What is the action of Adenocard
Also known as Adenosine: Naturally occurring nucleoside which slows electrical conduction through the AV node.
Whats the indications for Adenocard
Also known as Adenosine: To convert PSVT to normal sinus rhythm, including PSVT that is associated with accessory bypass tracts (e.g., WPW).
Contraindications for Adenocard
Also known as Adenosine:
1. 2nd or 3rd degree heart block (except in patients with a functioning artificial pacemaker)
2. Sick sinus syndrome (except in patients with a functioning artificial pacemaker)
3. Pregnancy (relative contraindication since no studies have been performed)
What is the dosage of Adenocard
Adenosine:
PSVT: 6 mg rapid IVP, 2nd dose of 12 mg may be repeated in 1-2 min if no change
Pediatric PSVT: MD order only. 0.1 mg/kg IVP, increase to 0.2 mg/kg if necessary
Whats a Key Point on Adenocard
Also known as Adenosine: May be used in pregnancy if benefit outweighs risk.
Whats the indications for Acetylsalicylic Acid?
Also known as Aspirin: Suspected MI or cardiac chest pain
Any contraindications for Acetylsalicylic Acid?
Also known as Aspirin:
1. Known allergy
2. Active or recent GI bleed
Whats the dosage of Acetylsalicylic Acid
Aspirin: Adult Cardiac chest pain 324 mg (4x81 mg chewable "baby aspirin")
Whats the action of Calcium Chloride 10%?
Increases force of myocardial contraction, increases excitability of muscle fibers, may either increase or decrease systemic vascular resistance.
Whats the indications for Calcium Chloride 10%?
1. Symptomatic calcium channel blocker or magnesium sulfate overdose.
2. Known or suspected Hyperkalemia or hypocalcemia with symptoms and/or ECG changes.
Whats are precautions for the use of Calcium Chloride 10%?
1. Do not give simultaneously with sodium bicarbonate. Flush tubing well between medications.
2. Use with caution in patients on digoxin. May precipitate digoxin toxicity. May cause arrhythmias.
3. Necrosis can occur if the medication infiltrates.
Whats the dosage of Calcium Chloride 10% in cardiac arrest?
Cardiac arrest in dialysis or suspected renal failure patient: 1 g IVP after first dose of epinephrine.
Whats the dosage of Calcium Chloride 10% in dialysis pt. with dysrhythmias?
CONSULT MD if possible: 1 gram slow IVP
Bradycardia: (follow Cardiac Algorithm Bradycardia)
WIde complex tachycardia: (follow Cardiac Algorithm Tachycardia)
Whats the dosage of Calcium Chloride 10% in Symptomatic Overdose on Calcium Channel Blocker?
1 gram slow IVP over 2 min.
Hypotension: <80 systolic (follow Shock Protocol)
Bradycardia: <50/min. (follow Cardiac Algorithm Bradycardia)
Whats the dosage of Calcium Chloride 10% to reverse Magnesium Sulfate Toxicity?
1 gram slow IVP over 2 min. MD Order.
Suspect Mag Sulfate toxicity in pregnant patients receiving Mag Sulfate and is developing decreased respiration or hypotension and has diminished or absent reflexes.
When is Calcium Chloride 10% indicated in Pediatric Pt. and what the dosage?
Hyperkalemia Associated with Crush Injury: MD Order
20 mg/kg (0.2 ml/kg) slow IVP over 5 min.
Whats are some Key Points of Calcium Chloride 10%?
1. Rapid administration can cause bradycardia or arrest, give slowly.
2. Some calcium channel blockers which may be taken in overdose include: diltiazem (Cardizem), felodipine (Plendil), nicardipine (Cardene), nifedipine (Adalat, Procardia), Verapamil (Calan, Isoptin).
3. Calcium should not be used during resuscitation except for uses listed under indications.
Whats the Action of Diltiazem?
Also known as Cardizem: Slows conduction and prolongs refractoriness in the AV node.
Whats the Indications for Diltiazem?
Also known as Cardizem: Control of symptomatic rapid ventricular rate (130 or greater) associated with atrial fibrillation and atrial flutter.
Contraindications for Diltiazem?
Also known as Cardizem:
1. Systolic blood pressure less than 90 mmHg
2. Sick sinus syndrome or AV block in the absence of a functioning pacemaker
3. WPW Syndrome
4. Wide QRS tachycardia unless it is known with certainty to be supraventricular and origin
5. Relative contraindication in patients with severe heart failure.
Precautions for Diltiazem?
Use caution in patients receiving beta blockers due to the potential of synergistic effects.
Side effects of Diltiazem?
Also known as Cardizem: Nausea, vomiting, headache, dizziness, bradycardia, heart block, hypertension and asystole.
Whats the dosage of Diltiazem?
Also known as Cardizem: Atrial fibrillation and atrial flutter with rapid ventricular rate: MD order: 0.25 mg/kg IVP over 2 min. second bolus dose of 0.35 mg/kg IVP after 10 to 15 minutes
*May maintain an established diltiazem drip during interhospital transfer with a written MD order.
Whats are some key points for Diltiazem?
Also known as Cardizem:
1. If the patient is exhibiting serious signs or symptoms of cardiac compromise, (i.e. SOB, chest pain, hypotension), cardioversion is the preferred method of conversion.
2. Bradycardia can occur if cardioversion is done immediately after administration of diltiazem.
What are the indications for Sublimaze?
Also known as Fentanyl:
1. Pain management.
2. RSI pretreatment for head injury/increased ICP or induction with no IV access.
3. Post RSI sedation.
4. Treatment of shivering - See Induced Hypothermia protocol
Precautions for Sublimaze?
Also known as Fentanyl:
1. Respiratory depression, peak depression occurs 5- 15 minutes after IV dose, continuous pulse oximetry required.
2. Respiratory depressive effects enhanced by simultaneously benzodiazepine administration (e.g., Versed).
3. In large doses and with rapid administration, may cause muscle rigidity, particularly respiratory muscles (rare); in emergency, can be overcome by neuromuscular blockage (e.g., succinylcholine); NOT by Narcan.
Side effects for Sublimaze?
Also known as Fentanyl:
1. May cause nausea/vomiting.
2. Will cause pupillary constriction.
Whats the Adult dosage of Sublimaze?
Also known as Fentanyl:
Pain management: (EMT-I, Paramedic)
50-100 mcg slow IV/IO. May repeat 50 mcg Q 5 minutes up to max dose of 300 mcg.
Pretreatment for RSI if suspected head injury/suspected increased ICP: (Paramedic only)
3 mcg/kg IV/IO Administered over 30-40 seconds immediately before RSI.
Sedation post RSI: (Paramedic only)
3 mcg/kg IV/IO
Induced Hypothermia Post Resuscitation: (EMT-I, Paramedic)
3 mcg/kg IV/IO.
May repeat in 20 minutes if needed to treat shivering.
If unsuccessful consider rocuronium 1 mg/kg MD Order
Whats the Pediatric dosage of Sublimaze?
Also known as Fentanyl:
Pain management:
1 mcg/kg, slow IV/IO initial dose. May repeat Q 5 minutes up to the maximum of 3 doses then contact MD. (EMT-I, Paramedic)
Sedation/pretreatment for RSI in suspected head injury or suspected ICP: (Paramedic only)
3 mcg/kg IV/IO
What are the Indications for Midazolam?
Also known as Versed:
1. Active seizure activity, status epilepticus.
2. For amnestic effect during uncomfortable external pacing.
3. Sedation of an awake patient prior to cardioversion.
4. Sedation prior to or after RSI.
5. Chemical restraint of combative patient.
What are the Precautions for Midazolam?
Also known as Versed:
1. Can cause marked respiratory depression.
2. Use with caution in pt. who have ingested alcohol or other depressant medications.
What are the side effects of Midazolam?
Also known as Versed:
1. Respiratory depression.
2. Fluctuations in vital signs, nausea, vomiting, ventricular ectopy, arrhythmias, and bronchospasm.
3. Excitement or stimulation may occur and may be manifested as agitation, involuntary movements, hyperactivity or combativeness.
Whats the adult dosage of Midazolam?
Also known as Versed:
Sedation for Cardioversion or Pacing:
2-4 mg IVP over 1-2 min.
Repeat 2 mg IV in 2 min PRN.
Additional doses MD order
Pre and /or Post RSI Sedation:
0.1mg/kg IV/IO to a max dose of 6 mg.
Combative Patient:
2mg IV/IM. Second line if droperidol & diphenhydramine are ineffective.
Additional Doses: MD Order
What is the pediatric dose for Midazolam?
Also known as Versed:
Pre and/or Post RSI Sedation:
0.1mg/kg up to 2mg IV/IO
What are the Key Points of Midazolam?
Also known as Versed:
1. Dosage should be reduced in elderly or debilitated patients.
2. Most likely to produce respiratory depression in elderly or young patients and in patients who have taken other depressant drugs, especially alcohol and barbiturates.
Side Effects of Morphine Sulfate?
1. May cause vomiting; administer slowly
2. Respiratory depression
3. Vasodilation/hypotension
4. Pupil constriction
Whats the Adult dosage of Morphine Sulfate?
Acute pain management:
0.1 mg/kg IV/IM/IO Starting dose typically 5 mg may repeat every 5-10 minutes up to 20 mg
What are the Key Points of Morphine Sulfate?
1. Side effects are more pronounced in elderly pt.
2. Gives slowly and have BVM and naloxone available.
3. Preferentially, use fentanyl for pt. with abdominal pain
Whats the Action of Nitroglycerin?
1. Dilation of coronary arteries.
2. Reduced venous tone and decreased peripheral resistance.
3. Generalized smooth muscle relaxation.
Indications for Nitroglycerin?
1. Angina.
2. Chest, arm, or neck pain thought possibly to be related to coronary ischemia.
3. Pulmonary edema.
4. Food impaction located in the esophagus
Precautions for Nitroglycerin?
1. Generalized vasodilation may cause reflex tachycardia.
2. Erectile dysfunction drugs within 24 hours MD Order
3. Use with caution with inferior MI, may cause severe hypotension.
Side Effects for Nitroglycerin?
1. Headache, flushing, dizziness, and burning under the tongue.
2. Hypotension, particularly orthostatic.
Adult dose for Nitroglycerin?
Angina Pectoris, MI, Pulmonary Edema: Tablet or Spray
0.4 mg sublingual spray or tablet may repeat every 5 min. x2 (total of 3). AEMT, EMT-I, Paramedic
>3 doses: MD order.
Consider use of nitropaste 2 inches to chest wall (approximately 2 g/2 packets, use paper applicator) Paramedic ONLY
Nitro drip start at 5mcg/min and titrate to effect or does per transfer orders. Decrease rate if hypotension develops.
Esophageal Food Impaction:
0.4 mg SL spray or tablet by MD order.
Indications for Cordarone?
Also known as Amiodarone:
1. For treatment of shock-refractory VF & pulseless VT.
2. For treatment of wide complex tachycardia with a pulse, including ventricular tachycardia and pre-excited atrial fibrillation (AF + WPW)
Contraindications for Cordarone?
Also known as Amiodarone:
1. Cardiogenic shock.
2. Marked sinus bradycardia.
3. Second or third degree AV block in the absence of a functioning pacemaker.
Precautions for Cordarone?
Also known as Amiodarone:
May cause vasodilation, hypotension, and/or prolonged QT interval. Use with caution if renal failure is present.
Whats the dosage of Cordarone?
Also known as Amiodarone:
Pulseless VF & VT:
300 mg IVP. repeat 150 mg in 3-5 min.
Post conversion: 150 mg over 10 min (150 mg in 100 ml @ 15mg/min).
Wide complex tachycardia with a pulse, including VT:
150 mg over 10 minutes repeat as needed if VT recurs
Key Points of Cordarone?
Also known as Amiodarone:
Incompatible with sodium bicarb and heparin. Do not administer in the same IV tubing without flushing between meds.
Whats the Action of Epinephrine?
1. Increased heart rate, myocardial contractile force, systemic vascular resistance, atrial blood pressure.
2. Potent bronchodilator.
Indications for Epinephrine?
1. Cardiac arrest.
2. Systemic allergic reaction/anaphylaxis.
3. Asthma and other forms of reactive airway disease.
4. Treatment of bradycardia with a pulse in pediatric resuscitation.
5. Croup.
Precautions for Epinephrine?
1. Must be used very cautiously in patients with hypertension, hyperthyroidism, ischemic heart disease or cerebrovascular insufficiency.
2. Should not me added directly to bicarbonate infusion.
Side Effects for Epinephrine?
1. Anxiety, tremor, palpitations, tachycardia, headache and hypertension.
2. At IM injection site, a temporary area of blanching may occur.
3. With nebulized administration, perioral pallor or blanching may be noted and requires no treatment.
Whats the dosage of Epinephrine?
Cardiac arrest: 1 mg (1:10,000) Q 3-5 minutes.
Asthma/Reactive airway disease:
0.3 mg (1:1,000) IM by standing order if < age 40 and no cardiac disease. Otherwise MD order.
Pediatric Croup by MD Order:
Nebulize 0.5ml/kg of 1,100 to maximum 5ml (5mg).
Indicated for child <6 Observe for rebound effect.
Key Points of Epinephrine?
Epinephrine increases cardiac work and can precipitate angina and?or MI in susceptible individual with ischemic heart disease.
Indications for Xylocaine?
Also known as Lidocaine:
1. Premedication during RSI for patients at risk of ICP.
2. Anesthetic for EZIO infusion.
Side Effects for Xylocaine?
Also known as Lidocaine:
Lidocaine toxicity symptoms include: drowsiness, disorientation, decreased hearing, paresthesia, muscle twitching, and agitation.
Whats the Adult dosage of Xylocaine?
Also known as Lidocaine:
RSI for suspected ICP: 1.5 mg/kg IVP.
EZIO Infusion: 20-40 mg slowly prior to saline flush.
Whats the Pediatric dosage of Xylocaine?
Also known as Lidocaine:
RSI for suspected ICP: 1.5 mg/kg IVP.
EZIO Infusion: 0.5 mg/kg slowly prior to saline flush.
Key Points of Xylocaine?
Also known as Lidocaine:
1. For RSI lidocaine should be given approx 3 minutes before induction.
2. Can cause focal or grand mal seizures, increased heart block, decreased myocardial contractibility, and rarely cardiovascular collapse.
Whats the Action of Magnesium Sulfate 10%
1. Affects impulse formation and conduction time in myocardium and thereby reduces incidence of dysrhythmias associated with hypomagnesemia or prolonged QT interval.
2. Decreases acetylcholine in motor end terminals which produces anticonvulsant properties.
Indications for Magnesium Sulfate 10%?
1. V-fib/pulseless VT
2. First line antiarrhythmic for torsades de pointes pattern.
3. Treatment & prevention of seizures due to pregnancy (eclampsia).
Precautions for Magnesium Sulfate 10%?
1. Since magnesium sulfate affects neuromuscular transmission in body it must be given carefully and monitored closely in the patients with a pulse.
2. Early warning that magnesium toxicity is developing is decrease in reflexes measured at petella, antecubital area or heel.
Side Effects for Magnesium Sulfate 10%?
1. In non-arrest patient, magnesium toxicity may cause hypotension, bradycardia and/or respiratory arrest.
2. Increase sweating, flushing and sensation of body warmth.
Whats the dosage of Magnesium Sulfate 10%
Pulseless Arrest V-fib/V-Tach: 1-2g IVP over 1 min.
Preeclampsia or Eclampsia: MD Order. 2-4g Slow IVP over 1 minute per gram.
Maintenance Drip: MD order only: 0.5-4g per hour
Key Points of Magnesium Sulfate 10%?
1. Pre-hospital use for preeclampsia or eclampsia is usually on interhospital transfers.
2. Pt. status must be monitored closely. Decreased reflexes, hypotension or respiratory rate <12/min are reasons to stop drug.
3. Antidote for Magnesium toxicity is Calcium Gluconate or Calcium Chloride.
4. Pt. who are at risk to develop torsades include:
a. Toxic level of certain antidysrhythmics including procainamide (Pronestyl) and quiniding.
b. Electrolyte disorders including hypokalemia, hypo magnesium, hypocalcemia.
c. Hypothyroidism
d. Coronary artery disease including AMI, left ventricular failure.
e. Pacemaker malfunction, tricyclic antidepressants, and some phenothiazines.
Whats the Action of Sodium Bicarbonate?
1. Acid buffer
2. Decreases circulating potassium level in the blood
Indications for Sodium Bicarbonate?
1. Cardiac arrest or dysrhythmias due to hyperkalemia
a) Dialysis patient
b) Suspected metabolic acidosis (i.e. DKA, sepsis)
c) Suspected acute renal failure
d) Prolonged cardio-respiratory arrest
2. Tricyclic antidepressant overdose (e.g. tachycardia/QRS widening).
3. Suspected acidosis associated with crush injury - prolonged entrapment of torso, pelvis, or lower extremities >1 hour.
Precautions for Sodium Bicarbonate?
Should not be given in mixture with epinephrine, norepinephrine, dopamine, or calcium.
Whats the Adult dosage of Sodium Bicarbonate?
1 mEq/kg or 50 mEq IVP.
VF/pulseless VT give after 1 shock & first vasopressor. Asystole/PEA give after first dose of vasopressor
Crush Injury:
50mEq IVP
Administer immediately prior to release of entrapped body part.
Give an additional 50mEq for each hour of entrapment to a maximum of 150mEq (adult).
Whats the Action of Albuterol 0.083%?
Sympathomimetic drug, Beta 2-selective. Dilates bronchioles, increases heart rate.
Indications for Albuterol 0.083%?
1. Respiratory distress with bronchospasms/wheezes.
2. Treatment for suspected hyperkalemia.
Precautions for Albuterol 0.083%?
1. HR over 160 or suspected myocardial ischemia (i.e. chest pain) consult MD prior to use.
2. Use cautiously in pt. with cardiovascular disease, dysrhythmias, CHF, convulsive disorders, diabetes, hyperthyroidism and patients who are unusually sensitive to drugs that stimulate the sympathetic nervous system.
Side Effects for Albuterol 0.083%?
1. Tachycardia, nervousness, tremors, dizziness, palpitations, nausea, vomiting, headache, nasal congestion, hypertension, bad taste & increased bronchial secretions.
2. Paroxysmal bronchialconstriction can occur in pt. with repeated excessive administration.
Whats the dosage of Albuterol 0.083%
Bronchial spasms and hyperkalemia:
Adult and pediatric:
Nebulized premeasured 2.5mg vial, may repeat as needed.
Key Points of Albuterol 0.083%?
1. Administer simultaneously with Atrovent.
2. Should be kept out of direct sunlight.
3. Albuterol by nebulizer is an adjunct drug in allergic reaction; is not a substitute for epinephrine in severe anaphylaxis.
Whats the Action of Ipratropium Bromide?
Also Known as Atrovent:
Anticholinergic and bronchodilator.
Indications for Ipratropium Bromide?
Also Known as Atrovent:
Maintenance treatment of bronchospasm associated with asthma and COPD.
Contraindications for Ipratropium Bromide?
Also Known as Atrovent:
Known allergy to Atrovent or atropine.
Precautions for Ipratropium Bromide?
Also Known as Atrovent:
1. in Pt. with heart rate >160, MD Order.
2. Use with caution in patients with suspected MI.
Side Effects for Ipratropium Bromide?
Also Known as Atrovent:
May cause palpitations, dry mouth, blurred vision, anxiety, dizziness, and/or headache in some pt.
Whats the dosage of Ipratropium Bromide?
Also Known as Atrovent:
Adults & children >5: 0.5mg combined with albuterol.
Children <5: 0.25 mg combined with albuterol.
Key Points of Ipratropium Bromide?
Also Known as Atrovent:
1. Administer simultaneously with albuterol.
2. Protect from light.
Whats the Action of Methylprednisolone?
Also known as Solu-Medrol:
Steroid used as an anti-inflammatory drug.
Indications for Methylprednisolone?
Also known as Solu-Medrol:
1. Severe restaurant distress due to suspected asthma /COPD.
2. Allergic reaction/anaphylaxis.
Precautions for Methylprednisolone?
Also known as Solu-Medrol:
1. Do not delay other interventions that will have more immediate effect.
2. Do not use in mild cases that responded to nebulizer treatments.
Whats the dosage of Methylprednisolone
Also known as Solu-Medrol:
Respiratory Distress Adult: 125 mg IVP/IM administered over at least one minute
Respiratory Distress Pediatric: MD order only.
1 mg/kg IV/IM over 1 minute Max dose is 125 mg.
Indications for Atropine Sulfate?
1. Symptomatic bradycardia.
2. Organophosphate poisoning.
3. Pre-treatment for RSI (<10 y.o.).
Precautions for Atropine Sulfate?
1. Use cautiously in atrial fibrillation and flutter because increased conduction may speed ventricular rate excessively.
2. Initiate pacing if any delay in administering atropine
3. Bradycardia in the setting of an acute MI is common and probably beneficial. Do not treat unless there are signs of poor perfusion (low blood pressure, mental confusion). Chest pain could be due to an MI or to poor perfusion caused by the bradycardia itself.
Whats the Adult dosage of Atropine Sulfate?
Symptomatic Bradycardia:
0.5mg Q 3-5 min to max 3 mg. (ET use 2x dose)
Organophosphate poisoning:
1mg IVP Q 2-3 min until drying of secretions.
Whats the Pediatric dosage of Atropine Sulfate?
Symptomatic Bradycardia:
0.02mg/kg IVP, not to exceed 0.5mg per dose, prn 3-5 min to max 1mg. child & 2mg adolescent. (ET use 2x dose)
Organophosphate poisoning:
0.02mg/kg IVP, not to exceed 0.5mg per dose, prn 2-3 min.
RSI Pretreatment:
0.02mg/kg (minimum 0.1mg) IV/IO given 3 min. before RSI
Whats the Action of Amidate?
Also Known as Etomidate:
1. Sedative hypnotic.
2. Onset 20-30 seconds, duration 7-10 min.
Side Effects for Amidate?
Also Known as Etomidate:
1. Can cause myoclonus (muscle jerking/twitching)
2. Can cause pain at injection site.
3. Can cause nausea/vomiting/hicups.
Whats the dosage of Amidate?
Also Known as Etomidate:
Adult RSI Induction: 0.3 mg/kg IV/IO (usual dose 20mg).
Pediatric RSI Induction: 0.3 mg/kg IV/IO
Whats the Action of Anectine, Quelicin?
Also known as Succinylcholine:
Short acting depolarizing paralytic.
Indications for Anectine, Quelicin?
Also known as Succinylcholine:
Temporary paralysis for endotracheal intubation.
Contraindications for Anectine, Quelicin?
Also known as Succinylcholine:
1. Known allergy to succinylcholine.
2. Suspected hyperkalemia:
Dialysis/renal failure patients.
Patients with a QRS width >0.12.
Crush injury.
3. Muscular dystrophy.
4. Suspected rhabdomyolysis.
5. Known personal or family history of malignant hyperthermia or pseudocholinesterase deficiency.
Precautions for Anectine, Quelicin?
Also known as Succinylcholine:
1. May cause bradycardia especially with repeat doses and in patience <5 years. This will usually respond to oxygenation and atropine.
2. Burn >72 hours.
Side Effects for Anectine, Quelicin?
Also known as Succinylcholine:
1. Tachycardia, hypotension, hypertension & cardiac arrest.
2. Transient hyperkalemia.
3. Increased ICP, pre-medication with lidocaine or fentanyl will blunt this effect.
Whats the Adult dosage of Anectine, Quelicin?
Also known as Succinylcholine:
RSI: 2mg/kg IVP/IO, Max Dose 200mg.
Post Intubation Paralysis: Initial dose may be repeated once.
Pediatric dosage of Anectine, Quelicin?
Also known as Succinylcholine:
RSI: 2mg/kg IVP/IO. Console MD prior to use on if possible.
Post Intubation Paralysis: Initial dose may be repeated once.
Key Points of Anectine, Quelicin?
Also known as Succinylcholine:
1. Pre-oxygenation prior to use is essential.
2. Perform cricoid pressure once paralytic is administered & until pt. is intubated & cuff inflated
3. Has no effect on consciousness or pain.
Indications for Zemuron?
Also known as Rocuronium:
1. Maintenance of paralysis of intubated patient
2. First line paralytic drug to be administered in dialysis pt., pt. with a wide QRS(>0.12 seconds), or any other times acetylcholine is contraindicated.
3. Shivering associated with induced hypothermia.
Whats the dosage of Zemuron?
Also known as Rocuronium:
Paralytic for dialysis pt. and/or pt. with wide QRS:
0.6-1mg/kg IV/IO
Maintenance dose: 0.1-0.2mg/kg IV/IO bolus as paralysis wears off, if sedation with midazolam and fentanyl is not adequate.