Antiarrhythmics, Beta and Ca++ Channel Blockers Flashcards
Amiodarone (Cordarone)
Class :Antiarrhythmic Class III agent (blocks potassium channels)
•Indications
Suppression of Ventricular Fibrillation, refractory to defibrillation
Suppression of Ventricular Tachycardia
•Mechanism of Action/Pharmacodynamics
Blocks K+ rectifying repolarizing currents responsible for phase 3 depolarization which prolongs refractory period
On Ca++, Na+ channels and beta adrenergic receptors:
Inhibition resulting in delayed automaticity (SA) and current speed (AV)
•Contraindications
Second or Third Degree heart blocks
Medication-induced Ventricular dysrhythmias
Hypotension
Bradycardia
Torsades de Pointes
Sinus Bradycardia
•Adverse Reactions
Hypotension
Bradycardia
Pulseless Electrical Activity (PEA)
Congestive Heart Failure
Nausea
Fever
Abnormal Liver Function Tests
•Drug Interactions
Incompatible with: Sodium Bicarbonate (will precipitate)
Compatible with: Dopamine, Dobutamine, Isoproterenol, Lidocaine, NTG, Norepinephrine, Phenylephrine, KCL, Procainamide.
•How Supplied:
150 mg in 3 ml ampules
•Dosage and Administration
Adult: 300 mg slow IV Push over 1-2 minutes in 10 cc Normal Saline, (For ACLS VF/ Pulseless VT)
150mg slow IV Push over 1-2 min in 10cc NaCl for VT with pulse IV Drip 0.5-1mg per minute. (For malignant ventricular arrhythmias) per ordering physician 100 mg over 10 minutes 150mg-50-100mls
Pediatric: 5mg/kg IV Push over 5 minutes
•Duration of Action:
Onset: Within 5-15 minutes
Peak Effect: Variable
Duration: Variable
•Special Considerations
Pregnancy safety: Category C
Maintain at room temperature and protect from light in storage (light protection not required during administration).
Hypotension usually responsive to slowing infusion rate, IV Normal Saline
Administer cautiously in patients with Heart Failure or poor systolic function
May be especially effective in high-risk patients with recent acute MI
RI OEMS Protocols
•3.03 Cardiac Arrest
For ventricular fibrillation (VF) or pulseless ventricular tachycardia (PVT): 300 mg IV, repeat 150 mg for VF/VT refractory to the first dose and at least one defibrillation attempt.
Pediatric: For ventricular fibrillation (VF) or pulseless ventricular tachycardia (PVT) unresponsive to initial electrical therapy and one dose of epinephrine: 5 mg/kg IV (may repeat x2).
RI OEMS Protocol •3.04 Post-Cardiac Arrest Care If either agent was effective, consider maintenance infusions of AMIODARONE at 1 mg/min or LIDOCAINE at 2-4 mg/min.
RI OEMS Protocols
•3.06 Narrow Complex Tachycardia Arrhythmias with suspicion of Wolff-Parkinson-White (WPW) syndrome should be treated with amiodarone following the dosing regimen in the wide complex tachycardia protocol
Pediatric: If adenosine is ineffective, consider AMIODARONE 5 mg/kg (max 150 mg) IV over 20 minutes.
Lidocaine HCL (2%)
Class
Antiarrhythmic Class I (blocks sodium channels)
•Mechanism of Action
Decreases automaticity by slowing the rate of
spontaneous Phase 4 depolarization
•Indications
Suppression of ventricular dysrhythmias
(V-tach, VF, PVCs)
Prophylaxis against recurrence after conversion from
V-tach, VF
Lidocaine HCL (2%)
•Contraindications
Second degree and third degree blocks
in absence of artificial pacemaker.
Hypotension
Stokes Adams Syndrome (sudden fainting due to heart block or arrythmia)
•Adverse Reactions
Slurred speech
Seizures
Altered mental status
Confusion
Lightheadedness
Blurred vision
Bradycardia
Lidocaine HCL (2%)
•Drug Interactions
Apnea induced with succinylcholine may be prolonged with high doses of Lidocaine
Cardiac depression may occur in conjunction with IV Dilantin
Procainamide may exacerbate the CNS effects
Metabolic clearance decreased in patients with liver disease or those patients taking beta-blockers
Lidocaine HCL (2%)
•How Supplied
100 mg in 5 ml solution prefilled syringes
1 and 2 gram additive syringes
100 mg in 5 ml solution ampules
1 and 2 gram vials in 30 ml of solution
Lidocaine HCL (2%)
•Dosage and Administration
Adult:
Cardiac arrest VT/ VF: 1-1.5 mg / kg IV/IO push; repeat q 3-5 minutes to maximum dose of 3 mg/kg.
After conversion to NSR, begin drip at 2-4 mg / min
Lidocaine HCL (2%) VT with pulse: 1-1.5 mg / kg IV/IO Push; then 0.5-75mg/kg q 5-10 min. to max.
of 3 mg/kg. Start drip at 2-4 mg/min
Nasotracheal Intubation: 2% Lidocaine Jelly
Intraosseous: 40mg 2% Lidocaine, slow bolus over two minutes, followed by 10mL then use for IO access for medications Lidocaine HCL (2%) •Pediatric Dose Bolus: 1 mg/kg
Infusion: 1 microgram/kg/min
RI OEMS Protocols
•3.03 Cardiac Arrest
For ventricular fibrillation (VF) or pulseless ventricular tachycardia (PVT): As alternative to amiodarone or for VF/VT refractory to amiodarone, LIDOCAINE 100 mg IV, repeat every 10 minutes x2
Pediatric: As an alternative to amiodarone or for VF/PVT refractory to amiodarone, administer LIDOCAINE 1 mg/kg IV [100 mg max] (may repeat x1 in 10 minutes)
RI OEMS Protocols
•3.04 Post-Cardiac Arrest Care
If either agent was effective, consider maintenance infusions of AMIODARONE at 1 mg/min or LIDOCAINE at 2-4 mg/min.
RI OEMS Protocols
•3.07 Wide Complex Tachycardia
1-1.5 mg/kg IV (may repeat x1 in 5 minutes). If lidocaine
7.44 Ocular Irrigation (Morgan Lens)
Procedure: 1. Instill topical ophthalmic anesthetic in to the affected eye(s).
2. Mix 100 mg of LIDOCAINE (5ml of a 2% solution) in 1000 ml LACTATED RINGER’S SOLUTION.
3. Attach the Morgan Lens© to a delivery set equipped with a macro drip chamber and open the flow control to start flow.
4. Instruct the patient to look down and insert the upper portion of the lens under the upper eye lid.
5. Instruct the patient to look up and retract the lower lid allowing placement of the lower portion of the lens under the lower lid.
6. Continue irrigation of the affected eye(s) using caution to ensure run off does not enter the unaffected eye. Do not allow the irrigation solution to run dry.
7. Tape the tubing to the patient’s face to prevent inadvertent removal.
8. Consider additional pain management as indicated.
9. To remove the lens, continue the flow of irrigation solution while instructing the patient to look up. Retract the lower lid and slide the lens from the upper lid.
10. All patients should be transported for evaluation for corneal injury.
RI OEMS Protocols
•7.45 Gastric Tube Placement
Nasal Route
1. Select appropriate tube size (16-18fr for most adults, pediatric tube size may be estimated by the following formula: Age in years + 18 /2 (8 y.o. patient example: 8+16 = 24/2 = 12fr).
2. Estimate the insertion length by superimposing the tube over the patient’s body from the xiphoid to the angle of the jaw to the corner of the nare (the insertion depth can be marked with tape).
3. If the patient is awake and cooperative, the patient can be asked to breathe through each nostril while occluding the opposite nostril to determine which is more patent.
4. Prepare the selected nares by instilling several drops of OXYMETAZOLINE or PHENYLEPHRINE.
5. Lubricate the distal tip of the gastric tube with water soluble lubricant or 2% VISCOUS LIDOCAINE.
6. If the patient is awake, cooperative and able to sit upright, have them sit upright and flex their head forward (if not contraindicated).
RI OEMS Protocols
7.45 Gastric Tube Placement (Continued)
7. Insert the tube into the selected nare and slowly advance the tube posteriorly parallel to the nasal canal (along the inferior aspect of the naris). The tube should not be directed upward as this may result in the tube being caught up in a blind recess at the middle turbinate.
8. The patient may gag as the tube approaches the larynx. If this occurs, temporarily halt advancement of the tube and instruct the patient to swallow. Advance the tube during swallowing as this will facilitate esophageal placement.
9. Advance the tube until gastric contents are returned or the desired depth of insertion is reached.
10. Confirm placement by auscultating for gastric sounds over the epigastrium while insufflating 20ml of air. Additionally, confirm placement by aspirating gastric contents.
11. Decompress the stomach of air and gastric contents by attaching the gastric tube to low suction or by manually aspirating with a large (Toomey) catheter tip syringe.
12. Secure the tube in place with tape. 13. Document gastric tube placement and confirmation by auscultation/aspiration of gastric contents. The volume of liquid output should also be documented.
Procainamide (Pronestyl)
Class
Antidysrhythmic Class Ia (Sodium block)
•Mechanism of Action
Suppresses phase 0 depolarization in normal
ventricular muscle and Purkinje fibers, reducing
automaticity of ectopic pacemakers; suppresses
reentry dysrhythmias by slowing intraventricular
conduction
•Indications
Suppress VT with a pulse refractory to Lidocaine
PSVTs with wide-complex tachycardia of unknown origin
Contraindications
Second and Third Degree block
Torsades de Pointes
Lupus
Digitalis toxicity
Myasthenia gravis
•Adverse Reactions
PR, QRS and QT widening
AV Block
Cardiac arrest
Hypotension
Seizures.
Nausea
Vomiting reflex tachycardia
PVCs
VT
VF
CNS depression
•Drug Interaction
Cumulative effect with other class I drugs
•How Supplied
1 gram in 10 ml vial (100 mg / ml)
1 gram in 2 ml vials (500 mg / ml) for infusion
•Dosage and Administration
Adult: 20-30 mg/min.; maximum total dose is 17 mg/kg. Maintenance infusion: 1-4 mg/min
Pediatric: 2-6 mg/kg IV, IO at less than 20 mg/min. Maximum dose is 17 mg/kg
Maintenance infusion: 20-80 mcg/kg/min.
•Duration of Action
Onset: 10-30 minutes
Peak effect: Variable
Duration: 3-6 hours
•Special Considerations
Discontinue infusion if hypotension develops, the QRS
complex widens by 50% of its original width or a total of 17 mg / kg has been administered or if the dysrhythmiais suppressed
Pregnancy safety: Category C. Potent vasodilating and inotropic effects.
Discontinue infusion if hypotension develops, the QRS complex widens by 50% of its original width or a total of 17 mg / kg has been administered or if the dysrhythmia
Hypotension with too rapid an infusion.
Carefully monitor vital signs and ECG.
Administer cautiously to patients with renal, hepatic or
cardiac insufficiency.
Administer cautiously to patients with asthma or
digitalis-induced dysrhythmias.
Diltiazem HCL (Cardizem)
•Class:
Calcium channel blocker
•Mechanism of Action:
Block influx of calcium ions into cardiac muscle:
prevents spasm of coronary arteries
Arterial and venous vasodilator
Reduces preload and afterload
Reduces myocardial oxygen demand
Diltiazem HCL (Cardizem)
•Indications:
Control of rapid ventricular rates due to atrial
flutter, atrial fibrillation, PSVT
Angina pectoris
•Contraindications:
Hypotension, sick sinus syndrome, second or third degree AV block
Cardiogenic shock
Wide-complex tachycardias
Acute Myocardial Infarction
Wolf-Parkinson White (WPW) Syndrome
Diltiazem HCL (Cardizem)
•Adverse Reactions:
Bradycardia
Second or third-degree AV blocks
Chest pain
CHF
Syncope
V-Fib
V-tach
Nausea/Vomiting
Dizziness
Dry mouth
Dyspnea
Headache
Diltiazem HCL (Cardizem)
•Drug Interactions:
Caution in patients using medications that affect cardiac contractility
In general, should not be used in patients on Beta-blockers
•How Supplied:
25 mg / 5 ml vial; 50 mg / 10 ml vial
Diltiazem HCL (Cardizem)
•Dosage and Administration:
Adult:
Initial bolus: 0.25 mg/ kg IV/IO over two (2) minutes. If inadequate response, may re-bolus in 15 minutes: 0.35 mg / kg IV/IO over two (2) minutes
Pediatric:
Not recommended
Diltiazem HCL (Cardizem)
•Duration of Action:
Onset: 2-5 minutes
Peak effect: Variable
Duration: 1-3 hours
•Special Considerations:
Pregnancy safety: Category C
Use in caution in patients with renal or hepatic
dysfunction
PVCs may be noted at time of conversion of PSVT to
sinus rhythm
Nifedipine (Procardia, Adalat)
Calcium Channel Blocker
•Inhibits movement of calcium ions across cell membranes
•Specific to Ca++ movement in contractile cells (L Type channels)
•Decreases cornoary vasospasm
•Relaxes vascular smooth muscle to cause vasodilation
Nifedipine
(Procardia, Adalat)
•Decreases afterload and preload
•Coronary vasodialtion
•Decreases platelet aggregation
•Decreases automaticity
•Decreases oxygen demand
•No effect on conduction
Nifedipine
(Procardia, Adalat)
•KINETICS
•Onset: 15 – 30 minutes
•Duration: 6 – 8 Hr.
•INDICATIONS
•Hypertensive Emergencies
•Angina
Nifedipine
(Procardia, Adalat)
•CONTRAINDICATIONS
•Hypersensitivity
•Hypotension
Nifedipine
(Procardia, Adalat)
•SIDE EFFECTS
•Hypotension
•Flushing
•Headache
•Dizziness
Nifedipine
(Procardia, Adalat)
•INTERACTIONS
•CNS depressants increase the effects
•Beta blockers increase the effects
•ROUTES
•SL, Oral
Nifedipine
(Procardia, Adalat)
•DOSE
•10-20 mg
•puncture capsule, squeeze contents under tongue
•bite capsule, then swallow
•PEDI: none
•SUPPLIED
•10 and 20 mg capsules
RI OEMS Protocols
•Not in the protocol, Nicardipine is used instead.
•Antihypertensives must be initiated by the sending hospital
Metoprolol (Lopressor, Toprol-XL )
Class:
Beta Blocker
Antianginal
Antihypertensive Agent
•Mechanism of Action:
Selective inhibitor of beta1-adrenergic
receptors; completely blocks beta1 receptors ,
with little or no effect on beta 2 receptors at
doses <100 mg;
Metoprolol
(Lopressor, Toprol-XL )
•Indications:
Treatment of hypertension and angina pectoris Prevention of myocardial infarction
Prevention of atrial fibrillation/atrial flutter
Symptomatic treatment of hypertrophic subaortic
stenosis
To reduce increased sympathetic stimuli in acute MI
Metoprolol
(Lopressor, Toprol-XL )
•Contraindications:
Hypersensitivity to metoprolol or any component of the
formulation
Sinus bradycardia
Heart block greater than first degree (except in patients
with a functioning artificial pacemaker)
Cardiogenic shock
Uncompensated cardiac failure
Pregnancy (2nd and 3rd trimesters)
Metoprolol
(Lopressor, Toprol-XL )
•Contraindications (continued)
Cardiogenic shock
Uncompensated cardiac failure
Pregnancy (2nd and 3rd trimesters)
Patients who have taken cocaine – enhances vasoconstrictive effect
Metoprolol
(Lopressor, Toprol-XL )
•Adverse Reactions:
Respiratory: Bronchospasm
Cardiovascular: Bradycardia, palpitations, edema,
congestive heart failure, reduced peripheral circulation.
Central nervous system: Drowsiness, insomnia. Metoprolol (Lopressor, Toprol-XL ) •Drug Interactions:
Drugs which slow AV conduction (digoxin):
effects may be additive with beta-blockers. Glucagon: Metoprolol may blunt the
hyperglycemic action of glucagon. Verapamil or diltiazem may have synergistic or additive
pharmacological effects when taken concurrently with
beta-blockers; avoid concurrent I.V. use. Metoprolol (Lopressor, Toprol-XL ) •How Supplied: Available as 50- and 100-mg tablets for
oral administration and in 5-ml (1mg/ml) ampules for
Intravenous administration Metoprolol (Lopressor, Toprol-XL ) •Dosage and Administration:
Adults:
I.V.: Hypertension:
Has been given in dosages 1.25-5 mg every 6-12
hours in patients unable to take oral medications
Myocardial infarction (acute):
I.V.: 5 mg every 5-10 minutes up to 3 doses in early
treatment of myocardial infarction. Metoprolol (Lopressor, Toprol-XL ) •Duration of Action: Peak antihypertensive effect:
Oral: Within 1.5-4 hours
Duration: 10-20 hours
Half-life: 3-4 hours; End-stage renal disease: 2.5-4.5
hours •Special Considerations:
Pregnancy Safety: Category C (manufacturer); D (2nd
and 3rd trimesters - expert analysis)
Not recommended in pediatric population. The safety
and effectiveness of Lopressor have not been
established in children RI OEMS Protocols •3.03 Cardiac Arrest For recurrent VF/PVT: 5 mg IV over 1 minute (may repeat every 5 minutes x3). RI OEMS Protocols
Calcium Chloride/Calcium Gluconate
Class
Electrolyte
•Mechanism of Action
Increases cardiac contractile state
(positive inotropic effect)
May enhance ventricular automaticity
Calcium Chloride/Calcium Gluconate
•Indications
Hypocalcemia
Magnesium Sulfate Overdose
Hyperkalemia
Calcium Channel Blocker Toxicity
Adjunctive therapy in treatment of insect bites & stings
Calcium Chloride/Calcium Gluconate
•Contraindications
Hypercalcemia
VF during cardiac resuscitation
Digitalis Toxicity
Calcium Chloride/Calcium Gluconate
•Adverse Reactions
Bradycardia
Asystole
Hypotension
Peripheral Vasodilation
Metallic Taste
Local Necrosis
Coronary & Cerebral Artery Spasm
Nausea/Vomiting
Calcium Chloride/Calcium Gluconate
•Drug Interactions
May worsen dysrhythmias secondary to digitalis.
May antagonize effects of Verapamil.
Flush line before and after administration of sodium
bicarbonate
•How Supplied
10% solution in 10 ml ampules, vials and prefilled
syringes (100 mg/ ml)
Calcium Chloride/Calcium Gluconate
•Dosage and Administration
Adult: 2-4 mg/kg of 10% solution slowly IV over 5 minutes; may repeat in 10 minutes
(maximum: 1 gm dose)
Pediatric: 20 mg/kg/dose of 10% solution slow IV/ IO (maximum: 1 gm dose); (may repeat in 10 minutes.)
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Calcium Chloride/Calcium Gluconate
•Duration of Action
Onset: 5-15 minutes.
Peak effects: 3-5 minutes.
Duration: 15-30 minutes but may persist for 4 hours (dose dependent).
•Special Considerations
Pregnancy safety: Category C.
For pediatrics: if calcium gluconate is unavailable, 1-2
ml of 10% calcium chloride solution, diluted with IV
fluid, may be substituted.
RI OEMS Protocols
•3.06 Narrow Complex Tachycardia
Consider CALCIUM CHLORIDE 1 gm SLOW IV/IO prior to administering DILTIAZEM if the BP is tenuous BP (SBP ~100)
RI OEMS Protocols
•4.18 Toxicological Emergencies
For suspected beta blocker or calcium channel blocker (CCB) toxicity, manage as indicated per Cardiac Dysrhythmia Protocol(s) and contact MEDICAL CONTROL for authorization to administer GLUCAGON 1-5 mg IV (may repeat x1 in 15 minutes) and CALCIUM CHLORIDE 1 gm IV or CALCIUM GLUCONATE 3 gm IV (may repeat x 1)
Pediatric: For suspected beta blocker or calcium channel blocker (CCB) toxicity: CALCIUM CHLORIDE 20 mg/kg or CALCIUM GLUCONATE 60 mg/kg IV (may repeat x1).
RI OEMS Protocols
•4.09 Crush Injury
For patients with ECG changes suggestive of hyperkalemia or if the patient progresses to cardiac arrest, manage per the age appropriate Cardiac Arrest Protocol and consider CALCIUM CHLORIDE 1 gm IV or CALCIUM GLUCONATE 3 gm IV and SODIUM BICARBONATE 50 mEq IV
RI OEMS Protocols
•2.11 Dialysis Emergencies and Renal Failure
For patients in cardiac arrest or with suspected hyperkalemia, manage per the age appropriate Cardiac Arrest Protocol (if applicable) and contact MEDICAL CONTROL for authorization to administer CALCIUM CHLORIDE 1 gm IV or CALCIUM GLUCONATE 3 gm IV and SODIUM BICARBONATE 50 mEq IV.
RI OEMS Protocols
•4.08 Chemical and Electrical Burn Injury
For patients with exposure to hydrofluoric acid (HF) with signs and symptoms of hypocalcemia, consider CALCIUM CHLORIDE 1gm slow IV push (may repeat x1). If inhalation injury is suspected, consider (if available) CALCIUM GLUCONATE 2.5% solution via SVN.
