Arrythmia Pharmacology (pdf prof)

are the following examples of supraventricular or ventricular arrythmias?

• assystole or pulseless electrical activity (PEA)

• atrial flutter

• atrial fibrilation

• sinus tachycardia/ bradycardia

• \paroxysomal supraventrical arythmias

supraventricular

which arrythmias are ventricular? below AV node?

what makes them life threatening?

1. Non sustained ventricular tachycardia (VTAC) - fixed in 30 seconds

2. sustained ventricular arrythmia (doesnt self-terminate—torsades de pointes)

3. ventricular fibrillation

life threatening bc/ cause abrupt decrease in cardiac output

what are some causes of arythmias?

1. hypoxia (decreased perfusion)

2. cardiac diseases

3. drug induced

4. increased sympathetic activity (exersize increase HR and force of contraction)

5. electrolyte imbalance

what electrolyte imbalances can lead to arrythmias?

must know magnesium and potassium regular levels!!!

hypo/ hyper

1. potassium (3.5-5.3)

2. magnesium (1.5-2.5)

3. sodium

4. calcium

hypo

1. phosphates

which antiarythmics dont fall under the vaghn williams classification?

which antiarrythmics could be considered apart of multiple classes?

digoxin and adenosine dont fall in classes

amiodarone, sotalol, dronedarone

which class medications are used for

• rate control

• rhythm control

rate = 2( beta blockers) and 4 (calcium channel blockers)

rhythem = 1 (Na+ channel blockers) and 3 (K+ channel blockers)

dogoxin is a cardioglycoside which inhibits ____ and is used for _______ and _______

inhibit Na+K+ATPase

used for

• Atrial Fibrilaiton

• Chronic Heart Failure

what changes would see on the EKG of a patient on class 1 antiarythmic (Na+ channel blocker)

prolonged QT interval (for 1A that also inhibits K+)

QRS widening (depolarization takes longer with blocked Na+)

how do class 1a (Na+ channel blockekrs) impact

• conduction velocity

• refractory period

• automaticity

• decrease conduction velocity

• increase refractory period

• decrease automaticity

SAME FOR CLASS 2 and 4

how do class 1b (weak Na+ channel blockers) impact

• conduction velocity

• refractory period

• automacity (HR)

• decrease conduction velocity

• decrease or increase refractory period

• decrease automaticity

how do class 1c (strong Na+ channel blockers) impact

• conduction velocity

• refractory period

• automaticity

• strongly decrease velocity

• no effect on refractory period

• decrease automacity

how do class 2 (b-blockers) drugs impact

• conduction velocity

• refractory period

• automaticity

• decrease conduction velocity

• increase refractory period

• decrease automaticity

SAME as 1A and 4

how do class 3 (K+-blockers) drugs impact

• conduction velocity

• refractory period

• automaticity

• NO effect on conduction velocity

• INCREASES refractory period

• minimally effect HR

how do class 4 (CCBs) impact:

• conduction velocity

• refractory period

• automaticity

• decrease

• increase

• decrease

SAME AS CLASS 1A and 3

Amiadorone has class ______ activity

what can it be used for?

3 AND 1, 2, 4

• supraventricular arrythmias

• ventricular arythmias

• heart failure patients

• post MI patients

what are some sideeffects of amiodarone (has class 1,2, 3, 4 activity)

cardio: bradyaryhtmia, hypotenison

CNS: tremor, visual changes, ataxia

derm: photosensitivity, blue-grey discoloration of skin

endocrine- HYPO and HYPERthydroidism due to iodine

hepatic: elevated LFT, hepatitis

respiratory: pulmonary fibrosis

opthalmic: corneal micro deposits

what are some drug-drug interactions to look out for on AMIODARONE?

highest dose you can take of simvastatin is 20mg

warfarin increased bleeding risk

digoxin concentration will increase by 100% DONT GIVE WITH DIGOXIN

has high protein binding so dont give with another durg that has high protein binding

Dronedarone is a derivative of amiodarone:

• does it also have iodine?

• what class activities does it have?

• what dose is given

what is it used for?

• NO iodine

• 3 AND 1,2,4

• 400mg po 2x a day with food

Dronedarone used for

• paraoxysomal fibrilation (intermittent)

• Persistent Atrial fibrilation

what are common side effects of Dronedarone?

increased sCr and HF exacrerbation

Dronedarone pk/pd:

• what is its oral bioavialbility?

• protein binding?

• how is ti metabolized?

• what is t1/2?

F= 15%

more than 98% bound to protein in blood

CYP3A4 in the liver

t1/2 = 20 houes which is less than amiodarone which is 40 days

what black box warning came out after the ANDROMEDA trial?

BBW for dronedarone

do not give to patients with NYKA Class 4 heart failure of those with class 2 and 3 who require hospitalization b/c of INCREASED RISK OF MORTALITY

what class actiivty does sotalol have?

what can it be used for?

how is it eliminated? does it require dose adjustments?

3 and 2 (beta blocker)

• A- fib

• A- flutter

renally eliminated so it DOES need renal adjustments

what levels should you check for BEFORE giving a patient at the hospital SOTALOL for Afib or Aflutter?

CrCl should be more than 40mL/min

K+ should be more than 4

QT interval should be less than 450msec because it can increase QT iinterval

what are adverse effectss of sotalol (has both 2 and 3 activity)?

QT prolongation

bronchospasm

beta blocker

Dofetilide

• used to treat ?

• what are some side effects?

• how long does a patient need to be in the hospital before considering htis medication?

• what should you look out for before giving this medication to a patient?

atrial fib/flutter (like sotalol)

side effects:

• QTc prolongation → torsades de pointes

• increased Scr (so must be aware of CrCl)

need to be in hopsital for at least 3 days

look for

• creatinine clearance (bc/ increse sCr)

• magnesium

• low potassium

• currenet QTc interval

Dofetalide dosing:

bc/ it can increase SrCr how do you dose people with the following CrCl?

• CrCl >60 ml/min

• CrCl = 40-59

• CrCl = 20-39

• CrCl= <20

if greater than 60 then 500mcgBID

40-59 = 250mcg BID

20-39 = 125mcg BID

less than 20 = DONT USE (will experience toxic levels of SrCr because your body cant get rid of it)

What drugs CANT you take with Dofetalide

Which drugs SHOULDNT you take with DOfetalide

CANT:

• verapamil

• HCTZ

• trimethoprim

SHOULDNT unless you absolutely have to:

• amiodarone

• diltiazem

a heartbeat of _____ is considered Sinus Bradycardia

which patient population is seen the most?

causes prolongation of _____ interval but has normal _____

what drug can be used to treat? what is the dosage

heartbeat less than 60bpm

mostly seen in student atheltes

prolongation of RR interval w/ normal RHYTHM

can use ATROPINE to treat (bind to m2 receptor to stop the cholinergic parasympathetic supression of SA excitability)

atropine dosage = 0.5mg every 3-5 minutes (max 3mg)

what are your other options if a sinus bradycardiac patient is not repsonsing to atropine?

dopamine or epinephrine infusion

what if you get a patients EKG with a minimal electrical activity (flat line)?

what do you check for?

what do you give?

CAB

C= circulation

A= airway

B= breathing

Acces for open airway, pt breathing, check for pulse

give Epinephrine (1mg IV every 5 minutes)

if you see a flatline on an EKG what 5Hs and 5Ts could be the caus of the Cardiac Arrest?

1. Hypothermia

2. Hypoxia

3. Hypo/Hyper Kalemia

4. Hypovolemia

5. High H+ (acidosis)

1. Toxins

2. Tension Pneumothroax

3. Tamponade

4. Thrombosis

5. Trauma

what class drug would you give if the patient is

• bradycardic

• tachycardia

• arrythmia due to SA or AV node

• arrythmia due to atrial or ventricular myocytes

bradycardic = atropine (dopamine/ epinpephine), Iv fluids, pacemarker

tachycardia: beta blockers (2) or Ca2+ blockers 4)

• SA or AV node= 2 or 4 (B-blocker or Ca2+)

• atrial or ventricular myocyte: 1 or 3 (K+ or Na+)

which drugs would cause sinus tachycardia?

1. beta adrenergic agonsits

   1. epinephrine/norepinephrine

   2. dopamine

   3. albuterol

2. alpha 1 blockers

   1. prazosin and doxasosin

3. decreased SVR—> vsodilation —> increase HR

   1. nitrates

   2. nifedipine

   3. hydralazine

4. recreational drugs

   1. marijuana

   2. cocaine

   3. amphetamines

5. anticholinergics

   1. diphenhydramine

   2. atropine

what can cause sinus tachycardia (HR>100pbm) and how can you treat it?

1. anxiety/pain= benzos and opiods

2. anemia = give blood transfusion

3. hypovolemia = give fluides (saline)

4. fever= cooling pads, treat infection

5. hypERthyroidism= radioactive iodine and propylthiouracil (PTU)

6. hypoxia = give oxygen

7. drug induced= take out of treatment

Which wave is missing in Atrial Fibrillation?

How fast is the atrial contraction rate? ventricular contraction rate?

Is the rhythm normal?

arythmias ABOVE the ventricles have a ______ QRS complex

__ intervals occur at irregular intervals

AFib missing P wave (atrial depolarization) before QRS

atrial contraction >300

ventricular contraction >200

ABNORMAL rhythm

NARROW QRS complex

RR intervals irregular (off rhythm beat) no synchorinized depolarization, there are different stimuluses causing the atrial contraction

what is considered

• paroxysomal Afib

• persistent AFib

• longstanding Aib

• peramanent Afib

• Nonvalvular Afib

• self terminates before 7 days

• takes longer than 7 days to self terminate

• more than 12 months

• treatment has failed, nothing more can be done

• Af in the absensse of mechanical or biprosethic heart valves

what would lead to paroxysomal afib which is usually recovered less than 7 days

(acute reversible causes) ?

1. alcohol intoxication / withdrawl

2. CABG surgery

3. hyperthyroidism

4. hypoxia

5. electroylyte abnormalities

what would lead to persistent AF (Afib longer than 7 days?)

1. HTN w/ atrial ENLARGEMNT

2. valvular heart disease

3. mitral stenoisis

4. rheumatic heart disease

5. atrial stretch

6. MI

7. HF

what are some signs and symptoms of Afib?

• Palpatations

• Ischemic Stroke (not meeting oxygen demands) — heart going crazy to meet them w/ increased heart rate

• Congestive heart failure

Hemodynamic complications of Afib are due to reductions in _____ _______

due to a loss/ enhancment of the atrial kick or ______ _________ complication

REDUCTION of CO due to LOSS of Atrial kick which increases pressure in atria to allow blood to flow to the ventricles

or thromboembolic complication (stasis of blood in atria)

what should be taken for patients w/ Afib for their

• rate control

• rhythm control

• cardioeversion

Rate control:

• beta blockers (2)

• CCB (4)

• digoxin (stimulate parasympathetic vagus system decrease AV conductio

• anticoagulation/antiplatelet

• ON THERAPY INDEFINITELY

Rhythm control:

• electrically or pharmacologically CARDIOVERT back to normal sinus rhythm

• anticoagulation must be given BEFORE and AFTER the attempt

• synronized current cardiversion

Cardioversion:

• electrical cardioversion (electric shock paddles)

what is cardiac ablasion and when is it used?

insert a catheter into arm or groin vein and apply heat to kill the tissue of the heart that is causing abnormal rhythem

can be used for Afib or Aflutter (most likel)

in Afib you can destroy and take out the patients AV node and replace it with a pacemaker

which medications can you use to maintain a normal sinus rhythm in a patient with Afib who has

• normal left ventricle function

• NO MI

• NO structual heart disease

1. Dofetallide (3 K+)

2. Dronedarone (3 K+ )

3. Flecainide (1C Na+)

4. Propafenon (1C Na+)

what can be used to RESTORE RHYTHM in a patient with atrial fibrilation WITH structural heart disease

if they are in class 3 or 4 and have also had recent decompensated HF what should you AVOID

Afib with structural disease =

• amiodatone (class 3 K+)

• dofetalide (class 3 K+)

DONT TAKE DRONEDARONE if youve had decompensated HF!

if patient presents w/ Afib and is hemodymaically stable vs ubstable what do you give them?

if they have valve issues but recover before 48 hours have passed, what can you give them, and if fthey havent recovered after 48 hours what do you do?

• if unstable = cardioeversion

• if stable = HR medications (CCB, b-blocker, digoxin) + consider heparin

• if valve issues less than 48 hours = antiarrythmic treatment- rythm (k+ and Na+ blockers) but if still valve issues then get them a TEE GUIDEED CARDIOVERSION or cardioversion

• with cardioversion MUST be on anticogulants for at least 3 weeks BEFORE and at least 4 weeks AFTER

How to go about maintancing the sinus rhytm w/ K+ and Na+ blockers:

• if the patient has minial heart disease what can you start them on and what do you do if that doesnt work?

• flecainamide

• propafenone

• sotalol

• dronedarone

if that doesnt work go to amiodaroneor dofetalide

if amiodarone dont work TAKE IT OUT (catheter abllation)

How to go about maintancing the sinus rhytm w/ K+ and Na+ blockers:

• if the patient has hypertension what can you start them and what do you do if that doesnt work?

check if they have had left ventricular hypertrophy

if they HAD LVF then

• amiodarone

• if that doesnt work then do cathetar

if they DIDNT have LVF then

• flencainabe

• profenone

• sotalol

• dronedaron

doesnt work

• amiodarone

• dofetalide

that doesnt work TAKE IT OUT (catherer abrasion)

How to go about maintancing the sinus rhytm w/ K+ and Na+ blockers:

• if the patient has coronary artery disease what can you start them and what do you do if that doesnt work?

start with K+ blockers (NO Na+ THIS TIME)

• dronedarone

• sotalol

• dofetalide

if that doesnt work then

• amiodarone

if amiodarone doesnt work

TAKE IT OUT (abrasion catheter)

How to go about maintancing the sinus rhytm w/ K+ and Na+ blockers:

• if the patient has heart failure what can you start them and what do you do if that doesnt work?

start with K+blocker (NO Na+ this time)

• amiodarone

• dofetalide

if they dont work then

TAKE OUT (catheter abrasion)

ONLY TIME AMIODARONE IS FIRST LINE IS WITH THOSE WITH HEART FAILURE

when treating patients with amiodarone or dofetalide (K+ channel blockers) to avoid torsades de pointes from QTc prolongation WHAT DOSES should you give?

amiodarone = NO MORE THAN 10g (oral , can be IV too)

dofetalide DONT USE IF LESS THAN 20CrCl (just oral)

which patient populations should you avoid Dronedarone?

• recent hospitalizations

• class 3/4 Heart Failure

what are advantages and disadvantages of the following rate controlled medications used for Afib?

1. beta-blockers

2. CCBs

3. digoxin

b-blockers:

benefit: fast onset, used after surgery

bad: asthma, worsen CHF, bradycardia, hypotension

CCBs:

benefit: fast onset

bad: worsen CHF, hypotension

digoxin

benefit: can help with CHF

bad: slow onset, requires a loading dose and renal adjustment

would you use rate or rhythm control medications for the folloiwng patient type?

• older than 65 years

• persisten Afib

• permanent Afib

rate control

• B-blockers

• CCBs

• Digoxin

would you use rate or rhythm control medications for the folloiwng patient type?

• younger generation

• new Afib

• symtpomatic but able to control rate

• unable to control rate

rhtyhm control

1. K+ blockers (dofetalite, dronedarone, sotalol, amiodarone)

2. Na+ blockers (flecainamide, proferenone)

what is apart of the CHADS2 score and when do you use it?

use CHADS2 score to determine risk of stroke and whetehre or not you should be put on an antithrombotic for Afib

• past TIA and prior stroke = 2 points

• older than 75 = 1 point

• diabetes= 1 point

• hypertension = 1 point

• heart failure = 1 point

what are the factors of the CHA2-DS2VASc ?

• older than 75= 2 points

• 65-74 = 1 points

• V= vascular disease (MI, PAD) = 1 point

• female= 1 point

what is CHAD2 of

• 78 year old male

• new Afib

• CHF

• HTN

• glucoma

• arthritis

78= 1 point

CHF= 1 point

HTN= 1 point

3

what CHAD Score would you NOT give anticoagulation therapy?

when would you CONSIDER antiagulation?

when would you HAVE to give anticoagulation DAILY>

NO THERAPY = 0 in men 1 in women

CONSIDER= 1 in men and 2 in women

MEN= 2 for men and 3 for women

a male patient has a CHAD of 2 and female has CHAD of 3 so they MUST be on anticoagulants

what are their options?

1. Warfarin with heparin or lovenox to reach INR 2-3 (if no valve issues) - if they have valve issues may change INR goal

2. Dabigitran- Pradaxa (direct thrombin ihibitor) if CrCl less than 15 DONT give

3. Rivaroxaban- Xarelto- (AntiFactor Xa)

if less than 15 CrCl or on dialysis can STILL GIVE 15mg

4. Apixaban- Eliquis (Antifactor Xa)

5mg but if SCr>1,5 or age or low body weight then 2.5mg

5. EndoXaban- Savaysa (Antifactor Xa)

DONT GIVE if CrCl more than 95 or less than 15

Aflutter:

• “____ ____” pattern on EKG

• which wave is missing

• what is the rate of the hearbeat?

• Saw tooth EKG

• P wave missing

• HR= 250 -350 (in Afib >300)

What is the most common type of flutter and which patients is it seen the most in?

paroxysomal (transient- self curing)

• irregular HR of 100-130bpm

• narrow QRS complex

• still regular rhythm

when do reentrant circuits occur? which type of supreventricular arrythmia is caused by this?

they occur when there is another stimulus that allows the signal from SA node to go directly to the ventricles without goin through the AV node first

• example Wolf Parkinson White Syndrome (self- sustained Action potential propogating tachycardia)

The most common type of Atrial flutter is paroxysomal atrial flutter which is caused by reentract pathways that can pass sinal to ventricle from atria without going through AV node first

What can be used as treatment?

1. direct current if acuteley hemodynaic and UNSTABLE

2. increase vagal tone -

   1. increasing thoracic pressure- holding breath and exhaling as forcefully as you can

   2. carotid sinus massage

   3. holding your nose and breathing out

3. use meds to stop reentractment

how do you treat a patient with Aflutter?

• if they are hemodynamically unstable?

• Narrow QRS

• Wide QRS

• hemodynamically unstable = direcct current

• narrow QRS= adenosine (max 30mg) or Ca2 + channel blockers

• wide QRS= adenosine OR VTACH meds

NARROW QRS signifies _____ arrythmia

Narrow = Supraventricular

what is the halflife of adenosine?

what follows its use?

when is it used?

Halflife = 10 seconds

MUST FLUSH WITH SALINE AFTER

Aflutter if QRS narrow

Aflutter if QRS wide + VTach treatment

NOT used for Afib b/c of short halflife

what is the treatment for patients who experience sudden cardiac death? is this common for patient with Premature Ventricular COntractions?

defibrillation is the treatment

not common for healthy individuals with ventricular contractions BUT IS common for patients with structural heart diseases

Premature Ventricular Contractions result in bizzare ______ on the EKG

what is treatment?

what should you AVOID bc/ of MORTALITY!

QRS bizzare (could be upsidedown and WIDE)

can be uniform or multiform

USE BETA BLOCKERS UNLESS 3 in a row bc/ then you have VTach not premature at this point

Avoid using CLASS 1C antiarythmics such as (profenone and flecainamide) in premature vesicular contraction with STRUCTURAL HEART DISEASE

When is one considered to have Vtach?

3 consecutive premature ventricular contraction that appear on the EKG as BIZZARE QRS (widened more than 120 ms) and HR more than 100 bpm

also no P waves

due to REENTRY

what is considered to be non-sustained VT vs what is considered sustained VT?

nonsustained = less than 30 seconds

sustained = more than 30 seconds (NEED DRUGS)

which Vtach ?

• due to re-enterant pathway looping in a ventricle that DOESNT allow for signal to propogate further

• SOMETIMES generates enough CO to produce pulse for a short time

• no P waves / wide QRS

• impulse originating in ventricles not SA

monomorphic

what are preventable causes for Vtach?

1. hypokalemia (K+ supplementation)

2. Hypoxia (ventilation)

3. acute MI (post MI care)

4. digoxin overdose (antidote)

what can cause reoccurent Vtach?

1. CAD (coronary artery disease)

2. post MI

3. Left Ventricular Ejection Fraction less than 40% (ischemic)

how do give drugs to patients with Vtach?

• hemodynamically unstable

• hemodynamically stable

if unstable work on cardiaversion

if stable

• amiodarone (max 2.2g/day or adenosine or cardiaversion

OR

• class 1a/ 1b: procainamide and lidocaine

Patient comes in and their heart rate is greater than 150bpm

• what if this patient is also experiencing hypotension, altered mental status, shock, chest pain?

• where get a EKG and see that their QRS wave is 120ns+ (0.12s) how do you proceed?

• if experiencing concurrent issues consider cardioeversion

• wide QRS (more than 120ns) = Vtach = adenosine (if regular and monomorphic) or antiarrythmic infusion (amiodarone)

• if NOT wide QRS than try vagal maneuvers, adenosine, beta blocker

what is an Implanatable Cardioverter defibrillator (ICD) and when is it used?

if a patient has an implant in, can they still use antiarythmics?

implantable electrical pulse generator

used for patients with monomorphic Vtach or Vfib who are at risk for sudden cardiac death

YES they can still use

• sotalol

• amiodarone

Polymorphic Vtach:

• irrelegular QRS complex — non uniform

• torsades de pointes (QTC prolongation) is a type of polymorphic Vtach, what is a normal QT interval?

• do all polymoprhic Vtachs include a prolonged QTc?

normally Q to end of T wave is less than 430ms but if its greater than 430 then QTC prolongation

how to count: count small boxes and multiple by 0.04

NO can also have normal QTC if polymorphic Vtach

what are the risk factors of drug induced fatal polymorphic vtach (Torsades de Pointe)?

1. female elderly

2. low magnesium, potassium, glucose, and thyroid

3. hypothermia

4. bradycardia or HTN

5. CHF, MI, ischemia, and stroke

QTc: corrected measurement of QT interval for HR variation

QT/ square root RR

which drugs CAN CAUSE torsades de pointes (polymorphic ventricular tachycardia)?

class 1A (moderate) - extend repolarization by blocking K+ channels

• quinidine

• disopyramide

• procainamide

class 3 - increase repolarizing

• sotalol

• dofetilide

• amiodarone

• dronedarone

which drugs shuld you avoid that can extend the halflife of QTC prolonging drugs?

how do these drugs extend halflife of QTC prolonging drugs?

QTC prolonging drugs are metabolized by CYP2D6 and 3A4

inhibitors of 2D6

• fluoxetine and haloperidol

inhibitors of 3A4:

• amiodarone, fluconazole, omeprazole, simetidine, metronidazole, ritonavir, clarithromycin

which drugs can INDUCE torsades de pointes and which cyp inhibitors should you AVOID?

1. Antibiotics (ertyhromycin, fluroquinolones)

2. antidepressants (Tricyclic)

3. atypical antipsychotics (quietapine + clozapine)

4. barbituates

5. methadone

what can you use to TREAT drug-induced torsades de pointes?

increase magnesium levels (even if normal)

and increase K+ if less than 4meQ

this will slow the rate of the SA node and prolong the impulse

what is FIRST line therapy BEFORE any medications for a patient experiencing ventricular fibrilation/ tachnycardia?

CPR and Defirbillation every minute delayed = 10% chance increase of death

WHILE you are giving a patient CPR, they can be admiinistered EPINEPHRINE (1: 10,000) 10mL IV

how does each agonism of epinephric help?

a1= increase BP and decrease epiglottal edema

b1= incrase CO and BP

b2= bronchodilate

what are the two antiarrythmic drugs that are used for ventricular arythmias?

1. amiodarone (3)

2. class 1b= lidocaine (blocks Na+ channels of ischemic tissues - which can have sporadic stimulation)

be careful of Lidocaine use in patients with

• live failure, heart failure, MI

• therapetuic levesls - 2-6mg/L (unbound+ bound)

Therapeutic hypothermia is also used for patients with pulsemless VT//Vfib

which temperature do you try to keep the patient in to jumpstart their heart?

what can be an issue of hypothermia?

try to get patient to 32-34 degrees celcius (normal 37) for 12-24 hours who has regained circulation after cardiogenic shock (ROSC)

• coagulopathy (blood comming together), hyoerglycemia, electrolyte imbalances

patient comes in with Vfib/tachycardia what do you do IMMEDIATELY?

• how long do you wait before starting shock in shockable patients? (Vfib and Polymorphic Ventricular Arythmia/ Torsades de Pointes)

CPR

• shock after 2 minutes of CPR

• THEN administer epinephrine during next cycle of CPR for two minutes

• then shock again and give lidocaine and amiodarone

patient comes in with Vfib/tachycardia what do you do IMMEDIATELY?

• what do you do if the patient is unshockable (Asystole/ pulseless electrical activity)

EPINEPHRINE THEN CPR

then

check if you can shock

if you cant

continue CPR and try to treat reversible causes

if you still cant

epinephrine and reversible causes

once you can go back and forth between CPR + infusion THEN (epi) — CPR +infusion THEN amiodarone/lidocaine