Pregnancy Classifications FDA Drug Classifications

Transcription

1 Pregnancy Classifications FDA Drug Classifications Drugs have been categorized by the FDA according to the level of risk to the fetus. Many of the medications included in this site refer to the Pregnancy Category. The following are descriptions of each category Category A Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester, and there is no evidence of risk on later trimesters; the possibility of fetal harm appears to be remote Category B Either (1) animal reproductive studies have not demonstrated a fetal risk but there are no controlled studies in women, or (2) studies in women and animals are not available. Drugs in this category should be given only if the potential benefit justifies the risk of the fetus Category C Either (1) studies in animals have revealed adverse effects on the fetus and there are no controlled studies in women, or (2) studies in women and animals are not available. Drug in this category should be given only if the potential benefit justifies the risk to the fetus Category D There is positive evidence of human fetal risk, but the benefits for pregnant women may be acceptable despite the risk, as in life-threatening diseases for which safer drugs cannot be used or are ineffective. An appropriate statement must appear in the Warnings section of the label of drugs in this category Category X Studies in animals or humans have demonstrated fetal abnormalities, there is evidence of fetal risk based on human experience or both; the risk of using the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are pregnant or may become pregnant. An appropriate statement must appear in the Contraindications section of the labeling of drugs in this category

2 Pregnancy Classifications FDA Drug Classifications Blank

3 Classification: Absorbent Activated Charcoal Actidose Indications: Orally ingested poisoning & overdose MOA: Binding of the toxin to prevent stomach and intestinal absorption. Contraindications: Not effective for cyanide, mineral acids, caustic alkalis, organic sol- vents, iron, ETOH, methanol poisoning, Li; do not use sorbitol in patients with fructose intolerance, intestinal obstruction, non-intact GI tracts Adverse Reactions: Nausea & Vomiting Drug Interactions: N/A Precautions and Considerations: Do not use in patients with depressed mental status unless via NG/OG tube Supplied: 25 g in 120 ml Dosage: Adult: g oral or NG/OG tube Pedi: 1 g/kg oral or NG/OG tube Protocol Locations: Overdose (Medical 17) (Pedi Medical 13) Pregnancy Classification - C

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5 Classification: Antiarrhythmic Adenosine Adenocard Indications: Narrow Complex Supraventricular Tachycardia (HR > 180 BPM) MOA: Slows conduction of electrical impulses through the sinoatrial (SA) node and atrioventricular (AV) node. Interrupts AV nodal reentry, which can restore normal sinus rhythm in patients with SVT Contraindications: High degree heart blocks (2 nd and 3 rd degree) Sick Sinus Syndrome A-fib A-flutter Adverse Reactions: Chest pain Dyspnea Hemodynamic instability Transient dysrhythmias Drug Interactions: Aminophylline Dipryridamole Precautions and Considerations: Use caution in heart transplants Due to short half-life (5-10 seconds), adverse reactions are transient and usually do not require intervention. Patients may respond only temporarily as recurrence of dysrhythmia is common Supplied: 6 mg in 2 ml 12 mg in 4 ml Dosage: Adult: 6mg then 12 mg; RAPID IVP followed by a RAPID 30 ml NS flush; repeated in 1-2 minutes Continued

6 Adenosine Adenocard Pediatric: 0.1 mg/kg, 0.2mg/kg; RAPID IVP followed by RAPID 5-10 ml NS flush; repeated in 1-2 minutes; Maximum combined pediatric dose is 12mg Protocol Locations: Narrow Complex Tachycardia PSVT / A-Fib / A-Flutter (ACLS 3) Wide Complex Tachycardia with a Pulse (ACLS 4) Narrow Complex Tachycardia PSVT / A-Fib / A-Flutter (PALS 3) Pregnancy Classification - C

7 Albuterol Proventil Classification: Beta-2 Sympathomimetic Bronchodilator Smooth Muscle Relaxer Indications: Asthma COPD Toxic Inhalation MOA: Stimulates beta-2 adrenergic receptors; acts primarily on bronchial musculature rather than on myocardium. Contraindications: Tachycardia Cardiac Asthma Digoxin Toxicity Adverse Reactions: Tremors Agitation Tachycardia Ectopy Nausea Drug Interactions: Antagonizes Beta Blockers Increased effects in the presents of some antidepressants Precautions and Considerations: Schizophrenia; Hyperthyroid; Prostatic Hypertrophy; Glaucoma Albuterol may be given continuously for patients in extremis. Do not withhold in pregnant asthmatics. Hypoxia is a greater risk to the fetus than the risk of adverse effects from the medication Supplied: 2.5 mg in 3 ml Continued

8 Albuterol Proventil Dosage: Adult: One unit dose (2.5 mg) via hand held nebulizer every minutes (max 3 doses) Pediatric: One unit dose (2.5 mg) every minutes (max 3 doses) Protocol Locations: Crush Injury / Compartment Syndrome (Trauma 4) (Pedi Trauma 4) Anaphylaxis / Allergic Reaction (Medical 3) (Pedi Medical 3) Respiratory - Acute Pulmonary Edema / CHF (Medical 19) Respiratory - Bronchospasm Asthma / COPD (Medical 21) (Pedi Medical 16) Pregnancy Classification - C

9 Classification: Platelet Aggregator Inhibitor Anti-inflammatory Anti-pyretic Aspirin ASA Indications: Chest Pain associated with ACS Fever Reducer MOA: Prevents platelet clumping and blood clot formation by irreversible changes in platelet shape and function. The analgesic, anti-inflammatory, and antipyretic effects are due to blocking prostaglandins. Contraindications: GI Bleed Peptic Ulcer Pregnancy Adverse Reactions: GI Bleeding Nausea and Vomiting Allergic Reactions Drug Interactions: Adverse reactions exacerbated by other NSAID use Precautions and Considerations: Pregnancy; Anemia; Renal Disease; Hodgkin s Disease Supplied: 81 mg chewable tablets Dosage: Adult: 324 mg po (4 tablets at once) Protocol Locations: Chest Pain (Acute Coronary Syndrome) (Medical 12) Pregnancy Classification - D

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11 Classification: Anticholinergic Parasympatholytic Atropine Atropine Indications: Bradycardia Asystole Dries mucus membranes in organophosphate poisoning Blocking vagal stimulation from laryngoscopy MOA: Blocks parasympathetic (vagal) action on the heart, thus increasing the rate of SA node discharge; enhances conduction through the AV junction; Blocks or antagonizes the effects of acetylcholine in the sweat glands, smooth and cardiac muscle. Contraindications: Tachycardia High degree heart blocks MI Adverse Reactions: Flushed skin Tachycardia Dry mouth Delirium Blurred Vision Headache Drug Interactions: Sodium Bicarb Effects enhanced by: antihistamines; procainamide; quinidine; benzodiazepines; antidepressants Precautions and Considerations: Renal disease; CHF; Down s Syndrome Administration should be rapid IV push to prevent reflex bradycardia. Atropine may result in an increased oxygen demand in patients suffering myocardial ischemia, thus worsening the ischemia or infarction size. Ineffective for bradycardia in heart transplant patients (denervated heart), proceed to pacing. Supplied: 1 mg in 10 ml

12 Atropine Atropine Dosage: Adult: Bradycardia: 0.5 mg rapid IV push every 3-5 minutes (max dose 3 mg); Pediatric: Bradycardia / Rapid Sequence Intubation: 0.02 mg/kg rapid IV push every 5 minutes, minimum dose 0.1 mg Max dose: 1 mg child; 2 mg adolescent Cholinergic & Calcium Channel Blockers Overdose: 0.05 mg/kg Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1) Overdose (Medical 17) (Pedi Medical 13) Bradycardia (ACLS 2) (PALS 2) Pregnancy Classification - C Continued

13 Classification: Anticholinergic Atrovent Ipratropium Indications: Asthma and COPD refractory to Albuterol MOA: It causes bronchodilation and dries respiratory tract secretions. It acts by blocking acetylcholine receptors, thus inhibiting parasympathetic stimulation. Contraindications: Peanut and/or Soy allergy Drug Interactions: None in prehospital Adverse Reactions: Palpitations Anxiety Dizziness Headache Nervousness Rash Vomiting Diarrhea Precautions and Considerations: Caution when used in the elderly patient; cardiac history; hypertension Supplied: 0.5 mg in 2.5 ml Dosage: Adult: 0.5 mg administered with 2.5 mg of Albuterol and nebulized for Bronchospasm refractory to Albuterol Pediatric o 250 mcg administered with 2.5 mg of Albuterol and nebulized for Bronchospasm refractory to Albuterol Continued

14 Atrovent Ipratropium Protocol Locations: Anaphylaxis / Allergic Reaction (Medical 3) (Pedi Medical 3) Respiratory - Bronchospasm Asthma / COPD (Medical 21) (Pedi Medical 16) Pregnancy Classification - B

15 Classification: Antihistamine Benadryl Diphenhydramine Indications: Allergic Reactions Dystonic reactions from antiemetic and antipsychotic medications MOA: Blocks cellular histamine response Contraindications: Asthma Attacks Narrow angle glaucoma MAO inhibitors Anticholinergic syndrome Adverse Reactions: Dizziness Sedation Wheezing Palpitations Hypotension Anticholinergic syndrome Drug Interactions: Ethanol Anticholinergic drugs Cannot be mixed with Solu-medrol Precautions and Considerations: Asthma In life-threatening anaphylactic reactions epinephrine should be given as the first-line medication Supplied: 50 mg in 5 ml Continued

16 Benadryl Diphenhydramine Dosage: o Adult: Allergic or dystonic reaction: Mild to Moderate Reaction mg IV/IM Moderate to Severe Reaction 75 mg IV/IM o Pediatric: Allergic or dystonic reaction: 1 mg/kg (max single dose 50 mg) IV (preferred) or for S-T segment depression) mg/kg IVP over 5 min q 10 min prn Protocol Locations: Anaphylaxis / Allergic Reaction (Medical 3) (Pedi Medical 3) Combative & Violent Patients (Medical 5) Pregnancy Classification - B

17 Classification: Electrolyte Calcium Chloride Kalcinate Indications: Acute hypocalcemia/hyperkalemia Mag, Calcium channel Blocker, and Beta blocker overdoses Relief of muscle spasm in bites from a black widow spider and scorpion MOA: Cation required for maintenance of nervous system, muscular, skeletal, and enzyme reactions, normal cardiac contractility, and coagulation of blood; increases cardiac contractility; may increase ventricular automaticity. Contraindications: Renal or cardiac disease with the exception of cardiac arrest Patient taking digitalis Hypercalcemia Adverse Reactions: Precipitate Sodium Bicarb; digitalis may cause or exacerbate arrhythmias Drug Interactions: Precipitate Sodium Bicarb; digitalis may cause or exacerbate arrhythmias Precautions and Considerations: Pregnancy Signs of Hypercalcemia decreased QT interval and T wave inversion Supplied: 50 g in 1 ml Dosage: Adult: o Overdoses: 1-2 g slow IV over 5 min, may repeat once q 10 min if no response Continued

18 Calcium Chloride Kalcinate o Prolonged entrapment: (Hyperkalemia, peaking T-wave, prolonged P- R intervals, and S-T segment depression) mg IVP over 5 min q 10 min prn. Pedi: o Overdose: mg/kg IVP over 5 min q 10 min may repeat once. o Prolonged Entrapment (Hyperkalemia, peaking T-wave, prolonged P- R intervals, and S-T segment depression) mg/kg IVP over 5 min q 10 min prn. Protocol Locations: Crush Injury / Compartment Syndrome (Trauma 4) Chest Pain (Acute Coronary Syndrome) (Medical 4) Excited Delirium (Medical 10) (Pedi Medical 9) Overdose (Medical 17) (Pedi Medical 13) Pregnancy Classification - C

19 Classification: Calcium Channel Blocker Cardizem Diltiazem Indications: A-Fib with rapid ventricular response A-Flutter MOA: Inhibits movement of calcium ions across cell membrane in systemic and coronary vascular smooth muscle; slows calcium ion movement across cell membranes in both cardiac muscle and cardiac pacemaker cells, decreasing sinoatrial and atrioventricular (AV) conduction. Contraindications: Sick sinus syndrome; secondor third-degree AV block; except with functioning pacemaker; systolic pressure less than 90 mm Hg; acute MI; pulmonary edema; hypersensitivity to the drug; ventricular tachycardia; atrial fibrillation or atrial flutter associated with an accessory bypass tract (WPW, short PR syn.); IV calcium channel blocker or beta-blockers administered (within a few hours) Adverse Reactions: Bradycardia; 1 st 2 nd or 3 rd degree AV block; angina, arrhythmia, bundle branch block, CHF, ECG abnormalities, hypotension, palpitations, syncope, tachycardia, ventricular asystole; peripheral edema, asystole, MI, nausea & vomiting, muscle cramps Drug Interactions: Cardiac effects of anesthetics and beta-blockers can be exacerbated. Elevates toxic and pharmacologic effects if benzodiazepines Precipitates with Lasix Continued

20 Cardizem Diltiazem Precautions and Considerations: Monitor and record BP and pulse frequently during treatment. Continuously monitor ECG during administration. **Given Slowly** Supplied: 100 mg powder mixed with ml NS Dosage: Adult: 0.25 mg/kg over 2 min, may repeat at 0.35 mg/kg over 2 min q min Adult Infusion: 5-15 mg/hr Pedi: None Protocol Locations: Narrow Complex Tachycardia-PSVT /A-Fib/A-Flutter (ACLS 3) Pregnancy Classification - C Continued

21 Classification: Antiarrhythmic Cordarone Amiodarone Indications: Wide complex tachycardia Narrow complex tachycardia A-fib and A-flutter with RVR MOA: Prolongs the action potential duration in all cardiac tissues Contraindications: Sick sinus syndrome High degree heart blocks Bradycardia Drug Interactions: Warfarin Digoxin Procainamide Adverse Reactions: Hypotension Bradycardia Increased ventricular beats Prolonged PR, QRS, & QT Quinidine Phenytoin Precautions and Considerations: Caution in CHF Administration to pulsing patients medication should be diluted and administered very slowly Supplied: 150 mg in 3 ml Dosage: Adult: o 150 mg over 10 minutes for patients with a pulse o Mix 150 mg in 100 ml of Normal Saline. Utilize a 10 gtts set and infuse at 100 gtts/minute over 10 minutes o May repeat once in 10 minutes Continued

22 Cordarone Amiodarone o 300 mg IVP for VF/PVT; may repeat at 150 mg in 5 minutes o Infusion 1 mg/min Pediatric: 5 mg/kg Protocol Locations: Wide Complex Tachycardia with a Pulse (ACLS 4) V-Fib / Pulseless V-Tach (ACLS 5) (PALS 5) Return of Spontaneous Circulation (ACLS 6) (PALS 6) Pregnancy Classification - B

23 Classification: Carbohydrate Dextrose 50% D-50 Indications: Hypoglycemia MOA: Cells use it as a source of energy and a metabolic intermediate. Contraindications: Hemorrhagic CVA Intracerebral Bleeding Adverse Reactions: Tissue damage from necrosis Drug Interactions: None Precautions and Considerations: Exacerbation of symptoms in alcohol addicted patients with a thiamine deficiency. Supplied: 25 g in 50 ml Dosage: Adult: grams slow IV push, may repeat as necessary Patient 1mo. 12yrs blood sugar <60, Dextrose 25% 2ml/kg IV/IO Patient < 1mo. Blood sugar <45, Dextrose 10% 5ml/kg IV/IO Dextrose Dilution Procedures D25W - Waste 25 ml D50W. Use pre-filled syringe (with remaining 25 ml) to withdraw 25 ml of NS from IV bag. Gently agitate syringe to mix solution D10W - Waste 40 ml D50W. Use pre-filled syringe (with remaining 10 ml) to withdraw 40 ml of NS from IV bag. Gently agitate syringe to mix solution Protocol Locations: Diabetic Emergencies (Medical 7) (Pedi Medical 5) Pregnancy Classification N/A

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25 Dopamine Intropin, Dopastat, Revimine Classification: Sympathomimetic - mimics the effects of the sympathetic nervous system Indications: Non-Traumatic Hypotension MOA: Stimulates alpha, beta, and dopaminergic receptors. Moderate doses (5-10 mcg/kg/min) increase heart rate; high doses (10-20 mcg/kg/min) increase peripheral vasoconstriction and hypertension Contraindications: Hypovolemia Tachyarrhythmia Drug Interactions: Sodium Bicarb Lasix Adverse Reactions: Chest pain; tachyarrhythmia; dyspnea; headache; nausea; vomiting; tissue damage from extraversion Precautions and Considerations: Use a large bore, patent IV to avoid extravasion. Use syringe pump when possible Supplied: 400 mg in 250 ml (1600 mcg/ml) Dosage: Adult: 5-20 mcg/kg/min Pedi: same as adult Continued

26 Dopamine Intropin, Dopastat, Revimine Protocol Locations: Medication: Dopamine / Drip Rate Chart (Procedure 15) Chest Pain (Acute Coronary Syndrome) (Medical 4) Hypotension / Hypovolemia / Shock (Medical 10) (Pedi Medical 3) Respiratory - Acute Pulmonary Edema / CHF (Medical 3) (Pedi Medical 13) Sepsis (Medical 23) (Pedi Medical 19) Bradycardia (ACLS 2) (PALS 2) Return of Spontaneous Circulation (ACLS 6) (PALS 6) Pregnancy Classification - C

27 Classification: Catecholamine Sympathomimetic Epinephrine Adrenaline Indications: Cardiac Arrest Anaphylaxis Bronchospasm Profound Hypotension Profound Bradycardia MOA: Stimulates alpha and beta-adrenergic receptors. Contractility, Chronicity, Conductivity (three C s) Contraindications: Intracranial hemorrhage Coronary artery disease Tachyarrhythmia Angina Adverse Reactions: Palpitations Tachycardia Ectopy Hypertension Tremors Anxiety Headache Cerebral hemorrhage Nausea/Vomiting Ischemia Drug Interactions: Inactivation by: o Aminophylline o Calcium chloride o Diazepam o Sodium Bicarb Antagonized by: o Vasodilators o Blockers o Diabetic meds Precautions and Considerations: CAD; Arrhythmias Continued

28 Supplied: 1:1,000 1 mg in 1 ml 1:10,000 1 mg in 10 ml Epinephrine Adrenaline Adult Epi-Pen Auto Injector Pedi Epi-Pen Jr. Auto Injector Dosage: Adult: o Cardiac arrest 1 mg 1:10,000 IV push q 3-5 minutes o Hypotension / Heart Transplant Infusion 2-10 mcg/min (2 mg in 250 ml = 8 mcg/ml) o Nebulizer Treatment Epinephrine 1:1000 1mg in 2 ml Normal Saline o Anaphylaxis 0.3 mg 1:1,000 SQ may be repeated in 20 minutes (max 3 doses) followed by an infusion of 1-4 mcg/min; Epi Pen (0.3 mg) IM if available Pediatric: o Cardiac arrest and Hypotension secondary to bradycardia 0.01 mg/kg (0.1 ml/kg) 1:10,000 IV o Hypotension / Heart Transplant Infusion 0.1-1mcg/kg/min (2 mg in 250 ml = 8 mcg/ml) o Nebulizer Treatment Epinephrine 1: mg/kg up to 0.3 mg IM or Autoinjector in the patient with a known history of asthma o Anaphylaxis 0.01 mg/kg 1:1,000 IM may be repeated in 10 minutes (may be repeated once in 10 minutes) mcg/kg/min IV infusion if refractory to IM Epi or Diphenhydramine Epi Pen Jr. (0.15 mg) IM o Bronchospasm 0.01 mg/kg 1:1,000 IM (max dose of 0.3 mg) may be repeated in 20 minutes (up to total of 1.2 mg) Continued

29 Epinephrine Adrenaline Newborn resuscitation (pulseless or heart rate less than 60 despite CPR) 0.01mg/kg 1:10,000 IV repeat every 3-5 minutes Protocol Locations: Anaphylaxis / Allergic Reaction (Medical 3) (Pedi Medical 3) Respiratory - Bronchospasm Asthma / COPD (Medical 21) (Pedi Medical 16) Newborn / Neonatal Care / Resuscitation (Pedi Medical 12) Respiratory - Croup / Epiglottitis (Pedi Medical 17) Asystole / PEA (ACLS 1) (PALS 1) V-Fib / Pulseless V-Tach (ACLS 5) (PALS 5) Return of Spontaneous Circulation (ACLS 6) (PALS 6) Pregnancy Classification - B

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31 Classification: Anesthetic, Hypnotic Etomidate Amidate Indications: Rapid Sequence Induction MOA: exact mechanism of action unknown, depresses brain stem reticular formation activity and produces hypnosis Contraindications: Allergy; Liver disease Pregnancy Immunosuppression Sepsis Adverse Reactions: Tonic and clonic movements Apnea Shock Drug Interactions: None Precautions and Considerations: Caution in use in the Elderly Adrenal Insufficiency Septic Shock **Given Slowly** Supplied: 20 mg in 10 ml Dosage: Adult: o RSI 0.3 mg/kg IV o Stunning 0.03 mg/kg IV Pediatric: o RSI 0.03 mg/kg o Stunning 0.03 mg/kg IV Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Crush Injury / Compartment Syndrome (Trauma 4) (Pedi Trauma 4) Pregnancy Classification - C

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33 Classification: Narcotic Analgesic Fentanyl Sublimaze Indications: Pain Management Blunting of the Reflex Sympathetic Response to Laryngoscopy MOA: The principal actions are that of an analgesic and sedative. It is synthetic narcotic with rapid onset and a short duration of action. Contraindications: MAO inhibitor use (antidepressant) Shock Severe hemorrhage Allergy Adverse Reactions: Dyspnea Muscle rigidity Bradycardia Drug Interactions: Potentiating other CNS depressants Precautions and Considerations: Bradycardia Respiratory drive Supplied: 100 mcg in 2 ml pending availability Dosage: Adult: o Pain: 1 mcg/kg IV/IM/IN 300 mcg max dose o RSI: 3 mcg/kg once MADD 1 mcg/kg (Adult/Pedi) Pediatric: o Pain: 1 mcg/kg may repeat once in mcg/kg o RSI: 3 mcg/kg Continued

34 Fentanyl Sublimaze Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Medication: MADD (Procedure 13) Abdominal Pain (Medical 1) (Pedi Medical 1) Chest Pain (Acute Coronary Syndrome) (Medical 12) Pain Management / Chemical Sedation (Medical 18) (Pedi Medical 14) Pregnancy Classification - C

35 Classification: Hormone Glucagon Glucagon Indications: Hypoglycemia Opioid overdose Calcium channel and beta blocker overdose MOA: Causes the liver to convert stored glycogen into glucose and release it into the bloodstream, raising blood glucose levels. Elevates conductivity and chronicity in the heart. Contraindications: Allergy Adverse Reactions: None Drug Interactions: None Precautions and Considerations: None Supplied: 1 mg powder mixed with 1 ml NS Dosage: Adult: 1 mg IN/IM Pediatric: (> 25kg) 1 mg IN/IM Neonate: (< 25kg) 0.5 mg IM Protocol Locations: Medication: MADD (Procedure 13) Anaphylaxis / Allergic Reaction (Medical 3) Diabetic Emergencies (Medical 7) (Pedi Medical 5) Overdose (Medical 17) (Pedi Medical 13)

36 Pregnancy Classification - C Glucagon Glucagon Blank

37 Haldol Haloperidol Classification: Antipsychotic Neuroleptic Indications: Delirium Psychosis Schizophrenia MOA: Dopamine-receptor blockage in CNS Contraindications: Parkinson s disease Dementia especially in the elderly Adverse Reactions: Extrapyramidal symptoms; Insomnia, Drowsiness Seizures; Respiratory depression Dry mouth Hypotension Tachycardia Drug Interactions: Lithium Anti-Hypertensive Precautions and Considerations: Hypotension Dystonic reactions treated with Benadryl Supplied: 5 mg in 1 ml Dosage: Adult: 5 mg administered IM or IV, may be repeated with doubling the last dose every 20 minutes Pedi: Ages 6-12, 2 mg IM or IV and may be repeated with doubling the last dose every 20 minutes Continued

38 Haldol Haloperidol Protocol Locations: Combative & Violent Patients (Medical 5) (Pedi Medical 4) Pregnancy Classification - C

39 Ibuprofen Motrin, Advil Classification: NSIAD Antipyretic Indications: Controlled Hyperthermia Fever MOA: exact mechanism of action unknown; inhibits cyclooxygenase, reducing prostaglandin and thromboxane synthesis Contraindications: Hypersensitivity ASA or NSAIDinduced asthma or urticarial Aspirin triad Pregnancy 3rd trimester CABG surgery perioperative use GI Bleed Adverse Reactions: Dyspepsia Nausea Abdominal pain Constipation Headache Dizziness Drowsiness Rash Elevated liver transaminases Fluid retention Tinnitus Ecchymosis Photosensitivity Drug Interactions: ASA Cidofovir CNS depressant Aspirin Caffeine combos COX 2 inhibitors Opiate/aspirin combos Pentoxifylline Probenecid Precautions and Considerations: NSAIDs can increase risk of life-threatening heart or circulation problems, including heart attack or stroke. This risk will increase the longer ibuprofen is taken. Do not use this medicine just before or after having heart bypass surgery (also called coronary artery bypass graft, or CABG). NSAIDs can also increase risk of serious effects on the stomach or intestines, including bleeding or perforation Continued

40 Ibuprofen Motrin, Advil (forming of a hole). These conditions can be fatal and gastrointestinal effects can occur without warning at any time while taking an NSAID Supplied: 100 mg per 5 ml (120 ml total) Dosage: Adult: mg PO q 4 to 6 h as needed Pedi: 10 mg/kg PO q 4-6 hours as needed (max 40 mg/kg per day) o Contraindicated in children < 6 months old Protocol Locations: Fever (Medical 11) (Pedi Medical 9) Pain Management / Chemical Sedation (Medical 18) (Pedi Medical 14) Pregnancy Classification - C

41 Classification: General Anesthetic KETAMINE Ketalar Indications: Crush injuries with prolonged extrication and potential compartment syndrome for pain and sedation Induction agent for Medication Facilitated Intubation Analgesia if Narcotic pain medication not available or ineffective Sedation agent as an alternative or in conjunction with Midazolam MOA: Direct acting alpha antagonist and non-selective beta antagonist Contraindications: AMI Uncontrolled severe Hypertension Adverse Reactions: Hypertension Flushing Palpitations Increased oral secretions Nausea / Vomiting Increased secretions Bronchorrhea Drug Interactions: Prolonged recovery time may occur if barbiturates and/or narcotics are used concurrently with Ketamine Precautions and Considerations: Interactions: additive effects if used with βeta Blockers Supplied: 100 mg/ml 5 ml Continued

42 KETAMINE Ketalar Dosage: Adult: o Rapid Sequence Induction 1 mg/kg RSI o Pain Management mg/kg IV/IO over 1 minute; May repeat once in 5 minutes as needed 3 mg/kg IM one dose 50 mg IN Pedi: o Rapid Sequence Induction 1 mg/kg RSI o mg/kg IV/IM/IO over 1 min may repeat in 5 minutes as needed Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Medication: MADD (Procedure 13) Crush Injury / Compartment Syndrome (Trauma 4) (Pedi Trauma 4) Excited Delirium (Medical 10) (Pedi Medical 8) Pain Management / Chemical Sedation (Medical 18) (Pedi Medical 14) Respiratory - Acute Pulmonary Edema / CHF (Medical 19) Pregnancy Classification X use with caution

43 Classification: General Anesthetic Labetalol Trandate Indications: Acute Hypertensive Crisis MOA: selectively antagonizes alpha-1 adrenergic receptors; antagonizes beta-1 and beta-2 adrenergic receptors (selective alpha and non-selective beta blocker) Contraindications: CHF Heart block Bradycardia Hypotension Ventricular arrhythmias Bronchospasm Lupus Hepatotoxicity Hepatic necrosis Adverse Reactions: Drowsiness Weakness Fatigue Respiratory distress Drug Interactions: Bronchodilators Beta Agonists Theophylline Mehyldopa Turbutaline Verapamil Cardizem Precautions and Considerations: Most hypertension can be tolerated in the field. Treatment of hypertension should be reserved for acute symptomatic cases Target blood pressure no greater than 20% of original MAP within the first 60 min of treatment Pregnancy induced hypertension, SBP > 140 and/or DBP > 90

44 Supplied: 20 mg in 4 ml Labetalol Trandate Dosage: Adult: o Acute Hypertensive Crisis: 20 mg slow over 2 min, repeat at double the original dose q 10 min, max 300 mg o Pregnancy induced hypertension: 10 mg slow over 2 min, repeat at 5 mg q 10 min once Pedi: None Protocol Locations: CVA / Stroke (Medical 6) Hypertensive Crisis (Medical 12) Pregnancy Classification C Continued

45 Classification: Diuretic Lasix Furosemide Indications: Pulmonary edema CHF MOA: Inhibits sodium and chloride reabsorption in the kidney Contraindications: Hypotension Drug Interactions: Incompatible with: Diazepam Adverse Reactions: Hypotension Arrhythmias Benadryl Thiamine Precautions and Considerations: Pregnancy; protect from light; given slowly Patients taking furosemide may require a larger dose to achieve desired effects in the acute setting. Cardiac monitoring should be performed. The onset of venous dilations is 5 minutes and the onset of urine production is 10 minutes Supplied: 40 mg in 4 ml Dosage: Adult: mg slow IV push or 2 times the patient s total daily dose to a maximum of 120 mg Protocol Locations: Respiratory - Acute Pulmonary Edema / CHF (Medical 19) Pregnancy Classification C

46 Lasix Furosemide Blank

47 Classification: Ventricular anti-dysrhythmic Anesthetic Indications: Pulseless VT Pulsing VT V-Fib Lidocaine Xylocaine Ventricular Ectopy in AMI ICP Inhibitor with Laryngoscopy MOA: Decreases automaticity and refractory period in cardiac arrest. Decreases cardiovascular response that can cause a rise in ICP during RSI Contraindications: Escape Rhythms High degree AV blocks Sinus Arrest Bradycardia Adverse Reactions: Drowsiness Numbness and tingling Disorientation Blurred vision Seizures Coma Respiratory arrest Hypotension Drug Interactions: None prehospital Precautions and Considerations: Exceedingly high doses can result in coma and death Lidocaine administration is not recommended in uncomplicated MI without associated ventricular ectopy. Ventricular escape rhythms associated with bradycardia or high-degree heart block should not be treated with Lidocaine. Suppressing ventricular escape rhythms may be FATAL. Once the Dysrhythmia is controlled with a bolus and perfusion restored, a continuous infusion may be used. Infusion should be decreased in elderly patients, those with liver disease and those with CHF Continued

48 Supplied: 100 mg in 5 ml Lidocaine Xylocaine Dosage: Adult: o Post arrest mg/kg IV bolus followed by 1-4 mg/min infusion; o Wide complex tachycardia 1 mg/kg; may repeat in 5-10 minutes at 0.5 mg/kg (max of 3 mg/kg); continuous infusion of 2-4 mg/min may be started following ROSC; o VF/PVT cardiac arrest mg/kg, every 3-5 minutes up to 3 mg/kg A single one-time dose of 1.5 mg/kg may be appropriate o IO for pain 30 mg Pediatric: o Post arrest 1 mg/kg IV bolus followed by mcg/kg/min infusion o Wide complex tachycardia 1 mg/kg IV over 3 minutes; o VF/PVT Cardiac Arrest 1 mg/kg IV push o IO for pain 20 mg Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Medication: Lidocaine Drip (Procedure 17) Other: EZ-IO (Procedure 22) Wide Complex Tachycardia with a Pulse (ACLS 4) (PALS 4) V-Fib / Pulseless V-Tach (ACLS 5) (PALS 5) Return of Spontaneous Circulation (ACLS 6) (PALS 6) Pregnancy Classification B

49 Classification: Electrolyte Smooth Muscle Relaxant Magnesium Sulfate Mag Indications: Seizures associated with toxemia of pregnancy Torsades de Pointes Reactive Airway refractory to Bronchodilators MOA: Increases intracellular potassium and alters calcium s effect on conduction; stabilizes muscle cell membranes Contraindications: Kidney failure Heart Block Respiratory Depression Adverse Reactions: Diaphoresis Flushing Hypotension Respiratory Depression/Arrest Bradycardia Drug Interactions: May interfere with effects of neuromuscular blocking agents and CNS depressants. Calcium chloride antagonizes the effects. May cause cardiac malfunction when given with cardiac glycosides Precautions and Considerations: Calcium should be available as an antidote in respiratory depression and/or arrest Supplied: 2 grams in 2 ml Continued

50 Magnesium Sulfate Mag Dosage: Adult: o Eclampsia 4 g given at 1g/min until a max dose of 4g is given (Mix 4 gm in 100 ml of Normal Saline and administer 1 mg/min or or 4 gm IM o Tricyclic Overdose 2 g o Bronchospasm 2 g IV Mix 2 gm in 100 ml of Normal Saline. Utilize a 10 gtts set / Diala-Flow and infuse at 50 gtts/min over 20 minutes o Torsades de Pointes 1-2 g Pedi: o Severe bronchospasm refractory to neb treatments, infusion mg/kg in 50 ml (2 g max) at 100 ml/hr via syringe pump Protocol Locations: OB /GYN - Childbirth / Labor / Delivery (Medical 15) Overdose (Medical 17) (Pedi Medical 13) Respiratory - Bronchospasm Asthma / COPD (Medical 21) (Pedi Medical 16) Seizures / Convulsions (Medical 22) (Pedi Medical 18) V-Fib / Pulseless V-Tach (ACLS 2) (PALS 2) Return of Spontaneous Circulation (ACLS 2) (PALS 2) Pregnancy Classification D

51 Classification: Opioid Narcotic Analgesic Morphine Sulfate Morphine Indications: Pain and Anxiety management in AMI Severe pain from: o Isolated fractures o Kidney stones o Burns MOA: Binds to opiate receptors in the central nervous system and decreases the transmission of pain. Contraindications: Respirator depression Head injury Acute bronchospasm or asthma Hypovolemia Adverse Reactions: CNS Depression Respiratory Depression Bronchospasm Hypotension Bradycardia Nausea Vomiting Drug Interactions: Other respiratory depressants Tricyclics and MAO inhibitors Precautions and Considerations: Narcan for overdose Phenergan for nausea and vomiting Supplied: 10 mg in 2 ml Continued

52 Morphine Sulfate Morphine Dosage: Adult: o Pain: 2-10 mg IV/IM q 3-5 min, 2 mg doses, max 20 mg total o AMI: 4.0 mg IV slowly. May repeat every 5 min to a total 8 mg Pedi: o Pain: 0.1 mg/kg IV/IM May repeat 1 additional dose of 0.1 mg/kg up to a Max dose of 5 mg in 10 minutes if systolic BP is > ( x age in years)mmhg Protocol Locations: Chest Pain (Acute Coronary Syndrome) (Medical 4) Pain Management / Chemical Sedation (Medical 18) (Pedi Medical 14) Pregnancy Classification C

53 Classification: Narcotic Antagonist Narcan Naloxon Indications: Unconscious Unknown Opioid overdose with respiratory depression or arrest MOA: Blocks opioid receptors Contraindications: Allergy Adverse Reactions: Pulmonary Edema Severe Agitation Hypertension Drug Interactions: Incompatible with alkaline solutions Dysrhythmias Tachycardia Precautions and Considerations: May precipitate opioid withdrawal syndrome Naloxone given for heroin or other narcotic overdose may precipitate acute agitation or violent behavior, when the patient wakes up. Therefore, administer slowly while observing patient s level of consciousness and respiratory status. Naloxone will remain effective for minutes, therefore, repeat doses may be required during prolonged transports Narcan should be given slowly in lower dosages (0.4 mg) and titrated to respiratory drive. The idea is not to bring the patient back to full consciousness, but to self maintain a patent airway. Slamming 2 mg into a patient with an opioid addiction can be detrimental. All opioid overdose cases should be treated as if the patient has an addiction until proven otherwise. Supplied: 2 mg in 2 ml Continued

54 Narcan Naloxon Dosage: Adult: 1-2 mg IV/IM titrated to respiratory drive (no maximum), 2 mg MADD Pediatric: 0.1 mg/kg IV, IM up to 2mg, or MADD titrated to respiratory drive (no maximum) Protocol Locations: Medication: MADD (Procedure 13) Newborn / Neonatal Care / Resuscitation (Pedi Medical 12)Overdose (Medical 17) (Pedi Medical 13) Pregnancy Classification C

55 Classification: Vasodilator Nitroglycerin Nitrostat, Tridil Indications: Cardiac related chest pain CHF with pulmonary edema Hypertension MOA: Relaxes vascular smooth muscle; dilates large coronary arteries and increases collateral coronary circulation; reduces left ventricular filling pressure and systemic vascular resistance; dilates systemic arteries and veins, which reduces work load of the heart, lowering myocardial oxygen demand Contraindications: Hypotension Head Trauma or TBI Cardiac Tamponade Constrictive Pericarditis Drug Interactions: Exacerbated by other vasodilators Adverse Reactions: Hypotension Headache Syncope Facial Flushing Diaphoresis Precautions and Considerations: Use caution when combined with other medications that potentially cause hypotension. ALWAYS inquire about medications that treat erectile dysfunction Nitroglycerin should be given with aspirin in suspected cases of AMI. Hypotension often responds to placing the patient in a recumbent position and elevation of legs. If not, IV fluids should be given. Bradycardia is treated with Atropine Nitroglycerin is not an analgesic and should not be administered as such. Patients suspected of having an AMI without chest pain should still receive nitro therapy. Administration in these cases should be titrated to blood pressure Continued

56 Nitroglycerin Nitrostat, Tridil Supplied: Sublingual mg tablets or 0.4 mg metered dose spray IV 25 mg in 250 ml Dosage: Adult: o Sublingual 0.4 mg every 3-5 minutes, max of three doses o IV 10 mcg/min doubled every 5 min until desired effect is reached i.e. relief of chest pain and/or systolic blood pressure of > 100 mmhg Protocol Locations: Chest Pain (Acute Coronary Syndrome) (Medical 4) Hypertensive Crisis (Medical 7) Respiratory - Acute Pulmonary Edema / CHF (Medical 19)

57 Norcuron Vecuronium Classification: NON-Depolarizing Neuromuscular Blocking Agent Indications: Status post RSI Prolonged neuromuscular blocking post intubation MOA: Blocks acetylcholine at the myoneutral junction Contraindications: Allergy Failed Intubation Adverse Reactions: None Drug Interactions: None prehospital Precautions and Considerations: Has no effect on consciousness, pain, or memory!! Will not be used without successful sedation of patient Always given slowly Continuous ECG, ETCO2 monitoring, and sedation Supplied: 10 mg in 10 ml after NS is added to powder and shaken well Dosage: Adult: 0.1 mg/kg once Pedi: 0.1 mg/kg once Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Pregnancy Classification C

58 Norcuron Vecuronium Blank

59 Classification: Antihistamine Antiemetic Pain/Sedative Adjunct Phenergan Promethazine Indications: General Nausea & Vomiting Nausea & Vomiting caused by drug administration Sedative (exacerbates sedative effects of narcotics) MOA: Blocks action of histamine (H-1) receptor sites Contraindications: Allergy Unresponsive patients CNS depression from alcohol and or barbiturates Asthma patients experiencing an attack (consider Zofran) Children < 2 years of age Adverse Reactions: Over sedation Dizziness Dysrhythmias Hallucinations (mostly in children) Drug Interactions: MAO inhibitors Precautions and Considerations: Caution with; asthmatics; peptic ulcers; and bone marrow depression When given with narcotics or CNS depressants continuous ECG and ETCO2 Large patent IV necessary. Medication can cause vascular necrosis. Dilute in pediatric and adult patients Supplied: 25 mg in 1 ml Continued

60 Phenergan Promethazine Dosage: Adult: mg slow IV or IM. Must be diluted and followed by a 100 ml flush Pedi: (> 2 years of age).25 mg/kg slow IV or IM. Max total 25 mg. Must be diluted and followed by a 100 ml flush Protocol Locations: Nausea & Vomiting (Medical 14) (Pedi Medical 11) Pregnancy Classification C

61 Rocuronium Zemuron Classification: Non-depolarizing neuromuscular blocking agent Indications: For sustained neuromuscular blockade in the intubated patient. As the first line agent for Rapid Sequence Induction in the patient where Succinylcholine is Contraindicated MOA: Rocuronium is a non-depolarizing neuromuscular blocking agent causing skeletal muscle relaxation. Neuromuscular blockade occurs within 1-2 minutes. Time to recovery is minutes Contraindications: Known sensitivity to Rocuronium Adverse Reactions: Tachycardia Hypo OR Hypertension Drug Interactions: None Prehospital Precautions and Considerations: Rocuronium has no affect on consciousness and must be used with a sedative or induction agent Patients with renal or hepatic failure may experience prolonged paralysis Due to the prolonged duration of action, the endotracheal tube or pharyngeal tube must be continually monitored to ensure correct placement with ETCO2 and pulse oximetry Supplied: 10 mg/ml, 10 ml or 5 ml vials Continued

62 Rocuronium Zemuron Dosage: Adult: o RSI 1 mg/kg o Post Intubation Paralysis 0.2 mg/kg Pedi: (3 months to 14 years) 0.6 mg/kg Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Pregnancy Classification C

63 Classification: Alkalinizing agent Indications: Metabolic Acidosis Crush syndrome Prolonged Resuscitation or prolonged down time prior to CPR Sodium Bicarbonate Bicarb Tricyclic antidepressant overdose Hyperkalemia MOA: Acts as a source of bicarbonate ions; increases ph (alkalization) in blood and urine; acts as a buffering (neutralizing) agent for acids in the blood and interstitial fluid Contraindications: CHF Metabolic or Respiratory Alkalosis Hypokalemia Hypocalcaemia Adverse Reactions: Hypoxia Paradoxical CNS Acidosis Metabolic Alkalosis Hypernatremia Seizures Drug Interactions: May precipitate when given with atropine, calcium chloride, calcium gluconate, morphine sulphate, aminophylline, and magnesium. Epinephrine, dopamine, and isoproterenol are inactivated when given with sodium bicarbonate Precautions and Considerations: Be sure to have good flow in IV prior to giving slowly; May worsen CHF Adequate ventilation is the mainstay of acid-base balance in cardiac arrest. Sodium bicarbonate is reserved for patients with severe acidosis (ph less than 7.1), or empirically for prolonged resuscitation efforts after Continued

64 Sodium Bicarbonate Bicarb ventilation, oxygenation, and perfusion have been established 4.2% Dilution in premature and newborn infants (neonates) Push out half of a vile and replace with NS Supplied: 50 meq in 50 ml Dosage: Adult: o Cardiac Arrest: With an extended down time1 meq/kg slow IV push o Crush Syndrome: 1 meq/kg bolus, infusion add 0.25 meq/kg to 1L NS and run at 1 L/hr o Tricyclic Overdose: 1 meq/kg slow IV push o Excited Delirium: 1 meq/kg slow IV push Pediatric: o Cardiac Arrest: 1 meq/kg slow IV push; may repeat at 0.5 meq/kg o Crush Syndrome: same as adult o Tricyclic Overdose: same as adult o Excited Delirium: same as adult Protocol Locations: Burns (Trauma 2) (Pedi Trauma 2) Crush Injury / Compartment Syndrome (Trauma 4) (Pedi Trauma 4) Excited Delirium (Medical 7) (Pedi Medical 8) Asystole / PEA (ACLS 5) (PALS 2) V-Fib / Pulseless V-Tach (ACLS 5) (PALS 2) Pregnancy Classification C

65 Classification: Glucocorticoid Solu-Medrol Methylprednisolone Indications: Reactive airway disease Allergic reactions MOA: Depresses formation, release, and activity of endogenous mediators of inflammation Contraindications: Patients taking Wellbutrin in large daily doses (> 300 mg). Allergy Premature neonates Pregnant Women Adverse Reactions: Dizziness Facial Flushing Headache Increased Sweating Mild nausea Pain Swelling, or redness at the injection site Stomach pain or bloating Vomiting Drug Interactions: Lasix (risk of hyperkalemia) Digoxin (arrhythmias) Antifungal agents Cardizem Antidiabetic agents Precautions and Considerations: If administered and patient is intubated using RSI, report the Solu-medrol usage and advise of elevated creatine kinase (CK) levels. Using Solu-medrol with neuromuscular blocking agent can cause quadriparesis (weakness in arms and legs) that can last up to two weeks Continued

66 Supplied: 125 mg in 2 ml Solu-Medrol Methylprednisolone Dosage: Adult: 125 mg IV/IO or deep IM gluteal muscle only Pedi: 2 mg/kg IV/IO or deep IM gluteal muscle only Protocol Locations: Anaphylaxis / Allergic Reaction (Medical 3) (Pedi Medical 3) Respiratory - Bronchospasm Asthma / COPD (Medical 21) (Pedi Medical 16) Respiratory - Croup / Epiglottitis (Pedi Medical 17) Pregnancy Classification C

67 Succinylcholine Anectine Classification: Depolarizing Neuromuscular Blocking Agent Indications: Initial blocking adjunct in Rapid Sequence Induction MOA: Blocks the effect of acetylcholine at the neuromuscular junction Contraindications: Allergy History of Malignant Hypothermia Skeletal Muscle myopathies Penetrating Eye Injuries Drug Interactions: Digitalis Adverse Reactions: Apnea Cardiac Arrhythmias Muscle Fasciculations (tremors) Increased Intraocular Pressure Hyperkalemia Quinidine Precautions and Considerations: Slowed reactions in patients with poor circulation Has no effect on consciousness, pain, or memory. Will not be used without successful sedation of patient Caution in burn patients, electrolyte imbalance, and hyperkalemia Supplied: 200 mg in 10 ml Dosage: Adult: 2 mg/kg IV/IO Pedi: 2 mg/kg IV/IO Continued

68 Succinylcholine Anectine Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Pregnancy Classification C

69 Tranexamic Acid TXA, Cyklokapron Classification: Anti-Fibrinolytic Agent, Antihemophilic Agent, Hemostatic Agent Indications: Adults (Age 15 or greater) with hemorrhagic shock from trauma Must have obvious bleeding external wounds neck to mid-thigh or suspected severe internal injuries from blunt or penetrating trauma Trauma occurred within last 3 hours Must have sustained tachycardia 110 beats per minute and/or sustained hypotension with systolic blood pressure 90 mmhg or less MOA: Inhibits both plasminogen activation and plasmin activity, thus preventing clot break-down rather than promoting new clot formation. With massive bleeding this may help stabilize clot formation and decrease extravascular bleeding. Onset of action within 4 hours after IV administration. Exact time of onset unclear and variable Contraindications: Traumatic Brain Injuries Non-hemorrhagic shock Non-traumatic hemorrhagic shock Hemorrhagic shock stabilized with other hemostatic agents/measures History if DVT or PEs Drug Interactions: Non Prehospital Adverse Reactions: While a theoretical concern, TXA has not been shown to cause significant increase in deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke in published trials to date Nausea Vomiting Diarrhea Continued

70 Tranexamic Acid TXA, Cyklokapron Precautions and Considerations: History of thrombotic events Renal Dieses Problems with vision (including color vision) Sudden numbness or weakness, especially on one side of the body Sudden severe headache, confusion, speech, or balance Chest pain, sudden cough, wheezing, rapid breathing, coughing up blood Pain, swelling, warmth, or redness in one or both legs Seizure Syncope Supplied: 1 Gram Dosage: Adult: 1 gram mixed in 100 ml Normal Saline infused over 10 minutes Pedi: Not Indicated Protocol Locations: Multiple System Trauma (Trauma 8)

71 Classification: General Anesthetic Tylenol Acetaminophen Indications: Controlled hyperthermia; Fever MOA: Inhibits prostaglandins in CNS, but lacks anti-inflammatory effects in periphery; reduces fever through direct action on hypothalamic heat-regulating center. Contraindications: Allergy Liver disease Adverse Reactions: Nausea & Vomiting Drug Interactions: None prehospital Precautions and Considerations: Interactions: additive effects if used with βeta Blockers Supplied: 325mg in 10 ml oral Elixir Dosage: Adult: mg PO. Round to the nearest 10 th Pedi: 15 mg/kg PO newborn to 12 years of age Protocol Locations: Fever (Medical 11) (Pedi Medical 9) Pain Management / Chemical Sedation (Medical 18) (Pedi Medical 15) Pregnancy Classification C Continued

72 Tylenol Acetaminophen Children s Tylenol Chart lb kg mg/kg Dose(cc) lb kg mg/kg Dose(cc)

73 Classification: Benzodiazepine Anticonvulsant Indications: Uncontrolled seizures Severe agitation ETOH withdrawal syndrome Valium Diazepam Chemical restraint Sedation prior to cardioversion MOA: Binds to specific benzodiazepine receptors in the CNS, which inhibits neuronal transmission and raises seizure threshold Contraindications: Allergy Shock CNS depression and or decreased LOC Respiratory depression Adverse Reactions: Respiratory Depression or Arrest Periods of Excitement Hypotension Confusion Prolonged Coma Ataxia Nausea & Vomiting Drug Interactions: Barbiturates and ETOH use Precipitates with other medications so IV should be flushed before and after administration Use with NS only Precautions and Considerations: Supplied: 10 mg in 2 ml Continued

74 Valium Diazepam Dosage: Adult: Anxiety & Seizures: 5 mg/kg IV, or 10 mg IM, titrate to effect or 100mmHg systolic. Max single dose 5mg Pedi: Anxiety & Seizures: 0.1 mg/kg IV, titrate to effect or 100mmHg systolic. (<5 years max 5 mg) (>5 years 10 mg max) Protocol Locations: Overdose (Medical 17) (Pedi Medical 13) Seizures / Convulsions (Medical 22) (Pedi Medical 18) Pregnancy Classification D

75 Classification: Benzodiazepine Versed Midazolam Indications: Sedation prior to paralyzing a patient for endotracheal intubation; Sedation prior to cardioversion; Chemical restraint; Seizures MOA: Works naturally to reduce anxiety and impair memory. Short acting (duration minutes) with onset of action within 2-5 minutes Contraindications: Hypersensitivity Shock Coma Alcohol or CNS Depressant Abuse Hypotension Adverse Reactions: Over sedation Blurred Vision Hypotension Amnesia Respiratory Depression Drug Interactions: Effects accentuated by concomitant use of barbiturates, alcohol, or narcotics Precautions and Considerations: Never give as a fast bolus Oxygen saturation and cardiac monitoring required with all patients who have been given any benzodiazepine; monitor patient s vital signs closely Supplied: 10 mg in 2 ml Continued

76 Dosage: Adult: Versed Midazolam o Anxiety: 2-5 mg IV in 2 mg doses titrate to effect or 100mmHg systolic or 5 mg deep IM may repeat once o Combative & Violent Patient: 10 mg IM, titrate to 100mmHg systolic. May repeat IM dose X 1 o RSI: 2-5 mg IV q 3-5 min titrating to systolic blood pressure of 90mmHg o MADD: 10 mg IN o Seizures: 2.5 mg IV prn Repeat every 5 minutes with one 5 mg dose to a maximum dose of 20 mg until cessation of visible seizure activity o Sedation 2-5 mg IV Pedi: o Anxiety: Versed mg/kg IV/IM prn, titrate to effect or 70mmHg +(age in years x2) systolic o Combative & Violent Patient: mg/kg (5 mg max) IV/IM, titrate to effect or 70mmHg +(age in years x2) systolic o RSI: mg/kg IVP q 2-5 min titrating to systolic blood pressure of 70mmHg + (age in years x2) o MADD: 0.2 mg/kg, Max 5 mg o Seizures 0.1 mg/kg IV/IO, up to a maximum single dose of 2 mg. Repeat once in 5 minutes o Sedation 0.1 mg/kg IV or 0.2 mg/kg IN Protocol Locations: Airway/Breathing: Rapid Sequence Intubation (Procedure 1/1A) Cardiac: Synchronized Cardioversion (Procedure 10) Cardiac: Transcutaneous Pacing (Procedure 11) Medication: MADD (Procedure 13) Traumatic Brain Injury (TBI) (Trauma 9) (Pedi Trauma 11) Combative & Violent Patients (Medical 5) (Pedi Medical 4) Excited Delirium (Medical 10) (Pedi Medical 8) Overdose / Poisoning (Medical 17) (Pedi Medical 13) Pain Management / Chemical Sedation (Medical 18) (Pedi Medical 14) Respiratory - Acute Pulmonary Edema / CHF (Medical 19) Seizures / Convulsions (Medical 22) (Pedi Medical 18) Bradycardia (ACLS 2) (PALS 2)