Presentaci

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ANTIARRÍTMICOS
-Sebastián Cárdenas V -Jaime Mella R..
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DEFINICION
TRATAMIENTO
FRECUENCIA
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Extracelular Na Ca2
Cl-
Intracelular K
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(No Transcript)
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Ca2
20 mV
K
Na
K
Na
-90 mV
Tiempo
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ECG
R
T
P
Q
S
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ESTRATEGIA
-50 mV
-65 mV
-75 mV
Pot. Umbral
-85 mV
Pot. Diastólico máx.
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• Clasificación de los Fármacos Antiarrítmicos
• Grupo I
• Grupo II
• Grupo III
• Grupo IV

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QUINIDINA
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-ADME -CONC. TERAPÉUTICAS Y TÓXICAS -CINCONISMO -R
IESGO DE MUERTE. -CATEGORÍA C
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TRATAMIENTO

• EMESIS - Not recommended because of the risk of
  significant dysrhythmias, seizures, and coma.
• ACTIVATED CHARCOAL Administer charcoal as a
  slurry (240 mL water/30 g charcoal). Usual dose
  25 to 100 g in adults/adolescents, 25 to 50 g in
  children (1 to 12 years), and 1 g/kg in infants
  less than 1 year old.
• GASTRIC LAVAGE Consider after ingestion of a
  potentially life-threatening amount of poison if
  it can be performed soon after ingestion
  (generally within 1 hour). Protect airway by
  placement in Trendelenburg and left lateral
  decubitus position or by endotracheal intubation.
  Control any seizures first. CONTRAINDICATIONS
  Loss of airway protective reflexes or decreased
  level of consciousness in unintubated patients
  following ingestion of corrosives hydrocarbons
  (high aspiration potential) patients at risk of
  hemorrhage or gastrointestinal perforation and
  trivial or non-toxic ingestion.
• Monitor plasma and serum potassium levels. If
  refractory dysrhythmia develops, assess Ca and
  Mg.
• E) Administration of SODIUM BICARBONATE (1 to
  2 mEq/kg IV in an adult, or 1/2 to 1 mEq/kg in a
  child) may decrease toxicity.

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• F) TORSADES DE POINTES Hemodynamically unstable
  patients require electrical cardioversion. Treat
  stable patients with magnesium, isoproterenol,
  and/or atrial overdrive pacing. Correct
  electrolyte abnormalities (hypomagnesemia,
  hypokalemia, hypocalcemia).
• MAGNESIUM SULFATE/DOSE ADULTS 2 g IV over 1 to
  2 min, repeat 2 g bolus and begin infusion of 0.5
  to 1 g/hr if dysrhythmias recur. CHILDREN 25 to
  50 mg/kg diluted to 10 mg/mL infuse IV over 5 to
  15 min.
• ISOPROTERENOL/DOSE Correct hypovolemia first.
  ADULT 2 to 10 mcg/minute (CHILD 0.1 to 1
  mcg/kg/minute) IV infusion titrate to heart rate
  and rhythm response. Mix 1 mg isoproterenol HCl
  in 500 mL D5W for a 2 mcg/mL solution.
• Avoid class Ia (quinidine, disopyramide,
  procainamide, aprindine) and most class III
  antidysrhythmics (N-acetylprocainamide, sotalol).
• G) PHENYTOIN OR LIDOCAINE (type I
  antiarrhythmics) may be used to control some
  types of dysrhythmias. Phenytoin theoretically is
  preferred as it increases AV conduction velocity.
  DO NOT use procainamide or disopyramide.
• 1) LIDOCAINE ADULT LOADING DOSE 1 to
  1.5 mg/kg IV push for refractory VT/VF may give
  an additional bolus of 0.5 to 0.75 mg/kg over 3
  to 5 min. Do not exceed 3 mg/kg or 200 to 300 mg
  over one hour. INFUSION Once circulation
  restored begin infusion of 1 to 4 mg/min.
  PEDIATRIC LOADING DOSE 1 mg/kg INFUSION 20 to
  50 mcg/kg/min. Monitor ECG continuously.

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• H) Initial treatment of bradycardia or heart
  block should include the use of atropine and
  isoproterenol.
• Consider temporary pacemaker insertion in
  patients with refractory bradycardia, Mobitz II
  block, or third degree heart block.
• HYPOTENSION - Theoretically, pure or predominant
  alpha agonists such as norepinephrine or
  metaraminol may be more effective.
• HYPOTENSION Infuse 10 to 20 mL/kg isotonic
  fluid. If hypotension persists, administer
  dopamine (5 to 20 mcg/kg/min) or norepinephrine
  (ADULT begin infusion at 0.5 to 1 mcg/min
  CHILD begin infusion at 0.1 mcg/kg/min) titrate
  to desired response.
• J) SEIZURES Administer a benzodiazepine IV
  DIAZEPAM (ADULT 5 to 10 mg, repeat every 10 to
  15 min as needed. CHILD 0.2 to 0.5 mg/kg, repeat
  every 5 min as needed) or LORAZEPAM (ADULT 2 to
  4 mg CHILD 0.05 to 0.1 mg/kg).
• 1) Consider phenobarbital if seizures recur after
  diazepam 30 mg (adults) or 10 mg (children gt 5
  years).
• 2) Monitor for hypotension, dysrhythmias,
  respiratory depression, and need for endotracheal
  intubation. Evaluate for hypoglycemia,
  electrolyte disturbances, hypoxia.

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LIDOCAÍNA
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TRATAMIENTO

• EMESIS - Contraindicated after oral overdose due
  to rapid development of seizures.
• Ingestion of most of these liquid formulations
  results in rapid absorption and gastric
  decontamination is of limited utility.
• C) ACTIVATED CHARCOAL Administer charcoal as a
  slurry (240 mL water/30 g charcoal). Usual dose
  25 to 100 g in adults/adolescents, 25 to 50 g in
  children (1 to 12 years), and 1 g/kg in infants
  less than 1 year old.
• SEIZURES - Administer diazepam IV bolus (DOSE
  ADULT 5 to 10 mg initially which may be repeated
  every 15 minutes PRN up to 30 mg. CHILD 0.25 to
  0.4 mg/kg dose up to 10 mg/dose) or lorazepam IV
  bolus (DOSE ADULT 4 to 8 mg CHILD 0.05 to 0.1
  mg/kg).
• 1) If seizures are uncontrollable
  or recur, give phenobarbital.
• 2) Phenytoin may worsen or
  precipitate cardiac arrhythmias from local
  anesthetics and should be avoided.
• COMA/RESPIRATION DEPRESSION - Protect the airway
  with an endotracheal tube and assist ventilation
  as necessary.
• BRADYCARDIA/BRADYARRHYTHMIAS - If symptomatic
  and heart rate is less than 60, consider
  administration of atropine 15 mcg/kg (up to 0.4
  to 0.6 mg/dose) IV, IM or subcutaneously.

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• G) HYPOTENSION Infuse 10 to 20 mL/kg
  isotonic fluid. If hypotension persists,
  administer dopamine (5 to 20 mcg/kg/min) or
  norepinephrine (ADULT begin infusion at 0.5 to 1
  mcg/min CHILD begin infusion at 0.1
  mcg/kg/min) titrate to desired response.
• H) ACIDOSIS - Severe metabolic acidosis (pH
  lt7.1) should be corrected with IV sodium
  bicarbonate. Respiratory acidosis should be
  treated by assisted ventilation. Monitor serum
  bicarbonate and arterial blood gases to guide
  therapy.
• METHEMOGLOBINEMIA Administer 1 to 2 mg/kg of 1
  methylene blue slowly IV in symptomatic patients.
  Additional doses may be required.
• J) ELIMINATION ENHANCEMENT - Hemodialysis,
  exchange transfusion, AV hemofiltration and
  forced diuresis have not been shown to increase
  clearance substantially. Urinary acidification is
  NOT recommended.

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PROPAFENONA
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TRATAMIENTO
A) In overdose ventricular dysrhythmias and
seizures have been reported. Patients should be
monitored for ventricular tachydysrhythmias and
provided with supportive care. No specific
antidote exists. B) EMESIS Ipecac-induced
emesis is not recommended because of the
potential for seizures. C) GASTRIC LAVAGE
Consider after ingestion of a potentially
life-threatening amount of poison if it can be
performed soon after ingestion (generally within
1 hour). Protect airway by placement in
Trendelenburg and left lateral decubitus position
or by endotracheal intubation. Control any
seizures first. 1) CONTRAINDICATIONS Loss of
airway protective reflexes or decreased level of
consciousness in unintubated patients following
ingestion of corrosives hydrocarbons (high
aspiration potential) patients at risk of
hemorrhage or gastrointestinal perforation and
trivial or non-toxic ingestion. D) ACTIVATED
CHARCOAL Administer charcoal as a slurry (240 mL
water/30 g charcoal). Usual dose 25 to 100 g in
adults/adolescents, 25 to 50 g in children (1 to
12 years), and 1 g/kg in infants less than 1 year
old.
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E) VENTRICULAR DYSRHYTHMIAS - Institute
continuous cardiac monitoring, obtain an ECG, and
administer oxygen. Evaluate for hypoxia,
acidosis, and electrolyte disorders. Intravenous
bicarbonate may be useful in patients with QRS
widening or ventricular dsyrhythmias. Administer
1 to 2 mEq/kg bolus and repeat as needed. Monitor
ECG and arterial blood gases maintain pH 7.45 to
7.55. 1) If unresponsive to bicarbonate,
lidocaine is generally the first line agent.
Consider bretylium and/or phenytoin if
dysrhythmias persist. F) HYPOTENSION Infuse 10
to 20 mL/kg isotonic fluid. If hypotension
persists, administer dopamine (5 to 20
mcg/kg/min) or norepinephrine (ADULT begin
infusion at 0.5 to 1 mcg/min CHILD begin
infusion at 0.1 mcg/kg/min) titrate to desired
response. G) SEIZURES - Administer a
benzodiazepine IV DIAZEPAM (ADULT 5 to 10 mg,
repeat every 10 to 15 minutes as needed. CHILD
0.2 to 0.5 mg/kg, repeat every 5 minutes as
needed) or LORAZEPAM (ADULT 4 to 8 mg CHILD
0.05 to 0.1 mg/kg). 1) Consider phenobarbital if
seizures are uncontrollable or recur after
diazepam 30 mg (adults) or 10 mg (children gt 5
years). 2) Monitor for hypotension,
dysrhythmias, respiratory depression and the need
for endotracheal intubation. 3) Evaluate for
hypoglycemia, electrolyte disturbances, and
hypoxia. 4) Phenytoin is generally NOT
recommended as it may exacerbate cardiotoxicity.

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H) ATROPINE ADULT DOSE BRADYCARDIA 0.5 to 1 mg
IV every 5 min. ASYSTOLE 1 mg IV every 5 min.
Maximum total dose 3 mg or 0.04 mg/kg. Minimum
single dose 0.5 mg. PEDIATRIC DOSE 0.02 mg/kg IV
repeat every 5 min, minimum single dose 0.1 mg
maximum single dose child 0.5 mg, adolescent 1
mg maximum total dose 1 mg child, 2 mg
adolescent.
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AHORA CONTINÚA CÁRDENAS...
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ANTIARRÍTMICOS CLASE II
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AMIODARONA
LD50254mg/kg ratones i.p., LD50885mg/kg ratas
i.p. BDoral29-100, Vd65.8L/kg, t1/29-44días
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SOTALOL
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SOTALOL

• Torsades de pointes
• Prolongado intervalo QT
• Fibrilación ventricular
• Asístole ventricular

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ANTIARRÍTMICOS CLASE III
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PROPRANOLOL
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RECEPTORES BETA
ß1
ß2
ß3
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TOXICOLOGÍA GENERAL

• Liposolubilidad
• Actividad estabilizante de membrana
• Actividad simpaticomimética intrínseca
• Metabolismo
• Cardioselectividad

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ANTIARRÍTMICOS CLASE IV
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ANTIARRÍTMICOS CLASE IV
Verapamilo
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TOXICOLOGÍA GENERAL

• Efectos cardiovasculares
• Efectos respiratorios
• Efectos sobre SNC
• Otros

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Fármacos Exposición letal mínima(g) Exposición máxima tolerada(g)
Amiodarona 8
Propranolol 2.06-9.6 2-3
Atenolol 1-1.8
Metoprolol 7.5-10 4.84
Verapamilo 4.16 16
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EMBARAZO
Droga Categoría
Amiodarona C
Propanolol C
Atenolol D
Metoprolol C
Verapamilo C
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TRATAMIENTO

• Apoyo cardiorespiratorio de funciones afectadas
• Tratamiento sintomático
• Monitoreo electrolitos, función renal, glicemia,
  presión arterial, ECG.
• Ingestión oral lavado gástrico, carbón activado.

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CONCLUSIÓN PEROGRULLESCA
TODOS
LOS
ANTIARRÍTMICOS
PRODUCEN
ARRITMIAS
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RESUMEN BIBLIOGRÁFICO
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La realidad tiene limites la estupidez no.
Napoleón
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