SPECIFIC

TEACHING/ LEARNING A.V.

S.NO. TIME OBJECTIV CONTENT EVALUATION
ACTIVITY ACTIVITY AIDS
E
1. ADRENALINE

Functional class: Adrenergic.

Chemical class: Catecholamine.

Mechanism of action: It is a β1 and β2 causing increased levels of

cyclic AMP producing bronchodilation, cardiac and CNS stimulation.
It’s large doses causes vasoconstriction and increases Blood pressure.
Small doses cause vasodilatation via β2 vascular receptors.

Indications:

 Acute asthmatic attacks.

 Anaphylactic shock.
 Bronchospasm.
 Allergic reactions Cardiac arrest.

Contraindication: Hypersensitivity to sympathomimetics.

Precautions: Never mix this drug with any other drug in the syringe.

Pharmacokinetics: When administered subcutaneously the onset is 3-

5 minutes and duration is 20 minutes. When administered
intravenously the onset of action is 3-5 sec.

Drug interactions:

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  Methyldopa, Urinary acidifiers, β blockers decreases the
effects of Adrenaline.
 Urinary alkalinizers increase the effects of Adrenaline.

Dosage and routes: Intravenous 0.01mg/kg and repeat every 20

minutes upto 4 hours. It can be given intracardiac, intravenous and
endotracheal 5-10 µg, may be given 0.1µg/kg/minute using syringe
pump after the initial dose.

Available forms: Inj. 1:200 (5mg/ml), 1:1000 (1mg/ml), 1:2000

(0.5mg/ml), 1:10000 (0.1mg/ml), 1:100000 (0.01mg/ml).

Side effects:

 GI: Anorexia, nausea and vomiting.

 RS: Dyspnoea.
 GU: Urinary retention.
 CNS: Tremors, insomnia, headache, dizziness, confusion,
hallucination, cerebral hemorrhage.
 CVS: Palpitations, tachycardia, hypertension, dysrrhythmias,
elevated T-wave.

NURSES’ RESPONSIBILITIES:
Assess

 ECG continuously.
 BP and Pulse every 5 minutes.
 CVP if possible.
 Injection site for tissue sloughing.

Administer only clear reconstituted solution prepared within the past

24 hours if it is refrigerated.
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 Evaluate therapeutic response- increase and stabilize blood pressure.

Treatment of overdose: Administer an α blocker and β blocker.

2. AMINOPHYLLINE

Functional class: Bronchodilator.

Chemical class: Xanthine, ethylene diamine

Mechanism of action: It relaxes the smooth muscles of respiratory

system by blocking phosphodiesterase which increases the cyclic AMP
which in turn alters intracellular calcium ion movements, produces
bronchodilation, increases pulmonary blood flow and relaxes the
respiratory tract.

Indications:

 Bronchial asthma
 Bronchospasm
 Cheyne-stokes respiration

Contraindications:

 Hypersensitivity to xanthines
 Tachydysrrhythmias

Precautions:

 Hepatic disease

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  Hypertension

Pharmacokinetics: Absorption is good in erratic in PO administration

and erratic when administered rectally. It is distributed widely and
crosses placenta. It is metabolized by liver and excreted by kidneys.
Half life is from 3 to 12 hrs, increased in renal disease.

Drug interactions:

 Its effectiveness is decreased by barbiturates, loop diuretics,

phenytoin, Rifampicin, ketoconazole.
 Aminophylline toxicity is precipitated when administered with
allopurinol, cemetidine, erythromycin, interferon, mexiletine,
thiabendazole, β- adrenergic blockers, fluoroquinolones and
glucocorticoids.

Dosage and routes:

 PO: 5-7 mg/kg/dose Q8h.

 IV: Loading dose 5.6mg/kg may be given over ½ an hour and
the rest of 1.9mg/kg may be given by continuous IV infusion at
the rate of 1mg/kg/hr (maintenance infusion).
 In case of neonates IV/PO, 1mg/kg initially for plasma increases
of each 2 mg/ml and then 1mg/kg Q6h.

Available forms: Inj. IV/ IM/ rectal suppositories of 250mg and 500mg,
Elixir of 105mg/5ml, Tablets of 100mg, 200mg and consistent release
tablets of 225mg.

Side effects:

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  CNS: anxiety, restlessness, insomnia, dizziness, convulsions
headache, lightheadedness, muscle twitching.
 CVS: Palpitation, sinus tachycardia, hypotension, flushing,
dysrrhythmias, increased respiratory rate.
 GI: Nausea, vomiting, anorexia, diarrhea, bitter taste,
dyspepsia, anal irritation (in case of rectal suppositories),
epigastric pain.

 GU: Urinary frequency.

 Integumentary: flushing, urticaria.
 RS: Tachypnoea.

NURSES’ RESPONSIBILITIES:
Assess:

 The theophyllin blood level (therapeutic level is 10-20 μg/ml);

Toxicity may occur with small increases above 20 μg/ml.
 The manifestations of Aminophylline toxicity such as nausea,
vomiting, anxiety, restlessness, insomnia, tachycardia,
dysrrhythmias, convulsions; if present report it to the
pediatrician promptly.
 Intake and output as diuresis caused by the drug may lead to
dehydration especially in children.
 Respiratory rate, rhythm, depth, lung sounds bilaterally, heart
rate for tachycardia and premature ventricular contraction on
the ECG monitor.
 For allergic reactions such as urticaria and rash, if present,
discontinue the drug and inform the pediatrician.

Administer:

 The drug in divided doses round the clock to keep within the
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 therapeutic serum levels of aminophylline.
 The drug IV in emergency situation and then can switch to oral
administration by using a controlled release tablet.
 Orally only after meals/ water to decrease GI symptoms.
 The drug without crushing/ breaking in case of enteric coated
and controlled release tablets.
 Intravenously only after diluting in 5% dextrose to reduce
tissue irritation and burning sensation at the injection site.
 If required in a syringe with heparin, metoclopramide,
pentobarbital and thiopental which are the only syringe
compatible drugs.

Evaluate:

 The positive therapeutic outcome in terms of.

 Decreased dyspnoea.
 Decreased respiratory distress in infants.
 Clarity of lung fields bilaterally on auscultation.

3. ATROPINE SULPHATE

Functional class: Anticholinergic parasympatholytic, mydriatic.

Chemical class: Belladona alkaloid.

Mechanism of action: It blocks acetylcholine at parasympathetic

neuroeffector sites, increases cardiac output and heart rate by
blocking vagal stimulation in heart. It also dries secretions, decreases
sweating and salivation in low dose administration. It increases heart
rate and causes mydriasis and cycloplegia in moderate doses.

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Indications:

 Bronchospasm.
 Respiratory distress.
 Bradycardia.
 Bradydysrrhythymia.
 Insecticide poisoning.
 Profuse bronchial secretions.
 For mydriasis and cycloplegia in ophthalmology.

Contraindications:

 Hypersensitivity to belladonna alkaloids.

 Intestinal obstruction.
 Tachycardia/ tachydysrrhythmia.
 Asthma.
 Acute hemorrhage.
 Hepatic disease.

Precautions:

 Renal disorders.
 Tachydysrrhythmias.
 Hypertension.
 Intraabdominal infections.
 Down’s syndrome.
 Spastic paralysis.

Pharmacokinetics: It is absorbed well when administered PO, SC, IV

and IM. It crosses the blood-brain barrier during its distribution. It is
metabolized by liver and excreted by kidneys with 70-90% of
unchanged drug. Half life is 13 –40 min.
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Drug interactions:

 Its effectiveness is increased when administered in conjunction

with amantadine, dyspyramide, quinidine and antihistamines.
 Its effectiveness is decreased when administered with antacids.

Dosage and routes:

 Bradycardia/ bradydysrrhythmia: IV bolus 0.01 –0.03mg/kg up

2
to 0.4mg or 0.3mg/m and may repeat Q4-6h.
 Insecticide poisoning: IM/IV 2mg every hour until muscarinic
symptoms disappear.
 Cycloplegic refraction: 1-2 drops of 0.5% solution Bd or Tid for
up to 3 days before and 1 hr after ophthalmic examination.

Available forms:

 Injection: 0.05mg, 0.1mg, 0.3mg, 0.4mg, 0.5mg, 0.8mg and

1mg/ml.
 Tablets: 0.4mg
 Soluble tablets: 0.4mg and 0.6mg.
 Ointment: 1%
 Eye drops: 0.5%, 1% and 2%.

Side effects:

 CNS: headache, involuntary movements, confusion, psychosis,

anxiety, coma, weakness, insomnia.
 CVS: hypotension, paradoxic bradycardia, premature
ventricular contractions, tachycardia, hypertension, ectopic
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 ventricular beats.
 EENT: blurred vision, photophobia, papillary dilation, nasal
congestion.
 GI: dry mouth, nausea, vomiting, abdominal pain, anorexia,
constipation, paralytic ileus, abdominal distension,
 GU: urinary retention, hesitancy, dysuria
 Integumentary: rash, urticaria, contact dermatitis, dry skin,
flushing, decreased sweating.

NURSES’ RESPONSIBILITIES:
Assess:

 Intake and output ratio and assess for urinary retention,

 ECG for ectopic ventricular beats, premature ventricular
contractions and tachycardia
 Bowel sounds and assess for constipation and abdominal
distension,
 Respiratory status: rate, rhythm, depth, cyanosis, wheezing,
engorged neck veins.
 Cardiac status: rate, rhythm, character and BP continuously
 For allergic reactions such as rash and urticaria.

Administer:

 The drug (IV) either undiluted or diluted with 10ml sterile

water for injection and give it at the rate of 0.6mg/min
 The drug using a 3 way with extension and never add it into IV
fluids to prevent paradoxic bradycardia.
 The drug oral route ½ hr before food.
 The drug along with high fiber diet to prevent constipation.

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 Evaluate:

 Positive therapeutic outcome: decreased dysrrhythmias,

increased heart rate, decreased secretions, GU and GI spasms,
bronchodilation and cycloplegic refractions.

Treatment for overdose:

 Oxygen therapy.
 Artificial ventilation.
 ECG monitoring.
 Administer Inj. Dopamine in case of circulatory depression.
 Administer Inj. Diazepam/ thiopental for convulsions.

4. CALCIUM GLUCONATE

Functional class: Electrolyte replacement- calcium product.

Mechanism of action: The cation is needed for the maintenance of

nervous, muscular, skeletal, enzyme reactions, normal cardiac
contractility, coagulation of blood. It affects the secretary activity of
endocrine and exocrine glands.

Indication: Prevention and treatment of hypocalcemia,

hypermagnesemia, hypoparathyroidism, neonatal tetany, cardiac
toxicity caused by hyperkalemia Contraindications: Hypercalcemia,
digitalis toxicity, ventricular fibrillation, renal calculi.

Precautions: renal disease, respiratory disease, digitalized child,

respiratory failure.

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Pharmacokinetics: Onset is immediate. Duration unknown.

Drug Interactions: It increases dysrrhythmias when it is used with

digitalis.

Dosage and routes: IV/ PO 500mg/kg/day is divided doses.

Available form: Multiple concentrations of tablets and injections are

available.

Side effects:

 CVS: shortened Q-T wave, heart block, hypotension,

bradycardia, dysrrhythmias, cardiac arrest.
 Hypercalcemia: drowsiness, lethargy, muscle weakness,
headache, constipation,
 Coma, anorexia, nausea, vomiting, polyuria and thirst
 Integumentary: pain and burning at IV site, severe venous
thrombosis, necrosis and extravasation.
 Drug interactions:

 Increased dysrrhythmias with digitalis glycosides.

 Decreased action with calcium channel blockers.

NURSES’ RESPONSIBILITIES:
Assess:

 ECG for decreased QT and T wave inversion.

 Hypercalcemia, drug should be reduced or discontinued.
 Serum calcium levels during treatment.

Administer:
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  Through small-bore needle into large vein (IV), give over several
minutes. If extravasation occurs, necrosis will result. It can be
given diluted with compatible.
 Solutions or even undiluted. IM injection may cause severe
burning, necrosis and tissue sloughing, warm solution to body
temperature before administration.
 In large vein, avoid scalp.

Evaluate:

 Therapeutic response: decreased twitching, muscle spasms,

absence of tremors, convulsions, dyspnea, negative trousseau’s
sign.
 Cardiac status: rate, rhythm, CVP, PWP, QAWP if being
monitored directly.

5. DEXTROSE

Functional class: Caloric agent.

Chemical class: Glucose.

Mechanism of action: It is needed for adequate utilization of amino

acids; decrease protein and Nitrogen loss and prevents ketosis.

Indications:

 Hypoglycemia (to increase intake of calories).

 Fluid administration when children are nil per oral.

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Contraindications:

 Hyperglycemia.
 Hemorrhage (cranial or spinal).

Precautions:

 Renal, hepatic or cardiac disease.

 Juvenile diabetes.

Pharmocokinetics: It is well absorbed in oral administration and is

completely absorbed when it is administered intravenously. It is widely
distributed but the metabolism, excretion and half life is unknown.

Drug interactions: Oral hypoglycemic agents can lower the blood

glucose level and may cause recommence of hypoglycemia.

Dosage and routes: It depends on the situation and the blood glucose
levels. 2-4ml/kg of 25% Dextrose or 5-10ml/kg of 10% Dextrose or 10-
20ml/kg of 5% Dextrose.

Available form: Inj. IV 2.5%, 5%, 10%, 20%, 40%, 50%, 60%, 70%, oral
gel of 40% and chewable tabs of 5gm.

Side effects:

 CNS: Confusion, loss of consciousness, dizziness

 CVS: hypertension, pulmonary edema
 Endocrine: Hyperglycemia, rebound hypoglycemia, hyper osmolar
syndrome.
 GU: glycosuria, osmotic diuresis
 Integumentary: Chills, flushing, warm feeling, rash, urticaria,
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 extravasation necrosis.

NURSES’ RESPONSIBILITIES:

Assess:

 The intake and output, skin turgor, edema, electrolytes (potassium,

sodium, calcium, chloride, magnesium), blood glucose, ammonia,
phosphate.
 Injection site for extravasation, redness along the vein, edema at
the site, necrois, pain, hard tender area, IV site should be changed
immediately to prevent necrosis.
 Vital signs every 4 hrs.
 Serum glucose to prevent hyperglycemia.

Administer:

 Oral glucose only when the child is above 5 yrs and conscious;
st
monitor serum glucose after 1 dose to see if the glucose level has
increased by at least 20mg% by 20-30 min, if not repeat the dose
and reassess serum glucose levels.
 Intravenously by using a central venous access.
 Undiluted in the prepared solution very slowly.

Evaluate:

 The blood glucose levels for normal values and diminished signs of
hypoglycemia.
 The hydration status of the child.

6. DIAZEPAM
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Functional class: Antianxietic.

Chemical class: Benzodiazepine.

Mechanism of action: It potentiates the action of Gamma Amino

Butyric Acid especially in the limbic system, reticular formation and
enhances presympathetic inhibition, inhibits spinal polysynaptic
afferent paths

Indications:

 Seizure disorder.
 Anxiety.
 Preoperative skeletal muscle relaxant.

Contraindications: Hypersensitivity to benzodiazepines

Precautions:

 Debilitation
 Hepatic disease
 Renal disease

Phamacokinetics: Absorption is rapid in oral administration and erratic

when administered intramuscularly. It is widely distributed, crosses
blood- brain barrier. The drug is metabolized by liver, excreted by
kidneys and the half-life is 20-80 hrs

Drug interactions

 The drug’s effects is decreased by cimetidine, Rifampicin, Valproic

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 acid and Narcotics
 Its affect is increased when CNS depressants are administered.

Dosage and routes:

 Seizure: child > 6 months: 1-2.5mg Tid/ Qid.

 Tetanic muscle spasm: Child < 5 yrs: IM/IV 5-10mg Q3-4 h prn.
 Status epilepticus: IV bolus 0.1-0.3mg/kg (1mg/min over 3 min) or
may repeat every 15 min for up to 2 doses.

Available form: Tabs 2, 5 and 10mg , Inj. 10mg/ml.

Side effects:

 CNS: Dizziness, drowsiness, confusion, headache, fatigue,

hallucinations.
 CVS: orthostatic hypotension, ECG changes, tachycardia.
 EENT: blurred vision, tinnitus, mydriasis.
 GI: constipation, dry mouth, nausea, vomiting, anorexia, diarrhea.
 Integumentary: rash, dermatitis, itching.

NURSES’ RESPONSIBILITIES:
Assess:

 The type, duration and frequency of seizures and restlessness.

 The blood pressure, pulse and respiration, if BP is low, withhold
the drug and inform the pediatrician.
 For seizure control and what precipitates seizures.
 For hepatic enzyme studies.

Administer:

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  Orally after food or milk to minimize GI symptoms.
 Intravenously into a large vein, do not dilute or mix with any other
drug, over a long period, more than 3 min for every 5 mg to avoid
thrombosis/ phlebitis precipitated by rapid administration.

Evaluate: Decrease in seizures and restlessness.

Treatment for overdose:

 Stomach wash.
 Supportive care.
 Monitoring of vital signs.

7. DIGOXIN

Functional class: Antidysrrhythmic, cardiac glycoside

Chemical class: Digitalis preparation.

Mechanism of action: It acts by inhibiting the sodium-potassium

Adinosine tryphosphatase which makes more calcium available for
contractile proteins, resulting in increased cardiac contractility and
cardiac output.

Indications: CHF, arterial fibrillation, atrial flutter, atrial tachycardia,

rapid digitalization in these cases.

Contraindications: Hypersensitivity to digitalis, ventricular fibrillation,

rd
ventricular tachycardia, carotid sinus syndrome, 2nd and 3 degree
heart block.

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Precautions: Renal disease, AV blocks, severe respiratory disease,
hypothyroidism, hypokalemia.

Pharmacokinetics: IV onset 5-30 min, peak 1-5 hrs, duration variable,

half life 1.5 days and is excreted in urine.

Drug Interactions:

 Hypokalemia is resulted when used with diuretics,

amphotericin B, carbenicillin, ticarcillin, corticosteroids.
 Digoxin toxicity is precipitated when administered in
conjunction with adrenergics, amphotericin B, corticosteroids,
diuretics, glucose, insulin, reserpine, quinidine.

 Incompatible with all medications in syringe or solution.

Dosage and routes:

 1 month to 2 years: IV 0.03- 0.05 mg/kg in divided doses > 5

min Q4-8 hrs. Change to PO as soon as possible; PO 0.035-
0.060 mg/kg in 3 divided doses Over 24 hrs; maintenance of
0.01- 0.02mg/kg in divided doses Q12 h.
 More than 2 years: PO 0.02-0.04 mg/kg in divided doses Q8h
over 24 hrs, maintenance 0.006-0.012 mg/kg Qid in divided
doses; IV loading dose 0.015 –0.035 mg/kg over >5 min.
 Neonates: IV loading dose 0.02-0.03 mg/kg over >5 min in
divided doses Q4-8h; change to PO at the earliest possible. PO
loading dose 0.035mg/kg divided in 3 doses/24 hrs, maintenance
dose of 0.01mg/kg divided in 2 doses/24 hrs.
 Premature infants: IV 0.015 – 0.025 mg/kg divided in 3
doses/24hrs, given over >5 min, maintenance 0.003 –0.009
mg/kg in divided doses (Q12h). As a thumb rule for digitalization, it
Page 18 of 44
 can be given according to the following: Premature babies-
0.04mg/kg/day, Mature newborn- 0.06mg/kg/day, infants- 0.06-
0.08mg/kg/day, Older children- 0.04mg/kg/day PO (Give 2/3 of the
PO dose if the drug is given Intravenously.

Available form: Elixir 50 μg/ml; tablets 125, 250, 500 μg/ml, Inj. 100,
250 μg/ml and caps 50, 100, 200 μg.

Side effects:

 CNS: headache, drowsiness, apathy, confusion, disorientation,

fatigue, depression, hallucination.
 CVS: dysrrhythmias, AV block, hypotension, bradycardia.
 GIT: nausea, vomiting, anorexia, diarrhea, abdominal pain.
 EENT: Blurred vision, yellow-green halos, photophobia,
diplopia.
 MS: muscular weakness.

NURSES’ RESPONSIBILITIES:

Assess:

 Apical pulse for 1 min before giving drug; if pulse <60/min do

not administer. If it were >60/min administer it. Also assess it
after 1 hour, if it had dropped to
 <60/min, reassess after 1 hour. If it is still <60/min call the
pediatrician.
 Electrolytes like potassium, sodium, magnesium, calcium
should be assessed for imbalance.
 Liver function tests and renal function tests are to be assessed
for impaired organ
 function.
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  Daily weight and intake and output ratio
 Monitor serum digoxin levels (therapeutic level is 0.5-2mg/ml).

Administer:

 Potassium supplements if ordered for potassium levels of <3.0

mEq/dl.
 IV undiluted or 1ml of drug/4ml sterile H2O, 5% Dextrose, or
normal saline; give over >5 min through Y-tube or 3-way stopcock.

Evaluate:

 Therapeutic response: decreased weight, edema, pulse,

respiratory and increased urine output.
 Cardiac status; apical pulse, character, rate and rhythm.

Treatment for overdose:

 Discontinue the drug.

 Monitor ECG.
 Administer Vit. K
 Administer Adrenergic blocking agent, Digoxin immune FAB
(Ovine).

8. DOBUTAMINE

Functional class: Adrenergic, direct acting, β1- agonist.

Chemical class: Catecholamine.

Mechanism of action: It causes increased contractility, increased

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coronary blood flow and heart rate by acting on β1 receptors in heart.

Indication: Cardiac surgery and refractory heart failure

Contraindication: Hypersensitivity, idiopathic hypertropic subaortic

stenosis.

Precautions: Hypertension.

Pharmacokinetics: IV; onset 1-5 min, peak 10 min, half-life 2 min,

metabolized in liver (inactive metabolites), excreted in urine.

Drug Interactions:

 Others and β blockers may decrease the effect of

dobutamine.
 Incompatible with sodium bicarbonate solution.

Dosage and routes: 2.5 – 15 μg/ kg/min. through intravenous

continuous infusion.

Available form: Inj. 250mg vial (IV)

Side effects:

 CNS: Anxiety, headache, dizziness

 CVS: Palpitation, tachycardia, hypertension, premature
ventricular contractions
 GIT: Heartburn, nausea, vomiting
 MS: muscle cramps in especially legs.

Page 21 of 44
 NURSES’ RESPONSIBILITIES:

Assess:

 Input and output ratio

 ECG during administration continuously, if BP increases, drug
dose is reduced

 BP and pulse Q5 min after parenteral administration.

 CVP or PWP during infusion if possible.

Administer:

 IV dilution each 250 mg/10ml of sterile H2O or 5% Dextrose for

Inj. It may further be diluted to 50 ml prior to loading it in the
syringe pump.
 Plasma expanders for hypovolemia
 Parenteral (IV) dose slowly, after reconstituting, then diluting
with at least 50 ml of 5% Dextrose, 0.9% NS or sodium lactate.

Evaluate: Therapeutic response: Increased BP with stabilization.

Treatment for overdose: Administer a β1 adrenergic blocker.

9. DOPAMINE

Functional class: Agonist, vasopressor, inotropic agent.

Chemical class: Catecholamine.

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Mechanism of action: It causes increased cardiac output, acts on -
receptors, causing vasoconstriction in blood vessels; when low doses
are administered, causes renal and mesenteric vasodilation.

Indications:

 Shock
 Severe hypotension

Contraindications: Hypersensitivity, ventricular fibrillation,

tachydysrrhythmias, pheochromocytoma

Precautions:

 Arterial embolism.
 Peripheral vascular disease.

Pharmacokinetics: It is completely absorbed when administered

intravenously and is distributed widely. It is metabolized by liver and
excreted by kidneys. Half life is 2 min.

Drug interactions: Its effect is increased by phenytoin and cardiac

glycosides.

Dosage and routes: 1-3 g/kg/min and to titrate according to the

child’s response.

Available forms: Inj. 0.8mg, 1.6mg, 40mg, 80mg and 160mg/ml.

Side effects:

 CNS: Headache.
Page 23 of 44
  CVS: Palpitation, tachycardia, Hypertension, ectopic beats.
 GIT: Nausea, vomiting, diarrhea.
 Integumentary: Gangrene, tissue sloughing with extravasation.
 Respiratory: Dyspnoea.

NURSES’ RESPONSIBILITIES:
Assess:

 ECGs for rhythm disturbances.

 or crackles in lungs, S3 gallop, dyspnea, neck vein distension as
these may indicate heart failure.
 Oxygenation for perfusion deficits.
 BP and Pulse Q5 min during infusion.
 For extravasation, change site Q4-8h.

Administer:

Intravenously by continuous infusion using a syringe pump/ infusion

pump in a large dilution.

Evaluate: Positive therapeutic response: increased cardiac output.

Treatment for overdose:

 Discontinue the drug

 Support circulation.

10. FRUSEMIDE

Functional class: Loop diuretic.

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Chemical class: Sulfonamide derivative.

Mechanism of action: It acts on the ascending loop of Henle in the

kidney, inhibiting the reabsorption of the electrolytes sodium and
chloride, causing excretion of sodium, calcium, magnesium, chloride,
water and some potassium, it also decreases reabsorption of sodium
and chloride and increase the excretion of potassium in the distal
tubules of the kidney. It is responsible for slight antihypertensive
effect and peripheral vasodilation.

Indications:

 Edema in nephritic syndrome, congestive heart failure, ascites

 Hepatic cirrhosis.

Contraindications:

 Hypersensitivity to sulfonamides
 Anuria
 Hypovolemia
 Electrolyte depletion.

Precautions:

 Dehydration
 Severe renal disease
 Juvenile diabetes

Pharmacokinetics: Absorption is 60 –70% in the GI tract, is widely

distributed. It is metabolized by liver and is excreted in urine and
stools. Its half-life is 30-60 min.
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Drug interactions:

Its effects are increased by Indomethacin, Adrenergic blockers,

clofibrate, ganglionic blockers.

Dosage and Routes: PO/ IM/ IV 2mg/kg, may increase upto 6mg/kg
and it can be given 1-2mg/kg/ Q6-8h

Available form:

 Tabs: 20mg, 40mg, 80mg.

 Oral solution: 10mg/ml.
 IV/ IM Injection 10mg/ml.

Side effects:

 CNS: headache, fatigue, weakness, vertigo.

 CVS: Orthostatic hypotension, circulatory collapse, ECG changes.
 ENT: Hearing loss, tinnitus, blurred vision.
 GI: Nausea, diarrhea, vomiting.
 GU: Polyuria, renal failure, glycosuria.
 Hematological: Leukopenia, anemia, agranulocytosis.
 Integumentary: Rash, Pruritis, purpura.
 Musculoskeletal: cramps, stiffness.

NURSES’ RESPONSIBILITIES:
Assess:

 For tinnitus, hearing loss, ear pain especially with IV route of

administration.
 Renal, cardiac, neurologic, GI and pulmonary manifestations of
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 hypokalemia, acidic urine, polyuria, nocturia, hypotension, broad
T-wave, tachycardia, weak pulse, drowsiness, lethargy, confusion,
anorexia, constipation, hypoventilation.
 For signs of hypocalcemia, nausea, vomiting, constipation,
abdominal pain, hypotension, muscle twitching, seizure, spasm of
muscles.
 Fluid volume status: intake and output ratio, daily weight,
distended veins, crackles in lungs, skin turgor.
 Electrolyte reports for imbalance
 Blood pressure and heart rate at regular intervals.

Administer:

 In the morning hours to avoid interferences with sleep.

 Orally along with food to avoid nausea.
 Only clear solution for injection using a 3-way. Stopcock, undiluted
drug, not more than 20 mg/min.
 As continuous infusion using normal saline, RL, 5% Dextrose or
10% Dextrose.

Evaluate:

 Positive therapeutic outcome:

 Decreased edema
 Decreased BP
 Lowered calcium level
 Increased diuresis.

Treatment for overdose:

 Lavage if the drug was given orally.

 Monitor electrolytes.
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  Administer Dextrose in saline.
 Monitor hydration, cardiovascular status and renal status.

11. HYDROCORTISONE SODIUM

Functional class: Corticosteroid.

Chemical class: Short-acting glucocorticoid.

Mechanism of action: It decreases inflammation by suppression of

migration of polymorphonuclear leukocytes, fibroblasts, reversal of
increased capillary permeability ad lysosomal stabilization.

Indications: Acute asthmatic attack, shock, adrenal insufficiency and

ulcerative colitis.

Contraindications: Idiopathic thrombocytopenic purpura, acute

glomerulonephritis, amoebiasis, fungal infection, nonasthmatic
bronchial disease, child less than 2 years, AIDS, Tuberculosis.

Precautions: Seizures, CHF, renal disease.

Pharmacokinetics:

 IM/ IV: onset 20 min, peak 4-8 hours and duration 1-1 ½ days.
 Metabolized by liver, excreted in urine.

Drug interactions:

 It decreases effects of barbiturates, rifampicin, ephedrine,

phenytoin, theophylline, anticonvulsants, anticoagulants,

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 neostigmine and salicylates
 Increases the side effects of indomethacin, salicylates, digitalis,
cyclosporine and diuretics.

Dosage and routes: In shock, IM/ IV 0.16-1mg/kg Bd or Tid. Available

form: Injection 25mg/ ml, 50mg/ml

Side effects:

 CNS: depression, flushing, sweating, headache

 CVS: hypertension, circulatory collapse, thrombophlebitis,
embolism,
 tachycardia, edema
 Integumentary: Ache, poor wound healing, ecchymosis,
petechiae
 Musculoskeletal: fractures, weakness
 GI: diarrhoea, nausea, abdominal distension, GI hemorrhage,
increased appetite, pancreatitis.
 EENT: fungal infection, blurred vision.

NURSES’ RESPONSIBILITIES:

Assessment:

 Potassium, blood sugar, urine glucose while on long term

therapy; hypokalemia and hyperglycemia are to be watched for.
 Daily weight and intake output ratio.

 BP and pulse every 4 hours, notify if chest pain occurs.

 Plasma cortisol levels.

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 Administer:

 IV undiluted or added to dextrose or saline 25mg or less per

minute.
 Shake the parenteral suspension well.
 Use lowest effective dose.
 IM injections into the deep muscle mass, rotate sites, avoid
deltoid muscle.
 Avoid subcutaneous routes to avoid tissue damage.
 Taper the drug to avoid withdrawal effects (adrenal crisis).

Evaluate:

 Therapeutic response: ease of respiration, decreased

inflammation.
 Infection manifested by increased temperature, WBC
 Potassium depletion as evidenced by paresthesia, fatigue,
nausea, vomiting, depression, polyuria, weakness and
dysrrhythmias
 Edema, hypertension, cardiac symptoms
 Mental status: affect, mood, behavior changes, aggression.

12. NALOXONE

Functional class: Opioid antagonist.

Chemical class: Thebaine derivative.

Mechanism of action: It competes with narcotics at narcotic receptor

sites

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Indications:

 Asphyxia neonatrum.
 Respiratory depression induced by narcotics, pentazocine,
propoxyphene.
 Refractory circulatory shock.

Contraindications: Hypersensitivity.

Precautions: Children above 30 days of age.

Pharmacokinetics: It is well absorbed (SC & IM) and completely

absorbed when it is administered intravenously. It is rapid in
distribution and is metabolized by liver and excreted by kidneys. Its
half life is 1 hr in children and upto 3 hrs in neonates.

Drug interactions: It is incompatible with alkaline drugs, bisulfites and

sulfites.

Dosage and routes:

 Asphyxia neonatrum: Neonates- IV 0.01 mg/kg given into umbilical

vein after delivery and may repeat in Q2-3 x 3 doses.
 Opioid induced respiratory depression: IV/IM/SC 0.01mg/kg Q2-3
prn.

Available forms: Inj. 0.4mg/ml, 1mg/ml, neonatal Inj. 0.02mg/ml

Side effects:

 CNS: drowsiness, nervousness.

 CVS: ventricular tachycardia, fibrillation, increased systolic Bp.
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  GI: nausea, vomiting.
 Respiratory: Hyperpnea.

NURSES’ RESPONSIBILITIES:

Assess:

 For opioid withdrawal: cramping, hypertension, vomiting.

 Vital signs for respiratory rate and rhythm.
 ABG reports.
 Cardiac status: tachycardia, hypertension and ECG.

Administer:

 By divided IV, undiluted 0.04mg or less over 15 seconds.

 By continuous IV infusion further diluted with 0.9% NaCl and 5%
Dextrose.
 Only with resuscitative equipment with Oxygen facility.
 Solution prepared within the last 24 hrs and stored at room
temperature in darkness.

Evaluate: Alertness as the drug reverses the respiratory depression.

13. PHENOBARBITAL SODIUM

Functional class: Anticonvulsant, sedative/ hypnotic.

Chemical class: Barbiturate.

Mechanism of action: It depresses the activity in the brain cells

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primarily in reticular activating system in brainstem. It also selectively
depresses neurons in the posterior hypothalamus and limbic
structures. It is able to decrease the seizure activity by inhibition of
impulses in CNS and it decreases motor activity.

Indications:

 All forms of epilepsy

 Status epilepticus
 Febrile convulsions
 Sedation
 Insomnia
 Premedication
 Hyperbilirubinemia
 Chronic cholestasis

Contraindications:

 Phenobarbital addiction (present/past).

 Hypersensitivity to barbiturates.
 Hepatic disease.
 Respiratory disease.
 Nephritis.
 Porphyria.

Precautions: Anemia.

Pharmacokinetics:

Absorption is slow and is limited to 70-90% in cases of PO/im/iv routes

of administration. It crosses placenta during the distribution of the
drug. It is metabolized upto 75% by the liver. Excretion is done by
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kidneys with 25% unchanged drug. Half life duration is 2-6 days.

Drug interactions:

 It decreases the effectiveness of chroramphenicol, cyclosporine,

Dacarbazine, quinidine, anticoagulants, glucocorticoids and
tricyclic antidepressants.
 It increases CNS depression when administered with valproic acid,
antidepressants, antihistamine, narcotics and sedatives.

Dosage and routes:

 Seizures: PO 4-6 mg/kg/day in single / 2 divided doses with 12

hours interval.
 Status epilepticus: IV infusion of 5-10 mg/kg and may be repeated
every 10-15 min upto 20mg/kg but do not infuse faster than
50mg/min.
 Sedation: PO 6mg/kg/day in 3 divided doses.
 Insomnia: PO / IM 3-6 mg/kg.
 Premedication for surgery: PO 6mg/kg/day in 3 divided doses.
 Hyperbilirubinemia: Neonate- PO 7mg/kg/day on days 1-5 after
birth. IM 5mg/kg/day on day 1 and then PO dose from 2-7 days
after birth.
 Chronic cholestasis: PO 3-12 mg/kg/day in 2-3 divided doses.

Available forms:

 Elixir of 15mg and 20mg /5ml

 Tablets of 8mg, 15mg, 16mg, 30mg, 32mg, 60mg, 65mg and
100mg.
 Capsules of 16mg
 Injection of 30mg, 60mg, 130mg/ml
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Side effects:

 CNS: drowsiness, lethargy, hangover headache, flushing, coma.

 GI: Nausea, vomiting, diarrhea, constipation.
 Integumentary: Rash, urticaria, Stevens-Johnson syndrome,
angioedema, local pain and swelling at the site of injection,
necrosis and thrombophlebitis.

NURSES’ RESPONSIBILITIES:

Assess:

 Mental status, sensorium, affect and

 Withdrawal insomnia in case of short-term use but do not restart
the drug administration
 Respiratory status for respiratory depression, character, rate and
rhythm disturbances in respiration
 For sign of barbiturate toxicity, hypotension, pulmonary
constriction, cols, clammy skin, central cyanosis, nausea, vomiting,
hallucination and pupillary constriction.
 For lowered pain threshold postoperatively
 The reduction in seizure activity.

Administer:

 The drug after trying conservative measures for insomnia

 On empty stomach for best absorption
 Intramuscular injection into deep muscle (gluteal) and split
injections > 5ml into 2 different sites to minimize soft tissue
irritation.
 IV only into a large vein to present extravasation at the rate of less
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 than 50mg/min.
 The drug using diluents from 5% Dextrose, 10% dextrose, 0.45%
NaCl, 0.9% NaCl, RL
 The drug using a separate syringe.

Evaluate the positive therapeutic outcome by

 Improved sleeping pattern

 Decreased seizure activity
 Sedation preoperatively.

Treatment for overdose: Inj. Calcium Gluconate IV.

14. SODIUM BICARBONATE

Functional class: Alkalinizer.

Chemical class: NaHCO3.

Mechanism of action: It increases the plasma bicarbonate level which

+
buffers H ion concentration and it reverses acidosis.

Indication: Metabolic acidosis.

Contraindications:

 Cardiac arrest
 Hypertension
 Renal disease

Precautions: CHF, cirrhosis, renal disease

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Pharmacokinetics: IV onset 15 min, duration 1-2 hrs and is excreted in
urine.

Drug Interactions:

 It increases the effects of amphetamines, quinidine and

psuedoephedrine.
 It decreases effects of chloropropamide, barbiturates and
salicylates
 The injection should not be mixed with other solutions as it is
incompatible.

Dosage and route:

 In acidosis; .2-5 mEq/kg IV depending upon CO 2 and pH

 In cardiac arrest; 1mEq/kg IV bolus and then 0.5 mEq/kg Q10
min and then based on ABG report.
 In case of infants, do not exceed 8 mEq/kg/day for IV bolus.

Available form: Injection with solution of 4%, 4.2%, 5%, 7.5%, 8.4%.

Side effects:

 CNS: Irritability, confusion, tremors, twitching, hyperreflexia,

tetany, convulsions.
 CVS: irregular pulse, cardiac arrest, water retension, Weight
gain and edema.
 GI: Flatulence, paralytic ileus, abdominal distension.
 Metabolism: alkalosis.
 GU: Calculi.

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 Respiratory: Shallow, slow respiration, cyanosis, apnea.

NURSES’ RESPONSIBILITIES:

Assess:

 Respiratory rate, pulse rate, rhythm, depth, lung sounds and notify
the abnormalities.
 Intake and output, daily weight.
 Electrolyte values and ABG reports.
 Urine PH.
 For extravasation which may cause tissue sloughing, ulceration and
necrosis..

Administer:

 IV diluted in an equal amount of saline.

Evaluate:

 The therapeutic response: ABGs, electrolytes, blood PH, H Co3.

 Alkalosis which may be indicated by irritability, confusion,
twitching, hyperreflexia, bradypnoea, cyanosis and irregular pulse
 Milk-alkali syndrome as manifested by nausea, vomiting, anorexia,
urinary stones, hypercalcemia.

Page 38 of 44
 CALCULATION OF DRUG DOSES

❖ CALCULATION OF MEDICATION DOSES

The commonest formula is:

Desired dose ‘x’ = Ordered dosage x volume in hand
Hand dosage

Example:
Inj. Valium 1mg is ordered by the pediatrician.

Desired dose ‘x’ = 1 mg x 1 ml

10 mg=0.1 ml
(1 ml of Inj. Valium contains 10 mg)

Dose calculation for children using body surface area.

Body surface area is determined by using a nomogram and

the child’s height and weight. This is the most accurate method
of calculating a child’s dosage. The formula is

Formula 1:
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 2
Child’s dosage=Surface area of child(m ) X normal adult dose
2
1.7 m
Formula 2:
BSA of child X Adult dose = estimated child’s
dose BSA of adult

2 2
Formula 3: BSA of child (m ) X dose /m = estimated child’s dose

Clark’s rule:
It is used for infants and toddlers and is based on the
weight of the child.
Child dose = weight in pounds x adult dose
150

In this formula ‘150’ represents the average adult weight in

pounds and thus it gives only an approximate child dose

Fried’s rule for infants and children upto 2 years of age:

Age in months x adult dose

150

Young’s rule for children from 1 year to 12 years:

It is based on the age of the child, regardless of the weight. ‘It

is a rule of the thumb’method for calculating the drug dose
for a child.

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 Age in years x adult dose
Age + 12

❖ CALCULATION OF FLOW RATE FOR IV FLUIDS:

ml/hr = Total volume to be infused (ml) Total time (hrs)

Rate of flow (gtt/min) =Total volume in milliliters X Drop factor

Total time in minutes

Example: 500ml of normal saline should be infused over 24 hrs

ml/hr = Total volume to be infused (ml) = 500=20.83 ml/hr

Total time (hrs) 24

Rate of flow (gtt/min) = Total volume in milliliters X Drop factor

Total time in minutes

= 500 (ml) x 60 (micro drops)

24hrs x 60min

= 20-21 micro drops/min

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 ❖ METHOD FOR RAPID CALCULATION OF DRUGS
GIVEN BY INFUSION:

Dose per hr= mg of drug x flow rate

ml of solution

Concentration = mg of drug
mg of solution

mg of drug = x mg
ml of solution ordered flow rate

x mg = mg of drug x ordered flow rate

ml of solution

Flow rate = hourly dose

concentration

Example: A pediatrician orders 5 μg/kg/min of Dobutamin. The

patient weighs 5 kgs and the pharmacist sends the solution with
1000μg.
Flow rate = 5mg of drug = 0.01 mg/ ml
Page 42 of 44
 = 10μg concentration 500ml

Doctors order = 5μg/min = 0.5ml/min 10μg

5μg /min x 60= 30ml/hr 10μg

WEIGHTS AND EQUIVALENTS

METRIC SYSTEM
Weight:
▪ 1 kilogram (kg) = 1000 grams
▪ 1 gram (gm) = 1000 milligrams
▪ 1 milligram (mg) = 1000 Micrograms

Volumes:
▪ 1 liter = 1000 milliliters
▪ 1 pint = 500 milliliters
▪ 1 ounce = 30 milliliters
▪ 1 milliliter = 15 macro drops or 60 micro drops
▪ 1 macro drop = 4 micro drops
15. 2 min To CONCLUSION:- Lecture They listen PPT
conclude method attentively. slide
the topic Pediatric Emergency Drugs play a vital role in protecting, maintaining
and restoring the health of the critically ill children when they are used
rationally and efficiently. Most of these drugs are chemicals and some
of these could be toxic if a medication error occurs. It is easy to

Page 43 of 44
administer the drug but it is difficult to remove these from the body in
case of adverse reactions. It requires a greater degree of knowledge
on Pediatric Emergency Drugs and the Calculation of Drug Doses and
needless to say the necessary confidence to apply this knowledge in
critical situations.

Acquiring adequate knowledge on Pediatric Emergency Drugs and the

Calculation of Drug Doses is the foundation for the acquisition of skills
and positive attitude towards the care of children who are critically ill.

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