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  1. Acetaminophen - Action
    Acetaminophen is a synthetic non-opiate derivative of p-aminophenol which produces analgesia and antipyresis. Acetaminophen is rapidly and almost completely absorbed from the GI tract. Following administration of acetaminophen, peak plasma concentrations are attained within 10-60 minutes.Therapeutic doses of acetaminophen appear to have little effect on cardiovascular and respiratory systems. Toxic doses may cause circulatory failure and rapid, shallow breathing.
  2. Acetaminophen - Indications
    Acetaminophen is used frequently to lower body temperature in pediatric febrile patients in whom fever may be deleterious or in whom considerable relief is obtained when fever is lowered.
  3. Acetaminophen - Precautions
    • A. Acetaminophen is relatively nontoxic in therapeutic does.
    • B. Acetaminophen should be used with caution in patients with preexisting anemia.
    • C. Repeated administration of acetaminophen is contraindicated in patients with anemia or cardiac, pulmonary, renal, or hepatic disease.
  4. Acetaminophen - Route/Dose
    General dose is 10 mg/kg. Pediatric patients over the age of 1yrs may receive 120 mg rectal suppository.
  5. Activated Charcoal - Action
    Adsorbs toxic substances ingested, and inhibits gastrointestinal absorption by forming an effective barrier between remaining particulate material and the gastrointestinal mucosa.
  6. Activated charcoal - Indications
    Effective in the management of poisoning or overdose of many substances.
  7. Activated charcoal - Precautions
    • A. May not be given to patients who are unconscious or with diminishing level of consciousness.
    • B. May be ineffective in ingestion such as mineral acids, alkalis, petroleum products or cyanide.
    • C. Never give simultaneously with Ipecac - may prevent emesis.
    • D. May result in aspiration or significant particulate obstruction of the airway.
  8. Activated Charcoal - Route/Dose
    • A. 1gm/kg. of Activated Charcoal. If administered, an aqueous-based solution must be used. Dosage may be higher as directed by a physician.
    • B.Consider administration per nasogastric tube if patient refuses oral ingestion.
  9. Adenosine - Action
    • 1. Adenosine is a naturally occurring nucleoside.
    • 2. Acts on AV node to slow conduction and inhibit reentry pathways. Half life of 10 seconds. Onset immediate.
  10. Adenosine - Indications
    To convert paroxysmal supraventricular tachycardia into sinus rhythm.
  11. Adenosine - Contraindications
    • 1. 2nd and 3rd degree heart block
    • 2. Sick Sinus Syndrome
    • 3. Ventricular tachycardia
    • 4. Known Atrial Fib./Flutter
    • 5. Patients taking Tegretol (carbamazepine)
    • 6. Denervated heart (heart transplant)
  12. Adenosine - Precautions
    • 1. Patients may develop a transient heart block, other transient dysrythmias, or asystole.
    • 2. Chest pain, dizziness, blurred vision; low BP, backache, headache, heaviness in arms, etc. are all possible side effects.
  13. Adenosine - Route/Dose
    • 1. IV should be started in AC region of arm or higher. Fluid should be Normal Saline for rapid bolus after administration.
    • 2. 6mg very rapid I.V. push, if not effective in 1-2 minutes, give 12 mg very rapid I.V. push ASAP. May repeat 12mg dose once if first two doses (18mgs) is unsuccessful. When 12mg used, both unit doses (6mg) must be mixed together, then flushed.
  14. Albuterol - Actions
    Aqueous solution administered by oral inhalation with the aid of hand-held nebulizer system. It is a very selective Beta-2 agonist with very little Beta-1 stimulation. Onset of action is 5-15 minutes. Duration of action is 4-6 hrs. Primary effect is to relax bronchial smooth muscles with resultant relief of bronchospasm.
  15. Albuterol - Indications
    • 1. Acute asthma.
    • 2. Reversible bronchospasm associated with obstructive airway disease, bronchitis or mild CHF.
  16. Albuterol - Precautions
    • 1. As with other adrenergic aerosols, the potential for paradoxical bronchospasm exists.
    • 2. Use with caution for patients being treated with monoamine oxidase inhibitors (i.e. Elavil, Sinequan) since the action of albuterol may be potentiated on the vascular system.
    • 3. Use with caution for patients with history of HTN, coronary artery disease, CHF or MI.
    • 4. Do not use in patients exhibiting signs of acute CHF, MI or cardiac arrythmia without consult from medical control.
    • 5. Use with caution in Pregnancy.
  17. Albuterol - Route/Dose
    • 1. Use one 3cc ampule containing 2.5mg of albuterol. Administer by nebulizer. If patient is intubated, double the dose and give ET (non nebulized).
    • 2. Use this dosage for adults and children over age of 12.
    • 3. For under age 12 dosage per medical control. WEIGHT // ALBUTEROL DOSE // SALINE DILUTION <15 kg 1cc (.83 mg) 2 cc // 15-25 kg 2cc (1.66 mg) 1 cc // >25 kg3cc (2.5 mg)0 cc* Total solution in nebulizer should be 3.0 cc.
    • ADMINISTRATION:
    • 1. Via nebulization with mouthpiece or aerosol mask.
    • 2. Oxygen source at 8 liters per min.
    • 3. Have patient inhale slowly and exhale passively through the nose.
    • 4. On every 4th breath, inhale deeply and pause 1-2 seconds before exhaling (may improve the anxious dyspneic patient and drug absorption).
  18. Albuterol - Side Effects
    Tremor is most common. Also palpitations, tachycardia, nervousness,dizziness, hypertension, nausea, vomiting, angina, headache, and drying of the oropharynx.
  19. Amiodarone - Actions
    • 1. Prolongation of myocardial cell action potential.
    • 2. Alpha and beta sympathetic blocking effect.
    • 3. Reduction of Sinoatrial Node automaticity.
    • 4. Exhibits Calcium Channel blocking effect.
  20. Amiodarone - Indications
    Ventricular Fibrillation/ Pulseless Ventricular Tachycardia, Wide Complex Tachycardia, Narrow Complex Tachycardia
  21. Amiodarone - Contraindications
    Bradycardia, Second or Third degree Heart Block, Hypotension, Known Hypersensitivity
  22. Amiodarone - Precautions
    • 1. Observe for hypotension and bradycardia. Treatment should include fluid bolus and consider pressor agents.
    • 2. Administer cautiously in patients with congestive heart failure or known low ejection fraction.
    • 3. Do not administer with Sodium Bicarbonate; a precipitate will form in the IV line.
  23. Amiodarone - Route/Dose
    • 1. Ventricular Fibrillation/Pulseless Ventricular Tachycardia:
    • A. 300mg IVP, may repeat in 3-5 minutes with 150mg IVP. Do not administer over 2.2grams IV in 24 hours.
    • B. PEDIATRIC – 5mg/kg IVP/IO
  24. 2. Narrow and Wide Complex Tachycardia:
    • 150mg slow IVP over 10 minutes. May repeat 150mg slow IVP once or for maintenance if rhythm converts.
    • Supplied in 150mg pre-loaded syringe; add 150-300mg of amiodarone to 100ml NaCl bag and run wide-open through a macrodrip. Ensure all air/foam remains at top of fluid bag.
  25. Ancef - Actions
    Cefazolin is a first generation semi-synthetic cephalosporin antibiotic. It works well against many gram positive cocci but has limited activity against gram-negative bacteria.
  26. Ancef - Indications
    For infection prophylaxis.
  27. Ancef - Contraindications
    • 1. Allergies to cephalosporins.
    • 2. Use with caution with known allergies to penicillin.
  28. Ancef - Route/Dose
    • 1. Adult:1gm may be given IV over 3-5 minutes.
    • 2. For IV dilute powder with 2.5cc of saline and shake or roll vial until completely dissolved. Then withdraw the contents of the vial into a 10cc syringe and dilute further with saline to a total volume of 10cc. Concentration shall be 100 mg/ml. Slowly push over 3-5 minutes.
  29. 1. Cefazolin may be diluted, as above, with 2-5cc of normal saline for deep IM administration.
    2. Pediatric: 15mg/kg given IV over 3-5 minutes. IM administration may have to be divided and given in two sites because of volume.
  30. Aspirin - Actions
    Aspirin exhibits analgesic, anti-inflammatory, and antipyretic activity. It also increases bleeding time.
  31. Aspirin - Indications
    • 1. Aspirin may be used to reduce the risk of death and/or nonfatal myocardial infarction in patients with unstable angina.
    • 2. Aspirin should be given when a high suspicion exists for chest pain related to a myocardial event.
  32. Aspirin - Contraindications
    • 1. Patients with bleeding disorders such as hemophilia, von Willebrand's disease, or telangiectasia.
    • 2. Active GI lesions (e.g., erosive gastritis, peptic ulcers).
    • 3. GI bleeding.
    • 4. Epistaxis
  33. Aspirin - Precautions
    • 1. Impaired renal function.
    • 2. Patients should be informed that alcohol has a synergistic effect with aspirin in causing GI bleeding.
    • 3. Cerebrovascular Disease.
  34. Aspirin - Route/Dose
    Give four 81.0 mg.(total dose 324mg)chewable tablets.
  35. Atropine - Actions
    • Atropine Sulfate is a muscarinic-cholinergic blocking agent. As such, it has the following effects:
    • 1. Increases the heart rate by blocking vagal influences.
    • 2. Increases conduction through AV node.
    • 3. Reduces motility and tone of gastrointestinal tract.
    • 4. Reduces action and tone of urinary bladder.
    • 5. Dilates pupils
  36. Atropine - Indications
    • 1. To increase the heart rate in bradycardias.
    • 2. To improve conduction in 2nd and 3rd degree heart block.
    • 3. As an antidote for some insecticide exposures (anticholinesterases, i.e., organophosphates) and nerve gas.
    • 4. To counteract excessive vagal influences responsible for some bradysystolic and asystolic arrests.
  37. Atropine - Precautions
    • 1. Use with caution in atrial fibrillation and atrial flutter because increased conduction will speed ventricular rate excessively.
    • 2. Use with caution in the Myocardial infarcted patient.
  38. Atropine - Route/Dose
    • 1. Adult: 0.5-1.0 mg IV/IO, repeated if needed at 3-5 min. intervals to a total dose of 2-3 mg (0.04 mg/kg) or when ventricular rate is 60 or better/min.
    • 2. Pediatric: 0.02 mg/kg IV/IO/ET. Minimum dose is 0.1mg.
    • 3. Organophosphate Overdose: 1.0-2.0 mg IV/IO every 5 minutes until secretions have substantially decreased.
  39. Atrovent - Actions
    Atrovent (ipratropium bromide), a quaternary ammonium derivative of atropine, produces a local, site-specific effect and is relatively free of the systemic side effects associated with earlier anticholinergic compounds. Pulmonary vagal tone is the major determinant of resting airway caliber and resistance. Parasympathetic or cholinergic receptors are found on bronchial smooth muscle. This anatgonizes the action of acetylcholine and thus decreases the formation of active cyclic GMP. Thus Atrovent improves impaired pulmonary function by decreasing resting bronchial smooth muscle tone and blocking reflex bronchospasm. Atrovent acts differently from sympathomimetic agents in that it directly inhibits bronchial smooth muscle contractility by cholinergic blockade. Sympathomimetics, on the other hand, stimulate adrenergic receptor sites, which results in a series of chemical events that serve to decrease bronchoconstriction.
  40. Atrovent - Indications
    Atrovent Inhalation solution administered either alone or with other bronchodilators, especially beta adrenergics, is indicated as a bronchodilator for maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD) including chronic bronchitis and emphysema.
  41. Atrovent - Precautions
    Atrovent is contraindicated in known or suspected cases of hypersensitivity to ipratropium bromide, or to atropine and its derivatives. The use of Atrovent inhalation solution as a single agent for the relief of bronchospasm in acute COPD exacerbation has not been adequately studied. Drugs with faster onset of action may be preferable as initial therapy in this situation.
  42. Atrovent - Route/Dose
    Supplied unit dose vial with 0.5mg per 2.5cc’s. May be given one time only. Atrovent shall be mixed with 2.5mg Albuterol (Proventil) and given by nebulizer.
  43. Blood Products - Description
    1. Leuko-Reduced Packed Red Blood Cells: Approximately 325-410ml unit containing red blood cells, small amounts of plasma, and an anticoagulant/preservative. (Prior to storage the blood is filtered to reduce the amount of white blood cells.) Packed RBC’s are indicated for restoration or maintenance of adequate organ oxygenation with minimal expansion of blood volume.

    2. Plas+SD: Approximately 180-330ml unit containing mostly water, with plasma proteins, clotting factors, and carbohydrates. Plasma is indicated in the treatment of blood clotting disorders, DIC, and over-anticoagulation from blood thinners.

    3. Plateletpheresis: Platelets suspended in plasma with a variable amount of fluid per unit based on platelet count and volume of plasma. Platelets are indicated in treatment of hemorrhage from thrombocytopenia or platelet dysfunction. These are administered at room temperature only.
  44. Blood Products - Indications
    • Prehospital (O-negative Packed RBC’s):All indications must be met to initiate prehospital administration!
    • 1. Active blood loss (internal or external).
    • 2. Prolonged scene time, i.e. lengthy extrication.
    • 3. Hemodynamically unstable patient after 2 liters crystalloid infusion:
    • A. Adult: Systolic blood pressure <80mmHg or absence of radial pulses
    • B. Pediatric: Systolic blood pressure <60mmHg and/or heart rate >140 after appropriate fluid boluses.
    • 4. Absence of isolated head injury.

    • Interhospital (RBC’s, Plasma, or Platelets):
    • 1. Blood products may be encountered on patients needing transfer and prescribed by the physician for various treatments.
  45. Blood Products - Precautions
    • 1. Consider LifeFlight as an option for treatment and transportation.
    • 2. If possible obtain verbal consent for administering blood products.
    • 3. Closely monitor vital signs, including temperature, for possible transfusion reaction.
    • 4. Do not add medications to the blood bag or in the IV line.
    • 5. Do not exceed 300 mmHg of pressure if using an infusion device.
    • 6. If hypothermia is a concern direct efforts to warm the patient not the blood.
    • 7. Blood must be kept on ice unless it is being infused.
  46. Blood Products - Administration
    • 1. Document Trauma Band number and obtain patient’s name if feasible.
    • 2. Contact West Valley Hospital via HEAR or phone and ask for the Emergency Department RN or the House Supervisor.
    • 3. Inform the RN of the need for prehospital blood administration and give he/she the Trauma Band number, name of patient (not required), and brief nature of injuries.
    • 4. Consult with the WVH/ED physician an obtain order for blood.
    • 5. Inform Incident Command of need for prehospital blood administration.
    • 6. Obtain baseline vital signs including temperature. Document on both the PCF and the Blood Bank/Transfusion Label.
    • 7. Examine unit of blood for abnormal appearance. Purple color, broken seal, gas bubbles, and/or clots indicate an unacceptable unit of blood.
    • 8. Connect blood bag to blood administration set and start infusion.
    • A. Adults: Run wide open until systolic blood pressure is = 100 mmHg.
    • B. Peds: Give as 10cc/kg bolus and repeat as necessary to achieve appropriate blood pressure.
    • C. Give interhospital blood products as directed at time of transfer.
    • 9. Repeat vital signs, including temperature, every 15 minutes.
    • 10. Place completed blood bag in biohazard red bag and discard appropriately.
    • 11. Any blood product not used (bag not spiked) MUST be delivered to the receiving hospital’s lab as soon as possible. Return any unused blood product back to WVH if patient not transported by ambulance.
    • 12. IN CASE OF TRANSFUSION REACTION:
    • A. STOP THE TRANSFUSION.
    • B. Keep the vein open with 0.9% NaCl.
    • C. Monitor vital signs.
    • D. Treat for specific reactions as necessary.
    • E. Collect blood bag and administration set and keep for analysis by the lab.
  47. Blood Products - Side Effects/Treatment
    1. Febrile: Chills, *fever, headache, flushing, and anxiety. Monitor VS and temperature

    2. Allergic: Flushing, itching or rash, hives, dyspnea with wheezing, edema, possible anaphylaxis. Consult for diphenhydramine, or epinephrine in anaphylaxis

    3. Hemolytic: Chills, *fever, low back pain, flushing, tachycardia, tachypnea, hypotension, renal failure. Monitor VS and temperature, treat for shock as indicated

    4. Overload: Increased venous pressure, JVD, dyspnea, cough, wet lung sounds. Treat for pulmonary edema, O2, Furosemide, and morphine

    *Fever (rise of 1ºC or 2ºF)
  48. Blood Products - Documentation
    • 1. Chart the blood product given, time started, and when completed or discontinued on the Prehospital Care Form and Blood Bank/Transfusion Label. Attach ID label from the back of blood bag to the white and yellow portions of the PCF.
    • 2. Chart any adverse reactions, with specific signs and symptoms, on the Prehospital Care Form and Blood Bank/Transfusion Label.
    • 3. Attach the yellow portion of the Blood Bank/Transfusion Label to the yellow portion of the PCF and leave with the patient.
    • 4. Return pink portion of Blood Bank/Transfusion Label to WVH lab within 24 hours.
  49. Calcium Chloride - Actions
    Calcium ions increase the force of myocardial contraction. In response to electrical stimulation of muscle, calcium ions enter the sarcoplasm from the extracellular space. Calcium may either increase or decrease systemic vascular resistance. In normal myocardium calcium’s positive inotropic and vasoconstricting effects produce a predictable rise in systemic arterial pressure.
  50. Calcium Chloride - Indications
    • 1. Calcium channel blocker toxicity
    • 2. Known or suspected hypocalcemia
    • 3. Known or suspected hyperkalemia
    • 4. Known or suspected hypermagnesemia
  51. Calcium Chloride - Precautions
    Calcium can, especially when given rapidly, produce slowing of the cardiac rate. Calcium must be used cautiously in the patient receiving digitalis because calcium increases ventricular irritability and may precipitate digitalis toxicity. In the presence of sodium bicarbonate, calcium salts will precipitate as carbonates, thus these drugs cannot be administered together. Calcium may produce vasospasm in coronary and cerebral arteries.
  52. Calcium Chloride - Route/Dose
    A 10ml prefilled syringe or ampule of 10% solution of calcium chloride (1ml=100mg) contains 13.6 mEq of calcium. Usual adult dose is 5 to 10mls and repeated as necessary at 10-minute intervals.
  53. Cardizem - Actions
    The therapeutic value of Diltiazem is due to its slow channel blocking properties, especially on cardiac and vascular smooth muscle. It also blocks the slow inward current of both calcium and sodium flux and causes coronary vasodilation. Diltiazem produces fewer hemodynamic effects than Verapamil. Intravenous diltiazem is highly effective in controlling the ventricular response rate in patients with atrial fibrillation.
  54. Cardizem - Indications
    • 1. Symptomatic atrial fibrillation or atrial flutter with a rapid ventricular response
    • 2. Paroxsymal supraventricular tachycardia
    • 3. Ventricular rate control in patients with atrial fibrillation or flutter and when the ventricular rate over rides the underlying rhythm on the ECG monitor. IV diltiazem, like verapamil, appears to be effective in terminating and preventing PSVT.
  55. Cardizem - Contraindications
    Second or third degree heart block, sick sinus syndrome, severe hypotension, cardiogenic shock, and WPW or accessory pathway conduction.
  56. Cardizem - Precautions
    A transient decrease in arterial pressure due to peripheral vasodilation should be expected in response to diltazem. Intravenous calcium injection will restore arterial pressure and has been recommended as a pretreatment. Should be used with caution with patients in CHF, acute MI or hypotension. Should also be used with caution in patients having impaired hepatic or renal systems.
  57. Cardizem - Route/Dose
    An initial bolus dose of 0.25mg/kg (20mg for the average patient) is administered IV over 2 minutes. A second dose of 0.35mg/kg (25mg for the average patient) has been used to convert to a sinus rhythm after the initial bolus was given. The second dose requires a physician consult.
  58. Dextrose - Actions
    Glucose is the body's basic fuel. It produces most of the body's quick energy. Its use is regulated by insulin, which stimulates storage of excess glucose from the bloodstream and glucagon which mobilizes stored glucose into the bloodstream.
  59. Dextrose - Indications
    • 1. Hypoglycemia states usually associated with insulin shock in diabetes.
    • 2. The unconscious, when a history is unobtainable.
    • 3. In patients with any focal or partial neurological deficit or altered state of consciousness.
    • 4. Generalized hypothermia
    • 5. In the stressed pediatric patient (i.e. respiratory distress).
  60. Dextrose - Precautions
    • 1. Attempt a CBG prior to administration.
    • 2. Extravasation of 50% Dextrose will cause necrosis of tissue. IV should be secure and have free return of blood into syringe or tubing. The IV should be checked 2-3 times during administration. If extravasation should occur, immediately stop administration of D50. Report extravasation of the drug to the receiving hospital personnel and document.
  61. Dextrose - Route/Dose
    • 1. Give thiamine, 100 mg IV, slow push, if dextrose is to be administered to a patient suspected of alcoholism or chronic malnutrition.
    • 2. Give D50, 50 ml in secure vein, if patient unable to take sugar orally.
    • 3. Saline plug is not to be utilized.
    • 4. Dilute dextrose to D25 in newborns, give 2 ml/kg.
  62. Dextrose - Side Effects/Special Notes
    • 1. Do not draw blood for glucose determination from site proximal to an IV containing Glucose or Dextrose.
    • 2. If glucose level is less than 80 mg/dl, reversal of hypoglycemia is indicated.
  63. Diazepam - Actions
    Diazepam acts as a tranquilizer, anticonvulsant, and a skeletal muscle relaxant.
  64. Diazepam - Indications
    • 1. Status seizures. In the field, this is any seizure which has lasted longer than 2 minutes or two consecutive seizures without regaining consciousness. Do not give unless patient is actively seizing.
    • 2. May be given prior to cardioversion.
    • 3. May be given for patient sedation.
    • 4. To provide a safe restraint for violent patients who are a threat to themselves and others.
    • 5. To be used as a light anesthesia and anterograde amnesia for invasive procedures.
  65. Diazepam - Precautions
    • 1. Since Diazepam can cause respiratory depression and/or hypotension, the patient should be monitored closely. Very rarely, cardiac arrest may occur.
    • 2. For the above reasons, Diazepam should not be given without a good IV line in place and a bag valve mask ready.
  66. Diazepam - Route/Dose
    • 1. Adult: 5-10 mg slow IV push (each 5 mg over at least one minute). Do not exceed 0.3 mg/kg.
    • 2. Pediatric: 2-5 mg slow IV push (0.25 mg/kg). Do not exceed 5 mg in Peds under the age of 5 years and 10mg if under the age of 10 years.
    • 3. Rectal administration 0.5 mg/kg (if unable to administer IV) in seizing patients.
  67. Diazepam - Side Effects/Special Notes
    • 1. Common side effects include: drowsiness, dizziness, fatigue and ataxia. Paradoxical excitement or stimulation sometimes occurs.
    • 2. Should not be mixed with other agents or diluted with IV solutions. Turn off IV flow while administering and give through the nearest port of the IV tubing to the entry site.
    • 3. Most likely to produce respiratory depression in patients who have taken other depressant drugs, especially alcohol and barbituates, or when given rapidly.
  68. Diphenhydramine - Actions
    • 1. An antihistamine which blocks action of histamines released from the cells during an allergic reaction.
    • 2. Direct CNS effects, which may be stimulant, or more commonly, depressant, depending on the individual variation.
    • 3 Anticholinergic, antiparkinsonism effect, which is used to treat acute dystonic reactions to antipsychotic drugs (e.g., Haldol, Thorizine, Compazine). These reactions include: oculogyric crisis, acute torticollis and facial grimacing.
  69. Diphenhydramine - Indications
    • 1. The second-line drug in anaphylaxis and severe allergic reactions after Epinephrine.
    • 2. To counteract acute dystonic reactions from antipsychotic (phenothiazine) drugs.
  70. Diphenhydramine - Precautions
    • 1. May have additive effect with alcohol or other CNS depressants.
    • 2. Although useful in acute dystonic reactions, it is not an antidote to Phenothiazine toxicity or overdoses.
    • 3. May cause hypotension when given IV.
    • 4. Relative contraindicated with Narrow angle (acute) glaucoma and prostate enlargement.
  71. Diphenhydramine - Route/Dose
    • A.Adult: 25 to 50 mg deep IM or slow IV push.
    • B.Pediatric: 1 mg/kg mg deep IM or slow IV push, maximum dose of 50mg.
  72. Diphenhydramine - Side Effects/Special Notes
    There is a relative contraindication in patients with asthma due to the thickening of bronchial secretions when Diphenyhdramine is administrated. May cause blurring of vision.
  73. Dopamine - Actions
    • Chemical precursor of Norepinephrine which occurs naturally in man and which has both Alpha and Beta receptor stimulating actions. Its actions differ with dosage given.
    • 1. 1-2 mcg/kg/min: Dilates renal and mesenteric blood vessels (no effect on the heart and blood pressure).
    • 2. 2-10 mcg/kg/min: Beta effects on heart which usually increase cardiac output without increasing heart rate or blood pressure.
    • 3. 10-20 mcg/kg/min: Alpha peripheral effects cause peripheral vasoconstriction and increased blood pressure.
    • 4. 20-40 mcg/kg/min: Alpha effects reverse dilation of renal and mesenteric vessels with resultant decreased flow.
  74. Dopamine - Indications
    • 1. Primary indication is cardiogenic shock.
    • 2. May be useful for other forms of shock, except hypovolemia.
    • 3. Useful in the treatment of profound bradycardia.
  75. Dopamine - Precautions
    • 1. May induce tachyarrythmias, in which case infusion should be decreased or stopped.
    • 2. High doses may cause extreme peripheral vasoconstriction. Conversely, low doses may cause a decreased blood pressure due to peripheral dilation.
    • 3. Certain antidepressants potentiate the effects of this drug. Check for medications and call Medical Control if other drugs are being used.
    • 4. Should not be added to Sodium Bicarbonate or other alkaline solutions since Dopamine will be inactivated in alkaline solutions.
  76. Dopamine - Route/Dose
    • A. Adult: IV infusion only: Mix 400 mg in 250 ml NaCl to produce a concentration of 1600 mcg/ml. Infusion rate should start at 5 mcg/kg/min.Gradual increase from 5-20 mcg/kg/min usually achieves desired effect.
    • B. Pediatric: Mix 400 mg in 250 ml NaCl to produce a solution of 1600 mcg/ml. Rate starts at 5-20 mcg/kg/min. Titrate to effect.
  77. Dopamine - Side Effects/Special Notes
    • 1. The most common side effects include ectopic beats, nausea and vomiting. Angina has been reported following treatment (tachycardia and dysrhythmias are less likely than with other catecholamines.)
    • 2. Can precipitate hypertensive crisis in susceptible individuals (i.e. patients on MAO inhibitors: Parnate, Nardil, Marplan).
    • 3. Consider hypovolemia and treat this with appropriate fluids before administration of Dopamine. Dopamine is contraindicated in hypovolemic shock.
    • 4. Dopamine is best administered by an infusion pump to accurately regulate rate. For this reason, it is hazardous when used in the field. Monitor closely.
  78. Epinephrine - Actions
    • 1. Catecholamine with alpha and beta effects.
    • 2. In general, the following cardiovascular responses can be expected:
    • A. Increased heart rate.
    • B. Increased myocardial contractile force.
    • C. Increased systemic vascular resistance.
    • D. Increased arterial blood pressure.
    • E. Increased myocardial O2 consumption.
    • F. Increased automaticity.
    • 3. Potent bronchodilator
  79. Epinephrine - Indications
    • 1. Ventricular fibrillation/ventricular tachycardia without a pulse.
    • 2. Asystole.
    • 3. Pulseless electrical activity.
    • 4. Systemic allergic reactions.
    • 5. Asthma in patients under 50.
    • 6. Sinus Bradycardia unresponsive to Dopamine, Bradycardia secondary to calcium channel blocker or beta-blocker overdose.
  80. Epinephrine - Precautions
    • 1. Should not be added directly to bicarbonate infusion, since catecholamines may be partially inactivated by alkaline solution.
    • 2. When used for allergic reactions, increased cardiac work can precipitate angina and/or MI in susceptible individuals. Epinephrine may also induce major arrhythmias.
    • 3. Due to peripheral vasoconstriction, epinephrine should be used with caution in patients with peripheral vascular insufficiency.
    • 4. Wheezing in an elderly person is pulmonary edema or pulmonary embolus until proven otherwise.
  81. Epinephrine - Route/Dose
    • 1. Adult:
    • A. Cardiac arrest:
    • 1. 1:10,000 administration. 1 mg (10ml 1:10,000 solution) every 3-5 minutes during arrest.
    • 2. 1:1000 administration. May be used in cardiac arrest. The dose is 1mg (1cc) for the initial dose every 3-5 minutes. It must be administered through a rapidly running IV (Marco drip). Epinephrine given through the E.T. tube must be either 1:10,000 or 1:1000 diluted with saline.
    • B. Allergic reaction (anaphylactic shock, laryngeal edema, severe asthma): 0.3 mg -0.5mg (0.3-0.5 ml of 1:1000 solution), SQ or IM, or if in profound shock,0.5-1.0mg of 1:10,000 solution IV. May be repeated x 2.
    • C. Bradycardia: Epinephrine 2 to 10ug/min (1mg/250cc equals 4ug/ml)2.

    • Pediatric:
    • A. Cardiac arrest: 0.01 mg/kg (1:10,000 = 0.1ml/kg) IV/IOMay also be given via endotracheal tube: 0.1mg/kg (1:1,000=0.1ml/kg).Repeat every 3-5 minutes.
    • B. Allergic reaction (anaphylactic shock, laryngeal edema, severe asthma) 0.01 mg/kg (0.01 ml/kg of 1:1,000 solution), SQ, IM, or if in profound shock, 0.01mg/kg 1:10,000 solution IV.
    • C. Severe Bradycardia with shock (patients close to the state of PEA, Asystole). IV/IO 0.01mg/kg (0.1ml/kg of 1:10,000) may repeat every 3-5 min if necessary.
  82. Epinephrine - Side Effects/Special Notes
    • 1. Anxiety, tremor, headache.
    • 2. Tachycardia, palpitations, PVC's
    • 3. Angina, hypertension.
  83. Etomidate - Actions
    Hypnotic drug, without analgesic activity, intended for induction of general anesthesia. Intravenous injection produces hypnosis characterized by a rapid onset of action, usually within one minute. The hypnotic effect usually lasts three to five minutes, but is dose dependant. Etomidate has little to no effect on myocardial metabolism, cardiac output, peripheral or pulmonary circulation. Administration has been associated with a transient 20-30% decrease in cerebral blood flow, which will result in roughly a proportional decrease in cerebral oxygen utilization. Etomidate induction is usually followed by a moderate lowering of intracranial pressure, lasting several minutes. The drug is rapidly metabolized in the liver. Limited data in patients with cirrhosis and esophageal varices suggest that the distribution and half-life are approximately double of those seen in healthy subjects.
  84. Etomidate - Indications
    • 1. To produce rapid hypnosis in the process of rapid sequence intubation for direct airway control.
    • 2. To produce a short acting rapid hypnosis and deep sedation in the awake patient needing invasive procedures (e.g. cardioversion).
  85. Etomidate - Contraindications
    1. Known hypersensitivity to Etomidate.
  86. Etomidate - Precautions
    • 1. Not indicated for pediatric patients under 10 years old.
    • 2. Benefit to the pregnant mother must outweigh the potential risk to fetus.
  87. Etomidate - Route/Dose
    0.3mg/kg slow (30-60 seconds) IV push. Effect is dose and weight dependant! Supplied in 10ml single-dose vial containing 2mg/ml (20mg).
  88. Etomidate - Side Effects/Special Notes
    • 1. Transient venous pain following administration about 20% of the time. More pronounced in small, distal veins.
    • 2. Transient skeletal muscle movements following administration 32% of the time, predominately myoclonic in nature.
  89. Fentanyl - Actions
    Binds to the opiate receptors in the central nervous system, altering the response to and perception of pain. Fentanyl has a rapid onset, peaks in 3-5 minutes, with a short duration of 30-60 minutes. It has less cardiovascular and hemodynamic effects than Morphine, but can still cause respiratory depression through its central nervous system actions. Fentanyl is a Class II scheduled drug.
  90. Fentanyl - Indications
    Use to control moderate through severe pain.
  91. Fentanyl - Contraindications
    1. Known allergy or hypersenitivity to narcotic analgesics.
  92. Fentanyl - Precautions
    • 1. Patients with respiratory depression or hypoventilation.
    • 2. Bradydysrhythmias.
  93. Fentanyl - Route/Dose
    50-200 mcg initial dose given IM or IV. Titrate fentanyl to effect up to a total dose of 500 mcg.Intranasal route dose is at total of 100 mcg and limited to 1ml of fluid per nostril.

    • Pediatric (2-12yrs, >15kg weight) dosing:
    • 1.0-2.0 micrograms/kg slow IV or IM, may repeat once
    • 1.0-2.0 micrograms/kg IN if no IV access, once only
  94. Fentanyl - Side Effects/Special Notes
    • 1. Skeletal and muscle rigidity, especially post IV administration.
    • 2. Bradycardia
    • 3. May cause nausea and vomiting.
  95. Flumazenil - Actions
    Flumazenil is a benzodiazepine antagonist that competitively inhibits the actions of the benzodiazepine on the gamma aminobutyric acidbenzodiazepine receptor complex.
  96. Flumazenil - Indications
    • 1. Complete or partial reversal of the sedative effects of benzodiazepines after sedation or overdose, particularly respiratory depression.
    • 2. Diagnostically in coma of unknown etiology to rule out or reverse benzodiazepine depression.
  97. Flumazenil - Contraindications
    • 1. Hypersensitivity
    • 2. Patients taking benzodiazepine for seizure control.
    • 3. Patient with a serious tricyclic sedation overdose.
  98. Flumazenil - Precautions
    • 1. May experience seizure activity with the withdrawal of the benzodiazepine.
    • 2. Be prepared to restrain the patient prior to administration.
  99. Flumazenil - Route/Dose
    • Management of overdose or sedation reversal, for IV/IO
    • 1st dose: 0.2mg over 15 seconds.
    • If unable to obtain desired effects
    • 2nd dose: 0.3mg over 30 seconds.
    • If unable to obtain desired effects
    • 3rd dose: 0.5mg over 30 seconds
  100. Furosemide - Actions
    Potent diuretic with a rapid onset of action and short duration of effect. It acts primarily by inhibiting sodium reabsorption throughout the kidney. Increase in potassium excretion occurs along with sodium excretion. As an IV bolus furosemide causes immediate (3-4 min) increase in venous capacitance. This decreases venous backup and probably accounts for its immediate effect in pulmonary edema. Peak effect: 1/2-1 hour after IV administration: duration about 2 hours (duration 6-8 hours if given orally, with peak in 1 - 2 hours).
  101. Furosemide - Indications
    1. Acute pulmonary edema: to decrease extracellular volume and reduce venous pressure on the lung in congestive heart failure.
  102. Furosemide - Precautions
    • A. Contraindicated in hypovolemia and hypotension.
    • B. Can lead to profound diuresis with resultant shock and electrolyte depletion. Therefore, do not use in hypovolemic states and monitor closely, particularly after IV administration.
    • C. Have urinal or bed pan available. Effect may be seen within 10-15 min.
  103. Furosemide - Route/Dose
    1 mg/kg slowly IV bolus over 2 minutes to a maximum of 80mg. May also be given IM. Physician consult required for doses greater than 80mg.
  104. Furosemide - Side Effects/Special Notes
    • 1. Hypovolemia, hypotension, hyponatremia and hypokalemia are the main toxic effects. Because of the potency and the need for close monitoring, should only be given with specific indications.
    • 2. Other toxicity is not related to single dose use.
    • 3. The side effect of hypokalemia (where potassium is an integral part of the sodium/potassium adenosine triphosphatase pump in myocardial contractility) is of concern in digitalized patients and particularly those who have digitalis toxicity.
    • 4. May cause acute and profound diarrhea.
    • 5. Patients with compromised respirations and poor lung sounds may be in pulmonary edema without wet lung sounds.
  105. Glucagon - Actions
    Glucagon is a hormone which causes glucose mobilization in the body.It works opposite to insulin, which causes glucose storage, and is present normally in the body. It is released at times of injury or insult when glucose in needed and mobilizes glucose from body glycogen stores. Return to consciousness should be within 20 min of IM dose if patient is hypoglycemic.
  106. Glucagon - Indications
    • 1. Known insulin shock when patient is stuporous or comatose, and D50 is not available and an IV cannot be started.
    • 2. Used for suspected beta blocker overdose/reaction
  107. Glucagon - Precautions
    D50 is the treatment of choice for insulin shock. Use of Glucagon is restricted to patients who are seizing, combative, or with collapsed veins and when an IV cannot be started. In these rare situations, it may be invaluable.
  108. Glucagon - Route/Dose
    • Adult: 1.0 mg IM or IV.
    • Pediatric: 0.1 mg/kg up to 1 mg.
    • Beta-blocker overdose: 1-5 mg IV.
  109. Glucagon - Side Effects/Special Notes
    • 1. Nausea and vomiting
    • 2. Persons with no liver glycogen stores (malnutrition, alcoholism) may not be able to mobilize glucose in response to Glucagon.
    • 3. May be useful in treating life threatening beta-blocker overdoses, although effective dose range is high.
  110. Haldol - Actions
    The precise mechanism of action has not been clearly established, but it is suspected that Haloperidol alters the effects of dopamine in the CNS. It also has anticholinergic activity.
  111. Haldol - Indications
    1. As an adjunct to control and restrain violent patients who are a threat to themselves and/or others
  112. Haldol - Contraindications
    • 1. Severe toxic CNS depression
    • 2. Coma
    • 3. Parkinson’s disease
    • 4. Known hypersensitivity to haloperidol
  113. Haldol - Precautions
    • 1. Severe cardiovascular disease may cause transient hypotension
    • 2. Seizure history with prescribed anticonvulsants. This may decrease the seizure threshold
    • 3. Unknown safety in pregnancy and lactation
  114. Haldol - Route/Dose
    5mg IM, may be repeated twice at 5 minute intervals to a total of 15mg.If possible use 2-5mg IVP
  115. Haldol - Side Effects/Spcial Notes
    • 1. CNS depression and sedation, extrapyramidal reactions, tardive dyskinesia
    • 2. Anticholinergic effects: dry mouth and eyes, blurred vision, constipation
    • 3. May cause hypotension and tachycardia
  116. Labetalol - Actions
    A relatively short acting alpha 1 and beta 1-2 blocking agent. Reduces blood pressure, systemic vascular resistance and heart rate. Onset is within 5-15 minutes.
  117. Labetalol - Indications
    • 1. Severe hypertension with associated signs and symptoms. Systolic BP greater than 220mmHg and/or diastolic 120mmHg.
    • 2. Acute myocardial infarction
    • 3. Rate control in narrow complex tachycardia
  118. Labetalol - Contraindications
    • 1. Severe bradycardia
    • 2. 2nd and 3rd degree heart blocks
    • 3. History of severe CHF
  119. Labetalol - Precautions
    • 1. May cause profound hypotension, especially orthostatic hyptotension
    • 2. May exacerbate CHF
    • 3. Asthma
  120. Labetalol - Route/Dose
    10mg (0.25mg/kg) IV over 2 minutes. May repeat with 20mg slow IV until the desired supine BP is achieved or a total of 30mg has been given.

    In AMI: may give up to 150mg total. Because Labetalol is short acting, continued bolus’ may be needed to reach the theraputic effect in AMI. Keep patient supine and monitor BP closely before and after administration.
  121. Lidocaine - Actions
    • 1. Depresses automaticity of purkinje fibers; therefore, raises stimulation threshold in the ventricular muscle fibers (makes ventricles less likely to fibrillate).
    • 2. Little antiarrhythmic effect at subtoxic levels on atrial muscle.
    • 3. CNS stimulation: Tremor, restlessness and clonic convulsions followed by depression and respiratory failure at higher doses.
    • 4. Cardiovascular effect: Decreased conduction rate and force of contraction, mainly at toxic levels.
    • 5. The effect of a single bolus on the heart disappears in 10-20 minutes due to redistribution in the body. Metabolic half-life is about 2 hours and therefore toxicity develops with repeated doses.
    • 6. There is limited case study evidence that may correlate a blunting to the effect of ICP created by endotracheal intubation if Lidocaine is administered prior to the procedure in head-injured patients.
  122. Lidocaine - Indications
    • 1. Ventricular tachycardia or suspected ventricular tachycardia if clinical condition is not rapidly deteriorating.
    • 2. Recurrent ventricular fibrillation.
    • 3. Following successful defibrillation.
    • 4. As a means to blunt ICP in head-injured patients during induced intubation.
    • 5. As an anesthetic after successful placement of an intraosseous needle.
  123. Lidocaine - Precautions
    • 1. Do not use in the presence of advanced AV block unless artificial pacemaker is in place.
    • 2. In atrial fibrillation or flutter, quinidine-like effect may cause alarming ventricular acceleration.
    • 3. Lidocaine is not recommended for treatment of supraventricular arrhythmias.
    • 4. Do not administer with heart rate less than 50; you may suppress the heart completely.
  124. Lidocaine - Route/Dose
    • A. CARDIAC ARREST: VENTRICULAR FIBRILLATION OR PULSELESSVENTRICULAR TACHYCARDIA:
    • 1. Lidocaine bolus 1-1.5 mg/kg load then 0.5 mg/kg every 5 minutes to a total dose of 3 mg/kg.
    • 2. Begin continuous infusion if successful resuscitation has occurred. Infusion should be initiated at 2-4 mg/min.

    • B. PARALYTIC THERAPY
    • 1. Lidocaine 1.0mg/kg one time dose.
    • E.T.T. ADMINISTRATION: Lidocaine may be administered through the ET tube 2 mg/kg not to exceed a totalvolume of 10 cc.

    • C. IO ANESTHETIC
    • 1. 20-40mg of 2% Lidocaine flushed through IO site.
    • 2. Pediatric: 0.5mg/kg 2% Lidocaine flushed through IO site.

    I.V. INFUSION:How supplied: Premixed IV Drip solution, 1 gm of Lidocaine Hydrochloride in 250 ml D5W, which yields a 0.4% solution or 4 mg/ml.
  125. Lidocaine - Side Effects/Special Notes
    • A. Side effects:
    • 1. CNS disturbances: sleepiness, dizziness, disorientation, confusion, and convulsions.
    • 2. Hypotension: decreased myocardial contractility and increased AV block at toxic levels only.
    • 3. Rare instance of sudden cardiovascular collapse and death.

    B. Lidocaine is metabolized in the liver and therefore patients with hepatic disease, shock or CHF will have impaired metabolism. All doses, except the initial loading dose, must be decreased by 50% in patients over 70 and those referred to above.

    C. Toxicity is more likely in elderly patients.
  126. Magnesium Sulfate - Actions
    Is essential for the activity of many enzymes. It also plays an important role in neurotransmission and muscular excitability. Hypomagnesemia can lead to cardiac dysrhythmias as well as sudden cardiac death.
  127. Magnesium Sulfate - Indications
    • 1. Known or suspected torsades de pointes dysrhythmia, with or without a pulse.
    • 2. Refractory ventricular fibrillation after Amiodarone and Lidocaine use.
    • 3. Cardiac arrest with known or suspected hypomagnesemia.
    • 4. Seizure activity associated with Pre-Eclampsia or Eclampsia
  128. Magnesium Sulfate - Precautions
    • 1. In the non-arrest patient, may cause hypotension and/or bradycardia.
    • 2. May depress the CNS and neurotransmission; therefore deep tendon reflexes should be assessed in the conscious patient.
  129. Magnesium Sulfate - Route/Dose
    Cardiac dysrhythmias or arrest: 1-2 grams slow IV. If the patient has a pulse administer much slower, over 10-15 minutes.

    Seizures: 4mg slow IV, followed by 4mg deep IM.

    Magnesium Sulfate is supplied as a 50% solution (1gram/2ml). For IV administration Magnesium Sulfate MUST BE DILUTED to a 20% solution. Draw up the 1gram/2ml and add 3mls of NaCl solution to make 1gram/5ml.

    Magnesium Sulfate 50% may be administered IM.

    May be infused at 0.5-1.0gms/hour. Add 2 grams to 250ml NaCl and run at 62-124gtts/min.
  130. Midazolam - Actions
    Midazolam shares the actions of other benzodiazepines. Although initial data indicated that the sedative potency of midazolam was about 1.5-2.5 times that of diazepam, clinical experience with the drug suggests that potency may be 3-4 times that of diazepam. Midazolam hydrochloride injection should be stored at 15-30C and protected from light.
  131. Midazolam - Indications
    • 1. Adult and pediatric patients with continuous seizures.
    • 2. Sedation for cardiac pacing
    • 3. Premedication for cardioversion
    • 4. Premedication for rapid sequence intubation
  132. Midazolam - Precautions
    • 1. Continuously monitor the patient’s respiratory and cardiac function.
    • 2. Never administer as a rapid IV bolus.
    • 3. Since this procedure will be performed in the presence of seizure activity, some assistance in restraining the patient may be required to maintain proper patient position during administration.
    • 4. Should be given with caution to patients in shock or with depressed vital signs.
    • 5. Can induce respiratory depression.
  133. Midazolam - Route/Dose
    • Cardiac pacing and cardioversion
    • Adult: IV 1-2mg slow IV pushIM or IN 2mg single dose
    • Pediatric: IV 0.1mg/kg not to exceed 5mgIM or IN 0.1 mg/kg single injection to a maximum dose of 7mg.

    • Seizure control
    • Adult: 2-5mg IM or IN if IV cannot be established for Diazepam administration.
    • Peds: IM or IN Dose 0.2mg/kg up to a maximum dose of 7.0mg
    • IV Dose 0.1mg/kg up to an initial dose of 1-2.5mg, not to exceed a total of 5mg.

    • Rapid sequence intubation
    • Adult: 2-5mg IV/IM
    • Peds: 0.1mg/kg IV to maximum dose of 5.0mg
    • 0.2mg/kg IM to a maximum dose of 7.0mg.
  134. Midazolam - Side Effects/Special Notes
    • 1. Respiratory depression and/or respiratory arrest.
    • 2. Oversedation
    • 3. HypotensionCare will be exercised to assure that the patient retains a patent airway and is protected from the occurrence of injury secondary to the seizure while this procedure is being performed.
  135. Morphine - Actions
    • Morphine sulfate is a narcotic with potent analgesic and hemodynamic properties. It exerts its analgesic effects on the central nervous system, simultaneously inducing drowsiness, mental clouding and mood changes. Morphine has several hemodynamic actions of considerable importance.
    • 1. It increases venous capacitance and thereby pools blood peripherally and decreases its return (reduced preload). This assists in relieving pulmonary congestion, reduces left ventricular and diastolic dimensions, and myocardial wall stress. These all result in decreased myocardial oxygen requirement.
    • 2. Reduces systemic vascular resistance at the arteriolar level (reduced after load). This reduction in afterload also tends to decrease myocardial oxygen requirement. Central sedative effects of morphine also will reduce myocardial oxygen requirements and the chance of malignant arrhythmias due to reduction of apprehension and fear in patients. The hemodynamic effects of Morphine are probably mediated through the central nervous system by a sympatholytic mechanism. Given intravenously, the onset of action is prompt (2-3 minutes), peaks at 7 - 10 minutes, and last 3 - 5 hours.
  136. Morphine - Indications
    • 1. Severe chest pain unaffected by respirations or body movements with suspected ischemic cardiac pain unresponsive to nitroglycerin.
    • 2. Pulmonary edema.
    • 3. Severe pain associated with burn or extremity injuries not affecting respiratory or hemodynamic status.
  137. Morphine - Contraindications
    • 1. Known allergy to morphine.
    • 2. Volume depletion.
    • 3. Hypotension.
    • 4. Undiagnosed head trauma.
    • 5. CNS Trauma, such as paralysis.
  138. Morphine - Precautions
    • 1. Morphine sulfate causes predictable respiratory depression. This is quickly reversible with naloxone (Narcan). Respiratory depression is much more likely to occur in patients with pre-existing respiratory insufficiency (COPD).
    • 2. Use with caution in undiagnosed abdominal pain or potential surgical emergencies, e.g. appendicitis or acute abdomen.
    • 3. Naloxone (Narcan) and respiratory support must be at hand when administering morphine.
  139. Morphine - Route/Dose
    • 1. Morphine should be given by titration of small intravenous doses at frequent intervals until the desired response is achieved. There is considerable variation from patient to patient in the amount of drug required to acquire the given effect.
    • 2. A dose of 2-5 mg IV is given and repeated at 5-30 minute intervals until the desired effect has been achieved. Total dose of 20mg with Physician Consult required exceeding 20mg.
    • 3. Pediatric Dose: Pediatrics less than 50 kg, 0.1mg/kg IV.4. Vital signs should be taken with particular attention to blood pressure and respiratory rate after every incremental dose is administered. The end points of administration should be:
    • A. Achievement of desired effects.
    • B. Blood pressure less than 90 mmHg systolic
    • C. Respiratory rate less than 12.
  140. Morphine - Side Effects/Special Notes
    • 1. Respiratory depression, nausea and vomiting.
    • 2. The analgesic effect of morphine should not be gauged solely by the total elimination of pain. More importantly, morphine reduces the perception of pain.
    • 3. Hypotension may develop as a consequence of the hemodynamic effect of morphine, especially in older patients, volume depleted patients, or patients who have required elevated systemic vascular resistance for the maintenance of their blood pressure. Hypotension is usually responsive to naloxone administration and the Trendelenburg position. If not, contact medical control, prepare for cautious fluid challenge with 100 cc of Normal Saline.
    • 4. Morphine has a high tendency for addiction/abuse and is classified as a schedule II drug under the Controlled Substances Act of 1970.
  141. Narcan - Actions
    Narcan is a narcotic antagonist which competitively binds to narcotic sites but which exhibits almost no pharmacologic activity of its own. Duration of action: 1-4 hours.
  142. Narcan - Indications
    • 1. Reversal of narcotic effects, particularly respiratory depression, due to narcotic drugs ingested, injected or administered in the course of treatment. Narcotic drugs include morphine, Fentanyl, Demerol, heroin, Dilaudid, Percodan, Codeine, Lomotil, propoxphene (Darvon), pentazocine (Talwin).
    • 2. Diagnostically in coma of unknown etiology to rule out (or reverse) narcotic depression.
  143. Narcan - Precautions
    1. In patients physically dependent on narcotics, frank and occasionally violent withdrawal symptoms may be precipitated.
  144. Narcan - Route/Dose
    • 1. Slowly inject up to 1-2mg IV, IM, SQ, IN, or by ET tube. If no, or inadequate, respiratory response is observed, this dose maybe repeated at 3-5 minute intervals up to 8 mg. in the patient suspected of having narcotic overdose.
    • 2. IV administration is preferred.
    • 3. Pediatric Dose: 0.1mg/kg IV, ET, IM, SQ, or IN.
  145. Narcan - Side Effects/Special Notes
    • 1. This drug is remarkably safe and free from side effects. Do not hesitate to use it if indicated.
    • 2. The duration of some narcotics is longer than Narcan and the patient must be monitored closely. Repeated doses of Narcan may be required. Patients who have received this drug should be transported to the hospital because coma may reoccur when Narcan wears off.
    • 3. May need large doses (8-10 ml) to reverse propoxphene (Darvon) overdose.
  146. Nitro - Actions
    • 1.Cardiovascular effects include:
    • A. Reduced venous tone causes pooling of blood in peripheral veins and decreased return of blood to the heart.
    • B. Decreased peripheral resistance.
    • C. Dilation of coronary arteries (if not already at maximum).
    • 2.General smooth muscle relaxation.
  147. Nitro - Indications
    • 1. Angina
    • 2. Chest, arm, or neck pain thought to be related to coronary ischemia; may be used diagnostically as well as therapeutically.
    • 3. Control of hypertension in angina or acute MI.
    • 4. Pulmonary edema: to increase venous pooling; lowering cardiac preload and afterload.
  148. Nitro - Precautions
    • 1. Generalized vasodilation may cause profound hypotension and reflex tachycardia.
    • 2. Nitroglycerin loses potency easily, should be stored in dark glass container with tight lid and not exposed to heat.
    • 3. Use with caution in hypotensive patients.
    • 4. Hypotension and bradycardia following nitroglycerin are usually responsive to atropine.
    • 5. Contraindicated within 24 hours post PDE-5 selective inhibitors, e.g. Viagra, Cialis, Levitra
  149. Nitro - Route/Dose
    • 1. Nitroglycerin (NTG): 0.4 mg sublingual if systolic pressure is greater than 90, when initially treating patients, q. 5 minutes if:
    • A. No sign of hypotension are present.
    • B. Patient did not show signs of hypersensitivity to initial dose of NTG.
    • 2. Blood pressure must be taken prior to and after all NTG doses.
    • 3. Nitroglycerin drip may be started if initial SL administration failed to completely control chest pain or blood pressure.
  150. Nitro - Side Effects/Special Notes
    • 1. Common side effects include throbbing headache, flushing, dizziness, and burning under the tongue (if these side effects are noted, the pills may be assumed potent, not outdated).
    • 2. Less common effects: marked hypotension; particularly orthostatic.
    • 3. NOTE: Therapeutic effect is enhanced but adverse effects are increased when patient is upright.
    • 4. Because nitroglycerin causes generalized smooth muscle relaxation, it may be effective in relieving chest pain caused by esophageal spasm.
  151. Oral Glucose - Actions
    Glucose is the body's basic fuel. It produces most of the body's quick energy. Its use is regulated by insulin, which stimulates storage of excess glucose from the bloodstream and glucagon that mobilizes stored glucose into the bloodstream.
  152. Oral Glucose - Indications
    1. Hypoglycemic states usually associated with insulin shock in diabetes.
  153. Oral Glucose - Precautions
    • 1. Attempt a CBG prior to administration.
    • 2. Give only to patients that have control of their airway and are able to chew or swallow food/liquids.
  154. Oral Glucose - Route/Dose
    1. Give entire tube of 15 grams glucose orally.
  155. Oral Glucose - Side Effects/Special Notes
    1. Discontinue use if patient becomes unresponsive or cannot swallow.
  156. Oxygen - Actions
    Oxygen added to the inspired air raises the amount of oxygen in the blood; therefore, the amount delivered to the tissues. Tissue hypoxia causes cell damage and death. Breathing in most persons is regulated by small changes in acid/base balance and CO2 levels. It takes relatively large drops in blood oxygen concentration to stimulate respiration.
  157. Oxygen - Indications
    • 1. Suspected hypoxemia or respiratory distress from any cause.
    • 2. Acute chest pain in which a myocardial infarction is suspected.
    • 3. Shock (decreased oxygenation of tissues) from any cause.
  158. Oxygen - Precautions
    • 1. If the patient has a slow respiratory rate or low tidal volume, do not use a cannula or mask for oxygen therapy. Assist volume and rate with a bag-valve-mask and high flow oxygen.
    • 2. A small percentage of patients with chronic lung disease breathe only when they are hypoxic. Administration of moderate to high flow O2 may shut off their respiratory drive. Do not withhold oxygen because of this possibility. Be prepared to assist ventilation if needed.
  159. Oxygen - Side Effects/Special Notes
    • 1. For low flow and moderate flow oxygen, use a nasal cannula. For high flow oxygen administration use a simple or non-rebreathing mask as necessary.
    • 2. Nonhumidified O2 is drying and irritating to mucous membranes.
    • 3. Restlessness may be an important sign of hypoxia. On the other hand, some persons become more agitated when a nasal cannula is applied, particularly when it is not needed.
    • 4. Oxygen supports combustion.
    • 5. Oxygen toxicity (overdose) is not a hazard during acute administration.
    • 6. Nasal prongs work equally well on nose and mouth breathers.
  160. Oxytocin - Actions
    • 1. Hormone which increases electrical and contractile activity in the uterine smooth muscle. Oxytocin can initiate or enhance rhythmic contractions at any time during pregnancy, but the uterus is most sensitive at term.
    • 2. Exhibits rapid onset (minutes), very short half-life, rapid inactivation and excretion.
  161. Oxytocin - Indications
    Control of post partum hemorrhage.
  162. Oxytocin - Precautions
    • 1. Prior to its administration, the presence of a second fetus must be considered. Administration with fetus in uterus can cause rupture of the uterus and/or death of the fetus.
    • 2. Administration should follow delivery of placenta whenever possible.
  163. Oxytocin - Route/Dose
    • 1. Dose: 20 units in 1000ml Normal Saline with maxi-drip IV set. Utilize IV pump, as feasible, and start at a flow rate of 1.0-2.0 ml/min titrated to severity of hemorrhage and uterine response.
    • 2. If unable to establish an IV, 10 units may be given IM.
  164. Oxytocin - Side Effects/Special Notes
    • 1. In large amounts, Oxytocin exhibits a transient but marked vasodilating effect and reflex tachycardia.
    • 2. Cardiac dysrhythmias may be precipitated or aggravated by Oxytocin.
  165. Promethazine - Actions
    • 1. Antiemetic
    • 2. Sedative
    • 3. As an antihistamine, it acts by competitive antagonism but does not block the release of histamine. In varying degrees it antagonizes most, but not all of, the pharmacological effects of histamine. It also possesses sedative antimotion, antiemetic and anticholinergic effects with a duration of action lasting 4-6 hours.
  166. Promethazine - Indications
    • 1. Active treatment for motion sickness.
    • 2. Prevention and control of nausea and vomiting.
  167. Promethazine - Contraindications
    • 1. Comatose patients.
    • 2. Asthmatic patients.
    • 3. Narrow-angle glaucoma.
    • 4. Prostatic hypertrophy and other urinary tract obstructions.
    • 5. Patients receiving monoamine oxidase inhibitors (antidepressants).
  168. Promethazine - Precautions
    • 1. Lowers the seizure threshold
    • 2. Do not use in patients less than 2 years of age
    • 3. Chronic alcohol use or abuse
    • 4. History of dystonic reactions
  169. Promethazine - Route/Dose
    • 1. Adult: 0.25-0.5mg/kg IM (25-50mg average). May be given IV at half of the IM dose (12.5-25mg average), but IV dose must be diluted with at least 10cc NaCl. Preferred method is to dilute syringe and then give in flowing IV line.
    • 2. Pediatrics (2-12 years): 0.125-0.25 mg/kg IM (12.5-25mg average). May be given IV at half the IM dose (6.25-12.5mg), but IV dose must be diluted with at least 10cc NaCl.
  170. Sodium Bicarb - Actions
    Acids are increased when body tissues become hypoxic due to cardiac or respiratory arrest. Sodium bicarbonate is an alkalotic solution which neutralizes acids found in the blood.
  171. Sodium Bicarb - Indications
    • 1. To correct acidosis found during cardiac arrest, asystole, or electromechanical dissociation by normalizing the ph.
    • 2. To control arrhythmias in tricyclic antidepressant overdose.
  172. Sodium Bicarb - Precautions
    • 1. There is little evidence to support the use of bicarbonate in the cardiac arrest setting to improve outcome. There is evidence to prove that bicarbonate has several negative effects.
    • A. Sodium bicarbonate does not improve the ability to defibrillate.
    • B Sodium bicarbonate inhibits the release of oxygen by shifting the oxyhemoglobin curve.
    • C Sodium bicarbonate induces hyperosmolarity and hypernatremia.
    • D. Sodium bicarbonate produces paradoxical acidosis due to production of CO2, which particularly effects myocardium and brain cells.
    • E. Sodium bicarbonate induces extracellular alkalosis.
    • F. Sodium bicarbonate makes central venous acidosis worse.
    • G Sodium bicarbonate inactivates catecholamines. Therefore, the mainstay of acid-base balance should be adequate ventilation in the routine arrest situation.
    • 2. The use of sodium bicarbonate is not recommended for use by the AHA except in certain circumstances such as preexisting acidosis, or hyperkalemia.
  173. Sodium Bicarbonate - Route/Dose
    • Bicarbonate should not be considered for use before other therapies have been tried. When it is used, the dose is:
    • A. Adult: 1 mEq/kg initially; 0.5 mEq to follow given every 10 minutes.
    • Children: 1 mEq/kg initially; 0.5 mEq given every 10 minutes during arrest. Dilute 1 to 1 with normal saline.
    • B. For tricyclic antidepressant overdose with life threatening arrhythmias, 1mEq/kg IV.
  174. Sodium Bicarbonate - Side Effects/Special Notes
    • 1. Each amp. of bicarbonate contains 50 mEq of NA+. In persons with cardiac disease, this will increase intravascular volume and further stress the heart.
    • 2. Hyperosmolarity of the blood can occur because the NaHCO3 is concentrated. This results in cerebral impairment.
    • 3. These dosages are a very rough guide. Blood gases should be obtained as soon as possible to direct further therapy.
    • 4. In the presence of a respiratory arrest without cardiac arrest, the treatment of choice is ventilation to correct the respiratory acidosis. No NaHCO3 should be given unless cardiac arrest has also occurred.
  175. Solu-Medrol - Actions
    Methylprednisolone is a synthetic glucocorticoid that is used as an anti-inflammatory and immunosuppressant drug.
  176. Solu-Medrol - Indications
    • 1. Asthma
    • 2. Allergic reaction/anaphylaxis
  177. Solu-Medrol - Precautions
    • 1. Administer slowly
    • 2. History of allergy to methylprednisolone
  178. Solu-Medrol - Route/Dose
    • 1. Reconstitute according to product packaging. Withdraw the desired dose and administer over at least 1 minute. IV route is the preferred method for emergency use, but IM is acceptable.
    • 2. Dosage Adult: 125 mg. IV Pediatric: 1.0 mg/kg IV
  179. Succinylcholine - Actions
    Succinylcholine is used principally to produce skeletal muscle relaxation during procedures of short duration such as endotracheal intubation. Because of its short duration of action, succinylcholine is generally considered the neuromuscular blocking agent of choice for procedures lasting less than 3 minutes. Repeated administration may lead to tachyphylaxis and therefore, multiple fractional doses of succinylcholine should generally not be used.Succinylcholine causes a slight, transient increase in intraocular pressure immediately after injection and during the fasciculation phase.
  180. Succinylcholine - Indications
    1. Required emergent intubation for airway protection with active gag reflex.
  181. Succinylcholine - Contraindications
    Succinylcholine is contraindicated in patients with known hypersensitivity to the drug, genetically determined disorders of plasmapseudocholinesterase, personal or familial history of malignant hyperthermia, myopathies associated with elevated serum creatine kinase (CK, creatine phosphokinase, CPK) values, angle-closure glaucoma, or penetrating eye injuries.
  182. Succinylcholine - Route/Dose
    Consider Valium 0.1mg/kg (5-10mg) IV or Versed 2-5mg IV or IM prior to giving Succinylcholine.Consider Lidocaine to blunt ICP in the head-injured patient.

    • Adult:
    • 1.5 mg/kg IV with the onset of action taking approximately 30 secounds to 1 minute. Can be given I.M. if unable to obtain an IV at 2mg/kg with the onset of action taking 3-5 minutes.For Bradycardias treat with Atropine (0.5mg IV push >6 years old).

    • Pediatric:
    • For children <6 years old, pre medicate with atropine 0.02mg/kg IV (minimum dose of 0.1mg). Succinylcholine is then given at 2mg/kg IV.
  183. Terbutaline - Actions
    • 1. Terbutaline sulfate is used as a bronchodilator in the symptomatic treatment of bronchial asthma and reversible bronchospasm which may occur in association with bronchitis and emphysema. Subcutaneous terbutaline is about as effective as an equal subcutaneous dose of epinephrine in improving pulmonary function.
    • 2. Subcutaneous or IV terbutaline has been used to inhibit spontaneous uterine activity during preterm labor.
  184. Terbutaline - Indications
    • 1. Bronchial asthma or bronchospasm.
    • 2. Anaphylaxis Reaction without signs or symptoms of cardiovascular shock.
  185. Terbutaline - Precautions
    • 1. Not recommended or dosed for children younger than 12 years of age.
    • 2. Used with caution in patients with diabetes mellitus, hypertension, or hyperthyroidism.
    • 3. History of seizures.
    • 4. It's use is contraindicated in patients who are known to be hypersensitive to sympathomimetic agents.
  186. Terbutaline - Route/Dose
    • 1. Adult: Dose is 0.25mg. subcutaneous. May be repeated in 15-30 minutes if no clinical improvement is evident. No more than 0.5mg should be given within a 4-hour period.
    • 2. Pediatric: 12 years or older, same as adult.
  187. Toradol - Actions
    Ketorolac Tromethamine is a non-steroidal anti-inflammatory drug. Although the exact mechanism is unknown, it is thought to act through inhibition of prostaglandin synthesis. Ketorolac Tromethamine exhibits anti-inflammatory, analgesic, and antipyretic effects.
  188. Toradol - Indications
    • Management of moderately severe, acute pain in:
    • 1. Trauma to an extremity.
    • 2. Suspected renal colic.
    • 3. Visceral pain associated with cancer.
    • 4. Patients with know allergies to narcotic analgesics or as a non-narcotic analgesic alternative.
  189. Toradol - Contraindications
    • 1. History of ASA/NSAID induced asthma or allergic reactions.
    • 2. Active GI lesions (e.g. erosive gastritis, peptic ulcers.)
    • 3. GI bleeding.
    • 4. Suspected or confirmed CVA.
    • 5. Renal insufficiency.
    • 6. Current ASA/NSAID/anticoagulant therapy.
    • 7. Pregnancy.
  190. Toradol - Precautions
    • 1. Monitor patients with liver disease closely.
    • 2. Reduce dose in elderly patients and those with renal insufficiency.
    • 3. DO NOT mix with meperedine HCL, morphine sulfate, promethazine HCL or hydroxyzine HCL as a precipitate will form.
    • 4. Do not use prior to surgery.
  191. Toradol - Route/Dose
    • 1. Adult: 60mg IM or 30mg IV. Adults over 70 and/or those with renal insufficiency reduce dose by 50% - 30mg IM or 15mg IV.
    • 2. Not recommended for pediatric patients less than two years old.
  192. Toradol - Side Effects/Special Notes
    • 1. Drowsiness, sedation.
    • 2. Dyspepsia, nausea.
    • 3. GI pain.
    • 4. Renal failure.
    • 5. Prolonged bleeding time.
  193. Vecuronium - Actions
    Vecuronium bromide is a synthetic, nondepolarizing neuromuscular blocking agent that produces pharmacologic effects similar to those of other nondepolarizing neuromuscular blocking agents. The manufacturer states that following IV administration of a vecuronium bromide dose of 0.1 mg/kg, neuromuscular blockade begins within 1 minute and is maximal at 3-5 minutes. Following intubation with succinylcholine, the duration of clinically sufficient neuromuscular blockade of initial vecuronium bromide doses is 20-30 minutes.The manufacturer states that the recovery time following administration of vecuronium is about 15-20 minutes to achieve 75% of the control response.
  194. Vecuronium - Indications
    After successful intubation or placement of the Combitube, and the patient begins to recover from Succinylcholine, vecuronium may be given as an intermediate paralytic every 20 minutes to maintain paralysis.
  195. Vecuronium - Precautions
    Since the onset of neuromuscular blockade and maximum effect of vecuronium bromide may be delayed secondary to impaired circulation or an increased volume of distribution of the drug, larger than usual doses of the drug are not recommended in patients with these conditions. Vecuronium bromide should be administered with caution in patients with hepatic dysfunction since the drug appears to be eliminated principally via bile and recovery from neuromuscular blockade may be prolonged in these patients. Neuromuscular blocking agents should be used with extreme caution, if at all in patients with myasthenia gravis.
  196. Vecuronium - Route/Dose
    Vecuronium requires that 10mls normal saline be used in order to reconstitute at 1 mg/1 ml.The usual initial (intubation) adult dose of vecuronium bromide is 0.1 mg/kg.. Procedures can be performed within 2.5-3.0 minutes in most patients and maximum neuromuscular blockade generally occurs within dose usually within 3-5 minutes.

    • Initial Dosage after succinylcholine.
    • Adult 0.1 mg/kg
    • Ped. 0.1 mg/kg

    • Second Dose every 20 minutes as needed.
    • Adult 0.05 mg/kg
    • Ped. 0.05mg/kg
  197. Zofran - Actions
    Ondansetron is a selective 5-HT3 antagonist. Ondansetron’s mechanism of action has not been fully characterized and it is not certain whether its antiemetic action in chemotherapy –induced nausea and vomiting is mediated centrally, peripherally, or both. Cytotoxic chemotherapy releases serotonin from cells in the small intestine. This released serotonin may stimulate the vagal afferents through the 5-HT3 receptors and initiate the vomiting reflex.
  198. Zofran - Indications
    1. The prevention and /or cessation of acute nausea and vomiting.
  199. Zofran - Contraindications
    1. Known hypersensitivity to Ondansetron hydrochloride.
  200. Zofran - Precautions
    • 1. May not be effective in preventing motion-induced nausea and vomiting.
    • 2. Should be avoided in pregnant or nursing mothers.
    • 3. Do not use in patients less than 4 years old.
    • 4. Half-life is two-fold in patients over 75 years old (>5 hours).
  201. Zofran - Route/Dose
    Supplied in 4mg/2ml Single Dose Vials and 4mg dissolving tablets for oral use.

    ADULT: 4-8mg IV push over 2-5 minutes or 4-8mg IM, or 4-8mg PO. Repeat doses (giving more than 8mg total) are not recommended. If nausea/vomiting continues after 15-20 minutes post-administration, administer Promethazine.

    PEDIATRIC: 0.1mg/kg IV push over 2-5 minutes in patients <40kg. For patients >40kg administer 4mg IV or 4mg PO.
  202. Zofran - Side Effects/Special Notes
    • The most common side effects are:
    • 1. Headache
    • 2. Diarrhea
    • 3. Dizziness
    • 4. Musculoskeletal pain

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