IT 2 Exam 2 Information

Venous Thromboembolism I & II

Identify the physiologic risk factors for developing VTEs.

• Venous thromboembolism (VTE) can develop into deep vein thrombosis (DVT) or pulmonary embolism (PE)
  • blood clot in distal location (CVT) → travels up the deep vein of the thigh → into inferior vena cava → goes into lungs (PE)
• VTE is the leading cause of death and disability worldwide

Based on variables, select an appropriate pharmacologic regimen to prevent VTE and treat VTE.

• prophylaxis options
  • remember: subq heparin is for prophylaxis

• risk assessment for VTE prophylaxis
  • bleeding risk
    • platelet count < 50,00 uL
    • bleeding within 3 months
    • active GI ulcer
  • thromboembolic risk
    • age> 60 years*
    • recent VTE*
  • hypercoagulable state
    • malignancy (cancer)
    • pregnancy
    • oral contraceptives/hormones
    • thrombophilia (increased risk of thrombosis)
    • circulatory stasis (period of low blood movement)
      • ICU stay
      • immobility - paralysis, sitting or sleeping for a whole
        • prolonged immobility > 3 days
      • polycythemia vera (production of too many blood cells)
      • obesity
    • vascular wall injury
      • atherosclerosis
    • conditions like DM, sepsis, HF, COPD

Identify variables that impact the safety and efficacy of anticoagulation therapy.

• s/s of vte
  • DVT
    • unilateral swelling
    • pain
    • erythema
  • PE
    • chest pain
    • SOB
• Revised Geneva Score or Wells Score for PE*
  • these give the Pre-Test Probability for PE (PTP)
  • High PTP ≥ 50%
• Diagnostic Testing
  • Lower Extremeties Dopplers or Ultrasound
  • V/Q Scan - looking for a mismatch of perfusion between left and right heart
  • CT Scan (CTPA or chest CT with contrast)*
    • this is the cold standard to diagnose PE
  • D-Dimer - this test is used to rule out VTE, <500
• Severity: PE > Proximal DVT > Distant DVT > Superficial VTE
  • hemodynamic instability and AKG changes indicate a severe VTE
  • cardiac arrest indicates very severe VTE
• CHEST guidelines are considered the Gold Standard for anticoagulation management
  • American Society of Hematology is the newer guideline with a first author being a pharmacist

Given subjective and objective patient information, select an initial pharmacologic regimen to maximize therapeutic efficacy and minimize potential toxicity.

• How to choose a treatment?
  • DOACs are preferred bc oral and greater safety
  • cancer - doac
  • pregnancy - heparins
  • heparin induced thrombocytopenia - warfarin/doac
  • use warfarin for lupus, antiphospholipid syndrome, clot in “strange places”
• UFH
  • onset: IV is immediate. “quick on quick off”
  • elimination: half life is short. non-renal so good for PT w/ kidney impairment
  • monitoring: anti-Xa and aPPT
  • reversal: protamine
  • dosing is actual body weight based
  • no drug interactions
  • great for patients that are hemodynamically unstable
• LMWH (enoxaparin (lovenox))
  • onset: longer than UFH
  • elimination: longer half life than UFH. renally excreted.
  • monitoring: Anti-Xa
  • reversal: protamine
  • dosing is actual body weight based
  • dosing is 1 mg/kg q12 or 1.5 mg/kg q24

exceptions to monitoring tests:

(1)baseline prolonged aPTT due to lupus anticoagulant require alternative testing

(2)anti-Xa assay is not viable in patients who take doacs

• Warfarin
  • onset: 2-3 days
  • elimination: cyp2C9 and 3A4
  • monitoring: INR
    • 1.5 - 2.0 for mechanical heart valve
    • 2.0 - 3.0 for stroke prevention in afib and VTE treatment
    • 2.5 - 3.5 for mechanical aortic valve w/ 1 risk factor and mechanical mitral valve
  • reversal: vitamin k
  • moa: vit k epoxidase inhibitor which inhibits factor SNOT (7, 9, 10, 2) and protein C and protein S (the natural anti-coag proteins)
  • CI: pregnancy, current bleed
  • strength and colors of warfarin
    • Please - 1mg Pink
    • Let - 2mg Lavender
    • Granny - 2.5mg Green
    • Brown - 3mg Brown
    • Bring - 4mg Blue
    • Peaches - 5mg Peach
    • To - 6mg Teal
    • Your - 7.5mg Yellow
    • Wedding - 10mg White
  • assessing for warfarin sensitivity - pt w/ multiple risk factors should receive lower dose warfarin (2.5 mg green)
    • baseline INR ≥ 1.5
    • age>65
    • abw<45kg or abw<ibw
    • current antiplatelet therapy
    • lower INR goal should start on lower dose
    • check CBC before starting (low platelet means higher bleed risk)
  • factors that increase INR
    • drug interactions with inhibitors should start on lower dose
    • malnourished
    • foods high in vit K (leafy green vegetables, basil in pesto)
    • excessive alcohol consumption
    • illness like diarrhea
  • initiating warfaring:
    • warfarin must be bridged with IV heparin for 5 days until INR is at goal
      • during the first 5 days, patient is hypercoagulable bc warfarin depletes protein C and S
  • drug interactions (slides 53 and 54)
    • PD have additive effects with antiplatelets (aspirin, clopidogrel) and NSAIDs
    • PK inhibitors (GPACMAN) increase INR while inducers reduce INR
    • in general increase or decrease warfarin dose by 25%
      • for amiodarone, decrease warfarin dose by 50% after 2 weeks of dual therapy
      • for rifampin increase warfarin dose by 50% after 2 weeks of dual therapy
• Subq Factor Xa inhibitors (fondaparinux)
  • good for pt allergic to heparin
  • CI: CrCl<30
    • prophylaxis is contraindicated when wt<50kg
  • dosing is only subq
    • DVT prophylaxis - wt>50kg: 2.5mg subq QD
    • VTE treatment -
      • wt<50kg: 5mg subq QD
      • wt 50kg-100kg: 7.5 mg subq QD
      • wt >100kg: 10 mg subq QD
• DOACs
  • onset: 2-4 hours
  • elimination: half life is 12 hours
  • monitoring: none!
  • reversal: Andexanet (factor Xa antidote) and Praxbind (dabigatrin)
  • these drugs have better efficacy/safety when compared to warfarin
  • absorption is mediated by P-gp, do not use w/ carbamazepine, phenytoin, barbiturates
  • dabigatran (pradaxa) - direct thrombin inhibitor
    • indication/dosing:
      • stroke prevention (nonvalvular afib(NVAF)) - 150 mg BID
      • VTE - start 5 days heparin bridging then 150 mg BID
    • CI: CrCl<30
    • AE: GI bleed (GI ulcers, Chron’s disease)
    • Pgp inhibitors increase dabigatran lvls
  • apixaban (eliquis)
    • indication/dosing:
      • prophylaxis in NVAF - 5 mg BID or 2.5 mg if (1) ≥80yo (2)≤60kg (3)SCr≥1.5
      • VTE - 10 mg BID for 7 days then 5 mg BID
  • rivaroxaban (xarelto)
    • good for patients who want a QD dosing
    • indication/dosing:
      • prophylaxis NVAF - 20 mg QD w/ dinner
      • VTE - 15 mg BID for 21 days then 20 mg QD w/ dinner
  • edoxaban
    • if you see this drug calculate creatinine clearance
    • CI: CrCl > 95
• inferior vena cava filter (IVC)
  • used for pt CI to anticoag meds
  • long term risk of DVT bc accumulation of thrombus on the filter

Given a therapeutic regimen for treating VTE, recommend a monitoring plan which includes duration of treatment, therapeutic efficacy, and toxicity.

• treatment duration: based on factors + risk of bleeding
  • phases of treatment:
    • initial management → primary treatment → secondary prevention
    • initial management: 5-21 days of loading or co-dose
    • primary treatment: 3-6 months of anticoag treatment
    • secondary prevention: indefinite duration, decision based on risk factors
  • always have an initial 3 months of anticoag therapy
    • do not stop anticoag in these 3 months
  • d/c if the VTE is provoked and risk factors are reversible
  • continue if VTE is (1)unprovoked (2)risk factors are chronic or (3)pt cancer
  • HAS-BLED Assessment Score for bleeding - the more risk factors the more like the patient will bleed
    • treat risk factors for bleeding
• toxicity
  • bleeding - s/s of internal bleed are gum bleeding, blood in pee (pink or red blood), large bruises, black or red poop
  • heparin induced thrombocytopenia (HIT) - a drop platelet count
• inactivated prothrombin concentrates (PCCs) - Kcentra, which is factor II, VII, IX, and X in inactive form

Given a clinical scenario, (1)recommend therapeutic agents to reverse the effect of anticoagulation. (2)recommend therapeutic intervention to manage warfarin anticoagulation. (3)recommend bridging/switching strategies and monitoring plans.

• transition from heparin to warfarin: initiate warfarin while still on heparin until INR is therapeutic for 1-2 consecutive days
• transition from heparin to doac: start doac w/in 12 hours of second BID dose (lmwh) or when infusion is stopped (ufh)
• transition from doac to warfarin: overlap doac and warfarin until INR is therapeutic. titrate warfarin
• transition from warfarin to doac: start doac when INR is therapeutic (~2)

Chronic coronary disease (formerly known ischemic heart diseases) aka angina

about chronic coronary disease

• definition
  • group of conditions that includes obstructive and nonobstructive CAD with or without previous myocardial infarction (MI) or revascularization
• prevalence
  • leading cause of death for men, women, and people of most racial and ethnic groups
  • One person dies every 33 seconds from cardiovascular disease
• diagnosed only by
  • noninvasive testing
  • angina symptoms
• s/s
  • angina*
  • cold sweats
  • dizziness
  • women are more likely to complain about
    • dizziness
    • nausea
    • no symptoms at all
• goal of treatment
  • minimize the likelihood of death (reduce premature CV death, prevent MI and HF)
  • maximize health and function (eliminate symptoms, restore satisfactory level of activity)
• risk factors of major adverse CV events in pt with chronic coronary disease
  • high troponin (sign of heart inury)
  • b-type natriuretic peptide (sign of HF)
  • smoking status
  • high lipoproteins
  • high cholesterol
  • high blood pressure
  • high A1c

treatment options

• risk factor modification
  • lifestyle modification
    • diet low in saturated fat and cholesterol reduce LDL and cholesterol
      • DASH (dietary approach to stopping hypertension) diet with more fruits, vegetables, whole grains, and low-fat dairy products
    • 10 lb weight loss reduce LDL and cholesterol
    • physical activity
      • aerobic or dynamic 90-150 min/wk
    • alcohol consumption - reduce consumption to men≤2 drinks and female≤1 drink
  • lipid management
    • goal: lower LDL by ≥50%
    • high risk should have high intensity statin on highest dose they can tolerate
    • not high risk use high intensity statin → if not tolerated (or pt is >75) use moderate intensity statin
    • ezetimibe can be added if LDL ≥70 mg/dL
      • then PCSK-9 inhibitors can be added after
      • if statins are not tolerated, use bile acid sequestrants, niacin or both
    • how to assess risk
      • very high risk -
        • history of multiple major ASCVD events
        • OR
        • one major ASCVD event and >2 high risk conditions
      • major ASCVD events include
        • recent (w/in a year) ACS (unstable angina, STEMI, and NSTEMI)
        • history of stroke
        • symptomatic PAD
      • high risk conditions include
        • age>65
        • smoker
        • genetics (familial hypercholesterolemia)
        • history of CABG (ACS) or PCI (first line for STEMI)
        • diabetes, htn, CKD, persistent hyperlipidemia, CHF
    • statins
      • High intensity: atorvastatin 40-80mg, rosuvastatin 20-40mg
      • Moderate intensity: atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg, lovastatin 40 mg
      • Monitoring: after 4 weeks to three months, do repeat labs
        • if someone is stable, check in 6 months to a year
      • CI: pregnancy, nursing mothers, liver disease
    • PCSK9
      • praluent (alirocumab) and repatha (evolocumab)
      • these are brand name only, monoclonal antibody therapies, injection therapy
  • blood pressure management
    • choice in therapy is guided by indications for each class of antihypertensive drug
    • pt may require combo therapy
    • slide 29 for chart
  • diabetes mellitus management
    • goal: <6.5%
      • goal is 7-8% in pt with history of severe hypoglycemia, hypoglycemia unawareness, limited life expectancy, and renal disease
    • rosiglitazone is CI in pt with SIHD
  • antiplatelet
    • aspirin 81 mg should be started indefinitely
      • use clopidogrel if aspirin is CI
    • there is a risk of bleeding with use of both
    • dual antiplatelet therapy (DAPT) is prescribed post MI or after stent placement
  • smoking cessation
  • getting vaccines (specifically flu, covid-19, and RSV vaccines)
  • decrease stress
• symptomatic relief
  • symptomatic CCD is defined as angina
  • beta blockers are the first line to CCD
    • lopressor metoprolol tartrate
    • toprol xl metoprolol succinate
    • tenormin atenolol
    • inderal propranolol hcl
  • CCB and/or long acting nitrates are used when beta blockers are CI
    • these two are added when beta blockers are unsuccessful in relieving symptoms
      • CCB names:
      • cardizem dilt
      • tiazac dilt
      • calan verapamil
      • norvasc amlodipine
      • procardia nifedipine
  • sublingual or spray nitroglycerin is recommended for immediate relief of angina
    • keep in the original container
    • do not store in a container with child-resistant safety cap
    • do no store in bathroom bc humidity may degrade
    • the sublingual tablet should NOT be chewed or swallow. both dosage forms should be place under tongue and let it dissolve
    • after administration, patient should sit down bc this drug can cause headache and lightheadedness
    • tablet should be refilled every 6 months and spray every 3 years
    • can be taken 30 minutes in advance of physical exertion
    • after 3 doses given every 5 minutes (15 minutes total), seek medical attention immediately
  • long acting nitrates require a nitrate free period bc of tolerance build up. pt should have 10-14 hour nitrate free period every day
    • for nitroglycerin patch (1)wear for 12-14 hr then remove (2)rotate sites on chest
  • ranolazine ER (ranexa)
    • moa: antiischemic and antianginal effect, doesnt effect HR or BP
    • this drug is a CYP3A4 substrate
    • interacts with Simvastatin (use 20 mg simvastatin), and NTI drugs like cyclosporine, tacrolimus, and sirolumus

Acute Coronary Syndrome I & II

Describe the etiology and pathophysiology of acute coronary syndrome (ACS)

• • ACS is an occlusion of the coronary artery
  • types of MI - Universal Classification of MI
    • Type 1 - spontaneous MI
    • Type 2 - MI secondary to ischemic imbalance (supply demand mismatch, drug use, increase sympathetic stimulation. no blockage)
    • Type 3 - MI resulting in death w/o biomarkers or ekg
    • Type 4a - MI related to percutaneous coronary intervention (PCI)
    • Type 4b - MI related to stent thrombosis
    • Type 5 - MI related to coronary artery bypass grafting (CABG)

List the signs and symptoms of myocardial infarction (MI)

• • cardiac troponin levels have to be elevated to be considered myocardial injury
    • acute myocardial injury is when there is a rise and fall of troponin values
  • myocardial infarction is elevated troponin (injury) + evidence of ischemia
  • signs of ischemia
    • ECG/AKG changes
    • symptoms of MI
    • imaging of heart
  • symptoms and clinical presentation
    • typical presentation: a crushing or pressure-like feeling radiating to the jaw or left arm
    • atypical: sweating, difficulty breathing, nausea, isolated jaw or left arm pain
      • typically females and older patients experience atypical presentations of MI
    • chest pain can be (1)cardiac, (2)possibly cardiac, (3)noncardiac
      • right sided is likely not ischemia
      • central, pressure, squeezing, and left side is more likely ischemia

Differentiate between NSTEMI, STEMI and unstable angina (UA)

• • types of ACS
    • unstable angina
      • chest pain
      • normal troponin
      • lack of ST elevation
    • NSTEMI
      • chest pain
      • high troponin
      • lack of ST elevation
    • STEMI
      • chest pain
      • high troponin
      • ST elevation
  • calculate TIMI (or GRACE) score for NSTEMI and UA patients - this guides treatment
    • 0-2 low risk
    • 3 intermediate
    • ≥4 high risk
  • do NOT calculate TIMI for STEMI
  • initial evaluation:
    • get an EKG/ECG
    • check cardiac troponin levels (I or T)
    • look at their symptoms and PMH

Recommend pharmacologic therapy for patients with STEMI and NSTE-ACS

• all patients with ACS should receive
  • MONA-B (unless CI)
    • M - morphine or other opioids
      • typically fentanyl is given instead of morphine if MONA-B is desired
      • second option for chest pain
    • O - oxygen
      • only for patients with SaO2<90%
    • N - nitroglycerin
      • everyone will likely receive
      • for chest pain
      • 0.3-0.4 mg spray or sublingual tablet q5min for up to 3 doses
      • then give IV continuous infusion after 3 doses
      • CI: pde-5 inhibitor, HR<50, SBP<90
      • never use oral for acute management
    • A - aspirin
      • everyone will likely receive
      • use chewable and non-enteric coated tablet
      • give 1 dose is 162-325 mg
      • then baby aspirin 81 mg
      • use clopidergril for pt that cannot have aspirin
    • B - beta blocker
      • everyone will likely receive
      • start oral beta-blocker within 24 hours
      • CI: cardiogenic shock, bradycardia
      • use non-DHP CCB is beta-blocker is CI
  • Antiplatelet
    • every pt with ACS needed dual antiplatelet therapy (DAPT)
    • for all ACS pt use Aspirin +
      • (1st choice) prasugrel
        • not used with NSTEMI treated with medical management
      • (2nd choice) ticagrelor
      • (3rd choice) clopidogrel
        • becomes #1 among

elderly

high bleed risk

if STEMI was treated with fibrinolytics (”-plase” drugs)

• • • continue dual therapy for at least 1 year/12 months
    • all antiplatelet therapy requires a loading dose
    • aspirin
      • LD: 162-325 mg
      • MD: 81 mg QD
    • oral P2Y12 inhibitor
      • clopidogrel (prodrug)
        • LD: 300-600 mg
        • MD: 75 mg
        • becomes #1 among

elderly

high bleed risk

if STEMI was treated with fibrinolytics (”-plase” drugs)

• • • • prasugrel (prodrug)
        • LD: 60 mg
        • MD: 10 mg QD or

5 mg QD in pt <60kg or ≥75yo

• • • • • CI: stroke or TIA
      • ticagrelor
        • LD: 180 mg QD
        • MD: 90 mg BID
        • efficacy decreases in aspirin doses greater than 300 mg QD
      • cangrelor is an IV options
  • Anticoagulant
    • options are
      • bivalirudin
      • fondaparinux
        • cannot be used for sole anticoag when pt is getting PCI
      • enoxaparin
      • UFH
    • how to treat
      • STEMI w/ fibrinolytics - enoxaparin
      • STEMI - UFH, bivalirudin, fondaparinux
      • NSTEMI w/ PCI - UFH, bivalirudin, fondaparinux
      • NSTEMI w/medical management - UFH, enoxaparin, fondaparinux
    • anticoag treatment for the duration of
      • invasive procedure (PCI and CABG) then d/c once procedure is done
      • hospital stay (up to 8 days) for pt treated with fibrinolysis
    • UFH
      • given bolus and maintainence IV
      • LD: 60u/kg (max 4000 u)
      • MD: 12u/kg/hr (max 1000u/hr)
      • goal aPTT: 50-70
    • enoxaparin
      • given subq
      • does not require monitoring
      • dosing is kidney function dependent
        • usually BID
        • if CrCl<30, give QD
    • fondaparinux
      • given subq
      • no monitoring
      • CI: CrCl<30
    • bivalirudin (think UFH)
      • goal aPTT: 50-70 (same as UFH)
      • dosing is kidney function dependent
        • if CrCl<30, reduce the infusion
• STEMI
  • reperfusion is the goal for treating STEMI
  • the FMC (first medical contact) starts when the medical professionals encounters pt (emt) or pt gets to ED
  • PCI is the first line for treating STEMI
    • should happen within 90 min of first medical contact (FMC)
    • when at hospitals w/o PCI capability, increase time to 120 min
    • should be done <12 hours of symptoms in pt w/ CI to fibrinolytic therapy
  • if PCI is contraindicated, use fibrinolytic therapy
    • alteplase
    • reteplase
    • tenecteplase
    • “-plase” drugs
    • should happen within 30 minutes of arrival at hospital
    • alteplase dose:
      • accelerated infusion (hour and 30 infusion)
        • *>67kg: 15mg IVP over 1-2min → 50mg over 30 min → 35 mg over 1 hr

most common

• • • • • ≤67kg: 15mg IVP over 1-2 min → 0.75mg/kg IV over 30 → 0.5 mg/kg over 1 hr
      • 3 hour infusion
        • ≥67kg: 10mg IVP → 50mg IV over 1hr → 20mg over 1hr → 20 mg over 1 hr
    • absolute CI:
      • hemorrhagic stroke
      • ischemic stroke w/in 3 months
      • active internal bleed
      • aortic dissection
      • BP>180/110 and unresponsive to therapy
    • relative CI:
      • BP>180/110, you have to lower the BP first
  • CABG
    • recommended in left main disease or triple vessel disease
    • hold antiplatelets and anticoag before CABG (memorize slide 66)
      • antiplatelets
        • aspirin: do not hold
        • clopidogrel ticagrelor: 5 days
        • prasugrel: 7 days
      • anticoagulants
        • bivalirudin: 1-3 hrs
        • UFH: 1-4 hour
        • enoxaparin: 12 hrs
        • fondaparinux: 3-5 days
• NSTEMI and UA
  • get the grace and TIMI score
    • low risk: use ischemia-guided management plan
    • intermediate or high risk: early invasive approach
  • ischemia-guided therapy (medication therapy without any procedures)
    • low risk GRACE or TIMI score
    • low life expectancy
    • pt or clinician expectancy (did I mean preference?)
    • this is using medication to treat
      • CCD/ISHD is for patients who had these things (ACS) in the past and now continue to
  • early invasive strategy (use of PCI and CABG)
    • high risk GRACE or TIMI score
    • cardiogenic shock
    • life threatening arrhythmias, like Vfib
    • prior CABG
    • PCI w/in the past 6 months

Secondary Prevention

• DAPT
  • continue for 12 months unless there is a high /risk of bleed
  • aspirin should be continued indefinitely
• lipid lowering
  • all pt should receive high intensity statin post-ACS (preferably before revascularization)
  • goal: 70 mg/dL or less
• beta blockers
  • for all pt
  • continue for at least 3 years (unless there is an indication)
• ACEi/ARB
  • for pt who just had STEMI/NSTEMI + HFrEF, HTN, CKD or DM
  • ARNI is only indicated for HF
• MRA
  • for pt who just had STEMI/NSTEMI + already on ACE and beta blocker + HFrEF
  • unless CI (CrCl<30, K>5, etc.)

ACLS

Describe the prevalence and causes of cardiac arrests

• causes of cardiac arrest can be categorized as the H’s and the T’s

• types of rhythms during cardiac arrest
  • VF - ventricular fibrillation
  • VT - ventricular tachycardia
  • asystole
  • PEA - pulseless electrical activity

Understand the role of a pharmacist in ACLS

• role of pharmacist
  • we verify the appropriateness of treatment
  • calculate appropriate doses
  • obtain and prepare medication
  • ensure proper administration of medication
• goal of treatment
  • rapid recognition
  • prompt CPR
  • defibrillation
  • timely administration of meds to treat underlying causes

Identify the agents encountered during different types of emergency responses

• protocol to achieve Return of Spontaneous Circulation (ROSC)
  • Always (1)start CPR [1]
  • (2)Give oxygen and
  • (3)Attach monitor/defibrillator
    • if rhythm is shockable (pulse is VF or pVT) →
      • give a shock [1]
      • CPR [2] (30 compressions + 2 rescue breaths)
        • +treat underlying issues with IV therapy
      • shock [2]
      • CPR [3]

give epinephrine every 3-5 minutes

• • • • • up to 5 doses of epinephrine
      • shock [3]
      • CPR [4]
        • +amiodarone (after 5 doses of epinephrine)
        • +lidocaine (after dose of amiodarone)
    • if rhythm is NOT shockable (pulse is asystole or PEA)
      • administer epinephrine ASAP
        • give epinephrine every 3-5 minutes
        • up to 5 doses of epinephrine
      • CPR [2]
        • if rhythm becomes shockable, switch to that protocol
      • CPR [3]
        • +treat underlying issues with IV therapy
• agents during emergency response
  • Cardiopulmonary resuscitation (CPR)
    • 30 chest compressions (allow chest to return to normal position after each compression)
    • 2 breaths
    • 2in depth
    • 100-120 BPM
  • epinephrine
    • for ALL types of rhythms
    • dosing: 1 mg q3-5min IVP
  • amiodarone
    • only for shockable rhythms (Vfib/VT)
    • dosing: 300mg IV 1x → (if vfib/pVT continues) 150mg IV over 1-2min 1x → (if more required) start infusion
  • lidocaine
    • only for shockable rhythms (Vfib/VT)
    • dosing: 1-1.5 mg/kg over 1-4min (bolus dose, max 25mg/min in pt w/ pulse) → 1-4 mg/min
    • monitoring: serum level 1-5 mcg/mL
• secondary agents during emergency response
  • only used as an adjunct/add on NOT a replacement
  • sodium bicarbonate
    • only for hyperkalemia
    • dosing: 50 mEq over 5 minutes
  • calcium
    • only for hyperkalemia or CCB overdose
  • magnesium sulfate
    • only for QT prolongation (torsades de pointes)
    • dose: 1-2g
  • alteplase
    • ECHO should be done during CPR to rule out PE
    • dose: 50-100mg as bolus
      • recommended is 50mg IV push → 50mg in 10-15 minutes
      • no more than two doses