Drug Monographs Flashcards
Classification of Ketamine?
Analgesic
Sedative
General anesthetic
What are the contraindications for Ketamine?
Hypersensitivity to ketAMINE
Unable to manage the adverse effects of ketAMINE
Conditions where elevated blood pressure may be harmful
ACP: Age < 6 months
What is the IN dosing for ketamine?
0.75 mg/kg (see intranasal ketamine dosing chart)
May repeat 0.5 mg/kg after 20 minutes
Maximum single dose 100 mg
What is the analgesia dosage for Ketamine for analgesia?
Intravenous/Intraosseous
0.3 mg/kg slow push
May repeat 0.15 mg/kg after 5 minutes
Maximum cumulative dose 0.6 mg/kg in 45 minutes
Intramuscular
0.5 mg/kg
May repeat 0.3 mg/kg after 45 minutes
What is the dose for ketamine for procedural sedation?
Intravenous/Intraosseous
0.1-0.5 mg/kg slow push every 60 seconds to effect
Consider starting at 0.5 mg/kg; use subsequent doses of 0.25 mg/kg or less as needed
Titrate to effect
What are the anasthesia doses for ketamine? (Induction and anesthesia)
ACP: Anesthesia Induction
Intravenous/Intraosseous: 2 mg/kg if shock index < 1
Intravenous/Intraosseous: 1 mg/kg if shock index ≥ 1
ACP: Maintenance of Anesthesia
Half of required induction dose every 10-15 minutes as required
What is the dosage of ketamine for treatment of excited delirium?
Intramuscular
4-5 mg/kg bolus
Maximum single/cumulative dose 500 mg
CliniCall consultation required if appropriate sedation is not achieved
Maximum volume of administration
Deltoid: 2 mL
Lateral thigh: 4-5 mL
Gluteal: 5 mL
What is the mechanism of action for ketamine?
Ketamine is a non-competitive NMDA receptor antagonist that blocks glutamate. Low doses produce analgesia and modulate central sensitization, hyperalgesia, and opioid tolerance. Reduces polysynaptic spinal reflexes.
What are the pharmacokinetics of ketamine?
Onset:
Intravenous: 30 seconds (anesthesia) Intramuscular: 3-4 minutes (anesthesia)
Intranasal: 5-10 minutes (analgesia)
Peak:
Intranasal: 20 minutes
Duration:
Intravenous: 5-10 minutes (anesthesia); recovery 1-2 hours
Intramuscular: 12-25 minutes; recovery 3-4 hours
Intranasal: 45 minutes (analgesia)
What are the adverse effects of ketamine?
Emergence phenomenon: confusion, delirium, excitement, hallucinations
Tachycardia and hypertension (> 10%)
Laryngospasm (< 1%)
Bradycardia and hypotension (1-10%)
Anaphylaxis (< 1%)
Hypersalivation (< 1%)
Extreme muscle rigidity or tone (< 1%)
Nystagmus, increased intraocular pressure
Apnea and respiratory depression (rare; transient reaction with rapid IV bolus dose)
Erythema, morbiliform rash, rash at injection site
Laryngospasm is a known and rare complication of ketAMINE administration; when it occurs, is usually transient
What are the warnings and precautions for ketamine?
Use with caution in:
Severe hypertension (systolic BP > 180 mmHg)
Subarachnoid hemorrhage or epidural hematoma with severe hypertension
Myocardial ischemia or cardiac arrhythmias
What is the classification for Midazolam?
Short-acting benzodiazepine
What are the indications for Midazolam?
ACP: Sedation of agitated patients
ACP: Control of seizures
ACP: Maintenance of anesthesia in intubated patients
What are the contraindications for Midazolam?
Hypersensitivity to MIDAZOLam or other benzodiazepines Acute narrow-angle glaucoma Shock Decreased level of consciousness Hypotension
What are the adult doses for Midazolam?
All indications
2-5 mg IV/IO in increments to effect
5-10 mg IM
May repeat as required in small increments
Maximum dose from all sources is 30 mg
What is the mechanism of action for Midazolam?
Like other benzodiazepines, MIDAZOLam intensifies the activity of gamma aminobutyric acid, the major inhibitory neurotransmitter in the central nervous system. This action is believed to result in hyperpolarization of neuronal cells, which then take longer to reach threshold and depolarize.
What are the pharmacokinetics of Midazolam?
Onset: 3-5 minutes (IM); 1-3 minutes (IV)
Peak: 15 minutes (IM); 10 minutes (IV)
Duration: 30 minutes (IM); 20 minutes (IV)
What are the potential adverse effects of Midazolam?
Sedation, headache, blurred vision Hypotension Nausea and vomiting Pain and tenderness if given IM Respiratory depression
How to manage a midazolam OD?
Benzodiazepine overdoses should be managed supportively, with oxygenation and ventilation supported as necessary, and fluids given to maintain an adequate blood pressure. Reversal agents are available in-hospital.
What are the warnings for Midazolam?
Use with caution when administering other central nervous system depressants or narcotic analgesics.
What are the notable drug interactions of midazolam?
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.
What is the classification of epinephrine?
Catecholamine
Sympathomimetic
What are the indications for epinephrine?
PCP: Anaphylaxis
PCP: Severe bronchospasm
PCP: Severe croup
ACP: Cardiac arrest
ACP: Peri-arrest hypotension
ACP: Significant bradycardia
What are the contraindications for epinephrine?
There are no absolute contraindications to EPINEPHrine use in life-threatening situations such as anaphylaxis. IT WAS A TRICK QUESTION.
What are the adult doses for Epi? (All indications)
Anaphylaxis: 0.5 mg IM every 5 minutes; may repeat up to 3 times
Severe bronchospasm with impending respiratory arrest: 0.5 mg IM every 5-20 minutes
Pre-arrest anaphylaxis or bronchospasm: 50-100 mcg IV/IO; may repeat as necessary
Cardiac arrest: 1 mg IV/IO every 3-5 minutes; suggested maximum dose 3-4 mg
Peri-arrest hypotension: 10 mcg IV/IO slow push every 2-3 minutes as required
Significant bradycardia: 2-10 mcg/minute IV/IO infusion
What is the mechanism of action for epinephrine?
EPINEPHrine acts on alpha and beta-adrenergic receptors. Alpha-adrenergic activity produces vasoconstriction and reduces vascular permeability; beta-adrenergic activity results in bronchial smooth muscle relaxation, increased heart rate, and increased force of cardiac contractility. EPINEPHrine also inhibits histamine release.
What is the mechanism of action for epi?
EPINEPHrine acts on alpha and beta-adrenergic receptors. Alpha-adrenergic activity produces vasoconstriction and reduces vascular permeability; beta-adrenergic activity results in bronchial smooth muscle relaxation, increased heart rate, and increased force of cardiac contractility. EPINEPHrine also inhibits histamine release.
What are the pharmacokinetics of epi
Onset: 30-90 seconds (IM); 30 seconds (IV)
Peak: 4-10 minutes (IM); 3-5 minutes (IV)
Duration: 5-10 minutes (IM/IV)
What are the adverse effects of epi?
Common reactions to systemically administered EPINEPHrine include anxiety, tremor, dizziness, sweating, palpitations, headache, and nausea
Rapid increases in blood pressure and heart rate can occur
Accidental injection of epinephrine into a digit, hands, or feet may result in a loss of blood flow to the area
What are the effects of an epinephrine OD?
EPINEPHrine overdose may produce significantly elevated blood pressures and heart rate, which may in turn cause cerebral hemorrhage.
What are the warnings for epi administration?
Patients with underlying coronary artery disease may develop signs and symptoms of angina or myocardial ischemia. Caution should be exercised in these cases.
Caution should be used in patients with significant tachydysrhythmias or in the context of hypothermia.
What are the potential drug interactions of epi?
Arrhythmias can develop in patients taking antiarrhythmic medications. Beta-adrenergic blocking drugs can limit the effectiveness of EPINEPHrine’s bronchodilating and inotropic effects.
What is the classification of ipratropium?
Anticholinergic bronchodilator
What are the indications for ipratropium administration?
ACP: Severe bronchospasm in asthma and chronic obstructive pulmonary disease
What are the contraindications to ipratropium administration?
Known hypersensitivity to ipratropium or any formulation components
Adult dosages for ipratropium?
ACP: Severe bronchospasm in asthma or chronic obstructive pulmonary disease
160 mcg via metered-dose inhaler (8 x 20 mcg sprays)
Spacer use recommended, but not required
What is the mechanism of action for ipratropium?
Ipratropium antagonizes the activity of acetylcholine in bronchial smooth muscle, producing bronchodilation and muscle relaxation.
What are the pharmacokinetics of ipratropium?
Onset: 3-5 minutes
Peak: 1.5-2 hours
Duration: 6 hours
What are the adverse effects of ipratropium?
Adverse effects are similar to other anticholinergics and can include atrial arrhythmias and blurred vision
Coughing is common
Paradoxical bronchospasm can occur during the use of inhaled bronchodilators; this is not the same thing as an inadequate response to treatment
What are the risks of an overdose of ipratropium?
Very high doses of ipratropium (up to 1.2 mg) have been given to volunteers without the development of serious systemic side effects.
What are the warnings and precautions for ipratropium?
Ipratropium is intended to act synergistically with salbutamol as part of a management plan for bronchospasm. It is not indicated for episodes of acute bronchospasm as monotherapy.
Avoid spraying ipratropium into the eyes of patients with narrow-angle glaucoma.
