Block 3 Flashcards
Chest compressions
Rate of _______ compressions per minute
100-120
30/2 – 30 compressions, 2 breaths
If an advanced airway is in place, __ breath every __ seconds
1 breath every 6 seconds
Which rhythms should you shock/not shock?
Pulseless vTac, VFib
Do not do on pulseless electrical activity (PEA) or asystole
Establish IV access (after/before) attempt of CPR and defibrillation
AFTER
Which drugs are absorbed in the trachea
NAVEL
Naloxone Atropine Vasopressin Epinephrine Lidocaine
Amiodarone class? MOA?
Class III antiarrhythmic agent
Inhibit ion flux through Na+, K+, Ca2+ channels
Has α- and β- blocking activities
Amiodarone dose in ACLS?
300 mg IVP/IO; may repeat 150 mg IVP/IO once; may start continuous infusion
Continuous infusion: 1 mg/min x 6 hrs followed by 0.5 mg/min x 18 hours
Max 2.2 grams in 24 hours
Lidocaine class? MOA?
Class IB antiarrhythmic agent
Inhibit ion flux through Na+ channels
Lidocaine dose in ACLS?
1 – 1.5 mg/kg IVP; may repeat if pVT/VF persists with 0.5 – 0.75 mg/kg IVP at 5- to 10-minute intervals
Can be given via ET tube at a dose of 2 – 4 mg/kg
Max dose: 3 mg/kg
Continuous infusion (after ROSC): 1 – 4 mg/min
Magnesium MOA in ACLS?
Facilitate prolongation of ventricular repolarization by enhancing intracellular myocardial K+ flux (a process that requires Mg2+)
Magnesium dose in ACLS?
1 – 2 gram (diluted in 10 mL D5W) IVP/IO
What are the H’s and T’s?
Hypothermia
Hypoxia
Hypovolemia
Hyper/hypokalemia
Hydrogen ions
Tablets (overdose, toxins)
Thrombosis, ACS
Thrombosis, PE
Tamponade, cardiac
Tension pneumothorax
In what situations should you give meds if a person is bradycardic? What meds can you give then?
Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure
Atropine, dopamine, epi
Atropine MOA?
Blocks acetylcholine receptors; inhibit the action of the vagus nerve on the heart
Atropine dosing?
1 mg IV, may repeat
Max dose: 3 mg
Dopamine dosing?
Infusion (begin at 5 – 10 mcg/kg/min, titrate to response)
As you increase dose of dopamine, what receptors are affected?
It goes from mostly dopamine and beta to just alpha and beta
Epi dosing for bradycardia?
Infusion (begin at 2 – 10 mcg/min, titrate to response)
No maximum doses
If tachycardic and have these symptoms, what do you do?
Hypotension
Acutely altered mental status
Signs of shock
Ischemic chest discomfort
Acute heart failure
Move on to synchronized cardioversion
What conditions are considered wide QRS? How is it treated
Anything ≥0.12 sec
Ventricular tachycardia
SVT with aberrancy
Pre-excited tachycardias (via accessory pathways)
Adenosine only if regular and monomorphic, Amiodarone Magnesium, and Procainamide
Anything else is narrow complex
How is narrow QRS treated?
Treated with vagal maneuvers, adenosine, BB, CCB
Adenosine dosing?
6 mg rapid IVP & 20-mL saline flush at the same time with elevation of the arm infused into
May repeat with 12 mg bolus x 2 if no conversion occurs within 1 – 2 min
Verapamil dosing?
Verapamil: 2.5 – 5 mg IV over 2 min, may repeat 5 – 10 mg Q 15 – 30 min (to a total dose of 20 mg)
Diltiazem dosing?
Diltiazem: 0.25 mg/kg (15 – 20 mg) IV over 2 min bolus; 0.35 mg/kg (20 – 25 mg) IV over 2 minutes (2nd bolus in 15 min); maintenance infusion 5 – 15 mg/hr (titrate to HR)
Metoprolol dosing?
Metoprolol: 5 mg slow IVP at 5-minute interval (to a total of 15 mg)
Atenolol dosing?
Atenolol: 5 mg slow IVP (over 5 minutes) may repeat x 1
Propranolol dosing?
Propranolol: 0.1 mg/kg slow IVP divided into 3 equal doses at 2- to 3-minute intervals (rate ≤ 1 mg/kg)
Esmolol dosing?
Esmolol: 500 mcg/kg bolus IVP (over 1 min), followed by a 4-minute infusion of 50 mcg/kg/min (total 200 mcg/kg)
Avoid adenosine, digoxin, diltiazem, verapamil in which conditions
AF + WPW syndrome
When should the dose of adenosine be reduced to 3mg instead of 6?
Reduce dose to 3 mg in recent heart transplant patients, in pts taking carbamazepine, dipyridamole
Differences in dosing of magnesium for tachycardia
1 – 2 gram (diluted in 50 – 100 mL D5W) over 5 – 60 min IV
Procainamide class?
Class IA antiarrhythmic agent
Procainamide dosing?
LD 20mg/min continuous infusion; until arrhythmia is suppressed
Maintenance infusion: 1 – 4 mg/min dilute in D5W or NS
Reduced in presence of renal failure
Max loading dose 17 mg/kg
DOC for the following conditions:
Torsades de pointes
Symptomatic bradycardia
Supraventricular tachycardia
Torsades - magnesium
Symptomatic bradycardia - atropine
Supraventricular tachycardia - adenosine
How is pulmonary HTN classified?
Group 1 - Pulmonary artery HTN
2 - Left heart disease
3 - Lung disease and/or hypoxia
4 - Chronic TE pulmonary HTN
5 - Unknown or multifactorial
How does endothelin, NO, and prostacyclin cause/treat PAH?
Endothelin -> leads to vasoconstriction and proliferation
Nitric oxide -> leads to production of cGMP which causes vasodilatation and antiproliferation
Prostacyclin -> also leads to production of cAMP which causes vasodilatation and antiproliferation
PAH class types?
I = no limitation of usual physical activity
II = Mild limitation of physical activity
III = Marked limitation of physical activity. There is no discomfort at rest,
IV = Unable to perform any physical activity at rest and who may have signs of right ventricular failure
How is PAH diagnosed?
Invasive tests
Requires echocardiography (transthoracic) and pulmonary artery catheterization (also known as right-heart catheterization)
What criteria must be met to be diagnosed with PAH?
mPAP≥25 + PCWP/LVEDP ≤15 + PVR>3
Whats given to assess mPAP?
Adenosine, NO, or epoprostenol
If reduced by 10-39, its considered postive
CCB indication for PAH?
Positive test required!
CCB AE?
Hypotension
Peripheral edema
Bradycardia (diltiazem only)
How is epoprostenol initiated?
Started at a low dose (2-4 ng/kg/min) and increased until rate-limiting side effects
Goal dose is 10-15 ng/kg/min
How is epoprostenol given?
IV infusion only, has a very short half life
What should be avoided with epoprostenol?
Nitrates; severe refractory hypotension
Brand differences of epoprostenol?
Flolan® - original formulation, requires ice packs, low stability
Veletri® - more basic, greater room temperature stability
How is Treprostinil given?
IV, SQ, oral, inhaled
Because Treprostinil has a longer half life than epoprostenol, what other advantage does it have on AE?
Decreasing the risk of rebound pulmonary vasoconstriction
What are some other issues (AE) of treprostinil vs epoprostenol?
More bloodstream infections via IV
Infusion site pain via SQ
Throat burn via inhalation
How is Iloprost given?
Inhalation only
What is an administration issue of Iloprost has that doesnt occur with treprostinil?
It takes 10-15 min to inhale
Treprostinil just takes longer to prepare
What are the endothelin receptor antagonists?
Bosentan (A + B)
Ambrisentan (A only)
Macitentan (A + B; but higher selectivity with A)
Bosentan
Ambrisentan
Macitentan
Letairis
Opsumit
Tracleer
Which programs need to be associated w/ each drug?
Bosentan - Tracleer
Ambrisentan - Letairis
Macitentan - Opsumit
Bosentan AE?
Preg cat: X
Anemia + Edema
If AST/ALT 3x upper limit, reduce dose or hold
Ambrisentan AE?
2 forms of birth control
Anemia + Edema
Transaminitis, Nasal congestion, flushing, and palpitations
Macitentan AE?
Females register only
Anemia + Edema
Transaminitis, Nasal congestion, flushing, and palpitations
PDE5 inhibitor MOA?
Increased intracellular cGMP concentration
PDE5i AE?
Vision change and loss can occur – therapy should be discontinued if this happens
Dyspepsia Diarrhea Systemic hypotension Headaches Flushing Epistaxis
PDE5i Interactions?
Nitrates – precipitous drop in blood pressure, avoid combination
Bosentan - 50% decrease of PDE5i concentration
What are the Soluble cGMP Stimulator Rx? MOA?
Riociguat
Works synergistically with nitric oxide and directly stimulates soluble guanylate cyclase
Increases intracellular cGMP concentration
Riociguat AE?
Headaches Peripheral edema Major bleeding GERD Systemic hypotension
Preg Cat: X
Riociguat interactions?
Nitrates, PDE5 inhibitors
What are the Prostacyclin Receptor Agonist Rx?
Selexipag
Selexipag AE?
Headaches Jaw pain Myalgia Flushing Anemia Rash
Selexipag interactions?
Gemfibrozil (will increase selexipag conc.)
What vaccines are recommended for PAH?
Maintain current influenza and pneumococcal vaccination
PAH I Tx plan?
Monitor patient
PAH II or III w/ NO rapid disease progression Tx plan?
Ask if pt can tolerate combo therapy
If yes, ambrisentan and tadalafil
If no, endothelin receptor antagonists, riociguat, sildenafil, or tadalafil
PAH III Tx plan w/ rapid disease progression
Ask if pt can tolerate parenteral prostanoids
If yes, continuous IV epoprostenol, IV treprostinil, or SC treprostinil
If no, addition of inhaled or oral prostanoid
PAH treatment if inadequate treatment from previous tx plan?
Add second line or third line (if REALLY bad)
PAH treatment if nothing works at all?
Lung transplant (if applicable) or palliative care
