Review of Cardiac Medications

Medication: Calcium Chloride 10%

• Classification(s): Cardiac

• Mechanism of Action:

  • Increases myocardial contractility and vasoconstriction.

• Indications for Use:

  • Premedication to Diltiazem if the patient is hypotensive.

  • Suspected hyperkalemia in a non-arrest patient.

  • Cardiac arrest from calcium channel blocker overdose.

• Contraindications: None

• Specific Side Effects or Adverse Reactions: None

• Adult Dosage and Route of Administration:

  • Premedication: 5 cc (500 mg) slow IV/IO.

  • Hyperkalemia: 10 cc (1000 mg) over 5 – 10 minutes IV/IO.

  • Overdose: 10 cc (1000 mg) over 5 – 10 minutes IV/IO.

• Pediatric Dosage and Route of Administration:

  • Hyperkalemia: 20 mg/kg slow IV/IO.

• Special Considerations:

  • Will precipitate if administered with sodium bicarbonate.

Medication: Epinephrine

• Classification(s): Cardiac, Respiratory

• Mechanism of Action:

  • Catecholamine with both alpha and beta effects.

• Indications for Use:

  • Cardiac arrests.

  • Symptomatic bradycardia.

  • Shock unresponsive to fluids.

  • Anaphylaxis.

  • Severe airway constrictions in pediatrics.

• Contraindications: None

• Specific Side Effects or Adverse Reactions:

  • Increases myocardial oxygen demands and cardiac irritability.

• Adult Dosage and Route of Administration:

  • Cardiac arrest: 1.0 mg (10 cc) of 1:10,000 IV/IO every 3 – 5 minutes.

  • Symptomatic bradycardia: 2 mcg/min IV/IO titrated to rate effect with a maximum of 10 mcg/min.

  • Shock (Push Dose): 5 mcg IV/IO every 1 – 5 minutes.

  • Anaphylaxis:

  • Initial dose: 0.5 mg (0.5 cc) of 1:1000 IM.

  • If no response, 5 mcg/min IV/IO titrated to pressure response with a maximum of 20 mcg/min.

• Pediatric Dosage and Route of Administration:

  • Cardiac arrest and symptomatic bradycardia: 0.01 mg/kg (0.1 cc/kg) of 1:10,000 IV/IO every 3 – 5 minutes.

  • Anaphylaxis: 0.01 mg/kg (0.01 cc/kg) of 1:1,000 IM.

  • Shock (Push Dose): 0.1 – 1 mcg/kg IV/IO over 1 – 2 minutes every 5 minutes.

  • Severe airway constrictions (Racemic Epi): 3.0 mg (3 cc) of 1:1,000 with 3 cc NS added via nebulizer.

• Special Considerations:

  • Attention must be paid to the concentration used.

Medication: Adenosine (Adenocard)

• Classification(s): Cardiac

• Mechanism of Action:

  • Slows conduction through the AV node.

• Indications for Use:

  • Conversion of Paroxysmal Supra-Ventricular Tachycardia (PSVT) to Normal Sinus Rhythm (NSR).

• Contraindications:

  • Second or third degree heart block.

  • Sick Sinus Syndrome.

• Specific Side Effects or Adverse Reactions:

  • Administration often causes a transient period of asystole.

• Adult Dosage and Route of Administration:

  • 6 mg rapid IV followed by 20 cc fluid bolus.

  • May repeat with 12 mg rapid IV x 2 if rhythm fails to convert.

• Pediatric Dosage and Route of Administration:

  • 0.1 mg/kg rapid IV followed by 10 cc fluid bolus.

  • May repeat with once 0.2 mg/kg rapid IV if rhythm fails to convert.

• Special Considerations:

  • All doses should be reduced by 50% for patients taking carbamazepine (Tegretol) and dipyridamole (Persantine).

Medication: Amiodarone (Cordarone)

• Classification(s): Cardiac (Antiarrhythmic)

• Mechanism of Action:

  • Slows conduction and reduces automaticity in the ventricles.

  • Sodium and potassium channel blocker.

• Indications for Use:

  • Refractory sustained ventricular fibrillation/pulseless ventricular tachycardia.

  • Ventricular tachycardia.

  • Post-resuscitation antiarrhythmic.

• Contraindications:

  • None in cardiac arrest.

  • Contact OLMC if perfusing patient is bradycardic or hypotensive.

• Specific Side Effects or Adverse Reactions:

  • In perfusing patient may cause bradycardia, hypotension, or ventricular fibrillation.

• Adult Dosage and Route of Administration:

  • VF/PVT Cardiac Arrest: 300 mg IV/IO.

  • Repeat once at 150 mg IV/IO.

  • Unstable VT with pulse: 150 mg IV/IO over 3 minutes.

  • Stable VT with pulse: 150 mg IV/IO in 100 cc NS over 10 minutes.

  • Repeat once at same dose.

  • Post-resuscitation: 150 mg IV/IO in 100 cc NS over 10 minutes.

• Pediatric Dosage and Route of Administration:

  • VF/PVT Cardiac Arrest: 5 mg/kg IV/IO.

  • Repeat once at 2.5 mg/kg IV/IO.

  • Unstable VT with pulse: 2.5 mg/kg IV/IO over 3 minutes.

  • Stable VT with pulse: 2.5 mg/kg IV/IO in 100 cc NS over 10 minutes.

  • Repeat once at the same dose.

  • Post-resuscitation: Not indicated.

Medication: Aspirin

• Classification(s): Cardiac

• Mechanism of Action:

  • Disrupts platelet aggregation.

• Indications for Use:

  • Acute Coronary Syndrome.

• Contraindications:

  • Active ulcer or GI bleeding.

• Specific Side Effects or Adverse Reactions: None

• Adult Dosage and Route of Administration:

  • 324 mg PO – chew and swallow.

• Pediatric Dosage and Route of Administration: Not indicated

• Special Considerations: None

Medication: Atropine Sulfate

• Classification(s): Cardiac

• Mechanism of Action:

  • Anticholinergic (blocks vagal stimulation) allowing sympathetic nervous system to take control.

  • Increases conduction through AV node, counteracts poisons designed to overstimulate the parasympathetic nervous system.

• Indications for Use:

  • Symptomatic bradycardias.

  • Organophosphate and nerve gas poisonings.

• Contraindications:

  • Atrial fibrillation and atrial flutter.

• Specific Side Effects or Adverse Reactions:

  • May increase myocardial oxygen demand resulting in increased infarction.

• Adult Dosage and Route of Administration:

  • Symptomatic bradycardia: 1.0 mg IV/IO.

  • Repeat every 3-5 minutes to a maximum of 3.0 mg.

  • Poisoning: 1.0 – 5.0 mg IV/IO/IM every 3-5 minutes until symptoms controlled.

• Pediatric Dosage and Route of Administration:

  • Symptomatic bradycardia: 0.02 mg/kg IV/IO with minimum dose of 0.1 mg.

  • Poisoning: contact OLMC.

• Special Considerations:

Medication: Calcium Gluconate

• Classification(s): Cardiac

• Mechanism of Action:

  • Increases myocardial contractility and vasoconstriction.

• Indications for Use:

  • Premedication to antidysrhythmics if patient is hypotensive.

  • Suspected hyperkalemia in arrested and non-arrest patient.

  • Calcium channel blocker overdose.

• Contraindications: None

• Specific Side Effects or Adverse Reactions:

  • Will cause severe tissue necrosis if extravasation occurs.

• Adult Dosage and Route of Administration:

  • Premedication: 1 g over 5 – 10 minutes IV/IO.

  • Hyperkalemia: 1 g over 5 – 10 minutes IV/IO.

  • Overdose: 1 g over 5 – 10 minutes IV/IO.

• Pediatric Dosage and Route of Administration:

  • Hyperkalemia: 0.5 mg/kg over 5 – 10 minutes IV/IO.

• Special Considerations:

  • Will precipitate if administered with sodium bicarbonate.

Medication: Diltiazem (Cardizem)

• Classification(s): Cardiac

• Mechanism of Action:

  • Calcium channel blocker that slows conduction through SA and AV nodes.

• Indications for Use:

  • Rapid ventricular response in atrial fibrillation, atrial flutter, or PSVT.

• Contraindications:

  • Hypotension.

  • Wide complex tachycardias.

  • Sick sinus syndrome.

• Specific Side Effects or Adverse Reactions:

  • Arrhythmias and bradycardia.

• Adult Dosage and Route of Administration:

  • 0.25 mg/kg IV/IO slow push over 1 minute with a maximum of 25 mg.

  • Repeat at 0.35 mg/kg with a maximum of 25 mg over 1 minute in 15 minutes.

• Pediatric Dosage and Route of Administration: Not indicated

• Special Considerations:

Medication: Dopamine (Intropin)

• Classification(s): Cardiac (Vasopressor)

• Mechanism of Action:

  • Precursor to norepinephrine with dose-dependent action stimulating alpha and beta receptors:

  • 1-2 mcg/kg: Dilates renal and mesenteric vasculature.

  • 2-10 mcg/kg: Beta effects on cardiac muscle (increasing contractility).

  • 10-20 mcg/kg: Alpha effects of peripheral vascularity (vasoconstriction).

• Indications for Use:

  • Cardiogenic shock.

• Contraindications:

  • Hypovolemic shock prior to volume replacement.

• Specific Side Effects or Adverse Reactions:

  • Systemic physiological impacts related to the dosage administered.

• Adult Dosage and Route of Administration:

  • Based on intended effect starting at 5 mcg/kg/min and increasing to a maximum of 20 mcg/kg/min as needed.

• Pediatric Dosage and Route of Administration: Same as adult

• Special Considerations:

Medication: Esmolol (Brevibloc)

• Classification(s): Cardiac

• Mechanism of Action:

  • Cardio-selective beta-blocking agent.

• Indications for Use:

  • Refractory VF/PVT following the second dose of an antidysrhythmic.

• Contraindications: None

• Specific Side Effects or Adverse Reactions: None

• Adult Dosage and Route of Administration:

  • 0.5 mg/kg IV/IO, repeat once in 5 minutes.

• Pediatric Dosage and Route of Administration: Not indicated

• Special Considerations:

Medication: Furosemide (Lasix)

• Classification(s): Cardiac (Diuretic)

• Mechanism of Action:

  • Inhibits sodium reabsorption in kidneys increasing urination.

• Indications for Use:

  • Extracellular fluid overload due to congestive heart failure.

• Contraindications:

  • Hypovolemia.

• Specific Side Effects or Adverse Reactions:

  • Systemic impact from sodium and potassium loss.

• Adult Dosage and Route of Administration:

  • 20 mg IV/IO.

• Pediatric Dosage and Route of Administration: Not indicated

• Special Considerations:

Medication: Lidocaine

• Classification(s): Cardiac (Antiarrhythmic)

• Mechanism of Action:

  • Depresses automaticity of Purkinje fibers increasing fibrillation threshold.

  • Causes localized anesthesia.

• Indications for Use:

  • Ventricular fibrillation and pulseless ventricular tachycardia.

  • Ventricular tachycardia.

  • Local anesthetic for IO placement.

• Contraindications:

  • Hypotension.

• Specific Side Effects or Adverse Reactions:

  • Seizures at toxic levels.

• Adult Dosage and Route of Administration:

  • VF/PVT and VT: 1.5 mg/kg IV/IO.

  • Repeat at 0.75 mg/kg IV/IO x 2 every 10 minutes.

  • IO placement: 40 mg (2cc of 2% over 2 minutes) IO.

• Pediatric Dosage and Route of Administration: Same as adult

• Special Considerations:

Medication: Magnesium Sulfate

• Classification(s): Cardiac (Antiarrhythmic)

• Mechanism of Action:

  • Cation that stabilizes smooth and cardiac muscle contractility.

• Indications for Use:

  • Polymorphic Ventricular Tachycardia (Torsade de Pointes).

  • Eclamptic Seizures.

• Contraindications: None

• Specific Side Effects or Adverse Reactions:

  • Hypotension and CNS depressant effects.

• Adult Dosage and Route of Administration:

  • PVT: 2 g diluted in 10cc IV/IO over 1-2 minutes.

  • Eclamptic Seizures: 4 g diluted in 10cc IV/IO over 1-2 minutes.

• Pediatric Dosage and Route of Administration:

  • 25 mg/kg over 1-2 minutes, maximum of 2 g.

• Special Considerations:

Medication: Nitroglycerin

• Classification(s): Cardiac

• Mechanism of Action:

  • Vasodilator decreasing vascular resistance in periphery and heart.

• Indications for Use:

  • Acute hypertension.

  • Pulmonary edema.

  • Acute Coronary Syndrome.

• Contraindications:

  • Hypovolemia.

  • Acute inferior myocardial infarction.

  • Patients who have taken Viagra (sildenafil) or Levitra (vardenafil) within 24 hours or Cialis (tadalafil) within 48 hours.

• Specific Side Effects or Adverse Reactions:

  • Hypotension.

• Adult Dosage and Route of Administration:

  • 0.4 mg SL every 5 minutes or IV/IO infusion starting at 5 mcg/min titrated to symptom relief while maintaining systolic BP > 100 mmHg.

• Pediatric Dosage and Route of Administration: Not indicated

• Special Considerations:

Medication: Norepinephrine (Levophed)

• Classification(s): Cardiac (Vasopressor)

• Mechanism of Action:

  • Stimulates alpha receptors in peripheral vasculature.

• Indications for Use:

  • Obstructive, cardiogenic, and distributive shock unresponsive to fluid with the goal of systolic blood pressure = 100 mmHg or greater for adults.

• Contraindications:

  • Hypovolemic shock.

• Specific Side Effects or Adverse Reactions:

  • Hypertension.

• Adult Dosage and Route of Administration:

  • 8 mcg/min initially, increase every 5 min in 8 mcg/min increments to a maximum of 48 mcg/min.

• Pediatric Dosage and Route of Administration:

  • 0.1 mcg/kg/min initially, increase in 5 min to 0.2 mcg/kg/min, increase in another 5 minutes to 0.4 mcg/kg/min with the goal of restored perfusion.

• Special Considerations:

  • Administer through a large vein.

  • Mixing Recommendations:

  • Add 8 mg to 250 cc or 16 mg to 500 cc for 32 mcg/cc concentration.

Medication: Sodium Bicarbonate

• Classification(s): Alkalotic solution

• Mechanism of Action:

  • Reduces circulatory and tissue acidity.

• Indications for Use:

  • Tricyclic antidepressant and sodium channel blocker overdose.

  • Suspected hyperkalemia.

  • Severe crush injuries with entrapment of limb.

• Contraindications: None

• Specific Side Effects or Adverse Reactions: None

• Adult Dosage and Route of Administration:

  • Cardiac arrest from overdose: 1.0 mEq/kg IV/IO with repeat dose of 0.5 mEq/kg every 10 minutes.

  • Overdose: 1.0 mEq/kg IV/IO.

  • Hyperkalemia or crush injury: 50 mEq IV/IO.

• Pediatric Dosage and Route of Administration:

  • All indications: 1.0 mEq/kg IV/IO.

• Special Considerations:

  • Packaged as a solution of 50 mEq in 50 cc.