EMERGENCY

SUPPORTING
DRUGS

SMF/BAG. ANESTESIOLOGI & REANIMASI

RSUD dr. MOEWARDI/FK UNS

These drugs have the advantages

in increasing on cerebral and
coronary perfusion. It also usefull
to control rate and rhythm of the
heart.

We administer

these drugs before, during and

after CPR

IMPORTANT DRUGS
BP
- Epinephrine / adrenaline
- Vasopresine
- Dopamine

HR
- Atropine

Ventricular arrhythmia
- Amiodarone - Procainamide
- Lidocaine - MgSO4

 Supraventriculare

arrhythmia
- Adenosine
- Diltiazem
- Amiodarone

AMI
- Morphine

- Aspirine
- Nitroglycerine - Fibrinolytica

MISC
- Sodium bicarbonate
- Calcium chloride

DECISION TO USE
AGENT
1. Understand mechanism of
action
2. Know indication for use
3. Know advert effect
4. Know potential interactions

1. EPINEPHRINE/
ADRENALINE

MECHANISM OF ACTION
- & adrenergic stimulation
- SVR, BP (S & D)
- coronary and cerebral blood
flow
- myocardial O2 requirement
- electrical & strength of
myocardium
- automaticity

INDICATION
- All patients in cardiac
arrest
- Severe hypotention
- Symptomatic bradycardia
- Anaphylaxis

 DOSAGE

a. Cardiac arrest :
1 mg I.V. flush with 20 ml NS +
arm
elevation for 10-20 s
2 2,5 x
i.v. dose through ETT

b. Non cardiac arrest :

2 20 mc/min
PRECAUTIONS

- Precipitable in alkaline solution

2.VASOPRESSIN
MECHANISM OF ACTION
- Potent vasoconstrictor
- SVR, BP (S&D)
- Coronary and cerebral blood flow

INDICATION
- alternative to 1st and 2nd dose of
epinephrine for VF / VT (-)

DOSAGE
40 I.V. Push 1x

PRE CAUTION
may provoke cardiac
ischemia

3.DOPAMINE

MECHANISM OF ACTION :
stimulation of dopaminergie &
adrenergic receptor

INDICATION
- Hipotension (70 100 mmHg)
- Second drug for hypotensive
bradycardia

DOSAGE :
- 5 20 mc/Kg/min
- titrate to response

PRECAUTIONS :
- Start after volume replacement
- tapper gradually
- do not mix with sodium bicarbonate
- monitor I.V. site

4.

ATROPINE

MECHANISME OF ACTION
- Block parasympathetic receptor of heart
- SA node automatically
- AV node conduction
- Not to stimulate the hear
INDICATION
- Symptomatic sinus bradycardia
- While waiting for pacing
- Second drug in asystole / PEA
- Organophosphate poisoning

DOSAGE
- Arrest
:

1 mg i.v.
2 - 3 mg ETT
- Bradycardia :
0,5 mg i.v
- Max 3 mg
- Extremely large doses may be need for
organophospate poisoning

PRECAUTIONS
- paradoxical bradycardia with < 0,5 mg
- worsen myocardial ischaemia
- avoid in hypothermia bradycardia
- not useful in AV block of :
2nd degree type II
3rd degree

AGENT FOR CONTROL OF RATE AND RHYTHM

Classification of antiarrhythm
Vw CLASS

CHANNEL EFFECT

EFFECT ON
ACTION POTENTIAL

DRUG

1a

Na channel blockers
moderate

Phase 0
Na influx

Procainamide
Disopyramide

1b

Na channel blockers
Weak

Phase 0
Na influx

lidocain

1c

Na channel blockers
strong

Phase 0
Na influx

Propafenon
Flecainamide

II

adrenergic blockers

Decreased SA node automaticity

Slow av node conduction

Atenolol,Propanolol,metopr
olol,esmolol,
labetolol

III

K channel blockers

Phase 3
K efflux

Amiodaron,bretilium,dofetili
de,ibutilide,sotaol

IV

ca channel blockers

Phase 4
Ca influx

Diltiazem,verapamil

5.AMIODARON

MECHANISME

OF ACTION
- block Na, K and Ca channels
- and blocking properties

INDICATION

- VF/ VT cardiac arrest refractory

to shock + epinephrine
- Recurrent life threatening VT
- Other arrhythmias
- VT narrow QRS

DOSAGE
- Cardiac arrest
300 mg i.v. push (in 20 ml D5)
+ 150 mg i.v. push in 3 5 min 1x

- Ventricular tachyarrhythmias
150 mg i.v. over 10 min

- Maintenance
1 mg/min i.v. for 6 hours then
0,5 mg/min i.v. for 18 hours

- Max dose 2,2 g/day

PRECAUTIONS
- Multiple drugs interaction
- Long half-life (up to 40 days)
- Hypotention with rapid/repeated dose
- Prolong QT interval

6.

LIDOCAINE /
LIGNOCAINE

MECHANISM OF ACTION
- block Na channel
- ventricular ectopy
- excitability in ischemic tissue
INDICATION
- alternative to amiodarone in cardiac
arrest for VT/VF
- stable VT with good LV

 DOSAGE
- Loading :
1 - 1,5 mg/Kg i.v. push (arrest)

0,5 0,75 mg/Kg i.v. push (stable VT)

ETT = 2 4 mg/Kg

- Maintenance :
1 4 mg/min i.v.

- Precautions
Not reccomended as prophylaxis in MI
Reduce dose
- Impaired liver function
- Poor LV
Stop infusion if sign of toxicity occurs

PROCAINAMID
7. E
MECHANISME

OF ACTION :

- block Na channel
- ventricular ectopy
- conduction
INDICATION

- suppression of recurrent VT/VF

- other tachy-arrhythmias

DOSAGE :
Reccurrent VT/VF :
- 20 mg/min
- maintenance = 1 4 mg/min

PRECAUTIONS :
- hypotension
- reduce to 12 mg/min in patient with
heart/renal failure
- prolong QT interval
- pro-arrhythmic, esp. in AMI, K, Mg

8. MAGNESIUM

SULPHATE

Drug of choice for Torsades de

pointes
Dosage :
- 1 2 gr i.v. over 5 20 min
- then infusion 0,5 1 gr/hr
- Titrate to control Torsades

ADENOSINE/AT
9.
P
MECHANISME OF ACTION :
- SA node and AV node
- short half life < 5 s

INDICATION :
- termination of PSVT
- unstable SVT during cardioversion
preparation
- will be difficult to indentify SVT with narrow QRS

 DOSAGE :
- 6 mg adenosine/10 mg ATP push 1
3 s follow by 20 ml NS if no
response in 1 2 min
- 12 mg adenosine/20 mg ATP push
- 3rd dose of 12 mg adenosine/20 mg
ATP

PRECAUTIONS :
flushing, dyspnoe, chest pain

DILTIAZE
10. M
MECHANISME OF ACTION :
- Ca channel blocker
- automaticity
- conduction

INDICATION :
- rate control for AF
- terminate stable re-entry SVT
if adenosine fails

 DOSAGE :
- 15 20 mg over 2 min
- repeat in 15 min at 20 - 25 mg i.v.
- then 5 15 mg/hr
- titrate of 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 = morphine
O = oxygen
N = nitrate
A = aspirine

11.

MORPHIN
E

MECHANISME OF ACTION :
- relieve pain and anxiety
- myocardial oxygen demand
- SVR
- venous capacitance
INDICATION :
- chest pain
- acute cardiogenic pulmonary edema

 DOSAGE :
- 2 4 mg i.v, slowly
- Goal = pain ( - )
PRECAUTIONS :
- hypotension
- CNS/respiratory
depression

12. NITROGLYCERIN
MECHANISME OF ACTION :
Vasodilatation :
- pre load, after load
- coronary artery vasodilatation
INDICATION :
- ischemic chest pain
- ongoing or recurrent ischaemia in MI
- pulmonary edema, hypertensive urgency

 DOSAGE :
- i.v. = start with 10 20
mc/min
- SL = 0,5 mg, repeat after 5
min
PRECAUTIONS :
- hypotension
- headache

13.

ASPIRIN
MECHANISM OF ACTION :
- anti platelet aggregation
- blocking production of tromboxane A2
- decrease mortality caused by IMA
- decrease reinfark risk
INDICATION :
- all patient with ACS

 DOSAGE :
- 160 320 mg PO
- chewing
PRECAUTIONS :
- ulcus pepticum, asthma
- hypersensitive

14.

FIBRINOLYTICS

MECHANISME OF ACTION :
reperfusion of myocardium
INDICATION :
- ST elevation MI or new LBBB
- < 12 hr from onset
CHOICE :
- streptokinase

 DOSAGE :
streptokinase 1,5 million unit i.v. dilute in 100 cc,
infused for 30 60 min

PRECAUTION :
- bleeding - allergy
- hypotension - reperfusion arrhythmia

CONTRA INDICATION :
- history of haemorhage stroke
- history of nonhaemorhage stroke
in the past year
- intra cranial tumor
- active internal bleeding

15.

CALCIUM
CHLORID
E

INDICATION :
- Hypo Ca
- Hyper K
- Ca channel blocker/-blocker
overdose
DOSAGE :
5 10 ml 10% CaCl2

16.

SODIUM
BICARBONATE
INDICATION :
- Hyper K
- Tricyclic antidepressant overdose
DOSAGE :
- 1 mmol/Kg i.v. bolus
- monitor BGA
PRECAUTION :
not routine for cardiac arrest

PHARMACOLOGIC ALTERATIONS
IN PREGNANCY
metabolism and volume of distribution
of drug
increased plasma volume
changes in the blood consentration
Local anesthetic drugs induce fetal
acidosis
blocker capable of causing fetal
bradycardia

 vasopressors can cause utero-placental

vasoconstriction, with reduced fetal
oxygenation & carbondioxide
elimination

sodium bicarbonate crosses

the placental barrier

Terima kasih ...

Guidelines for Resuscitation

2005
1. Main changes
support
2. Main changes
defibrillation
3. Main changes
support
4. Main changes
support

in adult basic life

in automated external
in adult advanced life
in paediatric life

Main changes in adult basic life support

unresponsive and not
breathing
normally
place the hands on the
centre
of the chest
1 sec rather than 2 sec

the ratio of compressions

to ventilations is 30 : 2
30 compressions is being

start CPR (.A-B-C

etc)
Using the rib margin
method is wasting
time
each rescue breath
over
1 sec
for all adult, and
children
( for a lay rescuer)

Main changes in adult advanced life support

1.
2.
3.
4.

CPR before defibrilation

Defibrilation strategy
Fine VF
Adrenaline ( epinephrine )

5. Anti-arrhythmic drugs
6. Thrombolytic therapy for cardiac arrest
7. Post resuscitation care therapeutic hypothermia

CPR before
defibrilation
in out of hospital C A
unwitness cardiac arrest
do not delay defibrilation

Give CPR for 2

minutes
(30 : 2 )
witnessed cardiac
arrest