PHARMACOPEIA MEDICAL VOLUNTEER S DRUG MANUAL

Transcription

1 PHARMACOPEIA MEDICAL VOLUNTEER S DRUG MANUAL

2 November 12, 2014 We are excited to introduce the new Operation Smile Pharmacopeia. This reference tool is created as the accepted standard of practice for Operation Smile medical volunteers in the delivery of safe medical care. The pharmacopeia is supported by international information and best practice data. The easy-to-use design presents important aspects of drug information in a concise format that addresses accepted medications used on Operation Smile missions. Additionally, it includes medications that are accepted substitutions in countries where our standard medications may not be available. This global resource will support our volunteers in providing consistently safe care to our patients. We would like to express our gratitude to Dr. George Politis for his guidance and the significant amount of time he invested in this project, a well as, the support of Dr. Henry Issenberg and Operation Smile s Medical Officers. Our deepest appreciation also goes to our volunteers around the world whose endless generosity is utterly inspiring. Cynthia R. Raglin Senior Director, Quality Assurance Operation Smile

3 Table of Contents ANALGESICS Acetaminophen (Paracetamol) Clonidine Fentanyl Ibuprofen Ketorolac Metamizole Nalbuphine SEDATIVES INTRAVENOUS ANESTHETICS Diazepam Etomidate Ketamine Lorazepam Midazolam Propofol LOCAL ANESTHETICS Bupivacaine / Bupivacaine with Epinephrine Lidocaine / Lidocaine with Epinephrine ANTICONVULSANTS Diazepam Lorazepam Phenytoin Midazolam ANTIEMETICS Dexamethasone Diphenhydramine Ondansetron Promethazine ANTIFIBRINOLYTICS Amicar Tranexamic Acid ANTIMICROBIALS Amoxicillin Azithromycin Cefazolin Cefotaxime Ceftriaxone Cephalexin Ciprofloxacin

4 Table of Contents ANTIPRURITICS Diphenhydramine ANTIPYRETICS Acetaminophen (Paracetamol) Ibuprofen Metamizole CARDIOVASCULAR Dopamine Ephedrine Esmolol Labetalol Phenylephrine DIURETICS Furosemide NEUROMUSCULAR BLOCKERS Rocuronium Succinylcholine POST- EXPOSURE PROPHYLAXIS Combivir Raltegravir Truvada Viracept RESPIRATORY / ASTHMA Albuterol Racemic Epinephrine Terbutaline Albuterol MD RESUSCITATION PATIENT CODE SHEET Adenosine Amiodarone Atropine Calcium Chloride 10% Epinephrine (Adrenaline) Flumazenil Lidocaine 2% Naloxone Sodium Bicarbonate 8.4% Vasopressin Verapamil

5 Table of Contents STEROIDS Dexamethasone Methlyprednisolone Prednisone TOPICALS Benzocaine Spray Lacri-lube Lidocaine 2% Jelly Silver Sulfadiazine cream Triple Antibiotic Ointment TOXICOLOGY REVERSAL AGENTS Dextrose 50% Flumazenil Naloxone Neostigmine MISCELLANEOUS Dantrolene Glycopyrrolate Hetastarch 6% Loperamide Mannitol 25% Methylene Blue Nitroglycerin Pseudoephedrine Simethicone ************************************ *********************************************************

6 ANALGESICS Acetaminophen (Paracetamol) *For PR doses in children, doses lower than 25 mg/kg fail to produce therapeutic levels. Repeat doses of mg/kg must be given AT LEAST 8 hours apart. ** A one-time intraoperative dose of RECTAL acetaminophen at mg/kg should be considered for all Operation Smile patients. ***DO NOT split suppositories. ORAL/RECTAL DOSING PO: mg/kg/dose; every 4-6 hours prn PR: mg/kg/dose; every 8 hours prn MAX: 90 mg/kg/day Children >12 years/ (if > 50 kg, otherwise use per kg doing above) PO: mg/dose; every 4-6 hours prn PR: 1300 mg/dose; every 4-6 hours prn MAX: 4 grams/day INTRAVENOUS DOSING Term Neonates/Children up to 1 year: IV: 7.5 mg/kg/dose; infuse over 15 minutes; every 6 hours MAX: 30 mg/kg/day Children >1 year/ IV: mg/kg/dose; infuse over 15 minutes; every 4-6 hours MAX: 75 mg/kg/day Clonidine Infants/Children/ IV: 1-2 micrograms/kg/dose; x1 as a single intraoperative dose *NOTE: Not indicated in patient in whom minimal or no postoperative pain is expected, such as cleft lip repair with infraorbital block. **CAUTION: Clonidine acts synergistically with volatile anesthetics and with narcotics. Fentanyl *Fentanyl may be administered by any anesthesiologist in the OR. **Fentanyl may be administered in the PACU only if it is administered by the Anesthesia Team Leader. Infants/Children/ IV: micrograms/kg/dose; may repeat after 5-10 minutes *Generally cleft lip patients require no narcotics. **Cleft palates typically require NO MORE THAN 2 MICROGRAMS/KG TOTAL intra-operatively.

7 ANALGESICS (cont.) Ibuprofen PO: 10 mg/kg/dose; every 6 hours prn MAX: 40 mg/kg/day PO: mg/dose; every 6 hours prn Ketorolac *Avoid around-the-clock ketorolac for >24 hours due to the risk of GI bleeding. **Do not use in patients with renal impairment. Infants > 6 months/children: IV: 0.5 mg/kg/dose; every 6 hours for 24 hours IV: mg/dose; every 6 hours for 24 hours *CAUTION: Ketorolac should be avoided in patients having cleft palate repair due to possible increased risk of palatal hemorrhage. Metamizole (Used in Latin/Central America) *IV infusion must be administered hypotension. **IV administration is not recommended for children 1 year of age due to the greater potential for hypotension. Children/ IV/IM: mg/kg/dose single intraoperative dose; Subsequent IV/IM: 15 mg/kg/dose; every 8 hours MAX dose: 1 Gram PO: 15 mg/kg/dose; every 8 hours MAX dose: 1 Gram * Do not use in patients with renal impairment. Nalbuphine Children/ IV/SQ/IM: mg/kg/dose; every 6 hours prn MAX: 10 mg/dose ************************************** ***************************************************

8 SEDATIVES / INTRAVENOUS ANESTHETICS Diazepam *Note: Administer PO dose minutes prior to desired effect. **IM dosing not recommended risk for extravasation injury. IV: mg/kg/dose; titrate to effect (peak effect 3-5 minutes) PO: mg/kg/dose MAX: 10 mg IV: 2-10 mg/dose; titrate to effect (peak effect 3-5 minutes) PO: mg/kg/dose MAX: 1o mg Etomidate Infants/Children/ IV PUSH: mg/kg/dose *Repeat boluses or infusion of Etomidate are not recommended. Ketamine *Administer PO dose prior to desired effect. Infants/Children/ IV: mg/kg/dose; titrate to effect (peak effect 1-2 minutes) IM: mg/kg/dose PO: 4-7 mg/kg/dose Lorazepam Children: PO/IV: mg/kg/dose; every 4-6 hours prn PO/IV: mg/dose; every 4-6 hours prn Midazolam Children: IV: mg/kg/dose; titrate to effect; titrate to effect (peak effect 3-5 minutes) PO: 0.5 mg/kg/dose Intranasal: 0.25 mg/kg/dose IV: 1-2 mg/dose; may repeat after 5-10 minutes prn; titrate to effect (3-5 minutes)

9 SEDATIVES / INTRAVENOUS ANESTHETICS (cont.) Propofol Infants/Children/ IV Induction: 1-4 mg/kg/dose; titrate to effect (peak effect 1 minute) IV Maintenance: micrograms/kg/minute IV Sedation: micrograms/kg/minute ************************************* *********************************************************

10 LOCAL ANESTHETICS Bupivacaine Bupivacine w/ Epinephrine *When using local anesthetic with epinephrine, the maximum volume may be limited by the dose of epinephrine, which should be Infants/Children/ Peripheral Nerve Block and Infiltration: 1.2 ml/kg of 0.25% 0.6 ml/kg of 0.5% *Infiltrate volume as needed up to a MAX of 3 mg/kg (for example: 1.2 ml/kg of 0.25% or 0.6 ml/kg of 0.5%) **MAX may be repeated after 4 hours. Epinephrine 1:200,000 = 5 micrograms/ml Epinephrine 1:100,000 = 10 micrograms/ml Epinephrine 1:50,000 = 20 micrograms/ml Lidocaine Lidocaine w/ Epinephrine Lidocaine (1% and 2% Xylocaine) *When using local anesthetic with epinephrine, the maximum volume may be limited by the dose of epinephrine, which should be Epinephrine 1:200,000 = 5 micrograms/ml Epinephrine 1:100,000 = 10 micrograms/ml Epinephrine 1:50,000 = 20 micrograms/ml Infants/Children/ Peripheral Nerve Block and Infiltration: 0.7 ml/kg of 1% 0.35 ml/kg of 2% *Infiltrate volume as needed up to a MAX of 7 mg/kg (for example: 0.7 ml/kg of 1% or 0.35 ml/kg of 0.2%) **MAX may be repeated after 4 hours ************************************* *********************************************************

11 ANTICONVULSANTS Diazepam IV: mg/kg/dose; may repeat every 5 min as needed for continued status epilepticus MAX: 10 mg IV: 2-10 mg/dose; may repeat every 5 min as needed for continued status epilepticus Lorazepam *Caution: Respiratory arrest is common, especially if administration is greater than 2 mg/minute for adults OR mg/kg/minute for children. IV: mg/kg/dose; may repeat every 5 min as needed for continued status epilepticus MAX: 4 mg/dose IV: mg/dose; may repeat every 5 min as needed for continued status epilepticus Midazolam Infants/Children/ IV: mg/kg/dose; titrate to effect; may repeat every 5 min as needed for continued status epilepticus MAX: 5 mg/dose Phenytoin Infants/Children/ IV loading dose: mg/kg; slow IV infusion, flush with normal saline following administration *The rate of intravenous infusion should not exceed 50 mg/minute for adults or 2 mg/kg/minute for infants and children (MAX of 50 mg/minute). **Faster rates may cause hypotension and cardiac arrhythmia. ************************************ ****************************************************

12 ANTIEMETICS Dexamethasone *For doses of dexamethasone used to prevent and treat airway edema, see section on Steroids. Infants/Children/ IV : mg/kg (as single intraoperative dose) MAX: 4 mg/dose *Optimal timing as antiemetic prophylactic is immediately after induction. Ondansetron Infants/Children/ PO/IV: 0.1 mg/kg (as single intraoperative dose), and every 6 hours prn MAX: 4 mg/dose *Optimal timing as antiemetic prophylactic is min prior to end of case. Promethazine *DO NOT split suppositories. Children: PO: mg/kg/dose; every 6 hours prn PR: mg/kg/dose; every 6 hours prn IV: 0.1 mg/kg/dose; every 6 hours prn PR: mg/dose; every 4 hours prn IV: mg/dose; every 4 hours *Do NOT use in children <2 years old. ************************************ ******************************************************

13 ANTIFIBRINOLYTICS Epsilon Amino Caprice Acid *Caution: Antifibrinolytic agents have not been proven to be effective for prophylaxis or management for post cleft palate repair hemorrhage. **Please restrict usage to patients with substantial intraoperative bleeding and no apparent surgical solution. Infants/Children/ IV initial bolus: mg/kg; slow infusion over minutes; followed if needed by mg/kg; every 4-6 hours. **Note: Decrease dose in patients with renal impairment ** Dilute to 20 mg/ml using Normal Saline, Lactated minutes to avoid hypotension, bradycardia, and dysrhythmia. Tranexamic Acid *Caution: Antifibrinolytic agents have not been proven to be effective for prophylaxis or management for post cleft palate repair hemorrhage. **Please restrict usage to patients with substantial intraoperative bleeding and no apparent surgical solution. Infants/Children/ IV initial bolus: mg/kg; slow infusion over minutes; followed if needed by mg/kg every 6-8 hours. PO: 10mg/kg; every 6-8 hours MAX PO: 1300 mg/dose *Note: Decrease dose in patients with renal impairment. ************************************* *********************************************************

14 ANTIMICROBIALS Amoxicillin Children/Infants: PO: mg/kg/day; divided every 8-12 hours PO: mg/dose; every 8 hours MAX: 2-3 grams/day Azithromycin PO: 10 mg/kg/dose (MAX 500 mg) x 1, then 5 mg/kg/dose daily x 4 days (MAX 250 mg) PO: 500 mg/dose x 1, then 250 mg/dose daily x 4 days Cefazolin INTRAOPERATIVE WOUND INFECTION PROPHYLAXIS Children/Infants: IV: 25 mg/kg/dose IV: 1-2 grams/dose *Ideal timing for dose is minutes prior to incision when possible TREATMENT FOR INFECTION IV: mg/kg/day; every 8 hours MAX: 2 grams/dose IV: grams/dose; every 6-8 hours Cefotaxime Infants/Children 12 years: IV/IM: 50 mg/kg/dose; every 8 hours MAX: 2 grams/dose Children > 12 years/ IV/IM: 1-2 grams/dose; every 8 hours

15 ANTIMICROBIALS (cont.) Ceftriaxone Infants/Children 12 years: IV/IM: 50 mg/kg/dose; every 24 hours; every 12 hours for treatment of meningitis. MAX: 2 grams/day Children > 12 years/ IV/IM: 1-2 grams/dose; every 24 hours; every 12 hours for treatment of meningitis. MAX: 2 grams Cephalexin PO: mg/kg/day; divided every 6 hours MAX: 500 mg/dose PO: mg/dose; every 6 hours Ciprofloxacin PO: mg/kg/day; divided every 12 hours MAX: 1.5 grams/day PO: mg/dose; every 12 hours **************************************** ****************************************************

16 ANTIPRURITICS/ANTIHISTAMINES Diphenhydramine Children: PO/IV: mg/kg/dose; every 6 hours prn MAX: 50 mg/dose IV: mg/dose; every 4-6 hours prn ********************************** *******************************************************

17 ANTIPYRETICS Acetaminophen (Paracetamol) *For PR doses in children, doses lower than 25 mg/kg fail to produce therapeutic levels. Repeat doses of mg/kg must be given AT LEAST 8 hours apart. **DO NOT split suppositories. ORAL/RECTAL DOSING Infant/Children: PO: mg/kg/dose; every 4-6 hours prn PR: mg/kg/dose; every 8 hours prn MAX: 90mg/kg/day Children >12 years/ (if > 50 kg, otherwise use per kg doing above) PO: mg/dose; every 4-6 hours prn PR: 1300 mg/dose; every 4-6 hours prn MAX: 4 grams/day INTRAVENOUS DOSING Term Neonates/Children up to 1 year: IV: 7.5 mg/kg/dose; infuse over 15 minutes; every 4-6 hours MAX: 30 mg/kg/day Children > 1 year/ IV: mg/kg/dose; infuse over 15 minutes; every 4-6 hours MAX: 75 mg/kg/day Ibuprofen PO: 10 mg/kg/dose; every 6 hours prn MAX: 40 mg/kg/day PO: mg/dose; every 6 hours prn Metamizole (Used in Lain/South America) *Metamizole can be used together with Acetaminophen. ** Do not use in patients with renal impairment. Children/ IV/IM/PO: 15 mg/kg/day; divided into 3 or 4 doses MAX dose: 1 Gram to avoid hypotension. **IV administration is not recommended for children 1 year of age due to the greater potential for hypotension. ************************************ *******************************************************

18 CARDIOVASCULAR Dopamine Infants/Children/ Infusion: 1-20 micrograms/kg/minute Ephedrine Children >1 year: IV 0.2 mg/kg/dose; titrate to effect IV/IM 5-10 mg/dose; titrate to effect Esmolol *CAUTION: Do NOT administer a beta blocker to infants or children who manifest hypertension due to phenylephrine or other alpha blockade because this is known to produce CARDIAC ARREST. Infants/Children/ IVP: micrograms/kg; may be repeated every 5-10 minutes as needed Infusion: micrograms/kg/minute Labetalol *CAUTION: Do NOT administer a beta blocker to infants or children who manifest hypertension due to phenylephrine or other alpha blockade because this is known to produce CARDIAC ARREST. Children: IV: mg/kg/dose; may repeat every 5-10 minutes as needed MAX: 10mg IV: 5-10 mg/dose; may repeat every 5-10 minutes as needed Phenylephrine Children: IV: 1-5 micrograms/kg; as needed to maintain blood pressure IV: mg; as needed to maintain blood pressure INFUSION: micrograms/minute; titrate to effect ************************************* *********************************************************

19 DIURETICS Furosemide IV/IM: mg/kg/dose; every 6-24 hours IV/IM: 20-80mg/dose; every 6-24 hours ************************************ *******************************************************

20 NEUROMUSCULAR BLOCKERS Rocuronium Children/ IV: mg/kg/dose *Monitor neuromuscular block and the need for administration of reversal agent (see dosing of neostigmine under TOXICOLOGY/REVERSAL AGENTS. Succinylcholine (Suxamethonium) *Succinylcholine should never be used for maintenance in a mission setting as this can lead to a phase 2 block. TRACHEAL INTUBATION IM/IV: 1-2 mg/kg/dose IV: mg/kg/dose; x1 TREATMENT FOR LARYNGOSPASM IV: mg/kg/dose IM: 3-5 mg/kg/dose IV: mg/dose IM: 3-5 mg/kg/dose ************************************** **********************************************************

21 POST-EXPOSURE PROPHYLAXIS Combivir (Iamivudine/Zidovudine) PO: 1 tablet (150mg/300mg); twice a day *This will be replaced by Raltegravir and Truvada see below. Viracept (Nelfinavir) PO: 750 mg; 3 times/day; or 1250 mg/dose; twice a day *This will be replaced by Raltegravir and Truvada see below. Raltegravir - CURRENT (Isentress RAL) PO: 1 tablet (400 mg); twice a day; x 4 weeks for post-exposure Truvada - CURRENT (Emtricitabine/Tenofovir) PO: 1 tablet; every day; x 4 weeks for post-exposure ************************************* **********************************************************

22 RESPIRATORY / ASTHMA Albuterol (salbutamol) Solution for nebulization *Subsequent doses of albuterol and infusing rate should be based on clinical response and may need to be reduced if causing excessive tachycardia. **Single dose of mg may be nebulized preoperatively as prophylaxis to adults/children/infants who have a history of asthma or an upper respiratory infection. Infants/Children 1-12 years: Severe Acute Bronchospasm: mg/kg/dose; every 20 minutes as needed MAX 2.5 mg/dose Ongoing Bronchospasm: mg/kg/dose; every 1-4 hours or continuously at 0.5 mg/kg/hour MAX: 15 mg/hour continuous Severe Acute Bronchospasm: 2.5 mg (0.5 ml of 5% solution); every 20 minutes as needed Ongoing Bronchospasm: 2.5 mg (0.5 ml of 5% solution); every 1-4 hours or continuously at mg/hour *Continuous monitoring and regular checks for hyperglycemia and hypokalemia, indicated if giving continuous albuterol. Albuterol (salbutamol) Metered Dose Inhaler *Repeat as needed every 5-10 minute, monitoring for excessive tachycardia. Infants/Children/ 2 puffs for preoperative prophylaxis of bronchospasm 2-6 puffs for management of intraoperative bronchospasm Racemic Epinephrine 2.25 % (for nebulization) *Note: If racemic epinephrine is unavailable, standard epinephrine (L-epi) 1: mg/ml may be substituted at a dose of 2-3 ml undiluted. Inhalation: Infants <10 kg: 0.25 ml in 2.5 ml saline Children/ 0.5 ml in 2.5 ml saline Terbutaline Children/ IV bolus 10 micrograms/kg Infusion: 0.2 micrograms/kg/minute - titrate up by 0.1 microgram/kg/minute every 30 minutes to 2 micrograms/kg/min ************************************* ********************************************************

23 RESUSCITATION Adenosine *Must administer by rapid bolus. **PALS indication for treatment of supraventricular tachycardia. Infants/Children/Adults < 50 kg: IV/IO: 0.1 mg/kg/dose MAX: 6 mg/dose If not effective within 1-2 minutes, repeat rapid bolus of 0.2 mg/kg/dose (x 2 doses prn) MAX: 12 mg/dose Adults > 50 kg: IV/IO: 6 mg; if not effective within 1-2 minutes, repeat rapid bolus at dose of 12mg (x 2 doses prn) Atropine Children: IV/IO: 0.02 mg/kg; repeat every 3-5 minutes as needed MAX IV: 1 mg / MIN IV: 0.1 mg IM/ETT: 0.04 mg/kg; repeat every 3-5 minutes as needed IV/IO: mg/dose; repeat every 3-5 minutes as needed IM/ETT: times the IV dose; diluted in 5-10 ml NS Calcium Chloride 10% solution *Not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia. IV: mg/kg/dose; administer slowly; may repeat in 10 minutes MAX: 1 gram/dose IV: mg/dose; over 5-10 minutes; may repeat as necessary *Preferred over Ca Gluconate in emergency **Administer by central venous access when possible; administration by peripheral IV okay in emergency situation Calcium Gluconate *Not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia. Infants and Children: IV/IO: 60 to 100 mg/kg/dose; may repeat in 10 minutes if necessary; if effective, consider IV infusion MAX: 3 grams/dose *Dosage expressed in mg of calcium gluconate IV: grams/dose; over 2-5 minutes

24 RESUSCITATION(cont.) Dextrose 50% Infants/Children/ IV/IO: gram/kg/dose *NOTE: gm/kg = 1-2 ml/kg of D50W = 2-4 ml/kg of D25W = 5-10 ml/kg of D10W **Concentrations of dextrose higher than D12.5W require administration by central IV access Epinephrine 1:10,000 (IV/IO) 1:1000 (ET) Children: IV/IO: 0.01 mg/kg/dose; every 3-5 minutes 1:10,000 ETT: 0.1 mg/kg/dose; every 3-5 minutes 1:1000 (if total volume less than 2 ml, dilute with normal saline to 2 ml ) IV/IO: 0.o1 mg/kg/dose; every 3-5 minutes 1:10,000 ETT: 0.1 mg/kg/dose; every 3-5 minutes 1:1000 Flumazenil *Caution: Duration of effect minutes; respiratory arrest may reoccur after flumazenil effect wanes. BENZODIAZEPINE REVERSAL Children: IV: Initial dose: 0.01 mg/kg; over 15 seconds MAX: 0.2mg IF after 45 seconds no response, repeat 0.01 mg/kg at 1 minute intervals, up to a total of 0.05 mg/kg or 1 mg, whichever is lower IV: 0.2 mg; over 15 seconds MAX in 1 hour: 3 mg IF after 45 seconds no response, repeat 0.2 mg at 1 minute intervals, up to a total of 1 mg (5 doses) Lidocaine Children: IV/IO: 1.0 mg/kg bolus IV/IO: 1.0 mg/kg bolus Sodium Bicarbonate 8.4% Infants/Children/ IV PUSH: meq/kg

25 RESUSCITATION(cont.) Vasopressin Treating: Asystole, VTach / VFib IV: 0.4 units/kg; after traditional resuscitation methods and at least two doses of epinephrine have been administered **Note: Due to insufficient evidence, no formal recommendations for or against the routine use of vasopressin during pediatric cardiac arrest are provided Adults > 40kg: Treating: VTach / VFib IV: 40 units once; followed by 20 ml of normal saline. *If spontaneous circulation is not restored within 3 minutes, another 40 units may be given intravenously. If spontaneous circulation is still not restored, 1 mg of epinephrine maybe given intravenously. All doses should be followed with 20 ml of normal saline Verapamil *PALS indication for treatment of supraventricular tachycardia Children 1-16 years: IV: mg/kg administer 2 nd dose after 30 minutes, if needed MAX: 10 mg/dose; 20 mg TOTAL IV: mg/dose; 2 nd dose after 30 minutes, if needed MAX: 10 mg/dose; 20 mg TOTAL ******************************** **************************************************

26 STEROIDS Dexamethasone IV: mg/kg/dose; every 6 hours as needed MAX: 15 mg/dose IV: 5-15 mg/dose; every 6-12 hours as needed Methylprednisolone Infants/Children/ IV: 1-2 mg/kg initial bolus; followed by 1-2 mg/kg/day; divided every 6 hours Prednisone Children <12 years: PO: 1-2 mg/kg/day; divided every hours MAX: 60 mg/day PO: mg/day; divided 1-4 times a day ************************************** **********************************************************

27 TOPICALS Eye ointment (Lacri-lube) Apply to eyes as needed Benzocaine Spray 3-5 puffs to posterior pharynx *CAUTION: Excessive use can cause methemoglobinemia Lidocaine 2% Jelly Children: 3 ml/10 kg to area MAX: 4 doses/24 hours Apply 5-20 ml to area MAX: 4 doses/ 24 hours Silver Sulfadiazine cream Apply 1-2 times daily to burned areas *Do NOT use in children < 2 months Triple Antibiotic ointment Apply 1-3 times/day to affected area ************************************** **********************************************************

28 TOXICOLOGY / REVERSAL AGENTS Dextrose 50%/Insulin *NOTE: gm/kg dextrose = 1-2 ml/kg of D50W = 2-4 ml/kg of D25W = 5-10 ml/kg of D10W **Concentrations of dextrose higher than D12.5W require administration by central IV access ACUTE SEVERE HYPERKALEMIA TREATMENT Hyperkalemia: grams/kg of dextrose followed by 1 unit regular insulin/5 grams dextrose, both given as IV bolus; check potassium and glucose levels minutes after Rx and repeat dextrose/insulin as needed Hyperkalemia: 50 grams of dextrose followed by 10 units of regular insulin, both given as IV bolus; check potassium and glucose levels minutes after treatment and repeat dextrose/insulin as needed Flumazenil *Caution: Duration of effect minutes; respiratory arrest may reoccur after flumazenil effect wanes. BENZODIAZEPINE REVERSAL Children: IV: Initial dose: 0.01 mg/kg; over 15 seconds MAX: 0.2mg IF after 45 seconds no response, repeat 0.01 mg/kg at 1 minute intervals, up to a total of 0.05 mg/kg or 1 mg, whichever is lower IV: 0.2 mg; over 15 seconds MAX in 1 hour: 3 mg IF after 45 seconds no response, repeat 0.2 mg at 1 minute intervals, up to a total of 1 mg (5 doses) Naloxone INTRAOPERATIVE REVERSL OF REPISRATORY DEPRESSION IV: micrograms/kg; may repeat every 2-3 minutes as needed IV: micrograms; may repeat every 2-3 minutes as needed RAPID, FULL REVERSAL OF NARCOTIC OVERDOSE Infants/Children/ IV: 0.1 mg/kg/dose, may repeat every 2-3 min PRN; MAX: 2 mg/dose

29 TOXICOLOGY / REVERSAL AGENTS (cont.) Neostigmine *Neostigmine must be given simultaneously with glycopyrrolate at a recommended dose of 1 microgram of glycopyrrolate for each microgram of neostigmine (1:5 ratio) IV: 1-5 mg; dose depends on degree of neuromuscular block MAX: Should not exceed total dose of 5 mg IV: mg/kg; dose depends on degree of neuromuscular block MAX: 5 mg or 0.08 mg/kg, whichever is lower ************************************* *********************************************************

30 MISCELLANEOUS Dantrolene *Dantrolene must be dissolved in sterile water; 60 ml of sterile water per 20 mg of Dantrolene *Regarding overall management of a case of MH, consider consulting or calling the MHAUS Hotline ( ) for additional advice. Outside the US, please call ( ) Children/ IV rapid bolus: 2.5 mg/kg/dose; repeat doses of 1 mg/kg every minutes; should be given prn until reversal of acute signs of Malignant Hyperthermia Maintenance: 1 mg/kg IV q4-6hr OR 0.25 mg/kg/hour IV infusion; continue for at least 24 hours Cumulative doses >10 mg/kg; may be required for patients with persistent contractures, HOWEVER an alternative diagnosis should be considered when 10 mg/kg fails to produce symptom resolution. Glycopyrrolate Children/ IV Preoperative Antisialagogue: 4 micrograms/kg/dose; repeat x1 as needed Hetastarch 6% Children: IV: 10 ml/kg/dose MAX: 20 ml/kg/day IV: ml (30-60 grams)/dose MAX 1500 ml/day Loperamide Children 6-11: PO: 1 tablet after first loose stool then 1 tablet as needed MAX: 3 tablets/day for 11-9 years MAX: 3 tablets/day for 6-8 years Adults > 12 years: PO: 2 tablets after first loose stool, then 1 tablet as needed MAX: 4 tablets/day Mannitol 25% *Indicated for treatment of intracranial hypertension. Children/ IV: grams/kg/dose; may repeat every 4-6 hours as needed

31 MISCELLANEOUS (cont.) Methylene Blue Used for topical markings for procedure Nitroglycerin tablets SL: 0.4 mg/dose; every 5 minutes MAX: 3 doses in 15 minutes Simethicone Infants/Children<2 years: PO: 20 mg; 4 times/day; prn MAX dose: 240 mg/24 hours Children 2-12 years: PO: 40 mg; 4 times/day; prn Children >12 years/ PO: mg before meals and at bedtime; prn MAX dose: 500 mg/24 hours ************************************* *********************************************************

32 REGION / COUNTRY SPECIFIC Central/South America Metamizole *Can be used together with Acetaminophen See ANALGESICS and ANTIPYRETICS Philippines India China *Adenosine Triphosphate to replace Adenosine See CARDIAC and RESUSCITATION Morocco

33 REGION / COUNTRY SPECIFIC (cont.) South Africa Paracetamol *Same name for Acetaminophen SEE ANALGESICS and ANTIPYRETICS Adrenaline *Same name for Epinephrine See CARDIOVASCULAR and RESUSCITATION Vietnam

34 References Engorn/Flerlage. The Harriet Lane Handbook. Twentieth Edition. Saunders American Pharmacists Association. Drug Information Handbook. 21 st Edition. Lexicomp Wiley, Katherine. Drugs and Classification. F.A. Davis Company

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