3/12/2018

OBJECTIVES
Upon completion of this session, you will be
Drugs in •
able to:
state 3 drugs commonly used in cardiac
emergencies.
Resuscitation • outline the major actions of these drugs.
• state 3 drugs that can be administered via the
ETT.
• list 2 side effects related to the use of the drugs.

DRUGS USED IN
CARDIAC EMERGENCIES
Additional Drugs mentioned in
• Adrenaline (Epinephrine) Guidelines 2000
• Atropine • Amiodarone
• Lignocaine (Lidocaine) • Vasopressin
• Dopamine
• Dobutamine
• Nitroglycerine (GTN)
• Verapamil
• Adenosine
• Calcium
• Sodium bicarbonate

Adrenaline (Epinephrine) Adrenaline (Epinephrine)

• 1st drug in cardiac arrest • Indications :-
VF
pulseless VT
pulseless electrical activity (PEA)
asystole

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Adrenaline (Epinephrine)
• Routes of administration :-
IV push (10 mls of 1:10,000 i.e. 1 mg)
ETT (2-2.5X IV dose)
Infusion (1 mg in 250 mls of D5% i.e.
4ug/ml to run at 1ug/ml titrated to
3-4 ug/ml
Adrenaline
Actions
• increases contractile force of the heart thus
increasing cardiac output
• increases conduction of SA node, AV node
and ventricle thus increasing heart rate
• increases systemic vascular resistance
through peripheral vasoconstriction thus
increasing perfusion pressure

Adrenaline
Side-effects
Adrenaline
• Ventricular irritability • Higher initial doses VS standard doses show
- tachycardia no difference in survival.
- PVCs • ? Escalating doses  insufficient data to
• Stroke show efficacy
• Acute MI • Conflicting evidence for and against higher
doses when standard doses have failed
• use with caution in pregnant patients

Atropine Atropine
Indications :-
• Asystole Routes of administration :-
• Haemodynamically unstable bradycardias
– 2nd degree (Mobitz Type I) or 3rd degree heart • IV push - neat i.e. 1 mg/0.6 mg
block (nodal) • ETT rapid push - no dilution needed
• Acute cholinergic poisoning • maximum 2.4 mg/3mg
(organophosphates)

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Atropine Atropine
Actions Side-effects
• Tachycardias
• Enhances conduction • Palpitations
– increasing heart rate and cardiac output. • Paradoxical bradycardia (if dose < 0.5mg)
• Seizure
• Decreases secretions. • Hypertension
• Reverses cholinergic response. • Respiratory failure
• Use with caution in MI cases (especially anterior wall MI)
• Rarely effective in infranodal block and should not be used
when there is
– Mobitz Type II Block
– Complete heart block with new wide QRS complexes

Lignocaine Lignocaine
Indications Routes of administration :-
• multi-focal PVCs (haemodynamically • IV push (1.0 to 1.5 mg/kg)
compromising) • ETT (2-2.5X IV dose)
• VT (pulseless and refractory) • Infusion 1gm lignocaine in 500 ml D5% or NS
• VF (refractory) i.e. 2 mg/ml to run at 1-4 mg/min.
• Stable VT

Lignocaine
Lignocaine
Side-effects
Actions
• Seizures
• Raises fibrillatory threshold • Respiratory depression/ arrest
– enhances the effect of DC shock • Widening of QRS complexes
• Decreases speed of electrical impulse • Bradycardia - cardiac arrest
– slows down heart rate • Use with caution in bradycardia with
PVCs

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Technique of intratracheal
SUMMARY
administration
Drugs used in cardiac emergencies
• Dilute the drug in 10 ml saline or distilled
• adrenaline water.
• atropine • Thread a long catheter through the ETT.
• lignocaine • Stop CPR chest compressions.
• Inject the drug through the catheter.
• Follow with 3-4 manual lung inflations.
• Can be given via ETT if IV access is
not available • Dosage:- 2-2.5x the recommended IV dose

Dopamine
Dopamine
Indications:
• cardiogenic shock Route of administration :-
• septicaemic shock
• neurogenic shock infusion via central vein
• anaphylactic shock
• hypovolaemic shock only after fluid
resuscitation has failed to raise BP

Dopamine Dopamine
Side-effects
Actions
Low Dose Medium Dose High Dose
• Dilates renal and mesenteric vessels
 Hypotension  Tachycardia  Same medium
(1-2 ug/kg/min) - enhancing renal BF  Tachycardia  Angina dose
• Increases myocardial contractility  Ventricular  Decreased
arrhythmias renal function
(2-10ug/kg/min) - increasing CO  Hypertension
• Causes peripheral vasoconstriction
(>10ug/kg/min) - elevating blood pressure • monitor BP, cardiac rhythm
• monitor drip site closely
• An inoconstrictor
– observe for onset of extravasation.

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Nitroglycerin
Dobutamine
• A synthetic catecholamine Indications :-
• Frequently used in concert with dopamine • unstable angina
• Increases stroke volume • AMI
• Vasodilatory effect  an inodilator • pulmonary edema with high BP
• A good agent for decompensated heart failure • hypertensive crisis
• Dosage :- 2-20 ug/kg/min

Nitroglycerin Nitroglycerin

Routes of administration: Actions

• sublingual • A venodilator
• transdermal • Dilates coronary arteries
• IV infusion 10-200ug/min titrated to • Relieves coronary spasm
response
• Opens up collateral vessels
– increasing blood flow to myocardium

Nitroglycerin
Side-effects VERAPAMIL
Indications :-
• Headache • PSVT
• Flushing
• Acute atrial fibrillation or atrial flutter
• Tachycardia with rapid ventricular response (WPW
• Hypotension has to be excluded first)
• Use with caution in hypotension & Route of administration :-
tachycardia • IV slow bolus - 5mg diluted in 5 ml of
• Beware in RV infarct distilled water and given at 1mg/min.
• Monitor BP and heart rate

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Verapamil Verapamil
Side-effects
Actions
• Blocks calcium channels - negative inotropic • Hypotension
effect, thus decreasing force of myocardial • Prolongation of PR intervals, bradycardia
contraction and asystole
• Slows conduction & prolongs refractory period • PVCs
at AV node, thus slowing down heart rate • Nodal escape rhythms
• Dilates coronary, systemic and peripheral • Heart blocks
vessels, thus increasing blood flow and lowering • VF in patient with WPW and AF
blood pressure
• Monitor cardiac rhythm and BP

Adenosine
Adenosine
Side-effects
• A short acting agent that depresses sinus • Transient Flushing
node and AV node function.
• Chest pain
• Half life :- 5 seconds
• Dyspnoea
• Initial dose of 6 mg iv bolus
• Hypotension
• Consider using 12 mg if the heart fails to
• Beware in AF and WPW
convert.
• Interaction with theophylline, caffeine

Calcium Sodium bicarbonate

Actions Actions
• Increases force of myocardial contraction • Undesirable effects :-
• No place in ALS except :- (i) increases formation of CO2
=>intracellular acidosis
acute hyperkalaemia
(ii) increased blood pH shifts the
ionized hypocalcaemia
oxyhaemoglobin dissociation
overdose of calcium channel blockers curve to the left => impaired O2
delivery to tissues

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Sodium bicarbonate Sodium bicarbonate

(iii) a significant sodium load • only beneficial in hyperkalaemia
• probably beneficial in
(iv) 8.4% solution is hypertonic => bicarbonate responsive acidosis
arterial vasodilatation and tricyclic overdose
hypotension urinary alkalinization
(v) extravasation => tissue necrosis • possibly beneficial in
protracted cardiac arrest
(vi) not to be added to IV bottle containing
postresuscitation acidoses
catecholamines • harmful in anaerobic lactic acidosis

Amiodarone Amiodarone
• A complex drug that possesses characteristics of • Refractory VT/VF
all 4 antiarrhythmic drug classes – Bolus dose 150 mg – 300 mg
• Used in – Infusion rate of 360 mg over 6 hours and 540 mg over
– Refractory VT/VF 18 hours
– Stable monomorphic or polymorphic VT • Other arrhythmias
– PSVTs, atrial tachycardia, AF
– Infusion 150 mg over 10 mins
– Wide complex tachycardia of uncertain origin
– Infusion rate of 360 mg over 6 hours and 540 mg over
– Pre-excited atrial arrhythmia
18 hours
• One of the safer anti-arrhythmics especially in – Supplementary doses of 150 mg repeated as necessary
heart failure
– Max dose of 2 g /day

Vasopressin
Vasopressin
Actions
• A naturally occuring hormone • Indications for use
– Considered as an alternative to adrenaline for
• At high doses (recommended dosage during
shock due to refractory VF
resuscitation)
– Used as a single bolus 40 units iv
– Shunting of blood to heart and brain
– Not firmly recommended presently as superior
– Intense vasoconstriction to adrenaline
– May not increase myocardial oxygen demand
unlike adrenaline

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SUMMARY
• Dopamine, dobutamine, nitroglycerin,
verapamil, adenosine and amiodarone are
drugs that are commonly used in cardiac
care.
• Nursing staff should be familiar with them.