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Bradycardia

Atropine
Dopamine infusion Epinephrine infusion

Atropine
Mechanism of Action

Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle, SA/AV nodes)

Atropine
Indications First drug for symptomatic sinus bradycardia May be beneficial in AV block or asystole Second drug in asystole or slow PEA Organophosphate poisoning; large dose may be needed Precautions MI and hypoxia atropine increases oxygen demand Avoid in hypothermia Not effective for 2nd type II or new 3rd degree block (may slow the rhythm) Doses < 0.5 mg may cause a paradoxical slowing

Atropine

Dont delay pacing for severely symptomatic (unstable) patients.

Asystole or slow (<60)PEA 1 mg IV/IO push Repeat every 3 to 5 minutes (if rhythm persists) to max. of 3 mg. Bradycardia 0.5 mg IV every 3-5 minutes as needed; max. of 3 mg. Use shorter dosing interval and higher doses in severe clinical situations Endotracheal Administration 2-3 mg diluted in 10 mL water or NS Organophosphate Poisoning Large doses (2-4 mg or higher) may be necessary

Dopamine
Mechanism of Action

Stimulates adrenergic receptors; dose dependent.

Dopamine
Indications Second-line drug for symptomatic bradycardia Hypotension with signs and symptoms of shock Precautions Correct hypovolemia with volume before initializing Use caution with cardiogenic shock and associated CHF May cause tachydysrhythmias; excessive vasoconstriction Dont mix with sodium bicarbonate IV Administration Infusion at 5-20 mcg/kg/min. Titrate to patient response; taper slowly

Epinephrine
Mechanism of Action

Stimulates adrenergic receptors and is not dose dependent like dopamine.

Epinephrine
Indications Cardiac arrest

VF; VT; asystole; PEA

Symptomatic bradycardia After atropine; alternative to dopamine Severe hypotension When atropine and pacing fail; hypotension accompanying bradycardia; phosphodiesterase enzyme inhibitors Anaphylaxis; severe allergic reactions Combine with large fluid volume; corticosteroids; antihistamines

Epinephrine
Precautions May increase myocardial ischemia, angina, and oxygen demand High doses do not improve survival; may be detrimental Higher doses may be needed for poison/drug induced shock Dosing Cardiac arrest 1 mg (1:10,000) IV/IO every 3-5 min. High dose up to 0.2 mg/kg for specific drug ODs Infusion of 2-10 mcg/min. Endotracheal of 2-2.5 times normal dose SQ/IM 0.3-0.5 mg

Tachycardia
Adenosine
Diltiazem Metoprolol Amiodarone Lidocaine Magnesium Sulfate

Adenosine
Mechanism of Action

Slows impulse formation in the SA node; slows conduction time through AV node; depresses left ventricular function and restores NSR.

Adenosine
Indications 1st drug for stable, narrow complex, regular SVT May consider for unstable SVT while preparing for cardioversion Wide-complex tachycardia thought to be, or determined to be reentry SVT Does not convert atrial fibrillation, atrial flutter, or VT Diagnostic maneuver; stable narrow-complex SVT

Adenosine
Contraindications/Precautions Poison/drug induced tachycardia is contraindicated 2nd and 3rd degree block is contraindicated Transient side effects; flushing, CP, asystole, brady, ectopy Less effective with theophylline or caffeine If used for VT may cause worsening of clinical condition Transient periods of sinus brady or ventricular ectopy common after termination of SVT Safe in pregnancy

Adenosine
Place supine or mild reverse Trendelenburg
6 mg rapidly followed by 20 mL flush May repeat at 12 mg every 1-2 minutes if unsuccessful

Diltiazem
Mechanism of Action

Inhibits calcium movement across cell membranes of cardiac and smooth muscle. Causes vasodilation, decreses heart rate and contractility, slows SA and AV conduction.

Diltiazem
Indications Controlling ventricular rate in a-fib or flutter After adenosine to treat refractory reentry SVT if adequate blood pressure Contraindications/Precautions Do not use with wide-complex rhythms Do not use with poison/drug induced tachycardia Avoid in WPW Avoid in AV nodal blocks Blood pressure may drop from peripheral vasodilation

Diltiazem
Rate control 15-20 mg (0.25 mg/kg) IV over 2 minutes After 15 min. another 20-25 mg (0.35 mg/kg) IV over 2 minutes, if needed Maintenance Infusion 5-15 mg/hour; titrated to physiologically appropriate heart rate

Metoprolol
Mechanism of Action

Selectively blocks beta-1 receptors, slowing sinus heart rate, decreasing cardiac output, and decreasing BP.

Metoprolol
Indications Administer to all patients with suspected MI or unstable angina, absent contraindications Second-line agent for SVT refractory to adenosine To reduce myocardial ischemia in MI patients with elevated heart rate and/or blood pressure Emergency antihypertensive therapy for acute hemorrhagic or ischemic stroke

Metoprolol
Contraindications/Precautions Hemodynamically unstable patients should not receive

Signs of heart failure Low cardiac output Increased risk for cardiogenic shock

Relative contraindications: 1st, 2nd, 3rd degree blocks;

active asthma; reactive airway disease; severe bradycardia; hypotension < 100 mmHg Concurrent administration of calcium channel blockers can cause serious hypotension Monitor cardiac and pulmonary status throughout

Amiodarone
Mechanism of Action

Prolongs myocardial cell action potential duration and refractory period by direct action on all cardiac tissue; decreases AV and SA conduction rates.

Amiodarone
Indications Life threatening dysrhythmias

VF/pulseless VT unresponsive to shock, CPR, and vasopressor Recurrent hemodynamically unstable VT Seek expert opinion for other uses

Contraindications/Precautions Bradycardia 2nd and 3rd degree block Do not administer with meds that prolong QT interval (procainamide)

Amiodarone
VF/VT 300 mg IV/IO in 20-30 mL NS. Can follow

with ONE dose of 150 mg in 3-5 minutes, if needed. Life threatening dysrhythmias
150 mg over 10 minutes. May repeat every 10 minutes as

needed.

Lidocaine
Mechanism of Action

Decreases depolarization, automaticity, and excitability of ventricle during diastole by direct action, reversing ventricular dysrhythmias.

Lidocaine
Indications Alternative to amiodarone in VF/VT arrest Stable monomorphic VT Malignant PVCs Can be used if Torsades is suspected Contraindications/Precautions Prophylactic use in AMI is contraindicated Reduce maintenance dose in liver impaired patients Discontinue infusion if toxicity develops

Lidocaine
Cardiac Arrest Initial dose is 1-1.5 mg/kg Refractory VF 0.5-0.75 mg/kg in 5-10 min. Max 3 mg/kg Endotracheal dose 2-4 mg/kg Perfusing Dysrhythmia 0.5-0.75 mg/kg up 1-1.5 mg/kg dosing range. Repeat if necessary at lower range to total dose of 3 mg/kg Maintenance Infusion 1-4 mg/min

Magnesium Sulfate
Mechanism of Action

Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia.

Magnesium Sulfate
Indications Torsades is suspected in cardiac arrest Lfe-threatening ventricular dysrhythmias in digitalis OD Precautions Fall in BP with rapid administration Use caution in renal failure Dosing Arrest 1-2 g over 5-20 min. Torsades w/ pulse 1-2 g over 5-60 min.

Vasopressin
Mechanism of Action

Causes vasoconstriction with reduced blood flow, increasing core perfusion during cardiac arrest.

Vasopressin
Indications Alternative to epinephrine in adult refractory VF/VT Alternative to epinephrine in asystole or PEA Contraindications/Precautions Potent peripheral vasoconstrictor (increased demand upon resuscitation) Dosing Single dose of 40 u that replaces either the 1st or 2nd dose of epinephrine. Epinephrine can be resumed 3-5 minutes after Can be used endotracheally; no suggested dose