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Advanced Life Support Study Guide
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ADVANCED CARDIAC LIFE SUPPORT

STUDY AND REVIEW INFORMATION

CLASSES OF THERAPEUTIC INTERVENTIONS

CLASS I A therapeutic option that is usually indicated, always acceptable and considered useful and effective.CLASS II A therapeutic option that is acceptable, is of uncertain efficacy, and may be controversial.

IIA The weight of the evidence is in favor of its usefulness and efficacy.IIB Not well established by evidence, but may be helpful and probably is not harmful.CLASS III A therapeutic option that is inappropriate, is without scientific supporting data and may be harmful.

ADJUNCTS FOR OXYGENATION-VENTILATION

OXYGEN DEVICES Class I

Do not withhold oxygen if hypoxemia is suspected.

Use 100% oxygen.

VENTILATORY DEVICES

Mouth to mask - Should have a one way valve. No studies have been done in humans.

Face shields have no exhalation port, (considered Class IIB)

Bag valve mask (B.V.M.) 1600 total volume, two users recommended (Class I)

B.V.M. should be refilling , have a non-jam valve allowing an inlet flow of 15 L/min, have no pop-off valve and should have a true non-rebreathing valve. B.V.M. should have a standard 15mm/22/mm fitting and oxygen reservoir for 100% oxygen.

A third user may provide cricoid pressure.

A transparent mask is preferable.

OXYGEN POWERED MANUALLY TRIGGERED DEVICES Class I

No pressure cycled ventilators - Class III

Must : 1) constant flow of 100% oxygen at less than 40 L/min.

2) inspiratory pressure flow that opens at 60 cm water pressure.

3) audible alarm if valve opens at high pressure to alert that volume getting to patient may be insufficient.

AUTOMATIC TRANSPORT VENTILATORS (ATV) Class I

Recommended for transport, especially intubated patients, need an oxygen source.

Not recommended for patients younger than 5 years of age, need an oxygen source.

AIRWAY ADJUNCTS

OROPHARYNGEAL AND NASOPHARRNGEAL AIRWAYS Class I

Use in patients when not intubated if indicated - use oral airways only in unconscious patients.

ENDOTRACHEAL INTUBATION Class I

The airway of choice for a deeply unconscious patient.

Intubate as soon as possible (in full respiratory or cardiac arrest). Provide tidal volumes or 10 - 15 ml/kg.

Do not interrupt ventilation for more than 30 seconds. Use cricoid pressure by a second rescuer.

Ventilation should be asynchronous at 12 - 15 per minute. NOT SYNCHRONIZED.Inflate with 10 - 20 cc air then check placement with the first breath by auscultation of the epigastrum and watching the chest. If the chest rises then listen to both lungs. Sound should be audible bilaterally.

When using expired carbon dioxide detector, keep in mind that in cardiac arrest CO2 may not be detected due to poor perfusion. These are still recommended.

ALTERNATE INVASIVE AIRWAYS Class IIB

Use MUST be authorized by EMS Medical Director.

ESOPHAGEAL OBTURATOR AIRWAY (EOA/EGTA)

Increased risk compared to endotracheal intubation

Ventilation and oxygenation definitely inferior to ET intubation.

PHARYNGOTRACHEL LUMEN AIRWAY (PTL)

Limited studies show good oxygenation, but needs more studies

Double lumen that is inserted blindly, tube that is appropriate is then ventilated through that lumen.

LARYNGEAL MASK AIRWAY (LMA)

superior to ETT for BLS level personnel

equal to ETT for ACLS level personnel

ESOPHAGEAL TRACHEAL COMBITUBE (ETC)

Simplified basic structure compared to PTL inserted the same.

experience is more in-hospital for the most part.

requires more and specialized training to use.

TRANSTRACHEAL CATHETER VENTILATION -CRICOTHYROTOMY

used rarely - only by trained and experienced professionals.

SUCTION DEVICES

Airflow of 30 L/min and vacuum of 300 mm Hg when clamped (and should be adjustable)

CONFIRM TRACHEAL TUBE PLACEMENT

Pulse oximetry - SpO2

End tidal CO2 indicators

Capnometric Devices & Capnographs

 

ADJUNCTS FOR ARTIFICIAL CIRCULATION

Cardiopulmonary Resuscitation

Used to stabilize and maintain cardiovascular function in patients suffering from cardiac arrest.

Unprotected airway patients - 30 compressions : 2 ventilations

Protected airway patients - asynchronous

Rate 100 compressions / minute

Increased Emphasis on Public Access Defibrillators

MECHANICAL AIDS TO CPR

Simple, manually operated mechanical chest compressors can be used.

MAST trousers not routinely indicated in cardiac arrest

Several devices are experimental

INVASIVE CPR

Open chest - May be beneficial if used early in very special situations.

Penetrating chest trauma is the only reason at present to do open chest CPR and then only if the victim has a reasonable chance of survival (i.e. Vital Signs on EMS arrival).

ASSESSMENT OF CPR

Use arterial lines placed prior to arrest to assess cardiac output with CPR if available.

CARDIAC MONITORING AND ARRHYTHMIA RECOGNITION

Quick look paddles or immediate monitoring is needed.

Most deaths are due to electrical derangement.

Student must recognize: (ALL 14)

Sinus Rhythm

Sinus Tachycardia

Sinus Bradycardia

Premature Atrial Complexes (PAC or APC)

Atrial Flutter

Atrial Fibrillation

Junctional Rhythms

Atrioventricular Blocks

Premature Ventricular Complexes (PVC or VPC)

Ventricular Tachycardia

Torsades de pointes

Ventricular Fibrillation

Asystole

Paroxymal Supraventricular Tachycardia (PSVT)

DRUG THERAPY

ADMINISTRATION OF MEDICATIONS DURING CARDIAC ARREST

CENTRAL vs. PERIPHERAL

Use peripheral vein first. Requires 1 - 2 min. to reach central circulation.

Use 20 cc bolus of IV fluid or NS following administration of any drug.

Internal jugular is preferred route for central line.

Avoid femoral line unless the catheter passes above the diaphragm. CPR provides poor flow upward from below the diaphragm.

Intraosseous route considered same as Intravenous

ENDOTRACHEAL DRUG ADMINISTRATION

May give A L E via ET tube.

Atropine, Epinephrine, Lidocaine (Xylocaine)

Dose is 2 to 2.5 times the IV dose and diluted with 10cc NS or water

Absorption from lung is faster with sterile water than NS.

Pass a catheter beyond tip of ET tube. Spray. Stop compressions from before time of spray until 1 - 2 ventilations later.

INTRA OSSEOUS MEDICATIONS

Good alternate source in children.

IO epinephrine dose may have to be higher.

Studies of effectiveness continue.

DRUGS USED IN ACLS

CORRECTION OF HYPOXEMIA WITH OXYGEN THERAPY

100 % oxygen (Class I)

IV Fluids

Acute blood loss - rapid volume expansion with NS or LR

D5W may be used to keep lines open, but NS is preferred

No volume expansion in cardiac arrest, except as indicated

MORPHINE SULFATE

(Class IIB - acceptable, possible helpful, probably not harmful for pulm. edema ) Preferred in MI for pain relief.

Useful in pulmonary edema - increases venous capacitance, decreases venous return, mild arterial vasodilation

good analgesic effects

use with care in respiratory distress patients.

give in titrated/divided doses of 2 - 3 mg at a time

 

 

 

CONTROL OF HEART RHYTHM AND RATE

 

Amiodarone (Cordarone)

used for atrial & ventricular tachyarrythmias

treatment for shock-refractory VF / pulseless VT

treatment of polymorphic VT , wide complex tachycardia & hemodynamically stable VT when cardioversion is unsuccessful

useful in presence of LV dysfunction

can be used in SVT, PSVT as an adjunct to electrical cardioversion

may produce vasodilation & hypotension.

negative inotropic effects

may prolong QT interval

use with caution in heart failure patients

Dose in Cardiac Arrest: bolus of 300 mg IVP. Consider repeating 150 mg IVP in 3-5 minutes. Maximum dose 2.2 gm IV q 24 hours.Dose in Stable wide complex tachycardias : Rapid loading infusion of 150 mg IVPB over 10 minutes followed by a maintenance infusion of 0.5 mg/ min over 18 hours

LIDOCAINE

Drug can be used in ventricular ectopy, VT, VF

Prophylactic use in MI reduces incidence of VF. NOT recommended unless multiple PVCs (Class IIB)

Dose: Initially 1.0 - 1.5 mg/kg then 0.5 mg/kg every 5 minutes to total dose of 3.0 mg/kg and a continuos infusion of 2 - 4 mg/min.

reduce dose in states of decreased cardiac output, patients > age 70 and liver dysfunctionToxicity: slurred speech, altered levels of consciousness, muscle twitching or seizures.

PROCANAMIDE

Used to suppress PVCs and recurrent VT

For wide complex tachycardia (Class IIA)

Dose: 20 mg/min to a total of 17 mg/kg. In urgent cases use 30 mg/min then use 1 - 4 mg/min continuos infusion.

Stop infusion if BP drops, QRS complex widens by 50% of original width or 17 mg/kg is reached.

BETA-ADRENERGIC BLOCKERS

If used less than 4 hours after fibrinolytic therapy - may reduce the rate of non-fatal re-infarction and recurrent ischemia.

Atenolol (Tenormin), metoprolol (Lopressor), propanolol (Inderal) have been shown to reduce the incidence of VF in post MI patients who do not receive fibrinolytic agents.

Dose: Atenolol 5 - 10 mg over 5 minutes

Metoprolol 5 mg every 5 minutes x 3 doses

Contraindications - Bradyarrythmias, 2nd degree or 3rd degree blocks, hypotension, bronchospasm or CHF

ATROPINE

useful in treating symptomatic sinus bradycardia (Class I)

treatment of AV block at nodal level (Class IIA)

used in ventricular asystole

Cardiac Arrest Dose : 1 mg repeat every 3 - 5 minutes to a total dose of 3 mg if asystole persists

Bradycardia dose - 0.5 - 1.0 mg every 3 - 5 minutes for sustained heart rate < 40 to maximum dose of 3 mg.

Doses < 0.5 mg may be parasympathomimetic and further slow the rate.

Well absorbed by endotracheal route.

ISOPROTERENOL (not commonly used at this time)

used for symptomatic bradycardia

if used, extreme caution should be exercised, at low doses can be helpful, at high doses can be harmful.

NOT USED IN MI

Increases myocardial oxygen demand

lowers fibrilatory threshold; can cause VF/VT

not used in cardiac arrest and hypotension!

VERAPAMIL AND DILTIAZEM

used to control ventricular response rate in atrial fibrillation/flutter or multifocal atrial tachycardia (MAT)

effective in narrow complex PSVT, but adenosine is the drug of choice

give Calcium prior to giving verapamil to avoid hypotension

Verapamil (Calan) dose 2.5 to 5.0 mg over 2 min IV then 5 - 10 mg every 15 - 30 min to a maximum dose of 20 mg.

Diltiazem (Cardizem) dose 20 mg IV initialinfusion may repeat a second dose of 25 mg IV followed by a continuos infusion of 15 mg/hr taper and D/C as indicated.

ADENOSINE

rapidly terminates re-entry PSVT. In Atrial Fibrillation/flutter will produce a transient AV block that may clarify the diagnosis

T50 > 5 seconds, push and flush rapidly ("slam-dunk" administration)

Dose: 6 mg over 1 - 3 seconds with 20cc NS flush, if no response, repeat with 12 mg bolus in 1 - 2 minutes and 20cc flush, may repeat for a 3 rd bolus of 12 mg.

Drug interactions: Theophylline / Aminophylline, Caffiene, Theobromine and other methylxanthines will block the receptor

Dipyramidamole (Persantine) blocks uptake and potentiates the effect

Carbamazepine (Tegretol) prolongs the effects

safe in Wolf-Parkinson-White (WPW) syndrome

 

 

MAGNESIUM

deficiency - associated with cardiac arrythmias and sudden cardiac death. Hinders replenishment of intracelluar potassium

recurrent VF/VT - correct low Mg. Level by giving MgSO4 1 - 2 Gm. In D5W 100 ml over 1 - 2 minutes.

Reduces the incidence of post-infarction ventricular arrythmias

Loading Dose: MgSO4 1 - 2 gm. In D5W 100 ml over 5 - 60 minutes, then 0.5 to 1 gm per hour for 24 hours.

Considered the treatment of choice in Toursades de Pointes

useful in treating pre-eclamptic seizures in toxemic female patients

IMPROVED CARDIAC OUTPUT AND BLOOD PRESSURE

EPINEPHRINE

Dose is 1 mg (10 cc of 1:10,000 solution) IV push every 3 - 5 minutes, followed by 20cc flush of IV fluid.

No indications that larger doses of epinephrine produced higher rates of survival

no indications for doses of > 1 mg.

Endotracheal dose is 2 to 2.5 times the IV dose

NOREPINEPHRINE

Indicated in severe hypotension (SBP < 70)

dose is 0.5 to 1.0 mcg/min (4 mg in 250 cc IVF)

do not use in hypovolemic states

use phentolamine (Reigitine) 5 - 10 mg in 10 - 15 cc NS if extravasation occurs, infiltrate area with mixture.

DOPAMINE

Chemical precursor to norepinephrine - alpha & beta actions

Dose is 2 -20 mcg/kg/min - (mix either 400 mg or 800 mg in 250 cc)

reduce or stop med if tachycardia occurs

MAO inhibitors potentiate the effects of dopamine

Inactivated by sodium bicarbonate

renal perfusion dose: 3 - 6 mck/kg/min pressure support 7 -20 mcg/kg/min

doses > 7 mcg/kg/min will result in renal & mesenteric artery constriction and lower urine output. Higher doses also reduce peripheral circulation.

DOBUTAMINE

used to treat heart failure - cardiogenic shock

increases myocardial contractility (+ inotrope)

if heart rate increases by >10%, decrease the dose

dose: 2 - 20 mcg/kg/min (500 mg in 250 cc IVF)

 

AMRINONE

hemodynamic effect similar to dobutamine, increases cardiac function and induces vasodilation

dose: 0.75 mg/kg over 2 - 3 minutes, then infusion of 5 - 15 mcg/kg/min

CALCIUM

not useful in most cardiac arrests (class III)

used in hyperkalemia, hypocalcemia (post multiple blood transfusions), or in toxicity secondary to calcium channel blockers

Dose: 2 - 4 mg/kg of 10% solution of CaCl2

repeated every 10 min

VASOPRESSIN

May be used as an alternative to epinephrine in adult shock-refractory VF (class IIB)as a substitute for the first or second dose of epinephrine in VF/VT or Asystole/PEA

may be useful in hemodynamic support in vasodilatory shock (septic shock)

potent peripheral vasoconstrictor, increased PVR may provoke cardiac ischemia

not recommended for responsive patients with CAD

Dose : 40units IVP x 1 dose IV, IO or ET

DIGITALIS

seldom if ever used in emergency conditions

can be used to decrease ventricular response rate in some tachyarrythmias.

Diltiazem or Verapamil are alternate drug choices

NITROGLYCERIN

Drug of choice in ischemic chest pain

Acute angina 1/150 gr. (0.4 mg) tablet sl or spray given q 5 min x 3 doses

IV NTG preferred in severe or unstable angina or CHF

may be used in severe hypertensive crises

dose 10 - 20 mcg/min. May be titrated to effect every 5 - 10 minutes. Use caution in higher doses exceeding 50 mcg/min. (Mix 50 mg in 250 cc IVF, use glass bottle and vented nitro infusion set)

toxicity : hypotension - administer fluids, Use care in cases of pump failure.

SODIUM NITROPRUSSIDE

potent, rapid acting direct peripheral vasodilator

very toxic agent need to carefully monitor methhemoglobin and thiocyanate levels

recommend using hemodynamic monitoring with this medication. Keep LV pressure (wedge) at 15 - 18 mm Hg

useful in MI & CHF if B/P rises and is unresponsive to nitroglycerin

Dose: 0.1 - 5 mcg/kg/min (50 mg in 250 IVF) protect from light

Toxicity: hypotension (can overshoot) metabolizes to cyanide and thiocyanate, eliminated renally, causes metabolic acidosis, confusion, hyperreflexia and convulsions.

 

SODIUM BICARBONATE

used as acid base buffer agent

used in certain conditions, metabolic acidosis, hyperkalemia, tricyclic antidepressant, aspirin or phenobarbital overdose

give based upon lab studies or Arterial Blood Gas results

OTHER MEDICATIONS

DIURETICS

Furosemide causes transient vasodilation, then diuresis - good in pulmonary edema using 0.5 to 1.0 mg /kg (Informal estimate of dose - age + BUN)

Bumetadine more potent diuretic in patients resistant to furosemide

FIBRINOLYTIC AGENTS

Activate plasminogen to plasmin which digests fibrin and dissolves the clot

non-specific action, screen carefully for contraindications

recommended for MI patients if administered within 6 hours of onset of chest pain

Medications:

Activase (t-PA)

Reteplase (r-PA)

Streptokinease

Tenectplase (TNKase)

ASPIRIN

used early in MI for antiplatelet actions

HEPARIN

used for anticoagulant effects in Acute Ischemic Coronary syndromes

Heparin administered in bolus and continuous infusions

Low molecular weight heparin can be administered subcutaneously

all require monitoring of PT or PTT to control effects.

GLYCOPROTEIN IIB/IIIA RECEPTOR-SITE BINDING AGENTS

used to prevent platelet aggregration in Acute Coronary Syndrome patients

useful post-PTCA and stenting procedure to prevent clotting off of implanted devices

Medications:

Abciximab (ReoPro)

Tirofiban (Aggrastat)

Eptifibatide (Integrilin)

 

 

ADVANCED CARDIAC LIFE SUPPORT

STUDY AND REVIEW INFORMATIONCLASSES OF THERAPEUTIC INTERVENTIONS

CLASS I A therapeutic option that is usually indicated, always acceptable and considered useful and effective.CLASS II A therapeutic option that is acceptable, is of uncertain efficacy, and may be controversial.

IIA The weight of the evidence is in favor of its usefulness and efficacy.IIB Not well established by evidence, but may be helpful and probably is not harmful.CLASS III A therapeutic option that is inappropriate, is without scientific supporting data and may be harmful.

ADJUNCTS FOR OXYGENATION-VENTILATION

OXYGEN DEVICES Class I

Do not withhold oxygen if hypoxemia is suspected.

Use 100% oxygen.

VENTILATORY DEVICES

Mouth to mask - Should have a one way valve. No studies have been done in humans.

Face shields have no exhalation port, (considered Class IIB)

Bag valve mask (B.V.M.) 1600 total volume, two users recommended (Class I)

B.V.M. should be refilling , have a non-jam valve allowing an inlet flow of 15 L/min, have no pop-off valve and should have a true non-rebreathing valve. B.V.M. should have a standard 15mm/22/mm fitting and oxygen reservoir for 100% oxygen.

A third user may provide cricoid pressure.

A transparent mask is preferable.

OXYGEN POWERED MANUALLY TRIGGERED DEVICES Class I

No pressure cycled ventilators - Class III

Must : 1) constant flow of 100% oxygen at less than 40 L/min.

2) inspiratory pressure flow that opens at 60 cm water pressure.

3) audible alarm if valve opens at high pressure to alert that volume getting to patient may be insufficient.

AUTOMATIC TRANSPORT VENTILATORS (ATV) Class I

Recommended for transport, especially intubated patients, need an oxygen source.

Not recommended for patients younger than 5 years of age, need an oxygen source.

AIRWAY ADJUNCTS

OROPHARYNGEAL AND NASOPHARRNGEAL AIRWAYS Class I

Use in patients when not intubated if indicated - use oral airways only in unconscious patients.

ENDOTRACHEAL INTUBATION Class I

The airway of choice for a deeply unconscious patient.

Intubate as soon as possible (in full respiratory or cardiac arrest). Provide tidal volumes or 10 - 15 ml/kg.

Do not interrupt ventilation for more than 30 seconds. Use cricoid pressure by a second rescuer.

Ventilation should be asynchronous at 12 - 15 per minute. NOT SYNCHRONIZED.Inflate with 10 - 20 cc air then check placement with the first breath by auscultation of the epigastrum and watching the chest. If the chest rises then listen to both lungs. Sound should be audible bilaterally.

When using expired carbon dioxide detector, keep in mind that in cardiac arrest CO2 may not be detected due to poor perfusion. These are still recommended.

ALTERNATE INVASIVE AIRWAYS Class IIB

Use MUST be authorized by EMS Medical Director.

ESOPHAGEAL OBTURATOR AIRWAY (EOA/EGTA)

Increased risk compared to endotracheal intubation

Ventilation and oxygenation definitely inferior to ET intubation.

PHARYNGOTRACHEL LUMEN AIRWAY (PTL)

Limited studies show good oxygenation, but needs more studies

Double lumen that is inserted blindly, tube that is appropriate is then ventilated through that lumen.

LARYNGEAL MASK AIRWAY (LMA)

superior to ETT for BLS level personnel

equal to ETT for ACLS level personnel

ESOPHAGEAL TRACHEAL COMBITUBE (ETC)

Simplified basic structure compared to PTL inserted the same.

experience is more in-hospital for the most part.

requires more and specialized training to use.

TRANSTRACHEAL CATHETER VENTILATION -CRICOTHYROTOMY

used rarely - only by trained and experienced professionals.

SUCTION DEVICES

Airflow of 30 L/min and vacuum of 300 mm Hg when clamped (and should be adjustable)

CONFIRM TRACHEAL TUBE PLACEMENT

Pulse oximetry - SpO2

End tidal CO2 indicators

Capnometric Devices & Capnographs

 

ADJUNCTS FOR ARTIFICIAL CIRCULATIONCardiopulmonary Resuscitation

Used to stabilize and maintain cardiovascular function in patients suffering from cardiac arrest.

Unprotected airway patients - 30 compressions : 2 ventilations

Protected airway patients - asynchronous

Rate 100 compressions / minute

Increased Emphasis on Public Access Defibrillators

MECHANICAL AIDS TO CPR

Simple, manually operated mechanical chest compressors can be used.

MAST trousers not routinely indicated in cardiac arrest

Several devices are experimental

INVASIVE CPR

Open chest - May be beneficial if used early in very special situations.

Penetrating chest trauma is the only reason at present to do open chest CPR and then only if the victim has a reasonable chance of survival (i.e. Vital Signs on EMS arrival).

ASSESSMENT OF CPR

Use arterial lines placed prior to arrest to assess cardiac output with CPR if available.

CARDIAC MONITORING AND ARRHYTHMIA RECOGNITION

Quick look paddles or immediate monitoring is needed.

Most deaths are due to electrical derangement.

Student must recognize: (ALL 14)

Sinus Rhythm

Sinus Tachycardia

Sinus Bradycardia

Premature Atrial Complexes (PAC or APC)

Atrial Flutter

Atrial Fibrillation

Junctional Rhythms

Atrioventricular Blocks

Premature Ventricular Complexes (PVC or VPC)

Ventricular Tachycardia

Torsades de pointes

Ventricular Fibrillation

Asystole

Paroxymal Supraventricular Tachycardia (PSVT)

DRUG THERAPY

ADMINISTRATION OF MEDICATIONS DURING CARDIAC ARREST

CENTRAL vs. PERIPHERAL

Use peripheral vein first. Requires 1 - 2 min. to reach central circulation.

Use 20 cc bolus of IV fluid or NS following administration of any drug.

Internal jugular is preferred route for central line.

Avoid femoral line unless the catheter passes above the diaphragm. CPR provides poor flow upward from below the diaphragm.

Intraosseous route considered same as Intravenous

ENDOTRACHEAL DRUG ADMINISTRATION

May give A L E via ET tube.

Atropine, Epinephrine, Lidocaine (Xylocaine)

Dose is 2 to 2.5 times the IV dose and diluted with 10cc NS or water

Absorption from lung is faster with sterile water than NS.

Pass a catheter beyond tip of ET tube. Spray. Stop compressions from before time of spray until 1 - 2 ventilations later.

INTRA OSSEOUS MEDICATIONS

Good alternate source in children.

IO epinephrine dose may have to be higher.

Studies of effectiveness continue.

DRUGS USED IN ACLS

CORRECTION OF HYPOXEMIA WITH OXYGEN THERAPY

100 % oxygen (Class I)

IV Fluids

Acute blood loss - rapid volume expansion with NS or LR

D5W may be used to keep lines open, but NS is preferred

No volume expansion in cardiac arrest, except as indicated

MORPHINE SULFATE

(Class IIB - acceptable, possible helpful, probably not harmful for pulm. edema ) Preferred in MI for pain relief.

Useful in pulmonary edema - increases venous capacitance, decreases venous return, mild arterial vasodilation

good analgesic effects

use with care in respiratory distress patients.

give in titrated/divided doses of 2 - 3 mg at a time

 

 

 

CONTROL OF HEART RHYTHM AND RATE

 

Amiodarone (Cordarone)

used for atrial & ventricular tachyarrythmias

treatment for shock-refractory VF / pulseless VT

treatment of polymorphic VT , wide complex tachycardia & hemodynamically stable VT when cardioversion is unsuccessful

useful in presence of LV dysfunction

can be used in SVT, PSVT as an adjunct to electrical cardioversion

may produce vasodilation & hypotension.

negative inotropic effects

may prolong QT interval

use with caution in heart failure patients

Dose in Cardiac Arrest: bolus of 300 mg IVP. Consider repeating 150 mg IVP in 3-5 minutes. Maximum dose 2.2 gm IV q 24 hours.Dose in Stable wide complex tachycardias : Rapid loading infusion of 150 mg IVPB over 10 minutes followed by a maintenance infusion of 0.5 mg/ min over 18 hours

LIDOCAINE

Drug can be used in ventricular ectopy, VT, VF

Prophylactic use in MI reduces incidence of VF. NOT recommended unless multiple PVCs (Class IIB)

Dose: Initially 1.0 - 1.5 mg/kg then 0.5 mg/kg every 5 minutes to total dose of 3.0 mg/kg and a continuos infusion of 2 - 4 mg/min.

reduce dose in states of decreased cardiac output, patients > age 70 and liver dysfunctionToxicity: slurred speech, altered levels of consciousness, muscle twitching or seizures.

PROCANAMIDE

Used to suppress PVCs and recurrent VT

For wide complex tachycardia (Class IIA)

Dose: 20 mg/min to a total of 17 mg/kg. In urgent cases use 30 mg/min then use 1 - 4 mg/min continuos infusion.

Stop infusion if BP drops, QRS complex widens by 50% of original width or 17 mg/kg is reached.

BETA-ADRENERGIC BLOCKERS

If used less than 4 hours after fibrinolytic therapy - may reduce the rate of non-fatal re-infarction and recurrent ischemia.

Atenolol (Tenormin), metoprolol (Lopressor), propanolol (Inderal) have been shown to reduce the incidence of VF in post MI patients who do not receive fibrinolytic agents.

Dose: Atenolol 5 - 10 mg over 5 minutes

Metoprolol 5 mg every 5 minutes x 3 doses

Contraindications - Bradyarrythmias, 2nd degree or 3rd degree blocks, hypotension, bronchospasm or CHF

ATROPINE

useful in treating symptomatic sinus bradycardia (Class I)

treatment of AV block at nodal level (Class IIA)

used in ventricular asystole

Cardiac Arrest Dose : 1 mg repeat every 3 - 5 minutes to a total dose of 3 mg if asystole persists

Bradycardia dose - 0.5 - 1.0 mg every 3 - 5 minutes for sustained heart rate < 40 to maximum dose of 3 mg.

Doses < 0.5 mg may be parasympathomimetic and further slow the rate.

Well absorbed by endotracheal route.

ISOPROTERENOL (not commonly used at this time)

used for symptomatic bradycardia

if used, extreme caution should be exercised, at low doses can be helpful, at high doses can be harmful.NOT USED IN MI

Increases myocardial oxygen demand

lowers fibrilatory threshold; can cause VF/VT

not used in cardiac arrest and hypotension!

VERAPAMIL AND DILTIAZEM

used to control ventricular response rate in atrial fibrillation/flutter or multifocal atrial tachycardia (MAT)

effective in narrow complex PSVT, but adenosine is the drug of choice

give Calcium prior to giving verapamil to avoid hypotension

Verapamil (Calan) dose 2.5 to 5.0 mg over 2 min IV then 5 - 10 mg every 15 - 30 min to a maximum dose of 20 mg.

Diltiazem (Cardizem) dose 20 mg IV initialinfusion may repeat a second dose of 25 mg IV followed by a continuos infusion of 15 mg/hr taper and D/C as indicated.

ADENOSINE

rapidly terminates re-entry PSVT. In Atrial Fibrillation/flutter will produce a transient AV block that may clarify the diagnosis

T50 > 5 seconds, push and flush rapidly ("slam-dunk" administration)

Dose: 6 mg over 1 - 3 seconds with 20cc NS flush, if no response, repeat with 12 mg bolus in 1 - 2 minutes and 20cc flush, may repeat for a 3 rd bolus of 12 mg.

Drug interactions: Theophylline / Aminophylline, Caffiene, Theobromine and other methylxanthines will block the receptor

Dipyramidamole (Persantine) blocks uptake and potentiates the effect

Carbamazepine (Tegretol) prolongs the effects

safe in Wolf-Parkinson-White (WPW) syndrome

 

 

MAGNESIUM

deficiency - associated with cardiac arrythmias and sudden cardiac death. Hinders replenishment of intracelluar potassium

recurrent VF/VT - correct low Mg. Level by giving MgSO4 1 - 2 Gm. In D5W 100 ml over 1 - 2 minutes.

Reduces the incidence of post-infarction ventricular arrythmias

Loading Dose: MgSO4 1 - 2 gm. In D5W 100 ml over 5 - 60 minutes, then 0.5 to 1 gm per hour for 24 hours.

Considered the treatment of choice in Toursades de Pointes

useful in treating pre-eclamptic seizures in toxemic female patients

IMPROVED CARDIAC OUTPUT AND BLOOD PRESSURE

EPINEPHRINE

Dose is 1 mg (10 cc of 1:10,000 solution) IV push every 3 - 5 minutes, followed by 20cc flush of IV fluid.

No indications that larger doses of epinephrine produced higher rates of survival

no indications for doses of > 1 mg.

Endotracheal dose is 2 to 2.5 times the IV dose

NOREPINEPHRINE

Indicated in severe hypotension (SBP < 70)

dose is 0.5 to 1.0 mcg/min (4 mg in 250 cc IVF)

do not use in hypovolemic states

use phentolamine (Reigitine) 5 - 10 mg in 10 - 15 cc NS if extravasation occurs, infiltrate area with mixture.

DOPAMINE

Chemical precursor to norepinephrine - alpha & beta actions

Dose is 2 -20 mcg/kg/min - (mix either 400 mg or 800 mg in 250 cc)

reduce or stop med if tachycardia occurs

MAO inhibitors potentiate the effects of dopamine

Inactivated by sodium bicarbonate

renal perfusion dose: 3 - 6 mck/kg/min pressure support 7 -20 mcg/kg/min

doses > 7 mcg/kg/min will result in renal & mesenteric artery constriction and lower urine output. Higher doses also reduce peripheral circulation.

DOBUTAMINE

used to treat heart failure - cardiogenic shock

increases myocardial contractility (+ inotrope)

if heart rate increases by >10%, decrease the dose

dose: 2 - 20 mcg/kg/min (500 mg in 250 cc IVF)

 

AMRINONE

hemodynamic effect similar to dobutamine, increases cardiac function and induces vasodilation

dose: 0.75 mg/kg over 2 - 3 minutes, then infusion of 5 - 15 mcg/kg/min

CALCIUM

not useful in most cardiac arrests (class III)

used in hyperkalemia, hypocalcemia (post multiple blood transfusions), or in toxicity secondary to calcium channel blockers

Dose: 2 - 4 mg/kg of 10% solution of CaCl2

repeated every 10 min

VASOPRESSIN

May be used as an alternative to epinephrine in adult shock-refractory VF (class IIB)as a substitute for the first or second dose of epinephrine in VF/VT or Asystole/PEA

may be useful in hemodynamic support in vasodilatory shock (septic shock)

potent peripheral vasoconstrictor, increased PVR may provoke cardiac ischemia

not recommended for responsive patients with CAD

Dose : 40units IVP x 1 dose IV, IO or ET

DIGITALIS

seldom if ever used in emergency conditions

can be used to decrease ventricular response rate in some tachyarrythmias.

Diltiazem or Verapamil are alternate drug choices

NITROGLYCERIN

Drug of choice in ischemic chest pain

Acute angina 1/150 gr. (0.4 mg) tablet sl or spray given q 5 min x 3 doses

IV NTG preferred in severe or unstable angina or CHF

may be used in severe hypertensive crises

dose 10 - 20 mcg/min. May be titrated to effect every 5 - 10 minutes. Use caution in higher doses exceeding 50 mcg/min. (Mix 50 mg in 250 cc IVF, use glass bottle and vented nitro infusion set)

toxicity : hypotension - administer fluids, Use care in cases of pump failure.

SODIUM NITROPRUSSIDE

potent, rapid acting direct peripheral vasodilator

very toxic agent need to carefully monitor methhemoglobin and thiocyanate levels

recommend using hemodynamic monitoring with this medication. Keep LV pressure (wedge) at 15 - 18 mm Hg

useful in MI & CHF if B/P rises and is unresponsive to nitroglycerin

Dose: 0.1 - 5 mcg/kg/min (50 mg in 250 IVF) protect from light

Toxicity: hypotension (can overshoot) metabolizes to cyanide and thiocyanate, eliminated renally, causes metabolic acidosis, confusion, hyperreflexia and convulsions.

 

SODIUM BICARBONATE

used as acid base buffer agent

used in certain conditions, metabolic acidosis, hyperkalemia, tricyclic antidepressant, aspirin or phenobarbital overdose

give based upon lab studies or Arterial Blood Gas results

OTHER MEDICATIONS

DIURETICS

Furosemide causes transient vasodilation, then diuresis - good in pulmonary edema using 0.5 to 1.0 mg /kg (Informal estimate of dose - age + BUN)

Bumetadine more potent diuretic in patients resistant to furosemide

FIBRINOLYTIC AGENTS

Activate plasminogen to plasmin which digests fibrin and dissolves the clot

non-specific action, screen carefully for contraindications

recommended for MI patients if administered within 6 hours of onset of chest pain

Medications:

Activase (t-PA)

Reteplase (r-PA)

Streptokinease

Tenectplase (TNKase)

ASPIRIN

used early in MI for antiplatelet actions

HEPARIN

used for anticoagulant effects in Acute Ischemic Coronary syndromes

Heparin administered in bolus and continuous infusions

Low molecular weight heparin can be administered subcutaneously

all require monitoring of PT or PTT to control effects.

GLYCOPROTEIN IIB/IIIA RECEPTOR-SITE BINDING AGENTS

used to prevent platelet aggregration in Acute Coronary Syndrome patients

useful post-PTCA and stenting procedure to prevent clotting off of implanted devices

Medications:

Abciximab (ReoPro)

Tirofiban (Aggrastat)

Eptifibatide (Integrilin)

 

 

 

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