Ch12 Emergency Medications.docx

Chapter Emergency Medications Unit Summary Paramedics are required to know the names class mechanism of action adverse reactions and side effects interactions indications contraindications complications routes of administration dose and specific administration considerations for all of the following emergency medications and intravenous fluids Individual states have the authority to include additional medications which may be taught by your local training agency National EMS Education Standard Competencies Pharmacology Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies and improve the overall health of the patient Emergency Medications Names pp - Effects pp - Indications pp - Routes of administration pp - Dosages for the medications administered p Actions p Contraindications p Complications p Side effects p Interactions pp - Knowledge Objectives Describe how drugs are classified p Use appropriate terminology related to pharmacology pp - List the components of a drug profile pp - Identify airway management medications used by the paramedic including indications contraindications dosages adverse reactions and side effects and interactions pp - Identify respiratory medications used by the paramedic including indications contraindications dosages adverse reactions and side effects and interactions pp - Identify cardiovascular system medications used by the paramedic including indications contraindications dosages adverse reactions and side effects and interactions pp - Identify medications for neurologic conditions that are used by the paramedic including indications contraindications dosages adverse reactions and side effects and interactions pp - Identify medications affecting the gastrointestinal system that are used by the paramedic including indications contraindications dosages adverse reactions and side effects and interactions pp - Identify any miscellaneous medications that are used by the paramedic including indications contraindications dosages adverse reactions and side effects and interactions pp - Give the generic and trade names actions indications contraindications routes of administration side effects interactions and doses of medications and intravenous fluids that may be administered by the paramedic as dictated by state protocols and local medical direction pp - Skills Objectives There are no skills objectives for this chapter Readings and Preparation Review all instructional materials including Chapter of Nancy Caroline s Emergency Care in the Streets Seventh Edition and all related presentation support materials Support Materials Lecture PowerPoint presentation Case Study PowerPoint presentation Medication Handbook or electronic application of your choice Enhancements Direct students to visit the companion website to Nancy Caroline s Emergency Care in the Streets Seventh Edition at http www paramedic emszone com for online activities American Heart Association Advanced Cardiac Life Support posters and or written materials for review Content connections The chapters on Medication Administration and Emergency Medications cover medication dosing and the chapter on Principles of Pharmacology covers medication regulations and a general discussion These chapters have direct application to all other chapters that discuss medications in relation to patient care Cultural considerations Traditional medicines such as those found in Asia have gained popularity throughout the world It is prudent for paramedics to inquire about all medications and preparations not just those filled through a pharmacy Teaching Tips There is no getting around the fact that pharmacology requires a great deal of memorization This does not mean that the topic cannot be covered in a creative way to help students to learn and remember important concepts Unit Activities Writing activities Assign students one medication from your local protocol s medication resume Students will research that medication including all handling and storage considerations for the given medication Student presentations The group activity makes an excellent presentation that will also provide visual learning experiences as well Group activities Assign groups of students to act the part of a given medication This is an effective way to demonstrate medications that are an agonist antagonist etc Example Have students act out how Naloxone binds to receptors so opioid medications cannot Visual thinking Provide students with original medication containers and or packaging Students will need to identify all information described in this chapter such as brand name generic name dosing instructions handling instructions etc Students should also be able to classify medications into one of the American Heart Association Classification of Recommendations and Level of Evidence Pre-Lecture You are the Medic You are the Medic is a progressive case study that encourages critical-thinking skills Instructor Directions Direct students to read the You Are the Medic scenario found throughout Chapter You may wish to assign students to a partner or a group Direct them to review the discussion questions at the end of the scenario and prepare a response to each question Facilitate a class dialogue centered on the discussion questions and the Patient Care Report You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper Lecture I Introduction A For all of the emergency medications and intravenous fluids presented in this chapter paramedics are required to know the Names Class Mechanism of action Adverse reactions and side effects Interactions Indications Contraindications Complications Routes of administration Dose Specific administration considerations B Individual states have the authority to include additional medications These may be taught by your local training agency C Pharmacology is one of the more difficult subjects to master Paramedics have to make quick decisions about a When to administer medications b What medications to administer c When administering certain medications would be harmful to the patient Pharmacology is constantly changing a New drugs are released frequently b Paramedics must stay up to date on the latest pharmacologic information D This formulary reflects the most current recommendations and resources Including the ILCOR Guidelines for emergency cardiac care E State and regional EMS systems have the right to include medications and indications for these medications that may not be covered in the chapter Always follow your local protocols II Medication References A AHA Classification of Recommendations and Level of Evidence A system of classifying recommendations based on strength of the supporting scientific evidence was used in this chapter a Class I i This indicates that a treatment should be administered b Class IIa i This indicates that it is reasonable to administer treatment c Class IIb i This indicates that treatment may be considered d Class III i This indicates that treatment should NOT be administered ii It is not helpful and may be harmful e Class Indeterminate i This indicates that either research is beginning on the treatment or that research is continuing on this treatment ii There are no recommendations until further research is performed ie cannot recommend for or against B Pregnancy category ratings for drugs Drugs have been categorized by the Food and Drug Administration FDA according to the level of risk to the fetus These categories are listed for each herein under Pregnancy Safety The categories are interpreted as follows a Category A i Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester ii There is no evidence of risk in later trimesters iii The possibility of fetal harm appears to be remote b Category B i Either a Animal reproductive studies have not demonstrated a fetal risk but there are no controlled studies in women or b Animal reproductive studies have shown an adverse effect other than decreased fertility that was not confirmed in controlled studies on women in the first trimester ii And there is no evidence of risk in later trimesters c Category C i Either a Studies in animals have revealed adverse effects on the fetus and there are no controlled studies in women or b Studies in women and animals are not available ii Drugs in this category should be given only if the potential benefit justifies the risk to the fetus d Category D i There is positive evidence of human fetal risk but the benefits for pregnant women may be acceptable despite the risk a As in life-threatening diseases for which safer drugs cannot be used or are ineffective ii An appropriate statement must appear in the Warnings section of the labeling of drugs in this category e Category X i Studies in animals and humans have demonstrated fetal abnormalities ii There is evidence of fetal risk based on human experience or both iii The risk of using the drug in pregnant women clearly outweighs any possible benefit iv The drug is contraindicated in women who are or may become pregnant v An appropriate statement must appear in the Contraindications section of the labeling of drugs in this category C Federal Controlled Substance Act of schedule summary Controlled Substances Act CSA Title II of the Comprehensive Drug Abuse Prevention and Control Act of a The legal foundation of the government s fight against abuse of drugs and other substances b This law is a consolidation of numerous laws regulating the manufacture and distribution of narcotics stimulants depressants hallucinogens anabolic steroids and chemicals used in the illicit production of controlled substances c The regulatory agency is the DEA Drug Enforcement Agency d Principles of Pharmacology provides additional information on drug schedules III Medical Terminology Related to Pharmacology A Paramedics need to be familiar with terms related to medications and medication administration such as common Prefixes Metric conversions Medical abbreviations B Drug dosage calculations Medication Administration discusses drug dosage calculations in detail The following terms are important to know when performing such calculations a Desired dose i The quantity of a medication that is to be administered to a patient ii This is usually expressed in milligrams grams or grains b Concentration of the medication on hand i The amount of a medication that is present in the ampule or vial ii This is usually expressed in milligrams grams or grains c Volume of the medication on hand i The amount of a fluid that is present in the ampule or vial in which the medication is dissolved ii This is usually expressed in milligrams grams or grains d Yield i The amount of drug in mL IV Medication Listings A Each entry in this formulary follows a standard format including the following information Name of medication other common names Class a How the medication is categorized as compared to other medications b This is usually done by grouping those medications with similar characteristics traits or primary components Mechanism of action a The way in which a medication produces the intended response Indications a A circumstance that points to or shows the cause pathology treatment or issue of an attack of disease b That which points out that which serves as a guide or warning Contraindications a Any condition especially any condition of disease that renders some particular line of treatment improper or undesirable Adverse reactions side effects a This is an abnormal or harmful effect to an organism caused by exposure to a chemical b It is indicated by some result such as death a change in food or water consumption altered body and organ weights altered enzyme levels or visible illness c An effect may be classed as adverse if it i Causes functional or anatomic damage ii Causes irreversible change in the homeostasis of the organism iii Increases the susceptibility of the organism to other chemical or biologic stress d A nonadverse effect will usually be reversed when the organism is no longer being exposed to the chemical Drug interactions a This refers to any potential effects that a medication may have when administered in conjunction or in the presence of another medication already in the patient s system a medication delivery device or fluid How supplied a This is how the manufacturer packages the medication for distribution and sale b Typical methods of packaging are prefilled syringes vials or ampules Dosage and administration a This is the typical or average volume of the medication that is to be administered to the patient and the route of introduction of the medication to the patient Duration of action a Three values are given i Onset The estimated amount of time it will take for the medication to enter the body system and begin to take effect ii Peak effect The estimated amount of time it will take for the medication to have its greatest effect on the patient system iii Duration The estimated amount of time that the medication will have any effect on the patient system Special considerations a Additional pertinent information concerning a medication V Drug Profiles A Activated charcoal EZ-Char Actidose Liqui-Char Class Adsorbent Mechanism of action a Absorbs toxic substances from the gastrointestinal tract Indications a Most oral poisonings and medication overdoses b Can be used after evacuation of poisons Contraindications a Oral administration to comatose patients b After ingestion of corrosives caustics petroleum distillates ineffective and may induce vomiting c Simultaneous administration with other oral drugs d Use caution in patients experiencing abdominal pain of unknown origin or known GI obstruction Adverse reactions side effects a If aspirated can induce fatal form of pneumonitis b Constipation c Black stools d Diarrhea e Vomiting f Bowel obstruction Drug interactions a Bonds with and generally inactivates whatever it is mixed with eg syrup of ipecac How supplied a g black powder -mL bottle mg mL b g black powder -mL bottle mg mL Dosage and administration a Adult to g kg PO or nasogastric tube b Pediatric to g kg PO or nasogastric tube Duration of action a Onset Immediate b Peak effect Depends on gastrointestinal function c Duration Will act until excreted Special considerations a Pregnancy safety Category C b Often used in conjunction with magnesium citrate c Must be stored in a closed container d Be sure to mix contents well before administration due to separation while being stored e Does not absorb cyanide lithium iron lead or arsenic B Adenosine Adenocard Class Antidysrhythmic Mechanism of action a Slows conduction through the AV node b Can interrupt reentrant pathways c Slows heart rate by acting directly on the sinus pacemaker cells by slowing impulse formation d The drug of choice for reentry SVT e Can be used diagnostically for stable wide-complex tachycardia of unknown origin after two doses of lidocaine Indications a Conversion of PSVT to sinus rhythm b May convert reentry SVT due to Wolff-Parkinson-White syndrome c Not effective in converting atrial fibrillation flutter or V-tach d Most forms of stable narrow-complex SVT Contraindications a Second- or third-degree AV block if no pacemaker is present b Sick sinus syndrome if no pacemaker present c Bronchoconstrictive or bronchospastic lung disease asthma COPD d Poison- or drug-induced tachycardia Adverse reactions side effects a Generally short duration and mild b Headache c Dizziness d Dyspnea e Bronchospasm f Dysrhythmias g Palpitations h Hypotension i Chest pain j Facial flushing k Cardiac arrest l Nausea m Metallic taste n Pain in the head or neck o Paresthesia p Diaphoresis Drug interactions a Methylxanthines theophylline-like drugs antagonize the effects of adenosine b Dipyridamole Persantine potentiates the effect of adenosine c Carbamazepine Tegretol may potentiate the AV node-blocking effect of adenosine How supplied a mg mL in -mL and -mL flip-top vials Dosage and administration a Adult -mg rapid IV bolus over - seconds followed by a -mL saline flush and elevate extremity i If no response after - minutes administer second dose of -mg rapid IV bolus over - seconds b Pediatric Initial dose mg kg rapid IV IO push maximum first dose mg followed by a - to -mL saline flush i Second dose mg kg rapid IV IO push maximum second dose mg followed by a - to -mL saline flush Duration of action a Onset Seconds b Peak effect Seconds c Duration seconds Special considerations a Pregnancy safety Category C b May cause bronchoconstriction in asthma patients c Evaluate elderly for signs of dehydration requiring fluid replacement prior to administering adenosine d Short half-life limits side effects in most patients C Albuterol Proventil Ventolin Class Sympathomimetic bronchodilator Mechanism of action a Selective beta- agonist that stimulates adrenergic receptors of the sympathomimetic nervous system b Results in smooth-muscle relaxation in the bronchial tree and peripheral vasculature Indications a Treatment of bronchospasm in patients with reversible obstructive airway disease COPD asthma b Prevention of exercise-induced bronchospasm Contraindications a Known prior hypersensitivity reactions to albuterol b Tachycardia c Dysrhythmias especially those caused by digitalis d Synergistic with other sympathomimetics Adverse reactions side effects a Often dose-related and include headache fatigue lightheadedness irritability restlessness aggressive behavior pulmonary edema hoarseness nasal congestion increased sputum hypertension tachycardia dysrhythmias chest pain palpitations nausea vomiting dry mouth epigastric pain and tremors Drug interactions a Tricyclic antidepressants may potentiate vasculature effects b Beta blockers are antagonistic and may block pulmonary effects c May potentiate hypokalemia caused by diuretics How supplied a Metered-dose inhaler g metered spray i Solution for aerosolization mg mL mg in -mL unit dose nebulizer Dosage and administration a Adult Administer mg Dilute in mL of solution for inhalation with mL normal saline in nebulizer and administer over - minutes b Adult Metered dose inhaler - inhalations - mg wait minutes between inhalations c Pediatric kg mg dose via handheld nebulizer or mask over minutes kg mg dose via hand-held nebulizer or mask over minutes i Repeat once in minutes Duration of action a Onset - minutes b Peak effect minutes to hours c Duration - hours Special considerations a Pregnancy safety Category C b May precipitate angina pectoris and dysrhythmias c In prehospital emergency care albuterol should be administered only via inhalation D Alteplase recombinant tissue plasminogen activator or rTPA Activase Class Fibrinolytic Mechanism of action a The enzyme binds to the fibrin-bound plasminogen at the clot site converting plasminogen to plasmin b Plasmin digests the fibrin strands of the clot restoring perfusion Indications a Acute myocardial infarction b STEMI c Massive pulmonary emboli d Acute ischemic cerebrovascular accident Contraindications a Active internal bleeding b Recent surgery within - weeks c Previous cerebral vascular accident or seizure at onset d Prolonged cardiopulmonary resuscitation e Intracranial or intraspinal surgery within months f Intracranial neoplasm g Arteriovenous malformation or aneurysm h Recent significant trauma especially head trauma i Uncontrolled hypertension systolic of greater than mm Hg diastolic of greater than mm Hg Adverse reactions side effects a Intracranial bleeding b Headache c Reperfusion dysrhythmias d Chest pain e Hypotension f GI bleeding g Nausea h Vomiting i Abdominal pain Drug interactions a Acetylsalicylic acid aspirin may increase risk of bleeding hemorrhage b Heparin and other anticoagulants may increase risk of hemorrhage How supplied a - and -mg powders requires reconstitution with sterile water to a concentration of mg mL Dosage and administration a Adult -mg IV bolus over minutes then mg kg over minutes not to exceed mg then mg kg over minutes maximum total dose of mg other doses may be prescribed by medical direction i For acute ischemic stroke mg kg infused over minutes administer of total dose in minute and the rest over the next minutes b Pediatric Safety not established Duration of action a Onset Clot lysis most often within - minutes b Peak effect Variable c Duration minutes with cleared within minutes Special considerations a Pregnancy safety Category C b Closely monitor vital signs c Observe for bleeding d Do not administer IM injections to patients receiving tissue plasminogen activator e Only administer with an infusion pump f Due to severe spontaneous bleeding risk invasive procedures eg IV starts injections NG tube or nasotracheal intubation should be avoided E Amiodarone Cordarone Pacerone Class Antidysrhythmic Mechanism of action a Blocks sodium channels and myocardial potassium channels delaying repolarization and increasing the duration of action potential Indications a Ventricular fibrillation b Pulseless ventricular tachycardia c Unstable ventricular tachycardia in patients refractory to other therapy Contraindications a Known hypersensitivity to amiodarone or iodine b Cardiogenic shock c Sinus bradycardia d Second- or third-degree AV block if no pacemaker is present e Severe sinus node dysfunction Adverse reactions side effects a Dizziness b Fatigue c Malaise d Tremor e Ataxia f Lack of coordination g Adult respiratory distress syndrome h Pulmonary edema i Cough j Progressive dyspnea k Congestive heart failure l Bradycardia m Hypotension n Worsening of dysrhythmias o Prolonged QT interval p Nausea and vomiting q Burning at IV site r Stevens-Johnson syndrome Drug interactions a Use with digoxin may cause digitalis toxicity b Antidysrhythmics may cause increased serum levels c Beta blockers and calcium channel blockers may potentiate bradycardia sinus arrest and AV heart blocks How supplied a mg mL vials and prefilled syringes b For rapid infusion add mg mL to a -mL D W mg mL run at mL h on infusion pump Dosage and administration a Adult Ventricular fibrillation pulseless ventricular tachycardia unresponsive to CPR defibrillation and vasopressors mg IV IO push Initial dose can be followed one time in - minutes at mg IV IO push Recurrent life-threatening ventricular dysrhythmias Maximum cumulative dose g IV h administered as follows Rapid infusion mg IV IO over minutes mg minute May repeat rapid infusion mg IV IO every minutes as needed b Pediatric Refractory ventricular fibrillation pulseless ventricular tachycardia mg kg IV IO bolus Can repeat the mg kg IV IO bolus up to a total dose of mg kg per h Maximum single dose mg Perfusing supraventricular and ventricular tachycardias Loading dose mg kg IV IO over - minutes maximum single dose of mg Can repeat to maximum dose of mg kg day g in adolescents Maximum single dose mg Duration of action a Onset Immediate b Peak effect - minutes c Duration - minutes Special considerations a Pregnancy safety Category D b Monitor patient for hypotension c May worsen or precipitate new dysrhythmias F Amyl nitrite Class Antidote cyanide poisoning adjunct Mechanism of action a Converts hemoglobin to methemoglobin which reacts with cyanide and chemically binds with it preventing any toxic effects Indications a Cyanide poisoning Contraindications a None in the emergency setting Adverse reactions side effects a Headache b Dizziness c Weakness d Increased ICP e Shortness of breath f Orthostatic hypotension g Tachycardia h Syncope i Cyanosis of the lips fingernails or palms signs of methemoglobinemia Drug interactions a Increased hypotensive effects with antihypertensives alcohol ingestion phenothiazines or beta blockers How supplied a -mL ampules for inhalation Dosage and administration a Adult - ampules crushed and inhaled for seconds of each minute until sodium nitrite is prepared or administer for - seconds every minutes until patient is conscious b Pediatric ampule crushed and inhaled for seconds of each minute until sodium nitrite is prepared or administer for - seconds every minutes until patient is conscious Duration of action a Onset seconds to minutes b Peak effect Varies c Duration to minutes Special considerations a Pregnancy safety Category X b Highly flammable Avoid exposure to heat or flame c Patient should remain seated or supine during and after administration due to hypotensive effects of this medication d Use caution in administering to patients with cerebral hemorrhage increased ICP or hypotension e This is the first step in a three-step treatment for cyanide poisoning followed by sodium nitrite and then sodium thiosulfate G Aspirin ASA Bayer Ecotrin St Joseph and others Class Platelet inhibitor anti-inflammatory agent Mechanism of action a Prevents platelets from clumping together or aggregating and forming emboli Indications a New onset chest pain suggestive of acute myocardial infarction Contraindications a Hypersensitivity b Relatively contraindicated in patients with active ulcer disease or asthma Adverse reactions side effects a Bronchospasm b Anaphylaxis c Wheezing in allergic patients d Prolonged bleeding e GI bleeding f Epigastric distress g Nausea h Vomiting i Heartburn j Reye syndrome Drug interactions a Use with caution in patients allergic to NSAIDs How supplied a Chewable and standard tablets i mg ii mg iii mg Dosage and administration a Adult mg to mg PO Chewing is preferable to swallowing b Pediatric Not recommended Duration of action a Onset - minutes b Peak effect Variable c Duration Variable Special considerations a Pregnancy safety Category D b Not recommended in pediatric population H Atenolol Tenormin Class Beta blocker beta- selective antidysrhythmic Mechanism of action a Decreases heart rate myocardial contractility and cardiac output b Inhibits dilation of bronchial smooth muscle Indications a To reduce myocardial ischemia and damage in acute myocardial infarction patients b Paroxysmal SVT c Atrial flutter d Atrial fibrillation e Hypertension Contraindications a Heart failure b Cardiogenic shock c Bradycardia d Lung disease e Hypotension f Second- or third-degree heart block Adverse reactions side effects a Dizziness b Bronchospasm c Bradycardia d AV conduction delays e Hypotension f Myocardial infarction g Heart failure Drug interactions a May potentiate antihypertensive effects when given to patients taking calcium channel blockers or MAOIs b Catecholamine-depleting drugs may potentiate hypotension c Sympathomimetic drugs may be antagonized d Signs of hypoglycemia may be masked How supplied a mg in -mL ampules Dosage and administration a Adult mg slow IV over minutes Wait minutes Give second dose of mg over minutes b Pediatric Not recommended Duration of action a Onset Within minutes b Peak effect minutes c Duration - hours Special considerations a Pregnancy safety Category D b Atenolol must be given slowly IV over minutes c Concurrent administration with IV calcium channel blockers such as verapamil or diltiazem can cause severe hypotension d Atenolol should be used with caution in patients with liver or renal dysfunction and COPD I Atropine sulfate Class Anticholinergic agent Mechanism of action a Inhibits the action of acetylcholine at postganglionic parasympathetic neuroeffector sites b Increases heart rate in life-threatening bradydysrhythmias Indications a Hemodynamically unstable bradycardia b Organophosphate poisoning c Nerve agent exposure d Rapid sequence intubation in pediatrics e Beta blocker or calcium channel blocker overdose Contraindications a Tachycardia b Hypersensitivity c Unstable cardiovascular status in acute hemorrhage with myocardial ischemia d Narrow-angle glaucoma e Hypothermic bradycardia Adverse reactions side effects a Drowsiness b Confusion c Headache d Tachycardia e Palpitation f Dysrhythmias g Nausea h Vomiting i Pupil dilation j Dry mouth nose skin k Blurred vision l Urinary retention m Constipation n Flushed hot dry skin o Paradoxical bradycardia when pushed too slowly or when given at low doses Drug interactions a Potential adverse effects when administered with digitalis cholinergics physostigmine b Effects enhanced by antihistamines procainamide quinidine antipsychotics enzodiazepines and antidepressants How supplied a Prefilled syringes containing mg in mL mg mL b Nebulizer mg in mL and mg in mL Dosage and administration a Adult Unstable bradycardia mg IV IO every - minutes as needed Not to exceed total dose of mg kg maximum mg total Use shorter dosing interval minutes and higher doses in severe clinical conditions Organophosphate poisoning Extremely large doses - mg or higher may be needed b Pediatric Unstable bradycardia mg kg IV IO minimum dose mg May repeat once Maximum single dose Child mg Adolescent mg Maximum total dose Child mg Adolescent mg ET dose - mg kg Rapid sequence intubation - mg kg IV IO minimum mg maximum mg Duration of action a Onset Immediate b Peak effect Rapid to - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Moderate doses may cause pupillary dilation c Paradoxical bradycardia can occur with doses lower than mg J Benzocaine spray Hurricane Class Topical anesthetic Mechanism of action a Stabilizes neuronal membrane which blocks the initiation and conduction of nerve impulses Indications a Used as a lubricant and topical anesthetic to facilitate passage of diagnostic and treatment devices b Suppresses the pharyngeal and tracheal gag reflex Contraindications a People with known hypersensitivity to benzocaine Adverse reactions side effects a Methemoglobinemia has been reported on extremely rare occasions following the use of benzocaine Drug interactions a No significant interactions found or known How supplied a Multidose aerosol can of benzocaine Dosage and administration a Adult - second spray repeat as needed b Pediatric - second spray repeat as needed Duration of action a Onset Immediate b Peak effect seconds c Duration minutes Special considerations a Pregnancy safety Category C b Topical use only not for ocular use or injection K Bumetanide Bumex Class Loop diuretic Mechanism of action a A potent loop diuretic with a rapid onset and short duration of action b Inhibits the reabsorption of sodium and chloride in the ascending limb of the loop of Henle Indications a Pulmonary edema b Congestive heart failure Contraindications a Hypersensitivity to bumetanide or sulfonamides b Hypovolemia c Anuria d Electrolyte deficiencies e Hepatic coma f Use caution hepatic cirrhosis ascites diabetes hypersensitivity to furosemide Adverse reactions side effects a Dizziness b Headache c Orthostatic hypotension d ECG changes due to electrolyte depletion e Nausea vomiting f Diarrhea g Muscle cramps h Metabolic alkalosis i Hypovolemia j Dehydration Drug interactions a NSAIDs reduce diuretic effect b May increase blood levels of lithium increasing risk of lithium poisoning c Antihypertensives and diuretics can cause further hypotension and fluid depletion How supplied a mg mL vials Dosage and administration a Adult to mg IV slowly over to minutes or IM b Pediatric Safety and effectiveness in pediatric patients is not established Duration of action a Onset Immediate b Peak effect to minutes c Duration to hours Special considerations a Pregnancy safety Category C b Bumetanide does not have the vasodilatory effects of furosemide mg bumetanide mg furosemide c May precipitate hypokalemic-induced digoxin toxicity L Calcium chloride Class Electrolyte anion Mechanism of action a Increases cardiac contractile state positive inotropic effect b May enhance ventricular automaticity Indications a Hypocalcemia b Hyperkalemia c Hypermagnesemia d Beta blocker e Calcium channel blocker toxicity Contraindications a Hypercalcemia b Ventricular fibrillation c Digitalis toxicity Adverse reactions side effects a Syncope b Cardiac arrest c Dysrhythmia d Bradycardia e Hypotension f Asystole g Peripheral vasodilation h Nausea i Vomiting j Metallic taste k Tissue necrosis at injection site l Coronary and cerebral artery spasm Drug interactions a May worsen dysrhythmias secondary to digitalis toxicity b May antagonize the effects of calcium channel blockers c Do not mix or infuse immediately before or after sodium bicarbonate without intervening flush How supplied a solution in mL mg mL ampules b Vials c Prefilled syringes Dosage and administration a Adult Calcium channel blocker overdose and hyperkalemia mg to mg - mL of solution IV push May repeat as needed b Pediatric Calcium channel blocker overdose and hyperkalemia mg kg mL kg slow IV IO push Maximum -g dose may repeat in minutes Duration of action a Onset - minutes b Peak effect Variable c Duration - minutes but may persist for hours dose dependent Special considerations a Pregnancy safety Category C b Do not use routinely in cardiac arrest c Comparable dose of calcium gluconate is - mL d Central venous administration is the preferred route in pediatrics if available M Calcium gluconate Class Electrolyte Mechanism of action a Counteracts the toxicity of hyperkalemia by stabilizing the membranes of the cardiac cells reducing the likelihood of fibrillation Indications a Hyperkalemia b Hypocalcemia c Hypermagnesemia d Beta blocker e Calcium channel blocker overdose Contraindications a Ventricular fibrillation b Digitalis toxicity c Hypercalcemia Adverse reactions side effects a Syncope b Cardiac arrest c Dysrhythmia d Bradycardia e Hypotension f Asystole g Peripheral vasodilation h Nausea i Vomiting j Metallic taste k Tissue necrosis at injection site l Coronary m Cerebral artery spasm Drug interactions a May worsen dysrhythmias secondary to digitalis toxicity b May antagonize the effects of calcium channel blockers c Do not mix or infuse immediately before or after sodium bicarbonate without intervening flush How supplied a mg mL of a solution Dosage and administration a Adult Hyperkalemia - mg slow IV IO push - mL minute to maximum of grams Beta blocker and calcium channel blocker overdose - grams - mL IV IO followed by a continuous hourly infusion of the same dose b Pediatric Hyperkalemia to mg kg IV IO slowly over a - minutes to a maximum of grams Beta blocker and calcium channel blocker overdose mg kg mL kg IV IO followed by a continuous hourly infusion of the same dose Duration of action a Onset Immediate b Peak effect Immediate c Duration minutes to hours Special considerations a Pregnancy safety Category C b Do not administer by IM or SQ as it causes significant tissue necrosis N Clopidogrel Plavix Class Thienopyridine antiplatelet Mechanism of action a Inhibits platelet aggregation by blocking activation of the glycoprotein IIb IIIa complex Indications a ST elevation MI STEMI b Moderate- to high-risk non-ST elevation MI NSTEMI c Acute coronary syndrome d Substitute for aspirin in patients unable to take aspirin Contraindications a Active GI bleeding b Intracranial hemorrhage c Known hypersensitivity Adverse reactions side effects a Severe neutropenia b Thrombotic thrombocytopenic purpura TTP c GI hemorrhage d Cerebral hemorrhage e Angioedema f Stevens-Johnson syndrome g Rash h Flulike symptoms Drug interactions a Should not to be taken with proton pump inhibitors omeprazole and similar drugs b Use with caution with other anticoagulants Warfarin enoxaparin streptokinase aspirin How supplied a -mg and -mg tablets Dosage and administration a Adult Loading dose of - mg PO b Pediatric Not recommended Duration of action a Onset Rapid b Peak effect hour c Duration - days Special considerations a Pregnancy safety Category B b Often given with other anticoagulants heparin eptifibatide in ACS and MI O Dexamethasone sodium phosphate Decadron Class Corticosteroid adrenal glucocorticoid Mechanism of action a Suppresses acute and chronic inflammation b Immunosuppressive effects Indications a Anaphylaxis b Asthma c Spinal cord injury d Croup e Elevated intracranial pressure prevention and treatment f As an adjunct in the treatment of shock Contraindications a Hypersensitivity b Use caution in suspected systemic sepsis Adverse reactions side effects None from single dose a Headache b Restlessness c Euphoria d Psychoses e Pulmonary tuberculosis f Hypertension g Peptic ulcer h Nausea i Vomiting j GI bleeding k Edema l Hyperglycemia m Immunosuppression n Sodium o Water retention Drug interactions a Calcium b Metaraminol How supplied a mg mL vials b mg mL vials Dosage and administration a Adult - mg IV mg kg slow IV bolus Considerable variance through medical control b Pediatric - mg kg IV IO IM Given one time with maximum dose of mg Duration of action a Onset Hours b Peak effect - hours c Duration - hours Special considerations a Pregnancy safety Category C b Protect medication from heat c Toxicity and side effects with long-term use P Dextrose Class Carbohydrate antihypoglycemic Mechanism of action a Rapidly increases serum glucose levels b Short-term osmotic diuresis Indications a Hypoglycemia b Altered level of consciousness c Coma of unknown origin d Seizure of unknown origin e Status epilepticus Contraindications a Intracranial hemorrhage Adverse reactions side effects a Extravasation leads to tissue necrosis b Cerebral hemorrhage c Cerebral ischemia d Pulmonary edema e Warmth pain burning from IV infusion f Hyperglycemia Drug interactions a Sodium bicarbonate b Warfarin Coumadin How supplied a mg mL b mg mL c mg mL prefilled syringes and vials Dosage and administration a Adult - grams of a solution slow IV push May be repeated as necessary b Pediatric year and older - g kg of a solution slow IV IO push May be repeated as necessary c Neonates and infants - mg kg of a - solution slow IV push see below May be repeated as necessary Maximum concentration of vasculature extremely sensitive to high concentrations Duration of action a Onset Less than minute b Peak effect Variable c Duration Variable Special considerations a Pregnancy safety Category C b Administer thiamine prior to D in known alcoholic patients c Draw blood to determine glucose level before administering d Do not administer to patients with known CVA unless hypoglycemia documented e How to prepare D D and D from D To make a solution - Take mL grams of a -mL stock solution of D and dilute with mL of injectable sterile water g mL mg mL mg mL D To make a solution - Take mL grams of a -mL stock solution of D and dilute with mL of injectable sterile water g mL mg mL mg mL D To make a solution - Take mL grams of a -mL stock solution of D and dilute with mL of injectable sterile water g mL mg mL mg mL D Q Diazepam Valium and others Class Benzodiazepine long-lasting sedative-hypnotic anticonvulsant schedule IV drug Mechanism of action a Potentiates effects of inhibitory neurotransmitters b Raises the seizure threshold induces amnesia and sedation Indications a Acute anxiety states and agitation b Acute alcohol withdrawal c Muscle relaxant d Seizure activity e Sedation for medical procedures eg intubation ventilated patients cardioversion f May be helpful in acute symptomatic cocaine overdose Contraindications a Hypersensitivity b Narrow-angle glaucoma c Myasthenia gravis d Respiratory insufficiency e Coma f Head injury Adverse reactions side effects a Dizziness b Drowsiness c Confusion d Headache e Respiratory depression f Hypotension g Reflex tachycardia h Nausea i Vomiting j Muscle weakness k Tissue necrosis l Ataxia m Thrombosis n Phlebitis Drug interactions a Incompatible with most drugs fluids How supplied a mg mL prefilled syringes b Ampules c Vials d Tubex syringes Dosage and administration a Adult Seizure activity - mg IV q - minutes PRN mg over minutes maximum dose mg Premedication for cardioversion - mg IV over - minutes prior to cardioversion b Pediatric Seizure activity mg kg to mg kg slow IV q - minutes up to mg maximum dose mg kg Rectal diazepam mg kg via rectal catheter and flush with - mL air after administration Duration of action a Onset - minutes b Peak effect minutes c Duration - minutes Special considerations a Pregnancy safety Category D b Short duration for anticonvulsant effect c Reduce dose by in elderly patients R Digoxin Lanoxin Class Inotropic agent cardiac glycoside Mechanism of action a Rapid-acting cardiac glycoside with direct and indirect effects b Increases force of myocardial contraction c Increases refractory period of AV node and increases total peripheral resistance Indications a Congestive heart failure b Reentry SVTs c Ventricular rate control in atrial flutter and atrial fibrillation Contraindications a Ventricular fibrillation b Ventricular tachycardia c Digitalis toxicity d Hypersensitivity to digoxin Adverse reactions side effects a Fatigue b Headache c Blurred yellow or green vision d Seizures e Confusion f Bradycardia g Dysrhythmia h Nausea i Vomiting j Anorexia k Skin rash Drug interactions a Amiodarone b Verapamil and quinidine may increase serum digoxin concentrations by - c Concurrent use of digoxin and verapamil may lead to severe heart block d Diuretics may potentiate cardiac toxicity How supplied a mg mL vials Dosage and administration a Adult Loading dose - g kg over minutes Second and third boluses of - g kg to follow at - to -hour intervals b Pediatric Not recommended in prehospital setting Duration of action a Onset - minutes b Peak effect - minutes c Duration Several days Special considerations a Pregnancy safety Category C b Patient receiving IV digoxin must be on a monitor c Patients with known renal failure are prone to developing digitalis toxicity d Hypokalemia hypomagnesemia and hypercalcemia potentiate digitalis toxicity e Use carefully in patients with Wolff-Parkinson-White syndrome S Diltiazem Cardizem Class Calcium channel blocker antidysrhythmic Mechanism of action a Slow calcium channel blocker that blocks calcium ion influx during depolarization of cardiac and vascular smooth muscle b Decreases peripheral vascular resistance and causes relaxation of the vascular smooth muscle resulting in a decrease of both systolic and diastolic blood pressure c Reduces preload and afterload d Reduces myocardial oxygen demand Indications a Controls rapid ventricular rates due to atrial fibrillation atrial flutter and reentry supraventricular tachycardia Contraindications a Hypotension b Sick sinus syndrome without functioning pacemaker present c Second- or third-degree AV block without functioning pacemaker present d Cardiogenic shock e Wide-complex tachycardia ventricular tachycardia may lead to hemodynamic deterioration and ventricular fibrillation f Poison- or drug-induced tachycardia Adverse reactions side effects a Dizziness b Weakness c Headache d Dyspnea e Cough f Dysrhythmias g CHF h Peripheral edema i Bradycardia j Hypotension k AV blocks l Syncope m Ventricular fibrillation n Ventricular tachycardia o Cardiac arrest p Chest pain q Nausea r Vomiting s Dry mouth Drug interactions a Caution in patients using medications that affect cardiac contractility in general should not be used in patients on beta blockers How supplied a mg mL vials requires refrigeration b -mg powder requires reconstitution with attached fluid for infusion mg mL c Add mg mL to a -mL bag of D W mg mL Dosage and administration a Adult Initial dose mg kg - mg for the average patient IV over minutes If inadequate response may re-bolus in minutes Secondary dose mg kg - mg for the average patient IV over minutes Maintenance infusion of - mg h titrated to physiologically appropriate heart rate b Pediatric Not recommended Duration of action a Onset - minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Use with caution in patients with renal or hepatic dysfunction c PVCs may be present on conversion of PSVT to sinus rhythm d -mg dose of calcium chloride minutes prior to administration of diltiazem can help to block the hypotensive effects in borderline hypotensive patients blocks baroreceptors in the great vessels T Diphenhydramine Benadryl Class Antihistamine anticholinergic Mechanism of action a Blocks cellular histamine receptors b Decreases vasodilation c Decreases motion sickness d Reverses extrapyramidal reactions Indications a Symptomatic relief of allergies b Allergic reactions and anaphylaxis c Blood administration reactions d Used for motion sickness and hay fever e Relief of acute dystonic reactions caused by phenothiazines f May be useful in phenothiazine overdoses Contraindications a Asthma b Glaucoma c Pregnancy d Hypertension e Narrow-angle glaucoma f Infants g Patients taking MAOIs Adverse reactions side effects a Drowsiness b Sedation c Seizures d Dizziness e Headache f Blurred vision g Paradoxical CNS excitement in children h Wheezing i Thickening of bronchial secretions j Palpitations k Hypotension l Dysrhythmias m Dry mouth n Diarrhea o Nausea p Vomiting Drug interactions a Potentiates effects of alcohol and other anticholinergics b May inhibit corticosteroid activity c MAOIs prolong anticholinergic effects of diphenhydramine How supplied a - and -mg tablets and capsules b mg mL and mg mL vials Dosage and administration a Adult - mg IM IV PO b Pediatric - mg kg IV IO slowly or IM If PO mg kg h Duration of action a Onset - minutes b Peak effect hour c Duration - hours Special considerations a Pregnancy safety Category B b Not used in infants c If used in anaphylaxis must be in conjunction with epinephrine and corticosteroids U Dobutamine hydrochloride Dobutrex Class Sympathomimetic inotropic agent Mechanism of action a Synthetic catecholamine b Increased myocardial contractility stroke volume and increased cardiac output c Minimal chronotropic activity d Increases renal blood flow Indications a Cardiogenic shock b CHF c Left ventricular dysfunction d Often used in conjunction with other drugs Contraindications a Tachydysrhythmias b Severe hypotension c Idiopathic hypertrophic subaortic stenosis IHSS d Suspected or known poison drug-induced shock Adverse reactions side effects a Headache b Dyspnea c Tachycardia d Hypertension e Chest pain f Dysrhythmias g PVCs h Nausea i Vomiting Drug interactions a Incompatible with sodium bicarbonate and furosemide b Beta blockers may blunt inotropic effects How supplied a mg mL vials b mg mL D W g mL Dosage and administration a Adult IV infusion at - g kg min titrated to desired effect Max dose g kg min b Pediatric IV infusion at - g kg min titrated to desired effect not recommended Duration of action a Onset minutes b Peak effect minutes c Duration - minutes after infusion discontinued Special considerations a Pregnancy safety Category B b Monitor blood pressure closely c Titrate dose to maintain a heart rate increase of no greater than of baseline d May increase infarct size in patients with MI e Elderly patients may have a significantly decreased response V Dolasetron Anzemet Class Serotonin receptor antagonist antiemetic Mechanism of action a Selectively blocks the action of serotonin a natural substance that causes nausea and vomiting Indications a For the prevention and control of nausea or vomiting b Used in-hospital for patients undergoing chemotherapy or surgical procedures Contraindications a Known hypersensitivity to dolasetron or other -HT receptor antagonists b Use caution in patients with cardiac dysrhythmias or electrolyte abnormalities Adverse reactions side effects a ECG changes prolonged PR interval and QT interval widened QRS b Dysrhythmias c Anaphylactic reaction d Headache e Hypotension f Dyspepsia g Fever h Dizziness i Headache j Constipation Drug interactions a Use with phenothiazines verapamil haloperidol diltiazem digoxin beta blockers and Class III antidysrhythmics can have increased cardiac side effects How supplied a -mg mL vials b -mg and -mg tablets Dosage and administration a Adult mg IV one time mg PO one time b Pediatric - years old mg kg IV one time to a maximum of mg dose mg kg PO one time to a maximum of mg dose c Safety and effectiveness in children younger than years not established Duration of action a Onset minutes b Peak effect minutes c Duration - hours Special considerations a Pregnancy safety Category B b Injectable form should no longer be used in any patient with chemotherapy-induced nausea and vomiting c Generally has no effect when symptoms are due to motion sickness W Dopamine hydrochloride Intropin Class Sympathomimetic vasopressor inotropic agent Mechanism of action a Immediate metabolic precursor to norepinephrine b Produces positive inotropic and chronotropic effects c Dilates renal and splanchnic vasculature d Constricts systemic vasculature increasing blood pressure and preload e Increases myocardial contractility and stroke volume Indications a Cardiogenic and septic shock b Hypotension with low cardiac output states c Distributive shock d Second-line drug for symptomatic bradycardia Contraindications a Hypovolemic shock b Pheochromocytoma c Tachydysrhythmias d Ventricular fibrillation Adverse reactions side effects a Extravasation may cause tissue necrosis b Headache c Anxiety d Dyspnea e Dysrhythmias f Hypotension g Hypertension h Palpitations i Chest pain j Increased myocardial oxygen demand k PVCs l Nausea m Vomiting Drug interactions a Incompatible with alkaline solutions sodium bicarbonate b MAOIs will enhance the effect of dopamine c Bretylium may potentiate effect of dopamine d Beta blockers may antagonize effects of dopamine e When administered with phenytoin may cause hypotension bradycardia and seizures How supplied a mg mL and mg mL prefilled syringes and vials for IV infusion b mg mL D W premixed solutions g mL Dosage and administration a Adult IV IO infusion at - g kg min slowly titrated to patient response b Pediatric IV IO infusion at - g kg min slowly titrated to patient response Duration of action a Onset - minutes b Peak effect - minutes c Duration Effects cease almost immediately after infusion is discontinued Special considerations a Pregnancy safety Category C b Effects are dose-dependent c Dopaminergic response - g kg min dilates vessels in kidneys increased urine output d Beta-adrenergic response - g kg min positive chronotropic and inotropic effects e Adrenergic response - g kg min primary alpha stimulant vasoconstriction f Greater than g kg min reversal of renal effects override of alpha effects consider other agents such as epinephrine or norepinephrine infusions g Should be administered by infusion pump X Epinephrine adrenalin Class Sympathomimetic Mechanism of action a Direct-acting alpha and beta agonist b Alpha vasoconstriction c Beta- positive inotropic chronotropic and dromotropic effects d Beta- bronchial smooth muscle relaxation and dilation of skeletal vasculature e Blocks histamine receptors Indications a Cardiac arrest asystole PEA ventricular fibrillation and pulseless ventricular tachycardia b Symptomatic bradycardia as an alternative infusion to dopamine c Severe hypotension secondary to bradycardia when atropine and transcutaneous pacing are unsuccessful d Allergic reaction e Anaphylaxis f Asthma Contraindications a Hypertension b Hypothermia c Pulmonary edema d Myocardial ischemia e Hypovolemic shock Adverse reactions side effects a Nervousness b Restlessness c Headache d Tremor e Pulmonary edema f Dysrhythmias g Chest pain h Hypertension i Tachycardia j Nausea k Vomiting Drug interactions a Potentiates other sympathomimetics b Deactivated by alkaline solutions c MAOIs may potentiate effect d Beta blockers may blunt effects How supplied a solution Ampules and vials containing mg mL b solution Prefilled syringes containing mg mL c Auto-injector EpiPen mg mL Dosage and administration a Adult Mild allergic reactions and asthma - mg - mL SC Anaphylaxis mg mL of IV IO over minutes Cardiac arrest IV IO dose mg mL solution - minutes during resuscitation Follow each dose with a -mL flush and elevate arm for - seconds after dose Continuous infusion Add mg mL of a solution to mL normal saline or D W g mL Initial infusion rate of g min titrated to effect typical dose - g min Endotracheal ET dose - mg diluted in mL normal saline Profound bradycardia or hypotension - g min titrate to patient response Higher dose Higher doses up to mg kg may be used for specific indications beta blocker or calcium channel blocker overdose Mild allergic reactions and asthma mg kg mL kg of a solution SC b Pediatric Mild allergic reactions and asthma mg kg mL kg of a solution SC maximum of mL Anaphylaxis severe status asthmaticus mg kg mL kg IM of a solution maximum single dose mg Cardiac arrest IV IO dose mg kg mL kg of a solution every - minutes during arrest All ET doses mg kg mL kg of a solution mixed in - mL of saline until IV IO access is achieved Maximum single dose mg Symptomatic bradycardia IV IO dose mg kg mL kg of a solution All ET doses mg kg mL kg of a solution Continuous IV IO infusion Begin with rapid infusion and then titrate to response Typical initial infusion - g min Higher doses may be effective Duration of action a Onset Immediate b Peak effect Minutes c Duration Several minutes Special considerations a Special considerations Pregnancy safety Category C b May cause syncope in asthmatic children c May increase myocardial oxygen demand d To mix an infusion add mg of epinephrine to mL D W for a yield of mcg mL e Many states and systems are pulling away from IV IO IM administration of and replacing it with auto-injectors due to the vascular side effects of solo epinephrine injection Y Epinephrine racemic Micronefrin Class Sympathomimetic Mechanism of action a Stimulates beta- receptors in lungs bronchodilation with relaxation of bronchial smooth muscles b Reduces airway resistance c Useful in treating laryngeal edema inhibits histamine release Indications a Bronchial b Asthma c Prevention of bronchospasm d Croup e Laryngotracheobronchitis f Laryngeal edema Contraindications a Hypertension b Underlying cardiovascular disease c Epiglottitis Adverse reactions side effects a Headache b Anxiety c Fear d Nervousness e Respiratory weakness f Palpitations g Tachycardia h Dysrhythmias i Nausea j Vomiting Drug interactions a MAOIs and bretylium may potentiate effect b Beta blockers may blunt effects How supplied a Metered-dose inhaler - mg spray Solution mL in solution Dosage and administration a Adult MDI - inhalations repeated every minutes PRN Solution dilute mL in mL saline administer over minutes b Pediatric Solution dilute mL in mL saline if less than kg dilute mL in mL saline if - kg dilute mL in mL saline if greater than kg Administer via hand-held nebulizer Duration of action a Onset Within minutes b Peak effect - minutes c Duration - hours Special considerations a May cause tachycardia and other dysrhythmias b Monitor vital signs c Excessive use may cause bronchospasm d May have a strong rebound effect after drug wears off Z Eptifibatide Integrilin Class Glycoprotein IIb IIIa inhibitor platelet aggregation inhibitor Mechanism of action a Prevents the aggregation of platelets by binding to the glycoprotein IIb IIIa receptor b Preventing the binding of fibrinogen and von Willebrand factors Indications a Unstable angina and NSTEMI ACS being managed medically b Patients undergoing percutaneous coronary intervention Contraindications a Any prior intracranial hemorrhage b Known malignant intracranial neoplasm c Suspected aortic dissection d Significant closed head trauma or facial trauma within months e Ischemic stroke within months except if acute within hours f Active internal bleeding or bleeding disorder in past days g Surgical procedure or trauma within preceding weeks h Platelet count X mL i Hypersensitivity to and concomitant use of another glycoprotein IIb IIIa inhibitor j Severe uncontrolled hypertension systolic BP mm Hg or diastolic BP mm Hg Adverse reactions side effects a Cerebral hemorrhage b Pulmonary hemorrhage c Hypotension d GI bleeding e Internal bleeding f Anaphylactic shock Drug interactions a Thrombolytics b Oral anticoagulants c Aspirin d NSAIDs e Dipyridamole f Ticlopidine and clopidogrel increase effect g Incompatible in the same IV line with furosemide How supplied a mg mL vials and mg mL bottles requires refrigeration Dosage and administration a Adult Medical management mg kg IV bolus over - minutes followed by a mg kg infusion for - hours Percutaneous coronary intervention percutaneous transluminal coronary angioplasty mg kg IV bolus over - minutes followed by a mg kg infusion then repeat bolus in minutes Maximum dose based on a -kg patient PCI -mg bolus mg h infusion infusion duration to hours after procedure b Pediatric Not recommended Duration of action a Onset A few minutes b Peak effect minutes to hours c Duration Platelet function recovers within to hours after discontinuation Special considerations a Pregnancy safety Category B b Must be administered only with an infusion pump direct from bottle with a vented IV set c Due to severe spontaneous bleeding risk invasive procedures eg IV starts injections NG tube or nasotracheal intubation should be avoided AA Etomidate Amidate Class Nonbarbiturate hypnotic anesthesia induction agent Mechanism of action a Short-acting hypnotic that acts at the level of the reticular activating system Indications a Premedication for tracheal intubation or cardioversion Contraindications a Hypersensitivity b Labor delivery Adverse reactions side effects a Apnea of short duration b Respiratory depression c Hypoventilation d Hyperventilation e Dysrhythmias f Hypotension g Hypertension h Nausea i Vomiting j Involuntary muscle movement k Pain at injection site Drug interactions a Effects may be enhanced when given with other central nervous system depressants How supplied a mg mL vials Dosage and administration a Adult - mg kg IV over - seconds typical adult dose is mg b Pediatric - mg kg IV IO over - seconds for rapid sequence intubation older than years time only Maximum dose mg Duration of action a Onset minute b Peak effect minute c Duration - minutes Special considerations a Pregnancy safety Category C b Carefully monitor vital signs c Etomidate can suppress adrenal gland production of steroid hormones which can temporarily cause gland failure d Consider decreasing dose in elderly and patients with cardiac conditions BB Fentanyl citrate Sublimaze Class Opioid analgesic schedule II narcotic Mechanism of action a Binds to opiate receptors producing analgesia and euphoria Indications a Pain management b Anesthesia adjunct Contraindications a Known hypersensitivity b Use with caution in traumatic brain injury Adverse reactions side effects a Confusion b Paradoxical excitation c Delirium d Drowsiness e CNS depression f Sedation g Respiratory depression h Apnea i Dyspnea j Dysrhythmias k Bradycardia l Tachycardia m Hypotension n Syncope o Nausea p Vomiting q Abdominal pain r Dehydration s Fatigue Drug interactions a Increased respiratory effects when given with other CNS depressants How supplied a mg mL ampules and Tubex syringes Dosage and administration a Adult to mg mg kg IM or IV IO slow push over - minutes to maximum of mg b Pediatric - mg kg IM IV or IO slow push over - minutes The safety and efficacy in children younger than years has not been established Duration of action a Onset - minutes b Peak effect - minutes c Duration - minutes Special considerations a Pregnancy safety Category C b Chest wall rigidity possible with a high-dose rapid infusion c A dose of mg of fentanyl citrate is equivalent to mg of morphine or mg of meperidine CC Flumazenil Romazicon Class Benzodiazepine antagonist antidote Mechanism of action a Antagonizes the action of benzodiazepines on the central nervous system reversing the sedative effects Indications a Reversal of respiratory depression and sedative effects from pure benzodiazepine overdose Contraindications a Hypersensitivity b Tricyclic antidepressant c Overdose d Seizure-prone patients e Coma of unknown etiology Adverse reactions side effects a Seizures b Dizziness c Agitation d Confusion e Headache f Visual disturbances g Dysrhythmias h Chest pain i Hypertension j Nausea k Vomiting l Hiccups m Rigors n Shivering o Pain at the injection site Drug interactions a Toxic effects of mixed drug overdose especially tricyclics How supplied a mg mL vials Dosage and administration a Adult First dose mg IV IO over seconds Second dose mg may be given over seconds if no response give third dose Third dose mg IV IO over seconds if no response repeat once every minute until adequate response or total of mg is given b Pediatric Not recommended Duration of action a Onset - minutes b Peak effect Related to plasma concentration of benzodiazepines c Duration Related to plasma concentration of benzodiazepines Special considerations a Pregnancy safety Category C b Be prepared to manage seizures in patients who are physically dependent on benzodiazepines or who have ingested larger doses of other drugs c Flumazenil may precipitate withdrawal syndromes in patients dependent on benzodiazepines d Monitor patients for resedation and respiratory depression be prepared to assist ventilations e Not recommended in combined drug overdoses especially with TCAs as it may result in death f Controversial use in unknown overdose or polysubstance overdose DD Fosphenytoin Cerebyx Class Hydantoin anticonvulsant Mechanism of action a Modulates voltage-dependent sodium and calcium channels of neurons b Inhibits calcium flux across neuronal membranes c Also selectively elevates the excitability threshold of the cell reducing its response to stimuli Indications a Status epilepticus b Seizure disorder Contraindications a Bradycardia b Adams-Stokes syndrome c Second- or third-degree AV blocks d Sinoatrial blocks e Known hypersensitivity to fosphenytoin phenytoin or other hydantoins Adverse reactions side effects a Severe hypotension b Bradycardia c Dysrhythmias d Stevens-Johnson syndrome e Cardiovascular collapse f Nystagmus g Dizziness h Headache i Nausea j Somnolence k Rash l Tremor Drug interactions a Dopamine may cause severe hypotension b Reacts with many medications decreasing their effect and increasing the risk of fosphenytoin toxicity c Additive effect with other CNS depressants How supplied a mg mL vials Dosage and administration a Adult Loading dose of - mg PE kg IM IV one time to a maximum of mg PE min IV b Pediatric Loading dose of - mg PE kg IM IV one time to a maximum of mg PE kg min up to mg PE min IV Duration of action a Onset minutes b Peak effect minutes c Duration to hours Special considerations a Pregnancy safety Category D b Use with caution in patients with hepatic and renal impairment and diabetic elderly and debilitated patients c Fosphenytoin dosing is expressed as phenytoin equivalents PE to avoid the need for dose conversion between products Each vial contains mg mL which is equivalent to mg mL of phenytoin EE Furosemide Lasix Class Loop diuretic Mechanism of action a Blocks the absorption of sodium and chloride at the distal and proximal tubules and the loop of Henle causing increased urine output Indications a CHF b Pulmonary edema c Hypertensive crisis Contraindications a Hypovolemia b Anuria c Hypotension relative contraindication d Hypersensitivity e Hepatic coma f Suspected electrolyte imbalances Adverse reactions side effects a Dizziness b Headache c ECG changes d Weakness e Orthostatic hypotension f Dysrhythmias g Nausea h Vomiting i Diarrhea j Dry mouth k May exacerbate hypovolemia and hypokalemia l Hyperglycemia due to hemoconcentration Drug interactions a Lithium toxicity may be potentiated because of sodium depletion b Digitalis toxicity may be potentiated by potassium depletion How supplied a mg mL vials Dosage and administration a Adult - mg kg IV over - minutes If no response double the dose to mg kg slowly over - minutes b Pediatric mg kg IV IO Duration of action a Onset minutes b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Ototoxicity deafness and projectile vomiting can occur with rapid administration c Should be protected from light d Vasodilatory effects within minutes diuretic effects within minutes e Expect a - mm Hg systolic and a - mm Hg diastolic drop in blood pressure f Being phased out due to nephrotoxic side effects and greater success rates with CPAP FF Glucagon GlucaGen Class Hyperglycemic agent pancreatic hormone insulin antagonist Mechanism of action a Increases blood glucose level by stimulating glycogenesis b Unknown mechanism of stabilizing cardiac rhythm in beta blocker overdose c Minimal positive inotropic and chronotropic response d Decreases gastrointestinal motility and secretions Indications a Altered level of consciousness when hypoglycemia is suspected May be used as a reversal agent in beta blocker and calcium channel blocker overdoses Contraindications a Hyperglycemia b Hypersensitivity Adverse reactions side effects a Dizziness b Headache c Hypertension d Tachycardia e Nausea f Vomiting g Rebound hypoglycemia Drug interactions a Incompatible in solution with most other substances b No significant drug interactions with other emergency medications How supplied a -mg powder in vials requires reconstitution with diluent provided Dosage and administration a Adult Hypoglycemia - mg IM may repeat in - minutes Calcium channel blocker or beta blocker overdose - mg IV slowly over - minutes initially followed by a - mg h infusion as necessary b Pediatric Hypoglycemia - mg kg IM IO SQ slow IV may repeat in minutes Maximum dose mg Calcium channel blocker or beta blocker toxicity - mg kg IV IO over - minutes initially followed by a - mg kg h infusion as necessary Duration of action a Onset minute b Peak effect - minutes c Duration - minutes Special considerations a Pregnancy safety Category B b Ineffective if glycogen stores depleted c Should always be used in conjunction with dextrose whenever possible d If patient does not respond to second dose of glucagon dextrose must be administered GG Haloperidol lactate Haldol Class Tranquilizer antipsychotic Mechanism of action a Inhibits central nervous system catecholamine receptors strong antidopaminergic and weak anticholinergic Acts on CNS to depress subcortical areas mid-brain and ascending reticular activating system in the brain Indications a Acute psychotic episodes Contraindications a Parkinson's disease b Depressed mental status c Agitation secondary to shock and hypoxia d Hypersensitivity Adverse reactions side effects a Seizures b Sedation c Confusion d Restlessness e Extrapyramidal reactions f Dystonia g Respiratory depression h Hypotension i Tachycardia j Orthostatic hypotension k QT prolongation l Sudden cardiac death m Constipation n Dry mouth o Nausea p Vomiting q Drooling r Blurred vision Drug interactions a Enhanced central nervous system depression and hypotension in combination with alcohol b Antagonized amphetamines and epinephrine c Other CNS depressants may potentiate effects How supplied a mg mL ampules and vials Dosage and administration a Adult - mg IM ONLY every - minutes until sedation is achieved b Pediatric Not recommended Duration of action a Onset minutes b Peak effect - minutes c Duration Variable generally - hours Special considerations a Pregnancy safety Category C b Treat hypotension secondary to haloperidol with fluids and norepinephrine not epinephrine c Patient may also be taking benztropine mesylate Cogentin if on long-term therapy with haloperidol HH Heparin sodium Class Anticoagulant Mechanism of action a Prevents conversion of fibrogen to fibrin b Affects clotting factors IX XI XII plasmin c Does not lyse existing clots Indications a Acute myocardial infarction prophylaxis and treatment of thromboembolic disorders eg pulmonary emboli and deep venous thrombosis Contraindications a Hypersensitivity b Active bleeding c Recent intracranial intraspinal or eye surgery d Severe hypertension e Bleeding tendencies f Severe thrombocytopenia Adverse reactions side effects a Pain b Anaphylaxis c Shock d Hematuria e GI bleeding f Hemorrhage g Thrombocytopenia h Bruising Drug interactions a Salicylates b Ibuprofen c Dipyridamole d Hydroxychloroquine may increase risk of bleeding How supplied a Common mix units mL yield units mL Dosage and administration a Adult If used with fibrinolytic therapy always obtain a blood sample for control of partial thromboplastin time before heparin administration Heparin is given as an IV bolus of U kg max IU weight adjusted A continuous infusion is given following the bolus at a rate of IU kg h rounded to the nearest max IU or units h Follow medical direction and local protocol b Pediatric Not recommended Duration of action a Onset IV Immediate SQ - minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Heparin dose not lyse existing clots c Heparin along with aspirin is part of the antithrombotic package II Hydrocortisone sodium succinate Solu-Cortef Class Adrenal glucocorticoid Mechanism of action a Anti-inflammatory b Immunosuppressive with salt-retaining actions Indications a Shock due to acute adrenocortical insufficiency b Anaphylaxis c Asthma d COPD Contraindications a Systemic fungal infections b Premature infants contains benzyl alcohol which is associated with fatal gasping syndrome characterized by CNS depression metabolic acidosis and gasping respirations c Known hypersensitivity Adverse reactions side effects a Headache b Vertigo c Pulmonary tuberculosis d CHF e Hypertension f Fluid retention g Nausea Drug interactions a Incompatible with heparin and metaraminol How supplied a mg mg or mg powder in vials requires reconstitution with solution provided Dosage and administration a Adult mg kg slow IV bolus b Pediatric mg kg slow IV bolus Maximum dose mg Duration of action a Onset hour b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b May be used in status asthmaticus as a second-line drug JJ Hydroxocobalamin Cyanokit Class Antidote cyanide poisoning adjunct Mechanism of action a Binds with cyanide to form nontoxic cyanocobalamin preventing its toxic effects b Excreted renally Indications a Treatment of known or suspected cyanide poisoning Contraindications a None in the emergency setting Adverse reactions side effects a Hypertension b Allergic reactions c GI bleeding d Nausea e Vomiting f Dyspepsia g Dyspnea h Dizziness i Headache j Injection site reactions Drug interactions a Do not administer in the same IV line with diazepam dobutamine dopamine fentanyl nitroglycerin propofol sodium nitrite and sodium thiosulfate How supplied a g -mL glass vials Dosage and administration a Adult g IV infusion over minutes at a rate of mL min one time may be repeated one time at the same dose to a maximum of g b Pediatric mg kg IV one time may be repeated one time at the same dose Duration of action a Onset Rapid b Peak effect - min c Duration Varies Special considerations a Pregnancy safety Category C b Make sure to reassess the patient s airway oxygenation and hydration during administration c The patient may become hypertensive during treatment greater than mm Hg systolic and mm Hg diastolic are not uncommon and will return to baseline within hours KK Hydroxyzine Atarax Vistaril Class Antihistamine antiemetic antianxiety agent anxiolytic Mechanism of action a Potentiates effects of analgesics b Calming effect without impairing mental alertness c Rapid-acting true ataraxic with probable action of suppressing activity in key locations of the central nervous system s subcortical area d Exerts bronchodilating antispasmodic antihistaminic analgesic and antiemetic effects Indications a Potentiates the effects of analgesics b Controls nausea and vomiting in anxiety reactions and motion sickness preoperative and postoperative sedation Contraindications a Hypersensitivity early pregnancy Adverse reactions side effects a Drowsiness b Agitation c Ataxia d Dizziness e Headache f Weakness g Wheezing h Chest tightness i Urinary retention j Dry mouth k Constipation l Pain at injection site Drug interactions a Potentiates the effects of central nervous system depressants such as narcotics barbiturates and alcohol How supplied a mg mL vials Dosage and administration a Adult - mg IM ONLY b Pediatric - mg kg dose IM ONLY Duration of action a Onset - minutes b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Should be administered by IM injection only c Localized burning at the injection site is a common complaint LL Insulin Class Antidiabetic hormone Mechanism of action a Allows glucose transport into cells of all tissues b Converts glycogen to fat c Produces intracellular shift of potassium and magnesium to reduce elevated serum levels of these electrolytes Indications a Not used in emergency prehospital setting b Diabetic ketoacidosis or other hyperglycemic state c Hyperkalemia insulin and D used together to lower hyperkalemic state nonketotic hyperosmolar coma Contraindications a Hypoglycemia b Hypokalemia Adverse reactions side effects a Weakness b Fatigue c Confusion d Headache e Seizure f Coma g Tachycardia h Nausea i Hypokalemia j Hypoglycemia k Diaphoresis l Itching m Swelling n Redness Drug interactions a Incompatible in solution with all other drugs b Corticosteroids dobutamine epinephrine and thiazide diuretics decrease the hypoglycemic effects of insulin c Alcohol and salicylates may potentate the effects of insulin How supplied a - units mL vials Dosage and administration Dosage adjusted relative to blood glucose levels Standard doses for diabetic coma a Adult - units SC IM or IV followed by infusion of units kg h b Pediatric - units kg h SC IM or IV followed by infusion of units mL units mL at a rate of - units kg h Duration of action a Onset Minutes b Peak effect Approximately hour short-acting - hours intermediate-acting - hours long-acting c Duration Approximately - hours short-acting hours intermediate-acting hours long-acting Special considerations a Pregnancy safety Category B b Insulin is the drug of choice for control of diabetes in pregnancy c Usually requires refrigeration d Most rapid absorption if injected in abdominal wall next most rapid absorption if injected in the arm slowest absorption if injected into the thigh MM Ipratropium Atrovent Class Anticholinergic bronchodilator Mechanism of action a Inhibits interaction of acetylcholine at receptor sites of bronchial smooth muscle resulting in decreased cyclic guanosine monophosphate and bronchodilation Indications a Persistent bronchospasm b COPD exacerbation Contraindications a Hypersensitivity to ipratropium atropine alkaloids peanuts Adverse reactions side effects a Headache b Dizziness c Nervousness d Fatigue e Tremor f Blurred vision g Cough h Dyspnea i Worsening COPD symptoms j Tachycardia k Palpitations l Flushing m MI n Dry mouth o Nausea p Vomiting q GI distress Drug interactions a None reported How supplied a Aerosol mg actuation b mg mL of a solution for nebulized inhalation Dosage and administration a Adult - mg via inhalation with hand-held nebulizer every minutes up to times b Pediatric Same as adult Duration of action a Onset - minutes b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category B Note When used in combination with beta-agonists eg metaproterenol and albuterol the beta-agonist is always administered first with a -minute wait before administering ipratropium b Shake well before use c Use with caution in patients with urinary retention NN Isoetharine Bronchosol Bronkometer Class Sympathomimetic Mechanism of action a Beta- agonist b Relaxes smooth muscle of the bronchioles Indications a Acute bronchial asthma b Bronchospasm especially in COPD patients Contraindications a Use with caution in patients with diabetes hyperthyroidism cardiovascular disease and cerebrovascular disease Adverse reactions side effects a Nervousness b Dose-related tachycardia c Palpitations d Nausea e Tremors f Multiple doses can cause paradoxical bronchoconstriction Drug interactions a Additive adverse effects if given with other beta- agonist drugs How supplied a Multidose inhalers and -mL unit dose of solution Dosage and administration a Adult - inhalations with MDI COPD - mg - mL diluted in mL normal saline and nebulized b Pediatric mg kg maximum dose mL in mL normal saline and nebulized Duration of action a Onset Immediate b Peak effect - minutes c Duration - hours Special considerations a None OO Ketorolac tromethamine Toradol Class Nonsteroidal anti-inflammatory NSAID analgesic Mechanism of action a Potent analgesic that does not possess any sedative or anxiolytic activities by inhibiting prostaglandin synthesis Indications a Short-term management of moderate to severe pain Contraindications a Allergy to salicylates or other nonsteroidal anti-inflammatory drugs b Patients with history of asthma bleeding disorders especially GI related such as peptic ulcer disease renal failure Adverse reactions side effects a Drowsiness b Dizziness c Headache d Sedation e Bronchospasm f Dyspnea g Edema h Vasodilation i Hypotension j Hypertension k GI bleeding l Diarrhea m Dyspepsia n Nausea Drug interactions a May increase bleeding time in patients taking anticoagulants How supplied a mg mL b mg mL vials Dosage and administration a Adult - mg IM b Pediatric Not recommended Duration of action a Onset minutes b Peak effect - hours c Duration - hours Special considerations a Pregnancy safety Category C b Use with caution in elderly patients due to higher risk of renal and fatal GI adverse reactions PP Labetalol Normodyne Trandate Class Selective alpha and nonselective beta-adrenergic blocker antihypertensive Mechanism of action a Blood pressure reduction without reflex tachycardia b Total peripheral resistance reduced without significant alteration in cardiac output Indications a Moderate to severe hypertension Contraindications a Bronchial asthma b Congestive heart failure c Cardiogenic shock d Second- and third-degree heart block e Bradycardia Adverse reactions side effects a Fatigue b Weakness c Depression d Headache e Dizziness f Bronchospasm g Wheezing h Dyspnea i Bradycardia j CHF k Pulmonary edema l Orthostatic hypotension m Ventricular dysrhythmias n Nausea o Vomiting p Diarrhea Drug interactions a Labetalol may block bronchodilator effects of beta-adrenergic agonists b Nitroglycerin may augment hypotensive effects How supplied a mg mL vials Dosage and administration a Adult mg IV push over - minutes May repeat or double every minutes to a maximum dose of mg Infusion - mg min titrated to supine blood pressure b Pediatric Not recommended Duration of action a Onset minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Blood pressure pulse rate and ECG should be monitored continuously c Observe for signs of congestive heart failure bradycardia and bronchospasm d Should only be administered with patient in the supine position QQ Levalbuterol Xopenex Class Sympathomimetic bronchodilator Mechanism of action a Stimulates beta- receptors resulting in smooth muscle relaxation of bronchial tree and peripheral vasculature Indications a Treatment of acute bronchospasm in patients with reversible obstructive airway disease COPD asthma b Bronchospasm prophylaxis in asthma patients Contraindications a Known hypersensitivity to the drug and other sympathomimetics b Angioedema tachydysrhythmias and severe cardiac disease c Avoid use in patients taking phenothiazines may cause prolonged QT interval and dysrhythmias d Avoid use in patients on sotalol may decrease bronchodilating effects and cause bronchospasm prolonged QT interval and dysrhythmias Adverse reactions side effects a Headache b Anxiety c Dizziness d Restlessness e Hallucinations f Throat irritation g Tachycardia h Hypertension i Hypotension j Dysrhythmias k Angina l Nausea m Vomiting n Dyspepsia o Tremors p Hypokalemia q Hyperglycemia Drug interactions a Increased actions of bronchodilators tricyclic antidepressants MAOIs and other adrenergic drugs How supplied a mg mg mL solution for inhalation Dosage and administration a Adult mg to mg in mL administered by nebulizer every minutes to a maximum of doses b Pediatric mg kg minimum of mg administered by nebulizer every minutes to a maximum of doses Duration of action a Onset - minutes b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Use with caution in patients with cardiac dysrhythmias and cardiovascular disorders RR Lidocaine hydrochloride Xylocaine Class Antidysrhythmic Mechanism of action a Decreases automaticity by slowing the rate of spontaneous phase depolarization Indications a Alternative to amiodarone in cardiac arrest from ventricular tachycardia ventricular fibrillation stable wide-complex tachycardia poly- or monomorphic with normal baseline QT interval stable monomorphic VT with preserved ventricular function Contraindications a Hypersensitivity b Second- or third-degree AV block in the absence of an artificial pacemaker c Stokes-Adams syndrome d Prophylactic use in AMI e Wide complex ventricular escape beats with bradycardia Adverse reactions side effects a Anxiety b Drowsiness c Confusion d Seizures e Slurred speech f Respiratory arrest g Hypotension h Bradycardia i Dysrhythmias j Cardiac arrest k AV block l Nausea m Vomiting Drug interactions a Apnea induced with succinylcholine may be prolonged with high doses of lidocaine b Cardiac depression may occur in conjunction with IV phenytoin c Procainamide may exacerbate CNS effect d Metabolic clearance is decreased in patients with liver disease or in patients taking beta blockers How supplied a mg mL of a solution prefilled syringe b mg mL in D W for infusion g mL D W Dosage and administration a Adult Cardiac arrest pulseless ventricular tachycardia ventricular fibrillation Initial dose - mg kg IV IO Repeat dose - mg kg IV IO repeated in - minutes Maximum total dose mg kg Stable ventricular tachycardia wide complex tachycardia of unknown etiology significant ectopy Dose range - mg kg and up to - mg kg Repeat - mg kg every - minutes Maximum total dose mg kg Endotracheal dose - mg kg Maintenance infusion - mg min - g kg min can dilute in D W or normal saline b Pediatric IV IO dose mg kg rapid IV IO push Maximum dose mg Continuous IV IO infusion - g kg min Repeat bolus dose mg kg when infusion is initiated if bolus has not been given within previous minutes Endotracheal dose - mg kg Rapid sequence intubation - mg kg IV IO one time only Duration of action a Onset - minutes b Peak effect - minutes c Duration Variable minutes to hours Special considerations a Pregnancy safety Category B b Reduce maintenance infusion by if patient is older than years of age has liver or renal disease is in CHF or is in shock d A - to -mg bolus maintains blood levels for only minutes if not in shock e Exceedingly high doses of lidocaine can result in death and coma f Avoid lidocaine for reperfusion dysrhythmias after fibrinolytic therapy g Cross-reactivity with other forms of local anesthetics SS Lorazepam Ativan Class Benzodiazepine short intermediate acting sedative anticonvulsant schedule IV drug Mechanism of action a Anxiolytic anticonvulsant and sedative effect b Suppresses propagation of seizure activity produced by foci in cortex thalamus and limbic areas Indications a Initial control of status epilepticus or severe recurrent seizures b Severe anxiety c Sedation Contraindications a Acute narrow-angle glaucoma b Coma c Shock d Suspected drug abuse Adverse reactions side effects a Dizziness b Drowsiness c CNS depression d Headache e Sedation f Respiratory depression g Apnea h Hypotension i Bradycardia Drug interactions a May precipitate central nervous system depression if already taking central nervous system depressant medications How supplied a and mg mL vials and Tubex syringes Dosage and administration a When given IV IO must be diluted with equal volume of sterile water or sterile saline When given IM lorazepam is not diluted b Adult - mg slow IM IV at mg min may be repeated in - minutes Maximum dose of mg For sedation mg kg up to mg IM c Pediatric - mg kg slow IV IO IM over minutes May be repeated once in - minutes Maximum dose of mg kg Duration of action a Onset - minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category D b Monitor respiratory rate and blood pressure during administration c Have advanced airway equipment readily available d Inadvertent arterial injection may result in vasospasm and gangrene e Lorazepam expires in weeks when not refrigerated TT Magnesium sulfate Class Electrolyte anti-inflammatory Mechanism of action a Reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction b Manages seizures in toxemia of pregnancy c Induces uterine relaxation d Can cause bronchodilation after beta-agonists and anti-cholinergics have been administered Indications a Seizures of eclampsia toxemia of pregnancy b Torsades de pointes c Hypomagnesemia d Ventricular fibrillation pulseless ventricular tachycardia that is refractory to amiodarone e Life-threatening dysrhythmias due to digitalis toxicity Contraindications a Heart block b Myocardial damage Adverse reactions side effects a Drowsiness b CNS depression c Respiratory depression d Respiratory tract paralysis e Abnormal ECG f AV block g Hypotension h Vasodilation i Hyporeflexia Drug interactions a May enhance effects of other central nervous system depressants b Serious changes in overall cardiac function may occur with cardiac glycosides How supplied a solution mg mL vials must be diluted to a solution before administering Dosage and administration a Adult Seizure activity associated with pregnancy - g of a solution IV IO over minutes maximum dose of - g day Cardiac arrest due to hypomagnesemia or torsades de pointes - g of a solution IV IO over - minutes Torsades de pointes with a pulse Loading dose of - g in - mL of D W over - minutes IV Follow with - g h IV titrate dose to control torsades b Pediatric Pulseless ventricular tachycardias with torsades de pointes - mg kg IV IO bolus of a solution to a maximum dose of grams Torsades de pointes with pulses hypomagnesemia - mg kg IV IO of a solution over - minutes to maximum dose of grams Status asthmaticus - mg kg IV IO of a solution over - minutes to a maximum dose of grams Duration of action a Onset IV IO immediate b Peak effect Variable c Duration IV IO minutes Special considerations a Pregnancy safety Category A b Recommended that the drug not be administered in the hours before delivery if possible c IV calcium gluconate or calcium chloride should be available as an antagonist to magnesium if needed d Use with caution in patients with renal failure UU Mannitol Osmitrol Class Osmotic diuretic Mechanism of action a Promotes the movement of fluid from the intracellular space to the extracellular space b Decreases cerebral edema and intracranial pressure c Promotes urinary excretion of toxins Indications a Cerebral edema b Reduce intracranial pressure for certain cause space-occupying lesions c Rhabdomyolysis myoglobinuria d Blood transfusion reactions Contraindications a Hypotension b Pulmonary edema c Severe dehydration d Intracranial bleeding e CHF Adverse reactions side effects a Headache b Confusion c Seizures d Pulmonary edema e Tachycardia f Chest pain g CHF h Hypotension i Hypertension j Edema k Nausea l Vomiting m Dehydration Drug interactions a May precipitate digitalis toxicity when given concurrently How supplied a mL and mL of a solution for IV infusion mg mL b solution in mL for slow IV push Dosage and administration a Adult - g kg IV infusion over - minutes Additional doses of - g kg can be given every - hours as needed b Pediatric - g kg dose IV IO infusion over - minutes may repeat after minutes if no effect Duration of action a Onset - hours for diuretic effect minutes for reduction of intracranial pressure b Peak effect Variable c Duration - hours for diuretic effect - hours for reduction of intracranial pressure Special considerations a Pregnancy safety Category C b May crystallize at low temperatures store at room temperature c In-line filter should always be used d Effectiveness depends on large doses and an intact blood-brain barrier e Usage and dosages in emergency care are controversial f Be sure to have ventilatory support available VV Meperidine hydrochloride Demerol Class Opioid analgesic schedule II drug Mechanism of action a Synthetic opioid analgesic whose effects on the central nervous system and smooth muscle organs are similar to morphine primarily acting as an analgesic and a sedative Indications a Analgesia for moderate to severe pain Contraindications a Hypersensitivity to narcotics b Diarrhea caused by poisoning c Patients taking MAOIs d During labor or delivery of a premature infant e Undiagnosed abdominal pain or head injury Adverse reactions side effects a Seizures b Confusion c Sedation d Dysphoria e Headache f Hallucinations g Increased ICP h Respiratory i Depression j Apnea k Hypotension l Orthostatic hypotension m Syncope n Bradycardia o Dysrhythmias p Nausea q Vomiting r Constipation s Sweating Drug interactions a Do not give concurrently with MAOIs even with a dose in the last days b Exacerbates CNS depression when given with other CNS depressants How supplied a mg mL b mg mL prefilled syringes c Tubex syringes Dosage and administration a Adult - mg IM SC - mg slowly IV b Pediatric - mg kg dose IV IO IM SC Duration of action a Onset IM - minutes IV immediate b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Use with caution in patients with asthma and COPD c May aggravate seizures in patients with known convulsive disorders d Naloxone should be readily available as antagonist WW Metaproterenol sulfate Alupent Class Beta- adrenergic agonist bronchodilator Mechanism of action a Acts directly on bronchial smooth muscle causing relaxation of the bronchial tree and peripheral vasculature Indications a Bronchial asthma b Reversible bronchospasm secondary to bronchitis c COPD Contraindications a Tachydysrhythmia b Hypersensitivity c Tachycardia caused by digitalis toxicity Adverse reactions side effects a Nervousness b Tremor c Headache d Anxiety e Cough f Paradoxical bronchospasm g Hypertension h Chest pain i Tachydysrhythmias j Palpitations k Cardiac arrest l Diarrhea m Nausea n Vomiting o Backache p Skin reactions q Sweating Drug interactions a Other sympathomimetics may exacerbate cardiovascular effects b MAOIs may potentiate hypotensive effects c Beta blockers may antagonize metaproterenol How supplied a Metered-dose inhaler mg spray -mL inhaler b Solution solution in bottles of and mL with calibrated dropper c Alupent inhalation solution unit-dose vial or Dosage and administration a Adult Metered-dose inhaler - inhalations q - hours minutes between inhalations Inhalation solution Via nebulizer - mL of a solution diluted in mL saline b Pediatric Metered-dose inhaler Not recommended Inhalation solution Age - years - mL of a solution diluted in mL saline Duration of action a Onset minute after inhalation b Peak effect minutes c Duration - hours Special considerations a Pregnancy safety Category C b Monitor for hypotension and tachycardia c Use with caution in patients with coronary artery disease seizures hypertension and diabetes mellitus XX Methylprednisolone sodium succinate Solu-Medrol Class Corticosteroid Mechanism of action a Highly potent synthetic glucocorticoid that suppresses acute and chronic inflammation b Potentiates vascular smooth muscle relaxation by beta-adrenergic agonists Indications a Acute spinal cord trauma b Anaphylaxis c Bronchodilator for unresponsive asthma Contraindications a Premature infants b Systemic fungal infections c Use with caution in patients with gastrointestinal bleeding Adverse reactions side effects a Depression b Euphoria c Headache d Restlessness e Seizure f Increased ICP g Pulmonary tuberculosis h Hypertension i CHF j Nausea k Vomiting l Peptic ulcer m Fluid retention n Hypernatremia o Hyperkalemia Drug interactions a Hypoglycemic responses to insulin and hypoglycemic agents may be blunted How supplied a mg powder requires reconstitution with solution provided Dosage and administration a Adult Acute spinal cord trauma mg kg IV over minutes followed by Infusion mg kg h Asthma COPD anaphylaxis - mg kg IV b Pediatric Acute spinal cord trauma Same as adult Status asthmaticus anaphylaxis mg kg dose IV IO IM to a maximum dose of mg Duration of action a Onset - hours b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Not effective if time of spinal cord injury greater than hours c Crosses the placenta and may cause fetal harm YY Metoprolol tartrate Lopressor Class Beta blocker beta- selective antihypertensive antidysrhythmic Mechanism of action a Decreases heart rate conduction velocity myocardial contractility and cardiac output b Used to control ventricular response in SVT PSVT atrial fibrillation atrial flutter c Considered second-line agent after adenosine diltiazem or digitalis derivative Indications a PSVT b Atrial flutter c Atrial fibrillation d Reduces myocardial ischemia and damage in patients with AMI Contraindications a Heart failure b Second- or third-degree AV block c First-degree heart block if PR interval is equal or greater than seconds d Sick sinus syndrome e Cardiogenic shock f Bradycardia Adverse reactions side effects a Weakness b Dizziness c Depression d Bronchospasm e Wheezing f Dyspnea g Bradycardia h Pulmonary edema i CHF j AV blocks k Hypotension l Heart failure m Nausea n Indigestion Drug interactions a Metoprolol may potentiate antihypertensive effects when given to patients taking calcium channel blockers or MAOIs b Catecholamine-depleting drugs may potentiate hypotension c Sympathomimetic effects may be antagonized d Signs of hypoglycemia may be masked How supplied a mg mL ampules and vials Dosage and administration a Adult mg slow IV push at -minute intervals to a total of mg b Pediatric Safety not established Duration of action a Onset - minutes b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Metoprolol must be given slow IV over minutes c Concurrent IV administration with IV calcium channel blocker such as verapamil or diltiazem can cause severe hypotension d Metoprolol should be used with caution in patients with liver or renal dysfunction hypotension and COPD ZZ Midazolam hydrochloride Versed Class Benzodiazepine short intermediate acting schedule IV drug Mechanism of action a Reversibly interacts with gamma-amino butyric acid GABA receptors in the central nervous system causing sedative anxiolytic amnesic and hypnotic effects Indications a Sedation for medical procedures eg intubation ventilated patients cardioversion Contraindications a Acute narrow-angle glaucoma b Shock c Coma d Alcohol intoxication e Overdose f Depressed vital signs g Concomitant use with barbiturates alcohol narcotics or other central nervous system depressants Adverse reactions side effects a Headache b Somnolence c Respiratory depression d Respiratory arrest e Apnea f Hypotension g Cardiac arrest h Nausea i Vomiting j Pain at the injection site Drug interactions a Should not be used in patients who have taken central nervous system depressants How supplied a mg mL and mg mL vials and Tubex syringes Dosage and administration a Adult - mg slow IV over - minutes May be repeated to total maximum mg kg b Pediatric - mg kg IV IO maximum single dose mg Duration of action a Onset - minutes IV and dose dependent b Peak effect Variable c Duration - hours dose dependent Special considerations a Pregnancy safety Category D b Administer immediately prior to intubation procedure c Requires continuous monitoring of respiratory and cardiac function d Decrease dose by in patients with hepatic and renal dysfunction AAA Morphine sulfate Roxanol MS Contin Class Opioid analgesic schedule II narcotic Mechanism of action a Alleviates pain through CNS action b Suppresses fear and anxiety centers in the brain c Depresses brainstem respiratory centers d Increases peripheral venous capacitance and decreases venous return e Decreases preload and afterload which decreases myocardial oxygen demand Indications a Severe CHF b Acute cardiogenic pulmonary edema c Chest pain associated with acute myocardial infarction d Analgesia for moderate to severe acute and chronic pain Contraindications a Head injury b Exacerbated COPD c Depressed respiratory drive d Hypotension e Undiagnosed abdominal pain f Decreased level of consciousness g Suspected hypovolemia h Patients who have taken MAOIs within days Adverse reactions side effects a Confusion b Sedation c Headache d CNS depression e Respiratory depression f Apnea g Bronchospasm h Dyspnea i Hypotension j Orthostatic hypotension k Syncope l Bradycardia m Tachycardia n Nausea o Vomiting p Dry mouth Drug interactions a Potentiates sedative effects of phenothiazines b CNS depressants may potentiate effects of morphine c MAOIs may cause paradoxical excitation How supplied a mg mL mg mL mg mL mg mL ampules vials and Tubex syringe Dosage and administration a Adult STEMI Initial dose - mg slow IV over - minutes Repeat dose - mg at - minute intervals NSTEMI Unstable angina - mg IV push if symptoms not relieved by nitrates use with caution b Pediatric - mg kg dose IV IO IM SC Maximum dose mg Duration of action a Onset Immediate b Peak effect minutes c Duration - hours Special considerations a Pregnancy safety Category C b Morphine rapidly crosses the placenta c Safety in neonates has not been established d Use with caution in the elderly those with asthma and in those susceptible to central nervous system depression e Vagotonic effect in patients with acute inferior MI bradycardia heart block f Naloxone hydrochloride Narcan should be readily available as an antidote BBB Nalbuphine hydrochloride Nubain Class Synthetic opioid agonist antagonist Mechanism of action a Activates opiate receptor in limbic system of the CNS b Analgesic similar to morphine on a milligram for milligram basis c Agonist and antagonist properties d May be preferred for chest pain in setting of acute MI because it reduces the myocardial oxygen demand without reducing the blood pressure Indications a Chest pain associated with acute MI moderate to severe acute pain Contraindications a Head injury b Undiagnosed abdominal pain c Diarrhea caused by poison d Hypovolemia e Hypotension Adverse reactions side effects a Headache b Dizziness c Vertigo d Seizure e CNS depression f Paradoxical CNS stimulation g Respiratory depression h Pulmonary edema i Hypotension j Hypertension k Palpitations l Bradycardia m Nausea n Vomiting o Dry mouth Drug interactions a CNS depressants may potentiate effects How supplied a mg mL and mg mL ampules and vials Dosage and administration a Adult - mg slowly IV May repeat mg doses PRN to a maximum dose of mg b Pediatric Not recommended Duration of action a Onset - minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category B b Use with caution in patients with impaired respiratory function c May precipitate withdrawal syndromes in narcotic-dependent patients d Naloxone should be readily available CCC Naloxone hydrochloride Narcan Class Opioid antagonist antidote Mechanism of action a Competitive inhibition at narcotic receptor sites b Reverses respiratory depression secondary to opiate drugs c Completely inhibits the effect of morphine Indications a Opiate overdose b Complete or partial reversal of central nervous system and respiratory depression induced by opioids decreased level of consciousness coma of unknown origin c Narcotic agonist for the following morphine sulfate heroin hydromorphone Dilaudid methadone meperidine Demerol paregoric fentanyl Sublimaze oxycodone Percodan codeine propoxyphene Darvon d Narcotic agonist and antagonist for the following butorphanol Stadol pentazocine Talwin nalbuphine Nubain Contraindications a Use with caution in narcotic-dependent patients b Use with caution in neonates of narcotic-addicted mothers Adverse reactions side effects a Restlessness b Seizures c Dyspnea d Pulmonary edema e Tachycardia f Hypertension g Dysrhythmias h Cardiac arrest i Nausea j Vomiting k Withdrawal symptoms in opioid-addicted patients l Diaphoresis Drug interactions a Incompatible with bisulfite and alkaline solutions How supplied a mg mL and mg mL ampules and vials Dosage and administration a Adult - mg IM IV IO SQ ET Intranasal diluted minimum single dose recommended mg Repeat at -minute intervals to a maximum total dose of mg medical control may request higher amounts b Pediatric mg kg dose IV IO IM SQ every minutes as needed Maximum total dose of mg If no response in minutes administer an additional mg kg dose Duration of action a Onset minutes b Peak effect Variable c Duration - minutes Special considerations a Pregnancy safety Category C b Assist ventilations prior to administration to avoid sympathetic stimulation c Seizures without causal relationship have been reported d May not reverse hypotension e Use caution when administering to narcotic addicts potential violent behavior f Half-life of naloxone is often shorter than the half-life of narcotics repeat dosing may be required DDD Nifedipine Procardia Adalat Class Calcium channel blocker Mechanism of action a Inhibits movement of calcium ions across cell membranes b Calcium channel blocker c Arterial and venous vasodilator d Reduces preload and afterload e Prevents coronary artery spasm and decreases total peripheral resistance f Reduces myocardial oxygen demands g Does not prolong AV nodal conduction Indications a Hypertensive crisis b Angina pectoris Contraindications a Compensatory hypertension b Hypotension c Cardiogenic shock Adverse reactions side effects a Headache b Dizziness c Nervousness d Weakness e Mood changes f Dyspnea g Cough h Wheezing i CHF j MI k Ventricular dysrhythmias l Hypotension m Syncope n Nausea o Abdominal discomfort p Diarrhea Drug interactions a Beta blockers may potentiate effects b Effects of theophylline may be increased c Antihypertensives may potentiate hypotensive effects How supplied a - and -mg liquid-filled capsules Dosage and administration a Adult mg SL or buccal puncture end of capsule with needle and squeeze or have patient bite and swallow May repeat in minutes b Pediatric Not recommended Duration of action a Onset - minutes b Peak effect - hours c Duration - hours Special considerations a Pregnancy safety Category C b Does not slow AV nodal activity c Have beta blocker available for control of reflex tachycardia d Use with caution in geriatric population Hypotension and angina pectoris may occur EEE Nitroglycerin Nitrostat Nitro-Bid Tridil Class Vasodilator Mechanism of action a Smooth muscle relaxant acting on vasculature bronchial uterine intestinal smooth muscle b Dilation of arterioles and veins in the periphery c Reduces preload and afterload decreasing workload of the heart and thereby myocardial oxygen demand Indications a Acute angina pectoris b Ischemic chest pain c Hypertension d CHF e Pulmonary edema Contraindications a Hypotension b Hypovolemia c Intracranial bleeding or head injury d Pericardial tamponade e Severe bradycardia or tachycardia f RV infarction g Previous administration in the last hours tadalafil Cialis hours vardenafil Levitra sildenafil Viagra Adverse reactions side effects a Headache b Dizziness c Weakness d Reflex tachycardia e Syncope f Hypotension g Nausea h Vomiting i Dry mouth j Muscle twitching k Diaphoresis Drug interactions a Additive effects with other vasodilators b Incompatible with other drugs IV How supplied a Tablets mg grain mg grain mg grain NTG spray mg actuation NTG IV Tridil g mL in D W glass vials Dosage and administration a Adult Tablet - mg sublingually may repeat in minutes to maximum of doses NTG spray - sprays for - second at -minute intervals to a maximum of sprays in minutes NTG IV infusion Begin at g min increase by g min every - minutes until desired effect To a maximum of g min b Pediatric Not recommended IV infusion - g kg min IV IO titrated by g kg min max dose g kg min Duration of action a Onset - minutes b Peak effect - minutes c Duration SL - minutes IV - minutes after discontinuation of infusion Special considerations a Pregnancy safety Category C b Hypotension more common in the elderly c If -lead ECG shows inferior wall infarct rule out right ventricular infarct via right-sided -lead ECG prior to administering nitroglycerin d Nitroglycerin decomposes when exposed to light or heat it must be kept in airtight containers e Must be administered only with an infusion pump direct from bottle with a vented IV set and non-PVC tubing f Active ingredient may have stinging effect when administered FFF Nitropaste Nitro-Bid Ointment Class Vasodilator Mechanism of action a Smooth muscle relaxant acting on vasculature bronchial uterine intestinal smooth muscle b Dilation of arterioles and veins in the periphery c Reduces preload and afterload decreasing workload of the heart and thereby myocardial oxygen demand Indications a Acute angina pectoris b Chest pain associated with AMI c Hypertension d CHF e Pulmonary edema Contraindications a Hypotension b Hypovolemia c Intracranial bleeding or head injury d Previous administration in the last hours of tadalafil Cialis hours vardenafil Levitra sildenafil Viagra Adverse reactions side effects a Headache b Dizziness c Weakness d Reflex tachycardia e Syncope f Hypotension g Nausea h Vomiting i Dry mouth j Muscle twitching k Diaphoresis Drug interactions a Additive effects with other vasodilators How supplied a - to -gram tubes of nitroglycerin paste with measuring applicators Transdermal units of varying doses Dosage and administration a Adult Paste Apply to - cm - mg cover with wrap and secure with tape Maximum mg per application Transdermal Apply unit to intact skin usually chest wall in varying doses b Pediatric Not recommended Duration of action a Onset minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Not a great value in prehospital arena c Wear gloves when applying paste d Store paste in a cool place with tube tightly capped e Erratic absorption rates quite common GGG Nitrous oxide Nitronox Class Gaseous analgesic and anesthetic Mechanism of action a Exact mechanism unknown affects central nervous system phospholipids Indications a Moderate to severe pain anxiety apprehension Contraindications a Impaired level of consciousness b Head injury c Inability to follow or comply with instructions d Decompression sickness nitrogen narcosis air embolism and air transport e Undiagnosed abdominal pain or marked distention f Bowel obstruction g Hypotension h Shock i COPD j Cyanosis k Chest trauma with pneumothorax Adverse reactions side effects a Lightheadedness b Drowsiness c Respiratory depression d Apnea e Nausea f Vomiting g Malignant hyperthermia Drug interactions a None of significance How supplied a D and E cylinders blue and green of a nitrous oxide and oxygen compressed gas Dosage and administration a Adult Instruct the patient to inhale deeply through demand valve and mask or mouthpiece b Pediatric Same as above Duration of action a Onset - minutes b Peak effect variable c Duration - minutes Special considerations a Pregnancy safety Category C b Nitrous oxide increases the incidence of spontaneous abortion c Ventilate patient care area during use d Nitrous oxide is nonflammable and nonexplosive e Nitrous oxide is ineffective in of the population HHH Norepinephrine bitartrate Levophed Class Sympathomimetic vasopressor Mechanism of action a Potent alpha-agonist resulting in intense peripheral vasoconstriction positive chronotropic and increased inotropic effect from beta effect with increased cardiac output b Alpha-adrenergic activity resulting in peripheral vasoconstriction and beta-adrenergic activity leading to inotropic stimulation of the heart and coronary artery vasodilation Indications a Cardiogenic shock b Unresponsive to fluid resuscitation c Significant hypotensive mm Hg states Contraindications a Hypotensive patients with hypovolemia pregnancy relative Adverse reactions side effects a Headache b Anxiety c Dizziness d Restlessness e Dyspnea f Bradycardia g Hypertension h Dysrhythmias i Chest pain j Peripheral cyanosis k Cardiac arrest l Nausea m Vomiting n Urinary retention o Renal failure p Decreased blood flow to the GI tract kidneys skeletal muscle and skin q Tissue necrosis from extravasation Drug interactions a Can be deactivated by alkaline solutions b Sympathomimetic and phosphodiesterase inhibitors may exacerbate dysrhythmias c Bretylium may potentiate the effects of catecholamines How supplied a mg mL vials Dosage and administration a Adult Dilute mg in mL of D W or mg in mL of D W g mL Infuse by IV piggyback at - g kg min titrated to response average dose for kg patient - g min b Pediatric Begin at - g kg min IV infusion adjust rate to achieve desired change in blood pressure and systemic perfusion Titrated to patient response Duration of action a Onset - minutes b Peak effect Variable c Duration - minutes and lasts only minute after infusion is discontinued Special considerations a Pregnancy safety Category C b May cause fetal anoxia when used in pregnancy c Infuse norepinephrine through a large stable vein to avoid extravasation and tissue necrosis d Often used with low-dose dopamine to spare decreased renal and mesenteric blood flow e Drug or poison-induced hypotension may require higher doses to achieve adequate perfusion III Ondansetron hydrochloride Zofran Class Serotonin receptor antagonist antiemetic Mechanism of action a Blocks action of serotonin which is a natural substance that causes nausea and vomiting Indications a For the prevention and control of nausea or vomiting b Used in hospital for patients undergoing chemotherapy or surgical procedures Contraindications a Known allergy to ondansetron or other -HT receptor antagonists Adverse reactions side effects a Headache b Malaise c Wheezing d Bronchospasm e Atrial fibrillation f Abnormal ECG g Prolonged QT interval h ST segment depression i Second-degree AV block j Constipation k Diarrhea l Hives m Skin rash Drug interactions a Not recommended if the patient is taking apomorphine mesoridazine pimozide or thioridazine How supplied a mg mL vials Dosage and administration a Adult mg IV IM may repeat in minutes b Pediatric mg kg IV IM Duration of action a Onset minutes b Peak effect hours c Duration - hours Special considerations a Pregnancy safety Category B JJJ Oral glucose Insta-Glucose Class Hyperglycemic carbohydrate Mechanism of action a After absorption in the GI tract glucose is distributed to the tissues providing an increase in circulating blood glucose levels Indications a Conscious patients with suspected hypoglycemia Contraindications a Decreased level of consciousness nausea vomiting Adverse reactions side effects a Nausea vomiting Drug interactions a None How supplied a Paste and gels in various forms Dosage and administration a Adult - g PO in patients with an intact gag reflex and the ability to manage their own secretions b Pediatric - g PO in patients with an intact gag reflex and the ability to manage their own secretions Duration of action a Onset minutes b Peak effect Variable c Duration Variable Special considerations a Must be swallowed b Glucose is not absorbed sublingually or buccally c Check a glucometer reading before administering oral glucose and repeat at least minutes after KKK Oxygen Class Naturally occurring atmospheric gas Mechanism of action a Reverses hypoxemia Indications a Confirmed or expected hypoxemia b Ischemic chest pain c Respiratory insufficiency d Prophylactically during air transport e Confirmed or suspected carbon monoxide poisoning f Decreased level of consciousness Contraindications a Certain patients with COPD will not tolerate oxygen concentrations over b Hyperventilation Adverse reactions side effects a Decreased level of consciousness COPD patients b Decreased respiratory drive in COPD patients c Dry mucus membranes Drug interactions a None How supplied a Oxygen cylinders usually green and white of compressed oxygen gas Dosage and administration a Adult Cardiac arrest and carbon monoxide poisoning i Hypoxemia - L min via nonrebreather ii COPD - L min via nasal cannula or - Venturi mask iii Be prepared to provide ventilatory support if higher concentrations of oxygen are needed b Pediatric Same as for adult with exception of premature infant Duration of action a Onset Immediate b Peak effect Not applicable c Duration Less than minutes Special considerations a Be familiar with liter flow and each type of delivery device used b Supports combustion LLL Oxytocin Pitocin Class Pituitary hormone Mechanism of action a Increases uterine contractions Indications a Postpartum hemorrhage after infant and placental delivery Contraindications a Presence of second fetus b Unfavorable fetal position Adverse reactions side effects a Coma b Seizures c Anxiety d Subarachnoid e Hemorrhage f Hypotension g Tachycardia h Dysrhythmias i Chest pain j Nausea k Vomiting l Painful uterine contractions m Uterine rupture Drug interactions a Other vasopressors may potentiate hypotension How supplied a units mL solution Dosage and administration a Adult IM administration units IM following delivery of the placenta IV administration Mix - units in mL of nonhydrating diluent Infused at - milliunits min Titrated to severity of bleeding and uterine response b Pediatric Not applicable Duration of action a Onset IM - minutes IV immediate b Peak effect Variable c Duration IM - minutes IV minutes after infusion is stopped Special considerations a Pregnancy safety Category C b Monitor vital signs including fetal heart rate and uterine tone closely MMM Pancuronium bromide Pavulon Class Nondepolarizing neuromuscular blocker paralytic Mechanism of action a Binds to the receptor for acetylcholine at the neuromuscular junction Indications a Induction or maintenance of paralysis after intubation to assist ventilations Contraindications a Hypersensitivity b Inability to control airway and or support ventilations with oxygen and positive pressure c Neuromuscular disease eg myasthenia gravis d Hepatic or renal failure Adverse reactions side effects a Weakness b Prolonged neuromuscular block c Bronchospasm d Apnea e Respiratory failure f Tachydysrhythmias g Transient hypotension h Hypertension i PVCs j Salivation Drug interactions a Positive chronotropic drugs may potentiate tachycardia How supplied a mg mL and mg mL ampules and vials Dosage and administration a Adult to mg kg slow IV Repeat every - minutes as needed b Pediatric to mg kg slow IV IO Duration of action a Onset seconds b Peak effect Paralysis in minutes c Duration - minutes Special considerations a Pregnancy safety Category C b If patient is conscious explain the effect of the medication before administration and always sedate the patient before administering pancuronium c Intubation and ventilatory support must be readily available monitor the patient carefully d Pancuronium has no effect on consciousness or pain e Will not stop neuronal seizure activity f Heart rate and cardiac output will be increased g Decreased doses for patients with renal impairment or myasthenia gravis NNN Phenobarbital Luminal Class Barbiturate long-acting anticonvulsant schedule IV drug Mechanism of action a Generally unknown but believed to reduce neuronal excitability by increasing the motor cortex threshold to electrical stimulation Indications a Prevention and treatment of seizure activity status epilepticus Contraindications a Patients with porphyria b History of sedative or hypnotic addiction c Severe liver or respiratory disease Adverse reactions side effects a Coma b Drowsiness c Headache d Vertigo e Paradoxic excitation f CNS depression g Ataxia h Bronchospasm i Laryngospasm j Respiratory depression k Hypotension l Bradycardia m Syncope n Nausea o Vomiting Drug interactions a Effects potentiated by other CNS depressants anticonvulsants and MAOIs b Incompatible with all other drugs Flush line before and after use How supplied a mg mL ampules mg mL mg mL mg mL ampules vials and Tubex syringes Dosage and administration a Adult - mg slow IV or IM May repeat as needed in - minutes b Pediatric - mg kg slow IV IO IM Repeat as needed in - minutes Duration of action a Onset - minutes b Peak effect minutes c Duration - hours Special considerations a Pregnancy safety Category D b Potential for abuse c Carefully monitor vital signs d Use with caution in patients with pulmonary cardiovascular hepatic or renal insufficiency e Elderly more likely to experience side effects consider decreasing dose to of the usual dose f Use large stable vein for injection OOO Phenytoin Dilantin Class Anticonvulsant Mechanism of action a Promotes sodium efflux from neurons thereby stabilizing the neuron s threshold against the excitability caused by excess stimulation b Decreases abnormal ventricular automaticity and decreases the refractory period in the myocardial conduction system Indications a Prophylaxis and treatment of major motor seizures b Digitalis-induced dysrhythmias Contraindications a Hypersensitivity b Bradycardia c Second-and third-degree heart block Adverse reactions side effects a Ataxia b Agitation c Dizziness d Headache e Drowsiness f CNS depression g Respiratory depression h Hypotension i Tachycardia j Vasodilation k Heart blocks l Dysrhythmias m Nausea n Vomiting o Hepatitis p Altered taste q Rash r Stevens-Johnson syndrome s Nystagmus t Pain at injection site Drug interactions a Serum phenytoin levels are increased by anticoagulants b Tagamet sulfonamides and salicylates c Metabolism increased by chronic alcohol use d Cardiac depressant effects increased by lidocaine propranolol and other beta blockers e Precipitation may occur when mixed with D W f Incompatible with many solutions and medications How supplied a mg mL vials prefilled syringes and Tubex syringes b May be diluted with NS - mg mL c Must use inline filter on administration set d IV line should be flushed with NS before and after the drug is administered Dosage and administration a Adult Seizures - mg kg slow IV not to exceed g or rate of mg minute Dysrhythmias - mg diluted slow IV every - minutes PRN maximum g b Pediatric Seizures - mg kg slow IV - mg kg min Dysrhythmias mg kg slow IV maximum g loading dose Duration of action a Onset - minutes b Peak effect - hours c Duration - hours but as long as days reported Special considerations a Pregnancy safety Category D b Carefully monitor vital signs c Venous irritation may occur use large stable vein PPP Pralidoxime -PAM Protopam Class Cholinesterase reactivator antidote Mechanism of action a Reactivates cholinesterase to effectively act as an antidote to organophosphate and pesticide poisonings This action allows for destruction of accumulated acetylcholine at the neuromuscular junction resulting in reversal of respiratory paralysis and paralysis of skeletal muscle Indications a As an antidote in the treatment of poisoning by organophosphate pesticides and chemicals Anticholinesterase overdoses Contraindications a Reduce dose in patients with impaired renal function patients with myasthenia gravis or inorganic phosphates poisoning Adverse reactions side effects a Dizziness b Drowsiness c Headache d Neuromuscular blockade e Seizure f Laryngospasm g Hyperventilation h Apnea i Tachycardia j Cardiac arrest k Nausea l Muscle rigidity m Muscle weakness n Rash o Pain at injection site Drug interactions a Avoid use of pralidoxime concurrently with succinylcholine morphine aminophylline theophylline and other respiratory depressants to include barbiturates narcotic analgesics and sedative hypnotics How supplied a gram powder to be added to solution for infusion mg mL auto-injector Dosage and administration a Adult Organophosphate poisoning Initial dose of - g as an IV infusion over - minutes after atropine administration Dose can be repeated in h if muscle paralysis is still present mg IM repeat twice more at -minute intervals as needed Anticholinesterase overdose - g as an IV infusion over - minutes Repeat at mg every minutes as needed b Pediatric - mg kg as IV infusion over - minutes Dose may be repeated in h if muscle paralysis is still present If IV administration is not feasible IM or SC injection may be used Duration of action a Onset Minutes b Peak effect Variable c Duration Variable Special considerations a Pregnancy safety Category C b Slow IV infusion prevents tachycardia laryngospasm and muscle rigidity c Consider drawing a blood sample prior to administering for hospital to run pretreatment levels d Rapid administration may cause tachycardia laryngospasm or muscle rigidity e Treatment will be most effective if given within a few hours after poisoning f Cardiac monitoring should be considered in all cases of severe organophosphate poisoning QQQ Procainamide hydrochloride Pronestyl Class Antidysrhythmic Mechanism of action a Suppresses phase depolarization in normal ventricular muscle and Purkinje fibers reducing ectopic pacemaker s automaticity b Suppresses intraventricular conduction Indications a Stable monomorphic ventricular tachycardia with normal QT interval b Reentry SVT uncontrolled by vagal maneuvers and adenosine c Stable wide complex tachycardia of unknown origin d Atrial fibrillation with rapid ventricular rate in patients with Wolff-Parkinson-White syndrome Contraindications a Torsades de pointes b Second- and third-degree heart atrioventricular block without functioning artificial pacemaker c Preexisting QT prolongation d Digitalis toxicity e Tricyclic antidepressant overdose Adverse reactions side effects a Confusion b Seizures c Hypotension d Bradycardia e Reflex tachycardia f Ventricular dysrhythmias g AV blocks h Asystole i Widening of PR QRS and Q-T intervals j Nausea k Vomiting Drug interactions a Increases plasma levels of amiodarone and quinidine How supplied a -mg and -mg vials Dosage and administration a Adult Recurrent ventricular fibrillation pulseless ventricular tachycardia mg min slow IV infusion maximum dose mg kg In urgent situation up to mg min may be administered maximum dose mg kg Other indications mg min slow IV infusion until any one of the following occurs Dysrhythmia suppression hypotension QRS widens by of its pretreatment width or total dose of mg kg has been given Maintenance infusion - mg min diluted in D W or normal saline Reduce dose in presence of renal insufficiency b Pediatric Loading dose mg kg IV IO over - minutes Duration of action a Onset - minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Potent vasodilation and negative inotropic effects c Hypotension may occur with rapid infusion d Administer cautiously to patients with cardiac hepatic or renal insufficiency e Administer cautiously to patients with asthma or digitalis-induced dysrhythmias RRR Promethazine hydrochloride Phenergan Class Phenothiazine antiemetic antihistamine Mechanism of action a H- receptor antagonist b Blocks action of histamine c Possesses sedative antimotion antiemetic and anticholinergic activity d Potentiates the effects of narcotics to induce analgesia Indications a Nausea vomiting b Motion sickness c Sedation for patients in labor d Potentiates the analgesic effects of narcotics Contraindications a Coma b Central nervous system depression from alcohol c Barbiturates or narcotics d Reye syndrome e Lower respiratory symptoms eg asthma Adverse reactions side effects a Headache b Dizziness c Drowsiness d Confusion e Restlessness f Wheezing g Chest tightness h Thickening of bronchial secretions i Palpitations j Bradycardia k Reflex tachycardia l QT prolongation m Postural hypotension n Diarrhea o Nausea p Vomiting Drug interactions a Additive with other central nervous system depressants b Increased extrapyramidal effects with MAOIs How supplied a mg mL mg mL ampules and Tubex syringes Dosage and administration a Adult - mg IV deep IM PO PR b Pediatric older than years - mg kg dose deep IM Duration of action a Onset Immediate b Peak effect - minutes c Duration - hours Special considerations a Pregnancy safety Category C b Convulsions and sudden death when used with children c Use caution in patients with asthma peptic ulcer and bone marrow suppression d Do not use in children with vomiting of unknown etiology e Avoid intra-arterial injection f Deep IM injections are the preferred route of administration SSS Propofol Diprivan Class Sedative hypnotic short-acting Mechanism of action a Produces rapid and brief state of general anesthesia Indications a Anesthesia induction b Anesthesia maintenance c Sedation for mechanically ventilated patients Contraindications a Hypovolemia b Known sensitivity including soybean oil peanuts and eggs Adverse reactions side effects a Seizure b Apnea c Dysrhythmias d Asystole e Hypotension f Hypertension g Nausea h Vomiting i Involuntary muscle movement j Acute renal failure Drug interactions a No known drug interactions in adults b In pediatric patients when used with fentanyl propofol can cause profound bradycardia How supplied a mg mL intravenous emulsion Dosage and administration a Adult Induction dose - mg kg IV IO Maintenance infusion - g kg min IV IO b Pediatric Induction dose - mg kg IV IO Maintenance infusion - g kg min IV IO Duration of action a Onset minute b Peak effect minute c Duration As long as infusion is running Special considerations a Pregnancy safety Category B b Avoid rapid administration in elderly patients to avoid hypotension and airway obstruction Continue to monitor vital signs and oxygenation c Use large stable vein to avoid injection site pain d Avoid in pregnancy due to neonatal depression TTT Propranolol hydrochloride Inderal Class Beta-adrenergic blocker Mechanism of action a Nonselective beta-adrenergic blocker that reduces chronotropic inotropic and vasodilator response to beta-adrenergic stimulation Indications a Hypertension b Angina pectoris c Ventricular tachycardia d Ventricular fibrillation refractory to lidocaine e Selected supraventricular tachycardia Contraindications a Sinus bradycardia if no pacemaker present b Second- or third-degree AV block if no pacemaker present c Bronchial asthma d Sick sinus syndrome if no pacemaker present e Cardiogenic shock f CHF g Acute pulmonary edema Adverse reactions side effects a Weakness b Depression c Fatigue d Anxiety e Dizziness f Bronchospasm g Wheezing h Hypotension i Bradycardia j CHF k AV blocks l Nausea m Vomiting n Diarrhea o Hypoglycemia p Hyperglycemia Drug interactions a Verapamil may worsen atrioventricular conduction abnormalities b Succinylcholine effects may be enhanced c Effects may be reversed by isoproterenol norepinephrine or dopamine Intropin How supplied a mg mL vials Dosage and administration a Adult Dilute - mg in - mL of D W Administer slowly IV at rate of mg min Maximum mg b Pediatric - mg kg dose slow IV over minutes Maximum mg Duration of action a Onset - minutes b Peak effect Variable c Duration - hours Special considerations a Pregnancy safety Category C b Closely monitor patient during administration c Use with caution in elderly patients d Atropine should be readily available UUU Rocuronium bromide Zemuron Class Nondepolarizing neuromuscular blocker Mechanism of action a Antagonizes acetylcholine at the motor end plate producing skeletal muscle paralysis Indications a Rapid sequence intubation Contraindications a Known sensitivity to bromides b Use with