THE CPR DRUGS (Used in all cardiac arrest patients) Oxygen- Never withholds oxygen from a patient during

cardiac arrest if it is available. WHY? (Actions) 1. Increases oxygen tension 2. Increases oxygen saturation WHEN? (Indications) 1. Acute chest pain suspected of being myocardial in origin 2. Cardiac arrest 3. Suspected hypoxemia HOW MUCH? (Dosage) 1. 100% in cardiac arrest 2. As needed to correct hypoxemia WATCH OUT! (Precautions) 1. Toxicity is not a concern in cardiac arrest 2. COPD is not a concern in cardiac arrest; Treat the same as other patients till stable. EPINEPHRINE- Always the first drug when CPR is in progress WHY (Actions) 1. Increases coronary and cerebral blood flow 2. Increases systolic and diastolic pressures 3. Increases electrical activity in the myocardium 4. Increases systemic vascular resistance 5. Increases strength of myocardial contractions 6. Increases myocardial oxygen consumption 7. Increases automaticity WHEN? (Indications) 1. Asystole from any other rhythm 2. Profound symptomatic bradycardia (use infusion) HOW MUCH? (Dosage) 1. 1.0mg (10ml of 10,000 solution) IV every 3-5min 2. Endotracheal route is 2-2.5 times the IV dose (mix 2.0-2.5mg EPi in NS to total 10cc) WATCH OUT! (Precautions) 1. May induce or exacerbate ventricular ectopic especially in patients on digoxin

ANTI ARRHYTHMICS Used for VF/pulseless VT/ PVCs LIDOCAINE Actions 1. Suppresses ventricular irritability by decreasing automaticity and decreases excitability in ischemic tissue 2. Elevates ventricular fibrillation threshold Indications 1. VF/ VT Lidocaine used first after Epinephrine 2. Symptomatic PVSs Dosage 1. Cardiac arrest : 1-1.5 mg/kg initial IV bolus repeat every 3-5 min at 1-1.5 mg/kg to total 3mg/kg until rhythm converts 2. Non-cardiac arrest 1-1.5mg/kg IV bolus repeat every 5-10mm at 0.5-0.75mg/kg to total 3mg/kg 3. After restoration of spontaneous circulation gtts at 2-4mg/min Precautions 1. Neurological changes, muscle twitching, slurred speech, altered LOC, Decreased hearing ringing, Paresthesia 2. Myocardial depression (in patients receiving large doses 3. Circulatory depression BRETYLIUM Actions 1. Suppresses vent, ectopy 2. Elevates VF threshold 3. Transient sympathomimetic effects of elevated BP, HR and cardiac output Indications 1. Second drug for VF/VT 2. Third drug for symptomatic PVCs Dosage 1. Cardiac arrest: 5mg/kg IV bolus, repeat 10mg/kg in 5 minutes intervals to max of 35mg/kg

2. After return of spontaneous circulation IV gtt at 2mg/min 3. Refractory or recurrent VT without a pulse: 500mg (10ml) diluted to 500ml and 5-10mg/kg can be injected over 810min. Precautions 1. Nausea, vomiting with rapid infusion in conscious patient 2. Postural hypotension in the non-cardiac arrest patient 3. Use with caution if patient take digoxin, it with exacerbate toxicity PROCAINAMIDE Actions 1. Suppresses ventricular ectopic by creasing automaticity and slowing intraventricular conductions Indications 1. Symptomatic PVCs and VT that cannot be controlled by Lidocaine (rarely used in VF) because of long admin time 2. SVT can be used to convert Dosage 1. 20-30mg/min until one of the following: a. Arrthymia suppressed b. Hypotension develops c. QRS widens by 50% of its normal width d. Total of 17mg/kg has been infused 2. After suppression of the arrthymia, infuse gtt at 1-4 mg/min Precautions 1. Hypotension 2. EKG changes- widening of PR, QRS and QT may lead to heart block and or cardiac arrest. If QRS widens by 50% of normal width, stop infusion immediately. **tendency to produce arrhythmias may be somewhat greater when hypokalemia and or hypomagnesaemia are present!

MAGNESIUM Not a true antiarrhythmic, but can be used in conjunction with antiarrhythmic. Actions 1. Magnesium deficiency is associated with arrhythmias, cardiac insufficiency, and sudden cardiac death. 2. Affects energy transfer and electrical stability in the myocardium Indications 1. Cardiac arrest with suspected hypomagnesaemia 2. Drug of choice for Torsades de pointes 3. May reduce the incidence of complications associated with an AMI Dosage 1. For VF/VT 1-2g IV bolus over 1-2 min 2. For unstable Torsades de pointes up to 5-10mg may be required 3. For documented hypomagnesaemia: a 24 hr infusion of 00.5-1.0g /hr Precautions 1. Flushing, diaphoresis, bradycardia, hypotension 2. Hypomagnesaemia may produce depressed reflexes flaccid paralysis, diarrhea, circulatory collapse and respiratory paralysis DRUGS TO SPEED UP THE HEART ISUPREL Actions 1. Pure beta adrenergic agonist (beta-1 and beta-2) 2. Has a potent inotropic and chronotropic affect Indications 1. Brady in the denervated transplanted heart 2. Hemodynamically significant Brady refractory to other treatments.

3. These treatments should be tried before ISUPREL: Atropine Pacing Dopamine Epinephrine Dosage 1. 2-10 ug.min titrated to increase HR to 60bpm Precautions 1. May induce VT/VF 2. Increases myocardial oxygen consumption 3. May exacerbate digoxin toxicity 4. May precipitate hypokalemia

DOPAMINE Actions 1. Alpha adrenergic effect 2. Peripheral arterial vasoconstriction 3. Increases pulmonary vascular resistance 4. Increases preload Indications 1. Hemodynamically significant hypotension in the absence of hypovolemia Dosage 1. Broad range 1-20ug/kg/min 2. Initial dose 1-5ug/kg/min to achieve organ perfusion then 3. Final dose 5-20ug/kg/min infusion (No bolus of loading dose) Precautions 1. Increases HR 2. May exacerbate or induce SVT or vent rhythms 3. May exacerbate pulmonary edema and decrease cardiac output 4. May induce or exacerbate ischemia

MEDICATIONS TO SLOW A RACING HEART CALCIUM CHANNEL BLOCKERS Actions 1. Slows conduction and prolongs refractoriness in the AV node 2. Negative inotropic and chronotropic effect Indications Verapamil: highly effective for acute and preventive treatment of SVT Diltiazem: effective in controlling vent response in patients with A-fib, also, good for SVT that does not need cardioversion Dosage Verapamil: 1. 2.5mg IV over 1-2min repeat 5-10mg every 15-30 min to max of 15 mg 2. In elderly inject over 3 min Diltiazem 1. 0.25mg/kg IV over 2 min follow-up with 0.35mg/kg over 2-5 min, within 15min of initial dose for SVT 2. IV gtt at 5-15mg/hr after conversion of A-fib/Flutter Precautions 1. Will cause hypotension do not use for V-tach ADENOSINE Actions 1. Slows conduction in the AV node 2. Interrupts AV nodal reentry pathways Indications 1. SVTs only 2. Will not convert A-fib, A-Tach, and Vtach Dosage 1. 6mg IV push over 1.3 seconds flush with 20cc NS repeat in 1-2min at 12mg over 1-3 seconds flush with 20cc NS repeat 12mg again to total of 30mg 2. Patients taking theophylline or caffeine are less sensitive to adenosine and may require larger doses Precautions 1. Flushing 2. Dyspnea

3. Chest pain 4. Sinus Brady with PVCs ** Patient should be supine during administration! DRUGS TO TREAT PULMONARY EDEMA FUROSEMIDE Actions 1. Vasodilation onset in 5min 2. Inhibit sodium reabsobtion 3. Potent diuretic (onset 10 min), peak 30 min, duration 6 hrs Indications 1. Pulmonary edema associated with left ventricular dysfunction Dosage 1. 20-40mg IV (0.5-1.0mg/kg) initially and up to 2mg/kg total Precautions 1. Dehydration 2. Hypotension 3. Depletions of Na, K, Ca, Mg 4. Metabolic alkalosis 5. Anaphylaxis in patients allergic to sulfonamides

COMMON DRUGS TAKEN BY PATIENTS AT HOME AND IN ACLS DIGITALIS Actions 1. Increases myocardial contractility 2. Slows conductions directly and indirectly in the SA and AV nodes Indications 1. To slow ventricular response in A-fib, and A-flutter 2. SVT 3. Has little value in emergency treatment for CHF Dosage 1. 10-15ug/kg loading dose per lean body weight 2. The EKG and serum levels will need to be monitored for further administrations Precautions 1. Anorexia 2. Nausea and vomiting 3. Diarrhea 4. Visual disturbances 5. Change in mental status 6. PACs and /or PVCs 7. Ventricular bigamy 8. V-tach

Dosage 1. Sublingual 1 tab (0.3-0.4mg) repeat every 3-5 min x 3 tabs 2. Paste 1-2 inches, apply with applicator patch/ paper 3. IV gtt at 10-20ug/min, increase by 510ug/min every 5-10 min Precautions 1. Use with extreme cautions if SBP is <90 2. Limit BP drop by 10% if normotensive 3. Limit BP drop by 30% if hypertensive 4. Watch for headache, syncope, hypotension and tachycardia 5. Have patient sit down before administration 6. Extreme caution in patients taking Viagra BETA BLOCKERS Actions 1. Depresses the pumping function of the heart 2. Decreases HR 3. Decreases myocardial oxygen consumption Indications 1. Recurrent VF/VT 2. SVTs refractory to their therapies Dosage 1. Atenolol : 5mg IV over 5 min repeat in 10 min. 50mg after 10 min and then BID 2. Metoprolol 5mg IV over 2.5 minutes, repeat at 5min intervals to total of 15mg. oral dose: 50mg PO BID for 24 hrs then increase to 100 mg PO BID 3. Propranolol: 1-3mg IV over 2-5 min, not exceed 1mg/min Oral dose: 180-320mg PO daily in divided doses

NITROGLYCERIN Actions 1. Decreases the pain of ischemia 2. Increases venous dilation 3. Decreases preload and oxygen consumption 4. Dilates coronary arteries Indications 1. Unstable angina 2. Acute pulmonary edema (if SBP> 100) 3. Routinely in an AMI 4. Hypertension if patient is at risk for an MI especially if signs of left vent failure

4. Esmolol: loading dose of 250500ug/min for one minute, then maintenance gtt at 25-50ug/ min Precautions 1. Hypotension 2. CHF 3. Bronchospasm 4. Bradycardia MORPHINE Actions 1. Reduces pain ischemia 2. Reduces anxiety 3. Increases venous capacity 4. Decreases SVR 5. Reducing myocardial Output demand Indications 1. Continuing chest pain 2. Acute pulmonary edema 3. SBP must >90 Dosage 1. 1-3mg at frequent intervals can be as often as every 5min 2. Goal to eliminate pain

Precautions 1. Hypotension may occur especially with hypovolemia increased SVR and Bblockers 2. Depresses respirations 3. Nausea and vomiting 4. Bradycardia 5. Itching and bronchospasm