page159
. Cardiac arrest,
by rapid intravenous
or
intracardiac
injection,
0.5–0.75 mL of a solution containing
noradrenaline acid tartrate 200 micrograms/mL
(equivalent to noradrenaline base 100 micrograms/
mL)
Noradrenaline/Norepinephrine
(Non-proprietary) A
Injection
,
noradrenaline acid tartrate 2 mg/mL
(equivalent to noradrenaline base 1 mg/mL).
For
dilution before use. Net price 2-mL amp = £2.40, 4-mL
amp = £4.40,
20-mL amp = £6.35
PHENYLEPHRINE HYDROCHLORIDE
Indications
acute hypotension (see notes above);
priapism (section 7.4.5) [unlicensed indication]
Cautions
see under Noradrenaline Acid Tartrate;
longer duration of action than noradrenaline (norepi-
nephrine),
see below; coronary disease
Hypertensive response
Phenylephrine has a longer dura-
tion of action than noradrenaline, and an excessive vaso-
pressor response may cause a prolonged rise in blood
pressure
Contra-indications
see under Noradrenaline Acid
Tartrate;
severe hyperthyroidism
Pregnancy
avoid if possible;
malformations reported
following use in first trimester;
fetal hypoxia and
bradycardia reported in late pregnancy and labour
Side-effects
see under Noradrenaline Acid Tartrate;
tachycardia or reflex bradycardia
Dose
. By subcutaneous
or
intramuscular injection,
2–5 mg,
followed if necessary by further doses of 1–10 mg
. By slow intravenous injection of a 1 mg/mL solution,
100–500 micrograms repeated as necessary after at
least 15 minutes
. By intravenous infusion,
initial rate up to 180 micr-
ograms/minute reduced to 30–60 micrograms/min-
ute according to response
Phenylephrine
(Sovereign) A
Injection
,
phenylephrine hydrochloride 10 mg/mL
(1%),
net price 1-mL amp = £5.50
2.7.3
Cardiopulmonary
resuscitation
The algorithm for cardiopulmonary resuscitation (see
inside back cover) reflects the most recent recommen-
dations of the Resuscitation Council (UK). These guide-
lines are available at www.resus.org.uk.
Cardiac arrest can be associated with ventricular fibril-
lation,
pulseless ventricular tachycardia,
asystole,
and
pulseless electrical activity (electromechanical dissocia-
tion).
Adrenaline (epinephrine)
1 in 10 000 (100 micr-
ograms/mL) is recommended in a dose of 1 mg (10 mL)
by intravenous injection repeated every 3–5 minutes if
necessary.
Administration through a central line results
in a faster
response than peripheral
administration,
however placement of a central
line must not interfere
with chest compressions;
drugs administered peripher-
ally must be followed by a flush of at least 20 mL Sodium
Chloride 0.9% injection to aid entry into the central
circulation.
Intravenous
injection
of
amiodarone
300 mg (from a prefilled syringe
or
diluted in 20 mL
Glucose 5%)
should be considered after adrenaline to
treat
ventricular
fibrillation or
pulseless
ventricular
tachycardia in cardiac arrest refractory to defibrillation.
An additional dose of amiodarone 150 mg can be given
by intravenous injection if
necessary,
followed by an
intravenous
infusion of
amiodarone 900 mg over
24
hours. Lidocaine, in a dose of 1 mg/kg, is an alternative
if amiodarone is not available;
a total
dose of 3 mg/kg
lidocaine should not be exceeded during the first hour.
Atropine is no longer recommended in the treatment of
asystole or pulseless electrical activity.
During cardiopulmonary arrest
if
intravenous access
cannot
be obtained,
the intraosseous
route can be
used instead.
Drug administration via the endotracheal
route is no longer recommended.
For the management of
acute anaphylaxis see section
3.4.3.
ADRENALINE/EPINEPHRINE
Indications
see notes above
Cautions
ischaemic heart disease,
severe angina,
obstructive cardiomyopathy,
hypertension,
arrhyth-
mias,
cerebrovascular disease,
occlusive vascular
disease,
arteriosclerosis,
monitor blood pressure and
ECG;
cor pulmonale;
organic brain damage,
psycho-
neurosis;
diabetes mellitus,
hyperthyroidism, phaeo-
chromocytoma;
prostate disorders;
hypokalaemia,
hypercalcaemia;
susceptibility to angle-closure
glaucoma;
elderly;
interactions: Appendix 1
(sympathomimetics)
Renal impairment
manufacturers advise use with
caution in severe impairment
Pregnancy
may reduce placental perfusion and can
delay second stage of labour;
manufacturers advise
use only if benefit outweighs risk
Breast-feeding
present in milk but unlikely to be
harmful as poor oral bioavailability
Side-effects
nausea,
vomiting,
dry mouth,
hypersala-
vation; arrhythmias,
syncope,
angina,
pallor,
palpita-
tion,
cold extremities,
hypertension (risk of cerebral
haemorrhage);
dyspnoea,
pulmonary oedema (on
excessive dosage or extreme sensitivity);
anxiety,
tremor,
restlessness,
headache,
weakness,
dizziness,
hallucinations;
hyperglycaemia;
urinary retention,
difficulty in micturition; metabolic acidosis; hypokal-
aemia;
tissue necrosis at injection site and of extre-
mities,
liver and kidneys;
mydriasis,
angle-closure
glaucoma,
and sweating
Dose
. See notes above
Adrenaline/Epinephrine 1 in 10 000, Dilute
(Non-
proprietary) A
Injection
,
adrenaline (as acid tartrate) 100 micr-
ograms/mL.
10-mL amp.
Brands include
Minijet
c
Adrenaline
2.8
Anticoagulants and
protamine
2.8.1 Parenteral anticoagulants
2.8.2 Oral anticoagulants
2.8.3 Protamine sulphate
The main use of anticoagulants is to prevent thrombus
formation or extension of
an existing thrombus in the
slower-moving venous side of the circulation, where the
BNF 61
2.7.3 Cardiopulmonary resuscitation
139
2
Cardiovascular system