Formulary Information - PDF

\ \ ~~ffle::J Acetaminophen (Tylenol®, APAP) \ (a SEET a MIN oh fen) \ Used to treat many conditions such as headache, muscle aches, arthritis, \ menstrual cramps, and fevers. \ Analgesic;...

\ \ ~~ffle::J Acetaminophen (Tylenol®, APAP) \ (a SEET a MIN oh fen) \ Used to treat many conditions such as headache, muscle aches, arthritis, \ menstrual cramps, and fevers. \ Analgesic; Anti-inflammatory; Anti-pyretic \ \ 1. Acts by reducing production of prostaglandins, which are involved in the pain and fever \ processes, by inhib ting the cyclooxygenase (COX)enzyme. ) 2. Relieves mild to moderate pain by elevating your body's overall pain threshold. 3. Lowers fever by helping your body eliminate excess heat. ) 4. Onset of action is within 10 minutes. ) 5. Duration of action is 4 to 6 hours. ) ) Use: 1. Mild to moderate pain reliever. ) 2. Fever reducer. ) Eiil:effi'ffents! CNS: Dizziness; Lethargy; Hives; Edema to face, lips, tongue, or throat ) Respiratory: Dyspnea Gastrointestinal: Nausea; Vomiting; Heartburn; Stomach pain; Dark urine; Clay colored stools ' ) Other: Jaundice (yellowing of the skin or eyes), Liver toxicity/failure ) ,:--ein:t'rea'iii'l:liG'atiitl'ifst Absolute: Known allergy to acetaminophen ' '\ Relative: Hepatic disease; Kidney disease (severe); Chronic alcoholism Note: Use with caution in patients who report allergies to NSAIDS. ) Drug Interactions: Ethanol (alcohol) may increase risk of liver damage while taking acetaminophen. ' ) Special Notes: 1. Maximum Dose is 1 g (1000 mg) and 3 g (3000 mg) per day. ) 2. Acetamjnophen is used in combination with other drugs in several over-the-counter ) medications and can be a possible cause for accidental overdose. ) ) VA"11u'llmlose1' 325 to 650 mg every 4 to 6 hours. Not to exceed 3250 mg/day. ) llmfi....~ Refer to Length Based Tape for appropriate dose. ) PO, Suppository ' ) ~ Pregnancy Safety: Category B / No possible adverse effect on fetus in laboratory testing. I ~ ' ) ) ' ' ) ) 3 ' ) Name: Activated Charcoal (Actidose®; Aquadose, lnsta-Char) (AK ti vay ted CHAR coal) Used in the emergency treatment of certain kinds of ingested poisoning. Class: Adsorbent; Antidote Action: 1. Binds with many drugs and chemicals inhibiting the absorption rate in the gastrointestinal tract. 2. Onset of action is immediate. 3. Duration of action continual while in the GI tract. Use: 1. Overdose and poisoning. 2. Most oral poisonings and medication overdoses. Side effects: Abdominal cramps; Black stools; Constipation; Nausea; Vomiting; Diarrhea Contraindications: Absolute: Altered mentation (comatose); Inability to maintain own airway (unless given by nasogastric/orogastric tube); Patient with aspiration or impending aspiration; Avoid use in Cyanide, Methanol, Organophosphate toxicity, and/or Caustic ingestion; GI obstruction Relative: Known minimal toxic ingestion Drug Interactions: 1. Do not use before Ipecac if vomiting is to be induced. Ipecac is absorbed by activated charcoal. 2. Bonds with and generally inactivates whatever it is mixed. Special Notes: 1. Often used in conjunction with magnesium citrate. 2. Must be stored in a closed container. 3. Not effective with cyanide, strong acids and alkalis, metals (iron, lead), arsenic, and hydrocarbons. 4. Milk products decrease activated charcoal's effectiveness. 5. Charcoal is often mixed with sorbitol to promote elimination from the gastrointestinal tract and to prevent constipation. 6. If aspirated, activated charcoal can possibly cause fatal pneumonia. 7. Consider contacting poison control and medical control for more information. Adult Dose: 1 g/kg (typically 50 to 100 g) mixed with a glass of water to form a slurry and administered PO or slowly by gastric tube. Pediatric Dose: 1 g/kg mixed with a glass of water to form slurry. Route: PO; Gastric tube Pregnancy Safety: Category C 4 ,,-:r:Name'f h Adenosine(Adenocard®, Adenoscan, C10H13N5O4) I I (ah DEN oh seen) I L - Used for treating supraventricular tachycardia, a rhythm disturbanc;e~o=iif7tfihFethiFe~a~rtt.-___:_:_---'----------- __ Endogenous nucleotide; Antiarrhythmic 1. Naturally occurring nucleoside that slows/interrupts the reentry pathways through. the AV node, thereby slowing conduction. 2. Has a direct effect on supraventricular tissue. 3. Blocks potassium and calcium channels in the conduction system, inhibiting the elimination of potassium and influx of calcium. Causing hyperpolarization and slowing down the heart rate. 4. Onset of action is immediate (half-life of 10 seconds or less). Use: Supraventricular tachycardia (SVT; PSVT)that is refractory to vagal maneuvers (Referred to as chemical cardioversion). :Sid·treffed:s:i CNS:APpfehensiom; :BlutredVision;-:Ditziness; Fadalflushing; Heaaach~; Nffmoness; ngct1 Tingling tn arms; SV11eati 1 Respiratory: DYSPrl~c!;Tightnessinthroat;flyperventilating,Brortthospasm' Cardiovascular: He.a1"tQl9¢ks;TransieritdYsrhy:thnifas;Bllrrringsehsati6ri;Chestpain; Hypgtemsionj Palpitations) Gastrointestinal: Nausea; Metallict:a~te Other:rE!c1ckpc1iri; Heavinesstnarrns andn.eck;_f>ressorein g:roiri t'contrain"dications: Absolute: Known hypersensitivity; Second- or third-degree heart block; Sick sinus syndrome; Poison induced tachycardia Relative: None Note: Use caution in patients with asthma and bronchospasm. Drug Interactions: 1. Methylxanthines (theophylline-type drugs) and caffeine prevent binding of adenosine at receptor sites. Larger doses may be needed. 2. Dipyridamole (Persantine) potentiates effects of adenosine. Smaller doses may be effective. 3. Carbamazepine (Tegretol) may result in the development of high-degree blocks. SpecialNotes: 1. Monitor heart rate and cardiac rhythm closely. 2. Warn patients of possible side effects, including dizziness and loss of consciousness. 3. May produce brief periods of asystole/heart block. 4. Transient PVCs,PACs,sinus bradycardia, or sinus tachycardia may occur after the administration of adenosine. 5. Medication must be pushed into the access port closest to the patient's heart. 6. Cardiac transplant patients may require only a small dose. 7. May produce bronchoconstriction in patients with asthma or other bronchopulmonary diseases. 5  8. Adenosine should be administered as a rapid bolus due to its rapid metabolism. Initial dose 6 mg (rapid bolus), followed by a rapid saline flush. May repeat at the 2-minute interval with 12 mg (rapid bolus) followed by a rapid saline flush, for a total dose of 18 mg. rea11a¥tte;:r56i~:;c_J0.1 mg/kg up to 6 mg (rapid bolus) followed by a rapid saline flush. May repeat in two minutes with 0.2 mg/kg (max. 12mg) followed by a rapid saline flush, for a m;3xdose of 18 mg. Follow guidelines on length-based tape (Brows/ow® Tape) Route: IVP, as rapid as possible. PregnancySafety: Category C / Not well established, crosses the placenta and may cause fetal damage. '- 6 '- ) ) Name: Albuterol (Ventolin®; Proventil®) ) (al BYOU ter ahl) ) Used to treat or prevent bronchospasm in patients with COPD(asthma, bronchitis, emphysema) and other ) lung diseases. Albuterol is also used to prevent wheezing caused by exercise (exercise-induced ) bronchospasm). ) Class: Beta-2 adrenergic agonist; Sympathomimetic (sympathetic agonist); Bronchodilator ) 1 Action: 1. Binds and stimulates beta-2 receptors, which results in relaxing bronchial smooth muscle. 2. Some beta 1 stimulation, no Alpha stimulation. 3. Activates cAMP via a non-beta receptor mechanism. For this reason, it is sometimes used in beta-blocker overdoses. 4. It also activates the Na-K pump by the same mechanism, which is useful in treating hyperkalemia. 5. Onset of action is from 5 to 15 minutes. 6. Duration of action approximately 3 to 6 hours. ) Use: 1. Treatment of bronchospasm in patients with reversible chronic obstructive airway disease ) (COPD). \ 2. Prevention of exercise induced bronchospasm. ) 3. Toxic gas inhalation. 4. Beta-blocker overdose. ) 5. Hyperkalemia ) ) Side effects: CNS: Headache; Tremor; Sweating; Anxiety; Dizziness; Insomnia; Restlessness; Dilated pupils ) (Mydriasis). \ Respiratory: Paradoxical bronchospasm. Cardiovascular: Angina (chest pain); Palpitations; Ectopic beats; Cardiac dysrhythmias; ) Hypertension; Tachycardia ) Gastrointestinal: Drying of oropharynx; Nausea; Vomiting; Unusual taste. ) Other: Hyperglycemia; Muscle cramps; Dry nose and throat. ) ) Contraindications: Absolute: Known hypersensitivity; Vomiting Relative: Cardiovascular disorders; Cardiac arrhythmias, hypokalemia ) Note: Use caution in patients who are lactating. \ 1 Drug Interactions: 1. Beta blockers antagonize (inhibit) effects of albuterol. 2. Tricyclic antidepressants may potentiate vascular effects. 3. May potentiate hypokalemia caused by diuretics. 4. Possibility of developing unpleasant side effects increases when administered with other sympathetic agonists. Has a synergistic effect with other sympathomimetics. ) 1 Special Notes: 1. Requires adequate tidal volume to distribute medication to the distal airways. ) 2. May cause severe paradoxical bronchospasm from repeated excessive use. 3. May precipitate angina pectoris and dysrhythmias. \ 4. Should be used with caution in patients with diabetes, hyperthyroidism, prostatic hypertrophy, or seizure disorder. 7  5. Should be administered only by nebulizer in the field. Adult Dose: 2.5 to 5 mg mixed with 3 ml saline into nebulizer and flow oxygen at 6 to 8 Lpm. Repeat PRN. Pediatric Dose: 0.63 to 2.5 mg into nebulizer and flow oxygen at 6 to 8 Lpm. Repeat every 20 minutes for a total of three doses. Route: Metered Dose inhaler, Nebulized inhalation Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 8  Name: Alteplase Recombinant(t-PA (tissue plasminogen activator); Activase®) (alt EH place ree KOM bi nant) Used for treating blood clots that have formed in certain blood vessels and to improve heart function and survival following an acute myocardial infarct (heart attack). Class: Thrombolytic enzyme; Anticoagulant, Fibrinolytic Action: 1. Enzyme which has the property of fibrin-enhanced conversion of plasminogen in plasm in. 2. It produces limited conversion of plasminogen in the absence of fibrin. 3. When introduced into systemic circulation, it binds to fibrin in the thrombus and converts the entrapped plasminogen to plasmin. 4. Plasmin initiates local fibrinolysis with limited systemic proteolysis, thus dissolving the thrombus at its site. 5. Onset of action is less than 90 minutes. 6. Duration of action is 4 to 6 hours. Use: 1. Evolving acute myocardial infarction (AMI) 2. Acute pulmonary embolism 3. Acute ischemic cerebrovascular accident (CVA) Side effects: Cardiovascular: Dysrhythmias; Minor bleeding to severe hemorrhage; Hypotension; Anemia Gastrointestinal: Nausea; Vomiting Other: Fever; Mild hypersensitivity may produce urticaria; Anaphylaxis (rare) Contraindications: Absolute: Active internal bleeding; History of hemorrhagic cerebrovascular accident; Recent intracranial surgery or trauma (within 2 months); lntracranial neoplasm, arteriovenous malformation, or aneurysm; Severe uncontrolled hypertension; Pregnancy; known bleeding disorders Relative: Peptic ulcer; Blood in stool; Current use of warfarin compounds; Known bleeding disorder; Liver dysfunction; Kidney failure Drug Interactions: 1. Using with other anticoagulants may increase risk of bleeding. 2. Incompatible with dextran. 3. Administer through a filter. 1 SpecialNotes: 1. Screen patients carefully for contraindications and relative contraindications before 1 administering. 2. Should ideally be used within 1½ hour after onset but can be used from 4 - 6 hours ) after onset. 1 3. Monitor vital signs and cardiac rhythms closely. 1 4. Perform baseline neurologic assessment and reassessevery 15 minutes. 1 5. Internal hemorrhage may be difficult to control. Examine regularly for signs of bleeding. If bleeding occurs, provide direct pressure to bleeding site for a minimum of five (5) minutes. 6. Avoid unnecessary vessel puncture and use a small-gauge needle. 7. Do not administer any other medications through the t-PA line. 9  8. Should be used with heparin sodium therapy. 9. Minimize patient handling. Adult Dose: Acute Ml: 100 mg IV over 3 hours. Mix 100 mg in 100 ml of sterile water for 1 mg/ml. For accelerated1.5-hour infusion:Administer 15 mg IV bolus over 2 minutes, followed by 0.75 mg/kg (max 50 mg) over next 30 minutes. Then administer 0.5 mg/kg (max 35mg) over the next hour. lschemic stroke: 0.9 mg/kg IV (max 90mg) over one hour. Give 10% of the total dose as IV bolus over 1 minute. Then administer the remaining 90% over the next hour. Pulmonary embolism: 100 mg IV over two hours. Pediatric Dose: Not routinely used in prehospital care. Route: IV Infusion Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 10  -- -,··-·:_·--~ 'N'ame:' Amiodarone Hydrochloride (Cordarone®, Pacerone®) (am ee OH da rone HIGH droe KLOR ide) Used to correct life-threatening ventricular arrhythmias in adults. Antiarrhythmic agent (Class Ill); Potassium channel blocker 1. Blocks sodium, calcium, and potassium channels, causing an increase in the duration of the myocardial cell action potential and refractory period. 2. Delays repolarization and decreases AV conduction and sinoatrial node function. 3. Produces a negative chronotropic effect in nodal tissues. 4. Relaxes vascular smooth muscle, reduces peripheral vascular resistance (after load), thus decreasing cardiac workload. 5. Reduces myocardial oxygen consumption. 6. Prolongs phase 3 of the cardiac action potential. 7. Onset within minutes with IV administration. 8. Duration of days (40 to 55 days in most patients). Use: 1. Ventricular fibrillation (V-fib) and Pulseless Ventricular tachycardia (V-tach). 2. Stable Ventricular tachycardia with a pulse refractory to other therapy. Sideeffects: Cardiovascular: Bradycardia; Hypotension; CHF; Increased ventricular beats: Prolonged P-R interval; Prolonged QRScomplex; Prolonged Q-T interval; Cardiac arrest; Ventricular tachycardia; AV heart blocks Respiratory: Signs and symptoms of pulmonary toxicity Gastrointestinal: Nausea; Vomiting; Abnormal liver function; Stevens-Johnson syndrome Other: Fever; Anorexia CcmtraUidications: Absolute: Known hypersensitivity; Marked sinus bradycardia; Iodine allergy Relative: Cardiogenic shock; Second- or Third-degree AV block; sick sinus syndrome Drug Interactions: 1. May react with Warfarin, Digoxin, Procainamide, Quinidine, Fentanyl, Lidocaine, Disopyramide, and Phenytoin. 2. Grapefruit juice may potentiate (increase) the effects of amiodarone. 3. Protease inhibitors may potentiate the effects of amiodarone. 4. Cimetidine may increase amiodarone levels. 5. Use with beta blockers and calcium channel blockers may increase occurrence of bradycardia, sinus arrest, and AV blocks. 6. Persistent use of echinacea can increase amiodarone's hepatotoxic effects. Special Notes: 1. Geriatric patients may be more sensitive. 2. Correct hypokalemia or hypomagnesaemia before administration. 3. Protect the vial from light. ', ,~~~tt:oose: Perfusing Ventricular dysrhythmias (VT with pulse and SVT): 150 mg IV over 10 minutes (15 mg/min). Mix 150mg in 100ml run at l0mL/minute. May "'\ repeat every 10 minutes PRN. \ ' 11  Maintenance drip: lmg/min infusion over first 6 hours then 0.5 mg/min over next 18 hours. Non-perfusing Ventricular dysrhythmias (VF and PulselessVT): 300 mg 10/10 push. May repeat 150mg IVP once in 3 to 5 minutes. ~:1!~,;ll;:1tr:!~j~.~~!:, 1 VT with a pulse and SVT:5 mg/kg IV/1Oover 20 minutes. May repeat dose at 5mg/kg up to 15mg/kg in 24 hours. VF and PulselessVT: 5 mg/kg IV/10 push {Max dose:300mg). May administer second dose at 5mg/kg. Max dose of 15 mg/kg per 24 hours. Route: IVP, 10, Infusion {bolus and maintenance infusion). PregnancySafety: Category D / Possible adverse effect on human fetus. tBolus~dminlstrationcin.Arrest.orUnstable-, ~~- 1ine Qjj!EJJ~~T~;ll!RJ:QRiiaie;-i:iis=e?ifii2:O:~3:Cftt'TctfthJ:frrrj1:1l, 1withYaJpt!ilse;);r.,§ tE~~-1.usGAdminist~atron'lAdU1t ~:.,~§; @2.mg:i.1J:2:tOJ)Ec~:DS1W{ 1 :···· · ·; 1 1:!~tgitt:r/lmtrs:et'i?Jl©OI.gtts/1:rril1fi=¥]1iSO;1111·g/c.l!(hrn i:n~-.rj ·IX6it'g1its)'tnt{sefl~t!fS'©}tgttS/mi.111:===2tSQ·:rmgf~@cET'li.fl-;..,o,~ep, ;,1tt1J~ [Bo:11rs,~amin,s1:ratidt1ili>~ti1nri'c: · 'A ,; ·'··,·'fi,i+'tA,t ,-,,.t:'·, ---· :'f1; '· ;;-,·"·-i1,;@·: ;:,.;;;--. ;, ··;;;;iJmg 1 1\gi>1n,,:t, t1 eC u::>·v·v 0 · ·-·.~; 60 mg/dl Drug Interactions: Interacts with Sodium bicarbonate and Coumadin. Special Notes: 1. Perform Dextrostix (BGL) prior to administration if possible. 2. Use the largest vein possible. Extravasation will cause tissue necrosis. If extravasation does occur, immediately STOPadministration. 10 administration is a last resort. 3. Use of D50 may complicate or worsen several medical conditions (e.g., AMI, CVA). 4. Thiamine should be administered before D50 to the alcoholic patient. Thiamine is necessary for carbohydrate metabolism. 5. May precipitate Wernicke's encephalopathy in patients who are malnourished. Adult Dose: 25 g of Dl0W to D50W IVP, 10. Repeat every 5 minutes PRN as blood glucose indicates. Pediatric Dose: 0.5 to lg/kg Dl0 to D25 IVP, 10. Repeat every 5 minutes PRN as blood glucose indicates. Neonates: 0.2 g/kg followed by 5 ml/kg Dl0W IV, 10 infusion. Note: D50 can be made into D25 by diluting the volume 1:1 (Mix well) D50 can be made into D10 by diluting the volume 4:1 (Mix well). Administration is easier when you push a small amount of medication, then flush with NS, and then repeat until the entire volume is given. Route: IVP; 10 Pregnancy Safety: Category C / Not well established, crosses the placenta, and may cause fetal damage. 31 llmlll Diazepam (Valium®, Diastat®) (dye AYZ eh pam) Used in the management of anxiety disorders, to treat agitation, shakiness, and hallucinations during alcohol withdrawal, to relieve certain types of muscle pain, and for sedation prior to cardioversion of a conscious patient..~ Benzodiazepine; Anticonvulsant; Sedative; Anxiolytic; Schedule IV drug 1. Suppresses the spread of seizure activity and raises the seizure threshold in the motor cortex. 2. Depresses the limbic system, thalamus, and hypothalamus (central nervous system) resulting in calming effects. 3. Muscle relaxant 4. Amnesic effect 5. Main action of effect is on GABA receptors. 6. Onset of action is 2 to 5 minutes for IVP and within 15 to 39 minutes for IM. 7. Duration of action is 15 minutes to 1 hour. Use: 1. Active seizures and/or status epileptics. 2. Sedation prior to cardioversion of a conscious patient. 3. Sedation prior to RSIof a patient. 4. Relief of agitation due to acute alcohol withdrawal (delirium tremens). 5. Short-term relief of acute anxiety. 6. Acetylcholinesterase inhibitor poisoning CNS:Confusion; Muscular weakness; Blurred vision; Dizziness; Drowsiness; Fatigue; Headache; Ataxia; Slurred speech; Paradoxical excitement and stimulation; Psychomotor impairment Cardiovascular: Bradycardia; Cardiac arrest; Hypotension; Reflex tachycardia; Thrombosis; Phlebitis Respiratory: Respiratory arrest; Respiratory depression Gastrointestinal: Nausea; Vomiting; Hiccups Other: Increased intraocular pressure URiffllibliia Absolute: Known hypersensitivity; Head injury; Coma: Hypotension; CNSdepression; Respiratory depression; Myasthenia gravis Relative: Glaucoma; Substance abuse Drug Interactions: 1. Potentiation of sedative effects in the presence of antihistamines, tricyclic antidepressants, alcohol, narcotics, sedatives, and hypnotics. 2. May precipitate if diluted. 3. incompatible with most drugs and fluids, do not mix with other medications. SpecialNotes: 1. Resuscitation equipment should be readily available prior to administration. 2. Convulsive Antidote Nerve Agent (CANA) is a commercial autoinjector that contains 10mg of diazepam. 3. Use with caution in the elderly (sensitive - reduce Dose 50%} and children (unpredictable). 4. Diazepam available for rectal administration. 32 1 ) 5. Respiratory depression and respiratory arrest may be reversed with Flumazenil ~ (Romazicon®) 0.2 to 1.0 IV. ~ \.Ul'til&Wsff Anxiety: 2 to 5 mg slow IV, IM. Seizure/Sedation: 5 to 10 mg slow IV, 10. Repeat every 10 to 15 minutes PRN Maximum \ dose 30 mg. \ ' OiWli atfJilm.We!I 1 Seizures: 0.1 mg/kg slowly, Maximum dose 4 mg. 1 Rectal: 0.2-0.5 mg/kg. Flush with 2-3 ml saline. IVP; 10; IM; Rectal suppository PregnancySafety: Category D / Possible adverse effect on the human fetus. 33 lmfflffie~ Digoxin (Lanoxin®,) (di JOX in) Used in combination with a diuretic and an st. to manage conge ive heart failure (CHF)and for reentry supraventricular tachycardia (i.e., atrial flutter, atrialfibrillation). lnotropic agent; Cardiac Glycoside; Antidysrhythmic fA'itijo~S;Sf 1. Rapid-acting cardiac glycoside with direct and indirect effects that increase the force of myocardial contractions. 2. Inhibits sodium-potassium-adenosine triphosphate membrane pump, which increases calcium in heart muscle cells and increases the force of the heart's contraction. 3. Stimulates the parasympathetic nervous system via the vagus nerve and decreases the heart rate. ,-..,, 5. Onset of action is 5 to 30 minutes. 6. Duration of action is 1½ to 4 hours. Use: 1. Congestive heart failure. ,--. 2. Re-entry SVTespecially atrial flutter and atrial fibrillation. bfs'ile~ff~lW CNS: Headache; Weakness; Vision disturbances; Confusion; Anxiety; Seizures; Psychosis Cardiovascular: Arrhythmias; Hypotension Gastrointestinal: Nausea; Vomiting; Diarrhea; Anorexia ) Other: Skin rash; Hyperkalemia --- ) R'liilffii'iiulleai1ansfll!lj' Absolute: Known hypersensitivity; Ventricular fibrillation; Ventricular tachycardia Relative: Digitalis toxicity Drug Interactions: 1. Amiodarone, anticholinergics, bepridil, benzodiazepines, ACE inhibitors, ~ ) clarithromycin, cyclosporine, diltiazem, erythromycin, indomethacin, itraconazole, propafenone, quinidine, quinine, tetracycline, verapamil may increase serum digoxin concentrations by 50% to 70%. 2. Concurrent use of digoxin and verapamil may lead to severe heart block. 3. Diuretics may potentiate cardiac toxicity. 4. Antacids, antineoplastics, cholestyramine, colestipol, kaolin/pectin, metoclopramide, and penicillamine may decrease absorption and effect of digoxin. 5. St. John's Wort, thyroid hormones, and thioamides may decrease the effect of digoxin. SpecialNotes: 1. Patients with known renal failure are prone to digoxin toxicity. 2. Hypokalemia, hypomagnesaemia, and hypercalcemia potentiate digitalis toxicity. 3. Use carefully in patients with Wolff-Parkinson-White Syndrome (ventricular arrhythmias). 4. Not used for right ventricular disorders. 0.5 to 1 mg IVP over 5 minutes. 1PW8Tatl:Tt;J0os.ec:0+'Vs''f Not recommended for prehospital use. 34 ·1 ) '1 Route: IVP; 10 1 Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. ) ' ') '..----._ l ,......,_ l 35 lftltam:eii:iili:}j Diltiazem Hydrochloride(Cardizem®, Cardizem (dil TYE a zem HIGH droe KLOR ide) Used to slow the electrical conduction in the heart, slow the heart to treat hypertension and angina. Calcium Channel Blocker; Class: IV antidysrhythmic; Antianginal agent 1. Blocks calcium channels, thus has a negative chronotropic effect (slows down heart rate). 2. Decreases SA and AV node conduction. · 3. Prolongs AV node effective and functional refractory periods. 4. Decreases myocardial contractility and peripheral vascular resistance. 5. Onset of action of 2 to 5 minutes. 6. Duration of action of 1 to 3 hours. Use: 1. Atrial Fibrillation (AF) or Atrial Flutter (A-Flutter) with a rapid ventricular response (RVR- sustained heart rate above 100 bpm). ,----, 2. Paroxysmal Supraventricular Tachycardia (PSVT).Unless contraindicated, vagal maneuvers should be attempted prior. 3. Multifocal Atrial Tachycardia (MAT). bSitl~Il;ft~S!~ZJI CNS:Weakness; Syncope; Tinnitus; Double vision; Photosensitivity; Dizziness (vertigo); Headache Cardiovascular: Bradycardia; Heart block; Congestive heart failure (CHF); Hypotension; Chest ,..._,_ pain (angina); Palpitations; Cardiac arrest Respiratory: Dyspnea Gastrointestinal: Constipation; Nausea; Vomiting; Diarrhea Other: Flushing; Dry mouth; Sweating W-Ganti~inc:IIc~ationsi,'4 Absolute: Known hypersensitivity; Sick Sinus Syndrome; Hypotension; Heart blocks; Acute Ml; Cardiogenic shock; Wolf-Parkinson-White (WPW) syndrome or short PR syndrome; Ventricular tachycardia; Heart failure Relative: Pulmonary congestion; Lactation Drug Interactions: 1. Incompatible with simultaneous furosemide injection. 2. Cimetidine or protease inhibitors (e.g., indinavir) may increase the actions and side effects. 3. Rifampin may decrease the effectiveness of Diltiazem. 4. Amiodarone, cisapride, digoxin, erythromycin, protease inhibitors (e.g., indinavir), quinidine, tricyclic antidepressants (e.g., desipramine), theophylline, or general anesthetics may cause effects on the heart. 5. Benzodiazepines (e.g., midazolam), beta-blockers (e.g., metoprolol), buspirone, carbamazepine, cilostazol, corticosteroids (e.g., prednisone), cyclosporine, HMGCoA reductase inhibitors (e.g., atorvastatin), macrolide immunomodulators (e.g., tacrolimus) may increase the risk of their side effects, some potentially life-threatening. SpecialNotes: 1. Do not administer with IV beta-blockers and use caution in patients taking oral beta- blockers. 36  2. Monitor vital signs, cardiac rhythms, and blood pressure. 3. Not recommended for infusion over 24 hours. 4. The half-life may be increased in geriatric patients. 5. Use with caution in patients with impaired hepatic function, renal function, and in CHFpatients. 6. PVCsmay be present on conversion of PSVTto sinus rhythm. MAY BESTOREDAT ROOM TEMPERATUREFORUP TO ONE (1) MONTH DESTROY AFTERONE (1) MONTH AT ROOM TEMPERATURE. 1 1 f"§f~~,!l'lt:l)ose~ ···~ 0.25 mg/kg over 2 minutes (Approximately 20 mg). May repeat after 15 minutes at 0.35 -,r mg/kg over 2 minutes (Approximately 25 mg). 1 Maintenance Drip: Dilute 125 mg (25 ml) in 100 ml of solution: infuse 5-15 mg/hr, 1 titrated to heart rate. 1 1 "l!ecl_iat:ti~giPp~e.,r. Not recommended for prehospital use. 1 Route: IVP; 10 1 1 Pregnancy Safety: Category C / Not well established, crossesthe placenta and may cause fetal damage. 1 1 1 1 37  ! Name: Diphenhydramine Hydrochloride (Benadryl®) / (dye fen HYE drah meen HIGH droe KLOR~ 1 Used to block Hl and H2 histamine receptors with antichdlinergic (d~ ry-i-ng_)_a_n_d_s_e_d_a-ti_v_e_s-id_e_e_f-fe-c- Class: Antihistamine; Antiemetic Action: 1. Blocks the effects of Hl histamine receptor stimulation (bronchoconstriction visceral contractions).. ' 2. Blocks the effects of H2 histamine receptor stimulation (peripheral vasodilation and secretion of gastric acids). 3. Inhibits histamine release from mast cells (Does not reverse histamine mediated responses). 4. Results in decreased capillary permeability and vasodilation. 5. Decreases dystonic reactions (extra pyramidal activity) from phenothiazines. 6. Onset of action is 10 tolS minutes. 7. Duration of effects is 6 to 8 hours. Use: 1. Allergic reactions and /or anaphylaxis in conjunction with epinephrine. 2. Dystonic reactions 3. Extrapyramidal signs and symptoms caused phenothiazine overdose (i.e., Haldol, Compazine, Thorazine, Stelazine). 4. Sedation of violent patients. 5. Antiemetic Side Effects: CNS: Drowsiness; Dizziness; Fever; Hallucinations; Headache; Paradoxical CNSexcitement in children; Seizures; Sedation; Visual disturbances Cardiovascular: Changes in T waves; Hypotension; Palpitations; Shortened diastole, which may cause reflex tachycardia; PVC's;Arrhythmias Respiratory: Thickening of bronchial secretions; Tightness in chest; Wheezing; Nasal stuffiness Gastrointestinal: Anorexia; Dry mouth; Diarrhea; Nausea; Vomiting; Constipation; Urinary retention Other: Anaphylaxis; Dysuria Contraindications: Absolute: Known hypersensitivity; Nursing mothers; Infants Relative: Asthmatic attack; Severe vomiting; Glaucoma; Alcohol intoxication Drug Interactions: 1. Enhances the properties of cocaine effects. 2. Atropine potentiates anticholinergic effects. 3. Potentiates central nervous system depression in the presence of alcohol, narcotics, sedatives/ hypnotics, or other antihistamines. 4. MAO inhibitors prolong the anticholinergic effects of diphenhydramine. Special Notes: Benadryl may precipitate an attack in chronic obstructive pulmonary disease (COPD) states. Adult Dose: Allergic Reaction: 25 to 50 mg SIVP. Repeat every 4-6 hours PRNor 50 mg deep IM. EPS:25 to 50 mg IV or IM Antiemetic: 12.5 to 25mg IV/IM or orally. 38 \ - \ \ Pediatric Dose: Allergic Reaction: 1 tol.25 mg/kg SIVP. Repeat every 4 to 6 hours PRN. Maximum single \ Dose of 50 mg. \ EPS:1 to 1.25 mg/kg IV, 10 or IM. Max dose 25 mg. Antiemetic: (pediatrics older than 2 years old, >12kg) 0.1 mg/kg IV, 10, or IM. Maximum \ dose: 25mg. \ \ Route: IVP; 10; Deep IM; PO (Benadryl elixir or tablets only) \ \ Pregnancy Safety: Category B / No possible adverse effect on fetus in laboratory testing \ \ \ \ \ \ ) ) ) ) ) ) ) 1 1 1 1 'I 'i 1 1 ) ""\ ) ) ) \ -1 ) ) ) 39 ) ) Name: Dobutamine Hydrochloride (Dobutrex®) (doe BYOU tah meen droe HYE ide) KLOR Used for correction of hemodynamic imbalances present in shock syndrome after Ml, trauma, endotoxic septicemia, open heart surgery, and renal failure or chronic cardiac decompensation (e.g., CHF). Class: Sympathomimetic; lnotropic agent; Vasopressor; Beta adrenergic agonist Action: 1. Synthetic catecholamine that has positive inotrope and dromotropic effect with small positive chronotropic effects resulting in an increase of cardiac output. 2. Increased renal and mesenteric blood flow following increase in cardiac output. 3. Slight vasodilation effects. 4. Onset of action is 1 to 2 minutes; peak after 10 minutes. 5. Duration of action is 1 to 2 min after cessation of infusion. Use: 1. Congestive heart failure (CHF) 2. lnotropic support in cardiogenic shock 3. Left ventricular dysfunction 4. Non-hypovolemic, hemodynamically significant hypotension Side Effects: CNS:Headache; Tremors; Anxiety Cardiovascular: Chest pain (angina); Hypertension; Tachydysrhythmias; Premature ventricular contractions (PVCs);AMI; Cardiac arrhythmias; Palpitations Gastrointestinal: Nausea; Vomiting; Tissue necrosis upon extravasation Contraindications: Absolute: Known hypersensitivity; Pre-existing hypertension; Hypovolemia; Severe hypotension; Uncorrected/ uncontrolled tachycardia; Idiopathic hypertrophic subaortic stenosis (IHSS);Poison-induced shock; shock with BP< 100mm Hg Drug Interactions: 1. Incompatible with sodium bicarbonate and furosemide. 2. Beta blockers may inhibit effects of dobutamine. 3. Alkaline solutions may inactivate dobutamine. 4. Hypersensitiv,epotentiation possible with oxytoxics and tricyclic antidepressants. 5. Works well with dopamine. Special Notes: 1. Use with caution with signs of myocardial ischemia. Acute myocardial infarction setting may aggravate or extend the infarct size. 2. Monitor blood pressure carefully. 3. May be administered through a Y-site with concurrent dopamine, lidocaine, nitroprusside, and potassium chloride infusions. 4. Ensure IV is patent due to possibility of necrosis. 5. Do not administer as an IV bolus. 6. Titrate dose to maintain a heart rate increase of greater than 10% of baseline. 7. Patients can become hypotensive due to vasodilatory effects. Adult Dose: 2-20 mcg/kg/minute IV infusion. Increase by 2 mcg/kg/minute PRNbased on inotropic effect. 40  Pediatric Dose: 2-20 mcg/kg/minute IVinfusion. Increase by 1 mcg/kg/minute PRNbased on inotropic effect. 1 Route: IV Infusion. Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 1 1 1 41 1!'iff~1i~JIJ Dopamine Hydrochloride (lntropin®; Dopastat®; Revimin (DOH pah meen HIGH droe KLOR ide) Used for correction of hemodynamic imbalances present in shock syndrome after Ml, trauma, en septicemia, open heart surgery, and renal failure or chronic cardiac decompensation (e.g., CHF). Catecholamine; lnotropic agent; Adrenergic agonist; Vasopressor ~:A'etionlrvr~::::,,,1. The effect on beta-1 receptors causes a positive inotropic effect on the heart. 2. Acts on alpha-adrenergic receptors causing peripheral vasoconstriction in higher doses. 3. Maintains renal and mesenteric blood flow because of its effect on the dopaminergic receptors. 4. Increases both systolic and pulse pressure. Usually, less effect on the diastolic pressure. 6. Effects are dose related: a. Low dose (2-10 mcg/kg/minute) provides primarily a Beta-1 response. This increases cardiac output by increasing myocardial contractility and cardiac impulse conduction. b. High dose (10-20 mcg/kg/minute) provides primarily an Alpha response resulting in peripheral vasoconstriction, increased peripheral vascular resistance, and increased blood pressure. c. Doses higher than 20 mcg/kg/minute, Alpha stimulation predominates the vasoconstriction may compromise circulation to the limbs. 7. Onset of action is within 5 minutes. 8. Duration of effects is less than 10 min after cessation of infusion. Use: 1. Cardiogenic shock (Myocardial infarction - Ml, Congestive heart failure - CHF). 2. Shock states with hemodynamically significant hypotension in the absence of hypovolemia (i.e., Septic shock, Spinal shock, Distributive shock). 3. Symptomatic bradycardia unresponsive to Atropine. 4. Hypotension post ROSC. CNS:Headache Cardiovascular: Angina; Arrythmias; Palpitations; Hypotension (low Dose); Hypertension (high Dose); Tachycardias; lschemia; Decreased peripheral perfusion Respiratory: Dyspnea Gastrointestinal: Nausea; Vomiting Other: Necrosis and tissue sloughing with extravasation ,sm:t.r:a.inc:liilati:0.~21.Til[F;~bsolute: Cardiac arrest; Hypovolemia; Pheochromocytoma; Uncorrected/uncontrolled tachycardia; Idiopathic hypertrophic subaortic stenosis (IHSS) Relative: Hypertension Drug Interactions: 1. Inactivates with alkaline solutions (e.g., sodium bicarbonate and furosemide). 2. Administration to patients on oxytocin may result in severe persistent hypertension. 3. Beta blockers may antagonize the effects of dopamine. 4. Tricyclic antidepressants ~nd other monoamine oxidase inhibitors (MOAI) will potentiate the effects of dopamine. s. Using dopamine with phenytoin may produce hypotension, bradycardia, and seizures. 42  6. Sympathominietics and phosphodiesterase inhibitors exacerbate dysrhythmia response. 1 Special Notes: 1. Infuse through a large stable vein to avoid the possibility of extravasation injury. 1 2. Use an infusion pump to ensure precise flow rates when available. 3. Pheochromocytoma is a benign catecholamine-producing tumor that causes hypertension in the patient. 4. Discontinue gradually. Sudden cessation can result in acute hypotension. 5. Monitor for signs of compromised circulation. ) ttAtfllilt,ilose::i_,-£ 2 to 20 mcg/kg/minute IV or 10 infusion titrated to effect. Start dose at Smcg/kg/min and gradually increase the infusion by 5 or 10 mcg/kg/min until desired effect. 1 Rarely should you go over 20 mcg/kg/minute in the field. 1 Dopaminergic response: 1 to 5 mcg/kg/min Beta 1 Adrenergic response: 5 to 10 mcg/kg/min Alpha ) Adrenergic response: 10 to 20 mcg/kg/min 1 ?sPe~d,afri't,oose:Administer same as adult. Do not go over 20 mcg/kg/minute without an order. ) Dopaminergic response: 1 to 5 mcg/kg/min Beta 1 Adrenergic response: 5 to 10 mcg/kg/min Alpha 1 Adrenergic response: 10 to 20 mcg/kg/min \ Route: IV infusion 1 1 Pregnancy Safety: Category CI Not well established, crosses the placenta and may cause fetal damage. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 \ 1 1 1 1 43 1 ~N~me;;}~ EpinephrineHydrochloride(Adrenalin ®) (ep in NEF rin HIGH droe KLOR ide) Used for relief of respiratory distress due to bronchospasm. To provide rapid relief of hypersensitivity reactions to drugs and other allergens (e.g., anaphylactic reactions). To restore cardiac rhythm in cardiac arrest due to various causes. Sympathomimetic; Adrenergic agent; Catecholamine; lnotropic agent 1. A naturally occurring catecholamine. Has potent alpha- and beta-adrenergic stimulation with more profound beta effects. 2. Stimulates Alpha, Beta-1 and Beta-2 receptors with effects of increased heart rate, cardiac contractile force, increased electrical activity in the myocardium, systemic vascular resistance, increased blood pressure, increased automaticity, and causes bronchodilation in dose related fashion. 3. Because of the Alpha and Beta-1 combinations, there is an associated increased myocardial oxygen consumption and irritability of the heart. 4. It antagonizes the effects of histamine by decreasing its release and decreasing membrane permeability. 5. Onset of action is less than 2 minutes for IVP or 10, from 3 to 10 minutes for IM. 6. Duration of effects is 5 to 10 minutes IV, 20 to 30 minutes IM. Use: 1. Bronchospasms; Asthma 2. Allergic reactions/ Anaphylaxis 3. Cardiac arrest 4. Vasopressor agent 5. Bradycardia 2Effee1:'s~~ l2itside CNS: Headache; Nervousness; Tremor; Anxiety; Restlessness; Psychomotor agitation; Weakness Cardiovascular: Angina; Cardiac dysrhythmias, Ectopic beats; Hypotension (low doses); Hypertension (high doses); Tachydysrhythmias; Palpitations; Respiratory: Pulmonary edema; Gastrointestinal: Nausea; Vomiting Other: Tissue necrosis with infiltration of IV; Transient elevations of blood glucose levels @ccln:tfamclications,:=::_:l[,ltbsolute: Hypersensitivity to synthetic catecholamines; Uncorrected tachycardia; Cardiovascular disease; Hypertension; Cerebrovascular disease Relative: Hypothermia; Pulmonary edema; None in the anaphylaxis/cardiac arrest setting; Women in active labor Drug Interactions: 1. Beta-blockers may inhibit the effects of epinephrine. 2. Do not mix isoproterenol and epinephrine, it results in exaggerated response. 3. May be deactivated by alkaline solutions (i.e., sodium bicarbonate, Furosemide, calcium chloride). 4. May increase ectopic beats in the "Dig-toxic" patient. 5. Monoamine oxidase (MAO) inhibitors and tricyclic antidepressants intensify and prolong epinephrine's effects. 44  SpecialNotes: 1. Do not use prefilled syringes for epinephrine infusions. 2. Syncope has occurred following epinephrine administration to asthmatic children. 3. Epinephrine increases cardiac workload and can precipitate angina, Myocardial Infarction, or major dysrhythmias in an individual with ischemic heart disease 4. Consider wheezing in an elderly patient as pulmonary edema in addition to COPD with bronchospasm. 6. Administer with caution to elderly patients with a history of heart disease, diabetes, or hypertension. 7. Because of the beta-adrenergic effects of epinephrine on the heart, the patient must be adequately ventilated to minimize myocardial ischemia. 8. High dose epinephrine vials contain a preservative that causes bronchoconstriction. 9. Causes hyperglycemia due to increased glycogenolysis (b2), increased release of 1 glucagon (b2), and a decrease release of insulin (a2). ) nose:J 1 11?,A'solute: Known hypersensitivity; Bradycardias; AV heart blocks; Bleeding; Thrombocytopenia; Hypotension; Adam-Stokes syndrome; Wolf-Parkinson-White syndrome; Prophylactic use in AMI; Wide-complex ventricular escape beats with bradycardia Relative: None Drug Interactions: 1. Apnea induced with succinylcholine may be prolonged with high doses of lidocaine. 2. Lidocaine used simultaneously with Procainamide, Propranolol, Dopamine, r Phenytoin, Quinidine, or Beta-blockers can have additive, antagonistic, or toxic effects. 3. Metabolic clearance is decreased in patients taking beta adrenergic blockers and in patients with decreased cardiac output or liver disease/dysfunction. Special Notes: 1. Exceedingly high doses of lidocaine can result in coma or death (toxicity). 2. Drug is metabolized in the liver and patients with hepatic disease, shock or congestive heart failure will have impaired metabolism. For these patients, all doses after the initial dose must be decreased. 3. Has a wide toxicity to therapeutic index ratio. Cardiac arrest (V-fib / pulse less V-tach): 1 to 1.5 mg/kg IV/10, may repeat at half the original dose (.5 to 0.75 mg/kg) every 5 to 10 minutes to a maximum dose of 3 mg/kg. 66  Perfusing Ventricular Rhythms and PVCs:0.5 to 0.75 mg/kg 10, 10 ( up to 1 to 1.5 mg/kg may be used). Repeat at 0.5 to 0.75 mg/kg every 5 to 10 minutes to maximum dose of 3 mg/kg. Premedication in RSI:1 to 1.5 mg/kg IV for closed head injuries only. Pain management in 10 therapy: 40 mg 10 Maintenance Infusion: Mix 1 gin 250 ml to yield a 4 mg/ml solution. Administer at 1 to 4 mg/minute. 1 1 Bolus: 1 mg/min t'J~B~~i.!t,il~'"~~~~r~~ IV, 10 maximum dose of 100mg. 1 Premedication in RSI:1 to 2 mg/kg IV, 10. Maintenance Infusion: 1 Mix 300 mg in 250 ml. Administer 20 to 50 mcg/kg/minute. 1 Note: For ETadministration, 2 to 3 mg/kg. ' 1 1 Route: IVP; 10; ET,IV Infusion (maintenance) ' 1 Pregnancy Safety: Category B / No possible adverse effect on fetus in laboratory testing. 1 ) \ ) ', ) 1 1 \ """\ \ 1 1 1 \ \ \ 1 \ \ \ \ ) \ \ \ 67 \ ~ Lorazepam (Ativan®) (lor AZ e pam) Used as an anticonvulsant, sedative, and hypnotic. Benzodiazepine; Anticonvulsant; Sedative; Schedule IV drug 1. Binds to specific sites on gamma-aminobutyric acid (GABA)Type A receptors within the brain. 2. Has no direct effect on the GABA receptors but does potentiate the effects of GABA within the brain. 3. Increased GABA levels cause sedation but no analgesic properties. 4. Suppresses the spread of seizure activity through the motor cortex of the brain. It does not appear to abolish the abnormal discharge focus. 5. Onset of action is 2 to 5 minutes. 6. Duration of action is 6 to 8 hours. Use: 1. Active seizures or Status epilepticus 2. Sedation 3. Anxiety --~ CNS: Drowsiness; Headache; Amnesia; Sedation; Delirium; Dizziness; Depression; Dysarthria; Euphoria; Fatigue; Tremor; Paradoxical CNSstimulation; Restlessness Cardiovascular: Hypotension; Bradycardia; Syncope Respiratory: Respiratory depression; Apnea; Ataxia Gastrointestinal: Nausea; Vomiting Uffl"fraiRi~ilAbsolute: Known hypersensitivity; Neurological or respiratory depression, Acute narrow- angle glaucoma; Sleep-apnea; Shock; suspected drug abuse Relative: Pregnancy Drug Interactions: 1. Produces additive effects when used in conjunction with other CNSdepressants and alcohol. 2. Patients taking passionflower or St. John's wort may have hand tremors, dizziness, and muscular fatigue. 3. Motherwort can potentiate the sedative effects and may result in coma. Special Notes: 1. Monitor respiratory rate and blood pressure during administration. 2. Should be diluted with NS or D5W prior to IV administration. 3. Have advanced airway equipment (intubation/ suction) readily available. 4. Flumazenil (Romazicon®) can be used as an antidote if required. 5. Inadvertent arterial injection may result in vasospasm and gangrene that may require amputation. 6. Lorazepam expires in six weeks if not refrigerated. Anxiety and Sedation: 0.1 mg/kg IV slowly over 2 minutes. Maximum single dose 4 mg. 4 mglM. Seizures: 2 to 4 mg IV, 10 given over 2 to 5 minutes; may repeat in 10 to 15 minutes. Maximum total dose 8 mg in 12 hours. 68 ) ) Anxiety and Sedation: 0.05 mg/kg slow IV, 10 (over 2 to 10 minutes) May be repeated in ) 15 to 20 minutes. The maximum single dose is 2 mg. ) Seizures: 0.1 mg/kg slow IV, 10, given over 2 to 4 minutes, max single dose 4 mg. May ) repeat at half the original dose in 10 to 15 minutes. ) Rectal: 0.1 - 0.2 mg/kg ) ◄odik+a­ IVP; 10; IM; Rectal ) 1 PregnancySafety: Category D / Possible adverse effect on human fetus. ) 1 1 ) ) ) ) ) ) 1 1 ' ) ' ' ' ) ) ' ' ' ) ) ' ' ) 1 1 1 ) ) ) 69 ) l&am:e'ill1! Magnesium Sulfate (MgSO4) (mag NEE zee um SUL fayt) Used to control low blood levels of magnesium; to prevent severe or toxemia of pregnancy; and used to treat life-threatening arrhythmias such as polymorphic VT (Torsade de Pointes). Anticonvulsant; Antiarrhythmic Class V; Electrolyte; Tocolytic 1. Acts as a physiological calcium channel blocker and blocks neuromuscular transmission. 2. Replaces magnesium levels which are associated with cardiac arrhythmias, symptoms of cardiac insufficiency, and sudden cardiac death. 3. Affects neuromuscular transmission, depressing the central nervous system reversing convulsions associated with toxemia of pregnancy (eclampsia). 4. Causes peripheral vasodilation. 5. Other uses include uterine relaxation (to inhibit contractions of premature labor), as a bronchodilator after beta-agonist and anticholinergic agents have been used, replacement therapy for magnesium deficiency, as a cathartic to reduce the absorption of poisons from the GI tract, and in the initial therapy for convulsions. 6. Inhibits acetylcholine release thus decreasing the excitability of motor nerve terminals. 7. Onset of action is immediate less than 1 minute. 8. The duration of action is 30 minutes. Use: 1. Torsades de Pointes or polymorphic ventricular tachycardia 2. Eclamptic seizures 3. Suspected hypomagnesemia state (e.g. Chronic alcoholism and chronic use of diuretics) 4. Refractory ventricular fibrillation 5. Status asthmaticus ~ae,;EffeGts't~ CNS: Drowsiness; Decreased deep tendon reflexes; CNSdepression; Facial flushing; Diaphoresis; Muscle paralysis Cardiovascular: Bradycardias; Hypotension; Asystole; Cardiac arrest; Vasodilation Respiratory: Respiratory depression Other: Hypothermia ll!Le~nf"tain.l;li'~~!iQJ1!?1 Absolute: AV heart block; GI obstruction; Hypermagnesemia; Hypocalcemia; Myocardial damage; Routine dialysis patients; Toxemia of pregnancy, if delivery is imminent Relative: Renal impairment Drug Interactions: 1. To reverse overdose effects, hyperventilate the patient with 100% oxygen and administer an IV bolus of 1 g calcium gluconate. 2. CNSdepressant effects may be enhanced if the patient is taking other CNS depressants. 3. Cardiac conduction changes may occur if administered with cardiac glycosides. 4. Antagonized by calcium products. Special Notes: 1. Monitor heart rate and cardiac rhythm closely. 2. Administer slowly, rapid IV administration may cause respiratory or cardiac arrest. 70  3. Signs of hypermagnesemia include: flushing, sweating, hypotension, depression of reflexes, flaccid paralysis, hypothermia, circulatory collapse, depression of cardiac function and central nervous system depression. These symptoms can precede fatal paralysis. 6. Have calcium gluconate available as antidote if overdose occurs. 7. Convulsions may occur up to 48 hours after delivery, necessitating continued therapy. 1 8. The "cure" for toxemia in pregnancy is usually delivery of the baby. 1 1 ~g~dglt,jlQ~~~"C£ Torsade de pointes (cardiac arrest): 1 to 2 g diluted in 10 ml of D5W IV, 10. 1 Torsade de pointes with pulse: 1 to 2 g diluted in 50 to 100 ml administered IV, 10 over 5 to 60 minutes. Follow with 0.5 to 1 g/hr IV, 10. Seizure associated with eclampsia: 4 to 6 g IV, 10 over 10 to 20 minutes followed by IV infusion of 1 to 2 g/hr. Asthma: 25 to 50 mg/kg over 10 to 20 minutes, maximum dose of 2 g. 1 ?t'Pgtlia,tr1c2Qp}~I~ Torsade de pointes (cardiac arrest): 20 to 50 mg/kg IV, 10, Maximum single dose of 2 g. Torsade de pointes with pulse: 20 to 50 mg/kg IV, 10 over 10 to 20 minutes. Maximum ) single dose 2 g. 1 Asthma: 25 to 50 mg/kg diluted in D5W IV, 10 over 10 to 20 minutes. 1 Route: IVP; 10; IV Infusion ) BolusInfusion 4 grams in 100 cc D5W 10 gtts/mL set - 50 gtts/min = 4 g/20 minutes 15 gtts/mL set - 75 gtts/min = 4 g/20 minutes Drip Infusion 5 g in 100 cc D5W 10 gtts/mL set - 7 gtts/min = 2 g/20 minutes 15 gtts/mL set -10 gtts/min = 2 g/20 minutes PregnancySafety: Category A/ Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy. Magnesium sulfate is administered for the treatment of toxemia of pregnancy. It is recommended that the drug not be administered in the 2 hours prior to deliveryJ if possible. 71 Name: Mannitol (Osmotrol®, Resectisol®) (MAN nih tol) Used to increase urine production to prevent the kidneys from shutting down and to speed up elimination of certain toxic substances in the body. Class: Osmotic diuretic Action: 1. Increases osmotic pressure in the kidney thereby inhibiting the reabsorption of water and electrolytes and promoting diuresis. 2. Pulls fluid out of the tissues into the interstitial fluid and blood. Therefor reducing swelling in the tissues including the brain. 3. Decreases sodium reabsorption and promotes urinary excretion of toxic substances. 4. Draws interstitial fluid into the intravascular space and increases the glomerular filtration rate (GFR). 5. Onset of action is 15 minutes for a reduction in intracranial pressure, and within 1 to 3 hours for diuretic effect. 6. Duration of actions is 3 to 8 hours in reduction in ICPand 4 to 6 hours for diuretic effect Use: 1. Cerebral edema with increased ICP Side Effects: CNS: Headache; Seizure; Coma; Dizziness Cardiovascular: Pulmonary edema; Angina; Hypertension (from transient volume overload); Hypotension (from excessive diuresis); Tachycardia; Congestive heart failure (CHF); Gastrointestinal: Nausea; Vomiting; Diarrhea Other: Acidosis; Dehydration; Electrolyte imbalance Contraindications: Absolute: Known hypersensitivity; Active intracranial bleeding; Severe hypotension; Pre- existing dehydration; Pulmonary edema; Profound hypovolemia; Electrolyte imbalances; Heart failure Relative: Renal failure Drug Interactions: 1. Mannitol tends to crystallize at temperatures below 450 F. To dissolve crystals, heat to 700 F. Cool to body temperature before administration. 2. Additive central nervous system depression when administered with other central nervous system depressants. 3. Additive adrenergic and anticholinergic effects when used with CNSdepressants. 4. When given concurrently with digitalis glycosides, an increase in digitalis toxicity may develop. 5. Should not be administered with whole blood or packed red blood cells as it can damage the red blood cells. Special Notes: 1. Use an in-line filter when administering mannitol to filter out any crystals from the solution. 2. Monitor urinary output closely. 3. Be alert for transient hypertension. 72  Adult Dose: 0.25 to 1 g/kg IV infusion over 5 to 10 minutes. Additional doses of 0.25 to 2 g/kg can be given every 4 to 6 hours as needed. PediatricDose: 0.25 to 1 g/kg IV infusion over 30 minutes. No generally used in prehospital section. Route: IV infusion, 10 \ , PregnancySafety: Category C / Not well established, crosses the placenta and may cause fetal damage. \ 1 ' I 73 Name: Meperidine Hydrochloride (Demerol®; Meperidine®; Pethidine®) (meh PER ih deen HIGH droe KLOR ide) Used as a CNSdepressant and as a potent analgesic. Class: Synthetic opioid; Opioid analgesic; Schedule II drug Action: 1. Binds to kappa opiate receptor (KOR)sites in the central nervous system to produce analgesia thus altering the awareness of and response to pain and causes a generalized depression of the central nervous system. 2. It is a synthetic substitute for morphine but is not as potent. 3. Onset of action is immediate with IV, and within 10 to 15 minutes IM. 4. Duration of action is 2 to 4 hours. Use: 1. For treatment of moderate to severe pain Side Effects: CNS:Altered mentation; Headache; Hallucinations; Seizures; Confusion; Sedation; Increased ICP;Syncope Cardiovascular: Hypotension; Orthostatic hypotension; Tachycardia; dysrhythmias Respiratory: Respiratory depression; Apnea Gastrointestinal: Nausea; Vomiting; Constipation Other: Allergic reaction Contraindications: Absolute: Known hypersensitivity; Seizure disorder; Respiratory depression; Undiagnosed head injury; Monoamine oxidase (MAO) inhibitors use within 14 days; During labor or delivery of a premature infant Relative: Hypotension Drug Interactions: 1. Monoamine oxidase inhibitors and barbiturates may cause an increased central nervous system excitation or depression which can be fatal. 2. Central nervous system depressants and tricyclic antidepressants potentiate effects 3. Phenytoin decreases its effects. Special Notes: 1. Naloxone (Narcan®) should be available for reversal of effects. 2. Often administered with an antiemetic to prevent nausea and vomiting. 3. Use with caution in patients with asthma and COPD. 5. May aggravate seizures in those with convulsive disorders. 6. Will not constrict pupils, but rather dilate them due to atropine-like activity. Adult Dose: 50 to 100 mg slowly IV, 10 or 50 to 100 mg IM. May repeat every 2 to 4 hours PRN. Pediatric Dose: Not recommended in prehospital settings. Route: IVP; 10; IM Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 74  Name: Metaproterenol Sulfate (Alupent®; Metaprel®) (met ah proh TER in nahl SULL fate) Used to relax the bronchial smooth muscle to improve breathing. Class: Sympathomimetic; Beta adrenergic agonist; Bronchodilator Action: 1. Relaxes bronchial and uterine smooth muscle through Beta2 adrenergic receptor stimulation. 2. Produces mild vasodilation. 3. Equal Beta 1 & 2 stimulation with little or no Alpha stimulation. 4. Onset of action is within 1 to 10 minutes after inhalation. 5. Duration of effects is 3 to 6 hours. Use: 1. Bronchospasm COPD 2. Toxic gas inhalation 3. Bronchial asthma Side Effects: CNS: Nervousness; Anxiety; Dizziness; Drowsiness; Headache; Sweating; Tremor Cardiovascular: Tachycardias; Chest pain; Hypertension; Palpitations Respiratory: Coughing Gastrointestinal: Nausea; Vomiting Other: Facial flushing; Diaphoresis Contraindications: Absolute: Known hypersensitivity; Tachydysrhythmias; Tachycardias due to digitalis toxicity Relative: Congestive heart failure; Hypertension 1 Drug Interactions: 1. Beta-blockers may antagonize (inhibit) effects. 2. History of monoamine oxidase (MAO) inhibitors may cause arrhythmias, ectopic beats, or potentiate hypotension. 3. Other sympathomimetics may exacerbate cardiovascular effects. 1 Special Notes: 1. Must be refrigerated. 2. Paradoxical bronchospasms in prolonged use. 1 3. Use with caution in patients with diabetes mellitus and coronary artery disease. 1 Adult Dose: 10 to 15 mg nebulized in 3 ml saline. Repeat PRN. Pediatric Dose: Not recommended for children under 12 years of age. 0.3 mg nebulized in 3 ml saline. Repeat PRN 1 1 Route: Nebulized inhalation ', 1 Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 1 75 Name: Methylprednisolone Sodium Succinate (Medrol®; Solu-Medrol®; Depo-Medrol®; A-methapred) (METH ill pred NISS ah lohn So DEE um SUX in ate) Used to treat severe inflammation caused by certain conditions, including severe asthma, severe allergies, rheumatoid arthritis, ulcerative colitis, certain blood disorders, lupus, multiple sclerosis, and certain eye and - skin conditions. Class: Corticosteroid; Anti-inflammatory; Glucocorticoid Action: 1. Synthetic corticosteroid that suppresses acute and chronic inflammation. 2. Potentiates vascular smooth muscle relaxation by beta-adrenergic agonists. 3. Suppresses immune response. 4. Onset of action is from 1 to 2 hours. 5. Duration of action is 8 to 24 hours. Use: 1. Severe allergic reactions and anaphylaxis 2. Bronchodilator for unresponsive asthma or exacerbation of COPD. Side Effects: CNS:Depression; Euphoria; Headache; Restlessness;Weakness; Paresthesia; Seizures; Increased ICP Cardiovascular: Arrhythmias; Heart failure; Hypertension; Angina; Hypernatremia; Hyperkalemia Gastrointestinal: Nausea; Vomiting; Diarrhea; Hyperglycemia; Fluid retention; Peptic ulcer Other: Swelling Contraindications: Absolute: Know hypersensitivity; Premature infants; Neonates; Fungal infections Relative: Active infection; Diabetes; GI bleeding Drug Interactions: 1. Hypoglycemic responses to insulin and oral hypoglycemic agents may be inhibited. 2. Potassium-depleting agents may potentiate hypokalemia induced by corticosteroids. Special Notes: 1. Use with caution in patients with Cushing's syndrome, gastrointestinal ulcerations, diabetes mellitus, psychotic tendencies. 2. Monitor the patient for hyperglycemia in nondiabetic patients. Adult Dose: 2 mg/ kg IV, 10, or IM. Maximum dose 125 mg. Pediatric Dose: 2 mg/ kg IV, 10, or IM. Maximum dose of 60 mg. Route: IVP; 10; IM PregnancySafety: Category C / Not well established, crosses the placenta and may cause fetal damage. 76 " 6 months of age: 0.05 to 0.1 mg/kg IV. Seizure: 0.1 mg/kg SIVP. May be repeated at½ initial dose after 5 minutes if seizures persist. 0.2 mg/kg intranasal. Using nasal atomizer and 5 mg/ml concentration, administer½ the total volume in each nare. May be repeated at½ initial dose after 5 minutes if seizures persist. -~ IVP; 10; IM; Intranasal PregnancySafety: Category D / Possible adverse effect on human fetus. 80 \ lilllnt6 Morphine Sulfate (MS Cantin; Duramorph; Astramorph®) \ (MOR feen SUL fayt) \ Used as a potent central nervous system depressant and analgesic. \ , lllii'"~f Opioid analgesic; Opiate agonist; Schedule II narcotic 1. Binds with opiate receptors in the sensory cortex of the frontal lobes and diencephalon, altering both perception and emotional response to pain. 2. Secondary pharmacologic effects of morphine include depressed responsiveness of alpha- adrenergic receptors (producing peripheral vasodilation) and baroreceptor inhibition. 3. Reduces anxiety, respiratory effort, preload, afterload, and cardiac workload thus decreasing myocardial oxygen demand. 4. Produces pupil constriction and peripheral vasodilation. 5. Onset of action is immediate. ) 6. Duration of action is 2 to 4 hours. Use: Moderate to severe pain §SffleYe':liffiai: CNS:Altered mentation; Dizziness; Lightheadedness; Sedation; Headache; Euphoria; Dysphoria; Seizures; Syncope Cardiovascular: Bradycardia; Hypotension; Cardiac arrest; Tachycardia Respiratory: Respiratory depression; Respiratory arrest; Bronchospasm; Dyspnea Gastrointestinal: Nausea; Vomiting; Dry mouth Other: Diaphoresis; Allergic reactions; Addiction with long term use Absolute: Known hypersensitivity; Respiratory depression; Altered mentation; Head injury; Acute asthma; Exacerbation of COPD; Hypotension; Shock; Undiagnosed abdominal pain; Presence of monoamine oxidase (MAO) inhibitors within 14 days Relative: Seizure disorders; Hepatic or renal insufficiency; Ingested poisoning 1 Drug Interactions: 1. Central nervous system depressants, tricyclic antidepressants, alcohol, l antihistamines, barbiturates, beta blockers, and chlorpromazine may potentiate effects. 2. Monoamine oxidase inhibitors (MAOI) may cause paradoxical excitation. 1 3. Do not mix with aminophylline, meperidine, or sodium bicarbonate. Special Notes: 1. Has a high tendency for addiction and abuse. 2. Morphine is detoxified by the liver. 3. Analgesic effect should not be gauged solely by the total elimination of pain. It reduces the perception of pain while the patient may still recognize the painful stimulus. 4. Respiratory support and Naloxone (Narcan) should always be available when administering medication. 5. Vagotonic effect in patients with acute inferior Ml (bradycardia, heart block) may worsen. 6. Hypotension may develop in geriatrics, volume depleted patients, or patients requiring elevated systemic vascular resistance for the maintenance of BP. 7. Can cause bronchoconstriction due to histamine release. 8. Rapidly crosses the placenta barrier to the fetus. 81  9. Safety in neonates has not yet been established. Cardiac: Initial dose 2 to 4 mg SIVPover 1 to 5 minutes. Repeat dose 2 to 8 mg at 5-to- 10-minute intervals. Pain relief: 0.1 mg/kg loading dose maximum dose of 10 mg. May repeatPRN. 0.1 to 0.2 mg/kg IV, 10, IM over 5 minutes. Maximum dose is 5mg. May repeat every 2 hours PRN. --- IVP; 10, IM, SQ PregnancySafety: Category C / Not well established, crosses the placenta and may cause fetal damage. MORPHINEhas a high tendency for addiction and abuse and is classified as a Schedule II drug under the Controlled Substance Act of 1970. Follow your Controlled Substance protocol or procedure for documentation, wasting, and replacement. 82  Naloxone Hydrochloride {Narcan®) (nal OX ohn HIGH droe KLOR Used as an effective narcotic antagonist. ~ ~ Antidote; Opioid reversal agent; Opioid antagonist 1. Competitive inhibition at opiate receptor sites within the CNS. 2. Displaces and blocks narcotic molecules from opiate receptors within the CNS. 3. Reverses respiratory depression secondary to opiate or opiate-like drugs. 4. Completely inhibits the effects of morphine. 5. Onset of action is less than 2 minutes IV and between 2 to 10 minutes IM, IN. 6. Duration of action 20 minutes to 120 minutes, this is shorter than narcotics. " Use: 1. Narcotic overdoses \ 2. Coma of unknown etiology/ Seizures of unknown etiology 3. Altered mentation \ lli~..g CNS:Tremor; Agitation; Pupillary dilation; Seizures Cardiovascular: Hypotension; Hypertension; Tachycardia; Cardiac arrest \ Respiratory: Pulmonary edema; Dyspnea Gastrointestinal: Nausea; Vomiting Other: Withdrawal symptoms (especially in neonates); Diaphoresis \ ~almmimJlea'.t!io'isit Absolute: Known hypersensitivity \ Relative: Use with caution in neonates of narcotic-addicted mothers; supraventricular arrhythmias; head trauma; brain tumor Drug Interactions: Incompatible with bisulfate and alkaline solutions. Special Notes: 1. Potential of violent behavior may occur after administration to narcotic addicts as level of consciousness increases (may precipitate withdrawal syndrome with hypertension, tachycardia, and violent behavior). 2. May cause seizures and bowel movements in patients when pushed too rapidly {no causal relationship established). 3. May need to repeat administration since duration of action of some narcotics may exceed that of naloxone. 4. Naloxone is not effective against respiratory depression due to non-opiate drug action. 0.4 to 2 mg titrated to effect. Repeat every 3 to 5 minutes PRN. If no effect within 10 mg, consider another cause {Fentanyl may require large doses to reverse effects). Lessthan 5 years old or< 20 kg: 0.1 mg/kg. Repeat PRNevery 2 to 3 minutes. 5 years or older or weight> 20 kg: 2 mg. Repeat PRN. IVP; 10; IM; IN; SUBQ; ET 83 PregnancySafety: Category C / Not well established, crosses the placenta and may cause fetal damage. 84 Name: Nifedipine (Ada lat®, Procardia®, Procardia XL®,Afeditab®, Nifediac®) (nye FED ih peen) Used to lower hypertension and to treat angina. Class: Calcium channel blocker Action: 1. Inhibits movement of calcium ions across cell membranes. 2.lnhibits cardiac and vascular smooth muscle contraction causing coronary and peripheral vasodilation. This decreases peripheral vascular resistance and myocardial oxygen demand. 3. Onset of action is from 15 to 30 minutes. 4. Duration of action is from 6 to 8 hours. Use: 1. Hypertensive crisis 2. Eclampsia in pregnancy Side Effects: CNS: Dizziness; Headache; Nervousness; Wea knells; Syncope; Mood changes Respiratory: Dyspnea; Cough; Wheezing Cardiovascular: Acute myocardial infarction (AMI ; Heart failure; Ventricular arrhythmias; Hypotension Gastrointestinal: Abdominal discomfort; Diarrhea; Nausea Other: Allergic reaction Contraindications: Absolute: Known hypersensitivity; Cardiogenic shock; Compensatory hypertension; Dissecting aneurysm; Hypotension Relative: Congestive heart failure; Heart block Drug Interactions: 1. Use with beta blockers or digoxin increases the risk of cardiac conduction defects, congestive heart failure, or severe hypotension. 2. Use with other antihypertensives may potentiate effects and cause severe hypotension. 3. Nifedipine should not be administered to patients receiving IV Beta blockers. 4. Effects of theophylline may be increased. Special Notes: 1. Grapefruit or grapefruit juice may render nifedipine ineffective. 2. Constantly monitor blood pressure. 3. Does not slow AV nodal activity. 4. With geriatric population, hypotension and angina pectoris may occur. Adult Dose: 10 to 20 mg PO (by mouth) every 4 to 8 hours for 48 hours or until symptoms subside. Pediatric Dose: Not recommended for prehospital use. Route: PO Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 85 Name: Nitroglycerine (Nitrostat®; Nitrolingual® Spray; Nitro-Bid® Ointment; (nye troh GLIH sir in) Tidril® IV) A potent smooth muscle relaxant used in the tre§tment of angina pectoris. Class: Nitrate; Antianginal; Vasodilator Action: 1. Decreases peripheral resistance and reduces afterload. 2. Vasodilation of coronary and cerebral arteries resulting in increased oxygen availability with decreased workload and myocardial oxygen demand, thereby relieving coronary vasospasms. 3. Peripheral vasodilation and reduces pre-load. 4. Onset of action is within 1 to 3 minutes. 5. Duration of action is 20 to 30 minutes SL, 1 to 10 minutes after discontinuation of IV infusion. Use: 1. lschemic chest pain 2. Hypertension 3. Congestive heart failure 4. Pulmonary edema with hypertension Side Effects: CNS: Headache; Lightheadedness; Dizziness; Syncope; Weakness; Diaphoresis Cardiovascular: Bradycardia; Hypotension; Tachycardia Gastrointestinal: Flushing; Dry mouth; Nausea; Vomiting Other: Methemoglobinemia Contraindications: Absolute: Known hypersensitivity; Cardiac tamponade; lntracranial bleeding; Head injury (increased ICP); Hypovolemia; Erectile dysfunction medication usage within 24 hours; Systolic BP< 100 mm Hg; Right ventricular infarction Relative: Glaucoma; Pericarditis; Anemia; Diabetes mellitus; Hepatic disease Drug Interactions: 1. Alcohol, beta blockers, calcium channel blockers, antihypertensives, benzodiazepines, phenothiazines, and other vasodilators may potentiate hypotension. 2. Incompatible with other drugs given IV. 3.Hawthorn increases NTG levels. 4. Use with aspirin can result in increased serum nitrate concentrations. 5. Use with Viagra or other erectile dysfunction medications results in uncontrollable hypotension and can result in cardiac arrest. Special Notes: 2. If using spray, shaking inactivates the nitroglycerine from the propellant resulting in no administration of medication. 3. Active ingredients of nitroglycerin will "sting" when administered SL. 4. Tablets can be inactivated by light, heat, air, and moisture. Keep in amber glass container with tight fitting lid. 5. Once opened, has a shelf life of 90 days. 6. May be necessary to remove nitro patch and wipe skin prior to cardioversion or pacing. 7. Administer IV nitroglycerin by infusion pump to ensure precise flow rate when available. 86  8. Tolerance to nitrates easily develops, requiring stopping the nitro drip for 6 to 8 hours. 9. Patient should not have nitro patch and IV nitro drip at the same time. Adult Dose: Sublingual: 0.4 mg (1 tablet or 1 spray). Repeat every 5 minutes to a maximum of 3 doses. Ointment: One inch of paste applied topically to the patient's chest for transdermal absorption. IV infusion: Mix SOmg in 100 ml DSW (glass bottle) and run infusion at 5 to 20 mcg/min and titrate to effect. Start at 5 mcg/min increasing by 5 to 10 mcg/ min every 5 to 10 minutes. End points of dose titration include a drop in blood pressure of 10%, relief of chest pain, and return of ST segment to normal on a 12-lead ECG. Pediatric Dose: Not recommended for prehospital use. Route: SL;Transdermal; IV Infusion; 10 Infusion....._,, 1 Pregnancy Safety: Category CI Not well established, crosses the placenta and may cause fetal damage. ' I 87 Name: Norepinephrine (Levophed ®; Levarterenol®; Noradrenaline) (NOR eh pih NEFF reen) Used to treat life-threatening hypotension that can occur with certain medical conditions or procedures. Class: Sympathomimetic; Adrenergic agonist; lnotropic; Vasopressor Action: 1. Norepinephrine is an alpha and beta 1 adrenergic agonist. 2. Predominately acts on alpha receptors causing peripheral vasoconstriction. This increases blood pressure and coronary artery perfusion. 3. Beta receptor action stimulates inotropic stimulation and dilation of coronary arteries. 3. Onset of effects is immediate. 4. Duration of effects is 1 to 12 minutes after discontinuation of infusion. Use: 1. lnotropic support for SBP< 70 mmHg and signs of decompensation. 2. Hemodynamically significant hypotension refractory to fluid resuscitation. 3. Hypotension associated with sympathectomy, spinal cord injury, poliomyelitis. Side Effects: CNS: Headache; Anxiety; Dizziness Cardiovascular: Dysrhythmias; Tachycardia; Cardiac arrest; Angina; AMI; Hypertension Respiratory: Dyspnea; Exacerbation of asthma Gastrointestinal: Nausea; Vomiting Other: Tissue necrosis from extravasation; Decreased renal perfusion; Decreased urine output Contraindications: Absolute: Known hypersensitivity; Patients taking MAOls; Hypovolemia; lschemic heart disease Relative: Mesenteric or peripheral vascular thrombosis; Pregnancy Drug Interactions: 1. Can be deactivated by alkaline solutions. 2. MAO inhibitors and bretylium may potentiate the effects of catecholamines. 3. Beta adrenergic antagonists may blunt inotropic response 4. Sympathomimetics and phosphodiesterase inhibitors may exacerbate dysrhythmia response. Special Notes: 1. Blood pressure and cardiac rhythms must be monitored closely. 2. Use cautiously in patients with hyperthyroidism and heart disease. 3. May cause fetal anoxia when used in pregnancy. 4. Infuse norepinephrine through a large stable vein to avoid tissue necrosis, ensure IV patency. 5. When available use an infusion pump to ensure a precise flow rate. Adult Dose: 0.5 to 30 mcg/min titrated to effect. Mix 4 mg om 250 ml of D5W (16 mcg/ml). Max dose 2mcg/kg/min. Pediatric Dose: Not recommended for prehospital use (epinephrine infusion preferred). Route: IV Infusion 88  PregnancySafety: Category C / Not well established, crosses the placenta and may cause fetal damage. ~ --------, --------, 1 89 ~ Ondansetron Hydrochloride (Zofran®) (ahn DAN SEH trahn HIGH droe KLOR ide) 1"-:c>:Cc'c,,40 kg: 0.75 ml in 2.5 ml saline and administer via neb. Route: N