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Nassau county protocol update notesPharmacology – study of drugs and their interaction with living systems Drug – any chemical that affects living tissues Pharmacokinetics – The study of how drugs enter the body, reach their sites of action and are eliminated from the body. Absorption, excretion, metabolism, excretion Agonist – Drugs that bind t specific receptors and elicit a physiological response Antagonist – A Drug which either competes with or blocks an agonist receptor site CONTROLLED SUBSTANCES AND SEDATIVES
Class - Short Acting benzodiazepine, sedative, hypnotic, antianxiety Action – depresses subcortical levels in CNS Clinical Uses – procedural sedation, med facilitated intubation, seizures, conscious sedation o Med Facilitated Intubation 1-5mg IV/IO/IN MCO o Procedural sedation 1-5mg IV/IO/IN MCO o Seizures / Stat Ep 1-5mg IV/IO/IM/IN Standing orders – repeat MCO o Poisoning, OD Cocaine, Amphetamine, ETOC Sympathomimetic withdrawal 1-2mg o Peds Stat Ep – 0.2mg/kg IM/IN (max 5mg) IN preferred std order medic if stat ep and good BG Side Effects – Amnesia, Hypotension, Respiratory Depression, Broncho or lyringo spasm, nausea vomiting Contraindications – shock, use with other cns depressants, glaucoma Pharmacokinetics – Onset: IV/IN 1-3 min; IM 15-30 min Class – Typical antipsychotic, dopamine receptor antagonist Action – blocks the effects of dopamine in the CNS, mild anticholinergic effects, decrease the signs and symptoms of psychoses o Behavioral emergencies – 2-5mg IM MCO Side effects – sedation, decreased LOC, resp depression, hypotension, tachycardia, dry mouth, constipation, extrapyramidal dystonic reactions Contraindications – hypersensitivity, CNS depression, circulatory compromise Precautions – May lower seizure threshold in patients with seizure history, may exacerbate effects of antihypertensive and vasodilator medications, PUSH SLOWLY, monitor lengthening QT interval, V-Tach, Torsades Pharmacokinetics – Onset - within minutes, Peak effect – 20 min IM, Duration 2-6 hours, half-life 21 days Action – decrease muscle activity, emotional response, and level of consciousness o Acts on subcortical levels with the brain and limbic system, blocks spinal cord neuronal transmission, relaxing skeletal muscle, causes CNS depression Clinical Uses – Sedation prior to cardioversion / pacing, mgmt. of grand mal status ep, eclampsia, sedation in acute behavioral emergencies, medication facilitated intubation o Med facilitated intubation – 5-10mg IV/IO w/ repeat to max 20mg MCO ▪ After intubation 5mg IV/IO for continued sedation MCO o Seizures / Stat Ep – 5mg w/ repeat 5mg IV/IO/IM/PR Standing order and MCO o Poisoning / OD – OD of Cocain, Amphetamine, Sympathomimetics, ETOC Withdrawal 2-10mg o Organophosphate, Nerve Agent Exposure – 2-10mg IV/IO/IN/PR Max ttl dose 20mg MCO o Eclampsia – 5mg IV/IM Refractory seizures MCO o Peds Stat Ep – 0.1mg/kg IV/IO slowly over 2 min MCO repeat is seizures persist ▪ If no IV/IO 0.1mg/kg PR (per rectum) MCO Contraindications – Hypersensitivity/allergy, Pre existing CNS depression, Shock/hypotension Class – benzodiazepine, anticonvulsant, sedative, hypnotic Action – binds to gamma-amniobutyric acid (GABA) A sites within the brain o GABA is a main inhibitory neurotransmitter of the CNS Clinical Uses – major motor seizures, stat ep, procedural sedation, acute agitation / anxiety Contraindications – hypersensitivity/allergy, caution with prior CNS depression o Medication facilitated intubation – 2-4mg IV/IO/IN repeat PRN (max 4mg) MCO o Procedural sedation – 2-4mg IN/IO/IN MCO o Seizures / Stat Ep – 2-4mg IV/IO/IM both standing and MCO o Behavioral emergencies / agitation – 1-2mg IV/IO/IM/IN MCO o Poisoning / OD Tox – Cocaine, Amphetamines, sympathomimetics, ETOH withdrawal o Peds Stat Ep – 0.05mg/kg IV/IN/IO (slowly over 2 minutes) repeat if seizures persist Side Effects – hypotension, CNS depression, Resp Depression, Nausea and Vomitting Pharmacokinetics – Onset IV 1-5 min, IM 15-30 min o Peak effects – IV 15-20 min, IM 2 Hours Action – 50-100 times more potent than morphine, shorter duration of action than other narcotic analgesics, used primarily for analgesia and sedation o Pain Mgmt, Procedural Sedation, ACS/Chest Pain 1mcg/kg IV/IO/IM/IN (max 100mcg) MCO Side Effects – resp depression, apnea, muscle rigidity, bradycardia, enhanced effect w/ CNS depressants, Potentiation by MAOI (avoid use within 14 days of taking MAOI) Contraindications – shock, hypersensitivity, severe hemorrhage Precautions – may cause bradycardia, liver and renal patients may have decreased ability to metabolize and excrete drug, monitor vital signs frequently Pharmacokinetics – Onset - immediate, peak effects – 3-5min, duration – 30-60min, half life 6-8hrs Action – Powerful CNS depressant, relieves pain, decreases systemic vascular resistance / venous return, produces vasodilatory effects Clinical Uses – pain management associated with burns, isolated extremity fractures/dislocations/long transport times or disentanglements, ACS/Chest Pain o Pain Management (non-Cardiac) 2-10mg (0.1mg/kg) IV/IM (max 20mg ttl) ▪ Standing orders for medic MCO for both o Procedural Sedation or ACS/chest pain 2-10 (0.1mg/kg) IV/IO MCO Side Effects – Hypotension, respiratory depression, dizziness, altered LOC, additive CNS depression when used with similar drugs, nausea/vomiitting Contraindications – Hypersensitivity, shock/hypotension, resp depression, head injury Class – Short Acting sedative / hypnotic Action – rapid induction of anesthesia with minimal respiratory and cardiovascular effects, useful in RSI for hypotensive patients, produces no histamine release, yields no analgesic effects. o Med facilitated intubation – 0.3mg/kg RAPID IV/IO push (max dose 20mg) MCO o Procedural Sedation – 0.15mg/kg IV/IO (max dose 10mg) MCO Precautions – significant hypotension, severe asthma patients, severe cardiovascular disease, arrhythmias, caution in use with elderly. Side effects – apnea, laryngospasm, myoclonic skeletal muscle movement, nausea/vomiting, use with verapamil may cause resp depression or apnea, arrythmias Pharmacokinetics – Onset 10-20 sec. Peak effects <1 min, Duration 3-5 min, Half Life 30-70 min !
Clinical uses of benzodiazepine include all of the following except - Management of acute chest pain. Side effects of benzodiazepines include all of the following except – Hypertension The best choice for very short term sedation for cardioversion due to its short half life and duration would be – Midazolam Valium is often used as a substitute for morphine because – it is 50-100 times more potent than morphine Side effects for fentanyl include all of the following except – tachycardia Typical dosages for fentanyl would be – 1mcg/kg slowly over one minute Morphine sulfate is under what class of controlled substances – Schedule II Morphine sulfate should be administered to – a 32M in 10/10 pain w/ amputated left foot Side effects of morphine sulfate admin include all of the following effect – hypertension Actions of ms include all of the following except - vasoconstrictive effects Etomidate belongs to which class of medications - short acting sedative/hypnotic All are actions of etomidate except – produce histamine release Side effects of etomidate include all of the following except – hypertension Etomidate should be used cautiously when being administered to severe asthma patients. Haldol belongs to which medication class – antipsychotic – dopamine receptor antagonist Common side effects of Haldol include all of the following except – bradycardia Haldol should be given with caution to some patients because it - all of the above !Cardiac Regulatory Centers – Medulla Oblongata Cardio-acceleratory center – SYMPATHETIC Cardio-inhibitory center – PARASYMPATHETIC Baroreceptors (aortic and carotid sinuses, RA) Chemoreceptors (aortic and carotid bodies) Alpha1 – peripheral effects – vasoconstriction Beta1 – Cardiac effects – vasoconstriction, +chronotropy, +inotropy, +dromotropy Beta2 – Pulmonary effects – bronchodilation, vasodilation Class – Class 3 antiarrythmic – cardiac ion channel blocker Action – blocks potassium, sodium and calcium channels along with adrenergic B-receptors; prolongs cardiac repolarization; increases refractory periods; slows heart rate; increases QT and PR intervals o Cardiac Arrest VF/Pulseless VT – 300mg IV/IO (diluted in 20-30 ml D5W) ▪ Repeat MCO 150mg IV/IO (diluted in 10ml D5W) o Wide complex Tachycardia w/ pulse – 150mg IV/IO in 10ml D5W IV/IO over 10 minutes medic o Narrow complex tachycardia – MCO only 150mg IV/IO over 10 min (diluted in 100ml D5W) o Peds non-trauma cardiac arrest – MCO only 5mg/kg IV/IO if VF/VT (max 300mg) Side effects – Hypotension, Bradycardia, Potentiates effects of coumadin, may worsen digitalis toxicity Contraindications – Bradycardia, AV Blocks, Pregnancy (relative), Caution in patients with decreased lung function, may cause pulmonary fibrosis Pharmacokinetics – Half life – 58 Days, Onset within minutes Class – Calcium Channel Blocker,Class IV antiarrythmic Action – Inhibits calcium movement across cardiac and smooth muscle membranes causing dilation of coronary arteries, peripheral arteries and arterioles; prolongs the conduction of electrical impulses through the AV node. o Narrow complex tachycardia – 0.25mg/kg SLOW IV (over 2 minutes) MCO Side effects – Flushing, headache, bradycardia, hypotension, heart block, myocardial depression, Severe AV block, in high doses – cardiac arrest Contraindications – Acute MI; CHF; Hypersensitivity to diltiazem or other calcium channel blockers; secnd/third degree AV blocks(unless in the presence of a pacemaker); severe hypotension(<90mgHg); sick sinus syndrome Precautions – renal/hepatic impairment; patients taking beta blocking medications – may potentiate effects of both medications. Pharmacokinetics – Onset – 3 minutes, Peak effect – N/A, Duration – N/A, Half –Life 3-8 hours. Class – Electrolyte, tocolytic, mineral Action – required for normal physiologic functioning; is a cofactor in neurochemical transmission and muscular excitability; controls seizures by blocking peripheral neuromuscular transmission; also acts as a peripheral vasodilator and inhibitor of platelet function. o Asthma / Bronchospasm – MCO only 2Gm IV/IO (In 100ml NaCl) over 10-20 min o Cardiac Arrest VF/Pulseless VT – 1-2Gm IV/IO MCO Only o Wide Complex Tachycardia – 1-2Gm IV/IO in 100ml NaCl over 10 min MCO only o Seizures / Stat Ep – MCO only 2Gm IV/IO (in 100cc NaCl) over 10 min if eclampsia o OB / Pregnancy related – MCO only 2Gm IV/IO (in 100ml NaCl) over 10 min for seizures (may o Peds Non trauma arrest – MCO only 25-50mg/kg (max2Gm) IV/IO for torsades de pointes Side effects – magnesium toxicity (signs include flushing of the skin, diaphoresis, hypotension, muscle paralysis, weakness, hypothermia, and cardiac, CNS or respiratory depression; prolonged PR interval’ widening of QRS Contraindications – AV Block, GI obstruction Pharmacokinetics – onset – immediate, peak effect – unknown, duration – 30-60 min, half life – NA Action – stimulates beta1 and alpha adrenergic receptors; increases peripheral resistance through vasoconstriction; enhances contractile myocardial force; increases cardiac output o Hypoperfusion/shock; acute pulmonary edema/anaphylaxis/ROSC ▪ MCO ONLY 2-4 mcg/min IV/IO initial dose (max dose 30 mcg/min) ▪ Use Large Vein / IV pump HIGHLY recommended Side effects – Anxiety, tremors, headache, dizziness, nausea, vomiting, reflex bradycardia, palpitations, increased myocardial oxygen demand – angina pain, dyspnea Contraindications – hypovolemic states; mesenteric/peripheral vascular thrombus; profound hypoxia Precautions – severe cardiac disease; hypothyroidism; patients taking MAOIs Pharmacokinetics – Onset – rapid, peak effect – 1-2 minutes, duration NA, Half Life short 1-2 min !Racemic Epinephrine / Micronefrin / S2 Vapoefrin Class – Bronchodilator; adrenergic agent; equivalent to 1:100 epinephrine Action – stimulates both alpha and beta receptors, causing vasoconstriction, reduced mucosal edema and bronchodilation. o Peds Resp Distress – MCO Only 0.05mg/kg in 3ml NS (max 5ml) via nebulizer for suspected Side effects – increased heart rate, nausea, anxiety, heart palpitiation and headache. Contraindications – epiglottitis, known sensitivity to sulfites Precautions – tachycardia and arrythmias Pharmacokinetics – Onset – 3-5 min, peak effect – 20 min, duration 1-3 hours, half life – 2min Questions
The receptors responsible for increasing heart rate and automaticity are - beta receptors Amiodarone is a class 3 antiarrythmic. Its action blocks – all of the above Side effects of amiodarone may include all – hypotension Diltiazem prolongs the conduction of electrical impulses through the - AV node Contraindications for diltiazem administration include all of the following except – Tachycardia Magnesium Sulfate is clinically used to treat the following conditions except – cardiac chest pain A sign of magnesium toxicity would be – hypotension Norepinephrine (levophed) is listed as what drug class – sympathomimetic A precaution for norepinephrine (levophed) administration is – severe cardiac disease Racemic Epinephrine - Stimulates both alpha and beta receptors causing vasoconstriction, reduced mucosal edema and bronchodilation. Side effects of the use of racemic epinephrine include – tachycardia Causes – Congenital adrenal insufficiency (CAH); Infection; injury; auto-immune reaction of the adrenal gland secondary to TB, trauma or addisons disease Signs and Symptoms – Hypoglycemia, dehydration, weight loss, AMS, weakness/lethargy, dizziness, hypotension, muscle aches, nausea / vomiting. Action – inhibits accumulation of inflammatory cells at inflammation sites; as a steroid, it replaces the steroids that are lacking in adrenalinsufficiency o Hypoperfusion / shock – 2mg/kg IV/IO (max dose 100mg) o Adrenal insufficiency MUST be confirmed by patient record, family or medical alert tag Side effects – insomnia; heartburn; anxiety; abdominal distention; diaphoresis; acne; mood swings; increased appetite; facial flushing; delayed wound healing; increased susceptibility to sepsis, diarrhea or constipation; leukocytosis; hyperglycemia Action – educes inflammation and immune responses by inhibiting the synthesis of pro-inflammatory enzymes; intermediate to long acting steroid o Asthma / Bronchospasm, COPD – 12mg IV/IO/IM Medic standing order MCO for both o Anaphylaxis – 12mg IV/IO/IM standing order and MCO for both o Peds resp distress – MCO only 0.6mg/kg IV/IO Side effects – nausea/vomiting, water retention – edema, hypertension, hyperglycemia, immunosupression Contraindications – fungal infections, hypersensitivity Precautions – respiratory TB; Untreated systemic infections; hyperthyroidism; cirrhosis; ulcerative colitis; hypertension; chf; seizure disorder; peptic ulcer disease; diabetes Pharmacokinetics – Onset - 1hr; peak effect - 1hr; duration – variable; half life – 3-4.5hrs Action – reduces inflammation by multiple mechanisms; inhibits the synthesis of pro-inflammatory enzymes; intermediate acting steroid. o Asthma / Bronchospasm – 125mg IV/IO/IM – Standing order medic; MCO for both o COPD – 125mg IV/IO – Standing order for medic; MCO for both o Anaphylaxis – 125mg IV/IO – Standing orders and MCO for both o Peds resp distress & Peds anaphylactic reaction– MCO only 2mg/kg IV/IO (max dose 60mg) Side effects – depression; euphoria; headache; restlessness; hypertension; bradycardia; nausea/vomiting; swelling; diarrhea; weakness; fluid retention (edema); parasthesias Contraindications – cushings syndrome; fungal infection; measles; varicella; known sensitivity (including sulfites) Precautions – active infections; renal disease; penetrating spinal cord injury; hypertension; seizures; CHF Pharmacokinetics – Onset – immediate; peak effect – 30min; duration 8-24hrs; half life 3-3.5hrs Class – Selective receptor (serotonin type 3) antagonist; antinausea; antiemetic Action – blocks serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone. o Procedural Sedation – 4mg IV/IO may be repeated MCO Only o Severe Nausea / vomiting – 4mg IV/IO over 2 min (may be repeated) medic standing order Side effects – Headache; dizziness; malaise; drowsiness; fatigue; weakness; extrapyramidal reactions; chest pain; hypotension constipation; diarrhea; abdominal pain; dry mouth; urinary retention; bronchospasm; rash; shivering; anaphylaxis Precautions – hepatic disease, not recommended for children under 12 years of age. Pharmacokinetics – Onset – immediate; peak effect 15-30min; duration 4-8hrs; half life 4hrs. Action – tetracaine blocks both the initiation and conduction of nerve impulses by decreasing the neuronal membranes permeability to sodium ions. This reversibly stabilizes the membrane and inhibits depolarization, resulting in the failure of a propagated action potential and subsequent conduction blockade. o Poisoning / OD / toxic exposure – MCO only eye injury 2 gtts in the effected eye(s) before Side effects – minor initial burning, redness and irritation. Pharmacokinetics – onset – immediate; peak effect – NA; Duration – 15-30min; Half Life 30-60sec Questions
Patients with adrenal insufficiency have signs & Symptoms which include – hypotension The correct medication for the treatment of adrenal insufficiency is – solucortef One side effect of dexamethasone is – hyperglycemia All are precautions for the administration of dexamethasone except – hypotension Clinical uses for methylprednisolone include – All of the above One side effect of solumedrol administration is – fluid retention Ondestetron (Zofran) falls into what drug class – Selective serotonin type 3 antagonist Which patient should ondansetron (zofran) NOT be administered to – 8M with acute appendicitis Tetracaine is used clinically for – acute eye pain from injury or chemical reaction Tetracaine is contraindicated for – known hypersensitivity
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