drugs in cpr - m.h.farjoo

8/11/2019 Drugs in CPR - M.H.farjoo

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Drugs in CPR

By

M.H.Farjoo M.D. , Ph.D.Shahid Beheshti University of Medical Science


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Epinephrine is a mixed - and -agonist thatincreases blood pressure, coronary perfusion

pressure,and cerebral blood flow.

it is the mainstay of pharmacologic therapy in the pulseless patient, regardless of the underlying rhythm.

Epinephrine may be given through an endotrachealtube if IV access cannot be obtained. (2.0-2.5 mg in10 cc of normal saline).High-dose epinephrine in adults is no longerrecommended .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Vasopressin (ADH) causes peripheralvasoconstrictionIt also constricts coronary, cerebral, and renalvasculature.vasopressin has no benefit over epinephrine incardiac arrest.


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Dopamine exhibits dopaminergic and both -and -adrenergic effects.

Doses > 20 g/kg/min may have adverseeffects on splanchnic perfusion and should beavoided.

If hypotension persists after optimization offilling pressures, norepinephrine or dobutamineshould be considered .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Norepinephrine affects -receptors in the vasculatureand 1-receptors of the heart.

It causes peripheral vasoconstriction and increased

heart rate and contractility.It is used in severe shock and is recommended formanagement of hypotension when systolic pressuresare less than 70 mm Hg.

The starting infusion rate is 0.5-1.0 g/min andtitrated to effect, with a maximal infusion rate of 30g/min .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Dobutamine has potent 1-agonist properties.

it improves myocardial contractility and increasecardiac output.

It is the agent of choice in patients with systolic blood pressure of 70-100 mm Hg.

Paradoxically it can worsen hypotension in patientswith inadequate preload.

In addition, it can provoke tachyarrhythmias.

It is run as an IV infusion of 2-20 mg/kg/min .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Adenosine is a potent but short-lived AV nodal blocking agent.

Along with vagal maneuvers, it is considered first-line therapy in paroxysmal supraventriculartachycardia (PSVT) secondary to a reentrant-typeconduction defect.

Adenosine should not be used as an aid indifferentiating between PSVT with aberrantconduction and VT.


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

It is associated with a prolonged sinus pause.

The initial dose is 6 mg, given as a rapid bolus

which can be increased to 12 mg IV.If there is no response, this dose may berepeated in 1-2 minutes


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Amiodarone is useful in treating both supra- andventricular tachydysrhythmias.

For VF and pulseless VT, the initial dose is 300 mg

IV, which can be followed with a second dose of 150mg if the arrhythmia persists.

While amiodarone has been found to increase the rateof survival from cardiac arrest, it has not been shownto increase survival to hospital discharge.Amiodarone is a second-line agent for PSVT and can

be used when adenosine fails.


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Atropine is useful in the treatment of symptomatic bradycardias that are due to increased parasympathetic tone.Atropine should not be used when infranodal

pathology is suspected such as with second-degreeAV blocks.Atropine is indicated in the setting of asystole and

bradycardic.Atropine is ineffective in the setting of previous hearttransplant and may worsen ischemia during amyocardial infarction.


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

-Blockers are indicated for SVT for rate control in patientswith preserved left ventricular function.

Atenolol and metoprolol are 1-blocking agents available in both IV and oral formulations.

Esmolol is a short- acting 1-agent that must be given in a bolus and then maintained through a continuous infusion.

this may be advantageous in patients who may respondnegatively to 2-blockade (e.g., patients with COPD).

If an adequate response is not achieved after 5 minutes, theloading dose may be repeated and the infusion rate doubled .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Calcium channel blockers (i.e., diltiazem andverapamil) are also indicated for rate control in SVT.

They slow AV nodal conduction and prolong the AV

nodal refractory period.they are contraindicated in atrial fibrillation or atrialflutter with rapid ventricular response when anaccessory pathway such as Wolf-Parkinson-Whitesyndrome exists.Diltiazem is better tolerated in patients with impairedleft ventricular function .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Lidocaine is commonly used for ventricular rhythms, both stable and unstable.

Its use has largely been replaced by amiodarone.

The initial dose in VF and pulseless VT is 1.0-1.5mg/kg.

Half of this dose may be repeated every 5-10 minutes,with a maximal total dose of 3 mg/kg.

If successful in terminating the offending rhythm, amaintenance infusion of 3-5 mg/min is administered .


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M.H.Farjoo MD, Ph.D

Cardiac Arrest

Magnesium is indicated for:those suspected to have a low magnesium levelrecurrent ventricular dysrhythmiasthose with torsades de pointes .


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Drug Name Adult Dose Pediatric Dose Indications Frequency Effects

Epinephrine 1 mg IVOR2-5 mg IV via ETT

0.01 mg/kg IV or10OR

0.1 mg/kg viaETT

Any pulselessrhythms

Every 3-5 min Increases perfusion tomyocardium and tobrain by increasing

peripheral vascularresistance

Vasopressin 40 units IV Not indicated VF, pulseless VT Single dose, may befollowed at 10 min byepinephrine

Increases peripheralvascular resistance

Amiodarone For VF orpulseless VT: 300mg IV push

For VF orpulseless VT: 5mg/kg IV push

VF, pulseless VT,VT with a pulse,SVT

May use seconddose of 150 mg forrecurrent VF/VT. Inchildren may berepeated in 5 mg/kgdoses to a total of 15mg/kg

Predominately class IIIantiarrhythmic, but hassodium, potassiumchannel, and and receptor blockade

Lidocaine 1.0-1.5 mg/kg IVpush

Same VF, pulseless VT,VT with a pulse

Second andsubsequent doses of0.75 mg/kg every 5min to a total dose of

3 mg/kg

Class IBantiarrhythmic;suppresses ventricularautomatically and

electrical conductionMagnesium 1-2 g IV slow push 25-50 mg/kg IV

slow pushTorsade depointes, knownhypomagnesemia

Single dose Can cause cutaneousflush, apnea, andhyporeflexia, if giventoo quickly

ETT, endotracheat tube; IO, intraosseoulsy; IV, intravenously; SVT, supraventriculartachycardia; VF, ventricular fibrillation; VT, ventricular tachycardia.

*Agents are listed from most effective (and most commonly used) to least.


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Procainamide 17 mg/kg IV slowbolus at maximumrate of 50 mg/min

15 mg/kg IV load;3-6 mg/kg over 5min, not toexceed 100mg/dose

VT with a pulse Continue infusion (4mg/min) until QRSwidening >50%,dysrhythmiaterminated, onset ofhypotension; or 17

mg/kg infused

Decreases myocardialexcitability andconduction velocity

Atropine Perfusing patients:0.5 mg IV push q 5min, to maximumof 3 mgPulseless patients:1.0 mg IV push q 5min, to maximumof 3 mg

0.02 mg/kg:minimum dose of0.1 mg

Bradycardia,asystole

May be repeatedonce up to maximumdose of 3 mg

Parasympatholytic,eliminates vagal tone

Adenosine 6 mg rapid IV pushthrough proximalperipheral line;central line dose isone-half

0.1 mg/kg rapidIV push;maximum dose,6 mg

SVT If needed, seconddose of 12 mg(pediatric, doubleinitial dose up to 12mg); third dose of 12-18 mg

Endogenousnucleoside causingbrief asystole allowingdominant pacemakerto resume function

Diltiazem 0.25 mg/kg to a

maximum dose of20 mg IV pushover 2 min

Same SVT Second dose of 0.35

mg/kg, maximumdose of 25 mg, at 15min; afterconversion, startdiltiazem drip at 5-15mg/h

Calcium channel

blocker

ETT, endotracheat tube; IO, intraosseoulsy; IV, intravenously; SVT, supraventriculartachycardia; VF, ventricular fibrillation; VT, ventricular tachycardia.

*Agents are listed from most effective (and most commonly used) to least.


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Dobutamine 2-20 ug/kg/min Same Hypotension Titrate to effect Inotropic agent ( -agonist)

Norepinephrine

Start at 8-12ug/min, then titrateto 2-4 ug/min formaintenance;maximum dose of30 ug/min ifhypotensionunresponsive tolower doses

0.05-2 ug/kg/min Hypotension Titrate to effect Vasopressor(predominately an -agonist)

Phenylephrine 100-500 ug bolusIV

0.1-0.5 ug/kg/min Hypotension Every 5 min untildesired effect, thencontinuous infusionof 40-180 ug/min

Vasopressor (pure -agonist)

ETT, endotracheat tube; IO, intraosseoulsy; IV, intravenously; SVT, supraventricular tachycardia; VF, ventricular fibrillation; VT,ventricular tachycardia.* Agents are listed from most effective (and most commonly used) to least.


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M.H.Farjoo MD, Ph.D

Drugs for Intubation

Many patients in the emergency department can be intubatedwithout the use of pharmacologic intervention other thanoxygen.

By pharmacologic adjuncts may dramatically reduce the

difficulty of intubation.Local, topical, or regional anesthesias are usually notconsidered options for an emergently compromised airway.

Occasionally, sedation alone may be useful in preparing forintubation.

For a semiobtunded or combative patient, use ofneuromuscular blockade with sedation, provides rapid controlof the airway.


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M.H.Farjoo MD, Ph.D


Drugs that induce apnea must be used by or under thedirect supervision of experienced clinicians.

They should be prepared to obtain a surgical airwayin the event of failed intubation.

Equipment necessary for intubation and surgicalairway must be prepared in advance

They must be available at the bedside before the patient is sedated or anesthetized


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M.H.Farjoo MD, Ph.D


in awake or semiconscious patients a short-actingsedative is given to decrease agitation.

A rapid-acting neuromuscular blocker is given to paralyze the patient.

The patient is intubated immediately after paralysis.Further sedation or paralysis may then be effected asindicated.

During the short period when the patient is paralyzedand not intubated, the airway must be protected fromaspiration with cricoid pressure.


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Rapid-sequence intubation protocol.

Preoxygenate with 100% oxygen. (Use bag-valve-maskventilatory assistance only as needed.)

Give rapid intravenous injection of sedative. *

For trauma patients: Maintain in-line cervical traction frominduction and until cervical collar can be replaced after theendotracheal tube has been secured.

Give rapid intravenous injection of succinylcholine, + 1-2 mg/kg(unless contraindicated).

Initiate cricoid pressure and stop bag-valve-mask ventilation.

Observe for fasciculations followed by apnea.

Immediately intubate upon onset of apnea.

Begin ventilation.

Inflate endotracheal tube cuff and release cricoid pressure.

Confirm tube position clinically to auscultate breath sounds, useend-tidal CO2 detector.

Secure tube.Provide additional sedation and paralysis as indicated.*Sedative drug choices: Etomidate, 0.3 mg/kg; Methohexital,0.5-1 mg/kg; Midazolam, 0.1-0.3 mg/kg; Fentanyl, 1-5 mg/kg;Ketamine, 1-2 mg/kg; Thiopental, 1-4 mg/kg. + Alternativeneuromuscular blocker: Vecuronium, 0.1-0.25 mg/kg;Rocuronium, 0.6 mg/kg. (Use only when succinylcholine iscontraindicated .)


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M.H.Farjoo MD, Ph.D

Succinylcholine

Succinylcholine is a depolarizing neuromuscular blockingagent .

The dose is 1.0-1.5 mg/kg in adults, 1.5-2.0 mg/kg in children .

Onset is 60 seconds to complete relaxation and duration is 5-10 min .

It is drug of choice for the RSI protocol under mostcircumstances owing to rapid onset, complete muscularrelaxation, and short duration .

One single dose suffices in emergency department setting andis well tolerated.


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M.H.Farjoo MD, Ph.D

Succinylcholine

It is contraindicated in :

If there is risk factors for hyperkalemia .

Hereditary pseudocholinesterase deficiency (1 in2800 patients)

Penetrating ocular trauma or glaucoma .

Known family or personal history of malignanthyperthermia .

Hypersensitivity to succinylcholine .


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M.H.Farjoo MD, Ph.D

Succinylcholine

Adverse effects and precautions

Causes arrhythmias, and hyper- and hypotension.Use with care in setting of irritable myocardium .

Fasciculations

Hyperkalemia

Pseudocholinesterase inhibition may occur in pregnancy, in renal and hepatic insufficiency


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M.H.Farjoo MD, Ph.D

Succinylcholine

Adverse effects and precautions (Contd)

Malignant hyperthermia (occurs in 1 in 50,000 patients)

Histamine release (bronchospasm or anaphylactoidreaction) . IOP is elevated during fasciculations .

ICP may increase .

Intragastric pressure may increase; use cricoid pressureuntil endotracheal tube cuff is inflated .

Always use sedation with alert patients


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M.H.Farjoo MD, Ph.D

Vecuronium

Vecuronium is a nondepolarizing neuromuscular blocking agent .

Standard dose is 0.1 mg/kg. To achieve rapidintubating conditions, 0.25 mg/kg may be used . Onset is dose dependent; standard doses achieve

paralysis in 3-5 minutes, larger doses in 1-1.5 min .

Duration is dose dependent; standard doses last 20-40minutes and larger dose prolong paralysis 2-3 timesthe usual duration .


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M.H.Farjoo MD, Ph.D

Drugs for IntubationSeveral agents may be added to the RSI protocol underspecific circumstances . Atropine, 0.01-0.02 mg/kg given immediately before thesedative, attenuates the vagal bradycardia associated withsuccinylcholine.Children, who tend to be more sensitive to the bradycardic andhypotensive effects of succinylcholine, benefit from

pretreatment with atropine.Therefore all children younger than 10 years should be

pretreated with atropine before succinylcholine isadministered.Pretreat adults with bradycardia and those receiving a seconddose of succinylcholine .


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M.H.Farjoo MD, Ph.D


Lidocaine, 1.5 mg/kg given 1 minute beforeintubation, may attenuate elevations in ICP associatedwith succinylcholine and intubation.It may have some protective effect againstlaryngospasm and ventricular arrhythmias duringintubation . If pain control is important, morphine sulfate, 0.1mg/kg or fentanyl, 1-2 g/kg IV should be addedafter intubation

barbiturates have little analgesic effect andneuromuscular blockers have none .


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Thank youAny question?


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M.H.Farjoo MD, Ph.D

CARDIAC ARREST

FIBRINOLYTIC THERAPYMost cases of sudden cardiac death are secondary to anintravascular thrombosis, with the majority of these casesrelated to either an intracoronary thrombus or massive

pulmonary embolus. The primary goal in treating these patients is restoring perfusion immediately. In the case ofmyocardial infarction, the two methods to restore coronary

blood flow are fibrinolytic therapy and percutaneous coronaryintervention (PCI). Multiple studies have found that in centers

that can provide rapid PCI, there is improved outcome and adecreased rate of reocclusion when compared to fibrinolytictherapy. However, the presentation to PCI should occur within90 minutes.


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M.H.Farjoo MD, Ph.D

CARDIAC ARREST

FIBRINOLYTIC THERAPY : (edaneh) Most facilities areunable to perform PCI, and many transfer the patient to centerswith catheterization capabilities. If the patient is unable toundergo PCI in the 90-minute period, initiation of fibrinolytic

therapy should be initiated if not contraindicated. Ideally, iffibrinolytic therapy is to be initiated, it should occur within 30minutes of the patient's presentation. Maximum benefit is seenin those patients who present within 3 hours from the onset ofsymptoms. There are current trials in which thrombolytics are

given by properly trained EMS personnel. However, there has been no demonstrated improvement in survival to hospitaladmission or discharge.


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M.H.Farjoo MD, Ph.D

Vecuronium4. Indications and advantages

a. One of the NDNMBs that can be used when succinylcholine iscontraindicated . b. Relative short duration allows neurologic reevaluation and providessatisfactory paralysis for procedures such as computed tomography scan inan emergency setting . c. Minimal cardiovascular effects at usual doses . d. Reversible after partial recovery (evidence of head lift, respiratoryeffort, or muscle twitch response) with neostigmine, 0.04 mg/kgintravenously. Atropine, 0.02 mg/kg intravenously, must also beadministered to prevent muscarinic side effects . e. Does not cause fasciculations or elevate intracranial pressure .


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Choking pic.

drugs in cpr - m.h.farjoo

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