Atropine Sulfate

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1. ATROPINE SULFATE
Indications
Hemodynamically significant bradycardia
Asystole
PEA
Organophosphate poisoning (drug of choice)
Pretreatment in pediatric patients receiving RSI.
Dosages
Bradydysrhythmias
0.5 – 1.0 mg IV, may be repeated at 5 min intervals until desired rate achieved. (max 0.03-0.04mg/kg)
Pediatric
0.02 mg/kg IV, IO, ET(diluted to 3-5ml). Min dose 0.1mg; max single dose fo 0.5 mg for a child and 1.0 mg for an
adolescent; may be repeated in 5 minutes for a max total fo 1.0 mg for a child and 2.0 mg for an adolescent.
Asystole
Adult
1.0 mg IV, ET, (1-2 mg diluted to a total of 10ml); may be repeated every 3-5 minutes (max 0.03 – 0.04mg/kg)
Pediatric
unknown efficacy
PEA
Adult
1 mg IV (if bradycardic), repeat every 3-5 minutes, max 0.03 – 0.04mg/kg.
Pediatric
unknown efficacy
Anticholinesterase Poisoning
Adult
2 mg IV push every 5-15 minutes to dry secretions. No max dose.
Pediatric
0.05 mg/kg/dose (usual dose 1-5 mg) IV, may be repeated in 15 minutes.
Mechanism of action
Atropine sulfate is a potent parasympatholytic. It inhibits actions of acetylcholine at postganglionic parasympathetic neuroeffector
sites, primarily at muscarinic receptors. Small doses inhibit salivary and bronchial secretions, moderate doses dilate pupils and
increase heart rate. Large doses decrease GI motility, inhibit gastric acid secretion. Blocked vagal effects result in positive
chronotropy and positive dromotropy (limited or no inotropic effect). In emergency care, it is primarily used to increase the heart
rate in life-threatening bradycardias. You can think of the effects of atropine as being 'anti-SLUDGE'.
Precautions
Do not administer unless solution is clear and seal is intact. Discard unused portion.
Atropine Sulfate Injection, USP should be used with caution in all individuals over 40 years of age. Conventional systemic doses may
precipitate acute glaucoma in susceptible patients, convert partial organic pyloric stenosis into complete obstruction, lead to
complete urinary retention in patients with prostatic hypertrophy or cause inspissation of bronchial secretions and formation of
dangerous viscid plugs in patients with chronic lung disease.

2. ADENOSINE
Indications
Tachycardia, supraventricular, paroxysmal - Adenosine is indicated for conversion to sinus rhythm of paroxysmal supraventricular
tachycardia, including those due to atrioventricular (AV) node reentry and associated with accessory bypass tracts (Wolff-Parkinson-
White syndrome)
after appropriate vagal maneuvers (e.g., Valsalva maneuver) have been attempted
Myocardial perfusion imaging radionuclide (adjunct) or[Stress echocardiography (adjunct)
In patients unable to exercise adequately,
to induce coronary artery vasodilation in conjunction with myocardial perfusion imaging (i.e., thallium-201 myocardial perfusion
scintigraphy) or two-dimensional echocardiography for the detection of perfusion defects or regional contraction abnormalities
associated with coronary artery disease.
Dosages
Mechanism of action
Antiarrhythmic—Slows impulse formation in the sinoatrial (SA) node, slows conduction time through the atrioventricular (AV) node, and can
interrupt reentry pathways through the AV node. Adenosine depresses left ventricular function, but because of its short half-life, the effect is
transient, allowing use in patients with existing poor left ventricular function.
Diagnostic aid—The precise mechanism of coronary vasodilation is not completely understood. However, it is speculated that adenosine may have
a direct effect on smooth muscle receptors and may influence cellular calcium dynamics. Coronary vasodilation by adenosine contributes to the
creation of heterogeneity of myocardial blood flow. The difference in coronary reserve in the vascular bed distal to a critical coronary stenosis
versus that supplied by normal coronary arteries accounts for a significantly greater, 3- to 5-fold, increase in regional myocardial blood flow to
normal epicardial vessels.

Administration of doses larger than 12 mg by intravenous infusion decreases blood pressure by reducing peripheral vascular resistance.
Physiologically, naturally occurring adenosine functions as an intermediate metabolite in a number of processes including regulation of coronary
and systemic vascular tone, platelet function, lipolysis in fat cells, and intracardiac conduction
Precautions
Mutagenicity
Mutagenicity tests in the Salmonella/mammalian microsome assay
(Ames test) were negative However, adenosine causes chromosomal
alterations
Pregnancy/Reproduction
Fertility—
In rats and mice, intraperitoneal administration of 50, 100, and 150
mg per kg of body weight (mg/kg) per day for 5 days caused
decreased spermatogenesis and increased numbers of abnormal
sperm
Pregnancy—
Studies have not been done in humans. Because adenosine occurs
naturally in the body, problems are not expected. Scant reports of
adenosine use in pregnant women have not revealed fetal or
maternal sequelae.
Breast-feeding
Because of rapid removal from circulation, adenosine is not
expected to be distributed into breast milk
Pediatrics
Studies performed to date on adenosine's use as an antiarrhythmic
have not demonstrated pediatrics-specific problems that would limit
the usefulness of this medication in the pediatric population.
The safety and effectiveness of adenosine, when used as an adjunct
to myocardial perfusion imaging, have not been established in
patients less than 18 years of age
Geriatrics
Appropriate studies on the relationship of age to the effects of
adenosine have not been performed in the geriatric population.
However, geriatrics-specific problems that would limit the
usefulness of this medication in the elderly are not expected

3. LIDOCAINE
Indications
to relieve postherpetic neuralgia (arising, for example, from shingles) in some patients, though there is not enough study evidence to
recommend it as a first-line treatment. It also has uses as a temporary fix for tinnitus. Although not completely curing the illness, it has
been shown to reduce the effects by around two thirds.
suitable for infiltration, block and surface anesthesia. Longer-acting substances such as bupivacaine are sometimes given preference for
spinal and peridural anesthesias; lidocaine, on the other hand, has the advantage of a rapid onset of action. Adrenaline vasoconstricts
arteries and hence delays the resorption of Lidocaine, almost doubling the duration of anaesthesia. For surface anesthesia several
formulations are available that can be used e.g. for endoscopies, before intubations etc.
used intravenously for the treatment of ventricular arrhythmias (for acute myocardial infarction, digitalis poisoning, cardioversion or
cardiac catheterization). However, a routine prophylactic administration is no longer recommended for acute cardiac infarction; the
overall benefit of this measure is not convincing.
efficient in refractory cases of status epilepticus.
proved effective in treating jellyfish stings, both numbing the affected area and preventing further nematocyst discharge
Dosages
The dose should generally be reduced in children, elderly, or debilitated patients. In normal healthy adults, the maximum recommended dose of
lidocaine injection with epinephrine for local anesthesia other than spinal should not exceed 7 mg/Kg, and the maximum total dose should not
exceed 500 mg. Lidocaine injection with epinephrine should not be used on fingers and toes. The maximum recommended dose of lidocaine
injection without epinephrine should not exceed 4.5 mg/Kg, and the maximum total dose should not exceed 300 mg. Once given the maximum
dose of lidocaine, it should not be repeated for 2 hours.
Viscous lidocaine 2% is typically dosed as 15 ml (300 mg) orally swish and spit/swallow every 3 hours as needed in adults. Patients should not
exceed 8 doses in 24 hours. Adverse effects such as dizziness, light-headedness, and numbness of the tongue have been reported with 500 mg oral
doses of lidocaine. Topical administration of lidocaine in adults and children should not exceed 3 mg/Kg/dose (e.g., 4.2 gm of a 5% ointment for a
70 Kg patient). The dose should not be repeated within 2 hours.
The maximum adult dose for the lidocaine 5% patch (Lidoderm) is up to 3 patches may be applied at a time for no more than 12 hours per 24-hour
period. Lidocaine 4% cream (L.M.X.4) should not be applied to an area over 100 cm
2
for patients under 10 Kg and an area over 600 cm2 for patients
between 10 and 20 Kg. The amount absorbed systemically is determined by the area over which it is applied and the duration of application,
particularly if it is left on for longer than 2 hours to a large surface area.
The recommended maximum dose, application area, and application time of lidocaine 2.5% with prilocaine 2.5% cream (EMLA), depend upon the
weight and age of the patient. Children under 3 months of age or less than 5 Kg can receive up to 1 gm over 10 cm
2
for up to 1 hour. Children 3 to
12 months of age and over 5 Kg can receive up to 2 gm per dose over 20 cm
2
for up to 4 hours. Children 1 to 6 years of age and more than 10 Kg
can receive up to 10 gm per dose over 100 cm
2
for up to 4 hours, and children 7 to 12 years old and greater than 20 Kg can receive up to 20 gm per
dose over a 200 cm
2
area for up to 4 hours.
Mechanism of action
Lidocaine alters signal conduction in neurons by blocking the fast voltage gated sodium (Na
+
) channels in the neuronal cell membrane that are
responsible for signal propagation
[4]
. With sufficient blockage the membrane of the postsynaptic neuron will not depolarize and will thus fail to
transmit an action potential. This creates the anaesthetic effect by not merely preventing pain signals from propagating to the brain but by
aborting their birth in the first place. Careful titration allows for a high degree of selectivity in the blockage of sensory neurons, whereas higher
concentrations will also affect other modalities of neuron signaling.
Precautions
Physician must be notified about patients medical history, especially: heart problems (e.g., heart block, heart failure), high or low blood pressure,
liver problems, kidney problems, any allergies. This medication is not recommended for use if patient have the following medical conditions: nerve
disease, spine problems. Causes dizziness or drowsiness; use caution engaging in activities requiring alertness such as driving or using machinery.
Avoid alcoholic beverages. Depending on how and where this drug is injected into the body, patient may experience temporary weakness. To
minimize dizziness and lightheadedness, tell patient get up slowly when rising from a seated or lying position. Notify physician if weakness or
problems with muscle control persist. Caution is advised when using this drug in the elderly because they may be more sensitive to the effects of
the drug. Caution is advised when using this drug in children because they may be more sensitive to the effects the drug. Tell physician if patient is
are pregnant before using this medication. This medication passes into breast milk. Consult physician before breast-feeding.

4. PROCAINAMIDE
Indications and dosages
Oral Intravenous
Ventricular arrhythmias
Adult: 50 mg/kg daily in divided doses every 3-6 hr.
Child: 15-50 mg/kg daily in 4 divided doses.
Elderly: Dosage reduction or increase in dosing intervals is
recommended.
Renal impairment: Dosage reduction or increase in dosing intervals is
recommended.
Hepatic impairment: Dosage reduction is recommended.

Ventricular arrhythmias
Adult: Dilute in 5% glucose soln and given in doses of 100 mg every 5
min at a rate not exceeding 50 mg/min until arrhythmia has been
suppressed or a max of 1 g has been reached. Alternatively admin by
continuous infusion of 500-600 mg over 25-30 min with ECG monitoring
followed by infusion at a rate of 2-6 mg/min.
Child: Loading dose of 10-12 mg/kg, followed by continuous infusion of
20-75 mcg/kg/min.
Elderly: Dosage reduction or increase in dosing intervals is
recommended.
Max Dosage: Adult: 1 g.
Renal impairment: Dosage reduction or increase in dosing intervals is
recommended.
Hepatic impairment: Dosage reduction is recommended.
Short-term management of severe or symptomatic arrhythmias
Adult: 50 mg/kg daily in divided doses every 3-6 hr.
Child: 15-50 mg/kg daily in 4 divided doses.
Elderly: Dosage reduction or increase in dosing intervals is
recommended.
Renal impairment: Dosage reduction or increase in dosing intervals is
recommended.
Hepatic impairment: Dosage reduction is recommended
Short-term management of severe or symptomatic arrhythmias
Adult: Dilute in 5% glucose soln and given in doses of 100 mg every 5
min at a rate not exceeding 50 mg/min until arrhythmia has been
suppressed or a max of 1 g has been reached. Alternatively admin by
continuous infusion of 500-600 mg over 25-30 min with ECG monitoring
followed by infusion at a rate of 2-6 mg/min.
Child: Loading dose of 10-12 mg/kg, followed by continuous infusion of
20-75 mcg/kg/min.
Elderly: Dosage reduction or increase in dosing intervals is
recommended.
Max Dosage: Adult: 1 g.
Renal impairment: Dosage reduction or increase in dosing intervals is
recommended.
Hepatic impairment: Dosage reduction is recommended.
Procainamide is an antiarrhythmic drug used in the treatment of abnormal heart rhythms such as:
early (premature) atrial and ventricular beats;
intermittent rapid rhythms (tachycardias) involving the atria and atrio-ventricular (AV) junction as well as abnormal pathways (bypass
tracts) between the atria and ventricles;
intermittent atrial fibrillation and flutter;
after conversion from atrial fibrillation or flutter to prevent recurrence; and
ventricular tachycardia.
The oral dose and interval of administration should be adjusted for the individual patient, based on clinical assessment of the degree of
underlying myocardial diseased, the patient's age, and renal function.
As a general guide, for younger adult patients with normal renal function, an initial total daily oral dose of up to 50 mg/kg of body weight of
PRONESTYL Capsules or Tablets may be used, given in divided doses, every three hours, to maintain therapeutic blood levels. For older
patients, especially those over 50 years of age, or for patients with renal, hepatic, or cardiac insufficiency, lesser amounts or longer intervals
may produce adequate blood levels, and decrease the probability of occurrence of dose-related adverse reactions. The total daily dose should
be administered in divided doses at three, four, or six hour intervals and adjusted according to the patient's response.


To provide approximately 50 mg per kg of body weight per day*
Patients weighing
lb kg
88-110 40-50 250 mg q3h to 500 mg q6h
132-154 60-70 375 mg q3h to 750 mg q6h
176-198 80-90 500 mg q3 hr to 1 g q6h
> 220 > 100 625 mg q3h to 1.25 g q6h
*Initial dosage schedule guide only, to be adjusted for each patient individually, based on age, cardiorenal function, blood level (if
available), and clinical response.

5. HOW SUPPLIED
PRONESTYL Capsules (Procainamide Hydrochloride Capsules USP)
250 mg: two-piece yellow gelatin capsules printed with 758
bottles of 100 NDC 0003-0758-50
bottles of 1000 NDC 0003-0758-80
cartons of 100 Unimatic* unit-dose capsules NDC 0003-0758-53
375 mg: white and orange gelatin capsules printed with 756
bottles of 100 NDC 0003-0756-50
cartons of 100 Unimatic* unit-dose capsules NDC 0003-0756-53
500 mg: yellow and orange gelatin capsules printed with 757
bottles of 100 NDC 0003-0757-50
bottles of 1000 NDC 0003-0757-80
cartons of 100 Unimatic* unit-dose capsules NDC 0003-0757-53
PRONESTYL Tablets (Procainamide Hydrochloride Tablets USP)
250 mg: yellow FILMLOK® tablets debossed with 431
bottles of 100 NDC 0003-0431-50
375 mg: orange FILMLOK® tablets debossed with 434
bottles of 100 NDC 0003-0434-50
500 mg: red FILMLOK® tablets debossed with 438
bottles of 100 NDC 0003-0438-50


Mechanisms of action
Procainamide directly interferes with depolarization of the cell membrane by blocking the fast inward current of Na into cardiac cells. It slows the
rate of change of the depolarization phase of the action potential, moderately prolong the PR, QRS and QT intervals on ECG monitoring. It also has
local anesthetic properties.
Procainamide (PA) increases the effective refractory period of the atria, and to a lesser extent the bundle of His-Purkinje system and ventricles of
the heart. It reduces impulse conduction velocity in the atria, His-Purkinje fibers, and ventricular muscle, but has variable effects on the
atrioventricular (A-V) node, a direct slowing action and a weaker vagolytic effect which may speed A-V conduction slightly. Myocardial excitability is
reduced in the atria. Purkinje fibers, papillary muscles, and ventricles by an increase in the threshold for excitation, combined with inhibition of
ectopic pacemaker activity by retardation of the slow phase of diastolic depolarization, thus decreasing automaticity especially in ectopic sites.
Contractility of the undamaged heart is usually not affected by therapeutic concentrations, although slight reduction of cardiac output may occur,
and may be significant in the presence of myocardial damage. Therapeutic levels of PA may exert vagolytic effects and produce slight acceleration
of heart rate, while high or toxic concentrations may prolong A-V conduction time or induce A-V block, or even cause abnormal automaticity and
spontaneous firing, by unknown mechanisms.
Precautions
Use cautiously in patients with Myocardial damage or severe organic heart disease, asthma. Perform regular blood tests. Screen for lupus
erythematosus. Serum antinuclear factor should be carried out before and regularly during therapy. Pregnancy, elderly, hepatic and renal
impairment. May worsen torsade de pointes. Pre-treatment with digoxin may be necessary if procainamide is used in the treatment of atrial
tachycardia. IV admin may cause severe hypotension, thus slow inj and monitoring of ECG and BP are recommended.
General
Immediately after initiation of PA therapy, patients should be closely observed for possible hypersensitivity reactions, especially if procaine or local
anesthetic sensitivity is suspected, and for muscular weakness if myasthenia gravis is a possibility.
In conversion of atrial fibrillation to normal sinus rhythm by any means, dislodgement of mural thrombi may lead to embolization, which should be
kept in mind.
After a day or so, steady state plasma PA levels are produced following regular oral administration of a given dose of PRONESTYL (Procainamide
Hydrochloride Tablets; Procainamide Hydrochloride Capsules) at set intervals, with peak plasma concentrations at about 90 to 120 minutes after
each dose. After achieving and maintaining therapeutic plasma concentrations and satisfactory electrocardiographic and clinical responses,
continued frequent periodic monitoring of vital signs and electrocardiograms is advised.
If evidence of QRS widening of more than 25 percent or marked prolongation of the Q-T interval occurs, concern for overdosage is appropriate, and
reduction in dosage is advisable if a 50 percent increase occurs. Elevated serum creatinine or urea nitrogen, reduced creatinine clearance, or
history of renal insufficiency, as well as use in older patients (over age 50), provide grounds to anticipate that less than the usual dosage and longer
time intervals between doses may suffice, since the urinary elimination of PA and NAPA may be reduced, leading to gradual accumulation beyond
normally predicted amounts. If facilities are available for measurement of plasma PA and NAPA, or acetylation capability, individual dose
adjustment for optimal therapeutic levels may be easier, but close observation of clinical effectiveness is the most important criterion.

6. SOURCES:
http://www.rxlist.com/atropine-drug.htm
http://www.templejc.edu/dept/ems/drugs/atropine.html
http://www.drugs.com/mmx/adenosine.html
http://en.wikipedia.org/wiki/Lidocaine#Indications
http://www.medicinenet.com/procainamide/article.htm
http://www.mims.com/Page.aspx?menuid=mng&name=procainamide
http://www.rxlist.com/pronestyl-drug.htm