ACP Rx BCEHS Indications/Contraindications

Question 1

Acetaminophen

Answer 1

Indication:
* Mild to moderate pain
* pyrexia

Contraindication:
* Allergy
* Alcoholic hepatitis or liver dysfunction with active ETOH consumption
* Acute liver injury
* Acetaminophen-induced liver disease

Question 2

ASA

Answer 2

Indication:
* CP or s/s consistent with cardiac ischemia

Contraindication:
* Allergy
* Hx of bronchospasm or resp rxn’s precipitated by ASA or NSAIDs
* Active or recent bleeds of any kinds (GI, peptic ulcers, head injury)
* Pediatric pt’s with S/s of viral illnesses (d/t Reyes’s Syndrome)
o Reyes syndrome is developed by giving ASA to peds/teens with chicken pox, influenza or other flu-like illnesses

Question 3

Adenosine

Answer 3

Indication:
* Conversion & termination of SVT’s

Contraindication:
* Allergy
* 2/3* HB in Pt w/o a PPM
* Sick sinus syndrome in Pt w/o a PPM

Caution: call clinical
* May cause Vfib (if Pt is taking digoxin, verapamil) = clinical
* May worsen bronchoconstriction in COPD/asthma
* Carbamazepine may produce high degree of HB during adenosine use
* Dipyridamole potentiates the effects of adenosine = use smaller doses
* Methylxanthines (caffeine or theophylline) = antagonize adenosine = use larger doses of adenosine

Question 4

Amiodarone

Answer 4

Indication:
* Cardiac arrest: Vfib or pulseless VT
* Unstable VT (with a pulse) (CHADs)
* Recurrent VT following cardioversion
* Stable monomorphic WCT or symptomatic runs of WCT (* must call clinical) (monomorphic)

Contraindication:
* Allergy
* Cardiogenic shock (hypotensive, tachycardic/bradycardic)
* Marked symptomatic bradycardia
* 2/3* AVN HB
(Extra: Never use for Na+ blocker OD - TCA, cocaine, methadone = risk of long QTI or arrest)

Caution:
* Extravasation = tissue necrosis
* Potentiates the effects of BB, CCB, digoxin

Question 5

Atropine

Answer 5

Indication:
* Restoration of HR in brady-dysrhythmias
* Sinus brady (<50/min) with hemodynamic
compromise
* Brady 2* to AVN-HBs (no 3* HB)
* Organophosphate poisoning (clinical consult)
* Secretion control in palliative Pts

Contraindication:
* Allergy to atropine or anticholinergics
* Tachycardia
* Narrow angle glaucoma
* Thyrotoxicosis
* Prostatic hypertrophy
* Myasthenia Gravis

Question 6

Calcium Chloride

Answer 6

Indication:
* Cardiac Arrest d/t suspected Hyperkalemia (renal failure, DKA)
* Suspected HyperK+ with cardiovascular toxicity (wide QRS, peaked T waves, hemodynamic instability)
* CCB-OD with symptomatic bradycardia or hemodynamic instability

Contraindication:
* Allergy
* Primary or 2* HYPERcalemia

Caution:
* Extravasation of tissue (never IM/SC)
* Must give slow or risk: hypotension, arrythmias, cardiac arrest
* May worsen/cause acidosis, cor pulmonale, renal or resp diseases
* Must flush line following bicarb use
* Digoxin = increased risk of arrythmia development

Question 7

Dextrose
(all concentrations/bags = 25g dextrose)

Answer 7

Indication:
* Suspected or known hypoglycemia

Contraindication:
* None
* If have brain bleed = clinical consult (risk of further ICP/edema)

Question 8

DimenhyDRINATE

Answer 8

Indication:
* Prevention/control of nausea caused by motion sickness
* Relief of moderate-severe N/V
* Prevention/control of nausea r/t narcotics

Contraindication:
* Allergy to dimenhydrinate, diphenhydramine, caffeine derivatives

Caution:
* Potentiates effects of: ETOH, benzo’s, CND depressants
* Synergistic effects with Rx that have anticholinergic properties: TCA, MAOIs, antihistamines

Question 9

DiphenhydrAMINE

Answer 9

Indication:
* Adjunct Tx to hypersensitivity rxn (never to be given w/o epi)

Contraindication:
* Allergy to antihistamines
* Neonates
* Premature infants

Caution:
* Narrow-angle glaucoma, stenosing peptic ulcers pyloroduodenal obstruction, symptomatic prostatic hypertrophy, bladder neck obstruction
* Synergistic effects with Rx that have anticholinergic properties: TCA, MAOIs, antihistamines

Question 10

Epinephrine

Answer 10

Indication:
* Anaphylaxis
* Severe bronchospasm
* Severe Croup
* Cardiac arrest
* Peri-arrest hypotension
* Severe bradycardia

Contraindication:
* None in life-threatening situations (ie. Anaphylaxis)

Caution:
* Development of arrhythmias in Pt’s using anti-arrhythmic Rx
* BB’s can limit the effect of EPI in bronchodilation or inotropic effects (contractility)

Question 11

Fentanyl

Answer 11

Indication:
* Mod-severe pain
* Adjunct for awake intubation

Contraindication:
* Allergy to opioids (incl morphine)
* Myasthenia Gravis
* Pre-existing resp depression
* Acute Asthma
* Upper Airway Obstruction

Caution:
* Concurrent use of benzo’s or CNS depressants = severe sedation/resp depression

Question 12

Glucagon

Answer 12

Indication:
* Suspected/confirmed hypoglycemia (IV access not available)
* Suspected BB or CCB OD
Anaphylaxis (on BB refractory to Episode)

Contraindication:
* Allergy
* Pheochromocytoma (glucagon causes a release of catecholamines = ++HTN tachycardia = risk of brain bleed)

Caution:
* Hypoglycemia induced by ETOH = is unlikely revered with glucagon

Question 13

Glucogel 40%

Answer 13

Indication:
* Known/suspected hypoglycemia in conscious Pt with no airway concerns or risk of aspiration/choking

Contraindication:
* none

Question 14

Ibuprofen

Answer 14

Indication:
* Mild-mod pain
* pyrexia

Contraindication:
* Allergy to ibuprofen or other NSAIDs
* Active GI bleeds or ulcers
* Pregnant (1, 2, 3 trimester)

Caution:
* Risk BP increase

Question 15

Ipratropium

Answer 15

Indication:
* Severe bronchospasm in asthma or COPD

Contraindication:
* Allergy

Question 16

Ketamine

Answer 16

Indication:
* PCP-Mod-severe pain (associated to trauma) – adults & 5-12 yrs peds, PCP- Palliative Pts for pain mgmt.
* PCP-Mod-severe non-traumatic back pain
* PCP-Mod-severe pain assoc to abdo pain or renal colic
* Analgesia
* Induction of sedation prior to intubation
* PSA
* Severe Agitation or excited delirium states

Contraindication:
* No sedation at PCP level
* Allergy
* Unable to manage the effects of Ketamine
* Conditions where elevated BP may be harmful
* < 6month old (PCP <5yrs)

Caution:
* Severe HTN (+180 SBP)
* SAH or epidural hematoma with severe HTN
* Myocardial ischemia or cardiac arrhythmias
* Risk of emergence phenomenon (confusion, delirium, excitement, hallucinations)
* Laryngospasm, hypersalivation

Question 17

Lidocaine

Answer 17

Indication:
* Ventricular arrhythmias (ectopy, brief or sustained VT, VF)
* Cardiac arrest – VF/VT
* Local anesthesia during IO cannulation
* Local anesthesia during awake intubation (topical)

Contraindication:
* Allergy
* For systemic IV/IO admin including rhythm control & IO anesthesia:
o 3* HB
o VEB
o WPW
* Consider alternatives to CHF pts = clinical consult
* * some sources state contraindicated in 2* HB (these are supraventricular, in the post-arrest Pt, the benefits outweigh the risk)

Caution:
* Risk of lidocaine toxicity with: cimetidine, ranitidine, BB’s
* Use with disopyramide may precipitate bradycardia leading to cardiac arrest

Question 18

Magnesium Sulphate

Answer 18

Indication:
* Vfib & VT refractory to 1st line antiarrhythmics
* Recurrent, intermittent episodes of WCTs (polymorphic)
* TDP
* *Bronchospasm refractory to bronchodilation in acute asthma
* Seizure mgmt. in pregnancy assoc to HTN (eclampsia) (clinical consult)
* TCA OD - cardiac arrest mgmt
* Sotalol OD - WCT or recurrent/transient WCT

Contraindication:
* Allergy
* 2/3* HB

Caution:
* May prolong the effects of non-polarizing neuromuscular blockers
* May potentiate the effects of CCBs

Question 19

Midazolam

Answer 19

Indication:
* Sedation of agitated Pts (RASS +2-+3)
* Seizure control
* Maintenance of anesthesia in intubated Pts

Contraindication:
* Allergy to midaz or other benzo’s
* Acute narrow angle glaucoma
* Shock
* DLOC
* Hypotension

Caution:
* Erythromycin, diltiazem, verapamil, ketoconazole, fluconazole, and itraconazole can significantly increase the bioavailability of MIDAZOLam and may produce prolonged sedation.
* Ritonavir and nelfinavir may cause deep and prolonged sedation that may progress to respiratory depression.
* Rifampin, carbamazepine, and phenytoin may markedly reduce the effectiveness of MIDAZOLam.

Question 20

Morphine

Answer 20

Indication:
* Palliative or end-of-life Pts = symptom relief of pain or SOB

Contraindication:
* Allergy to any opioids

Caution:
* Asthma, bronchospasm, COPD

Question 21

Naloxone

Answer 21

Indication:
* Reversal of Resp depression caused by suspected narcotic intoxication

Contraindication:
* Allergy
* Neonate

Question 22

Nitroglycerin

Answer 22

Indication:
* Relief from CP suggestive of ACS
* Reduction of preload in acute cardiogenic P. Edema

Contraindication:
* Allergy
* Use of Viagra (sildenafil) or Levitra (Vardenafil) in 24 hrs
* Use of Cialis (Tadalafil) in 48hrs
* Severe anemia
* Restrictive pericarditis or pericardial tamponade
* Documented RV-MI
* Hypotension or uncorrected hypovolemia
* SBP <110 & HR btwn 50-150/min (for EMR/PCP)

Caution:
* SBP <110 with signs of hypo-perfusion = don’t give
* Hepatic or renal insufficiency
* Inferior ischemia (rule out RV-MI)
* Significant aortic stenosis
* Anti-HTN agents may act synergistically with Nitro

Question 23

Nitrous Oxide

Answer 23

Indication:
* Mod-severe pain (extremities, burns, no inhalation injuries)
*pregnancy- contraction pain

Contraindication:
* Traumatic or spontaneous pneumothorax
* Air embolism or decompression sickness following a recent SCUBA dive
* Bullous emphysema
* Gross abdominal distension
* Altered mental status or an inability to comply with instructions
* Inhalation injury (i.e., smoke or chemicals)
* Nitroglycerin use within five minutes prior to administration of nitrous oxide
Consider the use of the mnemonic CDCPAIN:
* Ability to Comply
* Decompression sickness
* Altered level of Consciousness
* Pneumothorax
* Air embolism
* Inhalation injury
* Nitroglycerin use within five minutes
Caution:
* hypotensive or in shock, have ingested or are suffering from the effects of depressant drugs, have a history of chronic obstructive pulmonary disease, or have suffered facial injuries.
* The depressant effects potentiated by the presence of other CNS depressants such as alcohol, sedatives, antihistamines, or psychotropic medications.

Question 24

Phenylephrine

Answer 24

Indication:
* Maintenance of BP in acute hypotensive states or shock following adequate fluid vol. replacement

Contraindication:
* Allergy
* Hypersensitivity to sulfites (contained in Rx)
* Severe HTN or VT
* Pheochromocytoma

Caution:
* Bradycardia, incomplete HB or underlying CVS disease
* Extravasation = necrosis
* Rapid IV admin = development of PVCs, VT, HTN
* Spinal cord injury or Spinal Shock = EPI better
* Post Cardiac Arrest = Epi better

Question 25

Salbutamol

Answer 25

Indication:
* Bronchospasm
* Adjunct mgmt. of HyperK+

Contraindication:
* Allergy
* Hemodynamically significant tachycardia

D/c:
* S/s toxicity: +150/min Hr (+200/min in peds), severe tremors, ventricular arrythmias

Question 26

Sodium Bicarb

Answer 26

Indication:
* Known/suspected HyperK+
* TCA or salicylate OD
* Suspected or confirmed metabolic acidosis
* Pre-Tx prior to weight release in crush injuries

Contraindication:
* Suspected metabolic alkalosis
* Hx of excessive vomiting (evidence of chloride loss)

Caution:
* Paradoxical worsening of metabolic acidosis if minute ventilation is inadequate (must have vent strategy in place)
* Metabolic alkalosis can cause hypoxia d/t left/upward shift of ODC
* Risk of: muscle tetany, seizures

Question 27

TXA

Answer 27

Indication:
* S/s of shock or hypoperfusion in association with an injury suggestive of occult or ongoing hemorrhage

Contraindication:
* Allergy
* GI bleed
* +3hrs since time of injury to administration
* <1yr old (ACP)
* <12 yrs old (PCP)

Caution:
* Hypotension if given to fast
* Only for IV admin