Drugs for CPR - 2005

Specific Drug Therapy in CPR : 

Specific Drug Therapy in CPR Directed By: Behdad Bazargani M.D. Anesthesiologist Ali ShahAbbasi M.D. Anesthesiologist

Slide 2: 

During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway.

Routes of Drug Administration : 

Routes of Drug Administration Peripheral veins Central veins Tracheal Intraosseous Intracardiac

Peripheral Venous Route : 

Peripheral Venous Route Peak effect 1.5 - 3 min. after injection at antecubital fossa IV push 20 ml NS flush after drug injection  circulation time by 40% Comparable to drug delivery through a central vein

Central Venous Route : 

Central Venous Route Faster, higher peak concentration and more potent effect compared to peripheral injection Should be used if it is already in situ Inserting a central line is associated with problems of interrupting CPR, bleeding arterial puncture and air embolism

Tracheal Route : 

Tracheal Route Second line route due to impaired absorption and unpredictable pharmacodynamics Need 2-3 times the IV dose, diluted in 5-10 ml water or 0.9% NS Non-ionic drugs only: adrenalin, atropine, lidocaine, vasopressin and naloxone NEVER calcium or sodium bicarbonate

Intracardiac Route : 

Intracardiac Route NOT recommended May produce pneumothorax, injury to a coronary artery and prolonged interruption of cardiac massage. Inadvertent injection into the myocardium may produce intractable arrhythmias

What if you can’t get a line? : 

What if you can’t get a line? ETT route is better than no route at all!!! With the advancement of adult IO, soon there will be other options for drug administration.

intraosseous injection devices : 

intraosseous injection devices

Recommended sites forintraosseous injection: : 

Recommended sites forintraosseous injection:

Drugs for Resuscitation : 

Drugs for Resuscitation Don’t forget that, Oxygen Is the first and the best drug in CPR

Drugs for Resuscitation : 

Drugs for Resuscitation Vasopressors Adrenaline Vasopressin Antiarrhythmic Drugs Other Agents Atropine Buffer agents Calcium

Vasopressors : 

Vasopressors After delivery of 1 or 2 shocks plus CPR, If VF/VT persists give a vasopressor: Epinephrine every 3 to 5 minutes during cardiac arrest Vasopressin (one dose) may replace either the first or second dose of epinephrine

Adrenaline : 

Adrenaline Adrenaline 1 mg (10 ml of 1:10,000 dilution) IV boluses every three minutes until pulse returns Short half life of 3-5 minutes -effect (vasoconstriction)  aortic pressure to maintain myocardial and cerebral blood flow β-adrenergic effects: they may increase myocardial work and reduce subendocardial perfusion.

Vasopressin : 

Vasopressin 40 U IV: powerful vasoconstriction V1 receptors in smooth muscle Longer half-life of 10-20 minutes If there is no response 10-20 min. after 40 U of IV vasopressin, resume epinephrine 1 mg IV push every 3 to 5 minutes

Antiarrhyhmic : 

Antiarrhyhmic If a perfusing rhythm is transiently restored but not successfully maintained between repeated shocks (recurrent VF/VT), the patient may be a candidate for early treatment with antiarrhythmic medications

Amiodarone : 

Amiodarone Amiodarone has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine Affects sodium, potassium, and calcium channels as well as α and β adrenergic blocking properties It can be considered for the treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor. Administer 150-300 mg of IV amiodarone over 10 minutes, followed by a 1 mg/min infusion for 6 hours and then a 0.5 mg/min maintenance infusion over 18 hours. Supplementary infusions of 150 mg can be repeated every 10 minutes as necessary for recurrent or resistant arrhythmias to a maximum total daily IV dose of 2.2 g.

Amiodarone : 

Amiodarone In patients known to have severely impaired heart function, IV amiodarone is preferable to other antiarrhythmic agents for atrial and ventricular arrhythmias. The major adverse effects of amiodarone are hypotension and bradycardia, which can be prevented by slowing the rate of drug infusion.

Lidocaine : 

Lidocaine Lidocaine should be considered an alternative treatment to amiodarone Initial bolus of 1.0-1.5 mg/kg Additional bolus of 0.5-0.75 mg/kg at 5- to 10-minute intervals Maximum total of 3 mg/kg Maintenance infusion of 1-4 mg/min

Magnesium sulfate : 

Magnesium sulfate recommended for the treatment of torsades de pointes VT (irregular/polymorphic VT associated with prolonged QT interval) with or without cardiac arrest, but it has not been shown to be helpful for treatment of non-torsades pulseless arrest

Magnesium sulfate : 

Magnesium sulfate In pulseless patient: at a dose of 1 to 2 g diluted in 10 mL D5W IV/IO push, typically over 5 to 20 minutes (Class IIa for torsades). In the patient with pulses: the same 1 to 2 g is mixed in 50 to 100 mL of D5W and given as a loading dose over 5 to 60 minutes IV.

Atropine : 

Atropine Good for haemodynamically significant bradycardia from high vagal tone, hypoxia or nodal ischemia For asystole or PEA 1 mg up to 3 doses or single dose of 3 mg will produce a fully vagolytic effect

Atropine : 

Atropine Increases in: Heart rate Systemic vascular resistance Blood pressure Atropine is: Inexpensive easy to administer few side effects therefore can be considered for asystole or PEA.

Buffer Agents : 

Buffer Agents Little data supports therapy with buffers during cardiac arrest Initial dose of 1 mEq/kg of NaHCO3 Problems Left shift of Hb dissociation curve compromises CPP by reducing systemic vascular resistance. High osmolality and Na load Inactivate simultaneously administered catecholamines It produces excess carbon dioxide, which freely diffuses into myocardial and cerebral cells and may paradoxically contribute to intracellular acidosis

Indications of NAHCO3 : 

Indications of NAHCO3 Preexisting metabolic acidosis Hyperkalemia Alkaline diuresis; overdose of tricyclic antidepressant, aspirin, etc.

Calcium : 

Calcium Only used in Hypocalcaemia Hyperkalaemia Calcium antagonist overdose 10% CaCl2 at 8-16 mg/kg (usually 5-10 ml) and repeated as necessary at 10-minute intervals The 10% solution contains 1.36 mEq of calcium or 27.2 mg elemental calcium per milliliter