- Indicated for paroxyxmal SVT
- Contraindicated in 2nd/3rd degree AVB, SSS, AF/AFib, VT/VF
- Metabolized by RBC's and vascular endothelial cells
- Serum half-life: < 10 sec
- 6mg IV, then 6mg IV, then 12mg IV by rapid injection
- Adverse effects include transient AVB, bradycardia, flushing, CP, SOB, lightheadedness, numbness, nausea
Angiotensin Converting Enzyme Inhibitors
- Indicated as antihypertensive, and vasodilation in CHF
- Adverse effects include hypotension, tachycardia, angina, arrythmias, cough, GI upset, renal failure, cytopenias, CNS symptoms, rash
Captopril (Capoten)
- Metabolized by liver, renal excretion
- Onset 15 min PO, Peak 0.5-1.5h
- Duration 2-6h
- Half-life < 2h
- 12.5-25mg PO bid-tid initially, up to max 150mg tid
Lisinopril (Prinivil, Zestril)
- Not metabolized, renal excretion
- Onset 1h PO, Peak 7h
- Duration 24h
- Half-life 12 hr
- 10mg PO qd, up to 20-40mg PO qd
Enalapril (Vasotec)
- Hepatic metabolism to active form, renal/fecal excretion
- Onset 1h PO/15min IV , Peak 0.5-1.5h PO/1-4h IV
- Duration 24h
- Half-life 1.3h, metabolite 35h
2.5-5.0mg PO qd, up to 10-40mg PO qd
1.25mg IV q6h (give over 5min), up to 5mg IV q6h
Atropine Sulfate
- Indicated for bradycardia
- Hepatic metabolism, renal/fecal/bile excretion
- Onset 1-2 min
- Half-life: biphasic 2h, then 12h
- Adult: 0.5-1mg IV push; repeat q5min up to max 2mg
- Ped: 0.01mg/kg to max 0.4mg
- Adverse effects include arrythmias, tachycardia, MI, HA, MS changes, urinary retention, Increased ocular pressure, other anticholinergic effects
Beta Antagonists
- Indicated in MI, hypertension, arrythmias, hyperthyroidism, migraine, essential tremor
- Adverse effects include bradycardia, worsening CHF, bronchospasm, hypoglycemia, vasoconstriction, asystole or AVB w/Ca blockers, rebound phenomenon w/abrupt withdrawal
Propranolol (Inderal)
- Nonselective B1 and B2 antagonist
- Hepatic metabolism and renal excretion
- Onset immediate IV
- Half-life 2.5h IV; 3-6h PO
0.5-1mg IV up to 0.1mg/kg IV
10-80mg PO bid-qid
80-160mg PO qd extended release
Esmolol (Brevibloc)
- B1 selective antagonist
- RBC esterase metabolism and renal excretion
- Onset immediate
- Half-life 9 min
0.5-1mg/kg IV loading, 50 ug/kg/min infusion up to 300 ug/kg/min titrated to effect
Labetolol (Trandate, Normodyne)
- Nonselective B1, B2, Alpha-1 antagonist
- Hepatic metabolism/excretion
- Onset immediate IV
- Half-life 6-8h
100mg PO bid initially, up to 600mg PO bid max
5 - 20 mg IV over 2 min, repeat q5-10min to max 100mg
Metoprolol (Lopressor)
- B1 selective antagonist
- Hepatic metabolism and renal excretion
- Onset immediate IV
- Half-life 3-7 hr
1-2mg IV up to 0.2mg/kg max
100-450mg PO qd or divided bid
Atenolol (Tenormin)
- B1 selective antagonist
- Hepatic metabolism and renal excretion
- Half-life 6-9h
- 50-100mg PO qd
Calcium Channel Blockers
- Ca++ antagonists
- Vasodilator, depressor of SA/AV node, negative inotrope
- Indicated for hypertension, ischemic heart disease
- Adverse effects include arrythmias, hypotension, bradycardia, GI upset, rash, CNS symptoms
Diltiazem (Cardizem)
- Hepatic metabolism, renal/bile excretion
- Half-life 3-9 h
- 30mg PO tid-qid up to 360 mg/d
Nifedipine (Procardia)
- Less nodal/myocardial depressant effect than diltiazem/verapamil
- More vasodilator effect than other Ca channel blockers
- Hepatic metabolism, renal excretion
- Onset 5min SL
- Half-life 2h
10-20 mg PO q4-8h up to max 180 mg/d
-SL if NPO
Verapamil (Calan, Isoptin)
- Additional indications are SVT (esp AV node reentry), rapid ventricular response in AF/AFib
- Hepatic metabolism, renal excretion
- Onset 2-3min IV
- Half-life 110 min IV, 4.5-10 hr PO
-
SVT:
adult 0.075-0.15 mg/kg bolus over 2 min (repeat in 10min if no response)
Infusion 0.005mg/kg/min AF/AFib HR control
80-120 mg PO tid-qid
ped 0.1-0.3 mg/kg IV over 2 min
- Angina:
80-120 mg PO q6-8h
- HTN:
80-120 mg PO tid or 240mg Ext Rel PO qd-bid
Clonidine (Catapres, Catapre-TTS)
- Central alpha-2 agonist, decreasing sympathetic outflow, reducing SVR, inhibits renin/catecholamine/aldosterone secretion
- Indicated in hypertension, opiate/Etoh/nicotine withdrawal
- Hepatic metabolism 50%, renal/fecal excretion
- Half-life 12-16h
- Onset 30-60 min after PO, Peak 2-4h PO
- Duration 8h PO
- Transdermal patch levels at 2-3d
0.1mg PO bid-tid up to max 2.4mg/d
- Apply patch 0.1mg q7d, up to 0.3mg
- For Withdrawal, 5 - 17 ug/kg PO divided tid
- Adverse effects include hypotension, bradycardia, rebound phenomenon when suddenly stopped, GI upset, constipation, urinary retention, impotence, rash, CNS symptoms, glucose intolerance, hypothermia
- Paradoxical hypertension w/B-blockers
Digoxin (Lanoxin)
- Indicated in SVT/AF/AFib, and CHF
- Minimal hepatic metabolism, renal excretion
- Onset 30-120min PO; 30 min IM; 5-30 min IV
- Half-life 36-48h
- Therapeutic level 0.6 - 1.8 ng/ml
- Initial dose 0.5mg IV, then 0.125-0.25mg IV q4-6h up to 0.75-1.25mg for effect
- Maintenance dose 0.125-0.25mg/d PO/IV
- Adverse effects include nearly any arrythmia, GI upset, neurologic effects
- Hypokalemia/hypomagnesemia increase dig effect
- Acute toxicity, give Digibind 800mg IV
Dobutamine (Dobutrex)
- B1 > B2 > Alpha-1 agonist
- Increases conduction, contractility, vasodilation
- Indicated in CHF, MR, Right heart failure w/ inc PVR
- Hepatic metabolism and renal excretion
- Onset immediate
- Half-life 2 min
- 2.5 - 10 ug/kg/min IV gtt
- Adverse effects include tachycardia, ventricular arrythmias, hypotension secondary to vasodilation
Dopamine (Intropin)
- Direct alpha, B1, and dopaminergic receptor stimulation (DA1-vasodilation renal/mesenteric/coronary/cerebral; DA2- inhibits preganglionic NE release), indirect release of NE
- Indicated in hypotension, and to improve RBF/UO
- Hepatic metabolism and renal excretion
- Onset immediate
- Half-life minutes
-
DOSES:
For primarily dopaminergic stimulation 0.5-2.0 ug/kg/min
For both DA stimulation and B1 action 2-5 ug/kg/min
For alpha, beta and DA effects > 10 ug/kg/min
- Adverse effects include arrythmias, tachycardia, hypertension, MI, tachyphylaxis w/in 24 hr, inc PCWP
Epinephrine
- B1 > B2 > Alpha effects
- Indicated in cardiopulmonary arrest, hypotension, severe asthma or allergic reactions
- Metabolized in liver, kidney, GI tract, and renally excreted
- Onset immediate
- Half-life minutes
-
DOSES:
Primarily B1, B2 effects 1-4 ug/min
B1, B2, alpha effects > 4 ug/min
- Adverse effects include tachycardia, inc myocardial demand, hypertension, arrythmias, decreased RBF, tissue necrosis
Hydralazine (Apresoline)
- Direct vasodilation of arterioles > venules, reducing diastolic > systolic BP, decreasing SVR, increasin HR/CO; increase in renal, cerebral, coronary, splanchnic circulations
- Indicated for chronic hypertension or acute lowering of BP in mild to moderate hypertension
- Metabolized in liver, renally excreted
- Onset 10-20 min IV, 20-30 min PO
- Half-life 3 hr
25 - 50 mg qid PO;
5mg IV boluses q15min up to 20-40mg, and then 5 - 10 mg IV q6h maintenance
- Adverse effects include angina exacerbation, HA, GI upset, hypotension, peripheral neuropathy, Lupus-like syndrome
TOP
Isoproterenol (Isuprel)
- Primarily B1 and B2 agonist, increased chronotropy/inotropy, decreased DBP, increased SBP, increased myocardial demand, bronchodilator
- Indicated in bradycardia, AVB, Pulmonary HTN, bronchospasm
- Hepatic metabolism and renal excretion
- Onset immediate
- Half-life < 5 min
- 1-10 ug/min (0.05-0.1 ug/kg/min) IV gtt
- For bronchospasm 1-2 inhalations of 0.25 - 1% MDI q3-4h
- Adverse effects similar to epinephrine
Lidocaine (Xylocaine)
- Indicated as local anesthetic and ventricular antiarrythmic
(class 1a)
- Hepatic metabolism and renal excretion
- Onset immediate IV
- Half-life 100 min
- Bolus 1-1.5 mg/kg IV repeated in 20 min;
then... 1-4 mg/min IV gtt
- Adverse effects include bradycardia, hypotension, myocardial depression, CNS toxicity (incl seizures), rash, edema, bronchospasm, anaphylaxis
Nitroglycerin
- Acts by direct venodilation, decreasing PVR/preload/LVEDP, and decreased myocardial demand, increased coronary blood flow, and causes arteriolar dilation at higher doses
- Indicated for MI, CHF, systemic and pulmonary HTN
- Hepatic metabolism and renal excretion
- Onset immediate IV/SL; slight delay for PO
- Half-life 1-4 min IV; 20 min SL; 4h PO
- Angina: 10-400 ug/min IV; ave. 75-100 ug/min
-Hypotension: 10-400 ug/min; arteriolar dilation occurs at > 150 ug/min
- Other forms:
Transdermal patch 2.5-15mg q24h
Ointment 0.5-2 in q6-12h
Sublingual 150/300/400/600 ug SL q5-10 min prn
- Adverse effects include tachyphylaxis, hypotension, HA, N/V, increased ICP
Norepinephrine (Levophed)
- Potent alpha > > B1 effect; no B2 effect
- Indicated in hypotension, cardiogenic shock
- Hepatic/renal/GI metabolism and reuptake in nerve terminals; renal excretion
- Onset immediate IV
- Half-life minutes
- 4 - 10 ug/min IV; maybe higher in sepsis, cardiogenic shock
- Adverse effects include decreased RBF, HTN, tissue necrosis, HA, angina, bradycardia, arrythmias, MI, stroke, seizures
Phenylephrine (Neo-Synephrine)
- Alpha-1 agonist leading to arterial/venous constriction, increased SVR/PVR
- Indicated for hypotension
- Hepatic metabolism and renal excretion
- Onset immediate IV
- Half-life minutes
- 20 - 30 ug/min IV titrate to effect
- Adverse effects include HA, HTN, reflex bradycardia, MI, decreased organ blood flow
Prazosin (Minipress)
- Alpha-1 antagonist resulting in arterial/venous dilation
- Indicated in HTN, afterload reduction in CHF
- Hepatic metabolism, fecal 90%/renal 10% excretion
- Onset 2hr PO, Peak 2-4hr
- Duration 18-24hr
- Half-life 2-4hr
- Initial dose 1 mg PO bid-tid up to max 20 mg/day
- Adverse effects include hypotension, tachycardia, edema, GI upset, CNS symptoms, impotence, blurred vision
Procainamide (Procan SR, Procainamide)
- Class 1a antiarrythmic used for SVT, ventricular arrythmias, and prevent recurrences of AF/AFib
- Hepatic metabolism to NAPA (active); renal excretion
- Half-life 3-5h
- 100 mg/min to effect or to total dose of 1000mg, followed by a infusion of 2-6 mg/min
- Adverse effects include torsades de pointe, junctional tachycardia, hypotension, GI upset, cytopenias
Sodium Nitroprusside (Nipride)
- Direct vasodilation of arteries > veins
- Indicated for hypertension, acute LV failure
- Nonenzymatic degradation to cyanide, then thiocyanate conversion by liver, then renal excretion
- Onset immediate
- Half-life minutes; thiocyanate 4 d
- 0.5-10 ug/kg/min titrate to effect
- Adverse effect include HA, N/V, hypotension, tachycardia, increased ICP, hypoxia (pulm shunting), tachyphylaxis, rebound, qualitative platelet defect
- Measure thiocyanate levels qd (< 10mg/100ml) if required longer than 48h
- Toxicity can be treated w/amyl nitrite and sodium nitrite, and sodium thiosulfate
