Medications Flashcards

Question

Albuterol (Proventil, Ventolin) Administration

Answer 1

- Use with 4-6 liters of O2 for handheld mouthpiece. | - Use with 6-10 liters of O2 for aerosol mask, CPAP, and ET tube.

Answer 2

-Consider anaphylaxis if wheezing in the patient with distress, especially if no history of asthma.

Answer 3

- Continuous nebulized Albuterol is the goal for hyperkalemia and patients in respiratory distress. - Decreases hyperkalemia associated with dialysis patients by facilitating the movement of potassium back into cells. - Fireline Paramedics (FEMP) without access to oxygen may use MDI delivery for Albuterol in place of nebulizer. (2.5mg inhaler = 2 puffs)

Answer 4

Class: -Antiarrhythmic Action: - Blocks sodium, potassium, and calcium channels in cardiac cells slowing conduction and prolongs repolarization. - Has alpha and beta adrenergic blocking properties causing negative inotropic effects and reduces peripheral vascular resistance (afterload). ``` Onset = minutes Duration = days ```

Answer 5

Dysrhythmias (S-127) [Adult only] -Stable Ventricular Tachycardia Dysrhythmias (S-172) [Adult only] -reported/witnessed >2 AICD firing, or >1 AED shock delivered with pulse >60 Dysrhythmias (S-127)(S-163) [Adult/Peds] -VF/Pulseless VT: After 1st shock if still refractory

Answer 6

Adult Only: (Stable Ventricular Tachycardia) -150mg in 100ml of NS over 10" IV/IO SO MR x1 in 10" SO Adult Only: (>2 AICD firing/>1 AED shock w/ pulse >60) -150mg in 100ml of NS over 10" IV/IO SO Adult: (VF/Pulseless VT) -300mg IV/IO SO, MR 150mg (max of 450mg) SO Peds: (VF/Pulseless VT) -PDC IV/IO SO, MR x1 in 3-5" SO

Answer 7

- Hypotension - 2nd & 3rd degree heart block - Idioventricular rhythms

Answer 8

-Hypotension -Exacerbation of the presenting arrhythmia AFTER DAYS OF USE -Liver injury -Pulmonary injury: pulmonary infiltrates, bronchospasm, SOB, cough, hemoptysis, hypoxia.

Answer 9

-150mg/3ml

Answer 10

-Piggyback infusion in 100ml of NS given over 10 min; (Drip rate with 60gtts/ml tubing = 10gtts/sec)

Answer 11

May interact with: - Beta Blockers - results in excessively slow heart rate or AV block - Digoxin - increases blood level of digoxin to toxic - Tricyclic Antidepressants - causes serious arrhythmias

Answer 12

-Amiodarone is an optional drug and may not be carried by some agencies

Answer 13

Class: -Platelet aggregation inhibitor Action: - Inhibits normal tendancy for platelets to accumulate inside injured or occluded coronary arteries, thereby improving blood flow through vessels to better perfuse the heart. - Blocks formation of Thromboxin A2 ``` Onset = 15-30 minutes Duration = days (antiplatelet effects) ```

Answer 14

-Discomfort/Pain of Suspected Cardiac Origin (S-126)

Answer 15

Adult Only: | -324mg PO (four 81mg chewable tablets)

Answer 16

- GI upset (indigestion, nausea/vomiting, epigastric pain, heartburn) - Occult or prolonged bleeding

Answer 17

-81mg tablets

Answer 18

-Tablets can be chewed or swallowed with a small amount of water prn

Answer 19

-Administer if patient had pain or discomfort of suspected cardiac origin that has been relieved PTA.

Answer 20

- Can give if patient is on anticoagulants | - Should be given regardless of prior daily dose(s).

Answer 21

Class: - Antiarrhythmic - Anticholinergic Action: - Competes with acetylcholine for receptor sites blocking the PNS response at SA & AV nodes. - Increases heart rate by increasing electrical conduction through the heart. - Positive chronotropic properties with little or not inotropic effects. - Inhibits secretions by decreasing PNS effect on bronchial, salivary, sweat, and GI glands. ``` Onset = IV/IO 2-4 minutes, IM 10-15 minutes Duration = 2-6 hours ```

Answer 22

Adult: Dysrhythmias (S-127) -Unstable Bradycardia: narrow complex Adult: Dysrhythmias (S-127) -Unstable Bradycardia: wide complex if external pacemaker unavailable Peds: Dysrhythmias (S-163) -Unstable Bradycardia: after BVM for 30 sec and 3rd dose of Epinephrine Poisoning/OD (S-134, S-165): [Adult/Peds] -Symptomatic organophosphate poisoning

Answer 23

Adult: (narrow complex bradycardia) -0.5mg IV/IO for pulse <60; MR q3-5" to max 3mg Adult: (wide complex bradycardia w/o pacing) -May give Atropine 0.5mg IV/IO for pulse <60 MR q3-5" to max 3mg Peds: (unstable brady after 30sec BVM and 3rd epi) -<9 years HR <60; 9-14 years HR <40 PDC IV/IO; MR x1 in 5" Adult: (poisoning/od) -2mg IV/IM/IO; MR x2 q3-5"; MR q3-5" prn BHO Peds: (poisoning/od) -PDC IV/IO/IM; MR x2 q3-5"; MR q3-5" prn BHO

Answer 24

- Tachycardia/palpitations - Dry mouth/nausea/vomiting - Pupil dilation/blurred vision - Flushed/hot/dry skin

Answer 25

-Single: 1mg/10ml or Multidose vial: 0.4mg/1ml

Answer 26

-Pacing is the treatment of choice for wide complex bradycardias. Use Atropine only if pacing is unavailable (adults).

Answer 27

- Use with caution for patients with possible MI (may extend infarct area). - May worsen bradycardia associated with second degree type II and third degree blocks.

Answer 28

- Atropine will not reverse the muscle weakness associated with OPP; 2-PAM is used. - May not work with cardiac transplant patient or artificial hearts as vagus nerve has been severed.

Answer 29

Class: -Bronchodilator: anticholinergic Action: - Antagonizes the action of acetylcholine, preventing the interaction of acetylcholine with muscarinic receptors in bronchial smooth muscle causing bronchodilation - Dries respiratory tract secretion. ``` Onset = within 15-30 minutes Peak = 1-2 hours Duration = 4-5 hours ```

Answer 30

``` Respiratory Distress (S-136, S-167) -Suspected Non-Cardiac ``` Allergic Reaction/Anaphylaxis (S-122, S-162) -acute allergic reactions or anaphylaxis

Answer 31

Adult: -2.5ml (0.02%) via nebulizer added to first dose of Albuterol Peds: -PDC via nebulizer added to first dose of Albuterol

Answer 32

- Nervous/dizziness - Headache - Cough - Paradoxical bronchospasm - Palpitations - Blurred vision/eye irritation (with direct contact of mist)

Answer 33

-0.5mg/2.5ml - 0.02% unit dose vial

Answer 34

- Use with 4-6 lpm O2 for handheld mouthpiece. | - Use with 6-10 lpm for aerosol mask, CPAP, and ET tube.

Answer 35

-Do not add to Albuterol as it is not indicated for respiratory burn patients or suspected hyperkalemia patients.

Answer 36

- Cholinergic effects are site specific in lungs - no systemic effects. - If a patient has self-medicated with bronchodilator prior to paramedic intervention, Atrovent should still be given with first prehospital Albuterol treatment.

Answer 37

Class: -Electrolyte Action: - Increases myocardial contractility - Enhances ventricular automaticity - Reverses cardio-electric changes produced by hyperkalemia - Shifts potassium back into cell to prevent intravascular hyperkalemia ``` Onset = 5-15 minutes Duration = may persist 4 hours after IV/IO ```

Answer 38

``` Hemodialysis Patient (S-131) -symptomatic, suspected hyperkalemia (widened QRS complex "or" peaked T waves if >72 hours since last dialysis ``` Trauma (S-139) -crush injury of extremity or torso with compression >2 hours. Give just prior to extremity being released

Answer 39

Adult Only: (Hemodialysis Patient) -500mg IV/IO over 30 seconds Adult Only: (Trauma: Crush injury) -500mg IV/IO over 30 seconds BHO

Answer 40

- Decreased heart rate (may cause asystole) - Hypotension - Syncope - Nausea/vomiting - Metallic taste

Answer 41

- In dialysis patients: Give Iv/IO over 30 seconds with Albuterol. - In crush injury patients: Give IV/IO over 30 seconds with end of fluid bolus. - Precipitates if mixed with NaHCO3, flush IV tubing between administration of drugs.

Answer 42

-Tissue necrosis occurs with infiltrationl Check IV patency before and during administration watching for sings of infiltration; if this occurs, discontinue the IV, circle infiltrated area, and inform receiving hospital.

Answer 43

-Calcium is used in crush injury to reverse the effects of hyperkalemia associated with muscle cell damage.

Answer 44

Class: -Absorbent Action: - Binds and absorbs ingested toxins present in the GI tract. - Inhibits intenstinal absorption, preventing systemic toxicity. ``` Onset = minutes Duration = 4-12 hours ```

Answer 45

Adult: Poisoning/OD (S-134) -Ingestion with ANY of the following within 60 minutes, if no vomiting: Acetaminophen, Colchicine, beta blockers, calcium channel blockers, Salicylates, Valproate, oral anticoagulants (including rodenticides), Paraquat, Amanita mushrooms. (Assure patient has gag reflex and is cooperative) Ped: Poisoning/OD (S-165) -If ingestion within 60 minutes & recommended by Poison Control Center (assure child has gag reflex and is cooperative).

Answer 46

Adult: -50Gm PO Ped: -PDC PO

Answer 47

- Isolated alcohol - Heavy metal - Caustic agent - Hydrocarbons - Iron ingestion

Answer 48

- Nausea/vomiting - Constipation/diarrhea - Abdominal cramping

Answer 49

-50Gm/240ml

Answer 50

-PO, assure patient can swallow and is cooperative. Most effective if administered immediately after the ingestion.

Answer 51

- Anticipate vomiting complications, consider Zofran. - Use with caution with OD of drugs known to cause rapid onset of seizures (TCA's, etc.) due to risk of vomiting and aspiration.

Answer 52

- Contraindications are due to marginal effectiveness and potential to cause harmful vomiting or burns. - Peds: Contact poison control early & administer promptly if recommended.

Answer 53

Class: -Carbohydrate Action: -Increases blood glucose by providing a quick release of free sugar into the circulation. ``` Onset = 1 minute Duration = depends on degree of hypoglycemia ```

Answer 54

``` Altered Neurologic (S-123)(S-161)(S-172) -Symptomatic Hypoglycemia: symptomatic patient with altered LOC or unresponsive to oral glucose agents and Blood Sugar: Adults/Ped/Infant = BS <60 Neonate = BS <45 ```

Answer 55

Adults/Ped: If patient is awake and has gag reflex -Oral glucose paste or 3 tablets (15g) Adult: -D50 25Gm IV; MR if patient remains symptomatic and BS <60 Ped: -D10 PDC IV; MR if patient remains symptomatic and BS <60 (neonate <45)

Answer 56

- Local venous irritation/infection | - Hyperglycemia

Answer 57

Adult D50 = 25Gm/50ml Ped D10 = 25Gm/250ml Adult/Ped: Glucose tablets: 3 = 15Gm Glucose paste: 1 tube = 15Gm

Answer 58

- IVP; Assure injection is intravenous by aspirating before and halfway through administration. - Oral glucose preferred for awake pt with gag reflex. - D10W can be created by mixing 25Gm into a 250ml IV bag of NS (discarb 50ml of NS prior to adding dextrose). - D25 can be created by discarding 25ml D50 and draw 25ml of normal saline back into pre-load which will yield 12.5Gm/50ml. - If D50 is not available, may give 25Gm of D10W by administering 250ml of Dextrose 10%.

Answer 59

- Tissue necrosis occurs with infiltration; watch for signs of infiltration; if this occurs, discontinue the IV, circle infiltrated area, and inform receiving hospital. - If you cannot access an IV or EJ consider Glucagon.

Answer 60

-Repeat BS not indicated enroute if patient is improving. Repeat BS must be done if patient left on scene and initial was abnormal (AMA).

Answer 61

Class: -Antihistamine Action: -Binds to histamine receptor sites, blocking H1 and H2 receptors. H1 causes bronchoconstriction, airway swelling, and vasodilation. H2 causes secretion of gastric acid. -Does not prevent histamine release. ``` Onset = 15-30 minutes Duration = 6-12 hours ```

Answer 62

Allergic Reaction/Anaphylaxis (S-122, S-162) -Hives (Urticaria)/Anaphylaxis Criteria/Angioedema Poisoning/OD (S-134, S-165) -Extrapyramidal reactions

Answer 63

Adult: -50mg slow IV/IM Ped: -PDC IV/IM

Answer 64

- Drowsiness/sedation (excitement in children) - Dry mouth/thickened bronchial secretions - Hypotension - Palpitations/tachycardia

Answer 65

-IV/IM, slow IV push

Answer 66

- Cumulative depressant effects occur in the presence of alcohol and/or other sedatives. - Priority in mild allergic reactions, Epinephrine is priority in moderate/acute reactions. - See S-122/S-162 for Anaphylaxis Criteria & Angioedema definitions.

Answer 67

- Anticholinergic properties help to correct drug-induced cholinergic and dopaminergic imbalances that cause extrapyramidal reactions. - Extrapyramidal reactions may be seen 7-10 after ingestion of medications.

Answer 68

Phenothiazine derivatives which may cause extrapyramidal reactions including: facial muscle twitch, full body spasm, neck muscle contraction, head deviation, occulogyrations, etc. - (Chlorpromazine) Thorazine - (Chlorprothixene) Taractan - (Fluphenazine) Prolixin - (Haloperidol) Haldol - (Perphenazine) Trilafon - (Thioridazine) Mellaril - (Trifluoperazine) Stelazine - (Thiothixene) Navane - (Loxapine) Loxitane - (Molindone) Moban

Answer 69

Class: -Vasopressor: Sympathomimetic (both alpha and beta properties) Action: - At low and medium doses, selectively dilates blood vessels supplying the brain, kidneys, heart, and gastrointestinal tract. - At medium and high doses, increases cardiac output by improving contractility and stroke volume, thereby increasing blood pressure. - At high doses, causes vasoconstriction and increased heart rate. ``` Onset = <5 minutes Duration = approximately 10 minutes after drip is stopped ```

Answer 70

Discomfort/Pain suspected Cardiac Origin (S-126) -with associated shock if BP is refractory to second fluid bolus Shock suspected Cardiac (S-138) -if BP refractory to second fluid bolus Shock suspected Anaphylactic, ?Neurogenic (S-138) -if BP refractory to fluid boluses Sepsis (S-134)** -if BP refractory to fluid boluses Anaphylaxis (S-122) -shock refractory to fluid boluses and Epinephrine IV/IO Dysrhythmias (S-127) -Bradycardia: after max Atropine or initiation of TCP

Answer 71

Adult only: 10-40mcg/kg/min IV/IO drip infusion; Titrate to maintain systolic BP >90 not to exceed >120 BHO **BHPO for Sepsis

Answer 72

- At high infusion rates, hypertension and extreme vasoconstriction may occur - At low infusion rates, hypotension may occur - Tachyarrhythmias/palpitations - Increased myocardial O2 demand

Answer 73

-400mg in 250ml NS = 1,600mcg/1ml

Answer 74

- Always confirm calculations and dose according to the Dopamine drip chart. - Titrate dosing to maintain systolic BP >90 not to exceed >120. - Always run as piggyback drip, never run as primary IV. Turn primary line off during Dopamine infusion.

Answer 75

-Tissue necrosis occurs with infiltration; Check IV patency before and during administration watching for signs of infiltration; if this occurs, discontinue the IV, circle infiltrated area, and inform receiving hospital.

Answer 76

-Approved optional premix solution of 400mg Dopamine in 250ml D5W.

Answer 77

Class: -Catecholamine: Sympathomimetic (both alpha and beta effects) Action: -On the bronchi: bronchodilation (beta-2) -On the peripheral vasculature: vasoconstriction (alpha) -On the heart: increased heart rate (beta-1)/chronotropic increased contractility/inotropic increased AV conduction/dromotropic increased automaticity/dromotropic ``` Onset = IV/IO 1-2 minutes, IM 5-10 minutes Duration = IV/IO 5-10 minutes, IM 1-4 hours ```

Answer 78

Allergic Reaction/Anaphylaxis (S-122, S-162) [Adult/Ped] -anaphylaxis/angioedema ``` Respiratory Distress (S-136, S-167) [Adult/Ped] -severe respiratory distress or inadequate response to Albuterol/Atrovent ``` ``` Respiratory Distress (S-167) [Ped] -with stridor at rest ``` Burns (S-170) [Ped] -with respiratory distress with stridor Dysrhythmias (S-127, S-163) [Adult/Ped] - cardiac arrest (pulseless patient) [Adult/Ped] - unstable bradycardia: after BVM for 30 sec [Ped only] ``` Newborn Deliveries (S-166) [Ped] -if HR remains <60 after 30 seconds of CPR ```

Answer 79

``` Allergic Reaction/Anaphylaxis Adult: -0.3mg IM 1:1,000, MR x2 q5" -0.1mg IV/IO 1:10,000 BHO; MR x2 q3-5" BHO Ped: -PDC IM 1:1,000; MR x2 q5" -PDC IV/IO 1:10,000 BHO; MR x2 q3-5" BHO ``` Respiratory Distress (severe/inadequate response) Adult: -0.3mg IM 1:1,000; MR x2 q5" if no definite history of asthma: dosing as above BHPO Peds: -PDC IM 1:1,000; MR x2 q5" ``` Respiratory Distress (Peds, stridor at rest) -PDC 1:1,000 via nebulizer, MR x1 ``` Burns (respiratory distress with stridor at rest) [Peds] - PDC 1:1,000 via nebulizer, MR x1 SO - PDC 1:1,000 IM SO, MR x2 q5" SO Dysrhythmias (cardiac arrest/peds-unstable brady) Adult: -1mg IV/IO 1:10,000; MR q3-5" Ped: -PDC IV/IO 1:10,000; MR x2 q3-5"; MR q3-5" BHO ``` Newborn Deliveries (if HR<60 after 30 sec CPR) [Ped] -PDC IV/IO 1:10,000; MR x2 q3-5"; MR q3-5" BHO ```

Answer 80

- Anxiety/restlessness - Palpitations/tachyarrhythmias - Ventricular irritability - Increased myocardial O2 demands - Hypertension - Angina

Answer 81

- 1:10,000 = 1mg/10ml | - 1:1,000 = 1mg/1ml

Answer 82

- Use caution in respiratory distress patients if: known cardiac HX or HX of HTN or BP >150 or age >40. - Monitor ECG, may aggravate pre-existing tachycardia. - Patients who meet Anaphylaxis criteria, Epinephrine is administered first. Not indicated for mild allergic reactions.

Answer 83

Use IV Epinephrine in anaphylaxis with S/S of poor perfusion: - Weak pulses/Hypotension - Pale/Cyanotic skins - Dizzy, faint/Syncope Nebulized Epinephrine 1:1,000 concentration only: - Can cause sensitivity/irritation to providers; may need goggles and face shield. - Is used full strength in nebulizer, do not dilute. - Up to 5 single dose ampules may be required if no multi-dose vials are available. In Allergic/Anaphylaxis patients, signs and symptoms can occur minutes to hours after exposure.

Answer 84

Class: -Analgesic; Opioid Agonist Action: -Potent narcotic analgesic and sedative ``` Onset = <1-2 minutes Duration = 30-60 minutes ```

Answer 85

For treatment of pain as needed (S-141, S-173) [Adult/Ped]: - Abdominal Pain (S-120, S-174) - Burns (S-124, S-170) - Envenemation Injury (S-129, S-164) - Trauma (S-139, S-169) For treatment of pain as needed (S-141) [Adult only] - Pain or Discomfort of Suspected Cardiac Origin (S-126) - Pain associated with external pacing (S-127)

Answer 86

For treatment of pain as needed (S-141, S-173) [Adult/Ped] (abd pain/burns/envenemation/trauma) ``` If <65 years of age: Titrate to pain and vital signs -Fentanyl up to 50mcg IV x1 SO -MR 25mcg IV q5" x2 SO -Maximum So dose is 100mcg **OR** -Fentanyl 50mcg IN q15" x2 SO -3rd IN dose Fentanyl 50mcg BHO Treatment of pain if BP <100 BHO ``` ``` If >65 years of age: Titrate to pain and vital signs -Fentanyl 25mcg IV x1 SO -MR 25mcg slow IVP q5" x2 SO -Maximum So dose is 75mcg **OR** -Fentanyl 25mcg IN q15" x2 SO -3rd IN dose Fentanyl 25mcg BHO Treatment of pain if BP <100 BHO ``` ``` Peds: <10kg: -Fentanyl IV/IN per drug chart BHO -MR per drug chart BHO >10kg: -Fentanyl IV/IN per drug chart SO -MR per drug chart BHO max 75mcg ``` For treatment of pain as needed (S-141) (pain/discomfort cardiac origin/pain related to pacing): Adult Only: -Fentanyl 25mcg IV x1 SO

Answer 87

- Isolated head injuries - Acute onset severe headache - Drug/ETOH intoxication - Multiple trauma with GCS <15 - Suspected active labor

Answer 88

- Respiratory depression/apnea - Decreased LOC - Transient hypotension - Nausea/vomiting/dizziness - Muscular rigidity - Bradycardia

Answer 89

-50mcg/ml (100mcg/2ml)

Answer 90

- Slow IVP. Medication has rapid onset. | - Document vital signs and pain scale before and after each administration.

Answer 91

- When changing route of administration a BHO is required. (e.g. IV to IM or IM to IN) - A change in analgesic while treating a patient requires BHO (e.g. changing from Morphine to Fentanyl) - Consider BLS methods of pain control prior to narcotic administration. - Consider dosing based on factors such as age, body weight, physical status, and medical history. - If respiratory arrest occurs, assist ventilations and obtain an order for Narcan. - If hypotension occurs, consider fluid bolus. Request order for Narcan if fluid bolus is refractory. - Rapid infusion may increase nausea/vomiting after administration, consider Zofran early.

Answer 92

- Fentanyl is a controlled substance and must be kept locked and signed for when used. - Pain level should be documented at administration and every 5 minutes.

Answer 93

Class: -Antihypoglycemic: Pancreatic hormone Action: - Increases blood glucose by converting glycogen stored in the liver to glucose. - Inhibits production of glycogen from glucose. ``` Onset = 20 minutes Duration = 60-90 minutes ```

Answer 94

Altered Neurologic (S-123, S-161): -Symptomatic hypoglycemia: symptomatic patient with altered LOC *OR* unresponsive to oral glucose agents "if no IV" and blood sugar: -Adult/Ped/Infant = <60 -Neonate = <45

Answer 95

Adult: -1ml (1unit) IM Ped: -PDC IM

Answer 96

- Nausea/vomiting | - Tachycardia/HTN

Answer 97

-1mg (1 unit)/1ml

Answer 98

- IM - Inject syringe fluid into medication vial. - To reconstitute, rub bottle back and forth in hands. - To check if mixed well, be sure that solution is transparent and does not have any un-dissolved medication.

Answer 99

- Exerts a positive inotropic & chronotropic effects on the heart, which may cause HTN & tachycardia. - Glucagon depletes glycogen stores. The patient should be given supplemental carbohydrates after he/she awakens and is able to swallow.

Answer 100

-Glucagon will not work if a ptient's liver glycogen stores are depleted (severe hypoglycemia, malnutrition, adrenal insufficiency).

Answer 101

Class: -Anesthetic/Analgesic Action: - Low & slow dosing provides strong analgesic effects acting on the limbic system and cortex to block afferent transmission of impulses associated with pain perception. - High & rapid dosing provides fast acting dissociative anesthetia (blocks sensory perception) which can lead to distortion of sights, colors, sounds, self, and one's environment. ``` Onset = IV: 30 seconds, IN: 2 minutes Duration = 15-30 minutes ```

Answer 102

For MODERATE-SEVERE pain (score >5) (S-141): - Burns (S-124, S-170) - Envenemation Injury (S-129, S-164) - Trauma (S-139, S-169)

Answer 103

>15 years old AND with GCS of 15 AND not pregnant AND no known or suspected alcohol or drug intoxication AND have not received opioid analgesic in past 6 hours (prior to medic arrival)

Answer 104

``` IV Dosing: -Ketamine 0.2mg/kg in 100ml of NS SO SLOW IV drip over 15 minutes Maximum of any IV dose is 20mg -MR x1 in 15 minutes if pain remains MODERATE or SEVERE SO ``` ``` IN Dosing: -Ketamine 0.5mg/kg IN SO (50mg/ml concentration) Maximum for any IN dose is 50mg -MR x1 in 15 minutes if pain remains MODERATE or SEVERE SO ``` BHO required for: - BP <100 - Change in analgesic administered - Change in administration route

Answer 105

- Pediatrics - Pregnancy - Severe hypertension - Alcohol intoxicated

Answer 106

-Increased heart rate -Increased blood pressure -Increased respiratory rate -Nausea -With higher doses and rapid infusion "disassociative effects": -Euphoria (pleasant: dream-like states, vivid imagery) -Dysphoria (unpleasant: anxiety, disorientation, hallucinations)

Answer 107

-50mg/ml (10ml multi-dose vials containing 500mg total)

Answer 108

IV-Intravenous: -Add 0.2mg/kg to 100ml Normal Saline IV bag. Administer Slow IV drip over 15 minutes (maximum single IV dose is 20mg) IN-Intranasal: -Administer 0.5mg/kg via 1ml syringe with MAD tip attached. (maximum intranasal dose is 50mg) -Ketamine dosing chart is recommended using 5mg/0.1ml incremental measurements. Round dose to next 5mg amount from weight based calculation.

Answer 109

Use with caution: BHPO only for the following: - Isolated head injuries - Acute onset severe headache - Drug/ETOH intoxication - Multiple trauma with GCS <15 - Suspected active labor

Answer 110

- Cardiac function should be continually monitored during administration in patients with hypertension or cardiac instability. Arrhythmia has occurred with administration. - Although respiration is frequently stimulated, severe respiratory depression may occur with high doses and too rapid a rate of administration, in which case supportive ventilation should be employed. - There is no antidote for Ketamine. - "Emergence Reactions" may occur during the recovery period. - Consider BLS methods of pain control prior to narcotic administration. - Ketamine is a controlled substance and must be kept locked and signed for when used. - Pain level should be documented at administration and every 5 minutes.

Answer 111

Class: -Antiarrhythmic/Anesthetic Action: - Depresses depolarization and automaticity in the ventricles - Increases the ventricular fibrillation threshold by increasing phase IV repolarization - Amide-type local anesthetic ``` Onset = 1-2 minutes Duration = 10-20 minutes ```

Answer 112

Dysrhythmias (S-127) [Adult only] -Stable Ventricular Tachycardia Dysrhythmias (S-127) [Adult only] -Reported/witnessed >2 AICD firing or >1 AED shock delivered with pulse >60 Dysrhythmias (S-127, S-163) [Adult/Ped] -VF/Pulseless VT: After 1st shock if still refractory ``` ALS Skills (S-104) [Adult only] -Conscious patient prior to IO infusion ```

Answer 113

Dysrhythmias (Stable VTach) [Adult only] -1.5mg/kg slow IV/IO; SO MR 0.5mg/kg IV/IO q8-10" SO to max of 3mg/kg (including initial bolus) SO Dysrhythmias (AICD/AED w/pulse >60) [Adult only] -1.5mg/kg slow IV/IO; SO MR 0.5mg/kg IV/IO q8-10" SO to max 3mg/kg (including initial bolus) SO ``` Dysrhythmias (VF/Pulseless VTach, after 1st shock) [Adult/Ped] Adult: -1.5mg/kg IV/IO, SO MR x1 in 3-5" (max 3mg/kg) SO Ped: -PDC IV/IO, MR x1 in 3-5" SO ``` ALS Skills (Conscious IO) [Adult only] -40mg slow IO SO prior to fluid administration

Answer 114

- 2nd & 3rd degree heart block | - Idioventricular rhythms

Answer 115

Early: - Anxiety -Euphoria - Combative -Nausea - Twitching -Numbness Late: - Seizure -Decreased BP - Coma -Widening QRS - Prolonged PRI -V-Fib

Answer 116

-100mg/5ml

Answer 117

- Do not push faster than 50mg/min in an awake patient. | - Recommended all adult doses be rounded off to the nearest 20mg.

Answer 118

-In conscious adult IO initiation; slowly infuse Lidocaine 2% (preservative free) 40mg prior to fluid administration. This DOES count toward to max dose of 3mg/kg so reduce the initial dose of Lidocaine by 40mg.

Answer 119

-Toxicity and delayed effect is more likely in elderly, CHF, and liver disease due to reduced ability to metabolize drug. Repeat doses in this patient population should be given at 10-minute intervals.

Answer 120

Class: -Benzodiazepine: Sedative/Anticonvulsant Action: - CNS depressant - Produces anterograde amnesia, then sedation - Stops and prevents seizures ``` Onset = IV/IO/IN: 2 minutes; IM: 15 minutes Duration = 1-4 hours ```

Answer 121

Seizures (S-123, S-133): [Adult] - generalized seizures lasting >5 minutes (includes seizure time prior to arrival of prehospital provider) - recurrent tonic/clonic seizures without lucid interval - eclamptic seizures of any duration Seizures (S-161): [Ped] - generalized seizures lasting >5 minutes (includes seizure time prior to arrival of prehospital provider) - partial seizure with respiratory compromise - recurrent tonic/clonic seizures without lucid interval Dysrhythmias (S-127): [Adult only] - unstable bradycardia: discomfort associated with TCP capture, after Morphine if BP >100 - unstable conscious VT: precardioversion Dysrhythmias (S-127, S-163): [Adult/Ped] -conscious SVT: precardioversion Dysrhythmias (S-127): [Adult only] -unstable conscious A-Fib, A-Flutter: precardioversion Overdose (S-134): [Adult only] -?stimulant intoxication with excited delirium Psychiatric Behavioral Emergencies (S-142): [Adult only] -combative patients

Answer 122

``` Seizures (S-123, S-133, S-161): [Adult/Ped] Adult: -IN, IM, IV, IO to max 5mg (d/c IV/IO dose if seizure stops) MR x1 in 10". Max 10mg total Ped: -PDC IV/IM/IN ``` Dysrhythmias (S-127) (unstable brady w/TCP, unstable conscious VT precardioversion) [Adult only] -1-5mg slow IV/IO (1mg/min) If age >60 consider lower dose with attention to age and hydration status Dysrhythmias (S-127, S-163) (conscious SVT precardioversion) [Adult/Ped] Adult: -1-5mg slow IV/IO (1mg/min) BHO If age >60 consider lower dose with attention to age and hydration status Ped: -PDC slow IV (1mg/min) BHPO Dysrhythmias (S-127) (unstable conscious AFib/AFlutter precardioversion) [Adult only] -1-5mg slow IV/IO (1mg/min) BHPO If age >60 consider lower dose with attention to age and hydration status Overdose (S-134) (?stimulant w/ excited delirium) Psychiatric Behavioral Emergencies (S-142) (combative patient) [Adult only for both] -IN, IM, IV 5mg MR x1 in 10"

Answer 123

-Respiratory depression/apnea

Answer 124

-5mg/1ml or 10mg/2ml

Answer 125

- Versed should be administered slowly at a rate of 1mg/minute when given IV/IO to prevent respiratory depression/failure. - Discontinue IV/IO administration if/when seizure activity stops. - Versed is not indicated for simple febrile seizures.

Answer 126

- 5-minute seizure time includes time prior to arrival of prehospital providers. - Carefully monitor respiratory rate, tidal volume, O2 saturation, and EtCO2 during administration. - Side effects of Versed i.e. respiratory depression, may be potentiated when combined with the use of ETOH, other sedative hypnotics, and other CNS depressants resulting in apnea. - When used for cardioversion: amnesia is desired effect, not sedation, therefore the dosage administered will NOT necessarily produce lethargy. - In the combative patient, IM route is usually safer and preferred in order to prevent injury to patient and personnel. If unable or patient too violent for needles consider IN route. - Injection may be given through clothing into the thigh for crew safety issues.

Answer 127

* *Emergency drug shortage concentration 1mg/ml is inappropriate for IN/IM doses and CANNOT be used with pediatric drug chart!!** - Versed is treated as a controlled substance and is to be secured/signed for when used.

Answer 128

Class: - Opioid - Narcotic analgesic Action: - CNS depressant acting on opiate receptors in the brain - Potent narcotic analgesic ``` Onset = 1-2 minutes Duration = 2-7 hours ```

Answer 129

For treatment of pain as needed (S-141, S-173): [Adult/Ped] - Abdominal Pain (S-120, S-174) - Burns (S-124, S-170) - Envenemation Injury (S-129, S-164) - Trauma (S-139, S-169) For treatment of pain as needed (S-141): [Adult only] - Pain or discomfort of suspected cardiac origin (S-126) - Pain associated with external pacing (S-127)

Answer 130

For treatment of pain as needed (S-141, S-173) (abd pain, burns, envenemation, trauma) [Adult/Ped] Adult: Morphine, if Fentanyl unavailable: -Morphine 0.1mg/kg IV SO -MR in 5" at half of the initial IV dose SO -MR in additional 5" at half of the initial IV dose BHO Maximum for ANY IV dose is 10mg Intramuscular dosing: -Morphine 0.1mg/kg IM SO -MR in 15" at half of the initial IM dose SO -MR in additional 15" at half of the initial IM dose BHO Maximum for ANY IM dose is 10mg Treatment of pain if BP <100 systolic BHO Ped: with signs of adequate perfusion: -PDC IV/IM. MR BHO For treatment of pain as needed (S-141) [Adult only] (pain of cardiac origin, pain associated with pacing) Adult Only: -Administer Morphine 0.05mg/kg IV x1 SO

Answer 131

- Isolated head injuries - Acute onset severe headache - Drug/ETOH intoxication - Multiple trauma with GCS <15 - Suspected active labor

Answer 132

- Respiratory depression - Decreased LOC - Transient hypotension - Nausea/vomiting - Pinpoint pupils

Answer 133

- Slow IVP | - Document vital signs and pain scale before and after each administration

Answer 134

- When changing route of administration a BHO is required (e.g. IV to IM or IM to IN). - A change in analgesic while treating a patient requires a BHO (e.g. changing from morphine to fentanyl). - NTG is the priority for cardiac patients and should be continued as Morphine is added. - Consider BLS methods of pain control prior to narcotic administration. - If respiratory arrest occurs, assist ventilations and obtain an order for Narcan. - If hypotension occurs, consider fluid bolus. Request order for Narcan if fluid bolus is refractory. - Rapid infusion may increase nausea/vomiting after administration, consider Zofran early. - During national drug shortages, contact BH and EMS coordinator to consider using expired MS - must inform patient and document thoroughly.

Answer 135

- Morphine is a controlled substance and must be kept locked and signed for when used. - Pain level should be documented at administration and every 5 minutes.

Answer 136

Class: -Opioid antagonist Action: -Reverses respiratory depression, sedation, and hypotensive effects of opioid overdose by occupying opiate receptor sites ``` Onset = IV/IN: 1-2 minutes; IM: 2-5 minutes Duration= IV: 30-60 minutes; IM: longer ```

Answer 137

Adult: Poisoning/OD (S-134) Altered Neurologic (S-123) -symptomatic suspected opioid OD with respirations <12 Ped: Poisoning/OD (S-165) Altered Neurologic (S-165) -symptomatic suspected opioid OD

Answer 138

Adult: -2mg IN/IM/IV; MR titrate IV dose to effect, to drive respiratory rate If patient refuses transport: -2mg IM additional dose Ped: -PDC IN/IM/IV; MR Adult/Ped: For opioid dependent pain management patients: "use caution and titrate"

Answer 139

- Acute withdrawal symptoms - Nausea/vomiting - Tachycardia/hypertension

Answer 140

If giving IV, titrate to effect of controlling respirations. For titrated dosing: -Adult: dilute IV dose (2mg) to 10ml with NS (new concentration = 0.1mg/0.5ml) -Pediatric: dilute 1mg to 10ml with NS (new concentration = 0.1mg/1ml)

Answer 141

- Manage airway with BLS prior to Narcan. Advanced airways are contraindicated prior to Narcan. Narcan should NOT be given once an advanced airway is in place. - When giving to opioid dependent pain management patients the goal is to increase the respiratory drive and not necessarily make them fully conscious. - Duration of Narcan is generally less than that of opioid; watch for relapse as long as opioid is still in the patient's system. - Narcan can precipitate withdrawal syndrome and/or combative behavior.

Answer 142

-IN route produces a more gradual improvement of LOC than respiratory effort. If IN dose ineffective, repeat doses should be IM/IV route.

Answer 143

Some of these analgesics are not true opiates yet work and react similarly. Naloxone is an effective antidote for all of these. - (Buprenorphine) Buprenex, Butrans, Suboxone, Subutex - (Butalbital) Fiorinal - (Butorphanol) Stadol - (Diacetylmorphine) Heroin - (Diphenoxylate) Lomotil - (Fentanyl) Abstral, Actiq, Duragesic, Fentora, Lazanda, Onsolis, Sublimaze, Subsys - (Hydrocodone) Anexsia, Lortab, Lorcet, Norco, Tussionex, Vicodin, Zydone - (Hydromorphine) Dilaudid, Exalgo, Palladone - (Levorphanol) Levo-Dromoran - (Meperidine) Demerol - (Methadone) Dolophine, Diskets, Methadose - (Methylmorphine) Codeine - (Morphine) Astromorph, Avinza, Kadian, MS Contin, MSIR, Oramorph, Roxanol - (Nalbuphine) Nubain - (Opium) Paregoric, Laudanum - (Oxycodone) Combunox, Oxycontin, Oxyfast, Percocet, Percodan, Primlev, Roxicet, Roxicodone, Tylox, Magnacet - (Oxymorphone) Opana, Numorphan - (Pentazocine) Talwin - (Propoxyphene) Darvocet, Darvon, Wygesic - (Tapentadol) Nucynta - (Tramadol) Ultram, Ryzolt

Answer 144

Class: -Vasodilator Action: - Produces vasodilation by relaxing systemic venous & arterial vessels, thereby: - Decreasing preload & afterload - Decreasing myocardial workload and - Decreasing myocardial O2 consumption - Dilates coronary arteries ``` Onset = SL 2 minutes, topical 30-60 minutes Duration = SL 30-60 minutes, topical 24 hours ```

Answer 145

Discomfort/Pain of ?Cardiac Origin (S-126) Fluid overload with rales (S-131) -hemodialysis patients ``` Respiratory Distress (S-136) -respiratory distress ?CHF/Cardiac origin ```

Answer 146

``` Discomfort/Pain of ?Cardiac Origin (S-126) If BP >100: -0.4mg SL; MR q3-5" -Topical paste 1" If BP <100: -0.4mg SL BHO; MR BHPO ``` ``` Fluid overload with rales (S-131) Respiratory Distress (S-136) If BP >100: Topical paste 1" If BP >100 but <150: 0.4mg SL; MR q3-5" If BP >150: -0.8mg SL; MR q3-5" If BP <100: 0.4mg SL BHO; MR BHPO ```

Answer 147

- Patient who has taken a sexual enhancement medication such as Viagra, Cialis, Levitra within 48 hours - Patients taking medication for pulmonary hypertension, usually Sildenafil (trade names: Revatio, Flolan, and Veletri)

Answer 148

- Orthostatic hypotension - Dizziness/syncope - Temporary pulsating headache - Facial flushing

Answer 149

- 1 metered spray or 1 tablet = 0.4mg | - Topical paste: 1 inch = 15mg

Answer 150

-Preparing the patient for administration of NTG: Start an IV before or soon after first dose. Place patient in a supine or semi-fowler's position whenever possible. - If using tablet, place tablet under tongue and allow to dissolve. - If unable to spray under tongue, spray inside mouth; is well absorbed. Do not shake NTG spray. - Apply 1" of NTG paste (on paper included with packaging) directly to skin. - Document vital signs and pain scale before and after each administration.

Answer 151

- Nitroglycerin is used for ADULT ONLY. - If patient becomes hypotensive, lay supine and consider fluid bolus. - Avoid application of NTG paste to areas that may be used for cardioversion. - Avoid irritated/broken skin and consider taping patch to prevent movement of paste. - If patient's chest pain is resolved on medic arrival (self-medicated with own NTG), continue treatment with NTG paste and ASA.

Answer 152

- Alcohol ingestion potentiates the hypotensive side effect. - Orthostatic hypotension are more commonly seen in patients taking beta-blockers. - Patients taking Viagra/Cialis/Levitra or other medications for sexual enhancement OR patients taking similar medication for pulmonary hypertension (Revatio, Flolan, and Veletri) may have a fatal drop in blood pressure of 50-60mmHg. Suspect patient may be on these medications if they have unexplained LOC.

Answer 153

Class: -Electrolyte/isotonic crystalloid Action: - Electrolyte solution, which is osmotically equivalent to blood - Increases the circulating volume of the vascular system (2/3 of infused volume leaves vascular space within 1 hour)

Answer 154

``` Definitive Therapy (S-104, S-101) -immediate or anticipated immediate need for administration of a fluid bolus or medications ``` Abdominal Discomfort GI/GU (non-traumatic) (S-120, S-174) - Adult & Peds: suspected volume depletion - Adult: symptomatic suspected AAA to maintain BP at 80 Anaphylaxis (S-122, S-162) - Adult: for BP <90 - Peds: to maintain adequate perfusion Altered Neuro Function (S-123) [Adult only] - Adult: CVA to maintain BP >120 - Adult: Hyperglycemia Burns (S-124, S-170) - Adult: with >20% BSA partial thickness or >5% BSA full thickness - Peds: with >10% BSA partial thickness of >5% full thickness Discomfort/Pain of suspected Cardiac Origin (S-126) [Adult only] Adult: with associated shock Dysrhythmias (S-127, S-163) - Adult: see protocol - Peds: see protocol ``` Environmental Exposure (S-130) [Adult only] -Adult: heat exhaustion ``` Overdose (S-134) [Adult only] -Adult: ?stimulant intoxication with Excited Delirium Shock (S-138, S-168) - Adult: see protocol - Peds: see protocol Trauma (S-139, S-169) - Adult & Peds: crush injury with extended compression >2 hours - Adult: to maintain BP >80 - Peds: to maintain adequate perfusion Sepsis (S-143) [Adult only] -Adult: see protocol ``` Respiratory Distress (S-136, S-167) -Adult & Peds: with croup-like cough via nebulizer ```

Answer 155

``` Definitive Therapy (S-104, S-101) -IV/IO; adjust prn ``` All others: -See specific protocol for routes and dosing

Answer 156

-Rales (exception for sepsis - S-143)

Answer 157

-0.9% NaCl: 1,000ml or 250ml

Answer 158

- Dose for Pediatric patients are WEIGHT related (20ml/kg PDC) - Dose for burn patients are AGE related (500ml: adults, 250ml: 5-14y/o, 150ml: <5y/o) TKO is approximately - 5gtts/min with maxi-drip (10gtts = 1ml) tubing - 30gtts/min with mini-drip (60gtts = 1ml) tubing

Answer 159

-Consider small bag (250ml) for patients with rales, significant HTN, and suspected intracranial bleed.

Answer 160

- BP goals: 1. 80 systolic in trauma and aortic aneurysm 2. 120 systolic in stroke patients 3. 90 systolic in all others

Answer 161

Class: -Antiemetic Action: -Blocks serotonin receptors in vagus nerve terminals and in small intestine that trigger the vomiting reflex. ``` Onset = IV/IM/ODT, up to 30 minutes Duration = IV/IM/ODT, 2 hours ```

Answer 162

Adult: Abdominal discomfort GI/GU (non-traumatic) (S-120) -for nausea or vomiting Pain Management (S-141) -for nausea or vomiting after Morphine administration Ped: GI/GU (non-traumatic) (S-174) -for nausea or vomiting

Answer 163

Abdominal discomfort (S-120)/Pain management (S-141) [Adult only]: -4mg IV/IM/ODT MR x1 in 10" ``` Abdominal discomfort (S-174) [Ped only] 6mo.-3yrs : -2mg ODT/IV >3yrs: -4mg ODT/IV If suspected head injury: BHPO ```

Answer 164

- GI symptoms, especially diarrhea | - Headache

Answer 165

-Vial = 4mg/2ml for IV/IM or ODT = 4mg for PO

Answer 166

- Oral dissolving tablets (ODT) dissolve quickly but are somewhat fragile. - Do not push tablet through foil package. - Do not remove tablets from packaging until ready to administer to patient. - Place tablet on patient's tongue and encourage patient to allow to dissolve; can be swallowed without water. - For pediatric patients 6mo-3yrs give 2mg ODT which is 1/2 of ODT.

Answer 167

-Anticipate the need for Zofran to treat nausea/vomiting side effect of Morphine administration.

Answer 168

-Pediatric patients with associated suspected head injury require BHPO.

Answer 169

Class: - Electrolyte - Alkalinizing agent Action: -Reduces acidosis or causes alkalosis by direct release of bicarbonate ion into the circulation. ``` Onset = 2-10 minutes Duration = 30-60 minutes ```

Answer 170

``` Hemodialysis Patient (S-131) [Adult only] -symptomatic, suspected hyperkalemia if >72 hours since last dialysis ``` Poisoning/OD (S-134, S-165) [Adult/Ped] -tricyclic OD with cardiac effects Trauma (S-139, S-169) [Adult/Ped] -crush injury of extremity or torso with extended entrapment >2 hours just prior to extremity being released

Answer 171

``` Hemodialysis Patient (S-131) [Adult only] -1mEq/kg IV/IO ``` ``` Poisoning/OD (S-134, S-165) [Adult/Ped] Adult: -1mEq/kg IV/IO Ped: -PDC IV/IO x1 BHO ``` ``` Trauma (crush injury >2 hours) (S-139, S-169) [Adult/Ped] Adult: -1mEq/kg IV/IO BHO Ped: -PDC IV/IO x1 BHO ```

Answer 172

-Electrolyte/pH imbalances

Answer 173

-50mEq/50ml

Answer 174

- Flush tubing between administration of meds: - Effectiveness of Epinephrine will be decreased if it is mixed with bicarb. - Calcium Chloride will precipitate with Bicarb. Be sure to flush tubing between drugs.

Answer 175

-TCA cardiac effects (for example) hypotension, heart block, or widened QRS.

Answer 176

- In hyperkalemia; slight alkalosis causes potassium to shift from the extracellular to the intracellular space causing a reduction in serum potassium levels. - In crush injuries, reverses effects of acidosis as lactic acid moves from the crushed part to circulation. Increases urine pH thus decreasing the amount of myoglobin precipitated in the kidneys. - In a tricyclic OD, slight alkalosis promotes binding of tricyclic to plasma protein, thus reducing toxic effects on the body.

Answer 177

May cause sudden onset of seizures and arrhythmias in overdose: - (Amitriptyline) Elavil, Triavil, Limbitrol, Vanatrip - (Amoxapine) Asendin - (Clomipramine) Anafranil - (Despiramine) Norpramin - (Doxepin) Sinequan, Silenor, Adapin - (Imipramine) Tofranil - (Maprotiline) Ludiomil - (Nortriptyline) Aventyl, Pamelor - (Protriptyline) Vivactil - (Trimipramine) Surmontil

Answer 178

- Amyl Nitrate inhaler - Sodium Thiosulfate 25% - Hydroxocobalamin ``` Onset = minutes Duration = days ```

Answer 179

Amyl Nitrate inhalation: - Indications: Significant symptoms such as seizures, LOC, or cardiac arrest - Dosage/Route: Given over 30 seconds BHPO Sodium Thiosulfate 25%: - Indications: Significant symptoms such as seizures, LOC, or cardiac arrest - Dosage/Route: 12.5Gm IV BHPO Hydroxocobalamin: - Indications: Significant symptoms such as seizures, LOC, or cardiac arrest - Dosage/Route: 5Gm given over 15 minutes IV BHPO

Answer 180

Amyl Nitrate: - Hypertension - Tachycardia - Palpitations - Syncope - Headache - Nausea Sodium Thiosulfate: - Cirrhosis of liver - Congestive heart failure - Renal function impairment Hydroxocobalamin: - Mild increase in BP - Reddish orange skin color which clears over days

Answer 181

1. Administer only if cyanide kit is available on site and patient has significant symptoms 2. Cyanides are fast acting poisons that can be lethal 3. Can be found in pesticides, fumigants, plastics, electroplating, photographic developing, and mining 4. Signs and symptoms of cyanide poisoning include: - A. Weakness and confusion - B. Headache - C. Nausea - D. Metabolic acidosis - E. Abrupt asphyxiation - F. Difficulty breathing, respiratory arrest - G. Loss of consciousness - H. Seizures prior to death - I. Cardiac arrest 5. Other supportive care includes high flow oxygen (BVM if necessary), decontamination, treatment of seizures, and supporting blood pressure 6. Amyl Nitrate: - Effective in the emergency management of cyanide poisoning by causing the oxidation of hemoglobin to the compound methemoglobin. Methemoglobin reacts with cyanide ion to form cyanomethemoglobin, which has less affinity for oxygen, thus freeing hemoglobin to react with oxygen - Onset 30 secons, duration 3-20 minutes 7. Sodium Thiosulfate: - Acts as a sulfur donor and reacts with ferric ion to prevent inhibition of cellular respirations - Protects against nephrotoxicity 8. Hydroxocobalamin: - Natural form of Vitamin B12 that contains hemoglobin-like molecule with cobalt - Binds to cyanide to pull it out of the mitochondria of the cell to become cyanocobalamin, which is excreted through the urine