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Paramedic Drug Cards Protocols Dallas
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Drugs for Dallas Ambulance Protocols
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  1. Acetaminophen
    PHARMACOLOGY AND ACTIONS

    • 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.





    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.





    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.





    ADMINISTRATION



    • General dose is 10 mg/kg. Pediatric patients over the age of 1yrs may
    • receive 120 mg rectal suppository.
  2. Activated Charcoal
    PHARMACOLOGY AND ACTIONS

    • Adsorbs toxic substances
    • ingested, and inhibits gastrointestinal absorption by forming an effective barrier
    • between remaining particulate material and the gastrointestinal mucosa.



    INDICATIONS

    • Effective in
    • the management of poisoning or overdose of many substances.





    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.





    ADMINISTRATION

    • 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.
  3. Adenosine
    PHARMACOLOGY AND ACTIONS

    • 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.



    INDICATIONS

    • To convert paroxysmal supraventricular
    • tachycardia into sinus rhythm.





    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)



    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.





    ADMINISTRATION

    • 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.
  4. Albuterol
    PHARMACOLOGY AND 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.



    INDICATIONS:

    1. Acute asthma.

    • 2. Reversible
    • bronchospasm associated with obstructive airway disease, bronchitis or mild
    • CHF.



    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.

    DOSAGE:

    • 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 kg 3cc
    • (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).

    ADVERSE REACTIONS:

    Tremor is most common. Also palpitations, tachycardia, nervousness,

    • dizziness, hypertension, nausea, vomiting, angina,
    • headache, and

    drying of the oropharynx.
  5. Amiodarone
    PHARMACOLOGY AND 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.



    INDICATIONS:

    • 1. Ventricular Fibrillation/
    • Pulseless Ventricular Tachycardia

    2. Wide Complex Tachycardia

    3. Narrow Complex Tachycardia



    CONTRAINDICATIONS:

    1. Bradycardia

    • 2. Second or Third degree Heart
    • Block

    3. Hypotension

    4. Known Hypersensitivity



    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.











    • ADMINISTRATION:
    • 1.
    • Ventricular Fibrillation/Pulseless Ventricular Tachycardia:

    • 300mg IVP, may
    • repeat in 3-5 minutes with 150mg IVP.
    • Do not administer over 2.2grams IV in 24 hours.
    • PEDIATRIC – 5mg/kg
    • IVP/IO


    • 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.
  6. Ancef
    PHARMACOLOGY AND 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.



    INDICATIONS



    For infection prophylaxis.



    CONTRAINDICATIONS



    • 1. Allergies
    • to cephalosporins.

    • 2. Use with
    • caution with known allergies to penicillin.



    ADMINISTRATION



    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.



    • 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.
  7. Aspirin
    PHARMACOLOGY AND ACTIONS:

    • 1. Aspirin exhibits analgesic,
    • anti-inflammatory, and antipyretic activity.
    • It also increases bleeding time.



    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.





    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





    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.





    ADMINISTRATION

    Give four 81.0 mg.(total dose 324mg)chewable tablets.
  8. Atropine
    PHARMACOLOGY AND 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





    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.





    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.





    ADMINISTRATION:

    • 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.
  9. Atrovent
    PHARMACOLOGY AND 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.



    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.




    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.



    ADMINISTRATION:

    • 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.
  10. Calcium Chloride
    • MECHANISM OF
    • ACTION

    • 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.



    INDICATIONS

    • 1. Calcium channel blocker
    • toxicity

    • 2. Known or suspected
    • hypocalcemia

    • 3. Known or suspected
    • hyperkalemia

    4. Known or suspected hypermagnesemia



    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.



    DOSAGE

    • 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.
  11. Cardizem
    PHARMACOLOGY AND 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.





    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.



    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.



    • Contraindications include
    • second or third degree heart block, sick sinus syndrome, severe hypotension,
    • cardiogenic shock, and WPW or accessory pathway conduction.





    ADMINISTRATION:



    • 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.
  12. Dextrose 50%
    PHARMACOLOGY AND 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.



    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).





    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.





    ADMINISTRATION:

    • 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.





    SIDE EFFECTS AND 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.
  13. Diazepam
    PHARMACOLOGY AND ACTIONS:

    • Diazepam acts as a
    • tranquilizer, anticonvulsant, and a skeletal muscle relaxant.





    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.





    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.





    ADMINISTRATION:

    • 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.





    • SIDE EFFECTS
    • AND 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.
  14. Diphenhydramine
    PHARMACOLOGY AND 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.





    INDICATIONS:

    • 1. The
    • second-line drug in anaphylaxis and severe allergic reactions after
    • Epinephrine.

    • 2. To
    • counteract acute dystonic reactions from antipsychotic (phenothiazine) drugs.





    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.





    ADMINISTRATION:

    • 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.





    SIDE EFFECTS AND 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.
  15. Dopamine
    PHARMACOLOGY AND 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.





    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.





    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.





    ADMINISTRATION:

    • 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.

    • SIDE EFFECTS
    • AND 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.
  16. Epinephrine
    PHARMACOLOGY AND 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



    INDICATIONS:

    • 1.
    • Ventricular fibrillation/ventricular tachycardia without a pulse.

    1. Asystole.

    • 2. Pulseless electrical
    • activity.

    1. Systemic allergic reactions.

    2. Asthma in patients under 50.

    • 3. Sinus Bradycardia
    • unresponsive to Dopamine, Bradycardia secondary to calcium channel blocker or
    • beta-blocker overdose.





    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.



    ADMINISTRATION:

    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/IO

    • May
    • 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.





    SIDE EFFECTS AND SPECIAL NOTES:

    1. Anxiety, tremor, headache.

    2. Tachycardia, palpitations, PVC's

    3. Angina, hypertension.
  17. Etomidate
    PHARMACOLOGY AND 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.



    INDICATIONS:



    • 1.
    • To produce rapid hypnosis in the process of rapid
    • sequence intubation for direct airway control.


    • To produce a short acting rapid hypnosis and
    • deep sedation in the awake patient needing invasive procedures (e.g.
    • cardioversion).




    CONTRAINDICATIONS:

    • 1.
    • Known hypersensitivity to Etomidate.



    PRECAUTIONS:

    • 1.
    • Not indicated for pediatric patients under 10 years
    • old.


    • Benefit to the pregnant mother must outweigh
    • the potential risk to fetus.




    SIDE EFFECTS:

    • 1.
    • Transient venous pain following administration about
    • 20% of the time. More pronounced in
    • small, distal veins.


    • Transient skeletal muscle movements following
    • administration 32% of the time, predominately myoclonic in nature.













    • ADMINISTRATION:
    • 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).
  18. Fentanyl
    PHARMACOLOGY AND 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.



    INDICATIONS:



    • Use
    • to control moderate through severe pain.



    CONTRAINDICATIONS:



    • 1.
    • Known allergy or hypersenitivity to narcotic
    • analgesics.



    PRECAUTIONS:



    • 1.
    • Patients with respiratory depression or
    • hypoventilation.

    • 2.
    • Bradydysrhythmias.
















    ADMINISTRATION:

    • 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





































    SIDE EFFECTS:



    • 1. Skeletal and muscle
    • rigidity, especially post IV administration.

    2. Bradycardia

    • 3. May cause nausea and
    • vomiting.
  19. Flumazenil
    PHARMACOLOGY AND ACTIONS:



    • Flumazenil is a
    • benzodiazepine antagonist that competitively inhibits the actions of the
    • benzodiazepine on the gamma aminobutyric acidbenzodiazepine receptor complex.



    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.



    CONTRAINDICATIONS:



    • 1.
    • Hypersensitivity

    • 2.
    • Patients taking
    • benzodiazepine for seizure control.

    • 3.
    • Patient with a serious
    • tricyclic sedation overdose.



    PRECAUTIONS:



    • 1.
    • May experience seizure
    • activity with the withdrawal of the benzodiazepine.

    • 2.
    • Be prepared to restrain the
    • patient prior to administration.











    ADMINISTRATION:

    • 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
  20. Furosemide
    PHARMACOLOGY AND 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).





    INDICATIONS:

    • 1. Acute pulmonary edema: to
    • decrease extracellular volume and reduce venous pressure on the lung in
    • congestive heart failure.







    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.





    ADMINISTRATION:

    • 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.





    • SIDE EFFECTS
    • AND SPECIAL EFFECTS:

    • 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.
  21. Glucagon
    PHARMACOLOGY AND 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.



    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





    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.





    ADMINISTRATION:

    Adult: 1.0 mg IM or IV.

    Pediatric: 0.1 mg/kg up to 1 mg.



    Beta-blocker overdose: 1-5 mg IV.



    SIDE EFFECTS AND SPECIAL EFFECTS:

    • 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.
  22. Haldol
    PHARMACOLOGY AND 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.



    INDICATIONS:


    • As an adjunct to
    • control and restrain violent patients who are a threat to themselves
    • and/or others




    CONTRAINDICATIONS:


    • Severe toxic CNS
    • depression
    • Coma
    • Parkinson’s disease
    • Known hypersensitivity
    • to haloperidol




    PRECAUTIONS:


    • Severe cardiovascular
    • disease may cause transient hypotension
    • Seizure history with
    • prescribed anticonvulsants. This
    • may decrease the seizure threshold
    • Unknown safety in
    • pregnancy and lactation

















    • ADMINISTRATION:
    • 5mg
    • IM, may be repeated twice at 5 minute intervals to a total of 15mg.
    • If possible use 2-5mg IVP
























    • SIDE EFFECTS AND SPECIAL
    • NOTES:


    • CNS depression and
    • sedation, extrapyramidal reactions, tardive dyskinesia
    • Anticholinergic
    • effects: dry mouth and eyes, blurred vision, constipation
    • May cause hypotension
    • and tachycardia
  23. Labetalol
    PHARMACOLOGY AND 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.



    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



    PRECAUTIONS



    • 1.
    • May cause profound
    • hypotension, especially orthostatic hyptotension

    • 2.
    • May exacerbate CHF

    • 3.
    • Asthma



    CONTRAINDICATIONS

    • 1.
    • Severe bradycardia

    • 2.
    • 2nd and 3rd
    • degree heart blocks

    • 3.
    • History of severe CHF



    ADMINISTRATION



    • 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.
  24. Lidocaine
    PHARMACOLOGY AND 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.



    • INDICATIONS
    • (Second line drug for cardiac dysrhythmias, Amiodarone is preferred):

    • 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.



    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.



    ADMINISTRATION:

    • 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 total

    volume 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.





    SIDE EFFECTS AND 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.
  25. Magnesium Sulfate
    PHARMACOLOGY AND 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.



    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



    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.
















    ADMINISTRATION:

    • 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
  26. Midazolam
    PHARMACOLOGY AND INDICATIONS

    • 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.

    INDICATIONS:

    • 1. Adult and pediatric patients
    • with continuous seizures.

    2. Sedation for cardiac pacing

    • 3. Premedication for
    • cardioversion

    • 4. Premedication for rapid
    • sequence intubation

    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.










    • ADMINISTRATION:
    • Cardiac pacing and cardioversion
    • Adult:
    • IV 1-2mg slow IV push
    • IM
    • or IN 2mg single dose
    • Pediatric: IV 0.1mg/kg not to exceed 5mg
    • IM
    • 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.











































    SIDE EFFECTS – WARNINGS

    • 1. Respiratory depression
    • and/or respiratory arrest.

    2. Oversedation

    3. Hypotension

    • Care 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.
  27. Morphine
    PHARMACOLOGY AND 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.





    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.





    CONTRAINDICATIONS:

    1. Known allergy to morphine.

    2. Volume depletion.

    3. Hypotension.

    4. Undiagnosed head trauma.

    5. CNS Trauma, such as paralysis.

















    MORPHINE SULFATE CONTINUE



    PRECAUTIONS:


    • 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).
    • Use with caution in undiagnosed
    • abdominal pain or potential surgical emergencies, e.g. appendicitis or
    • acute abdomen.
    • Naloxone (Narcan) and
    • respiratory support must be at hand when administering morphine.




    ADMINISTRATION:

    • 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.





    SIDE EFFECTS AND 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.
  28. Narcan
    PHARMACOLOGY AND 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.





    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.





    PRECAUTIONS:

    • 1. In patients physically dependent on
    • narcotics, frank and occasionally violent withdrawal symptoms may be precipitated.





    ADMINISTRATION:

    • 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.





    SIDE EFFECTS AND 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.
  29. Nitroglycerine
    PHARMACOLOGY AND 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.

    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.

    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.

    • 1. Hypotension and bradycardia
    • following nitroglycerin are usually responsive to atropine.

    • 2. Contraindicated within 24
    • hours post PDE-5 selective inhibitors, e.g. Viagra, Cialis, Levitra

    ADMINISTRATION:

    • 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.










    • Nitroglycerin Drip Chart for
    • 50mg/250cc
    • 200mcg/ml



    3mls/hr


    6mls/hr


    9mls/hr


    12mls/hr


    15mls/hr


    18mls/hr


    21mls/hr


    24mls/hr




    10mcg/min


    20mcg/min


    30mcg/min


    40mcg/min


    50mcg/min


    60mcg/min


    70mcg/min


    80mcg/min
























    SIDE EFFECTS AND 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.
  30. Oral Glucose
    PHARMACOLOGY AND 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.



    INDICATIONS:

    • 1.
    • Hypoglycemic states usually associated with insulin shock in diabetes.



    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.









    ADMINISTRATION:

    1. Give entire tube of 15 grams glucose orally.











    SIDE EFFECTS AND SPECIAL NOTES

    • 1. Discontinue use if patient
    • becomes unresponsive or cannot swallow.
  31. Oxytocin
    PHARMACOLOGY AND 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.





    INDICATIONS:

    Control of post partum hemorrhage.





    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.





    ADMINISTRATION:



    • 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.



    SIDE EFFECTS AND 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.
  32. Promethazine
    PHARMACOLOGY AND 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.





    INDICATIONS:

    • 1. Active
    • treatment for motion sickness.

    • 2. Prevention
    • and control of nausea and vomiting.





    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).



    PRECAUTIONS:


    • Lowers the seizure threshold
    • Do not use in patients less than 2 years
    • of age
    • Chronic alcohol use or abuse
    • History of dystonic reactions













    ADMINISTRATION:

    • 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.
    • 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.
  33. Sodium Bicarbonate
    PHARMACOLOGY AND 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.





    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.





    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.





    ADMINISTRATION:

    • 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.


    SIDE EFFECTS AND 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.
  34. Solu-Medrol
    PHARMACOLOGY AND ACTIONS:

    • Methylprednisolone is a
    • synthetic glucocorticoid that is used as an anti-inflammatory and
    • immunosuppressant drug.





    INDICATIONS

    1. Asthma

    2. Allergic reaction/anaphylaxis





    PRECAUTIONS

    1. Administer slowly

    2. History of allergy to methylprednisolone





    ADMINISTRATION

    • 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
  35. Succinylcholine
    PHARMACOLOGY AND 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.





    INDICATIONS:

    • 1. Required emergent intubation for airway
    • protection with active gag reflex.







    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.





    ADMINISTRATION:

    • 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.



    • Succinylcholine should be used during pregnancy only when clearly
    • needed for airway management.
  36. Terbutaline
    PHARMACOLOGY AND 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.





    INDICATIONS:

    1. Bronchial asthma or bronchospasm.

    • 2. Anaphylaxis Reaction without signs or
    • symptoms of cardiovascular shock.





    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.





    ADMINISTRATION:

    • 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.
  37. Toradol
    • PHARMACOLOGY AND
    • 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.



    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.



    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.










    • ADMINISTRATION:
    • 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.


    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.



    SIDE EFFECTS:

    • 1.
    • Drowsiness, sedation.

    • 2.
    • Dyspepsia, nausea.

    • 3.
    • GI pain.

    • 4.
    • Renal failure.

    • 5. Prolonged
    • bleeding time.
  38. Vecuronium Bromide
    PHARMACOLOGY AND 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.



    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.



    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.





    ADMINISTRATION:

    • 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
  39. Zofran
    PHARMACOLOGY AND 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.



    INDICATIONS:

    • 1. The prevention and /or
    • cessation of acute nausea and vomiting.



    CONTRAINDICATIONS:

    • 1. Known hypersensitivity to
    • Ondansetron hydrochloride.



    PRECATIONS:

    • 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).



    SIDE EFFECTS:

    The most common side effects are:

    1. Headache

    2. Diarrhea

    3. Dizziness

    4. Musculoskeletal pain


    • ADMINISTRATION:
    • 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.

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