Muhammad Yusuf Muharam

,
MBBS (UM), MMed. Emergency (USM)
Emergency & Trauma Department,
Hospital Queen Elizabeth
Kota Kinabalu, Sabah
23rd September 2014

 Introduction
 Resuscitative

drugs

 Pharmacology

 Summary

 Severe,

often lifethreatening consequences
can occur if paramedics
make a mistake.

 ???

Pharmacology

scientific study of how various
substances interact with or
alter the function of living
organisms.

 Chemicals

have been used
for centuries.

 Formal

scientific study began in the 17th and
18th centuries.

 Some

ancient remedies are still used today.

Atropa belladonna, poppy seed Papaver
somniferum etc

 EBM

guidelines assist clinicians using
pharmacologic interventions.

Medications undergo extensive testing and
clinical trials.

 Medications

for desired effect in the body.

 Pharmacodynamics:

as a medication is
administered, it alters a function or process
of the body.

Any medication can cause toxic effects.

 Pharmacokinetics: action of the body on a medication  Process     of medication administration (ADME): Absorption Distribution Metabolism/Biotransformation Elimination .

 Cardiac  Output = HR X SV Heart Rate x Stroke Volume      SV stroke volume cardiac output stroke volume cardiac output heart rate cardiac output heart rate cardiac output = EDV – ESV .

 Mean   (average) Arterial Pressure (MAP) (Diastolic Pressure + Pulse Pressure) / 3 DBP + 1/3 (SBP-DBP)  Blood Flow (vascular system) = Cardiac Output   relatively constant but will vary in the individual organs. At rest:      brain 13% internal organs 24% heart 4% skeletal muscle 20% kidneys 20% .

.  Cardiac output is affected by blood volume. Blood pressure is affected by cardiac output and resistance.  So blood volume also affects blood pressure.

 Adrenaline / epinephrine  Magnesium sulphate  Amiodarone  Dopamine  Atropine  Dobutamine  Adenosine  Sodium Bicarbonate .

it increases blood pressure (BP). .and β-agonist.   mainstay Rx in the pulseless patient  regardless of the underlying rhythm.  coronary perfusion pressure (CPP). im.  Route: iv. ETT  High-dose epinephrine ?? no longer recommended.  cerebral blood flow (CBF). α. io.

severe allergic reactions Combine with large fluid volume. asystole. Pulseless VT. antihistamines Severe hypotension . Indications      Cardiac arrest VF. corticosteroids. PEA Anaphylaxis.

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 .

 Precautions    Standard preparation   May increase myocardial ischemia. and oxygen demand High doses do not improve survival. HPT. angina. may be detrimental 1 mg/ml ampoule S/E:  tachy. arrhythmias .

1 mg every 10 mins + 9 ml NS as required ADRENALINE Anaphylaxis (0.M: 0.2 – 0.CPR – all pulseless conditions 1 mg every 3 – 5 min Undiluted IV: 0.5 mg (1:1000) every 5 – 15 mins (1 mg/ml) Strength 1:1000) - Start 2 – 20 mcg/min Or 2– 20 ml/hr Hypotension / Shock 3mg in 47ml of D5% (0.1 mg/ml) I.06mg/ml) or .

and ventricular tachydysrhythmias.  In PSVT. BUT has not been shown to increase survival to hospital discharge. Amiodarone useful in treating both supra. Amiodarone is a second-line agent. .  Increase the rate of survival from cardiac arrest. and can be used when adenosine fails.

2 grams. may repeat dose at 150 mg Loading dose: Step 1: 150 mg stat AMIODARONE (150 mg/3ml) Non-cardiac arrest  Stable VT/ SVT Maintenance dose: Step 2: 360 mg over 6 hrs (run  Atrial 33.3 ml/hr) fibrillation Step 3: 540 mg over 18 hrs (run 16.7 ml/hr) . The maximum dose in 24 hour: not exceed 2. Cardiac arrest Pulseless VT or VF Initial 300 mg.

 photosensitivity.  corneal microdeposits.  Pulmonary toxicity (pneumonitis) . hyper/hypothyroidism.  bradycardia.  proarrhythmia.  nausea.  anorexia.

 Heart transplant???  Atropine is ineffective in the setting of previous heart transplant and may worsen ischemia during a myocardial infarction. Atropine  For symptomatic bradycardia that are due to increased parasympathetic tone. .  Atropine should not be used when infranodal pathology is suspected such as with seconddegree AV blocks.

 Mechanism of Action Inhibits the actions of acetycholine on structures innervated by postganglionic sites (smooth/cardiac muscle. SA/AV nodes) .

  Indications  First line drug for symptomatic sinus bradycardia  Organophosphate poisoning.5 mg may cause a paradoxical slowing . large dose may be needed Precautions  Not effective for type II 2nd or 3rd degree block (may slow the rhythm)  Doses < 0.

5 mg every 3 – 5 mins (Max : 3 mg total dose) 1 – 2 mg and with doubling of Organo-phosphate each subsequent dose every 3-5 poisoning minutes until full atropinisation effect.04 mg/kg) Symptomatic bradycardia 0.Don’t delay pacing for severely symptomatic (unstable) patients. . PEA 1 mg every 3 – 5 mins (Max: 0. ATROPINE (1 mg/ml) CPR – Asystole.

 convulsion.  eye dryness.  VT.  dry mouth.  flushed skin .  paradoxical bradycardia. HA.  constipation.

.

. Mechanism of Action Slows impulse formation in the SA node. Depress LV function and restores NSR. Slows conduction time through AV node.

narrow complex. regular SVT  May consider for unstable SVT while preparing for cardioversion . Indications  1st drug for stable.

 Place supine or mild reverse Trendelenburg. IV nearest to the heart  Ampoule: 6mg / 2 ml  Half-life??? .

ADENOSINE (6 mg/2ml) Supraventricular tachycardia (SVT) 6 – 12 mg .12 mg (Max. single dose: 12 mg) f/by 20 ml NS bolus .

.

flushing. CP. bronchospasm  Transient periods of sinus brady or ventricular ectopy common after termination of SVT  Safe in pregnancy . asystole. ectopy. Contraindications/Precautions  2nd and 3rd degree block is contraindicated  Transient side effects. brady.

 Complete HB  Ventricular standstill  Dyspnoea  Nausea  Angina like chest pain  Bronchospasm  Raised ICP . Transcient brady.

 Mechanism of Action Increases magnesium levels in cases where prolonged QT interval is thought to be secondary to hypomagnesemia. .

. Indications   Torsades is suspected in cardiac arrest Life-threatening ventricular dysrhythmias in digitalis OD  Precautions  Fall in BP with rapid administration  Dosing   Arrest 1-2 g over 5-20 min. Torsades w/ pulse 1-2 g over 5-60 min.

MAGNESIUM SULPHATE AEBA 2 g (4 ml) over 20 min Torsade de pointes 1 – 2 g over 15 mins Treatment for hypomagnesemia 1 – 2 g over 5 to 60 mins (2.47 g/5ml) Pre-eclampsia/ Eclampsia 4 – 5 g over 20 mins. followed by 1 – 2 g/hr (Max: 40 g/24 hr) 20gm (40ml) in 450NS (40mg/ml) .

SOB  Vomiting  Weakness  Reduce reflex . Bradycardia  Diplopia  HA  Hypotension  Nausea.

 Mechanism of Action Stimulates adrenergic receptors (dose dependent) .

 Indications    Second-line drug for symptomatic bradycardia Hypotension with signs and symptoms of shock Precautions    Correct hypovolemia with volume before initializing May cause tachydysrhythmias. excessive vasoconstriction Don’t mix with sodium bicarbonate .

1 – 20 mcg/kg/min (Max: 20 mcg/kg/min) DOPAMINE Hypotension (200 mg/5 ml) / shock (200mg in 45 ml of NS: 4mg/ml) .

arrythmia  weakness. chest  fast. or pounding heartbeats. pain.  swelling  N. slow. in your feet or ankles. .V confusion.

.

 Mechanism 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 .

5 – 20 mcg/kg/min (Max: 20 mcg/kg/min) (250mg in 30 ml: 5mg/ml) .DOBUTAMINE (250 mg/20 ml) Hypotension/ shock 2.

uncommon if < 10mcg/kg/min  Tachycardia  Arrhythmias  Tremors  HPT  Angina like chest pain  Nausea  Vomiting . Generally dose related.

as in metabolic acidosis HCO3. Cardiac arrest . Mechanism of action  Reacts with H+ ion.+ H+ H2CO3 CO2 + H20  No definite evidence of benefit in arrest   Indication  Consider in severe metabolic acidosis – eg.

4% NaHCO3 over 30-60 mins  Precautions  Worsened intracellular acidosis from CO2 formation and retention  Hyperosmolality and hypernatremia  Metabolic alkalosis  Acute hypokalemia . Dose  1 mmol/kg initially. OR 50-100 ml of 8.

8 mmol/L Ca)  S/E:   Brady. Indication  PEA d/t. Arrythmias. tissue irrtation (local) . HyperK. hypoCa. CCB overdose  Dose:  10 ml of 10% calcium gluconate (6.

 MUST KNOW DRUGS in Emergency Department  Local protocol of drug  Always re-confirm before giving ANY drugs to patient  Report any drug reaction .