Cardiac/Vascular

  • Adenosine
  • Amiodarone
  • Aspirin
  • Atorvastatin
  • Clopidogrel
  • Diltiazem
  • Dobutamine
  • Epinephrine
  • Esmolol
  • Labetalol
  • Lidocaine
  • Metoprolol
  • Nitroglycerin
  • Nitroprusside
  • Norepinephrine
  • Phenylephrine
  • Procainamide
  • Propranolol
  • Vasopressin

Adenosine

Rapid Review

  • Mechanism of Action: Transient AV nodal blocker; works on adenosine receptors to slow cardiac conduction.
  • Indications: cardioversion of stable, narrow complex tachycardia. 
  • Contraindications: Reentrant SVTs, 2nd/3rd degree AV block, sick sinus syndrome, allergy
  • Dosage: 6 mg IV (rapidly); may give 12 mg IV two more times if unsuccessful
  • Onset: 20-30 seconds
  • Duration: 60-90 seconds
  • Adverse Reactions: hypotension (if given too slow), bradyarrhythmia, bronchoconstriction
  • Special Considerations: May be given via stopcock w/ immediate secondary flush, or as a single push mixed with saline.

Pearls

Video Credit: ICU Advantage


Amiodarone

Rapid Review

  • Mechanism of Action: Class III antiarrhythmic. Inhibits potassium channels; causing prolonged refractory periods, decreased automaticity, and slowed SA/AV node conduction which helps suppress and prevent dysrhythmias. Also has sodium channel blocking (class I), beta blocking (class II), and calcium channel blocking (class IV) properties.
  • Indications: Wide complex tachyarrhythmias, pulseless V-fib/V-Tach
  • Contraindications: allergy to drug, iodine or shellfish allergy, pregnancy
  • Dosage:
    • V-fib/pulseless V-Tach: 300 mg IV bolus, followed by 150 mg at next pulse check if needed. 
    • Stable wide-complex tachycardia: 150 mg IV over 10 minutes, followed by infusion of 1 mg/min over 6 hrs. Then 0.5 mg/min drip over next 18 hours.
  • Onset: 1 – 30 minutes
  • Duration: 1- 3 hours
  • Adverse Reactions: Bradycardia, hypotension, prolonged QT, thyrotoxicosis.
  • Special Considerations: Between 5 – 20% of patients treated with amiodarone will develop thyrotoxicosis due to amiodarone’s iodine content. May also have long term use side effects, such as pulmonary fibrosis, elevated hepatic enzymes, and CHF. It has an incredibly long half-life (up to 58 days).

Pearls

Video Credit: Drug Chug


Aspirin

Rapid Review

  • Mechanism of Action: Antiplatelet/NSAID; irreversible cyclooxygenase inhibitor, preventing prostaglandin synthesis and platelet aggregation. Makes platelets “slippery”. 
  • Indications: Used for prevention and treatment of acute coronary syndrome
  • Contraindications: allergy to class/drug; syndrome of asthma, rhinitis, and nasal polyps (“Samter’s Triad), hx of peptic ulcers.
  • Dosage: 81 mg daily for prevention; 324 mg for acute episode
  • Half-life: 20 – 60 minutes. However, because platelets cannot generate new COX, antiplatelet effects last for duration of the platelet (10 days)
  • Adverse Reactions: aspirin toxicity (if over 10 grams consumed), GI ulcer, bronchospasm
  • Special Considerations: Avoid use in children, particularly those with viral syndrome, due to the risk of Reye syndrome.

Pearls

Video Credit: Med Today


Atorvastatin

Rapid Review

  • Mechanism of Action: Antilipemic agent; HMG-CoA inhibitor. Lowers total LDL, cholesterol, and serum triglyceride levels.
  • Indications: Hyperlipidemia. May be used in the ED for acute myocardial infarction to reduce mortality.
  • Contraindications: hypersensitivity, liver disease, pregnancy
  • Dosage: 10 – 80mg PO daily; depending on desired intensity.
  • Half-life: 14 hours
  • Adverse Reactions: abdominal pain, myalgia, hepatotoxicity, rhabdomyolysis
  • Special Considerations: N/A

Pearls

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Clopidogrel

Rapid Review

  • Mechanism of Action: Antiplatelet; irreversibly binds to P2Y12 adenosine diphosphate receptors, thus reducing platelet activation and aggregation
  • Indications: Used to decrease risk of MI/Stroke. In acute settings, it may be used prior to percutaneous coronary intervention in AMI. 
  • Contraindications: active bleeding, allergy to drug/class
  • Dosage: 75mg PO daily for prevention; 300 mg PO for acute ischemic event
  • Onset: 2 hours
  • Duration: 5 days
  • Adverse Reactions: bleeding, pruritus, hypersensitivity reaction
  • Special Considerations: N/A

Pearls

Video Credit: Picmonic Video


Diltiazem

Rapid Review

  • Mechanism of Action: Calcium channel blocker (non-dihydropyridine); class IV antiarrhythmic that inhibits calcium influx, thus slowing AV nodal conduction and causing vasodilation of the coronary vessels.
  • Indications: Rate control for Atrial fibrillation/Atrial flutter; conversion of PSVT to sinus rhythm.
  • Contraindications: Allergy to drug/class, wide-complex tachycardia, severe hypotension. Use caution if patient is on beta-blockers. 
  • Dosage: Generally 0.25mg/kg (max 20mg) bolus over 2 minutes as loading dose; followed by infusion of 5-15 mg/hr
  • Onset: 2-3 minutes (IV)
  • Duration: 1-3 hours (IV); half life of 3-5 hours
  • Adverse Reactions: Hypotension, bradycardia
  • Special Considerations: N/A

Pearls

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Dobutamine

Rapid Review

  • Mechanism of Action: Vasopressor; beta 1 agonist > beta 2 agonist. Exerts both ionotropic and chronotropic effects depending on dose.
  • Indications: Cardiogenic shock, septic shock
  • Contraindications: Allergy, acute MI, severe hypertension, arrhythmias
  • Dosage: 2-20 mcg/kg/min IV
  • Onset: Immediate
  • Duration: 2 minutes
  • Adverse Reactions: Dysrhythmias, tachycardia, anxiety, tremors

Pearls

Video Credit: ICU Advantage


Epinephrine

Rapid Review

  • Mechanism of Action: Vasopressor; sympathomimetic catecholamine that binds to beta 1, beta 2, and alpha 1 receptors. Increases HR, myocardial contractility, vasoconstriction, and bronchodilation.
  • Indications: Anaphylaxis, cardiac arrest, severe asthma, hypotension
  • Contraindications: Allergy to drug/class
  • Dosage:
    • Anaphylaxis or Asthma: 0.3-0.5 mg of 1:1000 IM
    • Cardiac Arrest: 1 mg 1:10,000 IV push
    • Hypotension: 1-10 mcg/min IV
  • Onset: Immediate
  • Duration: < 5 minutes
  • Adverse Reactions: Dysrhythmias, myocardial ischemia, tachycardia

Pearls

Video Credit: ICU Advantage


Esmolol

Rapid Review

  • Mechanism of Action: Short acting beta blocker; antagonizes beta 1 receptors in the myocytes.
  • Indications: Aortic dissection, hypertensive emergency refractory V-fib
  • Contraindications: Allergy to drug/class, cardiogenic shock, 2nd-3rd degree AV block
  • Dosage: Generally 500 mcg/kg loading dose, followed by infusion of 50-300 mcg/kg/min
  • Onset: Within 60 seconds
  • Duration: 9 minutes
  • Adverse Reactions: Hypotension, dizziness, peripheral ischemia, infusion site reaction
  • Special Considerations: Avoid giving together with calcium channel blockers

Pearls

Video Credit: egpat


Labetalol

Rapid Review

  • Mechanism of Action: Beta blocker; antagonism of alpha 1, beta1, and beta 2 receptors
  • Indications: Hypertensive crisis, intracranial hemorrhage
  • Contraindications: Asthma, bradycardia, hypotension, cardiogenic shock
  • Dosage:
    • Bolus dose: 20-80 mg IV q10 minutes PRN
    • Infusion: 1-8 mg/min titrated to effect
  • Onset: 2-5 minutes (IV)
  • Duration: 4 hours (IV)
  • Adverse Reactions: Orthostatic hypotension, sweating, flushing

Pearls

Deep Dive

Video Credit: egpat


Lidocaine

Rapid Review

  • Mechanism of Action: Local anesthetic/antiarrhythmic; As a local anesthetic it acts on sodium ion channels on the internal surface of the nerve cell membranes to prevent nerve depolarization, thus blocking pain signals. In cardiac myocytes, lidocaine slows the action potential during phase 0.
  • Indications: Local anesthesia for injury reduction/repair
  • Contraindications: Known hypersensitivity, wolf-parkinson-white syndrome, dysrhythmias secondary to local anesthetic toxicity
  • Dosage:
    • Local anesthetic: 5 mg/kg (max 300mg)
    • Antiarrhythmic: 1-1.5 mg/kg IV loading dose, followed by infusion of 2 mg/min
  • Onset: 1-2 minutes
  • Duration: 10-20 minutes (IV), 30-90 min 
  • Adverse Reactions: CNS toxicity, urticaria, venous inflammation, bronchospasm

Pearls

Deep Dive

Video Credit: ProCPR


Metoprolol

Rapid Review

  • Mechanism of Action: Beta blocker; cardioselective beta-1 receptor inhibitor with minimal or no effects on beta-2 receptors. Decreases cardiac output via negative inotropic and chronotropic effects.
  • Indications: Atrial fibrillation (rate control), hypertension, heart failure, acute MI, migraine
  • Contraindications: Sick sinus syndrome, 2nd-3rd degree heart block, hypersensitivity 
  • Dosage:
    • Atrial fibrillation: 2.5 – 5 mg IV over 2 minutes (up to 3 doses). Transition to PO afterwards.
    • Acute MI: 5 mg IV q 2 minutes (up to 3 doses)
  • Onset: Peaks at 20 minutes (after 10 minute IV infusion)
  • Duration: 5-8 hours
  • Adverse Reactions: Bradycardia, heart failure, bronchospasm, fatigue, dizziness

Pearls

Video Credit: Medical Videos


Nicardipine

Rapid Review

  • Mechanism of Action: Dihydropyridine calcium channel blocker; inhibits influx of extracellular calcium ions across myocardial cells and vascular smooth muscle cells, causing coronary vasodilation and decrease in peripheral resistance
  • Indications: Hypertension, intracranial hemorrhage
  • Contraindications: Hypersensitivity, aortic stenosis
  • Dosage: 5 mg/hour IV infusion, increase by 2.5 mg q5 minutes until target BP achieved (Max 15mg/hr). Decrease to 3mg/hr once goal BP achieved. 
  • Onset: 5-10 minutes
  • Duration: 2-6 hours
  • Adverse Reactions: Headache, peripheral edema, hypotension 

Pearls

Video Credit: Medical Videos


Nitroglycerin

Rapid Review

  • Mechanism of Action: Vasodilator; stimulates cGMP production, causing vasodilation of venous and arterial vasculature, reducing pulmonary vascular resistance. Functions as an analgesic for angina by improving coronary blood flow and reducing ischemia. For CHF exacerbation, it improves preload and promotes redistribution of fluid from the pulmonary system
  • Indications: Angina, CHF exacerbation
  • Contraindications: Systolic BP < 90. Recent viagra or cialis use.
  • Dosage:
    • Angina: 0.3 – 0.6mg SL q5min, max 3 doses in 15 min
    • CHF: 5-200mcg/min (IV), start at 5 mcg/min and increase 10mcg q3-5 minutes until desired effect
  • Onset: 1-3 minutes
  • Duration: 30 minutes
  • Adverse Reactions: Hypotension, headaches
  • Special Considerations: N/A

Pearls

Video Credit: Simple Nursing

Nitroprusside

Rapid Review

  • Mechanism of Action: Vasodilator; water-soluble salt comprised of ferrous iron complexed with nitric oxide. Produces peripheral vasodilation of both arteries and veins (slightly more selective for veins)
  • Indications: Hypertensive crisis, congestive heart failure
  • Contraindications:
  • Dosage: 0.25 mcg/kg/min IV, titrate slowly by 0.2mcg/min q5 minutes until goal BP achieved. 
  • Onset: < 1 minutes
  • Duration: 3-5 minutes
  • Adverse Reactions: Cyanide toxicity, methemoglobinemia, hypotension

Pearls

Video Credit: Level Up RN


Norepinephrine

Rapid Review

  • Mechanism of Action: Vasopressor; similar to epinephrine, but primarily agonistic at alpha 1 and beta 1 receptors, with little-to-no beta 2 or alpha 2 activity
  • Indications: Hypotension refractory to IV fluids
  • Contraindications: No absolute contraindications. Be cautious using in low-volume states.
  • Dosage: Generally 8-12 mcg/min IV, titrate up to effect (max dose 25 mcg). Maintenance dosage 2-4 mcg/min
  • Onset: Immediate
  • Duration: 1-2 minutes after infusion stops
  • Adverse Reactions: Extravasation injury, decreased end-organ perfusion, reflex bradycardia, headache

Pearls

Video Credit: ICU Advantage


Phenylephrine

Rapid Review

  • Mechanism of Action: Vasopressor; selective alpha 1 adrenergic agonist causing peripheral vasoconstriction. No beta-adrenergic activity.
  • Indications: Hypotension (best in distributive or neurogenic shock), low flow priapism
  • Contraindications: Hypersensitivity, severe hypertension, closed angle glaucoma
  • Dosage:
    • Hypotension: Start 100-200 mcg/min, then taper down
      • Consider push-dose (50-200 mcg) boluses
    • Low flow priapism: 100-500 mcg injection q 3-5 minutes until resolution
  • Onset: 1-3 minutes (IV)
  • Duration: 5-20 minutes (IV)
  • Adverse Reactions: Reflex bradycardia, hypertension, pulmonary edema, extravasation

Pearls

Video Credit: Medzcool


Procainamide

Rapid Review

  • Mechanism of Action: Class Ia Antiarrhythmic; binds to fast sodium channels inhibiting recovery after repolarization. Prolongs action potential and reduces the speed of impulse conduction.
  • Indications: Ventricular arrhythmias, atrial fibrillation/flutter, WPW syndrome
  • Contraindications: Allergy, prolonged QT, myasthenia gravis, 2nd-3rd AV block
  • Dosage: Generally 100 mg IV every 5 minutes
  • Onset: 10-30 minutes
  • Duration: 2.5 – 4.7 hours
  • Adverse Reactions: Bradycardia, hypotension, QRS/QT prolongation

Pearls

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Propranolol

Rapid Review

  • Mechanism of Action: Non-selective beta blocker; competitively blocks beta-1 and beta-2 adrenergic stimulation in the heart. Results in decrease in heart rate, blood pressure, myocardial contractility, and myocardial oxygen demand.
  • Indications: Thyroid storm, hypertension, angina, atrial fibrillation, anxiety
  • Contraindications: Bradycardia, COPD/asthma/emphysema
  • Dosage:
    • Thyroid storm: 0.5 – 1mg IV over 10 minutes (redose 1-3 mg every few hours) or 60-80 mg PO q4 hours
  • Onset: 2-10 minutes (IV), 1-2 hours (PO)
  • Duration: Half-life of 3-6 hours in patients with healthy renal systems.
  • Adverse Reactions: Bradycardia, abdominal pain, nausea, erectile dysfunction, wheezing

Pearls

Video Credit: Medical Videos


Vasopressin

Rapid Review

  • Mechanism of Action: Vasopressor; stimulates V1 and V2 receptors, causing vasoconstriction (without inotropic or chronotropic effects), as well as renal water retention.
  • Indications: Vasodilatory shock, diabetes insipidus, bleeding esophageal varices
  • Contraindications: Hypersensitivity
  • Dosage: 0.01 – 0.1 U/min
  • Onset: Peak in 15 minutes (IV)
  • Duration: Fades within 20 minutes of stopping infusion
  • Adverse Reactions: Splanchnic vasoconstriction, uterine contraction, oliguria

Pearls

Video Credit: MED CRAM


Brandon Simpson, PA-C
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