Class Anticholinergic agent. Mechanism of action Inhibits the action of acetylcholine at postganglionic parasympathetic neuroeffector sites. Increases heart rate in life-threatening bradydysrhythmias. Indications Hemodynamically unstable bradycardia, organophosphate poisoning, nerve agent exposure, rapid sequence intubation in pediatrics, beta blocker or calcium channel blocker overdose. Contraindications Tachycardia, hypersensitivity, unstable cardiovascular status in acute hemorrhage with myocardial ischemia, narrow-angle glaucoma, hypothermic bradycardia. Adverse reactions/side effects Drowsiness, confusion, headache, tachycardia, palpitations, dysrhythmias, nausea, vomiting, pupil dilation, dry mouth/nose/skin, blurred vision, urinary retention, constipation, fl ushed, hot, dry skin; paradoxical bradycardia when pushed too slowly or when given at low doses. Drug interactions Potential adverse effects when administered with digitalis, cholinergics, physostigmine. Effects enhanced by antihistamines, procainamide, quinidine, antipsychotics, benzodiazepines, and antidepressants. How supplied Prefi lled syringes containing 1 mg in 10 mL (0.1 mg/mL). Nebulizer: 0.2% (1 mg in 0.5 mL) and 0.5% (2.5 mg in 0.5 mL). Dosage and administration Adult: Unstable bradycardia: 0.5 mg IV/IO every 3–5 minutes as needed. Not to exceed total dose of 0.04 mg/kg (maximum 3 mg total). Use shorter dosing interval (3 minutes) and higher doses in severe clinical conditions. Organophosphate poisoning: Extremely large doses (2–4 mg or higher) may be needed. Pediatric: Unstable bradycardia: 0.02 mg/kg IV/IO (minimum dose: 0.1 mg). May repeat once. Maximum single dose: Child: 0.5 mg. Adolescent: 1 mg. Maximum total dose: Child: 1 mg. Adolescent: 3 mg. ET dose: 0.04–0.06 mg/kg. Rapid sequence intubation: 0.01–0.02 mg/kg IV/IO (minimum: 0.1 mg, maximum: 0.5 mg). Duration of action Onset: Immediate. Peak effect: Rapid to 1–2 minutes. Duration: 2–6 hours. Special considerations Pregnancy safety: Category C. Moderate doses may cause pupillary dilation. Paradoxical bradycardia can occur with doses lower than 0.1 mg.

Atropine Sulfate

Class Antidysrhythmic. Mechanism of action Blocks sodium channels and myocardial potassium channels, delaying repolarization and increasing the duration of action potential. Indications Ventricular fi brillation, pulseless ventricular tachycardia, unstable ventricular tachycardia in patients refractory to other therapy. Contraindications Known hypersensitivity to amiodarone or iodine, cardiogenic shock, sinus bradycardia, second- or thirddegree AV block (if no pacemaker is present), severe sinus node dysfunction. Adverse reactions/side effects Dizziness, fatigue, malaise, tremor, ataxia, lack of coordination, adult respiratory distress syndrome, pulmonary edema, cough, progressive dyspnea, congestive heart failure, bradycardia, hypotension, worsening of dysrhythmias, prolonged QT interval, nausea, vomiting, burning at IV site, Stevens-Johnson syndrome. Drug interactions Use with digoxin may cause digitalis toxicity. Antidysrhythmics may cause increased serum levels. Beta blocker and calcium channel blockers may potentiate bradycardia, sinus arrest, and AV heart blocks. How supplied 50 mg/mL vials and prefi lled syringes. For rapid infusion, add 150 mg/3 mL to a 10-mL D 5 W (1.5 mg/mL) run at 600 mL/h on infusion pump. Dosage and administration Adult: Ventricular fi brillation/ pulseless ventricular tachycardia unresponsive to CPR, defi brillation, and vasopressors: 300 mg IV/IO push. Initial dose can be followed one time in 3–5 minutes at 150 mg IV/IO push. Recurrent life-threatening ventricular dysrhythmias: Maximum cumulative dose: 2.2 g IV/24 h administered as follows: Rapid infusion: 150 mg IV/IO over 10 minutes (15 mg/minute). May repeat rapid infusion (150 mg IV/IO) every 10 minutes as needed. Pediatric: Refractory ventricular fi brillation/pulseless ventricular tachycardia: 5 mg/kg IV/IO bolus. Can repeat the 5 mg/kg IV/IO bolus up to a total dose of 15 mg/kg per 24 h. Maximum single dose: 300 mg. Perfusing supraventricular and ventricular tachycardias: Loading dose 5 mg/kg IV/IO over 20–60 minutes (maximum single dose of 300 mg). Can repeat to maximum dose of 15 mg/kg/day (2.2 g in adolescents). Maximum single dose: 300 mg. Duration of action Onset: Immediate. Peak effect: 10–15 minutes. Duration: 30–45 minutes. Special considerations Pregnancy safety: Category D. Monitor patient for hypotension. May worsen or precipitate new dysrhythmias.

Amiodarone (Cordarone, Pacerone)

Class Sympathomimetic, inotropic agent. Mechanism of action Synthetic catecholamine. Increased myocardial contractility, stroke volume, and increased cardiac output. Minimal chronotropic activity. Increases renal blood fl ow. Indications Cardiogenic shock, CHF, left ventricular dysfunction, often used in conjunction with other drugs. Contraindications Tachydysrhythmias, severe hypotension, idiopathic hypertrophic subaortic stenosis (IHSS), suspected or known poison/drug-induced shock. Adverse reactions/side effects Headache, dyspnea, tachycardia, hypertension, chest pain, dysrhythmias, PVCs, nausea, vomiting. Drug interactions Incompatible with sodium bicarbonate and furosemide. Beta blockers may blunt inotropic effects. How supplied 12.5 mg/mL vials. 250 mg/250 mL D 5 W (1,000 μg/mL). Dosage and administration Adult: IV infusion at 2–20 μg/ kg/min titrated to desired effect. Max dose 40 μg/kg/min. Pediatric: IV infusion at 2–20 μg/kg/min titrated to desired effect (not recommended). Duration of action Onset: 2 minutes. Peak effect: 10 minutes. Duration: 1–2 minutes after infusion discontinued. Special Considerations Pregnancy safety: Category B. Monitor blood pressure closely. Titrate dose to maintain a heart rate increase of no greater than 10% of baseline. May increase infarct size in patients with MI. Elderly patients may have a significantly decreased response.

Dobutamine Hydrochloride (Dobutrex)

Class Sympathomimetic, vasopressor, inotropic agent. Mechanism of action Immediate metabolic precursor to norepinephrine. Produces positive inotropic and chronotropic effects. Dilates renal and splanchnic vasculature. Constricts systemic vasculature, increasing blood pressure and preload. Increases myocardial contractility and stroke volume. Indications Cardiogenic and septic shock, hypotension with low cardiac output states, distributive shock, second-line drug for symptomatic bradycardia. Contraindications Hypovolemic shock, pheochromocytoma, tachydysrhythmias, ventricular fi brillation. Adverse reactions/side effects Extravasation may cause tissue necrosis. Headache, anxiety, dyspnea, dysrhythmias, hypotension, hypertension, palpitations, chest pain, increased myocardial oxygen demand, PVCs, nausea, vomiting. Drug interactions Incompatible with alkaline solutions (sodium bicarbonate). MAOIs will enhance the effect of dopamine. Bretylium may potentiate effect of dopamine. Beta blockers may antagonize effects of dopamine. When administered with phenytoin, may cause hypotension, bradycardia, and seizures. How supplied 40 mg/mL and 80 mg/mL prefi lled syringes and vials for IV infusion. 400 mg/250 mL D 5 W premixed solutions (1,600 μg/mL). Dosage and administration Adult: IV/IO infusion at 2–20 μg/kg/ min, slowly titrated to patient response. Pediatric: IV/IO infusion at 2–20 μg/kg/min, slowly titrated to patient response.

Dopamine Hydrochloride (Intropin)

Class Corticosteroid, adrenal glucocorticoid. Mechanism of action Suppresses acute and chronic infl ammation; immunosuppressive effects. Indications Anaphylaxis, asthma, spinal cord injury, croup, elevated intracranial pressure (prevention and treatment), as an adjunct in the treatment of shock. Contraindications Hypersensitivity, use caution in suspected systemic sepsis. Adverse reactions/side effects Headache, restlessness, euphoria, psychoses, pulmonary tuberculosis, hypertension, peptic ulcer, nausea, vomiting, GI bleeding, edema, hyperglycemia, immunosuppression, sodium and water retention. None from single dose. Drug interactions Calcium, metaraminol. How supplied 100 mg/5 mL vials or 20 mg/1 mL vials. Dosage and administration Adult: 10–100 mg IV (1 mg/kg slow IV bolus). Considerable variance through medical control. Pediatric: 0.25–1.0 mg/kg IV/IO/IM. Given one time with maximum dose of 16 mg. Duration of action Onset: Hours. Peak effect: 8–12 hours. Duration: 24–72 hours. Special considerations Pregnancy safety: Category C. Protect medication from heat. Toxicity and side effects with long-term use.

Dexamethasone Sodium Phosphate (Decadron)

Class Benzodiazepine, long-acting; sedative-hypnotic; anticonvulsant; schedule IV drug. Mechanism of action Potentiates effects of inhibitory neurotransmitters. Raises the seizure threshold. Induces amnesia and sedation. Indications Acute anxiety states and agitation, acute alcohol withdrawal, muscle relaxant, seizure activity, sedation for medical procedures (eg, intubation, ventilated patients, cardioversion), may be helpful in acute symptomatic cocaine overdose. Contraindications Hypersensitivity, narrow-angle glaucoma, myasthenia gravis, respiratory insuffi ciency, coma, head injury. Adverse reactions/side effects Dizziness, drowsiness, confusion, headache, respiratory depression, hypotension, reflex tachycardia, nausea, vomiting, muscle weakness, tissue necronecrosis, ataxia, thrombosis, phlebitis.

Drug interactions Incompatible with most drugs, fl uids.

How supplied 5 mg/mL prefi lled syringes, ampules, vials, and

Tubex syringes.

Dosage and administration Adult: Seizure activity: 5–10 mg

IV q 10–15 minutes PRN (5 mg over 5 minutes) (maximum

dose: 30 mg). Premedication for cardioversion: 5–15 mg IV over

5–10 minutes prior to cardioversion. Pediatric: Seizure activity:

0.2 mg/kg to 0.5 mg/kg slow IV q 2–5 minutes up to 5 mg

(maximum dose 10 mg/kg). Rectal diazepam: 0.5 mg/kg via 2"

rectal catheter and fl ush with 2–3 mL air after administration.

Duration of action Onset: 1–5 minutes. Peak effect: 15 minutes.

Duration: 20–50 minutes.

Special considerations Pregnancy safety: Category D. Short

duration for anticonvulsant effect. Reduce dose by 50% in

elderly patients.

Diazepam (Valium and others)

Class Calcium channel blocker, antidysrhythmic. Mechanism of action Slow calcium channel blocker that blocks calcium ion infl ux during depolarization of cardiac and vascular smooth muscle. Decreases peripheral vascular resistance and causes relaxation of the vascular smooth muscle, resulting in a decrease of both systolic and diastolic blood pressure. Reduces preload and afterload. Reduces myocardial oxygen demand. Indications Controls rapid ventricular rates due to atrial fi brillation, atrial fl utter, and re-entry supraventricular tachycardia. Contraindications Hypotension, sick sinus syndrome (without functioning pacemaker present), second- or third-degree AV block (without functioning pacemaker present), cardiogenic shock, wide-complex tachycardia (ventricular tachycardia may lead to hemodynamic deterioration and ventricular fi brillation), poison- or drug-induced tachycardia. Adverse reactions/side effects Dizziness, weakness, headache, dyspnea, cough, dysrhythmias, CHF, peripheral edema, bradycardia, hypotension, AV blocks, syncope, ventricular fi brillation, ventricular tachycardia, cardiac arrest, chest pain, nausea, vomiting, dry mouth. Drug interactions Caution in patients using medications that affect cardiac contractility. In general, should not be used in patients on beta blockers. How supplied 5 mg/mL vials (requires refrigeration). 100-mg powder (requires reconstitution with attached fl uid) for infusion (1 mg/mL). Add 125 mg/25 mL to a 100-mL bag of D 5 W (1 mg/mL). Dosage and administration Adult: Initial dose: 0.25 mg/kg (15–20 mg for the average patient) IV over 2 minutes. If inadequate response, may re-bolus in 15 minutes. Secondary dose: 0.35 mg/kg (20–25 mg for the average patient) IV over 2 minutes. Maintenance infusion of 5–15 mg/h titrated to physiologically appropriate heart rate. Pediatric: Not recommended. Duration of action Onset: 2–5 minutes. Peak effect: Variable. Duration: 1–3 hours. Special considerations Pregnancy safety: Category C. Use with caution in patients with renal or hepatic dysfunction. PVCs may be present on conversion of PSVT to sinus rhythm. 500-mg dose of calcium chloride 5 minutes prior to administration of diltiazem can help to block the hypotensive effects in borderline hypotensive patients (blocks baroreceptors in the great vessels).

Diltiazem (Cardizem)

Class Antihistamine, anticholinergic. Mechanism of action Blocks cellular histamine receptors; decreases vasodilation; decreases motion sickness. Reverses extrapyramidal reactions. Indications Symptomatic relief of allergies, allergic reactions, and anaphylaxis. Blood administration reactions; used for motion sickness and hay fever, relief of acute dystonic reactions caused by phenothiazines; may be useful in phenothiazine overdoses. Contraindications Asthma, glaucoma, pregnancy, hypertension, narrow-angle glaucoma, infants, patients taking MAOIs. Adverse reactions/side effects Drowsiness, sedation, seizures, dizziness, headache, blurred vision, paradoxical CNS excitement in children, wheezing, thickening of bronchial secretions, palpitations, hypotension, dysrhythmias, dry mouth, diarrhea,nausea, vomiting. Drug interactions Potentiates effects of alcohol and other anticholinergics. May inhibit corticosteroid activity. MAOIs prolong anticholinergic effects of diphenhydramine. How supplied 25- and 50-mg tablets and capsules. 10 mg/mL and 50 mg/mL vials. Dosage and administration Adult: 25–50 mg IM, IV, PO. Pediatric: 1–2 mg/kg IV, IO slowly, or IM. If PO: 5 mg/kg/24h. Duration of action Onset: 15–30 minutes. Peak effect: 1 hour. Duration: 3–12 hours. Special considerations Pregnancy safety: Category B. Not used in infants. If used in anaphylaxis, must be in conjunction with epinephrine and corticosteroids.

Diphenhydramine (Benadryl)

Class Sympathomimetic. Mechanism of action Direct-acting alpha and beta agonist. Alpha: vasoconstriction. Beta-1: positive inotropic, chronotropic, and dromotropic effects. Beta-2: bronchial smooth muscle relaxation and dilation of skeletal vasculature. Blocks histamine receptors. Indications Cardiac arrest (asystole, PEA, ventricular fi brillation and pulseless ventricular tachycardia), symptomatic bradycardia as an alternative infusion to dopamine, severe hypotension secondary to bradycardia when atropine and transcutaneous pacing are unsuccessful, allergic reaction, anaphylaxis, asthma. Contraindications Hypertension, hypothermia, pulmonary edema, myocardial ischemia, hypovolemic shock. Adverse reactions/side effects Nervousness, restlessness, headache, tremor, pulmonary edema, dysrhythmias, chest pain, hypertension, tachycardia, nausea, vomiting. Drug interactions Potentiates other sympathomimetics. Deactivated by alkaline solutions. MAOIs may potentiate effect. Beta blockers may blunt effects. How supplied 1:1,000 solution: Ampules and vials containing 1 mg/mL. 1:10,000 solution: Prefi lled syringes containing 0.1 mg/mL. Auto-injector (EpiPen): 0.5 mg/mL (1:2,000). Dosage and administration Adult: Mild allergic reactions and asthma: 0.3–0.5 mg (0.3–0.5 mL 1:1,000) SC. Anaphylaxis: 1 mg (10 mL of 1:10,000) IV, IO over 5 minutes. Cardiac arrest: IV/IO dose: 1 mg (10 mL, 1:10,000 solution) 3–5 minutes during resuscitation. Follow each dose with a 20-mL fl ush and elevate arm for 10–20 seconds after dose. Continuous infusion: Add 1 mg (1 mL of a 1:1,000 solution) to 250 mL normal saline or D 5 W (4 μg/mL). Initial infusion rate of 1 μg/ min titrated to effect (typical dose: 2–10 μg/min). Endotracheal (ET) dose: 2–2.5 mg diluted in 10 mL normal saline. Profound bradycardia or hypotension: 2–10 μg/min; titrate to patient response. Higher dose: Higher doses (up to 0.2 mg/kg) may be used for specifi c indications: (beta blocker or calcium channel blocker overdose). Pediatric: Mild allergic reactions and asthma: 0.01 mg/kg (0.01 mL/kg) of a 1:1,000 solution SC (maximum of 0.3 mL). Anaphylaxis/severe status asthmaticus: 0.01 mg/kg (0.01 mL/kg) IM of a 1:1,000 solution (maximum single dose: 0.3 mg). Cardiac arrest: IV/IO dose: 0.01 mg/kg (0.1 mL/kg) of a 1:10,000 solution every 3–5 minutes during arrest. All ET doses 0.1 mg/kg (0.1 mL/kg) of a 1:1,000 solution mixed in 3–5 mL of saline until IV/IO access is achieved. Maximum single dose 1 mg. Symptomatic bradycardia: IV/IO dose: 0.01 mg/kg (0.01 mL/kg) of a 1:10,000 solution. All ET doses 0.1 mg/kg (0.1 mL/kg) of a 1:1,000 solution. Continuous IV/IO infusion: Begin with rapid infusion, and then titrate to response. Typical initial infusion: 0.1–1 μg/min. Higher doses may be effective. Duration of action Onset: Immediate. Peak effect: Minutes. Duration : Several minutes. Special considerations Pregnancy safety: Category C. May cause syncope in asthmatic children. May increase myocardial oxygen demand. To mix an infusion add 1 mg of epinephrine 1:1,000 to 500 mL D 5 W for a yield of 2 mcg/mL. Many states and systems are pulling away from IV/IO/IM administration of 1:1,000 and replacing it with auto-injectors due to the vascular side effects of solo epinephrine 1:1,000 injection.

Epinephrine (Adrenalin)

Class Opioid analgesic, schedule II narcotic. Mechanism of action Binds to opiate receptors, producing analgesia and euphoria. Indications Pain management, anesthesia adjunct. Contraindications Known hypersensitivity. Use with caution in traumatic brain injury. Adverse reactions/side effects Confusion, paradoxical excitation, delirium, drowsiness, CNS depression, sedation, respiratory depression, apnea, dyspnea, dysrhythmias, bradycardia, tachycardia, hypotension, syncope, nausea, vomiting, abdominal pain, dehydration, fatigue. Drug interactions Increased respiratory effects when given with other CNS depressants. How supplied 50 μg/mL ampules and Tubex syringes. Dosage and administration Adult: 50 to 100 μg (1μg/kg) IM or IV, IO slow push (over 1–2 minutes) to maximum of 150 μg. Pediatric: 1–2 μg/kg IM, IV, or IO slow push (over 1–2 minutes). The safety and effi cacy in children younger than 2 years has not been established. Duration of action Onset: 1–3 minutes. Peak effect: 3–5 minutes. Duration: 30–60 minutes. Special considerations Pregnancy safety: Category C. Chest wall rigidity possible with a high-dose rapid infusion. A dose of 100 μg of fentanyl citrate is equivalent to 10 mg of morphine or 75 mg of meperidine.

Fentanyl Citrate (Sublimaze)

Class Tranquilizer, antipsychotic. Mechanism of action Inhibits central nervous system catecholamine receptors: strong antidopaminergic and weak anticholinergic. Acts on CNS to depress subcortical areas, mid-brain, and ascending reticular activating system in the brain. Indications Acute psychotic episodes. Contraindications Parkinsons disease, depressed mental status, agitation secondary to shock and hypoxia, hypersensitivity. Adverse reactions/side effects Seizures, sedation, confusion, restlessness, extrapyramidal reactions, dystonia, respiratory depression, hypotension, tachycardia, orthostatic hypotension, QT prolongation, sudden cardiac death, constipation, dry mouth, nausea, vomiting, drooling, blurred vision. Drug interactions Enhanced central nervous system depression and hypotension in combination with alcohol. Antagonized amphetamines and epinephrine. Other CNS depressants may potentiate effects. How supplied 5 mg/mL ampules and vials. Dosage and administration Adult: 2–5 mg IM ONLY every 30–60 minutes until sedation is achieved. Pediatric: Not recommended. Duration of action Onset: 10 minutes. Peak effect: 30–45 minutes. Duration: Variable (generally 12–24 hours). Special considerations Pregnancy safety: Category C. Treat hypotension secondary to haloperidol with fl uids and norepinephrine, not epinephrine. Patient may also be taking benztropine mesylate (Cogentin) if on long-term therapy with haloperidol.

Haloperidol Lactate (Haldol)

Class Nonsteroidal anti-infl ammatory (NSAID) analgesic. Mechanism of action Potent analgesic that does not possess any sedative or anxiolytic activities by inhibiting prostaglandin synthesis. Indications Short-term management of moderate to severe pain. Contraindications Allergy to salicylates or other nonsteroidal anti-infl ammatory drugs. Patients with history of asthma, bleeding disorders (especially GI related, such as peptic ulcer disease), renal failure. Adverse reactions/side effects Drowsiness, dizziness, headache, sedation, bronchospasm, dyspnea, edema, vasodilation, hypotension, hypertension, GI bleeding, diarrhea, dyspepsia, nausea. Drug interactions May increase bleeding time in patients taking anticoagulants. How supplied 15 mg/mL and 30 mg/mL vials. Dosage and administration Adult: 30–60 mg IM. Pediatric: Not recommended. Duration of action Onset: 10 minutes. Peak effect: 1–2 hours. Duration: 2–6 hours. Special considerations Pregnancy safety: Category C. Use with caution in elderly patients due to higher risk of renal and fatal GI adverse reactions.

Ketorolac Tromethamine (Toradol)

Class Benzodiazepine, short/intermediate acting; sedative, anticonvulsant, schedule IV drug. Mechanism of action Anxiolytic, anticonvulsant, and sedative effect; suppresses propagation of seizure activity produced by foci in cortex, thalamus, and limbic areas. Indications Initial control of status epilepticus or severe recurrent seizures, severe anxiety, sedation. Contraindications Acute narrow-angle glaucoma, coma, shock, suspected drug abuse. Adverse reactions/side effects Dizziness, drowsiness, CNS depression, headache, sedation, respiratory depression, apnea, hypotension, bradycardia. Drug interactions May precipitate central nervous system depression if already taking central nervous system depressant medications. How supplied 2 and 4 mg/mL vials and Tubex syringes. Dosage and administration Note: When given IV/IO, must be diluted with equal volume of sterile water or sterile saline. When given IM, lorazepam is not diluted. Adult: 2–4 mg slow IM/IV at 2 mg/min; may be repeated in 15–20 minutes. Maximum dose of 8 mg. For sedation: 0.05 mg/kg up to 4 mg IM. Pediatric: 0.05– 0.20 mg/kg slow IV/IO/IM over 2 minutes. May be repeated once in 5–20 minutes. Maximum dose of 0.2 mg/kg. Duration of action Onset: 1–5 minutes. Peak effect: Variable. Duration: 6–8 hours. Special considerations Pregnancy safety: Category D. Monitor respiratory rate and blood pressure during administration. Have advanced airway equipment readily available. Inadvertent arterial injection may result in vasospasm and gangrene. Lorazepam expires in 6 weeks when not refrigerated.

Lorazepam (Ativan)

Class Corticosteroid. Mechanism of action Highly potent synthetic glucocorticoid that suppresses acute and chronic infl ammation; potentiates vascular smooth muscle relaxation by beta-adrenergic agonists. Indications Acute spinal cord trauma, anaphylaxis, bronchodilator for unresponsive asthma.

Methylprednisolone Sodium Succinate (Solu-Medrol)

Class Benzodiazepine, short/intermediate acting; schedule IV drug. Mechanism of action Reversibly interacts with gamma-amino butyric acid (GABA) receptors in the central nervous system causing sedative, anxiolytic, amnesic, and hypnotic effects. Indications Sedation for medical procedures (eg, intubation, ventilated patients, cardioversion). Contraindications Acute narrow-angle glaucoma, shock, coma, alcohol intoxication, overdose, depressed vital signs. Concomitant use with barbiturates, alcohol, narcotics, or other central nervous system depressants. Adverse reactions/side effects Headache, somnolence, respiratory depression, respiratory arrest, apnea, hypotension, cardiac arrest, nausea, vomiting, pain at the injection site. Drug interactions Should not be used in patients who have taken central nervous system depressants. How supplied 1 mg/mL and 5 mg/mL vials and Tubex syringes. Dosage and administration Adult: 2–2.5 mg slow IV (over 2–3 minutes). May be repeated to total maximum: 0.1 mg/ kg. Pediatric: 0.1–0.3 mg/kg IV/IO (maximum single dose: 10 mg). Duration of action Onset: 1–3 minutes, IV and dose dependent. Peak effect: Variable. Duration: 2–6 hours, dose dependent. Special considerations Pregnancy safety: Category D. Administer immediately prior to intubation procedure. Requires continuous monitoring of respiratory and cardiac function. Decrease dose by 50% in patients with hepatic and renal dysfunction.

Midazolam Hydrochloride (Versed)

Class Opioid analgesic (schedule II narcotic). Mechanism of action Alleviates pain through CNS action. Suppresses fear and anxiety centers in the brain. Depresses brainstem respiratory centers. Increases peripheral venous capacitance and decreases venous return. Decreases preload and afterload, which decreases myocardial oxygen demand. Indications Severe CHF, acute cardiogenic pulmonary edema, chest pain associated with acute myocardial infarction, analgesia for moderate to severe acute and chronic pain. Contraindications Head injury, exacerbated COPD, depressed respiratory drive, hypotension, undiagnosed abdominal pain, decreased level of consciousness, suspected hypovolemia, patients who have taken MAOIs within 14 days. Adverse reactions/side effects Confusion, sedation, headache, CNS depression, respiratory depression, apnea, bronchospasm, dyspnea, hypotension, orthostatic hypotension, syncope, bradycardia tachycardia, nausea, vomiting, dry mouth.

Drug interactions Potentiates sedative effects of phenothiazines.

CNS depressants may potentiate effects of morphine.

MAOIs may cause paradoxical excitation.

How supplied 2 mg/mL, 4 mg/mL, 8 mg/mL, 10 mg/mL

ampules, vials, and Tubex syringe.

Dosage and administration Adult: STEMI: Initial dose: 2–4 mg

slow IV (over 1–5 minutes). Repeat dose: 2–8 mg at 5–15 minute

intervals. NSTEMI/Unstable angina. 1–5 mg IV push if

symptoms not relieved by nitrates, use with caution. Pediatric:

0.1–0.2 mg/kg/dose IV, IO, IM, SC. Maximum dose: 5 mg.

Duration of action Onset: Immediate. Peak effect: 20 minutes.

Duration: 2–7 hours.

Special considerations Pregnancy safety: Category C. Morphine

rapidly crosses the placenta. Safety in neonates has not

been established. Use with caution in the elderly, those with

asthma, and in those susceptible to central nervous system

depression. Vagotonic effect in patients with acute inferior MI

(bradycardia, heart block). Naloxone hydrochloride (Narcan)

Morphine Sulfate (Roxanol, MS Contin)

Class Opioid analgesic, schedule II drug. Mechanism of action Synthetic opioid analgesic whose effects on the central nervous system and smooth muscle organs are similar to morphine, primarily acting as an analgesic and a sedative. Indications Analgesia for moderate to severe pain. Contraindications Hypersensitivity to narcotics, diarrhea caused by poisoning, patients taking MAOIs, during labor or delivery of a premature infant, undiagnosed abdominal pain or head injury. Adverse reactions/side effects Seizures, confusion, sedation, dysphoria, headache, hallucinations, increased ICP, respiratory depression, apnea, hypotension, orthostatic hypotension, syncope, bradycardia, dysrhythmias, nausea, vomiting, constipation, sweating. Drug interactions Do not give concurrently with MAOIs (even with a dose in the last 14 days). Exacerbates CNS depression when given with other CNS depressants. How supplied 50 mg/mL and 100 mg/mL prefi lled syringes and Tubex syringes. Dosage and administration Adult: 50–100 mg IM, SC. 25–50 mg slowly IV. Pediatric: 1–2 mg/kg/dose IV, IO, IM, SC. Duration of action Onset: IM: 10–45 minutes; IV: immediate. Peak effect: 30–60 minutes. Duration: 2–4 hours. Special considerations Pregnancy safety: Category C. Use with caution in patients with asthma and COPD. May aggravate seizures in patients with known convulsive disorders. Naloxone should be readily available as antagonist.

Meperidine Hydrochloride (Demerol)

Class Vasodilator. Mechanism of action Smooth muscle relaxant acting on vasculature, bronchial, uterine, intestinal smooth muscle. Dilation of arterioles and veins in the periphery. Reduces preload and afterload, decreasing workload of the heart and thereby myocardial oxygen demand. Indications Acute angina pectoris, ischemic chest pain, hypertension, CHF, pulmonary edema. Contraindications Hypotension, hypovolemia, intracranial bleeding or head injury, pericardial tamponade, severe bradycardia or tachycardia, RV infarction, previous administration in the last 24 hours: tadalafi l (Cialis) (48 hours), vardenafi l (Levitra), sildenafi l (Viagra). Adverse reactions/side effects Headache, dizziness, weakness, refl ex tachycardia, syncope, hypotension, nausea, vomiting, dry mouth, muscle twitching, diaphoresis. Drug interactions Additive effects with other vasodilators. Incompatible with other drugs IV. How supplied Tablets: 0.3 mg (1/200 grain). 0.4 mg (1/150 grain). 0.6 mg (1/100 grain). NTG spray: 0.4 mg/actuation. NTG IV (Tridil). 200 μg/mL in D 5 W glass vials. Dosage and administration Adult: Tablet: 0.3–0.4 mg sublingually; may repeat in 5 minutes to maximum of 3 doses. NTG spray: 1–2 sprays for 0.5–1 second at 5-minute intervals to a maximum of 3 sprays in 15 minutes. NTG IV infusion: Begin at 10 μg/min; increase by 10 μg/min every 3–5 minutes until desired effect. To a maximum of 200 μg/min. Pediatric: Not recommended. IV infusion: 0.25–0.5 μg/kg/min IV, IO titrated by 1 μg/kg/min (max dose: 5 μg/kg/min). Duration of action Onset: 1–3 minutes. Peak effect: 5–10 minutes. Duration: SL: 20–30 minutes. IV: 1–10 minutes after discontinuation of infusion. Special considerations Pregnancy safety: Category C. Hypotension more common in the elderly. If 12-lead ECG shows inferior wall infarct, rule out right ventricular infarct via right-sided 12-lead ECG prior to administering nitroglycerin. Nitroglycerin decomposes when exposed to light or heat, must be kept in airtight containers. Must be administered only with an infusion pump direct from bottle with a vented IV set and non-PVC tubing. Active ingredient may have stinging effect when administered.

Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)

Class Serotonin receptor antagonist; antiemetic. Mechanism of action Blocks action of serotonin, which is a natural substance that causes nausea and vomiting. Indications For the prevention and control of nausea or vomiting. Used in hospital for patients undergoing chemotherapy or surgical procedures. Contraindications Known allergy to ondansetron or other 5-HT 3 receptor antagonists. Adverse reactions/side effects Headache, malaise, wheezing, bronchospasm, atrial fi brillation, abnormal ECG, prolonged QT interval, ST segment depression, second-degree AV block, constipation, diarrhea, hives, skin rash. Drug interactions Not recommended if the patient is taking apomorphine, mesoridazine, pimozide, or thioridazine. How supplied 2 mg/mL vials. Dosage and administration Adult: 4 mg IV/IM may repeat in 10 minutes. Pediatric: 0.1 mg/kg IV/IM. Duration of action Onset: 30 minutes. Peak effect: 2 hours. Duration: 3–6 hours. Special considerations Pregnancy safety: Category B.

Ondansetron Hydrochloride (Zofran)

Class Neuromuscular blocker, depolarizing; skeletal muscle relaxant. Mechanism of action Ultra-short-acting depolarizing skeletal muscle relaxant that mimics acetylcholine as it binds with the cholinergic receptors on the motor end plate, producing a phase 1 block as manifested by fasciculations. Indications Rapid-sequence intubation. Contraindications Acute narrow-angle glaucoma, penetrating eye injuries, malignant hyperthermia. Acute injury after multisystem trauma, major burns, or extensive muscle injury. Inability to control airway or support ventilations with oxygen and positive pressure. Adverse reactions/side effects Apnea, respiratory depression, bradydysrhythmia, tachydysrhythmia, dysrhythmia, cardiac arrest, salivation, prolonged muscle rigidity, rhabdomyolysis, malignant hyperthermia, increased intraocular pressure, hyperkalemia (trauma patients). Drug interactions Oxytocin, beta blockers, and organophosphates may potentiate effects. Diazepam may reduce duration of action. How supplied 20 mg/mL vials. Dosage and administration Adult: 1–1.5 mg/kg rapid IV. Repeat once if needed. Pediatric: 1–1.5 mg/kg rapid IV/IO. Repeat once if needed. 2 mg/kg in infants. Duration of action Onset: 1 minute. Peak effect: 1–3 minutes. Duration: 5–10 minutes. Special considerations Pregnancy safety: Category C. If the patient is conscious, explain the effects of the drug before administration. Consider premedication with atropine, particularly in pediatric age group. Premedication with lidocaine may blunt any increase in intracranial pressure during intubation. Etomidate, diazepam, or midazolam should be used in any conscious patient before undergoing neuromuscular blockade.

Succinylcholine Chloride (Anectine)

Class Neuromuscular blocker, nondepolarizing. Mechanism of action Neuromuscular agent with intermediate duration of action that competes with acetylcholine for receptors at the motor end plate, resulting in neuromuscular blockade. Indications Rapid-sequence intubation. Contraindications Acute narrow-angle glaucoma, penetrating eye injuries, inability to control airway or support ventilations with oxygen and positive pressure, newborns, myasthenia gravis, hepatic or renal failure. Adverse reactions/side effects Weakness, prolonged neuromuscular block, bronchospasm, apnea, dysrhythmias, bradycardia, tachycardia, PVCs, transient hypotension, cardiac arrest, excessive salivation. Drug interactions Use of inhalation anesthetics will enhance neuromuscular blockade. How supplied 10- and 20-mg powder (requires reconstitution before administration). Dosage and administration Adult: 0.1–0.2 mg/kg IV push. Maintenance dose within 45–60 minutes: 0.8–1.2 mg/kg IV push. Pediatric: 0.1–0.3 mg/kg IV/IO. Maintenance dose within 20–35 minutes: 0.01–0.05 mg/kg IV/IO push. Duration of action Onset: 1–3 minutes. Peak effect: Varies. Duration: 45–90 minutes. Special Considerations Pregnancy safety: Category C. If patient is conscious, explain the effect of the medication before administration and always sedate the patient before using vecuronium. Intubation and ventilatory support must be readily available. Monitor the patient carefully. Vecuronium has no effect on consciousness or pain. Will not stop neuronal seizure activity. Pulse rate and cardiac output are increased. Decrease doses for patients with renal disease.

Vecuronium Bromide (Norcuron)