MCCCD Paramedic Drug Profiles v6.1-1-65.pdf

Maricopa County Community College District Paramedicine Education Program Paramedic Drug Profiles V6.0 Authorization For the Paramedic to Administer Drugs In the State of Arizona The Arizona Department of Health Services Bureau of Emergency Medical Services & Trauma System (AzDHS/BEMSTS), medica...

Maricopa County Community College District Paramedicine Education Program Paramedic Drug Profiles V6.0 Authorization For the Paramedic to Administer Drugs In the State of Arizona The Arizona Department of Health Services Bureau of Emergency Medical Services & Trauma System (AzDHS/BEMSTS), medical direction, and scope of practice protocols authorize the Paramedic to administer specific drugs in the State of Arizona. GENERIC NAME acetaminophen / APAP TRADE, BRAND, OR PROPRIETARY NAMES • Tylenol® • Others CLASSES • Analgesic • Antipyretic STANDARD SUPPLIES • 325 mg, 500 mg capsule • 325,mg, 500 mg, 650 mg tablet • 20 mg/5.0 mL liquid suspension • 160 mg/5.0 mL, 500 mg/15 mL solution • Others MECHANISMS OF ACTION • Inhibits cyclooxygenase to increase the pain threshold • Acts on the hypothalamus to reduce fever INDICATIONS • Mild to moderate pain • Fever CONTRAINDICATIONS • The patient cannot protect their airway • Known hypersensitivity to the drug • Severe hepatic disease ADVERSE REACTIONS/SIDE EFFECTS • Nausea • Vomiting ROUTE OF ADMINISTRATION • Oral ONSET OF ACTION • 35 to 45 minutes ACETAMINOPHEN / APAP 1 ADULT DOSAGES • 325 to 1,000 mg every 4 to 6 hours • Maximum 4.0 g daily PEDIATRIC DOSAGES • 10 to 15 mg/kg every 4 to 6 hours • Maximum >75 mg/kg daily SPECIAL CONSIDERATIONS • This not a nonsteroidal anti-inflammatory drug (NSAID) • The drug can cause acute liver failure and death when taken as an overdose • Consider decreased dosages for elderly patients and patients with liver disease due to their slower metabolic function • The peak effect of the drug is 30 to 60 minutes • The duration of the drug is 4 to 6 hours ACETAMINOPHEN / APAP 2 GENERIC NAME acetylsalicylic acid / ASA TRADE, BRAND, OR PROPRIETARY NAMES • Bayer Aspirin® • Anacin® • Bufferin® • Excedrin® • St. Joseph Adult Low Dose Aspirin® • Others CLASSES • Platelet aggregator inhibitor • Nonsteroidal anti-inflammatory STANDARD SUPPLIES • 81 mg tablet • 325 mg tablet MECHANISMS OF ACTION • Blocks formation of thromboxane A2 which prevents platelets from clumping (aggregating) • Prevents clots from forming INDICATIONS • Chest pain and/or signs and symptoms suggestive of the acute coronary syndrome • Abnormal ECG waveforms suggestive of the acute coronary syndrome CONTRAINDICATIONS • Known hypersensitivity to the drug • Not recommended for use with pediatric patients ADVERSE REACTIONS/SIDE EFFECTS • None in the emergency setting ROUTE OF ADMINISTRATION • Oral (chewed) ONSET OF ACTION • 5 to 30 minutes ACETYLSALICYLIC ACID/ASA 1 ADULT DOSAGES • 160 to 325 mg SPECIAL CONSIDERATIONS • The drug may increase adverse reactions and side effects when administered with anti-inflammatory and anticoagulant drugs such as warfarin (Coumadin®) • The peak effect of the drug is 1 to 2 hours • The duration of the drug is 4 to 6 hours ACETYLSALICYLIC ACID/ASA 2 GENERIC NAME activated charcoal TRADE, BRAND, OR PROPRIETRARY NAMES • Actidose® • EZ-Char® • Liqui-Char® • Others CLASS • Adsorbent STANDARD SUPPLIES • Tube • Bottle MECHANISM OF ACTION • Binds (adsorbs) and inactivates toxic substances in the gastrointestinal tract INDICATIONS • Oral poisonings • Oral overdoses CONTRAINDICATIONS • The patient cannot protect their airway • Ingestion of o Caustics o Hydrocarbons o Acids o Corrosives o Cyanide o Solvents o Iron o Lithium o Lead o Petroleum products ADVERSE REACTIONS/SIDE EFFECTS • Aspiration • Nausea • Vomiting ACTIVATED CHARCOAL 1 ROUTE OF ADMINISTRATION • Oral ONSET OF ACTION • Variable ADULT DOSAGES • 30 to 60 gm (1.0 to 2.0 gm/kg) PEDIATRIC DOSAGES • 0.5 to 1.0 gm/kg SPECIAL CONSIDERATIONS • If aspirated, the drug can cause serious pulmonary complications • The peak effect of the drug is variable • The duration of the drug is variable ACTIVATED CHARCOAL 2 GENERIC NAME adenosine TRADE, BRAND, OR PROPRIETARY NAME • Adenocard® CLASS • Antidysrhythmic STANDARD SUPPLIES • Prefilled syringe • Vial MECHANISM OF ACTION • Slows atrioventricular conduction INDICATIONS • Supraventricular tachycardia • Wolff-Parkinson-White (WPW) syndrome • Monomorphic wide-complex tachycardia CONTRAINDICATIONS • Atrial fibrillation • Atrial flutter • Polymorphic ventricular tachycardia (Torsades de pointes) • Second-degree and third-degree heart block ADVERSE REACTIONS/SIDE EFFECTS • Transient dysrhythmias • Chest pain • Palpitations • Nausea • Dyspnea • Dizziness • Hypotension • Blurred vision • Cardiac arrest • Asystole ROUTES OF ADMINISTRATION • IV • IO ADENOSINE 1 ONSET OF ACTION • 20 to 30 seconds ADULT DOSAGES • 6.0 mg RAPID bolus over 1 to 3 seconds followed by 20 mL normal saline flush • If no response to the initial bolus after 1 to 2 minutes, administer 12 mg RAPID bolus over 1 to 3 seconds followed by 20 mL normal saline flush PEDIATRIC DOSAGES • 0.1 mg/kg (up to 6.0 mg) RAPID bolus over 1 to 3 seconds followed by 5 to10 mL normal saline flush • If no response to the initial bolus after 1 to 2 minutes, administer 0.2 mg/kg (up to 12 mg) RAPID bolus over 1 to 3 seconds followed by 5.0 to 10 mL normal saline flush SPECIAL CONSIDERATIONS • Constant monitoring of the patient’s cardiac rhythm is required during administration of the drug • The half-life of the drug is 6 to 10 seconds • The peak effect of the drug is 20 to 30 seconds • The duration of the drug is 30 seconds ADENOSINE 2 GENERIC NAME albuterol sulfate TRADE, BRAND, OR PROPRIETARY NAMES • Proventil® • Ventolin® CLASSES • Sympathomimetic • Bronchodilator • Beta2 agonist STANDARD SUPPLY • Premixed solution in a unit dose MECHANISM OF ACTION • Relaxes bronchial smooth muscle resulting in bronchodilation INDICATIONS • Asthma • Bronchospasm associated with chronic bronchitis and emphysema • Hyperkalemia CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • Tachycardia • Hypertension • Dysrhythmias • Muscle tremors • Palpitations • Chest pain • Dizziness • Nervousness • Anxiety • Headache • Nausea • Vomiting ROUTE OF ADMINISTRATION • Nebulized for inhalation ALBUTEROL SULFATE 1 ONSET OF ACTION • 5 to 15 minutes ADULT DOSAGES • 2.5 mg in 3.0 mL normal saline (unit dose) via small volume nebulizer • 2.5 mg in 3.0 mL normal saline (unit dose) via in-line small volume nebulizer with a bag-valve-mask • May repeat the dosage PEDIATRIC DOSAGES • 2.5 mg in 3.0 mL normal saline (unit dose) via small volume nebulizer • 2.5 mg in 3.0 mL normal saline (unit dose) via in-line small volume nebulizer with a bag-valve mask • May repeat the dosage SPECIAL CONSIDERATIONS • The drug may be used in conjunction with ipratropium bromide (Atrovent®) • The peak effect of the drug is 1 to 1½ hours • The duration of the drug is 3 to 6 hours ALBUTEROL SULFATE 2 GENERIC NAME amiodarone TRADE, BRAND, OR PROPRIETARY NAME • Cordarone® CLASS • Antidysrhythmic STANDARD SUPPLY • Prefilled syringe MECHANISMS OF ACTION • Blocks sodium, potassium, and calcium channels • Prolongs the action potential and repolarization • Slows the sinus rate • Increases the length of the PR interval and QT interval INDICATIONS • Ventricular fibrillation • Pulseless ventricular tachycardia • Wide complex tachycardia CONTRAINDICATIONS • Cardiogenic shock • Hemodynamically significant bradycardia • Second-degree and third-degree heart block • Hemodynamically significant hypotension ADVERSE REACTIONS/SIDE EFFECTS • Bradycardia • Hypotension • Heart block • Congestive heart failure • Headache • Dizziness • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • Infusion AMIODARONE 1 ONSET OF ACTION • 1 to 3 minutes ADULT DOSAGES • Cardiac arrest: 300 mg • If no response, administer 150 mg over 3 to 5 minutes • Tachydysrhythmias: 150 mg in 50 mL D5W infused over 10 minutes • Infusion: 1.0 mg/minute PEDIATRIC DOSAGES • Ventricular fibrillation: 5.0 mg/kg • May repeat the dosage every 5 minutes twice • Maximum dosage 300 mg • Ventricular tachycardia: 5.0 mg/kg over 20 minutes • May repeat the dosage twice SPECIAL CONSIDERATIONS • The peak effect of the drug is 10 minutes • The duration of the drug is variable AMIODARONE 2 GENERIC NAME atropine sulfate CLASSES • Anticholinergic • Parasympathetic blocker • Antidote STANDARD SUPPLIES • Prefilled syringe • Vial MECHANISMS OF ACTION • Blocks the action of acetylcholine • Increases the heart rate • Reverses the symptoms of cholinergic poisoning INDICATIONS • Hemodynamically significant bradycardia • Organophosphate poisoning • Carbamate poisoning • Nerve agent exposure CONTRAINDICATIONS • Known hypersensitivity to the drug • Tachycardia • Hypothermia-induced hemodynamically significant bradycardia ADVERSE REACTIONS/SIDE EFFECTS • Tachycardia • Palpitations • Flushed, hot, dry skin • Dizziness • Drowsiness • Confusion • Anxiety • Headache • Dilated pupils • Blurred vision • Dry mouth • Nausea • Vomiting ATROPINE SULFATE 1 ROUTES OF ADMINISTRATION • IV • IO • ET ONSET OF ACTION • Immediate ADULT DOSAGES • Hemodynamically significant bradycardia: 1.0 mg • May repeat the dosage every 3 to 5 minutes to maximum dosage 3.0 mg • Organophosphate poisoning/carbamate poisoning/nerve agent exposure: 1.0 to 4.0 mg • May double the dosage every 5 minutes • ET: 2.0 to 2.5 mg diluted in 10 mL normal saline PEDIATRIC DOSAGES • Hemodynamically significant bradycardia: 0.02 mg/kg • May repeat the dosage every 3 to 5 minutes to maximum dosage 1.0 mg in children and 2.0 mg in adolescents • Organophosphate poisoning/carbamate poisoning/nerve agent exposure: 0.03 to 0.05 mg/kg every 10 to 20 minutes SPECIAL CONSIDERATION • Consider transcutaneous pacing for bradydysrhythmias refractory to administration of the drug ATROPINE SULFATE 2 GENERIC NAME bumetanide TRADE, BRAND, OR PROPRIETARY NAME • Bumex® CLASS • Loop diuretic STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Inhibits the reabsorption of sodium and chloride in the kidneys • Increases the output of urine INDICATIONS • Pulmonary edema • Congestive heart failure CONTRAINDICATIONS • Hemodynamically significant hypotension • Hemodynamically significant hypovolemia • Not recommended for use with pediatric patients ADVERSE REACTIONS/SIDE EFFECTS • Muscle cramps • Dizziness • Hypovolemia • Hypokalemia • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • IM ONSET OF ACTION • 1 to 2 minutes BUMETANIDE 1 ADULT DOSAGES • 0.5 to 1.0 mg SPECIAL CONSIDERATIONS • Bumetanide 1.0 mg has the diuretic potency of furosemide 40 mg • The peak effect of the drug is 15 to 30 minutes • The duration of the drug is 3 to 4 hours BUMETANIDE 2 GENERIC NAME calcium chloride CLASS • Electrolyte STANDARD SUPPLY • Prefilled syringe MECHANISMS OF ACTION • Increases intracellular calcium levels • Increases myocardial contractility INDICATIONS • Hyperkalemia • Acute hypocalcemia • Calcium channel blocker overdose • Beta-blocker overdose CONTRAINDICATION • None in the emergency setting ADVERSE REACTIONS/SIDE EFFECTS • Extravasation may cause tissue necrosis • Syncope • Asystole • Bradycardia • Dysrhythmias • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO ONSET OF ACTION • 1 to 3 minutes ADULT DOSAGES • 500 to 1,000 mg (0.5 to 1.0 gm) • May repeat the dosage in 10 minutes CALCIUM CHLORIDE 1 PEDIATRIC DOSAGES • 0.2 to 0.25 mL/kg 10% solution SPECIAL CONSIDERATIONS • The drug may be used as a pretreatment to the administration of diltiazem (Cardizem®) • The drug may cause bradydysrhythmias with a patient prescribed digoxin (Lanoxin®) • The peak effect of the drug is variable • The duration of the drug is variable CALCIUM CHLORIDE 2 GENERIC NAME calcium gluconate 2.5% topical gel TRADE, BRAND, OR PROPRIETARY NAMES • Calgonate® • H-F Antidote Gel® • C-gel® • Calgoogel® CLASS • Electrolyte STANDARD SUPPLY • Tube of gel MECHANISMS OF ACTION • Combines with hydrofluoric acid to neutralize the fluoride ion, forming insoluble calcium fluoride • Stops the fluoride ion from penetrating into tissue and bone, preventing further damage INDICATION • Contact with hydrofluoric acid CONTRAINDICATION • None in the emergency setting ADVERSE REACTIONS/SIDE EFFECTS • None in the emergency setting ROUTE OF ADMINISTRATION • Topical application ONSET OF ACTION • Immediate ADULT DOSAGE • If possible, the patient should wash the affected area and massage the gel into the skin PEDIATRIC DOSAGE • Assist the patient to wash the affected area and massage the gel into the skin CALCIUM GLUCONATE 2.5% TOPICAL GEL 1 SPECIAL CONSIDERATIONS • The peak effect of the drug is variable • The duration of the drug is variable CALCIUM GLUCONATE 2.5% TOPICAL GEL 2 GENERIC NAME calcium gluconate CLASS Electrolyte STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Increases intracellular and extracellular calcium levels • Increases cardiac automaticity • Increases cardiac contractility • Stabilizes myocardial membranes in hyperkalemia INDICATIONS • Hyperkalemia • Beta-blocker overdose • Calcium channel blocker overdose CONTRAINDICATIONS • Known hypersensitivity to the drug • Digoxin (Lanoxin®) toxicity ADVERSE REACTIONS/SIDE EFFECTS • Extravasation may cause tissue necrosis • Dysrhythmias ROUTES OF ADMINISTRATION • IV • IO ONSET OF ACTION • Immediate ADULT DOSAGES • Hyperkalemia: 1.0 gm • May repeat the dosage PEDIATRIC DOSAGE • Hyperkalemia: 30 mg/kg CALCIUM GLUCONATE 1 SPECIAL CONSIDERATIONS • The peak effect of the drug is immediate • The duration of the drug is 30 to 120 minutes CALCIUM GLUCONATE 2 GENERIC NAME dexamethasone TRADE, BRAND, OR PROPRIETARY NAME • Decadron® CLASSES • Corticosteroid • Glucocorticoid • Anti-inflammatory STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Suppresses acute and chronic inflammation • Produces immunosuppressive effect • Stabilizes cell membranes INDICATIONS • Asthma • Chronic bronchitis • Emphysema • Other reactive airway conditions • Anaphylaxis CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • None for a single dosage ROUTES OF ADMINISTRATION • IV • IO ONSET OF ACTION • 4 to 8 hours ADULT DOSAGES • 8.0 to 24 mg DEXAMETHASONE 1 PEDIATRIC DOSAGES • 0.25 to 0.6 mg/kg • Maximum dosage 16 mg SPECIAL CONSIDERATIONS • Peak effect of the drug is 6 to 12 hours • Duration of the drug is 24 to 72 hours DEXAMETHASONE 2 GENERIC NAME dextrose 50% TRADE, BRAND, OR PROPRIETRARY NAME • D50® CLASSES • Carbohydrate • Antihypoglycemic STANDARD SUPPLY • Prefilled syringe MECHANISM OF ACTION • Increases the glucose levels in the blood INDICATIONS • Hypoglycemia • Unconsciousness of unknown etiology CONTRAINDICATION • Head injury ADVERSE REACTIONS/SIDE EFFECTS • Extravasation may cause tissue necrosis ROUTES OF ADMINISTRATION • IV • IO • Infusion ONSET OF ACTION • Less than 1 minute ADULT DOSAGES • 12.5 to 25 gm PEDIATRIC DOSAGES • IV/IO/infusion: 0.5 to 1.0 gm/kg D10 solution over 20 minutes DEXTROSE 50% 1 SPECIAL CONSIDERATIONS • The drug may be used in conjunction with thiamine (vitamin B1) for a patient with malnutrition or alcohol abuse • Check the blood glucose level before administering the drug • Check the blood glucose level after each additional dosage of the drug • The peak effect of the drug is variable • The duration of the drug is variable DEXTROSE 50% 2 GENERIC NAME diazepam TRADE, BRAND, OR PROPRIETARY NAME • Valium® CLASSES • Benzodiazepine • Anticonvulsant • Sedative • Hypnotic STANDARD SUPPLIES • Vial • Ampule MECHANISMS OF ACTION • Produces sedation by acting on the limbic system, the thalamus, and hypothalamus • Binds to gamma-amino butyric acid (GABA) benzodiazepine receptors in the brain • Raises the seizure threshold • Produces tranquilizing (antianxiety) effect on the central nervous system INDICATIONS • Seizure activity • Status epilepticus • Procedural sedation for rapid sequence intubation and cardioversion • Chemical restraint for agitated (excited) delirium • Delirium tremens • Severe anxiety CONTRAINDICATIONS • Known hypersensitivity to the drug • Head injury DIAZEPAM 1 ADVERSE REACTIONS/SIDE EFFECTS • Sedation • Transient amnesia • Respiratory depression • Respiratory arrest • Bradycardia • Hypotension • Dizziness • Drowsiness • Blurred vision • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • IM • Rectal ONSETS OF ACTION • IV/IO: 2 to 5 minutes • IM: 15 to 30 minutes • Rectal: variable ADULT DOSAGES • 2.0 mg increments over 2 minutes PEDIATRIC DOSAGES • IV/IO: 0.2 to 0.3 mg/kg • IM: 0.1 to 2.0 mg/kg • Rectal: 0.2 to 0.5 mg/kg SPECIAL CONSIDERATIONS • The peak effect of IV/IO administration of the drug is 15 minutes • The peak effect of IM administration of the drug is 30 to 45 minutes • The duration of IV/IO administration of the drug is 15 to 60 minutes • The duration of IM administration of the drug is 15 to 60 minutes • The peak effect of rectal administration of the drug to pediatric patients is variable • The duration of rectal administration of the drug to pediatric patients is variable • Efficacy of rectal administration of the drug to adults has not been established DIAZEPAM 2 GENERIC NAME diltiazem TRADE, BRAND, OR PROPRIETARY NAME • Cardizem® CLASSES • Calcium channel blocker • Antidysrhythmic STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Slows extracellular calcium ion influx across myocardial cell membranes • Slows conduction through the sinoatrial node and the atrioventricular node • Slows ventricular conduction rates in atrial fibrillation and atrial flutter INDICATIONS • Atrial fibrillation with rapid ventricular rate • Atrial flutter with rapid ventricular rate • Supraventricular tachycardia second-line to administration of adenosine CONTRAINDICATIONS • Known hypersensitivity to the drug • Hypotension • Myocardial infarction • Cardiogenic shock • Ventricular tachycardia • Second-degree and third-degree heart block • Wolff-Parkinson-White (WPW) syndrome • Not recommended for use with pediatric patients ADVERSE REACTIONS/SIDE EFFECTS • Hypotension • Dysrhythmias • Bradycardia • Dizziness • Weakness • Headache • Nausea • Vomiting DILTIAZEM 1 ROUTES OF ADMINISTRATION • IV • IO • Infusion ONSET OF ACTION • 2 to 5 minutes ADULT DOSAGES • 0.25 mg/kg (usually 20 mg) over 2 minutes • May repeat the dosage 0.35 mg/kg (usually 25 mg) in 15 minutes • Infusion: 5.0 to 15 mg/hour SPECIAL CONSIDERATIONS • Consider decreasing the dosage for elderly patients • Consider pretreatment with calcium chloride • The peak effect of the drug is 7 minutes • The duration of the drug is 1 to 3 hours • An infusion pump should be used to administer the drug when possible DILTIAZEM 2 GENERIC NAME diphenhydramine TRADE, BRAND, OR PROPRIETARY NAME • Benadryl® CLASSES • Antihistamine • Anticholinergic STANDARD SUPPLIES • Vial • Prefilled syringe MECHANISMS OF ACTION • Blocks H1 histamine receptors • Reverses a phenothiazine reaction with extrapyramidal symptoms INDICATIONS • Allergic reaction • Anaphylaxis • Phenothiazine reaction with extrapyramidal symptoms CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • Hypotension • Dysrhythmias • Sedation • Euphoria • Dizziness • Headache • Blurred vision • Palpitations ROUTES OF ADMINISTRATION • IV • IO • IM ONSET OF ACTION • 15 to 30 minutes DIPHENHYDRAMINE 1 ADULT DOSAGES • Allergic reaction/anaphylaxis: 25 to 50 mg • Phenothiazine reaction with extrapyramidal symptoms: 10 to 50 mg PEDIATRIC DOSAGES • 1.0 to 1.25 mg/kg SPECIAL CONSIDERATIONS • The peak effect of the drug is 1 hour • The duration of the drug is 6 to 8 hours DIPHENHYDRAMINE 2 GENERIC NAME dopamine TRADE, BRAND, OR PROPRIETARY NAME • Intropin® CLASSES • Sympathomimetic • Vasopressor STANDARD SUPPLY • Premix bag for infusion MECHANISMS OF ACTION • Increases the heart rate • Increases the force of myocardial contractility • Increases the blood pressure • Increases preload INDICATIONS • Cardiogenic shock • Hemodynamically significant bradycardia • Hemodynamically significant hypotension CONTRAINDICATION • Hemodynamically significant hypovolemic shock ADVERSE REACTIONS/SIDE EFFECTS • Extravasation may cause tissue necrosis • Increased myocardial oxygen demand • Tachycardia • Hypertension • Dysrhythmias • Dyspnea • Tremors • Palpitations • Headache • Nausea • Vomiting ROUTE OF ADMINISTRATION • Infusion DOPAMINE 1 ONSET OF ACTION • 1 to 4 minutes THERAPEUTIC DOSAGE RANGE & RESPONSES • 2.0 to 5.0 mcg/kg/minute: o Negligible beta-adrenergic response • 5.0 to 10 mcg/kg/minute: o Beta-adrenergic responses  Positive chronotropic effects  Positive inotropic effects • 10 to 20 mcg/kg/minute: o Alpha-adrenergic responses  Vasoconstriction  Increased blood pressure  Increased preload • > 20 mcg/kg/minute: o May increase the heart rate and myocardial oxygen demand to undesirable limits ADULT DOSAGES • Infusion: 2.0 to 20 mcg/kg/minute (reference the Dopamine Dosage Table) PEDIATRIC DOSAGES • Infusion: 2.0 to 20 mcg/kg/minute SPECIAL CONSIDERATIONS • The peak effect of the drug is 5 to 10 minutes • The duration of the drug is variable • An infusion pump should be used to administer the drug when possible DOPAMINE 2 DOPAMINE DOSAGE TABLE Infusion preparation: 400 mg dopamine added to 250 mL NS or D5W = 1600 mcg dopamine per mL. Use the 60 drops per mL administration set (“pediatric” tubing or microdrop tubing). WEIGHT Lbs Kg 88 100 110 120 132 143 154 165 176 187 198 209 220 231 242 253 264 275 286 297 308 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 DESIRED DOSAGE (drops/minute) 5 10 20 mcg/kg/min mcg/kg/min mcg/kg/min 8 15 30 8 17 34 9 19 38 10 21 41 11 23 45 12 24 49 13 26 53 14 28 56 15 30 60 16 32 64 17 34 68 18 36 71 19 38 75 20 39 79 21 41 83 22 43 86 23 45 90 23 47 94 24 49 98 25 51 102 26 53 106 DOPAMINE 3 GENERIC NAMES epinephrine TRADE, BRAND, OR PROPRIETARY NAME • Adrenalin® CLASS • Sympathomimetic STANDARD SUPPLIES • Prefilled syringe • Vial • Ampule • Auto-injectors o Adult EpiPen® o EpiPen Jr.® MECHANISMS OF ACTION • Alpha-adrenergic response o Vasoconstriction • Beta1-adrenergic responses o Increases the heart rate o Increases myocardial contractility • Beta2-adrenergic response o Relaxes bronchial smooth muscle resulting in bronchodilation • Blocks histamine receptors INDICATIONS • Cardiac arrest o Asystole o Pulseless electrical activity o Ventricular fibrillation o Pulseless ventricular tachycardia • Asthma • Bronchospasm associated with chronic bronchitis and emphysema • Allergic reaction • Anaphylaxis • Hemodynamically significant bradycardia • Hemodynamically significant hypotension from a cause other than hypovolemia CONTRAINDICATION • None in the emergency setting EPINEPHRINE 1 ADVERSE REACTIONS/SIDE EFFECTS • Extravasation of the IV/IO may cause tissue necrosis • Tachycardia • Increased myocardial oxygen demand • Hypertension • Dysrhythmias • Dyspnea • Palpitations • Chest pain • Nervousness • Anxiety • Dizziness • Headache • Tremors • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • IM • ET • Infusion ONSETS OF ACTION • IV/IO/ET/infusion: less than 2 minutes • IM: 3 to 10 minutes ADULT DOSAGES • Cardiac arrest: 1.0 mg (1:10,000) IV/IO • May repeat the dosage every 3 to 5 minutes during resuscitation • Cardiac arrest: 2.0 to 2.5 mg (1:1,000) ET diluted in 10 mL normal saline • May repeat the dosage every 3 to 5 minutes during resuscitation • Hemodynamically significant bradycardia: 2.0 to 10 mcg/minute infusion • Hemodynamically significant hypotension: 2.0 to 10 mcg/minute infusion • Bronchospasm associated with chronic bronchitis and emphysema/allergic reaction/anaphylaxis: 0.3 to 0.5 mg (1:1,000) IM o Adult EpiPen® auto-injector 0.3 mg IM EPINEPHRINE 2 PEDIATRIC DOSAGES • Cardiac arrest: 0.01 mg/kg (1:10,000) IV/IO • May repeat the dosage every 3 to 5 minutes during resuscitation • Cardiac arrest: 0.1 mg/kg (1:1,000) ET diluted in 3.0 to 5.0 mL normal saline • May repeat the dosage every 3 to 5 minutes during resuscitation • Hemodynamically significant bradycardia: 0.01 mg/kg (1:10,000) IV/IO • Hemodynamically significant bradycardia: 0.1 mg/kg (1:1,000) ET diluted in 3.0 to 5.0 mL normal saline until IV/IO access • Bronchospasm associated with asthma/allergic reaction/anaphylaxis: 0.01 mg/kg (1:1,000) IM o EpiPen Jr. ® auto-injector 0.15 mg IM SPECIAL CONSIDERATIONS • The drug can increase adverse reactions and side effects when administered with another sympathomimetic drug • The peak effect of IV/IO/ET administration of the drug is less than 5 minutes • The duration of IV/IO/ET administration of the drug is 5 to 10 minutes • The peak effect of IM administration of the drug is less than 20 minutes • The duration of IM administration of the drug is 20 to 30 minutes • An infusion pump should be used to administer the drug when possible EPINEPHRINE 3 GENERIC NAME etomidate TRADE, BRAND, OR PROPRIETARY NAME • Amidate® CLASSES • Anesthesia induction agent • Hypnotic • Sedative STANDARD SUPPLIES • Prefilled syringe • Vial MECHANISMS OF ACTION • Produces depression of the central nervous system • Produces anesthesia INDICATION • Procedural sedation for rapid sequence intubation CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • Respiratory depression • Respiratory arrest • Laryngospasm • Hypotension • Hypertension • Tachycardia • Bradycardia • Involuntary muscle movement • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO ONSET OF ACTION • 10 to 20 seconds ETOMIDATE 1 ADULT DOSAGES • 0.2 to 0.6 mg/kg (usually 20 mg) over 30 to 60 seconds PEDIATRIC DOSAGES • Older than 10 years: 0.2 to 0.4 mg/kg over 30 to 60 seconds • Maximum dosage 20 mg SPECIAL CONSIDERATIONS • Peak effects of the drug is less than 1 minute • Duration of the drug is 3 to 5 minutes ETOMIDATE 2 GENERIC NAME fentanyl TRADE, BRAND, OR PROPRIETARY NAMES • Duragesic® • Sublimaze® CLASSES • Narcotic analgesic • Narcotic agonist STANDARD SUPPLIES • Ampule • Vial MECHANISMS OF ACTION • Alleviates pain by depressing the central nervous system • Depresses respiratory centers in the brainstem • Decreases venous return to the heart • Decreases preload • Decreases afterload INDICATION • Pain management CONTRAINDICATIONS • Known hypersensitivity to the drug • Head injury • Decreased level of consciousness • Respiratory depression • Hemodynamically significant hypotension FENTANYL 1 ADVERSE REACTIONS/SIDE EFFECTS • Central nervous system depression • Respiratory depression • Respiratory arrest • Hypotension • Bradycardia • Tachycardia • Dysrhythmias • Syncope • Dyspnea • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • IM ONSET OF ACTION • 1 to 3 minutes ADULT DOSAGES • 25 to 50 mcg • Maximum dosage 200 mcg PEDIATRIC DOSAGES • 1.0 to 2.0 mcg/kg • Maximum dosage 50 mcg SPECIAL CONSIDERATIONS • Peak effect of the drug is 3 to 5 minutes • Duration of the drug is 30 to 60 minutes • Fentanyl 100 mcg is equivalent in analgesia to morphine10 mg FENTANYL 2 GENERIC NAME furosemide TRADE, BRAND, OR PROPRIETARY NAME • Lasix® CLASS • Loop diuretic STANDARD SUPPLIES • Prefilled syringe • Vial MECHANISMS OF ACTION • Inhibits the reabsorption of sodium and chloride in the kidneys • Increases the output of urine INDICATIONS • Pulmonary edema • Congestive heart failure CONTRAINDICATIONS • Hemodynamically significant hypotension • Hemodynamically significant hypovolemia ADVERSE REACTIONS/SIDE EFFECTS • Hypovolemia • Hypokalemia ROUTES OF ADMINISTRATION • IV • IO ONSET OF ACTION • 5 to 10 minutes ADULT DOSAGES • If the patient is prescribed furosemide: the initial dosage is 2 times the patient’s total daily prescribed dosage of the drug (usually 40 to 80 mg) • If the patient is not prescribed furosemide: 0.5 to 1.0 mg/kg (usually 30 to 40 mg) FUROSEMIDE 1 PEDIATRIC DOSAGE • 1.0 mg/kg SPECIAL CONSIDERATIONS • The peak effect of the drug is 20 to 30 minutes • The duration of the drug is 3 to 6 hours FUROSEMIDE 2 GENERIC NAME glucagon TRADE, BRAND, OR PROPRIETARY NAME • GlucaGen® CLASSES • Hyperglycemic • Pancreatic hormone STANDARD SUPPLY • The vial containing the drug requires reconstitution with the supplied solution MECHANISMS OF ACTION • Increases the glucose levels in the blood by releasing glycogen stores in the liver • Increases the force of myocardial contractility • Increases the heart rate INDICATIONS • Hemodynamically significant hypoglycemia • Beta-blocker overdose CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • Nausea • Vomiting ROUTE OF ADMINISTRATION • IM ONSET OF ACTION • 1 to 20 minutes ADULT DOSAGES • 1.0 mg • May repeat the dosage in 7 to 10 minutes GLUCAGON 1 PEDIATRIC DOSAGES • 5 years or younger or less than 44 pounds (20 kg): 0.5 mg • 5 years or older or more than 44 pounds (20 kg): 1.0 mg • May repeat the dosage in 7 to 10 minutes SPECIAL CONSIDERATIONS • Check the blood glucose level before administering the drug • Check the blood glucose level after each additional dosage of the drug • The peak effect of the drug is 30 minutes • The duration of the drug is 1 to 2 hours • The drug may be used in conjunction with dextrose 50% • The drug may be used in conjunction with thiamine (vitamin B1) for a patient with malnutrition or alcohol abuse GLUCAGON 2 GENERIC NAME hydroxocobalamin TRADE, BRAND, OR PROPRIETARY NAME • CyanoKit® CLASS • Antidote STANDARD SUPPLY • Contents of the CyanoKit® MECHANISM OF ACTION • Binds with cyanide to form cyanocobalamin INDICATIONS • Cyanide poisoning by o Inhalation o Ingestion o Exposure CONTRAINDICATION • None in the emergency setting ADVERSE REACTIONS/SIDE EFFECTS • Hypertension ROUTES OF ADMINISTRATION • IV/IO ONSET OF ACTION • 2 to 15 minutes ADULT DOSAGE • 5.0 gm over 15 minutes PEDIATRIC DOSAGE • 100 mg/kg over 15 minutes SPECIAL CONSIDERATIONS • The peak effect of the drug is variable • The duration of the drug is variable HYDROXOCALAMIN 1 GENERIC NAME ibuprofen TRADE, BRAND, OR PROPRIETARY NAMES • Motrin® • Advil® • Others CLASSES • Nonsteroidal anti-inflammatory drug (NSAID) • Analgesic • Antipyretic STANDARD SUPPLIES • 100 mg, 200 mg tablet • 200 mg liquid gel • 40 mg/1.0 mL, 100 mg/5.0 mL liquid suspension • 50 mg/1.25 mL infants’ drops • Others MECHANISM OF ACTION • Inhibits prostaglandin synthesis INDICATIONS • Mild to moderate pain • Fever CONTRAINDICATIONS • The patient cannot protect their airway • Known hypersensitivity to the drug and other NSAIDs • Bleeding disorders • Peptic ulcer disease ADVERSE REACTIONS/SIDE EFFECTS • Nausea • Vomiting • Gastrointestinal discomfort ROUTE OF ADMINISTRATION • Oral IBUPROFEN 1 ONSET OF ACTION • 30 to 60 minutes ADULT DOSAGES • 400 to 800 mg every 6 to 8 hours PEDIATRIC DOSAGES • 10 mg/kg (up to 400 mg) every 4 to 6 hours SPECIAL CONSIDERATIONS • The peak effect of the drug is 30 to 60 minutes • The duration of the drug is 4 to 6 hours IBUPROFEN 2 GENERIC NAME ipratropium bromide TRADE, BRAND, OR PROPRIETARY NAME • Atrovent® CLASSES • Anticholinergic • Bronchodilator STANDARD SUPPLY • Premixed solution in a unit dose MECHANISMS OF ACTION • Blocks acetylcholine receptors on bronchial smooth muscle • Dilates the larger airways resulting in bronchodilation INDICATIONS • Asthma • Bronchospasm associated with chronic bronchitis and emphysema CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • Tachycardia • Tremors • Palpitations • Nervousness • Anxiety • Headache • Nausea • Vomiting ROUTE OF ADMINISTRATION • Nebulized for inhalation ONSET OF ACTION • 1 to 3 minutes IPRATROPIUM BROMIDE 1 ADULT DOSAGES • 500 mcg (0.5 mg) in 2.5 mL normal saline (unit dose) via small volume nebulizer (SVN) • In-line with a bag-valve mask (BVM): 500 mcg (0.5 mg) in 2.5 mL normal saline (unit dose) via SVN • May repeat the dosage PEDIATRIC DOSAGES • 500 mcg (0.5 mg) in 2.5 mL normal saline (unit dose) via small volume nebulizer (SVN) • In-line with a bag-valve mask (BVM): 500 mcg (0.5 mg) in 2.5 mL normal saline (unit dose) via SVN • May repeat the dosage SPECIAL CONSIDERATIONS • The drug may be used in conjunction with albuterol (Proventil®) • The peak effect of the drug is 1½ to 2 hours • The duration of the drug is 4 to 6 hours IPRATROPIUM BROMIDE 2 GENERIC NAME ketamine TRADE, BRAND, OR PROPRIETARY NAME • Ketalar® CLASSES • Sedative • Anesthetic • Analgesic STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Blocks pain receptors • Produces a dissociative state • Produces anesthesia INDICATIONS • Procedural sedation for rapid sequence intubation • Chemical restraint for agitated (excited) delirium • Pain management CONTRAINDICATIONS • Known hypersensitivity to the drug • Not recommended for use with pediatric patients ADVERSE REACTIONS/SIDE EFFECTS • Respiratory depression • Respiratory arrest • Bradycardia • Tachycardia • Dysrhythmias • Hallucinations • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • IM KETAMINE 1 ONSETS OF ACTION • IV/IO: less than 1 minute • IM: 3 to 4 minutes ADULT DOSAGES • IV/IO: 1.0 to 2.0 mg/kg over 1 minute • IM: 2.0 to 4.0 mg/kg SPECIAL CONSIDERATION • The peak effect of IV/IO administration of the drug is 15 minutes • The peak effect of IM administration of the drug is 30 to 45 minutes • The duration of IV/IO administration of the drug is 15 to 60 minutes • The duration of IM administration of the drug is 15 to 60 minutes • The duration of rectal administration of the drug is variable KETAMINE 2 GENERIC NAME lidocaine TRADE, BRAND, OR PROPRIETARY NAME • Xylocaine® CLASS • Antidysrhythmic STANDARD SUPPLIES • Prefilled syringe • Premix bag MECHANISMS OF ACTION • Suppresses ventricular ectopic activity • Increases the threshold of ventricular fibrillation INDICATIONS • Ventricular fibrillation • Ventricular tachycardia • Ventricular dysrhythmias o Frequent premature ventricular complexes and couplets o Monomorphic wide-complex tachycardia CONTRAINDICATIONS • Known hypersensitivity to the drug • Premature ventricular complexes in conjunction with bradycardia • Second-degree and third-degree heart block ADVERSE REACTIONS/SIDE EFFECTS • Drowsiness • Confusion • Anxiety • Dizziness ROUTES OF ADMINISTRATION • IV • IO • ET • Infusion ONSET OF ACTION • 1 to 5 minutes LIDOCAINE 1 ADULT DOSAGES • VF and pulseless VT: 1.0 to 1.5 mg/kg • May repeat the dosage 0.5 to 0.75 mg/kg every 3 to 5 minutes during resuscitation • Maximum dosage 3.0 mg/kg • Ventricular dysrhythmias with a pulse: 1.0 to 1.5 mg/kg • May repeat the dosage 0.5 to 0.75 mg/kg in 5 to 10 minutes • Maximum dosage 3.0 mg/kg • Maintenance infusion: 2.0 to 4.0 mg/minute • ET: 2.0 to 2.5 times the bolus dosage diluted in 10 mL normal saline PEDIATRIC DOSAGES • VF and pulseless VT: 1.0 mg/kg • May repeat the dosage 1.0 mg/kg one time in 3 to 5 minutes during resuscitation • Ventricular dysrhythmias with a pulse: 1.0 mg/kg • May repeat the dosage in 5 to 10 minutes • Maximum dosage 3.0 mg/kg • Maintenance infusion: 20 to 50 mcg/kg/minute • ET: 2.0 to 2.5 times the bolus dosage diluted in 3.0 to 5.0 mL normal saline SPECIAL CONSIDERATIONS • Consider decreased dosages for elderly patients and patients with liver disease due to their slower metabolic function • The peak effect of the drug is 5 to 10 minutes • The duration of the drug is 10 to 20 minutes • An infusion pump should be used to administer the drug when possible LIDOCAINE 2 GENERIC NAME lorazepam TRADE, BRAND, OR PROPRIETARY NAME • Ativan® CLASSES • Benzodiazepine • Anticonvulsant • Sedative • Hypnotic STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Produces sedation by acting on the limbic system, the thalamus, and cortex • Binds to gamma-amino butyric acid (GABA) benzodiazepine receptors in the brain • Raises the seizure threshold • Produces tranquilizing (antianxiety) effect on the central nervous system INDICATIONS • Seizure activity • Status epilepticus • Procedural sedation for intubation and cardioversion • Chemical restraint for agitated (excited) delirium • Severe anxiety CONTRAINDICATION • Known hypersensitivity to the drug LORAZEPAM 1 ADVERSE REACTIONS/SIDE EFFECTS • Sedation • Transient amnesia • Respiratory depression • Respiratory arrest • Bradycardia • Hypotension • Dizziness • Drowsiness • Blurred vision • Nausea • Vomiting ROUTES OF ADMINISTRATION • IV • IO • IM ONSETS OF ACTION • IV/IO: 1 to 5 minutes • IM: 15 to 30 minutes ADULT DOSAGES • Seizure IV/IO: 2.0 to 5.0 mg over 2 minutes • Seizure IM: 2.0 to 5.0 mg • Procedural sedation IV/IO: 2.0 mg over 2 minutes • Procedural sedation IM: 4.0 mg • Maximum dosage: 10 mg PEDIATRIC DOSAGES • Seizure IV/IO/IM: 0.05 to 0.1 mg/kg over 2 minutes • Maximum dosage 4.0 mg SPECIAL CONSIDERATIONS • The drug may produce longer periods of sedation with elderly patients • The peak effect of IV/IO administration of the drug is less than 15 minutes • The duration of IV/IO administration of the drug is 6 to 8 hours • The peak effect of IM administration of the drug is 2 to 3 hours • The duration of IM administration of the drug is 6 to 8 hours LORAZEPAM 2 GENERIC NAME magnesium sulfate CLASSES • Electrolyte • Anti-inflammatory • Tocolytic (labor suppressant) STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Decreases ventricular irritability • Decreases release of acetylcholine that inhibits muscular excitability • Causes uterine relaxation • Relaxes bronchial smooth muscle resulting in bronchodilation • Raises the seizure threshold in eclampsia and preeclampsia INDICATIONS • Seizures caused by toxicity of pregnancy (toxemia) • Pregnancy induced hypertension (pre-eclampsia and eclampsia) • Pre-term labor • Torsades de pointes (polymorphic ventricular tachycardia) • Ventricular fibrillation and pulseless ventricular tachycardia refractory to amiodarone or lidocaine • Reactive airway conditions including bronchoconstriction and bronchospasm CONTRAINDICATION • Hemodynamically significant heart block ADVERSE REACTIONS/SIDE EFFECTS • Central nervous system depression • Drowsiness • Hypotension • Respiratory depression • Dysrhythmias ROUTES OF ADMINISTRATION • IV • IO • Infusion MAGNESIUM SULFATE 1 ONSET OF ACTION • Immediate ADULT DOSAGES • Torsades de pointes infusion: 1.0 to 2.0 gm in 50 to 100 mL over 5 minutes • May repeat the dosage 1.0 to 2.0 gm over 1 hour • Pre-term labor/pre-eclampsia/eclampsia infusion: 3.0 to 6.0 gm in 100 mL over 10 to 20 minutes • May repeat the initial dosage • Maintenance infusion: 1.0 to 4.0 gm/hour • Reactive airway conditions: 2.0 gm in 50 mL over 5 to 10 minutes • Cardiac arrest IV/IO: 1.0 to 2.0 gm over 1 to 2 minutes PEDIATRIC DOSAGES • Reactive airway conditions infusion: 25 to 50 mg/kg 10% solution infused over 15 to 30 minutes • Maximum dosage 2.0 gm SPECIAL CONSIDERATIONS • The peak effect of the drug is variable • The duration of the drug is 1 hour • An infusion pump should be used to administer the drug when possible MAGNESIUM SULFATE 2 GENERIC NAME methylprednisolone TRADE, BRAND, OR PROPRIETARY NAME • Solu-Medrol® CLASSES • Corticosteroid • Glucocorticoid • Anti-inflammatory STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Suppresses acute and chronic inflammation • Produces immunosuppressive effect • Stabilizes cellular membranes INDICATIONS • Asthma • Chronic bronchitis • Emphysema • Other reactive airway conditions • Anaphylaxis • Burns involving the airway CONTRAINDICATION • None in the emergency setting ADVERSE REACTIONS/SIDE EFFECTS • None for a single dosage ROUTES OF ADMINISTRATION • IV • IO ONSET OF ACTION • 1 to 6 hours ADULT DOSAGE • 125 mg METHYLPREDNISOLONE 1 PEDIATRIC DOSAGES • 2.0 to 4.0 mg/kg SPECIAL CONSIDERATIONS • The peak effect of the drug is 8 hours • The duration of the drug is 18 to 36 hours METHYLPREDNISOLONE 2 GENERIC NAME midazolam TRADE, BRAND, OR PROPRIETARY NAME • Versed® CLASSES • Benzodiazepine • Anticonvulsant • Sedative • Hypnotic STANDARD SUPPLY • Vial MECHANISMS OF ACTION • Produces sedation by acting on the limbic system, the thalamus, and hypothalamus • Binds to gamma-amino butyric acid (GABA) benzodiazepine receptors in the brain • Raises the seizure threshold • Produces tranquilizing (antianxiety) effect on the central nervous system INDICATIONS • Seizure activity • Status epilepticus • Procedural sedation for intubation and cardioversion • Chemical restraint for agitated (excited) delirium CONTRAINDICATION • Known hypersensitivity to the drug ADVERSE REACTIONS/SIDE EFFECTS • Sedation • Transient amnesia • Respiratory depression • Respiratory arrest • Bradycardia • Hypotension • Dizziness • Blurred vision • Nausea • Vomiting MIDAZOLAM 1 ROUTES OF ADMINISTRATION • IV • IO • IM ONSETS OF ACTION • IV/IO: 2 to 5 minutes • IM: 15 to 30 minutes ADULT DOSAGES • Seizure IV/IO: 0.1 mg/kg • Maximum dosage: 4.0 mg • Seizure IM: 0.2 mg/kg • Maximum dosage: 10 mg • Procedural sedation IV/IO: 0.5 to 2.5 mg • Maximum dosage: 0.1 mg/kg • Chemical restraint IV/IO: 0.05 to 0.1 mg/kg • Chemical restraint IM: 0.1 to 0.15 mg/kg PEDIATRIC DOSAGES • Seizure IV/IO: 0.05 to 0.1 mg/kg • Seizure IM: 0.2 mg/kg • Maximum dosage: 10 mg • Procedural sedation IV/IO: 0.05 to 0.5 mg/kg • Maximum dosage 0.1 mg/kg SPECIAL CONSIDERATIONS • Consider decreased dosages for elderly patients and patients with liver and kidney disease due to slower metabolic function • The peak effect of IV/IO administration of the drug is 3 to 5 minutes • The duration of IV/IOI administration of the drug is less than 2 hours • The peak effect of IM administration of the drug is 30 to 60 minutes • The duration of IMI administration of the drug is 1 to 6 hours MIDAZOLAM 2