Drug Box 2-2A

adenosine

Adenocard

antiarrhythmic, endogenous nucleoside

• * Slows conduction time through AV node; can interrupt re-entrant pathways through the AV node.
• * Slows sinus rate.
• * Larger doses decrease BP by decreasing peripheral resistance.

• * Conversion of supraventricular tachycardias with no known atrial fibrillation or atrial flutter.
• * Wide complex tachycardia of uncertain origin unresponsive to lidocaine.

• * Sick sinus syndrome, 2nd or 3rd degree AV blocks; except in patients with a functioning ventricular pacemaker.
• * Use cautiously in patients with known asthma
• * Patients on theophylline and related methylxanthines.
• * Patients on dipyridamole (Persantine) or carbamazepine (Tegretol).
• * Cardiac transplant patients are more sensitive to adenosine and require only a small dose (relative).
• * Known atrial fibrillation or atrial flutter.
• * Pregnancy (no controlled studies)

• * CV: Transient dysrhythmias (systole, bardycardia, PVC's) occur in 55% of patients (none reported as irreversible). Palpitations, chest pressure, chest pain, hypotension, transient hypertension; facial flushing, sweating.
• * Resp: Dyspnea, hyperventilation, tightness in throat, bronchospasm.
• * CNS: Lightheadedness, headache, dizziness, paresthesias, apprehension, blurred vision, neck-back pain.
• * GI: Nausea, metallic taste

• * Initial: 6 mg rapid IV/IO push over 1-3 seconds
• * Administration procedure: 18ga IV/IO, AC↑, Press Print on Monitor, Use hub closest to IV catheter to push drug, immediate 20mL flush in other hub.
• * Repeat: 12 mg rapid IV/IO push over 1-3 seconds if needed.

• * Initial: 0.1 mg/kg as a rapid IV/IO push.
• * Administration procedure: Largest IV/IO, Press print on monitor, Use hub closest to IV Catheter to push drug, immediate 2-3mL flush in other hub.
• * Repeat: If no response, dose may be doubled 1 time (0.2 mg/kg) using same administration procedure. Maximum singe dose: Should not exceed 12 mg.
• * Infants with SVT associated with shock: Adenosine may precede cardioversion if vascular access is available, but cardioversion should not be delayed while IVaccess is achieved.

• * Adenosine is not blocked by Atropine.
• * Theophylline and related methylxanthines (caffeine ) in therapeutic concentrations decrease effectiveness.

• * Dysrhythmias may recur (short half life).
• * Second dose must be prepared and available.
• * Check for crystallization in cold climates.

Amiodarone

Amiodarone

Antiarrhythmic Agent

• * Multiple effects on sodium, potassium and calcium channels.
• * Prolongs action potential, refractory period.
• * Ventricular automaticity (potassium channel blockade).
• * Slows membrane depolarization and impulse conduction (sodium channel blockade).
• * Negative chronotropic activity in nodal tissue, rate reduction, and antisympathetic activity (calcium channel and β-blockade).
• * Dilates coronary arteries due to calcium channel and alpha-adrenergic blocking action.

• * Treatment of: defibrillation-refractory VF/pulseless VT, polymorphic VT, and wide complex tachycardia of uncertain origin.
• * Control hemodynamically stable ventricular tachycardia when cardioversion unsuccessful.
• * Adjunct to cardioversion of SVT and PSVT.
• * Rate control in atrial fibrillation or flutter

• * Bradycardia
• * Second or third degree heart block unless a functioning pacemaker is present
• * Cardiogenic shock
• * Hypotension
• * Pulmonary congestion

• * Cardiovascular: bradycardia, hypotension, asystole/cardiac arrest, atrio-ventricular block
• * Torsades de Pointes (prolongs QT interval), congestive heart failure
• * GI & Hepatic: nausea, vomiting, abnormal liver function tests
• * Skin: slate-blue pigmentation
• * Other: fever, headache, dizziness, flushing, abnormal salivation, photophobia

• * VF/Pulseless VT - 300 mg IV/IO push over 30 – 60 seconds, may repeat in 3-5 minutes with 150 mg IV/IO push
• * Wide-Complex Tachycardias, Atrial Flutter, Atrial Fibrillation, SVT with cardioversion - 150 mg IV/IO over 10 minutes (mix in 50 mL bag of D5W) may repeat every 10 minutes.
• * Maintenance Infusion Post Resuscitation/Conversion - After successful defibrillation, follow with up to 1mg/min IV/IO infusion for 6 hours, then up to 0.5 mg/min IV/IO infusion for up to 18 hours, maximum daily dose is 2.2 grams

• * VF/Pulseless VT - 5 mg/kg IV/IO push (max 300 mg single dose), may repeat every 5 minutes two times to a total maximum of 15 mg/kg/day
• * Probable VT with pulse - 5 mg/kg IV/IO administered over 20 minutes may repeat two more times to a total of 15 mg/kg/day

Half-life may exceed 40 days.

• * Draw from ampule with at least an 18 gauge needle.
• * Mix with 20 – 30 mL of D5W prior to administration.
• * Patient must be on a cardiac monitor–monitor heart rate and rhythm.
• * Must be administered with an IV infusion pump during interfacility transports.

Diltiazem

Cardizem

• * Calcium Channel Blocker
• * Calium antagonist

• * Pharmacological: Inhibits calcium ion influx across cell membranes during cardiac depolarization, decreases SA and AV conduction and dilates coronary and peripheral arteries and arterioles.
• * Clinical effects: Slows the rapid ventricular rate associated with atrial fibrillation and atrial flutter, and reduces coronary and peripheral vascular resistance.

Rapid ventricular rates associated with atrial fibrillation and atrial flutter, and for PSVT refractory to adenosine.

• * Hypotension (less than 90 mmHg systolic)
• * Acute Myocardial infarction
• * Cardiogenic shock
• * Ventricular tachycardia or wide-complex VT of unknown origin
• * Second or third-degree AV block
• * Wolff-Parkinson-White (WPW) syndrome
• * Sick Sinus syndrome
• * Beta Blocker Use

• * CV: hypotension, bradycardia, heart block, chest pain, and asystole
• * GI: nausea and vomiting
• * CNS: headache, fatigue, drowsiness

* Administer: 0.25 mg/kg IV/IO (usually 20 mg) administered over 2 minutes. Contact medical control for additional Diltiazem orders if rhythm persists

The safety and efficacy of this drug for use in children has not been established.

• * Avoid use in patients with poison- or drug-induced tachycardia.
• * Calcium chloride can be used to prevent the hypotensive effects of this drug and treat patients with a calcium channel blocker overdose.
• * Beta blocker use

Calcium Chloride

Calcium Chloride

Electrolyte

• * Increases extracellular and intracellular calcium levelsStimulates release of catecholamines
• * Increases cardiac contractile state (positive inotropic effect)
• * May enhance ventricular automaticity
• * Inhibits the effects of adenosine on mast cells

• * Acute hypocalcemia
• * Calcium channel blocker OD
• * Acute hyperkalemia (known or suspected)
• * Hypermagnesemia (Magnesium OD)
• * Pre-treatment for IV verapamil administration

• * Hypercalcemia
• * Concurrent digoxin therapy (relative)

• * Brady-asystolic arrest
• * Severe tissue necrosis if solution extravasates
• * Use cautiously in patients on digitalis; may cause serious arrhythmias

• * Hypocalcemia, calcium channel blocker OD, hyperkalemia and hypermagnesemia: 5-10 ml (0.5-1Gm) of CaCl 10% IV/IO. May repeat in 10 minutes.
• * Pre-treatment for IV verapamil administration: 3 ml of 10% calcium chloride. May be repeated once.

* Hypocalcemia, calcium channel blocker OD, hyperkalemia and hypermagnesemia: 0.2 - 0.25 ml/kg of a 10% solution IV/IO infused slowly.

All drugs -- flush line before and after administration

Concurrent administration of sodium bicarbonate and calcium chloride will produce a precipitate, calcium carbonate (chalk).