Cardiac Flashcards
1
Q
Acetylsalicylic acid trade name
A
Novasen, Aspirin, ASA, Bufferin
2
Q
ASA class
A
salicylate, antiplatelet, antipyretic, anti-inflammatory, non-opioid analgesic (NSAID)
3
Q
ASA MOA
A
Anticoagulant: at low doses, impedes clotting by inhibiting the enzyme COX-1 and prostaglandin synthesis, which
prevents formation of platelet-aggregating substance thromboxane A2 (this is irreversible and can prolong bleeding
time).
4
Q
ASA Indications
A
Acute coronary syndromes suggestive of an acute myocardial infarction
5
Q
ASA Dose
A
160-325 mg PO – Chewed and swallowed
*Note: May be given even if patient has taken a partial dose of ASA prior to incident
6
Q
ASA Contraindications
A
Hypersensitivity to ASA and NSAIDS or other salicylates
Hypersensitivity to tartrazine (FDC yellow dye #5)
Active GI Bleed
Known bleeding disorders or thrombocytopenia (excessive low platelet levels)
Breastfeeding - Children with viral infections, chicken pox or flu-like symptoms (can increase risk or Reye’s
syndrome)
Pregnancy after 30 weeks gestation
Hemorrhagic stroke
Acute bronchospasm
Asthma with history of induced bronchospasm by salicylates or NSAIDS
7
Q
Adenosine trade name
A
Adenocard
8
Q
Adenosine class
A
antiarrhythmic, (a naturally occurring nucleoside)
9
Q
Adenosine MOA
A
Antiarrhythmic:
Decreases automaticity in the SA node and greatly slows conduction through the AV node and inhibit reentry
pathways.
Also useful in PSVT linked to accessory bypass tracts (Wolf-Parkinson White Syndrome)
10
Q
Adenosine indications
A
Stable, narrow-complex regular tachycardia (SA and AV nodal origin)
Therapeutic and diagnostic maneuver for stable narrow complex SVT (Not AV nodal in origin)
May be considered for: Unstable narrow-complex regular tachycardias while preparations are made for electrical
cardioversion
Stable, regular, monomorphic, wide complex tachycardia thought or previously defined to be re-entry SVT with
aberrancy.
11
Q
Adenosine Adult Dose
A
6 mg FIVP (over 1-3 seconds), repeat in 1-2 mins if needed once at 12 mg FIVP
*Note: Each dose of adenosine is to be followed immediately with a 20 ml flush while elevating the arm
12
Q
Adenosine Pediatric Dose
A
0.1 mg/kg FIVP (over 1-3 secs) to a single max dose of 6 mg per repeat once in 1-2 mins if needed at 0.2mg/kg FIVP
to a max single dose of 12 mg
*Note: Each dose of adenosine is to be followed immediately with a 5-10 ml flush while elevating the arm
13
Q
Adenosine Contraindications
A
Hypersensitivity to drug or any component
Poisoning / drug induced tachycardia
2nd or 3rd degree block; symptomatic bradycardia
Sick sinus syndrome
Atrial fibrillation / atrial flutter; may induce ventricular arrhythmias
14
Q
Amiodarone trade name
A
Codarone, Nexteribem Oaceribe
15
Q
Amiodarone Class
A
benzofuran derivative, ventricular & supraventricular antiarrhythmic (class III)
16
Q
Amiodarone MOA
A
Inhibits alpha and beta adrenergic receptors producing vasodilation and AV nodal suppression (this slows
the conduction through the AV node and decreases peripheral vascular resistance PVR)
Inhibits the outward potassium current so it prolongs the QT duration, prolongs the action potential and
refractory period (repolarization inhibition).
Inhibits sodium channels, which slows conduction in the ventricles and prolongs the QRS duration.
17
Q
Amiodarone Indications
A
VF/pVT unresponsive to shock delivery, CPR, and a vasopressor
Recurrent, hemodynamic unstable VT
With expert consultation amiodarone may be used for tx of some atrial (SVT) and ventricular arrhythmias
18
Q
Amiodarone Adult Dose
A
VF/pVT:
300 mg IVP, repeat 3-5 minutes if pt remains in VF pVT administer second dosage of 150 mg The
maximum total accumulative dosage is 450mg. Micron filter is not required in cardiac arrest
Wide Complex tachycardias with a pulse:
Rapid Infusion:
150 mg over 10 minutes, if required repeat 150 mg q 10 minutes (until suppression of arrhythmia or max
cumulative dose is reached).
Mix 150mg in 100ml bag of D5W with a micron filter (Conc
1st Maintenance Infusion (Immediately post suppression of arrhythmia):
360 mg over 6 hours (1 mg/min) (with micron filter)
2nd Maintenance Infusion:
540 mg over 18 hours (0.5 mg/min) (with micron filter)
*Note: Max cumulative dose of 2.2 G/24 hrs
19
Q
Amiodarone pediatric dose
A
VF/pVT:
5 mg/kg IVP to a single max dose of 300 mg, q 5 mins, can repeat to a cumulative maximum of 15 mg/kg
/day or 2.2 g IV per 24 hours.
Wide complex tachycardias with a pulse:
5 mg/kg IV (over 20 to 60 mins) to a single max dose of 300 mg, q 5 mins, can repeat to a cumulative
maximum of 15 mg/kg /day or 2.2 g IV per 24 hours
20
Q
Amiodarone contraindications
A
AV block, pre-existing 2nd or 3rd degree block (without artificial pacemaker); Sinus node dysfunction
Bradycardia
Do not administer with other drugs that prolong QT interval (ie, procainamide)
Sensitivity to amiodarone or iodine, (contains iodine)
21
Q
Atropine trade name
A
atropine
22
Q
Atropine MOA
A
Antiarrhythmic: blocks the effects of acetylcholine on the SA and AV nodes, thereby increasing the SA and AV
conduction velocity resulting in increased heart rate.
Has variable and clinically negligible effects on the His-Purkinge system. Small doses (less than 0.5 mg) may lead to
paradoxical slowing of the heart rate, which may be followed by a more rapid rate.
Anticholinergic: decreases the action of the parasympathetic nervous system on certain glands (bronchial, salivary and
sweat), resulting in decreased secretions.
23
Q
Atropine indications
A
First drug for symptomatic bradycardias on adults
May be beneficial in presence of AV nodal block
Organophosphate poisoning (antidote)
Bradycardia due to increased vagal tone can be considered with pediatrics patients including after intubation causing
bradycardia.
24
Q
Atropine adult dose
A
Symptomatic Bradycardia: 1.0 mg IVP q 3-5 minutes prn to a total max dose of 0.04 mg/kg not to exceed total
accumulative dose of 3mg
Organophosphate Poisoning: 1- 4 mg IVP q 5 minutes until bronchial secretions dry
25
Atropine pediatric dose
Dosage for Bradycardia: 0.02 mg/kg (minimum dose of 0.1 mg) to a single max of 0.5 mg IV/IO may repeat dose once
in 5 minutes
Organophosphate Poisoning Under 12 y/o 0.01 – 0.04 mg/kg max 1mg (minimum dose of 0.1 mg) IV/IO, then repeated
and doubling the dose q 5 minutes until bronchial secretions dry
26
Atropine contraindications
Hypersensitivity to atropine, belladonna alkaloids or sulfites
Tachycardia
Closed-angle Glaucoma
Acute MI
Myasthenia gravis
GI obstruction
Heart transplant patients
27
Clopidogrel bisulfate trade name
Plavix
28
clopidogrel class
P2Y12 Adenosine Diphosphate Receptor (ADP) antagonist
29
clopidogrel MOA
Irreversibly inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor and the
subsequent ADP-mediated activation of glycoprotein IIb/IIIa complex, thereby inhibiting platelet
aggregation
30
clopidogrel indications
Acute STEMI/NSTEMI ACS
31
clopidogrel dose
Under age 75 years: Loading dose of 300-600 mg PO/OG
Over age 75 years: Loading dose of 75 mg PO/OG
32
clopidogrel contraindications
Hypersensitivity
Active bleeding
Significant liver impairment or cholestatic jaundice
Suspected liver impairment with history of hepatitis; long term ETOH abuse; or a presentation of
jaundice
Thrombotic thrombocytopenic purpura
Suspected aortic dissection
Do not give if coronary bypass graft (CABG) surgery is planned, withhold for 5 days before CABG unless
need for revascularization
33
diltiazem trade name
cardizem
34
diltiazem class
Class IV: Calcium Channel Blocker
35
diltiazem MOA
Antiarrhythmic action: By inhibits the inward influx of calcium at the AV node, diltiazem decreases conduction
velocity and increases refractory period, thereby decreasing the impulses transmitted to the ventricles in A-fib or Aflutter. The result is a decreased ventricular rate
36
diltiazem indications
To control rate of ventricular response in patients with A-Fib or A-Flutter
Use after adenosine to treat refractory reentry SVT in patients with narrow QRS complex and adequate blood
pressure
37
diltiazem dose
Only Adults – no Pediatric dose:
0.25 mg/kg SIVP q 15 mins may repeat once if needed at 0.35 mg/kg SIVP.
Maintenance Infusion:
For acute rate control of A-Fib or atrial flutter maintenance is initiated at a rate of 5 to 15 mg/hr titrated to the
patient’s heart rate. Mix: 50 mg in 500ml NS or D5W (concentration 0.1 mg/ml)
38
diltiazem contraindications
Hypersensitivity to drug
Wide-QRS tachycardia of uncertain origin
Poison-or drug-induced tachycardia.
Sick sinus syndrome
WPW
Bradycardia; second- or third-degree AV block
LV dysfunction; Heart Failure
Hypotension <90 systolic
Recent MI
Severe heart failure (ie: with pulmonary edema)
IV Calcium Channel Blockers, Beta Blockers or cardiac depressant drugs that can produce reduction in myocardial
contractility of the AV conduction.
39
dopamine HCL trade name
intropin
40
dopamine class
adrenergic agonist (sympathomimetic), vasopressor, inotropic (dose dependent)
41
dopamine MOA
Vasopressor: an immediate precursor to norepinepherine, dopamine stimulates the dopaminergic, beta-adrenergic and
alpha-adrenergic receptors of the sympathetic nervous system.
42
dopamine indications
Second line drug for symptomatic bradycardia (after atropine)
Use for hypotension with signs and symptoms of shock – correct hypovolemia with volume replacement before
initiating dopamine
43
dopamine dose
Adult:
5 – 20 mcg/kg/min IV Infusion; titrate to patient response; initiate dose at 5 mcg/kg/min and titrate to patient
response
Pre-Mix bag or mix as: 400 mg/250ml N/S [1600mcg/ml]
44
dopamine contraindications
Uncorrected tachydysrhythmias
Ventricular fibrillation/Ventricular Tachycardia
Pheochromocytoma – may precipitate hypertensive crisis
Allergies to corn or corn products
45
enoxaparin sodium trade name
lovenox
46
enoxaparin class
low-molecular-weight heparin (LMWH) / anticoagulant
47
enoxaparin MOA
Anticoagulation action: LMWH that accelerates formation of antithrombin III-thrombin complex and deactivates
thrombin preventing conversion of fibrinogen to fibrin, inhibits factor Xa.
48
enoxaparin indications
Acute STEMI /NSTEMI/ACS
49
enoxaparin dose
<75 yr: Initial dose: 30mg IVP followed by a Second dose of 1mg/kg SQ
Note: maximum dose of 100mg SQ (Maximum SQ dose does NOT include IV dose)
>75 yr: Eliminate initial IV dose; Give 0.75 mg/kg SQ
Note: maximum dose 75mg SQ
50
enoxaparin contraindications
Hypersensitivity to Sulfite or heparin
Active major bleeding or bleeding disorders
Type II Heparin or LMWH induced thrombocytopenia
Severe thrombocytopenia (low platelets)
Peptic ulceration
Aortic aneurysm
51
epinephrine trade name
adrenalin
52
epinephrine class
adrenergic agonist (Sympathomimetic)
53
epinephrine MOA
A catecholamine that stimulates the alpha and beta-adrenergic receptors in the sympathetic nervous
system.
Alpha1 Receptors: causes vasoconstriction used to delay absorption of local anesthetics, control
superficial bleeding, suppress glottal edema and elevate blood pressure by increasing peripheral vascular
resistance. Alpha1 receptors on the iris produces mydriasis during ophthalmologic procedures
Beta1 Receptors: produces inotropic (strength of contraction), chronotropic (rate of contraction) and
dromotropic (speed of conduction) effects, increasing cardiac output and myocardial oxygen consumption.
Beta2 Receptors: Relaxes bronchial smooth muscle increasing tidal volume and vital capacity.
Activation of these three types of adrenergic receptors can reverse the degranulation of the
anaphylactic reaction caused largely by the release of leukotrienes with histamine.
54
epinephrine indications
Cardiac Arrest – V-fib, Pulseless V-Tach, Asystole, PEA
Symptomatic bradycardia, particularly if associated with hypotension, for whom atropine may be
inappropriate or after atropine fails
Used to treat severe hypotension
Maintain cardiac output during Post-Cardiac Arrest Care
Anaphylaxis
Severe status asthmaticus
Croup with stridor
Beta Blocker/Ca+ channel Blocker overdose
55
epinephrine adult dose
Cardiac Arrest: 1 mg of 1mg/10 mL (0.1 mg/ml concentration) IVP q 3-5 minutes
ROSC (Hypotension): 2 - 10 mcg/min infusion
Symptomatic Bradycardia with Hypotension: 2 – 10 mcg/minute IV infusion
Croup / Anaphylaxis: 0.5 mg/kg of (1mg/1 mL) to max 5mg neb. Repeat every 5 minutes to a max of 10mg
Anaphylactic Shock/ Asthma (refractory to initial treatment): 0.3 to 0.5 mg IM (1mg/1 mL) q 5
minutes prn to a maximum of 3 doses, then transition to a continuous infusion if needed starting at
1 mcg/min
56
epinephrine pediatric dose
Cardiac Arrest: 0.01 mg/kg to a max of 1mg/10 mL (0.1 mg/ml concentration) IVP q 3-5 minutes
ROSC (Hypotension): 0.03 - 0.2 mcg/kg/min
Symptomatic Bradycardia with Hypotension: 0.01 mg/kg of 1mg/10 ml (0.1 mg/ml concentration) to a max
of 1 mg IVP/I.O. q 3-5 minutes followed by:
Infusion of 0.1-0.3 mcg/kg/min may be followed for persistent bradycardia
Croup / Anaphylaxis: 0.5 mg/kg of (1 mg/1 mL) to max 5mg neb. Repeat every 5 minutes to a max of
10 mg
Anaphylactic Shock/ Asthma (refractory to initial treatment): 0.01 mg/kg IM of (1 mg/1 mL) to a
single max dose of 0.5 mg q 5 minutes prn, (maximum of 3 doses) then transition to continuous infusion if
needed at 0.1 – 0.3 mcg/kg/min
57
epinephrine push dose
Adult/pediatric: 1 mcg/kg to a single max dose of 50 mcg Repeat q 2 minutes PRN
58
epinephrine post rosc infusion
*Mix 4 mg of Epinephrine (1mg/1mL) in 250 ml of N/S (concentration 16 mcg/ml)
Pediatric: 0.03 – 0.3 mcg/kg/min IV infusion
Adult: 1 – 10 mcg/min Infusion
59
epinephrine contraindications
none in the emergent setting
60
ephedrine trade name
emerphed
60
ephedrine MOA
Mixed acting drug because it activates adrenergic receptors by direct and indirect mechanisms. Direct activation
results from binding of the drug to alpha and beta receptors. Release of norepinephrine from its storage sites is one
of its indirect effects.
In therapeutic doses, ephedrine relaxes bronchial smooth muscles and produces cardiac stimulation with increased
systolic and diastolic blood pressure when norepinephrine stores aren’t depleted.
Non-catecholamine as a result has a longer half life than catecholamines (i.e. norepinephrine, epinephrine)
60
ephedrine class
adrenergic, vasopressor
61
ephedrine indications
To correct hypotensive states (i.e. sepsis, spinal trauma, head injury, anaphylaxis, shock states, etc.)
Ephedrine can be given as a “bridge drug” (due the drugs half life) until an inotropic / vasopressor infusion is started
to maintain an adequate BP.
62
ephedrine dose
0.2 mg/kg IV/IO to a single dose of 10 mg q 5 minutes prn
63
ephedrine contraindications
Hypersensitivity to drug or other sympathomimetics
Severe CAD
Patients taking MAO inhibitors
64
furosemide trade name
lasix
65
furosemide class
loop diuretic
66
furosemide MOA
Diuretic: Inhibits sodium and chloride reabsorption in the proximal part of the ascending loop of Henle
and distal renal tubule, promoting excretion of sodium, water, chloride and potassium.
Non-potassium (K+) sparing diuretic; potassium (K+) excreted from the body in the urine.
67
furosemide adult dose
Congestive Heart Failure and Pulmonary Edema:
No usual prescription of Lasix:
20-40 mg SIVP/IO
If patient has a usual prescription of Lasix:
Dose may be increased 2 times the patient’s usual prescribed dose to a maximum of 160 mg
Hyperkalemia:
40-80 SIVP/IO
Hypertensive Emergencies:
40 mg SIVP/IO
67
furosemide indications
Acute pulmonary edema (BP >100 mmHg without S&S of shock)
Hypertensive emergencies
Removal of Potassium for management of Hyperkalemia
68
furosemide pediatric dose
Congestive Heart Failure and Pulmonary Edema:
1 mg/kg slow IV/IO push. q 1-2 hours if no response has occurred. You may repeat at 2 mg/kg.
Hyperkalemia (with normal renal function, non-hypovolemic)
0.5-1.0 mg/kg to max of 40 mg SIVP
Hypertensive Emergencies:
1 mg/kg mg IV/IO (over 1-2 minutes)
69
furosemide contraindications
Hypersensitivity to furosemide and sulphonamides
Complete renal shutdown (anuria except acute)
Hypokalemia
Severe hypovolemia, hypotension, dehydration, BP < 100 systolic
Electrolyte imbalance
70
hydrocortisone trade name
Cortef, Anusol HC, Caldecort, Colocort, Solu-Cortef
71
hydrocortisone class
Adrenal corticosteroid; Glucocorticoid
72
hydrocortisone MOA
Inhibits accumulation of inflammatory cells at inflammation sites, phagocytosis, lysosomal enzyme release,
synthesis and or release of mediators of inflammation.
Reverses increased capillary permeability
Prevents/suppresses cell-mediated immune reactions. Decreases/prevents tissue response to
inflammatory process
73
hydrocortisone indications
Management of adrenocortical insufficiency, anti-inflammatory, immunosuppressive
Anaphylactic shock
74
hydrocortisone adult dose
Adrenal Insufficiency emergencies: 100 mg SIVP/IO; reconstitution – as per manufactures
instructions; may further dilute with NS; for IVP dilute to 50mg/ml; no repeat dose
Anaphylaxis: 250 - 500 mg IV
75
hydrocortisone pediatric dose
Adrenal Insufficiency emergencies: 1 – 2 mg/kg slow IV. To a maximum dose of 100 mg; no repeat dose
(Don’t use a low dose or less than 25 mg daily)
Anaphylaxis: 5 - 10 mg/kg to single max dose of 500 mg IV
76
hydrocortisone contraindications
Active untreated infections
Hypersensitivity to hydrocortisone
Systemic Fungal infections
Tuberculosis
77
labetalol hydrochloride trade name
trandate
78
labetalol class
alpha and beta-adrenergic blocker, antihypertensive
79
labetalol MOA
Antihypertensive: Inhibits catecholamine access to both beta and postsynaptic alpha-adrenergic receptor sites. Has
vasodilating effect).
80
labetalol indications
Severe hypertension and hypertensive emergencies
Hypertension in acute Ischemic stroke patients who are potential candidates for acute reperfusion therapy with a
blood pressure level of Systolic >185 mmHg or diastolic >110 mmHg
Management of blood pressure during reperfusion therapy and after reperfusion therapy; blood pressure level
under 180 mmHg Systolic or under 105mmHg diastolic
80
labetalol dose
Severe Hypertension / Hypertensive emergency:
10 - 20 mg SIVP over 2 minutes initially; may repeat at 40 – 80 mg SIVP q 10 min to total maximum dose of 300 mg.
Hypertension in acute Ischemic stroke prior to reperfusion therapy:
10 – 20 mg SIVP, may repeat X 1
Management of blood pressure during reperfusion therapy and after reperfusion therapy for Ischemic Strokes:
10 mg SIVP followed by a continuous IV infusion of 2 -8 mg/minute: Do not exceed a total cumulation of 300 mg
labetalol.
Mix infusion to concentration of 1 mg/1ml may be mixed in D5W, NS or RL initiate at 2 mg/min titrate to response
80
labetalol contraindications
Hypersensitivity to beta blockers
CHF – severe LV failure
Pulmonary Edema
2nd or 3rd degree AV blocks
Bradycardia
Hypotension
Cardiogenic shock
Sick sinus syndrome
Bronchospasm
Cocaine in past 24 hours which causes chest pain
Children
80
lidocaine HCL trade name
Xylocaine; Synera (lidocaine / tetracaine)
80
lidocaine class
anesthetic, antiarrhythmic (class IBVW)
81
lidocaine MOA
Ventricular antiarrhythmic: Suppresses automaticity of conduction tissue; increases electrical
stimulation threshold of ventricle, His Purkinje system and spontaneous depolarization of ventricles during
diastole.
Local anesthetic: acts to block initiation and conduction of nerve impulses by decreasing the permeability
of the nerve cell membrane to sodium ions.
82
lidocaine indications
Alternative to amiodarone in cardiac arrest from VF / pVT
Stable VT, wide complex tachycardia of uncertain ectopy (with normal baseline QT interval and preserved
LV function when ischemia is treated, and electrolyte imbalance is corrected)
Can be used for stable polymorphic VT with baseline QT-interval prolongation if torsade is suspected.
Premature ventricular beats (PVCs) of a life-threatening nature
Procedural anesthetic
IO infusion pain
83
lidocaine adult dose
Cardiac arrest from VF/VT (pulseless) (2% lidocaine preload)
Initial dose: 1 - 1.5 mg/kg IVP repeat 5- 10 mins for refractory VF at 0.5 to 0.75 mg/kg IVP maximum 3
doses or total max dose of 3 mg/kg – followed by a maintenance infusion if indicated
Perfusing Arrhythmia (VT/Torsade) (2% lidocaine preload)
0.5 to 0.75 mg/kg SIVP, repeat in 5 to 10 minutes; maximum total of 3 mg/kg – Followed by a maintenance
infusion if indicated
Maintenance Infusion: A continuous maintenance infusion MAY be initiated when indicated
Mix 1 gm in 250 ml NS (concentration 4 mg/ml); Infuse at 1-4 mg/min (30-50 mcg/kg/min)
IO infusion pain (2% lidocaine preload)
If patient is responsive to pain or complains of pain when you flush the marrow cavity:
First dose 40 mg (2ml) IO over 2 mins q 60 seconds if needed 20 mg (1ml) IO over 1 min
Local Anesthetic for male urethra – urinary catheterization:
5-10 ml of the 2% lidocaine jelly – prior to catherization
Injection for local infiltration:
(subdermal) 0.5% - 1% - Inject small volumes SQ until the entire area is anesthetized Maximum dose is 4
mg/kg
83
lidocaine pediatric dose
Cardiac Arrest from VF/VT (pulseless) (2% lidocaine preload)
1mg/kg IV/IO, q 5 minutes prn to a total max dose of 3 mg/kg – Followed by a maintenance infusion if
indicated
Perfusing Arrhythmia (VT/Torsade) (2% lidocaine preload)
1mg/kg IV/IO, q 5 minutes prn to a total max dose of 3 mg/kg – Followed by a maintenance infusion if
indicated
Maintenance Infusion: A continuous maintenance infusion MAY be initiated when indicated
20 to 50 mcg/kg/min IV/IO
IO infusion pain (2% lidocaine preload)
If patient is responsive to pain or complains of pain when you flush the marrow cavity:
0.5 mg/kg IO to a total maximum of 40 mg (2ml) delivered over 2 minutes, repeat if needed with 0.25
mg/kg max 20 mg (1 ml)
Injection for local infiltration:
(subdermal) 0.5% - 1% - Inject small volumes SQ until the entire area is anesthetized Maximum dose is 4
mg/kg
84
lidocaine contraindications
Hypersensitivity to lidocaine and to amide-type local anesthetics
Idioventricular rhythms
3rd degree AV blocks
Stroke Adams syndrome
Wolf Parkinson White (WPW) syndrome
85
mag adult dose
Cardiac Arrest VT polymorphic / VF due to hypomagnesaemia or Torsade’s de Pointes)
Adult-1 - 2 g SIVP diluted in 10 ml of NS over 20 mins
Torsades de Pointes with a pulse or cardiac arrythmias with hypomagnesemia:
Loading dose: 1 - 2 g IV diluted in 50 -100 ml of NS or D5W IV given over 5 – 60 minutes;
Follow with 0.5 – 1 g/hr IV (titrate rate to control torsade’s or arrythmias).
Bronchospasm
2 g IV diluted in 50 ml NS infused over 20 -30 minutes
TCA Overdose:
2 g IV diluted in 50 ml NS infused over 10- 20 minutes
Eclampsia/Tocolytic:
Loading dose: 4 g IV in 50 ml over 20-30 minutes IV/IO followed by an maintenance infusion 1-2 g/hr. for
24 hours. (Mix 2 G/250 ml NS or D5W)
85
mag sulfate trade name
MgSO4
85
mag class
mineral/electrolyte
85
mag MOA
Replaces magnesium and maintains magnesium level
As an anticonvulsant, reduces muscle contractions by interfering with release of acetylcholine at
myoneural junction
As an anti-arrhythmic magnesium inhibits calcium currents which slows the sinoatrial node activity,
prolongs myocardial conduction time and stabilizes excited membranes.
Acts as a bronchodilator by inhibiting smooth muscle contractions
85
mag indications
Refractory ventricular fibrillation/tachycardia with suspected hypomagnesemia (alcoholism, malnutrition
or protracted diarrhea)
Polymorphic ventricular tachycardia / Torsades de Pointes
Life threatening ventricular arrhythmias due to digitalis toxicity
Hypomagnesemia
Adjunctive therapy in severe bronchospasm refractory to nebulized medications
Tricyclic Antidepressant (TCA) overdose
Moderate to severe eclampsia symptoms
Preterm Tocolytic – Medical Control
86
mag pediatric dose
Cardiac Arrest VT polymorphic / VF due to hypomagnesaemia, Torsade’s de Pointes with or without
perfusion, or cardiac arrythmias with hypomagnesemia
20 – 50 mg/kg to a single max dose of 2 G SIVP over 10-20 mins
Bronchospasm
25 – 50 mg/kg IV to a max dose of 2 G in 50 ml NS or D5W infused over 10-20 minutes
TCA Overdose:
25 mg/kg IV to a max dose of 2 G in 50 ml NS infused over 15-20 minutes
86
mag contraindications
Heart Blocks
Renal failure
Hyper-magnesia, hypocalcemia
87
metoprolol tartrate trade name
lopressor
88
metoprolol class
beta blocker, antihypertensive
89
metoprolol MOA
Selectively blocks beta 1 adrenergic receptors; slow heart rate, decreases cardiac output, decreases
myocardial ischemia severity
90
metoprolol indications
Stable, narrow-complex tachycardias if rhythm remains uncontrolled or unconverted by adenosine or vagal
maneuvers or if SVT is recurrent
Control ventricular rate in patients with atrial fibrillation or atrial flutter
91
metoprolol dose
Treatment of SVT (post-adenosine) / Atrial Fibrillation / Atrial Flutter:
5 mg SIVP (over 2 minutes) doses q 5 minutes prn total max accumulative dose of 15 mg (vital signs must
remain stable)
92
metoprolol contraindications
Hypersensitivity
CHF – severe LV failure – pulmonary edema
Sick sinus syndrome – in absence of a pacemaker
Systolic blood pressure less then 100 mmHg
Cocaine used in past 24 hours with chest pain
AV Heart block
Bradycardia < 60 bpm
Cardiogenic shock
93
nitro trade name
Nitrostat, Nitro-Bid, Tridil
94
nitro class
nitrate, anti-anginal, vasodilator
95
nitro MOA
Antianginal: relaxes vascular smooth muscle of both venous and arterial beds, resulting in a net decrease
in the myocardial oxygen consumption. It also dilates coronary vessels, leading to redistribution of blood
flow to ischemic tissue and improves collateral circulation.
Vasodilating: dilates peripheral vessels, decreasing venous return to the heart (preload) useful in treating
pulmonary edema and heart failure. Arterial vasodilation decreases afterload, thereby decreasing left
ventricular work and aiding the failing heart.
96
nitro indications
Initial antianginal for suspected ischemic chest pain
For initial 24 – 48 hours in patient with AMI and CHF, large interior wall infarction, persistent or
recurrent ischemia
Continued use (beyond 48 hours) for patients with recurrent angina or persistent pulmonary congestion
Pulmonary Edema
97
nitro adult dose
SL - 0.3 mg tab or 0.4 mg spray q 5-minute intervals (prn); max of 3 doses
IV - begin infusion at 5 mcg/min; titrate to effect; increase prn by 5 – 10 mcg/min q 5 min. Max dose of
200 mcg/min;
Mix: 25 mg of nitroglycerin to a 250 ml NS or D5W (100 mcg/ml)
Transdermal Patch – 0.2 – 0.8 mg/hr. Topical nitrates are acceptable alternatives for antianginal therapy
with hemodynamic stability in the absence of ongoing refractory ischemic symptoms.
98
nitro pediatric dose
0.25 - 0.5 mcg/kg/min IV/IO increase by 0.5- 1 mcg/kg/min prn as tolerated q 15-20 mins to a max of 5
mcg/kg/min.
99
nitro contraindications
Hypersensitivity to nitrates
Right ventricular infarction (Sublingual Spray Administration- 0.3mg to 0.4 mg are too large a dose and
will drop preload and significantly decreasing cardiac output. These increases mortality rates in these
patients)
Avoid use in extreme bradycardia (<50 bpm) or extreme tachycardia (>160 bpm)
Hypotension (<90 mmHg) or a drop of >30 mmHg below baseline (systolic BP)
Uncorrected hypovolemia
sildenafil (Viagra), vardenafil (Levitra), avanafil (Stendra),) use within 24 hours or tadalafil (Cialis) within
48 hours
Severe anemia
Pericardial Tamponade and pericarditis
100
norepi trade name
levophed
101
norepi class
adrenergic agonist (sympathomimetic), vasopressor
102
norepi MOA
Vasopressor: direct stimulation of alpha-adrenergic receptors, constricting both capacitance and
resistance blood vessels. This result in increased total peripheral vascular resistance, increased systolic
and diastolic blood pressure, and decreased blood flow to vital organs, skin, skeletal muscle and renal
blood flow.
Produces a positive inotropic response of the heart (beta1 receptors).
103
norepi indications
Hypotension MAP less than 65
Septic, Cardiogenic and Neurogenic shock
Treatment of shock after appropriate fluid resuscitation
Beta & Calcium Channel Blocker OD, Cholinesterase inhibitor poisoning, Cyclic Antidepressant OD, Digoxin
OD, Ethanol poisoning, Head injury with MAP <70mmHg, Non-cyclic Antidepressant OD, Salicylate OD,
Sedative OD
Vasopressor infusions may be administered after ROSC to support cardiac output, especially blood flow to
the heart and brain.
104
norepi adult dose
0.1 – 1.0 mcg/kg/min. IV infusion (*start at low dose and titrate to desired blood pressure)
Mix 4 mg in 250 mL D5W or NS (16 mcg/mL)
105
norepi pediatric dose
0.05 – 1.0 mcg/kg/min IV infusion
Mix 4 mg in 250 mL D5W or NS (16 mcg/mL)
The pediatric initial dose for NE range is chosen on the patient condition and problem, titrate infusion as
needed/required:
ROSC dosing - 0.05 – 0.5 mcg/kg/min
Common dose initiation for a hypotensive pediatric patient after adequate fluid replacement - 0.1 -
1.0 mcg/kg/min.
*Always start at low dose and titrate to desired blood pressure
106
norepi contraindications
Mesenteric or peripheral vascular thrombosis
Hypotension related to hypovolemia without appropriate fluid replacement
107
procainamide trade name
pronestyl
108
procainamide class
ventricular and supraventricular antiarrhythmic (Class Ia)
109
procainamide MOA
Antiarrrhythmic: Blocks open sodium channels and prolongs the cardiac action potential (outward
potassium (K+) currents maybe blocked.) Decreases myocardial excitability, conduction velocity and may
depress contractility.
Prolongs PR and QT intervals.
Has peripheral vasodilatory properties which may result in hypotension.
110
procainamide indications
Useful for treatment of a wide variety of arrhythmias, including stable monomorphic VT with normal QT
interval and preserved LV function
May use for treatment of reentry SVT uncontrolled by adenosine and vagal maneuvers if BP is stable
Stable Wide complex tachycardia of unknown origin
Atrial fibrillation with rapid rate in WPW
111
procainamide adult dose
Administer IV loading dose:
20 to 50 mg/min until arrhythmia suppressed or hypotension ensues or QRS prolonged by 50% or total
cumulative dose of 17 mg/kg;
If conversion is successful, may use maintenance infusion (avoid if prolonged QT or CHF); Mix: 1
gm/250 ml NS (4mg/mL); Infuse at 1-4 mg/min
112
procainamide pediatric dose
15mg/kg slow IV/IO over 30 to 60 minutes
113
procainamide contraindications
Hypersensitivity to procainamide, ester type local anesthetics, benzyl alcohol or sulphites
QT prolongation
A typical V-tach or Torsade de Pointe
Any dysrhythmia induced by digoxin toxicity
TCA antidepressant induced dysrhythmia
2nd or 3rd degree AV block
114
sodium bicarb trade name
none
115
sodium bicarb class
alkalinizing agent
116
sodium bicarb MOA
Alkalinizing agent: is a systemic alkalizer, which increases plasma bicarbonate, buffers excess hydrogen
ion concentration, and raises blood pH, thereby reversing the clinical manifestations of acidosis. It also is
a urine alkalizer, increasing the excretion of free bicarbonate ions in the urine, thus effectively raising
the urinary pH.
117
sodium bicarb indications
Patients with documented preexisting metabolic acidosis i.e.; diabetic ketoacidosis
Overdoses associated with QRS > 0.12 seconds or ventricular tachycardia in tricyclic antidepressant,
sympathomimetic, beta / calcium channel blocker, opioid
Known preexisting Hyperkalemia
Cardiac arrest in special situations; prolonged resuscitation, excited delirium
Rhabdomyolysis
ASA overdose (urine alkalization)
118
sodium bicarb dose
Adult/Pediatric:
Cardiac arrest in special situations/ Metabolic Acidosis / Overdoses (listed above) / Rhabdomyolysis
/ Urinary Alkalization / Hyperkalemia:
1.0 mEq/kg SIVP; repeat (prn) q 10 minutes at 0.75 mEq/kg to achieve hemodynamic stability and QRS
narrowing
TCA/ASA overdose:
1.0-2.0 mEq/kg SIVP; repeat (prn) q 10 minutes at 1.0 mEq/kg to achieve hemodynamic stability and QRS
narrowing bolus then initiate infusion.
Infusion: 150 mEq in a 1000ml D5W or NS = 0.15 mEq /ml - rate of 2-3 ml/kg/hour
Adjustments of the IV are made based on blood pH and clinical response to the therapy.
119
sodium bicarb contraindications
Respiratory acidosis
Early in cardiac arrest (unless a specific reason to administer)
Respiratory and metabolic alkalosis
Hypocalcemia
Avoid extravasation due to risk of tissue irritation / necrosis
120
tenecteplase trade name
TNKase
121
TNK class
thrombolytic enzyme
122
TNK MOA
A modified form of human tissue plasminogen activator (tPA) that binds to fibrin and converts
plasminogen to plasmin.
This fibrin specificity produces local fibrinolysis in the area of recent clot formation, with limited
systemic proteolysis.
tenectaplase is administered as a single bolus with an initial half-life of 20-24 minutes, cleared through
liver metabolism
123
TNK indications
ST elevation (threshold values: J-point elevation of 2 mm (men) or 1.5 mm (women) in leads V2 and V3 and
1 mm in all other leads) or new presumably new LBBB; in context of signs and symptoms of AMI and time
of onset of signs and symptoms <12 hrs
124
TNK dose
Once diluted with 10 ml NS TNKase™ concentration is 5 mg/ml
Single bolus delivered over 5 seconds (not compatible with dextrose solutions)
*** ½ amount of dose is administered to age 76 and older.
weight based chart
125
TNK contraindications
Any prior intracranial hemorrhage
Known structural cerebrovascular lesion
Ischemic stroke within past 3 months except ischemic stroke within 4.5 h
Known intracranial neoplasm
Active internal bleeding (other than menses)
Severe uncontrolled hypertension unresponsive to emergency therapy
Suspected aortic dissection
For streptokinase, prior treatment within the previous 6 months
Intracranial or intraspinal surgery within 2 months
Significant closed head or facial trauma within 3 months
Suspected aortic dissection or pericarditis
126
ticagrelor trade name
brilinta
127
ticagrelor class
P2Y12 platelet aggregation inhibitor; Antiplatelet
128
ticagrelor MOA
Reduces platelet aggregation – reversibly inhibits platelet P2Y12 ADP receptor to prevent signal
transduction and platelet activation
129
ticagrelor indications
Reduction of thrombolytic cardiovascular events in conjunction with aspirin in patients with acute
coronary syndrome.
Treatment of STEMI patients
130
ticagrelor dose
PO – 180 mg once
131
ticagrelor contraindications
Hypersensitivity
Active bleeding
Intercranial Bleed
5 days prior to any surgery including CABG
132
tissue plasminogen activator (tPA), alteplase trade name
activase
133
tPA class
thrombolytic enzyme
134
tPA MOA
Binds to fibrin in a thrombus and converts entrapped plasminogen to plasmin, initiating fibrinolysis
Degrades fibrin clots, fibrinogen and other plasma proteins
Acts on the dissolution stage. Protease which activates plasmin release from endothelial cells, due to
ischemic conditions, thrombin, systemic adrenaline and histamine. It acts on plasminogen converting it to
plasmin, which cleaves fibrin.
135
tPA indications
Lysis of thrombi obstructing coronary arteries in management of acute MI.
Lysis of thrombi obstructing cerebral arteries in the management of acute ischemic stroke.
136
tPA dose
STEMI 6- 12 hours of symptoms:
>67 kg: 15 mg initial IV bolus; followed by 50 mg infused over the next 30 mins; then 35 mg infused over
the next 60 mins
< 67 kg: 15 mg initial IV bolus; followed by 0.75 mg/kg (not to exceed 50 mg) over the next 30 min; then
0.5 mg/kg (not to exceed 35 mg) over 60 min
Acute Ischemic Stroke within 4.5 hours or wake-up and unknown time of onset:
Ages 18 - 80
0.9 mg/kg (maximum 90 mg) IV, infused over 60 minutes; give 10% of total dose as an initial IV bolus over
1 min; give remaining 90% of total dose IV over next 60 minutes.
137
tPA contraindications
Ensure BGL is above 3.3 mmol/l (Stroke)
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 4.5 hours
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head trauma or facial trauma within 3 months
Intracranial or intraspinal surgery within 2 months
Severe uncontrolled hypertension (unresponsive to emergency therapy)
138
txa trade name
cyklokapron
139
txa class
antifibrinolytic
140
txa moa
Inhibits the normal process of fibrin breakdown by preventing the formation of plasmin from plasminogen.
Most useful for preventing recurring bleeding; it is less useful for stopping an on-going bleed.
141
txa indications
Bleeding within 3 hours of injury and presenting at any point with HR greater than 110 bpm or systolic BP
less than 90 mmHg. Ex. TBI, Post-Partum hemorrhage, significant traumatic injury with internal bleeding.
142
txa dose
(>16 years old): 1 g IV/IO dilute in 250 mL D5W or 100ml Normal Saline bag and infuse over 10 minutes;
followed by as soon as practical an infusion of 1 g over 8 hours
(<16 years old): 15mg/kg IV/IO to a max of 1g over 10 minutes. Follow bolus dose with 2mg/kg/hr IV/IO
to a max of 1g over 8 hours.
143
txa contraindications
Hypersensitivity to Tranexamic Acid
Active thromboembolic disease (pulmonary embolus, DVT or stroke)
Unable to initiate bolus within 3 hrs of injury onset
GI Bleeds
Subarachnoid hemorrhage
