CCLS - Pharmacology

CCLS - Emergency Drugs

• Adrenaline / Epinephrine
• Noradrenaline
• Atropine
• Amiodarone
• Lignocaine
• Adenosine
• Magnesium sulphate
• Dopamine
 Objectives

• Dosage
• Indications
Aim is to discuss only relevant pharmacology related to
cardiac arrest and pre arrest rhythms
 Epinephrine /
Adrenaline
• Ionotropic vasopressor
• Stimulates adrenergic receptors
• Alpha and beta agonist
• + Inotrope, + Chronotrope
•  SVR,  BP
•  Myocardial 0 requirements
2

•  Automaticity
•  Coronary and Cerebral blood flow
 Epinephrine /
Adrenaline
Indications
• Cardiac arrest
VF, VT, Asystole, PEA
• Symptomatic
bradycardia After
atropine
•Severe hypotension
Not responding to
vasopressors
•Anaphylaxis, severe
allergic reactions
Along with fluid resuscitation, corticosteroids,
 Epinephrine /
Adrenaline
Dosage & Administration
1 mg IV/IO repeated every 3-5 min (1:10,000)
- Diluted in 10 ml NS
- Followed by 20 ml saline flush
- Raise the limb for 10 to 20 seconds

After restoration of spontaneous circulation

- Continuous infusion rate: 0.05-2 mcg/kg/min

Endotracheal dose: 2 to 2.5 mg diluted in 10 ml NS

 Noradrenaline
• Vasopressor
MECHANISM OF ACTION
• Noradrenaline is a naturally occurring catecholamine. It
stimulates the alpha and beta-1 receptors in the sympathetic
nervous system.

• Stimulation causes peripheral, renal, splanchnic and

pulmonary vasoconstriction.

• Beta-1 stimulation increases myocardial contractility, with less

tachycardia produced than with adrenaline.

DOSAGE
• 0.05-0.3 mcg/kg/min by infusion
• Titrated - Low to high dose as per requirement
 Noradrenaline
Indications:
• Septic shock.
• Anaphylaxis with labile BP unresponsive to adrenaline.
• Hypotension unresponsive to fluid resuscitation.
• Cardiogenic shock unresponsive to other inotropes.
• Maintenance of adequate blood pressure in the
presence hypotension associated with brain stem
death.
• Hypertensive agent of choice in the management of
subarachnoid haemorrhage.
 Noradrenaline
Contraindications & Precautions:
• Hypovolaemia
• Patients taking mono-amine-oxidase inhibitors (MAOIs),
or within 14 days of such treatment.
• Mesenteric or peripheral vascular thrombosis
(unless life saving)
• Severe peripheral vascular disease

• Weaning by gradual tapering of dose and not sudden

withdrawal
 Noradrenaline

Adverse effects & Complications

• Tachycardia, Arrhythmias.
• Hypertension.
• Exacerbation of myocardial ischaemia.
• Tissue necrosis if extravasation occurs.
• Reduced blood flow to ‘less-vital’ tissues, especially the
skin and gut.
• Renal vasoconstriction may decrease renal blood flow.
 Atropine

• Anticholinergic
Mechanism of action:
• Blocks action of acetylcholine at parasympathetic
sites in smooth muscle, secretory glands, and
the central nervous system
 HR,  CO
 Atropine

• 0.6 mg q 3-5 min for symptomatic bradycardia

Max. = 3 mg (5 doses)

• Usually 2-3 mg is a full vagolytic dose in most

patients
 Atropine

Indications
• First drug for symptomatic sinus bradycardia
• May be beneficial for AV nodal block
• Organophosphate poisoning- large doses may
be needed

Not indicated for PEA and Asystole

 Atropine

Precautions
• MI and hypoxia- atropine increases myocardial
oxygen demand
• Not effective for type II 2nd degree or new 3rd
degree heart block (may slow down the rhythm)
• Doses less than 0.6 mg can paradoxically slow
down the heart rate
 Amiodarone

• Amiodarone is a Class ΙΙΙ antiarrhythmic.

MECHANISM OF ACTION
• Prolongs the cardiac action potential and the refractory
period of atrial, nodal and ventricular tissues.

• It has effects on sodium, potassium and calcium

channels as well as alpha and beta-adrenergic blocking
properties.
 Amiodarone

• Amiodarone increases coronary blood flow,

decreases cardiac oxygen requirements and
suppresses ectopic pacemakers.

• It is used to treat severe tachyarrhythmia

 Amiodarone

Dose Administration
• VF/VT- 300mg IV/IO in 30 ml NS.

• Can follow with one dose of 150 mg after 3-5 min if

needed

• Life threatening arrhythmias – 150 mg over 10 min.

Repeat as needed.

• Maximum 2.2 g in 24 hours

 Amiodarone

Indications

• Life threatening arrhythmias

• VF, pulseless VT - unresponsive to shock, CPR
and vasopressors
• Recurrent hemodynamically unstable VT
 Amiodarone
Adverse Effects
• Bradycardia, heart block
• Hypotension
• Excessive prolongation of QT interval (>0.6 seconds)
• Potentiates the effects of warfarin, calcium channel
blockers and beta-blockers
• Long term administration may cause photosensitivity,
hyper/hypothyroidism, lung fibrosis, prolonged PT,
corneal deposits
 Lignocaine

Alternative to Amiodarone
• For VF or Pulse less VT
Dose:
•1 to 1.5 mg/kg IV or IO
•Infusion 1 to 4 mg per minute
 Adenosine
Antiarrhythmic actions:
• Slows impulse formation of the sino-atrial node
• Slows conduction time through the atrio-ventricular node
• Can interrupt re-entry pathways through the
atrioventricular node
• Coronary vasodilator

Pharmacokinetics
• Onset: Immediate - Peak: 10 seconds
• Duration: 10 –30 seconds
 Adenosine
Dose & Administration
• To be administered as a rapid bolus (2 seconds), followed by a
rapid 20mL sodium chloride 0.9% flush - Preferred to have two
prefilled syringes attached with two-way valve
• Dose 1 : Adenosine 6 mg rapid peripheral IV bolus OR 3mg if
administered by central venous access
• Dose 2 : If the first dose is ineffective but well tolerated, after
2
minutes give
Adenosine 12 mg rapid peripheral IV bolus OR 6mg if
administered by central venous access.
 Adenosine
Indications
• Therapeutic : Rapid conversion to a normal sinus rhythm
of Paroxysmal Supraventricular Tachycardia(SVT),
including those associated with accessory bypass tracts
(Wolff-Parkinson-White syndrome).
• Does not convert AF, Afl, or VT
• Diagnostic: As an aid to differential diagnosis of narrow
or broad complex tachycardia due to the slowing of AV
conduction which makes atrial activity more visible on
ECG.
 Adenosine
Contraindications
• Hypersensitivity to adenosine
• Second or third degree heart block
• Sinus node dysfunction, such as sick
sinus syndrome or symptomatic
bradycardia
• Bronchoconstriction or bronchospastic lung
disease (e.g. asthma) either known or suspected
• Severe hypotension
 Adenosine

Side effects
• Resolve rapidly on stopping treatment due to the
drugs short duration of action.
• Explain possible adverse effects to patient
before administration.
• Ensure patient understands that these effects
will be short-lived.
 Adenosine
Adverse Side effects
• Common: flushing, dyspnoea, chest
pain/pressure, nausea or abdominal discomfort,
headache, dizziness, apprehension, burning
sensation, bradycardia, asystole, sinus pause &
A-V block
• Infrequent: transient arrhythmias, recurrence of SVT,
hypotension, tingling in arms or legs, metallic taste
• Rare: bronchospasm, injection site reaction
 Magnesium sulphate
Physiological calcium channel blocker

Indications
• Cardiac arrest with Torsades de pointes
Polymorphic VT
Digitalis toxicity
• Hypomagnesaemic states that may lead to
arrhythmias
• Prevention and treatment of seizures in severe
pre-eclampsia or eclampsia
 Magnesium sulphate
DOSAGE
• VT, Torsades in Cardiac arrest
-1 to 2 g in 10 ml 5 % Dextrose or NS
IV/IO over 5 – 20 min.
• Torsades with pulse or AMI
with hypomagnesaemia
- 1 to 2 g in 50 – 100 ml 5 %
Dextrose
over 5 – 60 min IV/IO then 0.5
g – 1 g/h
 Magnesium sulphate

• Side Effects:
• Flushing, sweating, mild  HR/BP
 Dopamine

Indications
• Hypotension
• Symptomatic bradycardia after Atropine

Administration
• By Infusion
• 2 to 20 mcg/kg per minute
• Titrate as per requirement
• Taper slowly
 Important points
Drugs for Bolus Drugs for Infusion
• Adrenaline Adrenaline
• • Amiodarone
• • Atropine
•
Amiodarone • Adenosine
•
Atropine • Lignocaine
•
Adenosine • Magnesium Sulphate
•
Lignocaine • Dopamine
Magnesium Sulphate • Noradrenaline

Cardiac arrest situation : Bolus, Saline flush & Raise limb

Pulse present : Always slow infusion