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PHARMACIST INTEGRATION INTO

CARDIAC ARREST RESPONSE TEAMS

(Am J Health-Syst PharmVol 70 Apr 15, 2013)

Cardiovascular disease is a significant cause of mortality, accounting for approximately

one in every three deaths in the United States. The management of sudden cardiac arrest events

in a standardized manner comprising early recognition, cardiopulmonary resuscitation (CPR),defibrillation, and advanced cardiac life support (ACLS) has saved hundreds of thousands of

lives worldwide. Collaboration among health care providers is paramount during resuscitation

attempts, as multiple interventions are commonly performed in rapid sequence. Previous

research has indicated increased survival and compliance with ACLS guidelines whenpharmacists are involved in managing in-hospital cardiopulmonary arrest events. Pharmacists are

ideally suited for inclusion on cardiac arrest response teams as a means of optimizing medication

recommendations, medication preparation, and provision of drug information.One study indicated that medication errors during code responses are 39 times more

likely to harm and 51 times more likely to result in patient death than non-code-related

medication errors. Incidents of medication errors during cardiac arrest events related to drugproduct, dose, concentration, device failure, and timing have been reported to the Institute for

Safe Medication Practices (ISMP). Pharmacist participation in the management of cardiac arrests

has been suggested by ISMP as a mechanism of preventing medication errors during codes and

improving access to drug information. In the current climate of widespread drug shortages,pharmacist participation on code response teams may be especially beneficial in reducing

medication errors related to the use of nonstandard products or drug availability problems.

Despite the multitude of benefits that can be offered by a pharmacist during the treatment ofpatients experiencing cardiac arrest, many institutions have yet to routinely integrate pharmacists

into this role.At St. John Hospital and Medical Center (SJHMC), a community teaching hospital, an

interdisciplinary team that historically lacked pharmacists responded to cardiac arrests. In aneffort to improve patient care during cardiac arrest events, approximately 10 years ago the


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beneficial and that pharmacists would be comfortable attending cardiac arrest events with the

appropriate training.

Training program development. The goal of the institutional training program was to train the

pharmacist to be an effective and contributing member of an interdisciplinary cardiac arrest

team. The desired role of pharmacists during the management of inpatient cardiac arrest eventswas defined by the pharmacy management team and members of the CPR committee. An eight-

hour training program consisting of didactic and practical training was created. At the

completion of the program, pharmacists were required to pass competency assessments related toelectrocardiogram (EKG) interpretation, ACLS management, and drug preparation.

Didactic training. We anticipated that our pharmacists would have limited experience readingand interpreting EKGs; therefore, each training session started with a one-hour review of

fundamental concepts of electrocardiography and arrhythmias commonly encountered during

cardiac arrest events. EKG interpretation is a required skill for enrollment in ACLS training and

essential in anticipating and recommending drug therapy during a cardiac arrest.Following the didactic EKG session, a two-hour review of ACLS protocols and drug

therapy was presented. Pharmacists were oriented to the various roles of the members of the

SJHMC cardiac arrest team. The importance of pharmacist involvement was highlighted byreferencing literature supporting this expanded clinical role. Routes of medication administration

(central, peripheral, intraosseous, and endotracheal) and dosing considerations were reviewed.

Pharmacists were educated on ACLS algorithms related to the management of pulselesselectrical activity/asystole, pulseless ventricular tachycardia and ventricular fibrillation,

bradycardia, tachycardia, and postacute care of patients with cardiac arrest. In addition,

reversible causes of cardiac arrest and suggested pharmacist interventions were emphasized.

Practical training. As most of our pharmacists practice in a decentralized model not involvingmedication preparation, a practical session on medication preparation was included in thetraining program. This review was designed to increase proficiency and reduce anxiety during

the management of patients in cardiac arrest Pharmacists practiced the assembly of prefilled


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SOURCES: ebscohost.com

SUMMARY AND REACTION:

Advanced cardiac life support or Advanced Cardiovascular Life Support (ACLS) refers

to a set of clinical interventions for the urgent treatment ofcardiac arrest, stroke and other life

threatening medical emergencies, as well as the knowledge and skills to deploy those

interventions.Basic life support (BLS) is the level of medical care which is used for victims of

life-threatening illnesses or injuries until they can be given full medical care at a hospital.

Although ACLS is the standardized training for health care professionals, I believe the program

provides additional essential knowledge to enable successful pharmacist participation on the

cardiac arrest team. Pharmacists who have completed the institutional program are also required

to obtain BLS and ACLS certification. An annual review program will be implemented to ensure

that pharmacist competency is maintained. In order to further promote the service and to

continue pharmacist education, clinical pearls are shared at staff meetings.
http://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Cardiac_arrest


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LEARNINGS:

In the Emergency Room, you will learn how to prioritize the patients. It is from

emergent, urgent then non-urgent. Emergent are those patients who needs fully emergency

treatment, example includes patients in life-threatening situation, cardiac arrest, ventricular

fibrillation, etc. Urgent are those patients who does not need emergency treatment but is better

to treat immediately. It involves patient with asthma, fractures, etc. Lastly, the non-urgent

patients are those who are not in critical state but needs proper treatment. It pertains to patients

with fever, headache, abdominal pain, etc.

The Emergency Room is divided in different areas (Acute Care, Critical Care, Pedia,

OB). I was assigned in the critical care area. It compromises the traumatic patient and patients in

life-threatening situation. You will also learn in this are the different equipments that are

important inside the emergency room. Like infusion pump which

infuses fluids, medication ornutrients into a patient's circulatory system, defibrillator (a device
http://en.wikipedia.org/wiki/Infusionhttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Nutrienthttp://en.wikipedia.org/wiki/Patienthttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Patienthttp://en.wikipedia.org/wiki/Nutrienthttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Infusion


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REQUIREMENT

IN

NCM 106 RLE


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ACTION CONTRAINDICATION ADVERSE

REACTION

NURSING

RESPONSIBILITIES

Generic Name:Adenosine

Brand Name:Adenocor

Route: IV

Dosage: 3mg/mlClassificationTherapeutic:

Antiarrythmics

Restores NSR by interrupting

reentrant pathways in the AV node.Slows conduction time through the

AV node. Also produces coronary

artery vasodilation.

Indication Conversion of paroxysmal

supraventricular tachycardia to

NSR when vagal maneuversare unsuccessful.

As a diagnostic agent to assessmyocardial perfusion defects

occurring as a consequence of

CAD.

Hypersensitivity 2

ndor 3

rddegree AV

block Sick Sinus Syndrome History of asthma

Unstable angina

Apprehension Dizziness Headache Shortness of breath Facial flushing

Transientarrhythmias

Throat tightness Chest pain

Monitor heart rate

frequently and ECGcontinuously during

therapy. Caution to change position

slowly to minimizeorthostatic hypotension.

Instruct patient to report

facial flushing, shortness of

breath or dizziness.

Generic Name:Amiodarone

Brand Name:Cordarone

Route: IV

Dosage: 50mg/ml

ClassificationTherapeutic:

Antiarrythmics(Class III)

Prolongs action potential and

refractory period. Inhibitsadrenergic stimulation. Slows the

sinus rate, increases PR and QTintervals, and decreases peripheral

vascular resistance. Suppression of

arrhythmias.

Indication Life-threatening ventricular

arrhythmias unresponsive toless toxic agents.

Supraventricular tachycardia Ventricular fibrillation Pulseless ventricular

tachycardia

Hypersensitivity bradycardia Patients with

cardiogenic shock Severe sinus node

dysfunction 2

ndand 3

rddegree AV

block History of CHF Thyroid disorders

Dizziness Fatigue Malaise Nausea and

vomiting Bradycardia Cornial

microdeposits Constipation Photosensitivity

Hypothyroidism Ataxia

Monitor ECG continuously

during IV therapy. Assess for signs of

pulmonary toxicity (rales,crackles, dyspnea, cough,

fever, wheezing). Assess for signs and

symptoms of acute

respiratory distresssyndrome.

Teach patient to monitor

pulse daily and report

abnormalities Protective clothing and

sunblock are recommended

during and for 4 months

after therapy. Avoid drinking grape juice

during therapy.


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REACTION

NURSING RESPONSIBILITIES

Generic Name:Atropine Sulfate

Brand Name:Route: SC/IV

Dosage: 1 mg/ml

ClassificationTherapeutic:Antiarrythmics

Pharmacologic:

Anticholinergics

Increase heart rate. Decreased

GI and respiratory secretions.Reversal of muscarinic effects.

May have a spasmolytic action

on the biliary and genitourinary

tracts.

Indication Sinus bradycardia and

heart block Adjunctive therapy in the

management of pepticulcer an irritable bowel

syndrome

Hypersensitivity Angle-closure

glaucoma Acute hemorrhage Tachycardia secondary

to cardiac insufficiencyor thyrotoxicosis.

Drowsiness Blurred vision Tachycardia Dry mouth Urinary hesitancy

Flushing Decreased

sweating

Caution patients to avoiddriving or other activities

requiring alertness until

response to medication is

known.

Instruct patient that oral rinses,

sugarless gum or candy, and

frequent oral hygiene may helprelieve dry mouth.

Caution patients that atropine

impairs heat regulation.

Strenuous activity in a hot

environment may cause heatstroke.

Generic Name:Digoxin

Brand Name:Lanoxin

Route: PO/IV/IMDosage: 0.5 mg

in 2 mlClassificationTherapeutic:

AntiarrythmicsPharmacologic:

Digitalis

Glycosides

Increases the force of

myocardial contraction.

Prolongs refractory period ofthe AV node. Decreases

conduction through the SAand AV node. Increased

cardiac output and slowing ofthe heart rate.

Indication Heart failure Atrial fibrillation Atrial flutter Paroxysmal atrial

tachycardia

Uncontrolled

ventricular arrythmias Hypersensitivity AV block Idiopathic hypertrophic

subaortic stenosis

Constrictive

pericarditis Hypokalemia hypercalcemia

Anorexia Fatigue Bradycardia Nausea and

vomiting Blurred vision

Thrombocytopenia

Monitor apical pulse before

administering. Withhold dose ifpulse rate is


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REACTION


Generic Name:Dobutamine

Brand Name:Dobutarex

Route: IV

Dosage: 12.5mg/ml


InotropicsPharmacologic:

Adrenergics

Stimulates beta1-adrenergic

receptors with relatively minoreffect on heart rate or

peripheral blood vessels.

Increased cardiac output

without significantly increasedheart rate.

Indication Short-term management of

heart failure caused by

depressed contractilityfrom organic heart disease

or surgical procedures.

Hypersensitivity Idiopathic hypertrophic

subaortic stenosis History of hypertension History of ventricular

atopic activity Hypovolemia Pregnancy or lactation

Headache Nausea and

vomiting Shortness of

breath

Hypertension Increased heart

rate Premature

ventricularcontractions

Angina pectoris Phlebitis

Advise the patient to inform

nurse immediately if chest pain;dyspnea; or numbness, tingling,

or burning of extremities occur.

Monitor BP, HR, ECG,

pulmonary capillary wedgepressure, cardiac output, CVP

and urinary output continuously

during administration.

Palpate peripheral pulses andassess appearance of extremities

routinely throughout

administration.

Monitor potassiumconcentrations during therapy;

may cause hypokalemia.

Generic Name:Dopamine

Brand Name:Intropin

Route: IVDosage: 200mg

in 5 mlClassificationTherapeutic:

Inotropics,Vasopressors

Pharmacologic:

Adrenergics

Increased cardiac output,

increased blood pressure, and

improved renal blood flow.

IndicationAdjunct to standard measures to

improve: Blood pressure; Cardiac output; Urine output in treatment

of shock unresponsive to

fluid replacement.

Tachyarrythmias Pheochromocytoma Hypersensitivity Hypovolemia MI Occlusive vascular

diseases

Headache Mydriasis Nausea and

vomiting Arrhythmias Hypotension

Palpitations Vasoconstriction Irritation at IV

site Dyspnea

Advise the patient to inform

nurse immediately if chest pain;

dyspnea; numbness, tingling, orburning of extremities occur.

Monitor urine output frequently

throughout administration.

If hypotension occurs,

administration rate should beincreased. If hypotension

contiuous, more potent

vasoconstrictors may beadministered.


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REACTION


Generic Name:Epinephrine

Brand Name:Adrenalin

Route: IV/IM/SC

Dosage: 1 mg/mlClassificationTherapeutic:

Antiasthmatic,

bronchodilators,vasopressors

Pharmacologic:Adrenergics

Produces bronchodilation.

Also has alpha-adrenegicagonist properties, which result

in vasoconstriction. Inhibits

the release of mediators of

immediate hypersensitivityreactions from mast cells.Maintenance of heart rate and

BP.

Indication Management of reversible

airway disease due to

asthma or COPD Management of severe

allergic reactions Management of cardiac

arrest Management of upper

airway obstruction

Hypersensitivity Cardiac arrhythmias Hypertension Hyperthyroidism Diabetes

Cerebral

arteriosclerosis Glaucoma

Nervousness Restlessness Tremor Angina Arrythmia

Hypertension Tachycardia Hyperglycemia

Assess lung sounds, respiratory

pattern, pulse and BP beforeadministration.

Instruct patient to contact health

care professionals immediately

if shortness of breath is notrelieved or is accompanied bydiaphoresis, dizziness,

palpitations or chest pain. Observe patient for drug

tolerance and rebound

bronchospasm. Advise patient to maintain

adequate fluid intake to help

liquefy tenacious secretions.

Generic Name:

Furosemide

Brand Name:LasixRoute: IV/IM

Dosage: 200mg/2ml

ClassificationTherapeutic:Diuretics

Pharmacologic:

Loop diuretics

Inhibits the reabsorption of

sodium and chloride from theloop of Henle and distal renal

tubule. Increases renalexcretion of water, sodium,

chloride, magnesium,potassium and calcium.

Dieresis and subsequent

mobilization of excess fluid.Decreased BP.

Indication Edema due to heart failure Hepatic impairment Renal disease hypertension

Hypersensitivity Hepatic coma or anuria Severe liver disease Electrolyte depletion DM

Increasing azotenia

Blurred vision Dizziness Headache Hearing loss Hypotension

Anorexia Constipation Photosensitivity Dehydration Hypokalemia Metabolic

alkalosis Hypovolemia

Assess fluid status. Monitor

daily weight, intake and outputratios, amount and location of

edema, lung sound, skin turgorand mucous membrane.

Monitor BP and pulse beforeand during administration.

Maybe taken with food or milk

to minimize gastric irritation. Caution to change position

slowly to minimize orthostatic

hypotension.


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REACTION


Generic Name:Hydrocortisone

Brand Name:Solu-Cortef

Route: IM/IV

Dosage: 250 mg/2 ml


Antiasthmatic,Pharmacologic:

Corticosteriod(systemic)

Suppression of inflammation

and modification of the normalimmune response.

Indication

Adrenocortical

insufficiency Used systematically and

locally in a wide variety of

chronic diseases including:Inflammatory, Allergic,

Hematologic, Neoplastic,Autoimmune disorders.

Active untreated

infections Lactation Hypothyroidism Cirrhosis

Depression Euphoria Hypertension Anorexia Nausea

Acne Decrease wound

healing Ecchymoses Fragility Hyperglycemia Petechiae Muscle wasting

Assess for signs of adrenal

insufficiency (hypotension,weight loss, weakness, nausea,

vomiting, anorexia, lethargy,

confusion, restlessness) before

and periodically during therapy.

Instruct patient to inform health

care professional promptly if

severe abdominal pain or tarrystools occur.

Corticosteroids cause

immunosuppression and may

mask symptoms of infection.

Generic Name:MagnesiumSulfate

Route: IM/IV

Dosage: 250 mg/ml

Essential for the activity of

many enzymes. Plays animportant role in

neurotransmission and muscular

excitability.

Indication Treatment/prevention of

hypomagnesemia Treatment of hypertension Severe eclampsia, pre-

eclampsia or acute nephritis.

Hypermagnesemia Hypocalcemia Anuria Heart block Any degree of renal

insufficiency

Diarrhea Bradycardia Drowsiness Muscle weakness Flushing Sweating Hypotension

Monitor pulse, BP, respirations

and ECG frequently throughoutadministration. Respirations

should be at least 16/min before

each dose.

Monitor neurologic statusbefore and throughout therapy.

Patellar reflex should be testedbefore each parenteral dose of

magnesium.

Monitor intake and output.

Urine output should be

maintained at a level of at least100ml/4 hr.


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REACTION


Generic Name:Nitroglycerin(Transdermal)

Brand Name:Minitran

Route:Transdermal


AntianginalsPharmacologic:

Nitrates

Increases coronary blood flow

by dilating coronary arteriesand improving collateral flow

to ischemic regions. Produces

vasodilation. Reduces

myocardial consumption.Relief or prevention of anginaattacks. Increased cardiac

output. Reduction of BP.

Indication Long-term prophylactic

management of anginapectoris

Adjunct treatment of CHF Adjunct treatment of acute

MI Production of controlled

hypotension during

surgical procedures.

Hypersensitivity Severe anemia Pericardial tamponade Constrictive

pericarditis

Alcohol intolerance Head trauma or

cerebral hemorrhage Glaucoma Severe liver

impairment

Dizziness Headache Hypotension Tachycardia Abdominal pain

Weakness Blurred vision Contact

dermatitis

Transdermal patches may be

applied to any hairless site(avoid distal extremities or

areas with cuts or calluses). Apply firm pressure over patch

to ensure contact with skin,especially around edges.

Apply new dose unit if the first

one becomes loose or falls off. Remove patches before MRI,

cardioversion, or defibrillation

to prevent patient burns. Patch may be worn 12-14 hr

and removed for 10-12 hr at

night to prevent development of

tolerance.

Generic Name:Norepinephrine

Brand Name:Levophed

Route: IVDosage: 1 mg/ml


Vasopressor

Stimulates alpha-adrenergic

receptors located mainly in

blood vessels, causingconstriction of both

capacitance and resistancevessels. Increased blood

pressure. Increased cardiacoutput.

Indication Produces vasoconstriction

and myocardial

stimulation, which may be

required after adequatefluid replacement in the

treatment of severehypotension and shock.

Hypersensitivity Vascular, mesenteric,

or peripheralthrombosis.

Low uterine blood flow Hypercarbia

Hypotension secondaryto hypovolemia

Concurrent use of

MAO inhibitors

Anxiety Dizziness Dyspnea Insomnia Tremor Weakness

Chest pain Decreased urine

output Renal failure Hyperglycemia Fever Phlebitis at IV

site

Monitor BP every 2-3 min until

stabilized and every 5 min

thereafter. Monitor urine output and notify

health care professional if itdecreases to 30 ml/hr.

Assess IV frequentlythroughout infusion.

Instruct patient to report

headache, dizziness, dyspnea,chest pain or pain at infusion

site promptly.


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REACTION


Generic Name:Phenobarbital

Brand Name:Ancalixir

Route: IV

Dosage: 130mg/ml


Anticonvulsants,sedative/hypnotics

Pharmacologic:Barbiturates

Produces all levels of CNS

depression. Depresses sensorycortex, decreases motor activity

and alters cerebellar function.

Inhibits transmission in the

nervous system and raises theseizure threshold. Capable ofinducing enzymes in the liver

that metabolizes drug, bilirubin

and other compounds.

Indication Tonic-clonic (grand mal),

partial and febrile seizures in

children Preoperative sedative and in

other situations in whichsedation may be required.

Hypnotic (short-term) Prevention of

hyperbilirubinemia inneonates

Hypersensitivity Comatose patients or

those with pre-

existing CNS

depression

Severe respiratory

disease with dyspneaor obstruction

Uncontrolled severe

pain Hepatic dysfunction Severe renal

impairment

Handover Delirium Depression Excitation Lethargy

Respiratory

depression Constipation Bronchospasm

Monitor respiratory status,pulse, and BP frequently in

patients receiving

Phenobarbital IV.

May cause daytime drowsiness.Caution patient to avoid driving

and other activities requiring

alertness until response tomedications.

Teach sleep hygiene techniques

(dark room, quiet, bedtime

ritual, daytime napping, avoid

nicotine and caffeine).

Generic Name:Phytomenadione

(Vitamin K)Route: IV

Dosage: 10mg/mlClassificationTherapeutic:

Antidotes,vitamins

Required for hepatic synthesis ofblood coagulation. Prevention of

bleeding.

Indication

Prevention and treatment ofhypoprothrombinemia, which may

be associated with: Excessive dosage of oral

anticoagulants, Salicylates, Certain anti-infective agent Nutritional deficiencies Prolonged TPN

Prevention of hemorrhagic disease

of the newborn.

Hypersensitivity Impaired liver

function Severe life-

threatening reactionshave occurred

following IV

administration.

Gastric upset Unusual taste Flushing Rash

Hemolyticanemia

Erythema Swelling Pain at injection

site Kernicterus

Monitor for frank and occult

bleeding.

Use a soft toothbrush, do notfloss, and shave with an electric

razor until coagulation defect is

corrected.

Advise patient to report any

symptoms of unusual bleedingor bruising.


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REACTION


Generic Name:Potassium

Chloride

Brand Name:Kalium Durule

Route: IV

Dosage: 2

mEq/ml

Maintain acid-base balance,isotonicity and

electrophysiologic balamce of

the cell. Essential totransmission of nerve

impulses; contraction ofcardiac, skeletal, and smooth

muscle; gastric secretion and

carbohydrate metabolism.

Indication Treatment/prevention of

potassium depletion

Arrhythmias due to digoxin

toxicity.

Hyperkalemia Severe renal

impairment

Untreated Addisons

disease Severe tissue trauma DM Hypomagnesemia

Abdominal pain Flatulence Nausea and

vomiting Diarrhea Weakness Confusion Paresthesia

Assess for signs and symptomsof hypokalemia (fatigue, U wave

on ECG, arrhythmias, polyuria,

polydipsia) and hyperkalemia. Administer with or after meals. Monitor pulse, BP, and ECG

periodically during IV therapy. Instruct patient to avoid salt

substitutes or low-salt milk orfood unless approved by health

care professional. Instruct patient to report dark,

tarry stools; weakness, unusual

fatigue or tingling of extremities.

Generic Name:Sodium

Bicarbonate

Brand Name:Citrocarbonate

Route: IV/PODosage: 1mEq/kg

Classification

Therapeutic:Antiulcer

Pharmacologic:Alkanizing agent

Acts as an alkanizing agent byreleasing bicarbonate ions.

Neutralization of gastric acid.

Indication Metabolic acidosis Used to alkanize urine and

promote excretion of

certain drugs in overdosesituation.

Stabilization of acid-basestatus in cardiac arrest

Treatment of life-threatening hyperkalemia.

Metabolic orrespiratory alkalosis

Hypocalcemia Hypernatremia Excessive chloride loss Renal failure CHF

Edema Flatulence Irritation at IV

site Tetany Cerebral

hemorrhage Gastric

distention

Assess fluid balance (intake andoutput, daily weight, edema,

lung sounds) throughout therapy. Assess for signs of acidosis

(disorientation, weakness,

dyspnea, hyperventilation),alkalosis (confusion, paresthesia,

tetany, altered breathing pattern),

hypernatremia or hypokalemiathroughout therapy.

Advise not to take milk productsconcurrently with this

medication. Avoid routine use of this drug

for indigestion. Sodium restricted diet to avoid

use of baking soda as a home

remedy for indigestion.

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