Neemsi Paramedic Pharmacology

Front 1

What is the functional class of oxygen?

Back 1

Oxidizer

Hint 1

Other oxidizing agents include ozone, chlorine, nitric acid, hydrogen peroxide and household bleach (NaClO).

Front 2

By what mechanism does oxygen act?

Back 2

A colorless, odorless, tasteless gas necessary for the breakdown of glucose into a usable energy form.

Hint 2

Gaseous oxygen is actually a very pale blue

Front 3

What are the indications for oxygen?

Back 3

Presence or suspicion of hypoxemia.

Hint 3

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.

Front 4

What are the listed contraindications for oxygen?

Back 4

None.

Hint 4

Never withhold oxygen from a patient for whom it is indicated.

Front 5

What are the listed precautions for oxygen?

Back 5

- Use cautiously with COPD patients
- Monitor long-term high concentrations in neonate as retrolental fibroplasia may develop
- Open flame

Hint 5

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.

Front 6

What is the dosage for oxygen?

Back 6

25-100%

Hint 6

High-flow oxygen systems include venturi masks, air-entrainment nebulizers and high-flow blender systems.

Front 7

What is the route for oxygen?

Back 7

BLS and/or ALS airway adjuncts as appropriate.

Hint 7

Or no adjunct, if indicated... (e.g. nasal cannula)

Front 8

What is the relationship between liters per minute of oxygen and oxygen concentration?

Back 8

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%

Hint 8

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%).

Front 9

What is the best-known trade name for diazepam?

Back 9

Valium

Hint 9

There are hundreds of trade names for diazepam around the world. In the US, Valium, Diastat and Valrelease are the most common.

Front 10

What is the functional class of diazepam?

Back 10

Benzodiazepine

Hint 10

Other prehospital benzodiazepines are lorazepam (Ativan) and midazolam (Versed).

Front 11

What is the mechanism of action of diazepam?

Back 11

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.

Hint 11

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.

Front 12

What are the listed indications for diazepam?

Back 12

- Seizures (status epilepticus)
- To induce sedation prior to painful procedures
- Acute anxiety

Hint 12

California offers diazepam to condemned inmates as a pre-execution sedative...

Front 13

What are the listed contraindications for diazepam?

Back 13

- Known hypersensitivity
- Shock
- Coma
- Acute alcohol intoxication

Hint 13

Contraindications not in the NEEMSI documentation include pregnancy, breastfeeding, sleep apnea and porphyria.

Front 14

What are the listed precautions for diazepam?

Back 14

- 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.

Hint 14

Myasthenia gravis (MG) is a disorder characterized by muscle weakness caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction.

Front 15

What are the listed side effects of diazepam?

Back 15

- Hypotension
- Drowsiness
- Tachycardia
- Ataxia
- Amnesia
- Slurred speech
- Edema
- Headache
- Dizziness
- N/V
- Blurred vision
- Respiratory depression

Hint 15

Ataxia (for the Greek for "lack of order") is a loss of muscle coordination that can affect balance, movement and speech.

Front 16

What are the listed interactions of diazepam?

Back 16

- Effects are enhanced when used in conjunction with other CNS depressants and alcohol
- Cimetidine (Tagamet) may increase diazepam plasma levels

Hint 16

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.

Front 17

What is the dosage and route of diazepam?

Back 17

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

Hint 17

Diazepam (unlike lorazepam and midazolam) may not be administered IM.

Front 18

What are the pharmacokinetics of diazepam?

Back 18

Onset: 1 - 5 minutes IV
Half-life: 20 - 50 hours

Hint 18

Diazepam has the longest half-life of the prehospital benzodiazepines.

Front 19

What medication is an antagonist to diazepam?

Back 19

Flumazenil

Hint 19

Flumazenil has trade names including Anexate, Lanexat, Mazicon & Romazicon.

Front 20

What is the best-known trade name for lorazepam?

Back 20

Ativan

Hint 20

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.

Front 21

What is the functional class of lorazepam?

Back 21

Benzodiazepine

Hint 21

The first benzodiazepine, chlordiazepoxide (Librium), was discovered in 1955 and first marketed in 1960.

Front 22

What is the mechanism of action of lorazepam?

Back 22

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.

Hint 22

1mg of lorazepam is equivalent to 10mg diazepam.

Front 23

What are the listed indications for lorazepam?

Back 23

- Seizures (status epilepticus)
- To induce sedation prior to painful procedures
- Acute anxiety

Hint 23

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.

Front 24

What are the listed contraindications for lorazepam?

Back 24

- Hypersensivity to benzodiazepines
- Acute narrow-angle glaucoma
- Coma
- Shock
- Acute alcohol intoxication

Hint 24

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).

Front 25

What are the listed precautions for lorazepam?

Back 25

- Renal or hepatic impairment
- Myasthenia gravis
- COPD

Hint 25

Lorazepam may be safer than most benzodiazepines in patients with impaired liver function as it does not require hepatic oxidation, but only hepatic glucuronidation.

Front 26

What are the listed side effects for lorazepam?

Back 26

- Anterograde amnesia
- Sedation
- Hypertension
- Hypotension
- Blurred vision
- N/V
- Confusion

Hint 26

Anterograde amnesia is a loss of the ability to create new memories after the event that caused the amnesia.

Front 27

What are the listed interactions for lorazepam?

Back 27

Effects of lorazepam will be increased when used in conjunction with other CNS depressants, alcohol, or cimetidine.

Hint 27

Other CNS depressants include barbiturates, opioids, disassociatives and antipsychotics.

Front 28

What is the dosage and route of lorazepam?

Back 28

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

Front 29

What are the pharmacokinetics of lorazepam?

Back 29

Onset: 1 - 5 minutes IV, 5 - 10 minutes IM
Peak: 15-20 minutes
Half-Life: 10 - 20hrs

Hint 29

Despite its higher potency, the half-life of lorazepam is much shorter than that of diazepam.

Front 30

What medication is an antagonist to lorazepam?

Back 30

Flumazenil

Hint 30

Flumazenil reverses the effects of benzodiazepines by competitive inhibition at the benzodiazepine binding site on the GABA receptor.

Front 31

What is the best-known trade name for midazolam?

Back 31

Versed

Hint 31

Other trade names include Dormicum and Hypnovel.

Front 32

What is the functional class of midazolam?

Back 32

Benzodiazepine

Hint 32

There are about 35 benzodiazepines that have been formulated and are used medically, several are not approved for use in the US.

Front 33

What is the mechanism of action of midazolam?

Back 33

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.

Hint 33

An amnestic is a drug that induces amnesia.

Front 34

What are the listed indications for midazolam?

Back 34

- Seizures (status epilepticus)
- To induce sedation prior to painful procedures

Hint 34

Unlike diazepam and lorazepam, midazolam is not indicated for acute anxiety.

Front 35

What are the listed contraindications for midazolam?

Back 35

- Hypersensivity to benzodiazepines
- Acute narrow-angle glaucoma
- Coma
- Shock
- Acute alcohol intoxication

Hint 35

These are the same as the contraindications for lorazepam.

Front 36

What are the listed precautions for midazolam?

Back 36

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

Hint 36

Many sources include hypotension as a precaution or relative contraindication.

Front 37

What are the listed side effects of midazolam?

Back 37

- N/V
- Burred vision
- Retrograde amnesia
- Excessive amnesia
- Apnea
- Hypotension
- PVCs

Hint 37

PVCs (premature ventricular contractions/complexes) occur when the heartbeat is initiated by the heart ventricles rather than by the sinoatrial node.

Front 38

What are the listed interactions of midazolam?

Back 38

- Prolonged respiratory depression when given in conjunction with other CNS depressants such as alcohol
- Cimetidine (Tagamet) increases plasma levels of midazolam.

Hint 38

The interactions of all three prehospital benzodiazepines are very similar.

Front 39

What is the dosage and route of midazolam?

Back 39

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.

Hint 39

There is evidence that buccal and intranasal midazolam are easier to administer and more effective than rectally administered diazepam for the control of seizures.

Front 40

What are the pharmacokinetics of midazolam?

Back 40

Onset: 1-3 minutes
Duration: 15-20 minutes up to 2 hours, occasionally 6 hours
Half-Life: 1 - 4 hours

Hint 40

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.

Front 41

What medication is an antagonist to midazolam?

Back 41

Flumazenil

Hint 41

Flumazenil has also been found to be effective in overdoses of non-benzodiazepine sleep enhancers, such as zolpidem (Ambien) and zaleplon (Sonata).

Front 42

What is the best-known trade name for succinylcholine?

Back 42

Anectine

Hint 42

Suxamethonium chloride, also known as suxamethonium or succinylcholine, is also sold under the trade names Quelicin and Scoline.

Front 43

What is the functional class of succinylcholine?

Back 43

Depolarizing neuromuscular blocker

Hint 43

The only other depolarizing neuromuscular blocker used in medicine -- and very rarely -- is decamethonium (Syncurine).

Front 44

What is the mechanism of action of succinylcholine?

Back 44

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.

Hint 44

Succinylcholine was originally known as diacetylcholine because of its structure.

Front 45

What are the listed indications for succinylcholine?

Back 45

To facilitate endotracheal intubation;
terminate laryngeal spasm;
promote muscle relaxation

Hint 45

Neuromuscular blocks are also in surgery, especially during intra-abdominal and intra-thoracic surgeries, to allow them to be conducted with fewer complications.

Front 46

What are the listed contraindications for succinylcholine?

Back 46

- 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

Hint 46

ALS is amyotrophic lateral sclerosis, also referred to as Lou Gehrig's disease

Front 47

What are the listed precautions for succinylcholine?

Back 47

Never paralyze without adequate sedation.

Hint 47

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".

Front 48

What are the listed side effects for succinylcholine?

Back 48

- Apnea
- Malignant hyperthermia
- Dysrhythmias
- Bradycardia
- Tachycardia
- Hypertension
- Hypotension
- Cardiac arrest
- Increased intraocular pressure
- Fasciculations
- Exacerbation of hyperkalemia in trauma
patients

Hint 48

Fasciculations are muscle twitches: small, local, involuntary muscle contractions and relaxations visible under the skin.

Front 49

What are the listed interactions for succinylcholine?

Back 49

- Effects potentiated by oxytocin, beta-blockers, and organophosphates
- Diazepam may reduce duration of action

Hint 49

Organophosphates include many pesticides and nerve agents.

Front 50

What is the dosage and route of succinylcholine?

Back 50

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

Hint 50

Succinylcholine has occasionally been used as a paralyzing agent for executions and as a means of murder and assassination.

Front 51

What are the pharmacokinetics of succinylcholine?

Back 51

Onset: 1 minute
Peak effect: 1 - 3 minutes
Duration: 5 minutes

Hint 51

Non-depolarizing blockers (e.g vecuronium, rocuronium) have a much longer duration but can be reversed.

Front 52

What is the best-known trade name for epinephrine?

Back 52

Adrenalin

Hint 52

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".

Front 53

What is the functional class of epinephrine?

Back 53

Sympathomimetic

Hint 53

In the human body, the most abundant catecholamines (which all have sympathomimetic effects) are epinephrine, norepinephrine and dopamine.

Front 54

What is the mechanism of action of epinephrine?

Back 54

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.

Hint 54

- Inotropic - increased contractility
- Dromotropic - increased conduction velocity
- Chronotropic - increased rate

Front 55

What are the listed indications for epinephrine?

Back 55

- Cardiac arrest: asystole, VF, pulseless VT, PEA
- Symptomatic bradycardia
- Anaphylaxis
- Severe reactive airway disease

Hint 55

Epinephrine is also used as a local vasoconstrictor in local anesthetics and in ointments to stop bleeding in contact sports such as boxing.

Front 56

What are the listed contraindications for epinephrine?

Back 56

Hypersensitivity to sympathomimetic amines

Hint 56

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.

Front 57

What are the listed precautions for epinephrine?

Back 57

- 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

Hint 57

Furosemide (Lasix) can also block the effects of epinephrine.

Front 58

What are the listed side effects for epinephrine?

Back 58

- Increases myocardial oxygen demand
- Can cause palpitations, anxiety, headache, CVA, syncope, HTN, tachydysrhythmias
- Tissue necrosis with repeated injections or extravasation of IV

Hint 58

Some sources add acute pulmonary edema as a side effect of epinephrine.

Front 59

What are the listed interactions for epinephrine?

Back 59

- May increase hypotension caused by phenothiazines, alpha and beta blockers
- Can be deactivated in alkaline solutions or sodium bicarbonate

Hint 59

Tricyclic antidepressants can potentiate epinephrine by inhibition of norepinephrine reuptake.

Front 60

What is the dosage and route of epinephrine for cardiac arrest?

Back 60

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

Front 61

What is the dosage and route of epinephrine for severe anaphylaxis/asthma?

Back 61

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.

Front 62

What is the dosage and route of epinephrine for symptomatic bradycardia (as an infusion)?

Back 62

Preparation: 1 mg of 1:1,000 in 500mL NS

Adult:
- 2 - 10mcg/min

Hint 62

This is high-dose epinephrine as it is being diluted for infusion.

Front 63

What are the pharmacokinetics of epinephrine?

Back 63

None listed.

Hint 63

One source states:

Onset: 5 - 10 min SQ, 1 - 2 min IV
Duration: 5 - 10 min

Front 64

What is the best-known trade name for vasopressin?

Back 64

Pitressin

Hint 64

Vasopressin is also known as argipressin, arginine vasopressin (AVP) and antidiuretic hormone (ADH).

Front 65

What is the functional class of vasopressin?

Back 65

Hormone (ADH), vasopressor

Hint 65

Vasopressin is mainly produced in the paraventricular nucleus (PVN) and supraoptic nucleus (SON) of the hypothalamus. It is very similar in structure to oxytocin.

Front 66

What is the mechanism of action of vasopressin?

Back 66

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.

Hint 66

Vasopressin has also been identified in memory formation and the regulation of social bonding and behavior.

Front 67

What are the listed indications for vasopressin?

Back 67

Cardiac arrest

Hint 67

Vasopressin is also used in the hospital treatment of septic shock.

Front 68

What are the listed contraindications for vasopressin?

Back 68

- Chronic nephritis
- Ischemic heart disease
- PVCs
- First stage of labor

Hint 68

And, of course, known hypersensitivity.

Front 69

What are the listed precautions for vasopressin?

Back 69

Use with caution in patients with:
- Epilepsy
- Migraine
- Asthma
- Heart failure
- Angina pectoris

Hint 69

Some sources also list renal insufficiency as a precaution.

Front 70

What are the listed side effects for vasopressin?

Back 70

- N/V
- Abdominal cramps
- HTN
- Bradycardia
- PACs
- MI

Hint 70

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.

Front 71

What are the listed interactions for vasopressin?

Back 71

- Epinephrine
- Heparin
- Alcohol
- Phenytoin
- Thiazide diuretics
- Carbamazepine
- Neostigmine

Hint 71

May decrease antidiuretic effects:
- Epinephrine
- Heparin
- Alcohol
- Phenytoin

May increase antidiuretic effects:
- Thiazide diuretics
- Carbamazepine

May increase vasoconstriction:
- Neostigmine

Front 72

What is the dosage and route of vasopressin?

Back 72

40 units IVP/IO (single dose only)

Hint 72

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.

Front 73

When should vasopressin be used in a cardiac arrest situation?

Back 73

May replace first or second dose of epinephrine in cardiac arrest.

Hint 73

This is for adult arrest only (AHA).

Front 74

What is the best-known trade name for atropine?

Back 74

None.

Hint 74

Atropine derives its name from Atropos, one of the three Fates who, according to Greek mythology, chose how a person was to die.

Front 75

What is the functional class of atropine?

Back 75

Parasympatholytic

Hint 75

Atropine is one of only two prehospital parasympatholytics - the other is Atrovent (ipratropium bromide).

Front 76

What is the mechanism of action of atropine?

Back 76

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.

Hint 76

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.

Front 77

What are the listed indications for atropine?

Back 77

- Symptomatic bradycardia

- Organophosphate/nerve agent poisoning

Hint 77

Atropine has many opthalmic uses including as a cyclopegic and mydriatic.

Front 78

What are the listed contraindications for atropine?

Back 78

None in the emergency setting.

Hint 78

In non-emergency situations, atropine is contraindicated in patients pre-disposed to narrow angle glaucoma.

Front 79

What are the listed precautions for atropine?

Back 79

- 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.

Hint 79

Atropine increases oxygen demand of the AV nodal tissue, thereby aggravating ischemia and any resulting heart block.

Front 80

What are the listed side effects for atropine?

Back 80

- Blurred vision
- Dilated pupils
- Dry mouth
- Tachycardia
- Drowsiness
- Convulsions
- HTN or hypotension
- Palpitations
- Paradoxical bradycardia (if given too slowly)
- AV dissociation
- Urinary retention

Hint 80

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".

Front 81

What are the listed interactions for atropine?

Back 81

Antihistamines, tricyclic antidepressants & procainamide can lead to the anticholinergic effects of atropine.

Hint 81

Procainamide is a cardiac medication and used to treat supraventricular and ventricular arrhythmias.

Front 82

What is the dosage and route of atropine in asystole/bradycardic PEA?

Back 82

It is no longer recommended for this (as of October 2010)

Front 83

What is the dosage and route of atropine in symptomatic bradycardia?

Back 83

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

Front 84

What is the dosage and route of atropine in organophosphate poisoning?

Back 84

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

Hint 84

Atropine is included in the US military's Mark 1 NAAK ("Nerve Agent Antidote Kit") and ATNAA ("Antidote Treatment Nerve Agent Auto-Injector").

Front 85

What are the pharmacokinetics of atropine?

Back 85

Onset: 1-5 minutes
Duration 20-50 minutes

Hint 85

As a therapeutic mydriatic, atropine's effects can last for 1-2 weeks.

Front 86

What is the best-known trade name for lidocaine?

Back 86

Xylocaine

Hint 86

Lidocaine was first marketed in 1949, it has also been called "lignocaine".

Front 87

What is the functional class of lidocaine?

Back 87

Class Ib antidysrhythmic (sodium channel blocker); decreases automaticity by slowing rate of spontaneous phase 4 depolarization.

Hint 87

Other Ib antidysrhythmics include phenytoin (Dilantin) and mexiletine (Mexitil).

Front 88

What is the mechanism of action of lidocaine?

Back 88

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.

Hint 88

Lidocaine blocks the fast voltage gated sodium (Na⁺) channels.

Front 89

What are the listed indications for lidocaine?

Back 89

suppression of ventricular dysrrhythmias;
prophyllaxis of recuurance after conversion of V-tach;
conscious IO infusions;
facilitating RSI

Hint 89

Lidocaine also has significant use as a local anesthetic, including during IO insertion. It is also used as an inhaled antitussive.

Front 90

What are the listed contraindications for lidocaine?

Back 90

- Hypersensitivity
- Supraventricular dysrhythmias
- Untreated sinus bradycardia
- 2nd Degree Mobitz II AV Block
- 3rd Degree AV Block
- Stokes-Adams syndrome

Hint 90

Some sources also include AIVR, the presence of an artificial pacemaker and the use of class I antidysrhythmics.

Front 91

What are the listed precautions for lidocaine?

Back 91

CNS depression may occur in doses greater than 300mg/hour
- Liver or renal disease
- CHF
- Hypovolemia
- Shock
- Myasthenia gravis.

Hint 91

Some sources state that lidocaine should not be used in patients with congenital or idiopathic methemoglobinemia or with pseudocholinesterase deficiency.

Front 92

What are the listed side effects for lidocaine?

Back 92

- Altered mental status including confusion
- Bradycardias,
- Hypotension
- Seizures

Hint 92

Prolonged use may produce permanent corneal opacification and ulceration with accompanying loss of vision.

Front 93

What are the listed interactions for lidocaine?

Back 93

Use caution when administered with beta blockers or procainamide as drug toxicity may result.

Hint 93

Cimetidine may increase serum levels of lidocaine due to reduced hepatic circulation.

Front 94

What is the dosage and route of lidocaine?

Back 94

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

Hint 94

Interestingly, lidocaine has no proven short-term or long-term efficacy in cardiac arrest.

Front 95

What is the dosage for an IV infusion of lidocaine?

Back 95

Adult:

- Infusion: 1 - 4 mg/minute using the "+1 Rule"--using infusion rate of 1 more mg/min that number of boluses given

Hint 95

The infusion and bolus should be administered together so no lag occurs.

Front 96

What are the pharmacokinetics of lidocaine?

Back 96

Onset = 1-5 minutes
Duration = 15 minutes - two hours
Half-Life = 1.5 - 2 hours

Hint 96

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).

Front 97

What is the best-known trade name for amiodarone?

Back 97

Cordarone

Hint 97

Another trade name in the US is Pacerone.

Front 98

What is the functional class of amiodarone?

Back 98

Class III antidysrhythmic (potassium channel blocker)

Hint 98

Other class III antidysrythmics are Sotalol, Ibutilide, Dofetilide, Dronedarone and the experimental E-4031

Front 99

What is the mechanism of action of amiodarone?

Back 99

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.

Hint 99

Amiodarone also resembles thyroid hormones and its binding to the nuclear thyroid receptors might contribute to some of its pharmacologic and toxic actions

Front 100

What are the listed indications for amiodarone?

Back 100

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

Hint 100

Amiodarone should not be used for hemodynamically unstable ventricular tachycardia.

Front 101

What are the listed contraindications for amiodarone?

Back 101

- Hypersensitivity
- Cardiogenic shock
- Severe sinus bradycardia,
- AV block

Hint 101

Some sources also caution against use with 2nd or 3rd degree heart block in the absence of an artificial pacemaker.

Front 102

What are the listed precautions for amiodarone?

Back 102

Use with caution in:
- severe liver disease
- pregnancy
- nursing mothers

Hint 102

The injectable forms of amiodarone containing benzyl alcohol should be avoided with neonates or infants because the

Front 103

What are the listed side effects for amiodarone?

Back 103

- CHF
- Angioedema
- Hypotension
- AV block
- Hepatotoxicity
- Cardiogenic shock
- Fatigue
- Bradycardia
- Sinus arrest
- Permanent blindness
- N/V
- Prolonged QT interval

Hint 103

Long-term administration of amiodarone is associated with a blue-gray discoloration of the skin that may fade once therapy is discontinued.

Front 104

What are the listed interactions for amiodarone?

Back 104

- 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

Hint 104

Amiodarone inhibits the action of the cytochrome P450 isozyme family.

Front 105

What is the dosage and route of amiodarone?

Back 105

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

Front 106

What is the best-known trade name for adenosine?

Back 106

Adenocard

Hint 106

A formulation of adenosine used as a pharmacologic stress agent is called Adenoscan. Adenosine is often abbreviated "Ado".

Front 107

What is the functional class of adenosine?

Back 107

Antidysrhythmic

Hint 107

Adenosine is a class V antidysrythmic (direct nodal inhibition). Adenosine also has topical anti-inflammatory properties

Front 108

What is the mechanism of action of adenosine?

Back 108

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.

Hint 108

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.

Front 109

What are the listed indications for adenosine?

Back 109

SVT refractory to vagal maneuvers including Wolff-Parkinson-White (WPW)

Hint 109

WPW features ventricular preexcitation due to an accessory pathway from the atria to the ventricles known as the bundle of Kent.

Front 110

What are the listed contraindications for adenosine?

Back 110

- 2nd and 3rd Degree AV heart blocks
- Symptomatic bradycardia
- Sick sinus syndrome
- Hypersensitivity

Hint 110

2nd and 3rd degree AV heart blocks and sick sinus syndrome may be permitted if a cardiac pacemaker is present.

Front 111

What are the listed precautions for adenosine?

Back 111

- Place patient in semi-Fowler position as patients will typically develop arrhythmias at the time of conversion
- Use cautiously in patients with asthma

Hint 111

This can be expanded to include patients with acute bronchospasm and other obstructive lung diseases.

Front 112

What are the listed side effects for adenosine?

Back 112

- Syncope
- Dizziness
- Dyspnea
- N/V
- Headaches
- Palpitations
- Chest pain
- Hypotension
- Dysrhythmias

Side effects are usually self-limiting due to short half-life.

Hint 112

A metallic taste in the mouth is a hallmark side effect of adenosine.

Front 113

What are the listed interactions for adenosine?

Back 113

- 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

Hint 113

Some sources state that verapamil (and related medications) may increase the risk of V Fib.

Front 114

What is the dosage and route of adenosine?

Back 114

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.

Hint 114

Because of the very short half-life, administer adenosine as close to the heart as possible.

Front 115

What are the pharmacokinetics of adenosine?

Back 115

Onset = rapid
Half-Life = approximately 10 seconds

Hint 115

Adenosine is broken down by adenosine deaminase, which is present in RBCs and vessel walls.

Front 116

What is the best-known trade name for diltiazem?

Back 116

Cardizem

Hint 116

There are over twenty brand names for diltiazem including Angizem, Cartia, Diltalen & Tiazac.

Front 117

What is the functional class of diltiazem?

Back 117

Class IV antidysrhythmic (calcium channel blocker)

Hint 117

Like verapamil, diltiazem is a non-dihydropyridine calcium channel blocker. Dihydropyridine calcium channel blockers have only vasodilatory rather than negative inotropic effects.

Front 118

What is the mechanism of action of diltiazem?

Back 118

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.

Hint 118

Diltiazem also affects dopaminergic and glutamatergic signalling in the brain and this may explain why it can be used to reduce cocaine cravings.

Front 119

What are the listed indications for diltiazem?

Back 119

- SVT refractory to adenosine
- Rapid A-Fib or A-Flutter

Hint 119

Diltiazem and other calcium channel blockers are also being investigated in the treatment and prophylaxis of migraine.a

Front 120

What are the listed contraindications for diltiazem?

Back 120

- Hypersensitivity
- Sick sinus syndrome
- 2nd and 3rd Degree AV block,
- Hypotension
- WPW
- Wide complex tachycardia

Hint 120

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.

Front 121

What are the listed precautions for diltiazem?

Back 121

- Avoid in patients receiving oral beta-blockers
- Monitor for hypotension resulting from peripheral vasodilation.
- Use with caution in CHF

Hint 121

Some sources list PAOD and COPD as relative contraindications.

Front 122

What are the listed side effects for diltiazem?

Back 122

- Chest pain
- Bradycardia
- Hypotension
- Syncope
- CHF
- Dysrhythmias
- N/V
- Headache
- Sweating
- Dizziness
- Dyspnea
- 2nd and 3rd Degree AV block
- Palpitations

Hint 122

Some sources include blurred vision and confusion.

Front 123

What are the listed interactions for diltiazem?

Back 123

Beta-blockers may increase digoxin (sic) levels

Hint 123

Beta blockers and quinidine may interact with diltiazem to increase the likelihood of dysrhythmias and AV node block.

Front 124

What is the dosage and route of diltiazem?

Back 124

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

Hint 124

NH protocols state that a diltiazem bolus should be administered over two minutes.

Front 125

What are the pharmacokinetics of diltiazem?

Back 125

None listed.

Hint 125

The half-life of diltiazem is approximately seven hours. There is a strong relation between plasma diltiazem concentration and percent heart rate reduction.

Front 126

What are the best-known trade names for nitroglycerin?

Back 126

Nitrostat, Nitro-Bid, Tridil

Hint 126

Other trade names include Nitrospan, Nitrol, Trinipatch, Nitro-Dur, Natispray and NitroMist.

Front 127

What is the functional class of nitroglycerin?

Back 127

Nitrate

Hint 127

Other nitrates include isosorbide mononitrate (Imdur), isosorbide dinitrate (Isordil) and pentaerythritol tetranitrate (Lentonitrat).

Front 128

What is the mechanism of action of nitroglycerin?

Back 128

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.

Hint 128

The effects of NTG (and other nitrovasodilators) is achieved by denitration to produce nitric oxide (NO) which is a potent vasodilator.

Front 129

What are the listed indications for nitroglycerin?

Back 129

- Chest pain associated with angina pectoris or AMI
- Acute pulmonary edema
- Congestive heart failure

Hint 129

NTG is also used to treat hypertension, coronary artery spasms due to cocaine and topically for anal fissures.

Front 130

What are the listed contraindications for nitroglycerin?

Back 130

- Hypersensitivity
- Head trauma
- Patients in shock (systolic BP < 100 mmHg), hypovolemia
- Patients with increased ICP (head trauma)

Hint 130

Some sources also list anemia.

Front 131

What are the listed precautions for nitroglycerin?

Back 131

- 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

Hint 131

There is no evidence that defibrillation across a transdermal NTG patch can cause explosion or fire.

Front 132

What are the listed side effects for nitroglycerin?

Back 132

- Hypotension
- Palpitations
- Tachycardia
- Syncope
- Dry mouth
- N/V
- Headache
- Dizziness
- Skin rash

Hint 132

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.

Front 133

What are the listed interactions for nitroglycerin?

Back 133

May cause hypotension when used in conjunction with alcohol and antihypertensives (beta-blockers)

Hint 133

Orthostatic hypotension has been reported when calcium channel blockers and nitrates were used concomitantly.

Front 134

What is the dosage and route of nitroglycerin?

Back 134

- 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)

Hint 134

NH protocols require an IV be established before SL NTG can be administered (with the exception of assisting a pt with their own medication).

Front 135

What are the pharmacokinetics of nitroglycerin?

Back 135

Onset: 1-3 minutes SL
peak effect 5-10 minutes
Duration 20-30 minutes; 1-10 minutes after IV DC'd

Hint 135

Effect reaches a maximum 5 minutes after SL administration and persists for at least 25 minutes.

Front 136

What should be performed before a nitroglycerin infusion is started?

Back 136

Recommend two IVs or a TwinCath in place to administer infusion.

Hint 136

This is a requirement in NH protocols, as is the use of an infusion pump.

Front 137

How should nitroglycerin spray be handled?

Back 137

Do not shake aerosol spray as it may affect metered dose.

Hint 137

However, medicinal NTG is not explosive...

Front 138

What is the chemical name for aspirin?

Back 138

Acetylsalicylic acid (ASA)

Hint 138

Aspirin, with a capital "A", remains a registered trademark of Bayer in Germany, Canada, Mexico, and in over 80 other countries.

Front 139

What are the functional classes of aspirin?

Back 139

- Salicylate
- Analgesic
- Antiplatelet
- Antipyretic

Hint 139

Salicylic acid is found in willow bark and is the source of the name, from the Latin "salix" meaning "willow".

Front 140

What is the mechanism of action of aspirin?

Back 140

- 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.

Hint 140

Asprin has other modes of action which are less well-understood, including affecting mitochondria and reducing inflammation by at least two other mechanisms.

Front 141

What are the listed indications for aspirin?

Back 141

Suspected AMI, chest pain, or ACS

Hint 141

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.

Front 142

What are the listed contraindications for aspirin?

Back 142

Hypersensitivity

Hint 142

Hypersensitivity to ibuprofen or naproxen may indicate hypersensitivity to aspirin.

Front 143

What are the listed precautions for aspirin?

Back 143

Peptic ulcer disease, asthma

Hint 143

Some sources include hemophilia and other disorders likely to result in excessive bleeding (such as Dengue fever).

Front 144

What are the listed side effects for aspirin?

Back 144

Overdose may result in considerable toxicity with dizziness, N/V, abdominal pain, thrombocytopenia, easy bruising, and/or metabolic acidosis.

Hint 144

Use of aspirin in children and teenagers can increase the likelihood of them devloping Reye's syndrome.

Large doses of aspirin can cause tinnitus.

Front 145

What are the listed interactions for aspirin?

Back 145

- Incompatible with uricosuric agents
- Anticoagulants increase the risk of bleeding

Hint 145

Ibuprofen can negate the antiplatelet effect of aspirin used for cardioprotection and stroke prevention.

Front 146

What is the dosage and route of aspirin?

Back 146

160 - 325mg PO (chewable) tablets

Hint 146

"Baby aspirin" are typically 81mg

Front 147

What is the best-known trade names for metoprolol?

Back 147

Lopressor and Toprol-XL

Hint 147

Lopressor is metoprolol tartrate which is immediate-release whereas Toprol-XL is metoprolol succinate which is an extended-release formulation.

Front 148

What is the functional class of metoprolol?

Back 148

Class II antidysrhythmic (beta blocker).

Hint 148

Other beta blockers include carvedilol (Coreg), labetalol (Normodyne, Trandate) and propranolol (Inderal). Most have generic names ending in "-lol".

Front 149

What is the mechanism of action of metoprolol?

Back 149

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.

Hint 149

Lopressor can mask tachycardia associated with hypoglycemia.

Front 150

What is the primary MICS listed indication for metoprolol?

Back 150

- Chest pain associated with AMI, ACS
T

Hint 150

Metoprolol is frequently prescribed for off-label use in anxiety disorders.

Front 151

What are the listed contraindications for metoprolol?

Back 151

- 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

Hint 151

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."

Front 152

What are the listed precautions for metoprolol?

Back 152

- Impaired hepatic or renal function
- CHF controlled by digitalis or diuretics
- Do not mix with IV calcium channel blockers

Hint 152

AstraZeneca, the manufacturer of Toprol-XL, also lists hyperthyroidism and arteriosclerosis.

Front 153

What are the listed side effects for metoprolol?

Back 153

- Bronchospasm
- Bradycardia
- Palpitations
- Edema
- CHF
- Reduced peripheral circulation
- Drowsiness
- Insomnia

Hint 153

Abrupt cessation of metoprolol therapy (or other beta blockers) may cause a thyroid storm

Front 154

What are the listed interactions for metoprolol?

Back 154

- 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

Hint 154

Drugs that inhibit CYP2D6 such as quinidine and fluoxetine may increase metoprolol plasma concentration, which can decrease its beta-1 selectivity.

Front 155

What is the dosage and route of metoprolol?

Back 155

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

Hint 155

Home PO dosages of metoprolol are in the range of 100-450mg/day

Front 156

What is the chemical formula for sodium bicarbonate?

Back 156

NaHCO₃

Hint 156

The "bi-" prefix means that the anion is the result of one hydrogen ion (H⁺) being added to the carbonate ion (CO₃²⁺)

Front 157

What is the functional class of sodium bicarbonate?

Back 157

- Electrolyte
- Alkalinizing Agent

Hint 157

Sodium bicarbonate can also be used as an exfoliant or mouthwash.

Front 158

What is the mechanism of action of sodium bicarbonate?

Back 158

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.

Hint 158

Sodium bicarbonate is integral to the body's acid-base homeostasis.

Front 159

What are the listed indications for sodium bicarbonate?

Back 159

- Severe acidosis (refractory to hyperventilation)
- Tricyclic antidepressant (TCA) overdose
- Barbiturate overdose
- Known hyperkalemia

Hint 159

Sodium bicarbonate has occasionally been used to treat ASA overdoses.

Front 160

What are the listed contraindications for sodium bicarbonate?

Back 160

None in the emergency setting

Hint 160

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!

Front 161

What are the listed precautions for sodium bicarbonate?

Back 161

- Not recommended for routine use in cardiac arrest
- Dosage must be specific to prevent metabolic alkalosis and is thus weight-based

Hint 161

In patients with diminished renal function, administration of solutions containing sodium ions may result in sodium retention.

Front 162

What are the listed side effects for sodium bicarbonate?

Back 162

- 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

Hint 162

The tissue acidosis in cardiac arrest is caused by CO₂ accumulation and that is what bicarbonate administration increases when it combines with H⁺ ions.

Front 163

What are the listed interactions for sodium bicarbonate?

Back 163

- Will deactivate most catecholamines and vasopressors
- Sodium bicarbonate will precipitate when used in conjunction with calcium chloride

Hint 163

Sodium bicarbonate can react with sodium polystyrene sulfonate, a different treatment for hyperkalemia, and grossly interferes with it.s function.

Front 164

What is the dosage and route of sodium bicarbonate?

Back 164

1mEq/kg IVP/IO push, repeat at 0.5mEq/kg q10 minutes prn

Hint 164

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".

Front 165

What is the best-known trade name for furosemide?

Back 165

Lasix

Hint 165

The name Lasix comes from the implication that the relatively short-acting medication "lasts six hours".

Front 166

What is the functional class of furosemide?

Back 166

Loop diuretic

Hint 166

Other loop diuretics include bumetanide (Bumex), torasemide (Demadex) and etacrynic acid (Edecrin).

Front 167

What is the mechanism of action of furosemide?

Back 167

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.

Hint 167

The loop of Henle runs from the proximal convoluted tubule to the distal convoluted tubule.

Front 168

What are the listed indications for furosemide?

Back 168

- CHF
- Acute Pulmonary Edema
-Hypertensive Crisis

Hint 168

Furosemide is also used to treat cerebral edema. It is also (legally) used in racehorses to help prevent exercise induced pulmonary hemorrhage (EIPH).

Front 169

What are the listed contraindications for furosemide?

Back 169

- Hypersensitivity
- Hypotension
- Dehydration
- Electrolyte depletion

Hint 169

Furosemide is a sulfonamide and therefore may be contraindicated in patients with sulfa allergies

Front 170

What are the listed precautions for furosemide?

Back 170

- Usage in pregnancy should be limited to life-threatening situations as furosemide may cause fetal abnormalities
- Protect from light
- Renal or hepatic insufficiencies

Hint 170

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.

Front 171

What are the listed side effects for furosemide?

Back 171

- Hypotension
- Dizziness
- Chest pain
- Dry mouth
- Hypochloremia
- Hypokalemia
- Hyponatremia
- Hypomagnesemia
- Hypocalcemia
- N/V
- Ototoxicity (tinnitus if pushed too rapidly)
- Hyperglycemia

Hint 171

Lasix can cause kidney stones or calcium deposits in the kidneys of premature infants

Front 172

What are the listed interactions for furosemide?

Back 172

- Digitalis
- Lithium toxicity

Hint 172

Lasix should not be combined with aminoglycoside antibiotics unless absolutely necessary as this can increase the chance of permanent hearing loss.

Front 173

What is the dosage and route of furosemide?

Back 173

- Adult-40-80 mg IV or IO slow push
- Pediatric-1mg/kg slow IV or IO

Hint 173

Dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range

Front 174

What is the functional class of magnesium sulfate?

Back 174

Electrolyte

Hint 174

Magnesium sulfate has the formula MgSO₄. It is often found naturally as the heptahydrate (MgSO₄·7H₂O) called epsomite or Epsom salts.

Front 175

What is the mechanism of action of magnesium sulfate?

Back 175

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.

Hint 175

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".

Front 176

What are the listed indications for magnesium sulfate?

Back 176

- Eclampsia; premature labor contractions
- Torsades de Pointes
- Severe asthma
- Digitalis toxicity
- Tricyclic overdose

Hint 176

Intravenous magnesium sulfate may be able to prevent cerebral palsy in preterm babies.

Front 177

What are the listed contraindications for magnesium sulfate?

Back 177

Do not administer to any patient with:
- Heart block
- Shock
- Persistent
- Hypertension
- Hypocalcemia
- Myocardial damage

Hint 177

Some sources include appendicitis and bowel obstruction/perforation

Front 178

What are the listed precautions for magnesium sulfate?

Back 178

- Renal failure
- Patients taking digoxin
- Concomitant use of other CNS depressants or neuromuscular blocking agents

Hint 178

It is recommended that magnesium sulfate not be administered in the 2 hours before delivery, if possible.

Front 179

What are the listed side effects of magnesium sulfate?

Back 179

- 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

Hint 179

Diarrhea is also a relatively common side-effect. Hypocalcemia has also been reported.

Front 180

What are the listed interactions of magnesium sulfate?

Back 180

Can cause cardiac conduction abnormalities when used in conjunction with digitalis

Hint 180

However, magnesium sulfate can be used to treat high-level blocks caused by digitalis toxicity.

Front 181

What is the dosage and route of magnesium sulfate?

Back 181

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

Hint 181

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.

Front 182

What substance can be used as an antidote to magnesium sulfate?

Back 182

Calcium chloride

Hint 182

As can calcium gluconate. The actions of magnesium in neuromuscular and cardiac function are antagonized by calcium.

Front 183

What is the best-known trade name for dopamine?

Back 183

Inotropin

Hint 183

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).

Front 184

What is the functional class of dopamine?

Back 184

Sympathomimetic

Hint 184

Dopamine is a precursor to norepinephrine and then epinephrine

Front 185

What is the mechanism of action of dopamine?

Back 185

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.

Hint 185

Dopmaine can produce significant CNS effects but does not cross the blood-brain barrier.

Front 186

What are the listed indications for dopamine?

Back 186

- Cardiogenic, septic, or neurological shock
- Hemodynamically significant hypotension (systolic BP of 70-100mmHg not resulting from hypovolemia) with low cardiac output;
- Symptomatic bradycardia

Hint 186

Dopamine is also used to treat nonobstructive oliguria (low urine output).

Front 187

What are the listed contraindications for dopamine?

Back 187

- Pheochromocytoma
- Tachydysrhythmias
- Ventricular fibrillation

Hint 187

And, of course, known hypersensitivity.

Front 188

What are the listed precautions for dopamine?

Back 188

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

Hint 188

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)

Front 189

What are the listed side effects for dopamine?

Back 189

- Dysrhythmias
- Palpitations
- Tachycardia
- Bradycardia
- Headaches,
- Anxiety
- N/V
- Tissue sloughing may result from dopamine extravasation
- Dyspnea
- HTN

Hint 189

Some sources include widened QRS complexes and azotaemia (abnormally high blood nitrogen levels).

Front 190

What is the dosage and route of dopamine?

Back 190

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

Hint 190

The "renal", "cardiac" and "pressor" doses.

Front 191

What is the preparation for dopamine?

Back 191

Place 800mg in 500mL D5W or NS = 1600mcg/mL
or
Place 400mg in 250mL D5W or NS = 1600mcg/mL

Hint 191

Dopamine is usually supplied in a 5mL (400mg) or 10mL (800mg) vial.

Front 192

How should dopamine be used to treat hypovolemic shock?

Back 192

Should not be used as the sole agent in the management of hypovolemic shock as fluid volume replacement is the primary treatment

Hint 192

"Tank before you crank".

Front 193

What is the best-known trade name for oxytocin?

Back 193

Pitocin

Hint 193

Oxytocin is also sold as Syntocinon and is available as a generic

Front 194

What is the functional class of oxytocin?

Back 194

Hormone

Hint 194

Oxytocin is released into the blood from the posterior lobe (neurohypophysis) of the pituitary gland.

Front 195

What is the mechanism of action of oxytocin?

Back 195

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.

Hint 195

Many studies have shown that oxytocin is also involved in human bonding, increases in trust and generosity, and decreases in fear.

Front 196

What are the listed indications for oxytocin?

Back 196

Postpartum hemorrhage

Hint 196

The Center of Cognitive Neuroscience in Lyon, France concluded that oxytocin may help reduce the negative symptoms of autism.

Front 197

What are the listed contraindications for oxytocin?

Back 197

Hypersensitivity and prior to delivery of the fetus. Administration prior to delivery may cause fetal hypoxia, asphyxia, and dysrhythmias

Hint 197

Oxytocin is used prior to delivery in the hospital setting.

Front 198

What are the listed precautions for oxytocin?

Back 198

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

Hint 198

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.

Front 199

What are the listed side effects for oxytocin?

Back 199

- Hypotension
- Anxiety
- N/V
- Dysrhythmias
- HTN
- Seizures
- Dyspnea
- Coma
- Intracranial bleeding

Hint 199

Fatal afibrinogenemia has also been reported

Front 200

What are the listed interactions for oxytocin?

Back 200

Can cause hypertension when used in conjunction with vasoconstrictors

Hint 200

Use with cyclopropane anesthesia can produce hypotension and cardiac dysrhythmias

Front 201

What is the dosage and route of oxytocin?

Back 201

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

Hint 201

Oxytocin is typically packaged in a 1ml (10 unit) vial.

Front 202

What is the best-known trade name for acetaminophen?

Back 202

Tylenol

Hint 202

Acetaminophen (also known as paracetamol or APAP - N-acetyl-para-aminophenol) has dozens of brand names in use around the world.

Front 203

What are the functional classes of acetaminophen?

Back 203

Antipyretic, analgesic

Hint 203

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).

Front 204

What is the mechanism of action of acetaminophen?

Back 204

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.

Hint 204

Acetaminophen does not significantly inhibit the production of the pro-clotting thromboxanes as it is selective for COX-2 inhibition.

Front 205

What are the listed indications for acetaminophen?

Back 205

Fever

Hint 205

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.

Front 206

What are the listed contraindications for acetaminophen?

Back 206

Hypersensitivity to acetaminophen or phenacetin

Hint 206

Acetaminophen is the active metabolite of phenacetin.

Front 207

What are the listed precautions for acetaminophen?

Back 207

Anemia, hepatic and renal disease, alcoholism

Hint 207

The risks of acetaminophen in alcoholics seem to be confined to overdosage; therapeutic doses do not seem to have adverse effects.

Front 208

What are the listed side effects for acetaminophen?

Back 208

- N/V
- Dizziness
- Hepatotoxicity
- Renal failure
- Hypoglycemia

Hint 208

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.

Front 209

What are the listed interactions for acetaminophen?

Back 209

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

Hint 209

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.

Front 210

What is the dosage and route of acetaminophen?

Back 210

Adult:
- 325-650mg PO/PR q 4-6 hours

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

Hint 210

In adults, acetaminophen has been found to be well-tolerated at maximum daily doses for several weeks.

Front 211

What are the best-known trade names for ibuprofen?

Back 211

Advil, Motrin, Nuprin

Hint 211

The name ibuprofen comes from iso-butyl-propanoic-phenolic acid. Ibuprofen has dozens of brand names worldwide.

Front 212

What are the functional classes of ibuprofen?

Back 212

Antipyretic, analgesic, NSAID

Hint 212

Ibuprofen also acts as a limited vasodialtor and mild antiplatelet.

Front 213

What is the mechanism of action of ibuprofen?

Back 213

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

Hint 213

Ibuprofen is considered a nonselective COX inhibitor and it is the inhibition of COX-1

Front 214

What are the listed indications for ibuprofen?

Back 214

Fever

Hint 214

As an OTC medication, ibuprofen is mainly used for its analgesic and NSAID properties.

Front 215

What are the listed contraindications for ibuprofen?

Back 215

- Hypersensitivity
- Children less than six months old
- GI intolerance such as colitis

Hint 215

Hypersensitivity to other NSAIDs may indicate hypersensitivity to ibuprofen.

Front 216

What are the listed precautions for ibuprofen?

Back 216

- Pregnancy
- Peptic ulcer disease
- Pulmonary edema
- HTN

Hint 216

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.

Front 217

What are the listed side effects for ibuprofen?

Back 217

- Nausea
- Abdominal pain
- Diarrhea
- Dizziness
- Tinnitus

Hint 217

Ibuprofen shares the side effects of other NSAIDs.

Front 218

What are the listed interactions for ibuprofen?

Back 218

- Reduces the effectiveness of loop diuretics and ACE-inhibitors
- Increases hemorrhage potential when given with aspirin

Hint 218

Ibuprofen increases plasma lithium levels and reduces renal lithium clearance so can induce lithium toxicity.

Front 219

What is the dosage and route of ibuprofen?

Back 219

Adult:
- 200-600mg PO/PR q 6-8 hours

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

Hint 219

OTC ibuprofen directions typically approximate to weight-based dosing and individual doses at home may be higher or lower than 10mg/kg.

Front 220

What is the functional class of calcium chloride?

Back 220

Electrolyte

Hint 220

Calcium chloride is a rare mineral in nature, occuring as sinjarite and antarcticite.

Front 221

What is the mechanism of action of calcium chloride?

Back 221

- 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.

Hint 221

Aqueous calcium chloride is used in genetic transformation of cells by increasing the cell membrane permeability, inducing competence for DNA uptake

Front 222

What are the listed indications for calcium chloride?

Back 222

- Calcium channel blocker toxicity/overdose
- Prophylactically prior to IV calcium channel blockers
- Acute hyperkalemia
- Acute hypocalcemia
- Acute hypermagnesemia

Hint 222

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.

Front 223

What are the listed contraindications for calcium chloride?

Back 223

- VF
- Hypercalcemia
- Digitalis toxicity

Hint 223

Some sources include hypophosphatemia

Front 224

What are the listed precautions for calcium chloride?

Back 224

- Flush IV line between calcium chloride and bicarbonate as precipitate will form.
- Monitor for tissue necrosis at injection site

Hint 224

Do not mix ceftriaxone (Rocephin) with calcium chloride during administration as this too can produce a precipitate

Front 225

What are the listed side effects for calcium chloride?

Back 225

- Arrhythmias including bradycardia or cardiac arrest
- Syncope
- N/V
- Hypotension
- Necrosis with extravasation

Hint 225

Calcium chloride administration can cause nephrolithiasis (kidney stones) but this is usually from long-term use.

Front 226

What are the listed interactions for calcium chloride?

Back 226

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

Hint 226

Calcium chloride can also affect the use of phosphate supplements

Front 227

What is the dosage and route of calcium chloride?

Back 227

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

Hint 227

The (now rarely used) dose for cardiac resuscitation is 20-40mg injected into the ventricular cavity.

Front 228

What are the best-known trade names for albuterol?

Back 228

Proventil and Ventolin

Hint 228

The International Nonproprietary Name (INN) for albuterol is salbutamol.

Front 229

What is the functional class of albuterol?

Back 229

Sympathomimetic bronchodilator

Hint 229

Other sympathomimetic bronchodilators include levalbuterol (Xopenex), terbutaline, metaproterenol (Alupent) and salmeterol (Serevent).

Front 230

What is the mechanism of action of albuterol?

Back 230

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.

Hint 230

Beta-2 agonists also cause vasodilation in muscles and the liver, relaxation of uterine muscle and release of insulin.

Front 231

What are the listed indications for albuterol?

Back 231

- Bronchospasm
- Patients with reversible obstructive airway disease

Hint 231

Intravenous salbutamol can be used as a tocolytic to relax the uterine smooth muscle to delay premature labor.

Front 232

What are the listed contraindications for albuterol?

Back 232

Hypersensitivity

Hint 232

There are many patients who have conditions that contraindicate regular albuterol administration but these do not apply in the emergency setting.

Front 233

What are the listed precautions for albuterol?

Back 233

- Consider monitoring peak expiratory flow rates (PEFR)
- Monitor vitals and respiratory status during treatment

Hint 233

Albuterol causes a transient reduction in serum potassium levels, which may have cardiovascular effects.

Front 234

What are the listed side effects for albuterol?

Back 234

- Tremors
- Anxiety
- HTN
- Tachycardia
- Headache
- Palpitations
- Seizures
- N/V
- Dizziness
- Rash

Hint 234

Albuterol (rarely) may cause a life-threatening, acute paradoxical bronchospasm.

Front 235

What are the listed interactions for albuterol?

Back 235

- Other sympathomimetic bronchodilators
- Beta-blockers
- Use with extreme caution with patients on MAOIs and TCAs as potentiation may occur

Hint 235

The chance of life-threatening, acute paradoxical bronchospasm is increased when albuterol is used with beta-blockers.

Front 236

What is the dosage and route of albuterol?

Back 236

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.

Hint 236

Albuterol is available as a multi-dose vial which must be diluted prior to inhalation but most people now use nebulizer "bullets".

Front 237

What is the best-known trade name for dobutamine?

Back 237

Dobutrex

Hint 237

Another brand name is Inotrex.

Front 238

What is the functional class of dobutamine?

Back 238

Sympathomimetic

Hint 238

Dobutamine is a structural analogue of isoprenaline (Isuprel), another sympathomimetic.

Front 239

What is the mechanism of action of dobutamine?

Back 239

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.

Hint 239

Dobutamine does not act on dopamine receptors to induce the release of norepinephrine (another α1 agonist) so is less likely to induce hypertension.

Front 240

What are the listed indications for dobutamine?

Back 240

- Short term management of CHF or cardiogenic shock
- Used to increase cardiac output without increasing rate

Hint 240

Dobutamine is also commonly used in the hospital setting as a pharmacologic stress testing agent to identify coronary artery disease.

Front 241

What are the listed contraindications for dobutamine?

Back 241

- Hypersensitivity
- VT

Hint 241

Some sources include obstructive hypertrophic cardiomyopathy, also known as hypertrophic obstructive cardiomyopathy (HOCM), idiopathic hypertrophic subaortic stenosis (IHSS) and asymmetric septal hypertrophy (ASH).

Front 242

What are the listed precautions for dobutamine?

Back 242

- Can increase myocardial oxygen demand
- Can be deactivated by sodium bicarbonate
- Preexisting HTN or A-Fib
- Hypotension from hypovolemia; always try volume restoration first

Hint 242

Caution should also be used in patients with a sensitivity to sulfites.

Front 243

What are the listed side effects for dobutamine?

Back 243

- Tachycardia
- HTN
- Dyspnea
- Dysrhythmias
- Palpitations
- Chest pain
- Headaches
- Anxiety
- N/V

Hint 243

Studies suggest that while this medication can improve symptoms in chronic CHF, it actually shortens a patient's lifespan.

Front 244

What are the listed interactions for dobutamine?

Back 244

- Absolute interaction with beta-blockers as they decrease
dobutamine’s effectiveness.
- Use with extreme caution with tricyclic
antidepressants

Hint 244

Some sources state that significant adverse affects can occur if dobutamine is used with stimulants, especially cocaine.

Front 245

What is the dosage and route of dobutamine?

Back 245

2-20mcg/kg/min IV infusion

Mix 250mg in 250mL (or 500mg in 500mL) D5W or NS,
which yields 1000mcg/mL

Hint 245

Dobutamine has been infused for up to 72 hours without decreased effectiveness.

Front 246

What is preferred to dobutamine in cases of cardiogenic shock?

Back 246

Dopamine

Hint 246

Dobutamine may be useful as an adjunct to volume replacement in patients with right ventricular infarction, since dopamine may increase pulmonary vascular resistance.

Front 247

What is the best-known trade name for ipratropium bromide?

Back 247

Atrovent

Hint 247

Other brand names include Apovent and Aerovent.

Front 248

What is the functional class of ipratropium bromide?

Back 248

Parasympatholytic bronchodilator

Hint 248

Ipratropium does not cross the blood-brain barrier so does not produce systemic anticholinergic effects.

Front 249

What is the mechanism of action of ipratropium bromide?

Back 249

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.

Hint 249

Ipratropium blocks the muscarinic acetylcholine receptors.

Front 250

What are the listed indications for ipratropium bromide?

Back 250

- Bronchospasm
- Patients with reversible obstructive airway disease

Hint 250

Ipratropium is also used as a nasal spray to treat rhinitis.

Front 251

What are the listed contraindications for ipratropium bromide?

Back 251

Hypersensitivity to ipratropium, atropine, soya lecithin and peanut oil

Hint 251

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.

Front 252

What are the listed precautions for ipratropium bromide?

Back 252

Use with caution in pregnancy and lactation

Hint 252

Ipratropium can cause urinary retention and, in non-emergency settings, may be avoided in patients with bladder obstructions, BPH, etc.

Front 253

What are the listed side effects for ipratropium bromide?

Back 253

- N/V
- Cramps
- Dry mouth
- Blurred vision
- Worsening bronchospasm
- Drying of bronchial secretions
- Cough
- Epistaxis

Hint 253

The inhalation itself can cause a sore throat.

Front 254

What are the listed interactions for ipratropium bromide?

Back 254

None

Hint 254

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).

Front 255

What is the dosage and route of ipratropium bromide?

Back 255

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

Hint 255

If mixed with albuterol or any other medication, the solution should be used within one hour. Premixed solutions are good until their expiration dates.

Front 256

What is the best-known trade name for methylprednisolone?

Back 256

Solu-Medrol

Hint 256

Another brand name is Medrol.

Front 257

What is the functional class of methylprednisolone?

Back 257

Corticosteroid

Hint 257

More specifically, methylprednisolone is a glucocorticoid.

Front 258

What is the mechanism of action of methylprednisolone?

Back 258

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.

Hint 258

Glucocorticoids also inhibit the release of prostaglandins, leukotrienes and cyclooxygenase.

Front 259

What are the listed indications for methylprednisolone?

Back 259

Severe asthma, anaphylaxis or COPD.

Hint 259

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.

Front 260

What are the listed contraindications for methylprednisolone?

Back 260

None in the management of anaphylaxis

Hint 260

When not treating life-threatening conditions, methylprednisolone is contraindicated for patients with a rectent history of certain infections such as varicella and rubeola (measles).

Front 261

What are the listed precautions for methylprednisolone?

Back 261

Patients with peptic ulcer disease, CHF, and TB.

Hint 261

Many sources add active infections, existing immunosuppression and many chronic disorders as precautions.

Front 262

What are the listed side effects for methylprednisolone?

Back 262

- Hypertension
- CHF
- Delayed wound healing
- Hyperglycemia
- Hypokalemia
- Headache
- Peptic ulcer
- Circulatory collapse
- N/V
- CNS depression

Hint 262

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.

Front 263

What are the listed interactions for methylprednisolone?

Back 263

Use caution in patients on salicylates, phenytoin, rifampin, theophylline, furosemide, and thiazide diuretics.

Hint 263

Caution should also be exercised with patients who have recently received a vaccination.

Front 264

What is the dosage and route of methylprednisolone?

Back 264

Adult:
- 125-250mg IVP/IM

Pediatric:
- 1mg/kg IVP

Hint 264

NH dosing is 62.5mg for adults and 1mg/kg (max of 62.5mg) for pediatrics.

Front 265

What is the best-known trade name for glucagon?

Back 265

GlucaGen

Hint 265

Glucagon was named in 1923, probably from the Greek γλυκός ("sweet") and ἄγειν ("to drive").

Front 266

What is the functional class of glucagon?

Back 266

Hormone

Hint 266

Glucagon is a peptide (nonsteroid) hormone as it consists of a short chain of amino acids.

Front 267

What is the mechanism of action of glucagon?

Back 267

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.

Hint 267

Glucagon is also a smooth muscle relaxant and can also be used for diverse conditions such as FBAO and asthma.

Front 268

What are the listed indications for glucagon?

Back 268

- Hypoglycemia without IV access
- Adjuvant treatment of toxic effects of CCB and beta-blockers

Hint 268

The effectiveness of glucagon for hypoglycemia is constantly debated.

Front 269

What are the listed contraindications for glucagon?

Back 269

Known hypersensitivity

Hint 269

Some sources include pheochromocytoma as a critical contraindication.

Front 270

What are the listed precautions for glucagon?

Back 270

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

Hint 270

The glycogen stores are only required if glucagon is being used to treat hypoglycemia!

Front 271

What are the listed side effects for glucagon?

Back 271

- Hypotension
- Headache
- Dizziness
- N/V
- Hyperglycemia
- Hypokalemia

Hint 271

Rashes and urticaria have also been reported

Front 272

What are the listed interactions for glucagon?

Back 272

None significant

Hint 272

Glucagon can potentiate the anticoagulant effects of warfarin.

Front 273

What is the dosage and route of glucagon?

Back 273

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

Hint 273

Glucagon can be administered as an infusion as part of definitive care for overdoses.

Front 274

What are the pharmacokinetics of glucagon?

Back 274

Onset = 5-20 minutes
Duration = 1-1.5 hours

Hint 274

Manufacturer's information for GlucaGen indicates half-lives of 8-18min (IV) and 45min (IM).

Front 275

What are the two main components of D50?

Back 275

D50 is 50% dextrose in water

Hint 275

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).

Front 276

What is the functional class of D50?

Back 276

Carbohydrate

Hint 276

Dextrose is so named because it consists of the dextrorotatory isomers of glucose

Front 277

What is the mechanism of action of D50?

Back 277

Principal form of glucose used by the body to create energy

Hint 277

Glycolysis, the metabolism of glucose, is found in nearly all known organisms.

Front 278

What are the listed indications for D50?

Back 278

Hypoglycemia

Hint 278

D50 is used with insulin for in-hospital treatment of hyperkalemia

Front 279

What are the listed contraindications for D50?

Back 279

None in a patient with documented hypoglycemia

Hint 279

Some people may claim to have an allergy to glucose/dextrose. As the body produces glucose, this is impossible.

Front 280

What are the listed precautions for D50?

Back 280

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

Hint 280

Wernicke's encephalopathy may be exacerbated if D50 is administered without thiamine.

Front 281

What are the listed side effects for D50?

Back 281

- Tissue necrosis
- Phlebitis
- Pain at injection site

Hint 281

D50's side effects result from its hypertonicity

Front 282

What are the listed interactions for D50?

Back 282

None

Hint 282

Hyperglycemia from D50 may interfere with the use of fludeoxyglucose f 18 (Gludef, Metatrace) in PET scans.

Front 283

What is the dosage and route of D50?

Back 283

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

Hint 283

D50 can be administered IO but is reported to be exceptionally painful due to the viscosity.

Front 284

What is the best-known trade name for diphenhydramine?

Back 284

Benadryl

Hint 284

Outside the United states and Canada Benadryl products may contain a different antihistamine (e.g. UK) or no antihistamine at all (e.g. Australia).

Front 285

What is the functional class of diphenhydramine?

Back 285

Antihistamine

Hint 285

Diphenhydramine also has anticholinergic, antitussive, antiemetic and sedative properties.

Front 286

What is the mechanism of action of diphenhydramine?

Back 286

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).

Hint 286

Diphenhydramine is actually an inverse agonist of the histamine H1 receptor

Front 287

What are the listed indications for diphenhydramine?

Back 287

- Anaphylaxis
- Moderate to severe allergic reactions
- Acute extrapyramidal (dystonic) reactions

Hint 287

Diphenhydramine is also used to treat motion sickness and insomnia

Front 288

What are the listed contraindications for diphenhydramine?

Back 288

- Hypersensitivity
- Newborns and nursing mothers

Hint 288

Some sources state that diphenhydramine is condraindicated in patients <2 years old

Front 289

What are the listed precautions for diphenhydramine?

Back 289

- Not considered a primary drug for the treatment of severe allergic reactions or anaphylaxis
- Use with caution if the patient has narrow-angle glaucoma

Hint 289

Diphenhydramine appears on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Front 290

What are the listed side effects for diphenhydramine?

Back 290

- Hypotension
- N/V
- Tachycardia
- Bradycardia
- Sedation
- Palpitations
- Drowsiness
- Disturbed coordination
- Dry mouth

Hint 290

There is some evidence that diphenhydramine can prolong the QT-interval, leading to cardiac arrhythmias.

Front 291

What are the listed interactions for diphenhydramine?

Back 291

- Potentiated by the administration of other CNS depressants, antihistamines, narcotics, and alcohol
- MAOIs may prolong or intensify the anticholinergic effects

Hint 291

As diphenhydramine slows GI transit, it can cause ulceration from local exposure when a patient is using solid forms of potassium

Front 292

What is the dosage and route of diphenhydramine?

Back 292

Adult:
- 25-50mg IVP or IM q 6-8 hours

Pediatric:
- 1mg/kg IVP or IO, maximum single dose is 50mg q6-8 hours

Hint 292

Diphenhydramine is used recreationally as a deliriant or potentiator of alcohol.

Front 293

What is another name for the Mark-1 kit?

Back 293

The NAAK: Nerve Agent Antidote Kit.

Hint 293

Militaries are now transitioning to an autoinjector, the ATNAA (Antidote Treatment Nerve Agent Autoinjector)

Front 294

What is the functional class of the Mark-1 kit?

Back 294

Atropine: parasympatholytic
Pralidoxime chloride: cholinesterase reactivator

Hint 294

Other oximes such as obidoxime and asoxime can also be used to restore enzyme functionality.

Front 295

What is the mechanism of action of the Mark-1 kit?

Back 295

- 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.

Hint 295

The US military issued servicemembers three Mark-1 kits with one CANA kit (Convulsive Antidote, Nerve Agent) containing diazepam.

Front 296

What are the listed indications for the Mark-1 kit?

Back 296

Organophosphate and nerve agent poisoning in mass casualty incidents

Hint 296

The Mark-1 kit is only effectve against Tabun (GA), Sarin (GB), Soman (GD) and VX.

Front 297

What are the listed contraindications for the Mark-1 kit?

Back 297

None in the emergency setting

Hint 297

Some sources list pediatric patients under the age of three as being relatively contraindicated.

Front 298

What are the listed precautions for the Mark-1 kit?

Back 298

- 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

Hint 298

Diazepam is the drug of choice for treating fasciculations.

Front 299

What are the listed side effects for the Mark-1 kit?

Back 299

- Dry mouth
- Flushing
- Pupil dilation
- Tachycardia

Hint 299

When atropine and pralidoxime are used together, these signs of atropinization may occur earlier than might be expected when atropine is used alone.

Front 300

What is the dosage and route of the Mark-1 kit?

Back 300

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

Hint 300

The military instructs that administration (to self or others) of antidote kits should be performed after donning appropriate protective gear.

Front 301

In what order are the two tubes of the Mark-1 kit administered?

Back 301

Tube one (atropine) is always administered before tube two
(pralidoxime chloride).

Hint 301

The alternative ATNAA (Antidote Treatment Nerve Agent Autoinjector) contains the two medications separately but administers them simultaneously.

Front 302

What is the trade name for hydroxocobalamin used as an antidote?

Back 302

Cyanokit

Hint 302

Unlike most other therapeutic uses of hydroxocobalamin, the Cyanokit uses IV administration.

Front 303

What is the functional class of hydroxocobalamin?

Back 303

- Vitamin
- Antidote

Hint 303

Hydroxocobalamin is one vitamer of vitamin B12. The others include cyanocobalamin, methylcobalamin, and adenosylcobalamin.

Front 304

What is the mechanism of action of hydroxocobalamin?

Back 304

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.

Hint 304

All of the vitamers of B12 have vitamin activity.

Front 305

What are the listed indications for hydroxocobalamin?

Back 305

Treatment of known or suspected cyanide poisoning

Hint 305

In addition to some pesticides and insecticides, cyanide is contained in tobacco smoke and smoke from building fires.

Front 306

What are the listed contraindications for hydroxocobalamin?

Back 306

Hypersensitivity to any component of the medication (including cobalt)

Hint 306

Cobalamins contain a single cobalt atom in the nucleus of each molecule.

Front 307

What are the listed precautions for hydroxocobalamin?

Back 307

Transient severe hypertension secondary to infusion

Hint 307

Administration of hydroxocobalamin may interfere with some clinical laboratory evaluations.

Front 308

What are the listed side effects for hydroxocobalamin?

Back 308

- Hypertension
- Pruritis
- Headache
- Chromaturia (up to 5 weeks)

Hint 308

Hematochezia can also occur.

Front 309

What are the listed interactions for hydroxocobalamin?

Back 309

Due to incompatibilities (particulate formation), the following medications need to be run through different tubing (separate from hydroxocobolamin):
- Diazepam
- Dobutamine
- Dopamine
- Fentanyl
- Nitroglycerin

Hint 309

There are very few interactions that occur in vivo, as opposed to during delivery.

Front 310

What is the dosage and route of hydroxocobalamin?

Back 310

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

Hint 310

Total doses up to 20g have been used.