Paramedic Drug Cards

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Diltiazem

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Class:Calcium Channel Blocker
MOA:Block influx of calcium ions into caridac muscle: prevents spasm of coronary arteries.
Arterial & Venous vasodilator
Reduces Preload & Afterload
Reduces Myocardial 02 demand
Indications:Control of rapid ventricular rates due to A-Fib/Flutter & PSVT
Angina Pectoris
Contraindications:Hypotension
Sick Sinus Syndrome
2nd or 3rd degree AV heart block
Cardiogenic Shock
Wide-complex tachycardias
Side Effects:Bradycardia, 2nd or 3rd degree AV block, CP, CHF, Syncope, Vfib, Vtach, dry mouth, dyspnea, n/v, headache
Dosage:25mg/5l vial
50/mg in 10ml vial
non-refrigerated lyo-ject
0.25mg/kg (average dose of 20mg) IV over 2 min. May rebolus in 15min @ 0.35mg/kg IV over 2 min

not for pediatrics

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Haloperidol (Haldol)

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Class: an antipsychotic or neuroleptic and a butyrophenone (chemical compound).
MOA: dopamine blocker / unknown
Indications: schizophrenic patients who need parenteral antipsychotic therapy and acute psychotic episodes.
Contraindications: Coma or pronounced central nervous depression. Pre-existing extrapyramidal disturbances, pregnant or nursing women, or children.
Side Effects: dizziness, fainting, fast or pounding heartbeat;restless muscle movements in your eyes, tongue, jaw, or neck; tremor (uncontrolled shaking);seizure (convulsions);pale skin, easy bruising or bleeding, flu symptoms;very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, feeling like you might pass out;stabbing chest pain, feeling short of breath, cough with yellow or green mucus;sudden mood changes, agitation, hallucinations, unusual thoughts or behavior; or
jaundice (yellowing of your skin or eyes).headache, dizziness, spinning sensation, drowsiness;sleep problems (insomnia);feeling restless or anxious;mild skin rash or itching;breast enlargement, irregular menstrual periods, loss of interest in sex; or dry mouth, blurred vision, urinating less than usual.
Precautions: severe cardiovascular disorders, Receiving anticonvulsant meds, anticoagulants, increased sensitivity to sun
Dosage:
Adults:0.5 to 5 mg orally 2 to 3 times a day
2 to 5 mg intramuscularly. May repeat every 4 to 8 hours. Doses up to 8 to 10 mg may be given intramuscularly. Acutely agitated patients may require hourly injections.
Children:Not recommended

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Dexamethasone (Decadron)

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Class: A synthetic adrenocortical steroid
Generic name: Baycadorn
MOA: Prevents the release of substances in the body that cause inflammation
Indications: acute asthma, croup, anti-inflammatory, cerebral edema, cushing syndrome, chemotherapy induced n/v, shock, multiple myeloma, multiple sclerosis, adrenal insufficiency, peds meningitis
Contraindications: hypersens. to drug/class/compon., systemic fungal infxn,
Side Effects: bloody, tarry stools, pancreatitis, low potassium, high blood pressure, vision problems, swelling, weight gain, shortness of breath, sleep problems, nausea, vomiting, slow wound healing, headache, muscle weakness. Precautions: Pregnancy category C, if CHF, seizure disorder, diabetes mellitus, HTN, TB infxn, osteoporosis, hepatic impairment
Dosage
Adult: 0.75 – 9 mg every 6-12 hrs po, im, iv
Pediatric: 1-2 mg/kg once iv, im

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Streptokinase

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Class: anticoagulant
Generic name: Streptase
MOA: An activator complex that converts plasminogen to the proteolytic enzyme plasmin.
Indications: acute evolving transmural MI, pulmonary embolism, deep vein thrombosis, arterial thrombosis or embolism, occlusion of arteriovenous cannulae
Contraindications: Active internal bleeding, recent CVA, intracranial or intraspinal surgery, intracranial neoplasm, uncontrolled hypertension
Side Effects/Precautions: bleeding, allergic reaction, respiratory depression, back pain, nausea, vomiting, MI, headaches,
Dosage
Adult: IV- 1,500,000 iu within 60 minutes, IC 20,000 iu by bolus followed by 2,000 iu/min for 60 minutes
Pediatric: N/A

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tPA (Tissue Plasmingen Activator)

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Class: Thrombolytic agent (clot busting drug)
Generic name: alteplase, activase
MOA: protein involved in breakdown of blood clots
Indications: blood clots, pulmonary embolism, MI, stroke, thrombolysis, frost bite
Contraindications: hemorrhagic shock, head trauma
Side Effects/Precautions: bleeding, pregnancy, nursing
Dosage
Adult: 0.9mg/kg (max of 90 mg) infused over 60 minutes with 10% of the total dose administered as an initial intravenous bolus over 1 minute
Pediatric: 18 and older

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Flumazenil (floo MAZ e nil)/ Romazicon

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Class: Emergency-Toxicity 1: Drugs
MOA: antagonizes benzodiazepine receptors
Indications: reverses the effects of certain types of sedatives from the benzodiazepine group of drugs. This includes Valium, Xanax, Tranxene, Librium, ProSom, Dalmane, Ativan, Restoril, Halcion, and others.,also used to treat benzodiazepine overdose.
Contraindications: hypersens. to drug/class/compon., TCA overdose, BZD for life-threatening dz, mixed overdose, tricyclic antidepressants
Side Effects: Serious Reactions: Seizures, withdrawal syndrome, arrhythmias, resedation, dizziness, nausea, vomiting, diaphoresis, headache, blurred vision, bradycardia, tachycardia, agitation, anxiety, fatigue, shivering, hiccups, cold sensation, confusion
Precautions: if seizure risk, alcoholism, hepatic impairment, psychiatric disorder, chronic BZD use for seizures, pregnancy c
Dosage:
Adult: 0.2 mg IV qmin x 1-5 doses, Max 1 mg total dose; 3 mg/h; Info: admin. IV push over 15sec; may repeat q20min for resedation
Peds: [>1 yo] Dose: 0.01 mg/kg IV qmin x1-5 doses; Max: 0.2 mg/dose; 0.05 mg/kg up to 1 mg total dose; Info: admin. IV push over 15sec

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Insulin
Brand Name: Novolog

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Class: Diabetes: Insulins
MOA: stimulates peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism
Indications: lowering levels of glucose (sugar) in the blood., used to treat type 1 (insulin-dependent) diabetes in adults and children who are at least 2 years old.
Contraindications: hypersens. to drug/class/compon., IV administration, hypoglycemia
Side Effects: hypoglycemia, severe, hypokalemia, hypersensitivity rxn-generalized, anaphylaxis, hypoglycemia, lipodystrophy at injection site, injection site rxn, pruritus, rash, weight gain, myalgia-generalized
Precautions: if infection, illness or stress, hypokalemia, hepatic impairment, renal impairment
Dosage:
Adult: diabetes mellitus [individualize dosing SC bid-qid]
usual total insulin requirement 0.5-1 units/kg/day;
Peds: diabetes mellitus [>2 yo]
Dose: individualize dosing SC bid-qid

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Isoproterenol (Isuprel)

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Class: Antiarrhythmics, Parenteral
MOA: stimulates beta adrenergic receptors
Indications: For mild or transient episodes of heart block that do not require electric shock or pacemaker therapy., For serious episodes of heart block and Adams-Stokes attacks (except when caused by ventricular tachycardia or fibrillation)., For use in cardiac arrest until electric shock or pacemaker therapy, the treatments of choice, is available., For bronchospasm occurring during anesthesia., As an adjunct to fluid and electrolyte replacement therapy and the use of other drugs and procedures in the treatment of hypovolemic and septic shock, low cardiac output (hypoperfusion) states, congestive heart failure, and cardiogenic shock.
Contraindications: hypersens. to drug/class/compon., hypersens. to sulfites, tachycardia, digitalis intoxication,angina; cocaine oronasolaryngeal, phenothiazines
Side Effects: stokes-adams seizures, arrhythmias, cardiac arrest, bronchospasm, hypotension-severe, nervousness, insomnia, restlessness, headache, tremor-minor, tachycardia, angina, nausea, vomiting, dyspepsia, skin flushing
Precautions: If renal impairment, cardiovascular dz, hyperthyroidism, diabetes mellitus, elderly pts
Dosage:
Adult: arrhythmias, emergent: [0.02-0.06 mg IV x1]-Info: then 0.01-0.2 mg IV or 2-20 mcg/min infusion, bradycardia, atropine-resistant: [2-10 mcg/min IV infusion], CHB after VSD closure: [0.02-0.06 mg IV x1]
Peds:N/A

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Ketamine (KET a meen)
Ketalar

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Class: Sedation; Anesthetic, general
MOA: exact mechanism of action unknown; acts on cortex and limbic receptors, producing dissociative analgesia and sedation
Indications: a general anesthetic to prevent pain and discomfort during certain medical tests or procedures, or minor surgery.
Contraindications: hypersens. to drug/class/compon., HTN, stroke, head trauma, intracranial mass or hemorrhage
Side Effects: respiratory depression, laryngospasm, ICP incr., IOP incr., hypotension-severe, bradycardia-severe, arrhythmias, emergence delirium, hallucinations, tonic clonic movements, anaphylaxis, withdrawal syndrome(long-term use), hypersalivation, anorexia, n/v, elevated BP, elevated HR, diplopia, nystagmus, fasciculations, depressed reflexes, hypotension
Precautions:if ICP incr, IOP incr., CAD, CHF, thyrotoxicosis, psychosis, hepatic impairment, acute alcoholism, chronic alcohol use, substance abuse
Dosage:
Adult: anesthesia induction-1-4.5 mg/kg IV over 1min; Alt: 0.5 mg/kg/min IV x2-4min; Info: onset 30sec, duration 5-10min for 2 mg/kg dose; give adjuvant antisialagogue and BZD
[IM route]- 6.5-13 mg/kg IM x1; Info: onset 3-4min, duration 12-25min for 10 mg/kg dose; give adjuvant antisialagogue and BZD
anesthesia maintenance [0.1-0.5 mg/min IV] Alt: 0.5-4.5 mg/kg IV prn; 3.25-13 mg/kg IM prn; Info: give adjuvant BZD prn
Peds:*procedural sedation [>3 mo, IV route] - 1.5 mg/kg IV over 1min; Info: onset 0.5-2min, duration 20-60min; consider adjuvant antisialagogue and BZD
[>3 mo, IM route] - 4-5 mg/kg IM x1; Info: onset 5-10min, duration 30-90min; consider adjuvant antisialagogue and BZD
[>3 mo, PO route] - 5 mg/kg PO x1; Info: onset 20-45min, duration 60-120min; mix injectable product in cola or other beverage; consider adjuvant antisialagogue and BZD

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Ketorolac (KEE toe ROLE ak)
Brand Names: Toradol, Toradol IM, Toradol IV/IM

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Class: Analgesics-NSAIDS
MOA: exact mechanism of action unknown; inhibits cyclooxygenase and lipoxygenase and reduces prostaglandin synthesis
Indications: reduces hormones that cause inflammation and pain in the body, used short-term (5 days or less) to treat moderate to severe pain.
Contraindications: hypersens. to drug/class/compon., ASA or NSAID-induced, asthma or urticaria, aspirin triad,GI bleed or PUD hx, cerebrovascular hemorrhage, coagulation disorder, active bleeding, CABG surgery (periop pain), epidural or intrathecal use, pregnancy 3rd trimester, labor and delivery, breastfeeding, renal impairment-severe, volume depletion
Side Effects: GI bleed, GI ulceration/perforation, ulcerative stomatitis, bleeding-severe, MI, stroke, thromboembolism, HTN, CHF, renal papillary necrosis, nephrotoxicity, hepatotoxicity-incl. fatal, bronchospasm, anaphylactoid rxns, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, anemia, blood dyscrasias, inflammatory bowel dx exacerbation, headache, nausea, abdominal pain, dyspepsia, dizziness, somnolence, constipation, diarrhea, edema, rash, elevated liver transaminases, fluid retention, tinnitus, injection site pain, pruritus, flatulence, sweating, ecchymosis, photosensitivity
Precautions: in elderly or debilitated pts, inflammatory bowel dz, anticoagulant use, coagulation disorder, corticosteroid use, alcohol use, smoker, asthma, hepatic impairment, renal impairment-mild to moderate, concurrent diuretics, ACEI or ARB use, CHF, HTN, cardiovascular dz, cardiac dz risk
Dosage:
Adult: pain, mod. severe [parenteral route, single dose tx] - 60 mg IM x1 or 30 mg IV x1; 30 mg IM x1 or 15 mg IV x1 if >65 yo or <50 kg; Info: use lowest effective dose
[parenteral route, multiple dose tx] - 30 mg IM/IV q6h; 15 mg IM/IV q6h if >65 yo or <50 kg; Max: 120 mg/day; 60 mg/day if >65yo or <50 kg; Info: combined duration of PO/IM/IV not to exceed 5 days; use lowest effective dose, shortest effective tx duration
[PO route] - 10 mg PO q4-6h; Max: 40 mg/day; Start: 20 mg PO x1 if <65 yo and >50 kg; Info: only for pts who received parenteral tx; duration of combined PO/IM/IV tx not to exceed 5 days; use lowest effective dose, shortest effective tx duration, renal dosing
[single dose tx] - renal impairment: 30 mg IM x1 or 15 mg IV x1; advanced impairment: contraindicated
[multiple dose tx] - renal impairment: 15 mg IM/IV q6h, max 60 mg/day or may switch to 10 mg PO q4-6h, max 40 mg/day; advanced impairment: contraindicated
Peds: *pain, mod. severe [>6 mo] - 0.5 mg/kg IM/IV q6h up to 72h; Alt: 1 mg/kg IM/IV q6h up to 24-48h; Max: 30 mg/dose IM, 15 mg/dose IV; Info: single dose tx FDA-approved for >2 yo; limited data on multiple dose tx; use lowest effective dose, shortest effective tx duration
renal dosing [adjust dose amount] renal impairment: decr. dose 50%; advanced impairment: contraindicated

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Labetalol (la BAY ta lol)
Brand Names: Normodyne, Trandate

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Class: Cardiovascular-Beta Blockers
MOA: selectively antagonizes alpha-1 adrenergic receptors; antagonizes beta-1 and beta-2 adrenergic receptors (selective alpha and non-selective beta blocker)
Indications: used to treat hypertension (high blood pressure).
Contraindications: hypersens. to drug/class/compon., sinus bradycardia, AV block - 2nd or 3rd degree, heart failure- uncompensated, cardiogenic shock, sick sinus syndrome w/o pacemaker, asthma-bronchial, avoid abrupt withdrawal
Side Effects: CHF, heart block, brdycardia-severe, hypotension, ventricular arrhythmias (IV), Raynaud phenomenon, bronchospasm, lupus erythematosus, hepatotoxicity, hepatic necrosis, hypersensitivity rxn, anaphylactoid rxns, intraoperative floppy iris syndrome, dizziness, paresthesias, n/v, elevated BUN-Cr, fatigue, dyspepsia, rhinitis, headache, ejaculatory dysfxn, dyspnea, edema
Precautions: if peripheral vascular dz, bronchospastic dz, major surgery, diabetes mellitus, thyroid disorder, WPW syndrome, hepatic impairment, renal impairment, pheochromocytoma, myasthenia gravis, severe anaphylactic rxn hx, in elderly pts
Dosage:
Adult:HTN [200-400 mg PO bid] Start: 100 mg PO bid, incr. 100 mg bid q2-3 days; Max 2400 mg/day; Info: may divide dose tid; taper dose over 1-2wk to D/C
hypertensive emergency [40-80 mg IV q10min] Start: 20 mg IV over 2min x1; Max: 300 mg IV; Alt: 2 mg/min IV; Info: to convert to PO give 200 mg PO x1 when BP controlled on IV, then 200-400 mg PO q6-12h; taper dose gradually to D/C
Peds: hypertensive emergency [0.4-1 mg/kg/h IV infusion] Max: 3 mg/kg/h; Info: taper dose gradually to D/C

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Lorazepam (lor A ze pam)
Brand Name: Ativan

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Class: Neurologic - Seizure Disorders; Insomnia; Sedation; BZDs 2: Mid-acting
MOA: binds to benzodiazepine receptors; enhances GABA effects
Indications: used to treat anxiety disorders.
Contraindications: hypersens to drug/class/compon, intra-arterial administration, neonates or infants (benzyl alcohol-containing forms), respiratory impairment-severe (IV), sodium oxybate
Side Effects: respiratory depression, apnea, respiratory failure, dependency-abuse, withdrawal if abrupt D/C, seizures, suicidality, tachycardia, hypotension, syncope, blood dyscrasias, jaundice, CNS stimulation, paradoxical, gangrene (intra-arterial), sedation, dizziness, asthenia, ataxia, local injection site rxn, respiratory depression, hypoventilation (IV), hypotension, fatigue, amnesia, confusion, disinhibition, irritability, libido changes, menstrual irregularities, diplopia, dysarthria, appetite change, constipation, incontinence, urinary retention, dystonia, elevated liver transaminases
Precautions: if pulmonary impairments, sleep apnea, CNS depression, alcohol use, alcohol or drug abuse hx, abrupt withdrawal, seizure hx, renal impairment, hepatic impairment, elderly or debilitated pts, depression
Dosage:
Adult: anxiety-[2-6 mg/day PO/IM/IV div bid-tid]
[2-4 mg PO qhs prn] Info: taper dose gradually to D/C if prolonged tx
status epilepticus [4 mg IV x1] Info: may repeat x1 after 10-15min
*nausea/vomiting, chemo-related [PO route]- 2.5 mg PO x2; Info: give night before and just after chemo
[IV route] - 1.5 mg/m^2 IV x1; Max: 3 mg/dose; Info: give 45min before chemo
*preoperative sedation
[IM route] - 0.05 mg/kg IM x1; Max: 4 mg/dose; Info: give >2h before surgery
[IV route] - 0.044-0.05 mg/kg IV x1; Max: 4 mg/dose; 2 mg/dose in elderly pts; Info: give 15-20min before surgery
Peds:*anxiety- 0.05 mg/kg PO/IV q4-8h; Max: 2 mg/dose; Info: periodically reassess need for tx; taper dose gradually to D/C if prolonged tx
*status epilepticus [0.05-0.1 mg/kg IV x1] Info: may repeat 0.05 mg/kg IV x1 after 10-15min
*nausea/vomiting, chemo-related - 0.02-0.05 mg/kg IV q6h prn; Max: 2 mg/dose
*preoperative sedation - 0.05 mg/kg PO/IM/IV x1; Max: 2 mg/dose; Info: give PO 1h, IM >2h, IV 15-20min before surgery

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Mannitol (MAN it ol)
Brand Name: Osmitrol

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Class: Neurologic: Other Neurologics; Diuretics 4: Other
MOA: elevates glomerular filtrate osmolarity (osmotic diuretic)
Indications: Diuretic, used to force urine production in people with acute (sudden) kidney failure. Increased urine production helps prevent the kidneys from shutting down, and also speeds up elimination of certain toxic substances in the body, also used to reduce swelling and pressure inside the eye or around the brain.
Contraindications: hypersens to drug/class/compon, anuria, pulmonary edema-severe, dehydration, intracranial hemorrhage
Side Effects: seizures, CHF, cardiovascular collapse, pulmonary edema, osmotic nephrosis, renal failure-acute, CNS depression, coma, extravasation necrosis, headache, n/v, polyuria, dizziness, rash, blurred vision, thrombophlebitis, fluid imbalance, electrolyte disorders, acidosis, dehydration, thrist, urticaria, hypotension, tachycardia
Precautions: if renal impairment
Dosage:
Adult: oliguria prevention [50-100 g IV x1] Start: 0.2 g/kg IV test dose, may repeat x1; Info: D/C if no response to test doses
oliguria tx [50-100 g IV] Start: 0.2 g/kg IV test dose, may repeat x1; Info: D/C if no response to test doses; titrate dose to maintain UO >30-50 mL/h
cerebral edema [0.25 g/kg IV q6-8h]
elevated IOP, ICP [0.25-2 g/kg IV x1] Info: give 60-90min before surgery
forced diuresis, adjunct tx [25-100 g IV] Info: for intoxications; titrate dose to maintain UO >100 mL/h
Peds: *oliguria tx [0.25-0.5 g/kg IV q4-6h] Start: 0.2 g/kg IV test dose, then 0.5-1 g/kg IV x1; Max: 12.5 g/dose; Info: D/C if no response w/in 2h
*cerebral edema [0.25-0.5 g/kg IV q4-6h] Start: 0.25 g/kg IV x1; Max: 1 g/kg/dose

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Metaproterenol (meh ta proe TER e nall)
Brand Names: Alupent, Metaprel

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Class: Asthma/Pulmonary: Beta-2 Agonists 3: Oral
MOA: stimulates beta-2 adrenergic receptors, relaxing airway smooth muscle (selective beta agonist)
Indications: Bronchodilator. It works by relaxing muscles in the airways to improve breathing, used to treat conditions such as asthma, bronchitis, and emphysema.
Contraindications: hypersens to drug/class/compon, arrhythmias-tachycardia-assoc., phenothiazines
Side Effects: cardiac arrest, bronchoconstriction-paradoxical, bronchospasm-acute, hypersensitivity rxn, nervousness, tachycardia, tremor, headache, palpitations, nausea,GI distress, dizziness, asthma exacerbation
Precautions: if HTN, CHD, CHF, diabetes mellitus, hyperthyroidism, convulsive disorder
Dosage:
Adult: Dosage forms: 10,20; 10/5 mL
asthma
[20 mg PO tid-qid]
Peds: asthma
[6-9 yo or <60 lb]
Dose: 10 mg PO tid-qid
[>9 yo or >60 lb]
Dose: 20 mg PO tid-qid

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Metoprolol (me TOE pro lol)
Brand Names: Lopressor, Metoprolol Succinate ER, Toprol-XL

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Class: Cardiovascular-Emergency-ACLS/PALS/NALS; Beta Blockers
MOA: selectively antagonizes beta-1 adrenergic receptors
Indications: used to treat angina and hypertension. It is also used to treat or prevent heart attack.
Contraindications: hypersens. to drug/class/compon., sinus bradycardia, HR <45 bpm (MI pts), AV block-2nd or 3rd degree, AV block-PR interval >0.24sec (MI pts), heart failure-uncompensated, heart failure-mod-severe (MI pts), SBP <100 mmHg (MI pts), cardiogenic shock, sick sinus syndrome w/o pacemaker, pheochromocytoma (beta blocker monotherapy), peripheral vascular dz, severe, avoid abrupt withdrawal
Side Effects: CHF, heart block, cardiogenic shock (MI pts), bradycardia-severe, Raynaud phenomenon, gangrene, bronchospasm, hepatitis, hypersensitivity rxn, photosensitivity, lupus erythematosus, agranulocytosis, fatigue, dizziness, diarrhea, pruritus, rash, depression, dyspnea, bradycardia
Precautions: if peripheral vascular dz, bronchospastic dz, major surgery, diabetes mellitus, thyroid disorder, WPW syndrome, hepatic impairment, myasthenia gravis, severe anaphylactic rxn hx, pregnancy 2nd or 3rd trimester, elderly pts
Dosage:
Adult:[immediate-release form] - 50-200 mg PO bid; Start: 50 mg PO bid, may incr. dose qwk; Max: 450 mg/day; Info: give w/ food; taper dose gradually over 1-2wk to D/C
[extended-release form] - 25-400 mg ER PO qd; Start: 25-100 mg ER PO qd, may incr. dose qwk; Max: 400 mg ER qd; Info: ER tabs may be cut in half, but do not crush/chew; taper dose gradually over 1-2wk to D/C
angina [immediate-release form] - 50-200 mg PO bid; Start: 50 mg PO bid, may incr. dose qwk; Max: 400 mg/day; Info: give w/ food; taper dose gradually over 1-2wk to D/C
[extended-release form] - 100-400 mg ER PO qd; Start: 100 mg ER PO qd may incr. dose qwk; Max: 400 mg/day; Info: ER tabs may be cut in half, but do not crush/chew; taper dose gradually over 1-2wk to D/C
MI, acute [100 mg PO bid] Start: 5 mg IV q2min x3; after 15min, give 50 mg PO q6h x48h, then incr. to target dose; Info: may give 25 mg PO q6h if unable to tolerate full IV dose; Info: taper dose gradually over 1-2wk to D/C
cardiovascular event prevention, post-MI
[100 mg PO bid] Info: start ASAP after pt stable; taper dose gradually over 1-2wk to D/C
CHF [12.5-200 mg ER PO qd] Start: 25 mg ER PO qd if NYHA class II, 12.5 mg ER PO qd if NYHA class III-IV; may double dose q2wk; Max: 200 mg/day; Info: ER tabs may be cut in half, but do not crush/chew; taper dose gradually over 1-2wk to D/C
Peds: hypertension [6-16 yo] - 1-2 mg/kg ER PO qd; Start: 1 mg/kg up to 50 mg ER PO qd, may incr. dose qwk; Max: 2 mg/kg/day up to 200 mg/day; Info: ER tabs may be cut in half, but do not crush/chew; taper dose gradually over 1-2wk to D/C

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Phenytoin (FEN i toyn)
Brand Names: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek, Phenytoin Sodium, Promt

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Class: Neurologic-Seizure Disorders
MOA: modulates neuronal voltage-dependent sodium and calcium channels
Indications: an anti-epileptic drug, also called an anticonvulsant. It works by slowing down impulses in the brain that cause seizures, is used to control seizures.
Contraindications: hypersens. to drug/class/compon., SA block (IV), AV block, 2nd or 3rd degree (IV), sinus bradycardia (IV), Adams-Stokes syndrome (IV)
Side Effects: ventricular fibrillation (IV), hypotension, severe (IV), cardiovascular collapse (IV), AV conduction abnormalities (IV), hepatotoxicity, thrombocytopenia, leukopenia, agranulocytosis, pancytopenia, anemia-megaloblastic, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, tissue necrosis (IV), purple glove syndrome (IV), hypersensitivity syndrome, lymphoma, lupus erythematosus, osteomalacia, toxic delirium, suicidality, nausea, vomiting, rash, nystagmus, ataxia, slurred speech, dizziness, confusion,blurred vision, somnolence, constipation, headache, insomnia, gingival hyperplasia, tremor, lymphadenopathy, coarse facies, hyperglycemia, osteomalacia, phlebitis (IV)
Precautions: if hypotension (IV), cardiovascular dz (IV), renal impairment, hepatic impairment, diabetes mellitus, pregnancy, elderly pts, porphyria, alcohol use, thyroid dz, avoid abrupt withdrawal, HLA-B*1502-positive, depression or hx
Dosage:
Adult: status epilepticus [15-20 mg/kg IV x1] Info: may give additional 10 mg/kg IV x1 after 20min if no response to initial dose; begin maint. dose 12h after loading dose
seizure disorder [300-400 mg/day PO div qd-tid] Start: load 15-20 mg/kg PO div in 3 doses 2-4h apart; Max: 400 mg/dose; Alt: 4-7 mg/kg/day PO div qd-tid; Info: if div doses unequal, give larger dose qhs; adjust dose based on levels; qd dosing w/ ER form only after stable on IR bid-tid dosing
seizure prophylaxis, neurosurgery-assoc.
[IV route] - 4-6 mg/kg/day IV div bid-tid; Start: load 10-20 mg/kg IV div in 3 doses 2-4h apart; Max: 400 mg/dose; Info: IV route preferred to IM route
[IM route] - 100-200 mg IM q4h; Max: x1wk; Alt: give 150% of usual daily PO dose by IM route div q4h; Info: decr. usual PO dose by 50% for same duration as IM was used when converting back from IM to PO
Peds:status epilepticus [15-20 mg/kg IV x1] Max: 1500 mg/day; Info: may give additional 10 mg/kg IV x1 after 20min if no response to initial dose; begin maint. dose 12h after loading dose
seizure disorder [<6 mo] - 5-8 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: if div doses unequal, give larger dose qhs; adjust dose based on levels
[6 mo-4 yo] - 8-10 mg/kg/day PO div bid-tid; Start: 5 mg/kg/day PO div bid-tid; Info: if div doses unequal, give larger dose qhs; adjust dose based on levels
[4-7 yo] - 7.5-9 mg/kg/day PO div bid-tid; Start: 5 mg/kg/day PO div bid-tid; Info: if div doses unequal, give larger dose qhs; adjust dose based on levels
[7-10 yo] - 7-8 mg/kg/day PO div qd-tid; Start: 5 mg/kg/day PO div bid-tid; Info: if div doses unequal, give larger dose qhs; adjust dose based on levels; qd dosing w/ ER form only after stable on IR bid-tid dosing
[10-16 yo] - 6-7 mg/kg/day PO div qd-tid; Start: 5 mg/kg/day PO div bid-tid; Info: if div doses unequal, give larger dose qhs; adjust dose based on levels; qd dosing w/ ER form only after stable on IR bid-tid dosing

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Physostigmine (antillirium)

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Class: Anesthesia Adjuncts; Toxicity 1: Drugs
MOA: reversibly binds to and inactivates acetylcholinesterase (cholinesterase inhibitor)
Indications: To reverse the effect upon the central nervous system, caused by clinical or toxic dosages of drugs capable of producing the anticholinergic syndrome.
Contraindications: hypersens. to drug/class/compon., hypersens. to sulfites, GI obstruction, GU tract obstruction, asthma, gangrene,diabetes mellitus, severe cardiovascular dz, arrhythmias, glaucoma - angle-closure, newborns
Side Effects: cholinergic crisis, bradycardia, AV block, arrhythmias, hypotension-severe, syncope, cardiac arrest, bronchospasm, respiratory depression, respiratory arrest, respiratory paralysis, pulmonary edema, paralysis, anaphylaxis, seizures, hallucinations, hypersalivation, nausea/vomiting, abdominal bloating/cramps, loose stools/diarrhea, flatulence, headache, dizziness, diaphoresis, lacrimation incr., rhinorrhea, pulmonary secretions incr., dyspnea, fasciculations, muscle weakness/cramps, urinary frequency/urgency, palpitations, miosis, blurred vision, restlessness, CNS stimulation
Precautions: if bradycardia, vagal tone incr., hypotension, peptic ulcer dz, GERD, hyperthyroidism, seizure disorder
Dosage:
Adult:anticholinergic toxicity
[0.5-2 mg IM/IV prn]
Info: may repeat q10-30min if severe sx persist or recur and cholinergic sx absent; have atropine available
nondepolarizing neuromuscular blockade reversal
[0.5-1 mg IM/IV prn]
Info: may repeat q10-30min until desired response
Peds:anticholinergic toxicity
[0.02 mg/kg IM/IV prn]
Max: 0.5 mg/dose, 2 mg total; Info: may repeat q5-10min if severe sx persist or recur and cholinergic sx absent; have atropine available

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Procainamide (Pronestyl)

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Class: Antiarrhythmics, Oral; Antiarrhythmics, Parenteral; ACLS/PALS/NALS
MOA: stabilizes membranes; depresses action potential phase 0 (class IA antiarrhythmic)
Indications: for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia
Contraindications: hypersens. to drug/class/compon., AV block-2nd or 3rd degree, myasthenia gravis, SLE, torsades de pointes, cisapride, dronedarone, phenothiazines, pimozide, quinolones-QT prolongers, toremifene, tricyclic antidepressants, ziprasidone
Side Effects: ventricular fibrillation, asystole, seizures, thrombocytopenia, neutropenia, anemia-hemolytic, lupus erythematosus, agranulocytosis, hypotension, bradycardia, flushing, urticaria, pruritus, angioedema, rash, fever, nausea, bitter taste, hallucinations, confusion, depression, vomiting, diarrhea, elevated LFTs, dizziness
Precautions: if bone marrow depression, renal impairment, CHF
Dosage:
Adult:ventricular arrhythmias [1-6 mg/min IV] Start: load 15-17 mg/kg IV over at least 30min, or 100 mg IV q5-10min, or 1-1.25 g PO; Alt: 50 mg/kg/day PO/IM/IV div q3-6h or PO div q6h (ER); Max: 1.5 g load, 9 g/day maintenance; Info: load until QRS widens 50%, arrhythmia suppressed, hypotension or max dose; adjust dose based on levels
*supraventricular arrhythmias [1-6 mg/min IV] Start: load 15-17 mg/kg IV over at least 30min, or 100 mg IV q5-10min, or 1-1.25 g PO; Alt: 50 mg/kg/day PO/IM/IV div q3-6h or PO div q6h (ER); Max: 1.5 g load, 9 g/day maintenance; Info: for atrial fib/flutter, reentrant tachycardias, PSVT, WPW; load until QRS widens 50%, arrhythmia suppressed, hypotension or max dose; adjust dose based on levels
renal dosing [IV route] CrCl 10-50: decr. dose 33%; CrCl <10: load 12 mg/kg x1, then decr. usual dose 67%; HD: give supplement; PD: no supplement; Info: monitor procainamide + NAPA levels
[PO route] CrCl 10-50: give q6-12h; CrCl <10: give q8-24h; HD: dose after dialysis; PD: give q12-24h, no supplement; Info: monitor procainamide + NAPA levels
Peds:ventricular arrhythmias [20-80 mcg/kg/min IV] Start: load 15 mg/kg IV over at least 30min, or 3-6 mg/kg up to 100 mg IV q5-10min; Alt: 15-30 mg/kg/day PO div q3-6h or 20-30 mg/kd/day IM div q4-6h; Max: 15 mg/kg load; 2 g/day IV, 4 g/day PO/IM maintenance; Info: load until QRS widens 50%, arrhythmia suppressed, hypotension or max dose; adjust dose based on levels
PALS, SVT [15 mg/kg IV x1] Info: may give additional doses if no response; not 1st-line tx; see PALS tables
PALS, VT [15 mg/kg IV x1] Info: may give additional doses if no response; not 1st-line tx; see PALS tables
*supraventricular arrhythmias [20-80 mcg/kg/min IV] Start: load 15 mg/kg IV over at least 30min, or 3-6 mg/kg up to 100 mg IV q5-10min; Alt: 15-30 mg/kg/day PO div q3-6h or 20-30 mg/kd/day IM div q4-6h; Max: 15 mg/kg load; 2 g/day IV, 4 g/day PO/IM maintenance; Info: for atrial fib/flutter, reentrant tachycardias, PSVT, WPW; load until QRS widens 50%, arrhythmia suppressed, hypotension or max dose; adjust dose based on levels
renal dosing [IV route] CrCl 10-50: decr. dose 33%; CrCl <10: load 12 mg/kg x1, then decr. usual dose 67%; HD: give supplement; PD: no supplement; Info: monitor procainamide + NAPA levels
[PO route] CrCl 10-50: give q6-12h; CrCl <10: give q8-24h; HD: dose after dialysis; PD: give q12-24h, no supplement; Info: monitor procainamide + NAPA levels

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Propranolol (pro PRAN oh lol)
Brand Names: Inderal, Inderal LA, InnoPran XL

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Class: Analgesics: Migraine/Headache; Beta Blockers
MOA: non-selectively antagonizes beta-1 and beta-2 adrenergic receptors
Indications: used to treat tremors, angina, hypertension, heart rhythm disorders, and other heart or circulatory conditions. It is also used to treat or prevent heart attack, and to reduce the severity and frequency of migraine headaches.
Contraindications: hypersens. to drug/class/compon., cardiogenic shock, sinus bradycardia w/o pacemaker, sick sinus syndrome w/o pacemaker, AV block-2nd or 3rd degree w/o pacemaker, heart failure-uncompensated, asthma-bronchial, avoid abrupt withdrawal, thioridazine
Side Effects: CHF, heart block, bradycardia-severe, Raynaud phenomenon, bronchospasm, lupus erythematosus, hypersensitivity rxn, Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis, erythema multiforme, anaphylactic/anaphylactoid rxns, agranulocytosis, fatigue, dizziness, constipation, bradycardia, hypotension, depression, insomnia, weakness, disorientation, nausea, diarrhea, allergic rxn, purpura, alopecia, impotence
Precautions: if peripheral vascular dz, bronchospastic dz, major surgery, diabetes mellitus, thyroid disorder, WPW syndrome, hepatic impairment, renal impairment, pheochromocytoma, pregnancy 2nd or 3rd trimester, myasthenia gravis, severe anaphylactic rxn hx, in elderly pts, if musculoskeletal dz
Dosage:
Adult: HTN [80-240 mg PO bid] Start: 40 mg PO bid, incr. dose q3-7 days; Max: 640 mg/day; Alt: start 80 mg ER PO qd, incr. dose q3-7 days to 120-160 mg ER PO qd; Info: taper dose gradually to D/C
angina [80-320 mg/day PO div bid-qid] Start: 80 mg/day PO div bid-qid, incr. dose q3-7 days; Max: 320 mg/day; Alt: start 80 mg ER PO qd, incr. dose q3-7 days; Info: taper dose gradually to D/C
cardiovascular event prevention, post-MI [180-240 mg/day PO div tid-qid] Start: 40 mg PO tid x1mo; Max: 240 mg/day; Info: start ASAP after pt stable; taper dose gradually to D/C
atrial fibrillation/flutter [10-30 mg PO tid-qid] Info: taper dose gradually to D/C
supraventricular arrhythmias [1-3 mg IV x1] Info: may give 2nd dose after 2min, subsequent doses q4h prn; reserved for life-threatening arrhythmias or those occurring under anesthesia; taper dose gradually to D/C
migraine headache prophylaxis [160-240 mg/day PO div bid-qid] Start: 80 mg/day PO div bid-qid; Alt: start 80 mg ER PO qd, incr. dose to 160-240 mg ER PO qd; Info: D/C if no response within 4-6wk; taper dose gradually to D/C
essential tremor [120 mg/day PO div bid-tid] Start: 40 mg PO bid; Max: 320 mg/day; Info: taper dose gradually to D/C
IHSS [20-40 mg PO tid-qid] Alt: 80-160 mg ER PO qd; Info: taper dose gradually to D/C
pheochromocytoma, adjunct tx [60 mg/day PO div bid-qid] Info: adjunct to alpha blockers; give x3 days prior to surgery; give 30 mg/day if inoperable tumor; taper dose gradually to D/C
*portal hypertension [10-60 mg PO tid-qid] Start: 10 mg PO tid; Info: titrate dose to reduce resting heart rate by 25%; taper dose gradually to D/C; for prevention of variceal bleeding
Peds: *HTN [1-5 mg/kg/day PO div q6-12h] Start: 0.5-1 mg/kg/day PO div q6-12h, may incr. dose q3-5 days; Max: 8 mg/kg/day; Info: taper dose gradually to D/C
*migraine prophylaxis [<35 kg] - 10-20 mg PO tid; Info: taper dose gradually to D/C
[>35 kg] - 20-40 mg PO tid; Info: taper dose gradually to D/C
*supraventricular arrhythmias [2-4 mg/kg/day PO div q6-8h] Start: 0.5-1 mg/kg/day PO div q6-12h, may incr. dose q3-5 days; Max: 16 mg/kg/day PO; 1 mg/dose IV (infants), 3 mg/dose IV (children); Alt: 0.01-0.1 mg/kg IV q6-8h prn; Info: taper dose gradually to D/C
*thyrotoxicosis [neonates] - 2 mg/kg/day PO div q6-12h; Info: taper dose gradually to D/C
[adolescents] - 10-40 mg PO q6h; Alt: 1-3 mg IV q4-6h prn; Info: taper dose gradually to D/C
*tetralogy spells [4-8 mg/kg/day PO div q6h] Start: 2-4 mg/kg/day PO div q6h; Max: 15 mg/kg/day; Alt: 0.15-0.25 mg/kg IV q15min prn x2

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Racemic Epinephrine

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Class: Asthma/Pulmonary-Other Pulmonary
MOA: stimulates alpha and beta adrenergic receptors, reducing mucosal secretions and relaxing bronchial smooth muscles (sympathomimetic)
Indications: moderate to severe croup, respiratory syncytial virus (Bronchiolitis)
Contraindications: hypersens. to drug/class/compon., hypersens. to sulfites (multi-dose vial)
Side Effects: arrhythmias, bronchospasm-paradoxical, nervousness, tremor, insomnia, nausea, tachycardia, dizziness, headache, loss of appetite
Precautions: if cardiac dz, HTN, hyperthyroidism, diabetes mellitus, glaucoma-angle-closure, BPH
Dosage:
Adult:Dosage forms: 2.25% neb
bronchospasm [0.5 mL NEB q3-4h] Info: onset 1-5min, duration 1-3h
Peds:croup [<4 yo] - 0.05 mL/kg NEB q2-4h; Max: 0.5 mL/dose q1-2h; Info: onset 1-5min, duration 1-3h
bronchospasm [>4 yo] - 0.5 mL NEB q3-4h; Info: onset 1-5min, duration 1-3h

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Calcium Gluconate

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Class:Electrolyte
MOA: repletes depleted stores of endogenous calcium
Indications: Hyperkalemia, calcium channel blocker OD, hypotension associated with magnesium sulfate or calcium channel blocker administration, and hydrofluoric acid burns
Contraindications: digitalis
Side Effects: Tissue necrosis
Interactions: sodium bicarbonate
Dosage: 10 – 30 mL

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aminophylline (a min OFF i lin)
Brand Names: Phyllocontin, Truphylline

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Class: bronchodilator, Other Asthma
MOA: exact mechanism of action unknown; increases cAMP; antagonizes adenosine receptors (methylxanthine)
Indications: asthma, bronchitis, and emphysema
Contraindicatons: hypersens. to drug/class/compon, febuxostat
Side Effects:seizures, arrhythmias, hypotension, shock, exfoliative dermatitis, nausea, vomiting, headache, insomnia, diarrhea, irritability, restlessness, tremor, diuresis-transient
Precaution: PUD, active, seizure disorder, arrhythmias, CHF, pulmonary edema, acute, cor pulmonale, hepatic impairment, hypothyroidism, febrile, sepsis w/ multi-organ failure, shock, smoking habit changes, neonates or infants, in elderly pts
Dosage:
Adult:asthma/COPD maintenance [380-760 mg/day PO/IV div q6-8h] Start: 380 mg/day x3 days, then 507 mg/day x3 days, then 760 mg/day if tolerated; Max: 1015 mg/day, 507 mg/day if reduced clearance; Info: note doses not equal to available tablet strengths; adjust dose based on serum levels; reduced clearance risk factors include elderly, hepatic impairment, CHF, fever, sepsis w/ multi-organ failure, shock, and hypothyroidism; 380 mg aminophylline = 300 mg theophylline
bronchospasm adjunct tx, acute
[healthy nonsmoker] - 0.5 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h, then 0.7 mg/kg/h IV x12h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.5 mg/kg/h aminophylline = 0.4 mg/kg/h theophylline
[smoker] - 0.8 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h, then 1 mg/kg/h IV x12h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.8 mg/kg/h aminophylline = 0.64 mg/kg/h theophylline
[elderly] - 0.3 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h, then 0.6 mg/kg/h IV x12h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.3 mg/kg/h aminophylline = 0.24 mg/kg/h theophylline
[pt w/ reduced clearance] - 0.25 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h, then 0.5 mg/kg/h IV x12h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; reduced clearance risk factors include hepatic impairment, CHF, fever, sepsis w/ multi-organ failure, shock, and hypothyroidism; 0.25 mg/kg/h aminophylline = 0.2 mg/kg/h theophylline
Peds:asthma maintenance [<45 kg] Start: 15.2-17.7 mg/kg/day up to 380 mg PO/IV div q4-6h x3 days, then 20.3 mg/kg/day up to 507 mg x3days, then 25.3 mg/kg/day up to 760 mg if tolerated; Max: 1015 mg/day, 507 mg/day if reduced clearance; Info: note doses not equal to available tablet strengths; adjust dose based on serum levels; reduced clearance risk factors include hepatic impairment, CHF, fever, sepsis w/ multi-organ failure, shock, and hypothyroidism; 380 mg aminophylline = 300 mg theophylline
[>45 kg] see Adult Dosing
bronchospasm adjunct tx, acute [<6 wk old] - 0.25 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.25 mg/kg/h aminophylline = 0.2 mg/kg/h theophylline
[6 wk old-6 mo] - 0.6 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.6 mg/kg/h aminophylline = 0.5 mg/kg/h theophylline
[6 mo-1 yo] - 0.75-0.8 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.75 mg/kg/h aminophylline = 0.6 mg/kg/h theophylline
[1-9 yo] - 1 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h, then 1.2 mg/kg/h IV x12h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 1 mg/kg/h aminophylline = 0.8 mg/kg/h theophylline
[9-12 yo or young smoker] - 0.9 mg/kg/h IV; Start: load 6 mg/kg IV x1 if no theophylline w/in 24h; Info: not recommended per NIH guidelines; adjust dose based on serum levels; 0.9 mg/kg/h aminophylline = 0.7 mg/kg/h theophylline
[>12 yo] see Adult Dosing
*apnea of prematurity [1-2 mg/kg PO/IV q6-8h] Start: 5-6 mg/kg PO/IV x1; Info: adjust dose based on serum levels