Functional Class: Narcotic agonist, analgesic

Mechanism of Action: Potent, short-acting, synthetic narcotic agonist analgesic. Principle actions are analgesia and sedation. Inhibits ascending pain pathways in CNS, Increases pain threshold, and alters pain perception by binding to opiate receptors

Indications: Pain management

Contraindications: Myasthenia gravis, hypersensitivity to opiates, MAOI use

Precations: Increased ICP, severe respiratory disorders, hypotension, bradydysrhythmias 

Side Effects: May result in severe respiratory depression, bronchoconstriction, chest wall rigidity, sedation, bradycardia, diaphoresis, N/V, miosis, blurried vision, hypotension, Cardiac arrest

Interactions: Effects may be increased with other CNS depressants such as alcohol, narcotic, and sedative/hypnotics. 

Dosage and route: ADULT: 25-50 mcg slow IVP or IM q 5 minutes up to 150 mcg

                               PEDI: 0.5 mcg/kg slow IVP q 5 minutes up to 1.5 mcg/kg

Pharmacokinetics: Absorption= immediate, duration= 30-60 minutes, half-life= 1.5-6 hrs

Functional Class: Analgesic, NSAID

Mechanism of Action: Reversibly blocks the actions of cyclooxygenase which in turn prevents the formation of prostaglandins. Ketorolac causes analgesia equivalent to that of morphine sulfate.

Indications: Acute moderate to severe pain

Contraindications: NSAID allergy, ASA sensitive asthma, known pepic ulcer disease, recent GI bleed, renal failure, confirmed cerebrovascular bleeding, recent CABG, pregnancy

Precations: use cautiously with CHF and cirrhosis pt's due to renal failure

Side Effects: GI bleeding, inhibtion of platelet aggregation, acute renal failure, N/V/D, upset stomach 

Interactions: Potentiates medications that inhibit platelet aggregation 

Dosage and route: ADULT: 15-30 mg IVP or 30-60 mg IV (single dose only)

Functional Class:  Narcotic Analgesic 

Mechanism of Action: A naturally occuring opiate which acts on opiate receptors in the brain, providing sedation and analgesia. Additionally, it's vasodilatory properties increase peripheral venous capacity and decrease venous return to the heart. This reduces cardiac workload, decreases myocardial oxygen demand, and decreases pulmonary venous congestion

Indications: Chest pain associated with ACS, pulmonary edema, CHF, pain management 

Contraindications: Hypersensitivity, undiagnosed head injury, hypovolemia or severe hypotension, acute asthma, COPD, respiratory depression

Precations: Administer slowly and titrate to effect. Undiagnosed abd injruy

Side Effects: Dizziness, N/V, cramps, blurried vision, AMS, miosis, headache, seizures, drowsiness, bradycardia, respiratory depression, syncope, palpations, hypotension, dry mouth

Interactions: Enhanced CNS depression when administered with antihistamines, sedatives, barbiturates, and ETOH

Dosage and route: ADULT: 1-5 mg slow IVP/IM q 5 minutes up to 15 mg. (tritrate to pain level and systolic bp>100mm/hg

                               PEDI: 0.1 mg/kg IV may repeat once after 10 minutes

Pharmacokinetics: Onset: immediate IV Duration: 2/7 hrs IV

Functional Class: Analgesic/anesthetic gas

Mechanism of Action: CNS depressant with analgesic properties. 50/50 mixture of nitrous oxide and oxygen

Indications: Chest pain and anxiety associated with AMI or ischemia, pain secondary to trauma/burns

Contraindications: Head injruy with AMS, thoracic trauma suspicious of pneumothroax, pt's who cannot comprehend verbal instructions, pt's with recent ETOH or drug use, COPD, or severe ABD pain and distention suggestive of bowel obstruction

Precations: Use in well-ventilated area, pt self-administration only

Side Effects: N/V, cramps, AMS, dizziness, light-headedness, headache, hallucinations

Interactions: Enhanced CNS depression with administered with narcotics, sedatives, barbiturates, and alcohol

Dosage and route: ADULT: Self-adminstered via inhalation and titrated to effect

Functional Class: Local anesthetic 

Mechanism of Action: Provides topical anesthesia to eye by preventing the transmission of nerve impulses by inhibiting the sodium channels along a nerve pathway, thus interrupting the action potential. 

Indications: Chemical injury to eye(s) without associated foreign body

Contraindications: Hypersensitivity

Precations: Remove contact lenses prior to applications, use longer than two hours may result in corneal ulcerations

Side Effects: Blurried vision, eye sensitivity, corneal irritation

Interactions: NONE

Dosage and route: ADULT: 1-2 drops of a 0.5 % solution in eavh affected eye q 5 minutes PRN

Functional Class: Adsorbent 

Mechanism of Action: A fine black powder that acts by binding and adsorbing ingested drugs/toxins/chemicals present in the gastrointestinal tract. This inhibits their adsorption and thus, bioavailability. It acts as an efficient adsorber due to its large surafce area. Once bound, the combined complex ia excreted from the body in the feces

Indications: Acute poison ingestion

Contraindications: Poisonings by cyanide, mineral acids, caustic alkalis, organic solvants, iron, ethanol, methanol

Precations: Protect airway and monitor mental status nd vitals. Use caution in pt's with an AMS unless a nasogastric tube is in place and the airway is protected

Side Effects: N/V, ABD cramps, ABD bloating, constipation or diarrhea

Interactions: Do not administer at the same time as syrup of ipecac. Ipecac will nullify the effetcs of activated charcoal. 

Dosage and route: 1 g/kg mixed with 6-8 oz water to form a slurry PO/NG/OG

Functional Class:  Amyl Nitrate: Nitrate  Sodium Nitrate: Nitrate  Sodium Thiosulfate: Sequestrant

Mechanism of Action: Cyanide (CN) binds to iron (Fe) in mitrochondria disrupting their ability to enter the citric acid cycle associated with aerobic metabolism  and thus the cell does not produce as adequate amount of ATP. Amyl nitrite and sodium nitrite oxidize the Fe in hemoglobin creating methemoglobin,  which is unable to bind to oxygen. CN then is able to bind to the methemoglobin instead of the Fe in the mitrocondira creating cyanmethemoglobin. Sodium thiosulfate then converts the cyanmethemoglobin into thiocyanate, sufute, abd hemoglobin. The thiocyanate and sulfite are then excreted

Indications: Cyanide poisoning 

Contraindications: NONE

Precations: Hypotension

Side Effects: Nitrates: Hypotension  Sodium Thiosulfate: N/V, arthralgias, timmitus, muscle cramps.

Dosage and route: ADULT:  Amyl Nitrite: Inhalation from crushed ampule until IV is established 

                                                     Sodium Nitrite: 300 mg slow IVP over 5 minutes

                                              Sodium Thiosulfate: 12.5 g IV infused over 15 minutes

If symptoms persist after 20 minutes administer: Sodium Nitrite 150 mg slow IVP over 5 minutes

                                                                        Sodium Thiosulfate: 6.25 g IV infused over 15 minutes

Functional Class: Vitamin, Antidote

Mechanism of Action: hydroxocobolamin is the precursor to vitamin b12(cyancobolamin). When exposed to hydroxocobolamin, the cyanide attaches itself to form vitamin B12. It is then safely excreted in urine.

Indications: Treatment of known or suspected cyanide poisoning

Contraindications: Hypersensitivity to any component of the medication (including cobalt)

Precations: Transient severe HTN secondary to infusion

Side Effects: HTN, pruritis, headache, chromaturia (up to 5 weeks)

Interactions:  Due to incompatibilities (particulate formation), the following medications need to be run through different tubing (seperate from hydroxocobolamin): Diazepam, dobutamine, dopamine, fentanyl, nitroglycerin

Dosage and route: ADULT: 1 kit (5 G) infusion over 15 minutes. May repeat giving 1 additional kit (5 G) over 15 minutes to  hours if needed based on symptoms. 

Administration Procedure (per kit)

1: Reconstitute each of the 2.5 g vitals with 100 ml NS

2: Repeatedly invert vial for 30 seconds to reconstitute; do not shake

3: Administer contents of first vital (2.5 g/100ml) over ~7.5 minutes

4: Administer contents of second vial (2.5g/100ml) over ~7.5 minutes

Functional Class: Benzodiazepine antagonist 

Mechanism of Action: Competitive inhibition of benzodiazepine receptors in the CNS. It blocks both the sedative and anticonvulsant actions of benzodiazepines 

Indications: Reversal of effects from EMS adminstered benzodiazepines 

Contraindications: Benzodiazepine overdose not caused by EMS administration. Epileptic pt's receiving prolonged benzodiazepine treatment. 

Precations: May cause benzodiazepine withdrawal symptoms (including life threatening seizures) in benzodiazepine dependant/ addicted pt's. Seizures may also be present in pt's takingother seizure promoting medications or those patients prone to seizure activity. Monitor pt's for resedation due to short half-life of flumazenil

Side Effects: Emotional lability, headache, seizures. 

Interactions: Not known

Dosage and route: ADULT: 0.2 mg IV over 30 seconds 

Functional Class: Atropine: Parasympatholytic; Pralidoxime Chloride: Cholinesterase reactivator

Mechanism of Action: Atropine counters the parasympathetic response from muscarinic receptor over-stimulation associated with organophosphate and nerve agent poisioning , thus alleviating "SLUDGEM" symptoms

Pralidoxime chloride reactivates acetylcholinesterase by binding to it and subsequently releasing the phosphoryl group associated with the poisioning. 

Indications: Organophospate and nerve agents poisioning in MCI's

Contraindications: None

Precations: Mark-1 kits offer no prophylactic protection and should be administered only if signs and symptoms are present. Mark-1 kits do not treat fasiculations associated with nicotinic receptor overstimulation

Side Effects: Dry mouth, flushing, pupil dilation, tachycardia

Dosage and route:   Each kit contains: Atropine 2 mg; pralidoxime chloride 600 mg. Minor initial symptoms: One mark-1 kit Im via autoinjector. If severe symptoms appear within 10 minutes of first dose, administer an additional mark 1 kit. If severe symptoms present initially administer a mark-1 kit vIm via autoinjector. 

Remember: Tube one (atropine) is always administered before tube two (pralidoxime chloride). Diazepam is the drug of choice for treating fasiculations

Pharmacokinetics:

Functional Class: Narcotic Antagonist

Mechanism of Action: Compets for, and displaces, narcotic molecules from opiate receptors in the brain. 

Indications: Opiate overdose,  coma of unknown origin

Contraindications: Known hypersensitivity

Precations: use caution on narcotic physically-dependent patients as naloxone can cause abrupt reversal of narcotic effects

Side Effects: N/V, HTN, Ventricular arrhythmias, tachycardia, hyperventilation, tremors, seizures. 

Interactions: May cause narcotic withdrawal in the narcotic-dependent patient so administeronly enough to reverse respiratory depression

Dosage and route: ADULT: 0.4-2 mg IVP/IM/SQ/ET (double the dose if adminstered via ET) q 2-3 minutes to a max of 10 Mg

                               PEDI: 0.1 mg/kg IVP/IO/IM/SQ.ET (double the dose if administered via ET) q 2-3 minutes to a max of 10

Pharmacokinetics:  Onset: 2-10 minuyes IM/ET, > 2 minutes IV. Duration= 20-120 minutes Half-life= 60-90 Minutes

Functional Class: Antidysrhythmic

Mechanism of Action: A naturally occuring nucleoside that decreases conduction through the AV node and interrupts AV and SA re-entry pathways thus restoring normal sinus rhythm in patients with SVT

Indications: SVT refactory tp vagal maneuvers including Wolff-parkinson-white (WPW). Symptomatic monomorphic wide complex tachycardia with regular rhythm

Contraindications: 2nd and 3rd degree AV heart blocks, symptomatic bradycardia, sick sinus syndrome, hypersensitivity

Precations: Place pt in semi-fowlers position as pt's will typically develop arrhythmias at the time of conversion. Use cautiously in pt's with asthma

Side Effects: Syncope, dizziness, dyspnea, N/V, headaches, palpitations. CP, hypotnsion, and dysrhythmias. side effects are usuallly self-limiting dur to short half-life

Interactions:  Pt's taking caffeine orxanrhines ( aminophylline or theophylline) may require larger doses at these drugs antagonize adenosine. pt's on dipyridamole (persantine) and carbamazepine (tegretol) may need smaller doses of adenosine as these drugs potentiate adenosine's effects

Dosage and route: ADULT: 6 MG IVP followed by a 10-20 mL NS flush. If no conversion after 1-2 minutes administer 12 mg rapid IVP followed by a 10-20 mL NS flush

                               PEDI: 0.1 mg/kg IVP/IO (max single dose is 6 Mg) may repeat only once in 1-2 minutes ay 0.2 mg/kg (max second dose is 12 mg)

Pharmacokinetics:  Onset: rapis, Half-life= approx. 10 minutes

Functional Class:  Class 3 antidysrthythmic (Potassium Channel Blocker)

Mechanism of Action:  Amiodarone is a unique class 3 antidysrthythmic that acts directly on all cardiac tissue. It prolongs the duration of the action and refactory period (by blocking potassium channels) without significantly affecting the resting membrane potential. It also blocks sodium channels. The IV form relaxes vascular smooth muscle, descreases peripheral vascular resistance and increase coronary blood flow. Additionally, it blocks the effects pf sympathetic stimulation

Indications: Life-threatening ventricular and supraventricular dysrhythmias (VF, VT, A-Fib, A-Flutter, SVT, WPW)

Contraindications: Hypersensitivity, cardiogenic shock, severe sinus bradycardia, AV block

Precations: Use with caution in severe liver disease, pregnancy, nursing mothers,

Side Effects: CHF, angioedema, hypotension, AV block, hepatotoxicity, cardiogenic shock, fatigue, bradycardia, sinus arrest, premanant blindness, N/V, prolongs the QT interval

Interactions: Imcreased digoxin levels and enhances pharmacological effects of procainamide, lidocaine, quinidine, and oral anticoagulats. Concurrent use of calcium channel blockers, beat blockers, fentanyl, or cimetidine may potentiate sinus bradycardia

Dosage and route: ADULT: Pulse: 150 mg (in 50-100 mL of NS) IV infusion over 10 minutes. may repeat dose once after 10 minutes

                                         Pulseless: 300 MG IVP, repeat in 3-5 minutes at 150 mg IVP

                                Maintenance infusion: 1 mg/min over the next 6 hours

PEDI: 5 mg/kg IV/IO

Digoxin (Lanoxin)

Functional Class: Cardiac Glycoside

Mechanism of Action: Increases cardiac contractile force and cardiac output. Reduces edema associated with CHF by reducing left ventricular diameter and decreasing venous pressure thereby hastening the reduction of peripheral and pulmonary edema. Slows AV conduction reducing rapid atrial rates in A-Fib and A-Flutter

Indications: To slow ventricular response in A-Fib or A-Flutter, third line choice for SVT

Contraindications: VF and/or any pt with signs and symptoms of digitalis toxicity

Precations: Monitor for signs of digitalis toxicity. Pt's recently recovering from a MI. Do not administer calcium to pt's receiving digitalis. Avoid electrical cardioversion if pt is receiving digoxin unless condition is life threatening.

Side Effects: N/V, arrhythmias, xanthopsia

Interactions: Amiodarone increases serum digoxin levels

Dosage and route: ADULT: 10-15 mcg/kg IVP loading dose

Functional Class: Class 4 antidysrhythmic (Calcium Channel Blocker)

Mechanism of Action: Inhibits calcium ion influx through slow channels into cells of myocardial and arterial smooth muscle. This causes intracellular calcium to remain at sub-threshold levels that are insufficient to stimulate cell excitation and contraction. It reduces peripheral vascular resistance by inhibiting the contractility of vascular smooth muscle much causes dilation of the coronary arteries. It also inhibits coronary artery spasm. Diltiazem also slows SA and AV node conduction without affecting atrial action potential

Indications: SVT refractory to adensoine, Rapid A-Fib or A-Flutter

Contraindications: Hypersensitivity, sick sinus syndrome, 2nd and 3rd degree AV blocks, hypotension, WPW, wide complex tachycardia

Precations: Avoid in pt's receiving oral beta-blockers. Monitor for hypotension resulting from peripheral vasodilation. USe caution in CHF

Side Effects: Bradycardia, CP, hypotension, syncope, CHF, dysrhythmias, N/V, headache, sweating, dizziness and dyspnea, 2nd and 3rd degree AV block, Palpitations.

Interactions: Beta-blockers may increase digoxin levels

Dosage and route: Bolus: 0.25 mg/kg slow IVP, may repeat in 15 minutes at 0.35 mg/kg slow IVP

                                 IV infusion: 5-15 mg/hr, titrate to heart rate

Functional Class: Class lb antidysrthythmic (Sodium Channel Blocker)

Mechanism of Action: Supresses depolarization and automaticity in the His-purkinje system. Also supresses ventricular ectopy and increases the ventricular threshold for dysrthythmias; however it decreases the ventricular threshold for defibrillation.

Indications: VF, pulseless VT, VT with a pulse, Malignant PVC's  (More than 6 unifocal PVC's a minute, multifocal PVC's. Couplets, R-on-T phenomena)

Contraindications: hypersensitivity, supraventricular dysrthythmias, untreated sinus bradycardia, 2nd degree mobitz 2 AV block, 3rd degree AV block, Stokes-adams syndrome.

Precations: CNS depression may occur in doses greater that 300 mg/hour, liver or renal disease, CHF, hypovolemia, shock, myasthenia gravis

Side Effects: AMS including confusion, bradycardias, hypotension, seizures

Interactions: USe cautions when administered with beta blockers or procainamide as drug toxicity may result

Dosage and route:

ADULT: Cardiac arrest: 1-1.5 mg.kg IVP, repeat at half the initial dose (0.5-0.75 mg/kg IV push) q 5 minutes up to a max of 3mg/kg. Note: A single dose of 1.5 mg/kg IVP in cardiac arrest is acceptable if moving on to amiodarone. ETT: 2-4 mg/kg q 3-5 minutes

   With pulse: 1-1.5 mg/kg IVP, repeat at half the initial dose (0.5-0.75 mg/kg IVP) q 5-10 minutes up to a max of 3 mg/kg

Adult IV infusion: 1-4 mg/minute using the "+1 rule"

 PEDI: Cardiac arrest: 1mg/kg IVP/IO/ETT

Functional Class: Clas 2 antidysrthythmic (Beta blocker)

Mechanism of Action: Selective inhibitor of Beta-1 adrenergic receptors located on cardiac muscle. Completely blocks beta-1 receptors, with little or no effect on beta-2 receptors at doses less than 100 mg. Redcues heart rate, cardiac output at rest and during exercise, and lowers BP.

Indications: CP associated with AMI, ACS, Angina pectoris, SVT

Contraindications: Hypersensitivity, sinus bradycardia, heart block greater that 1st degree(except pt's with a functioning artificial pacemaker)., cardiogenic shock (BP<100 mmHg), uncompensated cardiac failure, pregnancy (2nd and 3rd thrimesters), asthma, COPD.

Precations: impaired hepatic or renal functions, CHF controlled by digitalis or diuretics, do not mix with IV calcium channel blockers

Side Effects: Bronchospasm, bradycardia, palpatations, edema, CHF, reduced peripheral circulation, drowsiness, insomnia.

Interactions: Drugs with slow AV conduction such as digoxin as the effects may be cumulative with beta-blockers. Glucagon: metoprolol may blunt the hyperglycemic action of glucagon. Verapamil or diltiazem may have synergistic pharmacological effects when taking concurrently with beta-blockers

Dosage and route: 5 mg slow IVP (over 2-5 minutes) q 5 minues x3 (max of 15). Acute MI: Maintain systolic BP >100 and heart rate >60/min. SVT: Maintain heart ratw 90-100/minute

Functional Class: Clas IA antidysrthythmic (Sodium Channel Blocker)

Mechanism of Action: Suppresses ventricular ectopy by reducing the excitability of the myocardium to electrical stimulation, and reducing conduction velocity in the atria, ventricles and the His-Purkinje system. It also increases the duration of the refractory period. Procainamide also produces peripheral vasodilation. 

Indications: Recurrent VF and pulseless VT refacotry to lidocaine., amiordarone and magnesium, VT, Rapid A-Fib, A-Flutter WPW. 

Contraindications: Hypersensitivity, 2nd and 3rd degree AV blocks, myasthenia gravis

Precations:  Do not administer for PVC's associated with bradycardia, hypotension, CHF, MI, hepatic or renal insufficiency 

Side Effects: Bradycardia, AV block, tachycardia, hypotension, VF, seizures, N/V, confusion, thrombocytopenia, prolonged QRS at QT duration

Interactions: Use caution when patients in on an antihypertensive agent

Dosage and route: ADULT:  Initial IV infusion: 20-50 mg/min up to a max of 17 mg/kg

                                 Maintenance IV infusion: 1-4 mg/min

                               PEDI: 15 mg/kg IV over 20-60 minutes 

Preparation: Mix 1 gram/50 mL NS

Functional Class: Class 4 antidysrhythmic (calcium Channel Blcoker)

Mechanism of Action: As a calcium-ion antagonist verapamil causes a relaxation of vascular smooth muscle and slows conduction through the AV node. This prevents the reentry mechanism of SVTs and decreases the rapid ventricular response seen in A-Fib/Flutter. Additionally, the myocardial oxygen demand is decreased due to its negative inotropic effects (vasodilation)

Indications: SVT refactory to adenosine 

Contraindications: WPW syndrome, hypotension, cardiogenic shock, VT

Precations:  Systemic hypotension can occur following verapamil. Calcium chloride can be used to prevent hypotension as well as CCB overdose

Side Effects: Syncope, dizziness, N/V, bradycardias, hypotension, heart blocks, asystole, headaches. 

Interactions: Do not administer to patients on IV beta-blockers as CHF, bradycardia, and asystole may develop. 

Dosage and route:  2.5-5 mg slow IVP (over 1-2 minutes) repeat at 5-10 mg prn in 15-30 minutes. Maximum dose 30 mg 

Functional Class: Anti-emetic

Mechanism of Action: A serotonin receptor antagonist that prevents acute emsis by blocking serotonin receptors in the chemoreceptors triggering zone (CTZ) and afferent vagal neurons in the upper GI tract. It does not have prophylactic properties, and therefore has no effect on delayed emesis. It will not cause extrapyramidal syndrome (EPS) or acute dystonic reactions because it does not block dopamine receptors

Indications: Acute N/V

Contraindications: Known hypersensitivity

Precations: Use cautiously with other drugs that prolong the QT interval (E.g amiordarone) or in patients with a known condition of prolonged QT interval, as lethal dysrhythmias (E.g Torsades de pointes) may result.

Side Effects: Headache, diarrhea, dizziness, fever, drowsiness, prolonged QT

Interactions:  May form precipitate when mixed with alkaline solutions (e.g sodium bicarbonate)

Dosage and route: ADULT: 4 MG slow iv/im, may repeat once after 10 minutes

                               PEDI: .01 mg/kg (max single dose 4 mg)

Functional Class: Anti-emetic, phenothiazine, antihistimine, anti-cholinergic

Mechanism of Action: Decreases nausea by blocking dopamine and H1 receptors associated with vagal stimulation of the emesis center in the medulla. It also decreases the effects of muscarinic receptors in the GI thus decreasing gastroc secretions and peristalsis

Indications: N/V, motion sickness

Contraindications: Children > 2 Y/o with emesis due to respiratory depression, hypersensitivity to phenothiazines, hypotension, use in conjuction with CNS depressants, decreased level of consciousness.

Precations: Use of MAOI's, use any anticholinergics, preganancy and lactating mothers

Side Effects: Sedation, dystonic reaction, tremors, dizziness, blurred vision, diplopia, tinnitus necrosis if administered SQ. Lowers seizure threshold.

Interactions: Used in conjuction with MAOI's may increase likelihood of dystonic reactions, antagonizes alpha effects of epinephrine

Dosage and route: ADULT: 6.25 mg slow IVP or 12.5 mg IM q 4 hours

                               PEDI: 0.25 mg/kg IV/IM

Pharmacokinetics: Onset= 5 minutes IV, 20 minutes IM

                                 Duration= 4-6 hours

                                Half-life= 9-16 hours

Note: May use diphenhydramine to counter acute dystonic reaction

Functional Class: Antipyretic, analgesic

Mechanism of Action: produces analgesia by elevation of the pain threshold. May block pain impulses by the inhibition of prostaglandin synthesis. Antipyretic actions result from inhibition of prostaglandins in the CNS. Does not poccess any anti-inflammatory or antiplatelet properties.  

Indications: Fever

Contraindications: Hypersensitivity to acetaminophen or phenacetin

Precations:  anemia, hepatic and renal disease, alcoholism

Side Effects: N/V, dizziness, hepatotoxicity, renal failure, hypoglycemia.

Interactions: Increased chance of hepatotoxicity when taken chronically or with alcohol, rifampin, carbamazepine, or barbiturates

Dosage and route: ADULT: 325-650 mg PO/PR q 4-6 hours

                                 PEDI: 15 mg/kg PO/PR q 4-6 hours

Functional Class: Antipyretic, analgesic, NSAID

Mechanism of Action: Ibuprofen inhibits cyclooxygenase (COX) decreasing production of prostaglandins thus decreasing pain sensation, fever, and inflammation.

Indications: fever

Contraindications: hypersensitivity, children less than six months old, GI intolerence such as colitis.

Precations: Pregnancy, peptic ulcer disease, pulmonary edema, HTN

Side Effects: Nausea, abd pain, diarrhea, dizziness, tinnitus

Interactions:  Reduces the effectiveness of loop diuretics and ACE-inhibitors. Increases hemorrhage potential when given with ASA

Dosage and route: ADULT: 200-600 mg PO/PR q 6-8 hours

                               PEDI: 10 mg/kg PO/PR q 6-8 hours

Functional Class: Benzodiazepine

Mechanism of Action: By intensifying the activity of GABA, it suppresses the spread of seizure activity through the motor cortex ofthe brain. it is effective in the management of stress, anxiety, and alcohol withdrawal due to its sedative properties. Additionally, it is effective as a premedication for minor orthopedic procedures due to its skeletal muscle relaxant properties, and as a premedication for cardioversion because it produces amnesia.

Indications: Seizures (Status epilepticus), to induce sedation prior to painful procedures, acute anxiety

Contraindications: known hypersensitivity, shock, coma, acute alcohol intoxication

Precations: Can cause local irritation, therefore, use large vein when possible. seizure activity may reoccur due to its lipid solubility. Use with caution in patients with myasthenia gravis, impaired renal or hepatic function, obstetrical patients, and the elderly.

Side Effects: Hypotension, drowsiness, tachycardia, ataxia, amnesia, slurried speech, edema, headache, dizziness, N/V, blurred vision, respiratory depression

Interactions:  Effects are enhanced when used in conjuction with other CNS depressants and alcohol. Cimetidine may increase diazepam plasma levels

Dosage and route: ADULT: 5 mg IVP, may repeat at 2.5 mg q 5 minutes prn, max 10mg

                               PEDI: 0.1-0.25 mg/kg IV/IO, max single IV/IO dose 10 mg may repeat once after 5 minutes.

                                        0.5 mg/kg PR, max single PR dose 20 mg may repeat once after 5 minutes

Note: Flumanzenil is an antagonist to diazepam

Functional Class: Benzodiazepine

Mechanism of Action: Most potent of the benzodiazepines. It acts as an anxiolytic, sedative, hypnotic, and skeletal muscle relaxant. It intensifies GABA. Because of its short half-life it is perferred benzodiazepine for the treatment of pediatric seizure.

Indications: Seizures (status epilepticus), to induce sedation prior to painful procedures, anxiety

Contraindications: Hypersensitivity to benzodiazepine, acute narrow-angle glaucoma, coma, shock, acute alcohol intoxication

Precations: Renal or hepatic impairment, myasthenia gravis, COPD

Side Effects: Anterograde amnesia, sedation, HTN or hypotension, blurried vision, N/V, confusion

Interactions:  Effects of lorazepam will be increased when used in conjuction with other CNS depressantsm alcohol, or cimetidine

Dosage and route: ADULT: 1-2 mg slow IVP or IM q 5 minutes, max 8 mg

                               PEDI: 0.1 mg/kg slow IVP or IM, max sungle dose 2 mg may repeat once every 5 minutes

Pharmacokinetics:
onset= 1-5 minutes IV, 5-10 minutes IM

Half-life: 10-20 hours

Functional Class: Benzodiazepine (Short acting)

Mechanism of Action: This short-acting benzodiazepine intensifies activity of GABA. It also has CNS depressant, anticonvulsant and anterograde amnestic properties. It also relaxes skeltal muscles and induces sleep

Indications: Seizures (Status Epileticus), to induce sedation prior to painful procedures

Contraindications: Hypersensitivity to benzodiazepines, acute narrow-angle gluacoma, coma, shock, acute alcohol intoxication

Precations: Use with caution in patients with COPD, CHF and/or renal failure.

Side Effects: N/V, blurried vision retrograde amnesia, excessive amnesia, apnea, hypotension, PVC's

Interactions:  Prolonged respiratory depression when given in conjuction with other CNS depressants such as alcohol, cimetidine(tagamet) increases plasma levels of midazolam.

Dosage and route: ADULT: 1.0-2.5 mg slow IVP or IM q 5 minutes until seizure abolished

                               PEDI: 0.1 mg/kg slow IVP or IM, max single dose 6 mg, may repeat once after 5 minutes

Pharmacokinetics: Onset= 3-5 minutes IV

                              Duration= less than 2 hours IV

                              Half-life= 1-4 hours

Functional Class: Electrolyte

Mechanism of Action: Replaces elemental calcium, which is essential for regulating excitation threshold of nerves and muscles. Calcium is also essential for blood clotting mechanisms, maintenance of renal function, and bone tissues. Calcum increases myocardial contractile force and ventricular automaticity. Additionally serves as an antidite for magnesium sulfate and calcium channel blocker toxicity. Calcium chloride has three times as much elemental calcium than calcium gluconate.

Indications: Calcium channel blocker toxicity/overdose, prophylactically prior to IV calcium channel blockers, acute hyperkalemia, acute hypocalcemia, acute hypermagnesemia

Contraindications: VF, hypercalcemia, digitalis toxicity

Precations: FLush IV line between calcium chloride and bicarbonate as precipitate will form. Monitor for tissue necrosis at injection site.

Side Effects: Arrhythmias including bradycardia or cardiax arrest, syncope, N/V, hypotension, necrosis with extravasation.

Interactions:  Calcium chloride will precipitate whe used in conjunction with sodium bicarbonate. Toxicity with digitalis. May antagonize the effects of calcium channel blockers

Dosage and route:  Hyperkalemia and calcium channel blocker overdose: 8-16 mg/kg of a 10% solution slow IVP q 10 minutes prn.

Prophylactic treatment prior to calcium channel blocker: 2-4 mg/kg of a 10% solution slow IVP

Functional Class: Electrolyte

Mechanism of Action: Physiologic calcium channel blocker and also blocks neuromascular transmission. Hypomagnesemia can cause cardiac dysrhythmias. It is also a CNS depressants effective in the management of seizures associated with eclampsia or pregnancy. It does this by decreasing the amount of acetylcholine liberated from motor nerve terminals. Magnesium is necessary for many biological processes and plays a role in the transmission of electrical impulses.

Indications: Eclampsia, torsades de pointes, anxiety

Contraindications: do not administer to any patient with heart block, shock, persistant HTN, hypocalcemia, or myocardial damage

Precations: Renal failure, patients taking digoxin, concomitant use of other CNS depressants or neuromuscular blocking agents.

Side Effects: Hypotension, sedation, confusion, N/V, bradycardia, pruritis, arrhythmias, decreased deep tendon reflexes, respiratory depression/paralysis, drowsiness, muscle weakness, complete heart block. When used prior to delivery, it can cause fetal hypoxia, asphysia, arrhythmias, and possible fetal intracranial bleeding.

Interactions:  Can cause cardiac conduction abnormalities when used in conjuction with digitalis.

Dosage and route: Eclampsia: 2-4 grams slow IVP in 10 mL NS over 5 minutes

                                Torsades de Pointes: 1-2 grams IVP diluted in 10 mL NS

                                Asthma: 2 grams slow IVP in 100 mL NS over 10 minutes

Functional Class: Electrolyte, Alkalinizing Agent

Mechanism of Action: GIven IV, it immediately raises the pH of blood plasma by buffering excess H+ cations. excess bicarbonate ions are excreted in the urine, thus rendering the urine less acidic

Indications: Severe acidosis (refractory to hyperventilation), tricyclic antidepressants )TCA) overdose, barbiturate overdose, known hyperkalemia

Contraindications: None in the emergency setting

Precations: Not recommended for routine use in cardiac arrest, dosage must be specific to prevent metabolic alkalosis and is thus weight-based.

Side Effects: Severe tissue damage if extravasation occurs. May produce paradoxical acidosis that can depress cerebral and cardiac function. May cause extracellular alkalosis, which may reduce the concentration of ionized calcium, decrease plasma potassium, and induce a left shift of the oxyhemoglobin curve which may inhibit oxygen release to the tissues and induce malignant arrhythmias.

Interactions:  Will deactivate most catecholamines and vasopressors. Sodium Bicarbonate will precipitate when used in conjuction with calcium chloride

Dosage and route: 1 mEq/ kg IVP/IO oush, repeat at 0.5 mEq/kg q 10 minutes prn

Functional Class: Hormone

Mechanism of Action: Glucagon is a protein secreted by the alpha cells of the islets of langerhans in the pancreas. It is used to convert stored glycogen in the liver to glucose. Additonally, it inhibits the synthesis of glycogen from glucose. It enhances conventional treatments for calcium channel blocker and beta-blocker overdose by producing a + inotropic and chronotropic effect on the heart via stimulation of glucagon specific receptors in the myocardium.

Indications: Hypoglycema w/o IV access, adjuvant treatment of toxic effects of CCB and beta-blockers

Contraindications: Hypersensitivity

Precations: Glucagon is only effective if there are sufficient stores of glycogen in the liver

Side Effects: hypotension, headache, N/V, dizziness, hyperglycemia, hypokalemia

Interactions:  none

Dosage and route: ADULT: hypoglycemia: 1mg (Unit) IM/SQ q 10-20 min, CCB/beat-blocker overdose: 2-5 mg IM/SQ/IV

                               PEDI: 0.01-0.1 mg/kg IM/SQ

Pharmacokinetics:  Onset= 5-20 minutes, Duration=1-1.5 hours

Functional Class: Hormone

Mechanism of Action: By direct action on myofibrils, it causes phasic contraction of the uterine smooth muscle characteristics of normal delivery. It also promotes milk "Letdown" in nursing mothers. Effective in inducing labor and uterine contractions following delivery, therby controlling postpartum hemorrhage.

Indications: postpartum hemorrhage

Contraindications: hypersensitivity and prior to delivery of the fetus. Administration prior to delivery may cause fetal hypoxia, asphyxia, and dysrthythmais

Precations: can cause over stimulation of the uterus resulting in uterine rupture thus vitals and uterine tone should be monitored

Side Effects: Hypotension, anxiety, N/V, dysrthythmias, HTN, seizures, dyspnea, coma in motherm intracranial bleeding

Interactions:  Can cause HTN when used in conjuction with vasoconstrictors.

Dosage and route: Bolus: 3-10 units IM or

                               Infusion: 10-20 units in 1000 mL NS vis 60 gtts/mL set and titrate to effect

Functional Class: Hormone (ADH), vasopressor

Mechanism of Action: Vasopressin possesses pressor and autidiuretic properties. It increases nephron distal tube reabsorption of water. In unnaturally high doses, it acts as a non-adrenergic vasoconstrictor by stimulation of smooth muscle receptors. It is used as an alternative to EPI during CPR

Indications: Cardiac arrest

Contraindications: Chronic nephritis, ischemic heart disease, PVC's first stage of labor

Precations: use w/ caution in pt's w/ epilepsy migraine, asthma, heart failure, or angina pectoris

Side Effects: N/V, adb cramps, HTN, bradycardia, PAC's, MI

Interactions:  EPI, heparin, alcohol, phenytoin, neostigmine, thiazide diuretics, carbamaepine.

Dosage and route: 40 Units IVP/IO (single dose only)

Note: May replace first or second dose of EPI in cardiac arrest

Functional Class: Parasympatholytic

Mechanism of Action: Blocks muscarinic acetylcholine receptors thus inhibitingparasympathetic stimulation. By blocking vagal impulses to the heart it accelerates SA node discharge, enhances conduction through the AV junction, and increases a cardiac output. It is also a potent bronchodilator when bronchoconstriction is caused by increased parasympathetic tone.

Indications: Symptomatic bradycardia, organphosphate/nerve agent poisoning

Contraindications: none

Precations: May worsen bradycardia associated with 2nd degree morbitz II and 3rd degree AV blocks thus consider TCP first. Use in caution in pt's w/signs and symptoms of Acute myocardial ischemia, MI, glaucoma.

Side Effects: Blurred vision, dilated pupils, dry mouth, tachycardia, drowsiness, convulsions ,HTN/hypotension, palpitations, paradoxical bradycardia (If given to slowly), AV dissociation, urinary retention

Interactions:  Antihistimines, tricyclic antidepressants, procainamide can lead to the anticholinergic effetcs of atropine

Dosage and route:  Symptomatic bradycardia= Adult: 0.5 mg IVP q 3-5 minutes max total 0.04mg/kg(normally 3mg)

Pedi: 0.02 mg/kg IVP or IO (min single dose is 0.1 mg and max is 0.5mg) repeat once if needed.

Organophosphate poisoning: Adult: 2mg IVP q 5 minutes prn PEDI: 0.05-0.1 mg/kg IV/IM(min dose of 0.1 mg and max single dose 5mg) repeat q 2-5 minutes prn

Functional Class: parasympatholytic Bronchodilator

Mechanism of Action: Acts directly on the smooth muscle of the bronchial tree by inhibiting interaction of acetylcholine at receptor sites on the bronchial smooth muscle, resulting in bronchodilation

Indications: Bronchospasm, pt's w/reversible obstructive airway disease

Contraindications: Hypersensitivity to ipratropium, atropine, soya lecithin and peanut oil

Precations: use with caution in pregnancy and lacation

Side Effects: N/V, cramps, dry mouth, blurried vision, worsening bronchospasm, drying of bronchial secretions, cough, epistaxis

Interactions:  None

Dosage and route: ADULT: 0.5 mg (500mcg) in 2.5-3 mL of NS via Neb q 6 hours

                               PEDI: 0.125-0.25 (125-250 mcg) in 2.5-3 mL of NS via Neb q 6 hours

Functional Class: Sympathomimetic bronchodilator

Mechanism of Action: Selectively stimulates beta-2 adrenergic receptors increasing bronchodilation. It produces these results by stimulating adenyl cyclase, which transforms ATP into cAMP. cAMP causes relaxation of bronchial smooth muscles. In therapeutic doses, albuterol also inhibits histamine release from mast cells, reducing mucus secretions

Indications: Bronchospasm, pt's w/reversible obstructive airway disease

Contraindications: Hypersensitivity

Precations: Consider monitoring peak expiratory flor rates (PEFR), monitor vitals and respiratory status during treatments.

Side Effects: Tremors, anxiety, HTN, tachycardia, headache, palpatations, seizures, N/V, dizziness, rash

Interactions:  Other sympathomimetic bronchodilators, beta-blockers. Use w/extreme caution with pt's on MAOI's and TCAs as potentiation may occur

Dosage and route: ADULT: 2.5 mg in 3 mL NS via aerosol Neb  prn

                               PEDI: 0.15 mg/kg in 2.5-3 mL NS via aerosol neb prn

Functional Class: Sympathomimetic

Mechanism of Action: Synthetic catecholamine which acts primarily on Beta-1 and alpha-adrenergic receptors. Balanced by Beta-2 receptors, it increases cardiac output via increased inotropic effects and decreases pulmonary wedge pressure (PWP) w/little or no effect on BP or HR. Dobutamine also increases conduction through the AV node

Indications: Short term management of CHF or cardiogenic shock, used to increase cardiac output w/o increasing rate.

Contraindications: hypersensitivity, VT

Precations: Can increase myocardial oxygen demand, can be deactivated by sodium Bicarb, preexisting HTN or A-Fib, hypotension from hypovolemia, always try volume restoration first

Side Effects: tachycardia, HTN, dyspnea, dysrthythmias, palpitations, CP, headaches, anxiety, N/V

Interactions:  absolute interaction w/ beta-blockers as they decrease dobutamine's effectiveness. Use w/extreme caution with tricyclic antidepressants

Dosage and route: 2-20 mcg/kg/min IV infusion

Preparation: mix 250 mg in 250 mL (or 500 mg in 500 mL) d5W or NS, which yields 1000mcg/mL

NOTE: dopamine is the drug of choice in cardiogenic shock

Functional Class: Sympathomimetic

Mechanism of Action: A naturally occuring neurotransmitter and catecholamine which acts on alpha and beta adrenergic receptos(dose-dependent), and dopaminergic receptors. In therapeutic dosages, dopamine maintains blood flow in the renal and mesenteric vascular beds. It is a +inotrope, therefore it increases cardiac output and systolic BP.

Indications: cardiogenic shock-hemodynamically significant hypotension (Sys. BP of 70-100 mmHg not resulting from hypovolemia), symptomatic bradycardia. 

Contraindications: Pheochromocytoma, tachydysrhthmias, VF

Precations: In doses 20mcg/kg/min or greater, its alpha effects dominate and it causes severe vasoconstriction. Monitor BP q 3-5 minutes. Can be deactivated by sodium bicarb

Side Effects: Dysthythmias, palpatations, tachycardia, bradycardia, headaches, anxiety, N/V, tissue sloughing may rsult from dopamine extravasation, dyspnea, HTN

Dosage and route:  2-20 mcg/kg/min IV infusion. Titrate to effect (BP)

2-5 mcg/kg/min- Dopaminergic effects

5-10 mcg/kg/min- Beta effects

10-20 mcg/kg/mim alpha effects

Preparation: Place 800 mg on 500 mL D5W or NS=1600 mcg/mL

place 400 mg in 250 mL D5W or NS = 1600 mcg/mL