RESUSCITATION PHARMACOLOGY

Dr. Beny Hartono, SpJP, FIHA

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 ?? COPD

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

Epinephrine / Adrenaline
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

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

dobutamine
WHY MOA WHEN indication Systolic heart faillure untolerate with vasodiltors SBP 70-100 no sign ,simp shock Right ventricle infarction Septic shock HOW dose 2-20 microgram/kg/mi n WATCH OUT precaution Tachyarrhythmias Myocardial ischemia Down regulated in chronic heart faillure

Receptors , 1, 2 ,predominant 1 Little effect on peripheral Increase renal mesenteric flow

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 (dont delay) Second drug in asystole / PEA Organophosphate poisoning

Atropine
Dosage Arrest 1mg IV/IO push Q3 5min 2 3mg ETT Bradycardia 0.5mg 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 II 3rd degree

Anti-arrhythmics
Pro-arrhythmics Negative inotrope ( force) (+) for Ca channel blocker, -blocker, procainamide, lignocaine (+) for amiodarone (-) for digoxin

Classification of antiarrhythmic
Vw CLASS 1a 1b CHANNEL EFFECT Na channel blockers moderate Na channel blockers Weak Na channel blockers strong adrenergic blockers EFFECT ON ACTION POTENTIAL Phase 0 Na influx Phase 0 Na influx Phase 0 Na influx Decreased SA node automaticity Slow av node conduction Phase 3 K efflux Phase 4 Ca influx DRUG Procainamide Disopyramide lidocain

1c

Propafenon Flecainamide Atenolol,Propanolol ,metoprolol,esmolol ,Labetolol Amiodaron,bretiliu m,dofetilide,ibutilid e,sotaol Diltiazem,verapamil

II

III

K channel blockers

IV

ca channel blockers

Anti-arrhythmics
Slow the heart (-ve chronotrope) AV node vs. accessory pathway AV node only Adenosine, digoxin AV node > accessory pathway Ca channel blocker, -blocker Lidocaine AV node = accessory pathway Amiodarone, 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 Tachyarrhythmias 150mg IV over 10min Maintenance 1mg/min IV for 6 hours then 0.5mg/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 Loading 1-1.5mg/kg IV push (arrest) 0.5-0.75mg/kg IV push (stable VT) + 0.5-0.75mg/kg IV Q3 - 5min Up to 3mg/kg ETT: 2-4mg/kg 1x Maintenance 1-4mg/min IV

Lidocaine / Lignocaine
Precautions Not recommended as prophylaxis in MI

Reduce dose Impaired liver function Poor 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 suppression o Hypotension o QRS widen by 50% o 17mg/kg given (60mins for 70kg patient) Maintenance o 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 ACTION Ca channel blocker automaticity conduction INDICATION Rate control for AF Terminate 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 = Morphine O = Oxygen N = Nitrate A = Aspirin

Morphine
MECHANISM OF ACTION Relieve pain myocardial oxygen demand INDICATION Chest pain no responding to nitrate Pulmonary edema

Morphine
DOSAGE 2-4mg IV Q5-30min Titrate to effect PRECAUTIONS Hypotension CNS / respiratory depression

Nitroglycerin
MECHANISM OF ACTION Vasodilation preload, afterload Coronary artery vasodilation INDICATION Ischemic chest pain Ongoing or recurrent ischaemia in MI Pulmonary edema, hypertensive urgency

Nitroglycerin
DOSAGE SL : 0.5mg Q 5min IV : start with 10-20g/min PRECAUTIONS Phosphodiesterase inhibitor for erectile dysfunction Hypotension Headache

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 K Hypo Ca Ca channel blocker / -blocker overdose DOSAGE 5-10ml 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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