Download CV drugs (4x6 index cards)

Kim Uddo RN MSN CCRN
Cardiovascular Drugs 2006
Cardiovascular Drugs Commonly Used for Dysrhythmias,
CV Surgery, and Codes
Supplement to ECG and Cardiovascular Lecture
1
Adenosine (Adenocard)
Indication: 1st Choice for PSVT.
Action: Potassium channel opener. Slows AV node conduction and
Converts AV node reentry pathways
Dose/Route: 6mg vials. Give 6mg RAPIDLY IVPush and flush
RAPIDLY with 20cc NS (half-life is 10 SECONDS) If it works, there will
be a scary short period of asystole, then the rhythm will be converted to
NSR or SB. If there is no response, may give 12 mg IVP same fashion in 3
minutes. If still unsuccessful, in 3 minutes, may repeat the 12mg dose one
more time. If it doesn’t work, explore the possibility the rhythm is a rapid
A-Flutter.
Problems: Flushing, dyspnea, chest pain , all which are transient.
Nursing May want to check out this rhythm via 12 lead ECG stat if the
patient is stable. 12 leads are better than one and it will help to identify the
rhythm. Two IV’s will be warranted, so start another peripheral line. Good
drug to use for nursing diagnosis: Decreased cardiac output R/T decreased
preload 2ndary to decreased ventricular filling time.
2
Amiodarone (Cordarone)
Indication: 1st choice anti-arrhythmic in VF, VT without a pulse,
bursts of VT, or frequent PVC’s. (Note epinephrine is not an antiarrhythmic). Use before using lidocaine. Can convert atrial dysrhythmias
such as AF or Aflutter.
Action: Decreases cardiac cell membrane excitability in irritable hearts.
Dose/Route: Large150mg ampules. Now comes in bristojet form for the
code cart! Dose varies in clinical situation.
Cardiac Arrest
(Dead Patient): Bolus of 300mg IV/IO and 10-20cc NS flush. If
ineffective, may repeat once with bolus of 150mg IV/IO in code. If it
converts the patient from VF/VT, then hang a drip. To make a drip, mix
900mg in 500ccD5W or NS and infuse at 1mg per minute for 6 hours
(360mg) then reduce drip to 0.5mg minute for the next 18 (540mg) or
more hours.
3
Amiodarone (cont'd)
Non-cardiac arrest (like bursts of VT or lots of ugly polymorphic
PVC’s): Bolus patient with a loading dose of 150mg IVPB in 100cc D5W
over 10 minutes which is 15 mg per minute (they are alive, we’re so
happy, we slow it down, but make it snappy). See drip calc at 2 NAC II.
Also comes in an oral form (800-1600mg per day x 3 weeks then 600800mg x 4weeks then 200-600mg per day as maintenance) for nonemergent situations.
Problems: Hypotension, asthma exacerbation, AV block, SB, PEA, CHF,
Asystole.
Nursing Responsibilities: Accurately measure the QT interval as it may
get prolonged due to the drug and increase danger of R on T.
Med Error Alert: Do not confuse this drug with Amrinone Inocor)
4
Atropine
Indication: 1st anti-arrhythmic choice in Symptomatic Bradycardia.
Also used in asystole, & bradycardic PEA.
Action: Blocks the effects of acetylcholine on the SA node and the AV
node.( Normally when acetylcholine is released, the vegas nerve
stimulates the slowing down of the SA and AV nodes and decreases HR.)
So atropine BLOCKS acetylcholine and INCREASES HR. In short, it’s an
anti-cholinergic drug that blocks the vegal effects on the heart. Also called
a parasympatholytic. (vagolytic). Nuff said. Atropine makes the heart go
ding ding ding.
Dose/Route: Comes in 1mg in 10cc bristojet. Packaging box is usually
purple on the code cart. Dead man’s dose: (Asystole and Bradycardic
PEA) 1mg IV/IO fast every 3 minutes for a total of 3 doses. Living sick
man’s dose (Symptomatic Brady) 0.5 mg IV Push while awaiting
transcutaneous pacer. May repeat every 3 minutes for a total of 3
doses. ETT in a Code: Double the dose, dilute in 10cc NS or sterile water
and aerate with ambu bag.
5
Atropine (cont'd)
Problems: Tachycardia, palpitations, chest pain, increased heart oxygen
consumption.
Nursing Responsibilities: Use caution in MI. Usually doesn’t work for
2nd Degree Type II Block and new 3rd Degree Block with a wide QRS
and could cause more of a bradycardic situation. Beware of using if MI in
progress, it can make things worse. Avoid use for acute-closure glaucoma
patients. Good drug for nursing diagnosis: Decreased cardiac output R/T
decreased HR 2ndary to vegal response. Make sure to call for the
transcutaneous pacer on the code cart and give atropin while awaiting
pacer.
6
Beta Blockers
(Atenolol, Esmolol, Metoprolol, Labetalol, Propranolol)
Indication: 2nd line choice to convert PSVT , AF, and AFib. Reduces
PVC’s. Many are antihypertensives.
Action: Beta-adrenergic blockers block beta receptors in the symptomatic
nervous system so they slow the heart rate (Beta 1) and cause
bronchospasms (Beta 2) and are antianginal agents. So they have a
negative chronotropic and inotropic effect on the heart. BB that just effect
the heart are cardioselective and those that effect both heart and lungs are
non-cardioselective.
Dose/Route: Atenolol: 5mg IVPush over 5 minutes, repeat in 10 min.
Esmolol: 0.5 mg/kg over one min followed by infusion at 0.05mg/kg/min
(max 0.3mg/kg/min).
Metoprolol: 5mg IV Push over 5 min and do not exceed 15 mg. Labetalol:
10mg IV Push, repeat or double every 10 min to max of 150mg. May give
one dose followed by infusion of 2-8mcg/min.
Propranolol: 0.1mg/kg IV Push divided into 3 equal doses every 3 min.
May repeat after 2 min.
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Beta Blockers (cont'd)
Problems: Hypotension, bradycardia, and some may cause bronchospasm.
Nursing Responsibilities: Push it SLOW. I often dilute my dose in NS
because these people are ALIVE. Watch the BP. Increase the NIBP to
cycle every minute during the push. It is very easy to bottom out the BP.
Then you have a real mess. OH well, “o-l-o-l”. Do not give if HR less than
60 or BP less than 100. May bottom out the BP if given with calcium
channel blockers.
8
Calcium Chloride
Indication: Acute hyperkalemia, hypocalcemia, calcium channel blocker
toxicity, or beta blocker overdoses.
Action: Increases myocardial contractility. Protects the heart.
Dose/Route:10mg in 10cc is a 10% solution. Give 8-16 mg SLOW IV
Push or even IVPB over 10 – 15 minutes.
Problems: Hypercalcemia especially in renal patients so check
Chevotek’s and Trousseau’s.
Nursing Responsibilities: Don’t give too fast, you’ll slow the heart rate.
If a PIV infiltrates, it causes tissue necrosis and sloughing Increases dig
toxicity in dig patients. Assess for it. Comes in Ca Chloride or Gluconate.
Nsg Dx: Altered electrolye balance (actual).
9
Digoxin (Lanoxin)
Indications: Second choice for AF, AFlutter, and PSVT.
Action: Anti-arrhythmic positive inotropic drug. Has a negative
chromotropic and dromatropic effect on the heart. Decreases conduction
through the AV node. Increases calcium inside the cell.
Dose/Route: Loading Dose: 0.75-1.25 divided in 2 doses every 6 hours IV
Push over 5 minutes or po. Maintenance Dose: 0.125 – 0.5 IV Push or
PO Daily.
Problems: Anorexia, nausea, vomiting, dysrhythmias
Nursing Responsibilities: Therapeutic serum levels are 0.5 – 2ng/ml.
Hold if HR less than 60. Avoid use with calcium salts. Dig toxicity –
nausea, vomit, anorexia, diarrhea, dysrhythmias, bradycardia, blurred or
yellow vision. MANY drugs cause dig toxicity (low potassium or mag or
high calcium), so check it out. Use Digoxin-immune Fab for toxicity. Can
cause prolonged PR, ST depression, QT to shorten, and flat or inverted T
waves. Good drug for nursing diagnosis: Decreased cardiac output R/T
decreased contractility 2ndary to MI induced necrotic muscle.
10
Diltiazem (Cardizem)
Indications: 1st drug of choice to slow down the HR in AFib or
Aflutter with rapid ventricular response. May also be used for PSVT if
adenosine doesn’t work.
Action: Calcium channel blocker. Slows the conduction through the AV
node and increases AV node refractoriness. Great for REENTRY
problems in the AV node.
Dose/Route: 15-20mg IV Push over 2 min. May repeat in 15 min with 2025mg. May start a drip, mix 125mg in 100ml D5W and infuse at 515mg/hour titrated to HR
Problems: Myocardial depression and hypotention
Nursing Responsibilities: For an overdose of this calcium channel
blocker, may need to give calcium! Good drug to use for nursing
diagnosis: Decreased cardiac output R/T decreased preload 2ndary to
tachycardia induced decreased ventricular filling time.
11
Dobutamine (Dobutrex)
Indication: Can use for low cardiac output and pulmonary edema.
Action: Adrenergic drug that selectively stimulates Beta1 receptor sites so
it causes increased contractility and stroke volume , thereby increasing
cardiac output without increasing the hearts o2 consumption. May cause
mild vasodilation thus decreasing afterload. Also decreases preload but the
BP doesn’t usually drop due to the increased cardiac ouput R/T increased
drug induced contractility. Cardiac stimulant.
Dose/Route: Put 250mg in 250ml D5W (This is 1000mcg/ml) and infuse
at 2 – 20 mcg/kg/min. Doses above 20 will increase HR. Titrate so HR is
not increased more than 10% from baseline.
Problems: Tachycardias, dysrhythmias,visual disturbances, and heart
ischemia at high doses. MUST correct volume deficits PRIOR to using
(Do not use in hypovolemic related shock).
Nursing Responsibilities: Avoid using if BP less than 100 and signs
of shock evident. Nsg Diagnosis: Decreased CO R/T decreased
contractility 2ndary to prolonged cardiac bypass duration.
12
Dopamine (Intropin)
Indication: Consider using as a continuous drip for all pulseless
rhythms (Dead Men):VT without pulse, VF, Asystole, and PEA if needed
for BP support. Also consider for Symptomatic Brady (Living Sick Men).
Action: Vasopressor, sympathomimetic, and positive inotropic effect.
Dose related effects.
Dose/Route: Low Dose: 1-2mcg/kg/min increases CO to help increase
urine output and facilitate effectiveness of diuretics Moderate Dose: 310mcg/kg/min: increases contractility and therefore, CO is . This is the
dose range used during codes and symptomatic brady. High Dose: 1020mcg/kg/min for vasopressor effect. Do not exceed 20mcg. Once at
20mcg, supplement the maxed out drip with a Levophed drip.
Problems: tachycardia and dysrhythmias
Nursing: If infused via PIV, guard closely, if infiltrates, DC immediately
and get orders for Regitine subq into affected tissues.
13
Epinephrine (Adrenalin)
Indication: 1st choice option drug for pulseless rhythms (Dead Man:
VF,VT,PEA, and Asystole) if vasopressin is not chosen and may consider
for use as a drip for each of these rhythms as well as for symptomatic
brady.
Action: Naturally occurring neurotransmitter adrenergic that has
vasopressor, cardiac stimulant, and bronchodilator effects. It’s an alpha
and beta adrenergic receptor stimulant so it increases contractility,
automaticity, SVR, and arterial BP. Helps to squeeze blood flow into the
coronary and cerebral arteries
Dose/Route: 1mg comes in a 10cc bristojet (1:10,000 solution).Dead
Man’s Dose: IV/IO Push Bolus: 1mg every 3 minutes. NO MAX DOSE.
Consider using as a drip for vasopressor support. Living Man in
symptomatic bradycardia, consider a continuous drip for vasopressor
support if needed. Continuous Drip: Mix 1mg of a 1:10,000 solution in
500ml NS and initiate at 2mcg/minute (this will
be 1-5mls per minute) and titrate up to 10mcg/min as needed. ETT:
14
Epinephrine (Adrenalin)(cont'd)
May double the dose diluted in 10ml NS and inject down the ETT and
aerate with ambu.
Problems: Hypertension, palpitations, tachycardia, nervousness, tremors,
dizziness
Other Nursing Responsibilities: Given with dig can cause ventricular
arrhythmias. Epi is Peppy!
15
Ibutilide (Corvert)
Indication: Atrial tachyarrhythmias.
Action: Short acting antiarrhythmic . Prolongs action potential. Converts
rhythms medically instead of electrically. Controls fast rates.
Dose/Route: For clients over 60kg, Give 1mg (10ml) over 10 min. May
repeat in 10 min if ineffective.
Problems: Can cause ventricular arrhythmias
Nursing: Make sure to correct potassium and magnesium deficiencies
prior to using. Patient must be on ECG with frequent vital
monitoring while receiving doses and must remain on ECG for 6 hours
afterwards. Don’t give if QT prolonged.
16
Isoproterenol (Isupril)
Indications: Some slow rates
Action: Beta Agonist so it increases HR and contractility.
Dose/Route: Mix 1mg in 250ml D5W for a concentration of 4mcg/ml.
Begin infusion at 2mcg/min and titrate up until HR is above 60 beats/min.
Problems: Heart ischemia
Nursing: Give your heart a thrill, give it Isupril. Beware, it increases
oxygen demand on the heart. Watch out for those go-fast drugs
17
Lidocaine (Xylocaine)
Indications: 2nd Choice dysrhythmic drug for VF/VT pulseless and to
treat PVC’s.
Action: Raises ventricular fibrillation threshold
Dose/Route: Bristojet comes 100mg in 10ml. In Arrest : Bolus IV/IO with
about 50mg for a small person, 75mg for medium, and 100mg for a large
person (1.0-1.5mg/kg). May repeat every 5 min to a max of 3mg/kg and
follow with a continuous drip.In a nonarrest: Bolus once and hang a drip.
Mix 2 Grams in 500cc D5W and infuse 1-4mg/min. 1mg=15ml,
2mg=30ml, 3mg=45ml, 4mg=60ml per hour. May double the dose and put
down the ETT per standards. Dilute with sterile water.
Problems: Toxic symptoms are slurred speech, decreased LOC, muscle
twitching, and seizures.
Nursing: Beware in the elderly for toxicity.
18
Magnesium
Indications: 1st Choice drug for Torsades de Pointes
Action: Antidysrhythmic, Electrolyed replenisher
Dose/Route: Dilute 1-2 Grams in 10ml D5W and give IV/IO push over 5
minutes. If the patient has a pulse, mix the 1-2 Grams in 50 – 100ml and
give little slower (5-60 min ).
Problems: Hypermag, flushing, bradycardia, hypotention.
Nursing: Know your patient’s QT interval. Measure carefully every shift.
Report to MD if prolonged. Certain meds can be reduced or lytes can be
evaluated.
19
Neo-Synephrine (Phenylephrine HCL)
Indication: Drug induced hypotention
Action: Sympathomimetic. Potent long lasting vasoconstrictor. Works like
epinephrine.
Dose/Route: Mix 10mg in 500ml NS or D5W and titrate to establish a low
normal BP per orders.
Problems: Hypertention, headache, tingles, vertigo, VT.
Nursing: Use Regitine if infiltrates per protocol.
20
Nitroglycerin (Tridil)
Indication: 1st Choice drug for unstable angina. Hypertention and or
Chest Pain
Action: Vasodilator. Reduces preload and afterload. Also dilates coronary
arteries that deliver that lovely oxygen to the heart muscle so it helps that
MI or angina induced chest pain to go away.
Dose/Route: IV Drip: Comes prepared from the manufacturer in various
concentrations. Mix 50mg in 250ml of D5W or NS for a concentration of
200mcg/ml. Mix 100mg in 250ml of D5W or NS for a concentration of
400mcg/ml. Begin infusing at 5mcg/min and titrate up every 5 minutes in
5mcg increments. Once titrated up to 20mcg/min, the nurse may step it up
and increase the titrated
increments up to 10mcg every 5 minutes. There is no fixed maximum
dose.
21
Nitroglycerin (Tridil)(cont'd)
Problems: HEADACHES and HYPOTENTION. Be ready to turn off
the drip for hypotention and give an aspirin for headache ( If ASA doesn’t
work, you may need to reduce the drip rate). Visual disturbances, flushing,
heart block.
Nursing: Beware of orthostatic hypotension when you get your patient up.
If you dangle them , ask if they are dizzy and assess for decreased BP and
a compensated increased HR. Know WHY it is ordered. Is it for chest pain
or for Hypertension. Look at your parameters on the MD Orders. They
will say something like “titrate until chest pain resolves or hypotension
warrants stopping” OR
“titrate until BP is less that 130mmHG systolic”.
22
Norepinephrine (Levophed)
Indications: SHOCK caused by trauma or cardiogenic. Use for
hypotension that causes hemodynamic instability.
Actions: Catecholamine with potent alpha effects (Vasoconstriction
causing increased SVR so it increases the workload of the heart) and
minimal beta effects (increased contractility). Decreases blood flow to all
organs except heart and brain.
Dose/Route: 4mg vials. Mix 8mg in 250cc D5W only. NOT NS!!! Begin
infusion at 0.5mcg/minute and titrate up every 3 – 5 minutes for BP. Do
not exceed 30mcg/min. Higher doses have been used but make sure the
MD knows when you hit 30mcg.
Problems: Hypertensive crisis. Metabolic Acidosis. Decreased urine
output. VT/VF.
Nursing Responsibilities: Should monitor hemodynamics. Ask for a swan
and an arterial line. Contraindicated in hypovolemia. Don’t use
with halothane or cyclopropane anesthesia. Continuous BP monitoring (at
least every 3 minutes so reset the NIBP cuff) PIV’s that infiltrate show
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Norepinephrine (Levophed)(cont'd)
blanching so stop the peripheral IV and get orders to inject area with
phentolamine 5-10mg in 10ml NS per subc needle. Report decreased urine
output.
24
Oxygen
Indication: Hypoxemia. Cardiac Arrests, Distress.
Action: Delivers oxygen to the tissues
Dose/Route: 100% in arrests. Non arrests: keep sats above 95%
Problems:
Nursing: Take care in the code during defibrillation. “I’m clear…You're
clear…We are all clear….The O2 is clear” Prevent sparks and fires.
25
Potassium Chloride
Nursing: Potassium imbalances can cause changes in the ECG and be
fatal to your patient. If replacement is needed on a living patient, do not
infuse faster than 10meq per hour. Faster rates of 20meq per hour may be
ordered if urgent. Dead people can get it fast. It BURNS via PIV, in a non
emergent situation, you may need to slow the rate in a PIV infusion even
slower than 10meq/hour. Try to start 18 gauge IV in a large peripheral
vein when they arrive to your unit. This drug is used frequently and MD’s
often leave routine sliding scale prn orders for the nurse to implement.
Check your K+ first thing in the morning, you may have orders to
implement. An example order is “If K+ is 3.4 – 3.8. give 10meq KCL in
100ml D5W over one hour, If K+ is 3.3 or below, give 10meq KCL in
100ml D5W over one hour and repeat once, Call MD for any K+ less than
3.0” Your lab result will be ready if done stat (which most ICU’s run
routinely) in about 10-20 minutes, depending on your lab.
26
Procainamide (Pronestyl)
Indication: Consider using for ventricular and supraventricular
arrhythmias when other drugs fail.
Action: Depresses Phase 0 of the action potential. Myocardial depressant.
Slows conduction.
Dose/Route: Begin an infusion drip at 20mg/min until the arrhythmia is
suppressed or if the QRS is prolonged by 50% , hypotension occurs, or a
total of 17mg/kg has been reached. If the infusion works, then maintain on
a maintenance drip of 1-4mg/min
Problems: Prolonged QT and QRS, heart block, VF, and confusion.
Nursing: If ECG shows QT and QRS prolonged, DC the drip and monitor
on ECG Do not give with amiodarone.
27
Regitine (Phentolamine)
Indication: Infiltrated IV of multiple cardiogenic drugs.
Dose/Route: Dilute 5 – 10mg in 10ml NS for subcutaneous injection.
Nursing: Many of these continuous drips are necrotic to the tissues. That
is a great reason why we try to give them through a central line (TLC). If
necrotic drugs infiltrate into the tissues, the nurse must stop the drip
immediately and call the MD for orders for Regitine to dilute and inject
into the affected tissues via multiple subcutaneous injections.
28
Sodium Bicarbonate
Indications: Pre-existing Acidosis
Action: Buffer
Dose/Route: Comes in 50ml bristojet. May give 1meq/kg IV Push
Nursing: Only give if the patient is experiencing acidosis. Not a routine
ACLS drug but may be seen in arrests with confirmed acidosis. Patients
do better in a slightly acidotic state over an alkalotic state. Be sure it is
needed.
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Sodium Nitroprusside (Nipride)
Indications: 1st Choice drug in Hypertensive Crisis
Action: Peripheral vasodilator. Decreases preload and afterload.
Dose/Route: Mix 50mg in 250ml D5W and Begin with 0.1mcg/kg/min.
May infuse up to 10mcg/kg/min.
Problems: Breaks down into cyanide and causes poisoning. Light breaks
it down. Hypotension.
Nursing: Cover bag to prevent light to react. Assess for cyanide tox:
tinnitus, blurred vision, decreased LOC, nausea, abd pain,
seizures, increased reflexes. Should have an arterial line . Must have
constant BP monitoring.
30
Sotalol
Indication: May be considered after other drugs have failed for
polymorphic VT or WPW.
Action: Anti-arrhythmic that prolongs action potential.
Dose/Route: 1 – 1.5 mg/kg bolus then drip at 10mg/min
Problems: Brady, hypotension, arrhythmias.
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TPA- Activase
Indication: AMI with thrombosis in progress in a patient without bleeding
issues.
Action: Thrombolytics. Clot buster!
Nursing: Lots
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Vasopressin (Antidiuretic Hormone Type)
Indication: 1st Choice drug option in All pulseless cardiac arrests. Shock.
Action: ADH activity, Nonadrenergic peripheral vasoconstriction. Causes
coronary and renal vasoconstriction. At high doses can vasoconstrict
capillaries and arterioles.
Dose/Route: Pulseless Arrest: 40 units IV/IO to replace the first or second
dose of epinephrine in a code. One dose only. If vasopressin is given, the
nurse must wait at least ten minutes before a dose of epinephrine can be
given. Can be given in a drip for vasodilatory shock syndrome . Mix 100
units in 250cc D5W and infuse at 0.2 – 0.4 units / minute. 0.1
u/min=15ml/hr, 0.2 u/min=30ml/hr, 0.3 u/min=45ml/hr,
0.4u/min=60ml/hr
Problems: Cardiac ischemia and angina.
Nursing: Necrotic to tissues if infiltrates.Be prepared to counteract over
effects.
33
Verapamil (Calan, Isoptin)
Indications: 2nd line choice to consider to slow AF/AFlut. Also consider
for PSVT with narrow QRS that’s unresponsive to adenosine.
Action: Calcium channel blocker with negative chronotropic and inotropic
effect. Decreases SVR.
Dose/Route: 5mg IV bolus over 2 min (3 min in older pop) every 15 min
until effective or to a total dose of 30mg. For a drip mix 100mg in 250ml
D5W and initiate at 0.075-0.15mg/kg over 3 min and if needed a second
dose at 0.15mg/kg in 15-30min then maintain drip at 1-10mg/hr infusion.
Problems: Hypotension
Nursing: Don’t give with WPW.
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Problems
6 H’s: Hypoxia, Hypovolemia, H+ acid (tricyclic acidosis, DKA),
Hypo/Hyperkalemia, Hypoglycemia, Hypothermia
5 T’s: Tablets(Overdose) , Tampanade – heart, Tension – pneumo,
Thrombus – heart or lung, Trauma.
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