You are on page 1of 46

Hairudi Sugijo, dr, Sp.

JPFIHA
EDUCATION
1980-1987 Medical, Airlangga University, Surabaya (M.D.)
1995-2001 Residency (Cardiology), Airlangga University, Surabaya
2012-present Post-graduate Programme, Brawijaya University,
Malang
MEDICAL SOCIETIES
2001-present Member, IHA
2009-present Member, HFA-ESC
2014-present Fellow, ASEAN College Of Cardiology
HOSPITAL APPOINTMENTS
2001-present Cardiologist, Sidoarjo General Hospital, Sidoarjo

Cardiac Arrest & Peri Arrest Drugs

Hairudi Sugijo, MD

Medical Error
is the fifth leading cause of death in US

Wrong Indication
Wrong Contra-indication
Wrong Dose
Wrong preparation
Wrong Route

Bless

Curse

Cardiac Arrest Drugs

Cardiac Arrest is the sudden, unexpected loss of


heart fungtion, breathing and unconsciousness

Epinephrine is First line cardiac arrest drug

Initial epinephrine dose for cardiac arrest is 1mg iv bolus

Epinephrine

at very low doses, at higher doses

Vasoconstriction

Inotropic +

Vasodilatation

Increases myocardial excitability


when the myocardium is hypoxic or ischaemic

If VF or pulseless VT persists after the first 3 shocks then

AMIODARONE 300mg is considered.

Amiodarone iv bolus dose of 300mg must be diluted in 5% dextrose to 20ml.


A supplementary dose of 150mg iv bolus can be given in 3 5 minutes.

Amiodarone

Class III agents significantly prolong the action potential duration (APD) by
blocking IKr , resulting in an increased Effective Refractory Period (ERP),
making ERP greater than the conduction time (CT) around a reentrant
circuit. This effect can prevent or abolish reentry.

Lidocaine Hydrochloride (Xylocaine)

Alternative to amiodarone in cardiac arrest


from ventricular tachycardia
Class IB agents inhibit the fast sodium
current reduce phase 0 upstroke velocity
and reduce refractoriness
shorten
conduction velocity abolish reentry
Are ineffective in treating atrial tachyarrhythmias
They have a negative inotropic effect and
peripheral vasodilator effect.

Lidocaine Hydrochloride (Xylocaine)


must be diluted in 5% dextrose to provide a
solution containing 1 mg/mL.
Cardiac arrest secondary to VF or pulseless VT:
11.5 mg/kg as initial loading dose, then 0.50.75
mg/kg as rapid IV injection
repeated at 5- to 10-minute intervals as
necessary, up to a total of 3 doses (or up to 3
mg/kg).
Maintenance infusion of 3050 mcg/kg per minute
(14 mg/minute in an average 70-kg adult)
Terminate infusion as soon as the basic cardiac
rhythm appears to be stable
Reduce dose by half if liver blood flow low (shock,
b-blockade, cirrhosis, cimetidine, severe heart
failure).

Magnesium Sulfate

Indication : Torsades de pointes


Hypomagnesaemia
Suppressing early afterdepolarization (EAD),
the triggering event for torsade, by decreasing
the influx of calcium, thus lowering the
amplitude of EADs.

Magnesium Sulfate
1-2g (2-4ml of 50% magnesium
sulphate) (diluted in 10 mL D5W)
slow IV over 1 - 2 minutes
can be repeated in 5-15 minutes.
maintenance: 1-2 g/hr IV for 12-24
hours
Adverse reactions
Drowsiness, CNS depression,
respiratory depression

Peri Arrest Period


the recognized period, either just before or
just after a full cardiac arrest, when the
patient's condition is very unstable and care
must be taken to prevent progression or
regression into a full cardiac arrest.
Sign and Symptom :
Hypotension, shock
Tachycardia, bradycardia
Shortness of breath, Acute pulmonary
edema

Peri Arrest Period

Hypotension / Shock

Fluid Challenge Test

Hypotension / Shock

Norepinephrine (Noradrenaline)
Potent alpha-agonist

Vasoconstriction

Inotropic +

Vasodilatation

Should be diluted in D5W or D5W/0.9%


NaCl.
Administration in saline solution alone
is not recommended.

Dopamine

Dopamine

Dopamine hydrochloride can be diluted with Sodium


Chloride (0.9%) Intravenous Infusion Dextrose (5%),
sodium chloride (0.45%) solution or Sodium Lactate
Intravenous Infusion.

Hypotension / Shock

Dobutamine

Increased myocardial contractility, stroke volume, and


increased cardiac output
Indications : Cardiogenic shock, CHF
can be diluted with 5% glucose solution, 0.9% sodium
chloride or 0.45% sodium chloride in 5% glucose solution.
If administered continuously for more than 72 hours,
tolerance may occur, requiring an increase in the dose.

Hypotension / Shock

Nitroglycerine

Venodilator at low doses, reduces CVP / PCWP (< 40mcg/min)

Arteriolar dilation at high doses (> 200 mcg/min).

Decrease coronary vasoconstriction by relaxing coronary arteries

Diluted in D5 or NS solution

initial infusion rate 10 mcg/min. May increase by 10 mcg/min


every 5 minutes until response.

AE- ICP, headache, caution in RV heart failure / STEMI

Peri Arrest Period

Peri Arrest Arrhythmias


Two main categories :
1. Arrhythmias that may lead to cardiac arrest
2. Arrhythmias that occur after initial resuscitation
from cardiac arrest
. Indicate that a patient is unstable and at risk of
deterioration
1. Shock - hypotension
2. Syncope - transient loss of consciousness
3. Heart failure pulmonary oedema
4. Myocardial ischaemia - typical ischaemic chest pain
5. Extremes of heart rate (e.g. > 150 min-1 or < 40
min-1)

Symptomatic Bradycardia

Sulfas Atropine
Anticholinergic drug
(parasympatholytic )
competitive antagonist
for the muscarinic
acetylcholine receptor
types M1-M5.
M2 found in the heart
( SA node & AV node )
It is usually not effective in second degree heart block mobitz type 2 and in
third-degree heart block with a low Purkinje or ventricular escape rhythm

Dopamine

Epinephrine

at very low doses, at higher doses

Vasoconstriction

Inotropic +

Vasodilatation

1mg epinephrine is mixed with 500ml of NS or D5W. The


infusion should run at 2-10 micrograms/min (titrated to effect)

Epinephrine, dopamine and sulfas atropine


should be used with caution in patients
suffering from myocardial infarction since
they increases heart rate and raises blood
pressure.
This increase in HR and BP can increase
myocardial oxygen demand and worsen
ischemia.

Supraventricular Tachyarrhthmia

Adenosine

slows conduction time through the A-V node,


can interrupt AV nodal reentry pathways
including that associated with accessory
bypass
tracts
(Wolff-Parkinson-White
Syndrome)
is not effective in converting rhythms other
than AVNRT.

Adenosine
Initial dose : 6 mg given as a rapid iv
bolus followed by rapid flush with 20
mL NS
if no conversion within 1-2 minutes
give 12 mg iv. Maximal total dose
30mg.
Don't administer through central line
(may cause asystole)
Don't dilute Adenocard.
should be avoided in patients with
bronchospasm (e.g., asthma).

Diltiazem
Blocks calcium channel
slow
atrioventricular
(AV)
nodal
conduction time and prolong AV nodal
refractoriness
interrupting the re-entry circuit in AV
nodal re-entrant tachycardias and
reciprocating tachycardias, e.g. WolffParkinson-White syndrome (WPW).
Decrease inward calcium current
decrease rate of phase 4 spontaneous
depolarization
slows the ventricular rate in patients
with a rapid ventricular response
during atrial fibrillation or atrial flutter
(AF/FL).

Diltiazem
Diluted in Normal Saline, D5W, or
D5W/0.45% NaCl.
The initial dose should be 0.25 mg/kg
body weight as a bolus administered
over 2 minutes.
If response is inadequate after 15
minutes , a second dose 0.35 mg/kg
body weight administered over two
minutes.
initial infusion rate of Diltiazem
Hydrochloride Injection is 5 - 15
mg/hr.

Digoxin
are potent inhibitors of cellular
Na+/K+-ATPase intracellular
sodium intracellular calcium
via the Na+-Ca++exchange
system calcium bind to
troponin-C contractility
increase vagal efferent activity to
the heart. negative chronotropy
and negative dromotropy.
increases the effective refractory
period within the atrioventricular
node.

Digoxin
diluted with a 4-fold or greater volume of Sterile
Water for Injection, 0.9% NS, or 5% Dextrose
Injection.
Initial dose : 500 mcg of digoxin intravenously.
Additional doses of 250 mcg may be given
cautiously at 6 to 8 hour intervals until clinical
evidence of an adequate effect is noted.
The injectable route is frequently used to achieve
rapid digitalization, with conversion to digoxin
tablets for maintenance therapy.
have a relatively narrow therapeutic safety
window.
side effects : anorexia, nausea, vomiting,
diarrhea,
AV

Ventricular Tachyarrhythmia
Amiodarone
150
mg
IV
(diluted in D5W) over 10 min,
repeat as needed. Followed by
360 mg over the next 6 hours (1
mg/min).
Maintenance infusion: 540 mg
over the remaining 18 hours
(0.5 mg/min).
Lidocaine is a second-line
choice: 1-1.5 mg/kg IV bolus
(diluted in D5W) followed by 14mg/min.
If
torsades
de
pointes
:

Peri Arrest Period

Acute Pulmonary Oedema


Oxygen / intubation as
needed
Nitroglycerine SL then
10-20mcg/min iv if SBP
100mmHg
Furosemide 0.5-1 mg/kg
IV over 1-2 minutes
Morphine iv 2-4mg
Captopril

Furosemide

inhibit reabsorption of NaCl and KCl by


inhibiting the Na+-K+-2Cl- symport in
the luminal membrane of the thick
ascending limb (TAL) of loop of Henle.
Resulting
in
increased
urine
production

Furosemide
Furosemide 0.5-1 mg/kg
IV over 1-2
minutes; may be increased to 80 mg if there
is no adequate response within 1 hour.
a
continuous
furosemide
infusion
is
generally to be preferred to repeated bolus
injections. A rate of 4 mg per minute must
not be exceeded.
In patients with severe impairment of renal
function
(s.creat>5mg/dl),
it
is
recommended that an infusion rate of 2.5
mg per minute is not exceeded.
The recommended maximum daily dose of
furosemide administration is 1,500 mg.

Morphine
Advantage :
Venodilator venous return ventricular
preload
Arteriodilator afterload
Sedative effect
Side effect :
Respiratory depression
severe hypotension
should not be used routinely in the treatment
of acute pulmonary oedema
Dose : IV 14 mg, repeated doses (up to every
5 minutes if necessary). Maximal dose 10 mg
Must be diluted in 5% dextrose

Take Home Message


Medics are required to know the names,
class, mechanism of action, adverse
reactions and side effects, interactions,
indications,
contraindications,
complications, routes of administration,
dose,
and
specific
administration
considerations for many emergency
medications and intravenous fluids.
it is critically important stay up to date
on the latest pharmacologic information.

First, Do No Harm
Physicians take an oath to care for their patients
to their full ability, to treat them with respect
and dignity, and treat them as whole persons

Thank You

You might also like