Amiodarone and Calcium Chloride

Amiodarone

• Has multiple effects on sodium, potassium, and calcium channels
• Prolongs action potential and repolarization
• Decreases AV conduction and sinus node function
• Has alpha- and beta-adrenergic blocking properties
• Indicated for ventricular fibrillation, pulseless ventricular tachycardia, regular wide complex tachycardia with a pulse, and irregular wide complex tachycardia
• Is absolutely contraindicated in second or third degree AV blocks or amiodarone allergy
• Can cause hypotension and bradycardia

Calcium Chloride

• Increases extracellular and intracellular calcium levels
• Stimulates the release of catecholamines
• Increases cardiac contractile state
• Essential to transmission of nerve impulses, contraction of cardiac, smooth, and skeletal muscles
• Has stabilizing effects on myocardial cell membranes in hyperkalemia
• Indicated in suspected hyperkalemia and calcium channel blocker overdose
• Should not be used in suspected digoxin toxicity, hypercalcemia, calcium chloride allergy, or suspected severe hypokalemia
• May cause discomfort at the injection site or can precipitate if mixed with sodium bicarbonate

Diltiazem

• A calcium channel blocker
• Exerts inhibitory effects on the cardiac conduction system, principally at the AV node, slowing the ventricular rate associated with Atrial Fibrillation and Flutter
• Inhibits extracellular calcium ion influx, resulting in inhibition of contraction and dilation of arteries
• Indicated for narrow complex tachyarrhythmias and SVT not responsive to adenosine
• Absolutely contraindicated in heart block/bradycardia, systolic blood pressure < 90 mmHg, sick sinus syndrome, ventricular tachycardia, or diltiazem allergy
• AV node conduction prolongation may result in second- or third-degree AV block; should not be administered to compromised myocardium; use caution with hypotensive patients

Dopamine

• An endogenous catecholamine that acts on both dopaminergic and adrenergic neurons
• Dose dependent effects:
  • 1-2 mcg/kg/min dilates renal and mesenteric blood vessels, little effect on heart rate/blood pressure
  • 2-10 mcg/kg/min increases cardiac output without great heart rate/blood pressure increase
  • 10-20 mcg/kg/min causes peripheral vasoconstriction, increases SVR and blood pressure
  • 20-40 mcg/kg/min reverses dilatation of renal and mesenteric vessels and increases heart rate/oxygen demand to undesirable limits
• Indicated for refractive cardiogenic or distributive shock
• Absolutely contraindicated in hypovolemia and dopamine allergy
• May induce tachyarrhythmias; high doses can cause peripheral vasoconstriction
• Should not be added to sodium bicarbonate or other alkaline solutions
• Treat hypovolemia with fluids before administering dopamine
• Best administered via infusion pump to regulate rate; monitor closely

Epinephrine

• A catecholamine with alpha and beta effects that increases heart rate and blood pressure
• A potent bronchodilator
• Indicated in cardiac arrest, bradycardia, anaphylaxis and shock
• Used via IM for severe refractory wheezing and nebulized for croup and bronchiolitis
• Uncontrolled hypertension and epinephrine allergy is an absolute contraindication
• Can increase cardiac work and precipitate angina, myocardial infarction, or major dysrhythmias in an individual with ischemic heart disease

Fentanyl

• An opioid agonist-analgesic
• Inhibits ascending pain pathways and increases pain threshold
• Produces analgesia, respiratory depression, and sedation
• Indicated for severe pain of any etiology
• Oxygen saturation less than 90% or significant respiratory depression, and fentanyl allergy is absolutely contraindicated
• Can cause neurologic and respiratory depression; respiratory support must be available when administering
• Can be reversed with naloxone
• Aim is reduction of pain, not total elimination

Glucagon

• Increases serum glucose by releasing glycogen stores from the liver
• Will only work if there are sufficient liver glycogen stores
• Counteracts effects of beta blocker or calcium channel blocker overdose
• Indicated for hypoglycemia and symptomatic bradycardia from beta blocker or calcium channel blocker overdose
• Is not the first line treatment for hypoglycemia and should ONLY be used if unable to obtain IV access; with Glucagon allergy absolutely contraindicated
• May cause nausea and vomiting

Lidocaine

• Antiarrhythmic drug that decreases automaticity by slowing the rate of depolarization
• Terminates re-entry by decreasing conduction in re-entrant pathways
• Local anesthetic for pain control caused by infusion of fluids/medications via an intraosseous site
• Indicated in cardiac arrest due to ventricular fibrillation of pulseless ventricular tachycardia or wide complex tachycardia with a pulse; and pain management after IO insertion in conscious patients
• Bradycardia or lidocaine allergy is an absolute contraindication
• Higher doses may cause CNS stimulation, seizure, depression, and respiratory failure; toxicity is more likely in the elderly and patients with CHF or impaired liver function

Magnesium Sulfate

• A smooth muscle relaxant
• Decreases early after depolarizations and reduces arrhythmias
• Decreases seizures in eclampsia and preeclampsia, possibly via cerebral vasodilation
• CNS depressant
• Indicated in eclampsia, preeclampsia, Torsades de pointes, and severe bronchospasm in patients with asthma or COPD
• Absolute contraindication is magnesium allergy
• May cause hypotension and respiratory depression in large doses; use caution in patients with renal insufficiency or chronic renal failure/dialysis

Midazolam

• A benzodiazepine that functions as a CNS depressant, anticonvulsant, and sedative
• Indicated for seizures, sedation, agitation/delirium with agitated behavior, and uncontrolled shivering in hyperthermia
• Respiratory and/or CNS depression or midazolam allergy is an absolute contraindication
• More potential than other IV benzodiazepines to cause respiratory depression
• Closely monitor for respiratory depression and/or hypotension occur
• Elderly patients may have more profound respiratory and/or CNS depression (half dose should be administered)

N-acetylcysteine

• Used for treatment of acetaminophen overdose
• Maintains or replenishes glutathione reserves in the liver
• Enhances non-toxic metabolism of acetaminophen
• A mucolytic for individuals experiencing thick mucus issues associated with chronic bronchopulmonary disorders
• Indicated for acetaminophen overdose or toxicity and respiratory conditions with thick mucus or excessive mucus production
• Hypersensitivity to the drug is an absolute contraindication
• Asthma, bronchospasm history or upper Gl bleeding should be administered with caution
• Side effects: hypersensitivity reaction, bronchospasm anaphylaxis, nausea, vomiting, and tachycardia

Nitroglycerin

• A potent smooth muscle relaxant
• Causes systemic venodilation, decreasing preload and arterial vasodilation, decreasing afterload
• Coronary artery vasodilation increases blood flow to the myocardium
• Decreases myocardial oxygen demand
• Indicated for chest pain, particularly when Acute Coronary Syndrome is suspected, hypertensive emergency, and congestive heart failure with pulmonary edema
• Hypotension, recent use of erectile dysfunction medications, nitroglycerin should not be given to children, and nitroglycerin allergy are absolute contraindications
• Generalized vasodilatation may cause profound hypotension and reflex tachycardia; use with caution in patients taking medication for erectile dysfunction
• Side effects include throbbing headache, flushing, dizziness and burning under the tongue

Norepinephrine

• Catecholamine that stimulates beta-1 and alpha-1 receptors in the sympathetic nervous system
• Results in vasoconstriction, increased blood pressure, enhanced contractility, and increased heart rate
• Indicated for hypotension unresponsive to IV fluid resuscitation
• Hypotension caused by hypovolemia and norepinephrine allergy are absolute contraindications
• Adequate fluid replacement before starting norepinephrine must be ensured
• Administer through largest vein possible to reduce risk of tissue necrosis if it extravasates; monitor blood pressure closely; must be administered via infusion pump

Octreotide

• Suppresses secretion of serotonin and gastrointestinal peptides
• Increases absorption of fluid and electrolytes from the gastrointestinal tract; increases transit time
• Increases cardiac contractile state
• Helps control symptoms of Gl bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis
• Indicated for treatment of severe diarrhea in patients with Gl endocrine tumors; management of diarrhea in AIDS patients or patients with fistulas; refractory hypoglycemia for sulfonylurea overdose; and variceal upper GI bleeding
• Hypersensitivity is an absolute contraindication
• Side effects: dizziness, weakness, orthostatic hypotension, nausea/vomiting, hyperglycemia, hypoglycemia

Antibiotics

• Bactericidal or bacteriostatic agents targeting bacterial infections
• Indicated for severe bacterial infections such as sepsis, pneumonia, or wound infections
• Known allergy to the antibiotic being used is an absolute contraindication
• Side effects include hypersensitivity reactions, Gl upset, and potential nephrotoxicity
• Onset: Variable; Peak: 30-90 min; Duration: Depends on agent

Blood Products

• Restore blood volume, oxygen-carrying capacity, and clotting factors
• Indicated in Hemorrhage, anemia, coagulopathy
• Severe allergic reactions and religious restrictions are absolute contraindications
• Side effects include transfusion reactions, volume overload and infection risk
• Onset: Immediate; Peak: Immediate; Duration: Varies (dependent on clearance)

Colloids

• Expand plasma volume by increasing oncotic pressure
• Indicated for hypovolemia, shock and burn resuscitation
• Absolute contraindications include severe cardiac failure, renal impairment and coagulopathy
• Side effects include fluid overload, anaphylaxis, and coagulopathy risk
• Onset: Rapid; Peak: Immediate; Duration: Varies (hours)

Corticosteroids

• Suppress inflammation and immune response
• Indicated in anaphylaxis, asthma, spinal cord injury, and septic shock
• Active uncontrolled infection and systemic fungal infections is an absolute contraindication
• Side effects include hyperglycemia, immunosuppression, and adrenal suppression
• Onset: 1-2 hours; Peak: 4-6 hours

Diuretics

• Increase urine output by inhibiting sodium and water reabsorption
• Indicated in pulmonary edema, heart failure, and renal failure
• Severe dehydration, anuria and hypokalemia are absolute contraindications
• Side effects include electrolyte imbalance, dehydration, and ototoxicity (loop diuretics)
• Onset: 5-60 min (IV); Peak: 1-2 hours; Duration: 4-6 hours

Fosphenytoin/Phenytoin IV

• Stabilizes neuronal membranes, decreases seizure activity through sodium ions channels across cell membranes
• Indicated in Status epilepticus
• Hypersensitivity/Allergy to hydantoin products or Sinus bradycardia, sinoatrial block, second- and third-degree AV block, or Adams-Stokes syndrome are absolute contraindications
• Cardiovascular: Severe hypotension and cardiac arrhythmias can occur, especially with rapid IV administration; Requires cardiac function monitoring
• Central Nervous System: Nystagmus, dizziness, somnolence, ataxia, and stupor
• Dermatologic: Local dermatologic reactions
• Other: Purple glove syndrome and hyperphosphatemia may occur

Glycoprotein IIb/IIIa Inhibitors

• Antiplatelet agents that prevent platelet aggregation and thrombus formation by inhibiting the GpIIb/Illa receptor on the surface of platelets
• Used during percutaneous coronary interventions (PCI) such as angioplasty with or without stent placement and for treatment of acute coronary syndromes (ACS)
• Absolute contraindications include major bleeding diathesis, active internal bleeding or history of hemorrhagic stroke within the previous 30 days
• Side effects include increased risk of bleeding, including gastrointestinal hemorrhage, severe drop in platelet count, and rare cases of anaphylaxis
• Rapid onset of action after IV administration
• Effects on platelet function can persist for up to 48 hours after discontinuation

H2 Blockers

• Competitively inhibit histamine at H2 receptors in gastric parietal cells, reducing acid secretion
• Indicated for GERD (Gastroesophageal Reflux Disease), PUD (Peptic Ulcer Disease), Stress ulcer prophylaxis, Zollinger-Ellison syndrome, and Aspiration pneumonitis prophylaxis
• Hypersensitivity to H2 receptor antagonists, acute porphyria, and severe renal dysfunction, are absolute contraindications
• CNS effects: Confusion and dizziness may occur as side effects
• Cardiovascular: Bradycardia with rapid IV administration, Hematologic: Thrombocytopenia can occur
• Gl: Gastrointestinal upset can occur
• Onset: 30-60 minutes, Peak Effect: 1-3 hours, Duration: 6-12 hours

Insulin IV

• Facilitates cellular glucose uptake, regulates carbohydrate metabolism, promotes glucose storage as glycogen, and inhibits hepatic glucose production to reduce blood glucose levels
• Used in patients with diabetes mellitus to manage hyperglycemia, to treat diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), and with glucose to manage hyperkalemia
• Absolute contraindications includes hypersensitivity to insulin or its excipients and episodes of hypoglycemia
• Hypoglycemia is the most common adverse effect
• IV insulin has a rapid onset of action, effectively lowering blood glucose levels within minutes
• The glucose-lowering effect is immediate with IV administration and typically lasts only for minutes

Pantoprazole IV

• A proton pump inhibitor (PPI) that suppresses gastric acid secretion, reducing gastric acidity
• Indicated for short-term treatment of gastroesophageal reflux disease (GERD) with erosive esophagitis in adults and for treatment of pathological hypersecretory conditions
• Known hypersensitivity to pantoprazole, substituted benzimidazoles, or any component of the formulation is an absolute contraindication
• Common side effects: Headache and Gl symptoms
• Serious Side Effects can include kidney problems and low magnesium levels; may worsen Lupus symptoms
• Onset: approximately 15 minutes, peak effect: 2 - 3 hours after administration, and duration is approximately 24 hours

Potassium Salts

• An electrolyte replenisher used to treat and prevent hypokalemia by restoring potassium balance
• Used in patients with hypokalemia, gastrointestinal losses, or digitalis toxicity
• Absolute contraindications include hyperkalemia, renal failure or severe renal impairment, or conditions associated with potassium retention
• Rapid or excessive administration can lead to hyperkalemia
• Onset: Rapid, Peak Effect: Dependent on rate of administration and individual patient factors, Duration: Varies

Propofol

• An intravenous anesthetic agent acting like a GABA_A receptor agonist, enhancing inhibitory neurotransmission in the central nervous system
• Provides sedation, hypnosis, and anesthesia, with a rapid onset and short duration of action
• Used for anesthetic induction and maintenance, sedation for mechanically ventilated patients, and procedural sedation
• Known hypersensitivity to propofol, egg lecithin, or soybean oil is an absolute contraindication
• Hypotension and respiratory depression may occur as side effects
• Onset: 15 - 30 seconds, Peak effect: Within 1 minute, Duration: Approximately 5-10 minutes

Total Parenteral Nutrition (TPN)

• Intravenous administration of nutrients to maintain anabolism and prevent catabolism in patients unable to receive nutrition orally or enterally
• Indicated for Non-functional gastrointestinal tract, conditions requiring bowel rest, or severe malnutrition
• Functional and accessible gastrointestinal tract, hemodynamic instability or severe metabolic imbalances, and severe liver disease or intractable coagulopathy are absolute contraindications
• Side effects include infections and metabolic irregularities
• Onset: Immediately and adjustments are based on monitoring