أدويه العنايه القلبيه

UNDERSTANDING CODE DRUGS

OBJECTIVES:
1. The student will be able to state the dosages and concentrations of each of the CODE Drugs.
2. The student will be able to describe the indications and nursing considerations for each of the CODE Drugs.
3. The student will be able to convert patient’s weight from pounds to kilograms and calculate the appropriate dosage of a mg/kg drug order.
OXYGEN
* Essential in cardiac arrest and emergency cardiac care
* Expired air = 16-17% oxygen
* Must given supplemental oxygen @ FIO2 of 100%
* Give to all patients with acute chest pain that may be due to cardiac ischemia, suspected hypoxemia of any cause and cardiopulmonary arrest
* Do not withhold from patients with COPD
* Nasal cannula, masks, positive pressure devices, volume ventilators
* Major precaution: ADEQUATE VENTILATION - ensure by measuring endtidal CO2 and pulse oximeter

MEDICATION

INDICATION/DOSAGES

NURSING CONSIDERATIONS

Epinephrine- catecholamine (alpha & beta-adrenergic agonist) 1mg epi= (10ml of a 1:10,000 solution) or (1ml of a 1:1000 solution in multidose vial)	0 VF,pulseless VT,PEA, or asystole -standard dosing: 1mg I.V. push q. 3-5min -intermediate dosing: 2-5mg I.V.push over 3-5min -escalating dosing: 1mg,3mg,5mg I.V. push 3 min apart - high dosing: 0.1mg/kg I.V. push q 3-5min 0 Symptomatic bradycardia: continuous infusion @ 2-10 mcg/min; titrate to hemodynamic response (not used as a first-line drug) MIX 1mg(1ml of a 1:1000 solution) in 500ml NSS or D5W	* Each dose given peripherally should be followed by 20ml fluid flush to ensure delivery to central circulation * If no IV access available, give 2- 2.5 times the dose via ET tube; follow with 10ml flush of NSS * Intracardiac administration used only when no other route available * Increases SVR, BP, cardiac electrical activity, coronary and cerebral blood flow, strength of myocardial contraction, automaticity and myocardial oxygen requirements
Atropine (parasympatholytic) 1mg atropine= 10ml bristojet	0 Symptomatic bradycardia: 0.5- 1.0mg I.V. push q. 3-5 min, not to exceed a total dose of 0.04mg/kg 0 Asystole or PEA: 1mg I.V push q. 3-5min, not to exceed total dose of 0.04mg/kg 0 Relative bradycardia- HR wnl but insufficient to meet demands	* Don’t give less than 0.5mg per dose because the possible paradoxical effect may further slow heart rate * Use cautiously in presence of MI * If given via ET tube: dilute 1-2mg in 10ml sterile water or saline- follow with 10 ml flush of NSS * Enhances SA node automaticity and AV conduction via direct vagolytic action
Lidocaine (Antiarrhythmic) 100mg = 10ml bristojet 1GM/250 D5W= Premix drip in first drawer of crash cart	0 VF or pulseless VT refractory to electrical countershocks and epinephrine: initially, 1-1.5mg/kg I.V. push; repeat q. 3-5min to max of 3mg/kg 0 Stable VT or stable wide-complex tachycardia of uncertain origin: repeat doses of half the original dose 0 If lidocaine successfully converts the VF/VT; begin a continuous infusion @ 2-4mg/min (1mg=15cc on pump)	* Use 2-2.5 times the IV dose when given via ET tube; followed by 10 ml saline flush * If toxic symptoms develop (slurred speech, altered LOC, muscle twitching and seizures), stop the drug or reduce the dose * Do NOT give this drug if PVCs occur with bradycardia or escape rhythm * No longer recommended for VF/VT prophylaxis in acute MI * Suppresses ventricular arrhythmias and elevates the fibrillation threshold (less likely to occur)

MEDICATION

INDICATION/DOSAGES

NURSING CONSIDERATIONS

Procainamide (suppresses ventricular ectopy and slows intraventricular conduction) Vial= 500mg MIX 1Gm/250 D5W for drip (1mg/min = 15cc on pump)	0 Persistent cardiac arrest due to VF 0 PVCs or recurrent VT - Dosing: 20-30mg/min until: 1) arrhythmia suppressed 2) hypotension occurs 3) PR or QRS widens by 50% of its original width or MAX dose of 17mg/kg has been given - if effective, start drip @ 1-4mg/min	* Monitor BP closely during administration; may cause precipitous hypotension; infuse cautiously in acute MI * Contraindicated in patients with preexisting long QT intervals or torsades de points * Hypokalemia and hypomagnesemia may exacerbate arrhythmias
Bretylium (Adrenergic neuronal blocking and antifibrillatory agent) Vial = 500 mg Mix 1Gm/250 D5W for drip (1mg/min = 15cc on pump)	0 VF or pulseless VT unresponsive to defibrillation, epinephrine and lidocaine: 5mg/kg IV push; if arrhythmia persists increase to 10 mg/kg repeated every 5-10min to MAX dose of 35mg/kg 0 Stable VT or stable wide-complex tachycardia of uncertain origin: 5-10mg/kg over 8-10 min; to MAX dose of 35 mg/kg over 24 hrs; if loading dose converts arrhythmia, start infusion @ 2 mg/min (30cc on pump)	* Not a first-line drug * May cause severe hypotension * May induce projectile vomiting * Follow boluses with 20 ml saline flush * Treat hypotension with IV fluids, supine position, Trendelenburg position, norepinephrine may be required since may be refractory to epinephrine * Hypertension and tachycardia are transient due to initial stimulation of norepinephrine release * Use with caution in arrhythmias induced by digitalis toxicity
Verapamil & Diltiazem (Calcium channel blockers-direct negative chronotropic & negative inotropic effect)	0 Acute and preventive treatment of PSVTs, and slowing ventricular response in atrial flutter and fibrillation Verapamil: 2.5-5mg IV bolus over 2 min; repeat dose 5-10mg in 15-30 min then 5mg q 15 until desired response or total dose of 30mg given Diltiazem: 0.25mg/kg (20mg for avg patient) IV over 2 min; may repeat 0.35mg/kg in 15 min; then infusion of 5-15mg/hr titrated to HR	* Reduce oxygen demand; decreased SVR caused by vasodilatation of vascular smooth muscle (coronary vasodilation)
Adenosine (slows conduction through AV node and interrupts AV node reentry pathways) Half-life= 10 seconds 1 vial = 6mg	0 PSVT including PSVT associated with WPW syndrome: 6mg rapid IVP over 1-3 seconds then 20 ml flush; if no response, repeat 12mg dose in 1-2min	* Side effects include- flushing, dyspnea, chest pain resolving within 1-2 min * Transient sinus bradycardia, ventricular ectopy or even a brief period of asystole * Interaction with theophylline, methylxanthines, and dipyridamole may require dose adjustment or another drug

MEDICATION

INDICATION/DOSAGES

NURSING CONSIDERATIONS

Magnesium (physiological calcium channel blocker and blocks neuromuscular transmission) 5Gm/10ml bristojet	0 Torsades de points: Drug of Choice: up to 5- 10 gms have been used 0 Acute MI with hypomagnesemia: intermittent or continuous infusion 0.5- 1.0 gm/hr 0 VF/VT with hypomagnesemia: 1-2Gms diluted in 10 ml D5W given IVP over 1-2 min	* Monitor for flushing, sweating, bradycardia and hypotension; also if toxicity may see depressed reflexes, flaccid paralysis, circulatory collapse, respiratory paralysis and diarrhea
Sodium Bicarbonate Bristojet= 8.4% 50meq/50ml	0 Pre-existing metabolic acidosis or prolonged cardiopulmonary arrest with abnormal ABG not corrected by CPR and ventilation: 1 meq/kg IV bolus then ½ dose in 10 min prn	* Monitor ABGs * Monitor for hypernatremia or hyperosmolarity
Morphine (increases venous capacitance and reduces SVR, relieving pulmonary congestion- decreasing intramyocardial wall tension and myocardial oxygen requirements)	0 Pulmonary Edema or Ischemic chest pain; 1 to 3 mg slow IV over 1 to 5 min until desired effect achieved	* Monitor for respiratory depression, hypotension, bradycardia, decreased LOC · Have Narcan available for reversal
Calcium Chloride (increases myocardial contractile function- positive inotropic effect modulated by effect on SVR + or -) 10ml bristojet = 1Gm (1ml= 100mg)	0 Hyperkalemia, hypocalcemia, after multiple transfusions or Calcium channel blocker toxicity: 8-16mg/kg of 10% solution; repeat if necessary	* May cause slowing of HR * May precipitate digitalis toxicity * Precipitates with Na Bicarb
Norepinephrine (catecholamine- potent alpha (arterial and venous vasoconstriction) with minimal beta (increase contractility) effect MIX 8mg/250cc D5W or NSS (32mcg/ml)	0 Refractory SHOCK 0 Hemodynamically significant hypotension refractory to other sympathomimetics (septic and neurogenic shock) - Start with 0.5-1.0 mcg/min and titrate to effect	* Increase BP by increasing SVR and thereby diminishing cardiac output (increases myocardial oxygen demand, causes myocardial ischemia) * Needs A-line for monitoring BP * Also monitor CO, PCWP, PA pressures * Contraindicated in hypovolemia * Extravasation leads to necrosis- phentolamine infiltration minimizes sloughing

MEDICATION

INDICATION/DOSAGES

NURSING CONSIDERATIONS

Dopamine- catecholamine-vasoconstrictor (dopaminergic, beta and alpha receptors) Premix= 400mg/250cc D5W in top drawer of crash cart	0 Hemodynamically significant hypotension: low dose- 1-2 mcg/kg/min= cerebral, mesenteric and renal vasodilation; UOP increase; HR & BP unchanged mid dose- 2-10 mcg/kg/min= increased cardiac output high dose- >10mcg/kg/min= increased SVR, PVR, preload secondary to renal, mesenteric, peripheral arterial and venous vasoconstriction toxic dose- >20mcg/kg/min ischemic changes 0 Symptomatic bradycardia- add norepinephrine if > 20mcg/kg/min required	* Use lowest dose that produces desired effect * Avoid in hypovolemia, high SVR, pulmonary congestion or increased preload * Avoid Na Bicarb line * Avoid extravasation * MAO inhibitors potentiate effects
Dobutamine- catecholamine- sympathomimetic-inotropic vasoactive- alpha and beta effects 1mg/kg/min = 1cc if 6Xwt in Kg/100cc D5W	0 Pulmonary congestion ; low cardiac output; hypotension; septic shock - 2-20 mcg/kg/min	* Avoid alkaline solutions (Bicarb) * Monitor for tachycardia, hypertension and ventricular ectopy * Side effects include headache, nausea, tremor and hypokalemia
Isoproterenol- sympathomimetic with pure beta- potent inotropic and chronotropic effects) 1mg/250 D5W Standard	0 Temporary control of hemodynamically significant bradycardia after atropine, pacing, dopamine and epinephrine used; 2-10mcg/min	* Monitor for tachyarrhythmias and myocardial ischemia * Contraindicated in digitalis toxicity
Amrinone- rapid acting inotropic. vasodilator similar to dobutamine Mix in NSS	0 CHF refractory to diuretics, vasodilators and conventional intropics; Load with 1mcg/kg then 2-15 mcg/kg/min	* Monitor for tachyarrhythmias * Do not mix with dextrose solutions
Sodium Nitroprusside (vasodilator) 50mg/250 D5W or NSS	0 Severe Hypertension; 0.5- 8.0mcg/kg/min	* Monitor for hypotension * Toxicity includes tinnitus, visual blurring, altered mental status, nausea, abdominal pain, hyperreflexia, and seizures

MEDICATION

INDICATION/ DOSAGES

NURSING CONSIDERATIONS

Nitroglycerin (vasodilator) 50mg/250 D5W	0 Angina Pectoris; dosing titration to effect	* Monitor for headache, hypotension, syncope, faintness
Beta Blockers- Propranolol Metoprolol Atenolol Esmolol	0 Recurrent VT, VF or rapid PSVT refractory to other therapies 0 Angina, atrial flutter and fibrillation	* Reduce HR, BP, myocardial contractility, myocardial oxygen consumption * Slows AV conduction * Administer slowly IV * Monitor for CHF, bronchospasm
Lasix (diuretic)	0 Pulmonary Edema - 20-40 mg IVP	* Monitor K+, dehydration and hypotension; electrolytes
Thrombolytics Streptokinase TPA	Acute MI with thrombosis; other types of thrombosis	Watch for coagulopathies, bleeding disturbances
Digoxin	* atrial fib/flutter; CHF. Slows heart rate, increases force of contraction and refractory period of AV node	Monitor for nausea, visual disturbances, atrial or junctional tachycardias, PVCs, heart blocks; K+
Heparin	Venous thrombosis and to prevent deep vein thrombosis and pulmonary embolism. Anticoagulant inhibits clotting of blood and fibrin clots.	Hemorrhage, prolonged PTT, GI bleeding, chills, fever, rhinitis, acute reversible thrombocytopenia. Antidote: Protamine Sulfate.
Potassium chloride	Low serum K+, low Cl -; digitalis toxicity.	Monitor K+ and Cl-. Monitor for signs of hyperkalemia (wide QRS complex, tall, peaked T waves, disappearing P wave and asystole. Watch for phlebitis, pain or redness at IV site.
Versed	To relieve anxiety in ventilated patients; pre-op sedation or anesthesia induction.	Monitor for respiratory depression, apnea, laryngospasm, dyspnea, respiratory arrest, PVCs, amnesia, confusion, and visual disturbances. Have emergency equipment available.
Neuromuscular blockers	To relax skeletal muscle; manage patients on ventilators	May need to provide sedatives/ analgesic.

CONVERSION
To change Pounds to Kilograms
2.2 pounds = 1 Kilogram
An easy way to calculate dosage in kilograms is simply to divide the weight of the patient in pounds by 2.2. This gives you the patient’s weight in kilograms.
Example
1. Patient’s weight is 160 pounds.
160/2.2 = 72.7 kg
2. Patient’s weight is 44 pounds.
44/2.2 = 20 kg
To convert to Milligrams per Kilogram
To calculate the dosage of a drug given in mg/kg, you multiply the number of milligrams needed times the patient’s weight in kilograms.
Example
If the patient is to receive a dose of 5 mg/kg of bretylium, multiply 5 times the patient’s weight in kilograms. The patients 44 pounds.
44/2.2 = 20 kg Then
5mg/kg x 20 kg = 100 mg bretylium

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