RESUSCITATION

PHARMACOLOGY

RESUSCITATION PHARMACOLOGY

Correct hypoxia
Establish spontaneous circulation at
an adequate blood pressure
Promote optimal cardiac function
Prevent or suppress arrhythmias
Relieve pain
Correct acidosis
Treat congestive heart failure

IMPORTANT DRUGS FOR ACLS

Oxygen
BP
Epinephrine/adrenaline
Vasopressin
Dopamine

Supraventricular arrhythmia
Adenosine
Diltiazem
Amiodarone

AMI
Morphine
Nitroglycerine
Aspirin
Fibrinolytics

Misc
Sodium bicarbonate
Calcium chloride

HR
Atropine
Ventricular arrhythmia
Amiodarone
Lidocaine / lignocaine
Procainamide
Magnesium sulphate

SCHEME FOR STUDY

Mechanism of action (why ?)
Indication (when ?)
Dosage (how ?)
correct dose for the
correct indication through the
correct route
Precautions (watch out !)

OXYGEN
Mechanism of action
O2 tension
hemoglobin saturation
tissue oxygenation
Indication
All patients in ACLS

OXYGEN
Dosage
Spontaneous breathing
1 6 L/min via nasal cannula
4 L/min for AMI
6 10 L/min via non-breathing face mask
Cardiac arrest
15 L/min using bag mask
Precaution
?? COAD

Epinephrine / Adrenaline
Mechanism of Action
& adrenergic stimulation
SVR, SBP, DBP
coronary and cerebral blood flow
electrical & strength of myocardium
myocardial O2 requirement
automaticity

Epinephrine / Adrenaline
Indication
All patient in cardiac arrest
Severe hypotension
Symptomatic bradycardia
Anaphylaxis

Epinephrine / Adrenaline
Dosage
Cardiac arrest
1 mg (10ml 1:10000) IV push Q3-5 min
Flush with NS + arm elevation for 10-20s
2 2.5x IV dose through ETT
Non-Cardiac arrest
2 - 20 g/min
Precautions
Precipitate in alkaline solutions

Vasopressin
Mechanism of action
Potent vasoconstrictor
SVR, SBP, DBP
coronary and cerebral blood flow
Indication
Alternative to 1st and 2nd dose of epinephrine
for VF/ pulseless VT

Vasopressin
Dosage
40 U IV push 1x
Precautions
May provoke cardiac ischemia

Dopamine
Mechanism of action
Stimulation of dopaminergic, &
adrenergic receptor
Indication
Hypotension (70 100mmHg)
Second drug for hypotensive bradycardia

Dopamine
Dosage
5 - 20 g/kg/min
Titrate to response
Precautions
Taper gradually
Start after volume replacement
Do not mix with sodium bicarbonate
Monitor IV site

Atropine
Mechanism of action
Block parasympathetic receptor of heart
SA node automaticity
AV node conduction
Not to stimulate the heart
Indication
Symptomatic sinus bradycardia
While waiting for pacing (dont delay)
Organophosphate poisoning

Atropine
Dosage
Bradycardia
0.5mg IV/IO Q3 5min
Max. 3mg
Extremely large dose may be need for
organophosphate poisoning

Atropine
Precautions
Paradoxical bradycardia with < 0.5mg
Worsen myocardial ischaemia
Avoid in hypothermic bradycardia
Not useful in AV block of
2nd degree Type II
3rd degree

Anti-arrhythmics
Pro-arrhythmics
Negative inotrope ( force)
(+) for Ca channel blocker, -blocker,
procainamide, lignocaine
(+) for amiodarone
(-) for digoxin

Anti-arrhythmics
Slow the heart (-ve chronotrope)
AV node vs. accessory pathway
AV node only
Adenosine, digoxin
AV node > accessory pathway
Ca channel blocker, -blocker
Lidocaine
AV node = accessory pathway
Amiodarone, procainamide

Amiodarone
Mechanism of action
Block Na, K and Ca channels
& blocking properties
Indication
VT/VF cardiac arrest refractory to shock +
epinephrine
Recurrent life-threatening VT
Other arrhythmias (need expert)

Amiodarone
Dosage
Cardiac Arrest
300mg IV push (in 20-30ml D5)
+ 150mg IV push in 3-5 min 1x
Ventricular Tachyarrhythmias
150mg IV over 10min
Maintenance
1mg/min IV for 6 hours then
0.5mg/min IV for 18 hours
Max dose 2.2g/day

Amiodarone
Precautions
Multiple drug interaction
Long half-life (up to 40 days)
Hypotension with rapid/repeated dose
Prolong QT interval

Lidocaine / lignocaine
Mechanism of Action
Block Na channel
ventricular ectopy
excitability in ischemic tissue
Indication
Alternative to amiodarone in cardiac
arrest from VT/VF
Stable VT with good LV

Lidocaine / Lignocaine
Dosage
Loading
1-1.5mg/kg IV push (arrest)
0.5-0.75mg/kg IV push (stable VT)
+ 0.5-0.75mg/kg IV Q3 - 5min
Up to 3mg/kg
ETT: 2-4mg/kg 1x
Maintenance
1-4mg/min IV

Lidocaine / Lignocaine
Precautions
Not recommended as prophylaxis in MI
Reduce dose
Impaired liver function
Poor LV
Stop infusion if signs of toxicity occurs

Procainamide
Mechanism of Action
Block Na channel
ventricular ectopy
conduction
Indication
Suppression of recurrent VF/VT
Other tachy-arrhythmias

Procainamide
Dosage
Recurrent VF/VT
20mg/min (up to 50mg/min) infusion until
o Arrhythmias suppression
o Hypotension
o QRS widen by 50%
o 17mg/kg given (60mins for 70kg patient)
Maintenance
o 1 4mg/min

Procainamide
Precautions
Hypotension
Reduce to 12mg/kg max in patient with
heart / renal failure
Prolong QT interval
Pro-arrhythmic, esp. in AMI, K, Mg

Magnesium Sulphate
Drug of choice for Torsades de Pointes
Dosage
1-2g IV over 5-20min
Then infusion 0.5 1g/hr
Titrate to control torsades

Adenosine / ATP
MECHANISM OF ACTION
SA node and AV node
Short half-life < 5s
INDICATION
Termination of PSVT
Diagnostic maneuver for stable narrow
complex SVT

Adenosine / ATP
DOSAGE
6mg adenosine / 10mg ATP, follow by 20ml
NS
12mg adenosine / 20mg ATP in 1-2min if no
response
PRECAUTIONS
Flushing, dyspnoea, chest pain

Diltiazem
MECHANISM OF ACTION
Ca channel blocker
automaticity
conduction
INDICATION
Rate control for AF
Terminate stable re-entry SVT if
adenosine fails

Diltiazem
DOSAGE
15-20mg IV over 2 min
Repeat in 15 min at 20-25mg IV PRN
Then 5-15mg/hr
Titrate to effect
PRECAUTIONS
Not to be used in
Wide complex tachycardia of uncertain origin
Drug induced tachycardia
WPW syndrome with AF

DRUGS for AMI

MONA greets all MI patients
M = Morphine
O = Oxygen
N = Nitrate
A = Aspirin

Morphine
MECHANISM OF ACTION
Relieve pain
myocardial oxygen demand
INDICATION
Chest pain no responding to nitrate
Pulmonary edema

Morphine
DOSAGE
2-4mg IV Q5-30min
Titrate to effect
PRECAUTIONS
Hypotension
CNS / respiratory depression

Nitroglycerin
MECHANISM OF ACTION
Vasodilation
preload, afterload
Coronary artery vasodilation
INDICATION
Ischemic chest pain
Ongoing or recurrent ischaemia in MI
Pulmonary edema, hypertensive urgency

Nitroglycerin
DOSAGE
SL : 0.5mg Q 5min
IV : start with 10-20 g/min
PRECAUTIONS
Phosphodiesterase inhibitor for
erectile dysfunction
Hypotension
Headache

Aspirin
MECHANISM OF ACTION
Inhibit platelet action
INDICATION
All patient with ACS
DOSAGE
162-325mg PO (300mg)
Chewing
PRECAUTIONS
Peptic ulcer, asthma

Fibrinolytics
MECHANISM OF ACTION
Reperfusion of myocardium
INDICATION
ST elevation MI or new LBBB
<12hr from onset
CHOICE
Streptokinase
Alteplase
PRECAUTIONS
Screen for contraindications

Calcium Chloride
INDICATION
Hyper K
Hypo Ca
Ca channel blocker / -blocker
overdose
DOSAGE
5-10ml 10% CaCI2

Sodium Bicarbonate
INDICATION
Hyper K
Bicarbonate responsive acidosis (DKA)
Tricyclic antidepressant overdose
DOSAGE
1mmol/kg IV bolus
Monitor ABG
PRECAUTIONS
Not routine for cardiac arrest

THANK YOU