Anti-Arrhythmic Agents |
|
Class |
Drug(s) |
Usual Dosing (adult) |
Indication |
Adverse Effects |
I |
Moricizine |
200-300mg q8h |
ventricular tachycardia |
dizziness, nausea, rash, seizures |
Ia |
Disopyramide |
150-200mg q6h or 300mg CR q12h |
atrial fibrillation, ventricular
tachycardia |
anticholinergic effects, CHF |
|
Procainamide |
250-500mg q3-6h or 500-100mg SR
q6h (oral); 15-18mg/kg loading dose, then 1-4mg/min maintenance (IV) |
atrial fibrillation, ventricular
tachycardia, Wolf-Parkinson-White arrhythmias |
GI effects, CNS effects,
lupus-like syndrome, fever, hematological effects, anticholinergic effects |
|
Quinidine |
sulfate: 100-600mg q4-6h,
gluconate: 324-972mg q8-12h (oral); 400mg q2-6h (IM); 200-400mg diluted &
given <10mg/min (IV) |
paroxysmal supraventricular
tachycardia, atrial fibrillation, ventricular tachycardia,
Wolf-Parkinson-White arrhythmias |
hypotension, GI effects,
thrombocytopenia, cinchonism |
Ib |
Lidocaine |
IV only: initial 1-1.5mg/kg (may
give 0.5-0.75mg/kg repeat dose if necessary), then 1-4mg/min maintenance |
ventricular tachycardia,
ventricular fibrillation, PVC |
CNS and GI effects |
|
Mexiletine |
200-300mg q8h |
ventricular tachycardia |
GI and CNS effects |
|
Tocainide |
1200-1800mg/day in 3 divided doses |
ventricular tachycardia |
GI, CNS, and pulmonary effects,
agranulocytosis |
Ic |
Flecainide |
50mg q12h for paroxysmial
supraventricular arrhythmias; 100mg q12h for life-threatening arrhythmias;
maximum dose 400mg/day |
ventricular tachycardia |
congestive heart failure, blurred
vision, GI and CNS effects |
|
Propafenone |
immediate release: 100-300mg q8h;
sustained release: 225-425 q12h |
ventricular tachycardia |
GI effects, blurred vision,
dizziness |
II |
Esmolol |
intraoperative tachycardia: 80mg
bolus over 30 seconds, followed by 150mcg/kg/min infusion (up to
300mcg/kg/min); supraventricular tachycardia: 500mcg/kg bolus over 1 minute,
then 50mcg/kg/min over 4 minutes, followed by infusion of 50-200mcg/kg/min |
ventricular tachycardia,
supraventricular tachycardia |
congestive heart failure,
lupus-like syndrome, hypotension, bradycardia, bronchospasm, CNS effects |
|
Propranolol |
10-30mg q6-8h (oral); 1mg/dose
slow IVP, may repeat every 5 minutes up to 5mg total (IV) |
supraventicular tachycardia,
ventricular tachycardia, PVC, digoxin toxicity |
congestive heart failure,
bradycardia, hypotension, fatigue, CNS effects |
III |
Amiodarone |
oral: ventricular arrhythmias -
800-1600mg/day in 1-2 doses for 1-3 weeks, then decrease to 600-800mg/day in
1-2 doses when control achieved (maintenance 400mg/day); atrial fibrillation
prophylaxis - 400mg bid for 7 days maximum; intravenous: breakthrough VF/VT -
150mg IV over 10 minutes; pulseless VF/VT - 300mg IV initial, then 150mg
additional if no response, then 1mg/min for 6 hours followed by 0.5mg/min;
A-fib prophylaxis - 1000mg IV over 24 hours for 2 days; stable VT/SVT - 150mg
IV bolus over 10 minutes, then infusion of 1mg/min for 6 hours followed by
0.5mg/min over 18 hours |
ventricular tachycardia |
CNS, GI and thyroid effects,
pulmonary fibrosis, liver toxicity, corneal deposits |
|
Bretylium |
immediate life-threatening
ventricular arrhythmia: 5mg/kg initial over 1 minute (repeat 10mg/kg dose as
necessary if arrhythmia persists, up to 30-35mg/kg); other life-threatening
ventricular arrhythmias: 5-10mg/kg initial, may repeat every 1-2 hours; 5-10mg/kg
every 6-8 hours maintenance |
ventricular tachycardia,
ventricular fibrillation |
orthostatic hypotension, GI and
CNS effects |
|
Dofetilide |
125-500mcg twice daily (dosing
based on renal function/QTc interval) |
atrial fibrillation |
headache, dizziness, ventricular
tachycardia, torsade de pointes |
|
Ibutilide |
IV: < 60 kg: 0.01mg/kg over 10
minutes; > 60 kg: 1mg over 10 minutes (may repeat x 1 if arrhythmia
persists) |
atrial fibrillation |
torsade de pointes, hypotension,
branch bundle block, AV block, nausea, headache |
|
Sotalol |
ventricular arrhythmia: 80mg bid
initial, 160-320mg/day usual dosing range; atrial fibrillation: 80mg bid
initial; 80-160mg bid usual dosing range |
atrial fibrillation, ventricular
tachycardia |
bradycardia, hypotension,
congestive heart failure, fatigue, CNS effects |
IV |
Diltiazem |
IV: 0.25mg/kg bolus over 2
minutes, followed by 5-15mg/hour maintenance infusion |
atrial fibrillation, paroxysmial
supraventricular tachycardia |
hypotension, GI and liver effects |
|
Verapamil |
IV: 2.5-5mg over 2 minutes, may
repeat in 15-30 minutes if inadequate response (maximum dose 20mg) |
atrial fibrillation, paroxysmial
supraventricular tachycardia |
hypotension, congestive heart
failure, bradycardia, vertigo, constipation |
Miscellaneous |
Adenosine |
IV: 6mg, may repeat with 12mg dose
in 1-2 minutes |
supraventicular tachycardia,
paroxysmial supraventricular tachycardia |
flushing, dizziness, bradycardia,
syncope |
|
Digoxin |
0.125-0.5mg daily |
atrial fibrillation, paroxysmial
supraventricular tachycardia |
arrhythmias, GI and CNS effects |
|
Magnesium |
life threatening arrhythmia: IV:
1-2g in 100ml D5W over 5-60 minutes, followed by infusion of 0.5-1g/hour OR
1-6g over several minutes, followed by 3-20mg/minute infusion for 5-48 hours |
ventricular tachycardia,
ventricular fibrillation |
hypotension, hypothermia,
myocardial depression, CNS effects |
|
Atrial Fibrillation |
|
Atrial Flutter |
1. Cardioversion (in unstable
patients) - 200J initially, increasing to 300-360J as needed (sedate patient
first if time permits) |
|
1. Cardioversion (in unstable patients) - 50J and repeat as
needed to maximum of 360J |
|
2. Rate control - Verapamil 5mg
IV over 2 minutes, followed by 5-10mg in 15-30 minutes if needed; Cardizem
0.25mg/kg IV over 2 minutes, then 0.35mg/kg over 2 minutes if needed;
Lopressor 5mg iv every 5 minutes to total of 15mg |
|
2. Rate control (normal LV function) - Cardizem 0.25mg/kg iv
over 2 minutes, then 0.35mg/kg iv over 2 minutes if needed; Verapamil 2.5-5mg
iv over 2 minutes, then 5-10mg in 15-30 minutes if needed |
|
|
|
3. Impaired LV function -
Amiodarone 150mg iv over 10 minutes, then 1mg/min infusion x 6 hours followed
by 0.5mg/min x 18 hours; Cardizem 0.25mg/kg over 2 minutes, then 0.35mg/kg
over 2 minutes if needed |
|
3. Rate control (impaired LV
function) - Digoxin 0.5mg iv, then 0.25mg iv every 6 hours (maximum 1mg
load); if needed Cardizem 0.25mg/kg iv over 2 minutes, then 0.35mg/kg iv over
2 minutes if needed |
|
|
|
4.
Anticoagulants: Heparin 80u/kg iv bolus, then 18u/kg/hr and adjust based on
aPTT (drawn every 6 hours until stable); start coumadin after 24 hours
(10mg/day x 2 days, then titrate to INR) |
|
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|
|
Ventricular
Fibrillation |
|
Ventricular Tachycardia |
1. Defibrillation - attempt
immediately: adults 200J, 200-300J, then 360J; pediatrics 2J/kg, 2-4J/kg,
then 4J/kg |
|
1. Pulseless
VT - treat as a VF with defibrilation and CPR |
|
2. Unstable VT - synchronized cardioversion: use 100J, 200J,
then up to 360J (peds: 0.5-1J/kg, up to 2J/kg) as needed (sedate first if
time permits) |
2. Airway management - 100% O2, intubate, and mechanical
ventilation |
|
|
3. Vasopressors - Epinephrine
(1:10000) 1mg iv every 3-5 minutes (ped 0.01mg/kg iv/io, or 0.1mg/kg et, if
unsuccessful, consider high dose: 0.1-0.2mg/kg iv/io/et every 3-5 minutes);
vasopressin 40u iv once |
|
3. Stable monomorphic VT (normal LV function) - consider
procainamide or sotalol |
|
|
4. Stable monomorphic VT (impaired LV function) - consider
amiodarone or lidocaine then cardioversion |
|
4.
Antiarrhythmics - Amiodarone 300mg iv, then 150mg iv if needed (peds: 5mg/kg
iv/io); follow each medication dose with countershock 360J (peds 4J/kg) |
|
5. Stable polymorphic VT (normal QT interval) - treat ischemia
and correct electrolytes; normal LV function - consider beta-blockers,
amiodarone, lidocaine; impaired LV function - consider amiodarone or
lidocaine then cardioversion |
|
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|
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6. Stable polymorphic VT
(prolonged QT interval) - stop causative medications, correct electrolytes,
consider magnesium, and cardiac pacing |
|
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|
|
Paroxysmal
Supraventricular Tachycardia |
|
Sinus Tachycardia |
1. Unstable patients -
cardioversion: 50J initially, then increase to 100J, 200J, 300J, 360J (sedate
with diazepam 5-10mg iv); peds: 0.5J/kg, increase to 1J/kg, 2J/kg) |
|
1. IV fluids (dehydration or blood loss) - 250ml NS iv boluses
(1-2L iv for major trauma) |
|
|
2. Beta blockers (myocardial ischemia, sympathomimetic
withdrawal, or thyroid storm) - Lopressor 5mg iv every 5 minutes up to 15mg;
Propranolol 0.5-1mg iv over 5 minutes, then 1mg increments every 2 minutes
(maximum 5mg) |
2.
Stable patients - adenosine 6mg rapid iv followed by rapid saline flush, then
12mg if no response after 1-2 minutes (peds 0.1mg/kg iv, then 0.2mg/kg);
Verapamil 2.5-5mg iv over 2 minutes, then 5-10mg in 15-30 minutes as needed |
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3. Calcium channel blockers (critically ill patients with
contraindication to beta-blockers) - Cardizem 10mg iv slowly, then continuous
infusion of 5-10mg/hr (may increase up to 30mg/hr) |
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4. Benzodiazepines (alcohol
withdrawal, cocaine) - Ativan 1-2mg iv, may repeat every 5 minutes as needed |
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