Cardiovascular Drugs in Advanced

Cardiac Life Support

A Member of the
The Asian Representative of
ACLS Guidelines
during cardiac arrest
drug intervention is
secondary only
to other interventions
Central Line
Subclavian vein
Internal jugular vein
Needs interruption
Higher peak concentration
central circulation time
Complications
Peripheral Line
Antecubital vein
External jugular vein
No interruption
Lower peak concentration
central circulation time
Complications

Intravenous Access
Peripheral IV site
Administer drugs by Bolus

20 cc of saline or distilled water

Elevate the extremity for 10 to 20 seconds
NAVEL (Naloxone, Atropine,
Vasopressin, Epinephrine, Lidocaine)
Administer 2 to 2.5 times the
recommended IV dose diluted in 10 ml
NSS or distilled water
Tracheal Drug Administration
ACLS Drugs
Agents used to Optimize
Cardiac Output and Blood
Pressure


Agents used to treat
Arrhythmias
Tachycardia Bradycardia
Cardiac Arrest Shock
Heart failure/
Pulmonary
edema
Misc; buffers
3 Dimensions of the Cardiovascular System
Peripheral vascular tone
Inotropic state of the heart
Chronotropic state of the heart

Clinically used in:
Acute ischemic heart disease
Acute and chronic heart failure
Shock
Cardiac arrest
Agents used to Optimize Cardiac Output and
Blood Pressure
Epinephrine
MOA - Increases SVR, BP, HR, Contractility, automaticity
- Increases blood flow to heart & brain, AV conduction velocity
- Alpha-adrenergic effects can increase coronary & cerebral
perfusion pressure during CPR
- Beta-adrenergic effects may increase myocardial work &
reduce subendocardial perfusion
No evidence to show that it improves survival
Dose: 1 mg IV bolus every 3-5 mins
Medications for Cardiac Arrest
Vasopressin
MOA - Non-adrenergic peripheral vasoconstrictor that causes
coronary & renal vasoconstriction
- Increases blood flow to heart & brain
Indications:
1. Alternative to epinephrine for treatment of adult shock-
refractory VF/pulseless VT, PEA and asystole
2. Hemodynamic support in vasodilatory shock
Dose: - 40U IV single dose to replace one dose of epinephrine
(for cardiac arrest)
- 0.02 0.04 U/min (for vasodilatory shock)
Medications for Cardiac Arrest
Norepinephrine
MOA - Naturally occurring potent vasoconstrictor and inotropic
agent
- Usually induces renal and splanchnic vasoconstriction
Indications:
1. Severe hypotension (SBP < 70mmHg)
2. Low total peripheral resistance
Dose: - 0.1 0.5 mcg/kg/min infusion
Note: Not used for cardiac arrest
Do not administer is same IV line as Na Bicarb
Agents used for shock
Dopamine
MOA - Catecholamine, alpha and beta-adrenergic receptor
agonist and peripheral dopamine receptor agonist
Indications:
1. Hypotension (SBP 70-100mmHg)
2. Symptomatic significant bradycardia
3. After ROSC (Return of Spontaneous Circulation)
Dose: - 2 20 mcg/kg/min infusion, titrate to patient response
Note: Do not administer is same IV line as Na Bicarb
Agents used for shock
Dobutamine:
MOA - synthetic sympathomimetic amine with positive
inotropic action and minimal positive chronotropic
activity at low doses (2.5 ug/kg per min), but
moderate chronotropic activity at higher doses
Indication:
Severe systolic heart failure (SBP 70-100mmHg)
Dose : 2-20 ug/kg/min
Note: vasodilating activity precludes its use when a
vasoconstrictor effect is required
Do not administer in same IV line as Na Bicarbonate
Agents used for Shock

Little data indicates that therapy with buffers improves outcome
1. Does not improve ability to defibrillate or improve survival rates in
animals
2. Can compromise coronary perfusion pressure
3. May cause adverse effects due to extracellular alkalosis,
including shifting the oxyhemoglobin saturation curve
4. May induce hyperosmolality and hypernatremia
5. Produce carbon dioxide
6. May inactivate simultaneously administered catecholamine
Agents used for Shock
Buffers: Sodium Bicarbonate
MOA : Reverses acidosis caused by global
hypoperfusion
Indications:
Hyperkalemia
Tricyclic or phenobarbital overdose
Patients with pre-existing metabolic acidosis
?After a protracted arrest or long resuscitative efforts
Dose: 1 mEq/kg
Agents used for Shock/Arrest
Buffers: Sodium Bicarbonate
Diuretics: Furosemide

MOA : Potent diuretic
- Direct venodilating effect in patients with acute pulmonary
edema
- Transient vasoconstrictor effect when heart failure is chronic
- Onset of vascular effect is within 5 minutes
Dose: 0.5 1 mg/kg IV injected slowly
Agents used for Heart Failure/Pulmonary
Edema
Question
Drug of first choice for SVT is:
A. Atropine
B. Adenosine
C. Lidocaine
D. Amiodarone
Antiarrhythmic Drugs for tachycardia
Adenosine
MOA : Depresses AV node & sinus node activity
Half-life is < 5 seconds (degraded in the blood & periphery)
Indications: Should be used if SVT is suspected

*Note : 2010 CPR Guideline
Recommended in the initial diagnosis & treatment of stable,
undifferentiated regular, monomorphic wide-complex tachycardia

Dose: 6 mg rapid IV push in 2-3 seconds, followed by 20ml saline flush.
If no response may give 2
nd
dose: 12 mg after 1-2 minutes.
May give a 3
rd
dose: 12 mg if still no response
Calcium Channel Blockers

MOA : Slow conduction & increase refractoriness
in the AV node
- May also control ventricular response rate in
patients with AF, Flutter, or MAT
- Systemic vasodilation
- Negative Inotropic effect
Antiarrhythmic Drugs for Tachycardia
Calcium Channel Blockers

Verapamil

Indication:
- Effective in stable narrow complex PSVT
- Alternative drug after Adenosine
- Should not be given in patients with impaired ventricular function
or heart failure
- Should not be given if hypotensive

Dose: 2.5 5 mg IV given in 2 minutes.
Administered every 15 30 mins to a max of 20 mg
Antiarrhythmic Drugs for Tachycardia
B-Adrenergic Blockers
Indications:
- Class I in acute coronary syndromes
- to convert to sinus or to slow ventricular response or both (AF/ flutter,
MFAT, re-entry SVT)
- Second line after adenosine
- *Labetalol recommended for emergency anti-hypertensive therapy for
hemorrhagic and acute ischemic stroke
Contraindication
-Hemodynamic instability
- 2
o
and 3
o
AV block
- Asthma
- Cocaine-induced ACS
Antiarrhythmic Drugs for tachycardia
Antiarrhythmic Drugs for tachycardia
B-Adrenergic Blockers

Labetalol Dose: 10 mg IV push (1-2mins), maybe repeated or
doubled every 10 mins; max dose 150mg

OR same initial bolus then infusion at 2-8mg/min

Esmolol Dose: 0.5 mg/ kg loading dose
50 mcg/ kg per minute maintenance infusion
2
nd
bolus of 0.5 mg/ kg infused in 1minute
repeated every 4 minutes for a total maximum
of 300 mcg/ kg per minute
Amiodarone
Class III anti-arrhythmic
MOA - Affects Na, K and Ca channels as well as alpha and beta
adrenergic blocking properties
- Prolongs action potential duration, refractory period,
decreases AV node conduction and sinus node function
Indications:
1. After defibrillation and epinephrine in cardiac arrest with
persistent pulseless VT or VF, stable/unstable VT
2. Ventricular rate control of rapid atrial arrhythmias in severely
impaired LV function
3. Adjunct to electrical cardioversion in refractory PSVTs, atrial
tachycardia & pharmacologic cardioversion of AF
Anti-arrhythmic Drugs for Tachycardia
Amiodarone
Side effects are hypotension and bradycardia

Dose:
1. VT with pulse 150mg IV over 10mins followed by
1mg/kg/min infusion for 6 hours,
then 0.5mg/kg/min
2. Pulseless VT/VF 300mg IV push
then 150mg IV - 2
nd
dose if needed
after another cycle of CPR

Anti-arrhythmic Drugs for Tachycardia
Lidocaine
Indications:
- VF/ pulseless VT that persist after defibrillation and
administration of epinephrine
- Control of hemodynamically compromising PVCs
- Hemodynamically stable VT
Alternative if Amiodarone unavailable
Dose: Initial bolus of 1 1.5 mg/ kg IV. Additional bolus of
0.5 to 0.75mg/ kg can be given over 3 5 minutes for
refractory VT/ VF.


Antiarrhythmic Drugs for Tachycardia
Anti-Arrhythmic for VF
Amiodarone administration to patients with refractory
VF and pulseless VT in the out of hospital setting
improved survival to hospital admission
ARREST trial
randomized double-blinded study
patients with ventricular fibrillation
(VF) or pulseless VT refractory to
defibrillation received either
amiodarone (300 mg IV bolus) or
placebo
Survival to hospital admission better
in amiodarone arm (44%) versus
placebo (34 %)
Kudenchuk, PJ, Cobb, LA, Copass, MK, et al. N Engl J Med 1999; 341:871
ALIVE trial
randomized double-blinded study
patients with VF or VT refractory to
defibrillation, CPR, and vasopressor
treatment received either amiodarone (5
mg/kg) and placebo lidocaine (n = 180)
or lidocaine (1.5 mg/kg) and placebo
amiodarone (n = 167)
Survival to hospital admission was better
with amiodarone (22.8 %) compared to
lidocaine (12 %)

Dorian, P, Cass, D, Schwartz, B, et al. N Engl J Med 2002; 346:884

Lidocaine
Delicate toxic-to-therapeutic balance
Routine use in AMI is not recommended
No proven short-term or long-term efficacy in cardiac
arrest
CNS Toxicity: muscle twitching, slurred speech, resp.
arrest, altered consciousness, seizures

Antiarrhythmic Drugs for Tachycardia
Antiarrhythmic Drugs
Magnesium
Effectively terminates torsades de pointes
Not effective in irregular/ polymorphic VT in patients with
normal QT
Not recommended in cardiac arrest except when arrhythmias
are suspected to be caused by magnesium deficiency
Dose: 1 2 gm (8-16meqs) mixed in 50 100 ml D5W given over 5 to
60 mins. Followed by 0.5 to 1gm IV infusion
1 to 2 gm diluted in 100 ml D5W administered over 1 2 mins in
emergency situations
Atropine
MOA : Parasympatholytic action:
- accelerates rate of sinus node discharge
- improves AV conduction
- Reverses cholinergic-mediated decreases in heart rate,
systemic vascular resistance, & blood pressure
Indication : Symptomatic sinus bradycardia (Class I)
- AV block Nodal level
- use with caution in AMI

Antiarrhythmic Drugs for Bradycardia
Atropine
Should not be relied fully in Mobitz type II block
Dose: 0.5 mg every 3 5 mins
A total dose of 3 mg (0.04 mg/kg) results in full
vagal blockade in humans
*Note: 2010 CPR guideline changes
1. Asystole & PEA indications have been deleted
2. If atropine is not effective, may give epinephrine infusion for
symptomatic bradycardia as an alternative to pacing

Epinephrine Dose : 2-10 mcg/min (1mg in 500cc of D5 W or normal
saline by continuous infusion)
- titrate to patients response
Antiarrhythmic Drugs for Bradycardia
Epinephrine
MOA - Increases SVR, BP, HR, Contractility, automaticity
- Increases blood flow to heart & brain, AV conduction velocity
- Alpha-adrenergic effects can increase coronary & cerebral
perfusion pressure during CPR

Dose: 2-10 mcg/min (1mg in 500cc of D5 W or normal saline by
continuous infusion)
- titrate to patients response
*Note: 2010 CPR guideline changes
If atropine is not effective, may give epinephrine infusion for
symptomatic bradycardia as an alternative to pacing
Antiarrhythmic Drugs for Bradycardia
Isoproterenol
MOA : Pure B-adrenergic agonist with potent inotropic and
chronotropic effects
Limited evidence
Indications: Temporizing measure for torsades de
pointes before pacing & in significant bradycardia
when atropine and dobutamine has failed and
pacing is not available
- Not indicated in patients with cardiac arrest or
hypotension
Dose: 2 10 mcg/ min titrated according to the heart rate
and rhythm response
Antiarrhythmic Drugs for Bradycardia
Miscellaneous Drugs
Digoxin
MOA: enhances central and peripheral vagal tone, slows SA node
discharge rate, shortens atrial refractoriness, and prolongs AV
nodal refractoriness through ANS effect
Indication: supraventricular arrhythmias (AF/flutter)
Peak effect - after 1.5 - 3 hours
Less effective than adenosine, verapamil, or beta blockers.
Dose : Acute loading dose 0.5 to 1.0 mg IV or PO
0.004 to 0.006mg/kg initially over 5 min.
Then 0.002 to 0.003mg/kg at 4-8hr interval.
Total of 0.008 to 0.012mg/kg divided to 8 to 16hrs

Nitroglycerine
Decreases chest pain in ACS
Indication : ACS, CHF, Hypertensive urgency w/ ACS
MOA
Increases venous dilation
Decreases preload & O2 consumption
Dilates Coronary Arteries
Increases Collateral flow in MI
Tolerance may develop



Miscellaneous Drugs

Nitroglycerine
IV bolus 12.5 to 25 mcg (if no SL or spray given)
Infusion 10mcg/min titrate to effect
Increase by 10 mcg /min every 3-5min until desired effect
Max dose 200mcg/min
Sublingual Tablet (0.3-0.4mg) 1 tab every 5min
Spray 1-2 sprays for 0.51sec every 5min
Max of 3 doses



Miscellaneous Drugs
ANTIARRHYTHMICS IN PREGNANCY
No antiarrhythmic drug is completely safe during
pregnancy, but most are well tolerated and can be given
with relatively low risk.
Close monitoring of serum concentration and patient
response
Drug therapy should be avoided during the first trimester
of pregnancy if possible
Drugs with the longest record of safety should be used as
first-line therapy

Anti-Arrhythmics in Pregnancy
Lidocaine generally well tolerated
Flecainide has been shown to be very effective in treating fetal supraventricular
tachycardia
Beta-Blockers are generally well tolerated and can be used with relative safety in
pregnancy
recent data - may cause intrauterine growth retardation if they are administered
during the first trimester
Amiodarone reported to cause congenital abnormalities
avoided during the first trimester and used only to treat life-threatening
arrhythmias that fail to respond to other therapies
Adenosine is generally safe to use in pregnancy
drug of choice for acute termination of maternal SVT
Digoxin has a long track record of treating both maternal and fetal arrhythmias,
and is one of the safest antiarrhythmics to use during pregnancy.

The PHA Council on Cardiopulmonary Resuscitation
BILL
Epinephrine 1mg (41.75) x 5 = 208.70
Atropine 0.5 mg (20.75) x 6 = 124.50
Amiodarone 150 mg (378) x 2 = 756
Dopamine drip 400mg = 940
Levophed drip = 1,620
IVF Plain NSS 1 L = 111.75
Intubation set = 440
ET tube = 505
O2 tank = 2,000
O2 regulator = 135
Use of defibrillator 705 + 360 = 1,065
IV insertion = 195
IV cannula = 110
Suction tube = 330
Tegaderm = 60
ECG leads x 5 = 200
TOTAL = PhP 8,800.90