Drug Profiles: Winter Final Flashcards
Vasopressin: Mechanism of Action
In high doses, vasopressin acts as a non-adrenergic peripheral vasoconstrictor. When given during CPR, vasopressin increases coronary perfusion pressure.
Diltiazem: Contraindications
Should not be administered to any patient with hypotension, cardiogenic shock, VT, or A flutter, and A fib with WPW (may percipitate ventricular fibrillation).
Succinylcholine: Pharmacokinetics
Onset: 1-2 minutes. Duration: 6-10 minutes.
Rocuronium (Zemuron): Precautions
Not routinely used in EMS as the initial paralytic due to the long duration of action.
Vasopressin: Pharmacokinetics
Onset:
Succinylcholine: Contraindications
Hyperkalemia, history of malignant hyperthermia, penetrating eye injury, neuromuscular disorder (MS), Paralysis >1 day, crush injury >3 days.
Succinylcholine: Mechanism of Action
Combines with cholinergic receptors in motor nerves to cause depolarization. Neuromuscular transmission is inhibited, causing temporary skeletal paralysis, untill it is metabolizedand the cells become repolarized.
Vasopressin: Precautions
Do not give to patients with perfusing rhythms.
Diltiazem: Dosage
0.25 mg/kg or 2 minutes Repeat 0.35 mg/kg if no response in 15 minutes. Maintenance infusion of 5-15 mg/hr
Succinylcholine: Class
Depolarizing neuromusculaar blocking agent.
Diltiazem: Pharmacokinetics
Onset: Immediate Peak: Immediate Duration: 1-3 hours
Etomidate: Note
Etomidate is able to lower ICP while maintaining CPP, making it a useful agent in patients with increased ICP.
Rocuronium (Zemuron): Interactions
Intensity and duration, or paralysis may be prolonged by pretreatment with succinylcholine, general anesthesia (inhalation), lidocaine, quinidine, procainamide, beta-adrenergenic-blocking agents, potassium-losing diuretics, or magnesium.
Rocuronium (Zemuron): Dosage
RSI: 0.6 mg/kg
Vasopressin: How Supplied
20 units/ml vial
Vasopressin: Dosage
Single bolus dose of 40 units IV. After 3 to 5 minutes, if no response, give 1 mg Epi doses
Rocuronium (Zemuron): Description
A non-depolarizing neuromuscular blocking agent with rapid to intermediate onset, depending on dose, and intermediate duration of action.
Ketamine: Mechanism of action
Phencyclidine derivitive causes “dissociative anaesthesia” characterized by profound analgesia and amnesia with retention of protective airway reflexes, spontaneous respirations and cardiopulmonary stability. Dissociative anesthesia results in a patient who does not appear to be anesthetized and can swallow and open eyes but does not process information or pain. Other actions: keeps airway reflexes intact; releases endogenous catecholamines; maintaines BP and heart rate; relaxes bronchial muscles; stimulates beta receptors in the lungs.
Rocuronium (Zemuron): Contraindications
None in EMS.
Etomidate: Mechanism of Action
Decreases activity of the reticular formation in the brain with minimal cardiac and respiratory effects.
Ketamine: Contraindications
Coronary artery disease, pregnany, infants < 3 months; tracheal stenosis or tracheomalacia, acute globe injury or laucoma; schizophrenia.
Ketamine: Pharmacokenetics
Onset: 30-60 seconds Duration: 5-15 minuets
Vasopressin: Class
Anti-diuretic hormone.
Diltiazem: Class
Calcium Channel Blocker
Succinylcholine: Indications
To achieve temporary paralysis when endotrachial intubation is indicated and muscletone impedes successful intubation.
Ketamine: Precautions
Administer with midazolam 2.5 mg IV/IO in adults to prevent/treat negitive emergnce reaction (not necessary in peds); monitor for laryngospasm (0.1%)
Diltiazem: Precautions
Can cause systemic hypotension (blood pressure should be constantly monitored). Calcium can be used to prevent the hypotensive effecs of calcium hannel blockers and in the management of calcium channel blocker OD.
Succinylcholine: Note
Store in refrigerator at 2-8 deg C (36-46 deg F). The multi dose vials are stable for upto 14 days at room temprature without significant loss of potency.
Ketamine: Side effects
Emergence reaction (5-30%); may cause hypertension, increase cardiac output and myocardial oxygen consumption; may transiently increase intracranial pressure and cardiac perfusion pressure.
Etomidate: Indications
General anasthesia, EMS intuation.
Rocuronium (Zemuron): pharmacokinetics
Onset: 60-90 seconds Duration: 30 minutes
Etomidate: Pharmacokinetics
Onset: 10-20 seconds Duration: 3-5 minutes
Etomidate: Class
General anasthetic.
Vasopressin: Indications
Ventricular fibrillation, pulseless VT, PEA, and or asystole.
Etomidate: Contraindications
None in prehospital.
Rocuronium (Zemuron): Indications
Rapid sequence intubation, maintenance of desired paralysis.
Rocuronium (Zemuron): Side Effects
Bronchospasm; associated with a slight elevation of the heart rates and BP. Tachycardia may occur in pediatric patients.
Diltiazem: Interactions
Should not be administered to patiens recieving IV B-blockers because of an increased risk of CHF, bradycardia, and asystole
Etomidate: Dosage
0.3 mg/kg IV. Max 20 mg.
Etomidate: Side effects
Involuntary muscle movements (myoclonus - rarely seen due to concurrent administration of paralytics)
Succinylcholine: Side Effects
Arhythmias, bradycardia, increased inraoccular pressure, increased intracrainial pressure, hyperkalemia.
Vasopressin: Contraindications
None in EMS.
Vasopressin: Side Effects
None in cardiac arrest.
Ketamine: Indications
Analgesia and sedation for painful procedures or painful conditions; induction agent for RSI (instead of etomidate).
Succinylcholine: Precautions
Make sure all intubation equipment is ready prior to administration of succinylcholine. Be wary of a patient’s potential to become bradycardicduring RSI, especially patients with CHF.
Diltiazem: Mechanism of Action
Diltiazem interferes with the entry influ of calcium into cardiac and vascular smooth muscle. In addition it slowes the rate of the SA node and the conduction velosity through the AV node. Diltiazem’s ability to relax coronary arteries, as well as its negitive inotropic and negitive chronotropic qualities makes it a useful antianginal. It is also used as an antihypertensive. however in the EMS setting, we use it primarily as an antidysrhythmic so its ability to slow the conduction through the AV node is most pertinent.
Ketamine: Class
Sedative, Analgesic
Succinylcholine: Dosage
Adult: 1-2 mg/kg IV (IM if in protocol) Pediatric: 2 mg/kg IV
Ketamine: Dosage
Induction agent: 2 mg/kg IV/IO Analgesia, sedation:
Diltiazem: Indications
To control rapid ventricular rates associated with atrial fibillation and atrial flutter, and SVT refractory to adenosine.
Diltiazem: Side Effects
Dizziness, headache, bradycardia, heart block, hypotension, and asystole.
Rocuronium (Zemuron): Mechanism of Action
Competitively binds to cholinergic receptors. Reversible in the presence of acetylcholinesterase inhibitors, such as neostigmine.
Rocuronium (Zemuron): Class
Non-depolarizing neuromuscular blocker.
Ketorolac: indications
mild to moderate pain
Calcium Gluconate: side effects
Tissue necrosis if given subcutaneously, or if it extravasates.
Calcium Chloride: pharmacokinetics
onset: immediate peak: immediate
Droperidol: dosage
14-60 y/o: 2.5-5 mg IV/IM (may be combined with 2 mg midazolam in same syringe for increased sedation), may be repeated once as needed. Over 60 y/o: 2.5 mg IV/IM (with or without midazolam). Not recommended as first-line N&V med because of “black box” warning from FDA.
Sodium Bicarbonate: contraindications
none prehospital setting
Promethazine: side effects
Drowsiness, sedation, blurred vision, tachycardia, bradycardia, and dizziness
Magnesium Sulfate: interactions
may block effects of digitalis
Calcium Chloride: interactions
Will precipitate if mixed with sodium bicarbonate.
Calcium Gluconate: precautions
Use with caution in patients with potential to dioxin toxicity. Consider contacting OLMC.
Ketorolac: mechanism of action
NSAIDs inhibit cyclooxygenase and prevent the synthesis of prostaglandins and thromboxane, which reduce inflammation and ultimately provide pain relief.
Diphenhydramine: class
antihistamine; H1 antagonist
Droperidol: indications
Chemical restraint requiring rapid tranquilizationn, anti-emetic.
Haloperidol: contraindications
Hypotension, prolonged QT interval
Calcium Gluconate: dosage
10-30 ml slow IV. topical application inside surgical glove (gel or not) for finger/ thumb/ hand fluoride burns. 10 ml vile of 10% calcium gluconate contains 4.6 mEq of calcium.
Promethazine: precautions
May impair mental and physical abilities. Never give subcutaneously. Extra-pyramidal symptoms have been reported following use. Diphenhydramine should be available.
Calcium Chloride: dosage
5-10 ml slow IVP. 10 ml of 10% solution contains 13.6 mEq of calcium
Droperidol: precautions
BP and respiratory status should be monitored frequently. If used for chemical restraint, patient should be restrained in a fashion that allows careful observation and the ability to breathe normally. Cardiac monitoring is required as the FDA has issued a “black box” warning stating that Droperidol may cause torsades de pointes.
Calcium Chloride: class
electrolyte
Droperidol: mechanism of action
Exact mechanism of action is unknown, but main action is antagonism of the dopamine (D2) within the CNS. Neuroleptic similar to how to parallel; reduces anxiety and produces a mental state of detachment and indifference; as anti-medic and anti-nausea properties.
Ondansetron: indications
Uncontrollable nausea and vomiting
Diphenhydramine: interactions
Sedation in presence of CNS depressants
Acetaminophen: mechanism of action
Produces analgesia by blocking generation of pain impulses probably by inhibition of prostaglandin synthesis. It relieves fever by central chain action in the hypothalamus heat regulating center.
Fentanyl Citrate: precautions
Monitor respiratory status. Naloxone will reverse the effects of fentanyl.
Acetaminophen: side effects
none
Magnesium Sulfate: mechanism of action
increases the magnesium levels, correcting for possible hypomagnesemia, which is associated with cardiac dysrhythmias. Magnesium interferes with neuromuscular transmission, which reduces muscle contractions in seizures. Additionally magnesium is a smooth muscle relaxer and vasodilator. The MOA’s of magnesium for all indications are complex and multifactorial, and therefore, not well understood.
Magnesium Sulfate: contraindications
hypotension, heart block
Droperidol: contraindications
Hypotension, prolonged QT interval
Sodium Bicarbonate: dosage
1 milliequivalent/kg IVP
Diphenhydramine: pharmacokinetics
Onset: < 2 minutes IV; 15-30 minutes IM Peak: 5 minutes IV; 20 minutes IM Duration: 5-10 minutes IV; 20-30 minutes IM
Acetaminophen: indications
fever
Fentanyl Citrate: note
100 mcg fentanyl equals 10 mg morphine. Schedule II narcotic.
Diphenhydramine: mechanism of action
Antagonizes central and peripheral H1 receptors, which decreases the itching and urticaria caused by histamine release. Additionally, possesses anticholinergic properties, resulting in anti-dyskinetic, anti-emetic and sedative effects.
Diphenhydramine: indications
Allergic and anaphylactic reactions. Dystonic reactions/extra-pyramidal symptoms (from phenothiazines, thioxanthins, and butyrophenones.
Calcium Chloride: side effects
Tissue necrosis if given subcutaneously, or if it extravasates. Because calcium chloride contains approximately 3 times as much calcium as calcium gluconate, it is far more irritating to blood vessels.
Calcium Gluconate: indications
Hyperkalemia, CCB OD, hypotension associated with magnesium sulfate or calcium channel blocker administration, and hydrofluoric acid burns.
Haloperidol: indications
Chemical restraint requiring rapid tranquilization
Fentanyl Citrate: side effects
Drowsiness, hypotension, bradycardia, and respiratory depression are the most common, however it may cause nausea and vomiting, weakness, and dizziness, increased excitability (paradoxical)
Sodium Bicarbonate: side effects
few in prehospital setting
Haloperidol: precautions
BP and respiratory status should be monitored frequently. Patients should be restrained in a fashion that allows careful observation and the ability to breathe normally. Cardiac monitoring is required
Calcium Chloride: precautions
Use with caution in patients with potential the jocks and toxicity. Consider contacting OLMC.
Fentanyl Citrate: contraindications
severe hemorrhage and shock. Patients who have taken MAOIs (Marplan, Eutonyl, Parnate, Nardil) within the last 14 days should avoid fentanyl. Severe and then predictable potentiation is possible. Use with caution, if at all in any patient with a head injury (except during RSI). If the patient’s mentation becomes altered after administration, assessment of the head injury because more difficult in the ED.
Calcium Gluconate: pharmacokinetics
onset: immediate peak: immediate
Ketorolac: precautions
Use cautiously, if at all, in patients with renal or hepatic disease.
Ondansetron: dosage
4 mg slow IVP/IM
Haloperidol: side effects
Extra-pyramidal or dystonic reactions, frequently given concurrently with diphenhydramine.
Haloperidol: interactions
Anti-hypertensive medications may increase the likelihood of a patient developing hypotension. haloperidol potentiates other CNS depressants
Fentanyl Citrate: interactions
Other CNS depressants enhance the opioid action, resulting in decreased LOC, hypotension, and respiratory depression. Careful monitoring is required.
Promethazine: contraindications
Coma, those who have received large amounts of depressants, nursing mother, neonate.
Droperidol: class
Sedative, butyrophenone anti-psychotic
Promethazine: class
Antihistamine and anti-emetic, phenothiazine anti-psychotic
Sodium Bicarbonate: precautions
Patients must be breathing spontaneously or adequately ventilated before receiving sodium bicarbonate.
Magnesium Sulfate: dosage
Cardiac arrest: 1-2 g IVP Torsades de pointes (with pulse): 1-2 g IV drip 5-60 minutes Preeclampsia and eclampsia: 2 g IV drip 5-60 minutes
Diphenhydramine: contraindications
None in acute prehospital use
Magnesium Sulfate: side effects
hypotension, respiratory depression, flushing, loss of deep tendon reflexes.
Fentanyl Citrate: pharmacokinetics
Onset: < 1 minute IV Duration: 30-60 minutes
Calcium Gluconate: mechanism of action
Calcium antagonizes cardiotoxicity of hyperkalemia by stabilizing cardiac cell membrane against undesirable depolarization. Soluble calcium ions bind with sodium fluoride ions to produce the insoluble and therefore inactive calcium fluoride salt.
Diphenhydramine: precautions
Altered mental status, asthma, nursing mothers
Promethazine: dosage
N&V: 12.5-25 mg IV/IM Analgesic adjunctive: 25 mg IV
Haloperidol: dosage
2-5 mg IM (may be combined with midazolam)
Diphenhydramine: dosage
Adult: 25-50 mg IV/IM/PO Pediatric: 1 mg/kg up to adult dose
Ketorolac: class
non-steroidal anti-inflammatory agent
Sodium Bicarbonate: note
mass actually effect = H2O + CO2 <> H2CO3 <> H+ +HCO3-
Acetaminophen: OD management
Early symptoms are sweating, anorexia, nausea or vomiting, abdominal pain or cramping and/or diarrhea; usually in 6-14 hours after ingestion, lasting up to 24 hours. Late symptoms include abdominal swelling (ascites), tenderness or pain 2-4 days post exposure. Give activated charcoal > 2 hours post ingestion. The patient will require N-acetylcysteine and will need serum acetaminophen levels determined at the ED.
Droperidol: side effects
Extra-pyramidal or dystonic reactions, especially in children. Diphenhydramine should be available.
Promethazine: pharmacokinetics
Onset: 3-5 minutes
Droperidol: interactions
Anti-hypertensive medications may increase the likelihood of a patient developing hypotension. Droperidol potentiates other CNS depressants.
Ketorolac: contraindications
allergy to any NSAID
Promethazine: mechanism of action
Blocks receptors for dopamine (D2), acetylcholine, and histamine (H1). All three of these neurotransmitter sites are implicated in the vomiting reflex, so thought to be involved in promethazine anti-emetic effects. Sedative effect is thought to be mostly related to antihistamine properties. EPS (adverse effects) are thought to be mostly related to dopamine antagonism.
Acetaminophen: dosage
Adult: 650-1000 mg PO Pediatric: 10-20 mg/kg
Haloperidol: class
Sedative, neuroleptic, butyrophenone anti-psychotic
Calcium Gluconate: interactions
Will precipitate if mixed with sodium bicarbonate.
Fentanyl Citrate: class
opioid analgesic (narcotic)
Sodium Bicarbonate: class
alkalinizing agent
Ondansetron: mechanism of action
Selective inhibitor of serotonin (5-HT3) receptors
Ondansetron: class
Anti-emetic
Fentanyl Citrate: indications
Moderate to severe pain, adjunct in rapid sequence induction (intubation).
Droperidol: pharmacokinetics
Onset: 3-10 minutes IV/IM
Acetaminophen: contraindications
none in prehospital setting
Haloperidol: mechanism of action
Not well understood but blocks dopamine (D2) receptors in brain; produces marked tranquilization and sedation.
Ketorolac: side effects
increased risk of bleeding, especially given with other NSAIDs.
Calcium Gluconate: class
electrolyte
Acetaminophen: precautions
Many nonprescription products contain acetaminophen, consider this when calculating dosage.
Sodium Bicarbonate: indications
TCA OD, late in the management of cardiac arrest, if at all. Hyperkalemia (controversial)- routine use of sodium bicarbonate for hyperkalemia is falling out of favor, but it is still present in some protocols.
Fentanyl Citrate: mechanism of action
Binds to various opioid receptors, producing analgesia and sedation (opioid agonist).
Magnesium Sulfate: indications
Torsades de pointes, cardiac arrest only if torsades de pointes is present or was the rhythm that preceded VF or if hypomagnesemia is suspected, preeclampsia and eclampsia, refractory bronchoconstriction, TCA OD (if QRS is wide) (controversial)- no longer universally thought to be effective for TCA ODs, but still in some protocols.
Sodium Bicarbonate: interactions
Deactivates catecholamines, forms precipitate with calcium chloride (if sodium bicarbonate is given before or after any of these drugs, flushed the IV line to prevent interactions)
Ondansetron: contraindications
None known, use with caution in setting of bowel obstruction.
Fentanyl Citrate: dosage
2 mcg/kg IV/IO/IM, usually up to 100 mcg
Acetaminophen: class
antipyretic, non-narcotic analgesic
Acetaminophen: how supplied
PO or rectal suppositories
Magnesium Sulfate: precautions
calcium chloride is antidote if respiratory depression ensues, caution in renal failure patients.
Ketorolac: dosage
60 mg IM or 30 mg IV (decreased dose by 1/2 if > 65 y/o)
Sodium Bicarbonate: mechanism of action
When disassociated, bicarbonate binds with hydrogen ions to decrease metabolic acidosis (mass action effect). When administered for TCA overdose, acts as an anti-dysrhythmic. It is unlikely that sodium bicarbonate decreases the effects of hyperkalemia by shifting potassium into cells as has been previously thought. However sodium bicarbonate can still be useful in the treatment of hyperkalemia, since this condition is frequently accompanied by metabolic acidosis.
Promethazine: indications
Nausea and vomiting, motion sickness, and sedation (to potentiate the effects of analgesics).
Calcium Chloride: mechanism of action
Calcium antagonizes cardiotoxicity of hyperkalemia by stabilizing cardiac cell membrane against undesirable depolarization. Soluble calcium ions bind with soluble fluoride ions to produce the insoluble and therefore inactive calcium fluoride salt.
Diphenhydramine: side effects
Anticholinergic effects. Most common are constipation, decreased sweating, difficulty in initiating her in stream, visual disturbances, photosensitivity, and dry mouth.
Calcium Chloride: indications
Hyperkalemia, CCB OD, hypotension associated with magnesium sulfate or calcium channel blocker administration, and hydrofluoric acid burns.
Acetaminophen: interactions
Increased risk of hepatic damage if patient has ingested ethanol.
Magnesium Sulfate: class
electrolyte, anti-dysrhythmic
