Adenosine class; indication.

; Contraindication

Anti-dysrhythmic SVT, including bypass tract disease. 2nd or 3rd degree AV block SSS, sensitivity, Afib or flutter.

Amiodarone Class III Antidysrhythmic Indicated for  Initial rx and prophylaxis of VF & unstable VT refractory to other therapy Contraindicated  Pulmonary congestion  Cardiogenic shock  hypotension Practice Points  May potentiate hemodynamic status when given with beta blocker and CaCl channel blockers  May increase risk of AV block when given with CaCl blockers  May increase effects of wafarin  Incompatible with lasix, heparin & bicar (y site) Aspirin Analgesic, anti-inflammatory, antiplatelet Indications  AMI CI  Only systemic sensitivity in the context of MI Atropine Sulfate Anticholinergic Indications  Symptomatic bradycardia  Asystole  PEA  ACE inhibitor OD  Exercise induced bronchospastic disorders CI  Tachycardia  Obstructive disease of GI tract  Unstable cardiovascular status in the context of cardiac ischemia & hemorrhage  Narrow angle glaucoma Practice Points  Dilates the pupils  Follow ETT with several PPV s  Effects are enhanced by; Thiazides, antidepressants, ant psychotics Antihistamines, Procainamide, quinidine  Adverse reactions with concurrent admin. Dig, cholinergics, neostigmine Calcium Chloride Electrolyte Indications  Hyperkalemia (except dig toxic)  Hypocalcaemia  CaCl blocker toxicity  Hypermagnesmia  To prevent hypotensive effects of CaCl blockers Contraindications  VF during cardiac resuscitation  Dig toxic

 Hyperkalemia  Renal or cardiac disease Practice Points.

    

May produce vasospasm in coronary/cerebral arteries Hypotension/bradycardia may result from rapid administration May antagonize the perp. Dilatory effects Ca channel blockers Severe tissue necrosis following IM use or extravasculation Must flush IV line if Bicarb was given- precipitation will occur

Diltiazem (Cardizem) Slow ca channel blocker or Ca channel antagonist. Indications  A Fib/flutter  Multifocal atrial tachycardia s  PSVT Contraindications  SSS  2nd or 3rd degree HB (unless pacer present)  Hypotension (SBP 90)  Cardiogenic shock  AF/flutter associated with WPW or short PR syndrome  Concomitant use of IV beta blockers  VT  Wide complex tachy of unknown origin  AMI Practice Points  Caution in pts who take agents that affect contractility or conduction  Incompatible with simultaneous lasix  Use with caution in renal/hepatic failure  Hypotension may occur  PVC s may be present on conversion of PSVT Dobutamine (Dobutrex) Sympathomimetic Indications  Inotropic support for patients with LV dysfunction Contraindications  AF/flutter  Severe hypotension  IHSS Practice Peals  Need accurate admin method (pump)  Closely monitor BP

   

Increase of HR of 10% may increase cardiac ischemia Lidocaine should be readily available Correct hypovolemia prior to use Incompatible with lasix & bicarb in the same line

Dopamine (Intropin) Sympathomimetic Indications  Hemodynamically significant hypotension in the absence of hypovolemia Contraindications  Tachydysrhythmias  VF  pheochromocytoma Practice Points  Avoid extravasculation  Use infusion pump  Monitor closely for signs of compromised circulation  Correct hypovolemia prior to use  Don t give concomitantly with lasix or bicarb Practice Points  MAO inhibitors may deactivate  Seizures may result if given with phenytoin, hypotension, bradycardia Flumazenil (Romazicon) Benzodiazepine antagonist Indications  Reversal of BZD Contraindications  TCA OD  Cocaine or other stimulant intoxication Practice Points  To avoid pain at site give through large vein IV  Be prepared to manage seizures in BZD addicted pts  Monitor for resedation effects  Be prepared to manage resp efforts Furosemide (Lasix) Loop Diuretic Indications  PE associated with CHF, hepatic or renal disease Contraindications  Anuria  Hypovolemia/dehydration Contraindications  Electrolyte depletion Practice Points  Known to cause fetal abnormalities  Protect from light  May potentiate dig toxicity (K depletion)  May potentiate lithium toxicity (Na deple)  May potentiate therapeutic effects of other antihypertensives Isoproterenol (Isuprel) Sympathomimetic Indications  Hemodynamically significant bradycardia refractive to other therapy  TDP Contraindications  VF/VT

 Hypotension (relative)  Pulse less idioventricular rhythm  Ischemia heart disease (relative)  Cardiac arrest Practice Points  Increases myocardial oxygen demand  Infusion pump  Last ditch- pace first  Beta adrenergic antagonists my blunt the inotropic response Labetol (Normodyne) Alpha-beta adrenergic blocker Indications  Hypertensive emergencies Contraindications  Bronchial asthma (relative)  Uncompensated CHF  2nd & 3rd AV block Contraindications  Bradycardia  Cardiogenic shock  Pulmonary edema Practice Points  VS should be constantly monitored  Observe for signs of CHF, bradycardia, bronchospasm  Keep the patient in the supine position  NTG may augment hypotensive effects Lidocaine (Xylocaine) Antidysrhythmic (Class 1-B) Indications  VT/VF  Wide complex tachycardia of uncertain origin  Significant ventricular ectopy in the setting of MI Contraindications  Adams-Stokes Syndrome  2nd or 3rd degree HB in the absence of a pacemaker Practice Points  75-100 mg bolus will maintain level for 20 mins  If bradycardia is present treat PVC s with Atropine  Avoid for use in reperfusion dysrhythmia  Use with caution in Hepatic disease/heart failure Marked hypoxia Respiratory depression Hypovolemia/shock Complete HB, AF Norepinephrine (Levophed) Sympathomimetic Indications  Cardiogenic shock  Neurogenic shock  Inotropic support  Hemodynamically significant hypotension refractory to other sympaths Contraindications  Hypotensive pts with hypovolemia Practice Points

    

May cause fetal anoxia Infuse through a large stable vein to avoid necrosis MAO inhibitors potentiate the effects Can be deactivated by alkaline sols May exacerbate dysrhythmia response

Propranolol (Inderal) Beta adrenergic blocker Indications  Hypertension  Angina  VF/VT and SVT refractory to other therapy Contraindications  Sinus bradycardia  2nd or 3rd degree AV block  Asthma  Cardiogenic shock  Pulmonary edema  Uncompensated CHF  COPD (relative) Practice Points  Catacholamine depleting drugs my potentiate hypotension  Verapamil may worsen AV conduction abnormalities  Sux effects may be enhanced  Effects are reversed by Isuprel, norepi, dopamine, dobutamine  Epi may cause a rise in BP decrease in HR and severe vasoconstriction  May produce life-threatening side effects-closely monitor patients  Use with caution in elderly  Use with caution in patients with impaired hepatic or renal function.  Atropine should be readily available

Sodium Bicarbonate Buffer, alkalinizing agent, electrolyte Indications  Known bicarbonate responsive acidosis  On return of ROSC following long arrest  Intubated pt with long arrest interval  PEA/DKA  TCA OD  Metabolic acidosis Contraindications  Chloride loss from vomiting & GI  Met or resp alkalosis  Severe pulmonary edema  Abdominal pain of unknown origin  Hypo; Calcemia, kalemia, natremia Practice Pearl  When possible ABG s should be the guide  Produces CO2 which may worsen cellular acidosis  May worsen CHF  Must maintain adequate ventilation  Cant be administered concomitantly with Calcium May deactivate vasopressors  Must maintain adequate ventilation

 Cant be administered concomitantly with  Calcium  May deactivate vasopressors Verapamil (Calan) Calcium channel blocker Indications  PSVT  A flutter with rapid response  A fib with rapid response  Vasospastic and unstable angina  Chronic stable angina Contraindications  SSS (without pacemaker)  2nd & 3rd degree AV block  Hypotension/Cardiogenic shock  Wide complex tachycardia  Severe CHF  WPW with A Fib/flutter  IV beta blockers Practice Points  Closely monitor VS  Give smaller doses over longer time when treating elderly  AV block or Asystole may occur due to slowed conduction  Increases serum dig  Antihypertensives may potentiate hypotensive effects. Albuterol (Proventil) Sympathomimetic that is selective for beta 2 it also relaxes the smooth muscle of the brachial tree and peripheral vasculature Indications  Relief of bronchospasm  Prevention of exercise induced bronchospasm Contraindications  dysrhythmia's associated with tachycardia Practice Points  Other sympathomimetics may exacerbate adverse cardiovascular effects.  Beta Blockers may antagonize albuterol.  May potentiate diuretic-induced hypokalemia.  May precipitate angina and dysrhymias  Should be used with caution in; diabetes, hyperthyroidism, seizure or cardiac disorder. Dextrose 50% Dextrose is the 6 carbon sugar that is the principal carbohydrate used by the body. Indications  Hypoglycemia  ALOC  Coma/seizure of unknown etiology Contraindications  Intracranial hemorrhage  Known or suspected CVA in absence of hypogly.  Increased intracranial pressure Practice Points  Draw a blood sample prior to infusion if possible.  Extravasculation may cause necrosis. Aspirate often.  May precipitate Wernicke s encephalopathy

 Wernicke s encephalopathy (severe neurological symptoms) may result in thiamine deficiency (alcoholics).  Administer Thiamine prior to D50 in; Alcoholics Frail Elderly malnourished Diazepam (Valium) Benzodiazepine Indications  Acute anxiety states/alcohol withdrawal  Skeletal muscle relaxation  Seizure activity  Premedication prior to cardioversion Contraindications  in coma (unless there is seizure activity)  CNS depression as a result of head injury  respiratory depression  Shock Practice Points  Its use as an anti-convulsant may be short lived due to rapid redistribution by the CNS.  Reduce dose by 50% in elderly patients.  May cause local venous irritation  May precipitate CNS depression & psychomotor impairment  Precipitates with almost everything Epinephrine (Adrenalin) Sympathomimetic Indications  Bronchial asthma  Acute allergic reaction  Cardiac arrest  Profound symptomatic bradycardia Contraindications  Hypovolemia shock- correct volume deficit  Use with caution in coronary insufficiency Practice Points  Don t use prefilled units to mix drips]  Increases oxygen demand  MAO inhibitors potentiate the effect  Exacerbate the dysrhythmia's response  May be deactivated by alkaline sols.  Complications of IV epic are significant Uncontrolled hypertension Vomiting seizures dysrhythmia's  IV Epi should only be used in severe cases GlucagonPancreatic Hormone, insulin antagonist Indications  Persistent hypoglycemia despite glucose Contraindications  Only hypersensitivity Practice Points  Not a first choice for hypoglycemia  Do not use dilutent to mix drips  IV glucose must be given if there is not response to second dose  May potentiate anticoagulants

 Glycogen must be available in the liver Thiamine (Betaxin) Vitamin B1 Indications  Coma of unknown origin (with D50)  DT s  Beriberi  Wernicke s encephalopathy Contraindications  None Practice Points  Used to metabolize glucose  Certain conditions predispose for defic. Alcoholism/malnourishment  Give before D50 Procainamide (Pronestyl) Practice Points  Potent vasodilating and inotropic effects  Rapid injection may cause hypotension  Use caution  Asthma, dig induced dysrhymias;s,, AMI  Hepatic or renal insufficiency  Increases effects of skeletal muscle relaxants Nitroglycerin (Nitrostat) Vasodilator Indications  Ischemia chest pain  Pulmonary hypertension  CHF  Hypertensive emergencies Contraindications  Hypotension  Head injury  Cerebral hemorrhage Practice Points  Caution with Viagra (intractable hypotension)  Elderly are susceptible to hypotension  very volatile  PVC tubing will absorb  Other dilators may have additive effects Naloxone (Narcan) Opiod antagonist Indications  Narcotic OD  Morphine, heroin, hydromophone  Methadone, meperidine, paregoric  Fentanyl, oxycodone, codeine  Propoxyphene  Coma unknown origin Contraindications Use with caution in addicted pts may precipitate violent withdrawal issuesPractice Points  May not reverse hypotension  Seizures are possible  Incompatible with bisulfate & alkaline sols

 May cause hypertension, tachycardia and violent reactions Morphine Sulfate Opiod analgesic Indications  Chest pain associated with MI  Pulmonary edema (with or without CP)  Moderate to severe acute or chronic pain Contraindications  Hypovolemia/hypotension Contraindications  Head injury or undiagnosed abdom. Pain  Increased ICP  Severe resp depression  MAO inhibitors within the last 14 days  CNS depressants may potentiate the effects  May worsen bradycardia or heart block in inferior MI  Should be used with caution in chronic pain syndromes  Phenothiazides may potentiate analgesia Magnesium Sulfate Electrolyte, Anticonvulsant Indications  Seizures of eclampsia  TDP  Hypomagnesaemia  Refractory VF Contraindications  Heart block or myocardial damage Practice Points  Don t administer 2 hrs prior to delivery  IV calcium gluconate or CaCl should be available as an antagonist  Convulsions may occur up to 48 hrs post delivery.  The cure for toxemia is delivery of the baby.  Use with caution in renal failure  CNS depressant effects may be enhanced in the presence of other CNS depressants Vasopressin Naturally occuring hormone (ADH) Indications  May be used as an alternate vasopressor in cardiac arrest  May be useful in hemodynamic support of dilatory shock Contraindications  Not recommended for responsive pts with CAD Practice Points  Potent vasoconstrictor- may promote cardiac ischemia Midazolam (Versed) Short acting BZD Indications  Premed for ETT or CV  Seizures Contraindications  Glaucoma (relative)  Shock, Coma, depressed VS Contraindications  Alcohol intox (relative)  Concomitant use of barbs, etoh, narc or other CNS depressants

Practice Points  Monitor continously  Never admin as IV bolus  Sedative effect may be enhanced by other CNS depressants Digoxin (Lanoxin) Cardiac Glycoside Indications  SVT esp A fib/flut  CHF  Cardiogenic shock Contraindications  VF/FT  AV Block  Dig toxicity  2nd or 3rd AV (without pacer) Practice Points  Amiodarone, verapamil, & quinidine may increase serum levels 50%  Concurrent admin with calan may lead to severe heart block  Antibiotics may increase serum levels by slowing hepatic breakdown  Diuretics may potentiate cardiac toxicity because of potassium loss Sympathomimetics may augment the inotropic & cardiotoxic effects. Pts with MI and or renal failure are prone to developing toxicity Avoid use in WPW Toxcity is potentiated in pts with; hypokalemia, hypomagnesemia & hypercalcemia Heparin Anti coagulent Two preparations  Unfractionated (UFH)  Low molecular weight (LWH) Indications  AMI  Begin with fibrin specific lytics (alteplase) Contraindications  Active bleeding  Recent intracranial, spinal or eye surgery Contraindications  Severe hypertension  Bleeding disorders  GI bleeding