Adrenaline

Adrenaline 1:1000 & 1:10,000

Adrenaline mini jet

Inotropic drugs

Epipen, Child/Adult

Adrenaline inj

Amiodarone

 Indications                                                                                  Dose

Refractory VF/ pulseless VT                                        300 mg IV

Use
Paradoxically amiodarone can be arrhythmogenic, especially if given together with other drugs that prolong the QT interval. But, it has a lower incidence of pro-arrhythmic effects compared to other antiarrhythmic agents if used under similar situations.
 
The main side effects are hypotension due to the solvent Polysorbate, which causes histamine release, and bradycardia, which may not be noticed till ROSC.
 
The side effects associated with prolonged oral use are photosensitivity, thyroid & hepatic dysfunction, peripheral neuropathy & pulmonary inflammation/fibrosis.
 
An initial intravenous bolus dose of 300 mg amiodarone, (may be diluted in 20ml 5% dextrose, and given over 20 seconds), is considered if VF/VT persists after the third shock.
 
If a peripheral vein is used, amiodarone may cause thrombophlebitis; a central vein is preferable otherwise use a large peripheral vein followed by a 20 ml flush.
 
For tachyarrythmias, amiodarone is given as 300 mg intravenously over 45-60 min. This loading dose is followed by an infusion of 900 mg over 24 h. Give additional doses of 150 mg as necessary for recurrent or resistant arrhythmias to a maximum total daily dose of 2 g.
 
In cases of severely impaired heart function, intravenous amiodarone is preferable to other antiarrhythmic drugs for atrial and ventricular arrhythmias. Hypotension and bradycardia can be prevented by slowing the rate of the infusion.
 
The plasma levels of warfarin and digoxin are increased by amiodarone; therefore their doses should be readjusted. INR for warfarin and digoxin levels should be monitored.
 
Amiodarone has an additive effect to that of beta-blockers and calcium channel blockers on the degree of AV nodal blockade and hypotension.
 
Actions:
Amiodarone is a membrane stabilising antiarrhythmic drug that increases the duration of both the refractory period and action potential in the myocardium.
 

AV conduction and accessory pathway conduction is slowed. Amiodarone has a very mild negative inotropic action and may cause peripheral vasodilation by non-competitive alfa blockade.

Amiodarone inj 150mg

Aspirin

Indications                                                                                                                                          Dose

Acute coronary syndromes                                                     300-325 mg to be chewed followed by 75 mg daily orally

Use:

The oral dose is 160-300 mg to patients with acute coronary syndromes irrespective of the delay to the first evaluation of the patient.

Chronic aspirin usage may cause acute or chronic upper GI bleeding. The risk is dose-related. If thrombolytic therapy is given in the early phase, give aspirin concomitantly to help reduce the risk of early coronary artery re-occlusion.

Actions:

Aspirin improves the prognosis of patients with acute coronary syndromes and reduces mortality. The effect is achieved by anti-platelet activity (Irreversibly acetylates platelets COX₁, thus inhibiting formation of thromboxane A2 preventing platelets adhesions.

Atropine

Indications                                                                                                                           Dose

Sinus, atrial, or nodal bradycardia when the patient is symptomatic              0.6mg increments IV to a maximum of 3 mg

Use:

For symptomatic bradycardia, give an initial dose of 0.6 mg IV. Repeated doses may be necessary, but consider pacing if this is ineffective.

Conduction disturbance or bradycardia associated with the high vagal activity may respond to atropine (e.g oculocardiac reflex).

There is no conclusive evidence that atropine is of any value in asystolic cardiac arrest.

Actions:

Atropine antagonizes the neurotransmitter acetylcholine at muscarinic receptors. Thus it blocks the effect of the vagus nerve on both the SA and AV nodes, increasing sinus automaticity and facilitating AV nodal conduction.

Side-effects of atropine are dose-related (blurred vision, dry mouth and urinary retention). Acute confusional states may occur following intravenous administration in elderly patients.

After cardiac arrest, do not attribute dilated pupils solely to atropine.

Adenosine

Indications                                                                                                                   Dose

Use:

Adenosine should be administered in a monitored environment only (e.g. coronary care unit, critical care unit, operating room, or emergency department); it may cause a transient period of ventricular asystole.

It may be used as a diagnostic tool, and unlike verapamil, it can be given to a patient with a broad-complex tachycardia of uncertain aetiology. The ventricular rate in SVT will be slowed but ventricular tachycardia (VT) is unchanged.

Adenosine is effective in terminating the re-entry tachycardias that originate in the AV node (SVT). It does not have significant negative inotropic effects and does not cause decreased cardiac output and hypotension, and may be given safely with a beta-blockers on board.

Patients may encounter transient unpleasant side-effects: nausea, flushing, and chest discomfort, sense of impending doom and should be clearly explained to them.

Theophylline (aminophylline) and related compounds antagonize adenosine. Patients on dipyridamole or carbamazepine or those with denervated (transplanted) hearts display a markedly hazardous exaggerated effect.

Adenosine is contraindicated in patients with WPW syndrome, as the conduction blockade through the AV node by adenosine may promote conduction down the accessory pathway. In the presence of pre-excited atrial fibrillation or flutter, this may cause a dangerously rapid ventricular response.

The initial dose is 6 mg; if unsuccessful follow this with 12 mg after 1-2 min.

Adenosine

Beta-adrenergic blocking agents

Indications                                                                                                    Dose

Use:

A beta-blocker may be used as a second-line drug for the treatment of narrow-complex tachycardia (or broad complex tachycardia known to be an SVT with aberrant conduction), when adenosine fails.

They may precipitate LVF in patients with a failing ventricle, hypotension, bradycardia or even heart block. The risk of developing heart block or asystole is increased if verapamil is given intravenously to a beta-blocked patient. For similar reasons, avoid the combination of beta-blockers and other antiarrhythmic drugs such as lidocaine.

Esmolol is short-acting with a half-life of 2-9 min. It is a ß1-selective beta-blocker administered IV.

Actions:

Beta-blocking drugs block the effects of circulating catecholamines with a resultant decrease

in heart rate and blood pressure. They also have a proven cardioprotective effect in patients with acute coronary syndromes.

Side effects of beta-blockade include bradycardia, AV conduction delay, hypotension and bronchospasm.

Contraindicated in second- or third-degree heart block, hypotensive states, CHF and asthma.

Ca channel blockers

Dopamine

Indications                                                                                                                                Dose

Hypotension in the absence of hypovolaemia                                                                             1-10 mcg kg^-1 min^-1

Use

There is a marked individual variability in the response to dopamine. Dopamine increases urine volume but has no beneficial effect on renal function as such. Dopamine should be given via a

central vein, using an infusion pump. Its use requires invasive haemodynamic monitoring in an intensive care or high-dependency care area.

Actions

Dopamine is the precursor of the naturally-occurring catecholamines adrenaline and noradrenaline. It has a dose-dependent positive inotropic effect that is mediated by dopamine (D1 and D2), α1- and β1- receptors.

Theoretically, low infusion rates (1-2 mcg kg^-1 min^-1) cause renal artery vasodilation (via D1 receptors), and increased glomerular filtration rate and sodium excretion.

Intermediate infusion rates (2-10 mcg kg^-1 min^-1) increase cardiac output and systolic blood pressure (β1). With higher infusion rates (> 10 mcg kg- ¹ min^-1) α1- and α2- effects dominate causing vasoconstriction.

Dopamine may cause cardiac arrhythmias, increase myocardial oxygen demand and worsen ischaemia. Dopamine and dobutamine may be administered together and titrated to effect.

Dobutamine

Indications                                                                                                                                Dose

Hypotension not caused by hypovolaemia                                                                       5-20 mcg kg^-1 min^-1

Cardiogenic shock

Use

Dobutamine is the inotropic drug of choice in the post-resuscitation period. It is indicated in poor cardiac output states with compromised tissue perfusion. It is useful in pulmonary oedema associated with a low BP which contraindicates the use of other vasodilators.

Close haemodynamic monitoring of the patient is essential and should be undertaken in a high-dependency or intensive care area. Tachycardia and cardiac arrhythmias may occur, particularly at higher doses. Reduce the infusion slowly to avoid hypotension.

The drug has a short half-life and is given by intravenous infusion using an infusion pump. The dose range is 5-20 mcg kg^-1 min^-1 titrated to effect.

Actions

A synthetic catecholamine with ß1 (positive inotropic effect on myocardium) ß2,( peripheral vasodilatation) and α1 -receptors stimulant effect. The net effect is to increase cardiac output. Renal blood flow is usually increased.

Dobutamine increases myocardial oxygen requirements less than other inotropic agents and is less arrhythmogenic.

Magnesium

 Indications                                                                                                                                   Dose

Nitroglycerine

 Actions:

1. Decreases pain of ischemia
2. Increases venous dilation
3. Decreases venous blood return to heart (pre-load)
4. Decreases preload and cardiac oxygen consumption
5. Dilates coronary arteries
6. Increases cardiac collateral flow                                                                                                                                                                                                                                                                                                             IV Nitroglycerin STEMI Indications: 

First 24 to 48 hours in patients with STEMI and one or more of the following: 

Key Concept:

Careful assessment of the patient before and during nitrate administration is necessary. Hypotension in ACS should be avoided because a drop in mean coronary perfusion pressure can propagate thrombus and increase infarct size.

Additional contraindications to nitrates: 

• Recent phosphodiesterase inhibitor use. If the patient has erectile dysfunction and has taken a phosphodiesterase inhibitor within the previous 24 hours (48 hours for tadalafil), nitrates may cause severe hypotension refractory to vasopressor agents.

• Hypotension, bradycardia, or tachycardia. Avoid use of nitroglycerin in patients with hypotension (systolic BP 100 bpm).

• RV Infarction. Nitroglycerin should be used with caution in patients with inferior wall MI with possible RV involvement. Patients with RV dysfunction and acute infarction are very dependent on maintenance of RV filling pressures to maintain cardiac output and blood pressure. 

• Transdermal preparations are relatively contraindicated in potentially unstable patients; topical application results in variability in the amount of drug delivered, and absorption is often erratic. Avoid long-acting oral preparations. 

Tenecteplase (Metalyse)

Reperfusion arrhythmias are common and include:

Bradycardia complete & heart block occurs most commonly with reperfusion of inferior MI. Usually, it resolves within minutes. If necessary treat with Atropine and fluids.

Non-sustained VT: runs are common and usually subside with time. Observe for 10 minutes before contemplating antiarrhythmics. Keep Potassium between 4-5 mmol/L.

Sustained VT / VF: Defibrillation and antiarrhythmics (including IV Mg)

How supplied:

Tenecteplase is supplied as a sterile, lyophilized powder in vials under partial vacuum. Each vial of tenecteplase is packaged with one vial of Sterile Water for Injection, USP for reconstitution.

Stability and Storage

Store lyophilized tenecteplase at controlled room temperature not to exceed 30°C (86°F) or under refrigeration 2–8°C (36–46°F). Do not use beyond the expiration date stamped on the vial.