Analgesics Opiod analgesics alone or in combination with adjuvant agents such as non steroidal anti inflammatory drugs have

been conventionally used in pain relief Anti inflammatory drugs Antibiotics Drug Classifications Class I: Recommendations

Excellent evidence provides support Proven in both efficacy and safety Class II: Recommendations

Level I studies are absent, inconsistent or lack power Available evidence is positive but may lack efficacy No evidence of harm Drug Classifications Class IIa Vs IIb Class IIa recommendations have Higher level of available evidence Better critical assessments More consistency in results Both are optional and acceptable, IIa recommendations are probably useful IIb recommendations are possibly helpful Less compelling evidence for efficacy Drug Classifications Class III: Not recommended Not acceptable or useful and may be harmful Evidence is absent or unsatisfactory, or based on poor studies

Indeterminate Continuing area of research; no recommendation until further data is available Oxygen Indications Any suspected cardiopulmonary emergency Saturate hemoglobin with oxygen Reduce anxiety & further damage Note: Pulse oximetry should be monitored Oxygen Dosing (How?) Oxygen Precautions (Watch Out!) Pulse oximetry inaccurate in: Low cardiac output Vasoconstriction Hypothermia NEVER rely on pulse oximetry! VF / Pulseless VT Case 3 VF / Pulseless VT Epinephrine Indications (When & Why?) Increases: Heart rate Force of contraction Conduction velocity Peripheral vasoconstriction

Bronchial dilation Epinephrine Dosing (How?) 1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route 2.0 to 2.5 mg diluted in 10 mL normal saline Epinephrine Dosing (How?) Alternative regimens for second dose (Class IIb) Intermediate: 2 to 5 mg IV push, every 3 to 5 minutes Escalating: 1 mg, 3 mg, 5 mg IV push, each dose 3 minutes apart High: 0.1 mg/kg IV push, every 3 to 5 minutes Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Vasopressin Indications (When & Why?) Used to clamp down on vessels Improves perfusion of heart, lungs, and brain No direct effects on heart Vasopressin Dosing (How?) One time dose of 40 units only

May be substituted for epinephrine Not repeated at any time May be given down the endotracheal tube DO NOT double the dose Dilute in 10 mL of NS Vasopressin Precautions (Watch Out!) May result in an initial increase in blood pressure immediately following return of pulse May provoke cardiac ischemia Amiodarone Indications (When & Why?) Powerful antiarrhythmic with substantial toxicity, especially in the long term Intravenous and oral behavior are quite different Has effects on sodium & potassium Amiodarone Dosing (How?) Should be diluted in 20 to 30 mL of D5W 300 mg bolus after first Epinephrine dose Repeat doses at 150 mg Amiodarone Precautions (Watch Out!) May produce vasodilation & shock May have negative inotropic effects Terminal elimination Half-life lasts up to 40 days Lidocaine Indications (When & Why?)

Depresses automaticity Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability Lidocaine Dosing (How?) Initial dose: 1.0 to 1.5 mg/kg IV For refractory VF may repeat 1.0 to 1.5 mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS Lidocaine Dosing (How?) Maintenance Infusion 2 to 4 mg/min 1000 mg / 250 mL D5W = 4 mg/mL 15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min Lidocaine Precautions (Watch Out!) Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction Discontinue infusion immediately if signs of toxicity develop Magnesium Sulfate Indications (When & Why?) Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic state

Refractory VF VF with history of ETOH abuse Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose Magnesium Sulfate Dosing (How?) 1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IV push Magnesium Sulfate Precautions (Watch Out!) Occasional fall in blood pressure with rapid administration Use with caution if renal failure is present Procainamide Indications (When & Why?) Recurrent VF Depresses automaticity Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability Procainamide Dosing (How?) 30 mg/min IV infusion May push at 50 mg/min in cardiac arrest In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable Maximum total dose: 17 mg/kg Procainamide Dosing (How?) Maintenance Infusion

1 to 4 mg/min 1000 mg / 250 mL of D5W = 4 mg/mL 15 mL/hr = 1 mg/min 30 mL/hr = 2 mg/min 45 mL/hr = 3 mg/min 60 mL/hr = 4 mg/min Procainamide Precautions (Watch Out!) If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min Remember Endpoints of Administration PEA Case 4 PEA Epinephrine Indications (When & Why?) Increases: Heart rate Force of contraction Conduction velocity Peripheral vasoconstriction Bronchial dilation Epinephrine Dosing (How?) 1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route

2.0 to 2.5 mg diluted in 10 mL normal saline Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Atropine Sulfate Indications (When & Why?) Should only be used for bradycardia Relative or Absolute Used to increase heart rate Atropine Sulfate Dosing (How?) 1 mg IV push Repeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS Maximum Dose: 0.04 mg/kg Atropine Sulfate Precautions (Watch Out!) Increases myocardial oxygen demand May result in unwanted tachycardia or dysrhythmia Asystole Case 5 Asystole Epinephrine Indications (When & Why?)

Increases: Heart rate Force of contraction Conduction velocity Peripheral vasoconstriction Bronchial dilation Epinephrine Dosing (How?) 1 mg IV push; may repeat every 3 to 5 minutes May use higher doses (0.2 mg/kg) if lower dose is not effective Endotracheal Route 2.0 to 2.5 mg diluted in 10 mL normal saline Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction Atropine Sulfate Indications Used to increase heart rate Questionable absolute bradycardia Atropine Sulfate Dosing (How?) 1 mg IV push Repeat every 3 to 5 minutes May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS

Maximum Dose: 0.04 mg/kg Atropine Sulfate Precautions Increases myocardial oxygen demand Other Cardiac Arrest Drugs Calcium Chloride Indications Known or suspected hyperkalemia (eg, renal failure) Hypocalcemia (blood transfusions) As an antidote for toxic effects of calcium channel blocker overdose Prevent hypotension caused by calcium channel blockers administration Calcium Chloride Dosing IV Slow Push 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose 2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers Calcium Chloride Precautions Do not use routinely in cardiac arrest Do not mix with sodium bicarbonate Sodium Bicarbonate Indications Class I if known preexisting hyperkalemia Class IIa if known preexisting bicarbonate-responsive acidosis Class IIb if prolonged resuscitation with effective ventilation; upon return of spontaneous circulation

Class III (not useful or effective) in hypoxic lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation) Sodium Bicarbonate Dosing 1 mEq/kg IV bolus Repeat half this dose every 10 minutes thereafter If rapidly available, use arterial blood gas analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration) Sodium Bicarbonate Precautions (Watch Out!) Adequate ventilation and CPR, not bicarbonate, are the major "buffer agents" in cardiac arrest Not recommended for routine use in cardiac arrest patients Acute Coronary Syndromes Case 6 Acute Coronary Syndromes Aspirin Indications Administer to all patients with ACS, particularly reperfusion candidates Give as soon as possible Blocks formation of thromboxane A2, which causes platelets to aggregate Aspirin Dosing (How?) 160 to 325 mg tablets Preferably chewed May use suppository Higher doses may be harmful Aspirin Precautions

Relatively contraindicated in patients with active ulcer disease or asthma Nitroglycerine Indications Chest pain of suspected cardiac origin Unstable angina Complications of AMI, including congestive heart failure, left ventricular failure Hypertensive crisis or urgency with chest pain Nitroglycerin Indications Decreases pain of ischemia Increases venous dilation Decreases venous blood return to heart Decreases preload and cardiac oxygen consumption Dilates coronary arteries Increases cardiac collateral flow Nitroglycerine Dosing (How?) Sublingual Route 0.3 to 0.4 mg; repeat every 5 minutes Aerosol Spray Spray for 0.5 to 1.0 second at 5 minute intervals IV Infusion Infuse at 10 to 20 g/min Route of choice for emergencies Titrate to effect Nitroglycerine

Precautions (Watch Out!) Use extreme caution if systolic BP <90 mm Hg Use extreme caution in RV infarction Suspect RV infarction with inferior ST changes Limit BP drop to 10% if patient is normotensive Limit BP drop to 30% if patient is hypertensive Watch for headache, drop in BP, syncope, tachycardia Tell patient to sit or lie down during administration Morphine Sulfate Indications (When & Why?) Chest pain and anxiety associated with AMI or cardiac ischemia Acute cardiogenic pulmonary edema (if blood pressure is adequate) Morphine Sulfate Indications (When & Why?) To reduce pain of ischemia To reduce anxiety To reduce extension of ischemia by reducing oxygen demands Morphine Sulfate Dosing (How?) 1 to 3 mg IV (over 1 to 5 minutes) every 5 to 10 minutes as needed Morphine Sulfate Precautions (Watch Out!) Administer slowly and titrate to effect May compromise respiration; therefore use with caution in acute pulmonary edema Causes hypotension in volume-depleted patients Acute Coronary Syndromes

ST Elevation Recognition of AMI Know what to look for ST elevation >1 mm 3 contiguous leads Know where to look Refer to 2000 ECC Handbook ST Elevation Beta Blockers Indications (When & Why?) To reduce myocardial ischemia and damage in AMI patients with elevated heart rates, blood pressure, or both Blocks catecholamines from binding to -adrenergic receptors Reduces HR, BP, myocardial contractility Decreases AV nodal conduction Decreases incidence of primary VF Beta Blockers Dosing (How?) Esmolol 0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min Titrate to effect, Esmolol has a short half-life (<10 minutes) Labetalol 10 mg labetalol IV push over 1 to 2 minutes 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 g/min Beta Blockers Dosing (How?)

Metoprolol 5 mg slow IV at 5-minute intervals to a total of 15 mg Atenolol 5 mg slow IV (over 5 minutes) Wait 10 minutes, then give second dose of 5 mg slow IV (over 5 minutes) Propranolol 1 to 3 mg slow IV. Do not exceed 1 mg/min Repeat after 2 minutes if necessary Beta Blockers Precautions (Watch Out!) Concurrent IV administration with IV calcium channel blocking agents like verapamil or diltiazem can cause severe hypotension Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction Monitor cardiac and pulmonary status during administration May cause myocardial depression Heparin Indications (When & Why?) For use in ACS patients with Non Q wave MI or unstable angina Inhibits thrombin generation by factor Xa inhibition and also inhibit thrombin indirectly by formation of a complex with antithrombin III Heparin Dosing (How?) Initial bolus 60 IU/kg Maximum bolus: 4000 IU Continue at 12 IU/kg/hr (maximum 1000 IU/hr for patients < 70 kg), round to the nearest 50 IU Heparin Dosing (How?)

Adjust to maintain activated partial thromboplastin time (aPTT) 1.5 to 2.0 times the control values for 48 hours or angiography Target range for aPTT after first 24 hours is between 50 & 70 seconds (may vary with laboratory) Check aPTT at 6, 12, 18, and 24 hours Follow Institutional Heparin Protocol Heparin Precautions (Watch Out!) Same contraindications as for fibrinolytic therapy: active bleeding; recent intracranial, intraspinal or eye surgery; severe hypertension; bleeding disorders; gastroinintestinal bleeding DO NOT use if platelet count is below 100 000 Glycoprotein IIb/IIIa Inhibitors Indications (When & Why?) Inhibit the integrin glycoprotein IIb/IIIa receptor in the membrane of platelets, inhibiting platelet aggregation Indicated for Acute Coronary Syndromes without ST segment elevation Glycoprotein IIb/IIIa Inhibitors Indications (When & Why?) Abciximab (ReoPro) Non Q wave MI or unstable angina with planned PCI within 24 hours Must use with heparin Binds irreversibly with platelets Platelet function recovery requires 48 hours Glycoprotein IIb/IIIa Inhibitors Indications Eptifibitide (Integrilin) Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI Platelet function recovers within 4 to 8 hours after discontinuation

Glycoprotein IIb/IIIa Inhibitors Indications Tirofiban (Aggrastat) Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI Platelet function recovers within 4 to 8 hours after discontinuation Glycoprotein IIb/IIIa Inhibitors Dosing Abciximab (ReoPro) ACS with planned PCI within 24 hours 0.25 mg/kg bolus (10 to 60 minutes before procedure), then 0.125 mcg/kg/min infusion PCI only 0.25 mg/kg bolus Then 10 mcg/min infusion Glycoprotein IIb/IIIa Inhibitors Dosing NOTE: Check package insert for current indications, doses, and duration of therapy. Optimal duration of therapy has NOT been established. Glycoprotein IIb/IIIa Inhibitors Dosing Eptifibitide (Integrilin) Acute Coronary Syndromes 180 mcg/kg IV bolus, then 2 mcg/kg/min infusion PCI 135 mcg/kg IV bolus, then begin 0.5 mcg/kg/min infusion, then repeat bolus in 10 minutes Glycoprotein IIb/IIIa Inhibitors

Dosing (How?) Tirofiban (Aggrastat) Acute Coronary Syndromes or PCI 0.4 mcg/kg/min infusion IV for 30 minutes Then 0.1 mcg/kg/min infusion Glycoprotein IIb/IIIa Inhibitors Precautions (Watch Out!) Active internal bleeding or bleeding disorder within 30 days History of intracranial hemorrhage or other bleeding Surgical procedure or trauma within 1 month Platelet count > 150 000/mm3 PTCA Fibrinolytics Indications For AMI in adults ST elevation or new or presumably new LBBB; strongly suspicious for injury Time of onset of symptoms < 12 hours Fibrinolytics Indications For Acute Ischemic Stroke Sudden onset of focal neurologic deficits or alterations in consciousness Absence of subarachnoid or intracerebral hemorrhage Alteplase can be started in less than 3 hours of symptom onset Fibrinolytics Dosing For fibrinolytic use, all patients should have 2 peripheral IV lines 1 line exclusively for fibrinolytic administration

Fibrinolytics Dosing for AMI Patients Alteplase, recombinant (tPA) Accelerated Infusion 15 mg IV bolus Then 0.75 mg/kg over the next 30 minutes Not to exceed 50 mg Then 0.5 mg/kg over the next 60 minutes Not to exceed 35 mg 3 hour Infusion Give 60 mg in the first hour (initial 6 to 10 mg is given as a bolus) Then 20 mg/hour for 2 additional hours Fibrinolytics Dosing for AMI Patients Anistreplase (APSAC) Reconstitute 30 units in 50 mL of sterile water 30 units IV over 2 to 5 minutes Reteplase, recombinant Give first 10 unit IV bolus over 2 minutes 30 minutes later give second 10 unit IV bolus over 2 minutes Streptokinase 1.5 million IU in a 1 hour infusion Tenecteplase (TNKase) Bolus 30 to 50 mg Fibrinolytics Adjunctive Therapy for AMI Patients (How?) 160 to 325 mg aspirin chewed as soon as possible

Begin heparin immediately and continue for 48 hours if alteplase or Retavase is used Fibrinolytics Dosing for Acute Ischemic Stroke Alteplase, recombinant (tPA) Give 0.9 mg/kg (maximum 90 mg) infused over 60 minutes Give 10% of total dose as an initial IV bolus over 1 minute Give the remaining 90% over the next 60 minutes Alteplase is the only agent approved for use in Ischemic Stroke patients Fibrinolytics Precautions Specific Exclusion Criteria Active internal bleeding (except mensus) within 21 days History of CVA, intracranial, or intraspinal within 3 months Major trauma or serious injury within 14 days Aortic dissection Severe uncontrolled hypertension Fibrinolytics Precautions Specific Exclusion Criteria Known bleeding disorders Prolonged CPR with evidence of thoracic trauma Lumbar puncture within 7 days Recent arterial puncture at noncompressible site During the first 24 hours of fibrinolytic therapy for ischemic stroke, do not give aspirin or heparin ACE Inhibitors Indications (When & Why?)

Reduce mortality & improve LV dysfunction in post AMI patients Help prevent adverse LV remodeling, delay progression of heart failure, and decrease sudden death & recurrent MI ACE Inhibitors Indications (When & Why?) Suspected MI & ST elevation in 2 or more anterior leads Hypertension Clinical signs of AMI with LV dysfunction LV ejection fraction <40% ACE Inhibitors Indications Generally not started in the ED but within first 24 hours after: Fibrinolytic therapy has been completed Blood pressure has stabilized ACE Inhibitors Dosing 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 ACE Inhibitors Dosing (How?) Enalapril 2.5 mg PO titrated to 20 mg BID IV dosing of 1.25 mg IV over 5 minutes, then 1.25 to 5 mg IV every six hours Captopril Start with 6.25 mg PO Advance to 25 mg TID, then to 50 mg TID as tolerated ACE Inhibitors

Dosing (How?) Lisinopril (AMI dose) 5 mg within 24 hours onset of symptoms 10 mg after 24 hours, then 10 mg after 48 hours, then 10 mg PO daily for six weeks Ramipril Start with single dose of 2.5 mg PO Titrate to 5 mg PO BID as tolerated ACE Inhibitors Precautions (Watch Out!) Contraindicated in pregnancy Contraindicated in angioedema Reduce dose in renal failure Avoid hypotension, especially following initial dose & in relative volume depletion Bradycardias Case 7 Bradycardia Bradycardia Atropine Sulfate Indications (When & Why?) First drug for symptomatic bradycardia Increases heart rate by blocking the parasympathetic nervous system Atropine Sulfate Dosing (How?) 0.5 to 1.0 mg IV every 3 to 5 minutes as needed May give via ET tube (2 to 2.5 mg) diluted in 10 mL of NS Maximum Dose: 0.04 mg/kg

Atropine Sulfate Precautions (Watch Out!) Use with caution in presence of myocardial ischemia and hypoxia Increases myocardial oxygen demand Seldom effective for: Infranodal (type II) AV block Third-degree block (Class IIb) Dopamine Indications (When & Why?) Second drug for symptomatic bradycardia (after atropine) Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock Dopamine Dosing (How?) IV Infusions (Titrate to Effect) 400 mg / 250 mL of D5W = 1600 mcg/mL 800 mg/ 250 mL of D5W = 3200 mcg/mL Dopamine Dosing (How?) IV Infusions (Titrate to Effect) Low Dose Renal Dose" 1 to 5 g/kg per minute Moderate Dose Cardiac Dose" 5 to 10 g/kg per minute High Dose Vasopressor Dose" 10 to 20 g/kg per minute Dopamine Precautions (Watch Out!) May use in patients with hypovolemia but only after volume replacement

May cause tachyarrhythmias, excessive vasoconstriction DO NOT mix with sodium bicarbonate Epinephrine Indications (When & Why?) Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb) Epinephrine Dosing (How?) Profound Bradycardia 2 to 10 g/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min) Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Isoproterenol Indications (When & Why?) Temporary control of bradycardia in heart transplant patients Class IIb at low doses for symptomatic bradycardia Heart Transplant Patients! Isoproterenol Dosing (How?) Infuse at 2 to 10 g/min Titrate to adequate heart rate Isoproterenol Precautions (Watch Out!) Increases myocardial oxygen requirements, which may increase myocardial ischemia

DO NOT administer with poison/drug-induced shock Exception: Beta Blocker Poisoning Stable Tachycardias Case 9 Diltiazem Indications (When & Why?) To control ventricular rate in atrial fibrillation and atrial flutter Use after adenosine to treat refractory PSVT in patients with narrow QRS complex and adequate blood pressure As an alternative, use verapamil Diltiazem Dosing (How?) Acute Rate Control 15 to 20 mg (0.25 mg/kg) IV over 2 minutes May repeat in 15 minutes at 20 to 25 mg (0.35 mg/kg) over 2 minutes Maintenance Infusion 5 to 15 mg/hour, titrated to heart rate Diltiazem Precautions (Watch Out!) Do not use calcium channel blockers for tachycardias of uncertain origin 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 Expect blood pressure drop resulting from peripheral vasodilation Concurrent IV administration with IV -blockers can cause severe hypotension Verapamil Indications (When & Why?)

Used as an alternative to diltiazem for ventricular rate control in atrial fibrillation and atrial flutter Drug of second choice (after adenosine) to terminate PSVT with narrow QRS complex and adequate blood pressure Verapamil Dosing (How?) 2.5 to 5.0 mg IV bolus over 1to 2 minutes Second dose: 5 to 10 mg, if needed, in 15 to 30 minutes. Maximum dose: 30 mg Older patients: Administer over 3 minutes Verapamil Precautions (Watch Out!) Do not use calcium channel blockers for wide-QRS tachycardias of uncertain origin Avoid calcium channel blockers in patients with Wolff-Parkinson-White syndrome and atrial fibrillation, sick sinus syndrome, or second- or thirddegree AV block without pacemaker Verapamil Precautions (Watch Out!) Expect blood pressure drop caused by peripheral vasodilation IV calcium can restore blood pressure, and some experts recommend prophylactic calcium before giving calcium channel blockers Concurrent IV administration with IV -blockers may produce severe hypotension Adenosine Indications (When & Why?) First drug for narrow-complex PSVT May be used diagnostically (after lidocaine) in wide-complex tachycardias of uncertain type Adenosine Dose (How?)

IV Rapid Push Initial bolus of 6 mg given rapidly over 1 to 3 seconds followed by normal saline bolus of 20 mL; then elevate the extremity Repeat dose of 12 mg in 1 to 2 minutes if needed A third dose of 12 mg may be given in 1 to 2 minutes if needed Adenosine Precautions (Watch Out!) Transient side effects include: Facial Flushing Chest pain Brief periods of asystole or bradycardia Less effective in patients taking theophyllines Beta Blockers Indications (When & Why?) To convert to normal sinus rhythm or to slow ventricular response (or both) in supraventricular tachyarrhythmias (PSVT, atrial fibrillation, or atrial flutter) -Blockers are second-line agents after adenosine, diltiazem, or digoxin Beta Blockers Dosing (How?) Esmolol 0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min Titrate to effect, Esmolol has a short half-life (<10 minutes) Labetalol 10 mg labetalol IV push over 1 to 2 minutes 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 g/min Beta Blockers Dosing (How?)

Metoprolol 5 mg slow IV at 5-minute intervals to a total of 15 mg Atenolol 5 mg slow IV (over 5 minutes) Wait 10 minutes, then give second dose of 5 mg slow IV (over 5 minutes) Propranolol 1 to 3 mg slow IV. Do not exceed 1 mg/min Repeat after 2 minutes if necessary Beta Blockers Precautions (Watch Out!) Concurrent IV administration with IV calcium channel blocking agents like verapamil or diltiazem can cause severe hypotension Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction Monitor cardiac and pulmonary status during administration May cause myocardial depression Digoxin Indications (When & Why?) To slow ventricular response in atrial fibrillation or atrial flutter Third-line choice for PSVT Digoxin Dosing (How?) IV Infusion Loading doses of 10 to 15 g/kg provide therapeutic effect with minimum risk of toxic effects Maintenance dose is affected by body size and renal function Digoxin Precautions (Watch Out!)

Toxic effects are common and are frequently associated with serious arrhythmias Avoid electrical cardioversion unless condition is life threatening Use lower current settings (10 to 20 Joules) Amiodarone Indications (When & Why?) Powerful antiarrhythmic with substantial toxicity, especially in the long term Intravenous and oral behavior are quite different Amiodarone Dosing (How?) Stable Wide-Complex Tachycardias Rapid Infusion 150 mg IV over 10 minutes (15 mg/min) May repeat Slow Infusion 360 mg IV over 6 hours (1 mg/min) Amiodarone Dosing (How?) Maintenance Infusion 540 mg IV over 18 hours (0.5 mg/min) Amiodarone Precautions (Watch Out!) May produce vasodilation & shock May have negative inotropic effects May prolong QT Interval DO NOT administer with other drugs that may prolong QT Interval (Procainamide) Terminal elimination

Half-life lasts up to 40 days Amiodarone Precautions (Watch Out!) Contraindicated in: Second or third degree A-V block Severe bradycardia Pregnancy CHF Hypokalaemia Liver dysfunction Lidocaine Indications Depresses automaticity Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability Lidocaine Dosing (How?) For stable VT, wide-complex tachycardia of uncertain type, significant ectopy, use as follows: 1.0 to 1.5 mg/kg IV push Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes; maximum total dose, 3 mg/kg Lidocaine Dosing (How?) Maintenance Infusion 2 to 4 mg/min Lidocaine

Precautions (Watch Out!) Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction Discontinue infusion immediately if signs of toxicity develop Magnesium Sulfate Indications (When & Why?) Torsades de pointes with a pulse Wide-complex tachycardia with history of ETOH abuse Life-threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose Magnesium Sulfate Dosing (How?) Loading dose of 1 to 2 grams mixed in 50 to 100 mL of D5W IV push over 5 to 60 minutes Magnesium Sulfate Dosing (How?) Maintenance Infusion 1 to 4 g/hour IV (titrate dose to control the torsades) Magnesium Sulfate Precautions (Watch Out!) Occasional fall in blood pressure with rapid administration Use with caution if renal failure is present Procainamide Indications (When & Why?) Depresses automaticity Depresses excitability Raises ventricular fibrillation threshold Decreases ventricular irritability Atrial fibrillation with rapid rate in Wolff-Parkinson-White syndrome

Procainamide Dosing (How?) Perfusing Arrhythmia 20 mg/min IV infusion until: Hypotension develops Arrhythmia is suppressed QRS widens by >50% Maximum dose of 17 mg/kg is reached In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable Procainamide Dosing (How?) Maintenance Infusion 1 to 4 mg/min Procainamide Precautions (Watch Out!) If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min Remember Endpoints of Administration Acute Ischemic Stroke Case 10 Acute Ischemic Stroke Nitroprusside Indications (When & Why?) Hypertensive crisis Nitroprusside

Dosing (How?) Begin at 0.1 mcg/kg/min and titrate upward every 3 to 5 minutes to desired effect Up to 0.5 mcg/kg/min Action occurs within 1 to 2 minutes Nitroprusside Dosing Precautions (How?) Use with an infusion pump; use hemodynamic monitoring for optimal safety Cover drug reservoir with opaque material Nitroprusside Precautions (Watch Out!) Light-sensitive; therefore, wrap drug reservoir in aluminum foil May cause hypotension and CO2 retention May exacerbate intrapulmonary shunting Other side effects include headaches, nausea, vomiting, and abdominal cramps Drugs used in Overdoses Calcium Chloride Indications (When & Why?) As an antidote for toxic effects of calcium channel blocker overdose Calcium Chloride Dosing (How?) 8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose Calcium Chloride Precautions (Watch Out!) Do not use routinely in cardiac arrest Do not mix with sodium bicarbonate Flumazenil

Indications (When & Why?) Reduce respiratory depression and sedative effects from pure benzodiazepine overdose Flumazenil Dosing (How?) First Dose 0.2 mg IV over 15 seconds Second Dose 0.3 mg IV over 30 seconds Third Dose 0.4 mg IV over 30 seconds Maximum Dose 3 mg Flumazenil Precautions (Watch Out!) Effects may not outlast effects of benzodiazepines Monitor for recurrent respiratory depression DO NOT use in suspected tricyclic overdose DO NOT use in seizure-prone patients DO NOT use if unknown type overdose or mixed drug overdose with drugs known to cause seizures Naloxone Hydrochloride Indications (When & Why?) Respiratory and neurologic depression due to opiate intoxication unresponsive to oxygen and hyperventilation Naloxone Hydrochloride Dosing (How?) 0.4 to 2 mg IVP every 2 minutes Use higher doses for complete narcotic reversal

Can administer up to 10 mg in a short time (10 minutes) Naloxone Hydrochloride Precautions (Watch Out!) May cause opiate withdrawal Effects may not outlast effects of narcotics Monitor for recurrent respiratory depression Review of Infusions Dobutamine Indications Consider for pump problems (congestive heart failure, pulmonary congestion) with systolic blood pressure of 70 to 100 mm Hg and no signs of shock Increases Inotropy Dobutamine Dosing (How?) Usual infusion rate is 2 to 20 g/kg per minute Titrate so heart rate does not increase by more than 10% of baseline Hemodynamic monitoring is recommended for optimal use Dobutamine Precautions (Watch Out!) Avoid when systolic blood pressure <100 mm Hg with signs of shock May cause tachyarrhythmias, fluctuations in blood pressure, headache, and nausea DO NOT mix with sodium bicarbonate Dopamine Indications (When & Why?) Second drug for symptomatic bradycardia (after atropine) Use for hypotension (systolic BP 70 to 100 mm Hg) with S/S of shock Dopamine

Dosing IV Infusions (Titrate to Effect) Low Dose Renal Dose" 1 to 5 g/kg per minute Moderate Dose Cardiac Dose" 5 to 10 g/kg per minute High Dose Vasopressor Dose" 10 to 20 g/kg per minute Dopamine Precautions (Watch Out!) May use in patients with hypovolemia but only after volume replacement May cause tachyarrhythmias, excessive vasoconstriction DO NOT mix with sodium bicarbonate Epinephrine Indications Symptomatic bradycardia: After atropine, dopamine, and transcutaneous pacing (Class IIb) Epinephrine Dosing Profound Bradycardia 2 to 10 g/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min) Epinephrine Precautions (Watch Out!) Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand Do not mix or give with alkaline solutions Higher doses have not improved outcome & may cause myocardial dysfunction

Norepinephrine Indications For severe cardiogenic shock and hemodynamic significant hypotension (systolic blood pressure < 70 mm/Hg) with low total peripheral resistance This is an agent of last resort for management of ischemic heart disease and shock Norepinephrine Dosing (How?) 0.5 to 1 mcg/min titrated to improve blood pressure (up to 30 mcg/min) DO NOT administer is same IV line as alkaline infusions Poison/drug-induced hypotension may higher doses to achieve adequate perfusion Norepinephrine Precautions Increases myocardial oxygen requirements May induce arrhythmias Extravasation causes tissue necrosis Calculating mg/min dose X gtt factor Solution Concentration 2 mg X 60 gtt/mL 4 mg Using a 60 gtt set: 30 gtt/min = 30 cc/hr Calculating mcg/kg/min dose X kg X gtt factor solution concentration 5 mcg/min X 75 kg X 60 gtt/mL 1600 mcg/cc

Using a 60 gtt set: 18.75 cc/hr = 18.75 gtts/min Furosemide Indications For adjuvant therapy of acute pulmonary edema in patients with systolic blood pressure >90 to 100 mm Hg (without S/S of shock) Hypertensive emergencies Increased intracranial pressure Furosemide Dosing (How?) 20 to 40 mg slow IVP If patient is taking at home, double their daily dose Furosemide Precautions (Watch Out!) Dehydration, hypovolemia, hypotension, hypokalemia, or other electrolyte imbalance may occur Questions? Summary To obtain a full understanding of ACLS pharmacology requires constant review of: Indications & Actions (When & Why?) Dosing (How?) Contraindications & Precautions (Watch Out!)