is suspected in cardiac arrest
      • Lfe-threatening ventricular dysrhythmias in digitalis OD
    • Precautions
      • Fall in BP with rapid administration
      • Use caution in renal failure
    • Dosing
      • Arrest 1-2 g over 5-20 min.
      • Torsades w/ pulse 1-2 g over 5-60 min.
  • 30. Vasopressin
    • Mechanism of Action
      • Causes vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.
  • 31. Vasopressin
    • Indications
      • Alternative to epinephrine in adult refractory VF/VT
      • Alternative to epinephrine in asystole or PEA
    • Contraindications/Precautions
      • Potent peripheral vasoconstrictor (increased demand upon resuscitation)
    • Dosing
      • Single dose of 40 u that replaces either the 1 st or 2 nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes after
      • Can be used endotracheally; no suggested dose