This document discusses drugs used in cardiopulmonary resuscitation (CPR) and emergencies. It provides details on the mechanism of action, indications, contraindications, adverse reactions and considerations for over 30 different drugs including epinephrine, vasopressin, atropine, lidocaine, sodium bicarbonate, amiodarone, magnesium sulfate, defibrillation, naloxone, flumazenil, atipamezole, activated charcoal, adenosine, albuterol, alteplase, amiodarone, amyl nitrite, aspirin, atenolol, atropine sulfate, calcium chloride, calcium gluconate,

1. Drugs used in CPR and
Emergency
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Dr. Binu Babu
Ph. D (N), MSN, MBA
Mrs. Jincy Ealias
MSN, RN

2. Drugs used in CPR
• Cardiopulmonary resuscitation is an
emergency procedure consisting of chest
compressions often combined with artificial
ventilation in an effort to manually preserve
intact brain function until further measures
are taken to restore spontaneous blood
circulation and breathing in a person who is
in cardiac arrest.
• The drugs which supports CPR are follows.
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3. Drug IV Dosage Indications
Epinephrine
Low dosage (0.01 mg/kg);
High dosage (0.1 mg/kg)
after prolonged CPR;
10 times the dosage may be
required when given IT
Administered every 3–5 minutes
early in CPR (every other cycle) for
asystole, ventricular fibrillation,
PEAb
Vasopressin 0.4–0.9 U/kg
As an alternative to epinephrine
every 3–5 minutes (every second
BLS cycle) for asystole,
bradycardia, PEA
Atropine
0.04 mg/kg;
0.1 mL/5 lb (0.5 mg/mL
solution)
Sinus bradycardia, asystole, or PEA
associated with high vagal tone
Lidocaine 2–4 mg/kg
Pulseless ventricular tachycardia,
ventricular fibrillation resistant to
defibrillation
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4. Drug IV Dosage Indications
Sodium
bicarbonate
1 mEq/kg (1 mEq/mL
solution)
Severe metabolic acidemia (pH < 7.0)
associated with prolonged (>10–15
minutes) CPR efforts (must be adequately
ventilated to be effective), hyperkalemia
Calcium gluconate
1 mL/5–10 kg (2% solution
without epinephrine)
Routine use not recommended; treat cases
with documented hypocalcemia or severe
hyperkalemia
Amiodarone 5 mg/kg
Refractory ventricular fibrillation or
pulseless ventricular tachycardia
Magnesium sulfate 30 mg/kg Hypomagnesemia, torsades des pointes
Defibrillation
4–6 J/kg external
monophasic;
2–4 J/kg external biphasic;
0.5–1 J/kg internal
monophasic;
0.2–0.4 J/kg internal
biphasic
Single shock for ventricular fibrillation or
pulseless ventricular tachycardia; resume
CPR efforts immediately after for one
cycle (2 minutes) and reassess ECG, after
which dosage escalation by 50% may
occur (maximum dosage of 10 joules/kg)
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5. Drug IV Dosage Indications
Naloxone 0.02–0.04 mg/kg To reverse opioids
Flumazenil 0.01–0.02 mg/kg
To reverse
benzodiazepines
Atipamezole
0.05 mg/kg (or same
volume as
dexmedetomidine)
To reverse
dexmedetomidine
Reversal Agents
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6. Drugs used in Emergency
• A patient may unexpectedly experience a
medical emergency needs to have the
equipment to deal with that emergency
efficiently.
• A crash cart contains all emergency
equipment and medications that would be
required to treat a patient in the golden
hours or so of a medical emergency.
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7. Activated Charcoal
• Mechanism of action
– Absorbs toxic substances
from the gastrointestinal
tract
• Indications
– Most oral poisonings/
medication overdoses
• Contraindications
– Oral administration to
comatose patients
• Adverse reactions
– If aspirated, can
induce fatal form
of pneumonitis
– Bowel obstruction
• Considerations
– Mix contents well before
administration.
– Does not absorb cyanide,
lithium, iron, lead, or
arsenic
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8. Adenosine
• Mechanism of action
– Slows conduction through
the AV node
– Can interrupt reentrant
pathways
– The drug of choice for
reentry SVT
• Indications
– Most forms of stable
narrow-complex SVT
• Contraindications
– Bronchoconstrictive or
bronchospastic lung
disease
• Adverse reactions
– Generally short duration
and mild
• Considerations
– Evaluate elderly for signs
of dehydration
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9. Albuterol
• Mechanism of action
– Results in smooth-muscle
relaxation in
the bronchial tree
• Indications
– Treatment of
bronchospasm in
patients with
COPD/asthma)
• Contraindications
– Hypersensitivity
reactions to albuterol
• Adverse reactions
– Often dose-related and
include headache, fatigue,
lightheadedness,
irritability, restlessness
• Considerations
– Pregnancy safety:
Category C
– May precipitate angina
pectoris and dysrhythmias
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10. Alteplase
• Mechanism of action
– Restores perfusion
• Indications
– Acute myocardial
infarction, STEMI, massive
pulmonary emboli, acute
ischemic cerebrovascular
accident
• Contraindications
– Active internal bleeding
– Recent surgery
• Adverse reactions
– Intracranial bleeding,
reperfusion dysrhythmias,
chest pain, hypotension,
GI bleeding, nausea,
abdominal pain
• Considerations
– Monitor vital signs closely.
– Observe for bleeding.
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11. Amiodarone
• Mechanism of action
– Delays repolarization and
increases the duration of
action potential
• Indications
– Ventricular fibrillation
• Contraindications
– Known hypersensitivity to
amiodarone or iodine
– Cardiogenic shock
• Adverse reactions
– Dizziness, fatigue, malaise
– Congestive heart failure
• Considerations
– Pregnancy safety:
Category D
– Monitor patient
for hypotension.
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12. Amyl Nitrite
• Mechanism of action
– Converts hemoglobin to
methemoglobin to prevent
toxic effects
• Indications
– Cyanide poisoning
• Contraindications
– None in emergency
settings
• Adverse reactions
– Headache, dizziness,
weakness
• Considerations
– Pregnancy safety:
Category X
– Highly flammable
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13. Aspirin
• Mechanism of action
– Prevents platelets from
clumping together and
forming emboli
• Indications
– New onset chest pain
suggestive of acute
myocardial infarction
• Contraindications
– Relatively contraindicated
in patients with active
ulcer disease or asthma
• Adverse reactions
– Bronchospasm,
anaphylaxis, wheezing
in allergic patients,
prolonged bleeding
• Considerations
– Pregnancy safety:
Category D
– Not recommended in
pediatric population
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14. Atenolol
• Mechanism of action
– Decreases heart rate,
myocardial contractility,
and cardiac output
• Indications
– To reduce myocardial
ischemia and damage in
acute myocardial
infarction patients
• Contraindications
– Heart failure, cardiogenic
shock, bradycardia
• Adverse reactions
– Dizziness, bronchospasm,
bradycardia
• Considerations
– Pregnancy safety:
Category D
– Atenolol must be given
slowly IV over 5 minutes
– Should be used with
caution in patients with
liver or renal dysfunction
and COPD
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15. Atropine Sulfate
• Mechanism of action
– Increases heart rate in
life-threatening
bradydysrhythmias
• Indications
– Hemodynamically
unstable bradycardia
• Contraindications
– Tachycardia,
hypersensitivity
• Adverse reactions
– Drowsiness, confusion,
headache, tachycardia,
palpitations
• Considerations
– Pregnancy safety:
Category C
– Moderate doses may
cause pupillary dilation.
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16. Calcium Chloride
• Mechanism of action
– Increases cardiac
contractile state
• Indications
– Hypocalcemia,
hyperkalemia,
hypermagnesemia
• Contraindications
– Hypercalcemia,
ventricular fibrillation,
digitalis toxicity
• Adverse reactions
– Syncope, cardiac
arrest, dysrhythmia,
bradycardia
• Considerations
– Pregnancy safety:
Category C
– Do not use routinely
in cardiac arrest.
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17. Calcium Gluconate
• Mechanism of action
– Counteracts the toxicity of
hyperkalemia
• Indications
– Hyperkalemia,
hypocalcemia
• Contraindications
– Ventricular fibrillation,
digitalis toxicity,
hypercalcemia
• Adverse reactions
– Syncope, cardiac
arrest, dysrhythmia,
bradycardia
• Considerations
– Pregnancy safety:
Category C
– Do not administer by
IM or SQ
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18. Clopidogrel
• Mechanism of action
– Inhibits platelet
aggregation
• Indications
– Acute coronary syndrome
– Substitute for aspirin in
patients unable to take
aspirin
• Contraindications
– Active GI bleeding,
intracranial hemorrhage
• Adverse reactions
– Severe neutropenia
– Hemorrhaging
• Considerations
– Pregnancy safety:
Category B
– Often given with
other anticoagulants
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19. Dexamethasone Sodium
Phosphate
• Mechanism of action
– Suppresses acute and
chronic inflammation
• Indications
– Anaphylaxis, asthma,
spinal cord injury
• Contraindications
– Hypersensitivity, use
caution in suspected
systemic sepsis
• Adverse reactions
– Headache, restlessness,
euphoria, psychoses
• Considerations
– Pregnancy safety:
Category C
– Protect medication from
heat. Toxicity and side
effects occur with long-
term use.
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20. Dextrose
• Mechanism of action
– Rapidly increases serum
glucose levels
• Indications
– Hypoglycemia, altered
level of consciousness
• Contraindications
– Intracranial hemorrhage
• Adverse reactions
– Cerebral hemorrhage
– Cerebral ischemia
– Pulmonary edema
• Considerations
– Pregnancy safety:
Category C
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21. Diazepam
• Mechanism of action
– Raises the seizure
threshold; induces
amnesia and sedation
• Indications
– Acute anxiety states and
agitation, acute alcohol
withdrawal
• Contraindications
– Hypersensitivity, narrow-
angle glaucoma
• Adverse reactions
– Dizziness, drowsiness,
confusion, headache
• Considerations
– Pregnancy safety:
Category D
– Short duration for
anticonvulsant effect
– Reduce dose by 50%
in elderly patients.
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22. Digoxin
• Mechanism of action
– Increases force of
myocardial contraction
• Indications
– Congestive heart failure,
reentry SVTs, ventricular
rate control in atrial flutter
and atrial fibrillation
• Contraindications
– Ventricular fibrillation,
ventricular tachycardia,
digitalis toxicity
• Adverse reactions
– Fatigue, headache, blurred
yellow or green vision,
seizures
• Considerations
– Pregnancy safety:
Category C
– Patient receiving IV
digoxin must be on a
monitor
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23. Dopamine Hydrochloride
• Mechanism of action
– Increases myocardial
contractility and stroke
volume
• Indications
– Cardiogenic and septic
shock, hypotension with
low cardiac output states
• Contraindications
– Hypovolemic shock,
pheochromocytoma,
tachydysrhythmias
• Adverse reactions
– Headache, anxiety,
dyspnea, dysrhythmias
• Considerations
– Pregnancy safety:
Category C
– Effects are dose-
dependent
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24. Epinephrine (Adrenalin)
• Mechanism of action
– Blocks histamine
receptors
• Indications
– Cardiac arrest,
symptomatic bradycardia
• Contraindications
– Hypertension,
hypothermia, pulmonary
edema
• Adverse reactions
– Nervousness, restlessness,
headache, tremor
• Considerations
– Pregnancy safety:
Category C
– May cause syncope in
asthmatic children
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25. Furosemide (Lasix)
• Mechanism of action
– Causes increased
urine output
• Indications
– CHF, pulmonary edema,
hypertensive crisis
• Contraindications
– Hypovolemia, anuria,
hypotension
• Adverse reactions
– Dizziness, headache, ECG
changes, weakness
• Considerations
– Pregnancy safety:
Category C
– Ototoxicity, deafness, and
projectile vomiting can
occur with rapid
administration.
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26. Hydrocortisone Sodium Succinate
• Mechanism of action
– Anti-inflammatory;
immunosuppressive with
salt-retaining actions
• Indications
– Shock due to acute
adrenocortical
insufficiency, anaphylaxis,
asthma, and COPD
• Contraindications
– Systemic fungal infections,
premature infants
• Adverse reactions
– Headache, vertigo,
pulmonary tuberculosis
• Considerations
– Pregnancy safety:
Category C
– May be used in status
asthmaticus as a
second-line drug
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27. Insulin
• Mechanism of action
– Allows glucose transport
into cells of all tissues
• Indications
– Not used in emergency
prehospital setting
• Contraindications
– Hypoglycemia,
hypokalemia
• Adverse reactions
– Weakness, fatigue,
confusion, headache
• Considerations
– Pregnancy safety:
Category B
– Insulin is the drug of
choice for control of
diabetes in pregnancy.
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28. Magnesium Sulfate
• Mechanism of action
– Reduces striated muscle
contractions
• Indications
– Seizures of eclampsia,
torsades de pointes,
hypomagnesemia
• Contraindications
– Heart block, myocardial
damage
• Adverse reactions
– Drowsiness, CNS
depression, respiratory
depression
• Considerations
– Pregnancy safety:
Category A
– Recommended that
the drug not be
administered in the
2 hours before delivery, if
possible
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29. Mannitol
• Mechanism of action
– Decreases cerebral edema
and intracranial pressure
• Indications
– Cerebral edema
• Contraindications
– Hypotension,
pulmonary edema,
severe dehydration,
intracranial bleeding,
CHF
• Adverse reactions
– Headache, confusion,
seizures, pulmonary
edema
• Considerations
– Pregnancy safety:
Category C
– May crystallize at low
temperatures; store at
room temperature
– Have ventilatory support
available.
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30. Naloxone Hydrochloride
• Mechanism of action
– Reverses respiratory
depression secondary to
opiate drugs
• Indications
– Opiate overdose, complete
or partial reversal of
central nervous system
and respiratory
depression induced by
opioids
• Contraindications
– Use with caution in
narcotic-dependent
patients
• Adverse reactions
– Restlessness, seizures,
dyspnea, pulmonary
• Considerations
– Pregnancy safety:
Category C
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31. Nifedipine
• Mechanism of action
– Inhibits movement
of calcium ions across cell
membranes
• Indications
– Hypertensive crisis,
angina pectoris
• Contraindications
– Compensatory
hypertension,
hypotension
• Adverse reactions
– Headache, dizziness,
nervousness, weakness,
mood changes
• Considerations
– Pregnancy safety:
Category C
– Have beta blocker
available for control of
reflex tachycardia
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32. Nitroglycerin
• Mechanism of action
– Smooth muscle relaxant
acting on vasculature,
bronchial, uterine,
intestinal smooth muscle
• Indications
– Acute angina pectoris,
ischemic chest pain
• Contraindications
– Hypotension,
hypovolemia, intracranial
bleeding or head injury
• Adverse reactions
– Headache, dizziness,
weakness, reflex
tachycardia
• Considerations
– Pregnancy safety:
Category C
– Hypotension more
common in the elderly
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33. Norepinephrine
• Mechanism of action
– Potent alpha-agonist
resulting in intense
peripheral
vasoconstriction
• Indications
– Cardiogenic shock,
unresponsive to fluid
resuscitation
• Contraindications
– Hypotensive patients with
hypovolemia
• Adverse reactions
– Headache, anxiety,
dizziness
• Considerations
– Pregnancy safety:
Category C.
– May cause fetal anoxia
when used in pregnancy
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34. Ondansetron Hydrochloride
• Mechanism of action
– Blocks action of serotonin
• Indications
– Prevention and control of
nausea or vomiting
• Contraindications
– Known allergy to
ondansetron
• Adverse reactions
– Headache, malaise,
wheezing
• Considerations
– Pregnancy safety:
Category B
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35. Phenytoin
• Mechanism of action
– Promotes sodium
efflux from neurons
• Indications
– Prophylaxis and treatment
of major motor seizures
• Contraindications
– Hypersensitivity,
bradycardia
• Adverse reactions
– Ataxia, agitation,
dizziness, headache,
drowsiness
• Considerations
– Pregnancy safety:
Category D
– Carefully monitor vital
signs.
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36. Sodium Bicarbonate
• Mechanism of action
– Buffers metabolic acidosis
and lactic acid buildup
• Indications
– Metabolic acidosis during
cardiac arrest, tricyclic
antidepressant, aspirin
• Contraindications
– Metabolic/respiratory
alkalosis, hypokalemia,
electrolyte imbalance
• Adverse reactions
– Hypernatremia, metabolic
alkalosis, tissue sloughing,
cellulitis
• Considerations
– Pregnancy safety:
Category C
– Repeat as needed in
tricyclic antidepressant
overdose until QRS
narrows
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37. Streptokinase
• Mechanism of action
– Combines with
plasminogen to convert
free plasminogen to the
proteolytic enzyme,
plasmin
• Indications
– Acute myocardial
infarction, massive
pulmonary emboli,
arterial thrombosis/
embolism, to clear
intraventricular cannula
• Contraindications
– Hypersensitivity, active
bleeding, recent cerebral
vascular accident
• Adverse reactions
– Intracranial hemorrhage,
bronchospastic
hemoptysis, ARDS
• Considerations
– Pregnancy safety:
Category C
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38. Vasopressin
• Mechanism of action
– Stimulation of smooth
muscle receptors
• Indications
– Alternative vasopressor
to the first or second
dose of epinephrine
in cardiac arrest
• Contraindications
– Use with caution in
patients with coronary
artery disease, epilepsy, or
heart failure.
• Adverse reactions
– Dizziness, headache,
bronchial constriction,
MI, chest pain, angina
• Considerations
– Pregnancy safety:
Category C
– May increase peripheral
vascular resistance and
provoke cardiac ischemia
and angina
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39. IV Solutions (Colloids and
Crystalloids)
• Colloids
– Expand plasma volume
– Most often used in hypovolemic shock states
• Crystalloid solutions are used for:
– Electrolyte replacement
– A route for medication
– Short-term intravascular volume expansion
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40. Dextran
• Mechanism of action
– Sugar-containing colloid
used as an intravascular
volume expander
• Indications
– Hypovolemic shock
• Contraindications
– Patients with congestive
heart failure, renal failure,
or known bleeding
disorders
• Adverse reactions
– Rash, itching, dyspnea,
chest tightness, and mild
hypotension
• Considerations
– In the management of
burn shock, it is especially
important to follow
standard fluid
resuscitation regimens to
prevent possible
circulatory overload.
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41. Lactated Ringer’s
(Hartmann’s Solution)
• Mechanism of action
– Replaces water
and electrolytes
• Indications
– Hypovolemic shock; keep
open IV
• Contraindications
– Should not be used in
patients with congestive
heart failure or renal
failure
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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42. 5% Dextrose in Water
(D5W)
• Mechanism of action
– Provides nutrients in the
form of dextrose as well as
free water
• Indications
– For dilution of
concentrated drugs for
intravenous infusion
• Contraindications
– Should not be used as a
fluid replacement for
hypovolemic states
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– Should not be used with
phenytoin or amrinone
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43. 10% Dextrose in Water (D10W)
• Mechanism of action
– Provides nutrients in the
form of dextrose
as well as free water
• Indications
– Neonatal resuscitation,
hypoglycemia
• Contraindications
– Should not be used as a
fluid replacement for
hypovolemic states
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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44. 0.9% Sodium Chloride
(Normal Saline)
• Mechanism of action
– Replaces water
and electrolytes
• Indications
– Heat-related problems
(heat exhaustion, heat
stroke), freshwater
drowning, hypovolemia
• Contraindications
– Should not be used
in patients with
congestive heart failure
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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45. 0.45% Sodium Chloride
(½ Normal Saline)
• Mechanism of action
– Replaces free water and
electrolytes
• Indications
– Patients with diminished
renal or cardiovascular
function for which rapid
rehydration is not
indicated
• Contraindications
– Cases in which rapid
rehydration is indicated
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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46. 5% Dextrose in 0.45% Sodium
Chloride (D5½NS)
• Mechanism of action
– Replaces free water
and electrolytes and
provides nutrients in the
form of dextrose
• Indications
– Heat exhaustion,
diabetic disorders
• Contraindications
– Should not be used when
rapid fluid resuscitation is
indicated
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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47. 5% Dextrose in 0.9% Sodium
Chloride (D5NS)
• Mechanism of action
– Replaces free water
and electrolytes and
provides nutrients in the
form of dextrose
• Indications
– Heat-related disorders,
freshwater drowning
• Contraindications
– Should not be given to
patients with impaired
cardiac or renal function
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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48. 5% Dextrose in Lactated Ringer’s
(D5LR)
• Mechanism of action
– Replaces water and
electrolytes and provides
nutrients in the form of
dextrose
• Indications
– Hypovolemic shock,
hemorrhagic shock
• Contraindications
– Should not be
administered to patients
with decreased renal or
cardiovascular function
• Adverse reactions
– Rare in therapeutic
dosages
• Considerations
– None
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49. References
• American Heart Association, Highlights of the 2020 AHA
Guidelines Update for CPR and ECC.
• Bernard SA, Gray TW, Buist MD, et al: Treatment of comatose
survivors of out-of-hospital cardiac arrest with induced
hypothermia. N Engl J Med 346:557–563, 2002. doi:
10.1056/NEJMoa003289
• Nielsen N, Wetterslev J, Cronberg T, et al: Targeted temperature
management at 33°C versus 36°C after cardiac arrest. N Engl J
Med 369:2197–2206, 2013. doi: 10.1056/NEJMoa1310519.
• Berman, A. J., Snyder, S., Kozier, B. J., & Erb, G. (2012). Kozier &
Erb’s Fundamentals of nursing (9th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall.
• Brunton, L. L., Lazo, J. S., & Parker, K. L. (Eds.). (2006). Goodman
& Gilman’s The pharmacological basis of therapeutics (11th ed.),
New York, NY: McGraw-Hill.
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50. THANK YOU
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