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310 Cards in this Set
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What is the functional class of oxygen?
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Oxidizer
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Other oxidizing agents include ozone, chlorine, nitric acid, hydrogen peroxide and household bleach (NaClO).
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By what mechanism does oxygen act?
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A colorless, odorless, tasteless gas necessary for the breakdown of glucose into a usable energy form.
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Gaseous oxygen is actually a very pale blue
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What are the indications for oxygen?
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Presence or suspicion of hypoxemia.
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Hypoxemia is the decreased partial pressure of oxygen in the blood. Hypoxemia is different from hypoxia, which is an low oxygen availability to tissue, but hypoxemia can cause hypoxia.
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What are the listed contraindications for oxygen?
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None.
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Never withhold oxygen from a patient for whom it is indicated.
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What are the listed precautions for oxygen?
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- Use cautiously with COPD patients
- Monitor long-term high concentrations in neonate as retrolental fibroplasia may develop - Open flame |
Retrolental fibroplasia (now known as "retinopathy of prematurity") is an eye disease that affects premature infants. Both oxygen toxicity and hypoxia can contribute to its development.
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What is the dosage for oxygen?
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25-100%
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High-flow oxygen systems include venturi masks, air-entrainment nebulizers and high-flow blender systems.
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What is the route for oxygen?
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BLS and/or ALS airway adjuncts as appropriate.
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Or no adjunct, if indicated... (e.g. nasal cannula)
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What is the relationship between liters per minute of oxygen and oxygen concentration?
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Every 1 L/minute (LPM) increase in oxygen is equal to a 4% increase in concentration.
Examples: - 1 L/minute = 25% - 2 L/minute = 29% |
Oxygen gas constitutes 20.9% of the volume of dry air. Other gases present are nitrogen (78.1%), argon (0.9%) and carbon dioxide (<0.1%).
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What is the best-known trade name for diazepam?
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Valium
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There are hundreds of trade names for diazepam around the world. In the US, Valium, Diastat and Valrelease are the most common.
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What is the functional class of diazepam?
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Benzodiazepine
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Other prehospital benzodiazepines are lorazepam (Ativan) and midazolam (Versed).
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What is the mechanism of action of diazepam?
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By intensifying the activity of GABA, it suppresses the spread of seizure activity through the motor cortex of the brain.
It is effective in the management of stress, anxiety, and alcohol withdrawal due to its sedative properties. Additionally, it is effective as a premedication for minor orthopedic procedures due to its skeletal muscle relaxant properties, and as a premedication for cardioversion because it produces amnesia. |
γ-aminobutyric acid is the chief inhibitory neurotransmitter in the CNS. As diazepam (and other benzodiazepines) requires GABA to act, it is safer than the barbiturates which were once used.
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What are the listed indications for diazepam?
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- Seizures (status epilepticus)
- To induce sedation prior to painful procedures - Acute anxiety |
California offers diazepam to condemned inmates as a pre-execution sedative...
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What are the listed contraindications for diazepam?
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- Known hypersensitivity
- Shock - Coma - Acute alcohol intoxication |
Contraindications not in the NEEMSI documentation include pregnancy, breastfeeding, sleep apnea and porphyria.
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What are the listed precautions for diazepam?
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- Can cause local irritation, therefore, use large vein when possible
- Seizure activity may reoccur due to its lipid solubility - Use with caution in patients with myasthenia gravis, impaired renal or hepatic function, obstetrical patients, and the elderly. |
Myasthenia gravis (MG) is a disorder characterized by muscle weakness caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction.
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What are the listed side effects of diazepam?
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- Hypotension
- Drowsiness - Tachycardia - Ataxia - Amnesia - Slurred speech - Edema - Headache - Dizziness - N/V - Blurred vision - Respiratory depression |
Ataxia (for the Greek for "lack of order") is a loss of muscle coordination that can affect balance, movement and speech.
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What are the listed interactions of diazepam?
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- Effects are enhanced when used in conjunction with other CNS depressants and alcohol
- Cimetidine (Tagamet) may increase diazepam plasma levels |
Cimetidine is a histamine H2-receptor antagonist that inhibits the production of stomach acid and is used in the treatment of heartburn and peptic ulcers.
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What is the dosage and route of diazepam?
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Adult:
- 5-10 mg IV, may repeat q 10-15 minutes prn, max 30mg for SEIZURES and 5-15 mg IV for CARDIOVERSION repeat up to 30 mg -0.5-2.0 mg to max dose of 5 mg (or physician order) for PAIN Pedi: - 0.2 - 0.3 mg/kg IV/IO, every 15-30 minutes, repeat once maximum single dose 20 mg - 0.5mg/kg PR, maximum single dose 10mg - may repeat either pedi dose once after 5 minutes |
Diazepam (unlike lorazepam and midazolam) may not be administered IM.
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What are the pharmacokinetics of diazepam?
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Onset: 1 - 5 minutes IV
Half-life: 20 - 50 hours |
Diazepam has the longest half-life of the prehospital benzodiazepines.
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What medication is an antagonist to diazepam?
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Flumazenil
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Flumazenil has trade names including Anexate, Lanexat, Mazicon & Romazicon.
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What is the best-known trade name for lorazepam?
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Ativan
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There are dozens of trade names for lorazepam around the world. When lorazepam was introduced in the US in 1971 it was known as Ativan and Temesta.
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What is the functional class of lorazepam?
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Benzodiazepine
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The first benzodiazepine, chlordiazepoxide (Librium), was discovered in 1955 and first marketed in 1960.
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What is the mechanism of action of lorazepam?
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Lorazepam is the most potent of the benzodiazepines.
It acts as an anxiolytic, sedative, hypnotic, and skeletal muscle relaxant. It intensifies the effects of GABA. Because of its short half-life it is the preferred benzodiazepine for the treatment of pediatric seizures. |
1mg of lorazepam is equivalent to 10mg diazepam.
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What are the listed indications for lorazepam?
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- Seizures (status epilepticus)
- To induce sedation prior to painful procedures - Acute anxiety |
Status epilepticus can be defined as defined as one continuous unremitting seizure lasting longer than 30 minutes, or recurrent seizures for greater than 30 minutes with no intervening consciousness.
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What are the listed contraindications for lorazepam?
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- Hypersensivity to benzodiazepines
- Acute narrow-angle glaucoma - Coma - Shock - Acute alcohol intoxication |
Glaucoma is an eye disorder in which the optic nerve is permanently and progressively damaged, resulting in complete blindness if untreated. It is often, but not always, associated with increased intraocular pressure (IOP).
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What are the listed precautions for lorazepam?
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- Renal or hepatic impairment
- Myasthenia gravis - COPD |
Lorazepam may be safer than most benzodiazepines in patients with impaired liver function as it does not require hepatic oxidation, but only hepatic glucuronidation.
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What are the listed side effects for lorazepam?
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- Anterograde amnesia
- Sedation - Hypertension - Hypotension - Blurred vision - N/V - Confusion |
Anterograde amnesia is a loss of the ability to create new memories after the event that caused the amnesia.
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What are the listed interactions for lorazepam?
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Effects of lorazepam will be increased when used in conjunction with other CNS depressants, alcohol, or cimetidine.
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Other CNS depressants include barbiturates, opioids, disassociatives and antipsychotics.
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What is the dosage and route of lorazepam?
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Adult:
- 1 - 2mg slow IV, IO or IM q 5 minutes, max 6mg Pedi: - 0.1mg/kg slow IVP, IO, or IM, max single dose 4mg, may repeat once after 5 minutes |
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What are the pharmacokinetics of lorazepam?
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Onset: 1 - 5 minutes IV, 5 - 10 minutes IM
Peak: 15-20 minutes Half-Life: 10 - 20hrs |
Despite its higher potency, the half-life of lorazepam is much shorter than that of diazepam.
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What medication is an antagonist to lorazepam?
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Flumazenil
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Flumazenil reverses the effects of benzodiazepines by competitive inhibition at the benzodiazepine binding site on the GABA receptor.
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What is the best-known trade name for midazolam?
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Versed
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Other trade names include Dormicum and Hypnovel.
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What is the functional class of midazolam?
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Benzodiazepine
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There are about 35 benzodiazepines that have been formulated and are used medically, several are not approved for use in the US.
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What is the mechanism of action of midazolam?
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This short-acting benzodiazepine intensifies activity of GABA.
It also has CNS depressant, anticonvulsant and anterograde amnestic properties. It also relaxes skeletal muscles and induces sleep. |
An amnestic is a drug that induces amnesia.
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What are the listed indications for midazolam?
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- Seizures (status epilepticus)
- To induce sedation prior to painful procedures |
Unlike diazepam and lorazepam, midazolam is not indicated for acute anxiety.
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What are the listed contraindications for midazolam?
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- Hypersensivity to benzodiazepines
- Acute narrow-angle glaucoma - Coma - Shock - Acute alcohol intoxication |
These are the same as the contraindications for lorazepam.
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What are the listed precautions for midazolam?
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Use with caution in patients with COPD, CHF and/or renal failure.
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Many sources include hypotension as a precaution or relative contraindication.
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What are the listed side effects of midazolam?
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- N/V
- Burred vision - Retrograde amnesia - Excessive amnesia - Apnea - Hypotension - PVCs |
PVCs (premature ventricular contractions/complexes) occur when the heartbeat is initiated by the heart ventricles rather than by the sinoatrial node.
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What are the listed interactions of midazolam?
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- Prolonged respiratory depression when given in conjunction with other CNS depressants such as alcohol
- Cimetidine (Tagamet) increases plasma levels of midazolam. |
The interactions of all three prehospital benzodiazepines are very similar.
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What is the dosage and route of midazolam?
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Adult:
- 2 mg slow IVP, IM, IO, IN q 5 min until SEDATION up to 10 mg 0.1 mg/kg IV or IO up to 10 mg dose for ASSISTED INTUBATION Pedi: - 6 months up to 6 years old- 0.05-0.1mg/kg slow IVP, IO, or IN to a max of 5 mg. 6-12 years old 0.1 mg/kg slow IV, IO, or IN, to a maximum single dose 8mg. |
There is evidence that buccal and intranasal midazolam are easier to administer and more effective than rectally administered diazepam for the control of seizures.
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What are the pharmacokinetics of midazolam?
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Onset: 1-3 minutes
Duration: 15-20 minutes up to 2 hours, occasionally 6 hours Half-Life: 1 - 4 hours |
The duration of apparent action is considerably less than the half-life. Noticeable effects wear off within a few hours but as long as the drug is present it will exert subtle effects. These effects may become apparent during continued use or may appear as withdrawal symptoms when dosage is reduced or the drug is stopped.
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What medication is an antagonist to midazolam?
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Flumazenil
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Flumazenil has also been found to be effective in overdoses of non-benzodiazepine sleep enhancers, such as zolpidem (Ambien) and zaleplon (Sonata).
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What is the best-known trade name for succinylcholine?
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Anectine
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Suxamethonium chloride, also known as suxamethonium or succinylcholine, is also sold under the trade names Quelicin and Scoline.
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What is the functional class of succinylcholine?
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Depolarizing neuromuscular blocker
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The only other depolarizing neuromuscular blocker used in medicine -- and very rarely -- is decamethonium (Syncurine).
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What is the mechanism of action of succinylcholine?
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Synthetic, ultra short-acting neuromuscular blocking agent. Succinylcholine is composed of two adjacent acetylcholine molecules and has a high affinity for acetylcholine receptors. It causes transient muscle contractions called fasciculations followed by skeletal muscle paralysis. There is no effect on level of
consciousness. |
Succinylcholine was originally known as diacetylcholine because of its structure.
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What are the listed indications for succinylcholine?
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To facilitate endotracheal intubation;
terminate laryngeal spasm; promote muscle relaxation |
Neuromuscular blocks are also in surgery, especially during intra-abdominal and intra-thoracic surgeries, to allow them to be conducted with fewer complications.
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What are the listed contraindications for succinylcholine?
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- Acute narrow angle glaucoma
- Penetrating eye injuries - Family history of malignant hyperthermia - Hyperkalemia - 24 - 48 hours post severe trauma including burns - Disorder of pseudocholinesterase - Neuromuscular disorders such as myasthenia gravis or ALS |
ALS is amyotrophic lateral sclerosis, also referred to as Lou Gehrig's disease
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What are the listed precautions for succinylcholine?
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Never paralyze without adequate sedation.
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Patients are still aware of pain even after full conduction block has occurred hence general anesthetics and/or analgesics must also be given to prevent the condition known as "anesthesia awareness".
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What are the listed side effects for succinylcholine?
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- Apnea
- Malignant hyperthermia - Dysrhythmias - Bradycardia - Tachycardia - Hypertension - Hypotension - Cardiac arrest - Increased intraocular pressure - Fasciculations - Exacerbation of hyperkalemia in trauma patients |
Fasciculations are muscle twitches: small, local, involuntary muscle contractions and relaxations visible under the skin.
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What are the listed interactions for succinylcholine?
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- Effects potentiated by oxytocin, beta-blockers, and organophosphates
- Diazepam may reduce duration of action |
Organophosphates include many pesticides and nerve agents.
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What is the dosage and route of succinylcholine?
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Adult:
- 1 - 2 mg/kg rapid IV or IO, repeat once if needed Pedi: - 1 - 1.5 mg/kg rapid IV or IO, repeat once if needed |
Succinylcholine has occasionally been used as a paralyzing agent for executions and as a means of murder and assassination.
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What are the pharmacokinetics of succinylcholine?
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Onset: 1 minute
Peak effect: 1 - 3 minutes Duration: 5 minutes |
Non-depolarizing blockers (e.g vecuronium, rocuronium) have a much longer duration but can be reversed.
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What is the best-known trade name for epinephrine?
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Adrenalin
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Epinephrine is known as "adrenaline" in most of the world but the term is not used in the US due to its similarity to the trademarked "Adrenalin".
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What is the functional class of epinephrine?
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Sympathomimetic
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In the human body, the most abundant catecholamines (which all have sympathomimetic effects) are epinephrine, norepinephrine and dopamine.
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What is the mechanism of action of epinephrine?
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A naturally-occurring catecholamine that acts directly on the alpha- and beta- (more profound) adrenergic receptors. This causes positive inotropic, dromotropic, and chronotropic effects as well as increased systemic vascular resistance and BP.
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- Inotropic - increased contractility
- Dromotropic - increased conduction velocity - Chronotropic - increased rate |
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What are the listed indications for epinephrine?
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- Cardiac arrest: asystole, VF, pulseless VT, PEA
- Symptomatic bradycardia - Anaphylaxis - Severe reactive airway disease |
Epinephrine is also used as a local vasoconstrictor in local anesthetics and in ointments to stop bleeding in contact sports such as boxing.
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What are the listed contraindications for epinephrine?
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Hypersensitivity to sympathomimetic amines
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Some sources state that epinephrine is contraindicated for patients on nonselective β-blockers because severe hypertension may result as only the α-adrenergic effects will be produced.
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What are the listed precautions for epinephrine?
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- Protect from light
- Can be deactivated by sodium bicarbonate, therefore flush IV line between administration of epinephrine and sodium bicarbonate. - Effects can be intensified by antidepressants |
Furosemide (Lasix) can also block the effects of epinephrine.
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What are the listed side effects for epinephrine?
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- Increases myocardial oxygen demand
- Can cause palpitations, anxiety, headache, CVA, syncope, HTN, tachydysrhythmias - Tissue necrosis with repeated injections or extravasation of IV |
Some sources add acute pulmonary edema as a side effect of epinephrine.
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What are the listed interactions for epinephrine?
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- May increase hypotension caused by phenothiazines, alpha and beta blockers
- Can be deactivated in alkaline solutions or sodium bicarbonate |
Tricyclic antidepressants can potentiate epinephrine by inhibition of norepinephrine reuptake.
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What is the dosage and route of epinephrine for cardiac arrest?
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Adult:
- 1.0mg of 1:10,000 IVP or IO q 3 - 5 minutes or infuse 1 mg in 500 ml NS at 2-10 mcg/min. Pedi: - 0.01mg/kg of 1:10,000 IV/IO |
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What is the dosage and route of epinephrine for severe anaphylaxis/asthma?
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Adult:
- 0.3 - 0.5mg of 1:1,000 IM or IV/IO Pedi: - 0.01mg/kg of 1:1,000 IM to a maximum of 0.5 mg. |
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What is the dosage and route of epinephrine for symptomatic bradycardia (as an infusion)?
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Preparation: 1 mg of 1:1,000 in 500mL NS
Adult: - 2 - 10mcg/min |
This is high-dose epinephrine as it is being diluted for infusion.
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What are the pharmacokinetics of epinephrine?
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None listed.
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One source states:
Onset: 5 - 10 min SQ, 1 - 2 min IV Duration: 5 - 10 min |
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What is the best-known trade name for vasopressin?
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Pitressin
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Vasopressin is also known as argipressin, arginine vasopressin (AVP) and antidiuretic hormone (ADH).
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What is the functional class of vasopressin?
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Hormone (ADH), vasopressor
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Vasopressin is mainly produced in the paraventricular nucleus (PVN) and supraoptic nucleus (SON) of the hypothalamus. It is very similar in structure to oxytocin.
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What is the mechanism of action of vasopressin?
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Vasopressin possesses pressor and antidiuretic properties:
- It increases nephron distal tube reabsorption of water. - In unnaturally high doses, it acts as a non-adrenergic vasoconstrictor by stimulation of smooth muscle receptors. - It is used as an alternative to epinephrine during CPR. |
Vasopressin has also been identified in memory formation and the regulation of social bonding and behavior.
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What are the listed indications for vasopressin?
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Cardiac arrest
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Vasopressin is also used in the hospital treatment of septic shock.
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What are the listed contraindications for vasopressin?
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- Chronic nephritis
- Ischemic heart disease - PVCs - First stage of labor |
And, of course, known hypersensitivity.
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What are the listed precautions for vasopressin?
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Use with caution in patients with:
- Epilepsy - Migraine - Asthma - Heart failure - Angina pectoris |
Some sources also list renal insufficiency as a precaution.
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What are the listed side effects for vasopressin?
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- N/V
- Abdominal cramps - HTN - Bradycardia - PACs - MI |
PACs (premature atrial contractions) are a benign arrhythmia that occurs in the atria. They are not as serious as premature ventricular contractions (PVCs) and usually require no medical care.
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What are the listed interactions for vasopressin?
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- Epinephrine
- Heparin - Alcohol - Phenytoin - Thiazide diuretics - Carbamazepine - Neostigmine |
May decrease antidiuretic effects:
- Epinephrine - Heparin - Alcohol - Phenytoin May increase antidiuretic effects: - Thiazide diuretics - Carbamazepine May increase vasoconstriction: - Neostigmine |
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What is the dosage and route of vasopressin?
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40 units IVP/IO (single dose only)
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Vasopressin international units are defined by comparing the pressor effects to that of the USP Posterior-pituitary Reference Standard. 1mg of vasopressin is 600 units.
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When should vasopressin be used in a cardiac arrest situation?
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May replace first or second dose of epinephrine in cardiac arrest.
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This is for adult arrest only (AHA).
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What is the best-known trade name for atropine?
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None.
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Atropine derives its name from Atropos, one of the three Fates who, according to Greek mythology, chose how a person was to die.
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What is the functional class of atropine?
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Parasympatholytic
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Atropine is one of only two prehospital parasympatholytics - the other is Atrovent (ipratropium bromide).
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What is the mechanism of action of atropine?
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Blocks muscarinic acetylcholine receptors thus inhibiting parasympathetic stimulation. By blocking vagal impulses to the heart it accelerates SA node discharge, enhances conduction through the AV junction, and increases cardiac output. It is also a potent bronchodilator when bronchoconstriction is caused by increased parasympathetic tone.
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One of the main actions of the parasympathetic nervous system is to stimulate the M2 muscarinic receptor in the heart, but atropine inhibits this action.
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What are the listed indications for atropine?
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- Symptomatic bradycardia
- Organophosphate/nerve agent poisoning |
Atropine has many opthalmic uses including as a cyclopegic and mydriatic.
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What are the listed contraindications for atropine?
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None in the emergency setting.
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In non-emergency situations, atropine is contraindicated in patients pre-disposed to narrow angle glaucoma.
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What are the listed precautions for atropine?
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- May worsen bradycardia associated with 2nd Degree Mobitz II and 3rd Degree AV blocks, consider TCP .
- Use with caution in patients with signs and symptoms of acute myocardial ischemia, myocardial infarction & glaucoma. |
Atropine increases oxygen demand of the AV nodal tissue, thereby aggravating ischemia and any resulting heart block.
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What are the listed side effects for atropine?
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- Blurred vision
- Dilated pupils - Dry mouth - Tachycardia - Drowsiness - Convulsions - HTN or hypotension - Palpitations - Paradoxical bradycardia (if given too slowly) - AV dissociation - Urinary retention |
In medieval Europe women used the juice of the berries of Atropa belladonna (a source of atropine) to enlarge the pupils of their eyes for cosmetic reasons; "bella donna" is Italian for "beautiful lady".
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What are the listed interactions for atropine?
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Antihistamines, tricyclic antidepressants & procainamide can lead to the anticholinergic effects of atropine.
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Procainamide is a cardiac medication and used to treat supraventricular and ventricular arrhythmias.
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What is the dosage and route of atropine in asystole/bradycardic PEA?
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It is no longer recommended for this (as of October 2010)
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What is the dosage and route of atropine in symptomatic bradycardia?
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Adult:
- 0.5mg IVP q 3 - 5 minutes max total 3mg for BRADYARRYTHMIAS Pedi: - 0.02mg/kg IVP or IO; max single dose is 0.5 mg for BRADYARRHYTMIAS .0.02 mg/kg IV/IO for RSI |
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What is the dosage and route of atropine in organophosphate poisoning?
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Adult:
2 mg IVP q 5 minutes prn Pedi: 0.05 – 0.1mg/kg IV/IM (min dose of 0.1mg and max single dose 5mg), repeat q 2 – 5 minutes prn |
Atropine is included in the US military's Mark 1 NAAK ("Nerve Agent Antidote Kit") and ATNAA ("Antidote Treatment Nerve Agent Auto-Injector").
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What are the pharmacokinetics of atropine?
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Onset: 1-5 minutes
Duration 20-50 minutes |
As a therapeutic mydriatic, atropine's effects can last for 1-2 weeks.
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What is the best-known trade name for lidocaine?
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Xylocaine
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Lidocaine was first marketed in 1949, it has also been called "lignocaine".
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What is the functional class of lidocaine?
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Class Ib antidysrhythmic (sodium channel blocker); decreases automaticity by slowing rate of spontaneous phase 4 depolarization.
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Other Ib antidysrhythmics include phenytoin (Dilantin) and mexiletine (Mexitil).
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What is the mechanism of action of lidocaine?
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Suppresses depolarization and automaticity in the His-Purkinje system. Also suppresses ventricular ectopy and increases the ventricular threshold for dysrhythmias; however it decreases the ventricular threshold for defibrillation.
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Lidocaine blocks the fast voltage gated sodium (Na⁺) channels.
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What are the listed indications for lidocaine?
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suppression of ventricular dysrrhythmias;
prophyllaxis of recuurance after conversion of V-tach; conscious IO infusions; facilitating RSI |
Lidocaine also has significant use as a local anesthetic, including during IO insertion. It is also used as an inhaled antitussive.
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What are the listed contraindications for lidocaine?
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- Hypersensitivity
- Supraventricular dysrhythmias - Untreated sinus bradycardia - 2nd Degree Mobitz II AV Block - 3rd Degree AV Block - Stokes-Adams syndrome |
Some sources also include AIVR, the presence of an artificial pacemaker and the use of class I antidysrhythmics.
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What are the listed precautions for lidocaine?
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CNS depression may occur in doses greater than 300mg/hour
- Liver or renal disease - CHF - Hypovolemia - Shock - Myasthenia gravis. |
Some sources state that lidocaine should not be used in patients with congenital or idiopathic methemoglobinemia or with pseudocholinesterase deficiency.
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What are the listed side effects for lidocaine?
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- Altered mental status including confusion
- Bradycardias, - Hypotension - Seizures |
Prolonged use may produce permanent corneal opacification and ulceration with accompanying loss of vision.
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What are the listed interactions for lidocaine?
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Use caution when administered with beta blockers or procainamide as drug toxicity may result.
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Cimetidine may increase serum levels of lidocaine due to reduced hepatic circulation.
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What is the dosage and route of lidocaine?
|
Adult:
- for VT, 1 - 1.5mg/kg IVP or IO, repeat at half the initial dose (0.5 - 0.75mg/kg IVP) q 5-10 minutes up to a maximum of 3mg/kg; maintenance infusions for CONSCIOUS IO-(site pain)-20-40 mg slow IO push every 20-45 minutes Pedi: - for CONSCIOUS IO (pain mgmt) 0.5 mg/kg slow IO, every 20-45 minutes |
Interestingly, lidocaine has no proven short-term or long-term efficacy in cardiac arrest.
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What is the dosage for an IV infusion of lidocaine?
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Adult:
- Infusion: 1 - 4 mg/minute using the "+1 Rule"--using infusion rate of 1 more mg/min that number of boluses given |
The infusion and bolus should be administered together so no lag occurs.
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What are the pharmacokinetics of lidocaine?
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Onset = 1-5 minutes
Duration = 15 minutes - two hours Half-Life = 1.5 - 2 hours |
The elimination half-life of lidocaine is approximately 90-120 minutes in most patients. This may be prolonged in patients with hepatic impairment (average 343 minutes) or congestive heart failure (average 136 minutes).
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What is the best-known trade name for amiodarone?
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Cordarone
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Another trade name in the US is Pacerone.
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What is the functional class of amiodarone?
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Class III antidysrhythmic (potassium channel blocker)
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Other class III antidysrythmics are Sotalol, Ibutilide, Dofetilide, Dronedarone and the experimental E-4031
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What is the mechanism of action of amiodarone?
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Amiodarone is a unique Class III antidysrhythmic that acts directly on all cardiac tissues. It prolongs the duration of the action potential and refractory period (by blocking potassium channels) without significantly affecting the resting membrane potential. It also blocks sodium channels. The IV form relaxes vascular smooth muscle, decreases peripheral vascular resistance and increases coronary blood flow. Additionally, it blocks the effects of sympathetic stimulation.
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Amiodarone also resembles thyroid hormones and its binding to the nuclear thyroid receptors might contribute to some of its pharmacologic and toxic actions
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What are the listed indications for amiodarone?
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Life-threatening ventricular and supraventricular dysrhythmias
(VF, VT, A-Fib, A-Flutter, SVT, WPW) |
Amiodarone should not be used for hemodynamically unstable ventricular tachycardia.
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What are the listed contraindications for amiodarone?
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- Hypersensitivity
- Cardiogenic shock - Severe sinus bradycardia, - AV block |
Some sources also caution against use with 2nd or 3rd degree heart block in the absence of an artificial pacemaker.
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What are the listed precautions for amiodarone?
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Use with caution in:
- severe liver disease - pregnancy - nursing mothers |
The injectable forms of amiodarone containing benzyl alcohol should be avoided with neonates or infants because the
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What are the listed side effects for amiodarone?
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- CHF
- Angioedema - Hypotension - AV block - Hepatotoxicity - Cardiogenic shock - Fatigue - Bradycardia - Sinus arrest - Permanent blindness - N/V - Prolonged QT interval |
Long-term administration of amiodarone is associated with a blue-gray discoloration of the skin that may fade once therapy is discontinued.
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What are the listed interactions for amiodarone?
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- Increases digoxin levels
- Enhances pharmacological effects of: -- Procainamide -- Lidocaine -- Quinidine -- Oral anticoagulants - Concurrent use of calcium channel blockers, beta blockers, fentanyl, or cimetidine may potentiate sinus bradycardia |
Amiodarone inhibits the action of the cytochrome P450 isozyme family.
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What is the dosage and route of amiodarone?
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Adult:
V-Tach with pulse: 150mg (in 100ml of D5W or NS) IV infusion over 10 minutes. Pulseless: 300mg IVP, repeat in 3 - 5 minutes at 150mg IVP Maintenance infusion: 1mg/min over the next 6 hours Pedi: 5mg/kg IV/IO |
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What is the best-known trade name for adenosine?
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Adenocard
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A formulation of adenosine used as a pharmacologic stress agent is called Adenoscan. Adenosine is often abbreviated "Ado".
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What is the functional class of adenosine?
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Antidysrhythmic
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Adenosine is a class V antidysrythmic (direct nodal inhibition). Adenosine also has topical anti-inflammatory properties
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What is the mechanism of action of adenosine?
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A naturally occurring nucleoside that decreases conduction through the AV node and interrupts AV and SA re-entry pathways thus restoring normal sinus rhythm in patients with SVT.
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Adenosine also indirectly causes a shortening of the refractory period in atrial tissue and can precipitate A Fib if administered via a central lumen catheter.
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What are the listed indications for adenosine?
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SVT refractory to vagal maneuvers including Wolff-Parkinson-White (WPW)
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WPW features ventricular preexcitation due to an accessory pathway from the atria to the ventricles known as the bundle of Kent.
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What are the listed contraindications for adenosine?
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- 2nd and 3rd Degree AV heart blocks
- Symptomatic bradycardia - Sick sinus syndrome - Hypersensitivity |
2nd and 3rd degree AV heart blocks and sick sinus syndrome may be permitted if a cardiac pacemaker is present.
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What are the listed precautions for adenosine?
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- Place patient in semi-Fowler position as patients will typically develop arrhythmias at the time of conversion
- Use cautiously in patients with asthma |
This can be expanded to include patients with acute bronchospasm and other obstructive lung diseases.
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What are the listed side effects for adenosine?
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- Syncope
- Dizziness - Dyspnea - N/V - Headaches - Palpitations - Chest pain - Hypotension - Dysrhythmias Side effects are usually self-limiting due to short half-life. |
A metallic taste in the mouth is a hallmark side effect of adenosine.
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What are the listed interactions for adenosine?
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- Patients taking caffeine or xanthines (aminophylline or theophylline) may require larger doses as these drugs antagonize adenosine
- Patients on dipyridamole (Persantine) and carbamazepine (Tegretol) may need smaller doses of adenosine as these drugs potentiate adenosine’s effects |
Some sources state that verapamil (and related medications) may increase the risk of V Fib.
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What is the dosage and route of adenosine?
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Adult:
- 6mg rapid IVP followed by a 10-20mL NS flush - If no conversion after 1-2 minutes administer 12mg rapid IVP followed by a 10-20mL NS flush - If no conversion after 1-2 minutes administer repeat 12mg rapid IVP followed by a 10-20mL NS flush Pedi: - 0.1-0.2 mg/kg IVP/IO (maximum single dose is 12mg) - Maximum pediatric dose is 30 mg. |
Because of the very short half-life, administer adenosine as close to the heart as possible.
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What are the pharmacokinetics of adenosine?
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Onset = rapid
Half-Life = approximately 10 seconds |
Adenosine is broken down by adenosine deaminase, which is present in RBCs and vessel walls.
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What is the best-known trade name for diltiazem?
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Cardizem
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There are over twenty brand names for diltiazem including Angizem, Cartia, Diltalen & Tiazac.
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What is the functional class of diltiazem?
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Class IV antidysrhythmic (calcium channel blocker)
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Like verapamil, diltiazem is a non-dihydropyridine calcium channel blocker. Dihydropyridine calcium channel blockers have only vasodilatory rather than negative inotropic effects.
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What is the mechanism of action of diltiazem?
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Inhibits calcium ion influx through slow channels into cells of myocardial and arterial smooth muscle. This causes intracellular calcium to remain at sub-threshold levels that are insufficient to stimulate cell excitation and contraction. It reduces peripheral vascular resistance by inhibiting the contractility of vascular smooth muscle which causes dilation of the coronary arteries. It also inhibits coronary artery spasm. Diltiazem also slows SA and AV node conduction without affecting atrial action potential.
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Diltiazem also affects dopaminergic and glutamatergic signalling in the brain and this may explain why it can be used to reduce cocaine cravings.
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What are the listed indications for diltiazem?
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- SVT refractory to adenosine
- Rapid A-Fib or A-Flutter |
Diltiazem and other calcium channel blockers are also being investigated in the treatment and prophylaxis of migraine.a
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What are the listed contraindications for diltiazem?
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- Hypersensitivity
- Sick sinus syndrome - 2nd and 3rd Degree AV block, - Hypotension - WPW - Wide complex tachycardia |
Hypotension may be a symptom of tachydysrhythmia caused by decreased ventricular filling and administration of diltiazem may still be considered. NH protocols allow diltiazem for tachycardic patients who are symptomatic but hemodynamically stable.
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What are the listed precautions for diltiazem?
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- Avoid in patients receiving oral beta-blockers
- Monitor for hypotension resulting from peripheral vasodilation. - Use with caution in CHF |
Some sources list PAOD and COPD as relative contraindications.
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What are the listed side effects for diltiazem?
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- Chest pain
- Bradycardia - Hypotension - Syncope - CHF - Dysrhythmias - N/V - Headache - Sweating - Dizziness - Dyspnea - 2nd and 3rd Degree AV block - Palpitations |
Some sources include blurred vision and confusion.
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What are the listed interactions for diltiazem?
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Beta-blockers may increase digoxin (sic) levels
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Beta blockers and quinidine may interact with diltiazem to increase the likelihood of dysrhythmias and AV node block.
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What is the dosage and route of diltiazem?
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Bolus
0.25mg/kg slow IVP, may repeat in 15 minutes at 0.35mg/kg slow IVP IV Infusion: 5-15mg/hr, titrate to heart rate |
NH protocols state that a diltiazem bolus should be administered over two minutes.
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What are the pharmacokinetics of diltiazem?
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None listed.
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The half-life of diltiazem is approximately seven hours. There is a strong relation between plasma diltiazem concentration and percent heart rate reduction.
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What are the best-known trade names for nitroglycerin?
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Nitrostat, Nitro-Bid, Tridil
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Other trade names include Nitrospan, Nitrol, Trinipatch, Nitro-Dur, Natispray and NitroMist.
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What is the functional class of nitroglycerin?
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Nitrate
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Other nitrates include isosorbide mononitrate (Imdur), isosorbide dinitrate (Isordil) and pentaerythritol tetranitrate (Lentonitrat).
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What is the mechanism of action of nitroglycerin?
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Rapid vascular smooth muscle relaxant that increases coronary blood flow and improves perfusion of the ischemic myocardium. This results in decreased venous return to the heart, alleviation of chest pain, and a decrease in preload and afterload in the left ventricle.
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The effects of NTG (and other nitrovasodilators) is achieved by denitration to produce nitric oxide (NO) which is a potent vasodilator.
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What are the listed indications for nitroglycerin?
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- Chest pain associated with angina pectoris or AMI
- Acute pulmonary edema - Congestive heart failure |
NTG is also used to treat hypertension, coronary artery spasms due to cocaine and topically for anal fissures.
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What are the listed contraindications for nitroglycerin?
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- Hypersensitivity
- Head trauma - Patients in shock (systolic BP < 100 mmHg), hypovolemia - Patients with increased ICP (head trauma) |
Some sources also list anemia.
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What are the listed precautions for nitroglycerin?
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- Protect from light and air.
- Monitor vitals closely as it may cause orthostatic hypotension - Phosphodiesterase-type 5 (PDE-5) inhibitors: -- Viagra (sildenafil) use within the past 24 hours -- Cialis (tadalafil) use within the past 48 hours -- Levitra (vardenafil) use within the past 48 hours |
There is no evidence that defibrillation across a transdermal NTG patch can cause explosion or fire.
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What are the listed side effects for nitroglycerin?
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- Hypotension
- Palpitations - Tachycardia - Syncope - Dry mouth - N/V - Headache - Dizziness - Skin rash |
Prolonged, repeated use of NTG can lead to tolerance. The severe headaches associated with NTG may necessitate analgesia in some patients and are a significant cause of lack of compliance.
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What are the listed interactions for nitroglycerin?
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May cause hypotension when used in conjunction with alcohol and antihypertensives (beta-blockers)
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Orthostatic hypotension has been reported when calcium channel blockers and nitrates were used concomitantly.
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What is the dosage and route of nitroglycerin?
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- 0.4mg SL (or 1/150gr) tablet or spray q 5 minutes prn with BP>100mmHg.
- 1-2 inches of TD paste Infusion: 10mcg/min via IV infusion pump increasing by 5-10mcg/minute q 5 minutes to relieve CP or pulmonary edema (if systolic BP>100mmHg) |
NH protocols require an IV be established before SL NTG can be administered (with the exception of assisting a pt with their own medication).
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What are the pharmacokinetics of nitroglycerin?
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Onset: 1-3 minutes SL
peak effect 5-10 minutes Duration 20-30 minutes; 1-10 minutes after IV DC'd |
Effect reaches a maximum 5 minutes after SL administration and persists for at least 25 minutes.
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What should be performed before a nitroglycerin infusion is started?
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Recommend two IVs or a TwinCath in place to administer infusion.
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This is a requirement in NH protocols, as is the use of an infusion pump.
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How should nitroglycerin spray be handled?
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Do not shake aerosol spray as it may affect metered dose.
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However, medicinal NTG is not explosive...
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What is the chemical name for aspirin?
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Acetylsalicylic acid (ASA)
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Aspirin, with a capital "A", remains a registered trademark of Bayer in Germany, Canada, Mexico, and in over 80 other countries.
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What are the functional classes of aspirin?
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- Salicylate
- Analgesic - Antiplatelet - Antipyretic |
Salicylic acid is found in willow bark and is the source of the name, from the Latin "salix" meaning "willow".
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What is the mechanism of action of aspirin?
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- Aspirin blocks the production of cyclooxygenase (COX), the precurser to thromboxane A2 (which is the physiological inducer of platelet aggregation).
- As an anti-inflammatory agent it appears to be involved in the inhibition of prostaglandin synthesis. Its anti-inflammatory actions also contribute to its analgesic effects. - Aspirin also acts to reduce fever by causing centrally-mediated peripheral vasodilation and sweating. |
Asprin has other modes of action which are less well-understood, including affecting mitochondria and reducing inflammation by at least two other mechanisms.
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What are the listed indications for aspirin?
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Suspected AMI, chest pain, or ACS
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In non-prehospital arenas, aspirin has been used as a prophylactic for DVT in air travellers, to treat Kawasaki disease in children and investigated as an anti-cancer drug.
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What are the listed contraindications for aspirin?
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Hypersensitivity
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Hypersensitivity to ibuprofen or naproxen may indicate hypersensitivity to aspirin.
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What are the listed precautions for aspirin?
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Peptic ulcer disease, asthma
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Some sources include hemophilia and other disorders likely to result in excessive bleeding (such as Dengue fever).
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What are the listed side effects for aspirin?
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Overdose may result in considerable toxicity with dizziness, N/V, abdominal pain, thrombocytopenia, easy bruising, and/or metabolic acidosis.
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Use of aspirin in children and teenagers can increase the likelihood of them devloping Reye's syndrome.
Large doses of aspirin can cause tinnitus. |
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What are the listed interactions for aspirin?
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- Incompatible with uricosuric agents
- Anticoagulants increase the risk of bleeding |
Ibuprofen can negate the antiplatelet effect of aspirin used for cardioprotection and stroke prevention.
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What is the dosage and route of aspirin?
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160 - 325mg PO (chewable) tablets
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"Baby aspirin" are typically 81mg
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What is the best-known trade names for metoprolol?
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Lopressor and Toprol-XL
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Lopressor is metoprolol tartrate which is immediate-release whereas Toprol-XL is metoprolol succinate which is an extended-release formulation.
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What is the functional class of metoprolol?
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Class II antidysrhythmic (beta blocker).
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Other beta blockers include carvedilol (Coreg), labetalol (Normodyne, Trandate) and propranolol (Inderal). Most have generic names ending in "-lol".
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What is the mechanism of action of metoprolol?
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Selective inhibitor of beta-1 adrenergic receptors located on cardiac muscle. Completely blocks beta-1 receptors, with little or no effect on beta-2 receptors at doses less than 100mg. Reduces heart rate, cardiac output at rest and during exercise, and lowers BP.
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Lopressor can mask tachycardia associated with hypoglycemia.
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What is the primary MICS listed indication for metoprolol?
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- Chest pain associated with AMI, ACS
T |
Metoprolol is frequently prescribed for off-label use in anxiety disorders.
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What are the listed contraindications for metoprolol?
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- Hypersensitivity
- Sinus bradycardia - Heart block greater than 1st degree (except in patients with a functioning artificial pacemaker) - Cardiogenic shock (BP < 100mmHg) - Uncompensated cardiac failure - Pregnancy (2nd and 3rd trimesters) - Asthma - COPD |
Metoprolol is pregnancy category C in the US: "Risk can not be ruled out- Adequate, well-controlled human studies are lacking, and animal studies have shown a risk to the fetus or are lacking as well.
There is a chance of fetal harm if the drug is administered during pregnancy; but the potential benefits may outweigh the potential risk." |
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What are the listed precautions for metoprolol?
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- Impaired hepatic or renal function
- CHF controlled by digitalis or diuretics - Do not mix with IV calcium channel blockers |
AstraZeneca, the manufacturer of Toprol-XL, also lists hyperthyroidism and arteriosclerosis.
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What are the listed side effects for metoprolol?
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- Bronchospasm
- Bradycardia - Palpitations - Edema - CHF - Reduced peripheral circulation - Drowsiness - Insomnia |
Abrupt cessation of metoprolol therapy (or other beta blockers) may cause a thyroid storm
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What are the listed interactions for metoprolol?
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- Drugs which slow AV conduction such as digoxin as the effects may be cumulative with beta-blockers
- Glucagon: metoprolol may blunt the hyperglycemic action of glucagon - Verapamil or diltiazem may have synergistic pharmacological effects when taken concurrently with beta-blockers |
Drugs that inhibit CYP2D6 such as quinidine and fluoxetine may increase metoprolol plasma concentration, which can decrease its beta-1 selectivity.
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What is the dosage and route of metoprolol?
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5mg slow IVP (over 1-2 minutes) q 5 minutes x 3 (max of 15mg)
Acute MI: Maintain systolic BP>100 and heart rate >60/minute SVT: Maintain heart rate 90-100/minute |
Home PO dosages of metoprolol are in the range of 100-450mg/day
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What is the chemical formula for sodium bicarbonate?
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NaHCO₃
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The "bi-" prefix means that the anion is the result of one hydrogen ion (H⁺) being added to the carbonate ion (CO₃²⁺)
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What is the functional class of sodium bicarbonate?
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- Electrolyte
- Alkalinizing Agent |
Sodium bicarbonate can also be used as an exfoliant or mouthwash.
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What is the mechanism of action of sodium bicarbonate?
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Given IV, it immediately raises the pH of blood plasma by buffering excess H⁺ cations. Excess bicarbonate ions are excreted in the urine, thus rendering the urine less acidic.
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Sodium bicarbonate is integral to the body's acid-base homeostasis.
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What are the listed indications for sodium bicarbonate?
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- Severe acidosis (refractory to hyperventilation)
- Tricyclic antidepressant (TCA) overdose - Barbiturate overdose - Known hyperkalemia |
Sodium bicarbonate has occasionally been used to treat ASA overdoses.
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What are the listed contraindications for sodium bicarbonate?
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None in the emergency setting
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Some sources list as contraindications patients with metabolic and respiratory alkalosis and in patients with hypocalcemia in which alkalosis may produce tetany. These are the exact opposites of the indications for the drug!
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What are the listed precautions for sodium bicarbonate?
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- Not recommended for routine use in cardiac arrest
- Dosage must be specific to prevent metabolic alkalosis and is thus weight-based |
In patients with diminished renal function, administration of solutions containing sodium ions may result in sodium retention.
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What are the listed side effects for sodium bicarbonate?
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- Severe tissue damage if extravasation occurs
- May produce paradoxical acidosis that can depress cerebral and cardiac function - May cause extracellular alkalosis, which may reduce the concentration of ionized calcium, decrease plasma potassium, and induce a left shift of the oxyhemoglobin curve which may inhibit oxygen release to the tissues and induce malignant arrhythmias |
The tissue acidosis in cardiac arrest is caused by CO₂ accumulation and that is what bicarbonate administration increases when it combines with H⁺ ions.
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What are the listed interactions for sodium bicarbonate?
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- Will deactivate most catecholamines and vasopressors
- Sodium bicarbonate will precipitate when used in conjunction with calcium chloride |
Sodium bicarbonate can react with sodium polystyrene sulfonate, a different treatment for hyperkalemia, and grossly interferes with it.s function.
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What is the dosage and route of sodium bicarbonate?
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1mEq/kg IVP/IO push, repeat at 0.5mEq/kg q10 minutes prn
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The (molar) equivalent, abbreviated Eq, is the amount of a substance that will react with or supply one mole of hydrogen ions (H+) in an acid–base reaction. The prefix "m" is the SI "milli".
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What is the best-known trade name for furosemide?
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Lasix
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The name Lasix comes from the implication that the relatively short-acting medication "lasts six hours".
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What is the functional class of furosemide?
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Loop diuretic
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Other loop diuretics include bumetanide (Bumex), torasemide (Demadex) and etacrynic acid (Edecrin).
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What is the mechanism of action of furosemide?
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Rapid-acting potent loop diuretic that inhibits sodium and chloride reabsorption in the nephron’s loop of Henle. Additionally, its vasodilatory properties reduce cardiac preload.
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The loop of Henle runs from the proximal convoluted tubule to the distal convoluted tubule.
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What are the listed indications for furosemide?
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- CHF
- Acute Pulmonary Edema -Hypertensive Crisis |
Furosemide is also used to treat cerebral edema. It is also (legally) used in racehorses to help prevent exercise induced pulmonary hemorrhage (EIPH).
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What are the listed contraindications for furosemide?
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- Hypersensitivity
- Hypotension - Dehydration - Electrolyte depletion |
Furosemide is a sulfonamide and therefore may be contraindicated in patients with sulfa allergies
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What are the listed precautions for furosemide?
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- Usage in pregnancy should be limited to life-threatening situations as furosemide may cause fetal abnormalities
- Protect from light - Renal or hepatic insufficiencies |
Furosemide can worsen gout and is passed in breast milk. Also, in patients susceptible to urinary retention, acute urinary retention may occur, which is a medical emergency.
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What are the listed side effects for furosemide?
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- Hypotension
- Dizziness - Chest pain - Dry mouth - Hypochloremia - Hypokalemia - Hyponatremia - Hypomagnesemia - Hypocalcemia - N/V - Ototoxicity (tinnitus if pushed too rapidly) - Hyperglycemia |
Lasix can cause kidney stones or calcium deposits in the kidneys of premature infants
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What are the listed interactions for furosemide?
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- Digitalis
- Lithium toxicity |
Lasix should not be combined with aminoglycoside antibiotics unless absolutely necessary as this can increase the chance of permanent hearing loss.
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What is the dosage and route of furosemide?
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- Adult-40-80 mg IV or IO slow push
- Pediatric-1mg/kg slow IV or IO |
Dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range
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What is the functional class of magnesium sulfate?
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Electrolyte
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Magnesium sulfate has the formula MgSO₄. It is often found naturally as the heptahydrate (MgSO₄·7H₂O) called epsomite or Epsom salts.
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What is the mechanism of action of magnesium sulfate?
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Physiologic calcium channel blocker and also blocks neuromuscular transmission. Hypomagnesemia can cause cardiac dysrhythmias. It is also a CNS depressant effective in the management of seizures associated with eclampsia or pregnancy. It does this by decreasing the amount of acetylcholine liberated from motor nerve terminals. Magnesium is necessary for many biochemical processes and plays a role in the transmission of electrical impulses.
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Eclampsia is an acute and life-threatening complication of pregnancy characterized by the appearance of tonic-clonic seizures. it is also known as "toxemia of pregnancy".
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What are the listed indications for magnesium sulfate?
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- Eclampsia; premature labor contractions
- Torsades de Pointes - Severe asthma - Digitalis toxicity - Tricyclic overdose |
Intravenous magnesium sulfate may be able to prevent cerebral palsy in preterm babies.
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What are the listed contraindications for magnesium sulfate?
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Do not administer to any patient with:
- Heart block - Shock - Persistent - Hypertension - Hypocalcemia - Myocardial damage |
Some sources include appendicitis and bowel obstruction/perforation
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What are the listed precautions for magnesium sulfate?
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- Renal failure
- Patients taking digoxin - Concomitant use of other CNS depressants or neuromuscular blocking agents |
It is recommended that magnesium sulfate not be administered in the 2 hours before delivery, if possible.
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What are the listed side effects of magnesium sulfate?
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- Hypotension
- Sedation - Confusion - N/V - Bradycardia - Pruritis - Arrhythmias - Decreased deep tendon reflexes - Respiratory depression/paralysis - Drowsiness - Muscle weakness - Complete heart block - When used immediately prior to delivery it can cause fetal hypoxia, asphyxia, arrhythmias and possible fetal intracranial bleeding |
Diarrhea is also a relatively common side-effect. Hypocalcemia has also been reported.
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What are the listed interactions of magnesium sulfate?
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Can cause cardiac conduction abnormalities when used in conjunction with digitalis
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However, magnesium sulfate can be used to treat high-level blocks caused by digitalis toxicity.
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What is the dosage and route of magnesium sulfate?
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Eclampsia: 2-4g slow IVP in 10mL NS over 5 minutes
Torsades de Pointes: 1-2g IVP diluted in 10 mL NS Asthma: 2g slow IVP in 100mL NS over 10 minutes |
NH pediatric dose for torsades is 25–50mg/kg (maximum 2g) IV over 1–2 minutes.
NH pediatric dosage for asthma is 40mg/kg in 100mL NS given IV over 20 minutes. |
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What substance can be used as an antidote to magnesium sulfate?
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Calcium chloride
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As can calcium gluconate. The actions of magnesium in neuromuscular and cardiac function are antagonized by calcium.
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What is the best-known trade name for dopamine?
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Inotropin
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Dopamine was first synthesized in 1910 by George Barger and James Ewens at Wellcome Laboratories in London, England. It was named dopamine as its precursor in synthesis is levodopamine (L-DOPA).
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What is the functional class of dopamine?
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Sympathomimetic
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Dopamine is a precursor to norepinephrine and then epinephrine
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What is the mechanism of action of dopamine?
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A naturally occurring neurotransmitter and catecholamine which acts on alpha and beta adrenergic receptors (dose-dependent), and dopaminergic receptors. In therapeutic dosages, dopamine maintains blood flow in the renal and mesenteric vascular beds. It is a positive inotrope, therefore it increases cardiac output and systolic BP.
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Dopmaine can produce significant CNS effects but does not cross the blood-brain barrier.
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What are the listed indications for dopamine?
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- Cardiogenic, septic, or neurological shock
- Hemodynamically significant hypotension (systolic BP of 70-100mmHg not resulting from hypovolemia) with low cardiac output; - Symptomatic bradycardia |
Dopamine is also used to treat nonobstructive oliguria (low urine output).
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What are the listed contraindications for dopamine?
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- Pheochromocytoma
- Tachydysrhythmias - Ventricular fibrillation |
And, of course, known hypersensitivity.
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What are the listed precautions for dopamine?
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In doses 20mcg/kg/min or greater, its alpha effects dominate and it causes severe vasoconstriction. Monitor BP q 3 - 5 minutes. Can be deactivated by sodium bicarbonate
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Some sources include a history of occlusive vascular disease (e.g, atherosclerosis, Raynaud's disease, Buerger's disease, diabetic endarteritis) and pregnancy (US FDA category C)
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What are the listed side effects for dopamine?
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- Dysrhythmias
- Palpitations - Tachycardia - Bradycardia - Headaches, - Anxiety - N/V - Tissue sloughing may result from dopamine extravasation - Dyspnea - HTN |
Some sources include widened QRS complexes and azotaemia (abnormally high blood nitrogen levels).
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What is the dosage and route of dopamine?
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2-20mcg/kg/min IV infusion, to a maximum of 20 mcg/kg/min. Titrate to effect (BP)
Dopamine Dosage Range Effects: Dose Range Result 2-4mcg/kg/min Dopaminergic Effects 4-10mcg/kg/min Beta Effects 10-20mcg/kg/min Alpha Effects |
The "renal", "cardiac" and "pressor" doses.
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What is the preparation for dopamine?
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Place 800mg in 500mL D5W or NS = 1600mcg/mL
or Place 400mg in 250mL D5W or NS = 1600mcg/mL |
Dopamine is usually supplied in a 5mL (400mg) or 10mL (800mg) vial.
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How should dopamine be used to treat hypovolemic shock?
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Should not be used as the sole agent in the management of hypovolemic shock as fluid volume replacement is the primary treatment
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"Tank before you crank".
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What is the best-known trade name for oxytocin?
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Pitocin
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Oxytocin is also sold as Syntocinon and is available as a generic
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What is the functional class of oxytocin?
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Hormone
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Oxytocin is released into the blood from the posterior lobe (neurohypophysis) of the pituitary gland.
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|
What is the mechanism of action of oxytocin?
|
By direct action on myofibrils, it causes phasic contraction of the uterine smooth muscle characteristic of normal delivery. It also promotes milk "letdown" in nursing mothers. Effective in inducing labor and uterine contractions following delivery, thereby controlling postpartum hemorrhage.
|
Many studies have shown that oxytocin is also involved in human bonding, increases in trust and generosity, and decreases in fear.
|
|
What are the listed indications for oxytocin?
|
Postpartum hemorrhage
|
The Center of Cognitive Neuroscience in Lyon, France concluded that oxytocin may help reduce the negative symptoms of autism.
|
|
What are the listed contraindications for oxytocin?
|
Hypersensitivity and prior to delivery of the fetus. Administration prior to delivery may cause fetal hypoxia, asphyxia, and dysrhythmias
|
Oxytocin is used prior to delivery in the hospital setting.
|
|
What are the listed precautions for oxytocin?
|
Can cause over stimulation of the uterus resulting in uterine rupture thus vitals and uterine tone should be monitored
|
Oxytocin has been shown to have an intrinsic antidiuretic effect, acting to increase water reabsorption from the glomerular filtrate. Consideration should, therefore, be given to the possibility of water intoxication, particularly when oxytocin is administered continuously by infusion and the patient is receiving fluids by mouth.
|
|
What are the listed side effects for oxytocin?
|
- Hypotension
- Anxiety - N/V - Dysrhythmias - HTN - Seizures - Dyspnea - Coma - Intracranial bleeding |
Fatal afibrinogenemia has also been reported
|
|
What are the listed interactions for oxytocin?
|
Can cause hypertension when used in conjunction with vasoconstrictors
|
Use with cyclopropane anesthesia can produce hypotension and cardiac dysrhythmias
|
|
What is the dosage and route of oxytocin?
|
Bolus: 3-10 units IM after delivery of placenta;
Infusion: 10 units in 1000mL NS via 60 gtts/mL set. infuse 20-40 milli-units/min (120/140 ml/hr) and titrate to effect |
Oxytocin is typically packaged in a 1ml (10 unit) vial.
|
|
What is the best-known trade name for acetaminophen?
|
Tylenol
|
Acetaminophen (also known as paracetamol or APAP - N-acetyl-para-aminophenol) has dozens of brand names in use around the world.
|
|
What are the functional classes of acetaminophen?
|
Antipyretic, analgesic
|
The World Health Organization (WHO) recommends that paracetamol only be used to treat fever in children if their temperature is greater than 38.5 °C (101.3 °F).
|
|
What is the mechanism of action of acetaminophen?
|
Produces analgesia by elevation of the pain threshold. May block pain impulses by the inhibition of prostaglandin synthesis. Antipyretic actions result from inhibition of prostaglandins in the CNS. Does not possess any anti-inflammatory or antiplatelet properties.
|
Acetaminophen does not significantly inhibit the production of the pro-clotting thromboxanes as it is selective for COX-2 inhibition.
|
|
What are the listed indications for acetaminophen?
|
Fever
|
The efficacy of acetaminophen by itself in children with fevers has been questioned and a meta-analysis has shown it to be less effective than ibuprofen.
|
|
What are the listed contraindications for acetaminophen?
|
Hypersensitivity to acetaminophen or phenacetin
|
Acetaminophen is the active metabolite of phenacetin.
|
|
What are the listed precautions for acetaminophen?
|
Anemia, hepatic and renal disease, alcoholism
|
The risks of acetaminophen in alcoholics seem to be confined to overdosage; therapeutic doses do not seem to have adverse effects.
|
|
What are the listed side effects for acetaminophen?
|
- N/V
- Dizziness - Hepatotoxicity - Renal failure - Hypoglycemia |
Acetaminophen toxicity is the foremost cause of acute liver failure in the Western world, and accounts for most drug overdoses in the United States, the United Kingdom, Australia and New Zealand.
|
|
What are the listed interactions for acetaminophen?
|
Increased chance of hepatotoxicity when taken chronically or with alcohol, rifampin, carbamazepine, or barbiturates
|
Rifampin (rifampicin) is a bactericidal antibiotic that, as well as being potentially hepatotoxic, increases the rate of metabolism of many medications by inducing liver enzymes.
|
|
What is the dosage and route of acetaminophen?
|
Adult:
- 325-650mg PO/PR q 4-6 hours Pediatric: - 15mg/kg PO/PR q 4-6 hours |
In adults, acetaminophen has been found to be well-tolerated at maximum daily doses for several weeks.
|
|
What are the best-known trade names for ibuprofen?
|
Advil, Motrin, Nuprin
|
The name ibuprofen comes from iso-butyl-propanoic-phenolic acid. Ibuprofen has dozens of brand names worldwide.
|
|
What are the functional classes of ibuprofen?
|
Antipyretic, analgesic, NSAID
|
Ibuprofen also acts as a limited vasodialtor and mild antiplatelet.
|
|
What is the mechanism of action of ibuprofen?
|
Ibuprofen inhibits cyclooxygenase (COX) decreasing production of prostaglandins thus decreasing pain sensation, fever, and inflammation.
|
Ibuprofen is considered a nonselective COX inhibitor and it is the inhibition of COX-1
|
|
What are the listed indications for ibuprofen?
|
Fever
|
As an OTC medication, ibuprofen is mainly used for its analgesic and NSAID properties.
|
|
What are the listed contraindications for ibuprofen?
|
- Hypersensitivity
- Children less than six months old - GI intolerance such as colitis |
Hypersensitivity to other NSAIDs may indicate hypersensitivity to ibuprofen.
|
|
What are the listed precautions for ibuprofen?
|
- Pregnancy
- Peptic ulcer disease - Pulmonary edema - HTN |
Ibuprofen use should be carefully monitored in patients who may be adversely affected by alterations in platelet function, such as those with coagulation disorders or patients receiving anticoagulants.
|
|
What are the listed side effects for ibuprofen?
|
- Nausea
- Abdominal pain - Diarrhea - Dizziness - Tinnitus |
Ibuprofen shares the side effects of other NSAIDs.
|
|
What are the listed interactions for ibuprofen?
|
- Reduces the effectiveness of loop diuretics and ACE-inhibitors
- Increases hemorrhage potential when given with aspirin |
Ibuprofen increases plasma lithium levels and reduces renal lithium clearance so can induce lithium toxicity.
|
|
What is the dosage and route of ibuprofen?
|
Adult:
- 200-600mg PO/PR q 6-8 hours Pediatric: - 10mg/kg PO/PR q 6-8 hours |
OTC ibuprofen directions typically approximate to weight-based dosing and individual doses at home may be higher or lower than 10mg/kg.
|
|
What is the functional class of calcium chloride?
|
Electrolyte
|
Calcium chloride is a rare mineral in nature, occuring as sinjarite and antarcticite.
|
|
What is the mechanism of action of calcium chloride?
|
- Replaces elemental calcium, which is essential for regulating excitation threshold of nerves and muscles. Calcium is also essential for blood clotting mechanisms, maintenance of renal function, and bone tissues. Calcium increases myocardial contractile force and ventricular automaticity.
- Additionally serves as an antidote for magnesium sulfate and calcium channel blocker toxicity. Calcium chloride has three times as much elemental calcium than calcium gluconate. |
Aqueous calcium chloride is used in genetic transformation of cells by increasing the cell membrane permeability, inducing competence for DNA uptake
|
|
What are the listed indications for calcium chloride?
|
- Calcium channel blocker toxicity/overdose
- Prophylactically prior to IV calcium channel blockers - Acute hyperkalemia - Acute hypocalcemia - Acute hypermagnesemia |
Calcium salts have been used as adjunctive therapy in a number of conditions including insect bites or stings and ensitivity reactions, particularly when characterized by urticaria.
|
|
What are the listed contraindications for calcium chloride?
|
- VF
- Hypercalcemia - Digitalis toxicity |
Some sources include hypophosphatemia
|
|
What are the listed precautions for calcium chloride?
|
- Flush IV line between calcium chloride and bicarbonate as precipitate will form.
- Monitor for tissue necrosis at injection site |
Do not mix ceftriaxone (Rocephin) with calcium chloride during administration as this too can produce a precipitate
|
|
What are the listed side effects for calcium chloride?
|
- Arrhythmias including bradycardia or cardiac arrest
- Syncope - N/V - Hypotension - Necrosis with extravasation |
Calcium chloride administration can cause nephrolithiasis (kidney stones) but this is usually from long-term use.
|
|
What are the listed interactions for calcium chloride?
|
- Calcium chloride will precipitate when used in conjunction with sodium bicarbonate
- Toxicity with digitalis. - May antagonize the effects of calcium channel blockers |
Calcium chloride can also affect the use of phosphate supplements
|
|
What is the dosage and route of calcium chloride?
|
Hyperkalemia and calcium channel blocker overdose:
8-16mg/kg of a 10% solution slow IVP q10 minutes prn Prophylactic treatment prior to calcium channel blocker: 2-4mg/kg of a 10% solution slow IVP |
The (now rarely used) dose for cardiac resuscitation is 20-40mg injected into the ventricular cavity.
|
|
What are the best-known trade names for albuterol?
|
Proventil and Ventolin
|
The International Nonproprietary Name (INN) for albuterol is salbutamol.
|
|
What is the functional class of albuterol?
|
Sympathomimetic bronchodilator
|
Other sympathomimetic bronchodilators include levalbuterol (Xopenex), terbutaline, metaproterenol (Alupent) and salmeterol (Serevent).
|
|
What is the mechanism of action of albuterol?
|
Selectively stimulates Beta-2 adrenergic receptors increasing bronchodilation. It produces these results by stimulating adenyl cyclase, which transforms ATP into cAMP. cAMP causes relaxation of bronchial smooth muscle. In therapeutic doses, albuterol also inhibits histamine release from mast cells, reducing mucus secretion.
|
Beta-2 agonists also cause vasodilation in muscles and the liver, relaxation of uterine muscle and release of insulin.
|
|
What are the listed indications for albuterol?
|
- Bronchospasm
- Patients with reversible obstructive airway disease |
Intravenous salbutamol can be used as a tocolytic to relax the uterine smooth muscle to delay premature labor.
|
|
What are the listed contraindications for albuterol?
|
Hypersensitivity
|
There are many patients who have conditions that contraindicate regular albuterol administration but these do not apply in the emergency setting.
|
|
What are the listed precautions for albuterol?
|
- Consider monitoring peak expiratory flow rates (PEFR)
- Monitor vitals and respiratory status during treatment |
Albuterol causes a transient reduction in serum potassium levels, which may have cardiovascular effects.
|
|
What are the listed side effects for albuterol?
|
- Tremors
- Anxiety - HTN - Tachycardia - Headache - Palpitations - Seizures - N/V - Dizziness - Rash |
Albuterol (rarely) may cause a life-threatening, acute paradoxical bronchospasm.
|
|
What are the listed interactions for albuterol?
|
- Other sympathomimetic bronchodilators
- Beta-blockers - Use with extreme caution with patients on MAOIs and TCAs as potentiation may occur |
The chance of life-threatening, acute paradoxical bronchospasm is increased when albuterol is used with beta-blockers.
|
|
What is the dosage and route of albuterol?
|
Adult:
- 2.5mg in 3mL NS via aerosol nebulizer PRN Pediatric: - 0.05 - 0.15mg/kg in 2.5-3mL NS via aerosol nebulizer. may repeat every 20 minutes to a maximum of three doses. |
Albuterol is available as a multi-dose vial which must be diluted prior to inhalation but most people now use nebulizer "bullets".
|
|
What is the best-known trade name for dobutamine?
|
Dobutrex
|
Another brand name is Inotrex.
|
|
What is the functional class of dobutamine?
|
Sympathomimetic
|
Dobutamine is a structural analogue of isoprenaline (Isuprel), another sympathomimetic.
|
|
What is the mechanism of action of dobutamine?
|
Synthetic catecholamine which acts primarily on Beta-1 and alpha-adrenergic receptors. Balanced by Beta-2 receptors, it increases cardiac output via increased inotropic effects and decreases pulmonary wedge pressure (PWP) with little or no effect on BP or heart rate. Dobutamine also increases conduction through the AV node.
|
Dobutamine does not act on dopamine receptors to induce the release of norepinephrine (another α1 agonist) so is less likely to induce hypertension.
|
|
What are the listed indications for dobutamine?
|
- Short term management of CHF or cardiogenic shock
- Used to increase cardiac output without increasing rate |
Dobutamine is also commonly used in the hospital setting as a pharmacologic stress testing agent to identify coronary artery disease.
|
|
What are the listed contraindications for dobutamine?
|
- Hypersensitivity
- VT |
Some sources include obstructive hypertrophic cardiomyopathy, also known as hypertrophic obstructive cardiomyopathy (HOCM), idiopathic hypertrophic subaortic stenosis (IHSS) and asymmetric septal hypertrophy (ASH).
|
|
What are the listed precautions for dobutamine?
|
- Can increase myocardial oxygen demand
- Can be deactivated by sodium bicarbonate - Preexisting HTN or A-Fib - Hypotension from hypovolemia; always try volume restoration first |
Caution should also be used in patients with a sensitivity to sulfites.
|
|
What are the listed side effects for dobutamine?
|
- Tachycardia
- HTN - Dyspnea - Dysrhythmias - Palpitations - Chest pain - Headaches - Anxiety - N/V |
Studies suggest that while this medication can improve symptoms in chronic CHF, it actually shortens a patient's lifespan.
|
|
What are the listed interactions for dobutamine?
|
- Absolute interaction with beta-blockers as they decrease
dobutamine’s effectiveness. - Use with extreme caution with tricyclic antidepressants |
Some sources state that significant adverse affects can occur if dobutamine is used with stimulants, especially cocaine.
|
|
What is the dosage and route of dobutamine?
|
2-20mcg/kg/min IV infusion
Mix 250mg in 250mL (or 500mg in 500mL) D5W or NS, which yields 1000mcg/mL |
Dobutamine has been infused for up to 72 hours without decreased effectiveness.
|
|
What is preferred to dobutamine in cases of cardiogenic shock?
|
Dopamine
|
Dobutamine may be useful as an adjunct to volume replacement in patients with right ventricular infarction, since dopamine may increase pulmonary vascular resistance.
|
|
What is the best-known trade name for ipratropium bromide?
|
Atrovent
|
Other brand names include Apovent and Aerovent.
|
|
What is the functional class of ipratropium bromide?
|
Parasympatholytic bronchodilator
|
Ipratropium does not cross the blood-brain barrier so does not produce systemic anticholinergic effects.
|
|
What is the mechanism of action of ipratropium bromide?
|
Acts directly on the smooth muscle of the bronchial tree by inhibiting interaction of acetylcholine at receptor sites on the bronchial smooth muscle, resulting in bronchodilation.
|
Ipratropium blocks the muscarinic acetylcholine receptors.
|
|
What are the listed indications for ipratropium bromide?
|
- Bronchospasm
- Patients with reversible obstructive airway disease |
Ipratropium is also used as a nasal spray to treat rhinitis.
|
|
What are the listed contraindications for ipratropium bromide?
|
Hypersensitivity to ipratropium, atropine, soya lecithin and peanut oil
|
The warnings about soya lecithin and peanut oil derive from the inclusion of soya lecithin in the MDI preparations of ipratropium. Nebulizer solutions of ipratropium do not contain this agent.
|
|
What are the listed precautions for ipratropium bromide?
|
Use with caution in pregnancy and lactation
|
Ipratropium can cause urinary retention and, in non-emergency settings, may be avoided in patients with bladder obstructions, BPH, etc.
|
|
What are the listed side effects for ipratropium bromide?
|
- N/V
- Cramps - Dry mouth - Blurred vision - Worsening bronchospasm - Drying of bronchial secretions - Cough - Epistaxis |
The inhalation itself can cause a sore throat.
|
|
What are the listed interactions for ipratropium bromide?
|
None
|
Combination with beta-adrenergic agonists, as well as theophylline and other xanthine derivatives, increases the dilating effect on the bronchi. This is a desired effect in some combinations like DuoNeb (ipratropum bromide with albuterol).
|
|
What is the dosage and route of ipratropium bromide?
|
Adult:
0.5mg (500mcg) in 2.5-3mL of NS via nebulizer q6 hours Pediatric: 0.125-0.25mg (125-250mcg) in 2.5-3mL of NS via nebulizer q6 hours |
If mixed with albuterol or any other medication, the solution should be used within one hour. Premixed solutions are good until their expiration dates.
|
|
What is the best-known trade name for methylprednisolone?
|
Solu-Medrol
|
Another brand name is Medrol.
|
|
What is the functional class of methylprednisolone?
|
Corticosteroid
|
More specifically, methylprednisolone is a glucocorticoid.
|
|
What is the mechanism of action of methylprednisolone?
|
Intermediate-acting, synthetic adrenal corticosteroid. Decreases inflammation by reversing increased capillary permeability. This suppresses the migration of leukocytes and fibroblasts to the site of injury. Methylprednisolone also stabilizes lysosomes.
|
Glucocorticoids also inhibit the release of prostaglandins, leukotrienes and cyclooxygenase.
|
|
What are the listed indications for methylprednisolone?
|
Severe asthma, anaphylaxis or COPD.
|
In the non-emergency setting, methylprednisolone is also used for the the treatment of autoimmune diseases such systemic lupus erythematosus and as a treatment for multiple sclerosis.
|
|
What are the listed contraindications for methylprednisolone?
|
None in the management of anaphylaxis
|
When not treating life-threatening conditions, methylprednisolone is contraindicated for patients with a rectent history of certain infections such as varicella and rubeola (measles).
|
|
What are the listed precautions for methylprednisolone?
|
Patients with peptic ulcer disease, CHF, and TB.
|
Many sources add active infections, existing immunosuppression and many chronic disorders as precautions.
|
|
What are the listed side effects for methylprednisolone?
|
- Hypertension
- CHF - Delayed wound healing - Hyperglycemia - Hypokalemia - Headache - Peptic ulcer - Circulatory collapse - N/V - CNS depression |
The most significant side-effects of methylprednisolone occur with chronic usage as it stops the natural production of cortisol, allowing for an Addisonian crisis if the methylprednisolone is suddenly stopped.
|
|
What are the listed interactions for methylprednisolone?
|
Use caution in patients on salicylates, phenytoin, rifampin, theophylline, furosemide, and thiazide diuretics.
|
Caution should also be exercised with patients who have recently received a vaccination.
|
|
What is the dosage and route of methylprednisolone?
|
Adult:
- 125-250mg IVP/IM Pediatric: - 1mg/kg IVP |
NH dosing is 62.5mg for adults and 1mg/kg (max of 62.5mg) for pediatrics.
|
|
What is the best-known trade name for glucagon?
|
GlucaGen
|
Glucagon was named in 1923, probably from the Greek γλυκός ("sweet") and ἄγειν ("to drive").
|
|
What is the functional class of glucagon?
|
Hormone
|
Glucagon is a peptide (nonsteroid) hormone as it consists of a short chain of amino acids.
|
|
What is the mechanism of action of glucagon?
|
Glucagon is a protein secreted by the alpha cells of the Islets of Langerhans in the pancreas. It is used to convert stored glycogen in the liver to glucose. Additionally, it inhibits the synthesis of glycogen from glucose. It enhances conventional treatments for calcium channel blocker and beta-blocker overdose by producing a positive inotropic and chronotropic effect on the heart via stimulation of glucagon specific receptors in the myocardium. These receptors are not affected by even massive doses of beta-blockers, thereby reversing hypotension and bradycardia.
|
Glucagon is also a smooth muscle relaxant and can also be used for diverse conditions such as FBAO and asthma.
|
|
What are the listed indications for glucagon?
|
- Hypoglycemia without IV access
- Adjuvant treatment of toxic effects of CCB and beta-blockers |
The effectiveness of glucagon for hypoglycemia is constantly debated.
|
|
What are the listed contraindications for glucagon?
|
Known hypersensitivity
|
Some sources include pheochromocytoma as a critical contraindication.
|
|
What are the listed precautions for glucagon?
|
Glucagon is only effective if there are sufficient stores of glycogen
in the liver |
The glycogen stores are only required if glucagon is being used to treat hypoglycemia!
|
|
What are the listed side effects for glucagon?
|
- Hypotension
- Headache - Dizziness - N/V - Hyperglycemia - Hypokalemia |
Rashes and urticaria have also been reported
|
|
What are the listed interactions for glucagon?
|
None significant
|
Glucagon can potentiate the anticoagulant effects of warfarin.
|
|
What is the dosage and route of glucagon?
|
Adult:
- Hypoglycemia: 1mg (unit) IM/SQ q10-20 minutes - CCB/beta-blocker overdose: 2-5mg IM/SQ/IV Pediatric: - 0.01-0.1mg/kg IM/SQ |
Glucagon can be administered as an infusion as part of definitive care for overdoses.
|
|
What are the pharmacokinetics of glucagon?
|
Onset = 5-20 minutes
Duration = 1-1.5 hours |
Manufacturer's information for GlucaGen indicates half-lives of 8-18min (IV) and 45min (IM).
|
|
What are the two main components of D50?
|
D50 is 50% dextrose in water
|
One may also encounter varying concentrations of dextrose (e.g. D5W is 5% dextrose in water) and different solvents (e.g. D5NS is 5% dextrose in normal saline).
|
|
What is the functional class of D50?
|
Carbohydrate
|
Dextrose is so named because it consists of the dextrorotatory isomers of glucose
|
|
What is the mechanism of action of D50?
|
Principal form of glucose used by the body to create energy
|
Glycolysis, the metabolism of glucose, is found in nearly all known organisms.
|
|
What are the listed indications for D50?
|
Hypoglycemia
|
D50 is used with insulin for in-hospital treatment of hyperkalemia
|
|
What are the listed contraindications for D50?
|
None in a patient with documented hypoglycemia
|
Some people may claim to have an allergy to glucose/dextrose. As the body produces glucose, this is impossible.
|
|
What are the listed precautions for D50?
|
Use with caution in patients with increasing ICP as the added glucose may worsen the cerebral edema. Consider blood glucose monitoring before and after administration. Monitor for localized venous irritation
|
Wernicke's encephalopathy may be exacerbated if D50 is administered without thiamine.
|
|
What are the listed side effects for D50?
|
- Tissue necrosis
- Phlebitis - Pain at injection site |
D50's side effects result from its hypertonicity
|
|
What are the listed interactions for D50?
|
None
|
Hyperglycemia from D50 may interfere with the use of fludeoxyglucose f 18 (Gludef, Metatrace) in PET scans.
|
|
What is the dosage and route of D50?
|
Adult:
- 25g of a 50% solution IVP PRN Pediatric - 0.5g/kg IVP or IO using a 25% solution - If under 10kg, use 10% solution |
D50 can be administered IO but is reported to be exceptionally painful due to the viscosity.
|
|
What is the best-known trade name for diphenhydramine?
|
Benadryl
|
Outside the United states and Canada Benadryl products may contain a different antihistamine (e.g. UK) or no antihistamine at all (e.g. Australia).
|
|
What is the functional class of diphenhydramine?
|
Antihistamine
|
Diphenhydramine also has anticholinergic, antitussive, antiemetic and sedative properties.
|
|
What is the mechanism of action of diphenhydramine?
|
Blocks histamine H1 (bronchoconstriction, peripheral vasodilation) receptors, and blocks acetylcholine receptor sites (anticholinergic). Also useful in reversing dystonic reactions caused by certain antipsychotic medications that block histamine receptor sites (Thorazine, Compazine, Reglan, Haldol, Phenergan).
|
Diphenhydramine is actually an inverse agonist of the histamine H1 receptor
|
|
What are the listed indications for diphenhydramine?
|
- Anaphylaxis
- Moderate to severe allergic reactions - Acute extrapyramidal (dystonic) reactions |
Diphenhydramine is also used to treat motion sickness and insomnia
|
|
What are the listed contraindications for diphenhydramine?
|
- Hypersensitivity
- Newborns and nursing mothers |
Some sources state that diphenhydramine is condraindicated in patients <2 years old
|
|
What are the listed precautions for diphenhydramine?
|
- Not considered a primary drug for the treatment of severe allergic reactions or anaphylaxis
- Use with caution if the patient has narrow-angle glaucoma |
Diphenhydramine appears on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
|
|
What are the listed side effects for diphenhydramine?
|
- Hypotension
- N/V - Tachycardia - Bradycardia - Sedation - Palpitations - Drowsiness - Disturbed coordination - Dry mouth |
There is some evidence that diphenhydramine can prolong the QT-interval, leading to cardiac arrhythmias.
|
|
What are the listed interactions for diphenhydramine?
|
- Potentiated by the administration of other CNS depressants, antihistamines, narcotics, and alcohol
- MAOIs may prolong or intensify the anticholinergic effects |
As diphenhydramine slows GI transit, it can cause ulceration from local exposure when a patient is using solid forms of potassium
|
|
What is the dosage and route of diphenhydramine?
|
Adult:
- 25-50mg IVP or IM q 6-8 hours Pediatric: - 1mg/kg IVP or IO, maximum single dose is 50mg q6-8 hours |
Diphenhydramine is used recreationally as a deliriant or potentiator of alcohol.
|
|
What is another name for the Mark-1 kit?
|
The NAAK: Nerve Agent Antidote Kit.
|
Militaries are now transitioning to an autoinjector, the ATNAA (Antidote Treatment Nerve Agent Autoinjector)
|
|
What is the functional class of the Mark-1 kit?
|
Atropine: parasympatholytic
Pralidoxime chloride: cholinesterase reactivator |
Other oximes such as obidoxime and asoxime can also be used to restore enzyme functionality.
|
|
What is the mechanism of action of the Mark-1 kit?
|
- Atropine counters the parasympathetic response from muscarinic receptor over-stimulation associated with organophosphate and nerve agent poisoning, thus alleviating "SLUDGEM" symptoms.
- Pralidoxime chloride reactivates acetylcholinesterase by binding to it and subsequently releasing the phosphoryl group associated with the poisoning. |
The US military issued servicemembers three Mark-1 kits with one CANA kit (Convulsive Antidote, Nerve Agent) containing diazepam.
|
|
What are the listed indications for the Mark-1 kit?
|
Organophosphate and nerve agent poisoning in mass casualty incidents
|
The Mark-1 kit is only effectve against Tabun (GA), Sarin (GB), Soman (GD) and VX.
|
|
What are the listed contraindications for the Mark-1 kit?
|
None in the emergency setting
|
Some sources list pediatric patients under the age of three as being relatively contraindicated.
|
|
What are the listed precautions for the Mark-1 kit?
|
- Mark-1 kits offer no prophylactic protection and should be administered only if signs and symptoms are present
- Mark-1 kits do not treat fasiculations associated with nicotinic receptor over-stimulation |
Diazepam is the drug of choice for treating fasciculations.
|
|
What are the listed side effects for the Mark-1 kit?
|
- Dry mouth
- Flushing - Pupil dilation - Tachycardia |
When atropine and pralidoxime are used together, these signs of atropinization may occur earlier than might be expected when atropine is used alone.
|
|
What is the dosage and route of the Mark-1 kit?
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Each kit contains:
- Atropine 2mg - Pralidoxime chloride 600mg Minor initial symptoms: - One Mark-1 kit IM via autoinjector If severe symptoms appear within 10 minutes of first dose, administer an additional: - Two Mark-1 kits IM via autoinjector If severe symptoms are present initially administer: - Three Mark-1 kits IM via autoinjector |
The military instructs that administration (to self or others) of antidote kits should be performed after donning appropriate protective gear.
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In what order are the two tubes of the Mark-1 kit administered?
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Tube one (atropine) is always administered before tube two
(pralidoxime chloride). |
The alternative ATNAA (Antidote Treatment Nerve Agent Autoinjector) contains the two medications separately but administers them simultaneously.
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What is the trade name for hydroxocobalamin used as an antidote?
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Cyanokit
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Unlike most other therapeutic uses of hydroxocobalamin, the Cyanokit uses IV administration.
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What is the functional class of hydroxocobalamin?
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- Vitamin
- Antidote |
Hydroxocobalamin is one vitamer of vitamin B12. The others include cyanocobalamin, methylcobalamin, and adenosylcobalamin.
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What is the mechanism of action of hydroxocobalamin?
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Hydroxocobolamin is the precursor to vitamin B12 (cyancobolamin). When exposed to hydroxocobolamin, the cyanide attaches itself to form vitamin B12. It is then safely excreted in the urine.
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All of the vitamers of B12 have vitamin activity.
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What are the listed indications for hydroxocobalamin?
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Treatment of known or suspected cyanide poisoning
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In addition to some pesticides and insecticides, cyanide is contained in tobacco smoke and smoke from building fires.
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What are the listed contraindications for hydroxocobalamin?
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Hypersensitivity to any component of the medication (including cobalt)
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Cobalamins contain a single cobalt atom in the nucleus of each molecule.
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What are the listed precautions for hydroxocobalamin?
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Transient severe hypertension secondary to infusion
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Administration of hydroxocobalamin may interfere with some clinical laboratory evaluations.
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What are the listed side effects for hydroxocobalamin?
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- Hypertension
- Pruritis - Headache - Chromaturia (up to 5 weeks) |
Hematochezia can also occur.
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What are the listed interactions for hydroxocobalamin?
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Due to incompatibilities (particulate formation), the following medications need to be run through different tubing (separate from hydroxocobolamin):
- Diazepam - Dobutamine - Dopamine - Fentanyl - Nitroglycerin |
There are very few interactions that occur in vivo, as opposed to during delivery.
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What is the dosage and route of hydroxocobalamin?
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Adult:
-1 kit (5g) infusion over 15 minutes. May repeat giving 1 additional kit (5g) over 15 minutes to 2 hours if needed based on symptoms. NOTE: Kit must be given immediately if poisoning is suspected! Administration Procedure (per kit) 1) Reconstitute both of the 2.5g vials with 100ml NS 2) Repeatedly invert vial for 30 seconds to reconstitute; Do not shake! 3) Administer contents of first vial (2.5g) over ~7.5 minutes 4) Administer contents of second vial (2.5g) over ~7.5 minutes |
Total doses up to 20g have been used.
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