PCIV Pharm List (OSP)

Question 1

Adenosine

Answer 1

BRAND NAME: Adenocard

CLASS: Anti-Tachydysrhythmia (Purine Nucleoside)

PHARMACODYNAMICS: Slows electrical conduction through the cardiac atrioventricular (AV) node, with ability to interrupt reentry pathways through the AV and sinoatrial (SA) nodes. Adenosine is administered to convert paroxysmal supraventricular tachycardia (PSVT) to normal sinus rhythm.

INDICATIONS: Tachycardia - Stable PSVT (sustained regular, narrow-complex tachycardia >150 bpm in adults) & systolic BP ≥ 100mmHg (After failed valsalva maneuver)

CONTRAINDICATIONS:
- 2nd/3rd degree AV Blocks (may induce asystole)
- Known Wolff-Parkinson-White Syndrome (may increase
heart rate)
- Known Sick Sinus Syndrome (may induce asystole)
- Bradycardia (may induce symptomatic hypotension)

PHARMACOKENETICS: Onset of action within 10-20 seconds after IV administration. Very rapid metabolism (and duration of effect) within 10-20 seconds after IV administration.

SIDE EFFECTS: Common, though transient, symptoms include chest pain, palpitations of irregular bradycardia, dyspnea, lightheadedness, numbness, and sweating. A constellation of these side effects may produce significant patient apprehension and/or sense of impending doom. The patient should be advised of these possibilities prior to adenosine administration and given reassurance such symptoms will be short-lived in duration of seconds. Transient asystolic or profound, irregular bradycardic rhythms may be observed on ECG monitoring.

DOSAGE: Tachycardia - Stable - Adult (PSVT)
6 mg rapid IVP (1 – 2 seconds) followed rapidly by 10 mL saline flush. May repeat twice at 12 mg.

**OLMC Order Only for use in pediatric patients. OLMC may direct use of adenosine in evaluating etiology of regular, monomorphic wide complex tachycardia.

HOW SUPPLIED: 12 mg/4 mL in prefilled syringe.

Question 2

Albuterol

Answer 2

BRAND NAME: Proventil, Ventolin

CLASS: Sympathomimetic Bronchodilator

PHARMACODYNAMICSS: Albuterol is a relatively selective beta2 adrenergic stimulant. Albuterol causes relaxation of the smooth muscles of the bronchial tree thus decreasing airway resistance, facilitating mucus drainage, and increasing vital capacity. It exerts mild effects on beta1 (heart) or alpha (peripheral vasculature) receptors. In therapeutic doses, albuterol, by inhibiting histamine release from mast cells, also reduces the mucus secretion, capillary leaking, and mucosal edema caused by an allergic response in the lungs.

INDICATIONS:

• Dyspnea - Asthma/COPD/Unknown Etiology
• Acute Allergic Reactions
• Smoke Inhalation

CONTRAINDICATIONS: Known hypersensitivity to albuterol. Albuterol should not be used if the sole etiology of dyspnea is strongly suspected to be CHF, as albuterol-induced tachycardia may worsen the compromised cardiac output in CHF.

PHARMACOKENETICS: Onset within 5 – 15 minutes; peak effect in 1 – 1.5 hours; duration of effect is up to 3 – 6 hours; half – life is less than 3 hours. Distribution: When inhaled, albuterol is distributed to muscle cells along the bronchial tree. Very little is systemically absorbed and distributed.

SIDE EFFECTS: Tremors, anxiety, dizziness, headache, cough, reflex bronchospasm, palpitations, tachycardia, and hypertension.

DOSAGE: 5 mg nebulized (with ipratropium bromide 0.5 mg for acute allergic reactions) may repeat twice

HOW SUPPLIED: 2.5 mg/3 mL (0.083%) in nebulizer vials.

Question 3

Amiodorone

Answer 3

BRAND NAME: Cordarone, Nexterone

CLASS: Class III Anti-Dysrhythmic (Vaughn William Classification)

PHARMACODYNAMICS: Prolongs the cardiac action potential’s refractory period, slowing conduction through the heart. Amiodarone also has secondary actions in the other three classifications of anti-dysrhythmics. Amiodarone blocks sodium channels (class I) which can prevent cardiac action potentials. It is a non-competitive anti-sympathetic (class II) which slows cardiac action potentials. Amiodarone also slows conduction through the cardiac atrioventricular (AV) node (class IV). In sum, all of these actions lead to slowing of conduction and prolongation of refractoriness in the cardiac conduction system.

INDICATIONS:
- V-Fib/Pulseless Ventricular Tachycardia
- Tachycardia - Stable
(Wide-Complex Tachycardia of Uncertain Type or
Monomorphic Ventricular Tachycardia (if heart rate ≥
150 beats) per minute with systolic BP ≥ 100 mmHg in
adults)
(Narrow-Complex Tachycardia (if heart rate ≥ 150 beats
per minute with systolic BP ≥ 100 mmHg in adults
**OLMC Order Only)
- Tachycardia - Unstable
(Post-Cardioversion of Ventricular Tachycardia)
- Premature Ventricular Contractions
(Symptomatic Premature Ventricular Contractions (with
BP < 100mmHg in adults due to frequent non
conducted ventricular impulses and in absence of
2nd/3rd degree AV blocks))

CONTRAINDICATIONS: 2nd/3rd degree AV blocks (may induce asystole) ; Bradycardia (may induce symptomatic hypotension)

PHARMACOKENETICS: Onset of action within 60 seconds after IV administration, with effects lasting up to 20-25 minutes.

SIDE EFFECTS: Hypotension is the most common side effect, requiring treatment in less than 20% of patients (transient effect). Bradycardia and AV Block may also result, requiring treatment in less than 10% of patients (transient effect). In a very rare circumstance, as with all
anti-dysrhythmics which can have pro-dysrhythmic effects, Torsades may result from excessive prolongation of the cardiac action potential. When indicated by protocol, the benefits of amiodarone administration exceed these risks of side effects.

DOSAGE:
- V-Fib/Pulseless Ventricular Tachycardia - Adult (refractory to initial defibrillation ATTEMPT)
300 mg IVP/IOP. Repeat at 150 mg IVP/IOP in 5 minutes to maximum cumulative dose of 450 mg. Epinephrine 1 mg (1:10,000) IVP/IOP is to be given with every
amiodarone administration.

• V-Fib/Pulseless Ventricular Tachycardia - Adult
  (post RETURN of sustained spontaneous circulation)
  150 mg over 10 minutes (15 mg/minute or 0.3 mL/minute very slow IVP/IOP/IVPB) IF maximum cumulative dose of 450 mg has not been achieved
• Tachycardia (stable or unstable) - Adult
  150 mg over 10 minutes (15 mg/minute or 0.3 mL/minute very slow IVP/IOP/IVPB)

HOW SUPPLIED:
150 mg/3 mL in vial, ampule, or pre-filled syringe.
150 mg/100 mL pre-mixed infusion.

Question 4

Atropine Sulfate

Answer 4

BRAND NAME: Atropine Sulfate

PHARMACODYNAMICS: Blocks parasympathetic impulses to the heart via the vagus nerve. Atropine increases the rate of cardiac sinoatrial (SA) node discharges, enhances conduction through the atrioventricular (AV) node, and by increasing heart rate, increases the cardiac output and blood pressure. Additionally, in the treatment of indicated poisonings (organophosphates) atropine reverses muscarinic effects of acetylcholine, including diaphoresis, diarrhea, urination, bronchorrhea (secretions from the lower respiratory tract), emesis, lacrimation (tearing), and salivation. Atropine produces dilation of pupils by blocking stimulation of the ciliary muscle surrounding the pupils.

INDICATIONS:

• Bradycardia
• Poisonings – General Management Organophosphate

CONTRAINDICATIONS: None absolute in indicated situations.

PHARMACOKENETICS: Typical onset within 60 seconds given IV. Effects can persist in excess of 1 hour.

SIDE EFFECTS: Tachycardia (either supraventricular or ventricular), hypertension, palpitations, blurred vision due to pupillary dilation, photophobia, dry mouth.

DOSAGE:
- Bradycardia – Symptomatic & Systolic BP < 100 mmHg
(Sinus, First Degree, 2nd Degree Type I) - Adult
In Non-Acute Coronary Syndrome, 1 mg IVP/IOP.
May repeat every 5 minutes to cumulative maximum
dose of 3 mg
- Adult Organophosphate Poisoning
2 mg IVP/IOP/IM. Use IVP for severe presentations
(May repeat as often as every 3-5 minutes if symptoms
progressive or persistent.)

HOW SUPPLIED:
- 1 mg/10 mL prefilled syringe
- 1 mg/1 mL vial 0.25 mg/5 mL prefilled syringe for
pediatric use

Question 5

Calcium Chloride

Answer 5

BRAND NAME: Calcium Chloride

CLASS: Electrolyte

PHARMACODYNAMICS: Calcium causes a significant increase in myocardial contractility and in ventricular automaticity. It is used as an antidote for some electrolyte imbalances (eg. stabilizing cardiac rhythm in the setting of hyperkalemia) and to minimize the side effects from calcium channel blocker overdose. The actions of calcium chloride are similar to those of calcium gluconate but, since it ionizes more readily, it is more potent than calcium gluconate.

INDICATIONS:
- Specific Causes of Cardiac Arrest (Hyperkalemia)
- Poisonings - General Management (Calcium Channel
Blocker Overdose)
- Dialysis-Related Issues (Hyperkalemia)
- Crush Injury Syndrome (Hyperkalemia Prophylaxis)

CONTRAINDICATIONS: Calcium chloride is contraindicated in ventricular fibrillation unless known hyperkalemia, in known hypercalcemia, and in suspected digitalis toxicity. It should be used with caution in patients taking digoxin as it may precipitate toxicity. Safe use in pregnancy and in children has not been established, though in indicated conditions, benefits outweigh risks.

PHARMACOKENETICS: Onset nearly immediate when given IVP/IOP. The peak effect time frame and duration of effect is not well established.

SIDE EFFECTS: Paresthesia (tingling), syncope, sensations of heat waves (peripheral vasodilation), pain and burning at IV site, skin necrosis and sloughing (with extravasation), hypotension, bradycardia, cardiac dysrhythmias, cardiac arrest.

DOSAGE:
For all indications adult & pediatrics its -
10 mg/kg (10% solution) IVP/IOP, max dose of 1 gram

HOW SUPPLIED: 1 gram in a 10 mL prefilled syringe (100 mg/mL)

SPECIAL COMMENTS: Calcium chloride will interact with sodium bicarbonate and form a precipitate. Do not give both medications via the same vascular access line unless giving a copious flush of NS - approximately 50+ mL - between medications. In general, use an 18-20 gauge angiocatheter in a proximal IV site or use an IO line and test line patency before administration. In non-cardiac arrest or non-impending cardiac arrest settings, administer at 0.5 -1.0 mL per minute to reduce chances of venous irritation and extravasation

Question 6

Diazepam

Answer 6

BRAND NAME: Valium

CLASS: Benzodiazepine (Schedule IV)
(Sedative; Anticonvulsant; Muscle Relaxant; Anxiolytic)

PHARMACODYNAMICS: Binds to Type A GABA receptors, causing sedation ; it has no effect on pain. (Diazepam has considerably more muscle relaxant properties than midazolam, though no substantial amnestic effects as with midazolam)

INDICATIONS:
- Post RSI Sedation (onset delay does not favor pre
intubation use)
- Seizure (Midazolam preferred due to faster onset)
- Dystonic Reactions
- Chemical Restraint (Midazolam preferred due to faster
onset)
- Poisonings (Suspected stimulant toxicity)
- Head/Neck/Spine Injury (Midazolam preferred due to
faster onset)
- Heat Illness (Midazolam preferred due to faster onset)

CONTRAINDICATIONS:
- Hypersensitivity
- Acute narrow - angle glaucoma, shock, or coma.
- Caution with use in patients with COPD, chronic
hepatic or renal failure, CHF, acute alcohol
intoxication, and the elderly due to increased risk of
respiratory depression.

DOSE:
- Post RSI Sedation (Adult)
0.1 mg/kg to max 5 mg IVP/IOP,
may repeat once if systolic BP > 100 mmHg
- Seizure ; Head/Neck/Spine Injury ; Heat Illness (Adult)
5 mg IVP/IOP or 10 mg IM for active seizure
May repeat once in 5 minutes if still seizing
- Dystonic Reactions (Adult) 5mg IVP
- Chemical Restraint (Adult) 5mg IVP/IOP or 10 mg IM
- Poisoning (Susp Stimulant Toxic)(Adult) 2.5-5 mg IVP

SIDE EFFECTS: Headache, euphoria, drowsiness, excessive sedation, confusion, dizziness, blurred vision, diplopia, nystagmus, respiratory arrest, hypotension, nausea, vomiting.

PHARMACOKENETICS: Onset is 3-5 minutes, IVP/IOP;
15-30 minutes IM with erratic absorption, mandating IM dosing only utilized as a last option in adults; peak effects in 15-45 minutes. Duration is 2+ hours IVP/IOP/IM; half – life can reach 20 – 50 hours

HOW SUPPLIED: 10 mg/2 mL in vials, ampules, or pre-filled syringes.

OTHER: Incompatible with other medication because it is not water soluble. Can cause irritation with injection. Flumazenil is an antagonist

Question 7

Diltiazem

Answer 7

BRAND NAME: Cardizem

CLASS: Calcium Channel Blocker

PHARMACODYNAMICS: Diltiazem is a slow calcium channel blocker with pharmacologic actions similar to those of verapamil. It inhibits calcium ion influx through slow channels into cells of myocardial and arterial smooth muscle (both coronary and peripheral blood vessels). As a result, intracellular calcium remains at sub-threshold levels insufficient to stimulate cell excitation and contraction. Diltiazem slows SA and AV node conduction (antidysrhythmic effect) without affecting normal atrial action potential or intraventricular conduction.

INDICATIONS: Tachycardia - Stable
(Sustained narrow-complex tachycardia > 150 bpm in
adults with systolic BP ≥ 100 mmHg) **OLMC Order Only

CONTRAINDICATIONS:
- Hypersensitivity
- 2nd/3rd degree AV Blocks (may induce asystole)
- Known Wolff-Parkinson-White Syndrome (may increase
heart rate)
- Known Sick Sinus Syndrome (may induce asystole)
- Hypotension
- Bradycardia

**Safe use in pregnancy and in children has not been established. Use with caution in CHF (especially if patient is also receiving a beta-blocker), conduction abnormalities, renal or hepatic impairment and the elderly due to exaggerated degree of effect.

PHARMACOKENETICS: Onset is 3 minutes; peak effect in 7 minutes; duration is 1-3 hours; half-life is 2 hours.

SIDE EFFECTS: Headache, fatigue, dizziness, dysrhythmias, 2nd/3rd degree AV block, bradycardia, CHF, hypotension, syncope, palpitations.

DOSAGE: Tachycardia - Stable - Adult
(Sustained narrow-complex tachycardia > 150 bpm in adults with systolic BP ≥ 100mmHg)*OLMC Order Only
Usual adult dose is 0.25 mg/kg slow IVP over 2 minutes

HOW SUPPLIED: 25 mg in 5 mL vial (5 mg/mL)

Question 8

Diphenhydramine

Answer 8

BRAND NAME: Benadryl

CLASS: Antihistamine, Anticholinergic

PHARMACODYNAMICS: Competes for H1 - histamine receptor sites on
effector cells, thus blocking histamine release

INDICATIONS: Dystonic Reactions, Acute Allergic Reactions, Bee/Wasp Stings

CONTRAINDICATIONS: Hypersensitivity

DOSE: 50mg IV/IM (25-50PO but that not in protocol)

ADVERSE EFFECTS: Drowsiness, dizziness, disturbed coordination.

PHARMACOKENETICS: Onset within 15 – 30 minutes; duration is approximately 6 hours

HOW SUPPLIED: 50 mg/1 mL in vial, ampule, or pre-filled syringe.

Question 9

Dopamine

Answer 9

BRAND NAME: Intropin

CLASS: Vasoconstrictor

PHARMACODYNAMICS: Dose dependent. Higher doses (5+ mcg/kg/min) increasingly stimulate alpha receptors in the peripheral vasculature, producing vasoconstriction-related increases in system blood pressure. Concurrent beta receptor stimulation may produce increases in heart rate and mild bronchodilation. Lower doses (<5 mcg/kg/min), as may be encountered infrequently in interhospital transfers, produce mesenteric (intestinal) and renal vascular dilation to ensure continued perfusion to these organ systems in complicated medical illness that would otherwise sacrifice such circulation.

INDICATIONS: For all listed situations, indication is hypotension (adult = systolic < 100 mmHg) due to cardiogenic, septic, or neurogenic shock either refractory to intravascular fluid boluses or in which intravascular fluid boluses is contraindicated (eg. pulmonary edema)

CONTRAINDICATION: Hypertension

PHARMACOKENETICS: Onset of action within 5 minutes after IV/IO infusion initiated. Rapid metabolism, requiring ongoing IV/IO infusion to maintain clinical effects.

SIDE EFFECTS: Palpitations, tachycardia, chest pain, and hypertension if not titrated

DOSE: For hypotension (shock) refractory to fluids or fluids contraindicated.
5 – 20 mcg/kg/minute - see dosage chart - titrate to a sys B/P ≥ 100 mmHg

HOW SUPPLIED: 400 mg/10 mL vial to be mixed into 250 mL D5W. (1600 mcg/mL concentration) OR pre-mixed dopamine infusion at 1600 mcg/mL concentration.

SPECIAL COMMENTS: Relative caution should be exercised prior to use in the setting of marked
tachydysrhythmias, due to the potential for further increase in heart rates. In the setting of tachydysrhythmia-induced cardiogenic shock, treat per
Protocol 5G - Tachycardia - Unstable. Ensure aggressive fluid resuscitation is accomplished (unless contraindicated) prior to dopamine use.

Question 10

Epinephrine 1:1K ; 1:10K

Answer 10

CLASS: Vasoconstrictor, Bronchodilator (Catecholamine)

PHARMACODYNAMICS: Stimulates alpha receptors in the peripheral vasculature, producing vasoconstriction-related increases in systemic blood pressure. Stimulates beta-1 receptors in the myocardium, producing increases in heart rate, myocardial contraction, and as a result, cardiac output. Stimulates beta-2 receptors in the lower respiratory tract smooth musculature, producing bronchodilation.

INDICATIONS: Dyspnea/Asthma (Severe & Refractory to Nebulization) , Asystole, V-Fib, Pulseless V-Tach, Pulseless Electrical Activity, Bradycardia (Pediatric), Anaphylaxis

CONTRAINDICATIONS: None

PHARMACOKENETICS: Onset within 2 minutes after IVP/IOP; within 5-10 minutes after IM.
Duration of effect ranges from 3-5 minutes after IVP/IOP to upwards of 30 minutes after IM.

SIDE EFFECTS: Restlessness, anxiety, generalized tremors, headache, dizziness, chest pain, palpitations,
hypertension, premature ventricular contractions, tachycardia.

DOSE:
Anaphylaxis (Adult) 1:1000 0.5 mg IM
If anaphylaxis refractory to above IM dose:
1:10,000 1 mg slow IVP/IOP over 3 minutes

Dyspnea/Asthma (Adult) 1:1000 0.3 mg IM
**OLMC Order Required if pt ≥ 50 years old, heart illness history, or blood pressure > 140/90 mmHg.

Asystole/V-Fib/Pulseless V-Tach/Pulseless Electrical Activity - 1:10,000 1 mg IVP/IOP
Repeat every 3 - 5 minutes while resuscitating cardiac arrest

HOW SUPPLIED:
Epinephrine 1:1000 in 1 mg/1mL ampules or 30 mg/30 mL vial
Epinephrine 1:10,000 in 1 mg/10 mL prefilled syringes

Question 11

Etomidate

Answer 11

BRAND NAME: Amidate

CLASS: Sedative/hypnotic (Non-barbiturate, non-benzodiazepine, non-narcotic)

PHARMACODYNAMICS: Appears to modulate GABA receptors ; Etomidate is an intravenous hypnotic drug without analgesia. Etomidate is safe to use in patients with cardiac illness and patients with traumatic injuries. Etomidate has little to no effect upon myocardial metabolism, cardiac output, or peripheral circulation. Etomidate has been shown to reduce cerebral blood flow, cerebral oxygen consumption, and intracranial pressure – helpful in head injury situations.

INDICATIONS: Sedation for RSI

CONTRAINDICATIONS: History of Hypersensitivity

DOSE: 0.3 mg/kg IVP/IOP over 15-30 seconds, given just prior to intubation

PHARMACOKENETICS: Rapid onset of action, seen as desired sedation within as little as 10-15 seconds, but nearly always within less than 1 minute. Duration of action, based upon a standard dose of 0.3 mg/kg (70 kg adult dose of 20 mg) is 5-15 minutes.

ADVERSE EFFECTS: Transient skeletal muscle movements, called (Myoclonic jerks), Transient venous pain at injection site, Nausea and/or vomiting, hypoventilation and apnea (very rare), hypotension on rapid push (rare)

HOW SUPPLIED: 40 mg/20 mL (2 mg/mL) vial or pre-filled syringe

OTHER: Repeated doses of etomidate should be avoided to minimize its effect upon adrenal function. Repeated doses and continuous infusions of etomidate have been linked to adrenal suppression.

Question 12

Fentanyl

Answer 12

BRAND NAME: Sublimaze

CLASS: Narcotic analgesic (opioid) (Schedule II)

PHARMACODYNAMICS: Stimulates central nervous system opiate receptors, producing systemic analgesia. Fentanyl is 50-100 times more potent than morphine but shorter lasting. An IV dose of 100 mcg of fentanyl is roughly equivalent to an IV dose of 10 mg of morphine. Fentanyl has less emetic effects than other narcotic analgesics.

INDICATIONS: acute pain in alert, hemodynamically stable patient

CONTRAINDICATIONS: Hypersensitivity, Hypotension
Respiratory Depression, Minor Degrees of Pain

DOSE: (ADULT) For acute pain - 1 mcg/kg slow IVP/IM/IN, maximum single dose of 100 mcg
*May repeat every 10 minutes to a maximum cumulative dose of 3 mcg/kg or 250 mcg, whichever is lesser

For unknown chest pain or acute coronary syndrome - 0.5 mcg/kg slow IVP/IM/IN, maximum single dose of 50 mcg
**May repeat every 10 minutes to a maximum cumulative dose of 1.5 mcg/kg or 125 mcg, whichever is lesser

PHARMACOKENETICS: Onset of action nearly immediate after IV administration. Peak effects occur within 3 – 5 minutes. Duration of effect is 30 - 60 minutes, with a half-life of 6 – 8 hours

ADVERSE EFFECTS: Hypotension, respiratory depression, euphoria, dizziness. Nausea and/or vomiting if rapid IV push

OTHER: Use Appropriate monitors. Naloxone is an antagonist

HOW SUPPLIED:
100 mcg/2 mL (50 mcg/mL) ampule, vial, or pre-filled syringe
250 mcg/5 mL (50 mcg/mL) ampule or vial
500 mcg/10 mL (50 mcg/mL) vial

Question 13

Hydralazine

Answer 13

BRAND NAME: Apresoline

CLASS: Anti-Hypertensive

PHARMACODYNAMICS: Reduces blood pressure via relaxation of arterial smooth muscle, resulting in vasodilation, decreasing peripheral resistance. Alters vascular smooth muscle cellular metabolism of calcium, leading to reduction of vascular muscle contraction.

INDICATIONS:

• Hypertensive Emergency
• Pregnancy Complication (Hypertensive Emergency)

CONTRAINDICATIONS:

• Hypersensitivity
• Cardiogenic shock
• Mitral valvular rheumatic heart disease
• Acute coronary syndrome

**Safe use during pregnancy and children is not firmly established in pharmaceutical studies, though hydralazine has been used effectively in pregnancy and in pediatrics.

PHARMACOKENETICS: Onset is within 10 minutes IV; peak effects between 10-80 minutes.

SIDE EFFECTS: Dizziness, headache, transient paresthesias (eg. scalp tingling), numbness, postural hypotension, angina, palpitations, tachycardia, syncope, pulmonary edema, dysrhythmias (tachycardias) following IV administration, dyspnea, nausea, vomiting.

DOSE:
- Hypertensive Emergency - Adult
- Pregnancy Complication (Hypertensive Emergency)
10 mg Slow IVP. May repeat 10 mg every 30 minutes as needed up to cumulative maximum dose of 30 mg.

HOW SUPPLIED: 20 mg/1 mL in a 1 mL vial

Question 14

Hydromorphone

Answer 14

BRAND NAME: Dilaudid

CLASS: Narcotic analgesic (opioid) (Schedule II)

PHARMACODYNAMICS: Stimulates central nervous system opiate receptors, producing systemic analgesia. Modest vasodilation effects increase peripheral venous capacitance, and reduce venous return, myocardial workload, and myocardial oxygen demand. Hydromorphone is roughly 10 times more potent than morphine. An IV dose of 1 mg of hydromorphone is equivalent to an IV dose of 10 mg of morphine.

INDICATIONS: Acute pain control in alert, hemodynamically stable patient

CONTRAINDICATIONS: Hypersensitivity, Hypotension, Respiratory Depression, Minor Degrees of Pain

DOSE: For acute pain give 0.5 – 1 mg slow IVP
May repeat every 10 minutes to a maximum cumulative dose of 2 mg

For Unknown Chest Pain or Acute Coronary Syndrome give 0.25 mg slow IVP
May repeat every 10 minutes to a maximum cumulative dose of 1 mg

ROUTES: IV, IO, IM, SQ, PO

PHARMACOKENETICS: Onset of action within 5-10 minutes after IV administration. Duration of effect can reach 4 - 6 hours depending upon end-organ function.

ADVERSE EFFECTS: Hypotension, respiratory depression, euphoria, dizziness. Nausea and/or vomiting if pushed fast b/c it causes a histamine release

OTHER: Use appropriate monitors. Naloxone is an antagonist

HOW SUPPLIED: 2 mg/1 mL vial or pre-filled syringe

Question 15

Ipratropium Bromide

Answer 15

BRAND NAME: Atrovent

CLASS: Parasympatholytic Bronchodilator

PHARMACODYNAMICS: Atrovent is an anticholinergic agent, chemically related to atropine. Given in a nebulized form, it acts directly on the smooth muscle of the bronchial tree by inhibiting acetylcholine at receptor sites. By blocking parasympathetic action, it dilates the
bronchial smooth muscle and decreases secretions. It also abolishes the vagally mediated reflex bronchospasm caused by inhaled irritants such as smoke, dust, and cold air and by a range of inflammatory mediators such as histamine.

INDICATIONS:

• Dyspnea - Asthma/COPD
• Acute Allergic Reactions

CONTRAINDICATIONS: Hypersensitivity. It should not be used as the sole pharmacologic treatment for acute
bronchospasm. By protocol, Atrovent is ALWAYS administered in conjunction with albuterol.

PHARMACOKENETICS: Absorption: 10% of inhaled dose reaches lower airway; approximately 0.5% of dose is systemically absorbed; onset within 5-15 minutes; peak effect in 1.5 – 2 hours; duration of effect is up to 4 – 6 hours; half – life is 1.5 – 2 hours.

SIDE EFFECTS: Cough, reflex bronchospasm, hoarseness, nasal/oral dryness, bitter taste.

DOSE: Dyspnea - Asthma/COPD - Adult
Acute Allergic Reactions - Adult
0.5 mg nebulized (with albuterol 5 mg), may repeat twice

HOW SUPPLIED: 0.5 mg/2.5 mL nebulizer solution vials.

Question 16

Labetalol

Answer 16

BRAND NAME: Normodyne, Trandate

CLASS: Anti-Hypertensive (Beta-1, Beta-2, and Alpha-1 Blocker)

PHARMACODYNAMICS: Adrenergic-receptor blocking agent that combines selective alpha activity and non-selective beta-adrenergic blocking actions. Both activities contribute to reduce blood pressure. Alpha blockade results in vasodilation, decreasing peripheral resistance. Beta blocking effects on sinus node, AV node, and ventricular muscle lead to slower heart rates, delay in AV conduction, and depression of cardiac contractility.

INDICATIONS:

• Hypertensive Emergency
• Pregnancy Complications (Hypertensive Emergency)

CONTRAINDICATIONS:

• Asthma (due to beta-2 blockade)
• Cardiogenic shock
• Uncontrolled congestive heart failure
• 2nd/3rd degree AV heart block
• Sinus bradycardia.

**Safe use during pregnancy and children is not firmly established in pharmaceutical studies, though labetalol has been used effectively in pregnancy and in pediatrics.

PHARMACOKENETICS: Onset is 2-5 minutes IV; peak effects in 5-15 minutes; duration is 2-4 hours; half-life is 3-8 hours.

SIDE EFFECTS: Dizziness, headache, transient paresthesia (eg. scalp tingling), numbness,
postural hypotension, angina, palpitations, bradycardia, syncope, pulmonary edema,
dysrhythmias (bradycardias) following IV administration, dyspnea, bronchospasm.

DOSE:
- Hypertensive Emergency - Adult
- Pregnancy Complications (Hypertensive Emergency)
20 mg Slow IVP. May repeat 40 mg every 10 minutes as needed up to cumulative maximum dose of 300 mg.

HOW SUPPLIED: 100 mg in a 20 mL Multi-Dose Vial (5 mg/mL)

Question 17

Lidocaine 2%

Answer 17

BRAND NAME: Xylocaine

CLASS: Intraosseous Local Anesthetic & Antidysrhythmic

PHARMACODYNAMICS: As a local anesthetic, reduces nerve activation that carries painful stimulus from intraosseous fluid and/or medication administration. As an antidysrhythmic, suppresses ventricular automaticity, chemically converting ventricular tachycardia.

INDICATIONS: 
- Tachycardia - Stable
  (Wide complex tachycardia, refractory to amiodarone,
  **OLMC Order Only)
- Vascular Access - Intraosseous

CONTRAINDICATIONS:
- Narrow complex tachycardia
- Second degree AV Block-Type II (Classic Type)
- Third degree AV Block (Complete Heart Block)
- Premature ventricular contractions with underlying
bradycardias
- No indication for IO anesthetic (unresponsive patients)

PHARMACOKENETICS: Onset of action within 3 minutes
IVP/IOP. Duration for 10-20 minutes.

SIDE EFFECTS: None expected in indicated dosing. Erroneous use in high degree heart blocks can lead to complete ventricular suppression/cardiac arrest.

DOSE:
Tachycardia - Stable - Wide Complex Tachycardia - Adult (Refractory to Amiodarone)
Up to 1 mg/kg, slow IVP/IOP at < 50 mg/minute
**OLMC Order Only

Vascular Access - Intraosseous (Local Anesthetic) - Adult & Pediatric
1 mg/kg up to 40 mg IOP

HOW SUPPLIED: 100 mg/5 mL (20 mg/mL of 2% lidocaine) prefilled syringe.

Question 18

Lorazepam

Answer 18

BRAND NAME: Ativan

CLASS: Sedative; Anticonvulsant; Muscle Relaxant; Anxiolytic (Benzodiazepine) (Schedule IV)

PHARMACODYNAMICS: Long - acting benzodiazepine with central nervous system depressant, anticonvulsant, muscle relaxant, and anxiolytic effects. Like the other benzodiazepines, it has no effect on pain. Ativan has less muscle relaxant properties than diazepam, though no substantial amnestic effects as with midazolam.

INDICATIONS:
- Post RSI Sedation (onset delay does not favor pre
intubation use)
- Seizure (Midazolam preferred due to faster onset)
- Dystonic Reactions
- Chemical Restraint (Midazolam preferred due to faster
onset)
- Poisonings (Suspected stimulant toxicity)
- Head/Neck/Spine Injury (Midazolam preferred due to
faster onset)
- Heat Illness (Midazolam preferred due to faster onset)

CONTRAINDICATIONS:
- Hypersensitivity
- Acute narrow - angle glaucoma, shock, or coma.
- Caution with use in patients with COPD, chronic
hepatic or renal failure, CHF, acute alcohol
intoxication, and the elderly due to increased risk of
respiratory depression.

DOSE:

• Post RSI Sedation
  0. 1 mg/kg to max 2 mg IVP/IOP, may repeat once if systolic BP > 100 mmHg
• Seizure/Heat Illness
  2 mg IVP/IOP/IM for active seizure
  May repeat once in 10 minutes if still seizing.
• Dystonic Reactions
  2 mg IVP/IM
• Chemical Restraint
  2 mg IVP/IOP/IM (May repeat once)
• Poisoning
  1 -2 mg IVP/IM
• Head/Neck/Spine Injury
  1 mg IVP/IM/IOP for active seizure.
  May repeat once in 5 minutes if still seizing

PHARMACOKENETICS: Onset is 5-10 minutes, IVP/IOP; up to 30 minutes IM; peak effects in 2-3 hours. Duration is 3-6+ hours IVP/IOP/IM; half – life can reach 20 – 50 hours.

ADVERSE EFFECTS: Headache, euphoria, drowsiness, excessive sedation, confusion, dizziness, blurred vision, diplopia, nystagmus, respiratory arrest, hypotension, nausea, vomiting

HOW SUPPLIED: 2 mg/1 mL or 4 mg/1 mL in vials, ampules, or pre-filled syringes.

OTHER: Flumazenil is an antagonist ; Ativan must be kept refrigerated

Question 19

Methylprednisolone

Answer 19

BRAND NAME: Solu-Medrol

CLASS: Steroid

PHARMACODYNAMICS: Methylprednisolone is an intermediate-acting synthetic adrenal corticosteroid with glucocorticoid activity. It exerts anti-inflammatory effects in the setting of inflammatory-mediated illness.

INDICATIONS: Dyspnea/Asthma/Chronic Obstructive Pulmonary Disease, Acute Allergic Reactions/ anaphylaxis

CONTRAINDICATIONS: hypersensitivity

DOSE: 125 mg IVP. Give IM if no IV access obtainable

PHARMACOKENETICS: Onset of action within 4 – 6 hours, may have effect in excess of 24 hours

ADVERSE EFFECTS: May occasionally see any of the following effects with onset of action: euphoria, insomnia, confusion, psychosis, edema, hypertension, nausea/ vomiting, hyperglycemia.

OTHER: effects are delayed and not typically seen in the prehospital setting

HOW SUPPLIED: 125 mg Act-O-Vial™ System (Single Dose Vial)

Question 20

Midazolam

Answer 20

BRAND NAME: Versed

CLASS: Sedative; Anticonvulsant; Amnestic; Muscle Relaxant, Anxiolytic, Benzodiazepine (Class IV)

PHARMACODYNAMICS: Short - acting benzodiazepine with central nervous system depressant, anticonvulsant, anterograde amnestic, muscle relaxant, and anxiolytic effects. Like the other benzodiazepines, it has no effect on pain.

INDICATIONS: 
- Pre & Post RSI
- Post Cardiac Arrest Treatment (Hypothermia Induced 
  Shivering Control) 
- Transcutaneous Pacing (Sedation)
- Synchronized Cardioversion (Sedation)
- Seizure
- Dystonic Reactions
- Chemical Restraint
- Poisonings (Suspected stimulant toxicity)
- Head/Neck/Spine Injury
- Heat Illness

CONTRAINDICATIONS:
- Hypersensitivity
- Acute narrow - angle glaucoma, shock, or coma.
- Caution with use in patients with COPD, chronic
hepatic or renal failure, CHF, acute alcohol
intoxication, and the elderly due to increased risk of
respiratory depression.

DOSE:
- Pre & Post RSI Sedation
0.1 mg/kg to max 5 mg IVP/IOP, may repeat once if
systolic BP > 100 mmHg

• Post Cardiac Arrest Treatment (Hypothermia Induced
  Shivering Control) -Adult & Pediatric
  0.1 mg/kg to max 5 mg IVP/IOP
• Transcutaneous Pacing (Sedation) - Adult
  2 - 5 mg IVP based upon weight and hemodynamics
  (0.1 mg/kg to max 5 mg)
• Synchronized Cardioversion (Sedation) - Adult
  
  0. 1 mg/kg to max 5 mg IVP/IOP/INP
• Seizure/Heat Illness - Adult
  0.1 mg/kg to max 5 mg IM/IVP/IN/IOP for active seizure
  May repeat once in 5 minutes if still seizing
• Dystonic Reactions - Adult
  
  2. 5 mg IVP/IM/IN
• Chemical Restraint - Adult
  0.1 mg/kg to max 5 mg IM/IVP/IN/IOP.
  May repeat once.
• Poisoning (Suspected Stimulant Toxic) - Adult
  
  0. 1 mg/kg to max 5 mg IVP/IN/IM
• Head/Neck/Spine Injury - Adult
  5 mg IM/IVP/IN/IOP for active seizure.
  May repeat once in 5 minutes if still seizing

PHARMACOKENETICS: Onset is 3-5 minutes, IVP/IOP; 6-14 minutes IN; up to 15 minutes IM (though clinically evident much faster); peak effects in 20-60 minutes. Duration is 2 hours IVP/IOP/IN; 1-6 hours IM; half – life is 1-4 hours

ADVERSE EFFECTS: Retrograde amnesia, headache, euphoria, drowsiness, weakness, excessive sedation, confusion, dizziness, blurred vision, diplopia, nystagmus, respiratory arrest, tachypnea, hypotension, nausea, vomiting

HOW SUPPLIED: 5 mg/1 mL in vials, ampules, or pre-filled syringes.

OTHER: Flumazenil is an antagonist

Question 21

Morphine Sulfate

Answer 21

BRAND NAME: Morphine Sulfate

CLASS: Narcotic Analgesic

PHARMACODYNAMICS: Stimulates central nervous system opiate receptors, producing systemic analgesia. Modest vasodilation effects increase peripheral venous capacitance, and reduce venous return, myocardial workload, and myocardial oxygen demand

INDICATIONS: Acute pain control in alert, hemodynamically stable patient

CONTRAINDICATIONS: Hypotension, Respiratory Depression, Minor Degrees of Pain, Pain Assessed as Factitious

DOSE:
- For unknown chest pain or acute coronary syndrome
2 mg slow IVP ; May repeat every 5 minutes to a
maximum cumulative dose of 10 mg

• For acute pain control
  2 – 4 mg slow IVP
  May repeat every 5 minutes to a maximum cumulative
  dose of 10 mg

PHARMACOKENETICS: Onset of action within 3-5 minutes after IV administration. Duration of effect can reach 4 hours depending upon end-organ function.

ADVERSE EFFECTS: Hypotension, respiratory depression, euphoria, dizziness. Nausea and/or vomiting are rarely seen if administration is slow IVP. Rapid IVP will lead to an accompanying histamine release, producing the nausea and/or vomiting often erroneously attributed to morphine itself.

HOW SUPPLIED: 
2 mg/1 mL pre-filled syringe
4 mg/1 mL vial, ampule, or pre-filled syringe
8 mg/1 mL pre-filled syringe
10 mg/1 mL vial
10 mg/10 mL vial

Question 22

Nitroglycerin

Answer 22

BRAND NAME: There is a lot of them

CLASS: Anti-Anginal, Vasodilator, Anti-Hypertensive (Nitrate)

PHARMACODYNAMICS: Arterial and venous vasodilator through relaxing vascular
smooth muscle. Reduces cardiac afterload resistance and cardiac preload volume respectively.
Myocardial oxygen consumption/demand is decreased. Systemic blood pressure is decreased.

INDICATIONS:

• Dyspnea - Congestive Heart Failure
• Chest Pain - Uncertain Etiology
• Acute Coronary Syndrome
• Hypertensive Emergency
• Pregnancy Complications (Hypertensive Emergency)

CONTRAINDICATIONS:
- Hypotension
- Asymptomatic Hypertension
- Erectile Dysfunction Medications (**Requires OLMC
Order Only) Such As: Sildenafil (Viagra®) or Vardenafil
(Levitra®) use within 24 hours OR Tadafil (Cialis®) use
within 48 hours

PHARMACOKENETICS: Rapid vascular uptake within 3 minutes of sublingual dosing, with duration of effect up to 30 minutes. Rapid vascular effect within 1-3 minutes of intravenous dosing, with ongoing effect while continuous infusion. Vascular effect within 15-30 minutes of transdermal dosing, with ongoing effect while continued transdermal absorption.

SIDE EFFECTS: The most serious side effect is hypotension, usually transient and responsive to supine positioning and intravenous fluid boluses.
Common, though non-serious, symptoms include: headache due to vasodilation, blurred vision, and dizziness.
**Paramedics should exercise caution when applying transdermal nitroglycerin ointment, avoiding contact with bare hands to avoid experiencing personal side effects, typically headache and dizziness

DOSE:
+ Dyspnea - Congestive Heart Failure - Adult
+ Acute Coronary Syndrome - Adult

0.4 mg sublingual spray or tablet if systolic BP > 100
mmHg. Single dose unless by Paramedic. May repeat
0.4 mg sublingual spray or tablet every 5 minutes if
systolic BP >100 mmHg until chest pain and/or respiratory distress resolves.

Following initial sublingual use, may utilize intravenous infusion start at 10 mcg/min, titrate slowly to effect. Maximum infusion rate without OLMC consult is 50 mcg/min.

Following initial sublingual use, may utilize transdermal application of 1½ inches ointment to chest wall.

+ Chest Pain - Uncertain Etiology - Adult

0.4 mg sublingual spray or tablet if systolic BP >100 mmHg. Single dose unless by Paramedic. If chest pain improved with initial dose, 0.4 mg sublingual spray or tablet every 5 minutes until chest pain and/or respiratory distress resolves.

Following initial sublingual use, may utilize intravenous infusion start at 10 mcg/min, titrate slowly to effect. Maximum infusion rate without OLMC consult is 50 mcg/min.

Following initial sublingual use, may utilize transdermal application of 1½ inches ointment to chest wall.

+ Hypertensive Emergency - Adult
+ Pregnancy Complications (Hypertensive Emergency)

0.4mg sublingual spray or tablet every 5 minutes until BP symptoms resolve or BP is reduced by 10%.

In place of or following initial sublingual use, may utilize intravenous infusion start at 10 mcg/min, titrate slowly to effect. Maximum infusion rate without OLMC consult is
50 mcg/min.

In place of or following initial sublingual use, may utilize transdermal application of 1½ inches ointment to chest wall.

HOW SUPPLIED:
- Metered dose spray 0.4 mg/spray
- Tablets for sublingual absorption 0.4 mg
- Transdermal ointment 2% nitroglycerin concentration
1½ inches = 22.5 mg of nitroglycerin
- Intravenous infusion:
a) Mix 50 mg into 250 mL D5W (200 mcg/mL)
b) 10 mcg/min using microdrip infusion set is 3
mL/hour rate
c) 20 mcg/min using microdrip infusion set is 6
mL/hour rate

Question 23

Norepinephrine

Answer 23

BRAND NAME: Levophed

CLASS: Vasoconstrictor

PHARMACODYNAMICS: Stimulates alpha receptors in the peripheral vasculature, producing vasoconstriction-related increase in systemic blood pressure. Concurrent beta receptor stimulation may produce increases in heart rate and mild bronchodilation, though norepinephrine is a weaker beta stimulator than dopamine.

INDICATIONS: For all listed situations, indication is hypotension (adult = systolic < 100mmHg) due to cardiogenic, septic, or neurogenic shock either refractory to intravascular fluid boluses or in which intravascular fluid boluses is contraindicated (eg. pulmonary edema).

CONTRAINDICATIONS: Hypertension

PHARMACOKENETICS: Onset of action within 5 minutes after IV/IO infusion initiated. Rapid metabolism, requiring ongoing IV/IO infusion to maintain clinical effects.

SIDE EFFECTS: Few, though at higher doses, symptoms may include headache, palpitations, tachycardia, chest pain, and eventual hypertension. Bradycardia can result reflexively from an increase in blood pressure

DOSE: Start at 2-4 mcg/minute - see dosage chart - titrated to a systolic B/P ≥ 100 mmHg. Maximum infusion rate is 12 mcg/minute

HOW SUPPLIED: 4 mg/4 mL ampule or vial.
Use only 2 mL in a 250 mL bag of D5W.
(8 mcg/mL concentration)

OTHER:
Norepinephrine should be given into a large, patent vein. The vein of choice for EMS use is the antecubital vein, as this will decrease the risk of overlying skin necrosis. Do not administer norepinephrine through an IV in the hand or leg. These veins are more likely to be affected by vasoocclusive diseases and more prone to ischemic complications.
Administration through IO in the proximal tibia or humeral head is permitted.

Safety in pregnancy not firmly established, though when clinically indicated the benefits outweigh risks. Safety in pediatrics not firmly established and OLMC is to be consulted prior to pediatric usage.

Question 24

Ondansetron

Answer 24

BRAND NAME: Zofran

CLASS: Antiemetic ; Serotonin antagonist

PHARMACODYNAMICS: Ondansetron reduces the activity of the vagus nerve, which activates the vomiting center in the medulla oblongata, and also blocks serotonin receptors in the chemoreceptor trigger zone. It has little effect on vomiting caused by motion sickness.

INDICATIONS: Nausea and Vomiting

CONTRAINDICATIONS: Hypersensitivity ; Current use of Apomorphine (Apokyn®), an anti – parkinsonian drug ; Use with caution with patients currently using medications which effect QT interval (eg. procainamide, amiodarone, tricyclic antidepressants, haloperidol) ; DO NOT GIVE TO POSSIBLY PREGNANT WOMEN

DOSE:
4 mg oral dissolving tablet on tongue, may repeat once in 10 minutes
4 mg slow IVP over 60 seconds, may repeat once in 10 minutes

ADVERSE EFFECTS: Sedation, dystonic reactions (rare), hypotension, tachycardia, angina, Torsades (rare).

HOW SUPPLIED:
4 mg/2 mL (2 mg/mL) vial.
4 mg rapid oral dissolving tablet (ODT)

OTHER: Commonly used in emergency medicine because of good safety profile

Question 25

Oxygen

Answer 25

CLASS: A naturally occurring gaseous element. Present at approximately 21% in the atmosphere.

ACTIONS:
• Necessary for the body to oxidize glucose to produce
ATP (Energy) (Aerobic metabolism)
• Catalyst for the combustion of hydrocarbons.

INDICATIONS:
• Suspected or confirmed hypoxia.
• Respiratory insufficiency.
• Confirmed or suspected carbon monoxide poisoning
and other causes of decreased tissue oxygenation.
• Used to nebulize certain bronchodilation medications
for inhalation delivery into the lower airways.
• Used to deliver CPAP with some oxygen driven
machines.

CONTRAINDICATIONS: Oxygen should never be withheld from any critical patient.

SPECIAL NOTES:
• It is recommended to monitor pulse oximetry levels if
available when administering oxygen. However, this
should not be the sole determinate of the
effectiveness of oxygen therapy.
• In the ROSC patient, it is preferred that the fiO2 be
titrated to maintain a SaO2 of 94% - 99% but less than
100%.

ADVERSE REACTIONS: Prolonged, high flow oxygen may depress the respiratory drive in
patients with chronic carbon dioxide retention.

ROUTES: Inhalation through a variety of means:
• nasal cannula
• venturi mask
• simple mask
• partial-rebreather mask
• non-rebreather mask
• bag-valve-mask
• hand held nebulizer
• “blow-by” devices of various types

ADULT DOSAGE:
• Variable
• 2 – 15 lpm generally
• Some devices may require higher

PEDIATRIC DOSAGE: SAME AS ADULT

Question 26

Phenylephrine 2%

Answer 26

BRAND NAME: Neosynephrine

CLASS: Topical Nasal Vasoconstrictor

PHARMACODYNAMICS: Phenylephrine is a direct-acting sympathomimetic amine. It stimulates alpha receptors in the blood vessels of the nasal mucosa which causes their constriction, thereby decreasing the risk of subsequent nasal bleeding.

INDICATIONS:

• Nasal Intubation
• Epistaxis

CONTRAINDICATIONS: None in the indicated settings.

PHARMACOKENETICS: Onset of action is within seconds.

SIDE EFFECTS: Rare with single dose. It is rarely absorbed systemically from nasal instillation.

DOSE:
- Nasal Intubation - Adult
2 sprays in each nostril

• Epistaxis - Adult & Pediatric (9C)
  2 - 4 sprays in affected nostril(s) for control of epistaxis
  (with compression of nose immediately after
  administration)

HOW SUPPLIED: Phenylephrine Nasal Spray 1% solution, 15 mL squeeze bottle for single patient use only.

Question 27

Sodium Bicarbonate

Answer 27

BRAND NAME: Sodium Bicarbonate

CLASS: Alkalinizing agent

PHARMACODYNAMICS Raises the pH of blood by buffering excess hydrogen ions that are present in acidotic states. The role of sodium bicarbonate is limited in cardiac arrest. Because ventilation is an effective tool in managing respiratory acidosis, sodium bicarbonate should rarely be administered for cardiac arrest, unless the arrest is suspected to be secondary
to hyperkalemia, a preexisting metabolic acidosis, or a tricyclic antidepressant over ingestion.

INDICATIONS:
- Specific Causes of Cardiac Arrest (Hyperkalemia)
- Poisonings – General Management (Tricyclic
Antidepressant)
- Dialysis-Related Issues (Hyperkalemia)
- Crush Injury Syndrome (Hyperkalemia Prophylaxis)

CONTRAINDICATIONS: Known metabolic alkalosis.

PHARMACOKENETICS: Onset of effect is observed within 3-5 minutes after IVP/IOP administration.

SIDE EFFECTS: Sodium bicarbonate may inhibit oxygen release secondary to a shift in oxyhemoglobin saturation. It also may produce a paradoxical acidosis that can depress cerebral and cardiac function. Severe soft tissue damage can occur in extravasated administrations.

DOSE:
For all indications above Adult & Peds
1 mEq/kg IVP/IOP with maximum dose of 50mEq

HOW SUPPLIED: 50 mEq/50 mL (1 mEq/mL) prefilled syringe.

OTHER: Do not administer with calcium chloride. A precipitate will form and obstruct the vascular access being utilized