EMERGENCY MEDICINE

Karsim

Emergency Department
Rumah Sakit Muhammadiyah Lamongan

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 What drug will you
administer?

Ny A 99 tahun datang ke IGD

dengan keluhan dada berdebar
debar, batu pilek 3 hari yang lalu
serta sesak nafas. Tensi 8030
mmHg, RR 30 x mnt, S 3C, GCS
456

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What drug will you
administer?

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What drug will you
administer?

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What drug will you
administer?

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 OBJECTIVES
Upon completion of this session, you
will be able to:
• state drugs commonly used in cardiac
emergencies
• outline the major actions of these
drugs
• state drugs that can be administered
via the ETT
• list 2 side effects related to the use of
the drugs
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 DRUGS USED IN
CARDIAC
1.
EMERGENCIES
2. Epinephrine (Adrenaline)
3. Norepinephrine (Noradrenaline)
4. Dopamine
5. Dobutamine
6. Amiodarone
7. Nitroglycerin
Atropine (GTN)
8. Verapamil
9. Diltiazem
10. Sodium bicarbonate

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Adrenergic Effects (Sympathomimetic Amines)

Receptor Vascular Inotropic Chronotropic

 Constriction + ve - ve
 Dilatation + ve + ve

Drug Dosage  
0.5-1 g/’ + ++
Epinephrine
1-200 g/' ++ +++

Norepinephrine 0.1-2 g/kg/min +++ ++

1-2 g/kg/' + +

Dopamine 2-10 g/kg/' ++ ++

10-30 g/kg/' +++ ++

Vasopressin 40u IV bolus +++ 0

Dobutamine 2-30 g/kg/' + +++

Isoprenaline 2-10 g/kg/' + +++

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 Emergency Management of Complicated STEMI
Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?

Hypovolemia Low Output - Arrhythmia

Acute Pulmonary Edema
Cardiogenic Shock

Administer Bradycardia Tachycardia

Administer
First line of action

• Furosemide IV 0.5 to 1.0 mg/kg

• Morphine IV 2 to 4 mg • Fluids
• Oxygen/intubation as needed • Blood transfusions
• Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP • Cause-specific Check Blood Pressure
greater than 100 mm Hg interventions See Section 7.7
• Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to Consider in the ACC/AHA Guidelines for
100 mm Hg and signs/symptoms of shock present vasopressors Patients With ST-Elevation
• Dobutamine 2 to 20 mcg/kg per minute IV if SBP Myocardial Infarction
70 to 100 mm Hg and no signs/symptoms of shock

Check Blood Pressure Systolic BP Systolic BP Systolic BP

Second line of action

Systolic BP
Greater than 100 mm Hg 70 to 100 mm Hg 70 to 100 mm Hg less than 70 mm Hg
Systolic BP NO signs/symptoms Signs/symptoms Signs/symptoms of
of shock of shock shock
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline Nitroglycerin Dobutamine Dopamine Norepinephrine
10 to 20 mcg/min IV 2 to 20 5 to 15 0.5 to 30 mcg/min IV
mcg/kg per mcg/kg per
ACE Inhibitors minute IV minute IV
Short-acting agent such as
captopril (1 to 6.25 mg)
Third line of action

Further diagnostic/therapeutic considerations (should be considered in

nonhypovolemic shock)
Diagnostic Therapeutic
Circulation 2000;102(suppl I):I-172-I-216.
♥ Pulmonary artery catheter ♥ Intra-aortic balloon pump
♥ Echocardiography ♥ Reperfusion/revascularization
♥ Angiography for MI/ischemia
♥ Additional diagnostic studies

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 1. EPINEPHRINE

• 1st drug in cardiac arrest

• Endogenous catecholamine
• Indications
 Cardiac arrest from VF
 pulseless VT unresponsive to initial counter
shock
 PEA
 Asystole
 Profoundly symptomatic bradycardia
• Routes of administration
 IV 1 mg push (10 ml of 1:10,000), followed by 20
ml flush, at interval of 3-5 min
 ETT 2-2.5 times peripheral dose (1 ml of 1:1000)
 Infusion 1 mg (1 ml of 1:1000) added to 500 ml
NS or D5%, titrate 2-10 /min
 EPINEPHRINE - ACTIONS

• increases contractile force (inotropic) of

the heart – improving contractility -
increasing cardiac output
• Increases conduction of SA Node, AV
node and ventricle thus increasing
heart rate
• Increases systemic vascular resistance
through peripheral vasoconstriction -
increasing perfusion pressure -
improving cerebral & coronary blood
flow
 EPINEPHRINE - Precaution

• Should not be added to infusions that

contain alkaline solution
• Can exacerbate ischemia, induce
ventricular irritability; may lead to stroke
and acute MI
– tachycardia
– PVCs

• High-dose not recommended for initial

use since no improved long-term
survival and neurological outcome has
been demonstrated
• Use with caution in pregnant patients
 2. NOREPINEPHRINE

Indications:
• cardiogenic shock
• septicaemic shock
• neurogenic shock
• anaphylactic shock
• hypovolemic shock
- after fluid
resuscitation has
failed to raise BP
Route of administration:
• increasing cardiac output by increasing
myocardial contractility & causing
peripheral vasoconstriction (0.1-2
ug/kg/min)
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 3. DOPAMINE

Indications:
• cardiogenic shock
• septicaemic shock
• neurogenic shock
• anaphylactic shock
• hypovolemic shock - after fluid
resuscitation has failed to raise BP

Route of administration:
• infusion via vein/central vein
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 DOPAMINE - ACTIONS
• Dilates renal and mesenteric vessels
(1-2 ug/kg/min)
– enhancing renal blood flow
• Increases myocardial
contractility
(2-10ug/kg/min)
– increasing cardiac output
•
Causes peripheral vasoconstriction
(>10ug/kg/min)
– elevating blood pressure

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DOPAMINE - SIDE EFFECTS

Low Dose Medium Dose High Dose

  Tachycardia  Same medium dose

Hypotension  Angina  Decreased renal
 Tachycardia  Ventricular function
arrhythmias  Hypertension

Nursing Implications
• monitor BP, cardiac rhythm
• monitor drip site closely
– observe for onset of extravasation

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 4. DOBUTAMINE

Indications:
• Acute-on-chronic refractory heart
failure
• Severe acute myocardial failure
• Cardiogenic shock

Route of Administration
• infusion via vein/central vein

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Actions
• β1 effects (predominant).
• Mild β2 and α1 effects.
• No specific effects on renal or splanchnic
blood flow, but may  renal blood flow due to
an  in cardiac output.

Adverse effects
• Tachycardia
• Ectopic beats

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Cautions
• Acute myocardial ischaemia or MI
• β-Blockers (may cause to be
dobutamine less effective)

How not to use dobutamine

• In the absence of invasive cardiac
monitoring.
• Inadequate correction of hypovolaemia
before starting dobutamine.

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Disadvantages
• In severe CHF, the β-receptors may be
downgraded or therapeutically blocked 
dobutamine may not be as effective as
• anticipated.
BP may decrease or stay unchanged, & not
• increase
Risk of serious arrhythmias
Precautions
• Hemodynamic or careful clinical monitoring of
patient required
• Check blood potassium (may fall) to minimize
arrhythmias
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 5. Amiodarone
Amiodarone is an antiarrhythmic agent
used for various types of cardiac
dysrhythmias, both ventricular and atrial.

Indications
• Narrow complex tachycardia
• Broad complex tachycardia

Special use
• WPW
• AFib RVR with Cardiac failure
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 Amiodarone - ACTIONS

• Class III antiarrhythmic agent

• Amiodarone shows beta blocker-like
and potassium channel blocker-like
actions on the SA and AV nodes,
increases the refractory period via
sodium- and potassium-channel effects,
and slows intra-cardiac conduction of
the cardiac action potential, via sodium-
channel effects.

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Amiodarone - ADMINISTRATION

Routes of administration:
• IV 150mg IV over 10 min; can be repeated
once

Use with caution:

• Hypovolemia state
• Hyperthyroid (Amiodarone resembles T4
thyroid hormone, and its binding to the nuclear
thyroid receptor)

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 6. ATROPINE
Indications:
• Haemodynamically unstable
bradycardias
– 1st, 2nd or 3rd degree heart block
• acute cholinergic poisoning
(organophosphates)
Routes of administration:
• IV push - neat
• ETT rapid push - no dilution needed
• maximum 3 mg

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ATROPINE - ACTIONS

• Enhances conduction
– increasing heart rate and cardiac
output
• Decreases secretions

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ATROPINE - SIDE EFFECTS

• Tachycardia
• Palpitations
• Paradoxical bradycardia
(if dose<0.5mg)
• Seizure
• Hypertension
• Respiratory failure
• Use with caution in MI cases
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 7. NITROGLYCERIN
Indications
• unstable angina
• AMI
• pulmonary oedema with high BP
• hypertensive crisis
Routes of administration:
• sublingual
• transdermal
• IV infusion 10-200ug/min titrated to
response

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NITROGLYCERIN - ACTIONS

• Vasodilator
• Dilates coronary arteries
• Relieves coronary spasm
• Opens up collateral vessels
 increases blood flow to
myocardium

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NITROGLYCERIN - SIDE EFFECTS

• Headache
• Flushing
• Tachycardia
• Hypotension
• Use with in hypotension &
caution
tachycardia
Nursing implications:
• monitor BP and heart rate
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 8. VERAPAMIL

Indications
• PSVT
• Acute atrial fibrillation or atrial
flutter with rapid ventricular
response (exclude WPW first)

Route of administration:
• IV slow bolus - dilute 5mg in 5 ml at
1mg/min

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 VERAPAMIL- ACTIONS
• Blocks calcium channel- negative
inotropic effect
– decreases force cardiac contraction
• Slows conduction & prolongs
refractory period at AV Node
– slows down heart rate
• Dilates coronary, systemic and
peripheral vessels
– increases blood flow and lowers
blood pressure

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VERAPAMIL - SIDE EFFECTS

• Hypotension
• Prolongation of PR intervals,
bradycardia - asystole
• PVCs
• Nodal escape rhythms
• Heart blocks
• VF in patient with WPW

Nursing implications
• monitor cardiac rhythm and BP
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 9. DILTIAZEM
Calcium Channel Blockers
Potent direct negative chronotropic &
negative inotropic effects

Primary beneficial effects:

• Both slow conduction and increase
refractoriness in the AV node
• Produces less myocardial
depression than verapamil, but is
equipotent as a negative
chronotrope
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 DILTIAZEM
Indication:
• Treatment of PSVT
• Slow down ventricular respopnse in atrial
flutter & fibrillation (but NOT for AF with
WPW)

Primary beneficial effects:

• Both slow conduction and increase
refractoriness in the AV node
• Produces less myocardial depression than
verapamil, but is equipotent as a negative
chronotrope
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 DILTIAZEM
Dosage:
• IV 0.24mg/kg (approx 20 mg) over 2
min
• May repeat 0.35 mg/kg 15 min later
• Infussion 5-15 mg/hr titrate to heart
rate for control of ventricular response
in AF
Precautions:
• May cause hypotension
• Not to use with IV beta blocker
• Avoid in sick sinus syndrome, AV block,
or heart failure
• Incompatible with simultaneous
furosemide
10. SODIUM BICARBONATE

Indication
• profound severe metabolic
acidosis

Route of administration
• IV infusion
• 1ml/kg based on blood gas results
• do not mix with other drugs
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SODIUM BICARBONATE
Action:
• Correct acidosis

Side Effects:
• hyperosmolarity
• hypernatremia
• CNS acidosis (Paradoxical alkalosis)
Should not be used unless blood gases
show severe metabolic acidosis or
patient collapse >10 mins.
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SODIUM BICARBONATE
Action:
• Correct acidosis

Side Effects:
• hyperosmolarity
• hypernatremia
• CNS acidosis (Paradoxical alkalosis)
Should not be used unless blood gases show
severe metabolic acidosis or patient collapse
>10 mins
•  preload (Na HCO = 2Na + H O + CO )
2 3 2 2

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 SUMMARY

 Drugs used cardiac arrest

 epinephrine
 Atropine

 can be given via ETT if IV access is

not available

 Daily practice is the best learning

ground

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