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15 - CCLS - Pharmacology
15 - CCLS - Pharmacology
• 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
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
• Anticholinergic
Mechanism of action:
• Blocks action of acetylcholine at parasympathetic
sites in smooth muscle, secretory glands, and
the central nervous system
HR, CO
Atropine
Indications
• First drug for symptomatic sinus bradycardia
• May be beneficial for AV nodal block
• Organophosphate poisoning- large doses may
be needed
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
MECHANISM OF ACTION
• Prolongs the cardiac action potential and the refractory
period of atrial, nodal and ventricular tissues.
Dose Administration
• VF/VT- 300mg IV/IO in 30 ml NS.
Indications
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