Pharm Flashcards
Albuterol Adult Dose
2.5mg via nebulizer up to max of 20mg
Albuterol Pedi Dose
<2 years old= 1.25mg via nebulizer
>2 years old= adult dose (2.5mg)
Albuterol Onset, PE, (Duration)
5-15 mins
30-120 mins
(3-6 hours)
Albuterol Class
B-2 agonist
Albuterol PA
B-2 receptor agaonist with some B-1 activity.
Relaxes bronchial smooth muscle w/ some effect on heart rate (can cause HR increase).
In setting of HyperK, simulates an intracellular shift of serum Potassium.
Albuterol Indications
Bronchospastic lung disease
Anaphylaxis w/ wheezing/respiratory distress
Hyperkalemia
Albuterol CI
Hypersensitivity
Tachycardia secondary to heart condition
Albuterol PP
The higher the flow rate, the faster the medication will be administered; 4-8 LPM is recommended.
Always use nebulizer mask when delivering nebulized medications as it ensured meds are continuously given.
Pedi’s may require blow-by administration as that may not tolerate mask on face. Consider “T-Piece”.
Aspirin Dose
162-324mg PO (2-4x81mg tablets)
Aspirin onset, PE, (Duration)
15-30 mins
1-2 hours
(4-6 hours)
Aspirin Class
NSAID (Non-Steroidal Anti-Inflammatory Drug)
Antiplatelet agent
Aspirin PA
Inhibits synthesis of prostaglandin by cyclooxygenase.
Inhibits platelet aggression.
Some antipyretic and analgesic activity.
Aspirin Indications
Antiplatelet agent for PT’s suspected of suffering from ACS/MI.
Aspirin CI
Hypersensitivity
Bleeding GI Ulcers
Anemia
thrombocytopenia
hemophilia
Ulcerative Colitis
Aspirin PP
Salicylate Toxicity-
Mild- <150 mg/kg
Moderate- 150-300 mg/kg
Severe- >300 mg/kg
Chronic- >40-50 mg/kg daily
Epi IM Adult Dose (Anaphylaxis, 1:1,000)
0.3 mg IM
2-10 mcg/min for infusion (shock/bradycardia)
Epi IM Pedi Dose (Anaphylaxis 1:1,000)
0.15 mg IM
0.1-1 mcg/kg/min for infusion (shock/bradycardia)
Epi IM (1:1,000) Onset, PE, (Duration)
<2 mins, <5 mins, (5-10 mins)
Epi Class
A and B adrenergic agonist
Epi PA
Strong B-1 adrenergic effects which causes increase in cardiac contractility and HR w/ variable effect on BP, resulting in systemic vasoconstriction and increased vascular permeability.
Strong B-2 effects at lower doses resulting in bronchial smooth muscle relaxation.
Constriction of vascular smooth muscle via A-1 receptors at moderate to high doses.
Epi IM (1:1,000) indications
Anaphylaxis
Shock
Cardiac Arrest
Bradycardia
Nebulized for Croup/Bronchiolitis
IM for refractory Asthma
Epi IM (1:1,000) CI
Hypersensitivity
Cardiac dilation and coronary insufficiency
Epi IM (1:1,000) PP
IM Epi has longer onset and duration than IV Epi.
This is also the concentration found in Epi pens which are commonly supplied in residences and other pre-hospital environments.
IM Epi can be recruited for angioedema in setting of allergic reaction, not just anaphylaxis.
Epi IV/IO (1:10,000) Adult Dose
1 mg every 3-5 mins
Epi IV/IO (1:10,000) Pedi Dose
0.01 mg/kg every 3-5 mins
Epi IV/IO (1:10,000) Onset, PE, (duration)
<2 mins, <5 mins, (5-10 mins)
Epi PP for Cardiac Arrest
Pedi Dose for arrest is best accomplished using 3-way stopcock
Ipratropium Bromide Adult Dose
500 mcg via nebulizer
Ipratropium Bromide Pedi Dose
<2 years- 250 mcg via neb.
>2 years- 500 mcg via neb.
Ipratropium Onset, PE, (Duration)
5-15 mins
1.5-2 hours
(4-6 hours)
Ipratropium Alt ID’s
Atrovent
Ipratropium Class
Anticholinergic
Respiratory expectorant
Ipratropium PA
Anticholinergic agent; inhibits cagally mediated reflexes by antagonizing acetylcholine action.
Prevents increase in intracellular calcium concentration that is caused by interaction of acetylcholine w/ muscarinic receptors on bronchial smooth muscle.
Ipratropium Indications
Asthma
COPD
Ipratropium CI
Hypersensitivity to Ipratropium, Atropine, or derivatives
Naloxone (Narcan) Adult Dose
0.4-2 mg IV/IO/IN/IM to max total dose of 10 mg
Naloxone Pedi Dose
0.1 mg/kg IV/IO/IM/IN to max of 2mg/dose. Max total dose of 10 mg
Naloxone Alt ID
Narcan
Naloxone Onset, PE, (Duration)
<2 mins
<2 mins
(20-120 mins)
Naloxone Class
Opioid reversal agent
Naloxone PA
Competitive Opioid antagonist.
Synthetic cogener of oxymorphone
Naloxone Indication
Reversal of acute opioid toxicity
Naloxone CI
Hypersensitivity
Naloxone PP
Admin of Naloxone can cause sudden onset of opiate withdrawal (agitation, tachycardia, nausea, vomit, pulm. edema, and seizures in neonates).
IM/IN has longer onset and PE than IV.
Nitroglycerin Adult Dose
0.4 mg SL spray/tab every 5 minutes to max dose of 3 doses for SBP >100 mmHg
Nitro Onset, PE, (Duration)
1-3 mins
5-10 mins
(20-30 mins)
Nitro Class
Nitrates
Anti-anginal
Nitro PA
Organic Nitrate which causes systemic vasodilation, decreasing preload.
Dilation of arterial and venous beds to reduce preload and after load.
Lower BP, Increase HR, occasional paradoxical bradycardia.
Nitro Indications
Anti-anginal med for management of chest pain as well as preload reducer in setting of acute pulm. edema.
Nitro CI
Hypersensitivity
Severe Anemia
Hypotension
Use of ED meds in last 24-48 hours (Viagra, Cialis, Levitra)
Nitro PP
Nitro isn’t only prescribed for men; can be prescribed for women with DX of Pulmonary Hypertension.
“Double-tap” of Nitro = 0.8 mg doses prior to admin of CPAP for pulm. edema.
Oral Glucose Adult Dose
Max of 25 gms PO
Oral Glucose Pedi Dose
0.5-1 g/kg PO to max of 25 gms
Oral Glucose Onset, PE, (Duration)
<10 mins
Variable
(Variable)
Oral Glucose PA
Oxidized into carbon dioxide and water and provides 3.4 kilocalories of d-glucose. Increases blood serum glucose levels
Glucose Indications
Hypoglycemia
Oral Glucose CI
AMS
Difficulty swallowing
Nausea
vomit
Oxygen/CPAP Doses
NC- 2-8 LPM
NRB- 12-15 LPM
Neb.- 4-8 LPM
BVM- 12-15 LPM
CPAP- varies
Amiodarone Adult Dose
Stabled, wide-complex tachycardia- 150 mg over 10 mins.
VF/VT arrest- 300 mg diluted in 20 mL of saline for 1st dose. 2nd dose- 150 mg diluted in 20 mL saline after 3-5 mins.
Amiodarone Pedi Dose
5 mg/kg IV/IO push
Amiodarone Onset, PE, (duration)
5 mins
10 mins
(variable)
Amiodarone Class
Class III antidysryhthmics
Amiodarone PA
Antidysrythmic agent
Inhibits adrenergic stimulation.
affects sodium, potassium, calcium channels.
prolongs action potential/repolarization.
Decreases AV node Conduction and sinus node function.
Amiodarone Indications
Wide complex tachycardia in stable patients.
irregular wide complex tachycardia in stable PT’s.
Refractory VFib and Pulseless VTach.
Amiodarone CI
Hypersensitivity
severe sinus node dysfunction
2nd/3rd degree heart block.
bradycardia causing syncope (except w/ functioning artificial pacemaker.
cardiogenic shock
Amiodarone PP
Avoid during breastfeeding
Prone to effervescence; draw into saline syringe slowly.
Dopamine Adult and Pedi Dose
2-20 mcg/kg/min
Dopamine Onset, PE, (Duration)
5 mins
5-10 mins
(<10 mins)
Dopamine Class
Inotropic agent
catecholamine
pressor
Dopamine PA
Endogenous catecholamine acting on both dopaminergic and adrenergic neurons. low dose stimulates dopaminergic producing renal and mesenteric vasodilation.
Higher dose stimulates both B-1 adrenergic and dopaminergic receptors producing cardiac stimulation and renal vasodilation. Large does- A-adrenergic receptors.
Dopamine Indications
Pressor if Norepi and Epi are unavailable.
Dopamine CI
Hypersensitivity
pheochromocytoma
VFib
Uncorrected Tachyarrythmias
Dopamine PP
Is a vesicant, can cause severe tissue damage if extravasation occurs.
Norepinephrine Adult and Pedi Dose
0.1-0.5 mcg/kg/min
Norepi Onset, PE, (Duration)
Immediate
<1 min
(1-2 mins)
Norepi Alt ID’s
Levophed
Norepi Class
a- and b- adrenergic agonist
Norepi PA
Strong b-1 effects at low doses which increases cardiac output and HR.
Primarily a-1 effects at mod. to high doses which increases vascular resistance.
Moderate b-2 effects, decreasing renal and visceral perfusion.
Norepi Indications
As a pressor agent used in management of shock.
Norepi CI
Hypersensitivity
HOTN from blood vol. deficit.
Peripheral vascular thrombosis.
Norepi PP
Is a vesicant; could cause severe tissue damage if extravasation occurs.
Do not use in same line as alkaline solutions.
Must use through pump.
Adenosine Adult Dose
6mg followed by 20mL flush
12mg followed by 20mL flush
12mg followed by 20mL flush
*Rapid Pushes
Adenosine Pedi Dose
0.1 mg/kg (max of 6 mg) followed by 10mL flush if >1 year old. 3 mL for <1 year old.
0.2 mg/kg (max of 12 mg)
0.2 mg/kg (“)
*Rapid Push
Adenosine Onset, PE, (Duration)
5-10 seconds
Seconds
(~10 seconds)
Adenosine PA
Slows conduction through AV node and interrupts AV nodal reentry pathways which restores normal sinus activity.
Adenosine Indication
Conversion of regular, narrow-complex tachycardia - Stable SVT
Adenosine CI
Hypersensitivity
2nd/3rd degree AV block
Sick Sinus Syndrome
AFlutter/Afib
VTach
Adenosine PP
Has extremely short half-life and therefore must be given rapidly to reach heart.
Most proximal IV access preferred.
Rapid Flush required.
Use of three way stopcock recommended.
Atropine Adult Dose
Bradycardia- 1 mg IV/IO
Cholinergic Tox- 2 mg IV/IO
Atropine Pedi Dose
Bradycardia- 0.02 mg/kg IV/IO
Cholinergic Tox- 0.02-0.05 mg/kg IV/IO (Max dingle Dose of 2 mg)
Atropine Onset, PE, (Duration)
Immediate
2-4 minutes
(2-4 hours)
Atropine Class
Anticholinergic
tox/antidotes
Atropine PA
Competitive acetylcholine antagonist by binding to muscarinic acetylcholine receptors on postsynaptic neuron or neuromuscular junction, reducing parasympathetic tone.
Atropine Indications
Nerve agent tox.
Bradycardia
organophosphate/insecticide tox.
Atropine CI
No absolute for ACLS.
Non-ACLS- relative hypersensitivity
glaucoma
GI Obstruction
Myasthenia Gravis
Hemorrhage w/ cardiac instability
Ulcerative Colitis
Atropine PP
Limited duration of action and therefore should not be seen as definitive treatment in cardiac emergencies.
Diltiazem Adult Dose
0.25 mg/kg IV/IO over 2 mins
After 15 mins, 0.35 mg/kg IV/IO over 2 mins
Diltiazem Onset, PE, (Duration)
2-5 mins
7 mins
(1-3 hours)
Diltiazem Alt ID’s
Cardizem
Diltiaz
Dilacor
Diltiazem Class
Calcium Channel Blocker
Antidysrrythmic type IV
Diltiazem PA
Inhibits extracellular calcium-ion influx across membranes of myocardial cells and vasc. smooth muscle cells, resulting in inhibition of cardiac and vascular smooth muscle contraction and thereby dilating main coronary and systemic arteries.
No effect on serum Calcium concentrations.
Substantial inhibitory effects on cardiac conduction system, acting principally at AV node, w/ effects on sinus node.
Diltiazem Indications
Narrow complex tachycardias (Afib/AFlutter)
Diltiazem CI
Hypersensitivity
Wolff-Parkinson-White Syndrome
Lown-Ganong-Levine Syndrome
Severe HOTN (SBP<90)
Sick Sinus Syndrome
2nd/3rd degree heart block
Newborns
Concomitant Beta-Blocker Therapy
Cardiogenic Shock
VTach
Diltiazem PP
True risk w/ Beta-Blocker Therapy is when both are given over short period of time. Still try to avoid.
When calculating med math, initial 0.25 mg/kg dose is the same as 25% on PT weight; 2nd dose is 25% + 10% of PT’s total weight.
EX: 80kg would get: 20mg 1st dose/28mg 2nd dose (10% of 80kg =8 + initial dose of 20mg)
Fentanyl Adult/Pedi Dose
1 mcg/kg IV/IO/IM/IN
Fentanyl Onset, PE, (Duration)
Immediate
3-5 mins
(30-60 mins)
Fentanyl Class
Synthetic Opioid Analgesics
Fentanyl PA
Narcotic agonist-analgesic of Opiate receptors.
Inhibits ascending pain pathways, thus altering response to pain.
Increases pain threshold.
Produces analgesia/respiratory depression/sedation.
Fentanyl Indications
Management of acute pain
Fentanyl CI
Hypersensitivity
Used w/ caution in elderly PT’s.
Caution w/ HOTN
Suspected GI Obstruct.
Head injury
Concomitant CNS depressants.
Fentanyl PP
Appropriate to use smaller aliquots to see how well-tolerated it is.
Opioids given to pregnant females for analgesia is safe when given for short therapeutic window. Becomes an issue when used habitually over course of pregnancy.
Should be w/held in active labor.
Metoprolol Adult Dose
2.5-5 mg IV/IO
Metoprolol Onset, PE, (Duration)
<3 mins
5-10 mins
(5-8 hours)
Metoprolol PA
Blocks response to B-Adrenergic stimulation.
Cardioselective for B-1 receptors at low doses, w/ little or no effect on B-2 receptors.
Metoprolol Indications
Stable Afib/AFlutter
Metoprolol CI
Hypersensitivity
When administered for HOTN: Sinus Bradycardia, 2nd/3rd degree heart block, cardiogenic shock, severe peripheral vasc. disease, pheochromocytoma.
When administered for MI: Severe sinus bradycardia w/ HR <45 BPM, BP <100 SBP, significant 1st degree heart block, moderate to severe cardiac failure.
Metoprolol PP
May cause 1st/2nd/3rd degree heart block.
Risk when used alongside calcium channel blockers when both given through same IV.
Nitroglycerin Adult Dose
ACS- 0.4mg SL spray/tab every 5 mins. Max doses: 3 so long as SBP>100.
Cardiogenic Pulm. Edema- 0.4-0.8 mg SL spray/tab every 5 mins to max of 3 doses if SBP>100.
Nitro Onset, PE, (Duration)
1-3 mins
5-10 mins
(20-30 mins)
Nitro Class
Nitrates
Anti-Anginal
Nitro PA
Causes systemic vasodilation, decreasing preload.
Enters vascular smooth muscle and converts to nitric oxide; relaxes smooth muscle of arterial and venous beds to reduce preload/after load and myocardial O2 demand.
Improves coronary collateral circulation.
Lower BP, increase HR, Occasional paradoxical bradycardia.
Nitro Indication
Anti-anginal med for PT’s suffering chest pain from suspected ACS.
Preload reducer for acute pulm. edema.
Nitro CI
Hypersensitivity
HOTN (SBP<100)
ED meds w/in 24-48 hours (Cialis, Viagra, Levitra)
Severe Anemia.
Nitro PP
Phosphodiesterase meds (ED meds) are not only prescribed for men; often prescribed for women for pulm. HTN.
Standard practice for pulm. edema is to administered 2 doses (0.8 mg SL) prior to administration of CPAP; Called “double-tap of Nitro”.
Calcium Chloride Adult Dose
1 gm IV/IO push over at least 5 minutes
Calcium Chloride Onset, PE, (Duration)
1-3 mins
Varies
(20-30 mins)
Calcium Chloride Class
Antidotes
Calcium salts
Calcium Chloride PA
Bone mineral component; cofactor in enzymatic reactions, essential for
neurotransmission, muscle contraction, and many signal transduction pathways. When
administered for hyperkalemia calcium chloride stabilizes the cardiac action potential.
Calcium Chloride Indications
Known or suspected hyperkalemia, calcium channel-blocker overdose, beta blocker
overdose, known or suspected Magnesium toxicity.
Calcium Chloride CI
Hypercalcemia, documented hypersensitivity, life-threatening cardiac arrhythmias may
occur in known or suspected severe hypokalemia
Calcium Chloride PP
WARNING: There is a risk for digitalis toxicity;
* Calcium Chloride is a potent vesicant and will result in severe local tissue necrosis if
extravasation occurs;
* Calcium Chloride must be given in separate IV/IO line from Sodium Bicarbonate in order to
avoid crystallization
Glucagon Adult Dose
Hypoglycemia- 1 mg IM/IN
β-blocker or Calcium Channel-Blocker Toxicity- 5-10 mg IV over 5 minutes repeated until bradycardia is resolved;
Glucagon Pedi Dose
Hypoglycemia- 0.1 mg/kg IM/IN to maximum dose of 1 mg
β-blocker or Calcium Channel-Blocker Toxicity- Seek expert consult.
Glucagon Onset, PE, (Duration)
1 min
5-20 mins
(60-90 mins)
Glucagon Class
Hypoglycemia- antidote
Glucose elevating agents
Other antidotes (B-Blocker, Calcium Channel Blocker)
Glucagon PA
Insulin antagonist. Stimulates cAMP synthesis to accelerate hepatic glycogenolysis and gluconeogenesis. Glucagon also relaxes smooth muscles of GI tract.
Glucagon Indications
For the management of hypoglycemic patients when IV access cannot be obtained as well
as patients suffering symptomatic bradycardia after β-blocker or calcium channel-blocker
overdose.
Glucagon CI
Hypersensitivity
pheochromocytoma
insulinoma
Glucagon PP
WARNING: Nausea and vomiting are common adverse effects following the administration of
glucagon;
Unfortunately, most agencies do not carry enough Glucagon to deliver the full therapy for βblocker or calcium channel-blocker toxicity.
Compounding this issue, once therapeutic the bolus requires a maintenance infusion. The
dose of maintenance infusion for antidote properties should equal effective IV bolus
dosing;
Also, Tachyphylaxis (less response with successive dosages) occurs quickly when treating
bradycardia.
Lidocaine Adult Dose
VF/VT Arrest
* 1.5 mg/kg IV/IO;
* May repeat at 0.5-0.75 mg/kg every 3-5 minutes up to
total dose of 3 mg/kg
* Consider maintenance infusion at 2-4 mg/min
Conscious IO Site Anesthesia
40 mg over 2 minutes
Lidocaine Pedi Dose
Conscious IO Site Anesthesia-
1 mg/kg (max 20 mg) over 2 minutes
Lidocaine Onset, PE, (Duration)
1-5 mins
5-10 mins
(10-20 mins)
Lidocaine Class
Class 1b antidysrythmics
Lidocaine PA
Class 1b antidysrhythmic; combines with fast sodium channels and thereby inhibits recovery after repolarization, resulting in decreasing myocardial excitability and conduction velocity.
Lidocaine Indications
Refractory/recurrent VFib/pulseless VT.
Local anesthetic for IO Placement in PT’s responsive to pain.
Lidocaine CI
Hypersensitivity to lidocaine or amide-type local anesthetic
Adams-Stokes syndrome SA/AV/intraventricular heart block in the absence of artificial pacemaker
Nitro (CHF)
cardiogenic shock
2nd/3rd-degree heart block (if no pacemaker is present)
Wolff-Parkinson-White Syndrome
Magnesium Adult Dose
Torsades de Pointes/Prolonged QTc/Refractory Ventricular
Fibrillation
1-2 gms IV/IO over 5 minutes
Severe Asthma (Bronchoconstriction)
2-4 gms IV/IO over 20 minutes
Eclamptic Seizures
2-4 gms IV/IO over 5 minutes
Magnesium Pedi Dose
Torsades de Pointes/Prolonged QTc/Refractory Ventricular
Fibrillation
Seek Expert Consultation
Severe Asthma (Bronchoconstriction)
25 mg/kg to maximum dose of 2 gms over 20 mins
Magnesium Onset, PE, (Duration)
Immediate
Variable
(30 mins)
Magnesium Class
Class V antidysrythmics
Electrolyte
Magnesium PA
Depresses CNS
Blocks peripheral neuromuscular transmission
Produces anticonvulsant
effects
Decreases the amount of acetylcholine released at the end-plate by motor nerve
impulse.
Slows rate of sinoatrial (SA) node impulse formation in myocardium and prolongs conduction time. Promotes movement of calcium, potassium, and sodium in and out of cells and stabilizes excitable membranes.
Magnesium Indications
Torsades de pointes
Prolonged QTc with evidence of ventricular dysrhythmia/ectopy.
Refractory ventricular fibrillation. Severe bronchoconstriction with
impending respiratory failure (primarily used in asthma, not COPD)
Seizure during the
third trimester of pregnancy or in the postpartum patient
Magnesium CI
Hypersensitivity
Myocardial damage
Diabetic coma
Heart block
Hypermagnesemia
Hypocalcemia
Magnesium PP
Magnesium is often supplied in a 50 mL pre-mixed bag containing 2 grams;
Rapid administration can result in HOTN
Sodium Bicarb Adult/Pedi Dose
1 mEq/kg IV/IO to maximum of 50 mEq
Sodium Bicarb Onset, PE, (Duration)
Seconds
<15 mins
(1-2 hours)
Sodium Bicarb Class
Antidote
Sodium Bicarb PA
Increases blood and urinary pH by releasing a bicarbonate ion, which in turn neutralizes hydrogen ion concentrations.
Sodium Bicarb Indications
Consider for the management of cardiotoxicity/ECG changes in the setting of sodium
channel-blocker/unknown poly-pharmaceutical toxicity (i.e. tricyclic antidepressant).
Cardiotoxicity/neurotoxicity secondary to salicylate poisoning.
Sodium Bicarb CI
Hypersensitivity
Severe Pulm. Edema
Known alkalosis
Hypernatremia
Hypocalcemia
Sodium Bicarb PP
Sodium Bicarbonate is not compatible with any medications.
Care should be taken to administer in a separate line from other medications.
If patient has limited access, the line should be flushed thoroughly before and after
administration to prevent deactivation of other medications;
May precipitate in calcium-containing solutions — Flush IV lines thoroughly or use a second
line for concomitant administration with Calcium Chloride.
Diphenhydramine Adult dose
25-50 mg IV/IO/IM/PO
Diphenhydramine Pedi Dose
1 mg/kg IV/IO/IM/PO to maximum of 50 mg
Diphenhydramine Onset, PE, (Duration)
10-15 mins
1 hour
(6-8 hours)
Diphenhydramine Alt ID
Benadryl
Diphenhydramine Class
Antihistamine
Diphenhydramine PA
Histamine H1-receptor antagonist of effector cells in respiratory tract, blood vessels, and GI smooth muscle
Diphenhydramine Indications
For urticarial and/or pruritis in the management of patients suffering from allergic reaction
Diphenhydramine CI
Documented hypersensitivity
Use controversial in lower respiratory tract disease (such as
acute asthma), premature infants and neonates
Diphenhydramine PP
Monoamine Oxidase Inhibitors (MAOI’s) can intensify and prolong the anticholinergic effects
of Diphenhydramine;
In-Hospital you may encounter use of Diphenhydramine in sedation of agitated or violent
patients, as well as treating extrapyramidal symptoms during dystonic reactions.
Furosemide Adult Dose
20-40 mg IV/IO, or;
40-80 mg IV/IO if patient is already on diuretics
Furosemide Onset, PE, (Duration)
<5 mins
<30 mins
(2 hours)
Furosemide Alt ID
Lasix
Furesemide PA
Blocks tubular reabsorption of sodium and chloride in the proximal and distal tubules of
the kidneys, as well as in the thick ascending loop of Henle, resulting in increased excretion of water.
Furosemide Indications
Acute Pulm. Edema IE CHF
Furosemide CI
Hypersensitivity
Anuria
Furosemide PP
It is important to note that Furosemide is not routinely given to all CHF exacerbations in the
field. It is commonly considered the terminal intervention of the treatment pathway provided
only to patients in severe respiratory failure;
CRITICAL — Cardiogenic shock can lead to pulmonary edema. This acute setting is an
absolute contraindication for Furosemide. The patient needs to be suffering pulmonary
edema due to a hypervolemic state caused by a chronic CHF exacerbation or due to renal
failure.
Patients taking Furosemide prescriptions can become hypokalemic
hydrocortisone succinate Adult Dose
100 mg IV/IO/IM
Hydrocortisone Pedi Dose
2 mg/kg IV/IO/IM to max dose of 100 mg.
Hydrocortisone Onset, PE, (Duration)
1 hour
Variable
(8-12 hours)
Hydrocortisone Alt ID’s
Cortef
SoluCortef
Hydrocortisone Class
Corticosteroid
Hydrocortisone PA
Glucocorticoid; elicits mild mineralocorticoid activity and moderate anti-inflammatory
effects
Controls or prevents inflammation by controlling rate of protein synthesis
suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts
Reversing capillary permeability
Hydrocortisone Indications
Preferred for adrenal insufficiency, but may be used in the management of acute
bronchospastic disease and anaphylaxis
Hydrocortisone CI
Untreated serious infections (except tuberculous meningitis or septic shock)
Idiopathic thrombocytopenic purpura
Intrathecal administration (injection)
Documented hypersensitivity
Hydrocortisone PP
Hydrocortisone is preferred over Methylprednisolone in the treatment of adrenal
insufficiency;
These patients require stress-dosing during major medical or traumatic events
Adrenal crisis should be suspected in patients presenting in a shock-like state who have limited or no response to IV fluid resuscitation and/or catecholamine vasopressor therapies.
Methylprednisolone Adult Dose
125 mg IV/IO/IM
Methylprednisolone Pedi Dose
2 mg/kg to maximum of 125 mg IV/IO/IM
Methylprednisolone Onset, PE, (Duration)
1-2 hours
Variable
(8-24 hours)
Methylprednisolone Alt ID’s
Medrol
Medrol Dosepak
SoluMedrol
DepoMedrol
Methylprednisolone Class
Corticosteroid
anti-inflammatory agent
Methylprednisolone PA
Potent glucocorticoid with minimal to no mineralocorticoid activity. Modulates carbohydrate, protein, and lipid metabolism and maintenance of fluid and electrolyte
homeostasis.
Controls or prevents inflammation by controlling rate of protein synthesis
Suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts
Reversing capillary permeability, and stabilizing lysosomes at cellular level.
Methylprednisolone Indications
Preferred for the management of acute bronchospastic disease and anaphylaxis over hydrocortisone, but may be used in adrenal insufficiency.
Methylprednisolone CI
Untreated serious infections, documented hypersensitivity
IM route is contraindicated in
idiopathic thrombocytopenic purpura
Traumatic brain injury (high doses)
Methylprednisolone PP
Methylprednisolone is preferred over Hydrocortisone in the treatment of anaphylaxis,
asthma, and chronic obstructive pulmonary disease (COPD).
Haloperidol Adult Dose
5-10 mg IM only
Haloperidol Onset, PE, (Duration)
10-20 minutes
30-45 minutes
(12-24 hours)
Haloperidol Alt ID’s
Haldol
Peridol
Haloperidol Class
Antipsychotic
Haloperidol PA
Antagonizes dopamine-1 and dopamine-2 receptors in brain; depresses reticular activating
system and inhibits release of hypothalamic and hypophyseal hormones.
Haloperidol Indications
Management of acute psychosis or agitated/violent behavior refractory to nonpharmacologic interventions.
Haloperidol CI
Documented hypersensitivity
Severe CNS depression (including coma)
Neuroleptic malignant syndrome
Poorly controlled seizure disorder Parkinson’s disease
Haloperidol PP
Due to Haloperidol’s prolonged onset time, it is not the ideal intervention to facilitate prehospital sedation, although it can serve well to maintain the sedation.
Hypertonic Saline Adult/Pedi Dose
3 mL/kg (Max of 150 mL) over 15 mins
Hypertonic Saline Onset, PE, (Duration)
Rapid
10 mins
(1 hour)
Hypertonic Saline PA
Hypertonicity causes shift of water from the extravascular space into the intravascular space, reducing intracranial volume, thereby reducing intracranial pressure, and
improving mean arterial pressure by increasing the intravascular volume directly.
Hypertonic Saline Indications
Increased ICP from trauma
Hypertonic Saline PP
Prehospitally Hypertonic Saline is not typically administered until the patient exhibits signs of
tentorial herniation, which is evidenced by Cushing’s Triad —
* Hypertension;
* Bradycardia;
* Disruption of the normal respiratory pattern;
Although indicated for adults as well, Hypertonic Saline is only routinely given to pediatric
patients in the prehospital environment.
Ketamine Adult/pedi Dose
Agitated or Violent Behavior
4 mg/kg IM only
Induction Agent for MAI
1-2 mg/kg IV/IO
Post-Intubation Sedation/Analgesia
1-2 mg/kg (max dose = 100 mg), may repeat at half the initial dose every 5-10
minutes to a maximum total dose of 200 mg
Analgesia
Non-Intubated Patient — 0.15 mg/kg slow IV/IO push,
may repeat dose one time in 20 mins
Ketamine Onset, PE, (duration)
30-60 seconds
<5 mins
(10-15 mins)
Ketamine Class
General anesthetics
analgesic
Ketamine PA
Produces dissociative anesthesia. Blocks N-methyl D-aspartate (NMDA) receptor. Causes dose
dependent sympathetic nervous system outflow. Also reduces pain impulses by binding to opioid
receptors.
Ketamine Indications
Agitated/violent behavior.
Sedation management in MAI
Ketamine CI
Hypersensitivity
RELATIVE/CONTROVERSIAL CONTRAINDICATIONS: Acute coronary syndrome
Aortic dissection/aneurysm
Head trauma
Intracranial mass/hemorrhage Hypertension, angina, and stroke
Underlying psychiatric disorder. Pediatrics < 28 days of age.
Ketamine PP
WARNING: Overdose may lead to panic attacks and aggressive behavior; rarely seizures,
increased ICP, and cardiac arrest;
Very similar in chemical makeup to PCP (phencyclidine), but it is shorter acting and less toxic;
Ketamine may cause hypotension in critically-ill patients, due to the depletion of endogenous
catecholamines and exhaustion of sympathetic compensatory mechanisms;
When Ketamine is supplied in high concentrations, dilution can make administration safer (i.e.
dilute 200 mg of Ketamine in 20 mL of normal saline to attain a 10 mg/mL concentration)
Ketorolac Adult Dose
15 mg IV, or;
30 mg IM
Ketorolac Pedi Dose
0.5 mg/kg IV/IM (maximum of 15 mg)
Ketorolac Onset, PE, (Duration)
10 mins
1-2 hours
(2-6 hours)
Ketorolac Alt ID
Toradol
Ketorolac Class
Non-steroidal anti-inflammatory drug (NSAID)
Ketorolac PA
Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase (COX) isoenzymes, COX-1 and COX-2.
May inhibit chemotaxis, alter lymphocyte activity
Decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation;
these effects may contribute to anti-inflammatory activity.
Ketorolac Indications
Acute pain
Ketorolac CI
Allergy to aspirin, ketorolac, or other NSAIDS
Women who are in active labor or are breastfeeding
Significant renal impairment particularly when associated with volume depletion
Previous or current GI bleeding Intracranial bleeding
Coagulation defects
Patients with a high-risk of bleeding
Ketorolac PP
Ketorolac is commonly used in the pre-hospital setting as an alternative (or primary
treatment) for patients suffering from musculoskeletal injuries and for those with known/
suspected kidney stones;
Ketorolac should be used with caution in any patient suffering active hemorrhage or those
who may undergo a surgical procedure for their illness/injury
Lorazepam Adult Dose
2-4 mg IV/IO
Lorazepam Pedi Dose
0.1 mg/kg IV/IO to Max of 4 mg
Lorazepam Onset, PE, (Duration)
2-5 mins
<15 mins
(6-8 hours)
Lorazepam Alt ID
Ativan
Lorazepam Class
Anticonvulsants
antianxiety agent
anxiolytics
benzodiazepines
Lorazepam PA
Sedative hypnotic with short onset of effects and relatively long half-life; by increasing the
action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter
in the brain
Lorazepam may depress all levels of the CNS, including limbic and reticular formation
Lorazepam Indications
Management of seizures
Uncontrolled shivering in hypothermia
Management of agitated or violent patients suffering behavioral emergencies.
Lorazepam CI
Documented hypersensitivity
Acute narrow angle glaucoma
Severe respiratory
depression
Sleep apnea
Lorazepam PP
IM Lorazepam has a longer onset (15-30 minutes) and peak effect (2-3 hours) than IV Lorazepam;
As with all benzodiazepines, after administration monitor the patient closely for potential hypotension and/or respiratory depression.
Midazolam Adult/Pedi Dose
Seizures- 0.1 mg/kg IV/IO/IM to maximum of 8 mg
0.2 mg/kg IN when IV access is unavailable to maximum
of 10 mg
Agitated or Violent Behavior, Procedural Sedation
0.1 mg/kg IV/IO/IM/IN to maximum dose of 6 mg
Midazolam Onset, PE, (Duration)
Immediate
3-5 mins
<2 hours
Midazolam Alt ID
Versed
Midazolam Class
Anticonvulsants
Anti-anxiety agent
anxiolytics
benzodiazepines
Midazolam PA
Binds receptors at several sites within the CNS, including the limbic system and reticular
formation
Effects may be mediated through gamma-aminobutyric acid (GABA) receptor system
Increase in neuronal membrane permeability to chloride ions enhances the inhibitory effects of GABA;
The shift in chloride ions causes hyper-polarization (less
excitability) and stabilization of the neuronal membrane
Midazolam Indications
management of seizures
The management of agitated or violent patients suffering
behavioral emergencies
Procedural sedation in intubation and electrical therapy
Midazolam CI
Documented hypersensitivity
Severe respiratory depression
Sleep apnea
Morphine Adult Dose
0.1 mg/kg IV/IO/IM to maximum dose of 10 mg
Morphine Pedi Dose
0.1 mg/kg IV/IO/IM to maximum dose of 5 mg
Morphine Onset, PE, (Duration)
Immediate
20 mins
(2-4 hours)
Morphine Class
Opioid Analgesic
Morphine PA
Narcotic agonist-analgesic of opiate receptors
Inhibits ascending pain pathways, thus altering response to pain
Produces analgesia, respiratory depression, and sedation
Suppresses cough by acting centrally in medulla.
Morphine Indications
Acute pain
Morphine CI
Hypersensitivity
Paralytic ileus
Toxin-mediated diarrhea
Respiratory depression
Acute or severe bronchial asthma
Upper airway obstruction
GI obstruction (extended release)
Hypercarbia (immediate release tablets/solution)
Upper airway obstruction (epidural/
intrathecal)
Heart failure due to chronic lung disease
Head injuries
Brain tumors
Delirium
Tremens
Seizure disorders
During labor when premature birth anticipated (injectable
formulation)
Cardiac arrhythmia
Increased intracranial or cerebrospinal pressure
Acute alcoholism
Use after biliary tract surgery
Surgical anastomosis (suppository formulation)
Morphine PP
Morphine should be used with caution in patients with or those at risk for HOTN
Morphine can cause dose dependent histamine release, leading to consequent
vasodilation and HOTN
Ondansetron Adult Dose
4 mg IV/IO/IM/IN/PO
Ondansetron Pedi Dose
< 25 kg: 2 mg IV/IO/IM/IN/PO
≥ 25 kg: Use adult dosing — 4 mg
Ondansetron Onset, PE, (Duration)
10 mins
30 mins
(3-6 hours)
Ondansetron Alt ID
Zofran
Ondansetron Class
Antiemetic
Selective 5-HT3 antagonist
Ondansetron PA
Mechanism not fully characterized; selective 5-HT3 receptor antagonist; binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract.
Has no effect on dopamine receptors and therefore does not cause extrapyramidal symptoms
Ondansetron Indications
Nausea/vomit
Ondansetron CI
Hypersensitivity
Coadministration with apomorphine; combination reported to cause profound HOTN and LOC
Ondansetron PP
WARNING: Some studies suggest dose-dependent QT prolongation (studied single dose of
16 mg - which is pretty high comparatively to normal prehospital dosing).
Avoid in patients with congenital long QT syndrome.
EKG monitoring is recommended in patients who have electrolyte abnormalities
CHF or bradyarrhythmia or who are also receiving other medications that cause QT prolongation.
Dextrose Adult Dose
12.5-25 gms IV/IO of D10 (may also give D50)
Dextrose Pedi Dose
0.5 gm/kg IV/IO of Dextrose 10%
Dextrose Onset, PE, (Duration)
<1 minute
Variable
(Variable)
Dextrose Class
Glucose elevating agents
Dextrose PA
Parenteral dextrose is oxidized to carbon dioxide and water, and provides 3.4 kilocalories/gram of d-glucose, increasing blood serum glucose levels
Dextrose Indications
Hypoglycemia
Dextrose CI
Hyperglycemia
Anuria
Intracranial or intraspinal hemorrhage
Dehydrated patients with
delirium
Glucose-galactose malabsorption syndrome
Documented hypersensitivity
Dextrose PP
D-50 (osmolarity of 2500 mOsm/L) is a potent vesicant and will result in severe local tissue necrosis if extravasation occurs;
D-10 (osmolarity of 500 mOsm/L) is much less likely to cause necrosis;
D-50 interrupts gluconeogenesis and glycogenolysis, and causes a rapid spike in serum insulin
resulting in rebound hypoglycemia. Administration should be followed by oral intake of complex carbohydrates in appropriate patients.
D-10 does mildly increase serum insulin levels but does not interrupt gluconeogenesis and glycogenolysis nor does it cause rebound hypoglycemia— The same oral intake of complex
carbohydrates should be considered however, as a best practice.
Activated Charcoal Adult/Pedi Dose
1 gm/kg PO w/in hour of ingestion.
Activated Charcoal Onset, PE, (Duration)
Immediate
Variable
Until Excreted
Activated Charcoal Class
Antidotes
Activated Charcoal PA
Adsorbs a variety of drugs and chemicals (e.g., physical binding of a molecule to the
surface of charcoal particles). Desorption of bound particles may occur unless the ratio of
charcoal to toxin is extremely high.
Activated Charcoal Indications
Overdose/Poison related to ingestion.
Activated charcoal CI
Unprotected airway (beware of aspiration)
Caustic ingestions
Intestinal obstruction.
Activated Charcoal PP
Some ingestions can benefit from activated charcoal, however some do not. Poison Control
& Medical Control should be contacted when dealing with acute toxicities;
* Boston Children’s Hospital Regional Poison Control Phone #(800) 222-1222.
Hydroxocobalamin Adult Dose
5 gms IV/IO over 15 mins (mixed in 200mL Saline)
Hydroxocobalamin Pedi Dose
70 mg/kg IV/IO over 15 mins (reconstituted concentration must not exceed 25 mg/mL
Hydroxocobalamin Onset, PE, (Duration)
Rapid
8-10 mins
(Variable)
Hydroxocobalamin Alt ID
Cyanokit
Hydroxocobalamin Class
Cyanide Antidote
Hydroxocobalamin PA
Vitamin B12 with hydroxyl group complexed to cobalt which can be displaced by cyanide resulting in cyanocobalamin that is renally excreted.
Hydroxocobalamin Indications
Cyanide toxicity
hydroxocobalamin CI
Hypersensitivity
Hydroxocobalamin PP
WARNING: Will cause discoloration of the skin and urine, and can interfere with pulse oximetry.
Due to its interference with certain diagnostic blood tests, the performance of prehospital phlebotomy is preferable prior to the administration of hydroxocobalamin.
The kit comes with a vented drip set that must be used since the Hydroxocobalamin is reconstituted in a rigid glass container.
This drip set does not have any med-administration ports — use of a three-way stopcock is strongly advised.
Naloxone Adult Dose
0.4-2 mg IV/IO/IM/IN to maximum total dose of 10 mg
Naloxone Pedi Dose
0.1 mg/kg IV/IO/IM/IN to maximum of 2 mg per individual dose (maximum total dose of 10 mg)
Naloxone Onset, PE, (Duration)
<2 minutes
<2 minutes
(20-120 mins)
Naloxone Alt ID
Narcan
Naloxone Class
Opioid reversal agent
Naloxone PA
Competitive opioid antagonist; synthetic congener of oxymorphone
Naloxone Indications
Suspected opioid toxicity
Naloxone CI
Hypersensitivity
Naloxone PP
WARNING: Administration of naloxone can result in the sudden onset of opiate withdrawal
(agitation, tachycardia, pulmonary edema, nausea, vomiting, and, in neonates, seizures).
IM/IN Naloxone has a longer onset (2-10 minutes) and peak effect (2-10 minutes) than IV Naloxone.
Pralidoxime Chloride Adult Dose
Mild Symptoms — 1 DuoDote Kit IM
Moderate Symptoms — 2 DuoDote Kits IM
Severe Symptoms — 3 DuoDote Kits IMP
Pralidoxime Pedi Dose
- For Severe Symptoms, when no vials or Pediatric Atropens
are available: - 13-25 kg — 1 DuoDote Kit IM
- 25-50 kg — 2 DuoDote Kits IM
- > 51 kg — 3 DuoDote Kits IM
Pralidoxime Chloride Onset, PE, (Duration)
1-2 mins
10-20 mins
(Variable)
Pralidoxime Chloride Class
Cholinergic
Toxicity antidote
Pralidoxime Chloride PA
Binds to organophosphates and breaks alkyl phosphate-cholinesterase bond to restore
activity of acetylcholinesterase.
Pralidoxime Indications
Management of toxicity caused by organophosphate insecticides and related nerve gases (e.g., tabun, sarin, soman).
Pralidoxime Chloride CI
Hypersensitivity
Pralidoxime Chloride PP
CAUTION: Refer to local protocols regarding Pediatric dosing of Atropine and Pralidoxime
Chloride.
Some EMS systems may have vials of medication for weight based dosing.
Other systems may use Pediatric Atropens and/or Adult DuoDote Kits.
An adult DuoDote kit contains 2.1 mg Atropine and 600 mg Pralidoxime Chloride
Labetalol Adult Dose
10 mg IV over 2 minutes
May repeat or double dose every 10 minutes to a maximum total dose of 150 mg.
Labetalol Onset, PE, (Duration)
2-5 mins
5-15 mins
(4 hours)
Labetalol Class
B-Blockers
a activity
Labetalol PA
Nonselective β-blocker with intrinsic sympathomimetic activity.
⍺-blocker.
Labetalol Indications
Severe hypertension with pre-eclampsia symptoms
Labetalol CI
Asthma/COPD
Severe bradycardia
cardiogenic shock
Cardiac failure
Hypersensitivity
Sick Sinus syndrome
Severe HOTN
Racemic Epinephrine Pedi Dose
- 11.25 mg in 2.5 mL normal saline via nebulizer repeated every 20 minutes as needed
Racemic Epinephrine Onset, PE, (Duration)
<10 mins
10-30 mins
(2-4 mins)
Racemic Epinephrine Class
a and b- adrenergic receptor agonist
Racemic Epinephrine PA
Causes smooth muscle relaxation due to direct vasoconstriction, alleviating swelling, and
bronchospasm.
Racemic Epinephrine Indications
Suspected non-foreign body upper airway obstruction (i.e. croup)
Racemic Epinephrine CI
Suspected epiglottitis
Racemic Epinephrine PP
The higher the flow rate (normal is 4-8 lpm) on a nebulizer the faster the medication will be delivered, and therefore run out. Higher flow rates can promote more prompt improvement, or increase the patient’s SPO2.
Always try to use a nebulizer mask when delivering nebulized medications, as it ensures the
medication is continuously delivered and enables use of both the patient’s arms as compared to the T-piece “pipe style” nebulizer setup.
This may be challenging in pediatric patients, so also consider blow-by nebulization from the top of the nebulizer with no mask or T-piece.
Tranexamic Acid Adult Dose
1 gm over 10 minutes (mix TXA in 100 mL of Normal Saline)
Tranexamic Acid Pedi Dose
If > 5 years of age: 15 mg/kg to maximum dose of 1 gm, over 10 minutes (mix TXA in 100 mL of Normal Saline)
Tranexamic Acid Onset, PE, (Duration)
5-15 mins
Unknown
(7-8 hours)
Tranexamic Acid Alt ID’s
TXA
Cyklokapron
Tranexamic Acid Class
Anti-fibronolytic
Tranexamic Acid PA
Reversibly binds to receptor sites on plasminogen, preventing its conversion to plasmin and maintaining clot stability.
Plasmin is responsible for binding to and degrading fibrin, which is responsible for stabilizing and preserving the meshwork of existing clots.
Tranexamic Acid Indications
Suspected non-compressible hemorrhage, in the setting of trauma, when the onset of
injury is known to be < 3 hours.
Tranexamic Acid CI
Hypersensitivity, > 3 hours since onset of injury (or unknown time of injury)
Tranexamic Acid PP
It is important to note that TXA is indicated for non-compressible hemorrhage.
Therefore, if hemorrhage has been controlled it is not given indiscriminately for previous
blood loss.
Etomidate Adult Dose
0.3 mg/kg IV/IO push
0.2 mg/kg (For patients that are hypotensive or > 65 y/o)
Etomidate Pedi Dose
0.3 mg/kg IV/IO push if > 10 years of age
Etomidate Onset, PE, (Duration)
30-60 seconds
1 min
(5-10 mins)
Etomidate Class
Sedative/hypnotic agent
Etomidate PA
Binds to the chloride ionophore on GABA receptors, increasing duration of time the chloride channel is open, leading to prolonged inhibitory effect of GABA.
Etomidate Indications
Induction agent in medication assisted intubation (MAI)
Etomidate CI
Hypersensitivity
HOTN associated with sepsis in pediatrics less than 10 years of
age.
Use with caution in patients with suspected or confirmed adrenal supression.
Etomidate PP
During MAI Etomidate should be paired with Fentanyl at 1 mcg/kg.
Etomidate is only a sedative, so the patient should also receive analgesia.
Rocuronium Adult/Pedi Dose
1.5 mg/kg IV/IO/IM
Rocuronium Onset, PE, (Duration)
45-60 seconds
1-3 mins
(30-60 mins)
Rocuronium Class
Non-depolarizing neuromuscular blocker
Rocuronium PA
Competes for nicotinic cholinergic receptors at the motor end plate, resulting in decreased opportunity for acetylcholine to bind, resulting in a prevention of depolarization and a lack of muscle contraction (paralysis)
Rocuronium Indications
Skeletal muscle relaxation to facilitate endotracheal intubation in medication assisted intubation (MAI).
Rocuronium CI
Hypersensitivity
Succinylcholine Adult Dose
1.5-2 mg/kg IV/IO (if administered IM; dose should be doubled)
Succinylcholine Pedi Dose
2mg/kg IV/IO (if administered IM; dose should be doubled)
Succinylcholine Onset, PE, (Duration)
45-60 seconds
1-3 mins
(4-6 mins)
Succinylcholine Class
Depolarizing neuromuscular blocker
Succinylcholine PA
Competes for nicotinic cholinergic receptors at the motor end plate, resulting in decreased opportunity for acetylcholine to bind, initially causing depolarization (fasciculations) and eventually resulting in a prevention of further depolarization and paralysis.
Succinylcholine Indications
Skeletal muscle relaxation to facilitate endotracheal intubation in medication assisted intubation (MAI)
Succinylcholine CI
Hypersensitivity
Hyperkalemia
Disorders of Plasma Pseudocholinesterase
Known Neuromuscular Disease
