Thursday, May 14, 2020

HEALTH- DRUGS FOR EMERGENCY

HEALTH- DRUGS FOR EMERGENCY
Acetylcysteine - Mucomyst

MOA:
replenishes glutathione stores, serves as glutathione substitute, and enhances sulfate conjugation of acetaminophen (Tylenol).

PO Dose:
140 mg/kg x 1, then 70 mg/kg q 4 hours x 17 doses (72 hours total).

IV Dose:
150 mg/kg in 200ml D5W over 1 hour, 50 mg/kg in 500ml D5W over 4 hours, 100 mg/kg in 1 liter D5W over 16 hours (21 total hours, may need to continue until LFTs and APAP level normalize).

Emergent Indications:
acetaminophen (Tylenol) overdose.

Where you’ll get in Trouble:
hypersensitivity reaction (stop infusion, switch to PO or slow infusion rate), while rare, you can also see hypersensitivity with PO as well, Preg B.


Adenosine - Adenocard/Adenoscan

MOA:
acts on A1 receptors in AV node causing temporary heart block.

Dose:
6mg IV RAPID push, may give 12mg IV q 2 minutes if no effect x2.

Emergent Indications:
stable SVT, stable narrow complex tachycardias.

Where you’ll get in Trouble:
prodysrhythmic, do not give in preexisting 2nd or 3rd degree block, Preg C.


Albuterol - Proventil, ProAir, Ventolin

MOA:
selective beta2 agonist.

Dose:
2.5 - 5 mg q 20 minutes for 1st hour, then 2.5-10 mg q 1-4 hours prn (alt, 10-15 mg over 1 hour).

Emergent Indications:
acute bronchospasm, hyperkalemia.

Where you’ll get in Trouble:
tachycardia, hyperglycemia, hypokalemia, Preg C.


Amiodarone - Pacerone

MOA:
blocks K efflux (Class III antidysrhythmic); also has Na channel blocking (class I), beta blocking (class II), and Ca channel blocking (class IV) properties.

Dose:
Pulseless VF/VT: 300mg IV rapid push followed by 150mg IV rapid push if necessary at next pulse check
Stable wide complex tachycardias: 150mg IV over 10 minutes, followed by infusion of 1mg/min x 6hours, then 0.5 mg/min thereafter.

Emergent Indications:
pulseless VF/VT, Wide complex tachydysrhythmias.

Where you’ll get in Trouble:
Causes hypotension, prodysrhythmic, Preg D.

Atropine - AtroPen

MOA:
direct anticholinergic.

Dose:
Organophosphate/carbamate toxicity: 1-6 mg IV q 3-5 minutes PRN, until dry secretions (can double dose each time until adequate response achieved)
Peds Bradycardia: 0.02 mg/kg IVx1; 0.5 mg maximum single dose; 1 mg max cumulative dose
Adult bradycardia: 0.5 mg IV, 3 mg max cumulative dose.

Emergent Indications:
Organophosphate/carbamate toxicity, bradycardia.

Where you’ll get in Trouble:
hyperthermic patients, tachydysrhythmias, Preg C.


Calcium Gluconate/Chloride

MOA:
increases serum calcium, stabilizes cardiac myocytes.

Dose:
10% IV solution (gluconate or chloride) contains 1 gram per 10 mL.

Emergent Indications:
hyperkalemia, hypocalcemia with dysrhythmia.

Where you’ll get in Trouble:
dysrhythmia, tetany, calcium chloride 3x more potent than calcium gluconate (severe phlebitis with peripheral administration of calcium chloride), Preg C.

Diazepam - Valium

MOA:
enhances inhibitory effects of GABA.

Dose:
2-10 mg PO/IV/IM q 6 hours PRN.

Emergent Indications:
Seizure abortion, alcohol withdrawal, agitation, muscle spasm.

Where you’ll get in Trouble:
respiratory depression, hypotension, Preg D.

Diltiazem - Cardizem

MOA:
inhibits calcium influx in myocardium > vascular smooth muscle; prolongs AV nodal conduction.

Dose:
0.25 mg/kg IV x1; may give 0.35 mg/kg IV x1 after 15 minutes; continuous infusion 5-15 mg/hr.

Emergent Indications:
stable Afib with RVR, stable SVT.

Where you’ll get in Trouble:
iatrogenic hypotension, bradycardia, Preg C.


Dobutamine

MOA:
beta1 agonist > beta2 agonist.

Dose:
2-20mcg/kg/min IV.

Emergent Indications:
decompensated heart failure, refractory hypotension.

Where you’ll get in Trouble:
tachycardia, hypotension if not euvolemic, PVCs, Preg B.

Dopamine

MOA:
alpha1, beta1, and dopaminergic agonist.

Dose:
< 5 mcg/kg/min IV dopaminergic effects (not recommended)
5-10 mcg/kg/min IV primarily beta effects
10-20 mcg/kg/min IV primarily alpha effects.

Emergent Indications:
decompensated heart failure, hypotension.

Where you’ll get in Trouble:
tachydysrhythmias, tissue necrosis if extravasation or arterial administration therefore needs to be given through central venous line, Preg C.

Droperidol - Inapsine

MOA:
antagonizes dopamine and alpha adrenergic receptors.

Dose:
1.25 - 2.5mg IV q 4 hours PRN.

Emergent Indications:
vomiting prevention, migraine abortion.

Where you’ll get in Trouble:
QT prolongation (Torsades), NMS, extrapyramidal side effects, Preg C.

Epinephrine - EpiPen, Adrenalin

MOA:
alpha and beta receptor agonist.

Dose:
ACLS: 1 mg 1:10,000 IV PALS: 0.01 mg/kg 1:10,000 IV
Anaphylaxis: 0.1-0.5 mg 1:1,000 IM/SQ (IM preferred)
Peds anaphylaxis/asthma: 0.01 mg/kg 1:1,000 IM/SQ (max single dose 0.3 mg)
Hypotension refractory to IVF: 1-10 mcg/min IV.

Emergent Indications:
anaphylaxis, ACLS arrest, PALS/NRP arrest, severe asthma.

Where you’ll get in Trouble:
dosing errors (10 fold errors), tissue necrosis (needs to administered via central venous line), dysrhythmias, Preg C.

Enoxaparin - Lovenox

MOA:
binds to antithrombin III and inactivates factor Xa > thrombin.

Dose:
1 mg/kg SQ q 12hours OR 1.5 mg/kg SQ q 24hours.

Emergent Indications:
PE, NSTEMI, unstable angina.

Where you’ll get in Trouble:
monitor anti Xa levels in renal impairment or obesity (> 150 kg actual body weight), concomitant use with spinal anesthesia/analgesia or spinal puncture is an absolute contraindication (black box warning), Preg B.

Esmolol - Brevibloc

MOA:
selective beta1 antagonist.

Dose:
500 mcg/kg loading dose, then continuous infusion of 50-300 mcg/kg/min.

Emergent Indications:
aortic dissection.

Where you’ll get in Trouble:
precipitated CHF, hypotension, bronchospasm, Preg C.


Esomeprazole - Nexium

MOA:
inhibits parietal cell hydrogen-potassium ATPase (PPI).

Dose:
80 mg IV bolus followed by 8 mg/hour.

Emergent Indications:
Upper GI bleed (non-variceal).

Where you’ll get in Trouble:
fairly benign when used acutely, Preg B.

Etomidate - Amidate

MOA:
GABA-like effects on brain stem reticular formation causing hypnosis.

Dose:
0.3 mg/kg IV.

Emergent Indications:
RSI induction.

Where you’ll get in Trouble:
cortisol depression (questionable clinical significance for single administration), lowers seizure threshold, Preg C.

Fosphenytoin - Cerebyx

MOA:
stabilizes voltage dependent neuronal Na channels to stop seizure activity.

Dose:
15-20 mg/kg IV loading dose administered at 150 mg/min.

Emergent Indications:
status epilepticus.

Where you’ll get in Trouble:
rapid administration can cause hypotension or dysrhythmias, give with patient on monitor, Preg D.


Furosemide - Lasix

MOA:
inhibits Na and Cl reabsorption in distal renal tubule and ascending loop of Henle.

Dose:
usual dose in ED 20-40 mg IV, reassess, increase to desired effect (maximum single dose 200mg).

Emergent Indications:
pulmonary edema, CHF exacerbation, hyperkalemia (if making urine).

Where you’ll get in Trouble:
volume depletion, hypokalemia, metabolic alkalosis, ototoxicity, Preg C.

Glucagon - GlucaGen

MOA:
stimulates cAMP production independent of beta receptor, increases gluconeogenesis and glycogenolysis.

Dose:
Beta-blocker/Ca channel blocker toxicity: 3-10 mg IV loading dose, then 1-10 mg/hour IV continuous infusion if responsive to loading dose
Hypoglycemia: 1 mg IV/SQ/IM.

Emergent Indications:
beta-blocker toxicity, Ca channel blocker toxicity, hypoglycemia.

Where you’ll get in Trouble:
anaphylactoid reaction, can cause hypotension, emesis (aspiration risk in altered patient), Preg B.

Haloperidol - Haldol

MOA:
Antagonist at D1 and D2 receptors.

Dose:
5-10 mg PO/IM/IV q 2 hours (max 100 mg/day).

Emergent Indications:
agitation, psychosis.

Where you’ll get in Trouble:
do not give for dementia-related psychosis, NMS, EPS, QT prolongation, Preg C.

Heparin

MOA:
binds to antithrombin III thereby potentiating inactivation of thrombin and factors IX, Xa, XI, XII; prevents fibrinogen → fibrin; preferential inactivation of thrombin over other clotting factors.

Dose:
Venous thromboembolism: 80 units/kg IV x 1, then 18 units/kg/hour
ACS or Afib: 60 units/kg IV x 1, then 12 units/kg/hr.

Emergent Indications:
thromboembolism; ACS (enoxaparin preferred for NSTEMI).

Where you’ll get in Trouble:
bleeding (protamine may be given for reversal), dosing errors, Preg C.

Hydrocortisone - SoluCortef

MOA:
produces multiple gluco and mineralocorticoid effects.

Dose:
Adrenal insufficiency: 100mg IV bolus, then 50 mg IV q 6 hours x24 hours followed by a taper
Septic shock: 50 mg IV q 6 hours
Status asthmaticus: 1-2 mg/kg IV q 6 hours x24 hours followed by a maintenance regimen.

Emergent Indications:
acute adrenal insufficiency, status asthmaticus, vasopressor refractory septic shock.

Where you’ll get in Trouble:
immunosuppression, hyperglycemia, Preg C.


Hydromorphone - Dilaudid

MOA:
opioid agonist producing analgesia with adjunctive sedative effects.

Dose:
1-2 mg IV q 3-6 hours.

Emergent Indications:
Analgesia.

Where you’ll get in Trouble:
Respiratory depression, vasodilation (hypotension), 1 mg of IV Dilaudid is approximately equal to 7 mg of IV morphine, Preg C.


Insulin Regular

MOA:
↑ peripheral glucose uptake, increased inotropy, shifts potassium intracellularly.

Dose:
Hyperkalemia: 5-10 units IV x 1
CCB overdose: 1 unit/kg bolus given with 25 grams of dextrose if initial BG
< 250 mg/dL; then initiate insulin drip at 0.1 – 1 unit/kg/hr titrated to SBP along with 0.5 g/kg/hr of dextrose titrated to maintain BG 100 – 200 mg/dL
DKA/HHS: 0.1 unit/kg bolus followed by continuous infusion 0.1 unit/kg/hour.

Emergent Indications:
hyperkalemia, DKA/HHS, CCB overdose.

Where you’ll get in Trouble:
hypokalemia, hypoglycemia, only regular insulin can be given IV, Preg B.

Ketamine - Ketalar

MOA:
Acts on cortex and limbic system, NMDA receptor antagonist.

Dose:
Subdissociative: 0.1-0.5 mg/kg IV
Procedural sedation: 0.5-1 mg/kg IV
RSI induction: 2 mg/kg IV.

Emergent Indications:
analgesia, sedation, RSI induction.

Where you’ll get in Trouble:
emergence reactions (treat with benzos or barbs), laryngospasm, IOP increase, ICP increase, tachycardia, hypertension, Preg D.


Labetolol - Trandate

MOA:
alpha1, beta1, and beta2 antagonist.

Dose:
Bolus dose: 20-80 mg IV q 10 minutes PRN
Continuous infusion: 1-8 mg/min titrated to effect.

Emergent Indications:
hypertensive emergency.

Where you’ll get in Trouble:
precipitated CHF, bradycardia, bronchospasm, Preg C.


Labetolol - Trandate

MOA:
alpha1, beta1, and beta2 antagonist.

Dose:
Bolus dose: 20-80 mg IV q 10 minutes PRN
Continuous infusion: 1-8 mg/min titrated to effect.

Emergent Indications:
hypertensive emergency.

Where you’ll get in Trouble:
precipitated CHF, bradycardia, bronchospasm, Preg C.


Magnesium Sulfate

MOA:
participates in physiologic processes.

Dose:
Eclampsia: 2-4 grams IV over 5 minutes
Pulseless torsades: 2 grams IV push
Asthma exacerbation: 2 grams over 15 minutes.

Emergent Indications:
torsades, ventricular dysrhythmias, eclampsia, status asthmaticus.

Where you’ll get in Trouble:
respiratory depression, hypotension, Preg A.



Mannitol - Osmitrol

MOA:
osmotic diuretic.

Dose:
1 gram/kg IV x 1.

Emergent Indications:
elevated ICP, impending herniation.

Where you’ll get in Trouble:
may cause dehydration, osmotic nephrosis.


Methohexital - Brevital

MOA:
produces cortical and cerebellar sedation, hypnosis (ultra short-acting barbiturate).

Dose:
1mg/kg IV, then 0.5 mg/kg q 2-5 minutes PRN.

Emergent Indications:
procedural sedation.

Where you’ll get in Trouble:
laryngospasm (give more brevital), respiratory depression, hypotension, Preg B.


Methylprednisolone - SoluMedrol

MOA:
multiple gluco and mineralocorticoid effects.

Dose:
Asthma: 1mg/kg IV
Hypersensitivity reaction: 1 mg/kg IV
PCP PNA: 30mg IV BID x 5 days followed by a gradual taper.

Emergent Indications:
severe asthma, PCP PNA with elevated A-a gradient or PaO2 < 70 mmHg, acute hypersensitivity reaction.

Where you’ll get in Trouble:
immunosuppresion, hyperglycemia, Preg C.


Metoclopramide - Reglan

MOA:
antagonizes dopamine receptors in the chemoreceptor trigger zone.

Dose:
10 mg IV q 6 hours PRN.

Emergent Indications:
vomiting prevention and treatment.

Where you’ll get in Trouble:
tardive dyskinesia, extrapyramidal symptoms, dystonia, methemoglobinemia, Preg B.


Midazolam - Versed

MOA:
enhances inhibitory effects of GABA.

Dose:
RSI induction: 0.1 mg/kg IV
Usual continuous infusion: 1-10 mg/hour
Procedural Sedation: 0.02 - 0.04 mg/kg IV.

Emergent Indications:
seizure abortion, procedural sedation, ventilator sedation, RSI.

Where you’ll get in Trouble:
respiratory depression, hypotensive effects, Preg D.


Morphine sulfate

MOA:
opioid agonist producing analgesia with adjunctive sedative effects.

Dose:
2-10 mg IV q 2-6 hours PRN; recommended dose 0.1 mg/kg IV.

Emergent Indications:
pain control.

Where you’ll get in Trouble:
respiratory depression, vasodilation (hypotension), Preg C.


Nimodipine - Nimotop

MOA:
Ca channel blocker that is selective for cerebral arteries.

Dose:
60 mg PO qh4.

Emergent Indications:
SAH.

Where you’ll get in Trouble:
hypotension although this is minimized due to its selectivity, Preg C.


Nitroprusside - Nipride

MOA:
direct vasodilator, breaks down to release NO.

Dose:
Initiate at 0.3 mcg/kg/min IV and titrate to effect; maximum dose 10 mcg/kg/min; if blood pressure not controlled after 10 minutes at max dose, nitroprusside should be discontinued.

Emergent Indications:
hypertensive emergency.

Where you’ll get in Trouble:
CN toxicity, methemoglobinemia, hypotension, Preg C.


Norepinephrine - Levophed

MOA:
alpha1 agonist > beta1 agonist.

Dose:
1-30 mcg/min IV.

Emergent Indications:
hypotension refractory to IVF.

Where you’ll get in Trouble:
tachydysrhythmias, tissue necrosis if catheter infiltrates or administered through an arterial line therefore needs to be given via a central venous line, Preg C.


Octreotide - Sandostatin

MOA:
vasoconstricts vessels (more selective for GI vessels), reduces portal vessel pressure.

Dose:
Bleeding esophageal varices: 50 mcg IV bolus, then 50 mcg/hour IV
Sulfonylurea toxicity: 50 mcg SQ q 6 hours PRN.

Emergent Indications:
bleeding esophageal varices, sulfonlyurea overdose.

Where you’ll get in Trouble:
Precipitated biliary dz, Preg B.


Olanzapine – Zyprexa

MOA:
antagonizes dopamine, histamine, alpha1, and 5HT2 receptors.

Dose:
5-10mg IM/ODT (max 30mg/day).

Emergent Indications:
agitation, psychosis.

Where you’ll get in Trouble:
do not give for dementia-related psychosis, NMS, EPS, orthostatic hypotension, QT prolongation, not to be given IV, Preg C.


Ondansetron - Zofran

MOA:
antagonizes serotonin 5-HT3 receptors, centrally acting antiemetic.

Dose:
usual dose 4-8 mg IV q 4-6 hours PRN.

Emergent Indications:
vomiting prevention and treatment.

Where you’ll get in Trouble:
QT prolongation, torsades (rare), Preg B.


Phenobarbital

MOA:
barbiturate, causes sedation, hypnosis and anesthesia.

Dose:
20 mg/kg IV x 1, may repeat with an additional 5-10 mg/kg dose in 20 minutes (max dose 30 mg/kg); max infusion rate 50 mg/min.

Emergent Indications:
status epilepticus.

Where you’ll get in Trouble:
respiratory depression, hypotension, Preg D.


Prednisone

MOA:
produces various gluco and mineralocorticoid effects.

Dose:
1 mg/kg/day PO (usual dose 5-60 mg based on patient response).

Emergent Indications:
Asthma exacerbation, PCP PNA with A-a gradient >35 or PaO2 < 70mmHg, allergic reaction.

Where you’ll get in Trouble:
immunosuppresion, GI ulceration/perforation, hyperglycemia, Preg C.


Propofol - Diprivan

MOA:
GABAa agonist, Na channel blocker.

Dose:
Procedural Sedation: 1 mg/kg IV bolus then 0.5 mg/kg q 3 minutes to effect
RSI induction: 1.5-2.5 mg/kg IV x 1
Ventilator Sedation: 5-50 mcg/kg/min).

Emergent Indications:
procedural sedation, RSI induction, ventilator sedation.

Where you’ll get in Trouble:
hypotension, anaphylaxis, bradycardia, apnea, Preg B.

Protamine sulfate

MOA:
ionically binds heparin.

Dose:
1 mg neutralizes 100 units of heparin (max dose 50 mg); administer at a rate of 5 mg/minute.

Emergent Indications:
heparin induced bleeding.

Where you’ll get in Trouble:
anaphylaxis in previous use or fish allergy, rapid infusion can cause hypotension, Preg C.


Rocuronium

MOA:
non-depolarizing neuromuscular agent.

Dose:
1mg/kg IV.

Emergent Indications:
RSI paralysis.

Where you’ll get in Trouble:
prolonged paralysis, Preg B.


Sodium Bicarbonate

MOA:
increases serum bicarbonate (increases buffer stores).

Dose:
Hyperkalemia or metabolic acidosis: 50 mEq IV x 1 (1 amp = 50 mEq)
TCA toxicity: 1-2 mEq/kg IV bolus to achieve a serum pH of 7.45-7.55 and QRS narrowing; effective serum alkalinization unlikely with continuous infusion
Salicylate toxicity: 3 amps (150mEq) in 1 liter D5W given as 10-20 ml/kg bolus, then 2-3ml/kg/hr; goal urine pH 7.5-8.0.

Emergent Indications:
hyperkalemia, TCA toxicity, salicylate toxicity, metabolic acidosis.

Where you’ll get in Trouble:
caution in CHF, overshooting into metabolic alkalosis, hypernatremia, Preg C.


Succinylcholine

MOA:
depolarizing neuromuscular agent.

Dose:
1.5 mg/kg (or 3-4 mg/kg IM).

Emergent Indications:
RSI paralysis.

Where you’ll get in Trouble:
hyperkalemia, subacute burn/crush with hyperkalemia, glaucoma (increases IOP), increases ICP, Preg C.



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