EMERGENCY SUPPORTING

DRUGS

SMF/BAG. ANESTESIOLOGI & REANIMASIRSUD dr. MOEWARDI/FK UNS

These drugs have the advantages in increasing on cerebral and

coronary perfusion. It also usefull to control rate and rhythm of the

heart. We administer these drugs before, during and

after CPR

IMPORTANT DRUGS• BP

- Epinephrine / adrenaline- Vasopresine- Dopamine

• HR- Atropine

• Ventricular arrhythmia- Amiodarone - Procainamide- Lidocaine - MgSO4

• Supraventriculare arrhythmia

- Adenosine- Diltiazem- Amiodarone

• AMI- Morphine - Aspirine- Nitroglycerine - Fibrinolytica

• MISC- Sodium bicarbonate- Calcium chloride

DECISION TO USE AGENT

1. Understand mechanism of action

2. Know indication for use3. Know advert effect4. Know potential interactions

EPINEPHRINE/ADRENALINE

MECHANISM OF ACTION- & adrenergic stimulation- SVR, BP (S & D)- coronary and cerebral blood flow- myocardial O2 requirement- electrical & strength of myocardium- automaticity

INDICATION - All patients in cardiac arrest- Severe hypotention- Symptomatic bradycardia- Anaphylaxis

DOSAGEa. Cardiac arrest :

1 mg I.V. flush with 20 ml NS + arm

elevation for 10-20 s 2 – 2,5 x i.v. dose through ETT

b. Non cardiac arrest : 2 – 20 mc/min

PRECAUTIONS- Precipitable in alkaline solution

VASOPRESSIN

MECHANISM OF ACTION- Potent vasoconstrictor- SVR, BP (S&D)- Coronary and cerebral blood flow

INDICATION- alternative to 1st and 2nd dose of epinephrine for VF / VT (-)

DOSAGE40 I.V. Push 1x

PRE CAUTIONmay provoke cardiac ischemia

MECHANISM OF ACTION :stimulation of dopaminergie & adrenergic receptor

INDICATION- Hipotension (70 – 100 mmHg)- Second drug for hypotensive

bradycardia

DOPAMINE

DOSAGE :- 5 – 20 mc/Kg/min- titrate to response

PRECAUTIONS :- Start after volume replacement- tapper gradually- do not mix with sodium bicarbonate- monitor I.V. site

MECHANISME OF ACTION - Block parasympathetic receptor of heart - SA node automatically - AV node conduction - Not to stimulate the hear

INDICATION - Symptomatic sinus bradycardia- While waiting for pacing- Second drug in asystole / PEA- Organophosphate poisoning

ATROPINE

DOSAGE- Arrest : 1 mg i.v. 2 - 3 mg ETT- Bradycardia : 0,5 mg i.v- Max 3 mg- Extremely large doses may be need for organophospate poisoning

PRECAUTIONS- paradoxical bradycardia with < 0,5 mg- worsen myocardial ischaemia- avoid in hypothermia bradycardia- not useful in AV block of : 2nd degree type II 3rd degree

AGENT FOR CONTROL OF RATE AND RHYTHMClassification of antiarrhythm

Vw CLASS CHANNEL EFFECT EFFECT ON ACTION POTENTIAL

DRUG

1a Na channel blockersmoderate

Phase 0Na influx

ProcainamideDisopyramide

1b Na channel blockersWeak

Phase 0Na influx

lidocain

1c Na channel blockersstrong

Phase 0Na influx

PropafenonFlecainamide

II adrenergic blockers Decreased SA node automaticitySlow av node conduction

Atenolol,Propanolol,metoprolol,esmolol,labetolol

III K channel blockers Phase 3K efflux

Amiodaron,bretilium,dofetilide,ibutilide,sotaol

IV ca channel blockers Phase 4Ca influx

Diltiazem,verapamil

AMIODARONE

MECHANISME OF ACTION- block Na, K and Ca channels- and blocking properties

INDICATION- VF/ VT cardiac arrest refractory to shock + epinephrine- Recurrent life – threatening VT- Other arrhythmias- VT narrow QRS

DOSAGE- Cardiac arrest 300 mg i.v. push (in 20 ml D5) + 150 mg i.v. push in 3 – 5 min 1x

- Ventricular tachyarrhythmias 150 mg i.v. over 10 min

- Maintenance 1 mg/min i.v. for 6 hours then 0,5 mg/min i.v. for 18 hours

- Max dose 2,2 g/day

PRECAUTIONS- Multiple drugs interaction- Long half-life (up to 40 days)- Hypotention with rapid/repeated dose- Prolong QT interval

LIDOCAINE / LIGNOCAINE

• MECHANISM OF ACTION- block Na channel- ventricular ectopy- excitability in ischemic tissue

• INDICATION - alternative to amiodarone in cardiac arrest for VT/VF - stable VT with good LV

• DOSAGE

- Loading : 1 - 1,5 mg/Kg i.v. push (arrest) 0,5 – 0,75 mg/Kg i.v. push (stable VT) ETT = 2 – 4 mg/Kg

- Maintenance :

1– 4 mg/min i.v.

- Precautions Not reccomended as prophylaxis in MI Reduce dose

- Impaired liver function - Poor LV

Stop infusion if sign of toxicity occurs

PROCAINAMIDE

MECHANISME OF ACTION :- block Na channel- ventricular ectopy- conduction

INDICATION :- suppression of recurrent VT/VF- other tachy-arrhythmias

DOSAGE :Reccurrent VT/VF :- 20 mg/min- maintenance = 1 – 4 mg/min

PRECAUTIONS :- hypotension- reduce to 12 mg/min in patient with heart/renal failure - prolong QT interval- pro-arrhythmic, esp. in AMI, K, Mg

MAGNESIUM SULPHATE• Drug of choice for Torsades de

pointes

• Dosage :- 1 – 2 gr i.v. over 5 – 20 min- then infusion 0,5 – 1 gr/hr- Titrate to control Torsades

ADENOSINE/AT

P• MECHANISME OF ACTION :

- SA node and AV node- short half life < 5 s

• INDICATION :- termination of PSVT- unstable SVT during cardioversion preparation - will be difficult to indentify SVT with narrow QRS

• DOSAGE :- 6 mg adenosine/10 mg ATP push 1 – 3 s follow by 20 ml NS if no response in 1 – 2 min- 12 mg adenosine/20 mg ATP push- 3rd dose of 12 mg adenosine/20 mg ATP

• PRECAUTIONS :flushing, dyspnoe, chest pain

DILTIAZEM

• MECHANISME OF ACTION :- Ca channel blocker- automaticity- conduction

• INDICATION :- rate control for AF- terminate stable re-entry SVT if adenosine fails

• DOSAGE :- 15 – 20 mg over 2 min- repeat in 15 min at 20 - 25 mg i.v.- then 5 – 15 mg/hr- titrate of effect

»PRECAUTIONS :Not to be used in :- wide complex tachycardia of uncertain origin- drug induced tachycardia- WPW syndrome with AF

DRUGS FOR AMI

greets all MI patients

MORPHINE

• MECHANISME OF ACTION :- relieve pain and anxiety- myocardial oxygen demand- SVR- venous capacitance

• INDICATION :- chest pain- acute cardiogenic pulmonary edema

• DOSAGE :- 2 – 4 mg i.v, slowly - Goal = pain ( - )

• PRECAUTIONS :- hypotension- CNS/respiratory depression

NITROGLYCERIN

• MECHANISME OF ACTION :Vasodilatation :- pre load, after load- coronary artery vasodilatation

• INDICATION :- ischemic chest pain- ongoing or recurrent ischaemia in MI- pulmonary edema, hypertensive urgency

• DOSAGE :- i.v. = start with 10 – 20 mc/min- SL = 0,5 mg, repeat after 5 min

• PRECAUTIONS :- hypotension- headache

ASPIRIN

• MECHANISM OF ACTION :- anti platelet aggregation- blocking production of tromboxane A2- decrease mortality caused by IMA- decrease reinfark risk

• INDICATION :- all patient with ACS

• DOSAGE :- 160 – 320 mg PO- chewing

• PRECAUTIONS :- ulcus pepticum, asthma- hypersensitive

FIBRINOLYTICS

• MECHANISME OF ACTION :reperfusion of myocardium

• INDICATION :- ST elevation MI or new LBBB- < 12 hr from onset

• CHOICE :- streptokinase

• DOSAGE :streptokinase 1,5 million unit i.v. dilute in 100 cc, infused for 30 – 60 min

• PRECAUTION :- bleeding - allergy- hypotension - reperfusion arrhythmia

• CONTRA INDICATION :- history of haemorhage stroke- history of nonhaemorhage stroke in the past year- intra cranial tumor - active internal bleeding

CALCIUM CHLORIDE

• INDICATION :- Hypo Ca- Hyper K- Ca channel blocker/-blocker overdose

• DOSAGE :5 – 10 ml 10% CaCl2

SODIUM BICARBONATE

• INDICATION :- Hyper K- Tricyclic antidepressant overdose

• DOSAGE :- 1 mmol/Kg i.v. bolus- monitor BGA

• PRECAUTION :not routine for cardiac arrest

PHARMACOLOGIC ALTERATIONSIN PREGNANCY

• metabolism and volume of distribution of drug

• increased plasma volume • changes in the blood consentration• Local anesthetic drugs induce fetal

acidosis • blocker capable of causing fetal

bradycardia

• vasopressors can cause utero-placental vasoconstriction, with reduced fetal oxygenation & carbondioxide elimination

• sodium bicarbonate crosses the placental barrier

Guidelines for Resuscitation 2005

1. Main changes in adult basic life support

2. Main changes in automated external defibrillation

3. Main changes in adult advanced life support

4. Main changes in paediatric life support

• unresponsive and not breathing

normally

• place the hands on the centre

of the chest

• 1 sec rather than 2 sec

• the ratio of compressions to ventilations is 30 : 2 • 30 compressions is being

given immediately (for adult)

• start CPR (….A-B-C etc)

• Using the rib margin method is wasting time

• each rescue breath over

1 sec

• for all adult, and children

( for a lay rescuer)

• the 2 initial rescue breaths are omitted

Main changes in adult basic life support

Main changes in adult advanced life support

1. CPR before defibrilation2. Defibrilation strategy3. Fine VF4. Adrenaline ( epinephrine )

5. Anti-arrhythmic drugs6. Thrombolytic therapy for cardiac arrest7. Post resuscitation care – therapeutic hypothermia

CPR before defibrilation

• in out of hospital C A• unwitness cardiac arrest

• do not delay defibrilation

• Give CPR for 2 minutes

(30 : 2 )

• witnessed cardiac arrest