PharmacologyPharmacology ofof AntiarrhythmicsAntiarrhythmics andand VasoactiveVasoactive SubstancesSubstances

PhillipPhillip L.L. Coule,Coule, M.D.M.D. MedicalMedical CollegeCollege ofof GeorgiaGeorgia DepartmentDepartment ofof EmergencyEmergency MedicineMedicine PleasePlease givegive properproper creditcredit toto thethe authorauthor ofof thisthis work:work:

PhillipPhillip L.L. Coule,Coule, M.D.M.D. andand thethe EMSEMS ResourceResource CenterCenter atat thethe MedicalMedical CollegeCollege ofof GeorgiaGeorgia http://www.mcg.http://www.mcg.eduedu//somsom//emergemerg ObjectivesObjectives

■ OverviewOverview ofof AntiarrhythmicAntiarrhythmic andand VasoactiveVasoactive MedicationsMedications • actions • pharmacokinetics • indications • dosing and Administration • adverse effects ■ ClassificationClassification ofof AntiarrhythmicsAntiarrhythmics ■ CardiacCardiac ArrestArrest MedicationsMedications

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AntiarrhythmicAntiarrhythmic ClassificationClassification

■ ClassClass II -- FastFast ChannelChannel BlockersBlockers •• IaIa -- ,Quinidine, ,Disopyramide, ProcainamideProcainamide •• IbIb -- ,Lidocaine, ,Phenytoin, Mexilitine,Mexilitine, TocainindeTocaininde •• IcIc -- Ecainide,Ecainide, ,Flecainide, ,Propafenone, Indecainide,Indecainide, MoricizineMoricizine

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AntiarrhythmicAntiarrhythmic ClassificationClassification

■ ClassClass IIII -- BetaBeta BlockersBlockers •• Propanolol,Propanolol, ,Acebutolol, ,Atenolol, Betaxolol,Betaxolol, Bisoprolol,Bisoprolol, ,Esmolol, Labetalol,Labetalol, ,Metoprolol, ,Nadolol, Oxprenolol,Oxprenolol, Penbutolol,Penbutolol, ,Pindolol, ,Sotalol, TimololTimolol

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AntiarrhythmicAntiarrhythmic ClassificationClassification

■ ClassClass IIIIII •• ,Bretylium, ,Amiodarone, SotalolSotalol

■ ClassClass IVIV -- CalciumCalcium ChannelChannel BlockersBlockers •• ,Verapamil, DiltiazemDiltiazem

■ UnclassifiedUnclassified -- ,Digoxin, ,Adenosine, MgMg

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide -- ActionsActions

■ SuppressesSuppresses automaticityautomaticity •• decreasingdecreasing thethe raterate andand amplitudeamplitude ofof phasephase 44 diastolicdiastolic depolarizationdepolarization •• prolongsprolongs actionaction potentialpotential durationduration •• reducesreduces thethe speedspeed ofof impulseimpulse conductionconduction •• suppressessuppresses fibrillatoryfibrillatory activityactivity inin thethe atriaatria andand ventriclesventricles ■ DoseDose dependantdependant anticholinergicanticholinergic activityactivity

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide -- ActionsActions

■ NegativeNegative InotropeInotrope •• moremore pronouncedpronounced inin ischemicischemic myocardiummyocardium ■ HypotensionHypotension inin highhigh dosesdoses •• vasodilatationvasodilatation ofof peripheralperipheral vasculaturevasculature

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide-- PharmacokineticsPharmacokinetics

■ OnsetOnset •• 55 -- 1010 minutesminutes IVIV •• 1515 -- 6060 minutesminutes IMIM ■ HalfHalf LifeLife •• 2.52.5 toto 4.74.7 hrshrs inin normalnormal renalrenal functionfunction •• increasedincreased inin CHF,CHF, RenalRenal FailureFailure ■ MetabolizedMetabolized toto NN--acetylacetyl ProcainamideProcainamide •• NAPANAPA

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide -- IndicationsIndications

■ VentricularVentricular arrhythmiasarrhythmias •• StableStable VentricularVentricular TachycardiaTachycardia •• PrematurePremature VentricularVentricular ContractionsContractions •• VentricularVentricular FibrillationFibrillation // PulselessPulseless VTVT ■ SupraventricularSupraventricular tachyarrhythmiastachyarrhythmias •• PSVT,PSVT, PAT,PAT, paroxysmalparoxysmal AVAV junctionaljunctional •• AtrialAtrial flutterflutter andand fibrillationfibrillation

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide-- ContraindicationsContraindications

■ AVAV blockblock •• SecondSecond oror thirdthird degreedegree ■ LongLong QTQT intervalinterval ■ TorsadeTorsade dede pointespointes ■ CautionCaution •• SLE,SLE, CHF,CHF, hepatichepatic oror renalrenal diseasedisease

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide -- AdministrationAdministration

■ ContinuousContinuous infusioninfusion safersafer thanthan bolusbolus ■ InfusionInfusion ofof 2020 -- 3030 mg/minmg/min untiluntil •• controlcontrol ofof arrhythmiaarrhythmia •• hypotensionhypotension •• QRSQRS widenswidens byby >> 50%50% •• QTQT intervalinterval prolongationprolongation •• TotalTotal ofof 1717 mg/kgmg/kg hashas beenbeen administeredadministered

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide -- AdministrationAdministration

■ OnceOnce ectopyectopy isis suppressedsuppressed •• maintenancemaintenance dripdrip ofof 11 toto 44 mg/minmg/min ■ LowerLower dosesdoses forfor CHFCHF andand renalrenal failurefailure

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine ProcainamideProcainamide -- AdverseAdverse EffectsEffects

■ MyocardialMyocardial DepressionDepression •• prolongedprolonged QRS,QRS, QT,QT, AVAV conduction,conduction, VFVF andand TorsadeTorsade dede pointespointes ■ HypotensionHypotension •• HighHigh dosesdoses oror rapidlyrapidly administeredadministered ■ HypersensitivityHypersensitivity •• angioedema,angioedema, bronchoconstriction,bronchoconstriction, vascularvascular collapse,collapse, febrilefebrile episodes,episodes, respiratoryrespiratory arrestarrest

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- ActionsActions

■ ClassClass IBIB antiarrhythmicantiarrhythmic •• blocksblocks fastfast sodiumsodium channelschannels •• decreasesdecreases slopeslope ofof phasephase 44 •• decreaseddecreased automaticityautomaticity inin thethe HisHis--purkinjepurkinje systemsystem •• actionaction potentialpotential durationduration andand effectiveeffective refractoryrefractory periodperiod ofof HisHis--purkinjepurkinje increasedincreased •• ActsActs preferentiallypreferentially onon ischemicischemic tissuetissue

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- ActionsActions

■ ContinuedContinued •• CausesCauses littlelittle oror nono effecteffect onon AVAV conductionconduction •• ElevatesElevates vv--fibfib thresholdthreshold •• SupressesSupresses ventricularventricular ectopyectopy •• negligiblenegligible effecteffect – autonomic nervous system – myocardial contractility – peripheral vascular tone

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine --PharmacokineticsPharmacokinetics

■ OnsetOnset ofof ActionAction •• 3030 toto 6060 secondsseconds IVIV •• 1010 minutesminutes IMIM ■ BolusBolus administrationadministration necessarynecessary •• infusioninfusion alonealone willwill notnot reachreach therapeutictherapeutic levelslevels forfor 3030 minmin toto severalseveral hrs.hrs. ■ FirstFirst passpass metabolismmetabolism •• NoNo POPO formform

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- PharmacokineticsPharmacokinetics

■ HalfHalf--LifeLife (elimination)(elimination) •• 8080 toto 108108 minutesminutes – healthy patients •• 77 hrshrs – in patients with CHF, liver disease ■ TherapeuticTherapeutic LevelsLevels •• 1.51.5 toto 66 ug/mlug/ml •• >5>5 ug/mlug/ml maymay causecause CNSCNS toxicitytoxicity

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- IndicationsIndications

■ DrugDrug ofof ChoiceChoice •• ventricularventricular arrhythmiasarrhythmias •• ventricularventricular ectopyectopy – frequent multifocal PVC’s (>6/min) – PVC couplets, salvos – long runs of VT – Not used for chronic PVC’s when asymptomatic ■ ProphylacticProphylactic useuse •• NoNo longerlonger recommendedrecommended

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- AdministrationAdministration

■ InitialInitial DoseDose IVIV •• VentricularVentricular EctopyEctopy – 1 mg/kg bolus – additional doses of 0.5 mg/kg q 5-10 min •• VentricularVentricular FibrillationFibrillation – 1.5 mg/kg ■ TotalTotal DoseDose IVIV •• 33 mg/kgmg/kg

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- AdministrationAdministration

■ EndotrachealEndotracheal •• IfIf IVIV notnot availableavailable •• 22 toto 22 1/2 timestimes thethe dosedose diluteddiluted toto totaltotal volumevolume ofof 1010 cc’scc’s ■ IMIM •• 300300 mgmg ofof 10%10% solution,solution, deltoiddeltoid vastusvastus lateralislateralis •• AutoAuto-- injectorsinjectors availableavailable

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine LidocaineLidocaine -- AdverseAdverse EffectsEffects

■ CNSCNS sideside effectseffects ■ AbruptAbrupt changechange inin mentalmental statusstatus ■ PlasmaPlasma levelslevels greatergreater thanthan 99 ug/mlug/ml •• psychosis,psychosis, seizures,seizures, respiratoryrespiratory depressiondepression ■ ContraindicatedContraindicated •• SASA oror AVAV blocksblocks •• KnownKnown hypersensitivityhypersensitivity

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BetaBeta BlockersBlockers -- ActionsActions

■ BlockBlock effectseffects ofof catacholaminescatacholamines onon BetaBeta receptorsreceptors ■ SelectiveSelective BetaBeta blockersblockers •• metoprololmetoprolol •• acebutololacebutolol •• atenololatenolol •• esmololesmolol •• metoprololmetoprolol

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BetaBeta BlockersBlockers -- ActionsActions

■ NegativeNegative •• ChronotropicChronotropic – slows sinus rate – depresses AV conduction – Decreases cardiac output •• InotropicInotropic ■ VasodilatationVasodilatation

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BetaBeta BlockersBlockers-- PharmacokineticsPharmacokinetics

■ OnsetOnset •• rapidrapid -- withinwithin 11 minuteminute IVIV ■ HalfHalf LifeLife •• 11 toto 2626 hourshours •• ExcretionExcretion isis renalrenal andand GIGI ■ DoseDose adjustmentadjustment necessarynecessary forfor renalrenal failurefailure forfor somesome betabeta blockersblockers

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BetaBeta BlockersBlockers -- AdministrationAdministration

■ MetoprololMetoprolol •• 55 mgmg IVIV pushpush •• selectiveselective B1B1 •• HalfHalf lifelife ofof 33--77 hrshrs ■ EsmololEsmolol •• ultraultra--shortshort halfhalf lifelife ofof 99 minutesminutes •• 2525--5050 ug/kg/minug/kg/min •• loadload ofof 500500 ug/kgug/kg notnot necessarynecessary

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BetaBeta BlockersBlockers -- AdverseAdverse EffectsEffects

■ SimilarSimilar forfor mostmost BetaBeta blockersblockers •• nausea,nausea, vomiting,vomiting, lightlight headedness,headedness, mentalmental depression,depression, bradycardia,bradycardia, hypotension,hypotension, bronchospasmbronchospasm ■ ContraindicatedContraindicated •• >> firstfirst degreedegree heartheart blockblock •• CHFCHF oror cardiogeniccardiogenic shockshock •• CautionCaution withwith calciumcalcium channelchannel blockersblockers

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BretyliumBretylium -- ActionsActions

■ ClassClass IIIIII ■ BiphasicBiphasic EffectsEffects •• NorepinephrineNorepinephrine releaserelease – effects last 20 minutes •• BlocksBlocks releaserelease ofof norepinephrinenorepinephrine – 45 to 60 minutes after administration •• AffectsAffects phasephase 33 (repolarization)(repolarization) prolongsprolongs refractorinessrefractoriness -- antifibrillatoryantifibrillatory

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BretyliumBretylium -- IndicationsIndications

■ VFVF •• refractoryrefractory VF,VF, afterafter epinephrine,epinephrine, lidocainelidocaine ■ VTVT •• refractoryrefractory VTVT withwith aa pulse,pulse, afterafter lidocainelidocaine andand procainamideprocainamide ■ WideWide ComplexComplex TachycardiaTachycardia UnknownUnknown •• afterafter lidocainelidocaine andand adenosineadenosine

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine BretyliumBretylium -- AdministrationAdministration

■ VFVF oror PulselessPulseless VTVT •• 55 mg/kgmg/kg rapidrapid IVIV pushpush •• repeatrepeat atat 1010 mg/kgmg/kg inin 1515 toto 3030 minutesminutes •• maximummaximum isis 3535 mg/kgmg/kg ■ VTVT // ventricularventricular arrhythmiasarrhythmias •• 55 -- 1010 mg.kgmg.kg overover 88 toto 1010 minutesminutes ■ MaintenanceMaintenance ofof 11--22 mg/minmg/min

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine DiltiazemDiltiazem -- ActionsActions

■ ClassClass IVIV -- CalciumCalcium ChannelChannel BlockerBlocker •• decreasesdecreases conductionconduction velocityvelocity inin diseaseddiseased tissuetissue •• prolongsprolongs refractoryrefractory periodperiod inin AVAV nodenode •• slowsslows dischargedischarge fromfrom SASA nodenode •• minimalminimal effecteffect onon normalnormal tissuetissue •• InterruptsInterrupts reentrantreentrant pathwaypathway inin PSVTPSVT

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine DiltiazemDiltiazem -- IndicationsIndications

■ RapidRapid ConversionConversion ofof PSVTPSVT •• asas effectiveeffective asas adenosineadenosine andand verapamilverapamil ■ SlowingSlowing ofof raterate inin AA--FibFib oror AA--flutterflutter ■ HypertensionHypertension

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine DiltiazemDiltiazem -- AdministrationAdministration

■ PSVT,PSVT, AA--fib,fib, AA--flutterflutter •• .25.25 mg/kgmg/kg (average(average 2020 mg)mg) overover 22 minutesminutes •• SecondSecond bolusbolus ofof .35.35 mg/kgmg/kg ■ MaintenanceMaintenance InfusionInfusion •• 55--1515 mg/hrmg/hr

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine DiltiazemDiltiazem -- AdverseAdverse EffectsEffects

■ CardiovascularCardiovascular •• angina,angina, bradycardia,bradycardia, asystole,asystole, CHF,CHF, AVAV block,block, BBB,BBB, flushing,flushing, hypotensionhypotension ■ NonNon--cardiovascularcardiovascular •• headache,headache, dizziness,dizziness, constipation,constipation, rashrash

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AdenosineAdenosine -- ActionsActions

■ EndogenousEndogenous NucleosideNucleoside •• producedproduced byby dephosphorylationdephosphorylation ofof ATPATP ■ NegativeNegative ChronotropicChronotropic effectseffects onon SASA andand AVAV nodenode •• DoesDoes notnot alteralter accessoryaccessory pathwayspathways •• blockadeblockade ofof thethe AVAV nodenode •• potentpotent vasodilatorvasodilator -- nono effectseffects duedue toto metabolismmetabolism

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AdenosineAdenosine -- PharmacokineticsPharmacokinetics

■ OnsetOnset •• 3030 secondsseconds ■ DurationDuration •• 6060 toto 9090 secondsseconds ■ HalfHalf--lifelife •• lessless thanthan 77 secondsseconds

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AdenosineAdenosine -- IndicationsIndications

■ EmergencyEmergency managementmanagement ofof PSVTPSVT •• involvinginvolving thethe AVAV nodenode ■ DiagnosticDiagnostic •• WideWide complexcomplex tachycardiatachycardia ofof uncertainuncertain originorigin •• detectiondetection ofof accessoryaccessory pathwayspathways

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AdenosineAdenosine -- AdministrationAdministration

■ 66 mgmg RapidRapid IVIV pushpush (over(over 11--22 seconds)seconds) •• mostmost proximalproximal portport •• followedfollowed byby 2020 mlml salinesaline flushflush •• elevateelevate thethe extremityextremity afterafter bolusbolus ■ RepeatRepeat DosingDosing •• 1212 mgmg rapidrapid IVIV pushpush ifif heartheart raterate notnot decreaseddecreased inin 22 minutesminutes

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AdenosineAdenosine -- AdverseAdverse EffectsEffects

■ MinorMinor andand wellwell toleratedtolerated •• lessless thanthan 11 minuteminute •• dyspnea,dyspnea, cough,cough, syncope,syncope, vertigo,vertigo, parasthesiasparasthesias ■ HigherHigher dosesdoses •• DipyramidoleDipyramidole •• CarbamazepineCarbamazepine •• Asthmatics,Asthmatics, excessiveexcessive coffeecoffee drinkersdrinkers

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine MagnesiumMagnesium -- ActionsActions

■ DirectlyDirectly •• Na,Na, K+,K+, ATPaseATPase pumppump ■ IndirectlyIndirectly •• calciumcalcium channelchannel blockingblocking activityactivity ■ EffectsEffects •• IncreasesIncreases membranemembrane potentialpotential •• prolongsprolongs AVAV conductionconduction •• CorrectsCorrects hypomagnesemia/hypokalemiahypomagnesemia/hypokalemia

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine MagnesiumMagnesium -- IndicationsIndications

■ IntractableIntractable VF/VTVF/VT ■ TorsadeTorsade dede pointespointes ■ MayMay bebe usefuluseful •• PVC’s,PVC’s, MAT,MAT, PSVT,PSVT, digoxindigoxin toxicitytoxicity

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine MagnesiumMagnesium -- AdministrationAdministration

■ IVIV LoadingLoading dosedose •• 11 toto 22 gramsgrams inin 5050--100100 cccc ofof D5WD5W overover 11 toto 22 minutesminutes ■ AcuteAcute MIMI •• 88 toto 1212 gramsgrams perper dayday inin acuteacute MIMI

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine VasoactiveVasoactive MedicationsMedications

■ EpinephrineEpinephrine ■ DopamineDopamine ■ NorepinephrineNorepinephrine ■ AtropineAtropine ■ NitroglycerinNitroglycerin

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine EpinephrineEpinephrine -- OverviewOverview

■ NonselectiveNonselective alphaalpha andand betabeta agonistagonist •• increasedincreased heartheart rate,rate, SVR,SVR, ventricularventricular contractilitycontractility ■ OnsetOnset •• 11 toto 22 minutesminutes ■ DurationDuration ofof actionaction •• 22 toto 1010 minutesminutes

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine EpinephrineEpinephrine -- ContinuedContinued

■ IndicationsIndications •• CardiacCardiac ArrestArrest •• BronchospasmBronchospasm •• AnaphylaxisAnaphylaxis // hypersensitivityhypersensitivity reactionsreactions ■ AdministrationAdministration •• CardiacCardiac ArrestArrest – 1 mg IV push every 3 - 5 minutes – escalating and high dose options

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine EpinephrineEpinephrine -- ContinuedContinued

•• EndotrachealEndotracheal – 2 to 2.5 the IV dose diluted to 10 cc ■ AdverseAdverse EffectsEffects •• maymay increaseincrease myocardialmyocardial oxygenoxygen consumptionconsumption

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine DopamineDopamine -- OverviewOverview

■ ActionsActions •• actsacts onon dopaminergic,dopaminergic, alphaalpha andand betabeta receptorsreceptors ■ LowLow DoseDose •• dilatationdilatation ofof renal,renal, mesenteric,mesenteric, coronary,coronary, andand intracerebralintracerebral vascularvascular bedsbeds •• improvesimproves organorgan perfusionperfusion andand increasesincreases urineurine outputoutput

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine DopamineDopamine -- ContinuedContinued

■ ModerateModerate DoseDose 22 -- 1010 ug/kg/minug/kg/min •• mostlymostly betabeta effectseffects – inotropic, chronotropic on heart – increased cardiac output ■ HighHigh DoseDose >10>10 ug/kg/minug/kg/min •• AlphaAlpha effectseffects predominatepredominate – increased peripheral resistance – decreased blood flow to kidney

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine NorepinephrineNorepinephrine -- OverviewOverview

■ EndogenousEndogenous CatacholamineCatacholamine •• powerfulpowerful alphaalpha agonistagonist •• potentpotent vasoconstrictorvasoconstrictor ■ OnsetOnset •• 11 toto 33 minutesminutes ■ IndicationsIndications •• severesevere hypotensionhypotension refractoryrefractory toto fluidsfluids andand otherother pressorpressor agentsagents

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine NorepinephrineNorepinephrine -- ContinuedContinued

■ SpecificSpecific UsesUses •• SepticSeptic ShockShock •• refractoryrefractory hypotensionhypotension duedue toto AMIAMI ■ DosingDosing •• 0.50.5 toto 11 ug/kg/minug/kg/min – increase by 1 to 2 ug/kg/min every 3-5 min – goal is systolic BP of 80 to 100

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine NorepinephrineNorepinephrine -- ContinuedContinued

■ AdverseAdverse EffectsEffects •• ventricularventricular irritabilityirritability •• cardiaccardiac depressiondepression •• decreaseddecreased renalrenal bloodblood flowflow •• reflexreflex bradycardiabradycardia •• acuteacute hypertensionhypertension – MAOI, TCA’s •• ExtravasationExtravasation necrosisnecrosis – pentolamine 5-10 mg/10 cc subcutaneous

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AtropineAtropine OverviewOverview

■ AntimuscarinicAntimuscarinic AgentAgent •• parasympatholyticparasympatholytic // vagolyticvagolytic – increases SA node automaticity by blocking vagus nerve ■ IndicationsIndications •• hemodynamicallyhemodynamically unstableunstable bradycardiasbradycardias •• PEA,PEA, Asystole,Asystole, bradyasystolicbradyasystolic rhythmsrhythms •• anticholinergicanticholinergic propertiesproperties

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine AtropineAtropine ContinuedContinued

■ DoseDose •• 0.50.5 toto 11 mgmg IVIV ■ EndotrachealEndotracheal •• 11 toto 22 mgmg IVIV (10(10 cccc volume)volume) ■ AdverseAdverse effectseffects •• increasedincreased MVO2MVO2 •• undesirableundesirable tachycardiatachycardia •• precipitateprecipitate ventricularventricular arrhythmiasarrhythmias

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine SummarySummary

■ PharmacologyPharmacology ofof antiarrhythmicantiarrhythmic andand vasoactivevasoactive medicationsmedications •• ActionsActions •• PharmacokineticsPharmacokinetics •• IndicationsIndications •• AdministrationAdministration •• AdverseAdverse EffectsEffects

Phillip L. Coule, M.D. Medical College of Georgia Emergency Medicine