Medication Card Guidelines – New by Vicki
Updated 10.2012
Medication Cards are part of the overall grade for EMSP 2348 Pharmacology Section. Keep in mind that the
student is preparing the cards to take into the clinical setting where they MUST know the drugs completely
before being allowed to administer them to a patient. The guidelines needed to successfully complete this
assignment are as follows:
1.
The cards need to be done on Index cards in a spiral notebook; the other alternative is to do them on index
cards and then place them in a binder of some sorts so the cards do not “fall out” after completing them. I will
NOT take them LOOSE or held together with a binder clip since they can come loose easily.
2. The size of the cards is up to the student in what you are willing to carry but keep in mind that the smaller they
are makes it easier
to place them in your lab coat.
3. The following information must be on EVERY card.
a.
Class
b. Mechanism of Action
c.
Indications
d. Contradictions
e.
Side Effects
f.
Precautions
g.
How Supplied
h. Administration/Dosage
4. THEY MUST BE LEGIBLE IN YOUR HANDWRITING –not anyone’s else’s.
5. Supplied in this packet is some information to help. You will be responsible to complete the medications in this
packet, but as health care evolves very rapidly, more medications may need to be added before Paramedic School
is completed. A good example is frequently cardiac medications may be added or deleted due to new research.
There will be adequate time to add these drugs if it is deemed necessary.
6. The Packet will NOT be scanned into computers and made into drug cards. Commercial Drug Cards are also NOT
acceptable either.
7. CARDS MUST BE HANDWRITTEN
8. Cards are due the 1st day of class, graded and then returned to the student. Keep in mind that this assignment
will help prepare you for the EMSP 2348 Pharmacology Final exam which has ¾ of the questions on the
medications themselves.
9. Under Side Effects Charts, the Key is the following:
When it is underlined and has a “C”=COMMON; When it is Bolded and has italics= LT-Life Threatening
TABLE OF CONTENTS
PAGE NUMBER
I. ALL EMERGENCIES
A. OXYGEN
1
II. CARDIOVASCULAR EMERGENCIES
VASOPRESSORS
A. EPINEPHRINE (1:10,000)
B. DOPAMINE
C. NOREPINEPHRINE
D. VASOPRESSIN
2/3
4/5
6/7
8/9
BETA BLOCKERS
A. PROPRANOLOL
B. METOPROLOL
C.ATENOLOL
10/11
12/13
14/15
ANTIDYSHYTHMICS
A LIDOCAINE
B. PROCAINAMIDE
C. AMIODARONE
D. MAGNESIUM SULFATE (CARDIAC)
E. ADENOSINE
F. CALCIUM CHLORIDE
16/17
18/19
20/21
22/23
24/25
26/27
CALCIUM CHANNEL BLOCKERS
A. VERAPAMIL
B. DILTIAZEM
28/29
30/31
IV. PARASYMATHOLYTICS
A. ATROPINE
32/33
V. CARDIAC GLYCOSIDES
A. DIGITALIS
34
VI. THROMBOLYTICS (FIBRINOLYTICS)
A. ASPIRIN
B. RETAPLASE
35/36
37/38
VII. ALKALINIZING AGENTS
A. SODIUM BICARBONATE
39/40
TABLE OF CONTENTS (CONT.)
PAGE NUMBERS
VIII. ANALGESICS
A. MORPHINE
B. FENTANYL
C. NITROUS OXIDE:OXYGEN (50:50) – NITRONOX
41/42
43
44
IX. DIURETICS
A. LASIX
45
X. ANTIANGINAL AGENTS
A. NITROGLYCERIN
46/47
XI. ANTIHYPERTENSIVES
A. LABETALOL
48/49
XII. RESPIRATORY EMERGENCIES
A. ALBUTEROL
B. EPINEPHRINE (1:1.000)
C. METHYPREDNISOLONE (SOLU-MEDROL)
D. DEXAMETHASONE (DECADRON)
E. RACEMIC EPINEPHRINE (MicroNefrin)
50/51
52/53
54
55
56
XIII. METABOLIC-ENDOCRINE EMERGENCIES
A. 50% DEXTROSE
B. THIAMIN
C. GLUCAGON
57
58
59
XIV. NONTRAUMATIC NEUROLOGICAL EMERGENCIES
A. DIAZEPAM
60/61
XV. HYPERTENSIVE DISORDERS OF PREGNANCY
A. MAGNESIUM SULFATE (NONCARDIAC)
62/63
XVI. TOXICOLOGICAL EMERGENCIES
A. ACTIVATED CHARCOAL
B. BENADRYL
C. EPINEPHRINE (1:1,000)
D. NARCAN
E. PROMETHAZINE (PHENERGAN)
64
65/66
67/68
69/70
71
CATIONS / ANIONS
Sodium
+
(Na )
Calcium
++
(Ca )
++
Mg
K
+
Information on Cations
Hypo- causes
Hypo- signs / symptoms
Hyper - causes
Hyper – signs /
symptoms
90% of extracellular ions;
needed for
depolarization;
maintains fluid /
electrolyte balance;
kidneys excrete and
conserve, prn; excreted
mostly in feces
Most abundant ion in
the body –
predominately
extracellular; combines
with HPO4 in teeth and
bone; involved in blood
coagulation;
depolarization &
contraction; excreted
mostly in feces – sm.
amt. In urine
50% found in bone; 45%
found in intracellular
+
space (with K ); 5%
found in extracellular
+ +
space; triggers Na /K
pump; nerve
transmission;
neuromuscular activity;
heart functions; excreted
in urine / feces
Most abundant
intracellular ion; needed
for nerve / muscle tissue
electrical trans-mission;
repolarization; most
excreted in urine
- Excessive perspiration
- vomiting / diarrhea
- diuretics
- burns
- muscle weakness
- dizziness
- headache
- decreased B/P
- increased pulse
- abdominal cramping
- seizures
- water loss without salt loss
- too much salt intake
- profuse watery diarrhea
Hypopara-thyroidism;
kidney failure; acute
pancreatitis; vitamin D
deficiency; inadequate
++
Mg & protein;
increased HPO4 levels
Numbness / tingling in
fingers; increased
reflexes; muscle /
abdominal cramping;
seizures; laryngeal spasms
(asphyxia); dysrhythmias
Parathyroid / thyroid
dysfunction; diuretics; too
much vitamin D
(Fish, liver oil,egg
yolk,fortified milk)
- thirst
- fatigue
- restless / agitation
- coma
- hyper-thermia
- oliguria / anuria
- dry, sticky, mucus
membranes
Lethargy; weakness;
anorexia; nausea /
vomiting; polyuria;
itching; bone pain;
depression; renal stones;
confusion, stupor, coma
Diarrhea; nasogastric
++
suctioning with a Mg
free fluid; alcoholism;
malnutrition; diabetes;
diuretics
Weakness; irritability;
decreased LOC; seizures;
arrhythmias
Renal failure; meds.
(cathartics/antacids) = too
++
much Mg ; severe
Dehydration; hypothermia
Low B/P; weakness;
paralysis; nausea;
vomiting; altered LOC
Vomiting / diarrhea;
poor absorption by the
body; kidney disease;
diuretics, steroids,
theophylline; increased
+
Na intake (too many +
+
charges = body dumps K
in urine)
Hypo - causes
Cramps / fatigue;
paralysis; nausea /
vomiting; confusion;
polyuria; shallow
respirations; dysrhythmias
Acute renal failure; burns;
crush injuries; infections; All
cause large shift from
intracellular to extracellular
Rx: Insulin, D50W, HCO3 =
+
shifts K intracellular
Irritability; anxiety;
abdominal cramping;
diarrhea; weakness;
paresthesia; V-fib.
Excessive vomiting;
dehydration; certain
diuretics
Muscle spasms; alkalosis;
hypoventilation; coma
Intracellular shifts;
polyuria; alcoholism
Decreased LOC; seizures;
more susceptible to
infections; muscle pain
Information on Anions
Chloride
(Cl )
-
HCO3
-
HPO4
Major extracellular
anion; diffuses easily
between extra- /
intracellular space;
regulates osmotic
pressure; follows
sodium; combines with
+
H to form HCL; most
excreted in urine
Weak base in buffer
system; combines with
+
H in metabolic acidosis;
20 bicarbonate ions for
every 1 carbonic acid
(normal body process
cause blood to be more
acidotic)
Principle intracellular
buffer; in bone and teeth
++
with Ca ; component of
cell membranes
Hypo – signs / symptoms
Hyper – causes
Hyper – signs /
symptoms
Renal insufficiency (not
excreted); extracellular
shifts
Anorexia; nausea /
vomiting; muscle
weakness; hyperreflexes; tachycardia
OXYGEN
Mechanism of action
- Increases arterial oxygen tension (PaO2) and hemoglobin saturation
- Transported by hemoglobin
- Enables cells to break down glucose into a usable form
Indications
- Chest pain
- Ischemia
- Hypoxemia
- Cardiac arrest
Contraindications
- None
Precautions / side effects
- Low flow with COPD patients not oxygen starved
- Mucous membrane irritation
Administration / dosage
- Nasal cannula, face masks, Venturi masks
- Nasal cannula 1-6 liters/minute delivers 24-44% oxygen
- Face mask - nonrebreather 10-15 liters/minute delivers 90-100% oxygen
- Venturi mask delivers various % of oxygen
Paramedic implications
- Use humidified when possible
- Use cautiously in nonhypoxic COPD patients
NEVER WITHHOLD OXYGEN IF PATIENT’S ARE HYPOXIC!!!!!
1
EPINEPHRINE (1:10,000)
Class: Sympathomimetic, vasopressor, bronchodilator
Mechanism of Action
- Catecholamine that stimulates alpha- and beta- adrenergic receptors
1. Beta1 stimulation leads to:
- positive inotropic effects (↑ force of cardiac contraction)
- positive chronotropic effects (↑ rate of cardiac contraction)
- positive dromotropic effects (↑ conduction velocity)
- 3 above help with rate post-arrest
- increased cardiac output (CO)
- increased myocardial oxygen requirements
2. Beta2 stimulation leads to:
- peripheral vasodilation and bronchodilation
3. Alpha1 stimulation leads to peripheral vasoconstriction:
- arterial / venous vasoconstriction (vasopressor) = increased SVR (perfusion pressure)
- constriction to renal, mesenteric, coronary, pulmonary and cerebral vessels
- makes the heart more susceptible to direct countershock in cardiac arrest (Ventricular fibrillation) (due to
increased hydrostatic pressure) = reason it is given during cardiac arrest
4. Inhibits histamine release (stops degranulation) during anaphylactic reaction
(Effects start within 90 seconds and are short lived)
Indications
1. Asystole
2. Ventricular-Fibrillation/pulseless Ventricular-Tachycardia
3. Pulseless electrical activity (PEA)
4. Severe anaphylaxis
Contraindications
1. Hypersensitvity
2. Patients with underlying cardiovascular disease
3. Tachyarrhythmias
5. Hypovolemic shock
6. Not with alkaline drugs
Side Effects
CNS
Cardiovascular
GI / GU
Anxiety
Anginal pain
Nausea
Dizziness
Vomiting
Dysrhythmias- LT
Headache
Hypertension
Urinary retention
Restlessness
Palpitations
Ischemia
Subarachnoid
Hemorrhage- LT
Tremors
Weakness
Bold italics = LT = life-threatening reactions
Respiratory
Dyspnea
2
Skin
Pallor
Coldness
Necrosis
Urticaria
Eyes
Pupil dilation
EPINEPHRINE (1:10,000)
Precautions:
1. increased myocardial workload may lead to ischemia, infarction
2. hypersensitivity (may have increased airway resistance due to sulfites in the preparation)
3. use cautiously in patients with:
- Heart disease
- Diabetes
- Hypertension
- Given along with other sympathomimetics or with phosphodiesterase inhibitors (caffeine, amiophylline,
Dipyridamole, Erectile dysfunction meds) may exacerbate dysrhythmia response
4. Deactivated with sodium bicarbonate / lasix (alkaline solutions)
5. Patients on MAO inhibitors (Marplan, Nardil, Parnate) ← (Anti-depressant drugs) – potentiates the effects
How Supplied
- 1mg/10ml = 1:10,000 (prefilled syringe)
Administration/Dosage
Administered by: - IVP, IO, ET
Cardiac Arrest
1mg (1:10,000) IVP or IO
Followed by a 20cc flush and raising the patients arm
Repeat every 3-5 minutes
Endotracheal dose
2-2.5 times the IVP dose
Use 1:1,000 and place in 10cc of fluid
Use ONLY if IV or IO site cannot be established
May produce transient β effects = vasodilation = ↓
Coronary perfusion pressure
Severe Anaphylaxis: 1.0mg SIVP (1:10,000) over 5 minutes
- Repeat in 5-15 minutes PRN (as needed))
Pediatric dose: Cardiac arrest - 0.01mg/kg IVP (0.1 mL/kg)
3
DOPAMINE (INTROPIN)
Class: Sympathomimetic, vasopressor
Mechanism of Action
Catecholamine that stimulates dopaminergic, beta and alpha adrenergic receptors (dose dependent)
Naturally occurring precursor of norepinephrine
1. Low doses (dopaminergic stimulation) leads to: (0.5 to 2 µg/kg/min) – NOT used in the field
- Renal, mesenteric, cerebral, coronary vasodilation
- Increased urinary output
2. Intermediate doses (Beta1 stimulation) leads to: (2 to 10 µg/kg/min)
- Positive inotropic response (↑ force of cardiac contractions) (β1)
- Positive chronotropic response (↑ rate of cardiac contractions) (β1)
- Positive dromotropic effects (↑ conduction velocity)
- Increased cardiac output (CO) (β1)
- Increased myocardial oxygen requirements (β1)
3. High doses (Alpha1 stimulation) leads to peripheral vasoconstriction: (10 to 20 µg/kg/min)
- Arterial and venous vasoconstriction (vasopressor)
- Increased SVR
- Vasoconstriction to renal, mesenteric, and coronary vessels
Indications
1. Cardiogenic shock
2. Neurogenic shock
3. Septic shock
4. Hypotension that occurs after return of spontaneous circulation (post-arrest)
4. Symptomatic bradycardia (refractory, not responding, to oxygen, and atropine)
5. Symptomatic heart blocks (second type II and third degree)
6. Severe CHF
Contraindications
1. Not used first line for hypovolemic shock
2. Tachyarrhythmias or Ventricular-Fibrillation
3. Patients with pheochromocytoma (catecholamine producing tumor on adrenal gland)
4. Known hypersensitivity
5. Not with alkaline solutions
4
DOPAMINE (INTROPIN)
Side Effects
CNS
Headache - C
Cardiovascular
Anginal pain- C
Eyes
Dilated pupils
(high doses)
Anxiety
Tachycardia-C
Ectopic beats,
palpitations-C
VasoconstrictionC
Aberrant
conduction
Hypertension
(rise in diastolic
pressure)
Italic = C = common side effects
GI
Nausea - C
Vomiting- C
Respiratory
Dyspnea- C
Skin
Gangrene (high doses
for a long time)
Necrosis
Tissue sloughing with
extravasation
Precautions
1. May cause increased workload on the heart
2. Hypoxia, hypercarbia, acidosis reduce drug effectiveness
3. Tissue necrosis if it infiltrates
4. High doses may cause paradoxical hypotension because the increased SVR = decrease in stroke volume (SV) and
cardiac output (CO)
5. Discontinue use gradually
6. Deactivated with sodium bicarbonate / lasix (alkaline solutions)
7. Patients on MAO inhibitors (Marplan, Nardil, Parnate) ← (Anti-depressant drugs) – potentiates the effects
8. Beta blockers may blunt the inotropic effects
9. When given with phenytoin (dilantin) - hypotension, bradycardia and seizures may develop
10. Given along with other sympathomimetics or with phosphodiesterase inhibitors (caffeine, amiophylline,
Dipyridamole, Erectile dysfunction meds) may exacerbate dysrhythmia response
How Supplied
- 200mg/5ml
- 400mg/5ml
- 800mg/5ml
READ LABEL CAREFULLY
Administration/Dosage
Administered: titrate intravenous infusion (IV infusion, Piggyback)
Infusion preparation
200, 400, 800mg in 250-500cc
Beta Dose range
2 - 10µg/kg/minute
Start at 2 – 5 µg/kg/minute
Alpha Dose range
10 - 20µg/kg/minute
Start at 10 -15µg/kg/minute
Pediatric dose
2-20ug/kg/min IV infusion
5
NOREPINEPHRINE (LEVOPHED)
Class: sympathomimetic, agonist, vasopressor
Mechanism of action
- Alpha1 stimulation leads to peripheral vasoconstriction:
- Arterial / venous vasoconstriction (vasopressor)
- Increased SVR
- Vasoconstriction to renal, mesenteric, and coronary vessels
- Pulmonary vasoconstriction
- Beta1 stimulation leads to:
- Positive inotropic response (↑ force of cardiac contractions) (β1)
- Positive chronotropic response (↑ rate of cardiac contractions) (β1)
- Positive dromotropic effects (↑ conduction velocity)
- Increased myocardial oxygen requirements
- Increased cardiac output (due to ↑ inotropic + chronotropic + dromotropic effects)
PREDOMINATELY ALPHA1 STIMULATING DRUG
Indications - use if other vasopressors are not working – severe hypotension SBP < 70mmHg – drug of last resort
1. Cardiogenic shock
2. Neurogenic shock
3. Septic shock
4. Poison / Drug induced hypotension
5. Blood pressure support after resuscitation from cardiac arrest
- if B/P is low due to ↓ PVR
Not used to treat hypovolemia
Contraindications
1. Hypotension due to hypovolemia (need appropriate fluid replacement first)
2. Profound hypoxia
3. Profound hypercarbia
4. Hypertension
5. Hypersensitivity
Side effects
CNS
Cardiovascular
Headache- C
Reflex
bradycardia
Restlessness
Dysrhythmias
- LT
Tremor
Chest pain LT
Dizziness
Hypertension
Anxiety
Palpitations
Tachycardia
Decreased CO
Italic = C = common side effects
GI
GU
Respiratory
Eyes
Skin
Nausea - C
Oliguria
Distress
Photophobia
Diaphoresis
Vomiting- C
Renal failure
Dyspnea
Gangrene
Organ
ischemia
Organ
ischemia
Apnea
Necrosis (with
infiltration)
Bold italic = LT = life-threatening reaction
6
NOREPINEPHRINE (LEVOPHED)
Precautions
1. Increases myocardial workload and oxygen consumption
2. If it infiltrates it can cause tissue necrosis
3. May contribute to hypoxia due to pulmonary vasoconstriction
4. Use cautiously with:
- Cardiogenic shock
- Acute MI
- CHF
- In the presence of hypoxia, hypercarbia, acidosis
- MAO inhibitor therapy within 14 days (Marplan, Nardil, Parnate) ← (Anti-depressant drugs)
- Beta adrenergic antagonists blunt the Beta1 effects
How supplied
- 4mg / 4ml
Administration / dosage
Administered – IV infusion (piggyback)
Infusion preparation
Mix: 4mg / 250cc D5NS
Dosage range
0.5 to 30µg / minute
Start infusion at 0.5 to 1µg / minute
Titrate to a B/P of 90-110 mmHg
Higher doses may be needed for Poison / Drug induced hypotension
CONSTANTLY ASSESS HEMODYNAMIC STATUS
7
VASOPRESSIN
Class: Hormone, Vasopressor, Antidiuretic
Mechanism of Action
1.
2.
-
Non-adrenergic vasoconstrictor
stimulates smooth muscle (V1 receptors)
Increases:
coronary perfusion pressure (hydrostatic pressure)
vital organ blood flow
ventricular fibrillation frequency (amplitude of the waves – may turn fine VF into coarse VF)
cerebral oxygen delivery
Vasoconstricts better than epinephrine with hypoxia and acidosis present – effects last longer
Produces greater arteriole tone than epinephrine
Does not increase myocardial O2 consumption like epinephrine (post-arrest)
Indications
Prehospital:
- Ventricular fibrillation / Pulseless ventricular tachycardia (may replace 1st or 2nd dose of Epinephrine) (one dose)
- May be useful alternative to epinephrine in Asystole / PEA (may replace 1st or 2nd dose of epinephrine) (one dose)
Other Uses:
- Control bleeding with esophageal varicies
- Distributive shock (high-space) →Septic shock
Contraindications
-
ischemic heart disease
PVCs = ischemia or necrosis
Advanced arteriosclerosis
During 1st stage of labor
Side effects
CNS
Drowsiness
Cardiovascular
Angina
GI
Cramps
Flushing
Headache
Lethargy
Arrest = LT
↓ CO
Dysrhythmias = LT
Heartburn
Nausea
Vomiting
GU
Uterine
cramping
Respiratory
Bronchial
constriction
Skin
Sweating
Urticaria
Gangrene
Tremors
Vertigo
Gangrene
↑ BP
MI = LT
Peripheral
vasoconstriction
Italic = C = common side
Bold italic = LT = life-threatening reactions
8
VASOPRESSIN
Precautions
-
-
Use cautiously in patients with:
- Epilepsy
- Migraine
- Asthma
- Heart failure
- Angina
- Vascular disease
- Renal disease
The young and old
How supplied
-
20 Units / ml
Administration / Dosage
Administered – IVP; IO; ET
Dose:
Cardiac arrest – 40 U - IVP / IO (only give one dose)
ET dose: 2 – 2.5 x IV dose in 10 cc of fluid
9
PROPRANOLOL (INDERAL)
Class: Non-selective beta-adrenergic blocker (β1and β2), sympatholytic, antihypertensive, antianginal
Mechanism of Action
1. Blocks Beta1 receptors leading to:
- depressed automaticity at the SA node
- decreased AV node and intraventricular conduction
- decreased heart rate and force of contraction
- decreased myocardial O2 consumption
- decreased blood pressure
2. Blocks Beta2 receptors leading to:
- possible bronchoconstriction
3. Decreases renin release from the kidneys (Blocks Beta1 receptors in kidneys)
- vasodilation
Indications
1. Supraventricular Tachyarrhythmias (refractory to other therapies – vagal maneuver, and adenosine)
2. To prevent recurrent Ventricular Tachycardia
3. Atrial-Fibrillation/Atrial-Flutter with a rapid ventricular response
4. MAT – Multifocal Atrial Tachycardia
5. To prevent angina
6. To treat hypertension
Contraindications
1. Asthma / COPD
2. Bradycardia / heart blocks (second and third degree)
3. CHF patients
4. Cardiogenic shock
5. Any patient with depressed cardiac function
6. Cocaine intoxication
Side Effects
CNS
Depression
Cardiovascular
Bradycardia
GI
Diarrhea
Dizziness- C
CHF- LT
Dry mouth
Drowsiness
Fatigue - C
Cold extremities
Postural
Hypotension
Hallucinations
Profound
hypotension
Insomnia
2nd or 3rd heart
block - LT
Lethary - C
Vasodilation
Italic = C = common side effects
Eyes / Ears
Dry, burning
eyes
Visual
disturbances
Metabolic
Hypoglycemia
Nausea - C
Vomiting
Respiratory
Bronchospasms
Dyspnea
Wheezing
Bold italic = LT = life-threatening reactions
10
PROPRANOLOL (INDERAL)
Precautions
-
diabetes mellitus
renal / hepatic disease
peripheral vascular disease
history of systemic insect sting reaction (anaphylactic reactions)
may mask the symptoms of hypoglycemia (except sweating) in the diabetic patient
myasthenia gravis
How Supplied
- 1mg/1ml
Administration/Dosage
Administered - Slow IVP
Initial Dose
1-3 mg Slow IVP (over 2-5 minutes)
May dilute in 9ml to deliver easier
Subsequent Dose
May repeat dose in 2 minutes
Total Dose
0.1 mg/kg
11
Metoprolol (Lopressor)
Class: Beta Blocker: Selective beta adrenegeric (β1) mainly in the cardiac muscle, sympatholytic, antihypertensive, antianginal; Does not
usually affect β2 receptors;
Mechanism of Action
1. Beta-blocking activity of metoprolol as shown by
-  HR and CO at rest and upon exercise
- SBP upon exercise
- Inhibition of isoproterenol-induced tachycardia
-reflex orthostatic tachycardia.
2. For Antihypertensive effects
- Antagonizes catecholamines at peripheral adrenergic receptors leading to cardiac output
- Central effect leading to sympathetic outflow to the periphery
- Suppression of renin activity – at higher doses
- Blocking catacholamine-induced HR and velocity = decreased myocardial contraction and BP
- O2 requirements of heart - making it useful for angina pectoris
4. At higher dosages, will inhibit B2 in bronchial and vascular musculature.
Indications
1. Hypertension
2. Angina pectoris
3. Prevention of MI
4. Decreased Mortality of Recent MI
5. CHF
6. Stable Narrow complex tachycardia – second line after vagal maneuver and Adenosine
7. Rate control in atrial fibrillation and atrial flutter and MAT
Contraindications
1. Uncompensated CHF
2. Pulmonary Edema
3. Cardiogenic Shock
4. Bradycardia or heart block
5. hypersensitivity to B-Blockers
6. Lung disease with bronchospasm
12
Metoprolol (Lopressor) (con’t)
Side Effects
CNS
Fatigue - C
Weakness
Cardiovac.
Bradycardia=LT
CHF = LT
GI / GU
Nausea=C
Vomiting=C
Eyes/Ears
Blurred vision
Stuffy nose
Depression
Insomnia
Nightmare
Pulm Edema
Diarrhea=C
Hypotension
Constipation
Vasoconstriction in
Dry mouth
extremities
Dizziness - C
Cardiac Arrest=LT
Impotence
Common side effect =C bold italics = LT = life-threatening reactions
Precautions
Renal impairment
Diabetes Mellitus
COPD/ Asthma
Heart failure
CAD
Well compensated CHF
Hepatic disease
How Supplied
5mg/5cc ampule
Administration/Dosage
Administered: Slow IVP over 1 minute
Initial Dose
5mg IVP
Subsequent Dose
Repeat in 5min x 3 doses
Total Dose
15mg
13
Metabolic
Hyperglycemia
Masked
hypoglycemia
response
Respiratory
Bronchospasm=LT
Wheezing
dyspnea
Atenolol (Tenormin)
Class: Beta Blocker, selective B1, B2 only at high doses
Mechanism of Action
1. Blocks stimulation of beta1 receptors
2. doesn’t affect B2
3. negative chronotropic and inotropic (increases rate of SA node, increases recovery time)
4. slows AV conduction time
5.  HR
6. O2 consumption
7. renin-aldosterone, angiotension system at high doses
Indications
Hypertension,
Angina
Prevention of MI
Stable Narrow complex tachycardias - second line after vagal maneuver and Adenosine
Rate control in atrial fibrillation and atrial flutter and MAT
Contraindications
Hypersensitivity to B-Blockers
Uncompensated CHF
Pulm edema
Cardiogenic shock
Bradycardia or heart block, 2nd/3rd
Side Effects
CNS
Fatigue=C
Weakness=C
Cardiovac.
Bradycardia /
Heart block =LT
CHF=LT
GI / GU
Nausea=C
Eyes/Ears
Blurred vision
Metabolic
Hyperglycemia
Respiratory
Bronchospasms
Vomiting
Stuffy nose
Masked
hypoglycemic
response
Wheezing
Depression=C
Insomnia=C
Nightmare
Pulm Edema=LT
Diarrhea=C
Hypotension=LT
Constipation
Vasoconstriction
Dry mouth
Cardiac Arrest
Impotence
Common side effect =C bold italics = LT = life-threatening reactions
Precautions
Renal impairment
Geriatric (reduce dose)
Pulm Disease,-COPD/Asthma
Diabetes Mellitus
Thyroid disease
Well compensated CHF
14
Dyspnea
Atenolol (Tenormin)
How Supplied 500mcg/cc (0.5mg)
Administration/Dosage
Administered: Slow IVP over 5 minutes
Initial Dose
5mg over 5min
Subsequent Dose
Repeat in 5mg in 10 min; give over 5min
15
Total dose
10 mg
LIDOCAINE (XYLOCAINE)
Class: Class I-B Antidysrhythmic, local amide-type anesthetic
Mechanism of Action
1. Blocks fast sodium channels leading to decreased automaticity in the bundle of His and purkinje system
- During pathological states – keeps Na++ from entering cells during Phase 4
2. Shortens repolarization times (refractory period) (does not block K+ = refractory period is NOT slowed)
3. Anesthetic properties help to suppress ventricular ectopy after MI
4. Decreases conduction velocity through ischemic zones in the ventricles
5. May terminate reentry ventricular arrhythmias
6. Raises the ventricular fibrillation threshold
Indications
1.Ventricular-Fibrillation / Pulseless Ventricular-Tachycardia (IF amiodarone is NOT available)
2. Stable Ventricular-Tachycardia of unknown origin
3. Post Arrest Ventricular irritability (if rate and rhythm support lidocaine) (ensure oxygenation first)
Contraindications
1. Bradycardia with PVC’s
2. Heart blocks (second or third degree) (Stokes-Adams syndrome)
3. Idioventricular rhythms
4. Wolff-Parkinson-White syndrome / Supraventricular Tachycardia
5. Hypersensitivity to amide anesthetics
Do not use prophylactically
Side Effects
CNS
1. paresthesia
2. Dizziness = C
3. Slurred speech
4. Drowsiness
Cardiovascular
Bradycardia =
LT
Collapse
Edema
Heart Block =
LT
Hypotension = C
5. Altered LOC
7. Muscle
twitching
8. Seizures = LT
Italic = C = common side effects
Eyes / Ears
6. Tinnitus
6. Blurred vision
GI
Nausea
Vomiting
Respiratory
9. Depression =
LT
9. Arrest = LT
Bold italic = LT = life-threatening reactions
(Numbers indicate signs of increasing toxicity)
IF USED IN THERAPEUTIC DOSES THESE PROBLEMS USUALLY DON’T OCCUR
16
Skin
Rash
Edema
Urticaria
LIDOCAINE (XYLOCAINE)
Precautions
1. May cause (or worsen) ventricular dysrhythmias or cause asystole when administered to patients with:
- Sinus bradycardia
- Heart blocks
- Atrial fibrillation or atrial flutter with accelerated ventricular response
- Junctional rhythm
2. Effectiveness is reduced in the presence of:
- hypoxia
- electrolyte imbalances
- acid-base disturbances
3. Use cautiously on:
- patients with respiratory depression, hypovolemia
- Elderly patients and patients with liver problems, CHF, or cardiogenic shock
- patients taking beta blockers
How supplied
- Ampule and prefilled syringes for IVP
- Vials of 1-2gm for IV infusions
READ LABEL CAREFULLY SO YOU ADMINISTER THE PROPER AMOUNT
Administration/Dosage
Administered by – IVP / IO, ET or IV Infusion (piggyback)
IVP / IO dose
Initial (loading) dose – 1-1.5mg/kg
Subsequent dose – 0.5-0.75mg/kg
ET dose
2-2.5 times the IVP dose in 10cc
Use ONLY if IV site is unavailable
IV infusion
Infusion preparation – 1-2gm / 250 or 500cc
Dose range – 1-4mg / minute
Total dose - 3mg/kg
- Repeat IVP dose every 3-5 minutes
- Elderly patients and patients with liver problems, CHF, or cardiogenic shock – deliver initial loading dose (1-1.5mg/kg)
- deliver infusion at ½ the normal range
- BOLUS PRIOR TO INFUSION
INFUSIONS ARE ONLY USED ON PULSING PATIENTS
Pediatric dose: 1mg/kg IVP, IO, ET
17
PROCAINAMIDE (PRONESTYL)
Class: Class I-A antidysrhythmic, ester-type local anesthetic
Mechanism of Action
1. Blocks slow sodium channels (SA and AV nodes) leading to decreased automaticity (atrial)
2. Blocks fast sodium channels (muscle cells and ventricular conduction system) to decrease muscle depolarization (ventricular)
3. Prolongs repolarization time in the conduction system (blocks K+ = slows repolarization)
4. Conduction velocity is decreased in the atrium, bundle of his and purkinje fibers
- 3 and 4 lead to prolonged QT intervals
5. Contractility may be decreased in a damaged myocardium = decreased delivery of stroke volume
6. Produces peripheral vasodilation
- with rapid IVP or toxic levels drug blocks Na+ and ACh decreasing smooth muscle depolarization
7. Increase the Ventricular fibrillation threshold
Indications
1. Stable pulsing ventricular tachycardia (monomorphic / polymorphic – unknown origin) (class IIb)
2. Stable Supraventricular dysrhythmias (not controlled by vagal maneuvers and adenosine)
3. Pharmacological conversion of Atrial fibrillation (with rapid ventricular response in WPW syndrome)
4. Ventricular irritability post arrest (if rate and rhythm support the drug) (if not controlled by Lidocaine)
Contraindications
1. Bradycardia with PVC’s
2. Heart blocks (second and third degree)
3. Idioventricular rhythms
4. Torsades de pointes (due to QT prolongation)
5. Digitalis toxicity (may further depress conduction)
6. Tricyclic Antidepressant toxicity
7. Hypersensitvity
Side effects
CNS
Depression
Cardiovascular
Hypotension
GI
Abdominal pain
Dizziness = C
Heart blocks = LT
Anorexia
Giddiness
Hallucinations
Headache
Q-T Prolongation
Torsades de points
Ventricular
arrhythmias = LT
Bitter taste
Diarrhea
Hepatomegaly
Psychosis
Weakness
Italic = C = common side effects
Blood
Reduction in:
neutrophils,
basophils,
eosinophils = LT
ThromboCytopenia = LT
Nausea
Vomiting
Bold Italic = LT = life-threatening reaction
18
Respiratory
Dyspnea
Skin
Angioneurotic
edema = LT
Depression = LT
Flushing
Arrest = LT
Pruritis
Rash
Urticaria
PROCAINAMIDE (PRONESTYL)
Precautions
1. May precipitate / worsen AV heart block
2. May cause ventricular arrhythmias
3. May cause hypotension (due to Na+ and ACh blocking with rapid IVP or toxic levels in the system)
4. Effectiveness is reduced in the presence of:
- hypoxia
- electrolyte imbalance
- acid-base disturbances
5. Use cautiously with:
- liver / kidney impairment
- acute MI
- CHF
- digitalis toxicity
- asthma – due to anticholinergic effect (inhibits secretions = thickens mucus secretions (plugs))
6. Conversion of atrial fibrillation may lead to clot dislodgement and PE developing
How supplied
- 1000mg/10ml (for IVP)
- 1gm/2ml (for infusion)
Administration / dosage
Administered - Slow IVP and IV infusion
Slow IVP
20-50mg SIVP (over 1 minute)
May dilute in 10cc to facilitate delivery
Total dose: 17 mg/kg
- SIVP until:
IV Infusion
Infusion preparation – 1-2gm / 250 or 500cc
Dose range – 1-4mg / minute
1. dysrhythmia is suppressed
2. hypotension develops
3. QRS widens more than 50%
4. 17mg/kg have been given
If any of the above 4 occurs – discontinue temporarily – contact physician
BOLUS PRIOR TO THE INFUSION
IV INFUSION USED AFTER CONVERSION OR MALIGNANCY HAS CLEARED
INFUSIONS ONLY USED ON PULSING PATIENTS
REDUCE MAINTENANCE INFUSION RATE WITH LIVER AND KIDNEY DYSFUNCTION
Pediatric dose:
- 15mg/kg slow IVP / IO (over 30 to 60 minutes)
19
AMIODARONE (CORDARONE)
Class: Antidysrhythmic
Mechanism of Action
1. Acts directly on all cardiac tissue.
2. Blocks Na+, Ca++, K+ and alpha and beta receptors
- Prolongs duration of action potential and refractory period = QT prolongation
- Decreases - automaticity, conductivity, contractility
- Relaxes coronary and vascular smooth muscle =
- Decreases peripheral vascular resistance
- Increases coronary blood flow
3. Useful for the treatment of atrial and ventricular arrhythmias
Indications for Use
1. Ventricular fibrillation / Pulseless ventricular tachycardia (class IIb)
2. Stable ventricular tachycardia (monomorphic)
2. Stable recurrent ventricular tachycardia (polymonorphoric) with normal QT segment (MAY be effective)
3. Rate control for atrial fibrillation / atrial flutter in patients with CHF (potential risk of conversion to sinus rhythm should be considered)
Contraindications
1. Hypersensitivity
2. Bradycardia
3. High degree heart blocks (second and third degree)
4. Cardiogenic shock
5. Pulmonary congestion
Side Effects
CNS
Cardiovascular
Respiratory
GI
Musculoskeletal
Skin
Fatigue
Conduction
abnormalities =
LT
Dysrhythmias =
LT
Bradycardia - C
Cough
Nausea
Pain in
extremities
Slate-blue
pigmentation
Eyes, Ears,
Nose,
Throat
Blurred
vision
Dyspnea
Vomiting
Weakness
Rash
Dry eyes
Pulmonary
fibrosis - LT
Inflammation
Diarrhea
Photosensitivity
Halos
HeadacheC
Dizziness C
Insomnia
Ataxia
Paresthesia
Hypotension
SA node
dysfunction =
LT
Sinus arrest =
LT
Malaise
CHF
Italics = C = common side effect
Abdominal
pain
Anorexia
Loss of
vision
Photophobia
Hepatoxicity
Corneal /
macular
degeneration
Constipation
Bold Italics = LT = life-threatening reactions
20
AMIODARONE
Precautions
1. Thyroid disease (can cause hypo- or hyperthyroidism)
2. 2nd or 3rd degree heart block (slow or stop infusion if seen)
3. Electrolyte imbalances (↓K+ and ↓Mg++ - may predispose to arrhythmias)
4. Bradycardia (slow or stop infusion if seen)
5. Pulmonary disease
6. May produce vasodilation and hypotension
7. May have (-) inotropic effects
8. May prolong QT interval = possible development of Torsades de Pointes
How supplied
- 150mg / 3cc (50mg / ml)
Administration/Dosage
Administered: slow IVP and IV infusion
Initial (loading) dose
CARDIAC ARREST
300 mg slow IVP over 3-5
minutes
Dilute in 20-30cc NS
Subsequent doses
CARDIAC ARREST
150 mg slow IVP in 3-5 minutes
PULSING TACHYCARDIAS
150 mg / 100cc over 10 minutes
PULSING TACHYCARDIAS
May repeat in 10 minutes, PRN
Dilute in 20-30cc NS
Pediatric dose:
- Cardiac arrest: 5mg/kg rapid IVP
- Perfusing tachycadias: 5mg/kg over 20-60 minutes
- Maximum dose – 15 mg/kg
21
Total Dose
CARDIAC ARREST
2.2 gm IV / 24 hours
MAGNESIUM SULFATE (CARDIAC)
Class: Electrolyte, Anticonvulsant
Mechanism of Action
1. CNS depressant
2. Believed to reduce the release of ACh by motor nerves so seizure activity is decreased (↓ grand mal activity)
3. Slows HR at the SA node, prolongs AV node conduction time = ↓ dromotropy
4. Causes peripheral vasodilation (Ca++ channel blocking properties)
5. Stabilize cell membranes (__↓__ Mg++ levels = ___↓__ membrane threshold potentials = ___↑___ cellular & Purkinje fiber excitability =
___↑___ chance for arrhythmia development)
6. Necessary for Na+ / K+ pump function
Indications
1. Hypomagnesemia
2. Torsades de pointes
3. Hypokalemia - Needed to replenish intracellular K+
4. Ventricular fibrillation / Pulseless VT – associated with torsades de pointes or hypomagnesemia
5. Severe asthma attack (Phase II / Status asthmaticus)
Contraindications
1. Renal disease
2. Shock
3. Heart block
4. Hypocalcemia
5. Hypermagnesemia
Side effects
CNS
Cardiovascular
GI
Metabolic
Decreased B/P - C
Belching
Hypermagnesemia
Coma = LT
Depressed deep
Cramps
Heart block - LT
tendon reflexes - C
Depression - C
Bradycardia - C
Lethargy - C
Increased pulse - C
Weakness - C
Decreased SVR - C
Italic = C = common side effects
Bold italic = LT = life-threatening reactions
Respiratory
Depression – LT
Arrest - LT
Paralysis - LT
CALCIUM CHLORIDE / CALCIUM GLUCONATE ANTAGONIZES = HAVE AVAILABLE
Precautions
1. May cause CNS depression and hypocalcemia
2. Rapid IV injection may cause hypotension, heart block, cardiac and/or respiratory arrest
3. Renal impairment may increase chance of toxicity
How Supplied
- 10%, 12.5%, 50 % solution in 40, 80, 100, and 125 mg/mL
22
MAGNESIUM SULFATE (CARDIAC)
Administration/Dosage
Adult:
- Ventricular Fibrillation / pulseless Ventricular Tachycardia = 1-2gm (2-4 mL) / 10ml D5W slow IVP / IO (over 1-2 min.) (50% solution)
- Torsades de Pointes (with a pulse) = 1-2 grams in 50 to 100 cc D5W slow IVP over 5 to 60 minutes
Pediatric:
- 25 – 50 mg/kg over 10-20 minutes
- Max. dose = 2 grams
23
ADENOSINE (ADENOCARD)
Classification: antidysrhythmic
Mechanism of Action
1. Decreases conduction of electrical impulse through the AV. node. (keeps K+ in and Ca++ out in SA & AV nodes
leads to hyperpolarization of the SA / AV nodes = ↓ SVT rates)
2. Interrupts AV re-entry pathways (causing paroxysmal supraventricular tachycardia (PSVT))
3. Slows sinus rate
4. Only works on tachycardias produced by re-entry pathways (PSVT / Wolfe-Parkinson White (WPW))
5. Found naturally in all body cells
6. Rapidly metabolized in the blood vessels (endothelium and RBCs)
Indications
1. Convert stable PSVT to NSR (if oxygen and vagal maneuvers do not work)
2. Convert Wolff-Parkinson-White (WPW) to NSR
• Have defibrillator available – could convert to Atrial Fibrillation with rapid ventricular response – may need to cardiovertConvert Stable
3. Junctional tachycardia (if oxygen and vagal maneuvers do not work)
4. May consider for unstable narrow-complex tachycardias while preparing for cardioversion (ONE dose)
5. Stable Monomorphic wide-complex tachycardias (could be SVT with aberrancy) (2 doses)
Contraindications
1. Patients who are hypersensitive
2. Second or third degree heart block
3. Sick sinus syndrome
4. Atrial fibrillation
5. Atrial flutter
6. Ventricular Tachycardia (unstable)
7. Tachycardia associated with asthma attack
8. Poison / drug induced tachycardia
Side Effects (self limiting due to short half-life)
CNS
Apprehension
Cardiovascular
GI
Metallic taste
Atrial tachydysrhythmiaLT
Arm tingling
Chest pain
Nausea
Blurred vision
Facial flushing- C
Throat tightness
Dizziness, lightheaded
Hypotension
Numbness
Palpitations
Sweating
Italics = C - common side effect
Bold Italics = LT - life-threatening reactions
Respiratory
Dyspnea- C
Bronchoconstriction
Hyperventilation
- HALF-LIFE IS 5 – 10 SECONDS
Precautions
1. May produce brief periods of heart blocks, asystole (up to 15 seconds), PVC's, PAC's, bradycardia or tachycardia.
2. Arrhythmias only last a few seconds due to the short half-life
3. Patients on theophylline (xanthine bronchodilator) / caffeine – require higher doses
4. Patients with transplanted hearts – require smaller doses (3mg – ½ dose)
5. Patients on dipyridamole and carbamazepine (inhibits thromboxane A2 = antiplatelet drug) – require smaller doses
(3mg = ½ dose)
24
ADENOSINE (ADENOCARD)
How supplied
-
6mg in 2ml
Administration/dosage
Administered: RAPID IV push – Elevate legs post delivery.
Draw up adenosine dose and flush in 2 separate syringes
Attach both syringes to IV port closest to patient – clamp IV tubing
Push IV Adenosine as quickly as possible – keep pressure on Adenosine plunger – push NS flush as rapidly as possible
Initial Dose
6mg rapid IV push (1-3 seconds)
Subsequent Doses –
(1-2 minutes later)
12mg rapid IV push (1-3 seconds)
FOLLOW EACH DOSE WITH A 20 CC BOLUS
Doses are delivered 1-2 minutes after each other, if the patient does not convert
Maximum single dose – 12 mg
Pediatric dose
- Initial dose: 0.1mg/kg IVP followed by 5ml flush
- Second dose: 0.2mg/kg IVP followed by 5ml flush
Maximum 1st dose – 6 mg
25
Total Dose
18mg
CALCIUM CHLORIDE
Class: Electrolyte
Mechanism of Action
1. Necessary for:
- transmission of nerve impulses
- contraction of cardiac muscle, smooth muscle, skeletal muscle
- renal function
- blood clotting
- regulation of neurotransmitter and hormones storage and release
- maintaining structural and functional integrity of cell membranes and capillary beds
2. Causes significant increase in myocardial contractility and ventricular automaticity
3. IVP administration improves vascular tone and myocardial contractility in hypocalcemic states
4. May increase or decrease peripheral vascular resistance (PVR)
Indications
1. Hyperkalemia (except when associated with digitalis toxicity)
2. Hypocalcemia
3. Hypermagnesemia
4. Calcium channel blocker overdose
5. Cardiac arrest resulting from: hypocalcemia, hyperkalemia, or overdose on calcium channel blocking drugs
6. Antidote for toxic effects from beta-blocking toxicity
7. To prevent hypotensive effects of calcium channel blocking agents (verapamil and diltiazem)
Contraindications
1. Cardiac arrest (not caused by hypocalcemia, hyperkalemia, or overdose on calcium channel blocking drugs)
2. Hypercalcemia
3. Not with sodium bicarbonate
4. Digitalis toxicity (calcium concentrations will be elevated due to toxicity)
5. Renal or cardiac disease
Side effects
Cardiovascular
Bradycardia
GI
Gastric irritation
GU
Renal dysfunction
Cardiac Arrest - LT
Anorexia
Renal Failure- LT
Constipation
Dysrhythmias - LT
Heart block
Flatulence
Hypotension
Nausea / Vomiting
Rebound
Diarrhea
Hypertension
Shortened Q-T
Bold Italics – LT = life-threatening reactions
Metabolic
Hypercalcemia
(coma) - LT
Metabolic Alkalosis
Renal stones
26
Skin
Burning at the IV site
Tissue necrosis (if it
infiltrates)
Pain
CALCIUM CHLORIDE
Precautions
1. Rapid injection may cause: hypertension, dysrhythmias, bradycardia, cardiac arrest
2. Coronary and cerebral vasospasms
3. Use cautiously on patients:
- with renal disease
- with cardiac disease
- with COPD
- on digitalis
- with GI obstruction or decreased motility
4. Flush line between calcium and sodium bicarb to avoid precipitation
How Supplied
- 1gm/10ml (10ml of 10% solution)
Administration/Dosage
Administered: slow IVP
- 8-16 mg/kg (usually 5-10 cc) slow IVP - repeat the dose in 10 minutes, prn
Pediatric dose:
- 20 mg/kg (0.2 cc/kg) slow IVP of a 10% solution – repeat once in 10 minutes for documented conditions
27
VERAPAMIL (ISOPTIN, CALAN)
Class: Ca++ channel blocker, antidysrhythmic, antihypertensive, antianginal
Mechanism of action 1.
Inhibits movement of calcium ions across cell membranes during depolarization
- Decreases afterload – dilation of arterioles
- Dilates coronary arteries
- Depresses myocardial contractility
2. Inhibits coronary vasospasm
3. Slows SA and AV node conduction
- Decreases atrial automaticity / AV conduction and prolongs AV node refractory period (will prolong PR interval)
- May cause high degree heart blocks (second and third degree)
4. Decreases myocardial oxygen requirements
Drug has greater effect on conduction system than the smooth muscle
Indications
1.
2.
3.
SVT / Junctional Tachycardia - after adenosine
Atrial-fibrillation or atrial-flutter with rapid ventricular response / Mulitfocal Atrial Tachycardia
Angina
- Prinzmetal’s angina
- Chronic stable angina
- Preinfarction angina (make sure patient is hemodynamically stable)
Hypertension
4.
Contraindications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Hypersensitivity
Cardiogenic shock
Severe CHF
Sick sinus syndrome
Bradycardia
Heart blocks (second and third degree)
Severe hypotension (< 90 mmHg)
Acute myocardial infarction (unless associated with SVT)
Wolff-parkinson-white syndrome (WPW) with atrial fibrillation or flutter
Ventricular tachycardia (all-wide complex tachycardias)
Side effects
CNS
Dizziness
Headache
Lightheadedness
Blurred vision
Cardiovascular
GI
Constipation
AV block = LT
Bradycardia
Nausea
CHF= LT
Edema
Hypotension
Palpitations
Italic = C - common side
Bold italic = LT = life-threatening reactions
28
GU
Nocturia
Polyuria
Respiratory
Dyspnea
Shortness of breath
VERAPAMIL (ISOPTIN, CALAN)
Precautions
1. Run a 12-lead EKG prior to administration
2. Use cautiously with:
- Liver impairment
- Older adults
- Patients on digitalis or beta blocker
- CHF
- Cirrhosis
- Duchenne’s muscular dystrophy
3. Concurrent with IV Beta blocker may produce severe hypotension
- Use with extreme caution in patients receiving oral β-blockers
How supplied
- 5mg / 2ml
Administration / dosage
Administered - Slow IVP (over 1-2 minutes)
Initial dose
2.5 to 5mg SIVP
Subsequent dose – 15 to 30 minutes
after initial dose
5 to 10mg SIVP - PRN
Total dose
20mg
Within 30 minutes
- MAKE SURE SYSTOLIC PRESSURE IS AT 100 mmHg OR HIGHER PRIOR TO ADMINISTRATION
- CONSTANTLY REASSESS HEMODYNAMIC STATUS
- IV calcium may restore blood pressure in toxic cases (some may give calcium prior to avoid ↓ BP and HR)
Pediatric dose:
- 0-1 year: 0.1-0.2mg / kg slow IVP (max. dose 2mg)
- 1-15 years: 0.1-0.3mg / kg slow IVP (max. dose 5mg)
29
Diltiazem (Cardiazem)
(dil-tye-a-zem)
Class: Calcium Channel Blocker
Mechanism of Action
1. Inhibits calcium ion influx across the cell membranes during depolarization
-Systemic vasodilation resulting in BP
-Coronary vasodilation resulting in  frequency and severity of attacks of angina
-Suppression of arrhythmias
-Relaxes coronary vascular smooth muscles
-Slows SA/AV conduction times; dilates peripheral arteries
Indications
Stable Supraventricular Dysrhythmia – after adenosine
Rapid Ventricular rates in:
- Atrial fibrillation
- Atrial flutter
- Multifocal Atrial Tachycardia
Contraindications
Hypersensitivity
Sick Sinus Syndrome
2nd/3rd degree Block
BP < 100 mmHg
Recent MI or pulmonary congestion
WPW – with atrial fib or flutter
Cardiogenic shock
Concomitant use of IV β-blockers
Wide complex tachycardias
Poison or drug induced tachyarrhythimas
Side Effects
CNS
Dizzy
Drowsiness=C
Headache=C
Nervousness
Abnormal
dreams
Cardiovac.
Arrhythmias=LT
CHF=LT
Peripheral edema=C
Bradycardia=LT
Hypotension
Palpitations
common side effect = C
GI
Nausea=C
Vomiting
Diarrhea
Constipation=C
GU
Nocturia
Acute renal failure=LT
Sexual dysfunction
polyuria
bold italics = LT - life-threatening reactions
30
Respiratory
Cough
Dyspnea
Diltiazem (Cardiazem)
Precautions:
Severe hepatic dysfunction/injury
Geriatric patients (reduced dose)
Severe renal insufficiency
History of serious ventricular dysrhythmias
CHF
Hypotension
How Supplied
25mg / 5cc vial / 50mg / 10cc vial
Administration/Dosage
Administered: slow IVP over
2 minutes
Initial Dose
0.25mg/kg SIVP - over 2
mintues
Subsequent Dose
Repeat in 15 minutes
0.35mg/kg - over 2 minutes
15-20 mg for average patient
20-25 mg for average patient
Maintenance Dose
Maintenance Dose:
125mg (25cc) / 100cc
Infuse at: 5-15 mg/hour
Titrate to HR
Diltiazem is incompatible with Lasix – don’t administer simultaneously
MAKE SURE SYSTOLIC PRESSURE IS AT 100 mmHg OR HIGHER PRIOR TO ADMINISTRATION
- CONSTANTLY REASSESS HEMODYNAMIC STATUS
3
ATROPINE SULFATE
Class: Anticholinergic (parasympatholytic); GI antispasmodic
Mechanism of Action
- Inhibits action of acetylcholine at the muscarinic receptors located within the myocardium, smooth muscle, and glands causing:
1. Increased SA node automaticity + Enhanced AV node conduction = Accelerated heart rate = Improved cardiac output (chronotropic /
dromotropic effects) – (affects rate NOT force of contraction)
2. Will reduce SLUDGE effects of Organophosphate overdose: decreases body secretions
- S = excessive salivation (drug will stop this)
- L = excessive lacrimation (drug will stop this)
- U = excessive urination (drug will stop this)
- D = excessive defecation (drug will stop this)
- G = increased gut motility (drug will stop this)
- E = emesis (drug will stop this)
3. Decreased GI / GU motility
4. Relaxes bronchial smooth muscles (bronchodilation)
4. Dilated pupils
Indications
1. Symptomatic bradycardia
2. Symptomatic heart blocks (first degree and second type I) ****
3. Organophosphate poisoning – Large doses may be needed
4. Nerve gas poisoning (sarin, soman) – Large doses may be needed
*****2nd type II and 3rd degree HB = Transcutaneous pacing (TCP) or sympathetic infusion is best for these patients*******
Contraindications
1. Hypersensitivity
2. Narrow angle acute glaucoma
3. GI obstruction
4. Tachycardia
5. Prostatic enlargement
6. Myocardial ischemia
7. Thyrotoxicosis
Side effects
CNS
Anxiety
Confusion
Dizziness
Drowsiness, Coma
Cardiovascular
Angina
PVC’s
Tachycardia = LT
Hyper - or Hypotension
Eyes
Blurred vision
Eye pain
Glaucoma
Photophobia
Psychosis / Hallucinations
Paradoxical
Bradycardia
Pupil dilation
Weakness
Headache
Bold italics = LT = Life threatening
Eye dryness
32
GI
Anorexia
Constipation
Dry mouth
Abdominal
distention / pain
Decreased gut
motility –
Paralytic Ileus LT
Nausea
Vomiting
GU
Dysuria
Impotence
Retention
Skin
Flushing
Dry skin
Rash
Decreased or
absent sweating
Urticaria
ATROPINE SULFATE
Precautions:
1. Hypersensitivity
2. Use cautiously in patients with:
- Coronary artery disease (CAD)
- Congestive heart failure (CHF)
- COPD (due to decreased bronchiole secretions = increased mucus plugging)
- Patients with fever or exposed to high temperatures
3. Large doses:
- Decrease GI motility
- Inhibit gastric acid secretion
- May block nicotinic receptors at the neuromuscular junctions = possible respiratory depression
How supplied
- Prefilled syringes containing 1mg/10ml (0.1mg/ml)
CHECK THE CONTAINER FOR CONCENTRATION
Administration/dosage
Administered: IVP = IV push / IO
Symptomatic Bradycardia
0.5 IVP
Repeat the dose every 3-5 minutes
Total dose: 3mg
Organophosphate Poisoning
1-2 mg IVP
IVP dose repeated every 5 -15 minutes
until secretions are decreased
IM dose may be given if IV site is not
available
Large doses 2-4 mg or more may be
needed
E.T. Dose
2 to 2.5 times the IVP dose
Repeat every 3-5 minutes
Total dose: 3mg (2-3 doses 1-1.5 mg
each time)
ONLY USED IF YOU CAN’T
START AN IV.
NEVER GIVE TOO SLOWLY OR LESS THAN 0.5MG IN A SINGLE BOLUS TO THE ADULT PATIENT
Pediatric doses:
- Bradycardia: 0.02mg/kg (0.2cc/kg) IVP / IO
- maximum single dose (bolus): 0.5mg (child) and 1.0mg (adolescent)
- maximum total dose: 1mg (child) and 2mg (adolescent) vm
- Organophosphate Poisoning
< 12 years old - 0.02 - 0.05mg/kg IV / IO every 20-30 minutes – until symptoms reverse
> 12 years old – 2 mg IV / IO then 1-2 mg IV / IO every 20-30 minutes – until symptoms reverse
NEVER GIVE LESS THAN 0.1MG IN A SINGLE BOLUS IN THE PEDIATRIC PATIENT
33
CARDIAC GLYCOSIDES
ONE OF THE OLDEST MEDICATIONS KNOW TO HUMANS. THEY INCREASE FORCE (INOTROPIC) OF
CONTACTIONS. WHEN USED FOR CHF THEY INCREAS CARDIAC OUTPUT BY REDUCING LEFT
VENTRICULAR DIAMETER AND DECREASE VENOUS PRESSURE. THESE EVENTS HASTEN THE
REDUCTION OF PERIPHERAL AND PULMONARY EDEMA.
THE THERAPEUTIC INDEX (THERAPEUTIC DOSE / TOXIC DOSE) OF DIGITALIS IS LOW, SO THE
POSSIBILITY OF DIGITALIS TOXICITY SHOULD ALWAYS BE CONSIDERED WITH PEOPLE ON THIS
DRUG.
DIGITALIS IS A POTENT AND POTENTIALLY TOXIC DRUG.
DIGOXIN (LANOXIN)
Class: Cardiac glycoside, antidysrhythmic
Mechanism of Action
1. Inhibits sodium / potassium pump = Increases influx of sodium and calcium ions into the intracellular space =
increased cardiac contractility (+ inotropic effect)
2. Increases vagal tone =
- Decreases SA node firing, prolongs conduction through the AV node (- chronotropic effect)
3. In atrial fibrillation or flutter it decreases number of atrial impulses reaching the ventricles (- chronotropic effect)
4. Improves cardiac output (CO) (↓ baroreceptor response = ↓ SNS discharge = ↓ BP)
- Due to (+) inotropic effects
Indications
1. Control ventricular rate with Atrial-Fibrillation
2. Control ventricular rate with Atrial-Flutter
3. Paroxysmal supraventricular tachycardia (PSVT)
4. CHF
5. Cardiogenic shock
Contraindications
1. Hypersensitivity
2. Ventricular fibrillation
3. Ventricular Tachycardia
4. 2nd (type II) or 3rd AV block (in the absence of a pacemaker)
5. Digitalis toxicity (low therapeutic index)
Side effects – usually due to toxicity
CNS
Cardiovascular
Eyes
GI
Blood
Anorexia = C
Diarrhea = C
Atrial fibrillation Blurred vision =
C
= LT
Apathy,
Yellow or green
Ventricular –
Hemorrhagic
Thrombocytopenia = LT
confusion,
vision
fibrillation or
necrosis of the
delirium
tachycardia = LT
intestines = LT
Hallucinations
Halo effect
Nausea = C
AV block = LT
Headache
Bradycardia
Vomiting = C
Depression
PVC’s
Anorexia
Hypotension
Seizures = LT
Restlessness
Weakness
Italic = C = common side effects
Bold Italic = LT = life-threatening reactions
Skin
Rash
Precautions
1. Use with caution when administered to patients:
- with heart blocks (1st and 2nd type I)
- with WPW
- with liver or kidney disease
- on beta blockers
- with severe pulmonary disease
2. Toxicity is potentiated in patients with: hypokalemia, hypomagnesemia, and hypercalcemia (make heart more
sensitive to digitalis)
3. Crosses the placenta and can effect fetal heart rate as it effects mother
4. Has a low therapeutic index
Supplied
Administration/dosage – Administered Slow IVP
- 0.25mg – 1mg / 1 - 2ml
Administered: slow IVP
Dose: Initial – 4-6mcg /kg (over 5 minutes) / 2nd and 3rd dose 2-3 mcg /kg
34
ASPIRIN
Class: Nonsteroidal Anti-inflammatory Drug (NSAID), antipyretic, platelet inhibitor, nonnarcotic analgesic
Mechanism of Action
1.
2.
3.
4.
-
Inhibits prostaglandin synthesis and release (from mast cells). This action:
decreases pain and fever produced
Antipyretic agent by:
inhibition of prostaglandins
action on hypothalamus heat-regulating center
vasodilation and sweating
Analgesic agent
acts on peripheral nervous system
Platelet inhibitor = prevents formation of thromboxane A2
Post-plaque rupture in vessels → “sticky” platelets adhere to damaged vessel (within 1-5 seconds) → platelets release thromboxane A2
(chemical causes → platelet aggregation and vasoconstriciton)
Aspirin delivery leads to:
- Vasodilation (platelet inhibitor / thromboxane A2 inhibitor)
- Decreased clot formation (platelet inhibitor / thromboxane A2 inhibitor)
- Reduces inflammation (inhibition of prostaglandin synthesis)
- Reduces fever (inhibition of prostaglandin synthesis and antipyretic properties)
- Pain reduction (analgesic property)
IF STARTED WITHIN 24 HOURS OF ONSET OF ACUTE MI – IT REDUCES MORTALITY ALMOST TO THE SAME DEGREE
OF THROMBOLYTIC THERAPY
Indications
1.
2.
3.
4.
5.
Mild to moderate pain and fever
Reducing the risk of recurrent transient ischemic attacks (TIA)
Chest pain or other signs/symptoms of acute MI
EKG changes suggestive of acute MI
To reduce inflammation
Contraindications
1.
2.
3.
4.
5.
Active ulcer disease
Hemophilia
Hemorrhagic states
- Active GI bleeding
- Hemorrhagic stroke
Known hypersensitivity to NSAIDs or salicylates
Children or adolescents with flu-like symptoms / chickenpox (Varicella)
35
ASPIRIN
Side effects
CNS
Confusion
Eyes / Ears
Dim vision
Dizziness
Reversible
hearing loss
Tinnitus
Drowsiness
Headache
Blood
↓ plasma iron
concentration
Leukopenia = LT
GI
Reversible
hepatotoxicity
Anorexia
Metabolic
Hypoglycemia
Respiratory
Hypernea
Skin
Angioedema
Hypokalemia
Wheezing
Bruising
Prolonged bleeding
Diarrhea
Hyponatremia
Bronchospasms
Laryngeal
edema
Hives
Shortened
erythrocyte survival
time
Thrombocytopenia=
LT
Italic = C = common side effects
Dyspepsia (inhibits
pepsin) = GI
discomfort = C
Peptic ulcer
formation
Bleeding
Heartburn
Nausea = C
Bold Italic = LT = life-threatening reactions
Precautions
1. Chronic use may lead to GI ulcerations, bleeding, or perforation
2. Alcohol may increase the risk of GI bleeding
3. Allergic reactions are more likely if the patient has a history of asthma (hypersensitivity)
4. Use cautiously with:
- GI disorders
- Asthma
- Impaired renal / liver function
- Dehydrated children
- Histories of coagulation defects
- Bleeding disorders
Administration / Dosage
Administered - PO (orally) –
Mild pain and fever
325-650mg - PO
Myocardial Infarction
160-325mg / day - PO
NON-ENTERIC – chewing is preferred
36
Rash
Urticaria
RETEPLASE (RETAVASE)
Class: Inhibitor of platelets
Mechanism of Action:
1.
2.
Converts endogenous plasminogen (plasma protein) to plasmin
Plasmin then degrades the fibrin matrix of the thrombus = clot breaks up
Indications:
1.
2.
Acute MI (to improve ventricular function)
Reduce mortality associated with AMI
Contraindications:
1.
2.
3.
4.
5.
6.
Active internal bleeding
History of stroke
Recent intracranial or intra-spinal surgery or trauma
Intracranial neoplasm, arteriovenous malformations, or aneurysm
Known bleeding diathesis (inherited physical condition predisposing to diseases or conditions)
Severe uncontrolled hypertension
Side effects:
Bleeding Disorders
Hemorrhage may occur in the:
Intracranial or retroperitoneal spaces
GI, GU, or Respiratory systems
Venous cutdowns, arterial punctures,
or sites of recent surgery
Cardiovascular
Cholesterol embolus - LT
Arrhythmias from reperfusion
Heart failure - LT
Cardiac arrest - LT
Cardiac tamponade - LT
Recurrent ischemia - LT
Dysrhythmias:
Ventricular fibrillation - LT
Sinus bradycardia
Accelerated idioventricular
PVC’s
SVT
Ventricular tachycardia
Many of these effects may be due to
to the MI and may or may not be due
to the medication
Hypersensitivity
Serious allergic reaction
Bold italics – LT = Life threats
Precautions:
1.
2.
3.
4.
IM injections and nonessential handling of the patient should be avioided during treatment
Monitor for bleeding complications
Perform venipunctures carefully and only when necessary (watch the sites once medication is delivered)
If arterial puncture is necessary, use an upper extremity that can be manually compressed
37
RETEPLASE (RETAVASE)
How supplied:
In a kit with components for reconstitution:
1.
2.
3.
4.
5.
Single use reteplase vials – 10.8 units each
Single use diluent vials of sterile water – 10 cc each
Sterile 10cc syringe with 20 gauge needle
Sterile dispensing pins
Sterile 20 gauge needle
Administration and dosage:
1.
2.
Reconstitute the retavase
Swirl (not shake) the vial gently to dissolve the retavase
Deliver the 10 units – slow IVP over 2 minutes
Deliver the second 10 units after 30 minutes
Heparin and aspirin should be administered concomitantly (simultaneously) –
Heparin should NOT be delivered through the same IV line
38
SODIUM BICARBONATE
Class: electrolyte replacement, alkalinizing agent
Mechanism of action
1. Neutralizes excess acid
- Helps blood and body fluid return to a normal physiological pH
- Improves metabolic processes
- Allows sympathomimetic agents to work more effectively
2. Raises the pH in serum and urine so drugs can be excreted from the body more rapidly by the kidneys
3. Encourages redistribution of K+ ions from extracellular to intracellular fluid
- ↑ H+ causes K+ to move out and H+ moves into the intracellular space
4. Electrolyte replacement (diarrhea)
H+ + HCO3- ↔ H2CO3 ↔ H2O + CO2
Indications
1. Metabolic acidosis
2. Certain poisonings (methanol / ethylene glycol)
3. Rhabdomyolysis
4. Hyperkalemia
5. Overdoses with:
- barbiturates
- tricyclic antidepressants
- aspirin
- lithium
- cocaine
- diphenhydramine
6. DKA
7. Prolonged resuscitation with effective ventilation
8. Return of spontaneous circulation after long arrest interval
Contraindications
1. Hypokalemia / hypocalcemia / hypernatremia
2. CHF
3. Metabolic / Respiratory alkalosis
4. Renal failure
5. Abdominal pain of unknown origin (due to distention side effect)
6. Hypertension
Side effects
CNS
Confusion
Headache
Hyperreflexia - C
Cardiovascular
Cardiac arrest - LT
Edema
Irregular pulse
GI
Belching - C
Cramps
Distention - C
Metabolic
Alkalosis -C
Hypocalcemia
Hypokalemia
Irritability
Water retention
Flatulence
Intracellular
acidosis (if not
ventilated)
Respiratory
Apnea - LT
Cyanosis
Shallow, slow
respirations
Induces left shift in
oxy-dissociation
curve
Seizures (caused
Weight gain
Increased thirst
by alkalosis) = LT
Tetany
Tremors
Twitching = C
Weakness
Italic = C = common side effects
Bold italic = LT = life-threatening reaction
AFTER ADMINISTRATION REASSESS VENTILATIONS OFTEN
(H+ + HCO3- ↔ H2CO3 ↔ H2O + CO2)
39
SODIUM BICARBONATE
Precautions
1. Temporary therapy in metabolic acidosis (best to give according to blood gases)
2. Rapid or excessive administration may cause - alkalosis, hypokalemia, hypocalcemia or dysrhythmias
3. Alkalosis leads to – hypoxia (left shift of oxyhemoglobin dissociation curve) + cerebral vasoconstriction
4. IV use may cause - fluid/electrolyte disturbances, fluid overload, and pulmonary edema
5. Can cause intracellular acidosis - H+ + HCO3- ↔ H2CO3 ↔ H2O + CO2
6. Do not give simultaneously with catecholamines – will reduce effectiveness
7. Precipitates with calcium chloride, atropine, morphine, magnesium sulfate (don’t give simultaneously)
8. Use cautiously with:
- CHF
- Cirrhosis
- Hypertension
- Toxemia – Pregnancy induced hypertension
- Renal disease
9. Infiltration can lead to severe tissue damage
How supplied
- 50 meq / 50ml
Administration / dosage
Administered - IVP
Initial dose
1mEq / kg - IVP
Repeat in 10 minutes using subsequent dose
Subsequent dose
0.5mEq / kg - IVP
Should be delivered according to blood gas analysis
REASSES VENTILATIONS OFTEN AFTER ADMINISTRATION!!!!
SUBSEQUENT DOSES SHOULD BE BASED ON - BLOOD GAS ANALYSIS
ADEQUATE VENTILATION AND CPR ARE MAJOR “BUFFER AGENTS” IN CARDIAC ARREST
Pediatric dose: 1mEq/kg IVP / IO
40
MORPHINE SULFATE
Class: narcotic analgesic
Mechanism of action
1. CNS depressant
- Inhibits pain perception
- Decreases emotional response to pain (SNS response)
- Causes sedation
- Depresses respiratory centers in the brainstem
2. Decreases preload (venous dilation)
3. Decreases afterload (arteriole dilation)
- #2 and #3 occur due to ↓ SNS response (↓ responsiveness of alpha receptors) /stimulate histamine release from Mast cells / baroreceptor
inhibition
- More venous dilation than arteriole
Pain inhibition = ↓ SNS response = ↓ preload and afterload = reduction in myocardial O2 requirements
Indications
1. To relieve pain and anxiety with:
- myocardial infarction
- unstable angina / non-STEMI – use ONLY if not responding to nitrates
- traumatic injury
- malignancy
2. To treat pulmonary edema (with or without chest pain and BP >100mmHg)
Contraindications
1. Significant hypotension
2. Respiratory depression (unless caused by pulmonary edema and BP isadequate)
3. Acute asthma attack
4. CNS depression due to:
- Head injuries
- Drug overdose (CNS depressants)
- Poisoning
5. Undiagnosed abdominal pain
6. Hypersensitivity
Side effects
CNS
Addiction
Confusion
Dizziness - C
Cardio-vascular
Bradycardia
Eyes / Ears
Blurred vision
GI
Anorexia
Reflex
tachycardia
Miosis (pupil
constriction) C
Constipation - C
Diplopia
Cramps
Tinnitus
Nausea - C
Hypotension LT
Palpitations
Drowsiness C
Euphoria
Headache
Sedation - C
Italic = C = common side effects
GU
Urinary
retention
Reduced
libido (with
prolonged
use)
Vomiting
Bold italic = LT = life-threatening reaction
41
Respiratory
Depression - LT
Other
Histamine release =
Decreased
cough reflex
↓ B/P; ↑ HR;
↑sweating; flushing
of the face;
wheezing; dyspnea C
MORPHINE SULFATE
Precautions
1. May cause severe respiratory depression and / or hypotension with rapid injection
2. Commercial preparations may contain sulfites causing allergic reactions =
- Hypersensitivity
3. Use cautiously with:
- Liver / kidney disease
- Head injury
- COPD, asthma, pulmonary disease
- Child < 18 years old
- Prostatic hypertrophy = decreased urination
4. May worsen bradycardia or HB with inferior MI or Right Ventricular infarct
How supplied
2mg / ml or 10mg / ml
Administration / dosage
Administered - slow IVP or IM
Relief of moderate to severe pain
Unstable Angina / Non-STEMI
1-5 mg SIVP – ONLY if not responding to nitrates
5-20 mg IM
Ensure systolic BP (SBP) remains ≥ 100 mmHg
-
Antagonized by Narcan (for respiratory depression)
-
Have atropine available in case bradycardia develops
To reduce preload (CHF / STEMI)
2 - 4mg SIVP
Repeat in 5-15 minutes until desired response is
obtained
Ensure systolic BP (SBP) remains ≥ 100 mmHg
- MONITOR VITALS FREQUENTLY - DISCONTINUE IF HYPOTENSION (BP less than 100 mmHg) or RESPRIATORY
DEPRESSION DEVELOPS
Pediatric doses:
- slow IVP: 0.1 / 0.2mg/kg - up to 15mg
42
Fentanyl (Sublimaze)
Class: narcotic analgesic
Mechanism of action
1. Inhibits ascending (sensory) pain pathways in CNS, increases pain threshold, and alters pain perception by binding to opiate receptors.
Indications
1. Pain control
2. Sedation for invasive airway procedures (rapid sequence induction) – conscious sedation
Contraindications
1.
2.
3.
4.
5.
6.
Hypersensitivity
Myasthenia gravis
Respiratory depression
Head injury
Cardiac dysrhythmia
Hypotension
Side effects
CNS
Dizziness
Delirium
Cardio-vascular
Bradycardia=LT
Arrest=LT
Eyes / ears
Blurred vision
Miosis (pupil
constriction)=C
GI
Nausea=C
Vomiting
Sedation=C
Hypotension=C
Euphoria
Hypertension
common side effects=C
bold italic = life-threatening reaction
GU
Respiratory
Depression=LT
Arrest=LT
Laryngospasm=LT
Precautions
1. elderly
2. respiratory depression
3. increased intracranial pressures
4. seizure disorders
5. severe respiratory disorders
6. dysrhythmias
How supplied
0.05 mg/ml
Administration / dosage
Administered – IM - slowly
Dosage:
Pain relief/anesthesia:
0.05-0.1 mg q 1-2 hours as needed to control pain – resuscitative equip available Dilute above amt in 5 cc NS
Narcan should be available to reverse respiratory depression
43
Other
Nitrous oxide:Oxygen (50/50)
Nitronox
Class: gaseous analgesic/anesthetic
Mechanism of action
A blend of 50% O2 and nitrous oxide. When inhaled, depresses the CNS causing anesthesia; In addition, the high concentration of oxygen delivered
along with the nitrous oxide increases oxygen tension in the blood, thereby reducing hypoxia. It is self administered
Indications
Moderate to severe pain
Anxiety
Apprehension
Contraindications
1. Impaired LOC
2. Head injury
3. Chest trauma (pnemothorax)
4. Inability to comply with instructions
5. Decompression sickness (nitrogen narcosis, air transport, air embolus)
6. Undiagnosed abdominal pain or marked distention
7. Bowel obstruction
8. Hypotention
9. Shock
10. COPD
Side effects
CNS
Dizzy
Cardiovascular
GI
GU
Malignant
Nausea/vomiting
hypertention
**Rare but
dangerous
common side effect=C
bold italic = LT = life-threatening reaction
Respiratory
Apnea (LT)
Skin
Cyanosis
How supplied
- D or E cylinders - blue and green in USA; blue and white in Canada
Administration / dosage – start an IVP prior to administration
Adult: ENSURE enough O2 is in the tank to ensure oxygenation - invert cylinder several times before use – this mixes O2 and nitrous oxide
Instruct the patient to inhale deeply through a patient held mask or mouthpiece
Pediatric: Same
Special Consideration:
Pregnancy: Nitrous oxide has been shown to increase the incident of spontaneious abortion
Nitrous oxide - is 34 times more soluble than nitrogen and will diffuse into pockets of trapped gas in the patient (intestinal obstruction,
pneumothorax, blocked middle ear. As nitrogen leaves and is replaced by larger amts of nitrous oxide, increase pressures or volumes may cause
serious damage, for example, intestinal rupture
Nitrous oxide is non-explosive gas
Patient must hold mask and self administer
44
FUROSEMIDE (LASIX)
Class: Sulfonamide-type loop diuretic
Mechanism of Action
1. Inhibits reabsorption of sodium and chloride in the proximal tubule and loop of Henle
2. Causes rapid diuresis (within 15-20 minutes)
3. Causes venodilation (within 5 minutes) = reduced preload
4. Decreases renal vascular resistance = increased renal blood flow
5. Results in excretion of Na+, Cl-, K+, H+, Ca++, Mg++, HCO-3, HPO46. May cause electrolyte imbalances
Indications
1. Edema associated with: (BP needs to be greater than 100 mmHg – no signs of shock)
- CHF
- Cirrhosis of the liver
- Renal disease
2. Cerebral edema
3. Hypertensive emergencies
Contraindications
1. Pregnancy
2. Hypotension
3. Electrolyte depletion
4. Hypovolemia / dehydration
5. Hypersensitivity to Sulfa drugs
6. Anuria
Side Effects
CNS
Dizziness
Headache
Cardiovascular
Collapse - LT
Chest pain
GI
Anorexia
Constipation
Fluids / Electrolytes
Electrolyte depletion - LT
Metabolic alkalosis - C
Weakness
Vertigo
EKG changes
Orthostatic
hypotension
Diarrhea
Nausea - C
Hypovolemia - LT
Restlessness
Common side effect=C
Eyes / Ears
Blurred vision
Ototoxic – Given too
quickly = tinnitis and
deafness
Vomiting
bold italic = LT = life-threatening reaction Precautions
1. Excessive diuresis may cause: hypovolemia, electrolyte depletion
2. Use cautiously with: sulfonamide sensitivity, renal impairment, digitalized patients, cirrhosis or liver failure
3. May precipitate with all catecholamines and deactivate Epinephrine
4. May develop transient deafness with rapid administration
How Supplied
- 10mg / mL in 2-, 4-, 8mL ampules or 10mg / mL in 10-mL vial
Administration and Dosage
- Slow IV Push
- 20-40 mg – (0.5 to 1mg/kg) IVP slowly (over 1-2 minutes)
- if no response to initial dose – give 2mg/kg (double dose)
- Start with low dose if patient not on Lasix
- Repeat in 1-2 hours
Pediatric dose: 1mg/kg slow IVP – Total dose 6mg/kg
45
NITROGLYCERIN (NITROSTAT)
Class: antianginal, vasodilator, and nitrate
Mechanism of action
1. Relaxes vascular smooth muscle - promoting vasodilation
2. Decreases preload (predominately)
- venous dilation = ↓ preload = ↓ heart size
- ↓ heart size = ↑ blood flow to coronary and collateral vessels = myocardial perfusion is improved
3. Decreases afterload
- ↓ arteriole pressure = ↓ aortic pressure = left ventricle works better
4. Decreases myocardial O2 consumption / workload
5. Improves collateral flow to ischemic regions
6. Dilates pulmonary capillary beds
- fluid in alveoli and interstitial space are pulled back into the vessels
Pain relief occurs within 2 minutes & therapeutic effects observed up to 30 minutes.
Indications – systolic pressure ≥ 100 mmHg
1. Angina
2. Chest pain with myocardial infarction
3. Pulmonary edema associated with CHF or MI
4. Hypertensive emergencies with Acute Coronay Syndromes or acute CHF
Contraindications
1. Increased ICP
2. Hypotension
3. Hypovolemia
4. Viagra use within 24 hours
5. Right ventricular infarct
6. Severe bradycardia or tachycardia
7. Hypersensitivity
Side effects
CNS
Anxiety
Confusion
Dizziness - C
Cardiovascular
Atrial fibrillation
Collapse - LT
Increase in angina
GI
Abdominal
pain
Diarrhea
Dyspepsia
GU
Dysuria
Impotence
Urinary
frequency
Uncoordination
Nausea
Dysrhythmias LT
Headache - C
Palpitations
Vomiting
Nervousness
Postural
hypotension - C
Vertigo
PVC’s
Weakness
Reflex
Tachycardia
Syncope
Italic = C = common side effects
Bold italic = LT = life-threatening reaction
46
Eyes
Blurred vision
Skin
Flushing - C
Pallor
Burning sensation in
contact area - C
Sweating
Pallor
NITROGLYCERIN (NITROSTAT)
Precautions
1. The drop in B/P may lead to decreased cerebral perfusion
2. Patient may develop tolerance to the drug
3. A reduction in the diastolic pressure may lead to ischemia and angina developing
4. Use cautiously with:
- the patient having an inferior wall MI with possible RV involvement
- severe renal / hepatic impairment
- glaucoma
Administration / dosage – ESTABLISH AN IV PRIOR TO ADMINISTRATION (on borderline patients- pressure close to 100mmHg)
Administered: - pills, spray, patches, ointments, IV infusion
- Prehospital - administer nitro. sublingually through pills or spray
Dose: - 1 - 0.3 - 0.4mg tablet sublingual - repeated every 5 minutes (give up to 3 tablets)
Sit or lie patient down – instruct not to swallow until tablet is entirely dissolved
Dose: - 1-2 sprays - 0.4mg per spray sublingual - every 5 minutes (up to 3 sprays in 15 minutes)
Spray for 0.5 to 1.0 seconds – Do not shake canister (may produce bubbles and alter medication delivery)
MONITOR VITALS AFTER EACH DOSE PRIOR TO ADMINISTERING MORE DRUG
SYSTOLIC BLOOD PRESSURE SHOULD NOT BE LESS THAN 100 mmHg PRIOR TO ADMINISTRATION.
When administering to patients with:
1. Acute MI – don’t let systolic pressure drop more than 10%
2. Hypertension – don’t let systolic pressure drop more than 30%
47
ANTIHYPERTENSIVES
HYPERTENSIVE TREATMENTS
HYPERTENISVE URGENCY
HYPERTENSIVE EMERGENCY
DIASTOLIC PRESSURE EXCEEDS 130 mmHg
B/P NEEDS TO BE LOWERED WITHIN
24 HOURS
B/P NEEDS TO BE LOWERED WITHIN
30-60 MINUTES HOURS
FUNCTIONAL DISTURBANCES OF CNS, HEART, KIDNEYS
FUNCTIONAL DISTURBANCES OF –
CNS, HEART, KIDNEYS
HYPERTENSIVE ENCEPHALOPATHY
LABETALOL (TRANDATE NORMODYNE) (done)
Class: Beta blocker
Mechanism of Action:
1. Alpha 1 blocking agent
- vasodilation, decreased peripheral vascular resistance, orthostatic hypotension
2. Nonselective beta blocking agent
- effects the SA, AV, ventricular muscle =
- bradycardia, delay in AV conduction, depressed cardiac contractility
More potent Beta blocker than Alpha blocker = BP reduces without reflex tachycardia
Indications:
-
Hypertensive Emergencies
All patients with suspected MI and unstable angina (if not contraindicated)
Useful as adjunctive agent with fibrinolytic therapy (may reduce nonfatal reinfarction and recurrent ischemia)
To convert SVT (reentry SVT, A-fib or A-flutter with rapid ventricular response) to NRS or to slow ventricular response
To reduce myocardial ischemia in AMI patients with elevated HR, BP or both
ENSURE BP is over 100 mmHg
Contraindications:
-
Bronchial Asthma
Uncompensated CHF
High Degree Heart Blocks (2nd and 3rd degree)
Cardiogenic Shock
Severe Bradycardia
Pulmonary edema
Hypersensitivity
Side effects:
CNS
Anxiety
CV
AV block =
LT
EENT
Double
vision
GI
Diarrhea =
C
GU
Dysuria
Dizziness
Bradycardia
Nausea = C
Ejaculatory
failure
Fatigue /
Malaise
Headache
Tremors
Chest pain
Dry
burning
eyes
Sore
throat
Tinnitus
Visual
changes
Vomiting
Impotence
HEME
Agranulocytosis =
LT
RESP
Bronchospasms =
LT
Dyspnea
Wheezing
Constipation
CHF= LT
Orthostatic
Taste
Hypotension
disturbances
Mental
Ventricular
depression Dysrhythmia
= LT
Drowsiness
Palpatations
Nightmares
Peripheral
edema
Scalp
Pulmonary
tingling
edema
Cold
extremities
Italic = C = common side Bold italic = LT = life-threatening reactions
MS
Muscle
cramps
SKIN
Fever
Pruritus
Rash
Urticaria
48
LABETALOL (TRANDATE NORMODYNE) (done)
Precautions:
-
Use with caution in:
- COPD patients (nonallergic bronchospastic disease)
- Well-compensated patients with history of heart failure
- Pheochromocytoma
- Impaired hepatic function
- Impaired renal function
- Jaundice
- Diabetes mellitus
- Peripheral vascular disease
- Thyroid disease
- Nitroglycerin may augment hypotensive effects
How Supplied:
- 5mg / ml (4, 8, 20, 40 ml vials)
Administration / Dosage:
-
Delivered Slow IVP and IV infusion
Slow IVP Dose:
Initial Dose
10 mg Slow IVP (over 1-2
minutes)
Subsequent doses
10 to 20 mg every 10 minutes, prn
IV infusion dose:
-
Mix: 200 mg / 250 cc
Infuse at – 2 to 8mg / minute (titrate to supine blood pressure)
49
Total dose
150 mg
ALBUTEROL (PROVENTIL)
Class: Beta2 adrenergic agonist
Mechanism of Action
1. Predominately stimulates β2 receptors
2. Minimal β1 stimulation
3. May cause reflex tachycardia (with high doses)
4. Promotes intracellular shift of K+ from serum
5. Inhibits histamine release from Mast cells
6. Increased diuresis
Indications
1. Relief of bronchospasms associated with asthma, chronic bronchitis, emphysema
- Reduces mucus secretions, capillary leaking, mucosal edema (by blocking histamine release)
2. Prevention of exercise-induced asthma and bronchospasms
Contraindication
1. Hypersensitivity
2. Tachydysrhythmias
3. Severe cardiac disease
Side Effects
CNS
Anxiety
Dizziness - C
Flushing
Hallucinations
Headache - C
Irritability
Stimulation - C
Tremors - C
Italic = C = common side
Cardiovascular
Angina
GI
Heartburn
Dysrhythmias
Hypertension
Palpitations - C
Tachycardia - C
Nausea - C
Vomiting
Musculoskeletal
Inhibition of uterine
contractions
Muscle cramps
Precautions
1. May develop tolerance with prolonged use (vm)
2. Repeated or excessive use may lead to paradoxical bronchoconstriction
3. Use cautiously with:
- cardiac disorders
- hypertension
- diabetes
- prostatic hypertrophy
50
Respiratory
Cough
ALBUTEROL (PROVENTIL)
How Supplied
- 2.5mg/ 2.5ml
Administration/Dosage
Two ways to administer:
1. Metered dose inhaler:
- 1- 2 sprays (90 - 180µg is delivered) q 4-6 hours – Max.: 12 inhalations / day
2. Nebulizer:
- Adults and children over 12: Dilute 2.5mg in 3.0 ml of NS
- Nebulizer should deliver 3.0 ml over 5 to 15 minutes – 3-4 times / day
Pediatric dose: 0.05 - 0.15mg / kg (0.01 - 0.03ml / kg) in 2ml NS via nebulizer – may be repeated q 20 minutes – 3 times
51
EPINEPHRINE (1:1,000)
Class: Sympathomimetic, vasopressor, bronchodilator
Mechanism of Action
- Catecholamine that stimulates alpha- and beta- adrenergic receptors
1. Beta1 stimulation leads to:
- positive inotropic effects (↑ force of cardiac contraction)
- positive chronotropic effects (↑ rate of cardiac contraction)
- positive dromotropic effects (↑ conduction velocity)
- increased cardiac output (CO)
- increased myocardial oxygen requirements
2. Beta2 stimulation leads to:
- peripheral vasodilation and bronchodilation
3. Alpha1 stimulation leads to peripheral vasoconstriction:
- arterial / venous vasoconstriction (vasopressor) = increased SVR
- constriction to renal, mesenteric, coronary, and cerebral vessels
- pulmonary vasoconstriction
- making the heart more susceptible to direct countershock in cardiac arrest (Ventricular fibrillation) = reason it is given during cardiac
arrest
4. Inhibits histamine release (stops degranulation) during anaphylactic reaction
(Effects start within 90 seconds and are short lived)
Indications
1. Acute asthma attacks
2. Exacerbation of some forms of COPD
3. Mild anaphylaxis
4. Symptomatic Bradycardia (refractory, not responding, to oxygen and atropine)
Contraindications
1. Hypersensitvity
2. Patients with underlying cardiovascular disease
3. Tachyarrhythmias
4. Not with alkaline drugs
5. Shock
6. Patients with hypertension
52
EPINEPHRINE (1:1,000)
Side Effects
CNS
Anxiety
Dizziness
Cardiovascular
Anginal pain
Dysrhythmias LT
Hypertension
Palpitations - LT
Ischemia
Headache
Restlessness
Subarachnoid
Hemorrhage =
LT
Tremors
Weakness
Italic = C = common side
GI / GU
Nausea - C
Vomiting-C
Respiratory
Dyspnea
Skin
Pallor
Coldness
Urinary retention
Necrosis
Urticaria
Bold italics = LT = life-threatening reactions
Precautions
1. Increased myocardial workload may lead to ischemia, infarction
2. May have increased airway resistance due to sulfites in the preparation = hypersensitivity
3. Use cautiously with:
- Heart disease
- Diabetes
- Hypertension
4. Excreted into breast milk – use cautiously on nursing mothers
How supplied
- Ampules and prefilled syringes containing
- 1mg/1ml
- Vials containing:
- 30mg/30cc
Administration / dosage
Administered – SQ / IM / IV infusion
Mild Anaphylaxis or Acute Asthma Attack
0.3 to 0.5mg - IM / SQ
Mix infusion:
Refractory Bradycardia
Every 15 – 20 minutes, PRN
Dosage range:
1-2mg / 250 or 500cc
2-10µg / minute
Low doses – 2-5µg / minute = β effects
High doses – 5-10µg / minute = α effects
Pediatric dose: 0.01mg/kg up to 0.3mg IVP, IO
53
Eyes
Pupil dilation
Methylprednisolone (Solu-Medrol)
Class:
Anti-inflammatory glucocorticoid
Mechanism of action:
suppresses acute and chronic inflammation
potentiates vascular smooth muscle relation by beta-adrenergic agonist.
Indications:
Acute Spinal cord trauma
Anaphylaxis
Bronchodilator for unresponsive asthma
Septic shock (controversial)
Adrenal insufficiency (SoluCortef)
Contraindications:
Psychosis;hypersensitivity
Idiopathic thrombocytopenia
Acute glomerulonephritis
Fungal infections
Nonasthmatic bronchial disease
Diabetes (causes hyperglycemia)
Side effects
CNS
Depression
Sweating
Headache
Cardiovascular
GI
Hypertension
Circulatory collapse
Embolism
Diarrhea=C
Nausea
GI
hemorrhage=LT
common side -C
GU
Respiratory
EENT
Fungal infection
Blurred vision
Cataracts
tachycardia
bold italic = LT - life-threatening reactions
How supplied
Injectable; acetate; 20 mg, 40mg , 80mg; succinate: 40mg; 125mg, 500mg 100mg
Administration / dosage
Adult:40-125 IM/IV
Onset of action: 1-2 hrs; duration 8-24 hrs
Administered – IM/IV
54
DEXAMETHASONE (DECADRON)
Class : Glucocorticoid
Mechanism of action:
1.
2.
3.
Synthetic steroid related chemically to the natural hormones secreted by the adrenal cortex
Suppress acute and chronic inflammation
Potentiates the relaxation of vascular and bronchial smooth muscles by beta-adrenergic agonistst
Indications:
1.
2.
3.
4.
5.
6.
Allergic reactions
Asthma
Reduce swelling in the CNS
Endocrine, rheumatic, hematological disorders
Septic shock
Chronic inflammation
Slow onset (4-8 hrs) not considered a first-line medication for allergic reactions.
Contraindications:
1.
2.
Hypersensitivity to the product
Active untreated infections
Side effects:
1.
2.
3.
4.
Decreased wound healing
Hypertension
GI bleeding
Hyperglycemia
Precautions:
Barbiturates and phenytoin (Dilantin) can decrease effects
How supplied:
1.
2.
3.
4.
4mg / mL in 1-, 5-, 10-, 25-, 30 mL vials
10 mg / mL in 10 mL vials, 1mL syringe, 1mL ampule
20 mg / mL in 5mL vials, 5mL syringe
24mg / mL (IV only) in 5- and 10mL vials
Administration / dose:
Adult: 4-24 mg IV
Pediatric: 0.25-0.5 mg/kg IV / IO
55
RACEMIC EPINEPHRINE (MicroNefrin)
Class : Sympathomimetic
Mechanism of action:
1.
2.
3.
Bronchodilator that stimulates B2 receptors in lungs = relaxation of bronchial smooth muscles
a. Alleviates bronchospasm
b. Increases vital capacity
c. Reduces airway resistance
Useful in treating laryngeal edema
Inhibits the release of histamine
Indications:
1.
2.
3.
4.
Bronchial asthma
Treatment of bronchospasm
Croup (laryngotracheobronchitis)
Laryngeal edema
Monitor vital signs closely
Contraindications:
1.
2.
3.
Hypertension
Underlying cardiovascular disease
Epiglottitis
Side effects:
1.
2.
Tachycardia
Dysrhythmias
Precautions:
1.
2.
3.
4.
5.
May produce tachycardia and other dysrhythmias
Excessive use may cause bronchospasm
Rebound exacerbation of severe croup may occur following during administration
MAO inhibitors may potentiate the effects
Beta antagonists may blunt the bronchodilating response
How supplied:
Meter dose inhaler: 0.16 – 0.25 mg / spray
Solution: 7.5, 15, 30 mL in 1% or 2.25% solution
Administration / dose: - Metered dose inhaler
Adult:
1.
2.
2-3 inhalations – repeat once in 5 minutes, prn
Dilute 5mL (1%) in 5mL saline – administer over 15 minutes
Pediatric: Administer by aerosolization
1.
2.
3.
Less than 20 kg - Dilute 0.25mL (0.1%) in 2.5cc saline
20-40kg – Dilute 0.5mL in 2.5mL saline
Over 40 kg – Dilute 0.75mL in 2.5mL saline
56
50% DEXTROSE (D50W)
Class: carbohydrate, caloric agent
Mechanism of action
1. Increases blood glucose concentrations
2. Provides calories
3. Decreases rate of ketone production
4. Osmotic diuretic
Indications
1. Acute alcoholism with coma (deliver thiamine prior to D50W)
2. Hypoglycemia
3. Coma of unknown cause (NEED TO CHECK BG)
4. Status epilepticus of uncertain cause
5. Hyperkalemia – with insulin may shift K+ back to the intracellular space
Contraindications
1. Hypersensitivity to corn or corn products
2. Thiamine deficient patients (may cause Korsakoff’s psychosis or Wernicke’s encephalopathy)
3. Intracranial hemorrhage (unless patient is hypoglycemic)
Side effects
Cardiovascular
Hypertension
CHF - LT
Pulmonary edema - LT
GU
Osmotic diuresis
Metabolic
↓ K+ and Mg++
Fluid overload
bold italic = LT - life-threatening reactions
Precautions
1. Excessive IV administration may cause fluid volume or solute overload
2. Use cautiously with:
- Carbohydrate intolerance; renal insufficiency; chronic alcoholism (give Thiamine first); diabetes
How supplied
- 25gm / 50ml (50% solution)
Administration / dosage
Administration - Slow IVP (in a large vein)
Dose – 12.5 to 25 grams (25 to 50 cc)
- Perform a D-stick prior to administration if possible
- Give Thiamine prior if alcohol use is suspected
Pediatric dose: 2 - 4ml / kg slow IVP - dilute 1:1 with sterile water to form a 25% solution (D25)
57
Skin
Irritation
Necrosis
THIAMINE
Class: vitamin B1
Mechanism of action
1.
2.
Required for metabolic processes
Co-enzyme important in carbohydrate metabolism
- helps the breakdown of glucose in the Kreb Cycle
- Thiamine is consumed in the process
Thiamine deficiency results in accumulation of pyruvic acid with subsequent conversion to lactic acid
Indications
1.
2.
3.
Coma of unknown origin
Alcoholic patients with altered sensorium and / or delirium tremens
Thiamine deficiency - due to:
- fasting or anorexia
- alcoholism
- cirrhosis
- prolonged vomiting
Thiamine is not produced by body – it must be obtained by diet (the above patients don’t take in, absorb, and utilize thiamine effectively)
Contraindications
1. Hypersensitivity (rare)
Side effects
CNS
Restlessness
Weakness
Cardiovascular
Collapse
Hypotension
Pulmonary edema LT
GI
Diarrhea - C
Hemorrhage
Nausea - C
Respiratory
Throat tightness
Dyspnea
Skin
Angioneurotic edema
Cyanosis
Pruritis
Sweating
Urticaria
Italic = C = common side effects
Bold italic = LT = life-threatening reaction
Precautions
1. Severe hypersensitivity
2. Cardiovascular collapse
3. Death
Usually occurs after repeated IV administration
How supplied
- 100mg / 1ml or 2 ml
Administration / dosage
Administered – Slow IVP or IM
Dose:
- 100mg IVP or
- 50mg IM and 50mg IVP
Pediatric dose: 10-25mg IVP (for critically ill children) – not usually recommended
58
Glucagon
Class:
Hyperglycemic agent; pancreatic hormone, insulin antagonist
Mechanism of action:
1. Protein secreted by alpha cells of the pancreas. When released results in blood glucose elevation by increasing the breakdown of glycogen
to glucose (glycogenolysis) and stimulating glucose synthesis (gluconeogenesis).
2. Only effective in treating hypoglycemia if liver glycogen is available and therefore may be ineffective in chronic states of:
a. Hypoglycemia
b. Starvation
c. Adrenal insufficiency
3. Exerts (+) inotropic action on the heart and decreases renal vascular resistance
a. Why used to manage patient with beta-blocker and calcium-channel blocker cardiotoxicity (that do not respond to other
conventional therapy)
Indications:
1. Altered LOC when hypoglycemia is suspected
2. Beta-blocker and calcium channel blocker toxicity.
Contraindications:
1. Hyperglycemia
2. Hypersensitivity to proteins
Side effects
CNS
Cardiovascular
GI
tachycardia
Hypotension
Vomiting=C
GU
Respiratory
Skin
Urticaria
common side effects=C
How supplied
1unit (1mg) white powder with 1 mL of diluting solution (supplied)
Reconstitute the powder with the diluent
DO NOT MIX WITH NORMAL SALINE
Administration / dosage - IM
Adult - 0.5mg-1mg IM - repeat in 7-10 min
Calcium Channel OD/Beta blocker OD: 3mg to 10 mg SIVP (over 3-5 minutes) – followed by infusion at 3 - 5mg / hour
59
DIAZEPAM (VALIUM)
Class: Sedative / hypnotic, antianxiety agent, anticonvulsant, skeletal muscle relaxant
Mechanism of Action
1. CNS depressant
- Reduces anxiety
- Causes sedation
- Induces amnesia
2. Relaxes skeletal and/or smooth muscle
3. Anticonvulsant (acts on the limbic, thalamic and hypothalamaic regions of the CNS)
- ↑ the chance of gammaaminobutyric acid (GABA) combing with receptors that make up Cl- channels on cell
membranes =↑ Cl- movement into the cells (intracellular space become negative) = ↓ cell depolarization
4. Decreases agitation, tremors, hallucinations associated with alcohol withdrawal
Indications
1. Status epilepticus
2. Pre – Cardioversion and / or Transcutaneous Pacing
3. Severe anxiety
4. Skeletal muscle spasm relaxation
5. Acute alcohol withdrawal
PREDOMINATELY USED FOR STATUS EPILEPTICUS AND PRECARDIOVERSION / TCP
IN THE PREHOSPITAL SETTING.
Contraindications
1. Pregnancy
2. Alcohol or other sedative drugs with depressed vital signs
3. Respiratory depression
4. Hypotension
5. Hypersensitivity
Side Effects
CNS
Anxiety
Cardiovascular
EKG changes
Eyes / Ears
Blurred
vision - C
GI
Anorexia
GU
Urine
retention
Confusion
Depression
Hypotension
Orthostatic
hypotension - C
Constipation
Diarrhea
Incontinence
Dizziness - C
Drowsiness C
Fatigue
Tachycardia
Phlebitis
Tinnitus
Mydriasis
(pupil
dilation)
Nystagmus
Diplopia
Vascular
impairment (if
IVP into sm.
hand vein)
Hallucinations
Headache
Insomnia
Tremors
Italic = c = common
Dry mouth
Nausea
Vomiting
Bold Italic = LT - life-threatening reactions
60
Respiratory
Respiratory
depression LT
Laryngospasm
Decreased gag
reflex
Skin
Dermatitis
Itching
Rash
DIAZEPAM (VALIUM)
Precaution
1. Rapid IV therapy can cause profound hypotension, and respiratory depression
2. Use cautiously with:
- COPD patients
- Hepatic / renal disease
- older adults
- children
- Myasthenia gravis patients
3. Precipitates with most fluids (don’t administer with other drugs)
- Administer through an IV of NS
How Supplied
- Prefilled syringe and ampule - 10mg / 2ml
Administration/Dosage
Administered - Slow IVP, IM, Rectally (usually for pediatric patients)
Status Epilepticus
5-10mg - Slow IVP
(over 2 minutes)
Pre-cardioversion
5-10mg - Slow IVP
(5-10 minutes prior to procedure)
Eclampsia
5-10 mg - Slow IVP
Anxiety
2-5mg - IM
- REPEAT DRUG AS NEEDED IF HEMODYNAMIC STATUS ALLOWS
- MONITOR VITALS FREQUENTLY
-
Do not mix with other medications or fluids - may precipitate
-
ANTAGONIZED BY FLUMAZENIL (Romazicon):
DOSE – 0.2 mg (2 mL) over 15 seconds – TOTAL DOSE – 3mg - Reverses the effects in 1-2 minutes
Pediatric dose: - 1 month to 5 years: 0.2-0.5mg slow IVP every 2-5 minutes up to 5mg.
- 5 years and older: 1mg slow IVP every 2-5 minutes up to 10 mg
Rectal dose: 0.5-0.7 mg/kg in a 1cc syringe
- place the patient in a prone position
- KY the syringe
- Insert the syringe 4-5 cm into the rectum
ELDERLY – Reduce dose by 50%
After rectal administration hold the buttocks together to prevent leakage
61
MAGNESIUM SULFATE (NON-CARDIAC)
Class: Electrolyte
Mechanism of Action
1. CNS depressant
2. Believed to reduce the release of ACh by motor nerves so seizure activity is decreased (↓ grand mal activity)
3. Slows HR at the SA node, prolongs AV node conduction time = ↓ dromotropy
4. Causes peripheral vasodilation (Ca++ channel blocking properties)
5. Stabilize cell membranes (__↓__ Mg++ levels = ___↓__ membrane threshold potentials = ___↑___ cellular & Purkinje fiber excitability =
___↑___ chance for arrhythmia development)
6. Necessary for Na+ / K+ pump function
Indications
1.
2.
3.
Eclampsia (seizures)
Preterm labor (labor prior to 36 weeks) – uterine relaxation
Bronchodilator – after B2 agonist and anticholinergic agents have been used (Status Asthmaticus)
Contraindications
1. Renal disease
2. Shock
3. Heart block
4. Hypocalcemia
5. Hypermagnesemia
6. Last 2 hours of labor
Side effects
CNS
Cardiovascular
GI
Metabolic
Decreased B/P - C
Belching
Hypermagnesemia
Coma - LT
Depressed deep
Cramps
Heart block - LT
tendon reflexes - C
Depression - C
Bradycardia - C
Lethargy - C
Increased pulse - C
Weakness - C
Decreased SVR - C
Italic = C = common side effects
Bold italic = LT - ife-threatening reactions
Respiratory
Depression - LT
Arrest - LT
Paralysis - LT
CALCIUM CHLORIDE / CALCIUM GLUCONATE ANTAGONIZES = HAVE AVAILABLE
Precautions
1. May cause CNS depression and hypocalcemia
2. Rapid IV injection may cause hypotension, heart block, cardiac and/or respiratory arrest
3. Renal impairment may increase chance of toxicity
How Supplied
- 10%, 12.5%, 50 % solution in 40, 80, 100, and 125 mg/mL
62
MAGNESIUM SULFATE (NON-CARDIAC)
Administration/Dosage (vm)
Administered - slow IVP, IV infusion, IM
Slow IVP dose
1-4gm / 10cc (10% solution) – IVP over 3 minutes
IV infusion:
IM dose
1-4gm / 10ml (50% solution) – use if IV cannot be started
Split the dose in half and deliver in 2 different muscles
Mix: 4-5gm / 250cc
Infusion should not exceed 3ml / min.
63
ACTIVATED CHARCOAL
Mechanism of Action
1. Binds to and absorbs ingested poisons thereby inhibiting their G.I. absorption
2. Effective with aspirin, amphetamines, strychnine, Dilantin, theophylline, and phenobarbital.
3. Absorbs enzymes, vitamins, minerals, and nutrients from G.I. tract
Most effective if given within 30 minutes of ingestion
Indications
1. Poisoning
2. Overdose
3. Following emesis
4. When emesis is contraindicated
Contraindications
1. Not with: cyanide, mineral acids, strong bases, methanol, ethanol, iron tablets, lithium, phenobarbital, ASA, lead, arsenic
2. Patients with decreased LOC if airway is not controlled (may cause vomiting)
3. Not with milk, ice cream, sherbet
4. Hypersensitivity
Side Effects
GI
Nausea / Vomiting; Black stools; Constipation; Diarrhea (with sorbitol); Abdominal cramping; Bloating
Precautions
1.
2.
Not with altered mental status unless ET and NG tubes are in place
Absence of bowel sounds
How supplied
Bottles containing 25 and 50 grams of drug – mixed with water or sorbitol (a cathartic)
Route and Dose
Administered: Orally or NG tube
Adult dose
1-2 gram/kg
or:
Approximately 10x the amount of poison ingested
Pediatric dose
<1 year old – 1 gm/kg
1-12 years old – 15 – 30 grams
64
DIPHENHYDRAMINE (BENADRYL)
Class: antihistamine
Mechanism of Action
1. Competes with H1 receptor sites found on the lungs, adrenal glands, veins, arterioles, capillaries, heart, gastrointestinal
muscles.
2. Histamine-mediated effects are blocked by diphenhydramine:
Effects of Histamine are as follows:
- bronchial constriction
- small vessel vasodilation
- excessive capillary permeability
Drug aids in reducing the effects of histamine
- hypotension
- edema
- pruritis (hives)
3. Reverses effects of phenothiazine tranquilizers (dystonic reactions)*
4. Causes CNS depression
5. Anticholinergic properties (blocks ACh)
6. Antiemetic
Indications
1. Anaphylactic shock (after administration of O2 and Epinephrine)
2. Allergic reactions
3. Acute dystonic (extrapyramidal) reactions*
4. Motion sickness
*Dystonic reaction signs /symptoms - unusual posture, change in muscle tone, drooling, uncontrolled movements all do to antipsychotic drugs
(Haldol, Thorazine, Mellaril) or certain antiemetics (Phenergan, Compazine, Reglan)).
Contraindications
1. Narrow angle acute glaucoma
2. Patients taking MAO inhibitors
3. Newborns and nursing mothers
4. Hypersensitivity
Side Effects
CNS
Cardiovascular
GI
GU
Anxiety
Confusion
Palpitations
Tachycardia
Dysuria
Urinary
retention
Dizziness - C
Drowsiness C
Euphoria
Hypertension
Hypotension
Anorexia
Constipation
-C
Diarrhea
Dry mouth C
Nausea
Fatigue
Paresthesia
Poor
coordination
Italic = C = common side effects
Vomiting
Eyes, Nose,
Throat
Blurred vision
Dilated pupils
Dry nose - C
Dry throat - C
Nasal
Stuffiness
Tinnitus
65
Respiratory
Skin
Chest tightness
Increased thick
secretions
Wheezing
Rash
Photosensitivity
Urticaria
DIPHENHYDRAMINE (BENADRYL)
Precautions
1. Use cautiously with (due to anticholinergic effects of the drug):
- COPD
- Narrow angle glaucoma
- Prostatic enlargement
- G.I. obstruction
2. Cardiovascular disease
3. Hypertension
4. Liver disease
5. Elderly
6. Patient’s with CNS depression
7. Patient’s with asthma
How supplied
- Ampules and prefilled syringes
- 50mg/1ml
Administration / Dosage
Administered - Slow IVP or IM
Allergic reaction or Mild
Anaphylaxis
25-50mg - IM
Severe Anaphylaxis
25mg-50mg - Slow IVP
Pediatric dose: Kids > 10kg
Allergic reaction or Mild
Anaphylaxis
1.25 mg/kg - IM
Severe Anaphylaxis
1.25 mg/kg - Slow IVP
66
EPINEPHRINE (1:1,000)
Class: Sympathomimetic, vasopressor, bronchodilator
Mechanism of Action
- Catecholamine that stimulates alpha- and beta- adrenergic receptors
1. Beta1 stimulation leads to:
- positive inotropic effects (↑ force of cardiac contraction)
- positive chronotropic effects (↑ rate of cardiac contraction)
- positive dromotropic effects (↑ conduction velocity)
- increased cardiac output (CO)
- increased myocardial oxygen requirements
2. Beta2 stimulation leads to:
- peripheral vasodilation and bronchodilation
3. Alpha1 stimulation leads to peripheral vasoconstriction:
- arterial / venous vasoconstriction (vasopressor) = increased SVR
- constriction to renal, mesenteric, coronary, and cerebral vessels
- pulmonary vasoconstriction
- making the heart more susceptible to direct countershock in cardiac arrest (Ventricular fibrillation) = reason it is given during cardiac
arrest
4. Inhibits histamine release (stops degranulation) during anaphylactic reaction
(Effects start within 90 seconds and are short lived)
Indications
1. Acute asthma attacks
2. Exacerbation of some forms of COPD
3. Mild anaphylaxis
4. Symptomatic Bradycardia (refractory, not responding, to oxygen and atropine) (infusion)
5. Symptomatic heart blocks (second type II and third degree) (infusion)
Contraindications
1. Hypersensitvity
2. Patients with underlying cardiovascular disease
3. Tachyarrhythmias
4. Not with alkaline drugs
5. Shock
6. Patients with hypertension
67
EPINEPHRINE (1:1,000)
Side Effects
CNS
Anxiety
Dizziness
Cardiovascular
Anginal pain
Dysrhythmias LT
Hypertension
Palpitations - LT
Ischemia
Headache
Restlessness
Subarachnoid
Hemorrhage =
LT
Tremors
Weakness
Italic = C = common side
GI / GU
Nausea - C
Vomiting-C
Respiratory
Dyspnea
Skin
Pallor
Coldness
Urinary retention
Necrosis
Urticaria
Bold italics = LT = life-threatening reactions
Precautions
1. Increased myocardial workload may lead to ischemia, infarction
2. May have increased airway resistance due to sulfites in the preparation = hypersensitivity
3. Use cautiously with:
- Heart disease
- Diabetes
- Hypertension
4. Excreted into breast milk – use cautiously on nursing mothers
How supplied
- Ampules and prefilled syringes containing
- 1mg/1ml
- Vials containing:
- 30mg/30cc
Administration / dosage
Administered – SQ / IM / IV infusion
Mild Anaphylaxis or Acute Asthma Attack
0.3 to 0.5mg - IM / SQ
Mix infusion:
Refractory Bradycardia
Every 15 – 20 minutes, PRN
Dosage range:
1-2mg / 250 or 500cc
2-10µg / minute
Low doses – 2-5µg / minute = β effects
High doses – 5-10µg / minute = α effects
Pediatric dose: 0.01mg/kg up to 0.3mg IVP, IO
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Eyes
Pupil dilation
NALOXONE (NARCAN)
Class: Opiate antagonist
Mechanism of Action
1. Reverses effects of narcotics or synthetic narcotics
- Competes for and displaces narcotic molecules from opiate receptors in the brain
- Reverses stupor, coma, respiratory depression caused by opiates
- Duration of action is shorter than opiates
Indications
- Narcotic / synthetic narcotic overdose
- Coma of unknown cause
- Coma from alcohol
Narcotics -
heroin, morphine, methadone, codeine, Demerol, Dilaudid, Paregoric, fentanyl, Percodan, hydromorphone, meperidine,
oxycodone, propoxyphene
Synthetic narcotics (narcotic agonists / antagonist) - Talwin, Darvon, Nubain, Stadol
Contraindications
-
Hypersensitivity to the drug
Respiratory depression is due to nonopiate drugs
Side effects
CNS
Seizures - LT
Tremors
Cardiovascular
Hypertension
Hypotension
Ventricular
Dysrhythmias - LT
Cardiac arrest - LT
Bold italic = LT - life-threatening
GI
Nausea
Respiratory
Pulmonary edema LT
Hyperventilation
Vomiting
Skin
Sweating
Side effects usually occur due to rapid IVP causing withdrawal to occur = deliver slow IVP to increase respirations
Precautions
- May need to repeat the dose (effects of Narcan may wear off before narcotic)
- May cause excitement, hypertension, tachycardia (due to rapid IVP)
- May cause hypertension or hypotension, pulmonary edema, ventricular fibrillation if given to patients with
cardiovascular disorders.
How supplied
- Ampoules or prefilled syringes containing - 2 mg / 2ml or 0.4mg / 1mL or 10mL
- Vials containing 10mg / 10ml
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NALOXONE (NARCAN)
Administration and dosage:
Administered - Slow IVP, IM, SQ, ET (diluted) , Infusion
Slow IVP
0.4-2mg SIVP
Repeat at 2-3 minute
intervals
ET
2-2.5 times the SIVP dose
Dilute in 10cc of fluid
After 10mg have been
given, with no response,
reevaluate diagnosis
Repeat S/A IVP route
Darvon / Alcohol
2-5mg SIVP
Infusion
8mg / 1000cc of D5W
Infuse at 2/3 of the initial
reversal dose – titrated to
desired effect
*** GIVE THE DRUG SLOWLY TO INCREASE THE PATIENTS MINUTE VOLUME
*** If GIVEN RAPIDLY IT CAN CAUSE WITHDRAWAL LEADING TO ADVERSE SIDE EFFECTS
Pediatric dosage:
- Less than 5 years old or less than 20kg - 0.1mg/kg – up to 10mg
- Over 5 years old or over 20kg - 2mg – up to 10mg
Titrate to effect
Incompatible with bisulfate (is an additive in epinephrine ) and alkaline solutions.
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PROMETHAZINE (PHENERGAN)
Class : Phenothiazine, antihistamine
Mechanism of action:
1.
2.
3.
H1 receptor antagonist that blocks the actions of histamine at the H1 receptors
Also possesses sedative, anti-motion, antiemetic and considerable anticholinergic activity.
Often administered with analgesics, particularly narcotics, to potentiate their effects
Indications:
1.
2.
3.
4.
5.
Nausea and vomiting
Motion sickness
Preoperative and postoperative, obstetric (during labor) sedation
To potentiate the effects of analgesics
Allergic reactions
Contraindications:
1.
2.
3.
4.
Hypersensitivity
Comatose states
CNS depression from alcohol, barbiturates, or narcotics
Signs associated with Reye’s syndrome
Side effects:
1.
2.
3.
4.
5.
6.
7.
Sedation
Dizziness
Allergic reactions
Dysrhythmias
Nausea and vomiting
Hyperexcitability
Dystonias when given with some MAO inhibitors
Precautions:
1.
2.
3.
4.
5.
May impair mental and physical ability
Use in children may cause hallucinations, convulsions, and sudden death
Used with epinephrine may decrease BP further
Used with other CNS depressants may have an additive sedative effect
Use with caution in patients with asthma, peptic ulcer and bone marrow depression.
How supplied:
25, 50 mg / mL in 1mL ampoules and Tubex syringes
Administration / dose: IV / IM
Adult: 12.5 – 25 mg IV or deep IM
Pediatric: Not indicated in pre-hospital setting
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