Essential Medications

In

Emergency Medicine:

 

An Introductory Guide

 

 

Created by: Dr. Sudip Bose 

Edited by:  Dr. Rolla Sweis

Formatted for the web by: Dr. Rohit Gupta

 

Last Updated: August 2008

 

 

 

 

This guide is intended for use in the Advocate Christ Medical Center Emergency Department.  It is designed as a reference tool and not intended to be all-inclusive and not meant to define the standard of care for the clinical practice of EM. Also, this guide should not replace clinical judgment. 

 

This guide is independent from and has no affiliation with pharmaceutical companies.

 

 

 

ACLS (Advanced Cardiac Life Support) Algorithms

Airway

 

Preparation (monitors, laryngoscope/BVM, ETT/stylet/syringe, all medications, suction,

-IV, LEMON for difficult airway, rescue devices)

            -Look; Evaluate 3-3-2 rule; Mallampati; Obstruction evidence; Neck mobility

 

Preoxygenation with 100% oxygen (NO positive pressure ventilation unless desat < 90%)

            -100% O2 for 5 minutes OR 2 to 6 Full Vital Capacity breaths of 100% O2

                        -Denitrogenizes alveoli and allows much longer time before desaturation occurs.

 

Pretreatment (LOAD)

            -Lidocaine- for RAD or increased ICP

            -Opioid (fentanyl)- blunts sympathetic responses (ICP/CAD/ruptured aneurysm)

            -Atropine- 10 years old and under

            -Defasciculation- increased ICP, penetrating eye injuries

 

Paralysis (and induction, which should be done first)

 

Protection with Sellick’s

 

Position for laryngoscopy

 

Placement with Proof (capnography the gold standard)

 

Post intubation management (hemodynamics, sedation and paralysis, vent settings)

 

Pretreatment

-Lidocaine 1.5mg/kg

-Opioid (fentanyl) 3mcg/kg

-Atropine 0.02mg/kg

-Defasciculating (pan/vec) 0.01mg/kg (10% of paralytic dose)

Induction

-Etomidate 0.3mg/kg

-Midazolam 0.3mg/kg

-Ketamine 1-2mg/kg

-Thiopental 3mg/kg

Paralytics

-Succinylcholine 1.5-2.0mg/kg

-Rocuronium 1mg/kg (0.6-1.2mg/kg)

-Pancuronium/Vecuronium 0.15mg/kg

Sample sequences for 70kg adult:

Generic

Zero – 5 min:    100% oxygen

Zero:                Etomidate 20-30mg

                        Succinylcholine 100mg

Increased ICP

Zero – 5min      100% oxygen

Zero – 3min      Lidocaine 100mg

                        Vecuronium 1mg

                        Fentanyl 200mcg

Zero                 Etomidate 20-30mg

                        Succinylcholine 100mg

 

RAD/COPD

Zero – 5min      100% oxygen

Zero – 3min      Lidocaine 100mg

Zero                 Ketamine 100mg

                        Succinylcholine 100mg

 

Post Intubation – Sedation

 

Propofol

-Max dose 75mcg/kg/minute

-Adverse effect – hypotension

 

Lorazepam

-2mg IVP q 30 minutes and start infusion at 1mg/hr.  Increase infusion by 1mg/hr every 30 minutes.  Consider alternate agent if > 20mg/hr is needed due to risk of metabolic acidosis.

Consider if patient hypotensive on propofol.

 

Midazolam

-Loading Dose: 5mg IVP. Drip can be started at 2mg/hr.  Increase infusion by 1mg/hr every 15 minutes and rebolus if needed.  Max 25mg/hr

-Avoid midazolam in renal failure

-Consider if patient hypotensive on propofol

 

Fentanyl

-Loading Dose: 0.5-2mcg/kg (start low). Infusion: 25-100mcg/hr. Increase infusion by 25mcg/hr at 30 minute intervals to a max of 150mcg/hr

-Option for patients still hypotensive on benzodiazepines

 

Aminoglycoside Dosing

 

this is FYI, you can also write “PharmD to dose” on the orders…)

 

Anaphylaxis

 

Benadryl 50mg IV (up to 100mg for severe reactions) (peds 1mg/kg) is H1 blocker

 

Pepcid 20mg IV (peds 0.5 mg/kg) is H2 blocker

 

Epinephrine 1:1000 0.01ml/kg to max 0.5ml (0.3ml peds) IM (normotensive)

            -Usual initial dose is 0.3ml IM

-Give 0.1 to 0.2ml of total dose at site of antigenic exposure

-Recall that 1cc of 1:1000 epinephrine is 1mg

 

Epinephrine IV if hypotensive or respiratory failure

            - 0.3mg & if no improvementà

            -Continuous drip at 1mcg/min to 4mcg/min (peds 0.1mcg/kg/min to 1.5mcg/kg/min)

 

Racemic epinephrine neb 0.5cc in 2.5ml NS to temporize airway management

 

Albuterol and atrovent (continuous neb may be necessary) if pt wheezing

 

Solu-medrol 125mg to 250mg (peds 1-2mg/kg IV) or Prednisone 60mg PO (peds 1mg/kg)

            -IV corticosteroids confer no greater benefit than PO

-Often ordered incorrectly:  Solu-medrol is IM/IV.  Prednisone is PO tablets.  Prednisilone (Orapred, Pediapred, Prelone) is PO syrup for pediatric dosing

 

Glucagon 1mg adults and 0.5mg peds w/ prn infusion 1 to 5 mg/hr

            -useful in refractory cases, especially in patients on beta-blockers

Analgesia (systemic)

 

Acetaminophen (Tylenol) 650-1000mg PO q4h (peds: 15mg/kg q4h)

            -Mild to moderate pain, not an anti-inflammatory, few CI’s (liver disease)

            -Works best combined with an NSAID, opioid-sparing agent

 

Ibuprofen (Motrin) 400-800mg PO q6-8h (peds: 10mg/kg q6-8h)

            -Mild to moderate pain, anti-inflammatory, opioid-sparing agent

            -More problems than Tylenol (GI upset, bleeding, renal damage)

                        -Avoid in known renal disease, PUD, elderly

 

Ketorolac (Toradol) 30mg IM or IV q6h (peds: 0.5mg/kg q6h)

            -The only FDA approved parenteral NSAID

            -More expensive and no more effective than PO NSAIDs

            -Avoid in elderly, renal disease and dehydration or loop diuretics (pre-renal)

            -No more than 5 days

            -Acute pain: 60mg IM unless < 65 years of age 30mg IV (max dose 120mg/24hrs)

 

Morphine 0.1mg/kg IV or IM (may start with 4mg and titrate to effect) lasts 2-4hrs

            -May cause hypotension

 

Fentanyl 0.5-2mcg/kg (may start with 50-100mcg and titrate to effect) lasts 30-45min

            -Beware chest wall rigidity

            -Avoid in children less than 4 months old

            -Short acting so good for abdominal pain of unknown etiology

 

Hydromorphone (Dilaudid) 1-4 mg IM/SC/IV

            -There may be a particular role in sickle cell disease

 

PO narcotic-analgesic combinations

            -Norco (hydrocodone/APAP 5-10/325) 1-2 tabs q4-6h prn

            -Percocet (oxycodone 5mg/APAP 325mg) 1-2 tabs q6h prn

 

-Tylenol w/codeine (APAP 300mg/codeine 15mg #2, 30mg #3, 60mg #4) 1-2 tabs q4h

            -Elixir for peds has 12mg codeine and 120mg APAP per tsp

-T#3 shown in studies to be no more effective than APAP alone

 

-Darvon 65mg PO q4h prn

-Used by some for liver disease pts (contains no APAP)

 

ALL narcotics may cause N/V.  May give prophylactic antiemetics.

 

Antibiotics

 

Must know Christ Medical Center Protocols well (ie sepsis protocol antibiotic regimen; pneumonia protocol)

 

Write for standing orders (ie. repeat doses q 6 hrs, etc) if patient will be signed out or be in the emergency room for several hours or make sure PharmD is aware to repeat further dosing.

 

Do NOT use in pregnancy:

 

Erythromycin estolate, lindane (Kwell), Flagyl (safe for use in 2^nd and 3^rd trimesters), Macrodantin (contraindicated in 3^rd trimester), quinolones, sulfonamides (safe in 1^st and 2^nd trimesters, avoid in 3^rd trimester due to possible kernicterus), tetracycline, doxycycline, Bactrim/Septra (kernicterus in 3^rd trimester, category C in 1^st and 2^nd trimester due to interference with folic acid metabolism)

 

TYPE OF INFECTION	FIRST LINE	ALTERNATIVE	NOTES
Appendicitis	Unasyn 1.5GM-3GM IV q6h or Zosyn 3.375GM IV q6H	Cipro 400mg IV q12H + Flagyl 500mg IV q8H PEDS: Cefoxitin: 25mg/kg/dose q 6 hours (give in consultation with surgeon)
Bites (outpatient tx)	Cat: Augmentin 875mg bid       Dog: Augmentin 875mg bid                   Human: Augmentin 875mg bid	Ceftin 500mg q12h OR Doxy 100mg bid   Clinda 300mg qid (peds 10mg/kg q 6h) PLUS [(adults) Cipro 500mg PO qd /(peds) Bactrim 5ml susp/10kg (up to 20 ml)/dose PO bid]   Clinda 300mg qid (peds 10mg/kg q 6h) PLUS [(adults) Cipro 500mg PO qd /(peds) Bactrim 5ml susp/10kg (up to 20 ml)/dose PO bid]	-Duration:  3-5 days prophylaxis (not needed if no infection 48 hours after bite).  10-14 days if infected -Remember RATS [Rabies, Antibiotics, Tetanus prophylaxis, Soap (irrigation)] -Give first dose in ED
Bites (inpatient tx-- includes cat/dog/human)	Unasyn 1.5g IV q6h OR Zosyn 3.375g IV q 6h	Clinda 900mg IV q8h PLUS Cipro 400mg q12h OR Bactrim 5mg/kg IV q 8h
Bowel perforation/Peritonitis	Unasyn 1.5g IV (3g if >80kg) q6h OR Zosyn 3.375g IV q6h	Cipro 400mg IV q12h PLUS Flagyl 500mg IV q6h
Breast Abscess	Keflex OR Dicloxacillin 500mg qid x 10-14d for mild cases Ancef 1g IV OR Nafcillin 2g IV OR Vanco 15mg/kg IV (max 1g)	If MRSA Possible: TMP/SMX  2 DS PO bid or Vanco 1gm IV (if MRSA)	I and D (probably should be done by surgery)
Bronchitis (smoker or chronic bronchitis/COPD exacerbation) (outpt)	Bactrim DS 1 tab bid OR Doxy 100mg bid OR Biaxin 500mg BID or Cefdinir (Omnicef)300mg BID
Bronchitis (acute episode in nonsmoker or young smoker without chronic bronchitis:			No antibiotics.  Usually viral.  Treat symptoms with Albuterol inhaler.
Cellulitis	Keflex 500mg qid+/-  Bactrim DS 2 tabs po BID  (community MRSA)	Clinda 300-450mg PO tid	Duration: until 3 days after inflammation disappears Note: increased resistance seen with clinda for community MRSA
Diabetic foot	Unasyn 1.5g IV (3g if >80kg) q 6h or Zosyn 3.375gm IV q6h  if late stage	Clinda 600mg IV q 8h PLUS Cipro 400mg q12h
Cholecystitis/Cholangitis	Unasyn 3g IV q 6h OR Zosyn 3.375g IV q 6h (give in consultation w/surgeon)	Cipro 400mg IV q 12h PLUS Flagyl 500mg IV q6h
Clostridium Difficile	MILD/MODERATE (WBC < 15, CR <1.5) Flagyl 500mg PO tid x 10-14d   SEVERE (WBC > 15, Cr>1.5): Vancomycin 125mg po QID X 10-14 DAYS   Complicated (perforation, megacolon): Vancomycin 500mg PO qid + Flagyl 500-750mg IV Q8H		-Contact isolation -D/c offending antibiotic -Note PO preferred over IV for flagyl.  Vanco only effective PO
Conjunctivitis	Emycin/sulfacetamide/ophthalmic bacitracin (gtts q2hrs, ointment qid) x 7d	-Cipro 2 gtts q2h while awake x 2d then q4h x 5d -Covers pseudomonas **Use for abrasions/conjunctivitis from contacts and organic materials	-Most cases are viral, but treat all in the ED as if bacterial -Bacterial will resolve without abx, but resolves quicker with abx -Avoid neomycin because causes allergic reactions frequently -Avoid gent/tobra as toxic to the eye and add little to the treatment coverage
Cystitis (<10yo)	-Amoxicillin 10mg/kg/dose tid x 10d -Augmentin 10mg/kg/dose tid x 10d	-Omnicef  14mg/kg/day up to 600mg/day PO divided qd or bid for 10 days	-In < 1yo there is no literature to support initial parenteral dose of abx if tolerating PO -Some docs admit all febrile UTIs if < 6mos old, others if < 3mos old (even if nontoxic)
Cystitis (adult)	3 days of: Bactrim DS bid	Levaquin 250mg qd OR Cipro XR 500mg PO qd for non-complicated cystitis OR Cipro 250mg po bid (some insurance plans and Medicaid do not cover cipro XR) OR Nitrofurantoin 100mg BID x 5-7 days OR Amoxicillin 500mg TID x 7 days	*FQ probably best choice now due to high resistance to Bactrim -10 days of: Bactrim DS, Levaquin, Ciprofloxacin, Augmentin, Keflex for complicated cystitis
Dental infections and intraoral lacs	PCN 500mg qid x 10d	Clindamycin 300mg qid
Diverticulitis	Outpatient Augmentin 875mg BID                          Inpatient: -Unasyn 1.5g IV (3g if >80kg) q6h OR Zosyn 3.375g IV q6h	Levaquin 750mg qd OR Cipro 750mg PO bid] PLUS Flagyl 500mg qid x 7-10d     - Cipro 400mg IV q12h PLUS Flagyl 500mg IV q6h	-May treat as an outpatient if nontoxic and can tolerate PO and no perf/abscess on CT
Epidydimitis/Orchitis /Prostatitis	- <35 yo (tx as GC/C): Should now treat the same as PID in a female Rocephin 250mg IM PLUS Doxycycline 100mg PO bid x 10d   - >35yo (coliforms): Bactrim DS 1 tab bid	Levaquin 250mg qd x 10-14d	Must treat prostatitis for longer (14-28d)
Gastroenteritis (suspected bacterial in adults)	Cipro 500mg bid x 3-5 days	Bactrim DS 1 tab bid x 5d	Dysentery symptoms, recent travel to 3rd world (o/w probably viral and no abx needed)
Mastitis	Keflex 500mg qid OR Dicloxacillin 500mg qid OR Clinda 300mg qid x 10-14d	MRSA Possible:  TMP-SMX DS 2 PO bid or Vanco 1gm IV q12h (if MRSA)
Meningitis	< 8 weeks: Claforan IV (100mg/kg q 8h) PLUS Ampicillin IV (50-100mg/kg q 6h +/- Vanc 15mg/kg IV– pharmacy to dose after first dose) -8wks to 18yrs: Rocephin IV (100mg/kg max 2g q12h) PLUS Vancomycin IV (15mg/kg to max 1.5g – pharmacy to dose after first dose) -18yrs to 50yrs: Rocephin IV (2g q 12h) PLUS Vanc IV (15mg/kg max 1.5 g - pharmacy to dose after first dose) - > 50yrs: Rocephin IV (2g q12h) PLUS Ampicillin IV (2g q4-6h) PLUS Vanc IV (15mg/kg max 1.5g - pharmacy to dose after first dose)	Rocephin IV (2g q12h)  PLUS Vanc IV (15mg/kg max 1.5g- pharmacy to dose after first dose)	Dexamethasone 0.15mg/kg q 6h (10 mg max) for 2-4 days – give prior to or at time of initial abx to prevent bacterial lysis. Give for suspected pneumococcal meningitis and continue only in proven cases
Neutropenic Fever with Septic Shock	Imipenem/Cilastin IV (500mg q 8h - need creatinine clearance calculated after first dose) OR Cefipime IV (2g q8h) PLUS Vancomycin IV (15 mg/kg IV max 1g - pharmacy to dose after first dose)	Amikacin IV (20mg/kg max 1.5g q 24h - pharmacy to dose subsequent doses) PLUS Aztreonam IV (2g q 8h PLUS Vancomycin IV (15mg/kg max 1g q 12h - pharmacy to dose subsequent doses)	-If no shock or or no risk factors for Gram + infection do not add Vancomycin -Indwelling line = vanco
Open Frx	-Ancef  (1-2g q 6-8h)  -If severe: PLUS Gent 2mg/kg (pharmacy to dose subsequent doses)	Vanc (15mg/kg max 1g – pharmacy to dose subsequent doses) OR Clinda (600mg q8h)
Osteomyelitis	Vancomycin (15mg/kg - max 1g IV – pharmacy to dose after first dose) PLUS Rocephin (50mg/kg - max 1g IV q24h)
Otitis externa	Cortisporin Otic 4gtt qid OR Floxin 5-10gtt bid x 10d -If refractory: Cipro HC 3gtt bid x 7d OR Dicloxacillin 500mg PO qid x 7d		*Use suspension (not solution) if TM perforation
Otitis media	Amoxicillin is first-line tx -Low-risk (> 2yrs old/no daycare/no abx for 2 months) gets 40mg/kg/day x 5d -High-risk (<2 yrs old/daycare/abx in past 2 months) gets 80-90mg/kg/day x 10d	Zithromax 10mg/kg on first day then 5mg/kg for 4 days is first-line tx for PCN allergic   Bactrim 1mL/kg/day divided bid x 10d Rocephin 50mg/kg IM x 1 dose	Do NOT use for amoxicillin failures
Otitis media (refractory)	Augmentin 80-90mg/kg/day divided bid or tid x 10d is first-line tx	Ceftin 10mg/kg/dose bid x 10d Rocephin 50mg/kg IM or IV qd for 3 days	One-time dose of Rocephin ONLY good for NON-treatment failures
Pharyngitis	PCN 500mg bid x 10d for adults (15mg/kg/dose tid for children)	Z pack (Azithromycin) -Erythromycin 500mg bid x 10d (10mg/kg/dose qid)
Pharyngitis (refractory cases)	Augmentin 875mg bid x 10d (10mg/kg/dose tid)	Clindamycin 300mg qid x 10d (5mg/kg/dose qid)
Pneumonia	- <6 months: Ampicillin 50mg/kg IV PLUS [Gent 2mg/kg OR Cefotaxime 50mg/kg IV] -Patients < 6 months of age should be admitted -6 months to 5yrs: Amoxicillin OR Augmentin 80-90mg/kg/day	-Pediazole 50mg/kg/day divided tid -5 to 18yrs: Azithromycin x 5d OR E-mycin x 10-14d	Use doxycycline instead of erythromycin if a patient has a prolonged QT. E-mycin not well tolerated.
Pneumonia	Adult: -Outpatient: Z-pack OR E-mycin 500mg OR Clarithromycin 500mg PO bid OR  Levo 500mg OR Doxy 100mg x 10d
	Floor: Ceftriaxone IV (1 gm q 24h) + Biaxin po (500 mg q 12h) OR: Ceftriaxone IV (1 gm q 24h) + Erythromycin IV (500 mg q6h    [if NPO]             ICU: Ceftriaxone IV (1 gm q 24h) + Erythro IV (500 mg q 6h)             NURSING HOME: Zosyn (piperacillin/tazobactam) IV (3.375 gm q 6h) + Erythromycin IV (500 mg q 6h)	- Avelox (moxifloxacin) IV (400 mg q 24h)  [single antibiotic] -Macrolide allergy: Doxycyline IV/PO  (100 mg q 12 h) [for Biaxin or erythro]        Avelox (moxifloxacin) IV (400 mg q 24h)             Clindamycin IV (600 mg q 8h) + Cipro (400 mg q 12h)	If pt is admitted to the ICU give Aztreonam 1g IV X 1 in addition to Avelox
Pyelonephritis	Outpatient:  Ciprofloxacin XR (extended release) 1000mg PO qd OR Cipro 500mg PO bid OR Levaquin 250mg qd OR Augmentin 875mg bid x 14d                                 -Pediatric Outpatient (FQ contraindicated):  Omnicef 14mg/kg PO qd x 10 days (refer <2yo to PMD for imaging)   -Inpatient:  Same as Urosepsis   -Urosepsis: Zosyn 3.375g IV q6h OR Gentamycin 7mg/kg IV x 1 (if not on dialysis), then pharmacy to dose		Do NOT use Bactrim for pyelonephritis (high resistance)
Sexual assault prophylaxis	-STD (GC/C): Azithromycin 2g PO alone -Trichomonas: Flagyl 2g PO -Pregnancy: Ovral 2 tabs now then 2 in 12h OR Lo/Ovral 4 tabs now then 4 in 12h OR Plan B	1GM Azithromycin + Rocephin 125mg IM x 1	-Must have negative urine hcg first (no pre-existing pregnancy) Phenergan 25mg PO for home (high-dose birth control will cause nausea)   -Plan B available in omnicell
Sinusitis	-Sudafed 60mg PO q 4-6h -Afrin 2-3 drops/sprays/nostril BID for 3 days (>3 days use results in rebound symptoms) -No prior antibiotics in the prior month:  -Amoxicillin 500 mg PO tid for 10 days (peds 90mg/kg/day divided bid for 10 days) - Antibiotics in the prior month:  -Augmentin 500-875mg PO bid for 10 days (peds 90mg amoxicillin component/kg/day divided bid)	-TMP/SMX (Bactrim) 1 double strength tablet PO bid for 10 days (peds 8-10 mg/kg/d divided bid).  -Doxycycline 100mg PO bid for 10 days -Clarithromycin 500mg PO bid for 10 days	-Antibiotics indicated if: ->7 days symptoms with maxillary/facial pain and purulent nasal discharge -<7 days if severe illness (pain/fever)   One study shows 3 days treatment equal to 10 days

 

 

Antiemetics

 

Phenothiazines: block dopamine D2 receptor in CTZ

-Compazine 5-10mg IV/IM/PO or 25mg PR

-Phenergan 12.5-25mg PO/PR

IV/IM no longer on ACMC formulary - adverse patient outcomes reported (documented cases of loss of limb if pushed arterially)

   Blackboxed <2yo:  apnea

   Watch for dystonic reactions and restlessness

 

Prokinetic agents (have dopamine antagonist activity at CTZ) and antichol/antiserotonin

-Reglan 10mg IV/IM/PO

            -Good all-purpose agent and great for gastroparesis

            -Watch for drowsiness/restlessness/diarrhea

 

Serotonin receptor antagonists (5HT-3) work in area postrema and intestinal sites

            -Zofran (ondansetron)

-Good for peds 0.15mg/kg IV or ODT

-Studied in chemotherapy patients, but very effective in other forms N/V

-Good side effect profile (HA and constipation, does NOT lower sz threshold)

 

Antihistamines good for N/V secondary to motion sickness and vertigo

            -Meclizine 25mg PO qid

 

Asthma

 

• Oxygen to maintain sats >90% (>95% pregnant and peds)
• Albuterol (racemic R and S isomers beta-2 agonist) with dosages that vary by institution

                        -No evidence that higher dosages produce better outcomes

                        -Usual dose is 2.5mg to 5mg neb q20min x 3 prn

                        -For severe asthma may use 5mg neb q20 min x 3 or a 1 hr 15mg continuous neb

-No incremental benefit of giving more than 15mg Albuterol for acute asthma.

-Should make admission or discharge decision after this first hour’s treatment.

                        -May also use MDI W/SPACER 6-12 puffs q 20min to deliver 90mcg/puff

                        -Cheap and just as effective as nebs, may do in waiting room or at home

• Levalbuterol (Xopenex, R-isomer) available in 0.63mg and 1.25mg neb solutions

            -Some trials indicate better for chronic asthma, but expensive, so use sparingly

            -Less tachycardia than racemic albuterol (of questionable significance)

• Atrovent (ipratropium bromide, anticholinergic) 0.5mg nebs x 3 mixed w/albuterol nebs

            -Albuterol combined with atrovent better than either alone

            -Affects large, central airways

• Epinephrine 0.2 to 0.5cc 1:1000 SQ q20-30 min

            -Severe side effects, almost never used as have terbutaline (causes MI if acidotic)

• Terbutaline 0.25mg SQ q 20min x 3 prn if pt can’t inhale neb treatments

            -IV dose is 10mcg/kg load then 4mcg/kg/min infusion (for severe exacerbation)

• Corticosteroids induce great debate over who gets them, when, and what route

            New literature weekly

            Give to mod/severe exacerbation

-Clinically: incomplete response to one neb or PEFR<70% pred after ED tx

-Give to pts on inhaled/oral corticosteroids, recent exacerbation or prolonged sx’s

                        -Works late on inflammation, but also may have an early (1-2 hrs) effect

            Solu-medrol 125mg IV no better than Prednisone 60mg PO

-IV corticosteroids confer no greater benefit than PO

                        -ONLY give IV if pt very ill and can’t tolerate PO

                        -Increased blood sugars in diabetics (check sugars more freq at home)

            Discharge with Prednisone 40-60mg qd for 3-10 days (burst, no taper needed)

            Often ordered incorrectly: 

-Solu-medrol is IM/IV 

-Prednisone is PO tablets

-Prednisilone (Orapred, Pediapred, Prelone) is PO syrup for pediatric dosing (give 2mg/kg max of 60mg PO in ED and discharge on 1mg/kg for 5 days).  Orapred is best tasting according to some studies.

Orapred ODT (oral dissolving tablets) in omnicell (10, 15mg)

            -Inhaled corticosteroids now recommended at ED discharge (especially >2 days asthma per week or >2 nights/month –this is highlighted in red in IBEX as a reminder)

§         Asmanex (mometasone) 220mcg bid or 440mcg qd one single puff daily [mnemonic A-smanex = A single puff daily in Adults (not approved <12yo)]

§         If on oral steroids start 440mcg bid

§         Make sure pt gets asthma education and IHCS education by PharmD or RT

§         For <12 yo, use Flovent (Asmanex not yet approved for peds).  88-220 mcg twice daily

§         Budenoside (pulmicort) is only inhaled steroid in nebulized form

• Magnesium 1-2gm IV over 30min for severe exacerbations

            -Never been proven efficacious, but probably can’t hurt pt about to be intubated

• Theophylline hardly ever given in ED, but check a level on any pt who takes this at home

• Heliox may also be used as last resort before intubation

• Ketamine (1-2mg/kg IV) may be used for intubation

Atrial fibrillation

 

Diltiazem 0.25mg/kg IV (20mg) followed in 15 minutes by 0.35mg/kg IV (25mg) if no response

            -Used for rate control

            -Preferred over Verapamil as may have less inotropic depression with less hypotension

                        -Administer over 5 minutes (not push) to decrease chance of hypotension

                        -Treat hypotension with calcium gluconate 5mL IV

                                    -May pretreat with calcium gluconate 5mL IV to prevent hypotension

-If effective, follow by a drip at 5-15mg/hour

-Start dosing lower if elderly/in CHF/hypotensive

-Concurrent use of diltiazem with erythromycin (ex. Pneumonia patient) prolongs QT – use doxycycline instead

 

Verapamil 2.5-5mg IV followed in 30min by 5-10mg IV if no response

            -Used for rate control

            -May cause more hypotension than diltiazem

-Drip at 5mg/hour for maintenance

-Start dosing lower if elderly/in CHF/hypotensive

-Not used very commonly

 

Esmolol 500mcg/kg IV bolus over 1min then 50-200 mcg/kg/min IV drip

            -Used for rate control

                        -Especially useful for pts with AMI or thyrotoxicosis

-Repeat bolus and increase drip as needed

-Caution in pts with severe RAD or active wheezing

-Half-life is approximately 9 minutes

 

Metoprolol (Lopressor) 5mg IV q5 min until rate control achieved

            - Used for rate control

                        -Especially useful for pts with AMI or thyrotoxicosis

            -Caution in pts with severe RAD or active wheezing

 

Digoxin not used in the acute setting.

            -Check a level if pt already on this medication

 

Amiodarone 150mg IV over 10min

            -Not FDA-approved for rate control of supraventricular tachycardias

            -Wide range of reported efficacies

-Less efficacious than diltiazem and magnesium for rate control and conversion

-Very little predisposition to hypotension as even less negative inotropy than diltiazem

 

Magnesium 2-4gm IV over 30 minutes

-Preliminary investigations suggest better rate control and conversion than dilt and amio

 

Heparin IV or Lovenox SQ administration in the ED is controversial.

 

ED conversion to NSR is VERY controversial.

            -Only do in consultation with Cardiology or Internal Medicine

Cardiac arrest

 

MUST know PALS and ACLS well…know all drug dosages and algorithms (see above)

 

Review ACC handbook monthly and while in ICUs

 

Epinephrine 1mg IV OR Vasopressin 40IU IV one time only

            -Repeat epinephrine q3-5min

-May give epinephrine standard dose if Vasopressin fails (Vasopressin lasts 10 minutes-so no need to give epi for 10 minutes)

-Peds:  0.1mL/kg 1:10,000 epinephrine (max 1mg)

 

Amiodarone

-300mg IVP for pulseless VT and Vfib (peds: 5mg/kg bolus IV)

            -150mg IV over 10min for all other indications

-Studies have suggested that Amiodarone increases pt survival to hospital admission but does NOT improve pt survival to hospital discharge

 

Atropine - 1mg IV q3-5 min to max of 0.04mg/kg

                 

Lidocaine 1.5mg/kg IV (may repeat x 1) with usual dose of 100mg IV

 

Magnesium - 1-2 grams IV

           

Procainamide 17mg/kg (administer at 20-30mg/min) – max dose 1gram

            -Stop if hypotension, QRS prolongs more than 50% or prolonged QT

 

 

Chest pain/Acute Coronary Syndromes

 

IV, O2, monitor and EKG within 5 minutes of arrival

 

Note: Hospital is graded on administration of ASA/Beta Blockers- document reason for withholding (vitals; allergy; taken at home prior to arrival; other contraindications)

 

ASA  81mg x 4 baby aspirins PO (chewed) or 300mg rectally

            -Plavix 600mg PO if severely allergic to ASA

 

Plavix 600mg PO

-Since plavix should be avoided in patients who will need a CABG and we cannot predict who these patients will be prior to cath lab, ask the admitting cardiologist if they desire plavix in addition to ASA

 

NTG 0.4mg (one tab) SL q5min prn x 3-4

-If now pain free can usually place on Nitropaste 1 inch for continued preload reduction after SLNTG

 

NTG IV—start at 10-20mcg/min and slowly increase

            -IV is best for unstable pts who may not tolerate large SL dose OR

            -For patients that are not pain free after SL NTG

-Remember than SL NTG is 400mcg over 5min so it delivers approx 80mcg/min of NTG

-Note Christ Medical Center Code 60 criteria (STEMI) requires IV NTG (not sublingual)

-Note Christ Medical Center CHF protocol requires IV NTG (not sublingual) since it is easily titratable and desired 20% decrease in mean arterial pressure can be more easily achieved

 

Lopressor (Metoprolol) 5mg IV x 3 q 5min prn HR > 60 and SBP >100 or 25 PO x 1

-Note Christ Medical Center Protocol requires beta blockers within 24 hours (hospital is graded on this)

-STEMI

-IV beta blocker use is controversial based on COMMIT trial (increased cardiogenic shock); may want to discuss with cardiologist before administering (usually no longer recommended)

-Oral beta blocker per AHA Guidelines in 24 hrs if:  no signs of heart failure, low output state, increased risk of cardiogenic shock (>70 yo, SBP <120, HR > 110, HR < 60,  increase time of onset since symptoms), other relative contraindications to beta blockers (PR > 0.24,  2^nd/3^rd degree heart block, active asthma or reactive airway disease)

-NSTEMI/UA

-PO beta blocker within 24hrs in the absence of contraindications

 

Lovenox 1mg/kg SQ after normal CXR and no blood on rectal exam

            -Lovenox and lopressor only for suspected UA/NSTEMI (not atypical CP)

-Preferred over Heparin. Heparin preferred if creatinine >1.6 or in STEMI protocol

  

Heparin 60units/kg bolus (max 4,000 units) followed by 12units/kg/hr (max 1,000 units/hr)

            -Note PE/DVT dose is larger (80 units/kg followed by 18 units/kg/hr)

-Heparin preferred over lovenox if there is a relative contraindication (ie. slightly guaic positive) because the drip can be turned off

 

Eptifibatide (Integrilin) (GPIIb/IIIa receptor blocker)

            -Evidence for use constantly changing, use in consultation w/cardiologist

            -Probably beneficial if pt will be going to the cath lab

-Contraindication (Creatinine >4.0); recent surgery; BP >180/110; low platelets; bleeding diathesis

 

Congestive Heart Failure

 

 

Must know Christ Medical Center CHF Protocol. 

 

Mnemonic: LMNOPQ.  Q=Quinton Catheter (ie. in the dialysis pt with CHF they need dialysis)

 

Lasix

-1mg/kg.

-1-2 x home daily dose (usually 60mg or 80mg IV)

-If urine output <200ml after 1hour, repeat same dose

            -Second line to NTG for preload reduction

-Stated reduction in preload is extrapolated from studies evaluating effects on forearm and wrist veins, however, Swan-Ganz catheter studies found no immediate benefit in preload

-Lungs can be thought of as buckets partially filled with fluid when patient is in pulmonary edema, however the patient may not be total-body hypervolemic thus diuretic often leads to hypotension the next day

Morphine

-2mg IV

-Not on CHF standing orders

-Limited data supporting efficacy in decreasing preload (based on study evaluating venous tone in wrist and forearm veins but numerous Swan-Ganz catheter studies show no benefit in preload reduction)

-Due to multiple side effects benzodiazepine preferred for anxiolysis

-Current literature “no role for morphine”

NTG

-IV NTG 20mcg/min and TTE by increasing gtt 10-20mcg q5min or doubling rate q5min

-Titrate to MAP decrease of 20% as per CHF protocol

-Recall SL tab is 400mcg/5min or 80mcg/min (20mcg IV is low dose) so be aggressive with drip or give sublingual initially

-First line for preload reduction

-Avoid in hypotension, valvular problems (acute mitral regurgitation, aortic stenosis, pulmonary hypertension), Viagra or other erectile dysfunction medication use in the last 24 hours

Nesiritide (Natrecor)

      -2 mcg/kg bolus IVP, then start drip at 0.01mcg/kg/min. Hold if SBP < 90.

      -Usually ordered after consultation with a cardiologist

      -40 times more expensive and not necessarily better than NTG

-VMAC study drug reps refer to criticized for using suboptimal doses of NTG and being manufacturer sponsored.  VMAC study proved that Nesiritide better than placebo but not that it is better than NTG

-Other studies trend towards worsening renal function and increased mortality

 

 

 

Oxygen (titrate to O2 sat > 92% by nasal cannula, ventimask or nonrebreather)

 

Position patient upright

 

Positive pressure ventilation prn

-Either BiPAP, CPAP or intubation with PEEP 

-Start BIPAP I 10/ E 4 to maintain sat >92%

-Positive pressure in only currently available treatment demonstrated to decrease mortality

 

Pressors/Drips if needed

            -NTG IV if SBP >90

-Preload reducer, will also reduce afterload at high doses

-Excellent single agent for preload and afterload reduction

-Nipride IV if SBP > 100

            -Outstanding afterload reducer but not used often

-More afterload reduction than NTG, coronary stealàischemia.  

-Nurses not as familiar with use 

-Need to wrap in foil

            -Dopamine IV 2-20mcg/kg/min if SBP <100

            -Dobutamine IV 2-20mcg/kg/min if SBP >100

                        -May drop BP due to beta-receptor mediated vasodilation

 

ACE Inhibitor: 

-Note that hospital is graded on ACE-I administration so document reason for withholding ACE or ARB (renal insufficiency; allergy; hx of severe cough with ACE; potassium elevated; hypotension; pregnant, severe aortic stenosis)

-Lisinopril (Prinvil/Zestril) 10 mg PO

            -Enalapril (Vasotec) 1.25mg IV

-First dose okay without creatinine or potassium, subsequent doses require creatinine and potassium level

-Contraindications: hypotension, dehydration, poor perfusion, allergy, angioedema, pregnancy, renal insufficiency (cr >3), renal artery stenosis, hyperkalemia

- Hold if patient already took ACE in dosing cycle

Angiotensin Receptor Blocker (ARB)

            Losartan (Cozaar) 25mg PO

                        -Use in ACE allergy

-First dose okay without creatinine, subsequent doses require creatinine

                        -Same contraindications as ACE Inhibitor. 

                        -Hold if already taken in dosing cycle

                        -Not much literature exists yet

 

Contrast Load in Renal Insufficiency

Contrast-induced nephropathy remains a common complication of radiographic procedures.

Prophylaxis of contrast induced renal failure:

 

1L 5% Dextrose (D5W) with 3 amps of Sodium Bicarbonate (150 mEq)

Infuse 3mL/kg/hr for one hour prior to contrast followed by 1ml/kg/hr for 6 hours post procedure

 

Or

 

Mucomyst (N-acetylcysteine) 600mg po bid x 4 doses

Or

 

Mucomyst (N-acetylcysteine) 1200mg po bid x 4 doses (one study showed higher doses was more protective for patients undergoing angioplasty)

 

Nursing Implication: Acetylcysteine is available in two concentrations.  Recommend using the 10% solution (100mg/ml).  Once appropriate volume is drawn up (6ml for 600mg dose) dilute in 4-6 ounces of juice.

 

Croup

 

Humidified oxygen

 

Decadron 0.6 mg/kg (max 10mg) IV/IM.  PO Decadron dose is the same. 

-PO Decadron is available in the omincell

-If no PO Decadron available the IV solution may be given PO at the same dose (some report that the IV Decadron tastes better than the PO Decadron!).  IV and PO are bioequivalent.  Mix IV solution with juice to dilute it.

 

Nebulized Epinephrine (0.5 mL of racemic epi  OR 5mL of 1:1000 epi)

-Epi not necessary in all croup patients.  STRIDOR AT REST usually requires epi because just decadron alone will result in inadequate resolution.  However in stridor only  with crying humidified oxygen and decadron alone may suffice. 

-Standard of care is to observe for 3 hours after epi neb because some patients have recurrence (debatable)

-Racemic epi is more expensive and 1:1000 epi works just as well

-Dosing recommendations as above- bur remember any excess just goes out to the environment anyways.

-Closely monitor patients with severe left ventricular outflow obstruction (IHSS, AS, etc).  Nebulized epi is relatively contraindicated in these patients.

 

Heliox

            -Consider in patients about to be intubated

            -Decreases turbulent airflow in airway

 

 

DKA (adult)

 

Be familiar with Christ Medical Center DKA protocol

 

Remember the entity is the definition

-Diabetic (hyperglycemic usually >250mg/dL) (Note may have DKA with glucose<250 if AG >16, ketones in urine)

            -Ketotic (acetoacetic acid and beta-hydroxybutyric acid in blood and urine)

            -Acidotic (bicarb usually < 15 and pH usually < 7.3)

-pH may be near normal if concurrent contraction alkalosis from dehydration

-Glucose may not be tremendously elevate

-Ketones:  only acetoacetate (ACAC) not betahydroxybutyrate (BHBA) is measured so ketones may be negative if predominantly BHBA (rare).  Mnemonic:  Acetoacetate is Assayed.

-Despite pH, glucose, and ketones not always being reliable a patient cannot have a normal anion gap and be in DKA.  A normal AG rules out DKA.

                        -A VBG is as useful as an ABG and is less painful and easier to obtain

 

Check EKG FIRST (to r/o hyperkalemia)

 

Labs:

dexi/CBC/PA7/CMP/VBG/UA/serum ketones. 

New onset <45yo:  Endocrine consultants at ACMC  want serum insulin level, ICA 512 (Islet cell antibody), AntiGAD 65, insulin AB, C-peptide:  all prior to initiating insulin therapy

Dexi, K+, pH (venous)- q 1 hour

Lytes/BUN/Cr– q 2 hours

Ca++, PO4, Mg++- q 4hours

 

Goals are to replace fluid and electrolyte deficits, identify precipitating cause and supply insulin

 

Remember FICKU:

-Fluids

-Insulin

-Check urine output

-K+

-Underlying cause (AMI, infection, noncompliance…)

 

Fluids

Place two IV’s

Initially IV#1 has 0.9NS in as bolus (0.45 NS if Na > 140meq/L), IV#2 is at TKO

First two liters in IV#1 over first 1-2hrs (pts usually have 100ml/kg water deficit)

Then change IV#1 to 0.9NS at 250cc/hr

When dexi < 250 change IV#2 to D5 1/2NS + (__)KCl

 

 

Insulin

IV Regular insulin is started at 0.1u/kg/hr with NO bolus dose needed

Increase drip if glucose not decreasing (q 1 hr dexis)

Continued until AG resolves (occurs AFTER glucose normalizes).  Residual ketones my persist due to conversion of BHBA to ACAC

Typically takes 12-18hours

Check urine output (before administering potassium!).  Foley for strict I and Os.

 

 

K+

-If initial K+ > 5.5 begin insulin drip at 0.1u/kg/hr and repeat K+

-If initial K+ from 3.5 to 5.5 begin IV#2 with 1/2NS + 40meq KCl at 250cc/hr and insulin -gtt at 0.1u/kg/hr

-If initial K+ < 3.5 hold insulin for 30min and begin IV#2 with 1/2NS + 60meq KCl at 250cc/hr (thru central line)

**When d-stick < 250 change IV#2 to D5 1/2NS + (__)KCl

 

Replace phosphate only if level < 1.0mg/dL

Replace magnesium if level < 1.2mg/dL or symptoms (tetany) develop

MUST RECHECK lytes q1-2hrs in the initial treatment phase

Bicarbonate is controversial since some literature associates it with increased cerebral edema:  Per ACMC protocol give 1meq/kg HCO3 if pH <7.1 or HCO3 below 10.  Give over 0.5-2 hours-do not push!

 

Underlying cause  (the “I” ‘s )

            Infection, Infarction, Ischemia, Infarct, Imbibing (alcohol), Infant (pregnancy)

 

 

DKA (pediatric)

Only bolus 10cc/kg 0.9NS to start to prevent possible cerebral edema

            -Literature varies on importance of this entity and its cause, but be cautious with IVF

 

 

DONT protocol

 

D50 one amp IV (or just check d-stick and give D50 only if <60 or 70)

 

Oxygen (check pulse ox)

 

Narcan 2mg IV/IM/ETT

-Full 2mg dose if apneic; 0.4 mg IV in known opioid addict who is not apneic

-May repeat up to 10mg total dose if no response to initial 2mg dose

 

Thiamine 100mg IV

 

 

 

Electrolyte Replacement

 

(these guidelines do not apply to patients with a Cr > 2 or dialysis patients)

 

Calcium replacement:

 

Ionized calcium (mmol/L)	Replacement
1.1-1.16	2 grams calcium gluconate in 100 ml NS over 2 hours
1 or less	4 grams calcium gluconate in 250 ml NS over 4 hours

 

Magnesium replacement:

 

Magnesium level (mg/dL)	Replacement
1.3-1.7	Magnesium Oxide 800mg po
1.3-1.7 (symptomatic)	2 grams IV
< 1.3	4 grams IV
< 1.5 and symptomatic	2 grams over 30 minutes, then as above after level rechecked after 1 hour

 

Phosphorus replacement:

 

Phosphorus level (mg/dL)	Replacement
2-2.5	2 packet Na/K Phos (NeutraPhos) q12h x 2 doses PO/NG/GT
1.3-1.9	20 mmol NaPhos IV over 4 hours
< 1.3	40 mmol NaPhos IV over 6 hours

 

Potassium replacement

 

Potassium level (mmol/L)	PO/NG/GT replacement	Peripheral IV replacement
3.6-3.8	40 mEq KCL liquid or tab x 1 dose	20 mEq over 2 hours
3.1-3.5	40 mEq KCL liquid or tab q4h x 2 doses	40 mEq over 4 hours
3 or less	40 mEq KCL liquid or tab q4h x 3 doses	60 mEq over 6 hours

 

 

 

 

Endocarditis

 

Prevention of Infective Endocarditis

American Heart Association 2007 Guidelines

 

Revisions to the 1997 guidelines were made based on published evidence over the last 20 years.  These guidelines have been approved by the ADA, IDSA, and PIDS.

 

Infective Endocarditis (IE)

Turbulent blood flow through the heart can cause damage to some of the endothelium of cardiac valves.  Platelets and fibrin can then build up at these damaged sites.  Certain invasive procedures, (e.g. dental extractions, GI or GU tract surgery) can release bacteria into the bloodstream which then has the potential to colonize the damaged endothelium in the heart.  Colonization and proliferation of bacteria at these sites result in infective endocarditis.

 

Reasons for antibiotic prophylaxis

• Viridans group streptococci (part of normal oral, skin, GI, respiratory flora), which is responsible for most community-acquired IE in non-IVDU, can be released into bloodstream as part of invasive procedure
• The normal flora that may cause bacteremia respond well to antibiotics
• In animal studies, antibiotic prophylaxis works to prevent IE
• Risks and cost of antibiotic prophylaxis is lower than morbidity and mortality associated with IE

 

Reasons against antibiotic prophylaxis

• Most data is on risk of IE from dental procedures; very little is available on risk or prevention of IE from GI or GU tract procedures
• The risk of bacteremia is much higher from daily activities (chewing food, brushing teeth, flossing) and poor oral hygiene than from dental extraction, which is the procedure thought to be most likely to cause transient bacteremia.  Brushing twice daily for a year results in 154,000 times more risk for bacteremia than one tooth extraction.
• Some studies find amoxicillin prophylaxis to reduce bacteremia after a dental procedure, but others find it does not.  No data shows that reduction in bacteremia from amoxicillin reduces risk of IE.  The same is true of other antibiotics used for prophylaxis, as well as chlorhexadine or povidone iodine rinses.
• Several studies are finding that there is no statistical benefit to antibiotic prophylaxis in high-risk groups undergoing dental procedures, even if the antibiotics are 100% effective.  According to these studies prophylaxis does not prevent IE in very many cases.
• Risk of adverse events from the antibiotic exceeds the benefit from prophylaxis.
• General oral hygiene recommendations could be more beneficial to high-risk patients than antibiotic prophylaxis before procedures.

 

 

 

Absolute risk rates for IE from a dental procedure in patients with underlying cardiac disease.*
Mitral valve prolapse (MVP)	1/1,100,000 procedures
Congenital heart disease (CHD)	1/475,000 procedures
Rheumatic heart disease (RHD)	1/142,000 procedures
Patient with prosthetic cardiac valve	1/114,000 procedures
Previous IE	1/95,000 procedures

*in general population risk is 1/14,000,000 procedures

 

 

Current Recommendations

Antibiotic prophylaxis during a dental procedure with manipulation of gingival tissue or periapical region of teeth or perforation of oral mucosa is recommended in patients with:

·         Prosthetic heart valve

·         Previous IE

·         Unrepaired cyanotic CHD, including palliative shunts and conduits

·         Completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure

·         Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialization)

·         Cardiac transplantation recipients who develop cardiac valvulopathy

 

Prophylaxis may also be considered in these patients if undergoing a respiratory procedure that involves incision or biopsy of the respiratory mucosa.  If these patients have an established respiratory infection, include an agent that will work against viridans group streptococci.  Prophylaxis is NOT recommended for patients undergoing an invasive GI or GU tract procedure.  However, if an active infection is present in the GI or GU tract in these patients, an agent may be chosen that is effective against enterococci (the bacteria most likely to cause bacteremia in the GI and GU tract).   When these patients are undergoing surgery on infected skin, skin structure, or musculoskeletal tissue, include an agent effective against staphylococci and b-hemolytic streptococci in the antibiotic regimen against the infection.

 

Antibiotic regimen 30-60 minutes prior to an invasive dental procedure.
	Antibiotic	Adults	Children
PO	Amoxicillin	2g	50mg/kg
NPO	Ampicillin  OR Cefazolin or Ceftriaxone	2g IM or IV   1g IM or IV	50mg/kg IM or IV   50mg/kg IM or IV
PCN allergy – PO	Cephalexin*^ OR Clindamycin OR Azithromycin or Clarithromycin	2g   600mg   500mg	50mg/kg   20mg/kg   15mg/kg
PCN allergy – NPO	Cefazolin^ or Ceftriaxone^ OR Clindamycin	1g IM or IV   600mg IM or IV	50mg/kg IM or IV   20mg/kg IM or IV

*or any other 1^st or 2^nd generation cephalosporin in equivalent dosing

^cephalosporins should be avoided if allergic reaction to PCN was severe

INR Elevation

 

INR above therapeutic range but less than 5 with no significant bleeding:

-Lower warfarin dose or omit dose

-Monitor more frequently

-Resume at lower dose when INR therapeutic

 

INR equal to or greater than 5 but less than 9 with no significant bleeding:

-Omit next 1 or 2 warfarin doses .Monitor more frequently and resume at lower dose when INR in therapeutic range or

-Alternatively, omit dose and give vitamin K (5 mg or less ORALLY), particularly if at increased risk of bleeding.

-If more rapid reversal is required because the patient requires urgent surgery, vitamin K (2 to 4 mg ORALLY) can be given with the expectation that a reduction of the INR will occur in 24 hours.

-If the INR is still high, additional vitamin K (1 to 2 mg ORALLY) can be given.

 

INR 9 or greater with no significant bleeding:

-Hold warfarin therapy and give higher dose of vitamin K (5 to 10 mg ORALLY) with the expectation that the INR will be reduced substantially in 24-48 hrs.

-Monitor more frequently and use additional vitamin K if necessary.

-Resume therapy at lower dose when INR therapeutic.

-Note that INR 5-9 does not necessarily mandate vitamin K but INR >9 does due to markedly increased risk of bleeding

 

INR greater than 20 with no significant bleeding:

-Hold warfarin therapy and give vitamin K (10 mg by slow intravenous (IV) infusion), supplemented with fresh frozen plasma, depending on the urgency of the situation

-Recombinant factor VIIa may be considered

-Vitamin K can be repeated every 12 hrs.

 

Life-threatening bleeding:

-Hold warfarin therapy and give vitamin K (10 mg by slow IV infusion)

-Fresh frozen plasma

-Recombinant factor VIIa may be considered 

-Repeat if necessary, depending on INR.

 

-When vitamin K is administered to lower INRs, it should be administered at a dose that will lower the INR into a safe range quickly, without it being subtherapeutic, causing warfarin resistance, or exposing the patient to anaphylaxis risk.

 

-Low doses and slow infusion rates of vitamin K are recommended. If continuing warfarin therapy is indicated after high doses of vitamin K, then heparin or low molecular weight heparin can be given until the effects of vitamin K have been reversed and the patient becomes responsive to warfarin therapy.

 

 

Intravenous Route of Administration:

-If the intravenous route of administration is considered unavoidable, the drug should not exceed an administrative rate of 1 milligram/minute. Preferably the drug should be diluted in 50-100 mL of 5% Dextrose and infused over 30 minutes.

 

Parenteral Route of Administration:

Severe reactions, including fatalities, have occurred during and immediately after intravenous injection of vitamin K, even when precautions have been taken to dilute the drug and to avoid rapid infusion. These reactions have also been reported following intramuscular administration. Typically these severe reactions have resembled hypersensitivity or anaphylaxis, including shock and cardiac and/or respiratory arrest. Some patients exhibited these severe reactions when they received vitamin K for the first time. Therefore the intravenous and intramuscular routes should be restricted to those situations where the subcutaneous route is not feasible and the serious risk involved is considered justified (ie serious bleeding or INR >20).

 

Subcutaneous vs. Oral Route of Administration:

One mg of oral vitamin K decreases the INR faster than 1mg of subcutaneous vitamin K in asymptomatic patients with elevated INR values.  While subcutaneous vitamin K (1-2mg) reverses warfarin, the response may be less predictable and delayed when compared to oral administration.  Thus the above protocol recommends PO instead of SQ vitamin K.

 

 

Insulin Sliding Scale

 

Also be familiar with Christ Medical Center “Insulin Infusion Orders-Excluding DKA” which can be used instead of a sliding scale for hyperglycemic patients not in DKA

 

Adults:

 

REGULAR INSULIN

	LOW DOSE	MODERATE DOSE	HIGH DOSE
IF Blood Sugar…	Regular Insulin	Regular Insulin	Regular Insulin
150-200	2	3	4
201-250	3	4	6
251-300	4	6	8
301-350	5	8	10
351-400	6	10	12
> 400	Notify physician	Notify physician	Notify Physician

 

NOVOLOG INSULIN

	LOW DOSE	MODERATE DOSE	HIGH DOSE
IF Blood Sugar…	Novolog Insulin	Novolog Insulin	Novolog Insulin
150-200	2	3	4
201-250	3	4	6
251-300	4	6	8
301-350	5	8	10
351-400	6	10	12
> 400	Notify physician	Notify physician	Notify Physician

 

 

 

Local Anesthesia

 

Lidocaine 1% (onset 2-5min, lasts 30-60min)

            -Max dose w/o epi is 4.5mg/kg or 0.45ml/kg and w/epi 7mg/kg or 0.7ml/kg

            - Avoid epi on, pinna of ear, nose, penis and digits

 

Bupivacaine 0.25% (onset 3-7min, lasts 90-360 minutes).  Higher cardiac toxicity than lido.     -Max dose w/o epi is 2mg/kg or 0.8ml/kg and w/epi is 3mg/kg or 1.2ml/kg

 

LET (lido/epi/tetracaine) for topical use on non-intact skin.

            -Drip some into wound and place some on gauze taped to wound for 20min

 

Viscous lidocaine for topical use   

            -Used in ED for intraoral lacs

            -Used for outpatients with intraoral ulcers and genital ulcers

-Remember maximum dose to avoid toxicity in the outpatient setting

 

LMX   for topical use on intact skin

            -30 minutes to effect

            -Useful for pediatric LPs

-Do not wipe skin with alcohol prior to application since LMX needs oils of skin to get absorbed

 

Nerve blocks: median/ulnar/radial/digital/inferior alveolar/infraorbital/intercostal

 

 

 

Migraine treatment

 

Compazine (prochlorperazine) 10mg IV

           

Toradol (ketorolac) 30mg IV or IM

            -No more effective than PO NSAIDs and much more expensive

            -Be sure pt does not have a SAH before using this

 

Reglan (metoclopramide) 10mg IV

 

Imitrex (Sumatriptan) 6mg SC, may repeat 6mg SC in 1h if not effective

            -Expensive but quick and easy to give as no IV access needed

            -CI’d in CAD/uncontrolled HTN/pregnancy (use cautiously if age>50)

 

Decadron 10mg IV (dose debatable in literature) for refractory migraines

 

**Some practitioners give Benadryl 25-50mg IV with Compazine/Reglan

            -Prophylaxis against side effects of medications

            -Also makes pt sleep which often helps resolve the headache

 

 

MRSA Treatment (soft tissue)

 

 

Risk Factors

 

·        Prior history of MRSA infection

·        History (within the past 12 months) of hospitalization, surgery, long-term care residence, indwelling catheter or medical device, dialysis, renal failure, or diabetes

·        Close contact with someone known to be infected with MRSA

 

Diagnosis

 

·        All MRSA infections should first be classified as hospital acquired vs. community acquired.

·        MRSA infections may be further broken down into four groups:

A. Superficial colonization of a wound, without signs of infection

B. Superficial soft tissue infection/cellulitis

C. Complex skin and skin structure infection

D. Osteomyelitis

 

Community vs Hospital

 

·        Diagnosis of MRSA was made in the outpatient setting or by a culture positive for MRSA within 48 hours after admission to the hospital.

·        No medical history of MRSA infection or colonization.

·        No medical history in the past year of:

Hospitalization

Admission to a nursing home, skilled nursing facility, or hospice

Dialysis

Surgery

No permanent indwelling catheters or medical devices that pass through the skin into the body.

 

Superficial colonization

 

·        May be treated without the use of oral or IV antibiotics.

·        Regular cleansing of the wound with Hibiclens

·        Close monitoring of the wound for possible signs of infection

 

Superficial skin and soft tissue infection/cellulitis

 

·        Local wound cleansing and debridement should be accompanied by antibiotic therapy.

·        Should be treated with antibiotics for at least ten days but may vary depending on severity of infection and clinical response.

·        Antibiotic choice should include one of the following:

Trimethoprim-sulfamethoxazole-2 tablet PO bid. 

Clindamycin 300mg bid (increasing resistance)

Doxycycline-100 mg PO bid

Rifampin (never use Rifampin as monotherapy due to rapid emergence of resistance.)

 

Complex skin and skin structure infection

·        Community acquired:

Treat same as superficial

·        Hospital acquired:

Vancomycin IV

Zyvox

 

Osteomyelitis (Hospital or Community Acquired)

 

·        Aggressive surgical resection of infected bone and soft tissue should be performed as soon as possible.

·        Peripheral vascular sufficiency should be established immediately and a vascular consult ordered if there are questions as to peripheral vascular diseases.

·        Once MRSA has been positively identified, the patient should be placed on a six-week course of Vancomycin with weekly monitoring of peaks and troughs with BUN and Creatinine.

·        Zyvox may be used in cases of Vancomycin resistant enterococci.

 

Pediatric common medications

 

Acetaminophen 15mg/kg PO q4h. 

-Mnemonic:  Every 10 kg=1 tsp Tylenol (160/tsp) q 4h.  10kg= 1tsp q 4h.  20kg=2 tsp q 4h.  25kg=2.5 tsp q4h.   Similar mnemonic for ibuprofen

 

Amoxicillin (low dose) 45mg/kg/d divided tid

 

Amoxicillin (high dose) 80-90mg/kg/d divided bid

 

Ampicillin 50-100mg/kg IV up to 2g

            -Neonatal fever < 6weeks to cover Listeria

            -Also used for meningitis in elderly patients and others at risk for Listeria

 

Azithromycin 10mg/kg the first day then 5mg/kg qd for 4 more days

 

Cefotaxime (Claforan) 50-100mg/kg IV

            -Used mostly in neonates < 4-6wks old when can’t use Rocephin due to biliary sludging

 

Ceftriaxone (Rocephin) 50mg/kg IV up to 1g

            -100mg/kg up to 2g for meningitis or suspicion of meningitis

            -Do not use in neonates < 4-6wks old due to possible biliary sludging

**Different sources and practitioners utilize varying dosages of Amp/Claf/Ceftriaxone

            Some use 50mg/kg while others use 100mg/kg

 

Decadron 0.6 mg/kg (max 10mg) IV/IM.  PO Decadron dose is the same. 

-PO Decadron is available in the omnicell

-If no PO Decadron available the IV solution may be given PO at the same dose (some report that the IV Decadron tastes better than the PO Decadron!).  IV and PO are bioequivalent

 

Dextrose 0.5g/kg IV (if unable to tolerate PO glucose)

            -Neonates get D10 5cc/kg (10 x 5 = 50)

            -Infants get D25 2cc/kg (25 x 2 = 50)

            -Children may get D50 1cc/kg (50 x 1 = 50) but preferably get D25 if possible

                        -Higher osmolarity solutions cause tissue necrosis/pain at IV site/rebound

                        -D25 is stocked in the PEC omnicell so have nurses use that concentration

 

Diphenhydramine (Benadryl) 1 mg/kg PO q6h

 

Nebulized Epinephrine (0.5 mL of racemic epi  OR 5mL of 1:1000 epi)

            -Croup, bronchiolitis

-Epi not necessary in all croup patients.  STRIDOR AT REST usually requires epi because just decadron alone will result in inadequate resolution.  However in stridor only  with crying humidified oxygen and decadron alone may suffice. 

-Standard of care is to observe for 3 hours after epi neb because some patients have recurrence (debatable)

-Racemic epi is more expensive and 1:1000 epi works just as well

-Dosing recommendations as above- bur remember any excess just goes out to the environment anyways.

-Closely monitor patients with severe left ventricular outflow obstruction (IHSS, AS, etc).  Nebulized epi is relatively contraindicated in these patients.

 

Ibuprofen 10mg/kg PO q6h

-Every 10 kg=1 tsp Motrin (100/tsp) q 6h.  10kg= 1tsp q 6h.  20kg=2 tsp q 6h.  25kg=2.5 tsp q6h.   Similar mnemonic for acetaminophen.

 

Methylprednisolone (Solu-Medrol) 1-2mg/kg (max 125mg) IV

 

Prednisone/Prednisilone (Oprapred, Pediapred, Prelone) 1-2mg/kg PO (max 60mg) then 1mg/kg PO qd for 5 days

Steroids often ordered incorrectly: 

-Solu-medrol is IM/IV only 

-Prednisone is PO tablets

-Prednisilone (Orapred, Pediapred, Prelone) is PO syrup for pediatric dosing (give 2mg/kg max of 60mg PO in ED and discharge on 1mg/kg for 5 days).  Orapred best tasting according to some studies

-Orapred ODT (oral dissolving tablets) in omnicell (10, 15mg)

-Remember IV is no more effective or quicker acting than PO prednisone

 

Robitussin (1/2tsp)/10kg PO q4h

 

Post Exposure Non-Occupational HIV Prophylaxis

 

The combination and the recommended doses, in the absence of known resistance to zidovudine (ZVD) or lamivudine in the source patient are:

 

·         ZDV 250-300mg twice a day                        or Combivir twice daily

·         Lamivudine 150 mg twice a day       

PLUS

·         Liponavir/Ritonavir (Kaletra) 2 tabs twice a day or Efavirenz (Sustiva) 600 mg once daily (not recommended for use in pregnant women)

Note: Kaletra is better tolerated than Sustiva

 

Post Exposure Occupational HIV Prophylaxis

 

·         ZDV 250-300mg twice a day                        or Combivir twice daily

·         Lamivudine 150 mg twice a day       

 

PLUS

Crixivan (Indinavir) 800 mg TID or Liponavir/Ritonavir (Kaletra) 2 tabs twice a day

 

Post LP Headache

 

Only proven technique is to use smaller gauge needle and non-cutting needle when performing the procedure.  Bedrest, caffeine, IVF have not been proven by evidence based methods

 

Some recommend caffeine 100-200mg PO or 500mg IV over 2 hours (severe).  Most cases are severe and require IV caffeine or epidural patch.

 

For IV Caffeine:

Order 1 L NS over 1 hour then caffeine drip (500mg in 1L NS) over 2 hours followed by 1L of NS over 1-2 hours.

 

Consult anesthesia to perform epidural patch if not resolved with caffeine.

Preeclampsia/eclampsia

 

Magnesium 4-6g IV over 15min then 1-2g/h IV

            -Monitor DTRs and watch for respiratory depression

 

Hydralazine 2.5mg IV then 5-10mg IV repeated up to 40mg max

            -May take up to 20min to see a response after dose is given

-Is “drug of choice” after Mg for eclamptic HTN

 

Labetolol 20mg IV then 40-80mg IV q10min up to 300mg max

            -Then start drip at 1-2mg/min and titrate

            -Less reflex tachycardia and hypotension than hydralazine

 

**Lab studies are: UA, CBC, LFT, PA7, uric acid, PT/PTT/INR

Procedural sedation

 

Agents have various properties: analgesia, sedation, amnesia, dissociation

 

Usually best to start on the lower end of dosing and titrate to effect

 

Etomidate 0.1-0.3mg/kg IV

 

Fentanyl 1-2mcg/kg IV AND Versed 0.02mg/kg IV good for ortho/lacs/adults

 

Ketamine (dissociative agent) 1-2mg/kg IV OR 4mg/kg IM

            -Agent of choice for peds because patients do not lose airway reflexes.

            -Increases airway secretions.  Some give atropine 0.02mg/kg in same syringe.

                        -May also use glycopyrrolate (Robinul)

            -Emergence reactions are more common in adults.  May decrease with Versed.

 

Methohexital (Brevital) 1mg/kg IV is a great drug.  Rapid onset and wears off in 2-10min.

 

Propofol (Diprivan) 1mg/kg over 1-3 minutes followed by 0.1mg/kg/min q 15 seconds

            -May cause apnea and hypotension

-Rapid onset, short duration (patients awake and responsive within 8 mins of discontinuation)

-Nurses can NOT push propofol in this setting, must be done by resident/attending

 

For reversal:

 

Narcan 0.4mg IV (peds: 0.05mg/kg IV).  Lasts 1-2hrs.

 

Flumazenil 0.2mg IV (peds 0.01mg/kg IV).  Beware seizures in pts with known d/o.

RABIES

Rabies Post Exposure Guidelines

 

Wild animals - especially bats - are the most common source of human rabies infection

in the United States.

 

Skunks, raccoons, dogs, and cats can also transmit the disease.

 

Human rabies is rare in the United States.  There have been only 39 cases diagnosed since 1990.  However, between 16,000 and 39,000 people are treated each year for possible exposure to rabies after animal bites. Also, rabies is far more common in other parts of the world, with about 40,000 - 70,000 rabies-related deaths each year.  Bites from unvaccinated dogs cause most of these cases.

 

Rabies vaccine can prevent rabies.

 

Rabies vaccine is given to people at high risk of rabies to protect them if they are exposed.  It can also prevent the disease if it is given to a person after they have been exposed.

 

Rabies vaccine is made from killed rabies virus.  It cannot cause rabies.

 

Vaccination After an Exposure

 

Anyone who has been bitten by an animal, or who otherwise may have been exposed to rabies, should see a doctor immediately.

 

A person who is exposed and has never been vaccinated against rabies should get 5 doses of rabies vaccine - one dose right away, and additional doses on the 3rd, 7th, 14th, and 28th days.  They should also get a shot of Rabies Immune Globulin at the same time as the first dose.  This gives immediate protection.

 

A person who has been previously vaccinated should get 2 doses of rabies vaccine - one right away and another on the 3rd day.  Rabies Immune Globulin is not needed.

 

Once a physician decides a patient needs to be started on post exposure therapy the following doses are recommended for both the rabies vaccine and immune globulin.

 

Rabies Vaccine

 

 

 

Rabies Immune Globulin

RSV Bronchiolitis

Deep suctioning by respiratory therapist

 

IV 0.9NS 20mL/kg bolus

            -insensible losses

            -poor intake due to congestion

 

Nebulized Epinephrine (0.5 mL of racemic epi  OR 5mL of 1:1000 epi)

-Standard of care is to observe for 3 hours after epi neb because some patients have recurrence (debatable)

-Racemic epi is more expensive and 1:1000 epi works just as well

-Dosing recommendations as above- bur remember any excess just goes out to the environment anyways.

-Closely monitor patients with severe left ventricular outflow obstruction (IHSS, AS, etc).  Nebulized epi is relatively contraindicated in these patients.

-Strongly consider admission if repeated doses of epi are required

 

-Note: Steroids and albuterol not proven to be helpful in RSV bronchiolitis.  A trial of albuterol is reasonable in case there is a bronchospastic component and may be discontinued if the child fails to show a response

 

Seizure-Adult

 

Ativan 0.1mg/kg IV @ 2mg/min IV up to 10mg IV is benzodiazepine of choice

            -Ativan preferred over Valium, as has longer effect

            -May give Versed 5mg IM if no IV access

            -If this is ineffective then:

 

Phenytoin (Dilantin) 10-15mg/kg IV @ 50mg/min (25mg/min in cardiac pt and 1mg/kg/min peds)

-pH of 13 may cause big problems if extravasates, give slowly and must be diluted

            -Must give while pt on monitors (may prolong QRS)

 

Fosphenytoin (Cerebyx) 15-20 mg PE/kg IV @ 150mg/min

            -Use when have no IV access to give phenytoin

-Used instead of phenytoin as can be administered more rapidly as no propylene glycol

-May give up to 30cc IM as is water soluble

-May repeat up to 30mg/kg max dose

-If either phenytoin or fosphenytoin ineffective then:

 

Phenobarbital 20mg/kg @ 100mg/min

            -May repeat up to 30mg/kg

            -May cause hypotension and depressed respirations

Sepsis

-Be familiar with ACMC Early Goal Directed Therapy (EGDT) Protocol for sepsis

 

-Start central line above the diaphragm (IJ or subclavian) if SBP <90 mmHg (after IVF bolus) or lactate > 4mmol/L

                        -Lactate is a better indicator of global tissue hypoxia than blood pressure

                        -Experts advocate sending more serum lactates (available on blood gas)

 

-IV fluids à until CVP 8-12mmHg

 

-Norepinephrine or dopamine first (make epinephrine alternative agent) à until MAP > 65.  (MAP is in parentheses on the monitor)

 

-Hydrocortisone 100mg IV x 1

            -Recommended if not responsive to fluids and pressors

-Some give to all patients receiving IVF with the logic that in the stressed state the adrenals may not be producing enough steroids

-Requires random cortisol draw prior to administration (for stim test).  May use 4mg decadron instead which does not alter the stim test

 

-Packed Red Blood Cells (PRBC) à if SVO2 <70% AND Hct <30%

-SVO2 is the oxygen saturation from the blood drawn from the central line

-Ask respiratory therapist to perform this

 

-Dobutamine if SVO2 <70%

 

-Ventilator settings:

            -6cc/kg tidal volume

            -Respiratory acidosis is okay (permissive hypercapnia)

            -Peak inspiratory pressures <25-30 cm H2O

STD’s and Genital Infections

BV: Flagyl 500mg PO bid x 7d OR Clinda cream 2% intravag qhs x 7d

       OR Metrogel intravag bid x 5d OR Clindamycin 300mg PO bid x 7d

            *If pregnant tx is the same but do not use Clinda cream (teratogenic)

            *Note: 2gm single dose Flagyl not as effective for BV

 

Candidiasis: Diflucan 150mg PO x 1 (easiest, but can’t use in pregnancy)

            -May also use various creams and suppositories (treat for 7 days if pregnant)

 

Chlamydia: Azithromycin 1g OR Doxy 100mg BID x 7d

            -Also treat for gonococcal infection, as these diseases frequently co-exist

 

Gonococcal: Rocephin 125mg IM OR Azithromycin 2grams PO

            -Also treat for chlamydial infection, as these diseases frequently co-exist

 

HSV (genital, first clinical episode): Valacyclovir (Valtrex) 1000mg PO bid x 10days OR Famciclovir (Famvir) 250mg PO tid x 7-10 days OR Acyclovir 400mg PO tid x 7-10d

            -Note: Valtrex and Famvir not on ACMC formulary; only acyclovir

 

 HSV (recurrent infection): Valacyclovir 500mg PO bid x 3 days OR Famciclovir 125mg PO bid x 3 days OR Acyclovir 400mg PO tid x 5d

            -Note: Valtrex and Famvir not on ACMC formulary; only acyclovir

 

PID (outpt): Rocephin 250mg IM PLUS [Doxy 100mg bid x 14d +/- Flagyl 500mg bid x14d]

 

PID (inpt): [Cefoxitin] PLUS [Doxy 100mg IV bid OR Azithro 500mg IV] 

 

Trichomoniasis: Flagyl 2g PO single dose OR Flagyl 500mg PO bid x 7d

 

Toxicology

Almost every pt with known or suspected ingestion needs: EKG/PA7/uhcg/APAP/ASA

-EKG to assess QRS and QT intervals and associated ingestions

-uhcg for all females so can provide genetic counseling referral if pregnant

            -PA7 to rule out an anion gap acidosis and associated ingestions

            -APAP and ASA to rule out associated deadly and potentially treatable ingestions

-APAP is always obtained, as initially overdose is asymptomatic and treatable

-Some argue that normal vitals and exam r/o a clinically significant ASA OD

-UDS is expensive, insensitive for many ingestants and almost never helps ED pt mgmt

 

Remember the ABCDE’s of toxicology:

-Antidotes (e.g. NAC, folate) and Alter Absorption (e.g. Activated Charcoal)

-Basics (the real ABCs)

-Change metabolism (e.g. fomepizole, ethanol)

-Distribute differently (e.g. oxygen)

-Enhance Elimination (e.g. diuresis, dialysis, hemoperfusion)

 

Gastric lavage rarely used, consider for lethal ingestions within 60min of ingestion

 

Activated Charcoal 1g/kg PO OR may give in ratio 10mg AC: 1mg ingested substance

            -Usual adult dose is 50g PO (combined with sorbitol in pre-mixed bottles)

            -Administer repeat dosages without sorbitol or may cause electrolyte abnormalities

            -In practice, given to most awake patients with known ingestion

-No studies have ever proven decreased mortality rate with AC

 

 

 

Acetylcysteine (Acetadote)

 

Mechanism of Action:

As an acetaminophen antidote, acetylcysteine increases the amount of glutathione in the liver, as well as, act as a glutathione substitute. Glutathione binds to and aids in the elimination of acetaminophen metabolites. In an acetaminophen overdose, endogenous glutathione is saturated, allowing hepatotoxic metabolites to accumulate; acetylcysteine increases elimination of these metabolites.

 

Dose:

Adult and Pediatric:

-          Intravenous (IV)

o        Loading dose: 150mg/kg in 250mL of D5W over 60 minutes

o        Maintenance doses:

§         50mg/kg in 500mL of D5W over 4 hours x 1 dose then

§         100mg/kg in 1000mL of D5W over 16 hours x 1 dose.

-          Oral

o        Loading dose: 140mg/kg

o        Maintenance dose:  70mg/kg every 4 hours for 17 doses

Adjustments:

For patients <40 kg or fluid restricted:

-          Loading Dose (IV):

o        30 kg: 100 mL D5W + 22.5 mL acetylcysteine; 25 kg: 100 mL D5W + 18.75 mL acetylcysteine; 20 kg:  60 mL D5W + 15 mL acetylcysteine; 15 kg: 45 mL D5W + 11.25 mL acetylcysteine; 10 kg: 30 mL D5W + 7.5 mL acetylcysteine.

-          Second Dose (IV):

o        30 kg: 250 mL D5W + 7.5 mL acetylcysteine; 25 kg: 250 mL D5W + 6.25 mL acetylcysteine; 20 kg: 140 mL D5W + 5 mL acetylcysteine; 15 kg: 105 mL D5W + 3.75 mL acetylcysteine; 10 kg: 70 mL D5W + 2.5 mL acetylcysteine.

-          Third Dose (IV):

o        30 kg: 500 mL D5W + 15 mL acetylcysteine; 25 kg: 500 mL D5W + 12.5 mL acetylcysteine; 20 kg: 280 mL D5W + 10 mL acetylcysteine; 15 kg: 210 mL D5W + 7.5 mL acetylcysteine; 10 kg: 140 mL D5W + 5 mL acetylcysteine.

 

How supplied:

-          Injection: 200 mg/mL (30 mL)

-          Inhalation/oral: 100 mg/mL (4 mL, 10 mL, 30mL); 200 mg/mL (4 mL, 10 mL, 30 mL)

-          Oral: capsule, extended release: 500 mg; tablet: 500 mg

 

Contraindications:

Hypersensitivity to acetylcysteine

 

Precautions:

-          Bronchospasm may occur, use with caution in asthma and history of anaphylaxis.

-          Use appropriate dose adjustment in patients with fluid restrictions and patients <40 kg.

 

Monitoring Parameters:

-          Acetaminophen levels and overdose (hepatic and renal function, glucose, electrolytes)

-          Fluid status and anaphylactic reactions

 

Adverse Effects:

-          Anaphylactoid reaction  (with IV)

-          Hypotension

-          Urticaria/rash

-          Nausea/Vomiting

-          Bronchospasm

 

Drug Interactions: None significant

Pregnancy Category: B

 

Atropine

 

Mechanism of Action:

                Atropine is a muscarinic receptor antagonist. It prevents the binding of acetylcholine at sites such as secretory glands, smooth and cardiac muscle, and the central nervous system. As such, it can be used for an anticholinesterase overdose, which causes an accumulation of acetylcholine.

 

Dose:

Adult

-          IV: 2-4 mg, then 2 mg every 5-10 minutes until cholinergic symptoms resolve. 

Pediatric

-          IV/IM: 1 mg, then 0.5-1 mg every 5-10 minutes until cholinergic symptoms resolve.

Adjustments:

No adjustments necessary

 

Administration:

Administer undiluted IV injection rapidly to prevent paradoxical bradycardia

 

How supplied:

Injection: 0.05mg/mL (5 mL), 0.1mg/mL (5 mL, 10 mL), 0.4mg/mL (0.5 mL, 1 mL, 20 mL),

0.5 mg/mL (1 mL), 1 mg/mL (1 mL)

 

Contraindications:

- Hypersensitivity to atropine or                           

anticholinergics

- Narrow-angle glaucoma
- Reflux esophagitis
- Obstructive GI disease or uropathy
- Ulcerative colitis or toxic megacolon
- Unstable cardiovascular status in acute hemorrhage or thyrotoxicosis
- Paralytic ileus or intestinal atony
- Myasthenia gravis

 

Precautions:

-          Elderly may require lower doses and experience more adverse effects.

-          Use with caution in hyperthyroidism, coronary heart disease, acute MI, CHF, tachyrhythmia, tachycardia, HTN, or prostatic hypertrophy

-          May cause symptoms of heat exhaustion

-          May cause neuromuscular blockade

 

Monitoring Parameters:

-          Heart rate

-          Blood pressure

-          EKG

-          Resolution of cholinergic symptoms

 

Adverse Effects:

-          Arrhythmia

-          Tachycardia

-          Hypotension

-          Constipation

-          Urinary retention

-          Blurry vision

 

Drug Interactions:

- Incompatible with IV administration of norephinephrine or sodium bicarbonate.

 

Pregnancy Category:

C

 

 

 

Calcium disodium edetate (Calcium Disodium Versenate)

 

Mechanism of Action:

Calcium disodium edetate binds and chelates to lead in the plasma; the complex is excreted in the urine. This creates a concentration gradient that draws lead from tissue to the plasma which again can be chelated and excreted.

 

Dose:

Adult and Pediatric:

-          Intramuscularly (IM)

o        1 g/m²/day in divided doses every 8-12 hours x 5 days, hold for 2-4 days then repeat as needed.

-          Intravenously (IV)

o        1 g/m²/day IV infusion over 8-12 hr x 5 days, hold for  2-4 days then repeat as needed. Maximum dose 75 mg/kg/day. 

Adjustments:

Dose with impaired renal function:

-          SCr 2-3 mg/dL: 500 mg/m² every 24 h x 5 days.

-          SCr 3-4 mg/dL: 500 mg/m² every 48 h x 3 doses

-          SCr > 4 mg/dL: 500 mg/m² once weekly

 

Administration:

-          To avoid pain with IM administration, give 1 mL of 1% lidocaine or procaine per mL of calcium disodium edetate.

-          For IV administration, dilute calcium disodium edetate to a concentration of less than 0.5% in D5W or NS (i.e. 5 mL of calcium disodium edetate (1 g) in 250-500 mL of D5W or NS)

 

How supplied:

-          Injection solution: 200 mg/mL (5 mL)

 

Contraindications:

-          Severe renal failure or anuria

-          Hepatitis

 

Precautions:

-          In patients with lead encephalopathy or cerebral edema, increased intracranial pressure may be experienced with IV administration; the preferred route for these patients is IM.

-          Ensure adequate hydration and urine flow during administration

-          Discontinue therapy if signs of renal dysfunction appear.

 

Monitoring Parameters:

-          Renal function (BUN, SCr, urinalysis)

-          ECG

-          Blood and urine lead concentrations.

 

Adverse Effects:

-          Pain at injection site

-          N/V

-          Headache

-          Hypotension

-          Nephrotoxicity

-          Thrombophlebitis

 

 

Drug Interactions:

- IV administration incompatible with LR, amphotericin B, or hydralazine.

 

Pregnancy Category: B

 

Deferoxamine (Desferal)

 

Mechanism of Action:

                Deferoxamine is chelates and binds to ferric iron to form ferrioxamine, which is excreted in the urine.

 

Dose:

Adult:

-          Acute Iron toxicity:

o        IV/ IM: 1 g loading dose then 500 mg every 4 hours for up to 2 doses. May give additional 500mg every 4-12 hours if needed. Maximum dose 6 g/day.  

-          Chronic Iron toxicity:

o        IV/IM: 500-1000 mg/day IM and 2 g given IV for each unit of blood transfused. Maximum 6 g/day

o        SC: 1-2 g infused over 8-12 hours.

 

Pediatric:

-          Acute Iron toxicity:

o        IM: 90mg/kg/dose every 8 hours. Maximum 6g/day

o        IV: 15mg/kg/hour. Maximum 6g/day

-          Chronic Iron toxicity:

o        SC: 20-40mg/kg/day infused over 8-12 hours. Maximum 1-2g/day.

 

Adjustments:

Renal Impairment: for CrCl <10 mL/min give 50% of dose.

 

Administration:

-          For IM, reconstitute with sterile water for a concentration of 250 mg/mL

-          For IV, dilute and administer reconstituted deferoxamine with D5W, LR, or NS.

-          Infuse IV deferoxamine at a rate of ≤15mg/kg/hour at a maximum rate of 125mg/hour.

 

How supplied:

Injection powder for reconstitution: 500mg, 2 g.

 

Contraindications:

-          Hypersensitivity to deferoxamine

-          Primary hemochromatosis

-          Anuria

 

Precautions:

-          Increased susceptibility to Yersinia enterocolitica, Yersinia pseudotuberculosis, mucormycosis

-          Visual and hearing disturbance may occur with prolonged use

-          High doses may cause acute respiratory distress syndrome (ARDS)

 

Monitoring Parameters:

-          Serum Iron

-          Respiration with high doses

-          Reduction in toxicity symptoms

 

Adverse Effects:

-          Flushing

-          Hypotension

-          Injection site reaction

-          N/V

-          ARDS

 

Drug Interactions:

-          No significant drug interactions

Pregnancy Category:  C

Note: The preferred route of administration is IM, unless the patient is in shock.

Digoxin Immune Fab (Digibind)

 

Mechanism of Action:

                Digoxin immune antigen-binding fragments (Fab) are antibodies that bind to digoxin in the plasma; the complex is then excreted in the urine. The clearance of digoxin from the plasma creates a concentration gradient that draws tissue-bound digoxin into the plasma, which also binds to digoxin immune Fab.

 

Dose:

Adult:

-          Acute digoxin ingestion toxicity:

o        Empirically: 20 vials of Digibind in 2 divided doses

o        If amount of digoxin ingested is known:

§         Number of Digibind vials to use = [(mg of digoxin ingested) x (bioavailability)] / 0.5

§         Bioavailability: 0.8 for 0.25mg tablets; 1 for 0.2 mg Lanoxicaps

-          Chronic digoxin ingestion toxicity:

o        Empirically: 6 vials of Digibind.

o        Based on serum digoxin levels:

§         Number of Digibind vials to use= [(level in ng/mL) x (weight in kg)]/ 100

Pediatric:

-          Acute digoxin ingestion toxicity:

o        Refer to adult dose

-          Chronic digoxin ingestion toxicity:

o        Empirically: If weight ≤20 kg then 1 vial of Digibind, if >20 kg refer to adult dose

o        Based on serum digoxin levels:

§         Refer to adult dose

 

Administration:

-          Reconstitute with 4 mL of sterile water

-          Infuse over 30 minutes with a 0.22 micron filter. Dilute in 50-100ml NS

 

How supplied:

- Injection powder for reconstitution: 38mg, 40mg

 

Contraindications:

No known contraindications

Precautions:

-          Allergy to sheep products or papaya extract

-          Hypokalemia may be worsened

-          Renal failure as excretion of Digibind-digoxin complex is decreased

-          Worsening in heart failure

Monitoring Parameters:

-          Potassium

-          EKG

 

Adverse Effects:

-          CHF exacerbation

-          Hypotension

-          Hypokalemia

-          Fever

 

 

Drug Interactions: No known drug interactions

Pregnancy Category:  C

Note:  Serum digoxin levels may be falsely elevated; monitoring of levels is not recommended.

Generic Name (Trade Name):  Dimercaprol (Bal In Oil)

 

MOA/Description: Heavy Metal Chelator; gold, lead, arsenic

 

Adult Dose:  3 mg/kg IM every 4 hr-6 hr for 2 days, then every 12hr

for 7 - 10 days or  recovery

 

Pediatric Dose: Same as adult

 

Dose Adjustment: 

 

Renal: use at a reduced dosage with extreme caution, or discontinue, in patients developing acute renal insufficiency during therapy

Hepatic: contraindicated with hepatic insufficiency

 

Administration: IM            

 

How Supplied:  Intramuscular Oil: 10 %

 

Contraindications: Hepatic insufficiency

 

Precautions:  Potentially a nephrotoxic drug, keep urine alkaline to protect   

kidneys, use with caution in patients with oliguria or GPD insufficiency

 

Monitoring Parameters:  decreased symptoms of toxicity, reduced concentrations  of toxic agents blood pressure, heart rate renal function

 

Adverse Reactions:

 

Common

Cardiovascular: Tightness sensation, Chest, limbs, jaw, abdomen

Gastrointestinal: Nausea, Vomiting

Neurologic: Headache, Paresthesia, Tremor

Ophthalmic: Blepharospasm, Conjunctivitis, Finding of lacrimation

 

Serious

Cardiovascular: Hypertension (frequent), Pulse fast (frequent)

 

Drug Interactions: Toxic complexes with iron, cadnium, selenium, or uranium

 

Pregnancy Category: C

 

 

Flumazenil (Romazicon^®)

 

Indications: Benzodiazepine toxicity, sedation reversal

Mechanism of Action: Competitively inhibits the activity at the benzodiazepine (BZD) recognition site on the GABA/BZD receptor complex

 

Dosing:

-          Adult

o        BZD Overdose:

§         Initial: 0.2 mg IV over 30 s (if desired response not obtained after additional 30 s, give dose of 0.3 mg IV over 30 s).  Further doses of 0.5 mg IV over 30 s may be given at 1-min intervals if needed to MAX total dose of 3 mg. 

·         Note: Patients with only partial response to 3 mg may require additional slow titration to a total dose of 5 mg. If no response 5 min after receiving total dose of  5 mg, overdose is unlikely to be BZD and further tx with flumazenil will not help

-          Pediatric (> 1 year old)

o        0.01 mg/kg (up to 0.2 mg) IV over 15 s; (if desired response not obtained after additional 45 s) further injections of 0.01 mg/kg may be repeated at 1-min intervals, as needed up to 4 times). Maximum total dose: 0.05 mg/kg or 1 mg.

 

Dose Adjustments:

-          Renal impairment: none necessary

-          Hepatic impairment: Initial dose for initial reversal is not changed; however, subsequent doses should be reduced in amount or frequency

 

Administration:

-          Administer in freely-running IV into large vein. 

-          Administer as a series of small injections and not as a single bolus dose

-          Compatible with D₅W, LR, NS

-          Stable for 24 hours if drawn into a syringe or mixed with solutions

 

How Supplied: IV solution: 0.1 mg/mL

 

Contraindications:

-          Hypersensitivity to flumazenil, BZDs

-          Patients given BZDs for control of life-threatening conditions (eg, control of intracranial pressure or status epilecticus)

-          Patients showing signs of serious cyclic-antidepressant overdosage

 

Precautions:

-          Drug and alcohol dependent patients

-          History of long-term BZD abuse

-          If neuromuscular blocking agents are used, do not use flumazenil until the effects of neuromuscular blockade is fully reversed

-          Liver disease

-          May induce panic attacks in patients with a h/o panic disorder

-          Patients with head injuries

-          Does not reduce the risks associated with the use of large doses of BZDs

-          Does not reverse respiratory depression/hypoventilation

 

Monitoring Parameters: monitor pts for return of sedation or respiratory depression

 

 

 

 

Adverse Reactions:

-          Common:

o        Diaphoresis

o        Injection site pain

o        Dizziness, HA

o        Blurred vision

o        Agitation, Anxiety

-          Serious:

o        Cardiac dysrhythmia

o        Seizure

 

 

Drug Interactions: Non-BZD Hypnotics (zaleplon, zolpidem, zopiclone)

 

Pregnancy Category: C

Fomepizole (Antizol^®)

 

Indication: Ethylene glycol poisoning

Mechanism of Action: Competitive inhibitor of alcohol dehydrogenase, an enzyme which catalyzes the metabolism of ethanol, ethylene glycol and methanol to their toxic metabolites

 

Dosing:

-          Adult:

o        Loading dose of 15 mg/kg, followed by 10 mg/kg q12h x 4 doses, then 15 mg/kg q12h until ethylene glycol level < 20 mg/dL and patient is asymptomatic with normal pH

-          Pediatric: Safety and efficacy have not been established in pediatric patients

Dose Adjustments:

-          Renal Impairment

o        Beginning of hemodialysis (HD):

§         < 6 hours since last fomepizole dose: Do not administer dose

§         ≥ 6 hours since last fomepizole dose: Administer next scheduled dose

o        During HD: Dose q4h

o        Following HD (based on time between last dose and the end of HD):

§         < 1 hour: Do not administer dose at end of hemodialysis

§         1-3 hours: Administer ½ of next scheduled dose

§         > 3 hours: Administer next scheduled dose

o        Maintenance dose when off HD: Give next scheduled dose 12 hours from last dose administered

 

Administration:

-          Do not administer undiluted due to venous irritation. Mix into at least 100 ml of sterile NS or D₅W.

-          All doses should be given as a slow 30-minute IV infusion

-          Stable for 24 hours after dilution

How Supplied:

-          IV solution, 1 g/ml

Contraindications:

-          Hypersensitivity to fomepizole or other pyrazoles

Precautions:

-          Do not give undiluted or by bolus injection

-          Liver disease (fomepizole primarily metabolized in liver)

-          Dosage adjustment required in HD; renal impairment

 

Monitoring Parameters:

-          Plasma/urine ethylene glycol or methanol concentrations

-          Urinary oxalate crystals

-          Plasma/urine osmolality

-          Renal/hepatic function

-          Serum electrolytes

-          Arterial blood gases (ABGs)

-          Anion and osmolar gaps

-          WBC

-          ECG/EEG

 

Adverse Reactions:

-          Common:

o        Hypotension

o        Hypertriglyceridemia

o        N/V

o        HA

o        Dizziness

o        Seizure

o        Anxiety

-          Serious: Disseminated intravascular coagulation (rare), Anuria

Drug Interactions: Ethanol

 

Pregnancy Category: C

 

 

 

Glucagon (GlucaGen^®, Glucagon^®)

 

Indications: β-blocker toxicity and CCB (verapamil) toxicity, severe hypoglycemia

 

Mechanism of Action:

-          Stimulates adenylate cyclase to produce increased cAMP, which promotes hepatic glycogenolysis and gluconeogenesis → increases blood glucose levels

-          Positive inotropic and chronotropic effect on the heart

 

Dosing (for β-blocker/CCB toxicity):

-          Adult:

o        5-10 mg IV infusion over 1 minute followed by an infusion of 1-10 mg/hr

o        Alternative for β-blocker OD: 3-10 mg or initially 0.5-5 mg bolus followed by continuous infusion of 1-5 mg/hr

 

Dose Adjustments: none

 

Administration:

-          Can be given IM, IV, or SubQ

-          Reconstitute with diluent to max concentration of 1 mg/mL

-          Use immediately; solution should be clear & water-like

-          1 unit = 1 mg

-          IV: Inject at a rate not exceeding 1 mg/min.  May be administered through line running D₅W or given at same time as a bolus of dextrose

 

How Supplied:

-          Injection powder for solution: 1 mg, 10 mg

 

Contraindications:

-          Hypersensitivity to glucagons

-          Pheochromocytoma

 

Precautions:

-          Malnutrition

-          Adrenal insufficiency

-          Chronic hypoglycemia

-          History of pheochromocytoma

-          Insulinoma

-          Allergic reactions

 

Monitoring Parameters:

-          BP

-          Heart rate

-          Blood glucose

 

Adverse Reactions:

-          Rash

-          N/V

-          HTN

-          Tachycardia

 

Drug Interactions:

-          Anticoagulants (warfarin) – may enhance anticoagulant effect

 

Pregnancy Category: B

 

 

Methylene Blue (Urolene Blue^®)

 

Indication: Drug-induced methemoglobinemia

 

Mechanism of Action:

-          Weak germicide in low concentrations

-          Accelerates the conversion of methemoglobin to hemoglobin

-          In high concentrations, it converts ferrous iron of reduced hemoglobin to ferric iron to form methemoglobin

 

Dosing:

-          Adult & Pediatric:

o        1-2 mg/kg or 25-50 mg/m² IV over several minutes; may be repeated in 1 hr if necessary

 

Dose Adjustments:

-          Severe renal impairment: adjustment should be considered (specific guidelines not available)

 

Administration:

-          Administer undiluted by direct IV injection slowly over several minutes.

-          Do not inject SubQ or intrathecally

 

How Supplied:

-          IV solution: 10 mg/ml

-          Oral tablet: 65 mg

-          Topical solution: 2%

 

Contraindications:

-          Hypersensitivity to methylene blue

-          Intraspinal injection

-          Methemoglobinemia in cyanide poisoning

 

Precautions:

-          Use with caution in young patients and in patients with G6PD deficiency (continued use can cause profound anemia)

-          Renal impairment

 

Monitoring Parameters:

-          Arterial blood gases

-          Blood pressure

-          CBC

-          Methemoglobin levels

-          Renal function (SCr/BUN)

-          Serum bilirubin (unconjugated)

 

 

 

Adverse Reactions:

-          Hypertension/hypotension

-          Cardiac dysrhythmia

-          Dizziness

-          Confusion

-          N/V/D

-          Abdominal pain

-          Hemolytic anemia

-          Diaphoresis

-          Skin/urine discoloration

 

Drug Interactions: none clinically significant

 

Pregnancy Category: C

 

Naloxone (Narcan^®)

 

Indication: Opiate overdose

 

Mechanism of Action: Pure opioid antagonist that competes and displaces narcotics at opioid receptor sites (mu, kappa, sigma). Greatest affinity for the mu receptor.

 

Dosing:

-          Adult:

o        IV: 0.4-2 mg q2-3 minutes prn; may repeat doses q20-60 minutes

o        Continuous IV infusion: Loading dose of 0.005 mg/kg, followed by 0.0025 mg/kg/hr

-          Pediatric:

o        Birth to 5 years or < 20 kg: 0.1 mg/kg IV; repeat q2-3 minutes prn; may need to repeat doses Q20-60 minutes

o        > 5 years or ≥ 20 kg: 2 mg/dose; if no response, repeat q2-3 minutes; may need to repeat doses Q20-60 minutes

 

Dose Adjustments: none needed. Use with caution in patients with hepatic impairment.

 

Administration:

-          May be administered IV (preferred), IM, SubQ

-          IV continuous infusion: dilute with NS or D₅W to a concentration of 0.004 mg/mL (2 mg in 500 mL). Rate titrated to patient effect.

-          IV push: Administer over 30 seconds as undiluted preparation

 

How Supplied:

-          Injection solution: 0.02 mg/mL, 0.4 mg/mL, 1 mg/mL

 

Contraindications: hypersensitivity to naloxone

 

Precautions:

-          Pre-existing cardiovascular disease

-          Concurrent cardiotoxic drugs

-          Known or suspected physical dependence on opioids

-          Neonates

-          IM or SubQ injections in patients who are hypotensive or have impaired peripheral circulation

 

Monitoring Parameters:

-          Reduction in opioid drug effects (i.e., respiratory depression)

-          BP, HR, RR

-          S/sxs of opioid withdrawal

 

Adverse Reactions:

-          Cardiac dysrhythmia, ventricular fibrillation

-          Hypertension/hypotension

-          Hepatotoxicity

-          Pulmonary edema

-          Opioid withdrawal

 

Drug Interactions:

-          Opiate agonists

-          Clonidine (probable)

-          Yohimbine

 

Pregnancy Category: C

Octreotide (Sandostatin^®)

 

Indication: Oral sulfonylurea overdose

 

Mechanism of Action: Inhibits growth hormone, glucagon, and insulin more effectively than the natural hormone, somatostatin

 

Dosing:

-          Adult (optimal dosage has not been established):

o        100-450 mcg/day SubQ given in 2-3 divided doses

o        Continuous SubQ infusion:300-1500 mgc/day

-          Pediatric (optimal dosage has not been established):

o        1-10 mcg/kg/day SubQ

 

Dose Adjustments:

-          Elderly: Dose adjustment may be necessary (elimination t_1/2 is increased by 46% and clearance is decreased by 26%)

-          Renal Impairment: severe renal failure requiring dialysis—clearance is reduced by ~50%; specific dosing guidelines not available

 

Administration:

-          IV push: give over 3 minutes

-          IV infusion: dilute in NS or D₅W to volume of 50-200 mL; infuse over 15-30 min

 

How Supplied:

-          Injection powder for solution: 10 mg, 20 mg, 30 mg

-          Injection solution: 50 mcg/mL, 100 mcg/mL, 200 mcg/mL, 500 mcg/mL, 1000 mcg/mL

 

Contraindications: Hypersensitivity to octreotide

 

Precautions:

-          Altered absorption of dietary fats

-          Biliary tract abnormalities

-          Decreased vitamin B_12­ levels

-          Thyroid abnormalities

-          Diabetes mellitus

-          Renal failure

 

Monitoring Parameters:

-          Symptomatic improvement

-          Thyroid function

-          Blood glucose

-          ECG

 

Adverse Reactions:

-          Common:

o        Injection site pain

o        Hyper-/hypoglycemia

o        Hypothyroidism

o        Abdominal discomfort

o        Cholelithiasis

o        N/V/D

o        Dizziness, HA

-          Serious:

o        Cardiac dysrhythmia, CHF, bradycardia, HTN

 

Drug Interactions:

-          Antidiabetic agents

-          Calcium channel blockers

-          β-agonists, β-blockers

-          Class IA, III antiarrhythmics

-          Diuretics

-          Local anesthetics

-          Opiate agaonists

-          Tricyclic antidepressants

 

Pregnancy Category: B

 

 

Penicillamine (Cuprimine, Depen)

 

MOA/Description: Heavy Metal Chelator; Copper, Lead

               

Adult Dose:           250mg – 500mg/dose every 8 – 12hr, continue until blood level

                                is <15 ug/dL         

 

Pediatric Dose: 25 – 35mg/kg/day in 3 to 4 divided doses; initiating treatment at 25% of dose and gradually increasing tp full dose over 2 – 3 weeks may minimize adverse reactions

 

Dose Adjustment:

                                Hepatic: 250mg/day tgo start, increase by 250mg every 2 weeks

                                up to a maintenance dose of 1g/day, in 4 divided doses

                                Renal: Cl_cr<50 mL/min: Avoid use

 

Administration: Give on empty stomach, 1 hour before meals and at bedtime        

 

How Supplied: Oral Capsule: 125 MG, 250 MG

                                     Oral Tablet: 250 MG       

 

Contraindications:              breastfeeding, pregnancy, hypersensitivity to penicillamine products, patients with history or evidence of renal insufficiency

 

Precautions: penicillamine should not be used in patients receiving concurrent gold therapy, antimalarial or cytotoxic drugs, oxyphenbutazone or phenylbutazone, possible cross-sensitivity in patients allergic to penicillin, renal dysfunction; avoid interruption of therapy - may cause sensitivity reaction after resuming therapy

 

Monitoring Parameters: urinalysis, WBC with differential, hemoglobin, direct platelet count, skin, lymph node, body temperature, liver function

 

Adverse Reactions:

               

Common

Dermatologic: Rash

Gastrointestinal: Disorder of taste, Epigastric pain,Nausea, Vomiting

Hematologic: Myelosuppression

 

Serious

Dermatologic: Pemphigus

Gastrointestinal: Oral lichenoid reaction

Hematologic: Agranulocytosis, Aplastic anemia, Thrombocytopenia

Musculoskeletal: Myasthenia gravis

Neurologic: Peripheral motor neuropathy, Sensory neuropathy

Ophthalmic: Optic neuritis

Otic: Tinnitus

Renal: Proteinuria, Renal glomerular disease, Renal vasculitis

 

Drug Interactions:

Increased effect of antimalarials, immunosuppresants, and phenylbutazone

Decreased digoxin levels may occur                                

 

Pregnancy Category: D

 

 

Physostigmine

 

MOA/Description: Cholinesterase Inhibitor

               

Adult Dose:  Anticholinergic drug overdose: 2 mg IV, no faster than 1 mg/min; dose may be repeated if no reversal has occurred or if anticholinergic symptoms return      

 

Pediatric Dose: Anticholinergic drug overdose: 0.02 mg/kg IV, no faster than 0.5 mg/min; dose may be repeated in 20 minutes  if no reversal has occurred or if anticholinergic symptoms return; maximum recommended dose is 2 mg   

 

Dose Adjustment: N/A

Administration:  IV injection or IM; no faster than 1 mg/min in adults, no faster than 0.5 mg/min in children

 

How Supplied: Injection solution, 1mg/ml in 2ml ampule

 

Contraindications:              asthma, cardiovascular disease, concomitant choline ester or depolarizing neuromuscular blocker use, diabetes, gangrene, hypersensitivity to physostigmine, mechanical obstruction of the intestine or urogenital tract

 

Precautions: atropine sulfate injection should be available to reverse toxic effects of physostigmine injection;   tricyclic antidepressant overdose

 

Monitoring Parameters: ECG, reversal of anticholinergic symptoms, symptoms of excessive sweating, salivation, emesis, urination, defecation; signs of cholinergic crisis

 

Adverse Reactions:

 

Common

Dermatologic: Diaphoresis

Gastrointestinal: Diarrhea, Excessive salivation, Hyperperistalsis, Nausea and vomiting

Ophthalmic: Finding of lacrimation, Miosis, Mydriasis

 

Serious

Cardiovascular: Bradyarrhythmia, Cardiac arrest, Cardiac dysrhythmia, Increased cardiac output

Neurologic: Seizure

Respiratory: Bronchospasm, Dyspnea

               

Drug Interactions: Succinylcholine, bethanecol

 

Pregnancy Category:  C

 

 

Phytonadione (Mephyton)

 

MOA/Description: Phytonadione is a vitamin which is necessary for the hepatic synthesis of prothrombin (factor II), proconvertin (factor VII), plasma thromboplastin component (factor IX), and Stuart factor (factor X,  Fat soluble vitamin, Vitamin K

               

Adult Dose:           Drug action reversal, Anticoagulant: 1 to 10 mg ORAL/IV/SQ depending on degree of INR elevaion; oral is preferred over SUBQ and IV

               

Pediatric Dose: Hemorrhage of newborn: 1 mg SC or IM (SC route preferred) Hemorrhage of newborn; Prophylaxis: 0.5-1 mg SC/IM within 1 hr of birth, SC route is preferred

 

Dose Adjustment: N/A

 

Administration: ORAL: anticoagulant, drug action reversal; ORAL is preferred over SQ (response to SQ is less predictable and sometimes delayed compared to ORAL) and IV. Oral vitamin K is also predictably effective, safe and more convenient   

 

How Supplied:  Injection Solution: 1 MG/0.5 ML, 10 MG/ML

    Oral Tablet: 0.1 MG, 5 MG, 100 MCG

 

Contraindications:              hypersensitivity to phytonadione products

 

Precautions: liver disease; severe reactions, including fatalities, have occurred with IV and IM administration

 

Monitoring Parameters: reduction in bleeding, PT

 

Adverse Reactions:            

 

Common

Dermatologic: Skin reaction - finding, IM

 

Serious

Immunologic: Anaphylaxis, IV and IM use

 

Drug Interactions: Anticoagulant effects warfarin are reversed by phytonadione

 

Pregnancy Category: C

 

 

Pralidoxime (Protopam)

 

MOA/Description: Nerve Gas Antidote; reactivates cholinesterase (mainly outside CNS) which was inactivated by organophosphate pesticides through phosphorylation               

 

Adult Dose:           Anticholinesterase overdose: initial, 1-2 g IV, maintenance, 250 mg IV every five minutes

Organophosphate poisoning: initial,1-2 g in 100 mL NS IV infused over 15-30 min, repeat 1-2 g in 1 hour if muscle weakness persists

 

Pediatric Dose: Organophosphate poisoning: 25-50 mg/kg IV; may repeat in 1-2hrs, then at 10-12hr intervals if necessary

 

Dose Adjustment:

Renal: dose should be reduced

 

Administration:   IV: infuse in 100 mL of NS over 15-30 min maximum rate of administration is 200 mg/min

                Can give IM or SQ if IV access not available

 

How Supplied: Injection Powder for Solution: 1 GM     

 

Contraindications:              hypersensitivity to pralidoxime

 

Precautions: myasthenia gravis (may precipitate myasthenic crisis), renal impairment

 

Monitoring Parameters: resolution of muscle weakness and respiratory depression, ECG

 

Adverse Reactions:

 

Common

Gastrointestinal: Nausea

Neurologic: Dizziness, Headache

Ophthalmic: Blurred vision

Respiratory: Hyperventilation, Laryngeal spasm

               

Drug Interactions: Use with aminophylline, morphine, theophylline, and succinylcholine in containdicated

 

Pregnancy Category: C

 

 

Protamine

 

MOA/Description: Heparin Antagonist; combines with strongly acidic heparin to form a stable complex salt neutralizing the anticoagulant activity of both drugs

               

Adult Dose: 1 mg IV for every 100 units of heparin remaining in patient; if 30 minutes have elapsed since the injection of heparin one-half the dose may be sufficient; maximum 50 mg given over 10 minutes

The dose can be given as a loading dose of 25 to 50 mg by slow IV injection, with the rest of the calculated dose over 8 to 16 hours by intravenous infusion

 

Pediatric Dose: safety and effectiveness in children have not been established

 

Dose Adjustment: N/A

 

Administration: administer by very slow intravenous injection over 10 minutes

 

How Supplied: Intravenous Solution: 10 MG/ML         

 

Contraindications:              hypersensitivity to protamine products

 

Precautions: Rapid administration may cause severe hypotensive and anaphylactoid reactions; heparin rebound or bleeding has been reported in cardiac surgery patients despite adequate neutralization of heparin with protamine; all of the following have been associated with an increased risk of hypersensitivity: hypersensitivity to fish, infertile or vasectomized men, and previous exposure to protamine

 

Monitoring Parameters: coagulation test, aPTT, blood pressure, heart rate

 

Adverse Reactions:

 

Common

Dermatologic: Flushing

Gastrointestinal: Nausea, Vomiting

Respiratory: Dyspnea

 

Serious

Cardiovascular: Bradyarrhythmia, Hypotension

Immunologic: Anaphylactoid reaction, Circulatory collapse, capillary leak, noncardiogenic pulmonary edema, Anaphylaxis

               

Drug Interactions: N/A

 

Pregnancy Category: C

 

 

Sodium Nitrite, Sodium Thiosulfate, Amyl Nitrite (Cyanide Antidote Package)

 

Mechanism of Action:

                Thiosulfate provides extra sulfur to increase the rate of activity of rhodanese, an enzyme that inactivates cyanide. Sodium nitrite and amyl nitrite work by forming methemoglobin, which has a high affinity for cyanide. Cyanmethemoglobin, a nontoxic compound, is formed and excreted in the urine.  

 

Dose:

Adult:

-          Crush 0.3 mL ampul of amyl nitrite and inhale vapor up to 30 seconds. Repeat every minute until IV sodium nitrite is infused.

-          Sodium Nitrite: 300mg IV

-          Sodium thiosulfate: infuse 12.5 g IV over 10 minutes

-          Repeat infusions of sodium nitrite and sodium thiosulfate at half the initial dose if needed

 

Pediatric:

-          Crush 0.3 mL ampul of amyl nitrite and inhale vapor up to 30 seconds. Repeat every minute until IV sodium nitrite is infused.

-          Sodium Nitrite: 6-8 mL/m²; maximum: 10 mL

-          Sodium thiosulfate: infuse  7 g/m² over 10 minutes; maximum 12.5 g

-          Repeat infusions of sodium nitrite and sodium thiosulfate at half the initial dose if needed

 

Administration:

-          Infuse sodium nitrite at a rate of 2.5-5 mL/min

 

How supplied:

Kit includes:

-          Sodium nitrite 300 mg/10 mL injection (2)

-          Sodium thiosulfate 12.5g/50 mL injection (2)

-          Amyl nitrite 0.3 mL inhalant (12)

-          Syringes, stomach tube, tourniquet

 

Contraindications:

-          Hypersensitivity to any component

-          Pregnancy due to amyl nitrite

-          Cerebral hemorrhage

-          Glaucoma

-          Recent head trauma