EPINEPHRINE by yurtgc548

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									CARDIOVASCULAR PHARMACOLOGY

        Prof.Alsaeed
    Objectives

Pharmacology 1
Pharmacology 2
     PHARMACOLOGY 1
  DRUGS AFFECTING:
• CO
• HR
• PVR
        PHARMACOLOGY 1
1. VASOPRESSORS USED TO TREATE
   CARDIAC ARREST
    •   ADRENERGIC VASOPRESSOR
           EPINEPHERINE
    •   NON- ADRENERGIC VASOPRESSOR
        VASOPRESSIN
2. INOTROPIC AND VASOPRESSOR AGENTS
   USED TO SUPPORT CIRCULATION
    •   ADRENERGIC AGONISTS
    •   NON- ADRENERGIC AGONISTS
        (VASOPRESSIN)
3-INODILATORS
 PHOSPHODIESTRASE INHIBITORS
  –   INAMRINONE
  –   MILRINONE
 CARDIAC GLYCOSIDES
  –   DIGOXIN
4-VASODILATORS & β BLOCKERS
 VASODILATORS
  –   NITROGLYCERINE
  –   SODIUM NITROPRUSSIDE
 β BLOCKERS
  –   PROPRANOLOL
  –   METOPRELOL
  –   ATENOLOL
  –   ESMOLOL
  –   LABETALOL
     PHARMACOLOGY 2
• AGENTS FOR CONTROL OF
  Rate&Rhythm
                               ADRENERGIC RECEPTORS
                                                                               DOPAMINERG
RECEPTORS           α1                β1             β2             β2
                                                                                   IC
 RECEPTOR
                 ARTERIES           HEART         ARTERIES       BRONCHI         KIDNEY
 LOCATION

                                      ↑HR                                        DILATION
RESPONSE TO
              CONSTRICTION      ↑CONTRACTIONS     DILATION       DILATION        OF RENAL
 RECEPTORS
                                ↑AV CONDUCTION                                 VASCULATURE



               Epinephrine       Epinephrine     Epinephrine    Epinephrine



              Norepinephrine    Norepinephrine



                                 Isoproternol    Isoproternol   Isoproternol



                                 Dobutamine


                                  Dopamine
                Dopamine                                                       Dopamine
                                 At moderate
               At high dose                                                    At low dose
                  EPINEPHRINE

Mechanism of Action

• Systemic vascular resistance
• Systemic arterial pressure
• Heart rate
• Contractile state
• Myocardial oxygen requirement
• Improved cerebral and myocardial blood flow from
  vasoconstriction and increased perfusion pressure
                  EPINEPHRINE

Indications

   Cardiac Arrest

         • Ventricular fibrillation
         • Asystole
         • EMD (consider noncardiac
              causes)
              EPINEPHRINE

Indications
• Symptomatic bradycardia after other
  measures(atropine,dopamine ,transcutaneouse
  pacing) have failed (Class IIb)
• Sever hypotension
• Anaphylaxis
                             EPINEPHRINE

Dosage
• In cardiac arrest
1 mg (10 mL 1:10,000 solution)
IV push every 3 to 5 minutes.
If this fails, higher doses of epinephrine (up to 0.2 mg/kg) are acceptable but not
    recommended (there is growing evidence that it may be harmful).

Precautions
• Be aware of increased MVO2
    can precipitate myocardial ischemia
• Avoid mixing with alkaline solutions
• Can induce myocardial ectopy
                    VASOPRESSIN

Mechanism of action
    Is a non-adrenergic peripheral vasoconstrictor by
    directly stimulating smooth muscle V1 receptors
    without increase of myocardial oxygen consumption
    because it has no B-adrenergic activity
Indications
• Alternative pressor to epinephrine for the treatment of
    shock-Refractory VF in adults
•   A systole or pulseless electrical activity
•   Refractory cardiac arrest after treatment with
    epinephrine
•   Septic shock and sepsis syndrome
                       VASOPRESSIN
Dose
 Shock-Refractory VF/pulseless VT
      40 U IV, single dose, 1 time only
As a Class Indeterminate action, it is acceptable to resume epinephrine
1 mg IV push every 3 to 5 minutes if there was no response in 5 to 10
  minutes to a single IV dose of vasopressin.

Precautions
• Skin pallor
• Nausea
• Intestinal cramps
• Bronchial constriction
• Uterine contractions in women
               NOREPINEPHRINE

Indications (temporarily only)
•   Cardiogenic shock
•   Absence of peripheral vasoconstriction with
    hypotension

Dosage
•   16µg/mL, bitartrate IV in 5% dextrose in water
Initial Infusion
•   0.5-2µg/min titrate (2-12µg/min)
               NOREPINEPHRINE

Precautions
•   Hypovolemia
•   Arrhythmias
•   Extravasation
•   Excessive elevations of BP
          Monitor BP, ECG and venous site
                      DOPAMINE

Mechanisms of Action
•    Precursor of epinephrine
•    Alpha- and beta- receptor stimulator
•    Dopaminergic receptor stimulator
    – Low dose
       Dilates renal and mesenteric vessels
       Venoconstricts
       Arterial resistance may vary
    – High dose
       Alpha effects dominate
       Arterial and venous constriction including
       renal and mesenteric vessels
‫للمقارنة‬
                     DOPAMINE

Indications
•   Cardiogenic shock
•   Hemodynamically significant hypotension
•   Congestive heart failure – with other agents

Dosage
•   Intravenous only
•   Initial infusion rate: 2µg/kg/min
•   Increase infusion rate according to BP, urine flow
    response, and clinical response
•   Adjust infusion rate as needed
                    DOPAMINE
Precautions

•   Excessive vasoconstriction
•   Fall in BP
•   Arrhythmias
•   Nausea and vomiting
•   Extravasation
•   Monoamine oxidase inhibitors
•   Pheochromocytoma
                  DOBUTAMINE

Mechanisms of Action
•   Direct beta-adrenergic stimulator
•   Potent inotropic effect but less chronotropic
•   Renal and mesenteric flow follows cardiac output
•   Myocardial work is balanced by increases in coronary
    flow at clinical doses

Indications
•   Congestive heart failure
•   Cardiogenic shock
•   Hemodynamically significant hypotension
                  DOBUTAMINE

Dosage
•   Initial infusion rate: 0.5µg/kg/min IV
•   Usual infusion rate 2.5-20.0 µg/kg/min IV
•   Titrated to not increase heart rate > 10%

Precautions
•   Tachycardia
•   Arrhythmias
•   Caution in coronary artery disease
                 ISOPROTERENOL

Mechanisms of Action
•    Pure beta-adrenergic stimulator (beta-1 and beta-2)
    – Potent inotropic effect
    – Potent chronotropic effect
•    Increases cardiac output
•    Increases myocardial oxygen consumption
•    Vasodilation – diastolic and mean BP may fall but
     systolic pressure maintained or increased due to
     increased cardiac output
                ISOPROTERENOL

Indications
•   Hemodynamically significant atropine-refractory
    bradycardia
•   Pacemaker better – as soon as possible
•   Contraindicated during cardiac arrest

Dosage
•   2-10 µg/min
•   Titrate to increase heart rate to 60/min
               ISOPROTERENOL

Precautions
•   Excessive tachycardia
•   Arrhythmias
•   Increased myocardial oxygen consumption
•   Exacerbate digitalis intoxication
•   Hypokalemia
                     AMRINONE

Mechanisms of Action
•   Potent inotropic effect
•   Independent of adrenergic effects

Indications
•   Severe refractory heart failure
•   Septic shock

Dosage
•   Loading 0.75 mg/kg over 2-3 min
•   Titrate to effect (2-20µg/kg/min
                   AMRINONE

Precautions
•   May induce or worsen ischemia
•   Thrombocytopenia
•   Allergic (sulphonamides)
                  NITROPRUSSIDE

Mechanisms of Action
•   Arterial vasodilation
•   Venous vasodilation
•   Enhanced systolic emptying
•   Increased cardiac output
•   Decreased LVEDP and pulmonary congestion
•   Decreased myocardial oxygen consumption

Indications
•   Hypertensive crisis
•   Congestive heart failure
                NITROPRUSSIDE

Dosage
•   Heart failure dose: 0.5µg/kg/min and titrate
•   Average dose: 0.5-8.0 µg/kg/min
•   Higher doses may be required for hypertension




      IV should be wrapped with aluminum foil
               NITROPRUSSIDE

Precautions - Hemodynamic Monitoring Essential

•   Imbalance between coronary supply and demand
•   Possible coronary “steal”
•   Right-to-left shunting
•   Thiocyanate toxicity
•   Cyanide intoxication
•   Hypotension
•   Apprehension, restlessness
•   Chest and abdominal pains
•   Palpitations
•   Dizziness
•   Muscle twitching
                  NITROGLYCERIN

Mechanisms of Action
•    Increased supply theory
    – Coronary artery vasodilation
    – Collateral blood flow
    – Decreases spasm
•    Decreased work theory
    – Venodilation decreases venous return
    – Decreased ventricular volume-less work
    – Arterial dilation if filling pressure is high
•    Smooth muscle relaxation
                NITROGLYCERIN

Indications
•    Sublingual
    – Angina pectoris
    – Myocardial infarction
•    Intravenous
    – Unstable angina pectoris
    – Acute myocardial infarction
    – Congestive heart failure
                 NITROGLYCERIN

Dosage
•    Sublingual
    – 0.3 or 0.4 mg sublingual may be repeated twice at
       3-5 minute intervals
•    Intravenous
    – Continuous infusions starting at 10-20 µg/min and
       increase by 5-10 µg/min every 5-10
       minutes until desired response is obtained or bolus
       of 50 µg followed by an infusion
              NITROGLYCERIN

Precautions
•   Headache
•   Hypotension
•   Syncope
•   Methemoglobinemia
•   Hypoxemia
•   Bradycardia
     BETA BLOCKERS-PROPRANOLOL
            & METOPROLOL

Mechanisms of Action
•   Beta-adrenergic receptor blockade
•   Competitive with adrenergic stimulants
•   Action depends on level of adrenergic influence
•   Antiarrhythmia effect (quinidine effect)

Indications
•   Recurrent VT/VF
•   Refractory PSVT
•   Post infarction protection
     BETA BLOCKERS-PROPRANOLOL
            & METOPROLOL

Dosage
- Propranolol
•   1.0-3.0 mg slow IV dose every 5 min
•   Do not exceed 0.1 mg/kg every 5 min

- Metoprolol
•   5 mg IV every 5 min to 15 mg
    BETA BLOCKERS-PROPRANOLOL &
            METOPROLOL

Precautions
•   Cardiac failure
•   Bradycardias or AV block
•   Asthma or bronchospastic disease
PHARMACOLOGY 2

 Anti-arrhythmic drugs
                  PROCAINAMIDE

Mechanisms of Action
• Suppresses ventricular ectopy
• Elevates VF threshold
Indications
• Usually used when lidocaine has not controlled
  ventricular arrhythmias
• Ventricular premature complexes
• Recurrent ventricular tachycardia
                PROCAINAMIDE

Dosage

• 100 mg over 5 min (20 mg/min) until one of the
  following
  –Arrhythmia suppressed
  –Hypotension
  –QRS complex widened by 50% of original width
  –Total of 1 gm administered
                 PROCAINAMIDE

Infusion Dosage
• 1-4 mg/min
• Reduce in presence of renal failure
• Monitor blood levels in renal failure and with infusions
  > 3 mg/min or > 24 hr

Precautions
• Monitor systemic pressure for hypotension
• Observe ECG for increased PR and QT intervals, QRS
  widening and heart block
                    LIDOCAINE

Mechanisms of Action
• Suppresses ventricular ectopy
• Elevates VF threshold
Indications
• Shock-Refractory VF/pulseless VT
• Ventricular premature complexes especially in
  ischemia/infarction
• Ventricular tachycardia
• Prophylactic administration
                    LIDOCAINE
Dosage: VF/VT
• 1-1.5 mg/kg IV push followed by 0.5-0.75mg/kg every
  5-10 min as needed          3 mg/kg
• Use infusion of 2-4 mg/min after termination of
  arrhythmia
Dosage: PVC’s
• 1 mg/kg followed by 0.5 mg/kg every 2-5 min as
  needed to 3 mg/kg
• Infusion Rate
   –2 mg/min after 1 mg/kg
   –3 mg/min after 2 mg/kg
   –4 mg/min after 3 mg/kg
                    LIDOCAINE

Dosage: Prophylaxis of VF
• 1.5 mg/kg followed by 0.5 mg/kg at 8-10 min intervals
  to a total of 2 mg/kg unless persistent ectopy
• Infusion at 2-4 mg/min
                     LIDOCAINE

Precautions


• Clinical indication of toxicity usually CNS-related
   –Muscle twitching
   –Slurred speech
   –Altered consciousness
   –Decreased hearing
   –Seizures
                   LIDOCAINE

Reduced Dosage
• Decreased cardiac output (cardiogenic shock, CHF)
• Hepatic dysfunction
• Elderly patients (> 70 yr)




In all of these, use one-half recommended bolus
               and observe response
                   Adenosine
•   Not in Vaughan Williams class
•   Purine nucleotide (activates adenosine receptors)
•   Slows AV nodal conduction
•   Acute Rx
•   Termination of SVT/ diagnosis of VT
•   Given IV only (rapid bolus)
•   T1/2 < 2seconds
    Adenosine- adverse effects
• Feeling of impending doom!
• Flushing, dyspnoea, chest pain, transient
  arrhythmias
• Contraindicated in asthma, heart block
                Verapamil
• Class IV (calcium channel blocker)
• Prolongs conduction and refractoriness in AV
  node, slows rate of conduction of SA node
• Acute Rx /prophylaxis
• Used IV/oral
• SUPRAVENTRICULAR NOT VENTRICULAR
  ARRHYTHMIAS (cardiovascular collapse)
• Do not use IV verapamil with ß- blocker (heart
  block)
• T1/2 6-8 hours
      Verapamil- adverse effects
•   Heart failure
•   Constipation
•   Bradycardia
•   Nausea
                  Digoxin
• Not in Vaughan Williams class
• Cardiac glycoside (digitalis, foxglove)
• Act on Na/K-ATPase of cell membrane (inhibits
  Na+/K+ pump, increases intracellular Na+ and
  calcium)/ increases vagal activity
• Increase cardiac contraction and slows AV
  conduction by increasing AV node refractory
  period
                       Digoxin
•   Atrial fibrillation or flutter (controls ventricular rate)
•   Acute Rx/prophylaxis
•   Oral/IV
•   Loading and maintenance doses
•   T1/2 36 hours
•   Excreted by kidneys
•   Narrow therapeutic index
•   Therapeutic drug monitoring
•   Reduce dose in elderly/renal impairment
     Digoxin – adverse effects
• Arrhythmias, heart block, anorexia, nausea,
  diarrhoea, xanthopsia, gynaecomastia,
  confusion, agitation
• AE potentiated by hypokalaemia and
  hypomagnesaemia
• Overdose –Digibind (digoxin binding
  antibody fragments), phenytoin for
  ventricular arrhythmias, pacing, atropine
AMIODARONE
                    AMIODARONE

Mechanism of action and properties

• Is a complex agent with multiple effects on Na,K,and
  Ca channels

• It prolong the refractory period and thus the QT
  interval on ECG

• Posses both alpha and beta adrenergic blocking
  properties
                     AMIDARONE


• It is iodine-containing and has a very long half-life (26-
  127 days).

• Protein binding can displace digoxin or warfarin, so
  increasing their actions.

• Given intravenously, the anti-arrhythmic action occurs
  within a few hours; given orally this may take 1-3
  weeks.

• Amiodarone is the least negatively inotropic anti-
  arrhythmic with the exception of digoxin.
                    AMIDARONE


Indications

• Shock-Refractory VF/ pulseless VT
• AF and Atrial flutter
• Stable narrow-complex tachycardia
• Stable monomorphic VT
                    AMIODARONE
Dose of administration
Cardiac arrest
• 300 mg IV push (diluted in 20 to 30 ml D5W)
• If VF/ pulseless VT recurs consider administration of
    150 mg IV infusion in 3-5 minutes
•   An infusion of 1 mg/min for 6 hours can be given and
    then 0.5 mg/min (maximum cumulative dose of 2.2 g
    IV per 24 hours
Stable tachycardias, AF, and Atrial flutter
• Rapid infusion of 150 mg IV followed by 1mg/min for 6
    hours and then 0.5mg/min for 18 hours
•   The initial dose my be repeated after 10 minutes
                               IV Amiodarone Dosing*
                          IV push       Rapid infusion 15 mg/min         1 mg/min       0.5 mg/min


                                                                     Max: 2.1g / 24 h
           1,200

           1,000                                  540 mg/18h
Total mg Dose




                800
                                                                                           720 mg/24h
                600
                                                  360 mg/6h
                400

                200          300 mg

                                                 150 mg/10min            150 mg
                  0
                       Cardiac Arrest        Perfusing Rhythm        Recurrences         Maintenance
                      * Amiodarone I.V. should, whenever possible, be administered through a CVL,
                        and an in-line filter should be used during administration.
                  AMIODARONE

Side effects
• Hypotension and bradycardia
• Reversible corneal micro-deposits
• Metallic taste
• Alveolitis
• Slate grey discoloration of skin
• Arrhythmias (torsades)
• Hypothyroidism
• Ataxia
• Peripheral neuropathy
• Hepatitis
• Photosensitivity
• Hyperthyroidism
                     MAGNESIUM

Mechanism of action
     Magnesium is essential for the proper function
     of myocardial cells


Indications
• Stable polymorphic VT with prolonged QT interval
    suggestive of torsades de pointes
•   Persistent or recurrent VF/pulseless VT associated with
    a known hypomagnesemic stats
•   Life-threatening ventricular arrhythmias caused by
    digitalis toxicity
                  MAGNESIUM

Dose
Persistent VF/pulseless VT
  1-2 g(2-4 ml of 50% solution) diluted in 10 ml of D5W
  IV push over 1 to 2 minutes
Polymorphic VT (torsades de pointes)
  Initial dose of 1-2 g diluted in 50-100 ml of
  D5W over 5 to 60 minutes IV and a maintenance
  dose of 0.5-1 g /h IV

Precautions
•Hypotension
•Use magnesium with caution if renal failure is present
       AHA Recommendations
• Class I - definitely helpful,
          - excellent Level I evidence

• Class IIa - acceptable, probably helpful
            - good supportive evidence

• Class IIb - acceptable, possibly helpful
            - fair supportive evidence

• Class III - not indicated, may be harmful

• Class Indeterminate - not recommended
                      - insufficient data
                      Tachyarrhythmic Agents
Drug/Recommeded Use (Class)             Amiodarone   -Blocker   Ca-Blocker   Lidocaine   Magnesium Procainamide

VF/Pulseless VT                           IIb                                  IND          IND         IIb

Wide-complex tachycardia                  IIb                                                           IIb

Stable VT                                 IIb                                   IIb                     IIa

PSVT (preserved cardiac function)         IIa           I           I                                   IIa

PSVT (impaired cardiac function)          IIb

Atrial fibrillation/flutter               IIa           I           I                                   IIa
(preserved cardiac function)

Atrial fibrillation/flutter               IIb                      IIb
(impaired cardiac function)

Atrial fibrillation/flutter (WPW)          IIb         III          III                                 IIb

Atrial fibrillation/flutter (impaired     IIb
cardiac function plus WPW)
                      Tachyarrhythmic Agents
Drug/Recommeded Use (Class)             Amiodarone   -Blocker   Ca-Blocker   Lidocaine   Magnesium Procainamide

VF/Pulseless VT                           IIb                                  IND          IND         IIb

Wide-complex tachycardia                  IIb                                                           IIb

Stable VT                                 IIb                                   IIb                     IIa

PSVT (preserved cardiac function)         IIa           I           I                                   IIa

PSVT (impaired cardiac function)          IIb

Atrial fibrillation/flutter               IIa           I           I                                   IIa
(preserved cardiac function)

Atrial fibrillation/flutter               IIb                      IIb
(impaired cardiac function)

Atrial fibrillation/flutter (WPW)          IIb         III          III                                 IIb

Atrial fibrillation/flutter (impaired     IIb
cardiac function plus WPW)
                      Tachyarrhythmic Agents
Drug/Recommeded Use (Class)             Amiodarone   -Blocker   Ca-Blocker   Lidocaine   Magnesium Procainamide

VF/Pulseless VT                           IIb                                  IND          IND         IIb

Wide-complex tachycardia                  IIb                                                           IIb

Stable VT                                 IIb                                   IIb                     IIa

PSVT (preserved cardiac function)         IIa           I           I                                   IIa

PSVT (impaired cardiac function)          IIb

Atrial fibrillation/flutter               IIa           I           I                                   IIa
(preserved cardiac function)

Atrial fibrillation/flutter               IIb                      IIb
(impaired cardiac function)

Atrial fibrillation/flutter (WPW)          IIb         III          III                                 IIb

Atrial fibrillation/flutter (impaired     IIb
cardiac function plus WPW)
                      Tachyarrhythmic Agents
Drug/Recommeded Use (Class)             Amiodarone   -Blocker   Ca-Blocker   Lidocaine   Magnesium Procainamide

VF/Pulseless VT                           IIb                                  IND          IND         IIb

Wide-complex tachycardia                  IIb                                                           IIb

Stable VT                                 IIb                                   IIb                     IIa

PSVT (preserved cardiac function)         IIa           I           I                                   IIa

PSVT (impaired cardiac function)          IIb

Atrial fibrillation/flutter               IIa           I           I                                   IIa
(preserved cardiac function)

Atrial fibrillation/flutter               IIb                      IIb
(impaired cardiac function)

Atrial fibrillation/flutter (WPW)          IIb         III          III                                 IIb

Atrial fibrillation/flutter (impaired     IIb
cardiac function plus WPW)
                      Tachyarrhythmic Agents
Drug/Recommeded Use (Class)             Amiodarone   -Blocker   Ca-Blocker   Lidocaine   Magnesium Procainamide

VF/Pulseless VT                           IIb                                  IND          IND         IIb

Wide-complex tachycardia                  IIb                                                           IIb

Stable VT                                 IIb                                   IIb                     IIa

PSVT (preserved cardiac function)         IIa           I           I                                   IIa

PSVT (impaired cardiac function)          IIb

Atrial fibrillation/flutter               IIa           I           I                                   IIa
(preserved cardiac function)

Atrial fibrillation/flutter               IIb                      IIb
(impaired cardiac function)

Atrial fibrillation/flutter (WPW)          IIb         III          III                                 IIb

Atrial fibrillation/flutter (impaired     IIb
cardiac function plus WPW)
                      Tachyarrhythmic Agents
Drug/Recommeded Use (Class)             Amiodarone   -Blocker   Ca-Blocker   Lidocaine   Magnesium Procainamide

VF/Pulseless VT                           IIb                                  IND          IND         IIb

Wide-complex tachycardia                  IIb                                                           IIb

Stable VT                                 IIb                                   IIb                     IIa

PSVT (preserved cardiac function)         IIa           I           I                                   IIa

PSVT (impaired cardiac function)          IIb

Atrial fibrillation/flutter               IIa           I           I                                   IIa
(preserved cardiac function)

Atrial fibrillation/flutter               IIb                      IIb
(impaired cardiac function)

Atrial fibrillation/flutter (WPW)          IIb         III          III                                 IIb

Atrial fibrillation/flutter (impaired     IIb
cardiac function plus WPW)
           SODIUM BICARBONATE

Mechanisms of Action
   Reacts with H+ ions, as in metabolic acidosis
     HCO3- + H+  H2CO3  CO2 + H2O

Indications
• Consider in cardiac arrest only after more   definitive
  treatment
• Metabolic acidosis
Dosage
• 1 mEq /kg initially, then no more than one-half this
  dose at 10 min intervals
           SODIUM BICARBONATE

Precautions
• Worsened mixed-venous (and intracellular) acidosis
  from CO2 formation and retention
• Hyperosmolality and hypernatremia
• Metabolic alkalosis
• Acute hypokalemia
             SODIUM BICARBONATE

Conclusions
• Clinically serious side effects,   especially CO2
  formation
• No definite evidence of benefit in arrest
• No basis for routine use
• Consider only after known beneficial therapy
• May be helpful in documented preexisting metabolic
  acidosis
                    MORPHINE

Mechanisms of Action

• CNS: Analgesic
• Hemodynamic
   –Increased venous capacitance
   –Decreased systemic vascular resistance
   –Reduced myocardial oxygen needs
Indications
• Acute myocardial infarction
• Acute pulmonary edema
                    MORPHINE

Dosage
• Small (2-5 mg) intravenous increments titrated to
  desired analgesic or hemodynamic effect

Precautions
• Depression of ventilation
• Systemic hypotension, especially in
   –Volume-depleted patients
  –Patients with increased systemic resistance
              CALCIUM CHLORIDE

Mechanisms of Action
• Increases cardiac contractile state
Indications
• Acute hyperkalemia
• Hypocalcaemia
• Calcium channel blocker adverse effects
• No indication in cardiac arrest if any of above
  conditions present
              CALCIUM CHLORIDE

Dosage
• 2-4 mg/kg of 10% solution IV and repeated as needed
  at 10 min intervals

Precautions
• Bradycardia with rapid injection
• Caution in digitalized patients
• Precipitates as carbonate salt in bicarbonate solution
                  FUROSEMIDE

Indications
•   Acute pulmonary edema

Dosage
•   40 mg slowly IV

Precautions
•   Dehydration
•   Hypovolemia
•   Hypotension
•   Hyperosmolality
•   Hypokalemia
                     ATROPINE

Mechanisms of Action
         Parasympatholytic (vagolytic) action
• Accelerates rate of sinus node discharge
• Improves atrioventricular conduction
• May restore cardiac rhythm in a systole
                 ATROPINE
Indications
• Bradycardia (sinus or AV nodal block) with
  hypotension or ventricular ectopy
• Ventricular a systole
  Dosage
• 0.5 mg IV every 5 min as needed in bradycardia
• For a systole use 1.0 mg IV and repeat in 5 min if
  needed
• Total maximum dose 3 mg (0.04 mg/kg)
• For endotracheal injection 1.0-2.0 mg diluted in 10
  mL water
                      ATROPINE

Precautions

• Increased myocardial oxygen demand: worsened
  ischemia
• Ventricular tachycardia or fibrillation
                         OXYGEN

Impairment of Oxygenation During Cardiac Arrest

•   Expired air: 16% to 17% oxygen
•   Low cardiac output
•   Intrapulmonary right-to-left shunt

•   Ventilation/perfusion mismatching

Effects of Oxygen Administration
•   Elevate Oxygen tension
•   Increase oxygen content
•   Improve tissue oxygenation
                 OXYGEN
Indications

• Acute chest pain
• Suspected hypoxemia of any cause
• Cardiopulmonary arrest
Precautions
• Toxicity
• Obstructive lung diseases
Thank U

								
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