1	Paramedic Emergency Pharmacology ACLS Drugs Used in the Treatment of Cardiovascular Emergencies
2	Oxygen
3	Class Gas
4	Description Oxygen is an odorless, tasteless, colorless gas necessary for life.
5	Mechanism of Action Oxygen is transported to the cells by hemoglobin. Oxygen is required for the efficient breakdown of glucose into a usable energy form.
6	Pharmacokinetics Onset Immediate Peak effects < 1 minute Duration < 2 minutes Half-life N/A
7	Indications Whenever hypoxia is suspected or possible In any critical patient
8	Contraindications There are no contraindications to oxygen. Hypoxic patients should never be deprived of oxygen for fear of respiratory depression.
9	Precautions Use cautiously in patients with chronic obstructive pulmonary disease (COPD). Monitor for respiratory depression if high concentrations of oxygen are delivered. High concentrations of oxygen to neonates for a prolonged period of time can damage the infant’s eyes (retrolental fibroplasia). Although this is rarely a problem in prehospital care, it is a consideration in long-distance and prolonged transport. Flow rates of 6 Lpm or greater should be humidified.
10	Side Effects Prolonged administration of high-flow, nonhumidified oxygen may cause drying of the mucous membranes.
11	Interactions There are no interactions associated with oxygen administration. Oxygen may increase the toxicity of certain herbicides that are sometimes sprayed on illicit agricultural products such as marijuana. Poisoning by these agents is uncommon.
12	Dosage
13	Sympathomimetics
14	Comparison of Sympathetic and Parasympathetic Actions
15	Effects of Alpha and Beta Adrenergic Receptor Activity on Selected Organs
16	List of Sympathomimetic Drugs with Adrenergic Actions
17	Epinephrine
18	Class Sympathetic agonist
19	Description Epinephrine is a naturally occurring catecholamine. It is a potent α- and β-adrenergic stimulant; however, its effect on β-receptors is more profound.
20	Mechanism of Action Epinephrine acts directly on α- and β-adrenergic receptors. Its effect on β-receptors is much more profound, and includes the following: Increased heart rate Increased cardiac contractile force Increased electrical activity in the myocardium Increased systemic vascular resistance Increased blood pressure Increased automaticity
21	Pharmacokinetics Onset < 2 minutes (IV/ET) Peak effects < 5 minutes (IV/ET) Duration 5-10 minutes (IV/ET) Half-life 5 minutes
22	Indications Cardiac arrest Asystole Ventricular fibrillation Pulseless ventricular tachycardia PEA (pulseless electrical activity) Severe anaphylaxis Severe reactive airway disease
23	Contraindications Epinephrine 1:10,000 is contraindicated in patients who do not require extensive cardiopulmonary resuscitative efforts. With simple allergic reactions and asthma, the 1:1000 dilution should be used and administered subcutaneously.
24	Precautions Should be protected from light Can be deactivated by alkaline solutions such as sodium bicarbonate The IV line must be adequately flushed between administrations of epinephrine and sodium bicarbonate.
25	Side Effects Palpitations Anxiety Tremulousness Headache Dizziness Nausea Vomiting Increased myocardial oxygen demand
26	Interactions The effects of epinephrine can be intensified in patients who are taking antidepressants.
27	Dosage Cardiac arrest (adult) 1 mg of 1:10,000 IV every 3-5 minutes 2-2.5 times the IV dose via the ET Cardiac arrest (pediatrics) First dose – 0.01 mg/kg of 1:10,000 IV Subsequent doses – 0.1 mg/kg of 1:1,000 IV Both are also calculated at 0.1 mL/kg.
28	Dosage (cont.) Severe anaphylaxis or asthma (adult) 0.3-0.5 mg of 1:1,000 SQ Repeat every 5-15 minutes Severe anaphylaxis or asthma (pediatrics) 0.01 mg/kg of 1:1,000 SQ Repeat every 5-15 minutes
29	Dopamine HCl Intropin
30	Class Sympathetic agonist
31	Description Dopamine is a naturally occurring catecholamine. It acts on α, β₁, and dopaminergic adrenergic receptors. Its effect on α-receptors is dose-dependent.
32	Mechanism of Action Chemically related to both epinephrine and norepinephrine and increases blood pressure by acting on both α- and β₁-adrenergic receptors Causes a positive inotropic effect on the heart Does not increase myocardial O₂ demand
33	Mechanism of Action (cont.) Does not have chronotropic effects Also acts on α-adrenergic receptors, causing peripheral vasoconstriction When used in therapeutic dosages, maintains renal and mesenteric blood flow
34	Mechanism of Action (cont.) Dopamine increases both the systolic blood pressure and the pulse pressure (the difference between the systolic and diastolic blood pressures), but, as a rule, there is usually less effect on the diastolic pressure.
35	Pharmacokinetics Onset < 5 minutes Peak effects 5-8 minutes Duration < 10 minutes Half-life 2 minutes
36	Indications Hemodynamically significant hypotension (systolic blood pressure of 70 to 100 mmHg) Not resulting from hypovolemia Cardiogenic shock
37	Contraindications Should not be used as the sole agent in the management of hypovolemic shock unless fluid resuscitation is well under way Should not be used in patients with known pheochromocytoma (a tumor of the adrenal gland)
38	Precautions Can induce or worsen supraventricular and ventricular dysrhythmias Whenever the dosage of dopamine surpasses 20 µg/kg/min, it functions very much like norepinephrine.
39	Side Effects Nervousness Headache Dysrhythmias Palpitations Chest pain Dyspnea Nausea and vomiting
40	Interactions Can be deactivated by alkaline solutions such as sodium bicarbonate Reduce doses if the patient is taking MAOIs May cause hypotension when used concomitantly with phenytoin (Dilantin)
41	Dosage 800 mg diluted in 500 mL of D₅W or 400 mg diluted in 250 mL of D₅W Concentration of 1600 µg/mL Initial infusion 2–5 µg/kg/min Titrate to blood pressure or until a maximum of 20 µg/kg/min
42	Dosage (cont.) The effects of dopamine are dose dependent.
43	Dosage (cont.)
44	Vasopressin Pitressin
45	Class Hormone; vasopressor
46	Description A polypeptide hormone extracted from the posterior pituitaries of animals Possesses pressor and antidiuretic hormone (ADH) properties
47	Mechanism of Action Acts as a non-α-adrenergic vasoconstrictor through direct stimulation of smooth muscle receptors Can be used as an alternative to epinephrine during cardiac arrest
48	Pharmacokinetics Onset Variable Peak effects Variable Duration 30-60 minutes Half-life 10-20 minutes
49	Indications Used to increase peripheral vascular resistance during cardiac arrest
50	Contraindications Chronic nephritis Ischemic heart disease Premature ventricular contractions Advanced arteriosclerosis When used in cardiac arrest, these contraindications may not apply.
51	Precautions Use with caution in patients with: Epilepsy Migraine Asthma Heart failure Angina
52	Side Effects Blanching of the skin Abdominal cramps Nausea Hypertension Bradycardia Minor dysrhythmias
53	Interactions None in advanced cardiac life support (ACLS) setting
54	Dosage Adult dose – 40 units IV (single dose only) May replace 1^st or 2^nd round of epinephrine Pediatric dose – usage in cardiac arrest not detailed
55	Antidysrhythmics
56	Antidysrhythmics
57	Antidysrhythmics (cont.)
58	Lidocaine Xylocaine
59	Class Antidysrhythmic
60	Description An amide-type local anesthetic Frequently used to treat life-threatening ventricular dysrhythmias
61	Mechanism of Action Most frequently used antidysrhythmic agent Suppresses depolarization and automaticity in the ventricles In therapeutic doses does not slow AV conduction and does not depress myocardial contractility
62	Pharmacokinetics Onset < 3 minutes Peak effects 5-7 minutes Duration 10-20 minutes Half-life 1.5-2.0 hours
63	Indications Ventricular tachycardia Ventricular fibrillation Acute myocardial infarction Electrical defibrillation
64	Indications (cont.) Malignant PVCs More than six unifocal PVCs per minute Multifocal PVCs PVCs that occur in couplets Runs of more than two PVCs R on T phenomena
65	Contraindications Second-degree Mobitz II and third-degree blocks Whenever PVCs occur in conjunction with bradycardia (heart rate less than 60 beats per minute), the bradycardia should be treated first. If PVCs are still present after increasing the rate, lidocaine should be administered.
66	Precautions Central nervous system depression may occur when the dosage exceeds 300 mg/hr. Exceedingly high doses can result in coma and death.
67	Side Effects Drowsiness Seizures Confusion Hypotension Bradycardia Heart blocks Nausea and vomiting Respiratory and cardiac arrest
68	Interactions Should be used with caution when administered concomitantly with procainamide, phenytoin, quinidine, and β-blockers because drug toxicity may result
69	Dosage Refractory V-fib and pulseless V-tach 1.0 to 1.5 mg/kg IV bolus Repeat every 3-5 minutes at 0.5 to 0.75 mg/kg Maximum bolus of 3.0 mg/kg With ROSC, use IV infusion therapy
70	Dosage (cont.) V-tach with a pulse and/or PVCs 1.0 to 1.5 mg/kg IV bolus Repeat every 5-10 minutes at 0.5 to 0.75 mg/kg Maximum bolus of 3.0 mg/kg Maintenance drip of 2-4 mg/min
71	Dosage (cont.) Dosage reduced 50% in patients: > 70 years of age With liver disease, heart failure, bradycardias, or conduction disturbances Should be increased to 2 to 2.5 times the intravenous dose when administering it endotracheally
72	Dosage (cont.) IV infusion of Lidocaine
73	Procainamide Pronestyl
74	Class Antidysrhythmic
75	Description An ester-type local anesthetic Frequently used to treat life-threatening ventricular dysrhythmias refractory to lidocaine
76	Mechanism of Action Effective in suppressing ventricular ectopy May be effective in cases in which lidocaine has not suppressed life-threatening ventricular dysrhythmias Reduces the automaticity of the various pacemaker sites in the heart Slows intraventricular conduction to a much greater degree than does lidocaine
77	Pharmacokinetics Onset 10-30 minutes Peak effects 15-20 minutes Duration 3-6 hours Half-life 3 hours
78	Indications Persistent cardiac arrest due to ventricular fibrillation and refractory to lidocaine Premature ventricular contractions refractory to lidocaine Ventricular tachycardia refractory to lidocaine
79	Contraindications Severe conduction system disturbances Second-degree heart blocks Third-degree heart blocks
80	Precautions Must not be administered to patients demonstrating PVCs in conjunction with bradycardia Hypotension is common with intravenous infusion.
81	Side Effects Drowsiness Seizures Confusion Hypotension Bradycardia Heart blocks Nausea and vomiting Respiratory and cardiac arrest
82	Interactions The hypotensive effects of procainamide may be increased if administered with antihypertensive drugs. The chance of neurological toxicity by both lidocaine and procainamide increases when the medications are administered together.
83	Dosage 100 mg should be administered every 5 minutes at a rate of 20 mg/min. Discontinue if any of the following occur: Arrhythmia is suppressed Hypotension ensues QRS complex is widened by 50% Total of 17 mg/kg has been administered
84	Dosage (cont.) The maintenance infusion is 1 to 4 mg/min. 1 g is placed in 500 mL of D₅W. Concentration of 2 mg/mL
85	Dosage (cont.)
86	Adenosine Adenocard
87	Class Antidysrhythmic
88	Description A naturally occurring nucleoside that slows AV conduction through the AV node Has an exceptionally short half-life Has a relatively good safety profile
89	Mechanism of Action A naturally occurring substance present in all body cells Decreases conduction of the electrical impulse through the AV node and interrupts AV re-entry pathways in PSVT Can effectively terminate rapid supraventricular arrhythmias
90	Mechanism of Action (cont.) Half-life is approximately 10 seconds Sometimes referred to as chemical cardioversion Effective in 90% of case studies Does not appear to cause hypotension to the same degree as does verapamil
91	Pharmacokinetics Onset 20-30 seconds Peak effects 20-30 seconds Duration 30 seconds Half-life 10 seconds
92	Indications Used in PSVT (including that associated with Wolff-Parkinson-White syndrome) refractory to common vagal maneuvers
93	Contraindications Second heart block Third heart block Sick sinus syndrome Known hypersensitivity
94	Precautions Typically causes dysrhythmias at the time of cardioversion In extreme cases, transient asystole may occur. Should be used cautiously in patients with asthma
95	Side Effects Flushing Headache Shortness of breath Dizziness Nausea
96	Interactions Methylxanthines (aminophylline, etc.) may decrease the effectiveness, thus requiring larger doses Dipyridamole (Persantine) can potentiate the effects, thus requiring smaller doses
97	Dosage Initial dose is 6 mg rapid IVP over 1-2 sec. Follow the initial dose with a rapid saline flush. Two repeat doses of 12 mg rapid IVP may be administered.
98
99	Class Antidysrhythmic
100	Description A salt that dissociates into the magnesium cation (Mg²⁺) and the sulfate anion when administered An essential element in numerous biochemical reactions that occur within the body
101	Mechanism of Action Acts as a physiological calcium channel blocker and blocks neuromuscular transmission Appears to reduce the incidence of ventricular dysrhythmias and other side effects following an acute myocardial infarction
102	Pharmacokinetics Onset Immediate (IV), 1 hour (IM) Peak effects Variable Duration 1 hour Half-life N/A
103	Indications Used in severe refractory ventricular fibrillation or pulseless ventricular tachycardia Post-myocardial infarction for prophylaxis of dysrhythmias Torsade de pointes (multiaxial ventricular tachycardia)
104	Contraindications Patients in shock Persistent severe hypertension Third-degree AV block Patients who routinely undergo dialysis Hypocalcemia
105	Precautions Should be administered slowly to minimize side effects Should have continuous cardiac monitoring Use with caution in patients with known renal insufficiency Calcium salts should be available as an antidote in case serious side effects occur.
106	Side Effects Flushing Sweating Bradycardia Decreased deep tendon reflexes Drowsiness Respiratory depression Dysrhythmias Hypotension Hypothermia Itching and rash
107	Interactions Can cause cardiac conduction abnormalities if administered in conjunction with digitalis
108	Dosage V-fib or v-tach: 1 to 2 g diluted in 10 ml of D₅W Slow IV push over 1 to 2 minutes Alternatively, 1 to 2 grams can be diluted in 100 ml of D₅W and administered IV piggyback over 1 to 2 minutes.
109	Dosage (cont.) Torsade de pointes: Higher doses are often required. Typically, 5 to 10 g are diluted in 100 mL of D₅W. Administered at a rate of 1 g/min until the dysrhythmia is suppressed or the maximum dose has been administered
110	Dosage (cont.) Post-myocardial infarction prophylaxis: 1 to 2 g of magnesium sulfate can be diluted in 100 mL of D₅W. Administered over 5 to 30 minutes as an IV piggyback Can be administered IM if no IV access: Divide in half and each half administered at a separate site (usually each gluteus)
111	"Cordarone" Cordarone
112	Class Antidysrhythmic agent
113	Description Class III antidysrhythmic agent used to treat ventricular dysrhythmias unresponsive to other antidysrythmics
114	Mechanism of Action Prolongs the action potential duration in all cardiac tissues
115	Pharmacokinetics Onset 2-3 days (oral) Peak effects 3-7 hours (oral) Duration Varies Half-life 40-55 days
116	Indications Life-threatening cardiac dysrhythmias such as ventricular tachycardia and ventricular fibrillation
117	Contraindications Breast-feeding patients in cardiogenic shock Severe sinus node dysfunction resulting in marked sinus bradycardia Second- or third-degree AV block Symptomatic bradycardia Known hypersensitivity
118	Precautions Use with caution in patients with latent or manifest heart failure because failure may be worsened by its administration.
119	Side Effects Monitor the patient’s ECG for: Bradycardia Increased ventricular beats Prolonged PR interval, QRS complex, and QT interval Watch for signs of pulmonary toxicity such as dyspnea and cough. Hypotension
120	Interactions May react with: Warfarin Digoxin Procainamide Quinidine Phenytoin
121	Dosage VF and Pulseless VT 300 mg IV initial Repeat once in 3-5 minutes at 150 mg IV
122	Dosage Loading dose of 150 mg over 10 minutes 15 mg/min IV or IO May be repeated as necessary for recurrent or refractory dysrhythmias Maintenance dose 1 mg/min for 6 hours Then 0.5 mg/min
123
124	Parasympatholytics Drugs that inhibit the actions of the parasympathetic nervous system Sometimes referred to as anticholinergics
125	Parasympathetic Nervous System Plays a major role in the maintenance of homeostasis Stimulation induces peristalsis and causes pupillary constriction and a decrease in the heart rate Primary nerve of the parasympathetic nervous system is the vagus nerve
126
127	Class Anticholinergic
128	Description Parasympatholytic (anticholinergic) that is derived from parts of the Atropa belladonna plant
129	Mechanism of Action Potent parasympatholytic Acts by blocking acetylcholine receptors, thus inhibiting parasympathetic stimulation Although has positive chronotropic properties, has little or no inotropic effect Mechanism by which atropine is effective in asystole is not clear
130	Pharmacokinetics Onset Immediate Peak effects 2-4 minutes Duration 4 hours Half-life 2-3 hours
131	Indications Hemodynamically significant bradycardia Asystole Organophosphate poisonings
132	Contraindications None in emergency situations
133	Precautions May actually worsen the bradycardia associated with second-degree Mobitz II and third-degree AV blocks Maximum dose should not be exceeded except in the setting of organophosphate poisoning
134	Side Effects Blurred vision Dilated pupils Dry mouth Tachycardia Drowsiness Confusion
135	Interactions There are few interactions in the prehospital setting.
136	Dosage Hemodynamically significant bradycardia 0.5 mg IV bolus every 3-5 minutes Maximum of 3 mg Asystole 1 mg IV bolus every 3-5 minutes 2-2.5 times via the ET 3 doses
137
138	Alkalinizing Agents Used to buffer the acids present in the body during and after cardiac arrest and other serious conditions Normal body pH is 7.4 (7.35 to 7.45) During hypoxia, the serum pH may fall quickly.
139	Alkalinizing Agents (cont.) Acid-base balance:
140	Sodium Bicarbonate
141	Class Alkalinizing agent
142	Description A salt that provides bicarbonate to buffer metabolic acidosis
143	Mechanism of Action Was the cornerstone of ACLS care Controlled studies have shown that sodium bicarbonate was ineffective in the treatment of cardiac arrest. Associated with many adverse reactions
144	Pharmacokinetics Onset Immediate Peak effects < 15 minutes Duration 1-2 hours Half-life N/A
145	Indications Used late in cardiac arrest, if at all Tricyclic antidepressants overdose Phenobarbital overdose Severe acidosis refractory to hyperventilation Known hyperkalemia
146	Contraindications None when used for the aforementioned indications
147	Precautions Can cause metabolic alkalosis when administered in large quantities It is important to calculate the dosage based on patient weight and size.
148	Side Effects Few side effects when used in the emergency setting
149	Interactions Most catecholamines and vasopressors (e.g., dopamine and epinephrine) can be deactivated by alkaline solutions. Used in conjunction with calcium chloride, a precipitate can form, clogging the IV line
150	Dosage 1 mEq/kg IV bolus Followed by 0.5 mEq/kg every 10 minutes Should be based on the results of arterial blood gas studies
151	"Analgesics" Analgesics
152	Analgesics Drugs that have proved effective in alleviating pain Used for the treatment of emergencies involving the cardiovascular system, especially myocardial infarction Analgesics are covered in detail in Chapter 15.
153
154	Class Narcotic analgesic
155	Description A central nervous system depressant A potent analgesic Also has mild hemodynamic properties
156	Mechanism of Action Acts on opiate receptors in the brain Increases peripheral venous capacitance and decreases venous return Decreases myocardial oxygen demand
157	Pharmacokinetics Onset Immediate (IV), 15-30 minutes (IM) Peak effects 20 minutes (IV), 30-60 minutes (IM) Duration 2-7 hours Half-life 1-7 hours
158	Indications Severe pain associated with: Myocardial infarction Kidney stones Other reasons Pulmonary edema either with or without associated pain
159	Contraindications Should not be used in patients who are volume-depleted or severely hypotensive A history of hypersensitivity Patients with undiagnosed head injury or abdominal pain
160	Precautions Has a high tendency for addiction/abuse Classified as a Schedule II drug Special considerations involved in handling Naloxone (Narcan) should be available
161	Side Effects Nausea and vomiting Abdominal cramps Blurred vision Constricted pupils Altered mental status Headache Respiratory depression
162	Interactions The CNS depression associated with morphine can be enhanced when administered with antihistamines, antiemetics, sedatives, hypnotics, barbiturates, and alcohol.
163	Dosage An initial dose of 2-10 mg IV Additional 2 mg every few minutes Continued until the pain is relieved or until signs of respiratory depression occur IM injection 5 to 15 mg Can be given with an antiemetic agent such as promethazine (Phenergan)
164	"Lasix" Lasix
165	Class Diuretic
166	Description A potent diuretic that inhibits sodium and chloride re-absorption in the kidneys and causes venous dilation
167	Mechanism of Action Causes venous dilation within 5 minutes Causes a reduction in preload, thus decreasing cardiac work Diuretic effect begins 5-15 minutes after administration
168	Pharmacokinetics Onset 5-10 min. (vasodilation), 5-30 min. (diuresis) Peak effects 30 min. (vasodilation), 20-60 min. (diuresis) Duration 2 hours (vasodilation), 6 hours (diuresis) Half-life 30 minutes
169	Indications Congestive heart failure Pulmonary edema
170	Contraindications Usage in pregnancy should be limited to life-threatening situations Has been known to cause fetal abnormalities Should not be administered to patients with a known allergy to the sulfa class of medications
171	Precautions Dehydration, electrolyte depletion, and hypotension can result from excessive doses of potent diuretics. Blood pressure should be frequently monitored. Should be protected from light
172	Side Effects Headache Dizziness Hypotension Volume depletion Potassium depletion Dysrhythmias Diarrhea Nausea and vomiting
173	Interactions Should not be administered in the same line as amrinone (Inocor) Causes the formation of a precipitate Usage with other diuretics can lead to severe volume depletion and electrolyte imbalance
174	Dosage 40 mg slow IVP in patients already on chronic oral furosemide therapy 20 mg slow IVP in patients who are not taking the drug orally on a regular basis Dosages as high as 80 to 120 mg IVP may be indicated in severe cases.
175
176	Antianginal Agents A common manifestation of advanced cardiovascular disease is angina pectoris Results from a narrowing of the coronary arteries due to the buildup of atherosclerotic plaques or coronary artery vasospasm Exercise and other stressful situations can result in myocardial hypoxia, causing pain.
177	"Nitrostat" Nitrostat
178	Class Nitrate
179	Description Potent smooth muscle relaxant used in the treatment of angina pectoris
180	Mechanism of Action Reduces cardiac work Dilates the coronary arteries Results in increased coronary blood flow and improved perfusion of the ischemic myocardium Relief of ischemia causes reduction and alleviation of chest pain.
181	Pharmacokinetics Onset 1-3 minutes (SL) Peak effects 5-10 minutes (SL) Duration 20-30 minutes (SL) Half-life 1-4 minutes
182	Indications Chest pain associated with angina pectoris Chest pain associated with acute myocardial infarction Acute pulmonary edema without hypotension
183	Contraindications Hypotension Increased intracranial pressure
184	Precautions Patients may develop a tolerance Deteriorates rapidly once the bottle is open Should be protected from light Monitor vital signs during administration
185	Side Effects Headache Weakness and dizziness Tachycardia Hypotension Orthostasis Skin rash Dry mouth Nausea and vomiting
186	Interactions Causes severe hypotension when administered to patients who have recently ingested alcohol Causes orthostatic hypotension when used in conjunction with beta-blockers
187	Dosage One tablet (0.4 mg) sublingually for routine angina pectoris Repeat in 3-5 minutes as needed Usually, no more than three tablets should be administered prehospitally. Also available in patches and in ointment
188	Summary