Cardiology

Question 1

Adenosine

Answer 1

For: PSVT

Adult dose: 6mg rapid IVP, followed by 20mL NS, If no response after 1-2 minutes, try 12mg.

Ped dose: 0.1mg/kg rapid IVP. If no response after 1-2 minutes, try 0.2mg/kg.

Contraindication: Second or third-degree AV block, or Sick Sinus Syndrome.

Notes: Avoid in WPW

Question 2

Amiodarone

Answer 2

For: (1) Ventricular dysrhythmias with pulse, or (2) Sudden cardiac arrest from VF or PVT

Adult dose (1): 150mg in 100mL NS over 10 minutes, then 1 mg/minute for 6 hours.

Adult dose (2): 300mg IVP in 14mL NS. If no improvement, then 150mg in 7mL

Ped dose (2): 5mg/kg slow IVP over 1-2min. May repeat twice

Contraindication: Allergy to iodine, sick sinus syndrome, second- or third-degree atrioventricular block, bradycardia leading to syncope without a functioning pacemaker; Cardiogenic shock; Torsades de Pointes

Note: Must dilute

Question 3

Aspirin

Answer 3

For: ACS chest pain

Dose: 162 - 324 mg PO (chewed)

Contraindications: Asthma, rhinitis, or nasal polyps; Signs and symptoms suggestive of recent CVA or GI bleeding

Note: Not recommended for peds

Question 4

Atropine

Answer 4

For: (1) Symptomatic bradycardia, or (2) anticholinesterase poisoning

Adult dose (1): 0.5-1mg IV/IM q 3-5min PRN for max dose of 3mg

Ped dose (1): 0.02 mg/kg IV/IO; 0.04 – 0.06 mg/kg ET (Minimum single dose is 0.1 mg, maximum single dose is 0.5 mg)

Adult dose (2): Variable. Initial 1-2mg bolus (mild-moderate sx) or 3-5mg bolus (severe sx) that is doubled every 3-5 minutes if no response induced.

Contraindications: Hypersensitivity

Question 5

Calcium Chloride / Calcium Gluconate

Answer 5

For: (1) Hypocalcemia, (2) Cardiac arrest w/ hyperK, hyperMg, or hypoCa, (3) HyperK including Crush syndrome, and (4) Beta- or Calcium channel-blocker overdose

Adult dose (1): For severe symptoms (e.g. seizure, tetany) 1000 mg IV over 10 minutes.

Ped dose (1): 2.7 to 5 mg/kg IV every 4-6 hours (maximum: 1g).

Adult dose (2 & 3): 500-1000 mg of 10% solution slowly IV over 2-5 minutes; May repeat in 10 minutes.

Ped dose (2 & 3): 20 mg/kg IV/IO (maximum: 2g); May repeat in 10 minutes. If calcium gluconate is unavailable, 1-2 ml of 10% calcium chloride solution, diluted with IV fluid, may be substituted.

Adult dose (4): Initial: Using a 10% solution: 20 mg/kg over 5 to 10 minutes (maximum: 1 to 2 g/dose); may repeat every 10 to 20 minutes for 3 to 4 additional doses

Ped dose (4): 20 mg/kg/dose IV infused over 5 to 10 minutes; if effective, consider IV infusion of 20 to 50 mg/kg/hour

Contraindications: Hypercalcemia; Digitalis toxicity; Not recommended as routine tx in cardiac arrest

Note: Don’t mix with sodium bicarbonate

Question 6

Digoxin

Answer 6

For: Tachyarrhythmias including atrial fibrillation and atrial flutter

Adult dose: 0.25 to 0.5mg IV over several minutes, with repeat doses of 0.25mg every 6 hours to a maximum of 1.5mg over 24 hours

Ped dose: 10 to 12 mcg/kg/dose IV every 8 hours for 3 doses

Contraindications: Ventricular fibrillation

Question 7

Diltiazem

Answer 7

For: (1) Atrial flutter / atrial fibrillation with rapid ventricular rates, and (2) Conversion of SVT

Adult dose (1 & 2): Initial bolus: 0.25 mg/ kg (average dose 20 mg) IV over two (2) minutes. If inadequate response may re-bolus in 15 minutes @ 0.35 mg/kg IV over two (2) minutes.

Ped dose: Not recommended

Contraindications: Wide-complex tachycardia. Sick sinus syndrome. Second- or third-degree AV block. Cardiogenic shock. Severe hypotension. Concomitant administration of beta-blockers. WPW. (In Canada: Pregnancy)

Question 8

Dobutamine

Answer 8

For: Cardiogenic shock (to maintain systemic perfusion and preserving end-organ performance)

Adult AND ped dose: 0.5 to 1 mcg/kg/minute IV / IO. May also initiate at higher doses (eg, 2.5 mcg/kg/minute) depending on severity of decompensation with titration to desired response.

Contraindications: Hypertrophic cardiomyopathy with outflow tract obstruction (formerly IHSS), hypersensitivity to sulfites

Question 9

Dopamine

Answer 9

For: Symptomatic bradycardia unresponsive to atropine or pacing; Hypotension with low cardiac output, especially in cases of distributive shock (in particular, septic and neurogenic shock) or cardiogenic shock.

Adult AND ped dose: 2-20 mcg / kg / min (rate determined by physician)

Contraindications: Hypersensitivity to sulfites (commercial preparation contains sodium bisulfite); pheochromocytoma; uncorrected tachyarrhythmias; ventricular fibrillation

Question 10

Epinephrine (cardiac)

Answer 10

For: (1) Cardiac arrest (asystole, PEA, VF unresponsive to initial defib) or (2) symptomatic bradycardia or AV block unresponsive to atropine

Adult dose (1): 1mg IV/IO push of 1:10 (0.1mg/mL) every 3-5 minutes

Ped dose (1): 0.01mg/kg IV/IO push of 1:10 (0.1mg/mL)

Adult dose (2): 2-10 mcg/minute IV/IO infusion of 1:10

Ped dose (2): 0.01 mg/kg IV/IO of 1:10 (max: 1mg or 10mL), every 3-5 minutes

Contraindications: Non-anaphylactic shock (particularly hypovolemic shock), coronary insufficiency, hypothermia, pulmonary edema, HTN

Question 11

Esmolol

Answer 11

For: (1) Treatment of noncompensatory sinus tachycardia, (2) Control of ventricular rate in patients with supraventricular tachycardia or atrial fibrillation/flutter, and (3) Hypertensive emergencies

Adult dose (1&2): Optional loading dose of 500 mcg/kg IV/IO over 1 minute, followed by a 50 mcg/kg/minute IV/IO infusion for 4 minutes

Ped dose (1&2): 100 to 500 mcg/kg over 1 minute followed by a continuous IV infusion: Initial rate: 25 to 100 mcg/kg/minute, titrate in 25 to 50 mcg/kg/minute increments; usual maintenance dose: 50 to 500 mcg/kg/minute

Adult dose (3): Start with a loading dose of 500 to 1,000 mcg/kg IV/IO over 1 minute, followed by a 50 mcg/kg/minute IV/ IO infusion

Ped dose (3): 100 to 500 mcg/kg/minute continuous IV/IO infusion

Contraindications: Severe sinus bradycardia; Heart block greater than first degree (except in patients with a functioning artificial ventricular pacemaker); Sick sinus syndrome; Cardiogenic shock; Decompensated heart failure; IV administration of calcium channel blockers in close proximity to esmolol (ie, while cardiac effects of other drug are still present); Pulmonary hypertension. (In Canada: Patients requiring inotropic agents and/or vasopressors to maintain cardiac output and systolic blood pressure; R ventricular failure secondary to pulmonary hypertension)

Question 12

Fentanyl Citrate

Answer 12

For: Pain

Adult dose (opiate naïve): 50-100 mcg IM OR 1 mcg/kg slow IV push (max IV dose: 75 mcg within 1 hour)

Ped dose: 1-2 mcg/kg/dose IM or slow IV/IO push, repeated every 30-60 minutes if opiate naïve

Contraindications: Known intolerance. (In Canada: Known or suspected mechanical GI obstruction; Suspected surgical abdomen; Acute or severe bronchial asthma; Severe CNS depression; Concurrent use or use within 14 days of an MAOI)

Question 13

Furosemide

Answer 13

For: Acute pulmonary edema

Adult dose: 0.5-1 mg/kg injected slowly IV (Medical Control Option)

Ped dose: 1 mg/kg/dose IV/IO (Medical Control Option)

Contraindications: Anuria. (In Canada: Hepatic coma, hypovolemia, hypotension)

Question 14

Lidocaine

Answer 14

For: (1) Acute suppression of ventricular dysrhythmias, and (2) Sudden cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia)

Adult dose (1&2): 1 to 1.5 mg/kg IV/IO; If refractory, repeat at 0.5 to 0.75 mg/kg every 5 to 10 minutes (maximum cumulative dose: 3 mg/kg). Follow with continuous infusion of 1 to 4 mg/minute.

Ped dose (1&2): 1mg/kg/dose IV/IO. Follow with continuous infusion of 20-50 mcg/kg/minute

Contraindications: WPW; Stokes-Adams syndrome; Second degree and third degree blocks in the absence of an artificial pacemaker;

Question 15

Magnesium (cardiac)

Answer 15

For: (1) Torsades de Pointes (w/ pulse), (2) Pulseless VF/VT associated with TDP

Adult dose (1): 1-2 grams IV/IO (diluted in 50-100mL D5W) over 15 minutes. If refractory, may repeat dose up to a total of 4g in 1 hour; May follow with a continuous IV infusion of 0.5-1g/hour

Ped dose (1): 25-50mg/kg/dose IV/IO (maximum dose: 2g)

Adult dose (2): 1-2g IV/IO over 1-2 minutes; If refractory, may repeat immediately (maximum total dose: 6g)

Ped dose (2): 25-50mg/kg/dose IV/IO (maximum dose: 2g)

Contraindications: Heart blocks; Myocardial damage

Question 16

Metoprolol

Answer 16

For: Atrial fibrillation or Atrial flutter

Adult dose: 2.5-5 mg slow IV push (over 2 minutes). May repeat every 5 minutes to a maximum of 15mg (Medical control option)

Ped dose: Not recommended

Question 17

Morphine (cardiology)

Answer 17

For: ACS chest pain

Adult dose: 0.1 mg/kg every 5-15 minutes to a maximum of 10 mg IV/IM/SC

Ped dose: 0.1 to 0.2 mg/kg/dose IV/IO/IM/SC every 5-15 minutes titrated to max. of 5 mg

Contraindications: Significant respiratory depression; Acute or severe chronic obstructive airway; Concurrent or recent use of MAOIs; GI obstruction; Undiagnosed abdominal pain. (In Canada: Hypotension; Head injury; Hypercarbia; Cor pulmonale; Increased ICP; Pregnancy; Suspected surgical abdomen)

Question 18

Nitroglycerin

Answer 18

For: ACS chest pain, CHF, Pulmonary edema

Adult dose: 1 SL tablet (0.3-0.4 mg) at 5-minute intervals to a max of 3 doses
OR 1 translingual spray (0.4 mg) at 5-minute intervals to a max of 3 doses
OR 5 mcg/min IV infusion; may increase rate by 5-10 mcg/min every 5-10 minutes PRN

Ped dose: Not recommended. IV dosage initially 0.25-0.5 mcg/kg/minute IV/IO titrated to 1 mcg/kg/minute every 15-20 minutes PRN. Maximum dose: 5 mcg/kg/minute

Contraindications: Acute circulatory failure or shock (hypotension, hypovolemia). Increased intracranial pressure, intracranial bleeding, or head injury. Concurrent use with PDE-5 inhibitors. Additional contraindications for IV product: pericardial tamponade. Hypersensitivity

Question 19

Levophed

Answer 19

For: Hypotension or shock: Treatment of severe hypotension (eg. <70 mm/Hg), cardiogenic shock, or septic shock (and other vasodilatory shock states) that persist after adequate fluid volume replacement

Adult dose: 0.05 to 0.15 mcg/kg/minute; Titrate to mean arterial BP (MAP) >65 mm Hg and preferably systolic BP of 80 to 100 mm

Ped dose: 0.05 to 0.1 mcg/kg/minute, titrate to desired effect; Maximum dose: 2mcg/kg/minute

Contraindications: In Canada: Hypotension from hypovolemia except as an emergency measure to maintain coronary and cerebral perfusion until volume could be replaced

Question 20

Oxygen

Answer 20

For: Confirmed or expected hypoxemia; Ischemic chest pain; Respiratory insufficiency; Prophylactically during air transport; Confirmed or suspected carbon monoxide poisoning. All other causes of decreased tissue oxygenation.

Cardiac arrest and Carbon Monoxide poisoning, all patients: 100%

Hypoxemia, all patients: 10-15 L/ minute via non-rebreather

COPD, all patients: 0-2 L/ min. via nasal cannula or 28-35% venturi mask. Be prepared to provide ventilatory support if higher concentrations of oxygen are needed.

Contraindications: Severe COPD / emphysema patients who do not tolerate oxygen concentrations that are > 35%; Hyperventilation

Question 21

Procainamide

Answer 21

For: Ventricular dysrhythmias refractory to lidocaine, including PVCs and ventricular tachycardia with a pulse. Wide-complex PSVTs of unknown etiology (especially when associated with WPW). Preexcitation atrial fibrillation

Adult dose, all indications: 10-17 mg/kg IV/IO at a rate of 20-50 mg/minute. Administer until dysrhythmia is controlled, hypotension occurs, or QRS complex widens by 50% of its original width. Then, maintenance dose of 1-4mg/minute

Ped dose, all indications: 10-15 mg/kg IV/IO infused over 30-60 minutes (maximum loading dose: 500 mg). Administer until dysrhythmia is controlled, hypotension occurs, or QRS complex widens by 50% of its original width. Then, maintenance dose of 20-80 mcg/kg/min

Contraindications: Second- and Third-Degree block, Torsades de Pointes, Lupus, Digitalis toxicity, Myasthenia gravis

Question 22

Sodium Bicarbonate

Answer 22

For: Known pre-existing bicarbonate-responsive acidosis (including ROSC after a long arrest interval); Hyperkalemia; Overdose of TCAs, ASA, or phenobarbital

Dose, all patients and indications: 1 mEq / kg IV/IO

Contraindications: Chloride loss from emesis or continuous GI suction; Concomitant use of diuretics known to produce a hypochloremic alkalosis; Metabolic or respiratory alkalosis; Hypocalcemia; Hypokalemia.

Question 23

tPA

Answer 23

For: Acute ischemic stroke; Acute myocardial infarction; Acute pulmonary embolism

Dose: 0.9 mg/kg (not to exceed 90mg), with 10% of the total dose administered as an initial intravenous bolus over 1 minute and the remainder infused over 60 minutes (Medical control option)

Contraindications: Prior intracranial hemorrhage (ICH); Known structural cerebral vascular lesion; Known malignant intracranial neoplasm; Ischemic stroke within three months; Suspected aortic dissection; Active bleeding or bleeding diathesis; Significant closed-head or facial trauma within three months. Important relative contraindications include HTN (eg. SBP > 180 mmHg), traumatic or prolonged CPR (eg. > 10 minutes), pregnancy, current use of anticoagulants, and dementia

Question 24

Vasopressin

Answer 24

For: (1) Vasodilatory shock, or (2) May be used as an alternative to epinephrine in adult cardiac arrest

Adult dose (1): ≤0.03 units/minute continuous IV infusion added to norepinephrine to raise MAP to target. Titrate to minimum effective dose

Ped dose (1): 0.17-2.0 milliunits/kg/min continuous IV infusion

Adult dose (2): 40 units IV/IO push; May replace either first or second dose of epinephrine

Ped dose (2): 0.4 units/kg IV/IO bolus (max dose: 40 units) as a single dose after traditional resuscitation methods and at least two doses of epinephrine have been administered

Contraindications: Responsive patients with CAD; Hypersensitivity

Question 25

Verapamil

Answer 25

For: (1) Acute ventricular rate control in atrial fibrillation or atrial flutter without preexcitation associated with an accessory pathway, or (2) Narrow-complex reentry SVTs that are refractory to vagal maneuvers and adenosine in hemodynamically stable patients

Adult dose (1): 5-10mg over ≥2 minutes; If inadequate, dose may be repeated after 15-30 minutes; If adequate after 1-2 bolus doses, may begin a continuous infusion of 5 mg/hour, titrated to goal heart rate (maximum dose: 20 mg/hour, 30mg in total)

Ped dose (1): Not recommended

Adult dose (2): 5-10 mg over ≥2 minutes; If inadequate 15-30 minutes later, a second bolus of 10 mg over 2 minutes may be given. Consider alternative therapy if second bolus ineffective

Ped dose (2): Not recommended

Contraindications: Sinus bradycardia; Sick sinus syndrome, second- or third-degree atrioventricular block (unless the patient has a functioning pacemaker); Hypotension (eg. SBP < 90 mmHg); Cardiogenic shock; severe left ventricular dysfunction or CHF; Atrial fibrillation or atrial flutter in the presence of an accessory pathway such as in WPW or LGL; Concurrent use of IV beta-blockers; Wide-complex tachycardias of uncertain etiology

Question 26

Heparin

Answer 26

For: Anticoagulation

Adult dose: Loading dose: 80 units/kg IV; maintenance dose: 18 units/kg/hour IV.

Pediatric: Loading dose: 50 u/kg IV; maintenance dose: 7.5 units/kg/hour IV

Contraindications: Concurrent antiplatelet use