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Drug management
Published in Gregory YH Lip, Atrial Fibrillation in Practice, 2020
In acute AF, the use of esmolol, a short- and rapidly acting intravenous beta-blocker, either alone or with digoxin is effective for rate control and can be titrated according to response, and may even cardiovert some patients. Esmolol is also useful in the postoperative setting and post-myocardial infarction, especially with some uncertainty over the use of long-acting beta-blockers in the acute stages.
Medical Management of Thyroid Disorders
Published in Madan Laxman Kapre, Thyroid Surgery, 2020
Himanshu Patil, Shailesh Pitale
Although Propranolol was the initial choice of drugs used in the dose of 80–160 mg/day in undivided doses, similar effects are produced by 50–200 mg of Atenolol or Metoprolol or 40–80 mg of Nadolol. Propranolol or Esmolol can be used intravenously for patients who are acutely ill.
Supraventricular tachyarrhythmias in the elderly
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Jason T. Jacobson, Sei Iwai, Ali Ahmed, Wilbert S. Aronow
Metoprolol can be given intravenously in a dose of 5.0 mg every 2 minutes to a maximum dose of 15 mg. After 15 minutes, oral metoprolol can be started at 25–50 mg every 6 hours, titrating up as needed to a maximum dose of 400 mg/day. Esmolol administered intravenously in a dose of 0.5 mg/kg over 1 minute followed by 0.05–0.1 mg/kg per minute may also be used to decrease a very rapid ventricular rate in AF. The short half-life of esmolol (9 minutes) allows for rapid offset of action should side effects occur. Other β-blockers can be used with appropriate doses administered.
Current pharmacotherapeutic strategies for cardiac arrhythmias in heart failure
Published in Expert Opinion on Pharmacotherapy, 2020
Ashish Correa, Yogita Rochlani, Wilbert S. Aronow
For AF with a rapid ventricular response, initial intravenous therapy may be used, but ultimately patients should be bridged to oral beta-blocker therapy (see Table 1 for details regarding the route of administration and dosing). Metoprolol and esmolol are usually used as intravenous agents for ventricular rate control. Intravenous metoprolol may be given as 2.5 to 5 mg bolus over 2 min, with the dose repeated every 5 min until adequate rate control is achieved, but to a maximum of 15 mg. After this point, the therapy should be switched to an oral regimen. Esmolol is often used as a trial of beta-blocker therapy, especially in patients in whom there is concern regarding starting beta-blockers. This is because esmolol as a very rapid onset of action, and due to its rapid metabolism in the blood, it has a short duration of action [33]; thus, when an esmolol infusion is discontinued, its effects are short-lasting. For acute rate control, esmolol may be given as an intravenous bolus, followed by an infusion until oral medications can be started (see Table 1 for details).
Multi-Organ System Injury from Inhalant Abuse
Published in Prehospital Emergency Care, 2019
H. Evan Dingle, Saralyn R. Williams
In the field, all patients with suspected inhalant abuse should be placed on a cardiac monitor. Obtain a 12-lead ECG to evaluate for evidence of ischemia and arrhythmias. Oxygen should be applied to maintain oxygen saturation. Basic Life Support measures should be initiated in the patient who is pulseless. Identification of the primary rhythm will assist with the management of the patient. Unlike standard ACLS treatment, epinephrine and other catecholamines should be avoided due to the increased sensitivity of the myocardium to catecholamines that is induced by halogenated hydrocarbons (5). Instead, beta blockers are recommended as a treatment for ventricular dysrhythmias caused by inhalants (2,5). Although often not available in the prehospital setting, esmolol is a good choice due to its rapid onset of action and short half-life (8). Medical directors should educate paramedics on the deleterious effects of epinephrine in ventricular dysrhythmias from hydrocarbon exposure and should consider modifying cardiac arrest protocols to avoid epinephrine administration in these situations. Otherwise, patients presenting with cardiac arrest should receive standard ACLS treatment. Seizures and agitated delirium are treated in standard fashion with benzodiazepines being the drug class of choice. Prior to drug administration, however, hypoxia and hypoglycemia should always be ruled out as the cause. Prolonged QT interval should be excluded by ECG prior to administration of QT-prolonging drugs, including anti-emetics such as ondansetron.
Cochlear implantation in children with congenital long QT syndrome: Introduction of an evidence-based pathway of care
Published in Cochlear Implants International, 2018
Victoria Scott-Warren, Anju Bendon, Iain A. Bruce, Lise Henderson, Jacques Diacono
The theatre team meets for the team brief before the child is brought to the operating theatre suite to ensure that all members are aware of the plan for the perioperative management of the child. In addition to the usual theatre team members, the consultant paediatric cardiologist is alerted to the impending anaesthesia, and a member of the cardiac catheterization team attends the team brief. A pacing defibrillator, a 4 french gauge (FG) introducer sheath, transvenous pacing wires and a pacemaker box are checked and made immediately available. This equipment will allow cardiac pacing for significant, un-resolving bradycardias or overdrive pacing of tachyarrhythmias. Whilst the precautionary insertion of a pacemaker wire in such patients preoperatively has been described in case reports, we do not feel the balance of risks in small children justifies this measure routinely. The correct weight-adjusted dose of esmolol is similarly immediately available as recommended (Staikou et al., 2012). On arrival in the anaesthetic room, the child has ECG leads applied and a baseline QTc is measured. QTc and delta QTc is measured thereafter at 5 minute intervals, in addition to standard anaesthetic monitoring.