Acute Coronary Syndromes Pharmacology

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  • Epinephrine (Class Indeterminate) 1 mg IV push every 3 to 5 minutes. If this fails, higher doses of epinephrine (up to 0.2 mg/kg) are acceptable but not recommended (there is growing evidence that it may be harmful). Vasopressin is recommended only for VF/VT; there is no evidence to support its use in asystole or PEA. There is no evidence about The value of repeated vasopressin doses or The best approach after the first single bolus of vasopressin As a Class Indeterminate action, it is acceptable to resume epinephrine 1 mg IV push every 3 to 5 minutes if there was no response in 5 to 10 minutes to a single IV dose of vasopressin. The evidence for this approach is based on rational conjecture. Suggestion to instructors Resist the requests to tell the learners whether you prefer epinephrine or vasopressin. The evidence, as of 2001, makes them equivalent, with vasopressin, as a nonadrenergic agent, associated with fewer adverse side effects. The supply chain from production to widespread distribution throughout all hospitals and the EMS system has been slow to develop.
  • Acute Coronary Syndromes Pharmacology

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

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