MED QUIZ 4 Flashcards
Diltiazem, Midazolam, Diazepam, Calcium Gluconate, Sodium Bicarbonate
DILTIAZEM - AKA
CARDIZEM
DILTIAZEM - CLASS
CALCIUM CHANNEL BLOCKER
DILTIAZEM - MOA
blocks calcium influx in cardiac cells, decreasing myocardial contractility
DILTIAZEM - INDICATIONS
RAPID ATRIAL FIBRILLATION/FLUTTER
DILTIAZEM - CONTRAINDICATIONS
- hypotension
- sick sinus syndrome
sinus bradycardia (heart rate < 40 bpm)
sinus pauses (sudden pauses of the sinus node shorter than 2–3 seconds)
sinus arrest (sudden pauses of the sinus node longer than 2–3 seconds) - second- or third-degree AV block
- Cardiogenic shock
- Wide-complex tachycardia (eg. VTach)
- poison or drug induced tachycardia
- Wolff-Parkinson-White (WPW)
syndrome, Lown-Ganong-Levine (LGL) or other pre-excitation syndromes (group of conditions that cause the heart’s ventricles to activate faster than normal due to atrial impulses.)
DILTIAZEM - ADVERSE REACTIONS/SE
- CNS: dizziness, weakness, headache
- RESPIRATORY: dyspnea
- CV: hypotension, bradycardia, arrhythmias, CHF, peripheral edema, AV blocks, syncope, VFIB, VTACH, cardiac arrest, chest pain
- GI/GU: N/V, dry mouth
DILTIAZEM - DRUG INTERACTIONS
none in emergency setting
DILTIAZEM - DOSAGE ADMINISTRATION ADULT NAT
INITIAL DOSE: 0.25 mg/kg IV/IO over 2 min (max dose: 25mg)
… no response in 15 min….
SECOND DOSE: 0.35 mg/kg IV/IO over 2 min (max dose: 25mg)
DILTIAZEM -DOSAGE ADMINISTRATION PEDI NAT
NOT RECOMMENDED
DILTIAZEM - DOSAGE ADMINISTRATION ADULT RI
NARROW COMPLEX TACHYCARDIA
initial dose: 0.25 mg/kg IV (max dose: 20 mg)
…. if SBP >/= 100 repeat x1….
second dose: 0.35 mg/kg IV (max dose 25 mg)
DILTIAZEM - DOSAGE ADMINISTRATION PEDI RI
NOT RECOMMENDED
DILTIAZEM - DURATION OF ACTION
onset: 2-5 min
peak: variable
duration: 1-3 hrs
DILTIAZEM - SPECIAL CONSIDERATIONS
- Diltiazem vials expire in 30 days if not kept refrigerated
- rapid push of diltiazem can cause severe hypotension/bradycardia
- Consider a fluid bolus (NORMAL SALINE 500-1000 ml IV/IO) in patients with a history
suggestive of dehydration and no evidence of overt heart failure/pulmonary edema. - Consider CALCIUM CHLORIDE 1 gm SLOW IV/IO prior to administering DILTIAZEM if the BP
is tenuous BP (SBP ~100)
MIDAZOLAM HYDROCHLORIDE - AKA
VERSED
MIDAZOLAM HYDROCHLORIDE - CLASS
BENZODIAZEPINE
[depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures - ALSO Valium®, Xanax®, Halcion®, Ativan®, and Klonopin®-]
MIDAZOLAM HYDROCHLORIDE - INDICATIONS
- SEIZURES
- SEDATION FOR ELECTRICAL THERAPY
- CHEMICAL RESTRAINT IN BEHAVIORAL EMERGENCIES
- STIMULANT TOXICITY
- ANXIETY DUE TO CPAP MASK
MIDAZOLAM HYDROCHLORIDE - CONTRAINDICATIONS
- SHOCK
- COMA
- ALCOHOL INTOXICATION
- OPIOID/BENZODIAZEPINE
- DEPRESSED VITAL SIGNS
MIDAZOLAM HYDROCHLORIDE - DOSAGE ADMINISTRATION ADULT NAT
ANXIETY DUE TO CPAP MASK:
1-2mg IV/IO slow push
SEIZURES:
2.5 mg. repeat every 3-5 min (x4) to MAX of 10 mg. IV/IO/IM/IN
SUSPECTED STIMULANT TOXICITY:
2.5 mg IV/IO slow push, may repeat in 5 min
SEDATION FOR ELECTRICAL THERAPY:
2.5-5mg IV/IO/IM/IN slow push
CHEMICAL RESTRAINT BEHAVIORAL EMERGENCY (>/= 16 Y/O):
2.5-5 mg IV/IO or 5 mg IM/IN may repeat PRN to MAX total dose 10 mg (5 mg if age >65y/o)
MIDAZOLAM HYDROCHLORIDE -ADVERSE REACTIONS/SE
CNS: headache, somnolence (sleepy or ready to fall asleep), anterograde amnesia (memory loss that occurs when you can’t form new memories)
RESPIRATORY: respiratory depression, respiratory arrest, apnea
CV: hypotension
MIDAZOLAM HYDROCHLORIDE -DRUG INTERACTIONS
NONE IN EMERGENCY SETTING
MIDAZOLAM HYDROCHLORIDE - DOSAGE ADMINISTRATION PEDI NAT
SEIZURES:
0.1 mg/kg IV/IO or 0.2mg/kg IM/IN (MAX single dose: 4mg) may repeat every 5 min to MAX of 1mg/kg
SEDATION FOR ELECTRICAL THERAPY:
0.1 mg/kg (MAX 2.5mg) IV/IO/IM/IN slow push
SUSPECTED STIMULANT TOXICITY:
0.05 mg/kg IV/IO/IN slow push, may repeat in 10 min (do not administer if <5kg)
MIDAZOLAM HYDROCHLORIDE -DOSAGE ADMINISTRATION ADULT RI
NARROW COMPLEX TACHYCARDIA:
2.5-5 mg IV [5 mg IM/IN] …..or DIAZEPAM
WIDE COMPLEX TACHYCARDIA:
2.5-5 mg IV [5 mg IM/IN] …..or DIAZEPAM
PATIENT COMFORT FOR ELECTRICAL THERAPY:
2.5-5 mg IV/IM/IN ……or DIAZEPAM
RESPIRATORY DISTRESS (ASTHMA/COPD/RAD) or ACUTE DECOMPENSATED HEART FAILURE:
CPAP mask compliance, contact MEDICAL CONTROL for authorization to administer MIDAZOLAM 1-2 mg IV
BEHAVIORAL EMERGENCIES -CHEMICAL RESTRAINT >/= 16Y/O aggressive or agitated behavior, without suspected acute substance abuse (alcohol):
2.5-5 mg IV or 5 mg IM/IN, may repeat PRN if the SBP >100 to a cumulative dose of 10 mg (5 mg if age ≥65).
EXCITED DELIRIUM SYNDROME (ExDS):
2.5-5 mg IV [5 mg IM/IN] (repeat as needed if the SBP >100 to a max
of 10 mg)…. MONITOR ETCO2, SPO2, ECG
SEIZURES:active generalized or focal seizures in the patient without IV access:
10 mg IM or 2 mg IN
active generalized or focal seizures in the patient with IV access or pt refractory to prior Midazolam (no IV):
2.5 mg IV [5 mg IM or 2 mg IN] (repeat 2 mg every 3-5 minutes to a max of 20 mg) OR LORAZEPAM OR DIAZEPAM
TOXICOLOGICAL EMERGENCIES:
2.5 mg IV/IN [5 mg IM] (may
repeat in 5 minutes, IM dose in 20 min) …..or LORAZEPAM
MIDAZOLAM HYDROCHLORIDE -DOSAGE ADMINISTRATION PEDI RI
PRE SHOCK SEDATION (NARROW/WIDE COMPLEX TACHY:
0.1 mg/kg [2.5 mg max] IV/IM/IN (may repeat x1) [do not administer if <5kg
….OR FENTANYL
PATIENT COMFORT FOR ELECTRICAL THERAPY:
0.1 mg/kg [2.5 mg max] IV/IM/IN
….. OR FENTANYL
SEIZURES:
`active generalized or focal seizures:
0.2 mg/kg IM/IN OR 0.1 mg/kg IV [4 mg max single dose via any route)] (may repeat every 5 minutes to a max of 1 mg/kg) OR LORASEPAM OR DIAZEPAM
TOXICOLOGICAL EMERGENCIES:
0.05 mg/kg IV/IN (may repeat x1 in 10 minutes) [do not administer if < 5 kg].
MIDAZOLAM HYDROCHLORIDE - DURATION OF ACTION
onset: immediate
peak effect: variable
duration: 26-31 hours
MIDAZOLAM HYDROCHLORIDE - SPECIAL CONSIDERATION
- dilution in 250 mL NS required to prevent vasotoxicity
- in cardiac arrest, hydroxocobalamin can be given as a rapid infusion
- mandatory continuous monitoring of waveform EtCO2, SpO2, ECG for any sedation drug
DIAZEPAM - AKA
Valium
DIAZEPAM - CLASS
benzodiazepine
DIAZEPAM -MOA
Increases effects of GABA (primary inhibitory neurotransmitter) causing sedation and increased seizure threshold
DIAZEPAM - INDICATIONS
- Seizure
- Sedation before electrical therapy
DIAZEPAM - CONTRAINDICATIONS
- hypersensitivity
- Narrow angle Glaucoma
- Myasthenia Gravis (chronic autoimmune disorder- breakdown in communication between nerves and muscles)
- Respiratory insufficiency
- Coma
- Head Injury
DIAZEPAM - ADVERSE REACTIONS/SE
- CNS: dizziness, drowsiness, confusion, headache
- RESPIRATORY: respiratory depression
- CV: hypotension, reflex tachycardia
- GI/GU: N/V
- MUSCULOSKELETAL: muscle weakness
- OTHER: tissue necrosis, ataxia (no coordination), thrombosis (blood clots block your blood vessels), phlebitis (inflammation of a vein near the surface of the skin)
DIAZEPAM - DRUG INTERACTIONS
potentiate effects of alcohol and opiates
DIAZEPAM - DOSAGE ADMINISTRATION ADULT NAT
SEIZURE:
5 mg IV/IO/IM/PR (repeat every 3-5 min to MAX of 20 mg)
PREMEDICATION FOR CARDIOVERSION:
2.5-5 mg IV/IO/IM
DIAZEPAM - DOSAGE ADMINISTRATION PEDI NAT
SEIZURE:
0.1 mg/kg IV/IO (5mg MAX single dose)
….OR
0.5 mg/kg PR (20 mg MAX single dose). May repeat every 3-5 min to a max of 1 mg/kg.
DIAZEPAM - DOSAGE ADMINISTRATION ADULT RI
PATIENT COMFORT-CARDIOVERSION/PACING (narrow/wide complex tachy rate >150):
2.5-5 mg IV/IM (if the SBP ≥100.)…..OR MIDAZOLAM
SEIZURE (active generalized or focal seizures in the patient with IV access):
5 mg IV (repeat every 3-5 min to a max of 20 mg)
DIAZEPAM - DOSAGE ADMINISTRATION PEDI RI
SEIZURE (active generalized or focal seizures):
0.1 mg/kg IV [5 mg max single dose] or 0.5 mg/kg PR [20 mg max single dose] (may repeat every five minutes to a max of 1 mg/kg).
DIAZEPAM - DURATION OF ACTION
onset: 1-5 min
peak: 15 min
duration: 20-50 min
DIAZEPAM - SPECIAL CONSIDERATION
- must have continuous quantitative waveform capnography in place
- LONGEST HALF-LIFE AND LEAST DESIRABLE CHOICE WHEN OTHER BENZODIAZEPINES ARE AVALIABLE
- only benzo EMS can administer rectally (patient may be prescribed DIAZEPAM rectal gel)
CALCIUM GLUCONATE - CLASS
ELECTROLYTE
CALCIUM GLUCONATE - MOA
- Increases cardiac contractility
- Counteracts effects of hyperkalemia by stabilizing the heart
CALCIUM GLUCONATE - INDICATIONS
- Beta blocker or calcium channel blocker overdose
- hyperkalemia
CALCIUM GLUCONATE - CONTRAINDICATIONS
- Hypercalcemia
- Ventricular fibrillation
- Digitalis toxicity (Antiarrhythmic and Blood pressure support)
CALCIUM GLUCONATE - ADVERSE REACTIONS/SE
CNS: syncope
CV: cardiac arrest, arrhythmia, bradycardia, hypotension, asystole, peripheral vasodilation
GI/GU: N/V, metallic taste
OTHER: tissue necrosis at injection site
CALCIUM GLUCONATE - DRUG INTERACTIONS
- May antagonize effects of calcium channel blockers
- DO NOT MIX OR INFUSE IMMEDIATLY BEFORE/AFTER SODIUM BICARBONATE WITHOUT INTERVENING FLUSH (forms salt crystals)
CALCIUM GLUCONATE - HOW SUPPLIED
100 mg/mL of 10% solution
CALCIUM GLUCONATE - DOSAGE ADMINISTRATION ADULT NAT
3 gm IV/IO (may repeat x1)
CALCIUM GLUCONATE - DOSAGE ADMINISTRATION PEDI NAT
60 mg/kg IV/IO (may repeat x1)
CALCIUM GLUCONATE - DOSAGE ADMINISTRATION ADULT RI
DIALYSIS EMERGENCY (cardiac arrest or with suspected hyperkalemia)
Cardiac Arrest Protocol - contact MEDICAL CONTROL for authorization to administer CALCIUM GLUCONATE 3 gm IV OR CALCIUM CHLORIDE (and SODIUM BICARBONATE)
CHEMICAL AND ELECTRICAL BURN INJURY (hydrofluoric acid HF):
2.5 topical gel to all contact points. If the hands or digits are involved, the gel
should be placed in an exam glove and the glove worn on the affected hand. If
there is ocular exposure, irrigate the affected eye with (if available) CALCIUM
GLUCONATE 1% solution.
CRUSH INJURY:
CALCIUM GLUCONATE 3 gm IV OR administer CALCIUM CHLORIDE (and SODIUM BICARBONATE)
TOXICOLOGICAL EMERGENCIES (beta blocker/calcium channel blocker CCB toxicity):
MED CONTROL to give 3 gm IV (may repeat x1) OR CALCIUM CHLORIDE AND GLUCAGON
CALCIUM GLUCONATE - DOSAGE ADMINISTRATION PEDI RI
TOXICOLOGICAL EMERGENCIES(CCB toxicity):
MED CONTROL 60 mg/kg IV (may repeat x1) OR CALCIUM CHLORIDE AND GLUCAGON
CALCIUM GLUCONATE - DURATION OF ACTION
onset: immediate
peak: immediate
duration: 30 min - 2hrs
CALCIUM GLUCONATE - SPECIAL CONSIDERATIONS
- Common situations to suspect hyperkalemia: crush injuries, dialysis emergencies
- do not administer by IM or SQ - causes significant tissue necrosis
SODIUM BICARBONATE - CLASS
Alkalizing (buffering) agent
SODIUM BICARBONATE - MOA
Buffers build up acids that cause metabolic acidosis in the body. Reverses sodium channel blocker effects.
SODIUM BICARBONATE - INDICATIONS
- Hyperkalemia
- Suspected metabolic acidosis in cardiac arrest
- sodium channel blocker overdose (tricyclic overdose)
SODIUM BICARBONATE - CONTRAINDICATIONS
- Metabolic and respiratory alkalosis
- Hypokalemia
- Electrolyte imbalance due to severe vomiting and GI loss
SODIUM BICARBONATE - REACTIONS/SE
- CNS: seizures
- CV: fluid retention
- OTHER: Hypernatremia, metabolic alkalosis, tissue sloughing, cellulitis, or necrosis at injection site, hypokalemia, electrolyte imbalance, tetany (low calcium involuntary muscle contraction), sodium retention, peripheral edema
SODIUM BICARBONATE - DRUG INTERACTIONS
NONE
SODIUM BICARBONATE - DOSAGE ADMINISTRATION ADULT NAT
HYPERKALEMIA OR CARDIAC ARREST WITH METABOLIC ACIDOSIS:
50 mEq IV/IO once
SODIUM CHANNEL BLOCKER OVERDOSE:
50 mEq slow IV/IO (repeat every 5 min as needed)
SODIUM BICARBONATE - DOSAGE ADMINISTRATION PEDI NAT
SODIUM CHANNEL BLOCKER OVERDOSE:
1mEq/kg slow IV/IO push (repeat every 5 min as needed)
SODIUM BICARBONATE - DOSAGE ADMINISTRATION ADULT RI
DIALYSIS EMERGENCIES AND RENAL FAILURE /CRUSH INJURY w/ cardiac arrest/suspected hyperkalemia:
MED CONTROL authorization to administer SODIUM BICARBONATE 50 mEq IV (and CALCIUM CHLORIDE or CALCIUM GLUCONATE.)
EXCITED DELIRIUM SYNDROME(ExDS) (CARDIAC ARREST):
SODIUM BICARBONATE 50 mEq IV (and cardiac arrest protocol.
CRUSH INJURY:
NORMAL SALINE 1000 ml with 150
mEq of SODIUM BICARBONATE added at 1.5 L/hr (reduce to 500 ml/hr once crush resolved ….OR D5W (preferred)
w/ suspected hyperkalemia/CA same as above
TOXICOLOGICAL EMERGENCIES:
1. suspected tricyclic antidepressant or other sodium channel blocking agent
toxicity (if seizures are present or the QRS is >0.12 sec):
contact MEDICAL CONTROL authorization to administer SODIUM BICARBONATE 50 mEq IV (repeat every 5 minutes as indicated)
SODIUM BICARBONATE - DOSAGE ADMINISTRATION PEDI RI
CRUSH INJURY (>30min):
NORMAL SALINE 1000 ml with 150
mEq of SODIUM BICARBONATE added at 20 ml/kg x3. once crush injury resolved reduce infusion rate to age appropriate maintenance rate….OR D5W (preffered)
TOXICOLOGICAL EMERGENCIES:
1. suspected tricyclic antidepressant or other sodium channel blocking agent
toxicity (if seizures are present or the QRS is >0.09 sec):
MEDICAL CONTROL authorization to administer SODIUM BICARBONATE 1 mEq/kg IV (repeat every five minutes as indicated)
SODIUM BICARBONATE - DURATION OF ACTION
Onset: Seconds
Peak: 1-2 minutes
Duration: 10 minutes
SODIUM BICARBONATE - SPECIAL CONSIDERATIONS
- Sodium bicarbonate and calcium preparations are not compatible and should be given through separate IV lines if possible. If they must be administered via the same IV line, the line should be flushed in between the administration of each. (WILL CRYSTALIZE WHEN MIXED)
- Sodium bicarbonate is preferentially mixed in D5W (150 mEq/1000ml), utilization of 0.9% saline for this purpose is less desirable.
- SODIUM BIC. USED ONLY WHEN METABOLIC ACIDOSIS IS SUSPECTED IN CARDIAC ARREST-(used to be common but not used infrequently).
