Pain / Sedative / Induction / RSI Flashcards
1
Q
Haloperidol
(mechansim of action)
A
The direct action of Haldol are unknown.
However Haldol produces calmness and reduces aggressiveness with the disappearance of hallucinations and delusions by depressing the cerebral cortex, hypothalamus and limbic system which controls activity and aggression.
Blocks postsynaptic dopamine (D1 and D2 receptors)
2
Q
Haloperidol
(onset and duration)
A
Haloperidol
Onset: 20 - 30 min
Half Life: 21 - 24 hrs
Duration: 4 - 8 hrs
3
Q
Haloperidol
(side effects)
A
Haloperidol
♦ Extrapyramidal symptoms
♦ Caution with elderly patients - may require smaller doses to achieve therapeutic effect.
♦ Haloperidol has been associated with cardiac arrest in patients with prolonged QT intervals.
♦ Closely monitor for cardiac arrhythmia, particularly when the medication is given IV.
May cause neuroleptic malignant syndrome.
4
Q
Haloperidol
(indications)
A
Haloperidol
Altered Mental Status when patient is combative and potential for harm to patient and/or personnel is present.
5
Q
Haloperidol
(contraindications)
A
♦ QT prolongation or hx of torsades de pointes.
♦ Tardive dyskinesia is a syndrome of potentially irreversible, involuntary, dyskinetic movements that may develop in pt’s treated w/ antipsychotics.
♦ Parkinson’s disease; have increased sensitivity to antipsychotics. May include severe extrapyramidal symptoms, confusion, sedation, and falls. Additionally, haloperidol may impair the antiparkinson effects of levodopa and other dopamine agonists.
6
Q
Haloperidol
(adult dose)
A
Haloperidol (adult)
♦ 5 mg IM
♦ q 15 minutes PRN up to a total of 20mg.
7
Q
Haloperidol
(pediatric dose)
A
Haloperidol (ped)
♦ 0.1 mg/kg IM
♦ Max dose of 5 mg
8
Q
Haloperidol
(pregnancy safe)
A
Pregnancy Class C
Haloperidol should be used during human pregnancy only when the benefits to the mother outweigh the potential risks to the fetus.
breast-feeding should be avoided during treatment with haloperidol. Haloperidol is excreted into breast milk.
9
Q
Etomidate (Amidate)
(mechanism of action)
A
♦ Etomidate is an ultra-short- acting nonbarbiturate that appears to act similar to GABA by depressing the activity of the brain stem reticular activating system, reducing subcortical inhibition and inducing sleep.
♦ Etomidate will induce apnea, cause a slight decrease in intracranial pressure and a moderate increase in intraocular pressure.
(will not cause significant hemodynamic changes)
10
Q
Etomidate (Amidate)
(onset and duration)
A
Etomidate
Onset: 10 - 20 sec
Half Life: 75 min
Duration: 4 - 10 min
11
Q
Etomidate (Amidate)
(side effects)
A
Etomidate Side Effects
♦ Respiratory depression,
♦ Venous pain,
♦ Skeletal muscle movement
12
Q
Etomidate (Amidate)
(indications)
A
For use in RSI protocol – for anesthesia induction
13
Q
Etomidate (Amidate)
(contraindications)
A
Etomidate Contraindications
♦ Adrenal Insufficiency
♦ Sepsis
14
Q
Etomidate (Amidate)
(adult dose)
A
Etomidate(adult)
♦ 0.3 mg/kg IV push over 30 seconds
Maximum of 40 mg
(same as pediatric)
15
Q
Etomidate (Amidate)
(pediatric dose)
A
Etomidate(pediatric)
♦ 0.3 mg/kg IV push over 30 seconds
Maximum of 40 mg
(same as adult)
16
Q
Etomidate (Amidate)
(pregnancy safe)
A
Pregnancy Class C
No adequate human studies
Potential benifits may warrant use if benifits outweigh the risks
17
Q
Rocuronium (Zemuron)
(mechanism of action)
A
Rocuronium _Non-_depolarizing NBA
♦ Causes total paralysis by blocking the binding of acetylcholine and the inotropic activity of Ach receptors
♦ Skeletal muscle relaxation proceeds in predictable order, muscles with fine movements, e.g., eyes, face, neck. → muscles of the limbs, chest, abdomen → diaphragm. Muscle tone returns in the reverse order.
18
Q
Rocuronium (Zemuron)
(onset and duration)
A
Rocuronium
Onset: 1 min
Half Life: 1.4 - 2.4 hrs
Duration: ~ 30 min
19
Q
Rocuronium (Zemuron)
(side effects)
A
Rocuronium Side Effects
♦ Hypotension,
♦ Hypertension,
♦ Increased pulmonary vascular resistance
20
Q
Rocuronium (Zemuron)
(disease related concerns)
A
♦ Conditions that may antagonize neuromuscular blockade (decreased paralysis): Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, and muscle trauma
♦ Conditions that may potentiate neuromuscular blockade (increased paralysis): Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), cachexia, neuromuscular diseases, metabolic acidosis, respiratory acidosis, Eaton-Lambert syndrome, and myasthenia gravis
♦ Hepatic impairment: clinical duration may be prolonged
♦ Pulmonary hypertension: may increase pulmonary vascular resistance worsening symptoms of right heart failure.
21
Q
Rocuronium (Zemuron)
(indications)
A
♦ Facilitates endotracheal intubation by paralysis of skeletal muscle
♦ To increase pulmonary compliance during mechanical ventilation
22
Q
Rocuronium (Zemuron)
(contraindications)
A
Rocuronium Contraindications
♦ Hypersensitivity
23
Q
Rocuronium (Zemuron)
(adult dose)
A
Rocuronium(adult)
♦ 1 mg/kg IO/IV
Maximum dose of 100 mg
(same as pediatric)
24
Q
Rocuronium (Zemuron)
(pediatric dose)
A
Rocuronium(pediatric)
♦ 1 mg/kg IO/IV
Maximum dose of 100 mg
(same as adult)
25
**Rocuronium** (Zemuron)
## Footnote
**(pregnancy safe)**
Pregnancy **Class C**
Rocuronium **crosses the placenta**
The manufacturer **does not recommend use** for rapid sequence induction during cesarean section.
26
**Succinylcholine** (Anectine)
## Footnote
**(mechanism of action)**
**_Succinycholine_ = *_Depolarizing_* NMBA**
## Footnote
♦ causes rapid *depolarization but remains bound to the receptor, preventing muscle fibers stimulation by Acetylcholine and being triggered again. (rapid onset, short duration 7-12 mins)*
*♦ **Depolarization results in fasciculation*** of the skeletal muscles ***followed by muscle paralysis***.
**Initially**, **paralysis involves** the _levator muscles of the ***face*** and muscles of the ***glottis***_. → ***_intercostals***_, _***diaphragm_***, _and all other skeletal muscles_. Recovery generally occurs in the reverse order.
27
**Succinylcholine** (Anectine)
## Footnote
**(onset and duration)**
**_Succinycholine_**
**Onset**: 1 min
**Duration**: 4 - 6 min
28
**Succinylcholine** (Anectine)
## Footnote
**(warnings/precautions)**
**_Succinylcholine Precautions_**
## Footnote
**♦ Bradycardia**: **Risk of bradycardia** may be **increased with 2nd dose** and **may occur more in children**. (may be reduced by pretreating with anticholinergic agents (eg, atropine)
**♦ Increased intraocular pressure;** avoid use in (eg, narrow-angle glaucoma, penetrating eye injuries).
**♦** **May cause a transient increase** **in ICP** (adequate anesthetic induction prior to administration of succinylcholine will minimize this effect).
**♦ Malignant hyperthermia**: risk may be increased with concomitant administration of volatile anesthetics
**♦ Hyperkalemia**: Use with **extreme caution** in patients with pre-existing hyperkalemia. **Severe hyperkalemia may develop** **in patients** with **chronic *_abdominal infections_***, ***_burn injuries_***, **_multi-trauma/*crush injuries*_**, extensive denervation of skeletal muscle, upper motor neuron injury, **subarachnoid hemorrhage**, or conditions which cause degeneration of the central and peripheral nervous system.
29
**Succinylcholine** (Anectine)
## Footnote
**(side effects)**
**_Succinycholine_****_Side Effects_**
♦ Cardiac arrhythmias,
♦ Increased Intraocular Pressure,
♦ Muscle Fasciculation
30
**Succinylcholine** (Anectine)
## Footnote
**(indications)**
♦ Skeletal muscle relaxation
♦ Facilitate management of patients undergoing mechanical ventilation
31
**Succinylcholine** (Anectine)
## Footnote
**(contraindications)**
**_Succinylcholine_****_Contraindications_**
## Footnote
♦ **Penetrating eye injury**
♦ Hypersensitivity to succinylcholine or any component of the formulation;
**♦ Personal/family hx of malignant hyperthermia**
♦ Use after the acute phase of injury following ***major burns****, **multiple trauma***, extensive denervation of skeletal muscle, or upper motor neuron injury.
32
**Succinylcholine** (Anectine)
## Footnote
**(adult dose)**
**_Succinycholine_**(**adult**)
♦ **2 mg/kg IO/IV** **over 30 seconds**
**Maximum dose of 200 mg**
**(same as pediatric)**
33
**Succinylcholine** (Anectine)
## Footnote
**(pediatric dose)**
**_Succinylcholine_**(**pediatric**)
♦ **2 mg/kg IO/IV** **over 30 seconds**
**Maximum dose of 200 mg**
***(same as adult)***
34
**Succinylcholine** (Anectine)
## Footnote
**(pregnancy safe)**
Pregnancy **Class C**
Small amounts cross the placenta.
Use succinylcholine during pregnancy **only if clearly needed.**
35
**Vecuronium Bromide** (Norcuron)
## Footnote
**(mechanism of action)**
***_Vecuronium_* *-* *_Non_**depolarizing* NMBA**
## Footnote
♦ Causes total paralysis by blocking the binding of acetylcholine and the inotropic activity of Ach receptors, (lasting 30 mins - 2 hours)
♦ Neuromuscular blockade begins with muscles associated with fine movements (e.g., ***eyes***, ***face***, and ***neck***), → muscles of the ***limbs***, ***chest***, and ***abdomen*** and, finally, the ***diaphragm***.
Muscle tone ***returns in the reverse order***.
36
**Vecuronium Bromide** (Norcuron)
## Footnote
**(onset and duration)**
**_Vecuronium_**
**Onset**: 2.5 - 3 min
Half Life: 1.5 hrs
**Duration**: 45 - 46 min
37
**Vecuronium Bromide** (Norcuron)
## Footnote
**(side effects)**
**_Vecuronium_****_Side Effects_**
Hypotension
Hypertension
Bronchospasm
Dysrythmias
Histamine Release
**Malignant Hyperthermia**
38
**Vecuronium Bromide** (Norcuron)
## Footnote
**(reversal agent)**
cholinesterase inhibitor
(e.g., neostigmine, **pyridostigmine**, edrophonium)
39
**Vecuronium Bromide** (Norcuron)
## Footnote
**(adult dose)**
**_Vecuronium_**(**adult**)
***for long transports (if needed)***
♦ **0.1 mg/kg IO/IV over 30 – 60 seconds**
**Maximum dose of 10 mg**
***(same as pediatric)***
***♦ Post Intubation** long acting paralytic should _only_ be used if appropriate nanlgesia/sedation are _not_ effective*
40
**Vecuronium** **Bromide** (Norcuron)
## Footnote
**(pediatric dose)**
**_Vecuronium_**(**pediatric**)
♦ **0.1 mg/kg IO/IV over 30 – 60 seconds**
**Maximum dose of 10 mg**
***(same as adult)***
41
**Vecuronium Bromide** (Norcuron)
## Footnote
**(pregnancy safe)**
Pregnancy **Class C**
It is not known if vecuronium can cause fetal harm when administered to a pregnant woman.
**It should be used during pregnancy *_only_* if clearly needed.**
42
**Malignant Hyperthermia**
**Following Succinycholine Administration**
**Facts**
The **risk** of developing malignant hyperthermia following succinylcholine administration **increases with the concomitant administration of volatile anesthetics.**
♦ Malignant hyperthermia frequently **presents** as intractable ***spasm of the jaw muscles*** (masseter spasm) which may progress to generalized ***rigidity***, ***increased oxygen demand***, ***tachycardia***, ***tachypnea*** and ***profound hyperpyrexia (temp)***
**♦ Recognition** of the syndrome is a signal for ***discontinuance of anesthesia***, attention to increased oxygen consumption, correction of acidosis, support of circulation, assurance of adequate urinary output and institution of measures to control rising temperature.
♦ Intravenous ***dantrolene sodium***
43
**Succinycholine Administration**
**Precautions / Warnings**
**(Pearls)**
**Hyperkalemia -** should be administered with **GREAT CAUTION** to patients suffering from **electrolyte abnormalities** and those who may have ***massive digitalis toxicity***, because in these circumstances succinylcholine ***_may induce serious cardiac arrhythmias or cardiac arrest due to hyperkalemia_.***
In both adults and pediatric patients the incidence of **bradycardia**, **which may progress to asystole**, is **higher following** a **second dose** of succinylcholine. The incidence and severity of bradycardia is **higher in pediatric patients than adults.**
Succinylcholine causes an **increase in intraocular pressure.** (e.g., narrow angle glaucoma, penetrating eye injury)
Succinylcholine ***_may cause a transient increase_*** *in **intracranial pressure***; however, adequate anesthetic induction prior to administration of succinylcholine will minimize this effect.
Succinylcholine *_**may increase** **intragastric pressure**_*, which could result in regurgitation and possible aspiration of stomach contents.
44
**Fentanyl** (Sublimaze)
## Footnote
**(mechanism of action)**
**_Fentanyl_ - Analgesic, Opioid**
## Footnote
Binds with stereospecific receptors at many sites within the CNS, ***increases pain threshold, alters pain reception, inhibits ascending pain pathways*** producing CNS depression and analgesia.
The actions of fentanyl are similar to those of morphine, although fentanyl is much more lipophilic as compared to morphine (580:1) and **has a more rapid onset of action.**
45
**Fentanyl** (Sublimaze)
## Footnote
**(onset and duration)**
**_Fentanyl_**
**Onset**: 1 - 2 min
Half Life: 2 - 4 hr
**Duration**: 30 min - 1 hr
46
**Fentanyl** (Sublimaze)
## Footnote
**(side effects)**
**Muscle rigidity**, (tight chest) _related to_ the **dose and speed of injection,** may be reduced by slow IV injection
**Respiratory depression,**
**Bradycardia**,
**Myoclonic movements,**
**Tachycardia**,
**Vein irritation,**
Dermatitis
47
**Fentanyl** (Sublimaze)
## Footnote
**(indications)**
## Footnote
**Acute Coronary Syndrome**
**RSI / Ventilator**
**Pain control**
48
**Fentanyl** (Sublimaze)
## Footnote
**(contraindications)**
**♦ Bronchial asthma** - Receipt of moderate doses in these patients may significantly decrease pulmonary ventilation
**♦ Concomitant MAO inhibitors** - it has been postulated that fentanyl may be a weak serotonin reuptake inhibitor. Symptoms of ***serotonin syndrome*** are possible.
**♦ Myasthenia gravis -** Fentanyl may cause **muscle rigidity** upon IV administration
49
**RSI - Fentanyl** (Sublimaze)
## Footnote
**(adult dose)**
**_Fentanyl_**(**adult**)
♦ **Induction = 1 mcg/kg** IM/IO/IV/IN **Max 100 mcg**
→ **May repeat dose at 1 mcg/kg**
♦ **Post Intubation** **1 mcg/kg** IV/IO/IN **max 100mcg** → ***repeated*** in **0.05 mcg/kg** doses ***PRN***
50
**Fentanyl** (Sublimaze)
## Footnote
**(pediatric dose)**
**_Fentanyl_**(**pediatric**)
♦ **1 mcg/kg** IM/IO/IV/IN
**Maximum 100 mcg**
**May repeat dose at 1 mcg/kg**
***(same as adult)***
51
**Fentanyl** (Sublimaze)
## Footnote
**(pregnancy safe)**
Pregnancy **Class C**
The drug readily crosses the placenta and should **only be given** to pregnant women **if** the potential **benefit justifies the risk**.
52
**Midazolam** (Versed)
| (mechanism of action)
Anticonvulsant, Benzodiazepine
## Footnote
Potentiates GABA by binding to specific stereospecific benzodiazipine receptors on the postsynaptic GABA neuron at different sites within the CNS. Versed also exerts ***sedative***, ***hypnotic***, ***muscle relaxant***, anxiolytic and ***anticonvulsant*** characteristics.
53
**Midazolam** (Versed)
| (onset and duration)
**_Midazolam_**
**Onset**: 1 - 5 min
Half Life: 2 - 17 hrs
**Duration**: 2 - 6 hrs
54
**Midazolam** (Versed)
## Footnote
**(side effects)**
**_Midazolam_****_Side Effects_**
♦ Apnea,
♦ Cardiac Arrhythmias,
♦ Hypotension
55
**Midazolam** (Versed)
## Footnote
**(indications)**
♦ Seizures and status epilepticus
♦ Conscious sedation
♦ Skeletal muscle relaxant
♦ Acute anxiety states
♦ Combative patients
56
**Midazolam** (Versed)
## Footnote
**(contraindications)**
**♦ Glaucoma** - can increase intraocular pressure
**♦ Shock** - ***can cause significant hypotension***
**♦ ETOH** - effects are additive to those of other CNS depressants, including alcohol
**♦ Pregnancy**
**♦ Renal Failure** - ***half-life** **may be prolonged,*** ***can experience more rapid induction of a*nd prolonged recovery from anesthesia**
**Coma**
57
**RSI Midazolam** (Versed)
## Footnote
**(adult dose)**
**_Midazolam_**(**adult**)
♦ **Post Intubation** = **0.1mg/kg IV/IO/IN** **max** of **10 mg**
***_And_***
Fentanyl 1 mcg/kg max 100 mcg
→ 1 mcg/kg q PRN
58
**RSI Midazolam** (Versed)
## Footnote
**(pediatric dose)**
**_Midazolam_** (**pediatric**)
♦ **Induction** - **0.1 mg/kg** IM/IO/IV **_max_ 5 mg**
♦ **Post Intubation** - **0.1 mg/kg _max_ 5 mg** → May repeat in **0.05 mg/kg doses *PRN***
59
**Ativan** (Lorazepam)
## Footnote
**(mechanism of action)**
♦ Benzodiazepines act at the level of the limbic, thalamic, and hypothalamic regions of the CNS, and can produce any level of **CNS depression** required including _sedation_, _hypnosis_, _skeletal muscle relaxation_, _anticonvulsant activity_, and coma.
♦ Benzodiazepines **block the cortical and limbic arousal that occurs following stimulation of the reticular pathways**.
60
**Ativan** (Lorazepam)
## Footnote
**(onset and duration)**
**_Ativan_**
**Onset**: 2-3 min
Half Life: 10 - 73 hrs
**Duration**: 9 - 12 hrs
61
**Ativan** (Lorazepam)
## Footnote
**(side effects)**
♦ Respiratory / cardiac arrest,
♦ Decreased LOC,
♦ Hypotension
62
**Ativan** (Lorazepam)
## Footnote
**(indications)**
♦ Seizures and status epilepticus
♦ Conscious sedation
♦ Skeletal muscle relaxant
♦ Acute anxiety states
♦ Combative patients
63
**Ativan** (Lorazepam)
## Footnote
**(contraindications)**
**_Respiratory depression_**
64
**Ativan** (Lorazepam)
## Footnote
**(adult dose)**
**_Ativan_** (**adult**)
♦ **Post Intubation = 1 - 2 mg IV/IO/IN**
**up to** _***4 mg* *maximum***_
♦ Behavioral Emergency
1 - 2 mg IM,IV,IO
65
**Ativan** (Lorazepam)
## Footnote
**(pediatric dose)**
**_Ativan_**(**pediatric**)
**♦ 0.05 – 0.1 mg/kg** IM/IO/IV
**May repeat up to *_4 mg_ maximum***
66
**Ativan** (Lorazepam)
## Footnote
**(pregnancy safe)**
Pregnancy **_Class D_**
## Footnote
**Ativan MAY CAUSE FETAL DAMAGE WHEN ADMINISTERED TO PREGNANT WOMEN.**
Injection should **not be used during pregnancy** _except in serious or life-threatening conditions where safer drugs cannot be used or are ineffective_.
67
**Ketamine** (Ketalar)
## Footnote
**(mechanism of action)**
♦ Ketamine **nonbarbiturate general anesthetic**
♦ Ketamine induces *sedation*, *immobility*, *amnesia*, and marked *analgesia*.
*_Increasing doses of ketamine result in anesthesia_.*
Ketamine acts on receptors in the cortex and limbic system.
Ketamine has a **sympathomimetic activity** resulting in **tachycardia**, **hypertension**, **increased** _myocardial_ and _cerebral oxygen consumption_, **increased** _cerebral blood flow_, and **increased** _intracranial and intraocular pressure_.
Ketamine is a **potent bronchodilator** and can be used to treat refractory bronchospasm.
68
**Ketamine** (Ketalar)
## Footnote
**(onset and duration)**
**Onset IV**: dissociation occurs in 60 seconds
♦ _Anesthesia_ occurs within 30 to 60 seconds and
**Duration**: 5 to 10 minutes
♦ _Analgesic effects_ of ketamine last from 20 to 45 minutes.
**Onset IM**: Anesthesia occurs within 3 to 5 minutes
**Duration**: 12 to 30 minutes
69
**Ketamine** (Ketalar)
## Footnote
**(side effects / precautions)**
***Hallucinations***, ***respiratory depression***, ***elevated B/P***
♦ Can cause psychosis and exacerbate symptoms of chronic schizophrenics, do not use.
♦ *EMERGENCE REACTIONS HAVE OCCURRED IN APPROXIMATELY 12 PERCENT OF PATIENTS.*
70
**Ketamine** (Ketalar)
## Footnote
**(indications)**
**♦ Induction agent for RSI**
**♦ Pain Management (***if opoids are not effective)*
71
**Ketamine** (Ketalar)
## Footnote
**(contraindications)**
♦ \< 3mos age
♦ Known schizophrenia
♦ *Severe* HTN
72
**RSI Ketamine** (Ketalar)
## Footnote
**(adult dose)**
**_Ketamine_**(**adult**)
♦ **Induction = 2 mg/kg** slow IO/IV push **max 200mg**
♦ **Post Intubation =** **1 mg/kg q 10 min *PRN***
♦ **Sedation/Pain Management** → **0.1 - 0.5 mg/kg** → ***may repeat q 10 min PRN***
73
**RSI Ketamine** (Ketalar)
## Footnote
**(pediatric dose)**
**_Ketamine_**(**pediatric**)
♦ **Induction** - **2 mg/kg slow IVP/IO _max_ 200 mg**
**→ Post Intubation - 1 mg/kg q 10 minutes *PRN***
***♦ Pain - 0.1 - 0.5 mg/kg IV/IO q 10 min PRN***
74
**Ketamine** (Ketalar)
## Footnote
**(pregnancy safe)**
Pregnancy **_Class X_**
Since the safe use in pregnancy, including obstetrics (either vaginal or abdominal delivery), has not been established, such **use is *_not_* recommended**
75
**Flumazenil** (Romazicon)
## Footnote
**(mechanism of action)**
♦ Flumazenil ***antagonizes the actions*** of ***benzodiazepines*** on the central nervous system
♦ Flumazenil competes with benzodiazepines at this receptor for binding. Because binding is competitive and ***_flumazenil has a much shorter duration of action than do most benzodiazepines_***, it is possible for the effects of flumazenil to dissipate sooner than the effects of the benzodiazepine
76
**Flumazenil** (Romazicon)
## Footnote
**(onset and duration)**
Onset: 1 to 2 minutes
80% response will be reached within 3 minutes,
with peak effect occurring at 6 to 10 minutes.
77
**Flumazenil** (Romazicon)
## Footnote
**(side effects)**
Dizziness, blurred vision, headache, seizures, dysrhythmia, GI distress, pain at injection site
Use of flumazenil can precipitate signs of benzodiazepine withdrawal, which may precipitate seizures.
78
**Flumazenil** (Romazicon)
## Footnote
**(indications)**
**Reversal** of sedative effects **of Benzodiazepines**
79
**Flumazenil** (Romazicon)
## Footnote
**(contraindications)**
♦ Hypersensitivity,
♦ Tricyclic overdose,
♦ benzodiazepine dependent patient,
♦ Status epilepticus patients who received benzodiazepines
80
**Flumazenil** (Romazicon)
## Footnote
**(adult dose)**
**_Romazicon_**(**adult**)
♦ **0.2 mg IO/IV**
May be ***repeated at 1 min intervals*** to a
**_Max_ dose of 1 mg.**
81
**Flumazenil** (Romazicon)
## Footnote
**(pediatric dose)**
**_Romazicon_**(**pediatric**)
**♦ 0.01 mg/kg** IO/IV, **up to 0.2 mg**.
May be ***repeated at 1 min intervals***
**to a _max_ dose of 1 mg**
82
**Flumazenil** (Romazicon)
## Footnote
**(pregnancy safe)**
Pregnancy **Class C**
there are no adequate and well-controlled studies in humans,
This drug should be used during pregnancy ***only if the benefit outweighs the risk*** to the fetus.
83
**Morphine Sulfate**
**(mechanism of action)**
Morphine sulfate is an **opioid agonist** indicated for the management of pain not responsive to non-narcotic analgesics.
***Binds to opioid receptors in the CNS, causing inhibition of ascending pain pathways***, altering the perception of and response to pain; produces generalized CNS depression
84
**Morphine Sulfate**
**(onset and duration)**
**_Morphine_**
**Onset**: Rapid
Half Life: 1 - 2 hrs
**Duration**: 4 - 6 hrs
85
**Morphine Sulfate**
**(side effects)**
♦ Respiratory Depression,
♦ Hypotension,
♦ Bradycardia,
♦ Nausea/Vomiting
86
**Morphine Sulfate**
**(indications)**
**_Morphine_****_Indications_**
♦ Acute Coronary Syndrome
Pain Management
♦ AMI
♦ Acute pulmonary edema
♦ Severe pain
87
**Morphine Sulfate**
**(contraindications)**
**_Morphine_****_Contraindications_**
♦ Head injury,
♦ Hypotension,
♦ Asthma,
♦ COPD,
♦ Respiratory depression not caused by pulmonary edema
88
**Morphine Sulfate**
**(adult dose)**
**⇒ Acute Coronary Syndrome**
♦ **2 mg – 10 mg** IM/IO/IV
**⇒ Pain Management**
♦ **0.1 mg/kg** IM/IO/IV (**_max_ 5 mg)**
**► May repeat dose up to 5mg**
89
**Morphine Sulfate**
**(pediatric dose)**
**_Morphine_**(**pediatric**)
**⇒ Pain Management**
♦ **0.1 mg/kg** IM/IO/IV (**_max_** **5 mg**)
► **May repeat dose up to 5mg**
90
**RSI Induction Medications (adult)**
♦ **Fentanyl**: (per pain protocol) - **1mcg/kg max 100**
♦ **Ketamine**: **2mg slow IV/IO** → **1mg/kg q 10 PRN**
**→ Push Dose Pressor if hypotensive**
***_OR_***
♦ **Etomidate**: **0.3mg/kg IV,O,N** **max** of **40mg**
**♦Succinylcholine** **2mg/kg IV/IO**
_***if******contraindicated***_→**Rocuronium 1mg/kg**IV/IO**Max 100 mg**
91
**RSI Post Intubation Medications (adult)**
♦ **Midazolam** - **0.1 mg/kg** IV,O,N **up to 10 mg** ***_AND_***
♦ **Fentanyl 1 mcg/kg** IV,O,N (**max 100 mcg**) **q 1mcg PRN *_OR_***
♦ **Lorazepam 1-2 mg** IV.O,N ***may*** ***repeat* to a *_total_* *_dose_* of 4 mg *_OR_***
♦ **Ketamine 1 mg/kg** ***q 10 min PRN***
♦ *_Long Txp's consider_* **Vecuronium 0.1 mg/kg max of 10 mg** ***_OR_*** **Rocuronium 1 mg/kg (max 100 mg)** (*only if analgesia/sedation not effective*)
92
**RSI Induction Medications (Pediatric)**
♦ Consider **Atropine**: **0.02 mg/kg** **(*****min 0.1mg, max 1mg)*** (prevent bradycardia in 2 y/o or younger)
♦ **Fentanyl**: per pain protocol - **1mcg/kg _max_ 100**
**→ Push Dose Pressor *_if hypotensive_***
♦ **Ketamine**: **2mg** slow IV/IO → **1mg/kg q 10 PRN**
♦ ***_OR_*****Etomidate**:**0.3mg/kg**IV,O,N**_max_ 40mg**may also***consider*****Versed 0.1mg/kg**IV,O,N**_max_ 5mg**
♦**Succinylcholine 2mg/kg** IV/IO ***if*** ***contraindicated***→ **Rocuronium 1mg/kg** IV/IO **_max_ 100 mg**
93
**RSI Post Intubation Medications (pediatric)**
♦ **Midazolam0.1 mg/kg** IV,O.N ***_max_* 5 mg** may be repeated → ***0.05 mg/kg doses PRN*** (watch for hypotension)
♦ **Fentanyl 1 mcg/kg** IV,O,N **_max_ 100 mcg** → repeat at ***0.5 mcg/kg PRN***
♦ ***OR*** - **Lorazepam 0.05 mg/kg** ***up to*** **4 mg _max_**
♦ **Ketamine 1 mg/kg *q 10 min PRN***
♦ *For long Txp's* (if needed) → **Vecuronium 0.1 mg/kg _max_ 10 mg** ***OR*** **Rocuronium 1 mg/kg _max_ 100 mg** (only if analgesia/sedation not effective)
94
**Pain Management Options (Adult)**
♦ **Morphine** - **0.1 mg/kg** (***_max_* 5 mg**) → may ***repeat*** *_once_* to a ***_max_* of 10 mg**
**♦ Fentanyl - 1 mcg/kg *_max_* 100 mcg →** ***repeat*** at **1 mcg/kg** (***_max_*** **single dose 100 mcg**)
♦ **Ketamine** - **0.1 - 0.5 mg/kg** (*if opioids not helping*) **q 10 min *PRN***
♦ **Zofran** - **4 mg** ***PRN***
95
**Pain Management Options (pediatric)**
If SBP is appropriate (see next)
**⇒** Administer **Zofran** - **0.1 mg/kg _max_ 4 mg *PRN***
***♦* Morphine - 0.1 mg/kg (up to 5 mg) may repeat for *_total_* of 10 mg**
**♦ Fentanyl - 1 mcg/kg _max_ 100 mcg: may repeat dose at 1 mcg/kg**
**♦ Ketamine - 0.1 mg/kg** (if opioids not helping) → **q 10 minutes *PRN***
96
**Age Based Hypotension Guideline for Pediatrics**
**Age based hypotension:**
♦ \< 1 year: *less than* 70 SBP
♦ 1 - 10 years: *less than* 80 + (2 x age) SBP
♦ 11 - 12 years: *less than* 90 + (2 x age) SBP
97
**Ketamine Adult**
**Pain Management**
**Ketamine Pain Management (*adult*)**
**0.1 - 0.5 mg/kg q 10 min PRN**
(***only if opoids are not managing pain***)
