Drugs used in the peri-arrest period

Question 1

Adenosine

Indication?

Dose?

Pharma?

Answer 1

Indication?
Paroxysmal SVT (AVNRT and AVRT)

Dose?
6mg IV bolus
After 1-2 minutes if unsuccessful, then 12 mg (2x)

Pharma?
Blocks transmission through the AV node with little effect on other cells or pathways

Very short half life (10-15s), fast in, big flush after

Question 2

Adrenaline

Indication?

Dose?

Answer 2

Indication / Dose?
Second line for cardiogenic shock (.05-1 mcg / kg / min)

Brady (alternative to pacing and has not responded to atropine) - 2-10 mcg / min

Anaphylaxis - 0.5mg IM and repeated every 5 mins
Or 50 mcg IV bolus doses titrated to effect

Question 3

Amiodarone

Indication?

Dose?

Pharma?

Answer 3

Indication?
Monomorphic VT, polymorphic VT and wide complex tachycardia of uncertain origin

After unsuccessful cardioversion

Control a rapid rate in pre-excited atrial arrythmias

Dose?
300mg IV over 10-60 min (depending on stability)
900mg over 24 hours

Pharma?
Has effects on sodium, potassium and calcium channels and alpha / beta blocking

In impaired HF, amiodarone is okay

Adverse effects like bradycardia and hypotension can be managed by slowing rate of infusion

Should use CVC but can use peripheral

Question 4

Aspirin

Indication?

Dose?

Pharma?

Answer 4

Indication?
ACS

Dose?
300mg orally (crushed or chewed)

Pharma?
Improves the prognosis of patients with ACS. It is antiplatelet.

Question 5

Atropine

Indication?

Dose?

Pharma?

Side effects?

Answer 5

Indication?
Sinus, atrial or nodal bradycardia or AV block when the patient is unstable. Blocks the vagus nerve on the heart.

Dose?
500-600mcg (IV)

Repeated to a max of 3mg

Pharma?
Antagonist of parasympathetic (blocks acetylcholine) - increases sinus automaticity and facilitates AV conduction

Can cause confusion, blurred vision, dry mouth, urinary retention

Question 6

Beta blockers

Indication?

Dose?

Pharma?

Side effects?

Who don’t you use it on?

Answer 6

Indication?
AF / Atrial flutter when not in HF
Tachy (Narrow complex) with preserved ventricular function

Dose?
Atenolol (beta 1)
5 mg IV over min, repeated if necessary after 10 mins

Metoprolol (beta 1)
2-5 mg IV at 5 min intervals to total of 15mg

Propranolol (beta 1 and beta 2)
100mcg / kg IV slowly in three equal doses at 2-3 mins

Esmolol (beta 1)
- short acting
- Load 500mcg / kg over 1 min
- Infuse 50-200 mcg / kg / min

Pharma?
Side effects low bp, brady, AV delay, bronchospasm

Reduce catecholamines
Decrease HR / BP
Don’t use with Heart failure, low BP, 3rd degree heart block and lung disease associated with bronchospasm

Question 7

Verapamil

Indication?

Dose?

Pharma?

What rhythm to definitely not give to?

Answer 7

Indication?
Narrow complex tachy unconverted by vagal / adenosine

AF / Atrial flutter (preserved pump function and less than 48 hrs)

Dose?
2.5 - 5mg IV over 2 mins
Give repeated doses of 5-10mg every 15-30 mins to 20 mg

Very much not for VT

Pharma?
Calcium channel blocker - slows AV node and increases refractoriness in AV node

GIVING it to VT may cause cardiovascular collapse
Can worsen cardiac output with HF

Question 8

Digoxin

Indication?

Dose?

Pharma?

Answer 8

Indication?
Fast AF

Dose?
500mcg IV over 30 mins

Pharma?
Increases vagal tone, decreases sympathetic activity by suppression of baroreceptors and prolongs AV refractory period

Question 9

Magnesium

Indication?

Dose?

Pharma?

Answer 9

Torsades de pointes

Digoxin toxicity

Low Mg

Dose?
2g IV over 20 mins and may be repeated

Pharma?
Decreases acetylcholine release and reduces sensitivity of the motor end plate

Question 10

Nitrates

Indication?

Dose?

Pharma?

Answer 10

Indication?
Angina
MI
LV Failure

Dose?
1-2 doses of 300mcg tablet or 400mcg spray

GTN IV infusion 10-200mcg / min

Isosorbide IV infusion 2-20 mg / h

Pharma?
Nitrates relax smooth muscles and reduces venous side and reduces left diastolic pressure, also dilate coronary arteries

Question 11

Positive inotropic drugs

Indication?

Dose?

Pharma?

Answer 11

Indication?
Hypotension in the absence of hypovolaemia

Cardiogenic shock

Dose?
Dobutamine 5-20 mcg / kg / min

Dopamine 1-10 mcg / kg min

Norad
0.05 - 1 mcg kg / min

Pharma?
Dobutamine is often positive inotrope of choice post resus. It causes vasodilation and increases HR. It is indicated for poor cardiac output and hypotension that reduces tissue perfusion. Particularly useful with pulmonary oedema and hypotension.

Dopamine is precusor to adrenaline and norad.

Norad is potent vasoconstrictor and positive inotropic effect.