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Anticholinergic (antimuscarinic)

• Competes reversibly w/ acetylcholine @ site of the muscarinic receptor
• Receptors affected, in order from most to least sensitive: salivary, bronchial, sweat glands, eye, heart, & GI tract

Symptomatic bradycardia, asystole or PEA, nerve agent exposure, organophosphate poisoning

decreased secretions resulting in dry mouth & hot skin temp, intense facial flushing, blurred vision or dilation of pupils w/ subsequent photophobia, tachycardia, restlessness; may cause paradoxical bradycardia if admin. is too low or too slow

Acute MI; myasthenia gravis; GI obstruction; closed-angle glaucoma; known sensitivity to atropine, belladonna alkaloids, or sulfites. Not effective for infranodal (type II) AV block & new third-degree block w/ wide QRS complex

• Symptomatic Bradycardia: ADULT: 0.5mg IV/IO every 3-5 min to max dose of 3mg; ADOLESCENT: 0.02mg/kg (range 0.1-1mg/dose)IV/IO up to total dose of 2mg; PEDI: 0.02mg/kg (range 0.1-0.5mg/dose)IV/IO to total dose of 1mg
• Asystole/PEA: 1mg IV/IO every 3-5 min, to max dose of 3mg. May admin ETT @2-2.5mg dilute in 5-10mL NS
• Nerve Agent/Organophosphate Poisoning: ADULT: 2-4mg IV/IM repeat if needed every 20-30 min til symptoms dissipate, severe cases, initial dose can be as large as 2-6mg admin IV, repeat doses of 2-6mg can be admin IV/IM every 5-60 min; PEDI: 0.05mg/kg IV/IM every 10-30 as needed until symptoms dissipate; INFANTS <15LBS: 0.05mg/kg IV/IM every 5-20 min as needed til symptoms dissipate

Adrenergic agent, inotropic

Binds strongly w/ both alpha & beta receptors, producing increased BP, increased HR, bronchodilation

Bronchospasm, allergic & anaphylactic reactions, restoration of cardiac activity in cardiac arrest

Anxiety, headache, cardiac arrhythmias, HTN, nervousness, tremors, chest pain, nausea/vomiting

Arrhythmias other than VF, asystole, PEA; cardiovascular disease; HTN; cerebrovascular disease; shock secondary to causes other than anaphylactic shock; closed-angle glaucoma; diabetes; pregnant women in active labor; known sensitivity to epinephrine or sulfites

• Cardiac Arrest: 1:10000 solution. ADULT: 1mg IV/IO; may repeat every 3-5 min; PEDI: 0.01mg/kg IV/IO repeat every 3-5 min as needed (max dose 1mg)
• Symptomatic Bradycardia: 1:10000 solution. ADULT: 1mcg/min as cont. IV infusion, usually 2-10mcg/min IV, titrate to effect; PEDI: 0.01mg/kg IV/IO may repeat every 3-5 min (max dose 1mg), if ETT admin 0.1mg/kg
• Asthma Attacks and Certain Allergic Reactions: 1:1000 solution. ADULT: 0.3-0.5mg IM/SC may repeat every 10-15 min (max dose 1mg); PEDI: 0.01mg/kg IM/SC (max dose 0.5mg)
• Anaphylactic Shock: 1:10000 solution. ADULT: 0.1mg IV slow over 5 min or IV infusion 1-4mcg/min titrate to effect; PEDI: cont. IV infusion rate 0.1-1mcg/kg/min titrate to respone

Adrenergic agonist, inotropic, vasopressor

Stimulates alpha & beta adrenergic receptors, @ moderate doses (2-10mcg/kg/min) stimulates beta1 receptors resulting in inotropy & increased cardiac output while maintaining dopaminergic-induced vasodilatory effects, @ high doses (>10mcg/kg/min)alpha adrenergic agonism predominates & increased peripheral vascular resistance & vasoconstriction result

hypotension & decreased cardiac output associated w/ cardiogenic shock & septic shock, hypotension after return of spontaneous circulation following cardiac arrest, symptomatic bradycardia unresponsive to atropine

Tachycardia, arrhythmias, skin & soft tissue necrosis, severe HTN from excessive vasoconstriction, angina, dyspnea, headache, nausea/vomiting

Pheochromocytoma, VF, VT, or other ventricular arrhythmias, known sensitivity (including sulfites); correct any hypovolemia w/ volume fluid replacement before admin.

ADULT AND PEDI: 2-20mcg/kg/min IV/IO infusion, starting dose 5mcg/kg/min, may gradually increase infusion by 5-10mcg/kg/min to desired effect. Cardia dose usually 5-10mcg/kg/min, vasopressor dose usually 10-20mcg/kg/min. little benefit beyond 20mcg/kg/min

Antiarrhythmic

Slows conduction of electrical impulses @ AV node

Stable reentry SVT. Does not convert AF, atrial flutter, or VT

Generally mild and short-lived: sense of impending doom, complaints of flushing, chest pressure, throat tightness, numbness. Patients will have a brief episode of asystole after admin.

Sick sinus syndrome, second- or third-degree heart block, poison-/drug-induced tachycardia

• ADULT & CHILDREN >50KG: initial 6mg rapid IV/IO (over 1-3 sec) immediately followed by 20mL NS flush, if rhythm not eliminated after 1-2 min 12mg rapid IV/IO, repeat a second time if required
• PEDI<50KG: initial 0.1mg/kg IV/IO (max dose 6mg) immediately followed by at least 5mL NS flush, may repeat @ 0.2mg/kg (max dose 12mg)

Calcium channel blocker, class IV antiarrhythmic

Blocks calcium from moving into heart muscle cell, prolonging conduction of electrical impulses through the AV node

Ventricular rate control in rapid AF

Flushing; headache; bradycardia; hypotension; heart block; myocardial depression; severe AV block; & @ high doses cardiac arrest

Hypotension, heart block, heart failure

• ADULT: optimum dose is 0.25mg/kg IV/IO over a 2 min period to control rapid AF; 20mg is reasonable for avg. adult patient. A 2nd higher dose of 0.35mg/kg IV/IO (25mg is a typical 2nd dose) may be admin. over a 2 min period if rate control not obtained w/ lower dose. For cont'd reduction in HR, a cont. infusion can be started @ range of 5-15mg/hr
• PEDI: not recommended

Calcium channel blocker; class IV antiarrhythmic

Blocks calcium from moving into heart muscle cell, prolonging conduction of electrical impulses through the AV node. Also dilates arteries

AF, HTN, PSVT, PSVT prophylaxis

Sinus bradycardia; first-, second-, or third-degree AV block; CHF; reflex sinus tachycardia; transient asystole; AV block; hypotension

Second- or third-degree AV block (unless functioning artificial pacemaker); hypotension (<90mmHg systolic) or cardiogenic shock; sick sinus syndrome ( unless functioning artificial pacemaker); WPW syndrome; LGL syndrome; severe left ventricular dysfunction; known sensitivity to verapamil or any component of the formulation; atrial flutter or AF and an accessory bypass tract; in infants <1yr

• ADULT: 2.5-5mg IV/IO over 2 min (3 min in elderly), may repeat @ 5-10mg every 15-30 min to max dose of 30mg
• PEDI: CHILDREN 1-16yrs: 0.1mg/kg IV/IO (max 5mg/dose) over 2 min, may repeat in 30 min to max dose of 10mg; INFANTS <1yr: not recommended

Beta adrenergic antagonist, antianginal, antihypertensive, antiarrhythmic class II

Nonselective beta antagonist that binds w/ both beta1 & beta2 receptors. inhibits the strength of the heart's contractions, as well as HR, resulting in decreased cardiac oxygen consumption

Angine; narrow-complex tachycardias that originate from either a reentry mechanism (reentry SVT) or an automatic focus (junctional, ectopic, or multifocal tachycardia) uncontrolled by vagal maneuvers & adenosine in patients w/ preserved ventricular function; AF & atrial flutter in patients w/ preserver ventricular function; HTN; migraine headaches

Beta agrenergic antagonist, antianginal, antihypertensive, class II antiarrhythmic

inhibits the strength of heart's contractions, as well as HR decreasing cardiac oxygen consumption. Saturates beta receptors & inhibits dilation of bronchial smooth muscle (beta2 receptor)

ACS, HTN, SVT, atrial flutter, AF, thyrotoxicosis

tiredness, dizziness, diarrhea, heart block, bradycardia, bronchospasm, drop in BP

Cardiogenic shock, AV block, bradycardia, known sensitivity. Use caution in hypotension, chronic lung disease (asthma & COPD)

• Cardiac Indications?
• ADULT: 5mg slow IV/IO over a 5 min period, repeat @ 5 min intervals up to a total of 3 infusions totaling 15mg IV/IO
• PEDI: Not recommended

Beta adrenergic antagonist, antianginal, antihypertensive, class II antiarrhythmic

inhibits the strength of the heart's contractions & HR, decreasing cardiac oxygen consumption. Saturates the beta receptors & inhibits dilation of bronchial smooth muscle (beta2 receptors)

ACS, HTN, SVT, atrial flutter, AF

Beta adrenergic antagonist, class II antiarrhythmic

inhibits the strength of the heart's contractions, as well as HR, decreasing cardiac oxygen consumption

ACS, MI, acute HTN, supraventricular tachyarrhythmias, thyrotoxicosis

antiarrhythmic, class III

Acts directly of the myocardium to delay repolarization & increase the duration of action potential

Ventricular arrhythmias; second-line agent for atrial arrhythmias

Burning @ injection site, hypotension, bradycardia

Sick sinus syndrome, second- & third-degree heart block, cardiogenic shock, when episodes of bradycardia have caused syncope, sensitivity to benzyl alcohol & iodine

• VF & pulseless VT:
• ADULT: 300mg IV/IO, may be followed by 1 dose of 150mg in 3-5 min; PEDI: 5mg/kg (max dose 300mg), may repeat 5mg/kg IV/IO up to 15mg/kg
• Relatively stable patients w/ arrhythmias such as PVCs pr wide-complex tachycardia w/ a strong pulse:
• ADULT: 150mg in 100mL D5W IV/IO over a 10 min period, may repeat in 10 min up to a max dose of 2.2g over 24 hr; PEDI: 5mg/kg very slow IV/Io (over 20-60 min), may repeat in 5mg/kg doses up to 15mg/kg (max dose 300mg)

Antiarrhythmic, class IB

Blocks sodium channels, increasing recovery period after repolarization; suppresses automaticity in the His-Purkinje system & depolarization in the ventricles

Ventricular arrhythmias, when amiodarone is not available; cardiac arrest from VF/VT, stable monomorphic VT w/ preserved ventricular function, stable polymorphic VT w/ normal baseline QT interval & preserved left ventricular function (when ischemia & electrolyte imbalance are treated), stable polymorphic VT w/ baseline QT prolongation suggestive of torsades de pointes

Toxicity (anxiety, apprehension, euphoria, nervousness, disorientation, dizziness, blurred vision, facial paresthesias, tremors, hearing disturbances, slurred speech, seizures, sinus bradycardia), seizures w/o warning, cardiac arrhythmias, hypotension, cardiac arrest, pain @ injection site

AV block; bleeding; thrombocytopenia; known sensitivity to lidocaine, sulfite, or paraben. Use w/ caution in bradycardia, hypovolemia, cardiogenic shock, Adams-Stokes syndrome, WPW syndrome

• Pulseless VT & VF: ADULT IV/IO: 1-1.5mg/kg, may repeat @ half the original dose (0.5-0.74mg/kg) every 5-10 min to a max dose of 3mg/kg, if maintenance infusion warranted, rate 1-4mg/min; ADULT ETT: 2-10mg/kg diluted in 10mL NS; PEDI IV/IO: 1mg/kg (max 100mg) if maintenance infusion warranted, rate 20-50mcg/kg/min; PEDI ETT: 2-3mg/kg followed by 5 mL NS flush
• Perfusing Ventricular rhythms: ADULT: 0.5-0.75mg/kg IV/IO (up to 1-1.5mg/kg may be used), repeat 0.5-0.75mg/kg every 5-10 min to max total dose 3mg/kg. Maintenance infusion of 1-4mg/min (30-50mcg/kg/min) acceptable; PEDI: 1mg/kg IV/IO, may repeat every 5-10 min to max dose of 3mg/kg. maintenance infusion rate 20-50mcg/kg/min

Antiarrhythmic, class IA

Blocks influx of sodium through membrane pores, consequently suppresses atrial & ventricular arrhythmias by slowing conduction in myocardial tissue

Alt. to amiodarone for stable monomorphic VT w/ normal QT interval & preserved ventricular function, reentry SVT if uncontrolled by adenosine & vagal maneuvers if BP stable, AF w/ rapid rate in WPW syndrome

electrolyte, tocolytic, mineral

required for normal physiologic functioning, a cofactor in neurochemical transmission & muscular excitability, controls seizures by blocking peripheral neuromuscular transmission, a peripheral vasodilator & an inhibitor of platelet function

Torsades de pointes, cardiac arrhythmias associated w/ hypomagnesemia, eclampsia & seizure prophylaxis in preeclampsia, status asthmaticus

Magnesium toxicity (flushing, diaphoresis, hypotension, muscle paralysis, weakness, hypothermia, & cardiac, CNS, or respiratory depression)

AV block, GI obstruction. Use caution w/ renal impairment

• Pulseless VF/VT w/ Torsades de Pointes or Hypomagnesemia: ADULT: 1-2g in 10mL D5W IV/IO over 5-10 min; PEDI: 25-50mg/kg IV/IO over 10-20 min, may admin faster for torsades de pointes (max single dose 2g)
• Torsades de Pointes w/ pulse or cardia arrhythmias w/ hypomagnesemia: ADULT: 1-2g in 50-100mL D5W IV/IO over 5-60 min, follow w/ 0.5-1g/hr IV/IO titrate to control torsades.; PEDI: 25-50mg/kg IV/IO over 10-20 min (max 2g/dose)
• Eclampsia & seizure prophylaxis in preeclampsia: ADULT: 4-6g IV/IO over 20-30 min then infusion @ 1-2g/hr
• Status Asthmaticus: ADULT: 1.2-2g slow IV/IO over 20 min; PEDI: 25-50mg/kg dilute in D5W slow IV/IO over 10-20 min

nonadrenergic vasoconstrictor

Causes vasooconstriction independent of adrenergic receptors or neural innervation

Adult shock-refractory VF or pulseless VT, asystole, PEA, vasodilatory shock

cardiac ischemia, angina

responsive patients w/ cardiac disease

• ADULT: 40 U IV/IO may replace either the 1st or 2nd dose of epinephrine
• May be given ET but optimal dose is not known