UNDERSTANDING CODE DRUGS



UNDERSTANDING CODE DRUGS



OXYGEN

• Essential in cardiac arrest and emergency cardiac care

• Expired air = 16-17% oxygen

• Must given supplemental oxygen @ FIO2 of 100%

• Give to all patients with acute chest pain that may be due to cardiac ischemia, suspected hypoxemia of any cause and cardiopulmonary arrest

• Do not withhold from patients with COPD

• Nasal cannula, masks, positive pressure devices, volume ventilators

• Major precaution: ADEQUATE VENTILATION - ensure by measuring end tidal CO2 and pulse oximeter

|MEDICATION |INDICATION/DOSAGES |NURSING CONSIDERATIONS |

|Adenosine |PSVT including PSVT associated with WPW syndrome: 6mg rapid IVP over 1-3 seconds |Side effects include- flushing, dyspnea, chest pain resolving within |

|(slows conduction through AV node and interrupts AV node reentry|then 2ml flush; if no response, repeat 12mg dose in 1-2min |1-2 min |

|pathways) | |Transient sinus bradycardia, ventricular ectopy or even a brief |

|Half-life= 1 seconds | |period of asystole |

|1 vial = 6mg | |* Interaction with theophylline, methylxanthines, and dipyridamole |

| | |may require dose adjustment or another drug |

|Amrinone- rapid acting inotropic. vasodilator similar to |CHF refractory to diuretics, vasodilators and conventional inotropics; Load with |Monitor for tachyarrhythmias |

|dobutamine |1mcg/kg then 2-15 mcg/kg/min |Do not mix with dextrose solutions |

|Mix in NSS | | |

|Atropine |Symptomatic bradycardia: 0.5- 1.0mg I.V. push q. 3-5 min, not to exceed a total |Don’t give less than 0.5mg per dose because the possible paradoxical |

|(parasympatholytic) |dose of 0.04mg/kg |effect may further slow heart rate |

|1mg atropine= 10ml bristojet |Asystole or PEA: 1mg I.V push q. 3-5min, not to exceed total dose of 0.04mg/kg |Use cautiously in presence of MI |

| |Relative bradycardia- HR wnl but insufficient to meet demands |If given via ET tube: dilute 1-2mg in 10ml sterile water or saline- |

| | |follow with 1ml flush of NSS |

| | |Enhances SA node automaticity and AV conduction via direct vagolytic |

| | |action |

|Beta Blockers- |Recurrent VT, VF or rapid PSVT refractory to other therapies |Reduce HR, BP, myocardial contractility, myocardial oxygen |

|Propranolol |Angina, atrial flutter and fibrillation |consumption |

|Metoprolol | |Slows AV conduction |

|Atenolol | |Administer slowly IV |

|Esmolol | |Monitor for CHF, bronchospasm |

|Bretylium |VF or pulseless VT unresponsive to defibrillation, epinephrine and lidocaine: |Not a first-line drug |

|(Adrenergic neuronal blocking and antifibrillatory agent) |5mg/kg IV push; if arrhythmia persists increase to 1mg/kg repeated every 5-10min |May cause severe hypotension |

|Vial = 50mg |to MAX dose of 35mg/kg |May induce projectile vomiting |

|Mix 1Gm/25D5W for drip |Stable VT or stable wide-complex tachycardia of uncertain origin: 5-10mg/kg over |Follow boluses with 2ml saline flush |

|(1mg/min = 15cc on pump) |8-1min; to MAX dose of 35 mg/kg over 24 hrs; if loading dose converts arrhythmia,|Treat hypotension with IV fluids, supine position, Trendelenburg |

| |start infusion @ 2 mg/min (30cc on pump) |position, norepinephrine may be required since may be refractory to |

| | |epinephrine |

| | |Hypertension and tachycardia are transient due to initial stimulation|

| | |of norepinephrine release |

| | |Use with caution in arrhythmias induced by digitalis toxicity |

|Calcium Chloride |Hyperkalemia, hypocalcemia, after multiple transfusions or Calcium channel |May cause slowing of HR |

|(increases myocardial contractile function- positive inotropic |blocker toxicity: 8-16mg/kg of 10% solution; repeat if necessary |May precipitate digitalis toxicity |

|effect modulated by effect on SVR + or -) | |* Precipitates with Na Bicarb |

|10ml bristojet = 1Gm | | |

|(1ml= 100mg) | | |

|Digoxin |atrial fib/flutter; CHF. Slows heart rate, increases force of contraction and |Monitor for nausea, visual disturbances, atrial or junctional |

| |refractory period of AV node |tachycardias, PVCs, heart blocks; K+ |

|Dobutamine- catecholamine- sympathomimetic-inotropic vasoactive-|Pulmonary congestion ; low cardiac output; hypotension; septic shock |Avoid alkaline solutions (Bicarb) |

|alpha and beta effects |- 2-2mcg/kg/min |Monitor for tachycardia, hypertension and ventricular ectopy |

|1mg/kg/min = 1cc if 6Xwt in Kg/100cc D5W | |Side effects include headache, nausea, tremor and hypokalemia |

|Dopamine- |Hemodynamically significant hypotension: |Use lowest dose that produces desired effect |

|catecholamine-vasoconstrictor |low dose- 1-2 mcg/kg/min= cerebral, mesenteric and renal vasodilation; UOP |Avoid in hypovolemia, high SVR, pulmonary congestion or increased |

|(dopaminergic, beta and alpha receptors) |increase; HR & BP unchanged |preload |

|Premix= 400mg/250cc D5W in top drawer of crash cart |mid dose- 2-1mcg/kg/min= increased cardiac output |Avoid Na Bicarb line |

| |high dose- >10mcg/kg/min= increased SVR, PVR, preload secondary to renal, |Avoid extravasation |

| |mesenteric, peripheral arterial and venous vasoconstriction |MAO inhibitors potentiate effects |

| |toxic dose- >20mcg/kg/min ischemic changes | |

| |Symptomatic bradycardia- add norepinephrine if > 20mcg/kg/min required | |

|Epinephrine- catecholamine |VF,pulseless VT,PEA, or asystole |Each dose given peripherally should be followed by 20ml fluid flush |

|(alpha & beta-adrenergic agonist) |-standard dosing: 1mg I.V. push q. 3-5min |to ensure delivery to central circulation |

|1mg epi= |-intermediate dosing: 2-5mg I.V.push over 3-5min |If no IV access available, give 2- 2.5 times the dose via ET tube; |

|(10ml of a 1:10,00solution) |-escalating dosing: 1mg,3mg,5mg I.V. push 3 min apart |follow with 10ml flush of NSS |

|or |- high dosing: 0.1mg/kg I.V. push q 3-5min |Intracardiac administration used only when no other route available |

|(1ml of a 1:100solution in multidose vial) |Symptomatic bradycardia: continuous infusion @ 2-1mcg/min; titrate to hemodynamic|Increases SVR, BP, cardiac electrical activity, coronary and cerebral|

| |response (not used as a first-line drug) |blood flow, strength of myocardial contraction, automaticity and |

| |MIX 1mg(1ml of a 1:100solution) in 500ml NSS or D5W |myocardial oxygen requirements |

|Heparin |Venous thrombosis and to prevent deep vein thrombosis and pulmonary embolism. |Hemorrhage, prolonged PTT, GI bleeding, chills, fever, rhinitis, |

| |Anticoagulant inhibits clotting of blood and fibrin clots. |acute reversible thrombocytopenia. |

| | |Antidote: Protamine Sulfate. |

|Isoproterenol- sympathomimetic with pure beta- potent inotropic |Temporary control of hemodynamically significant bradycardia after atropine, |Monitor for tachyarrhythmias and myocardial ischemia |

|and chronotropic effects) |pacing, dopamine and epinephrine used; 2-10mcg/min |Contraindicated in digitalis toxicity |

|1mg/25D5W Standard | | |

|Lasix |Pulmonary Edema |Monitor K+, dehydration and hypotension; electrolytes |

|(diuretic) |- 20-4mg IVP | |

|Lidocaine |VF or pulseless VT refractory to electrical countershocks and epinephrine: |Use 2-2.5 times the IV dose when given via ET tube; followed by 1ml |

|(Antiarrhythmic) |initially, 1-1.5mg/kg I.V. push; repeat q. 3-5min to max of 3mg/kg |saline flush |

|100mg = 10ml bristojet |Stable VT or stable wide-complex tachycardia of uncertain origin: repeat doses of|If toxic symptoms develop (slurred speech, altered LOC, muscle |

|1GM/25D5W= Premix drip in first drawer of crash cart |half the original dose |twitching and seizures), stop the drug or reduce the dose |

| |If lidocaine successfully converts the VF/VT; begin a continuous infusion @ |Do NOT give this drug if PVCs occur with bradycardia or escape rhythm|

| |2-4mg/min |No longer recommended for VF/VT prophylaxis in acute MI |

| |(1mg=15cc on pump) |* Suppresses ventricular arrhythmias and elevates the fibrillation |

| | |threshold (less likely to occur) |

|Magnesium |Torsades de points: Drug of Choice: up to 5- 1gms have been used |Monitor for flushing, sweating, bradycardia and hypotension; also if |

|(physiological calcium channel blocker and blocks neuromuscular |Acute MI with hypomagnesemia: intermittent or continuous infusion 0.5- 1.gm/hr |toxicity may see depressed reflexes, flaccid paralysis, circulatory |

|transmission) |VF/VT with hypomagnesemia: 1-2Gms diluted in 1ml D5W given IVP over 1-2 min |collapse, respiratory paralysis and diarrhea |

|5Gm/10ml bristojet | | |

|Morphine |Pulmonary Edema or Ischemic chest pain; 1 to 3 mg slow IV over 1 to 5 min until |Monitor for respiratory depression, hypotension, bradycardia, |

|(increases venous capacitance and reduces SVR, relieving |desired effect achieved |decreased LOC |

|pulmonary congestion- decreasing intramyocardial wall tension | |Have Narcan available for reversal |

|and myocardial oxygen requirements) | | |

|Neuromuscular blockers |To relax skeletal muscle; manage patients on ventilators |May need to provide sedatives/ analgesic. |

|Nitroglycerin |Angina Pectoris; dosing titration to effect |Monitor for headache, hypotension, syncope, faintness |

|(vasodilator) | | |

|50mg/25D5W | | |

|Norepinephrine |Refractory SHOCK |Increase BP by increasing SVR and thereby diminishing cardiac output |

|(catecholamine- potent alpha (arterial and venous |Hemodynamically significant hypotension refractory to other sympathomimetics |(increases myocardial oxygen demand, causes myocardial ischemia) |

|vasoconstriction) with minimal beta (increase contractility) |(septic and neurogenic shock) |Needs A-line for monitoring BP |

|effect |- Start with 0.5-1.mcg/min and titrate to effect |Also monitor CO, PCWP, PA pressures |

|MIX 8mg/250cc D5W or NSS | |Contraindicated in hypovolemia |

|(32mcg/ml) | |Extravasation leads to necrosis- phentolamine infiltration minimizes |

| | |sloughing |

|Potassium chloride | |Monitor K+ and Cl-. Monitor for signs of hyperkalemia (wide QRS |

| |Low serum K+, low Cl -; digitalis toxicity. |complex, tall, peaked T waves, disappearing P wave and asystole. |

| | |Watch for phlebitis, pain or redness at IV site. |

|Procainamide |Persistent cardiac arrest due to VF |Monitor BP closely during administration; may cause precipitous |

|(suppresses ventricular ectopy and slows intraventricular |PVCs or recurrent VT |hypotension; infuse cautiously in acute MI |

|conduction) |Dosing: 20-30mg/min until: |Contraindicated in patients with preexisting long QT intervals or |

|Vial= 500mg |arrhythmia suppressed |torsades de points |

|MIX 1Gm/25D5W for drip |hypotension occurs |* Hypokalemia and hypomagnesemia may exacerbate arrhythmias |

|(1mg/min = 15cc on pump) |PR or QRS widens by 50% of its original width | |

| |or MAX dose of 17mg/kg has been given | |

| |……..if effective, start drip @ 1-4mg/min | |

|Sodium Bicarbonate |Pre-existing metabolic acidosis or prolonged cardiopulmonary arrest with abnormal|Monitor ABGs |

|Bristojet= 8.4% 50meq/50ml |ABG not corrected by CPR and ventilation: 1 meq/kg IV bolus then ½ dose in 1min |Monitor for hypernatremia or hyperosmolarity |

| |prn | |

|Sodium Nitroprusside |Severe Hypertension; 0.5- 8.0mcg/kg/min |Monitor for hypotension |

|(vasodilator) | |Toxicity includes tinnitus, visual blurring, altered mental status, |

|50mg/25D5W or NSS | |nausea, abdominal pain, hyperreflexia, and seizures |

|Thrombolytics |Acute MI with thrombosis; other types of thrombosis |Watch for coagulopathies, bleeding disturbances |

|Streptokinase | | |

|TPA | | |

|Verapamil & Diltiazem |Acute and preventive treatment of PSVTs, and slowing ventricular response in |Reduce oxygen demand; decreased SVR caused by vasodilatation of |

|(Calcium channel blockers-direct negative chronotropic & |atrial flutter and fibrillation |vascular smooth muscle (coronary vasodilation) |

|negative inotropic effect) |Verapamil: 2.5-5mg IV bolus over 2 min; repeat dose 5-10mg in 15-3min then 5mg q | |

| |15 until desired response or total dose of 30mg given | |

| |Diltiazem: 0.25mg/kg (20mg for avg patient) IV over 2 min; may repeat 0.35mg/kg | |

| |in 15 min; then infusion of 5-15mg/hr titrated to HR | |

|Versed |To relieve anxiety in ventilated patients; pre-op sedation or anesthesia |Monitor for respiratory depression, apnea, laryngospasm, dyspnea, |

| |induction. |respiratory arrest, PVCs, amnesia, confusion, and visual |

| | |disturbances. Have emergency equipment available. |

CONVERSIONS

To change Pounds to Kilograms

2.2 pounds = 1 Kilogram

An easy way to calculate dosage in kilograms is simply to divide the weight of the patient in pounds by 2.2. This gives you the patient’s weight in kilograms.

Example

1. Patient’s weight is 16pounds.

160/2.2 = 72.7 kg

2. Patient’s weight is 44 pounds.

44/2.2 = 2kg

To convert to Milligrams per Kilogram

To calculate the dosage of a drug given in mg/kg, you multiply the number of milligrams needed times the patient’s weight in kilograms.

Example

If the patient is to receive a dose of 5 mg/kg of bretylium, multiply 5 times the patient’s weight in kilograms. The patients 44 pounds.

44/2.2 = 2kg Then

5mg/kg x 2kg = 10mg bretylium

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