No nurse would be there who has not done or assisted a Cardio Pulmonary Cerebral Resuscitation (CPCR). Even though responsibility of nurses vary during CPCR, you must be thorough with the medications – CPCR Drugs, used during CPCR. As it is an emergency procedure, question makers are very fond of this particular area. Even for MOH interviews and all we have heard people telling that so many questions were asked from these particular drugs. So its better to read and study this article (with MCQ’s) if you are preparing for staff nurse competitive exams or licensure exams like NCLEX RN, CRNE, OSCE, CBT and Indian exams like AIIMS, JIPMER, PGIMER, NIMHANS, SGPGI, AMU, ESIC, Railways etc. So lets start with the common drugs, their action and special considerations while administering them.
Most Common CPCR Drugs
Adrenaline causes vasoconstriction of blood vessels. This in turn causes blood to concentrate around vital organs especially brain and heart. This increases the chance of survival following cardiac arrest. It also stimulates cardiac muscle by strengthening cardiac contractions. This action will increase the amount of blood going or circulating through the vital organs and increases the chance of the heart returning to a normal rhythm.
Adrenaline can be given repeatedly during a cardiac arrest IE after every 3-5 minutes.
Modes of administration – Best method is by a central venous access. You can also administer through a cannula in a peripheral vein. Adrenaline can be given endotracheally too. If no other route is available, you can administer adrenaline directly into heart through the chest wall.
Dosage – 1mg IV/IQ Q 3 minutes
Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube.
When to stop adrenaline administration?
Once an organised rhythm has been established, the use of adrenaline has to be reassessed as excess amount can precipitate Ventricular Fibrillation.
Drug Interaction – Adrenaline will react with sodium bicarbonate to produce a solid material. So both of these can be administered in same iv line after adequate flushing with 0.9% sodium chloride.
Amiodarone is the specific drug of choice during cardiac arrest to treat specific cardiac arrhythmia especially Ventricular fibrillation and Ventricular tachycardia.
Recommended method for treatment of ventricular fibrillation is first administration of electrical defibrillation. If this goes unsuccessful, 3 attempts of amiodarone should be given.
Main effects of Amiodarone – Main effect is slowing down of metabolism of cardiac tissue. Another action is blocking of hormones that speeds up the heart rate.
Drug Interaction – Amiodarone is not compatible with sodium chloride and must be all times diluted with 5% dextrose.
Major Side effect – Bradycardia. The bradycardia caused by Amiodarone can be readily reversed by Atropine.
Dosage – 300mg or 5mg/kg
Secondary drug of choice if Amiodarone is not available during events like Ventricular fibrillation and Ventricular tachycardia in cardiac arrest. It reduces electrical activity of cardiac tissues and is able to slow down a very fast heart rate.
Side Effect – When compared to Amiodarone, Lidocaine can cause bradycardia together with hypotension.
Dose : Initial dose: 1 to 1.5 mg/kg IV/IO. For refractory VF may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; maximum 3 doses or total of 3mg/kg
The primary action of Atropine is to block the effect of the vagus nerve on the heart. The normal effect of vagus nerve is stimulation is slowing of heart rate and causes systole during the event of cardiac arrest. Conduction system of heart also get effected with Atropine and thereby it accelerates the transmission of electrical impulses through cardiac tissue.
Specific use of Atropine – Reverse Asystole and Bradycardia during event of cardiac arrest. Recommended usage is when there is a pulse less activity with a rate of less than 60 beats/minute or in case of complete asystole.
Preferred route of administration is intravenous route. For bradycardia a dose of 0.5mg should be given and repeated every five minutes until the desired heart rate is reached.
For asystole a single dose of 3mg should be given and this should not be repeated unless the cardiac rhythm changes to bradycardia or pulse less electrical activity.
If there is no IV access available for administration of Atropine, Endotracheal route is preferred and doe would be 2 – 3 times as high as that given intravenously.
Dose: 0.5 mg IV, 3 mg max cumulative dose
Additional CPCR Drugs
These drugs are given once the above drugs have been tried and there is no improvement in hte patient’s condition. For administration of these drugs knowledge of patient’s past medical history or history of circumstances of the arrest must be known.
1. CALCIUM CHLORIDE
Calcium Chloride causes contraction of muscle tissue throughout the body and in turn its important for contraction of cardiac tissue.
It is said that calcium can improve weak or inefficient myocardial contractions when Adrenaline has failed.
Calcium also protects against raised potassium levels, lowered blood calcium level and an overdose of Magnesium or calcium channel blocking drugs.
Administration – DO NOT administer the drug directly through an iv line due to the high risk of tissue necrosis. It should be given in a small bore cannula placed in a large vein, to reduce the damage to surrounding tissue.
Drug interaction – Due to chance of chemical interaction, Calcium chloride should not be given in same iv line used for sodium bicarbonate.
Major Side Effects – Increases Blood Acidity. So should be used with caution in patients with lowered blood pH. Also, IV administration of calcium chloride can cause hypotension due to peripheral vasodilation.
Dose: 10% IV solution (gluconate or chloride) contains 1 gram per 10 mL
2. MAGNESIUM SULPHATE
Magnesium also helps in contraction of muscular tissue including cardiac muscle. Reduced Magnesium level in blood can cause cardiac arrhythmia’s often leading to cardiac arrest.
Reasons for Magnesium Deficiency – Excessive use of Potassium losing diuretics, Alcohol misuses and diarrhea.
What to watch for? While giving magnesium intravenously it is important to monitor BP, urine output and respiratory rate.
Dose: 2-4 grams IV over 5 minutes
– Oxygen Though not really a drug, per se, adequate oxygen supply to the brain is at the core of CPR. Expired air delivers 16 – 17% of oxygen to the patient. This will produce an average alveolar oxygen tension of 80 mmHg.
This general anti arrhythmic is used mainly as a diagnostic agent to identify the origin of an underlying narrow-QRS-complex tachycardia. It briefly depresses the atrioventricular (AV) node and sinus node activity. When given by rapid I.V. bolus, the drug’s primary action is to slow electrical impulse conduction through the AV node. Be aware that adenosine commonly causes a few seconds of asystole, but because of its short half-life (6 to 10 seconds), the asystole usually is brief. The drug sometimes restores a normal sinus rhythm; if it doesn’t, calcium channel blockers and beta blockers may be given immediately to control the heart rate while amiodarone or ibutilide may be used to help restore a normal sinus rhythm.
3. Intravenous fluids
– Expansion of the circulating blood volume is critical in patients with acute blood loss. Until blood is available, this can be achieved by the rapid administration of crystalloid (preferably 0,9% saline or Ringer’s lactate) and colloid solutions (starches e.g. Voluven, or gelatines e.g. Gelofusine).
4. Morphine sulphate
Morphine is not an antidysrhythmic agent and is only mentioned here because of its essential role in the management of patients with myocardial infarction which may result in cardiac arrest. It increases the venous capacitance, decreasing venous return and inducing mild arterial vasodilatation.
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