Atropine (parasympatholytic) 1mg atropine= 10ml bristojet Symptomatic bradycardia: 0.51.0mg I.V. push q.

3-5 min, not to exceed a total dose of 0.04mg/kg Asystole or PEA: 1mg I.V push q. 3-5min, not to exceed total dose of 0.04mg/kg Relative bradycardia- HR wnl but insufficient to meet demands Dont give less than 0.5mg per dose because the possible paradoxical effect may furtherslow heart rate Use cautiously in presence of MI If given via ET tube: dilute 1-2mg in 10ml sterile water or saline- follow with 10 ml flush of NSS Enhances SA node automaticity and AV conduction via direct vagolytic action. Epinephrine catecholamine (alpha & beta-adrenergic agonist) Mix: 2 mg in 250 ml NS or D5W Dose 1-4 mcg/kg/min Incompatable with Aminephylin Ampicillin Cephapiran Sodium Bicarb. (10ml of a 1:10,000 solution) or (1ml of a 1:1000 solution in multidose vial) VF,pulseless VT,PEA, or asystole

Standard dosing: 1mg I.V. push q. 3-5min Intermediate dosing: 2-5mg I.V.push over 3-5min Escalating dosing: 1mg,3mg,5mg I.V. push 3 min apart High dosing: 0.1mg/kg I.V. push q 3-5min Symptomatic bradycardia: continuous infusion @ 2-10 mcg/min; titrate to hemodynamic response (not used as a first-line drug) MIX 1mg(1ml of a 1:1000 solution) in 500ml NSS or D5W * Each dose given peripherally should be followed by 20ml fluid flush to ensure delivery to central circulation * If no IV access available, give 2- 2.5 times the dose via ET tube; follow with 10ml flush of NSS Intracardiac administrationsed only when no other route available * Increases SVR, BP, cardiac electrical activity, coronary and cerebral blood flow, strength of myocardial contraction, automaticity and myocardial oxygen requirements. Digoxin Lanoxin Dose 1-2 mg Toxic level 2.4 mg. Can'tt dialize out. Causes ST depression. Shortened QT interval T Wave flat or inverted. Digoxin atrial fib/flutter; CHF. Slows heart rate, increases force of contraction and refractory period of AV node Monitor for nausea, visual disturbances, atrial or junctional tachycardias, PVCs, heart blocks; K+

Dilatizem Cardizem 1. Mix 125 mg in 100 ml D5W. Diltiazem (Calcium channel blockers-direct negative chronotropic & negative inotropic effect) Acute and preventive treatment of PSVTs, and slowing ventricular response in atrial flutter and fibrillation Diltiazem: 0.25mg/kg (20mg for avg patient) IV over 2 min; may repeat 0.35mg/kg in 15 min; then infusion of 5-15mg/hr titrated to HR * Reduce oxygen demand; decreased SVR caused by vasodilatation of vascular smooth muscle (coronary vasodilation) Lidocaine 1. Mix 2gms in 500mg D5W. 2. Give 1-4mg per minute Iinitially, 1-1.5mg/kg I.V. push; repeat q. 3-5min to max of 3mg/kg 1mg per minute is 15ml per hour. 2mg per minute is 30ml per hour. 3mg per minute is 45ml per hour. (Antiarrhythmic) 100mg = 10ml bristojet 1GM/250 D5W= Premix drip VF or pulseless VT refractory to electrical countershocks and epinephrine. Stable VT or stable wide-complex tachycardia of uncertain origin: repeat doses of half the original dose If lidocaine successfully converts the VF/VT; begin a continuous infusion @ 24mg/min (1mg=15cc on pump) * Use 2-2.5 times the IV dose when given via ET tube; followed by 10 ml saline flush * If toxic symptoms develop (slurred speech, altered LOC, muscle twitching and seizures), stop the drug or reduce the dose * Do NOT give this drug if PVCs occur with bradycardia or escape rhythm. * No longer recommended for VF/VT prophylaxis in acute MI

* Suppresses ventricular arrhythmias and elevates the fibrillation threshold (less likely to occur) Procainamide 1. Used when Lidocaine is ineffective. (suppresses ventricular ectopy and slows intraventricular conduction) 2. Persistent cardiac arrest due to VF. 3. PVCs or recurrent VT Mix 2 Gms in 500 ml NS or LR. 1 mg/min=15ml/hr 2 mg/min=30ml/hr 3 mg/min=45ml/hr Bolus 20-50 mg/min - Dosing: 20-30mg/min until: 1) arrhythmia suppressed 2) hypotension occurs 3) PR or QRS widens by 50% of its original width or MAX dose of 17mg/kg has been given - if effective, start drip @ 1-4mg/min * Monitor BP closely during administration; may cause precipitous hypotension; infuse cautiously in acute MI * Contraindicated in patients with preexisting long QT intervals or torsades de points. * Hypokalemia and hypomagnesemia may exacerbate arrhythmias Procainamide Give bolus slowly with patient in supine position. Bolus 100 mg every 5 minutes at a rate of 20-30mg per minute until: -Arrhythmia is suppressed. -Hypotension develops. -QRS is widened by 50%. -17mg/kg Gm has been given. Maintenance infusion - 1-4mg per minute. Mix 2 Gm in 500ml D5W at 15-60cc/Hr. May be given orally 1 Gm initially, followed by 250-500mg every 3-4 hours. Countraindications: a. Complete, second, or third degree heart block. b. CHF,BBB, hepatic or renal impairment. c. Myasthenia gravis. Uses:

a. Treatment of ventricular arrhythmias, especially when lidocaine has been unsuccessful. b. May be used to treat atrial arrhythmias. Actions: a. Decreases excitability and slows conduction. b. Depresses automaticity. Propranolol (Inderal) Beta Blocker. For arrhythmias. Dose: 1-3 mg not to exceed 1 mg/minute every 5 minutes. Total dose should not exceed 0.1mg/Kg Give slowly. Lasix (diuretic) Mix 200 mg in 200 ml D5W NS RL 1Mg psr ml Incompatable with Dobutamine 0.25-0.75 mg per kg per min Pulmonary Edema - 20-40 mg IVP Monitor K+, dehydration and hypotension; electrolytes Magnesium Sulphate (MSO4) Mix in D5W NS 1gm in 50 ml - Give over 1 hour 2gm in 50 ml - Give over 2 hour 3gm in 50 ml - Give over 3 hour (physiological calcium channel blocker and blocks neuromuscular transmission) 5Gm/10ml bristojet Torsades de points: Drug of Choice: up to 5- 10 gms have been used Acute MI with hypomagnesemia:

intermittent or continuous infusion 0.5- 1.0 gm/hr VF/VT with hypomagnesemia: 1-2Gms diluted in 10 ml D5W given IVP over 1-2 min Monitor for flushing, sweating, bradycardia and hypotension; also if toxicity may see depressed reflexes, flaccid paralysis, circulatory collapse, respiratory paralysis and diarrhea Magnesium Mg 1.5-2.4 Action: Acts as coenzyme in metabolism of CHO and proteins, Regulates neuromuscular excitability and phosphate level, acts as a cofactor in ATP maintenance. Regulated by kidney function and parathyroid hormone. Daily requirement 250 mg. has higher concentration in cerebrospinal fluid than in serum. 35% is bound to protein. Stored in bone, muscle and soft tissue. Calcium Ca 1. Mix 500mg/100ml D5W or NS. 2. Give over 30 minutes. Calcium Chloride (increases myocardial contractile function-positive inotropic effect modulated by effect on SVR + or -) 10ml bristojet = 1Gm (1ml= 100mg) 0 Hyperkalemia, hypocalcemia, after multiple transfusions or Calcium channel blocker toxicity: 8-16mg/kg of 10% solution; repeat if necessary -May cause slowing of HR - May precipitate digitalis toxicity -Precipitates with Na Bicarb Normal Lab values: 8.8-10.5 Action: Serves as framework for bones and teeth. Essential for blood clotting, for normal functioning of the central nervous system and for muscle contraction and neuromuscular stability. Stabilizes cell membranes. Regulated by Parathyroid hormone, thyrocalcitonin, vitamin D, kidney

function. Daily requirement 800 mg Major concentration is in the bone. 50% of serum Ca++ is bound to protein. Normal gastric acidity is necessary for absorption in the gut. Dopamine catecholamine-vasoconstrictor (dopaminergic, beta and alpha receptors) Rember to fill the tank. Mix 200 or 400 mg in 500 mg of D5W. Premix= 400mg/250cc D5W Hemodynamically significant hypotension: low dose1-2 mcg/kg/min=cerebral, mesenteric and renal vasodilation; UOP increase; HR & BP unchanged mid dose- 2-10 mcg/kg/min= increased cardiac output high dose- >10mcg/kg/min= increased SVR, PVR, preload secondary to renal, mesenteric, peripheral arterial and venous vasoconstriction toxic dose- >20mcg/kg/min ischemic changes Symptomatic bradycardia- add norepinephrine if > 20mcg/kg/min required If infiltrates use regitine phentolamine. Give multiple 1ml iniections SQ in a circle around area of infiltration. Ehould be given via central line. * Use lowest dose that produces desired effect * Avoid in hypovolemia, high SVR, pulmonary congestion or increased preload

* Avoid Na Bicarb line * Avoid extravasation * MAO inhibitors potentiate effects Levophed (Norepinephrine) Mix 2mg in 250 ml D5W ONLY Dose: 2-12 mcg per minute Titrate to keep SBP 90-120 Action: Decreased blood flow to all organs except heart and brain. (catecholamine- potent alpha (arterial and venous vasoconstriction) with minimal beta (increase contractility) effect MIX 8mg/250cc D5W or NSS (32mcg/ml) Refractory SHOCK Hemodynamically significant hypotension refractory to other sympathomimetics (septic and neurogenic shock) - Start with 0.5-1.0 mcg/min and titrate to effect * Increase BP by increasing SVR and thereby diminishing cardiac output (increases myocardia oxygen demand, causes myocardial ischemia) * Needs A-line for monitoring BP * Also monitor CO, PCWP, PA pressures * Contraindicated in hypovolemia Extravasation leads to necrosis- phentolamine infiltration minimizes sloughing Dobutamine Dobutrex Dose - 1-10 mcg/kg/hr Mix 500mg in 250 ml D5W Max 40 mcg catecholamine- sympathomimetic-inotropic vasoactive- alpha and beta effects

Stimulates cardic beta recgptors. Incompatable with Acyclovir Alkalyne Solutions Altapase Aminophylline Lasix Dont mix with bicarb solutions. 1mg/kg/min = 1cc if 6Xwt in Kg/100cc D5W Pulmonary congestion ; low cardiac output; hypotension; septic shock - 2-20 mcg/kg/min -Avoid alkaline solutions (Bicarb) -Monitor for tachycardia, hypertension and ventricular ectopy -Side effects include headache, nausea, tremor and hypokalemia Nipride (Sodium Nitroprusside) 1. Mix 50 mg in 250 ml in D5W 2. Dose- 0.5-10 mcg/kg/min Breaks down into Cynide. Cynide levels should be checked every 24 hours. Antidote for Cynide is Sodium Thiosulfate. Mix 12.5 gm in 50 ml Give every 24-48 hours. Early confusion Monitor blood pressure via art. line. (vasodilator) 50mg/250 D5W or NSS Severe Hypertension; 0.5- 8.0mcg/kg/min * Monitor for hypotension * Toxicity includes tinnitus, visual blurring, altered mental status, nausea, abdominal pain, hyperreflexia, and seizures.

Nitroglycerin (TNG)

Mix 50 mg in 500 ml D5W. Mix in glass bottles only. Special tubing. Start at 5 mcg/min then titrate up every 3-9 minutes. (vasodilator) 50mg/250 D5W Angina Pectoris; dosing titration to effect Monitor for headache, hypotension, syncope, faintness. Vasopressin Mix 100 units in 250 ml D5W Run with Have TNG hooked up and ready to counteract it. 0.2-0.4 units/min 0.1u/min=15 ml/hr 0.2u/min=30ml/hr 0.3u/min=45ml/hr 0.4u/min=60ml/hr Ativan Lorazapam 1. Mix 50 mg in 100 ml. 2. If giving IV dilute with sodium chloride in a syrange first it is very thick.