Emergency Medications for Cardiac Disorders

As presented by: Chery Lynn Arzaga & Romulo Basañes II

 Client Background/History
Patient is a 30y/0 known case of epilepsy presented with
generalized tonic clonic seizures and got intubated in the emergency
department secondary to low GCS. Initially he was managed in line
with status epilepticus and kept on 4 antiepileptic drugs but EEG was
unremarkable. Later on found to have OTCs prolongation on digging
history, the patient’s family revealed use of loperamide tablets around
100-200 tablets per day. During stay he had recurrent VT and Vfib for
which a temporary pacemaker was applied and got reverted back.
 Lidocaine
 ACTION: Combines with fast sodium channels in myocardial cell membranes, which inhibits
sodium influx into cells and decreases ventricular depolarization, as well as automaticity and
excitability during diastole. Lidocaine also blocks nerve impulses by decreasing the
permeability of neuronal membranes to sodium, which produces local anesthesia.
 INDICATION: To treat ventricular fibrillation or ventricular tachycardia
 DOSAGE AND FORMS: Loading: 50 to 100 mg (or 1 to 1.5 mg/kg), given at 25 to 50 mg/min.
If desired response isn’t achieved after 5 to 10  min, second dose of 25 to 50 mg (or 0.5 to 0.75
mg/kg) given every 5 to 10 min until maximum loading dose (300 mg in 1 hr) has been given.
 CONTRAINDICATIONS: Adams–Stokes syndrome; hypersensitivity to lidocaine, amide
anesthetics, or their components; severe heart block (without artificial pacemaker); Wolff–
Parkinson– White syndrome
 Cont.
 SPECIAL PRECAUTIONS:
 Use caution when administering lidocaine to patients with compromised myocardial function
because of risk of electrolyte disturbances or fluid overload.
 ADVERSE REACTIONS: CNS: Anxiety; apprehension; confusion; difficulty speaking;
dizziness; drowsiness; euphoria; hallucinations; lethargy; lightheadedness; malignant
hyperthermia; paresthesia; seizures; sensation of cold, heat, or numbness; tremors; twitching;
unconsciousness CV: Bradycardia, cardiac arrest, hypotension, new or worsening arrhythmias
EENT: Blurred vision, diplopia, tinnitus GI: Nausea, vomiting HEME: Methemoglobinemia
MS: Muscle weakness, myalgia RESP: Respiratory arrest or depression Other: Anaphylaxis,
other less severe hypersensitivity reactions; injection-site burning, irritation, petechiae, redness,
stinging, swelling, and tenderness; worsened pain
 Cont.
 NURSING CONSIDERATIONS:
 Observe for respiratory depression after bolus injection and during I.V. infusion of lidocaine.
 Keep life-support equipment and vasopressors nearby during I.V. use in case of respiratory depression or other
reactions.
 Carefully check prefilled syringes before using. Use only syringes labeled “for cardiac arrhythmias” for I.V.
administration.
 As ordered, titrate I.V. dose to minimum amount needed to prevent arrhythmias. If administration is controlled by a
pumping device, stop pump before container runs dry because an air embolism may result. Change intravenous
administration apparatus at least once every 24 hours.
 During I.V. administration, place patient on cardiac monitor, as ordered, and closely observe her at all times. Monitor
for prolonged PR interval, widening QRS complex, or worsening arrhythmias— possible signs of drug toxicity. If
present, notify prescriber and expect to discontinue lidocaine therapy immediately. Although infrequent, also
monitor her for hypersensitivity reactions that can be as severe as anaphylaxis following lidocaine administration. If
anaphylaxis occurs, discontinue drug, notify prescriber, and provide supportive care.
 If signs of toxicity, such as dizziness, occur, notify prescriber and expect to discontinue or slow infusion.
 Monitor vital signs as well as BUN and serum creatinine and electrolyte levels during and after therapy.
Magnesium Sulfate
• ACTION: Assists all enzymes involved in phosphate transfer reactions that use adenosine triphosphate
(ATP). Magnesium is required for normal function of the ATP-dependent sodium–potassium pump in
muscle membranes. It may effectively treat digitalis glycoside–induced arrhythmias because correction of
hypomagnesemia improves the sodium–potassium pump’s ability to distribute potassium into intracellular
spaces and because magnesium decreases calcium uptake and potassium outflow through myocardial cell
membranes
• INDICATION: To correct magnesium deficiency and to treat severe hypomagnesemia
• DOSAGE AND FORMS: 5 g diluted in 1 L I.V. solution and infused over 3 hr.
• CONTRAINDICATIONS: Hypersensitivity to magnesium salts or any component of magnesium-
containing preparations For magnesium chloride: Coma, heart disease, renal impairment For magnesium
sulfate: Heart block, MI, preeclampsia 2 hours or less before delivery (I.V. form) For use as laxative: Acute
abdominal problem (as indicated by abdominal pain, nausea, or vomiting), diverticulitis, fecal impaction,
intestinal obstruction or perforation, colostomy or ileostomy, severe renal impairment, ulcerative colitis
 Cont.
 SPECIAL PRECAUTIONS:
 warning Observe for and report early evidence of hypermagnesemia: bradycardia, depressed
deep tendon reflexes, diplopia, dyspnea, flushing, hypotension, nausea, slurred speech,
vomiting, and weakness.
 warning Be aware that magnesium may precipitate myasthenic crisis by decreasing patient’s
sensitivity to acetylcholine.
 ADVERSE REACTIONS: CNS: Confusion, decreased reflexes, dizziness, syncope CV:
Arrhythmias, hypotension GI: Flatulence, vomiting MS: Muscle cramps RESP: Dyspnea,
respiratory depression or paralysis SKIN: Diaphoresis Other: Allergic reaction,
hypermagnesemia, injection-site pain or irritation (I.M. form), laxative dependence, magnesium
toxicity.
 Cont.
 NURSING CONSIDERATIONS:
 Always consider the 5 rights: right patient, right drugs, right dose, right time and right route
 Frequently assess cardiac status of patient taking drugs that lower heart rate, such as beta
blockers, because magnesium may aggravate symptoms of heart block.
 Monitor serum electrolyte levels in patients with renal insufficiency because they’re at risk for
magnesium toxicity.
 Monitor v/s
 Nitroglycerine
 Action:Nitroglycerin is converted by mitochondrial aldehyde dehydrogenase (mtALDH) to nitric oxide
(NO), an active substance which then activates the enzyme guanylate cyclase.The activation of this
enzyme is followed by the synthesis of cyclic guanosine 3',5'-monophosphate (cGMP), activating a
cascade of protein kinase-dependent phosphorylation events in smooth muscles. This process eventually
leads to the dephosphorylation of the myosin light chain of smooth muscles, causing relaxation and
increased blood flow in veins, arteries and cardiac tissue.. The above processes lead to decreased work of
the heart decreased blood pressure, relief of anginal symptoms, and increased blood flow to the
myocardium.
 Indications: indicated for the acute relief of an attack or acute prophylaxis of angina pectoris due to
coronary artery disease.
 Dosage and Forms: Sublingual. Administer one tablet under the tongue or in the buccal pouch at the first
sign of an acute anginal attack. Allow tablet to dissolve without swallowing. One additional tablet may
be administered every 5 minutes until relief is obtained. No more than three tablets are recommended
within a 15-minute period.
 Cont.
 Contraindications: Known history of increased intracranial pressure, severe anemia, right-
sided myocardial infarction, or hypersensitivity to nitroglycerin are contraindications to
nitroglycerin therapy.
 Special Precautions:
i. Excessive use may lead to the development of tolerance. Only the smallest dose required for
effective relief of the acute angina attack should be used.
ii. Severe hypotension, particularly with upright posture, may occur with small doses of
nitroglycerin particularly in patients with constrictive pericarditis, aortic or mitral stenosis,
patients who may be volume-depleted, or are already hypotensive
iii. Nitroglycerin produces dose-related headaches, especially at the start of nitroglycerin therapy,
which may be severe and persist but usually subside with continued use.
 Cont.
 Adverse Reactions: severe or throbbing headaches, pounding heartbeats,
fluttering in your chest, slow heart rate, lightheadedness, blurred vision, dry
mouth, chest pain or pressure, pain spreading to your jaw or shoulder, nausea,
and sweating
 Nursing Considerations:
i. Check blood pressure and pulse before each administration of NTG–blood
pressure can drop precipitously after a single dose.  Hold dose if systolic BP <
90 mm Hg or more than 30 mm Hg below baseline.
ii. NTG is highly unstable and should be stored in light resistant container in cool
environment
 Amiodarone
 Action: Amiodarone is primarily a class III antiarrhythmic. Like other antiarrhythmic drugs of this class,
amiodarone works primarily by blocking potassium rectifier currents responsible for the repolarization of
the heart during phase 3 of the cardiac action potential. This potassium channel-blocking effect results in
increased action potential duration and a prolonged effective refractory period in cardiac myocytes.
Myocyte excitability is decreased, preventing reentry mechanisms and ectopic foci from perpetuating
tachyarrhythmias.
 Indications: commonly used off-label to treat supraventricular tachyarrhythmias such as atrial fibrillation
as well as for the prevention of ventricular tachyarrhythmias (VTs) in high-risk patients.
 Dosage and forms: Injectable solution. 50mg/ml, 150mg/100ml, 360mg/200ml
 Contraindications:
i. Hypersensitivity
ii. Severe sinus node dysfunction, 2°/3° AV block or bradycardia causing syncope (except with functioning
artificial pacemaker), cardiogenic shock
iii. Avoid during breastfeeding
 Cont.
 Special Precautions:
i. Indicated only for life-threatening arrhythmias because of risk for substantial toxicity; poses
major management problems that could be life-threatening in patients at risk of sudden death;
therefore, make every effort to utilize alternative agents first
ii. amiodarone may remain in your body for several months after you stop taking it. You may
continue to experience side effects of amiodarone during this time. Be sure to tell every
health care provider who treats you or prescribes any medication for you during this time that
you have recently stopped taking amiodarone.
 Adverse Reactions: constipation loss of appetite headache, decreased sex drive, difficulty
falling asleep or staying asleep, flushing, changes in ability to taste and smell, changes in
amount of saliva
 Cont.
 Nursing Responsibilities:
i. Monitor blood pressure and apical pulse prior to administration.
ii. Cardiac monitor should be used on patients receiving amiodarone therapy.
iii. Baseline assessments should be checked of liver function and thyroid function.
iv. Monitor serum level frequently.