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RESUSCITATION PHARMACOLOGY

RESUSCITATION PHARMACOLOGY

• Correct hypoxia• Establish spontaneous circulation

at an adequate blood pressure• Promote optimal cardiac function• Prevent or suppress arrhythmias• Relieve pain• Correct acidosis• Treat congestive heart failure

IMPORTANT DRUGS FOR ACLS

• Oxygen BP

Epinephrine/adrenaline Vasopressin Dopamine

HR Atropine

Ventricular arrhythmia Amiodarone Lidocaine / lignocaine Procainamide Magnesium sulphate

Supraventricular arrhythmia Adenosine Diltiazem Amiodarone

• AMI Morphine Nitroglycerine Aspirin Fibrinolytics

• Misc Sodium bicarbonate Calcium chloride

SCHEME FOR STUDY

• Mechanism of action (why ?)

• Indication (when ?)

• Dosage (how ?) correct dose for the correct indication through the correct route

• Precautions (watch out !)

OXYGEN

• Mechanism of action O2 tension hemoglobin saturation tissue oxygenation

• Indication All patients in ACLS

OXYGEN

• Dosage Spontaneous breathing

1 – 6 L/min via nasal cannula 4 L/min for AMI 6 – 10 L/min via non-breathing face mask

Cardiac arrest 15 L/min using bag mask

• Precaution ?? COAD

Epinephrine / Adrenaline

• Mechanism of Action & adrenergic stimulation SVR, SBP, DBP coronary and cerebral blood flow electrical & strength of myocardium

myocardial O2 requirement automaticity

Epinephrine / Adrenaline

• Indication All patient in cardiac arrest

Severe hypotension Symptomatic bradycardia Anaphylaxis

• Dosage Cardiac arrest

1 mg (10ml 1:10000) IV push Q3-5 min Flush with NS + arm elevation for 10-20s 2 – 2.5x IV dose through ETT

Non-Cardiac arrest 2 - 20g/min

• Precautions Precipitate in alkaline solutions

Epinephrine / Adrenaline

Vasopressin

• Mechanism of action Potent vasoconstrictor SVR, SBP, DBP coronary and cerebral blood flow

• Indication Alternative to 1st and 2nd dose of

epinephrine for VF/ pulseless VT

Vasopressin

• Dosage 40 U IV push 1x

• Precautions May provoke cardiac ischemia

Dopamine

• Mechanism of action Stimulation of dopaminergic, &

adrenergic receptor

• Indication Hypotension (70 – 100mmHg) Second drug for hypotensive

bradycardia

Dopamine

• Dosage 5 - 20g/kg/min Titrate to response

• Precautions Taper gradually Start after volume replacement Do not mix with sodium bicarbonate Monitor IV site

Atropine• Mechanism of action

Block parasympathetic receptor of heart SA node automaticity AV node conduction Not to stimulate the heart

• Indication Symptomatic sinus bradycardia While waiting for pacing (don’t delay) Second drug in asystole / PEA Organophosphate poisoning

Atropine• Dosage

Arrest1mg IV/IO push Q3 – 5min2 – 3mg ETT

Bradycardia0.5mg IV/IO Q3 – 5min

Max. 3mg Extremely large dose may be need for

organophosphate poisoning

Atropine

• Precautions Paradoxical bradycardia with < 0.5mg Worsen myocardial ischaemia Avoid in hypothermic bradycardia Not useful in AV block of

2nd degree Type II3rd degree

Anti-arrhythmics

• Pro-arrhythmics

• Negative inotrope ( force) (+) for Ca channel blocker, -blocker,

procainamide, lignocaine (+) for amiodarone (-) for digoxin

Anti-arrhythmics

• Slow the heart (-ve chronotrope) AV node vs. accessory pathway AV node only

Adenosine, digoxin AV node > accessory pathway

Ca channel blocker, -blockerLidocaine

AV node = accessory pathwayAmiodarone, procainamide

Amiodarone• Mechanism of action

Block Na, K and Ca channels & blocking properties

• Indication VT/VF cardiac arrest refractory to shock

+ epinephrine Recurrent life-threatening VT Other arrhythmias (need expert)

Amiodarone

• Dosage Cardiac Arrest

300mg IV push (in 20-30ml D5)+ 150mg IV push in 3-5 min 1x

Ventricular Tachyarrhythmias150mg IV over 10min

Maintenance1mg/min IV for 6 hours then0.5mg/min IV for 18 hours

Max dose 2.2g/day

Amiodarone

• Precautions Multiple drug interaction Long half-life (up to 40 days) Hypotension with rapid/repeated dose Prolong QT interval

Lidocaine / lignocaine

• Mechanism of Action Block Na channel ventricular ectopy excitability in ischemic tissue

• Indication Alternative to amiodarone in cardiac

arrest from VT/VF Stable VT with good LV

Lidocaine / Lignocaine• Dosage

Loading1-1.5mg/kg IV push (arrest)0.5-0.75mg/kg IV push (stable VT)+ 0.5-0.75mg/kg IV Q3 - 5minUp to 3mg/kgETT: 2-4mg/kg 1x

Maintenance1-4mg/min IV

Lidocaine / Lignocaine• Precautions

Not recommended as prophylaxis in MI

Reduce dose Impaired liver functionPoor LV

Stop infusion if signs of toxicity occurs

Procainamide

• Mechanism of Action Block Na channel ventricular ectopy conduction

• Indication Suppression of recurrent VF/VT Other tachy-arrhythmias

Procainamide• Dosage

Recurrent VF/VT 20mg/min (up to 50mg/min) infusion until

o Arrhythmias suppressiono Hypotensiono QRS widen by 50%o 17mg/kg given (60mins for 70kg

patient)

Maintenanceo 1 – 4mg/min

Procainamide

• Precautions Hypotension Reduce to 12mg/kg max in patient

with heart / renal failure Prolong QT interval Pro-arrhythmic, esp. in AMI, K, Mg

Magnesium Sulphate

• Drug of choice for Torsades de Pointes

• Dosage 1-2g IV over 5-20min Then infusion 0.5 – 1g/hr Titrate to control torsades

Adenosine / ATP

• MECHANISM OF ACTION SA node and AV node Short half-life < 5s

• INDICATION Termination of PSVT Diagnostic maneuver for stable

narrow complex SVT

Adenosine / ATP

• DOSAGE 6mg adenosine / 10mg ATP, follow by

20ml NS 12mg adenosine / 20mg ATP in 1-2min if

no response A third dose of 12mg / 20mg ATP in 1-

2min

• PRECAUTIONS Flushing, dyspnoea, chest pain

Diltiazem

• MECHANISM OF ACTIONCa channel blocker automaticity conduction

• INDICATIONRate control for AFTerminate stable re-entry SVT if

adenosine fails

Diltiazem• DOSAGE

15-20mg IV over 2 min Repeat in 15 min at 20-25mg IV PRN Then 5-15mg/hr Titrate to effect

• PRECAUTIONS Not to be used in

Wide complex tachycardia of uncertain origin

Drug induced tachycardia WPW syndrome with AF

DRUGS for AMI

• “MONA greets all MI patients”

M = MorphineO = OxygenN = NitrateA = Aspirin

Morphine

• MECHANISM OF ACTIONRelieve pain myocardial oxygen demand

• INDICATIONChest pain no responding to nitratePulmonary edema

Morphine

• DOSAGE2-4mg IV Q5-30minTitrate to effect

• PRECAUTIONSHypotensionCNS / respiratory depression

Nitroglycerin

• MECHANISM OF ACTION Vasodilation

preload, afterloadCoronary artery vasodilation

• INDICATION Ischemic chest pain Ongoing or recurrent ischaemia in MI Pulmonary edema, hypertensive urgency

Nitroglycerin

• DOSAGESL : 0.5mg Q 5minIV : start with 10-20g/min

• PRECAUTIONSPhosphodiesterase inhibitor for

erectile dysfunctionHypotensionHeadache

Aspirin• MECHANISM OF ACTION

Inhibit platelet action

• INDICATION All patient with ACS

• DOSAGE 162-325mg PO (300mg) Chewing

• PRECAUTIONS Peptic ulcer, asthma

Fibrinolytics• MECHANISM OF ACTION

Reperfusion of myocardium

• INDICATION ST elevation MI or new LBBB <12hr from onset

• CHOICE Streptokinase Alteplase

• PRECAUTIONS Screen for contraindications

Calcium Chloride• INDICATION

Hyper KHypo CaCa channel blocker / -blocker

overdose

• DOSAGE5-10ml 10% CaCI2

Sodium Bicarbonate• INDICATION

Hyper K Bicarbonate responsive acidosis (DKA) Tricyclic antidepressant overdose

• DOSAGE 1mmol/kg IV bolus Monitor ABG

• PRECAUTIONS Not routine for cardiac arrest

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