Drugs in CPR

By
M.H.Farjoo M.D. , Ph.D.
Shahid Beheshti University of Medical Science
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Epinephrine is a mixed - and -agonist that
increases 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 endotracheal
tube if IV access cannot be obtained. (2.0-2.5 mg in
10 cc of normal saline).
High-dose epinephrine in adults is no longer
recommended.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Vasopressin (ADH) causes peripheral
vasoconstriction
It also constricts coronary, cerebral, and renal
vasculature.
vasopressin has no benefit over epinephrine in
cardiac arrest.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Dopamine exhibits dopaminergic and both -
and -adrenergic effects.
Doses > 20 g/kg/min may have adverse
effects on splanchnic perfusion and should be
avoided.
If hypotension persists after optimization of
filling pressures, norepinephrine or dobutamine
should be considered.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Norepinephrine affects -receptors in the vasculature
and 1-receptors of the heart.
It causes peripheral vasoconstriction and increased
heart rate and contractility.
It is used in severe shock and is recommended for
management of hypotension when systolic pressures
are less than 70 mm Hg.
The starting infusion rate is 0.5-1.0 g/min and
titrated to effect, with a maximal infusion rate of 30
g/min.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Dobutamine has potent 1-agonist properties.
it improves myocardial contractility and increase
cardiac output.
It is the agent of choice in patients with systolic blood
pressure of 70-100 mm Hg.
Paradoxically it can worsen hypotension in patients
with inadequate preload.
In addition, it can provoke tachyarrhythmias.
It is run as an IV infusion of 2-20 mg/kg/min.
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 supraventricular
tachycardia (PSVT) secondary to a reentrant-type
conduction defect.
Adenosine should not be used as an aid in
differentiating between PSVT with aberrant
conduction and VT.
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 be
repeated in 1-2 minutes
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Amiodarone is useful in treating both supra- and
ventricular tachydysrhythmias.
For VF and pulseless VT, the initial dose is 300 mg
IV, which can be followed with a second dose of 150
mg if the arrhythmia persists.
While amiodarone has been found to increase the rate
of survival from cardiac arrest, it has not been shown
to increase survival to hospital discharge.
Amiodarone is a second-line agent for PSVT and can
be used when adenosine fails.
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-degree
AV blocks.
Atropine is indicated in the setting of asystole and
bradycardic.
Atropine is ineffective in the setting of previous heart
transplant and may worsen ischemia during a
myocardial infarction.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
-Blockers are indicated for SVT for rate control in patients
with 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 respond
negatively to 2-blockade (e.g., patients with COPD).
If an adequate response is not achieved after 5 minutes, the
loading dose may be repeated and the infusion rate doubled.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Calcium channel blockers (i.e., diltiazem and
verapamil) 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 atrial
flutter with rapid ventricular response when an
accessory pathway such as Wolf-Parkinson-White
syndrome exists.
Diltiazem is better tolerated in patients with impaired
left ventricular function.
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 1.0-1.5
mg/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, a
maintenance infusion of 3-5 mg/min is administered.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Magnesium is indicated for:
those suspected to have a low magnesium level
recurrent ventricular dysrhythmias
those with torsades de pointes.
M.H.Farjoo MD, Ph.D
Cardiac Arrest
Procainamide is capable of suppressing both atrial
and ventricular arrhythmias.
It may be used in treatment of atrial fibrillation and
atrial flutter (even in the presence of WPW
syndrome) in patients with preserved left ventricular
function.
procainamide may be used in SVT when vagal
maneuvers and adenosine are ineffective.
Its use should be avoided in patients with long QT
intervals or when drugs that prolong the QT interval,
such as amiodarone, have already been administered.
Drug Name Adult Dose Pediatric Dose Indications Frequency Effects
Epinephrine 1 mg IV
OR
2-5 mg IV via ETT
0.01 mg/kg IV or
10
OR
0.1 mg/kg via
ETT
Any pulseless
rhythms
Every 3-5 min Increases perfusion to
myocardium and to
brain by increasing
peripheral vascular
resistance
Vasopressin 40 units IV Not indicated VF, pulseless VT Single dose, may be
followed at 10 min by
epinephrine
Increases peripheral
vascular resistance
Amiodarone For VF or
pulseless VT: 300
mg IV push
For VF or
pulseless VT: 5
mg/kg IV push
VF, pulseless VT,
VT with a pulse,
SVT
May use second
dose of 150 mg for
recurrent VF/VT. In
children may be
repeated in 5 mg/kg
doses to a total of 15
mg/kg
Predominately class III
antiarrhythmic, but has
sodium, potassium
channel, and and
receptor blockade
Lidocaine 1.0-1.5 mg/kg IV
push
Same VF, pulseless VT,
VT with a pulse
Second and
subsequent doses of
0.75 mg/kg every 5
min to a total dose of
3 mg/kg
Class IB
antiarrhythmic;
suppresses ventricular
automatically and
electrical conduction
Magnesium 1-2 g IV slow push 25-50 mg/kg IV
slow push
Torsade de
pointes, known
hypomagnesemia
Single dose Can cause cutaneous
flush, apnea, and
hyporeflexia, if given
too quickly
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.
Procainamide 17 mg/kg IV slow
bolus at maximum
rate of 50 mg/min
15 mg/kg IV load;
3-6 mg/kg over 5
min, not to
exceed 100
mg/dose
VT with a pulse Continue infusion (4
mg/min) until QRS
widening >50%,
dysrhythmia
terminated, onset of
hypotension; or 17
mg/kg infused
Decreases myocardial
excitability and
conduction velocity
Atropine Perfusing patients:
0.5 mg IV push q 5
min, to maximum
of 3 mg
Pulseless patients:
1.0 mg IV push q 5
min, to maximum
of 3 mg
0.02 mg/kg:
minimum dose of
0.1 mg
Bradycardia,
asystole
May be repeated
once up to maximum
dose of 3 mg
Parasympatholytic,
eliminates vagal tone
Adenosine 6 mg rapid IV push
through proximal
peripheral line;
central line dose is
one-half
0.1 mg/kg rapid
IV push;
maximum dose,
6 mg
SVT If needed, second
dose of 12 mg
(pediatric, double
initial dose up to 12
mg); third dose of 12-
18 mg
Endogenous
nucleoside causing
brief asystole allowing
dominant pacemaker
to resume function
Diltiazem 0.25 mg/kg to a
maximum dose of
20 mg IV push
over 2 min
Same SVT Second dose of 0.35
mg/kg, maximum
dose of 25 mg, at 15
min; after
conversion, start
diltiazem drip at 5-15
mg/h
Calcium channel
blocker
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.
Esmolol 500 ug/kg bolus
over 1 min
100-500 ug/kg
bolus over 1 min
SVT May give another
bolus if desired
effect is not
achieved; start drip
50 ug/kg/min
-Blocker (short
acting)
Atenolol 5 mg IV over 5
min
Not indicated SVT, myocardial
infarction
Repeat in 10 min,
then give 50-mg oral
load
-Blocker (1
selective)
Metoprolol 5 mg IV push Not indicated SVT, myocardial
infarction
Repeat twice at 5-
min intervals, then
give 50-mg oral load
-Blocker (1
selective)
Dopamine 2-20 ug/kg/min Same Hypotension Low doses are
predominantly ;
higher doses
become
predominantly
Inotropic
agent/vasopressor
(combined - and -
agonists)
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.
Dobutamine 2-20 ug/kg/min Same Hypotension Titrate to effect Inotropic agent (-
agonist)
Norepinephrin
e
Start at 8-12
ug/min, then titrate
to 2-4 ug/min for
maintenance;
maximum dose of
30 ug/min if
hypotension
unresponsive to
lower doses
0.05-2 ug/kg/min Hypotension Titrate to effect Vasopressor
(predominately an -
agonist)
Phenylephrine 100-500 ug bolus
IV
0.1-0.5 ug/kg/min Hypotension Every 5 min until
desired effect, then
continuous infusion
of 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.
M.H.Farjoo MD, Ph.D
Drugs for Intubation
Many patients in the emergency department can be intubated
without the use of pharmacologic intervention other than
oxygen.
By pharmacologic adjuncts may dramatically reduce the
difficulty of intubation.
Local, topical, or regional anesthesias are usually not
considered options for an emergently compromised airway.
Occasionally, sedation alone may be useful in preparing for
intubation.
For a semiobtunded or combative patient, use of
neuromuscular blockade with sedation, provides rapid control
of the airway.
M.H.Farjoo MD, Ph.D
Drugs for Intubation
Drugs that induce apnea must be used by or under the
direct supervision of experienced clinicians.
They should be prepared to obtain a surgical airway
in the event of failed intubation.
Equipment necessary for intubation and surgical
airway must be prepared in advance
They must be available at the bedside before the
patient is sedated or anesthetized
M.H.Farjoo MD, Ph.D
Drugs for Intubation
in awake or semiconscious patients a short-acting
sedative 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 as
indicated.
During the short period when the patient is paralyzed
and not intubated, the airway must be protected from
aspiration with cricoid pressure.
Rapid-sequence intubation protocol.
Preoxygenate with 100% oxygen. (Use bag-valve-mask
ventilatory assistance only as needed.)
Give rapid intravenous injection of sedative.
*

For trauma patients: Maintain in-line cervical traction from
induction and until cervical collar can be replaced after the
endotracheal 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, use
end-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.
+
Alternative
neuromuscular blocker: Vecuronium, 0.1-0.25 mg/kg;
Rocuronium, 0.6 mg/kg. (Use only when succinylcholine is
contraindicated.)
M.H.Farjoo MD, Ph.D
Succinylcholine
Succinylcholine is a depolarizing neuromuscular blocking
agent.
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 most
circumstances owing to rapid onset, complete muscular
relaxation, and short duration.
One single dose suffices in emergency department setting and
is well tolerated.
M.H.Farjoo MD, Ph.D
Succinylcholine
It is contraindicated in :
If there is risk factors for hyperkalemia.
Hereditary pseudocholinesterase deficiency (1 in
2800 patients)
Penetrating ocular trauma or glaucoma.
Known family or personal history of malignant
hyperthermia.
Hypersensitivity to succinylcholine.
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
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 anaphylactoid
reaction).
IOP is elevated during fasciculations.
ICP may increase.
Intragastric pressure may increase; use cricoid pressure
until endotracheal tube cuff is inflated.
Always use sedation with alert patients
M.H.Farjoo MD, Ph.D
Vecuronium
Vecuronium is a nondepolarizing neuromuscular
blocking agent.
Standard dose is 0.1 mg/kg. To achieve rapid
intubating 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 20-40
minutes and larger dose prolong paralysis 2-3 times
the usual duration.
M.H.Farjoo MD, Ph.D
Drugs for Intubation
Several agents may be added to the RSI protocol under
specific circumstances.
Atropine, 0.01-0.02 mg/kg given immediately before the
sedative, attenuates the vagal bradycardia associated with
succinylcholine.
Children, who tend to be more sensitive to the bradycardic and
hypotensive effects of succinylcholine, benefit from
pretreatment with atropine.
Therefore all children younger than 10 years should be
pretreated with atropine before succinylcholine is
administered.
Pretreat adults with bradycardia and those receiving a second
dose of succinylcholine.
M.H.Farjoo MD, Ph.D
Drugs for Intubation
Lidocaine, 1.5 mg/kg given 1 minute before
intubation, may attenuate elevations in ICP associated
with succinylcholine and intubation.
It may have some protective effect against
laryngospasm and ventricular arrhythmias during
intubation.
If pain control is important, morphine sulfate, 0.1
mg/kg or fentanyl, 1-2 g/kg IV should be added
after intubation
barbiturates have little analgesic effect and
neuromuscular blockers have none.
Thank you
Any question?
M.H.Farjoo MD, Ph.D
CARDIAC ARREST
FIBRINOLYTIC THERAPY
Most cases of sudden cardiac death are secondary to an
intravascular thrombosis, with the majority of these cases
related to either an intracoronary thrombus or massive
pulmonary embolus. The primary goal in treating these
patients is restoring perfusion immediately. In the case of
myocardial infarction, the two methods to restore coronary
blood flow are fibrinolytic therapy and percutaneous coronary
intervention (PCI). Multiple studies have found that in centers
that can provide rapid PCI, there is improved outcome and a
decreased rate of reocclusion when compared to fibrinolytic
therapy. However, the presentation to PCI should occur within
90 minutes.
M.H.Farjoo MD, Ph.D
CARDIAC ARREST
FIBRINOLYTIC THERAPY : (edaneh) Most facilities are
unable to perform PCI, and many transfer the patient to centers
with catheterization capabilities. If the patient is unable to
undergo PCI in the 90-minute period, initiation of fibrinolytic
therapy should be initiated if not contraindicated. Ideally, if
fibrinolytic therapy is to be initiated, it should occur within 30
minutes of the patient's presentation. Maximum benefit is seen
in those patients who present within 3 hours from the onset of
symptoms. There are current trials in which thrombolytics are
given by properly trained EMS personnel. However, there has
been no demonstrated improvement in survival to hospital
admission or discharge.
M.H.Farjoo MD, Ph.D
Vecuronium
4 . Indications and advantages
a. One of the NDNMBs that can be used when succinylcholine is
contraindicated.
b. Relative short duration allows neurologic reevaluation and provides
satisfactory paralysis for procedures such as computed tomography scan in
an emergency setting.
c. Minimal cardiovascular effects at usual doses.
d. Reversible after partial recovery (evidence of head lift, respiratory
effort, or muscle twitch response) with neostigmine, 0.04 mg/kg
intravenously. Atropine, 0.02 mg/kg intravenously, must also be
administered to prevent muscarinic side effects.
e. Does not cause fasciculations or elevate intracranial pressure.
M.H.Farjoo MD, Ph.D
Vecuronium
5 . ContraindicationKnow hypersensitivity to vecuronium.
6 . Adverse effects and precautions
a. Reduce dosage in patients with myasthenia gravis to avoid
prolonged blockade.
b. Maintain cricoid pressure until inflation of endotracheal
tube cuff.
c. Must use sedation or anesthesia in awake patients.
d. Block is prolonged by aminoglycosides, lithium, quinidine,
lidocaine, and propranolol and in hypermagnesemia,
hyperkalemia, dehydration, hypothermia, and respiratory
acidosis.
e. Use during pregnancy only if clearly indicated.
Choking pic.