Cardiology

SVT Algorithm Atrial Fibrillation/Atrial Flutter Pharmacology

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SVT Algorithm Regular/Narrow-Complex Tachycardia

1) 2) 3) 4) This algorithm is used for all patients with a heart rate of 150 or greater with narrow QRS complexes and pulses. Initial determination is whether the patient is Stable vs. Unstable. 4 Parameters for unstable patients: Altered Mental Status/ALOC Hypotension Ongoing Chest Pain Other signs of shock (i.e. dyspnea, diaphoresis, etc.)
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SVT Algorithm
The difference in therapy between Stable and Unstable patients: Stable Patients pharmacology first. Unstable Patients electricity first. The form of electricity is Cardioversion This will be covered in detail during the lab sessions.

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SVT Stable Patient

1) 2) 3) Initiate oxygen therapy Initiate an IV line Obtain 12 lead ECG (if available) Attempt Vagal/Valsalva Maneuvers Drug of choice is: Adenosine. Can be given up to 3 times if needed. 6 mg, rapid IVP, followed by a 20 ml bolus of NSS if no conversion 12 mg, rapid IVP, followed by a 20 ml bolus of NSS if no conversion 12 mg, rapid IVP, followed by a 20 ml bolus of NSS

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SVT Stable Patient

After Adenosine if the rhythm does NOT change, the next drug of choice is either a Calcium Channel Blocker or a Beta Blocker. Calcium Channel Blockers: 1) Diltiazem (Cardizem): Calcium Channel Blocker of choice a) 15 to 20 mg (0.25 mg/kg) over 2 minutes, can be repeated in 15 minutes with 20-25 mg (0.35 mg/kg) b) If patient converts hang a drip (100mg/100ml) and run at 1 mg/minute.
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SVT Stable Patient

If choosing a Beta-Blockade administer as follows: Metoprolol: 5mg q 5min, total 15minute Atenolol: 5mg slow over 5min, repeat q10min Propanolol: .1mg/kg slow IV push. Divide into 3 equal doses and administer q3min <= 1mg/min. Esmolol: .5mg/kg over 5 min over 1 min, follow with 4 minute infusion at 50ug/kg Labetalol: 10mg IVP over 2 min, may repeat or double q10 min. Total dose 150mg. ** use B-blockers with caution in pulmonary disease or CHF

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SVT Stable Patient

If unsuccessful, consider expert consultation.

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SVT Unstable Patient

If the patient meets the parameters of being unstable, perform immediate Synchronized Cardioversion at the listed energy levels listed later in this lecture. Remember that unstable patients cannot perform a Vagal/Valsalva maneuver. Remember to obtain IV access. If patient is still conscious sedate (versed/valium).

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A-Fib/A-Flutter Irregular Narrow-Complex Tachycardia

Again treatment is reserved for those with heart rates above 150 with irregular narrow complex tachycardia. Determine if the patient is stable vs. unstable. Using the same guides as for SVT. If stable, consider expert consultation and if indicated control rate with: 1) Calcium Channel Blockers 2) Beta Blockers If unstable, perform immediate synchronized cardioversion.

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Treatment Modalities
Adenosine Calcium Channel Blockers Beta Blockers Synchronized Cardioversion

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Adenosine
Generic Name: Adenosine Trade Name: Adenocard

Classification: Class IVb antiarrhythmic, endogenous nucleoside How Supplied: 3 mg/ml

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Adenosine Mechanism of Action

Found naturally in all body cells. Rapidly metabolize in the blood vessels. Slows sinus rate Slows conduction time through AV node Can interrupt reentry pathways through AV node Can restore sinus rhythm in SVT

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Adenosine Indications
First line medication for most forms of narrow-QRS supraventricular tachycardia (SVT)

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Adenosine Dosing (adult)

Peripheral IV dose: 6 mg rapid IV push over 1 to 3 seconds. If no response within 1 to 2 minutes administer 12 mg. May repeat 12 mg dose once in 1 to 2 minutes. Follow each dose immediately with a 20 ml NSS bolus. Recommended IV site is the antecubital fossa. Nothing lower. Use the injection port nearest the hub of the IV catheter. Constant ECG monitoring is essential.

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Adenosine Precautions
Facial flushing Coughing/dyspnea, bronchospasm Nausea Headache Hypotension Chest pressure Lightheadedness Paresthesias Dysrhythmias at time of rhythm conversion Use with caution in patients with emphysema, bronchitis Avoid in patients with asthma Discontinue in any patient who develops severe respiratory difficulty

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Adenosine Contraindications
Poison/drug-induced tachycardia Asthma 2nd or 3rd degree AV Block Sick sinus syndrome (except in clients with a functioning artificial pacemaker) Atrial flutter/atrial fibrillation Ventricular tachycardia

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Adenosine Special Considerations

Must be injected into the IV tubing as fast as possible. Failure to do so may result in breakdown of the medication while still in the IV tubing. Adenosine may cause fatal cardiac arrest, sustained ventricular tachycardia requiring resuscitation, and nonfatal MI. Transient or prolonged episodes of asystole have been reported with fatal outcomes in some cases. If central line is in place may only require 3 mg for IV administration.

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Adenosine Onset of Action

SECONDS!!!!!

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Calcium Channel Blockers

Generic/Trade Name: Verapamil (Calan, Isoptin, Verelan), Diltiazem (Cardizem) Classification: Calcium channel blocker (calcium antagonist). How Supplied: Verapamil injection: 5mg/2ml Diltiazem injection: 5 mg/ml monovial; 100 mg freeze-dried; powder for injection 10 mg, 25 mg

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Calcium Channel Blockers Mechanism of Action

1) 2) 3) 4) Inhibit movement of calcium ions across cell membranes in the heart and vascular smooth muscle, resulting in: Depressant effect on the hearts contractile function (negative inotropic effect) Slowed conduction through the AV node (negative dromotropic effect) Dilation of coronary arteries and peripheral arterioles Decreased myocardial oxygen demand

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Calcium Channel Blockers Indications

1) 2) 1) 2) SVT Patients with normal LV function (diltiazem Class I) Patients with impaired LV function (diltiazem Class IIb) Atrial Tachycardia Patients with normal LV function (diltiazem Class IIb) Patients with impaired LV function (diltiazem Class IIb)

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Calcium Channel Blockers Indications

1)
2) 1)

Atrial flutter/fibrillation: for rate control Patients with normal LV function (diltiazem, verapamil Class I) Patients with impaired LV function (diltiazem Class IIb) Pre-excited atrial fibrillation (WPW) Patients with normal LV function (diltiazem, verapamil Class III)

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Calcium Channel Blockers Indications

Junctional Tachycardia 1) Verapamil, diltiazem Class indeterminate Inappropriate Sinus Tachycardia 1) Verapamil, diltiazem Class indeterminate

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Calcium Channel Blockers Dosing

Verapamil 2.5 5 mg IV bolus over 2 minutes (administer over 3 to 4 minutes in elderly or if BP is within the lower range of normal). May repeat with 5 to 10 mg in 15 to 30 minutes (if no response and BP remains normal or elevated). Maximum dose 20 mg

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Calcium Channel Blockers Dosing

Diltiazem 15 to 20 mg (0.25 mg/kg) over 2 minutes. If needed, follow in 15 minutes with 20 to 25 mg (0.35 mg/kg) IV over 2 minutes. Maintenance infusion 1 mg/min, titrated to heart rate.

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Calcium Channel Blockers Precautions

Avoid calcium channel blockers in patients with wideQRS tachycardia unless it is known with certainty to be supraventricular in origin. Calcium channel blockers decrease peripheral resistance and can worsen hypotension. IV calcium channel blockers and IV beta-blockers should not be administered together or in close proximity (within a few hours) may cause severe hypotension.

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Calcium Channel Blockers Contraindications

Wide-QRS tachycardia of uncertain origin Poison/drug induced tachycardias Digitalis toxicity (may worsen heart block) Atrial fibrillation/flutter with an accessory bypass tract (WPW) Severe CHF Sick sinus syndrome (bradycardia-tachycardia syndrome) except with a functioning ventricular pacemaker. Hypotension (SBP < 90 mmHg) Cardiogenic shock 2nd or 3rd degree AV block

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Calcium Channel Blockers Special Considerations

Diltiazem depresses myocardial contractility to a lesser degree than verapamil and causes less hypotension. During administration, monitor closely for hypotension and AV block.

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Calcium Channel Blockers Onset of Action

Verapamil IV: 2 to 5 minutes Diltiazem IV: to 1 hour

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Calcium Channel Blockers Durations

Verapamil IV: 2 hours

Diltiazem IV: 1 to 3 hours

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Calcium Channel Blockers Drug Interactions

Beta-blockers may have additive negative inotropic and chronotropic effects. In some cases, coadministration of verapamil or diltiazem may prolong bleeding time. Concurrent use of amiodarone and diltiazem can result in bradycardia and decreased cardiac output by an unknown mechanism. Verapamil has bee found to significantly inhibit elimination of alcohol, resulting in elevated blood alcohol concentrations that may prolong the intoxicating effects of alcohol.
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Beta Blockers
Generic/ Trade Names: Atenolol (Tenormin) Esmolol (Brevibloc) Labetalol (Normodyne, Trandate) Metoprolol (Lopressor) Propranolol (Inderal) Classification: Beta-blockers

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Beta Blockers
1) 2) 3) 4) 5) How Supplied: Atenolol injection: 5mg/10m Esmolol injection: 100 mg/10 ml single-dose vial Labetalol injection: 5 mg/ml in 20 ml ampule; 20, 40, 60 ml multi-dose vials Metoprolol injection: 1 mg/ml in 5 ml ampule Propranolol injection: 20 mg/5 ml unit-dose containers; 40 mg 5 ml unit dose containers

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Beta Blockers Mechanism of Action

Slows sinus rate Depresses AV conduction Reduces blood pressure Decreases myocardial oxygen consumption Reduces the incidence of dysrhythmias by decreasing catecholamine levels Reduces risk of sudden death in patients with an acute coronary syndrome

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Beta Blockers Indications

Non-ST segment elevation MI or unstable angina (Class I) Adjunctive agent with fibrinolytic therapy To reduce incidence of VF in post-MI patients who did not receive fibrinolytics (atenolol, metoprolol, propranolol)

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Beta Blockers Indications

1) 2) 3) 4) To slow the ventricular response in: (esmolol) SVT (Class I) Atrial fibrillation or atrial flutter (Class I) Multifocal atrial tachycardia (Class IIb) Inappropriate sinus tachycardia (Class IIb) Control of blood pressure in hypertensive emergencies (labetalol)

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Beta-Blockers Dosing (adult)

Atenolol 5 mg IV over 5 minutes followed by another 5 mg IV dose 10 minutes later. Monitor BP, heart rate, and ECG closely. If patient tolerates full IV dose (10 mg), begin oral atenolol therapy 10 minutes after last IV dose

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Beta Blockers Dosing (adults)

Esmolol 0.5 mg/kg over 1 minute, followed by a maintenance infusion at 50 mcg/kg/min for 4 minutes. If the response is inadequate, administer a 2nd bolus of 0.5 mg/kg over 1 minute and increase the maintenance infusion to 100 mcg/kg/min. Preferred by many physicians in the management of narrow-QRS tachycardias because it is short-acting (halflife 9 minutes)

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Beta Blockers Dosing (adults)

Labetalol 5 to 20 mg slowly IV push over 2 minutes. Additional doses of 10 to 40 mg may be administered until a desired supine BP is achieved or a total of 150 mg has been administered. May be administered by IV infusion. Mix two 20 ml vials in 160 ml of IV solution. The resulting concentration contains 200 mg/200 ml IV solution (1 mg/ml). Administer at a rate of 2 ml/min to deliver 2 mg/min.

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Beta Blockers Dosing (adults)

Metoprolol 5 mg slow IV push over 5 minutes x 3 as needed to a total dose of 15 mg over 15 minutes. Closely monitor BP, heart rate, and ECG In patients who tolerate the full IV dose (15 mg), begin oral metoprolol therapy 15 minutes after last IV dose.

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Beta Blockers Dosing (adults)

Propranolol 1 mg slow IV push. Repeat every 5 minutes to a maximum of 5 mg. Usual dose required is 2 to 4 mg. Do not push faster than 1 mg/min to diminish the possibility of lower BP and causing cardiac standstill. Monitor BP, heart rate, and ECG closely.

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Beta-Blockers Precautions
Atenolol Use with caution in patients with impaired renal function

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Esmolol In clinical trials 20 to 50% of patients experienced hypotension, SBP <90 mmHg and/or DBP < 50 mmHg. Monitor patients closely, especially if pretreatment BP low. Decrease of dose or termination of infusion reverses hypotension, usually within 30 minutes. Infiltration and extravasation may result in skin sloughing and necrosis. Administer with caution in patients with impaired renal function Fatal cardiac arrests have occurred in patients receiving esmolol and verapamil

Beta Blockers Precautions

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Beta Blockers Precautions

Labetalol Use with caution in patients with impaired hepatic function. Symptomatic postural hypotension is likely to occur if patients are tilted or allowed to assume the upright position within 3 hours of receiving IV labetalol

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Beta Blockers Precautions

Metoprolol Use with caution in patients with impaired hepatic functions

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Beta Blockers Precautions

Propranolol Use with caution in patients with impaired hepatic or renal functions

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Beta Blockers Contraindications

Heart rate < 60 beats/minute AV block greater than first degree Moderate to severe heart failure Cardiogenic shock Use with caution in conjunction with medications that slow conduction and in those that decrease myocardial contractility

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Beta Blockers Special Consideration

In general, patients with bronchospastic disease should not receive beta-blockers.

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Cardiology Diazepam
Generic Name: Diazepam Trade Name: Valium

Classification: Anticonvulsant and sedative. Benzodiazepine. How Supplied: Ampules and prefilled syringes containing 10 mg in 2 ml of solvent.

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Diazepam Mechanism of Action

Suppresses the spread of seizure activity through the motor cortex of the brain. It does not appear to abolish the abnormal discharge focus. It induces amnesia

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Diazepam Indications
Major motor seizures. Status epilepticus Premedication before cardioversion Skeletal muscle relaxant Acute anxiety states

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Diazepam Contraindications
Should not be administered to any patient with a history of hypersensitivity to the drug.

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Diazepam Precautions
Because of its relatively short-action, seizure activity may recur. Flumazenil (Romazicon), a benzodiazepine antagonist, should be available to use as antidote if required. Injectable diazepam can cause local venous irritation. To minimize irritation, it should only be injected into relatively large veins and should not be given faster than 1 ml/min.

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Diazepam Side Effects

Hypotension Drowsiness Headache Amnesia Respiratory depression Blurred vision Nausea/vomiting

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Diazepam Dosage
In the management of seizures, the usual dose is 5 to 10 mg IV. In acute anxiety reactions, the standard dosage is 2 to 5 mg administered intramuscularly. To induce amnesia prior to cardioversion, a dosage of 5 to 15 mg is given IV.

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Midazolam
Generic Name: Midazolam

Trade Name: Versed

Classification:Benzodiazepine, sedative and hypnotic How Supplied: Ampule and vials containing 5 mg/ml.

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Midazolam Mechanism of action

Potent but short-acting benzodiazepine used widely in medicine as a sedative and hypnotic. It is 3 to 4 times more potent than diazepam. Has impressive amnestic properties.

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Midazolam Indications
Premedication before cardioversion and other painful procedures.

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Midazolam Contraindications
Should not be administered to any patient with a history of hypersensitivity to the drug. It should not be used in patients who have narrow-angle glaucoma. Should not be administered to patients in shock, with depressed vital signs, or who are in alcoholic coma.

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Midazolam Precautions
Intubation equipment must be available prior to the administration of midazolam. Vital signs must be continuously monitored during and after drug administration. Has more potential than the other benzodiazepines to cause respiratory depression and respiratory arrest. Flumazenil (Romazicon), should be available to use as antidote if required

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Midazolam Side Effects

Laryngospasm Bronchospasm Dyspnea Respiratory depression Respiratory Arrest Drowsiness Amnesia Altered mental status Bradycardia Tachycardia PVCs Retching

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Midazolam Dosage
For sedation typically .1 to 2. mg are administered by slow IV injection. Best to dilute midazolam with NSS or D5W.

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Synchronized Cardioversion Indications

All tachycardias (rate > 150bpm) with serious signs and symptoms related to the tachycardia

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Synchronized Cardioversion Technique

1. 2. 3. 4. 5. Premedicate whenever possible (if time permits) Engage sync mode before each attempt, looking for sync markers on the R wave. Clear the patient before each and every shock. For SVT and A-Flutter, start with lower energy levels. If initial dose fails, increase in stepwise fashion. For A-Fib, use 100 to 200J initial monophasic shock, or 100 to 120J initial (selected) biphasic shock, and then increase in stepwise fashion. Deliver monophasic shocks in the following sequence: 100J, 200J, 300J, 360J.

6.

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