Cardiac Drugs Emergency

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wwwAmericanNurseTodaycom July 2010 American Nurse Today 19

IN THE HOSPITAL SETTING emer-gencies typically occur in emer-gency departments (EDs) and inten-sive care units (ICUs) But many

also take place in progressive careunits or general nursing units And when they do they can causemarked anxiety for nursesmdashespe-cially those unfamiliar or inexperi-enced with the drugs used in theseemergencies

Generally the goal of usingemergency drugs is to prevent thepatient from deteriorating to anarrest situation This article helpsnurses who donrsquot work in ICUs or

EDs to understand emergency drugs and their use

Under normal circumstancesa registered nurse (RN) needs aphysicianrsquos order to administermedications In emergencies RNs with advanced cardiac life support(ACLS) certification can give select-ed drugs based on standing ordersrelying on algorithms that outlinecare for certain emergencies Wher-ever possible nurses should strive

to maintain proficiency in basic lifesupport (BLS) as the latest researchshows the importance of effectivecardiopulmonary resuscitationSome non-ICU nurses may wantto pursue ACLS training as well

Drugs for acute coronarysyndrome Acute coronary syndrome (ACS)refers to a spectrum of clinicalmanifestations associated with acute

myocardial infarction and unstableangina In ACS a plaque in a coro-

nary artery ruptures or becomeseroded triggering the clotting cas-cade A blood clot forms occludingthe artery and interrupting blood

and oxygen flow to cardiac muscleMany healthcare providers usethe acronym MONA to help themremember the initial medical treat-ment options for a patient with ACS

M morphineO oxygenN nitroglycerin A aspirinBut keep in mind that while

MONA might be easy to rememberthe drugs arenrsquot given in the MONA

sequence Theyrsquore given in the or-der of OANM

Oxygen

Oxygen (O2) is given if the pa-tientrsquos O2 saturation level level is

below 94 The heart uses 70 to75 of the oxygen it receives com-pared to skeletal muscle whichuses roughly 20 to 25

Aspirin

The standard recommended aspirindosage to treat ACS is 160 to 325mg given as chewable ldquobabyrdquo as-pirin to speed absorption Aspirinslows platelet aggregation reducingthe risk of further occlusion or re-occlusion of the coronary artery ora recurrent ischemic event

Nitroglycerin

To help resolve chest pain from ACS nitroglycerin 04 mg is givensublingually via a spray or rapidly dissolving tablet If the first dosedoesnrsquot reduce chest pain the dosecan be repeated every 3 to 5 min-utes for a total of three doses

A potent vasodilator nitroglyc-erin relaxes vascular smooth-musclebeds It works well on coronaryarteries improving blood flow toischemic areas It also decreases

myocardial oxygen consumptionallowing the heart to work with alower oxygen demand In peripher-al vascular beds nitroglycerin caus-es vasodilation and reduces preloadand afterload resulting in de-creased cardiac workload

If chest pain recurs once the ini-tial pain resolves or decreases thepatient may be placed on a contin-uous IV infusion of nitroglycerinBecause of the drugrsquos vasodilatory

effects be sure to institute continu-ous blood-pressure monitoring

Emergency cardiac drugsEssential facts for

med-surg nursesEmergencies on a med-surg unit can be daunting

By Ira Gene Reynolds MSNEd RN PCCN-CMC

L E A R N I N G O B J E C T I V E S

1 Identify the actions of and

indications for drugs used tomanage emergencies involvingacute coronary syndromebradycardia and tachycardia

2 State the standard dosages for thesedrugs

3 Describe nursing implications of these drugs

The author and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to this activ-ity See the last page of the article to learn how toearn CNE credit

Expiration 123114

CNE 16 contact Rx 16 contacthours hours

CNERx



20 American Nurse Today Volume 5 Number 7 wwwAmericanNurseTodaycom

Morphine

If chest pain doesnrsquot resolve withsublingual or IV nitroglycerinmorphine 2 to 4 mg may be givenevery 5 to 15 minutes via IV push

An opioid acting primarily on re-ceptors that perceive pain mor-phine also acts as a venodilator re-ducing ventricular preload andcardiac oxygen requirements

As with nitroglycerin the pa-tientrsquos blood pressure needs to bemonitored continuously If hypoten-sion occurs elevate the patientrsquoslegs give IV fluids as ordered andmonitor for signs and symptoms of pulmonary congestion

Other medications for ACS

Metoprolol may be used in the ini-tial treatment of ACS A cardioselec-tive (beta1 receptor) drug itrsquos a beta-adrenergic blocker that dilatesperipheral vascular beds in turn re-ducing blood pressure decreasingcardiac workload and lowering car-diac oxygen demands It also may have a mild analgesic effect in ACS-related chest pain The patientrsquos

blood pressure must be monitored(See Be cautious with beta blockers ) A primary goal of ACS treat-

ment is to minimize muscle celldamage which necessitates restor-ing blood flow to cardiac muscleDrugs that may be used to reduceexpansion of the arterial occlusionor restore blood flow to cardiacmuscle includebull heparin or enoxaparin (a low-

molecular-weight heparin)

which helps prevent the originalarterial clot from expanding andallows it to break down on itsown as a result the vesselopens and new clot formation isinhibited

bull glycoprotein IIB-IIIa inhibitorssuch as abciximab (Reopro)These drugs bind to glycoproteinIIb-IIIa receptor sites onplatelets preventing further ag-gregation and stopping expan-

sion of the original clot or for-mation of new clots

bull fibrinolytics such as reteplase(Retavase) and alteplase (Acti- vase) These agents break downthe original clot opening the vessel for blood flow (See Drugs used to treat acute coro-

nary syndrome )

Drugs for arrhythmiasBradycardias and tachycardias com-monly arise during medical emer-gencies The primary goal of drugtherapy for these arrhythmias is toreturn the heart rate and rhythm tonormal thereby maximizing cardiacpumping and restoring hemo-dynamic stability To achieve thisgoal antiarrhythmics are given toslow speed or block conduction of the heartrsquos electrical impulses A

combination of drugs in the properdosages may resolve bradycardiasand tachycardias (See Drugs used

to treat arrhythmias )

Intervening for bradycardia

In bradycardia the heart rate slowsto a critical point and hemodynamicinstability occurs Usually bradycar-dia is defined as a heart rate slowerthan 60 beatsminute (bpm) But insome patients hemodynamic insta-

bility may occur at faster rates Thisinstability may manifest as dizzinesslight-headedness nausea vomitinghypotension syncope chest painand altered mental status Atropineepinephrine and dopamine may beused to treat bradycardia withdosages depending on the acuity andseverity of hemodynamic instability

For symptomatic patients thehealthcare team must determine thecause of bradycardia In many cas-

es bradycardia results from use of other drugs specifically other an-

tiarrhythmicsmdashfor instance betablockers and calcium channelblockers So those drugs may needto be withheld temporarily untiltheir effects wear off Beta blockersreduce circulating catecholaminelevels decreasing both the heartrate and blood pressure

Typically atropine is the drug of choice for symptomatic bradycardia An anticholinergic and potent bel-ladonna alkaloid it increases theheart rate which improves hemody-namic stability

Epinephrine may be used as asecondary measure if atropine andtemporary heart pacing donrsquot im-prove hemodynamic stability Among other actions epinephrinestimulates beta1 receptors causing

cardiac stimulation which in turnincreases the heart rateDopamine also may be used to

support hemodynamic status by correcting hypotension It enhancescardiac output minimally increasingoxygen consumption and causingperipheral vasoconstriction

If your patient is receiving theseIV drugs be sure to monitor forextravasation which could lead totissue damage If possible use a

central line to deliver epinephrineand dopamine

Intervening for tachycardia

Tachycardia which usually refers toa heart rate faster than 100 bpmmay result from various cardiacmechanisms The first step inchoosing the right drug is to identi-fy the origin of the arrhythmiaMost tachycardias are classified asone of two types

bull narrow-QRS-complex tachycar-dias (for instance atrial fibrilla-

Be cautious with beta blockersAlthough metoprolol and certain other beta blockers are cardioselective they

must be used cautiously in patients with known respiratory diseases such as asth-

ma Why No beta blocker is 100 cardioselective Respiratory tissue also has beta

receptors and beta blockade may exacerbate respiratory illnesses Other condi-

tions calling for cautious use of beta blockers include heart block hypotension

and severe left ventricular failure




tion atrial flutter or atrial ormultifocal atrial tachycardia)

bull wide-QRS-complex tachycardias(for example ventricular tachy-cardia or supraventricular tachy-cardia with aberrancy)Each type calls for a slightly

different treatment Narrow-QRS-complex tachycardias with a regular

rate generally are treated withadenosine along with beta blockerscalcium channel blockers andoramiodarone or ibutilide

With a wide-QRS-complex tachy-cardia the first step is to determineif the arrhythmia is a ventricular

tachycardia or is conducted withaberrancy Wide-QRS-complex

tachycardias with aberrancy call forthe same treatment as narrow-QRS-complex tachycardias On the otherhand ventricular tachycardia in apatient with a pulse is treated withamiodarone alone or with amio-darone in conjunction with synchro-

nized cardioversion Adenosine This general antiar-

This table lists drugs used in the emergency treatment of acute coronary syndrome and other types of chest pain After oxygen

aspirin and nitroglycerin are given the patientrsquos status and presentation determine which other drugs should be used

Drug Dosage and delivery Action Nursing implications

Oxygen (O2) 2 to 15 Lminute via Maximizes O2 delivery bull Use appropriate delivery device for

appropriate device to cells amount of O2 orderedbull Monitor O2 saturation regularly

bull Avoid excessive administration in

patients with concurrent chronic

obstructive pulmonary disease

Aspirin 160 to 325 mg PO Slows platelet aggregation bull Monitor patient for drug allergy

reduces further arterial bull Watch for signs and symptoms of bleeding

occlusion or reocclusion and bull Check for concurrent use of similar

reduces chance of recurrence agents (nonsteroidal anti-inflammatory

drugs)

Nitroglycerin 03 to 06 mg SL or Dilates blood vessels bull Start at low dosage and titrate upward

5 to 100 mcgkgminute to achieve pain reliefby IV infusion bull Monitor for hypotension

bull Allow patient to rest

bull Monitor for complaints of headache

Morphine 2 to 4 mg by IV push every Reduces ventricular preload bull Watch for hypotension and sedation

5 to 15 minutes to a and cardiac O2 requirements bull Monitor patientrsquos respiratory efforts

maximum of 15 mg and function

bull Assess for pain relief

Metoprolol 5 mg by IV push every Dilates peripheral vascular beds bull Watch for hypotension

5 minutes to a maximum reducing blood pressure cardiac bull Monitor heart rhythm for changes

of 15 mg workload and cardiac oxygen particularly heart block

demands bull Donrsquot give to patients with severe leftventricular heart failure

Heparin Heparin per facility Stop original clot from bull Watch for bleeding

enoxaparin protocol expanding and prevent bull Monitor platelet count for drug-induced

Enoxaparin 1 mgkg additional clots from forming thrombocytopenia

subcutaneously

Glycoprotein Per manufacturerrsquos Bind to platelets and slow bull Monitor patient for bleeding

IIb-IIIa inhibitors protocol aggregation stop expansion bull Monitor platelet count

(such as abciximab of original clot and prevent

eptifibatide additional clots from forming

tirofiban)

Fibrinolytics Per facility protocol Break down original clot bull Monitor patient for bleeding

(such as alteplase bull Be aware of contraindications for

reteplase) fibrinolytics

Drugs used to treat acute coronary syndrome




This table lists some of the more common drugs used in the emergency treatment of arrhythmias particularly bradycardia and

tachycardia Other types of arrhythmias may require other medications and interventions

Drug Dosage and delivery Indication Action Nursing implications

Adenosine 6 mg by rapid IV push Tachycardia Depresses sinoatrial bull Know that drug causes brief period

followed by 10 to 20 mL and atrioventricular of asystole Monitor for underlyingof normal saline solution node activity atrial activity during this time

(NSS) flush may repeat slowing the bull Be aware that drug triggers a

a 12-mg dose twice heart rate flushing sensation

followed by NSS flush

Amiodarone 150-mg bolus given IV Tachycardia Reduces the heart bull Know that drug has long half-life

over 10 minutes followed rate (28 to 110 days) rarely affects blood

by continuous IV infusion pressure and may cause thrombo-

at 1 mgminute for 6 hours phlebitis

then 05 mgminute for bull Monitor for drug allergy or reaction

18 hours bull Mix infusion in glass bottle

Atenolol 5-mg IV bolus over Tachycardia Reduce bull Monitor for bradycardia andormetoprolol 5 minutes may repeat catecholamines pauses in heart rhythm

atenolol dose once and leading to slower bull Monitor blood pressure for

metoprolol dose twice heart rate and lower hypotension

blood pressure

Atropine 05 to 1 mg by IV push Bradycardia Increases the heart bull Be aware that dosages below

rate through 05 mg may further slow the

anticholinergic effect heart rate

bull Monitor for rebound tachycardia

bull Monitor blood pressure for

improvement

Diltiazem 5 to 20 mg by IV push Tachycardia Lengthens cardiac bull Monitor for bradycardia andorover 2 to 5 minutes cycle slowing the pauses in heart rhythm

followed by IV infusion heart rate bull Monitor blood pressure for

or additional 20 to 25 mg hypotension

by IV push after 15 minutes bull Titrate dosage in small increments to

achieve desired heart rate

bull Begin oral drugs before stopping

infusion unless severe bradycardia

pauses in heart rhythm andor

hypotension occur

Dopamine 5 to 15 mcgkgminute Bradycardia Stimulates bull Monitor for rebound tachycardia

by IV infusion dopamine receptors andor hypertension

and increases cardiac bull Monitor blood pressure foroutput with minimal improvement

increase in oxygen bull Titrate dosage in small increments

consumption causes to desired effect

peripheral bull If possible deliver via central line

vasoconstriction

Epinephrine 2 to 10 mcgminute by Bradycardia Stimulates beta1 bull Monitor for rebound tachycardia

IV infusion receptors causing andor hypertension

cardiac stimulation bull Monitor blood pressure for

improvement

bull If possible deliver via central line

Drugs used to treat arrhythmias




rhythmic is used mainly as a diag-nostic agent to identify the origin of an underlying narrow-QRS-complextachycardia It briefly depresses theatrioventricular (AV) node and sinus

node activity When given by rapidIV bolus the drugrsquos primary actionis to slow electrical impulse con-duction through the AV node Beaware that adenosine commonly causes a few seconds of asystolebut because of its short half-life (6to 10 seconds) the asystole usually is brief The drug sometimes re-stores a normal sinus rhythm if itdoesnrsquot calcium channel blockersand beta blockers may be given im-

mediately to control the heart rate while amiodarone or ibutilide may be used to help restore a normal si-nus rhythm

Diltiazem A first-line agent incontrolling heart rate in narrow QRS-complex tachycardias this drugcan be used both in patients withpreserved cardiac function and inthose with impaired ventricular func-tion (ejection fraction below 40) orheart failure (Verapamil another

calcium channel blocker should beused only in patients with preservedcardiac function)

A calcium channel blocker dilti-azem slows andor blocks electricalimpulse conduction through the AV node reducing the number of im-pulses that arrive at the ventriculartissue and slowing the heart rateIt may cause hypotension second-

ary to vascular smooth-muscle re-laxation Also it may block impuls-es in some narrow-QRS-complextachycardias that involve AV nodalreentry thereby terminating the

rhythm and restoring normal sinusrhythmOther drugs Occasionally select-

ed beta blockers are used to helpcontrol the heart rate associated withnarrow-QRS-complex tachycardiasThey include metoprolol atenololpropranolol and esmolol Propra-nolol isnrsquot cardioselective and canaffect pulmonary function so itrsquosused less often Typically esmolol isgiven only in the ICU

Atenolol is administered as a 5-mg IV bolus over 5 minutes If thepatient tolerates the dose and thearrhythmia persists after 10 minutesan additional bolus of 5 mg may begiven over 5 minutes Metoprololalso is administered IV in 5-mg in-crements over 5 minutes the dosemay be repeated twice to a total of 15 mg

Donrsquot give beta blockers or calci-um channel blockers to patients

with narrow-QRS-complex tachycar-dias suspected of being pre-excita-tion arrhythmias such as Wolff-Parkinson-White (WPW) syndromeSuch arrhythmias allow impulses toflow from the atria to the ventriclesthrough an accessory or alternatepathway Beta blockers and calciumchannel blockers may increase thenumber of impulses arriving at ven-

tricular tissue further speeding theheart rate

Amiodarone This drug is usedto treat certain narrow- and wide-QRS complex tachycardias identi-

fied as ventricular tachycardia ortachycardias of unknown origin Although a class III antiarrhythmicit has some properties of all antiar-rhythmic classes Its primary actionis to block potassium channels inthe cell but it also prolongs the ac-tion potential duration depressesconduction velocity slows conduc-tion through and prolongs refrac-toriness in the AV node and hassome alpha- beta- and calcium-

channel blocking capabilitiesDosing depends on circum-stances When used to treat ventric-ular tachycardia in patients with apulse runs of paroxysmal ventricu-lar tachycardia or narrow-QRS-complex tachycardias amiodarone isgiven as a bolus of 150 mg over 10minutes followed by a continuousIV infusion starting at 1 mgminutefor 6 hours and then 05 mgminutefor 18 hours If the patient is on

nothing-by-mouth status for an ex-tended time the infusion can bekept running at 05 mgminute Oth-erwise an oral dose usually is start-ed before the infusion ends

Any time any placeCardiac emergencies can occur atany time in any patient Being fa-miliar with the actions dosages

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To take the post-test for this article and earn contact hour credit

please go to wwwAmericanNurseTodaycomContinuingEducation

aspx Simply use your Visa or MasterCard to pay the processing

fee (Online ANA members $15 nonmembers $20) Once yoursquove

successfully passed the post-test and completed the evaluation

form yoursquoll be able to print out your certificate immediately

If you are unable to take the post-test online complete the

print form and mail it to the address at the bottom of the next

page (Mail-in test fee ANA members $20 nonmembers $25)

Provider accreditation The American Nurses Association Center for Continuing Education and Profes-sional Development is accredited as a provider of continuing nursing educationby the American Nurses Credentialing Centerrsquos Commission on AccreditationANA is approved by the California Board of Registered NursingProvider Number 6178

Contact hours 16 Pharmacology contact hours 16

Expiration 123114 Post-test passing score is 75

ANA Center for Continuing Education and Professional Developmentrsquos ac-credited provider status refers only to CNE activities and does not imply thatthere is real or implied endorsement of any product service or company re-ferred to in this activity nor of any company subsidizing costs related to theactivity




and rationales for commonly usedemergency drugs will help youmanage any crisis with confidenceand efficiency 983119

Jolly M Lincoff AM Chapter 7 Medications

used in the management of acute coronary syndrome The Cardiac Care Unit Survival

Guide Philadelphia Lippincott Williams amp

Wilkins 2012

Bradberry S Vale A 2012 Management of poi-

sons Antidotes Medicine 201240(2)69-70

Link MS Evaluation and initial treatment of

supraventricular tachycardia N Engl J Med 20123671438-1448

Visit wwwAmericanNurseTodaycomarchives

aspx for a list of selected references

Ira Gene Reynolds is a full-time faculty member in

the Nursing Program at Provo College in Provo Utah

Please circle the correct answer

1 The acronym MONA refers to the four drugs

(morphine oxygen nitroglycerin and aspirin) used

initially to treat acute coronary syndrome (ACS) In

which order should these drugs be given

a MONAb OANM

c OMNAd MANO

2 The standard recommended dosage of aspirin

for the treatment of ACS is

a 75 to 100 mg

b 125 to 150 mgc 160 to 325 mgd 325 to 350 mg

3 If an initial dose (04 mg) of nitroglycerin doesnrsquot

reduce chest pain the dose can be repeated every 3

to 5 minutes for a total of how many doses

a Threeb Four

c Fived Six

4 Which drug reduces ventricular preload and car-

diac oxygen requirements

a Reteplase

b Abciximabc Enoxaparind Morphine

5 W hi ch d ru g ac ts o n be ta1 receptors

a Alteplase

b Aspirin

c Eptifibatide

d Metoprolol

6 What is the usual drug of choice for patients

with symptomatic bradycardia

a Atenololb Heparin

c Atropined Amiodarone

7 Patients with severe left ventricular failure

should not receive

a amiodaroneb enoxaparin

c metoprolol

d nitroglycerin

8 Which drug may cause a short period of asystole

when given to treat tachycardia

a Diltiazem

b Adenosinec Amiodaroned Metoprolol

9 Which drug lengthens the cardiac cycle thus

slowing the heart rate

a Diltiazemb Atropinec Dopamine

d Epinephrine

10 For a patient who has hypotension stemmingfrom bradycardia what dosage of dopamine typically

is given

a 2 to 5 mcgkgminute by IV infusion

b 5 to 8 mcgkgminute by IV infusionc 5 to 15 mcgkgminute by IV infusiond 15 to 20 mcgkgminute by IV infusion

11 An example of a wide-QRS-complex tachycardia

is

a atrial flutterb heart block

c atrial fibrillationd ventricular tachycardia

12 Which drug is used to treat ventricular tachycar-

dia in patients who have a pulse

a Amiodaroneb Adenosine

c Atenolol

d Diltiazem

13 Patients with narrow-QRS-complex tachycardias

suspected of being pre-excitation arrhythmias such

as Wolff-Parkinson-White (WPW) syndrome should

not receive

a heparinb morphine

c metoprolold alteplase

14 Which drugrsquos primary action is to block potassi-

um channels in the cell

a Dopamine

b Amiodaronec Atropine

d Epinephrine

15 An infusion for which drug should be mixed in a

glass bottle

a Amiodaroneb Dopaminec Epinephrine

d Heparin

POST-TEST bull Emergency cardiac drugs Essential facts for med-surg nurses

Earn contact hour credit online at wwwamericannursetodaycomContinuingEducationaspx (ANT100701) CNE 16 contact hoursRx 16 contact hours

Rx



Drugs for acute respiratorydistress Acute respiratory distress refers to asituation in which a patient be-comes short of breath and may

need emergency treatment to avoidan untoward outcome For instanceacute pulmonary edema can resultfrom changes in the Starling forces(hydrostatic and oncotic pressure)that allow ventilation in the lungfields these changes permit fluid toenter the alveoli Acute decompen-sated heart failure is a primary car-diogenic cause of acute respiratory distress and pulmonary edema

Pulmonary edema manifests as

rapid movement of fluid into thealveoli causing acute shortness of breath ldquowetrdquo breath sounds (crack-les in the lung fields) decreasedability to maintain adequate O2 sat-uration and in some cases pinkfrothy sputum Increased anxiety al-so may occur Treatment focuses onrestoring the Starling forces to nor-mal Usually this entails reducingthe amount of fluid entering thelung fields from the right side of

the heart (called preload)In many cases pulmonary edema

results from fluid overload Typical-ly the patientrsquos fluid and sodium in-take are limited and a diuretic (com-

monly furosemide) is given toeliminate excess fluid Furosemideacts on the kidneyrsquos proximal anddistal tubules and the loop of Henlecausing excretion of water and someelectrolytes (most notably potassi-um) The typical dosage is 20 to 40mg by IV push delivered over 1 to2 minutes Watch the patient for hy-potension excessive diuresis andhypokalemia also monitor urineoutput closely Be aware that sup-

plemental potassium may be givenorally to offset urinary potassiumlosses As excess fluid is excretedalveolar fluid returns to the intravas-cular compartment shortness of breath ldquowetrdquo breath sounds andanxiety levels decrease and O2 satu-ration returns to baseline

Supplemental O2 should be givenduring this emergency Morphinemay be used to relieve pulmonary congestion lower myocardial oxy-

gen demands and reduce anxietyTypically morphine is given as 2 to4 mg by IV push over 1 to 2 min-utes It usually causes a flushedfeeling and can lead to hypotension

and sedation so be sure to monitorthe patient carefully (See Drugs

used to treat pulmonary edema)

Peberdy MA Kaye W Ornato JP et al Car-diopulmonary resuscitation of adults in thehospital a report of 14720 cardiac arrests

from the National Registry of Cardiopul-monary Resuscitation Resuscitation 200358(3)297-308

2005 American Heart Association Guidelinesfor Cardiopulmonary Resuscitation and Emer-

gency Cardiovascular Care Management of cardiac arrest Circulation 2005112(suppl 1)IV-58ndashIV-66

2005 American Heart Association Guidelines

for Cardiopulmonary Resuscitation and Emer-gency Cardiovascular Care Management of symptomatic bradycardia and tachycardia Cir-

culation 2005112(suppl 1)IV-67ndashIV-77


gency Cardiovascular Care Stabilization of thepatient with acute coronary syndromes Circu-

lation 2005112(suppl 1)IV-89ndashIV-110

This table presents selected drugs used to treat emergency episodes of acute pulmonary edema To prevent further episodes the

healthcare team should identify and treat the underlying cause of pulmonary edema


Furosemide 20 to 40 mg by IV push Acts on proximal and distal bull Monitor urine output to evaluate drug

over 2 minutes repeat tubules and loop of Henle to efficacy

if needed cause excretion of water and bull Monitor blood pressure

some electrolytes (most bull Monitor blood potassium level give

notably potassium) potassium supplements if needed and

ordered

Morphine 2 to 4 mg by IV push over Relieves pulmonary congestion bull Monitor for hypotension

1 to 2 minutes lowers myocardial oxygen bull Watch for sedation

demands and reduces anxiety bull Monitor respiratory effort and function

Oxygen (O2) 1 to 15 L via appropriate Increases amount of oxygen bull Use appropriate delivery device for

delivery device available to red blood cells for amount of O2 delivered

delivery to body tissues bull Use carefully in patients with chronic


bull Titrate dosage downward as appropriate

Drugs used to treat pulmonary edema




Morphine

If chest pain doesnrsquot resolve withsublingual or IV nitroglycerinmorphine 2 to 4 mg may be givenevery 5 to 15 minutes via IV push

An opioid acting primarily on re-ceptors that perceive pain mor-phine also acts as a venodilator re-ducing ventricular preload andcardiac oxygen requirements

As with nitroglycerin the pa-tientrsquos blood pressure needs to bemonitored continuously If hypoten-sion occurs elevate the patientrsquoslegs give IV fluids as ordered andmonitor for signs and symptoms of pulmonary congestion

Other medications for ACS

Metoprolol may be used in the ini-tial treatment of ACS A cardioselec-tive (beta1 receptor) drug itrsquos a beta-adrenergic blocker that dilatesperipheral vascular beds in turn re-ducing blood pressure decreasingcardiac workload and lowering car-diac oxygen demands It also may have a mild analgesic effect in ACS-related chest pain The patientrsquos

blood pressure must be monitored(See Be cautious with beta blockers ) A primary goal of ACS treat-

ment is to minimize muscle celldamage which necessitates restor-ing blood flow to cardiac muscleDrugs that may be used to reduceexpansion of the arterial occlusionor restore blood flow to cardiacmuscle includebull heparin or enoxaparin (a low-

molecular-weight heparin)

which helps prevent the originalarterial clot from expanding andallows it to break down on itsown as a result the vesselopens and new clot formation isinhibited

bull glycoprotein IIB-IIIa inhibitorssuch as abciximab (Reopro)These drugs bind to glycoproteinIIb-IIIa receptor sites onplatelets preventing further ag-gregation and stopping expan-

sion of the original clot or for-mation of new clots

bull fibrinolytics such as reteplase(Retavase) and alteplase (Acti- vase) These agents break downthe original clot opening the vessel for blood flow (See Drugs used to treat acute coro-

nary syndrome )

Drugs for arrhythmiasBradycardias and tachycardias com-monly arise during medical emer-gencies The primary goal of drugtherapy for these arrhythmias is toreturn the heart rate and rhythm tonormal thereby maximizing cardiacpumping and restoring hemo-dynamic stability To achieve thisgoal antiarrhythmics are given toslow speed or block conduction of the heartrsquos electrical impulses A

combination of drugs in the properdosages may resolve bradycardiasand tachycardias (See Drugs used

to treat arrhythmias )

Intervening for bradycardia

In bradycardia the heart rate slowsto a critical point and hemodynamicinstability occurs Usually bradycar-dia is defined as a heart rate slowerthan 60 beatsminute (bpm) But insome patients hemodynamic insta-

bility may occur at faster rates Thisinstability may manifest as dizzinesslight-headedness nausea vomitinghypotension syncope chest painand altered mental status Atropineepinephrine and dopamine may beused to treat bradycardia withdosages depending on the acuity andseverity of hemodynamic instability

For symptomatic patients thehealthcare team must determine thecause of bradycardia In many cas-

es bradycardia results from use of other drugs specifically other an-

tiarrhythmicsmdashfor instance betablockers and calcium channelblockers So those drugs may needto be withheld temporarily untiltheir effects wear off Beta blockersreduce circulating catecholaminelevels decreasing both the heartrate and blood pressure

Typically atropine is the drug of choice for symptomatic bradycardia An anticholinergic and potent bel-ladonna alkaloid it increases theheart rate which improves hemody-namic stability

Epinephrine may be used as asecondary measure if atropine andtemporary heart pacing donrsquot im-prove hemodynamic stability Among other actions epinephrinestimulates beta1 receptors causing

cardiac stimulation which in turnincreases the heart rateDopamine also may be used to

support hemodynamic status by correcting hypotension It enhancescardiac output minimally increasingoxygen consumption and causingperipheral vasoconstriction

If your patient is receiving theseIV drugs be sure to monitor forextravasation which could lead totissue damage If possible use a

central line to deliver epinephrineand dopamine

Intervening for tachycardia

Tachycardia which usually refers toa heart rate faster than 100 bpmmay result from various cardiacmechanisms The first step inchoosing the right drug is to identi-fy the origin of the arrhythmiaMost tachycardias are classified asone of two types

bull narrow-QRS-complex tachycar-dias (for instance atrial fibrilla-

Be cautious with beta blockersAlthough metoprolol and certain other beta blockers are cardioselective they

must be used cautiously in patients with known respiratory diseases such as asth-

ma Why No beta blocker is 100 cardioselective Respiratory tissue also has beta

receptors and beta blockade may exacerbate respiratory illnesses Other condi-

tions calling for cautious use of beta blockers include heart block hypotension

and severe left ventricular failure
























drugs)
















subcutaneously





tirofiban)

























blood pressure






improvement









hypotension occur







vasoconstriction




improvement













































Wilkins 2012














a MONAb OANM

c OMNAd MANO



a 75 to 100 mg





a Threeb Four

c Fived Six



a Reteplase



a Alteplase

b Aspirin

c Eptifibatide

d Metoprolol



a Atenololb Heparin



should not receive


c metoprolol

d nitroglycerin



a Diltiazem





d Epinephrine


is given




is






c Atenolol

d Diltiazem




not receive

a heparinb morphine




a Dopamine


d Epinephrine


glass bottle


d Heparin



Rx

































ordered

































drugs)
















subcutaneously





tirofiban)

























blood pressure






improvement









hypotension occur







vasoconstriction




improvement













































Wilkins 2012














a MONAb OANM

c OMNAd MANO



a 75 to 100 mg





a Threeb Four

c Fived Six



a Reteplase



a Alteplase

b Aspirin

c Eptifibatide

d Metoprolol



a Atenololb Heparin



should not receive


c metoprolol

d nitroglycerin



a Diltiazem





d Epinephrine


is given




is






c Atenolol

d Diltiazem




not receive

a heparinb morphine




a Dopamine


d Epinephrine


glass bottle


d Heparin



Rx

































ordered






























blood pressure






improvement









hypotension occur







vasoconstriction




improvement













































Wilkins 2012














a MONAb OANM

c OMNAd MANO



a 75 to 100 mg





a Threeb Four

c Fived Six



a Reteplase



a Alteplase

b Aspirin

c Eptifibatide

d Metoprolol



a Atenololb Heparin



should not receive


c metoprolol

d nitroglycerin



a Diltiazem





d Epinephrine


is given




is






c Atenolol

d Diltiazem




not receive

a heparinb morphine




a Dopamine


d Epinephrine


glass bottle


d Heparin



Rx

































ordered




















































Wilkins 2012














a MONAb OANM

c OMNAd MANO



a 75 to 100 mg





a Threeb Four

c Fived Six



a Reteplase



a Alteplase

b Aspirin

c Eptifibatide

d Metoprolol



a Atenololb Heparin



should not receive


c metoprolol

d nitroglycerin



a Diltiazem





d Epinephrine


is given




is






c Atenolol

d Diltiazem




not receive

a heparinb morphine




a Dopamine


d Epinephrine


glass bottle


d Heparin



Rx

































ordered

















Wilkins 2012














a MONAb OANM

c OMNAd MANO



a 75 to 100 mg





a Threeb Four

c Fived Six



a Reteplase



a Alteplase

b Aspirin

c Eptifibatide

d Metoprolol



a Atenololb Heparin



should not receive


c metoprolol

d nitroglycerin



a Diltiazem





d Epinephrine


is given




is






c Atenolol

d Diltiazem




not receive

a heparinb morphine




a Dopamine


d Epinephrine


glass bottle


d Heparin



Rx

































ordered










































ordered










Documents

Cardiac Drugs Emergency