Drug Therapy Protocols Flashcards
What drug class is atropine?
Anticholinergic/antimuscarinic
How does atropine work?
Atropine inhibits the action of the parasympathetic nervous system allowing for an unchallenged sympathetic response.
It blocks the action of the vagus nerve on the heart and increases rate of SA node, conductions through the AV node, and blocks exocrine activity
Atropine blocks the action of the vagus nerve which results in what?
Increased rate of SA node
increased conduction through AV node
blocks exocrine activity
How is atropine metabolised and excreted?
Atropine is metabolised by the liver and excreted by the kidneys
What are the 4 indications for atropine?
Bradycardia with poor perfusion
Hypersalivation associated with ketamine
Envenomation with increased parasympathetic activity
Organophosphate toxicity with cardiac and/or respiratory compromise
What is the 1 contraindication for atropine?
Allergy and/or adverse reaction
What are the 4 precautions for atropine?
AF
Atrial flutter
AMI
Glaucoma (causes mydriasis which can precipitate vision loss)
What are the 5 side effects of atropine? Anticholinergic toxidrome
Mad as a hatter - hallucinations, agitation
Dry as a bone - dry mouth and skin, urine retention
Hot as a dessert -
Blind as a bat - mydriasis
Red as a beet - flushed skin
What is the presentation of atropine?
1.2mg in 1mL
What is the onset of atropine?
1-2 minutes (peak 15-50 minutes)
What is the duration of action of atropine?
Up to 5 hours
What is the half-life of atropine?
3-4 hours
What is the adult dose of atropine for bradycardia with poor perfusion?
600 micrograms
Repeated once after 2 minutes
Total max dose 1.2mg
What is the adult dose of atropine for envenomation with increased parasympathetic activity?
1.2mg
Repeat at 5 minute intervals
No maximum dose
What is the adult dose for atropine for hypersalivation secondary to ketamine administration?
600 micrograms
Single dose only
What is the adult dose of atropine for organophosphate toxicity?
1.2mg
Repeated at 5 minute intervals
No maximum dose
What is adrenaline?
Adrenaline is a naturally occuring catecholamine which primarily acts on alpha and beta adrenergic receptors.
What are the actions of A1, B1, and B2 adrenergic receptors?
A1: Peripheral vasoconstriction
B1: Inotropic + chronotropic + increased ventricular irritability
B2: Bronchodilation
How is adrenaline metabolised and where?
Adrenaline is metabolised at the synapse level of sympathetic nerve endings by monoamine oxidase.
What are the 6 indications for adrenaline?
1 - Cardiac arrest
2 - Anaphylaxis or severe allergic reaction
3 - Severe life threatening bronchospasm or silent chest (must only be speaking single words/ALOC/haemodynamic compromise)
4 - Shock despite adequate fluid resuscitation
5 - Bradycardia with poor perfusion (unresponsive to atropine or TCP)
6 - Croup
Are there any contraindications for adrenaline?
No
What are the 4 precautions for adrenaline?
Hypertension
Hypovolaemic shock
Concurrent MAOI therapy
Quetiapine toxicity
Why is concurrent MAOI therapy a precaution for adrenaline?
MAOI’s inhibit the metabolism of adrenaline which can potentiate and prolong its effects
Why is quetiapine toxicity a precaution for adrenaline?
Adrenaline can cause paradoxical hypotension in quetiapine overdose. Other vasopressors such as noradrenaline should be used.
What are the 5 side effects of adrenaline?
1 - Hypertension
2 - Anxiety
3 - Palpitations and tachyarrhythmias
4 - Tremor
5 - Dilated pupils/mydriasis
What are the 4 presentations of adrenaline?
Ampoule 1:1000 (1mg/1mL) - 0.1mL=100mcg
Ampule 1:10000 (1mg/10mL) - 1mL=100mcg
EpiPen auto injector 300mcg
EpiPen Jr auto injector 150mcg
What is the onset of adrenaline for IV and IM administration?
IV = 30 seconds
IM = 60 seconds
What is the duration of action of adrenaline?
5-10 minutes
What is the half-life of adrenaline?
The half-life of adrenaline is 2 minutes.
What preparation of adrenaline should be used for all low dose IM/IV/IO injections?
For all low dose IM/IV/IO administrations of adrenaline 1:10,000 (100mcg/1mL) or 1:100,000 (10mcg/1mL) should be used.
How do you prepare a 1:100,000 adrenaline?
For a 1:100,000 (10mcg/1mL) preparation, draw up 1mL of 1:10,000 adrenaline ampoule and dilute with 9mL saline leaving a final concentration of 1:100,000 or 10mcg/1mL.
How often should BP be recorded with an adrenaline infusion and where should you place the NIBP cuff?
Patients on adrenaline infusions must have their blood pressure recorded every 5 minutes and the NIBP cuff must not be placed on an arm with an adrenaline infusion.
What is the dose of adrenaline for adult cardiac arrest?
1mg, every 3-5 minutes, no max dose
What is the IM dose of adrenaline for adult anaphylaxis?
500mcg IM every 5 minutes, no max
What is the indication for nebulised adrenaline in anaphylaxis and what is the dose?
Nebulise 5mg adrenaline for upper airway obstruction refractory to 3x IM adrenaline administrations.
What is the indication for adrenaline infusion in anaphylaxis?
Adrenaline infusion is indicated for anaphylaxis refractory to 2x IM adrenaline administrations and adequate fluid administration.
What is the dose and preparation for adrenaline infusion?
20-50mcg bolus followed immediately by adrenaline infusion commencing at 10mcg/minute (10mL/hr) titrating up to a maximum of 50mcg/minute (50mL/hr).
How do you prepare an adrenaline infusion?
Combine 3mg adrenaline (3x 1:1000 ampoules) with 47mL sodium chloride to achieve concentration of 3mg/50mL (60mcg/mL)
What is the indication for adrenaline infusion in shock?
Shock unresponsive to adequate fluid administration
What is the indication for adrenaline infusion in severe life threatening bronchospasm?
Severe life threatening bronchospasm with haemodynamic compromise despite 2x IM adrenaline administrations and adequate fluid administration.
What is the dose and route of administration of adrenaline for bradycardia with poor perfusion?
20-50mcg bolus IV or IO repeated at 1 minute intervals, no maximum dose.
What is the paediatric dose of adrenaline for cardiac arrest?
> 10kg (>1yo) = 10mcg/kg
<10kg (<1yo) = 100mcg
Newborn = 50mcg
What is the dose of adrenaline infusion for paediatrics over 6yo?
1mcg/kg bolus followed by infusion at 0.2mcg/kg/min (0.2mL/kg/hr) titrated up to maximum 0.5mcg/kg/min (0.5mL/kg/hr)
What is the IM dose of adrenaline for paeds?
Less than 6 months old = 50mcg
6 months to 1yo = 100mcg
1yo to 6yo = 150mcg
6 years or older = 300mcg
For paediatrics, can you administer adrenaline for shock or bradycardia?
QAS consult line consultation required in all situations.
What is the mechanism of action of amiodarone?
Amiodarone prolongs the duration of the action potential and therefore prolongs the refractory period of atrial, nodal, and ventricular tissues. It also reduces conduction across all cardiac tissues including myocardial cells and conducting system cells.
What class of anti-arrhythmic is amiodarone?
Amiodarone is a class III anti-arrhythmic but has properties in all 4 of the Vaughan-Williams class groups.
How is amiodarone metabolised?
Via the liver and the GI tract but there may be some hepatic recirculation.
What are the 2 indications for amiodarone?
Cardiac arrest refractory to 3 DCCS
Sustained conscious VT (hemodynamically stable)
What are the contraindications for amiodarone in cardiac arrest and in hemodynamically stably sustained conscious VT (5)?
Cardiac arrest = nil
Conscious sustained VT:
KSAR
Concurrent amiodarone therapy
Severe conduction disorders (unless pacemaker or ICD)
Long QT or other QT prolonging medications
Pregnancy and/or lactation
What is the only precaution for amiodarone administration?
For patients with sustained conscious VT, the precaution is hypotension.
What are the 4 side effects of amiodarone?
The four side effects of amiodarone are:
Hypotension
Bradycardia
Nausea and/or vomiting
Peripheral paraesthesia
What is the presentation of amiodarone?
150mg/3mL
What is the onset, duration, and half-life of amiodarone?
The onset of amiodarone is 5 minutes, duration is 30 minutes, half life is 14-110 days (with chronic dosing)
What is the adult dose of amiodarone for cardiac arrest?
300mg slow push over 1-2 minutes
Repeat at 150mg after total 5 DCCS
Total max dose 450mg
What is the adult dose of amiodarone for haemodynamically stable sustained conscious VT and how do you prepare it?
300mg over 30 minutes
Mix 300mg amiodarone (6mL) with 44 mL of glucose 5% in a 50 mL syringe to achieve concentration of 300mg/50mL and infuse via space perfusor library (100mL/hr)
What is the paediatric dose of amiodarone in cardiac arrest?
5mg/kg
For >150mg, draw up 150mg (3mL) amiodarone with 12mL glucose 5% in a 20mL syringe = 150mg/15mL (10mg/mL)
For >300mg, draw up 300mg (6mL) amiodarone with 24mL glucose 5% in 50mL syringe = 300mg/30mL (10mg/mL)
What drug class is benzatropine?
Benzatropine is an anticholinergic
What is the pharmacology of benzatropine?
Benzatropine is synthesised from atropine and diphenhydramine. It restores the balance between acetylcholine and dopamine in the CNS thereby alleviating acute dystonic reactions.
How is benzatropine metabolised?
Hepatic.
What is the indication for benzatropine?
Acute dystonic reaction
What are the 3 contraindications for benzatropine?
Allergy
Tardive dyskinesia
<3yo
What are the 2 precautions for benzatropine?
- Sedative effects of other drugs may be enhanced
- patients <12 years old
What are the 6 side effects of benzatropine?
Anticholinergic toxidrome
Mydriasis
Dry mouth
Nausea and vomiting
tachycardia
Toxic psychosis
Urinary retention
What is the presentation of benzatropine?
2mg/2mL
What Is the onset, duration, and half-life of benzatropine?
Onset = 1-2 minutes
Duration = 1-2 hours
Half-life = 16 hours
What is the adult dose for benzatropine?
1-2mg, IM or IV, single dose only
What is the paediatric dose for benzatropine?
> 3yo = 20mcg/kg, IM or IV, single dose only
What is the pharmacology of calcium gluconate?
Calcium gluconate acts as a positive inotropic agent in the post cardiac arrest patient. It additionally acts as a cardiac membrane stabiliser in the hyperkaliaemic patient and it is effective in treating pain and systemic symptoms of hydrofluoric acid inhalation.
How is calcium gluconate metabolised?
Hepatic
What are the 6 indications for calcium gluconate?
Suspected hyperkalaemic cardiac arrest
Severe hyperkalaemia (with haemodynamic compromise and/or severe ECG changes)
Diltiazem and verapamil toxicity
Hypotension following magnesium infusion (that does not respond to IV fluids)
Hydrofluoric acid inhalation
Following pre-hospital blood administration
What are the 2 contraindications for calcium gluconate?
Allergy
Digoxin (digitalis) overdose
What is the 1 precaution for calcium gluconate?
The 1 precaution for calcium gluconate is respiratory acidosis
What are the 5 side effects of calcium gluconate?
Bradycardia
Hypotension
Syncope
Dysrhythmias
Cardiac arrest
What are the 2 presentations of calcium gluconate?
2.2mmol/10mL calcium gluconate 10%
4.4mmol/25mL calcium gluconate 8%
What are the adult doses of calcium gluconate for Suspected hyperkalemic cardiac arrest?
2.2mmol stat, IV, repeat at 10 minutes if required
What are the adult doses of calcium gluconate for severe hyperkalaemia, hypotension associated with magnesium infusion, and following prehospital blood administration?
2.2mmol, IV slow push of 2-3 minutes, repeat at 10 minutes if required
What is the dose of calcium gluconate for verapamil or diltiazem toxicity?
6.6mmol IV slow push of 2-3 minutes, repeat at 10 minutes if required
What is the dose of calcium gluconate for hydrofluoric acid inhalation?
Nebulised 2mL of 2.5% calcium gluconate
Draw up 2.5mL of calcium gluconate with 7.5mL sodium chloride in a 10 mL syringe creating 10mL of calcium gluconate 2.5%
What is the paediatric dose of calcium gluconate?
All IV calcium gluconate for paediatrics is 0.1mmol/kg, single dose not to exceed 2.2mmol, repeat once at 10 minutes if required.
All doses slow push over 2-3 minutes except for in hyperkalemic cardiac arrest which is stat dose.
What class of drug is ketamine?
Ketamine is an anaesthetic and analgaesic
What is the pharmacology of ketamine?
Ketamine is an anaesthetic and analgaesic.
It works as an NMDA receptor antagonist.
At low doses ketamine provides significant analgaesia while preserving the airway reflexes and respiratory drive.
At higher doses ketamine can be used as an induction agent for anaesthesia and produces less haemodynamic instability due to its actions as a sympathomimetic agent.
Ketamine produces a trance like/dissociative state that can result in disinhibition or emergence phenomena.
How is ketamine metabolised?
Ketamine is metabolised by the liver and 90% is excreted in the urine.
What are the indications for ketamine:
Severe traumatic pain (following 0.1-0.2mg/kg morphine or 1-2mcg/kg fentanyl) associated with:
Fracture reduction or splinting
Multiple or significant fractures requiring facilitated extrication
Patients with splinted fractures requiring ongoing narcotics for transport
Severe traumatic pain associated with burns following 0.2-0.3mg/kg morphine or 2-3mcg/kg fentanyl and 1-2.5mg (adult) or 0.05mg/kg (paeds) midazolam
Induction agent for anaesthesia
Sedation for ABD with sat >2 and received max dose droperidol
Ongoing traumatic pain unresponsive to narcotics (following 0.2-0.3mg/kg morphine or 2-3mcg/kg fentanyl
What are the contraindications for ketamine?
Analgesia:
KSAR
patients <1 year old
GCS <12
Uncontrolled hypertension with sys >180mmhg
Suspected ACS or acute heart failure
Known hydrocephalus or raised intraocular pressure
Induction for anaesthesia
KSAR
What are the precautions for ketamine?
Patients >65yo
Patients who have been administered other CNS depressants
Patients with hypovolaemia due to exaggerated effects and delayed onset
Globe injuries
Facial injuries
Impaired respiratory function
Psychosis
What are the side effects of ketamine?
Hypersalivation
Transient hypertonicity and nystagmus
Tachycardia
Hypertension
Laryngospasm
Nausea and/or vomiting
Emergence phenomena
Disinhibition
Depression of consciousness
Respiratory depression
What is the adult dose for ketamine for Severe traumatic pain and what are the indications? And how do you prepare the syringe?
Severe traumatic pain (following 0.1-0.2mg/kg morphine or 1-2mcg/kg fentanyl) associated with:
Fracture reduction or splinting
Multiple or severe fractures requiring facilitated extrication
Splinted fractures requiring ongoing narcotics for transport
and
Ongoing traumatic pain unresponsive to narcotics (following 02.-0.3mg/kg morphine or 2-3mcg/kg fentanyl)
10-30mg
Repeat every 2-3 minutes, total max dose 1mg/kg
Syringe prep:
Draw up 200mg (2mL) ketamine in 20 mL syringe, dilute with 18mL sodium chloride to achieve concentration of 10mg/mL
What is the adult dose for ketamine in burns and what is the indication? And how do you prepare the syringe?
Severe traumatic pain associated with burns following 0.2-0.3mg/kg morphine or 2-3mcg/kg fentanyl and 1-2.5mg (adutls) or 0.05mg/kg (paeds) midazolam.
10-30mg
Repeat every 2-3 minutes, total max dose 1mg/kg
Syringe prep:
Draw up 200mg (2mL) ketamine in a 20mL syringe, dilute with 18mL sodium chloride to achieve concentration of 10mg/mL
What is the adult dose for ketamine for sedation of patients with ABD and SAT score >2?
ABD with SAT score >2 and max dose of droperidol administered
QAS Consult line call required
> 16yo = 200mg IM
12-15yo = 2mg/kg
What is the story to remember the precautions for ketamine?
Ketamine is a horse who was >65 YEARS OLD, Ketamine was sad and PSYCHOTIC so they took some CNS DEPRESSING MEDICATIONS. They then tried to commit suicide by stabbing themselves causing HYPOVOLAEMIA. They also smacked their head on the ground causing GLOBE INJURES and other COMPLEX FACIAL INJURES. Because of this they had RESPIRATORY DEPRESSION
