Catecholamines such as isoproterenol and epinephrine have been utilized in the temporary

emergency management of complete heart block and cardiac arrest. Epinephrine may be useful in
cardiac arrest in part by redistributing blood flow during cardiopulmonary resuscitation to
coronaries and to the brain. However, electronic pacemakers are both safer and more effective in
heart block and should be inserted as soon as possible if there is any indication of continued high-
degree block.

Heart failure may respond to the positive inotropic effects of drugs such as dobutamine. These
applications are discussed in Chapter 13: Drugs Used in Heart Failure. The development of
tolerance or desensitization is a major limitation to the use of catecholamines in heart failure.

Pulmonary Applications

One of the most important uses of sympathomimetic drugs is in the therapy of bronchial asthma.
This use is discussed in Chapter 20: Drugs Used in Asthma. Nonselective drugs (epinephrine), -
selective agents (isoproterenol), and 2-selective agents (metaproterenol, terbutaline, albuterol) are
all available for this indication. Sympathomimetics other than the 2-selective drugs are now rarely
used because they are likely to have more adverse effects than the selective drugs.

Anaphylaxis

Anaphylactic shock and related immediate (type I) IgE-mediated reactions affect both the
respiratory and the cardiovascular systems. The syndrome of bronchospasm, mucous membrane
congestion, angioedema, and severe hypotension usually responds rapidly to the parenteral
administration of epinephrine, 0.3–0.5 mg (0.3–0.5 mL of 1:1000 epinephrine solution).
Intramuscular injection may be the preferred route of administration, since skin blood flow (and
hence systemic drug absorption from subcutaneous injection) may be unpredictable in hypotensive
patients. In some patients with impaired cardiovascular function, very cautious intravenous
injection of epinephrine may be required. Epinephrine is the agent of choice because of extensive
experimental and clinical experience with the drug in anaphylaxis and because epinephrine activates
, 1, and 2 receptors, all of which may be important in reversing the pathophysiologic processes
underlying anaphylaxis. Glucocorticoids and antihistamines (both H1 and H2 receptor antagonists)
may be useful as secondary therapy in anaphylaxis; however, epinephrine is the initial treatment.

Ophthalmic Applications

Phenylephrine is an effective mydriatic agent frequently used to facilitate examination of the retina.
It is also a useful decongestant for minor allergic hyperemia and itching of the conjunctival
membranes. Sympathomimetics administered as ophthalmic drops are also useful in localizing the
lesion in Horner's syndrome. (See An Application of Basic Pharmacology to a Clinical Problem.)

Glaucoma responds to a variety of sympathomimetic and sympathoplegic drugs. (See box in

Chapter 10: Adrenoceptor Antagonist Drugs: The Treatment of Glaucoma.) Epinephrine and its
prodrug dipivefrin are now rarely used, but -blocking agents are among the most important
therapies. Apraclonidine and brimonidine are 2-selective agonists that also lower intraocular
pressure and are approved for use in glaucoma. The mechanism of action of these drugs in treating
glaucoma is still uncertain; direct neuroprotective effects may be involved in addition to the benefits
of lowering intraocular pressure.

Genitourinary Applications