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2. after appropriate vagal maneuvers (e.g., Valsalva maneuver) have been attempted

3. Myocardial perfusion imaging radionuclide (adjunct) or[Stress echocardiography (adjunct)

4. In patients unable to exercise adequately,

6. suitable for infiltration, block and surface anesthesia. Longer-acting substances such as bupivacaine are sometimes given preference for spinal and peridural anesthesias; lidocaine, on the other hand, has the advantage of a rapid onset of action. Adrenaline vasoconstricts arteries and hence delays the resorption of Lidocaine, almost doubling the duration of anaesthesia. For surface anesthesia several formulations are available that can be used e.g. for endoscopies, before intubations etc.

7. used intravenously for the treatment of ventricular arrhythmias (for acute myocardial infarction, digitalis poisoning, cardioversion or cardiac catheterization). However, a routine prophylactic administration is no longer recommended for acute cardiac infarction; the overall benefit of this measure is not convincing.

8. efficient in refractory cases of status epilepticus.

9. proved effective in treating jellyfish stings, both numbing the affected area and preventing further nematocyst dischargeDosages<br />The dose should generally be reduced in children, elderly, or debilitated patients. In normal healthy adults, the maximum recommended dose of lidocaine injection with epinephrine for local anesthesia other than spinal should not exceed 7 mg/Kg, and the maximum total dose should not exceed 500 mg. Lidocaine injection with epinephrine should not be used on fingers and toes. The maximum recommended dose of lidocaine injection without epinephrine should not exceed 4.5 mg/Kg, and the maximum total dose should not exceed 300 mg. Once given the maximum dose of lidocaine, it should not be repeated for 2 hours. <br />Viscous lidocaine 2% is typically dosed as 15 ml (300 mg) orally swish and spit/swallow every 3 hours as needed in adults. Patients should not exceed 8 doses in 24 hours. Adverse effects such as dizziness, light-headedness, and numbness of the tongue have been reported with 500 mg oral doses of lidocaine. Topical administration of lidocaine in adults and children should not exceed 3 mg/Kg/dose (e.g., 4.2 gm of a 5% ointment for a 70 Kg patient). The dose should not be repeated within 2 hours. <br />The maximum adult dose for the lidocaine 5% patch (Lidoderm) is up to 3 patches may be applied at a time for no more than 12 hours per 24-hour period. Lidocaine 4% cream (L.M.X.4) should not be applied to an area over 100 cm2 for patients under 10 Kg and an area over 600 cm2 for patients between 10 and 20 Kg. The amount absorbed systemically is determined by the area over which it is applied and the duration of application, particularly if it is left on for longer than 2 hours to a large surface area.<br />The recommended maximum dose, application area, and application time of lidocaine 2.5% with prilocaine 2.5% cream (EMLA), depend upon the weight and age of the patient. Children under 3 months of age or less than 5 Kg can receive up to 1 gm over 10 cm2 for up to 1 hour. Children 3 to 12 months of age and over 5 Kg can receive up to 2 gm per dose over 20 cm2 for up to 4 hours. Children 1 to 6 years of age and more than 10 Kg can receive up to 10 gm per dose over 100 cm2 for up to 4 hours, and children 7 to 12 years old and greater than 20 Kg can receive up to 20 gm per dose over a 200 cm2 area for up to 4 hours.<br />Mechanism of action<br />Lidocaine alters signal conduction in neurons by blocking the fast voltage gated sodium (Na+) channels in the neuronal cell membrane that are responsible for signal propagation[4]. With sufficient blockage the membrane of the postsynaptic neuron will not depolarize and will thus fail to transmit an action potential. This creates the anaesthetic effect by not merely preventing pain signals from propagating to the brain but by aborting their birth in the first place. Careful titration allows for a high degree of selectivity in the blockage of sensory neurons, whereas higher concentrations will also affect other modalities of neuron signaling.<br />Precautions<br />Physician must be notified about patients medical history, especially: heart problems (e.g., heart block, heart failure), high or low blood pressure, liver problems, kidney problems, any allergies. This medication is not recommended for use if patient have the following medical conditions: nerve disease, spine problems. Causes dizziness or drowsiness; use caution engaging in activities requiring alertness such as driving or using machinery. Avoid alcoholic beverages. Depending on how and where this drug is injected into the body, patient may experience temporary weakness. To minimize dizziness and lightheadedness, tell patient get up slowly when rising from a seated or lying position. Notify physician if weakness or problems with muscle control persist. Caution is advised when using this drug in the elderly because they may be more sensitive to the effects of the drug. Caution is advised when using this drug in children because they may be more sensitive to the effects the drug. Tell physician if patient is are pregnant before using this medication. This medication passes into breast milk. Consult physician before breast-feeding.<br />procainamide<br />Indications and dosages<br />OralIntravenousVentricular arrhythmiasAdult: 50 mg/kg daily in divided doses every 3-6 hr.Child: 15-50 mg/kg daily in 4 divided doses. Elderly: Dosage reduction or increase in dosing intervals is recommended. Renal impairment: Dosage reduction or increase in dosing intervals is recommended. Hepatic impairment: Dosage reduction is recommended. Ventricular arrhythmiasAdult: Dilute in 5% glucose soln and given in doses of 100 mg every 5 min at a rate not exceeding 50 mg/min until arrhythmia has been suppressed or a max of 1 g has been reached. Alternatively admin by continuous infusion of 500-600 mg over 25-30 min with ECG monitoring followed by infusion at a rate of 2-6 mg/min. Child: Loading dose of 10-12 mg/kg, followed by continuous infusion of 20-75 mcg/kg/min.Elderly: Dosage reduction or increase in dosing intervals is recommended. Max Dosage: Adult: 1 g.Renal impairment: Dosage reduction or increase in dosing intervals is recommended. Hepatic impairment: Dosage reduction is recommended. Short-term management of severe or symptomatic arrhythmiasAdult: 50 mg/kg daily in divided doses every 3-6 hr.Child: 15-50 mg/kg daily in 4 divided doses. Elderly: Dosage reduction or increase in dosing intervals is recommended. Renal impairment: Dosage reduction or increase in dosing intervals is recommended. Hepatic impairment: Dosage reduction is recommendedShort-term management of severe or symptomatic arrhythmiasAdult: Dilute in 5% glucose soln and given in doses of 100 mg every 5 min at a rate not exceeding 50 mg/min until arrhythmia has been suppressed or a max of 1 g has been reached. Alternatively admin by continuous infusion of 500-600 mg over 25-30 min with ECG monitoring followed by infusion at a rate of 2-6 mg/min. Child: Loading dose of 10-12 mg/kg, followed by continuous infusion of 20-75 mcg/kg/min.Elderly: Dosage reduction or increase in dosing intervals is recommended. Max Dosage: Adult: 1 g.Renal impairment: Dosage reduction or increase in dosing intervals is recommended. Hepatic impairment: Dosage reduction is recommended.<br />Procainamide is an antiarrhythmic drug used in the treatment of abnormal heart rhythms such as: <br />early (premature) atrial and ventricular beats; <br />intermittent rapid rhythms (tachycardias) involving the atria and atrio-ventricular (AV) junction as well as abnormal pathways (bypass tracts) between the atria and ventricles; <br />intermittent atrial fibrillation and flutter; <br />after conversion from atrial fibrillation or flutter to prevent recurrence; and<br />ventricular tachycardia.<br />The oral dose and interval of administration should be adjusted for the individual patient, based on clinical assessment of the degree of underlying myocardial diseased, the patient's age, and renal function.<br />As a general guide, for younger adult patients with normal renal function, an initial total daily oral dose of up to 50 mg/kg of body weight of PRONESTYL Capsules or Tablets may be used, given in divided doses, every three hours, to maintain therapeutic blood levels. For older patients, especially those over 50 years of age, or for patients with renal, hepatic, or cardiac insufficiency, lesser amounts or longer intervals may produce adequate blood levels, and decrease the probability of occurrence of dose-related adverse reactions. The total daily dose should be administered in divided doses at three, four, or six hour intervals and adjusted according to the patient's response.<br />To provide approximately 50 mg per kg of body weight per day*Patients weighinglbkg88-11040-50250 mg q3h to 500 mg q6h132-15460-70375 mg q3h to 750 mg q6h176-19880-90500 mg q3 hr to 1 g q6h> 220> 100625 mg q3h to 1.25 g q6h*Initial dosage schedule guide only, to be adjusted for each patient individually, based on age, cardiorenal function, blood level (if available), and clinical response.<br />HOW SUPPLIED<br />PRONESTYL Capsules (Procainamide Hydrochloride Capsules USP)250 mg: two-piece yellow gelatin capsules printed with 758 bottles of 100NDC 0003-0758-50bottles of 1000NDC 0003-0758-80cartons of 100 Unimatic* unit-dose capsulesNDC 0003-0758-53375 mg: white and orange gelatin capsules printed with 756 bottles of 100NDC 0003-0756-50cartons of 100 Unimatic* unit-dose capsulesNDC 0003-0756-53500 mg: yellow and orange gelatin capsules printed with 757 bottles of 100NDC 0003-0757-50bottles of 1000NDC 0003-0757-80cartons of 100 Unimatic* unit-dose capsulesNDC 0003-0757-53PRONESTYL Tablets (Procainamide Hydrochloride Tablets USP)250 mg: yellow FILMLOK® tablets debossed with 431 bottles of 100NDC 0003-0431-50375 mg: orange FILMLOK® tablets debossed with 434 bottles of 100NDC 0003-0434-50500 mg: red FILMLOK® tablets debossed with 438 bottles of 100NDC 0003-0438-50<br />Mechanisms of action<br />Procainamide directly interferes with depolarization of the cell membrane by blocking the fast inward current of Na into cardiac cells. It slows the rate of change of the depolarization phase of the action potential, moderately prolong the PR, QRS and QT intervals on ECG monitoring. It also has local anesthetic properties.<br />Procainamide (PA) increases the effective refractory period of the atria, and to a lesser extent the bundle of His-Purkinje system and ventricles of the heart. It reduces impulse conduction velocity in the atria, His-Purkinje fibers, and ventricular muscle, but has variable effects on the atrioventricular (A-V) node, a direct slowing action and a weaker vagolytic effect which may speed A-V conduction slightly. Myocardial excitability is reduced in the atria. Purkinje fibers, papillary muscles, and ventricles by an increase in the threshold for excitation, combined with inhibition of ectopic pacemaker activity by retardation of the slow phase of diastolic depolarization, thus decreasing automaticity especially in ectopic sites. Contractility of the undamaged heart is usually not affected by therapeutic concentrations, although slight reduction of cardiac output may occur, and may be significant in the presence of myocardial damage. Therapeutic levels of PA may exert vagolytic effects and produce slight acceleration of heart rate, while high or toxic concentrations may prolong A-V conduction time or induce A-V block, or even cause abnormal automaticity and spontaneous firing, by unknown mechanisms.<br />Precautions<br />Use cautiously in patients with Myocardial damage or severe organic heart disease, asthma. Perform regular blood tests. Screen for lupus erythematosus. Serum antinuclear factor should be carried out before and regularly during therapy. Pregnancy, elderly, hepatic and renal impairment. May worsen torsade de pointes. Pre-treatment with digoxin may be necessary if procainamide is used in the treatment of atrial tachycardia. IV admin may cause severe hypotension, thus slow inj and monitoring of ECG and BP are recommended.<br />General<br />Immediately after initiation of PA therapy, patients should be closely observed for possible hypersensitivity reactions, especially if procaine or local anesthetic sensitivity is suspected, and for muscular weakness if myasthenia gravis is a possibility.<br />In conversion of atrial fibrillation to normal sinus rhythm by any means, dislodgement of mural thrombi may lead to embolization, which should be kept in mind.<br />After a day or so, steady state plasma PA levels are produced following regular oral administration of a given dose of PRONESTYL (Procainamide Hydrochloride Tablets; Procainamide Hydrochloride Capsules) at set intervals, with peak plasma concentrations at about 90 to 120 minutes after each dose. After achieving and maintaining therapeutic plasma concentrations and satisfactory electrocardiographic and clinical responses, continued frequent periodic monitoring of vital signs and electrocardiograms is advised.<br />If evidence of QRS widening of more than 25 percent or marked prolongation of the Q-T interval occurs, concern for overdosage is appropriate, and reduction in dosage is advisable if a 50 percent increase occurs. Elevated serum creatinine or urea nitrogen, reduced creatinine clearance, or history of renal insufficiency, as well as use in older patients (over age 50), provide grounds to anticipate that less than the usual dosage and longer time intervals between doses may suffice, since the urinary elimination of PA and NAPA may be reduced, leading to gradual accumulation beyond normally predicted amounts. If facilities are available for measurement of plasma PA and NAPA, or acetylation capability, individual dose adjustment for optimal therapeutic levels may be easier, but close observation of clinical effectiveness is the most important criterion.<br />SOURCES:<br />http://www.rxlist.com/atropine-drug.htm <br />http://www.templejc.edu/dept/ems/drugs/atropine.html<br />http://www.drugs.com/mmx/adenosine.html <br />http://en.wikipedia.org/wiki/Lidocaine#Indications<br />http://www.medicinenet.com/procainamide/article.htm<br />http://www.mims.com/Page.aspx?menuid=mng&name=procainamide<br />http://www.rxlist.com/pronestyl-drug.htm<br />