4.1. Therapeutic indications

• Supraventricular tachycardia (except for pre-excitation syndromes) or non-compensatory sinus tachycardia

Brevibloc is indicated for for the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other circumstances where short-term control of the ventricular rate with a short acting agent is desirable.

Brevibloc is also indicated for non-compensatory sinus tachycardia where, in the physician's judgement the rapid heart rate requires specific intervention.

• Tachycardia and hypertension occurring in the perioperative phase

Treatment of tachycardia and hypertension that occur during induction of anesthesia and tracheal intubation, during surgery, on emergence from anesthesia, and in the postoperative period, when in the physician's judgment such specific intervention is considered indicated.

Brevibloc is not indicated for use in children aged up to 18 years (see section 4.2). Brevibloc is not intended for use in chronic settings.

4.2. Posology and method of administration

Posology

Brevibloc Premixed 10 mg/ml Solution for Injection is a ready-to-use 10 mg/ml solution recommended for intravenous administration.

This dosage form is used to administer the appropriate Brevibloc loading dose or bolus dose by hand held syringe.

SUPRAVENTRICULAR TACHYARRYTHMIA (except for pre-excitation syndromes) OR NON-COMPENSATORY SINUS TACHYCARDIA

The Brevibloc dosage in supraventricular tachyarrhythmias should be individually titrated as indicated in the below flow chart.

Loading dose

Loading dose adjustment may be necessary depending on the haemodynamic response (heart rate, blood pressure)

Maintenance dose

For a continuous and progressive dosage an effective maintenance dose is between 50 to 200 micrograms/kg/minute. 25 micrograms/kg/minute doses may be used.

Maintenance dose adjustment may be necessary depending on the desired haemodynamic response.

Administration of doses greater than 200 mcg/kg/min provides little added heart rate-lowering effect, and the rate of adverse reactions increases.

Loading dose and maintenance doses of Brevibloc to administer for different patient weights are outlined in Table 1 and Table 2 respectively.

Table 1

Volume of Brevibloc 10 mg/ml required for an INITIAL LOADING DOSE of 500 mcg/ kg / minute

Patient weight (kg)

40

50

60

70

80

90

100

110

120

Volume (ml)

2

2.5

3

3.5

4

4.5

5

5.5

6

Table 2

Volume of Brevibloc 10 mg/ml required to provide MAINTENANCE DOSES at infusion rates between 12.5 and 300 mcg/kg/minute

Patient weight (kg)

Infusion Dose Rate

12.5 mcg/kg/min

25 mcg/kg/min

50 mcg/kg/min

100 mcg/kg/min

150 mcg/kg/min

200 mcg/kg/min

300 mcg/kg/min

Amount to administer per hour to achieve the dose rate (ml / hr)

40

3 ml/hr

6 ml/hr

12 ml/hr

24 ml/hr

36 ml/hr

48 ml/hr

72 ml/hr

50

3.75 ml/hr

7.5 ml/hr

15 ml/hr

30 ml/hr

45 ml/hr

60 ml/hr

90 ml/hr

60

4.5 ml/hr

9 ml/hr

18 ml/hr

36 ml/hr

54 ml/hr

72 ml/hr

108 ml/hr

70

5.25 ml/hr

10.5 ml/hr

21 ml/hr

42 ml/hr

63 ml/hr

84 ml/hr

126 ml/hr

80

6 ml/hr

12 ml/hr

24 ml/hr

48 ml/hr

72 ml/hr

96 ml/hr

144 ml/hr

90

6.75 ml/hr

13.5 ml/hr

27 ml/hr

54 ml/hr

81 ml/hr

108 ml/hr

162 ml/hr

100

7.5 ml/hr

15 ml/hr

30 ml/hr

60 ml/hr

90 ml/hr

120 ml/hr

180 ml/hr

110

8.25 ml/hr

16.5 ml/hr

33 ml/hr

66 ml/hr

99 ml/hr

132 ml/hr

198 ml/hr

120

9 ml/hr

18 ml/hr

36 ml/hr

72 ml/hr

108 ml/hr

144 ml/hr

216 ml/hr

1ml of Brevibloc is equivalent to 10mg of esmolol.

As the desired heart rate or safety end-point (e.g., lowered blood pressure) is approached, OMIT the loading dose and reduce the incremental dose in the maintenance infusion from 50 micrograms/kg/minute to 25 micrograms/kg/minute or lower. If necessary, the interval between the titration steps may be increased from 5 to 10 minutes.

PERIOPERATIVE TACHYCARDIA AND HYPERTENSION

For perioperative tachycardia and hypertension the dosing regimen may vary as follows:

For intraoperative treatment - during anaesthesia when immediate control is required:

• A bolus injection of 80 mg is given over 15 to 30 seconds followed by a 150 micrograms/kg/minute infusion. Titrate the infusion rate as required up to 300 micrograms/kg/minute. The volume of infusion required for different patient weights is provided in Table 2.

Upon awakening from anaesthesia

• An infusion of 500 micrograms/kg/minute is given for 4 minutes followed by a 300 micrograms/kg/minute infusion. The volume of infusion required for different patient weights is provided in Table 2.

For post-operative situations when time for titration is available

• A loading dose of 500 micrograms/kg/minute is given over 1 minute before each titration step to produce a rapid onset of action. Use titration steps of 50, 100, 150, 200, 250 and 300 micrograms/kg/minute given over 4 minutes and stopping at the desired therapeutic effect. The volume of infusion required for different patient weights is provided in Table 2.

Recommended maximum dose:

• For adequate control of blood pressure, higher dosages (250-300 mcg/kg/min) may be required. The safety of dosages above 300 mcg/kg/min has not been adequately studied.

Potential effects to be aware of during dosing with Brevibloc:

In the event of an adverse reaction, the dosage of Brevibloc may be reduced or discontinued. Pharmacological adverse reactions should resolve within 30 minutes.

If a local infusion site reaction develops, an alternative infusion site should be used and caution should be taken to prevent extravasation.

The administration of Brevibloc for longer than 24 hours has not been thoroughly evaluated. Infusion durations greater than 24 hours should only be used with caution.

It is advised to terminate the infusion gradually because of the risk of rebound tachycardia and rebound hypertension. As with all beta-blockers, because withdrawal effects cannot be excluded, caution should be used in abruptly discontinuing Brevibloc administration in coronary artery disease (CAD) patients.

Replacing Brevibloc therapy by alternative drugs

After patients achieve an adequate control of the heart rate and a stable clinical status, transition to alternative drugs (such as antiarrhythmics or calcium antagonists) may be accomplished.

Reducing the dosage:

When Brevibloc is to be replaced by alternative drugs, the physician should carefully consider the labeling instructions of the alternative drug selected and reduce the dosage of Brevibloc as follows:

• Within the first hour after the first dose of the alternative drug, reduce the Brevibloc infusion rate by one-half (50%).

• After administration of the second dose of the alternative drug, monitor the patient's response and if satisfactory control is maintained for the first hour, discontinue the Brevibloc infusion.

Additional dosing information

As the desired therapeutic effect or a safety endpoint (e.g., lowered blood pressure) is approached, omit the loading dose and reduce the incremental infusion to 12.5 to 25 micrograms/kg/minute.

Also, if desired, increase the interval between titration steps from 5 to 10 minutes.

Brevibloc should be discontinued when heart rate or blood pressure rapidly approach or exceed a safety limit, and then restarted without a loading infusion at a lower dose after the heart rate or blood pressure has returned to an acceptable level.

Special populations

Elderly

The elderly should be treated with caution, starting with a lower dosage.

Special studies in the elderly have not been conducted. However, analysis of data from 252 patients over 65 years of age indicated that no variations in pharmacodynamic effects occurred as compared with data from patients under 65.

Patients with renal insufficiency

In patients with renal insufficiency caution is needed when Brevibloc is administered by infusion, since the acid metabolite of Brevibloc is excreted unchanged through the kidneys. Excretion of the acid metabolite is significantly decreased in patients with end-stage renal disease, with the elimination half-life increased to about ten-fold that of normal, and plasma levels considerably elevated.

Patients with liver insufficiency

In case of liver insufficiency no special precautions are necessary since the esterases in the red blood cells have a main role in the Brevibloc metabolism.

Paediatric population

The safety and efficacy of Brevibloc in children aged up to 18 years have not yet been established. Therefore, Brevibloc is not indicated for use in the paediatric population (see section 4.1). Currently available data are described in section 5.1 and 5.2 but no recommendation on a posology can be made.

4.3. Contraindications

• Hypersensitivity to the active substance, to any of the excipients or other beta-blockers (cross sensitivity between beta-blockers is possible);

• Severe sinus bradycardia (less than 50 beats per minute);

• Sick sinus syndrome; severe AV-nodal conductance disorders (without pacemaker); 2nd or 3rd degree AV-block;

• Cardiogenic shock;

• Severe hypotension;

• Decompensated heart failure;

• Concomitant or recent intravenous administration of verapamil. Brevibloc must not be administered within 48 hours of discontinuing verapamil (see section 4.5);

• Non-treated phaeochromocytoma;

• Pulmonary hypertension;

• Acute asthmatic attack;

• Metabolic acidosis.

4.4. Special warnings and precautions for use

Warnings

It is recommended to continuously monitor the blood pressure and the ECG in all patients treated with Brevibloc.

The use of Brevibloc for control of ventricular response in patients with supraventricular arrhythmias should be undertaken with caution when the patient is compromised haemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium. Despite the rapid onset and offset of the effects of Brevibloc, severe reactions may occur, including loss of consciousness, cardiogenic shock, cardiac arrest. Several deaths have been reported in complex clinical states where Brevibloc was presumably being used to control ventricular rate.

The most frequently observed side effect is hypotension, which is dose related but can occur at any dose. This can be severe. In the event of a hypotensive episode the infusion rate should be lowered or, if necessary, be discontinued. Hypotension is usually reversible (within 30 minutes after discontinuation of administration of Brevibloc). In some cases, additional interventions may be necessary to restore blood pressure. In patients with a low systolic blood pressure, extra caution is needed when adjusting the dosage and during the maintenance infusion.

Bradycardia, including severe bradycardia, and cardiac arrest has occurred with the use of Brevibloc. Brevibloc should be used with special caution in patients with low pretreatment heart rates and only when the potential benefits are considered to outweigh the risk.

Brevibloc is contraindicated in patients with pre-existing severe sinus bradycardia (see section 4.3). If the pulse rate decreases to less than 50-55 beats per minute at rest and the patient experiences symptoms related to bradycardia, the dosage should be reduced or administration stopped.

Sympathetic stimulation is necessary in supporting circulatory function in congestive heart failure. Beta-blockade carries the potential hazard of further depressing myocardial contractility and precipitating more severe failure. Continued depression of the myocardium with beta-blocking agents over a period of time can, in some cases, lead to cardiac failure.

Caution should be exercised when using Brevibloc in patients with compromised cardiac function. At the first sign or symptom of impending cardiac failure, Brevibloc should be withdrawn. Although withdrawal may be sufficient because of the short elimination half-life of Brevibloc, specific treatment may also be considered (see section 4.9). Brevibloc is contraindicated in patients with decompensated heart failure (see section 4.3).

Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block or other cardiac conduction disturbances (see section 4.3).

Brevibloc should be used with caution and only after pre-treatment with alpha-receptor blockers in patients with pheochromocytoma (see section 4.3).

Caution is required when Brevibloc is used to treat hypertension following induced hypothermia.

Patients with bronchospastic disease should, in general, not receive beta-blockers. Because of its relative beta-1 selectivity and titratability, Brevibloc should be used with caution in patients with bronchospastic diseases. However, since beta-1 selectivity is not absolute, Brevibloc should be carefully titrated to obtain the lowest possible effective dose. In the event of bronchospasm, the infusion should be terminated immediately and a beta-2-agonist should be administered if necessary.

If the patient already uses a beta-2-receptor stimulating agent, it may be necessary to re-evaluate the dose of this agent.

Brevibloc should be used with caution in patients with a history of wheezing or asthma.

Precautions

Brevibloc should be used with caution in diabetics or in case of suspected or actual hypoglycaemia. Beta-blockers may mask the prodromal symptoms of a hypoglycaemia such as tachycardia. However, dizziness and sweating may not be affected. Concomitant use of beta-blockers and antidiabetic agents can increase the effect of the antidiabetic agents (blood glucose–lowering) (see section 4.5).

Infusion site reactions have occurred with the use of both Brevibloc 10 mg/ml and 20 mg/ml. These reactions have included infusion site irritation and inflammation as well as more severe reactions such as thrombophlebitis, necrosis, and blistering, in particular when associated with extravasation (see section 4.8). Infusions into small veins or through a butterfly catheter should be avoided. If a local infusion site reaction develops, an alternative infusion site should be used.

Beta-blockers may increase the number and the duration of anginal attacks in patients with Prinzemetal's angina due to unopposed alpha-receptor mediated coronary artery vasoconstriction. Non-selective beta-blockers should not be used for these patients and beta-1 selective blockers should only be used with the utmost care.

In hypovolemic patients, Brevibloc can attenuate reflex tachycardia and increase the risk of circulatory collapse. Therefore, Brevibloc should be used with caution in such patients.

In patients with peripheral circulatory disorders (Raynaud's disease or syndrome, intermittent claudication), beta-blockers should be used with great caution as aggravation of these disorders may occur.

Some beta-blockers, especially those administered intravenously, including Brevibloc, have been associated with increases in serum potassium levels and hyperkalemia. The risk is increased in patients with risk factors such as renal impairment and those on haemodialysis.

Beta-blockers may increase both the sensitivity toward allergens and the seriousness of anaphylactic reactions. Patients using beta-blockers may be unresponsive to the usual doses of epinephrine used to treat anaphylactic or anaphylactoid reactions (see section 4.5).

Beta-blockers have been associated with the development of psoriasis or psoriasiform eruptions and with aggravation of psoriasis. Patients with a personal or family history of psoriasis should be administered beta-blockers only after careful consideration of expected benefits and risks.

Beta-blockers, such as propranolol and metoprolol, may mask certain clinical signs of hyperthyroidism (such as tachycardia). Abrupt withdrawal of existing therapy with beta-blockers in patients at risk or suspected of developing thyrotoxicosis may precipitate thyroid storm and these patients must be monitored closely.

This medicinal product contains approximately 1.22 mmol (or 28 mg) of sodium per vial. To be taken into consideration by patients on a controlled sodium diet.

4.5. Interaction with other medicinal products and other forms of interaction

Care should always be exercised whenever Brevibloc is used with other antihypertensive agents or other drugs that may cause hypotension or bradycardia: the effects of Brevibloc may be enhanced or the side-effects of hypotension or bradycardia may be exacerbated.

Calcium antagonists such as verapamil and to a lesser extent diltiazem have a negative influence on contractility and AV conduction. The combination should not be given to patients with conduction abnormalities and Brevibloc should not be administered within 48 hours of discontinuing verapamil (see section 4.3).

Calcium antagonists such as dihydropyridine derivatives (e.g., nifedipine) may increase the risk of hypotension. In patients with cardiac insufficiency and who are being treated with a calcium antagonist, treatment with beta-blocking agents may lead to cardiac failure. Careful titration of Brevibloc and appropriate haemodynamic monitoring is recommended.

Concomitant use of Brevibloc and Class I anti-arrhythmic drugs (e.g., disopyramide, quinidine) and amiodarone may have potentiating effect on atrial-conduction time and induce negative inotropic effect.

Concomitant use of Brevibloc and insulin or oral anti-diabetic drugs may intensify the blood sugar lowering effect (especially non-selective beta-blockers). Beta-adrenergic blockade may prevent the appearance of signs of hypoglycaemia (tachycardia), but other manifestations such as dizziness and sweating may not be masked.

Anaesthetic drugs: in situations where the patient's volume status is uncertain or concomitant antihypertensive drugs are utilized, there may be attenuation of the reflex tachycardia and an increased the risk of hypotension. Continuation of beta-blockade reduces the risk of arrhythmia during induction and intubation. The anaesthetist should be informed when the patient is receiving a beta-blocking agent in addition to Brevibloc. The hypotensive effects of inhalation anaesthetic agents may be increased in the presence of Brevibloc. The dosage of either agent may be modified as needed to maintain the desired haemodynamics.

The combination of Brevibloc with ganglion blocking agents can enhance the hypotensive effect.

NSAIDs may decrease the hypotensive effects of beta-blockers.

Special caution must be taken when using floctafenine or amisulpride concomitantly with beta-blockers.

Concomitant administration of tricyclic antidepressants (such as imipramine and amitriptyline), barbiturates or phenothiazines (such as chlorpromazine), as well as other antipsychotic agents (such as clozapine) may increase the blood pressure lowering effect. Dosing of Brevibloc should be adjusted downward to avoid unexpected hypotension.

When using beta-blockers, patients at risk of anaphylactic reactions may be more reactive to allergen exposure (accidental, diagnostic, or therapeutic). Patients using beta-blockers may be unresponsive to the usual doses of epinephrine used to treat anaphylactic reactions (see section 4.4).

The effects of Brevibloc may be counteracted by sympathomimetic drugs having beta-adrenergic agonist activity with concomitant administration. The dose of either agent may need to be adjusted based on patient response, or use of alternate therapeutic agents considered.

Catecholamine-depleting agents, e.g., reserpine, may have an additive effect when given with beta-blocking agents. Patients treated concurrently with Brevibloc and a catecholamine depletor should therefore be closely observed for evidence of hypotension or marked bradycardia, which may result in vertigo, syncope or postural hypotension.

Use of beta-blockers with moxonidine or alpha-2-agonists (such as clonidine), increases the risk of withdrawal rebound hypertension. If clonidine or moxonidine are used in combination with a beta-blocker and both treatments have to be discontinued, the beta blocker should be discontinued first and then the clonidine or moxonidine after a few days.

The use of beta-blockers with ergot derivatives may result in severe peripheral vasoconstriction and hypertension.

Data from an interaction study between Brevibloc and warfarin showed that concomitant administration of Brevibloc and warfarin does not alter warfarin plasma levels. Brevibloc concentrations, however, were equivocally higher when given with warfarin.

When digoxin and Brevibloc were concomitantly administered intravenously to normal volunteers, there was a 10-20% increase in digoxin blood levels at some time points. The combination of digitalis glycosides and Brevibloc may increase AV conduction time. Digoxin did not affect Brevibloc pharmacokinetics.

When intravenous morphine and Brevibloc interaction was studied in normal subjects, no effect on morphine blood levels was seen. The Brevibloc steady-state blood levels were increased by 46% in the presence of morphine, but no other pharmacokinetic parameters were changed.

The effect of Brevibloc on the duration of suxamethonium chloride-induced or mivacurium-induced neuromuscular blockade has been studied in patients undergoing surgery. Brevibloc did not affect the onset of neuromuscular blockade by suxamethonium chloride, but the duration of neuromuscular blockade was prolonged from 5 minutes to 8 minutes. Brevibloc moderately prolonged the clinical duration (18.6%) and recovery index (6.7%) of mivacurium.

Although the interactions observed in studies of warfarin, digoxin, morphine, suxamethonium chloride or mivacurium are not of major clinical importance, Brevibloc should be titrated with caution in patients being treated concurrently with warfarin, digoxin, morphine, suxamethonium chloride or mivacurium.

4.6. Fertility, pregnancy and lactation

Pregnancy

There are limited amount of data from the use of esmolol hydrochloride in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3).

Esmolol hydrochloride is not recommended during pregnancy.

Based on the pharmacological action, in the later period of pregnancy, side effects on the foetus and neonate (especially hypoglycemia, hypotension and bradycardia) should be taken into account.

If treatment with Brevibloc is considered necessary, the uteroplacental blood flow and foetal growth should be monitored. The newborn infant must be closely monitored.

Breastfeeding

Esmolol hydrochloride should not be used during breast-feeding.

It is not known whether esmolol hydrochloride/metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded.

Fertility

There are no human data on the effects of esmolol on fertility.

4.7. Effects on ability to drive and use machines

Not relevant.

4.8. Undesirable effects

In case of undesirable effects, the dose of Brevibloc can be reduced or discontinued.

Most of the undesirable effects observed have been mild and transient. The most important one has been hypotension. The following undesirable effects are ranked according to MedDRA System Organ Class (SOC) and to their frequency.

Note: The frequency of occurrence of adverse events is classified as follows:

Very common (≥ 1/10)

Common (≥ 1/100 to < 1/10)

Uncommon (≥ 1/1000 to < 1/100)

Very rare (<1/10000)

Not known (Cannot be estimated from the available data)

System Organ Class

Frequency

Very common

Common

Uncommon

Very rare

Not known

Metabolism and nutrition disorders

Anorexia

Hyperkalemia

Metabolic acidosis

Psychiatric disorders

Depression

Anxiety

Thinking abnormal

Nervous system disorders

Dizziness 1

Somnolence

Headache

Paraesthesiae

Disturbance in attention

Confusional state

Agitation

Syncope

Convulsion

Speech disorder

Eye disorders

Visual impairment

Cardiac disorders

Bradycardia

Atrioventricular block

Pulmonary arterial pressure increased

Cardiac Failure

Ventricular extrasystoles

Nodal rhythm

Angina pectoris

Sinus arrest

Asystole

Accelerated idioventricular rhythm

Coronary arteriospasm

Cardiac arrest.

Vascular disorders

Hypotension

Peripheral ischaemia

Pallor

Flushing

Thrombophlebitis 2

1 Dizziness and diaphoresis are in association with symptomatic hypotension. 2 In association with Injection and Infusion site reactions.

System Organ Class

Frequency

Very common

Common

Uncommon

Very rare

Not known

Respiratory, thoracic and mediastinal disorders

Dyspnoea

Pulmonary oedema

Bronchospasm

Wheezing

Nasal congestion

Rhonchi

Rales

Gastrointestinal disorders

Nausea

Vomiting

Dysgeusia

Dyspepsia

Constipation

Dry mouth

Abdominal pain

Skin and subcutaneous tissue disorders

Diaphoresis 1

Skin discolouration 2

Erythema 2

Skin necrosis 2

(due to extravasation)

Psoriasis 3

Angioedema

Urticaria

Musculoskeletal and connective tissue disorders

Musculoskeletal pain 4

Renal and urinary disorders

Urinary retention

General disorders and administration site conditions

Asthenia

Fatigue

Injection site reaction

Infusion site reaction

Infusion site inflammation

Infusion site induration

Chills

Pyrexia

Oedema 2

Pain 2

Infusion site burning

Infusion site ecchymosis

Infusion site phlebitis

Infusion site vesicles

Blistering 2

1 Dizziness and diaphoresis are in association with symptomatic hypotension. 2 In association with Injection and Infusion site reactions.

3 Beta-blockers as a drug class can cause psoriasis in some situations, or worsen it. 4 Including midscapular pain and costochondritis

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse events via the Yellow Card Scheme. Website: www.mhra.gov.uk/yellowcard.

4.9. Overdose

Cases of massive accidental overdoses with concentrated solutions of Brevibloc have occurred. Some of these overdoses have been fatal while others have resulted in permanent disability. Loading doses in the range of 625 mg to 2.5 g (12.5 to 50 mg/kg) have been fatal.

Symptoms

In case of overdose the following symptoms can occur: severe hypotension, sinus bradycardia, atrioventricular block, heart insufficiency, cardiogenic shock, cardiac arrest, bronchospasm, respiratory insufficiency, loss of consciousness to coma, convulsions, nausea, vomiting, hypoglycaemia and hyperkalaemia.

Treatment

Because of the short elimination half-life of Brevibloc (approximately 9 minutes), the first step in the management of toxicity should be to discontinue the administration of the drug. The time taken for symptoms to disappear following overdosing will depend on the amount of Brevibloc administered. This may take longer than the 30 minutes seen with discontinuation at therapeutic dose levels of Brevibloc. Artificial respiration may be necessary. Based on the observed clinical effects, the following general measures should also be considered:

Bradycardia: atropine or another anticholinergic drug should be given i.v. When the bradycardia cannot be treated sufficiently a pacemaker may be necessary.

Bronchospasm: nebulised beta-2-sympathomimetics should be given. If this is not sufficient intravenous beta-2-sympathomimetics or aminophylline can be considered.

Symptomatic hypotension: fluids and/or pressor agents should be given i.v.

Cardiovascular depression or cardiac shock: diuretics or sympathomimetics can be administered. The dose of sympathomimetics (depending on the symptoms: dobutamine, dopamine, noradrenaline, isoprenaline, etc.) depends on the therapeutic effect.

In case further treatment is necessary, the following agents can be given i.v. based on the clinical situation and judgement of the treating healthcare professional:

• Atropine;

• Inotropic agents;

• Calcium ions.