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Drugs that affect the Cardiovascular system Peggy Andrews, Instructor Chemeketa Community College LEAD Drugs • Lidocaine – Interferes with sodium channels to block conduction abnormalities • Epinephrine – Increases heart rate, blood pressure and stimulates liver • Atropine – Blocks actylcholine, speeds heart • Dopamine – Increases contractile force Let’s Review First • Most drugs treat dysrhythmias • Most prevalent – Tachycardia – Bradycardia • Generated through abnormal impulse formation (automaticity) • OR abnormal conductivity • Dysrhythmias - Most often caused by imbalance between sympathetic and parasympathetic nervous systems Bradycardia • Excessive parasympathetic stimulation through muscarinic receptors Tachycardia • Variety of causes • Ischemia, mycoardial infarction, excessive sympathetic stimulation • Develop phase 4 depolarization, generate abnormal impulse – Ectopic foci • Abnormal conduction; – One-way valve Antidysrhythmics • SODIUM CHANNEL BLOCKERS What do they do, anyway? • -amide, ester forms of local anesthetics elevate the threshold of electric excitation of the nerve – Enter open, inactive sodium channels – Anesthetic closes the channel, blocking sodium influx • Delays impulse • Decreases action potential • Blocks conduction Procainamide • Class: antiarrhythmic • Indications • Treatment of ventricular and arial arrhythmias – PACs, PVCs, VT, PAT, post conversion from Af or AF • Action – Decreases myocardial excitability – Slows conduction velocity – Suppresses arrhythmias • Contraindications – Hypersensitivity – Poisonings from tricyclic antidepressants • Caution – MI – CHF – geriatrics • Adverse reactions – – – – – Seizures Asystole Heart block Ventricular arrhythmias Diarrhea • Route & dose – IV, 20-30 mg/min IV until • • • • Dysrhythmia converted Hypotension QRS widens > 50% 17 mg/kg administered – Cardiac Arrest: 100 mg IVP q 5 min. – Infusion: 1 – 4 mg/min (1 gm in 250 ml NS) • How supplied • 10 mg/ml in 100 mg preload Lidocaine • Class – Antidysrhythmic • Indications – VT, Vf, malignant PVC’s • Action – Decreases ventricular automaticity & excitability – Raises fibrillation threshold – Decreases conduction in ischemic cardiac tissue without affecting normal conduction • Contraindications – Advanced AV block (Mobitz II , 3rd degree blocks – Torsades de pointes – Stokes-Adams syndrome • Precaution: – Heart rate less than 60 – Hepatic disease - reduce by 50% – >70 y/o – reduce by 50% • Side effects – – – – – – – – Drowsiness Dizziness Confusion Hypotension Nausea, vomiting Dysrhythmias Respiratory depression Cardiac arrest • Route & Dosage: – Loading dose of 1 – 1.5 mg/kg IVP q 5 min. Max dose of 3 mg/kg – After perfusion is reestablished, admin. Lidocaine gtt at 2-4 mg/min (start gtt at 1 mg/min if pt > 70 y/o • How supplied – 10 mg/ml in 100 mg preload Lidocaine is drug of choice for • Most types of drug-induced monomorphic VT or Vf, and for VT, Vf associated with cocaine-induced myocardial ischemia Antidysrhythmics • Potassium Channel Blockers Bretylium Tosylate (Bretylol) • Class; antiadysrhythmic – Different from all other antidysrhythmics – Does not suppress automaticity – Has no effect on conduction velocity • Indications – VT, Vf refractory to lidocaine and defibrillation – Recurrent Vf – VT with a pulse that fails to respond to lidocaine or procainamide – Wide complex tachycardias not controlled by lidocaine and adenosine • Action – Causes an initial but transient release of norepinephrine; effect lasts ~ 20 min. – Then inhibits release of norepinephrine and blocks reuptake of norepinehprine, resulting in depletion of norepinephrine. Results in: • Increased fibrillation threshold • Prolonged effective refractory period • Suppression of reentry dysrhythmias • Contraindication and precautions – No contraindications when used for Tx of lifethreatening dysrhythmias – Contraindicated in Torsades – Can result in prolonged hypotension in postresuscitation phase • Side effects – – – – – Initial transient elevated BP followed by hypotension Dizziness, syncope Angina Bradycardia If administered by rapid IVP, N/V • Dosage – Vf, pulseless VT: 5 mg/kg IVP • Repeat with 10 mg/kg q 15 min to max dose of 3035 mg/kg – If conversion, administer bretylium drip at 1-2 mg/min. • How supplied – 50 mg/ml in 10 ml preload amiodarone (Amrinone, Cordarone) • Class – antiarrhythmic • Indications – recurrent VF, unstable VT – When other therapies are ineffective • Action – Prolongs action potential and refractory period – Slows sinus rate, increases PR, QT intervals • Contraindications – Severe sinus node dysfunction – 2nd and 3rd degree AV block • Precautions – CHF, severe pulmonary or liver disease • Adverse reactions – ARDS, pulmonary fibrosis, CHF, worsening of arrhythmias – Liver function abnormalities – Anorexia, constipation, N/V, ataxia, involuntary movement, paresthesia, periphreal neuropathy, tremors – Bradycardia, hypotension – Dizziness, fatigue, malaise, corneal microdeposits • Route & dosage – Requires large initial loading dose (IV route) to prevent delay in onset action – Must use filter needle – Draw up slowly – Foams! • For VT hemodynamically stable (SBP> 85) – 150 mg IV over 10-30 minutes – 900 mg IV over 24 hrs by infusion – Repeat 150 mg IV bolus for VT • For VT/VF unstable or no BP – 150-300 mg IV bolus – IV infusion (1mg/min) – May repeat bolus • Not water soluble – must use solvent Polysorbate 80 • Polysorbate 80 clinical effects: – Decrease heart rate – Depress AV node conduction – Increase atria and ventricular refractory periods – Available only in glass ampules • How supplied – 50mg/ml in 3-ml ampules Antidysrhythmics • Calcium Channel Blockers Verapamil (Isoptin, Calan) • Class – Antianginal, Antiarrhythmic, antihypertensive agent • Indications – Hypertension, angina, Prinzmetal’s angina, Af or AF with rapid ventricular response • Action – Inhibits transport of calcium into myocardial and vascular smooth muscle – Decreases SA and AV conduction • Contraindications – Hypersensitivity • Precautions – Severe hepatic impairment • Adverse reactions, SE – Arrhythmias, CHF • Dosage and route – 5 – 10 mg, IV • How supplied – 2.5 mg/ml in 2 & 4 ml vials, ampules and syringes diltiazem (Cardizem) • Class – Antianginal, antiarrhythmic, antihypertensive • Indication – Hypertension, angina, SVTs and Af & AF with rapid ventricular response • Action – Inhibits the transport of calcium into myocardial and vascular smooth muscle • Contraindications – Hypersensitivity – Sick sinus syndrome – 2nd or 3rd degree AV block • Precautions – Severe hepatic impairment • Adverse reactions, SE – Arrhythmias – CHF – Peripheral edema • Dosage & route – 0.25 mg/kg – May repeat in 15 minutes with dose of 0.35 mg/kg – Follow with gtt at 10 mg/hr • How supplied – 5 mg/ml in 10 ml vials – 25 mg preloads Antidysrhythmics • Miscellaneous Adenosine (Adenocard) • Class – Antiarrhythmic agent • Indication – Conversion of PSVT – As a diagnostic tool to assess myocardial perfusion • Action – Restores normal sinus rhythm by interrupting re-entry pathways in AV node – Slows conduction through AV node • Contraindications – 2nd or 3rd degree block • Precautions – Asthma – Unstable angina • Adverse reactions & side effects – SOB – Facial flushing – Transient arrhythmias • Dosage & route – 6 mg rapid IVP – Repeat in 1 – 2 min. prn at 12 mg rapid IVP – Repeat in 1 – 2 min. prn at 12 mg rapid IVP • How supplied – 6 mg and 12 mg preload syringes or vials • Onset is immediate • Duration is 1 – 2 min • Note: Proximal IV, RAPID bolus, 20 ml flush with arm raised is critical!! digoxin (Lanoxin) • Class – Antiarrhythmic agent – Cardiotonic and inotropic agent • Indications – – – – CHF Tachyarrhythmias Af & AF PAT • Action – Increases force of myocardial contractility – Prolongs refractory period of AV node – Decreases conductiion through SA and AV nodes • Contraindications – – – – Hypersensitivity Uncontrolled ventricular arrhythmias AV block IHSS • Precautions – Electrolyte abnormalities • Adverse reactions, SE – – – – Dysrhythmias Fatigue Blurred, yellow vision Anorexia, N/V • Dosage & route – 0.6 – 1.0 mg (10-15 mcg/kg) initially – Give additional fractions at 4 – 8 h intervals – Total dose 200 mg • How supplied – 0.25 mg/ml in 1 ml preload Magnesium Sulfate • Class: CNS depressant, anticonvulsant. • Indications – – – – Refractory Vf/pulseless VT Torsades de Pointes Digoxin-induced VT/Vf Seizures 2ndary to eclampsia • Contraindications and precautions – – – – None in refractory Vf, VT, Torsades Renal disease Heart block Hypermagnesemia • Side effects – – – – – – Hypotension Asystole Cardiac arrest Respiratory and CNS depression Flushing Sweating • Dosage & Route – – – – Refractory VT: 1-2 gm IVP over 1-2 min. Refractory Vf: 1-2 gm IVP over 1-2 min. Digoxin-induced VT/Vf: 2 gm IVP Seizures 2ndary to eclampsia: 1-4 gm slow IVP Anticholingergics Atropine Sulfate • Class – Anticholinergic (parasympatholytic) – Muscarinic antagonist • Indications – – – – Symptomatic bradycardia Asystole PEA if bradycardia Insecticide poisoning • Action – Blocks the effects of acetylcholine at muscarinic receptors which would cause a decrease in heart rate. • Contraindications and precautions – Glaucoma or myasthenia gravis – Can cause tachycardia – Administer cautiously in pt. With MI or myocardial ischemia • Side effects – – – – – Dry mouth Blurred vision Urinary retention Constipation Tachycardia; possibly VT, Vf • Dosage & Route – Symptomatic bradycardia; 0.5 mg IVP q 5 min. Max dose 0.04 mg/kg – Asystole; 1.0 mg IVP q 5 min. Max dose 0.04 mg/kg – PEA; 1.0 mg IVP q 5 min. Max dose 0.04 mg/kg – Pesticide poisoning; 2-5 mg IV q 15-30 min. Antihypertensives • Diuretics Furosemide (Lasix) • Class – Loop diuretic agent – Antihypertensive agent • Indication – Edema 2ndary to CHF – hypertension • Action – Inhibits reabsorption of sodium and chloride from the loop of Henle and distal renal tubule • Contraindictions – Hypersensitivity; cross-sensitivity with thiazides and sulfonamides may occur • Precautions – Severe liver disease with cirrhosis or ascites • Adverse reactions, SE – Dehydration, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic acidosis • Dosage & route – 20 – 80 mg/day (prehospital setting: generally double the patient’s home dose up to 80 mg IVP) • How supplied – 10 mg/ml in 4 or 8 ml preloads Bumetanide (Bumex) • Class – Loop diuretic agent – Antihypertensive agent • Indication – Edema 2ndary to CHF – Hepatic or renal disease – Hypertension • Action – Inhibits reabsorption of sodium and chloride from the loop of Henle and distal renal tubule – Increases renal excretion of water, sodium, chloride, magnesium, hydrogen, calcium • Contraindication – Hypersensitivity; cross sensitivity with thiazides and sulfonamides • Precautions, – Pre-existing liver disease with cirrhosis or ascites • Adverse reactions, SE – Dehydration, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis • Dosage & Route – 0.5 – 1.0 mg/day IV – May be repeated q 2-3 h prn up to 10 mg/day • How supplied – 0.25 mg/ml in 10 ml syringes or preloads Aldactone (spironolactone) • Class – Potassium sparing diuretic • Indications – Counteract potassium loss caused by other diuretics – Commonly used with other agents ( diazides) to treat edema or hypertension • Action – Causes loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions. – Weak diuretic and antihypertensive agent when compared with other diuretics • Contraindication – Hypersensitivity – hyperkalemia • Precautions – Hepatic dysfunction – Geriatrics – Diabetics • Adverse reactions & SE – Hyperkalemia – Dizziness • Route & dosage – PO 25 – 400 mg/d as a single dose or 2-4 divided doses. CHF – 12.5 – 25 mg day • How supplied – 25, 50 or 100 mg tablets Antihypertensives • ACE Inhibitors - Angiotension converting enzyme enalapril (Enalaprilat, Vasotec) • Class – Antihypertensive • Indication – Hypertension – CHF • Action – ACE inhibitors block conversion of angiotension I to vasoconstrictor angiotension II. – Causes systemic vasodilation • Contraindications – Hypersensitivity • Precautions – – – – – Renal impairment Hepatic impairment Hypovolemia Geriatrics Concurrent diuretic therapy • Adverse reactions, SE – – – – – Angioedema Cough Hypotension Taste disturbances Proteinuria • Dosage & route – 0.625 – 1.25 mg q 6 h IV • How supplied – 1.25 mg in 1 mg preload or vial Antihypertensives • Calcium Channel Blocking Agents Nifedipine (Procardia) • Class – Antianginal agent – Antihypertensive agent – Calcium channel blocker • Indication – Hypertension – Angina – Prinzmetal’s angina • Action – Inhibits transport of calcium into myocardial and vascular smooth muscle cells – Systemic vasodilation, resulting in decreased BP • Contraindication – Hypersensitivity – Sick sinus syndrome – 2nd or 3rd degree block • Precautions – Severe hepatic impairment • Adverse reactions, SE – – – – Arrhythmias, CHF Headache Peripheral edema flushing • Dosage & route – 10 mg SL – May be repeated in 10 minutes • How supplied – 10 mg capsules Antihypertensive • Beta Blocking agent Labetalol • Class – Antianginal agent – Antihypertensive agent – Nonselective beta-adrenergic blocking agent • Indication – Management of hypertension • Action – Blocks stimulation of beta1 and beta2 adrenergic receptor sites • Contraindications – – – – Uncompensated CHF Pulmonary edema Cardiogenic shock Bradycardia or heart block • Precautions – Renal impairment – Hepatic impairment – Geriatrics • Adverse reactions, SE – – – – – – – Arrhythmias Bradycardias CHF Pulmonary edema Orthostatic hypotension Fatigue, weakness impotence • Dosage & route – – – – 20 mg (0.25 mg/kg) initially Additional doses of 40-80 mg q 10 min prn Max dose 300 mg Gtt 2 mg/min • How supplied – 5 mg/ml in 4 mg preload syringe • Direct Vasodilators Sodium Nitroprusside (Nitroprusside, Nitropress • Class – Antihypertensive agent • Indications – Hypertensive crisis – Cardiogenic shock • Action – Produces peripheral vasodilation by direct action on venous and arteriolar smooth muscle • Contraindications – Hypersensitivity – Decreased cerebral perfusion • Precautions – Renal disease – Hepatic disease – Geriatrics • Adverse reactions, SE – Cyanide toxicity – Dizziness, H/A – Abdominal pain, N/V • Route & dosage – 0.3 mcg/kg/min initially – May be increased prn up to 10 mcg/kg/min not to exceed 10 min. of therapy • How supplied – Powder for injection: 50 mg/vial – Reconstitute in 500 cc D5W – Concentration is 100 mcg/ml Other Vasodilators and Antianginals Nitroglycerin • Class: Antianginal agent; Nitrate • Indications: – Relief of acute anginal pain – Hypertension – CHF with APE • Action: – Relaxes vascular smooth muscle; decreases myocardial workload and oxygen demand • Contraindications – – – – – Hypotension Hypovolemia Intracranial bleed Aortic stenosis Recent Viagra use • Side effects – – – – – H/A 2ndary to vasodilation Hypotension N/V Tachycardia Flushing • Dosage & Route – Tablets • 0.3 - 0.4 mg SL q 3-5 min. • Max 3 doses – Paste • 1 – 2 cm (6-12 mg) topically – Spray • 1 - 2 sprays (0.4 - 0.8 mg) SL – IV • Mix 25 mg in 250 ml D5W (100 mcg/ml); infuse at 5 mcg/min, titrated to effect Atenolol (Tenormin) • Class – Antianginal agent – Antihypertensive agent – Selective beta-adrenergic blocking agent • Indication – Hypertension – Angina • Action – Blocks stimulation of beta1 receptors. Does not usually affect beta2 receptors. – Decreases BP and heart rate • Contraindications – – – – Uncompensated CHF Pulmonary edema Cardiogenic shock Bradycardia or heart block • Precautions – – – – Renal impairment Hepatic impairment Geriatrics Pulmonary disease (beta selectivity may be lost) – Diabetes (may mask signs of hypoglycemia) • Adverse reactions, SE – Bradycardia, CHF, pulmonary edema – Fatigue, weakness – Impotence • Dosage & route – 5 mg IV – Repeat in 10 min • How supplied – 0.5 mg/ml in 10 ml preload or vial Hemostatic Agents Antiplatelets Aspirin (Salicylate) • Class – Antiplatelet agent • Indication – – – – Inflammatory disorders Fever TIA MI • Action – Produces analgesia – Reduces inflammation and fever by inhibiting the production of prostoglandins – Decreases platelet aggregation • Contraindications – Hypersensitivity – Bleeding disorders or thrombocytopenia • Precautions – – – – – GI bleeds or ulcers Chronic alcohol use/abuse Severe renal disease Viral infections Pregnancy • Adverse reactions, SE – – – – – GI bleeding Anaphylaxis Laryngeal edema Dyspepsia, epigastric distress Heartburn, nausea • Dosage & route • Pain, Fever – PO, Rectal • 325 – 500 mg q 3 h OR • 325 – 650 mg q 4 h • Not to exceed 4 g/day • Cardiac chest pain – PO – 81 mg x 3 chewable childrens aspirin (243 mg) • (UNLESS TAKING COUMADIN) • How supplied • Childrens aspirin, 81 mg tablets • Aspirin 325 - 500 mg tablets • Anticoagulants Heparin • Class – Anticoagulant • Indication – Venous thromboembolism – Pulmonary emboli – Af with embolization • Action – Potentiates inhibitory effect of antithrombin on factor Xa and thrombin – Prevents conversion of fibrinogen to fibrin • Contraindications – Hypesensitivity – Uncontrolled bleeding – Severe thrombocytopenia • Precautions – – – – – Severe liver or kidney disease Untreated hypertension Ulcers Spinal cord or brain injury Women > 60 y/o • Adverse reactions, SE – Bleeding – Anemia – Thrombocytopenia • Route & dosage – 10,000 units, followed by 5,000 – 10,000 units q 4-6 h IV – Gtt: 15 – 18 units/kg/hr • How supplied – 1,000 – 5,000 units/ml in 10 ml tubex or preload syringes • Thrombolytics Alteplase (Activase, t-PA) • Class – Thrombolytic agents (plasminogen activators) • Indications – Coronary thrombosis – Acute ischemic stroke • Action – Converts plasminogen to plasmin, which is then able to degrade fibrin in clots. • Contraindications – – – – – Active internal bleeding Hx of CVA Recent CNS trauma or surgery Severe uncontrolled hypertension Known bleeding tendencies • Precautions – Recent (10 days) major surgery – GI or GU bleeding • Adverse reactions, SE – – – – – Intracranial hemorrhage GI bleeding, retroperitoneal bleeding GU tract bleeding Anaphylaxis Reperfusion arrhythmias • Dosage & route – MI • 60 mg over first hour, 20 mg over 2nd hour, 20 mg over 3rd hour for total dose of 100 mg. • How supplied powder for injection, packaged with sterile water for injection 20 mg vial or 50 mg vial Reconstitute with 20 mg or 50 mg using 18-ga needle Avoid excess agitation; solution may foam • Start two IV lines first Other Cardiac Medications Calcium Chloride & Calcium Gluconate • Class – Mineral, electrolyte • Indications – Hyperkalemia – Hypermagnesemia – Cardiac arrest • Action – Acts as an activator in transmission of nerve impulses and contraction of cardiac, skeletal, smooth muscles • Contraindications – Hypercalcemia – Vf • Adverse reactions,SE – – – – Cardiac arrest Arrhythmias Constipation, nausea Phlebitis • Route & dosage: cardiac arrest – 7 – 14 mEq IVP • How supplied • Calcium chloride 10% – 1.36 mEq/ml in 20 ml preloads • Calcium gluconate 10% – 0.45 mEq/ml in 20 ml preloads Dopamine (intropin) • Class – Cardiotonic and inotropic agent – Vasopressor • Indications – Improve BP – Improve cardiac output • Action – Small doses stimulate dopaminergic receptors, producing renal vasodilation – Large doses stimulate dopaminergic and betaadrenergic receptors, producing cardiac stimulation and renal vasodilation – Larger doses stimulate alpha-adrenergic receptors and may cause renal vasoconstriction • Contraindications – Tachyarrhythmias – Pheochromoctoma – Hypersensitivity to bisulfites • Precautions – Hypovolemia – MI • Adverse reactions, SE – Arrhythmias, hypotension • Route & dosage – Renal vasodilation – 0.5 – 3 mcg/kg/min IV – Cardiac stimulation – 2.0 – 10.0 mcg/kg/min IV – Increased peripheral vascular resistance – 10 mcg/kg/min; titrate to effect • How supplied – 40 mg/ml or 80 mg/ml in preload or vial – Premixed injection: 1600 mcg/ml in 250 and 500 ml D5W Dobutamine • Class – Cardiotonic and inotropic agent • Indications – Short-term management of heart failure caused by depressed contractility • Action – Stimulates beta1 receptors with minor effect on heart rate or peripheral vessels • Contraindications – Hypersensitivity – IHSS • Precautions – – – – – History of hypertension MI Af Ventricular ectopic beats hypovolemia • Adverse reactions, SE – Hypertension, increased heart rate – PVCs • Route & dosage – 0.5 – 1.0 mcg/kg/min, titrated to effect (range 2 - 20 mcg/kg/min • How supplied – 12.5 mg/ml in 20 ml vial Epinephrine 1:10,000 • Class – Direct-acting catecholamine secreted by the adrenal medulla in response to sympathetic stimulation. • Indications – – – – – Asystole Vf Pulseless VT PEA Acute bronchospasm associated with asthma or COPD – Anaphylaxis • Action – Stimulates beta1, beta2 and alpha1 receptors. – Effect on beta receptors significantly more profound than on alpha receptors. – Beta1 stimulation results in increased contractility, increased heart rate, increased AV conduction – Can cause spontaneous myocardial contraction in asystole. – Increases likelihood of successful defibrillation – Beta2 stimulation results in bronchodilation, vasodilation in skeletal muscle – Stimulation of alpha1 receptors causes vasoconstriction • Note: Vascular effects are dose-related. – At low doses, beta2 receptors predominate with decreased total peripheral resistance and decreased BP – With larger doses, alpha effects predominate with increased peripheral vascular resistance and increased BP. • Contraindications and precautions – No contraindications in cardiac arrest – Protect Epi from light – Unstable in alkaline solutions I.e., Sodium Bicarbonate • Side effects – – – – CNS stimulation H/A, dizziness, pallor N/V Palpitations • Dosage – Cardiac Arrest: 1 mg IVP q 3-5 min. – Endotracheal admin. 2 – 2.5 x IV dose – Acute bronchospasm assoc. with asthma, COPD: 0.3 mg – 0.5 mg 1:1,000 solution SC q 5-20 min. • How supplied – 1 mg/ml in 10 ml preload Isoproterenol (Isuprel) • Class – Beta-adrenergic agonist • Indications – Refractory torsade de pointes – Immediate temporary control of hemodynamically significant bradycardia of heart transplant patients • Action – Causes an increase in rate and force of heart contractions • Contraindications – Ischemic heart disease – Hypotension – Cardiac arrest • Adverse reactions, SE – Arrhythmias – VT, Vf – NOTE: increases cardiac oxygen demand • Dosage & route – 2 – 10 mcg/min IV; titrate to HR and rhythm – Mix 1 mg in 250 ml of D5W; gtt at 2 mcg/min • How supplied – 1 mg in 1 ml preload Metaprolol (Lopressor) • Class – Antianginal agent – Antiarrhythmic • Indications – Hypertension – angina • Action – Blocks stimulation of beta1 adrenergic receptors. • Contraindications – – – – Uncompensated CHF Pulmonary edema Cardiogenic shock Bradycardia or heartblock • Precautions – Renal impairment – Hepatic impairment – Geriatrics • Adverse reactions, SE – Bradycardia, CHF, pulmonary edema – Fatigue, weakness • Dosage & route – MI: 5 mg q 2 min for for total of 15 mg. Then 50 mg orally bid for at least 24 hours; then increase to 100 mg bid • How supplied – 1 mg/ml in 5 mg preload or vial Propranolol (Inderal) • Class – Antianginal agent – Arrhythmic agent – Antihypertensive agent • Indication – – – – VT, Vf, Af, AF, PSVT Hypertension Angina Anterior MI w/ HTN, tachycardia • Action – Blocks stimulation of beta1 and beta2 adrenergic receptor sites • Contraindication – – – – Uncompensated CHF Pulmonary edema Cardiogenic shock Bradycardia or heart block • Adverse reaction, SE – Arrhythmias, bradycardia, CHF, pulmonary edema – Fatigue, weakness • Dosage & route – 1 – 3 mg; repeat after 2 min and again in 4 hours prn • How supplied – 1 mg/ml in 3 ml preload Norepinephrine (Levophed) • Class – Adrenergic – Vasopressor • Indications – Hemodynamically significant hypotension – Septic or neurogenic shock • Action – Beta1 adrenergic effect increases myocardial contractility and potent alpha adrenergic effect causes arterial and venous vasoconstriction • Contraindications – Hypotension 2ndary to hypovolemia – Myocardial ischemia or infarction • Precautions – Hypertension – Cardiac disease – Increases cardiac oxygen demand but does not increase coronary blood flow • Adverse reactions, SE – Bradycardia, hypertension, arrhythmias, chest pain – Dyspnea – Necrosis at IV site • Route & dosage – 0.5 – 30 mcg/min titrate to effect – Mix 4 mg in 250 ml D5W (16 mcg/ml) Sodium Bicarbonate • Class: Alkalinizing agent • Indications: – Metabolic acidosis 2ndary to cardiac arrest – Cyclic antidepressants • Action: – Neutralizes excess acid • Contraindications and precautions – None in confirmed metabolic acidosis – Precaution: Tissue necrosis if infiltrates • Side effects: – Metabolic alkalosis – Decreased potassium – Fluid overload • Dosage: – 1 mEq/kg IVP followed by 0.5 mEq/kg q 10 min. • How supplied – 1 mEq/ml in 50 ml preload Vasopressin • Class – Antidiuretic hormone – Non-adrenergic peripheral vasoconstrictor • Indications – Alternative to Epinephrine in refractory Vf – May be effective with asystole, PEA • Action – Directly stimulates smooth muscle receptors – Increases coronary perfusion pressure • Contraindications, precautions – None in cardiac arrest • Adverse reactions, SE – unknown • Dosage & route – 40 units, IVP, one time only • How supplied – unknown