Drugs in resus

Drugs used during advanced life support resuscitation

1. DRUGS IN CARDIO P ULMO N ARY RESUSCITATION

2. OBJECTIVES Upon completion of this session, you will be able to: state the drugs commonly used in resuscitation outline the major actions of these drugs list 2 side effects related to the use of the drugs

3. D RUGS U SED I N R ESUSCITATION Adrenaline Atropine A m iodarone Lignocaine Adenosine Dopamine

4. A CCESS T O D RUG A DMINISTRATION Intravenous - Peripheral or central Intra-osseous (2 nd preferred route after failed x2 attempts on IV access) In t r a -tracheal Only if intravenous and intraosseous not available “NAVEL” ( Naloxone,Atropine,Vasopressin,Epinephrine,Lidocaine )

5. T ECHNIQUE F OR IV D RUG A DMINISTRATION Use upper extremity veins Keep the access site elevated Each IV drug administration to be followed by 20-30mls bolus of normal saline The cannula should be as large as possible Use normal saline as the fluid of resuscitation

6. T ECHNIQUE F OR E NDOTRACHEAL D RUG A DMINISTRATION Dilute the drug in 10 ml saline Thread a long catheter through the ETT Stop chest compressions Inject the drug through the catheter Follow with 3-4 manual lung inflations Dosage: 2-2.5x the recommended IV dose

7. I NTRAOSSEOUS Available for adult usage Site: Iliac crest, sternum As effective as intravenous line for resuscitation

8. A DRENALINE 1st drug in cardiac arrest

9. A DRENALINE Indications:- VF Pulseless VT Pulseless electrical activity (PEA) Asystole

10. A DRENALINE Routes of administration:- › IV push OR Intraosseus 1 mg Infusion (3mg in 50 mls N/S at 1ml/hr =1ug/min), titrate accordingly › ETT (2-2.5X IV dose)

11. A DRENALINE ---- A CTIONS increases contractile force of the heart thus increasing cardiac output increases conduction of SA node, AV node and ventricle thus increasing heart rate increases systemic vascular resistance through peripheral vasoconstriction thus increasing perfusion pressure

12. A DRENALINE ---- S IDE - EFFECTS Ventricular irritability – tachyarrthymias ↑ Myocardial Oxygen demand - risk of ischaemia and MI Cerebrovascular event

13. A TROPINE Anticholinergic (parasympatholytic) inhibits effect of acetylcholine on SA and AV node increases SA node and AV node conduction velocity decreases effective refractory period AV node Increases heart rate and cardiac output

14. A TROPINE Indication: Sinus, atrial or nodal bradycardia with hemodynamic instability

15. A TROPINE Routes of administration:- IV: 1 mg for Acute symptomatic /unstable bradycardia ( Max 3mg ) ETT: 2-3 mg diluted in 10 mls saline

16. A TROPINE ---- S IDE - EFFECTS Tachycardia Palpitations Paradoxical bradycardia (if dose < 0.5mg) Seizure (rare) Hypertension (rare)

17. A MIODARONE Has characteristics of all 4 antiarrhythmic drug classes affect sodium, potassium and calcium channel alpha and beta blocking properties Used in BOTH supraventricular and ventricular tachyarrthymias Refractory VT/VF Stable monomorphic or polymorphic VT PSVTs, atrial tachycardia, atrial fibrillation Wide complex tachycardia of uncertain origin Pre-excited atrial arrhythmia

18. A MIODARONE VF, pulseless VT and refractory VT/VF Drug of Choice IV bolus dose 300 mg repeat IV bolus 150 mg in 3-5 mins followed by IV Infusion 900 mg over 24h Other arrhythmias › IV Infusion 150 mg over 10 min followed by IV infusion 900 mg over 24h

19. L IGNOCAINE Indication: Refractory VT/ VF (when amiodarone is not available)

20. L IGNOCAINE ---- A CTIONS Raises fibrillatory threshold enhances the effect of DC shock Suppresses automaticity and shortens effective refractory period and action potential duration slows down heart rate Inhibits reentry mechanism – halts arrhythmias

21. L IGNOCAINE Routes of administration:- – IV push (1.0 to 1.5 mg/kg) Additional 0.5-0.75 mg/kg Max: 3 mg/kg Infusion 1 gm Lignocaine in 500 ml N/S 30 to 120 ml/hr (1 – 4 mg/min) – ETT (2-2.5X IV dose)

22. L IGNOCAINE - S IDE - EFFECTS Seizures Respiratory depression / arrest Widening of QRS complexes Bradycardia - cardiac arrest

23. A DENOSINE A short acting agent that depresses SA node and AV node function Used in narrow complex supraventricular tachycardia Half life : 5 seconds Initial dose of 6 mg rapid IV push (may be repeated at 12 mg )

24. A DENOSINE - S IDE - EFFECTS Transient bradycardia or even ASYSTOLE Hypotension Chest pain Dyspnoea Bronchospasm (caution in asthma ) Transient flushing

25. D OPAMINE Indications: cardiogenic shock septicaemic shock neurogenic shock anaphylactic shock hypovolaemic shock only after fluid resuscitation has failed to raise BP

26. D OPAMINE Route of administration: Infusion via central vein

27. D OPAMINE - A CTIONS Dose dependant effects - Usual dose: 5– 20ug/kg/min Increases myocardial contractility Increases cardiac output Causes peripheral vasoconstriction Increases blood pressure

28. D OPAMINE - S IDE - EFFECTS Tachycardia Tachyarrhythmias Excessive peripheral vasoconstriction

29. S ODIUM B ICARBONATE A significant sodium load 8.4% solution is hypertonic => arterial vasodilatation and hypotension Extravasation => tissue necrosis Not to be injected via same IV line as catecholamines and calcium

30. S ODIUM B ICARBONATE only beneficial in hyperkalaemia probably beneficial in - bicarbonate responsive acidosis possibly beneficial in protracted cardiac arrest with effective ventilation postresuscitation acidosis with effective venti l ation

31. REVIEW OBJECTIVES Are you be able to? State the drugs commonly used in resuscitation outline the major actions of these drugs list 2 side effects related to the use of the drugs

32. THANK YOU NATIONAL COMMITTEE ON RESUSCITATION TRAINING SUBCOMMITEE FOR ADVANCED LIFE SUPPORT Dr Tan Cheng Cheng Dr Luah Lean Wah Dr Ismail Tan Dr Wan Nasrudin Dr Chong Yoon Sin Dr Priya Gill Dr Ridzuan bin Dato’Mohd Isa Dr Thohiroh Abdul Razak Dr Adi Osman