Cardiac

  • Adenosine
  • Aspirin
  • Atorvastatin
  • Clopidogrel
  • Diltiazem
  • Nitroglycerin

Adenosine

  • 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. 
Video Credit: ICU Advantage

*Deep Dive: Single Syringe Adenosine for SVT? (REBEL EM)



Aspirin

  • 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.
Video Credit: Med Today

*Deep Dive: Aspirin (Drugs.com)



Atorvastatin

  • 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
Video Credit: NURSINGcom

*Deep Dive: ACS? Start My Statins! (EP Monthly)



Clopidogrel

  • 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
Video Credit: Picmonic Video

*Deep Dive: A Case of Identity Part Two (EMNerd)



Diltiazem

  • 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
Video Credit: BlueJFilms

*Deep Dive: Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter w/ Rapid Ventricular Rate in the Emergency Department (JEM)



Nitroglycerin

  • Mechanism of Action: Vasodilator; stimulates cGMP production, causing vasodilation of venous and arterial vasculator, 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
Video Credit: Simple Nursing

*Deep Dive: The Death of MONA in ACS: Nitroglycerin (REBEL EM)


Brandon Simpson, PA-S2
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