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Oxygen as an Emergency Drug O2 is a drug, without O2 brain death begins within 6 minutes), its a 1st line drug for

r all emergency situations Depending on the circumstances, oxygenation may be all that is necessary to treat physiologic disturbances: chest pain, bradycardia, & cardiac dysrhythmias. Before pharmacologic are administered, ensure that the clients airway & breathing are patent. o Giving a drug to treat a disorder cause by hypoxemia w/o correcting the patent of airway 1st is ineffective Ideally O2 saturation should be kept at or above 95%. Vasoconstriction, severe anemia, hypothermia, CO poisoning, & shock inaccurate pulse oximetry readings The ambient room air contains 21% O2. Fraction of inspired oxygen (FiO2): 21% of O2 of total volume air. Clients suffering from severe physiologic stress: shocks, traumatic injury, AMI with hemodynamic instability, and cardiac arrest initially require high [O2] (i.e. an FiO2 100%). The O2 devices for these conditions: o Nonrebrealher mask with an O2 reservoir (O2flow rate set at 10-15 L/min) for spontaneously breathing o Bag-valve-mask device attached to an O2 source at a flow rate of 15 L/min for ventilation assistant. Caution with clients with COPD, who may lose their hypoxic respiratory drive when given high [O2] o Prepared to ventilate the client manually with a bag-valve-mask if respiratory depression/arrest occurs. A FiO2 > 50% for long period O2 toxicity & other detrimental effects to the pulmonary system For emergency situations that do not involve severe physiologic stress (e.g. angina, dysrhythmias, pulmonary disease), supplemental O2 delivered by nasal cannula may have significant physiologic benefit. Young children may better tolerate a face tent with a high O2 flow of 10 to 15 L than a face mask. Emergency Drugs for Cardiac Disorders Cardiac emergencies such as angina, MI, cardiac dysrhythmias, & cardiac arrest. In a resuscitation situation, the foundation of client therapy is based upon oxygenation & ventilation, CPR & electrical therapy (cardioversion & defibrillation) according to established treatment algorithms and standards. Drugs are used as adjuncts in synchrony with these efforts to enhance the likelihood of a successful outcome. These drugs often must be prepared and administered rapidly. A sound knowledge base as well as easy access to the drugs and necessary equipment is essential for the best client response in a cardiac emergency. Usually in an emergency, detailed personal, medical, drug, and herbal histories are unavailable. o Treatment is based on client presentation. A. Nitroglycerin Nitroglycerin dilates coronary arteries & improves blood flow to an ischemic myocardium o Treatment for angina pectoris and MI. A focused medication history is essential prior to administration, even in emergency situations, because nitroglycerin in combination with sildenafil [Viagra], rardenafil [Levitra], tadalafil [Cialis]) causes hypotension when taken within a 24-48 hour period; its contraindicated Nitroglycerin is available in sublingual, translingual aerosol spray, oral, topical, and IV forms. For acute angina attack: o Sublingual (0.3-0.4 mg): s/he should sit/lie down, put 1 tablet under the tongue & allow it to dissolve Not all sublingual nitroglycerin preparations cause a burning sensation under the tongue, so a lack of burning sensation should not be relied on to indicate potency, If chest pain is not relieved, repeat the dosage at 5 minute intervals for a total of 3 tablets o Translingual aerosol spray (0.4 mg-metered dose): sprayed (not inhaled) onto or under the tongue. DO NOT swallow for 10 seconds to allow absorption of the drug. As with sublingual nitroglycerin, up to three doses may be taken within 15 minutes. o If pain persists, further interventions are necessary in an emergency/critical care setting. o Hypotension is a common adverse effect, especially the first time a client takes nitroglycerin. Tachycardia (in adults > 100 bpm) or bradycardia may occur. Therefore, Monitor BP & HR closely o Clients who take these drugs while wearing a nitroglycerin patch are at higher risk for hypotension. o Though tolerance to nitrates can develop in individuals who take nitroglycerin daily (have some protection against hypotension), the nitroglycerin patch need to be removed if BP instability occurs. o To prevent arcing & skin burns, remove the nitroglycerin patch before cardioversion/defibrillation.

For unstable angina or an AMI: IV nitroglycerin o Initiated @ 10-20 mcg/min, increased by 5-10 mcg/min q 5-10 min, based on angina & BP response o Continuous BP & heart monitoring are required, because hypotension is a common adverse effect. Hypotension is treated by reducing/discontinuing the infusion & by placing the client in a supine position with legs elevated if tolerated. B. Morphine Sulfate its a narcotic analgesic; is used to treat angina associated with AMI & acute cardiogenic pulmonary edema Morphine relieves pain, dilates venous vessels, and reduces the workload on the heart. o Standard dosage: 1-4 mg IV over 1-5 minutes, repeat every 5-30 minutes until chest pain is relieved o Closely monitoring is essential because respiratory depression & hypotension are common adverse effects; administer the drug slowly & titrate it carefully Morphine can relieve dyspnea caused by pulmonary edema. o In this situation, respiratory distress is not a contraindication to morphine administration. The narcotic antagonist naloxone (Narcan) is the antidote to reverse the action of morphine sulfate o The dose is 0.4 to 2 mg every 2 minutes as indicated C. Atropine Sulfate Atropine sulfate is indicated in the treatment of hemodynamically bradycardia and some types of heart block (e.g. AV block at nodal level), as well as asystole and pulseless electrical activity. Atropine acts to increase heart rate by inhibiting the action of the vagus nerve (parasympatholytic effect). Atropine sulfate is an antidote to reverse organophosphate pesticide toxicity and nerve agent exposure, which include bradycardia and excessive secretions In symptomatic bradycardia: 0.5-1 mg IV at 3-5 min intervals until the desired heart rate is achieved OR until 0.04 mg/kg (no more than 3 mg) is given. In asystole (cardiac arrest): 1 mg IV bolus followed by a 20 ml IV fluid bolus and elevation of the extremity to speed drug delivery during CPR; may be repeated q 3-5 min / up to 0.04 mg/kg [< 3 mg IV]. o Adult IV dose should never be < 0.5 mg. Doses < 0.5 mg can produce a paradoxical bradycardia; o At doses of 0.04 mg/kg, vagal activity is blocked; further atropine administration has no benefits. If IV access is not available, atropine sulfate should be given thru intraosseous (1O) route. As a last resort, it may be given via the endotracheal tube (ETT) if venous or intraosseous access cannot be achieved. The dose for ETT administration is 2-2.5x the IV dose, diluted with normal saline or sterile water. o 2-3 mg diluted in 5-10 ml of normal saline/sterile water and instilled into the ETT via a feeding tube o The client should be ventilated vigorously with a bag-valve device to enhance absorption of the drug. Adverse effects: cardiac dysrhythmias, tachycardia, myocardial ischemia, restlessness, anxiety, mydriasis, thirst, and urinary retention. Continuous cardiac & BP monitoring is essential Pediatric Implications For infants < 6 months, cardiac output is depended on HR; bradycardia (HR < 100 bpm) must be treated. A HR < 60 bpm in an infant requires performance of CPR. o B4 drugs are given, efforts should targeted first toward restoring adequate ventilation & oxygenation For neonates in cardiac arrest / with a spontaneous HR < 80 bpm, epinephrine 0.01 to 0.03 mg/kg IV/IO q 3-5 minutes should be given prior to atropine to elevate the HR; o Stressed neonates quickly deplete their own stores of catecholamine. o If these interventions do not work, atropine is indicated in the presence of vagal tone or AV block The pediatric dose of atropine is 0.02 mg/kg IV/IO. The minimum single pediatric dose is 0.1 mg & the maximum single child dose is 0.5 mg IV. The maximum total pediatric dose is 1 mg in a child and 2 mg in an adolescent. D. Isoproterenol Isoproterenol is a beta-adrenergic drug given to increase the heart rate. Because of the deleterious effects, isoproterenol IV is only initiated as a temporary measure while awaiting the availability of a transcutaneous pacemaker after the maximum dose of atropine (3 mg) has been given to clients with refractory hemodynamically significant bradycardia.

Its administered to treat bradycardia in clients with -blocker poisoning or after a heart transplant. o The transplanted heart is denervated; atropine will be ineffective in treating bradycardia (< 60 bpm). o Isoproterenol IV is administered, 1 mg diluted in 250 ml of D5W or normal saline, at 2-10 mcg/min o An electronic infusion device must be used to provide precise infusion control. Myocardial O2 consumption is greatly increased; carefully monitor the client receiving isoproterenol. Adverse effects: myocardial ischemia, tachycardia, and life-threatening dysrhythmias (e.g. ventricular tachycardia & ventricular fibrillation). Alert the doc promptly if any increase in premature ventricular contractions or if the heart rate exceeds 100 beats/min, because the dosage may need to be decreased or the infusion stopped. Isoproterenol should never be used to treat clients in cardiac arrest. Pediatric Implications Isoproterenol infusions are not indicated for treating bradycardia in children; epinephrine infusions instead. E. Adenosine Adenosine is the 1st line drug to treat paroxysmal supraventricular tachycardia (PSVT), a sudden, uncontrolled, rapid rhythm (exceeding150 beats/min in adults) that originates above the ventricles. Adenosine slows impulse conduction thru the AV node, interrupts dysrhythmia-producing reentry pathways, and restores a normal rhythm in clients with PSVT. Convert PSVT sinus rhythm. Because t is < 5 seconds: 1. 1st dose is given rapidly as a 6-mg IV bolus over 1-3 seconds followed by a 20-ml saline flush. 2. 2nd dose is given if PSVT persists: a 12-mg bolus given 1-2 minutes after the initial dose. 3. 3rd dose of 12 mg may be considered after 1-2 minutes if needed. o Continuously monitor cardiac and frequent assessment of vital signs. Adenosine is inhibited by methylxanthines (e.g. caffeine & theophylline), so higher doses may be needed. SE: ventricular ectopy, bradycardia, flushing, chest pain & dyspnea may occur. o a short period of asystole may follow injection of adenosine (up to 15 seconds). Contraindicated: in clients with poison or drug related tachycardia, 2nd & 3rd degree heart block, and in clients with sick sinus syndrome, except those with functioning pacemakers. o If the tachycardia originated in the ventricles, the client could deteriorate and become hypotensive after adenosine administration. F. Verapamil Verapamil, a Ca channel blocker, for the treatment of narrow complex PSVT as an alternative to adenosine in clients with normal BP and adequate left ventricular function (i.e. no evidence of HF). It slows conduction (negative chronotropic) thru the heart & has negative inotropic & vasodilating effects. It can be administered by: 1) Verapamil IV bolus 2.5-5 mg slowly over 2 minutes. o Repeated doses of 5-10 mg may be ordered in 15-30 minutes. The maximum total dose is 20 mg. 2) Verapamil IV 5 mg of q 15 minutes until a maximum of total dose of 30 mg Carefully monitor HR, rhythm, & BP; cardiac conduction disturbances and hypotension can occur, especially with concurrent use of beta-blockers. An IV injection of Ca is ordered to treat Ca channel blocker induced hypotension. Contraindicated: preexisting heart block / sick sinus syndrome in client without a pacemaker, WolffParkinson-White syndrome, HF, and simultaneous use of Ca channel blockers & -blockers together. o Their (-) inotropic & chronotropic effects are synergistic myocardial depression & bradycardia. G. Diltiazem Diltiazem, a 2nd line Ca channel blocker agent after adenosine, is administered as an IV bolus to treat PSVT & to slow the ventricular response rate in atrial fibrillation or flutter;. Diltiazem has less of a negative inotropic effect than verapamil, but strong negative chronotropic actions. Therefore, IV diltiazem is less likely to cause cardiac depression, but is very effective in controlling HR. 1) 1st dose of diltiazem IV bolus is 0.25 mg/kg given over 2 minutes. 2) 2nd dose of diltiazem IV bolus is 0.35 mg/kg over 2-5 minutes if PSVT does not convert normal sinus rhythm in 15 minutes,.

3) A continuous infusion of diltiazem at a dose range of 5-15 mg/hour is given for ongoing control of the ventricular rate in clients with atrial fibrillation or flutter, titrated according to the desired heart rate. The nurse must carefully monitor BP, HR, and rhythm after administering IV diltiazem. SE & AR: Arrhythmias, bradycardia, heart block and hypotension may develop. o Diltiazem can elevate serum digoxin levels, predisposing the client to digitalis toxicity. Contraindicated: preexisting heart block / sick sinus syndrome in client without a pacemaker, WolffParkinson-White syndrome, HF, and simultaneous use of Ca channel blockers & -blockers together. o Their (-) inotropic & chronotropic effects are synergistic myocardial depression & bradycardia. H. Amiodarone Amiodarone IV is a 1ST line agent for treating life-threatening ventricular dysrhythmias & cardiac arrest. It has alpha and beta adrenergic blocking effects and acts on Na, K, and Ca channels. Indications for use: pulseless ventricular tachycardia & fibrillation (after defibrillation and epinephrine), hemodynamically stable ventricular tachycardia, PSVT refractory to adenosine, ventricular rate control in atrial fibrillation, and for pharmacologic treatment of atrial fibrillation. Amiodarone is esp. good for clients with HF who have atrial and ventricular dysrhythmias. o Its more effective and has fewer proarrhythmic properties than other agents with similar actions. For clients who have a pulse (i.e. not in cardiac arrest): o Amiodarone 150 mg IV over 10 minutes o Followed by a continuous infusion of 1 mg/min for 6 hours, o Maintenance infusion of 0.5 mg/min over 18 hours For clients in cardiac arrest because of pulseless ventricular tachycardia or ventricular fibrillation: o Amiodarone 300 mg diluted in 20 to 30 ml D5W at a rapid infusion o Followed by a continuous infusion of 1 mg/min for 6 hours, o Additional doses of 150 mg at a rapid infusion if ventricular fibrillation/tachycardia recurs. o The maximum daily dose is 2.2 grams per 24 hour period. Adverse effects: hypotension & bradycardia. slow the infusion rate to prevent or treat these effects o Administer IV fluids, vasopressors, and agents to increase heart rate. o A temporary pacemaker may be needed. Amiodarone has a long t . It should not be given concurrently with drugs that prolong the Q-T interval (e.g., procainamide). Pediatric Implications For pulseless ventricular tachycardia and fibrillation: o Amiodarone 5 mg/kg rapid IV/IO bolus. For responsive children who have supraventricular (junctional & atrial) tachycardia & ventricular dysrhythmias with pulses present: o Amiodarone 5 mg/kg IV/IO over 20-60 min and repeated to a maximum daily IV dose of 15 mg/kg I. Lidocaine Lidocaine is an alternative agent to amiodarone to treat ventricular dysrhythmias (e.g. frequent premature ventricular contractions (PVCs), ventricular tachycardia, and ventricular fibrillation). Lidocaine exerts a local anesthetic effect on the heart, thus decreasing myocardial irritability. o Lidocaine 1-1.5 mg/kg IV bolus o Followed by 0.5-0.75 mg/kg q 5-10 minutes until the dysrhythmia is controlled or 3 mg/kg via IV/IO o A continuous infusion rate of 1-4 mg/min to maintain a therapeutic serum level. o OR Lidocaine 2-4 mg/kg via ETT Lidocaine toxicity: confusion, drowsiness, hearing impairment, cardiac conduction defects, myocardial depression, muscle twitching, seizures). Continuous cardiac monitoring, asses for signs & symptoms Contraindicated: hepatic impairment, HF, shock, and advanced age (older than 70 years) are at higher risk for toxicity. In these clients, the lidocaine dose may need to be reduced by as much as 50% Pediatric Implications Ventricular ectopy is uncommon in children; a metabolic cause is suspected if ventricular dysrhythmias occur Lidocaine 1 mg/kg IV/IO OR 2-3 mg/kg ETT. Follow by a maintenance infusion of 20-50 mcg/kg/min

J. Procainamide Procainamide is an antidysrhythmic agent prescribed for ventricular tachycardia, PVCs, and rapid supraventricular dysrhythmias unresponsive to adenosine. o Procainamide of 20 mg/min IV loading dose until dysrhythmia is treated OR a total of 17 mg/kg o Following by a continuous maintenance infusion of 1 to 4 mg/min o Monitor vital signs and ECG (heart rate, rhythm, BP, and the width of the QRS complex). Adverse effects: severe hypotension, heart block, rhythm disturbances, and cardiac arrest. Contraindicated: in clients with torsades de pointes (an unusual ventricular tachycardia often associated with a prolonged Q-T interval), and renal failure Pediatric Implications Procainamide is for ventricular tachycardia that is recurrent or refractory to other measures and for PSVT. The loading dose is 15 mg/ kg/ via IV/IO over 30-60 minutes. Monitor vital signs and ECG (heart rate, rhythm, BP, and the width of the QRS complex) Adverse effects: severe hypotension, heart block, rhythm disturbances, and cardiac arrest. Contraindicated: in clients with torsades de pointes (an unusual ventricular tachycardia often associated with a prolonged Q-T interval), and renal failure K. Magnesium Sulfate Magnesium is an essential element in enzymatic reactions in the body, including the Na/K ATPase pump. Its Physiologic effects can be likened to a Ca channel blocker with neuromuscular blocking properties. Hypomagnesemia is associated with the development of atrial and ventricular dysrhythmias. Magnesium sulfate is for refractory ventricular tachycardia & fibrillation, cardiac arrest associated with hypomagnesemia, life-threatening ventricular dysrhythmias from digitalis toxicity. & torsades de pointes Magnesium is administered by diluting 1 to 2 g (2 to 4 ml of a 50% solution) in 10 ml of D5W For cardiac arrest caused by hypomagnesemia or torsades de pointes: o Magnesium is given direct IV push or via the IO route over 5-20 minutes. For clients experiencing torsades de pointes who are not in cardiac arrest: o Magnesium infusion of 1-2 g diluted in 50-100 ml of D5W via IV/IO over 5-60 minutes o Followed by a continuous infusion of 0.5 to 1 g/hour Monitor the clients response to magnesium administration. Adverse effect: Hypotension, mild bradycardia, flush, and sweating. o True hypermagnesemia can cause diarrhea, respiratory depression, deep tendon reflex impairment, flaccid paralysis, and circulatory collapse. Caution: in clients with renal impairment, because most of it its eliminated via kidney Pediatric implications Indications for magnesium sulfate in pediatric clients include torsades de pointes, hypomagnesemia, and status asthmaticus unresponsive to beta-adrenergic agents. Magnesium sulfate 25-50 mg/kg IV/IO given slowly over 10-20 minutes with a maximum dose of 2 g. The drug may be pushed faster to treat torsades de pointes, L. Epinephrine Epinephrine is a catecholamine with alpha and beta adrenergic effects. It has multiple uses. Cardiac indications: bradycardia, hypotension, asystole, & pulseless ventricular tachycardia & fibrillation. It improves perfusion of the heart & brain in cardiac arrest by constricting peripheral blood vessels; increases the chances for successful electrical countershock (defibrillation) in ventricular fibrillation. Epinephrine is available in two primary concentrations: 1:1000 and 1:10,000. o 1:10,000 concentration is used when administering a single IV/IO dose of epinephrine. o 1:1000 form is used when preparing a continuous epinephrine infusion or via IM/subQ For profound bradycardia or hypotension: An epinephrine infusion at 2-10 mcg/min. For asystole, pulseless ventricular tachycardia and ventricular fibrillation: o Epinephrine 1-mg (1:10,000) IV/IO Q 3-5 minutes until the desired clinical response is achieved (usually return of effective cardiac activity). o Epinephrine 2 to 2.5 mg diluted in 10 ml of normal saline via the ETT route may also be given.

Constant cardiac & hemodynamic monitoring. Adverse effects: myocardial ischemia and cardiac dysrhythmias. Drug interactions: do not give epinephrine in the same site as an alkaline solution (e.g. Na bicarbonate) because alkaline solutions inactivate epinephrine. The presence of metabolic/respiratory acidosis decreases the effectiveness of epinephrine. o All efforts should be made to correct acid-base imbalances in the client. Pediatric Implications For cardiac arrest: the pediatric dose of epinephrine is 0.01 mg/kg (1:10,000 solution) q 3-5 minutes IV/IO. Or ETT dose of 0.1 mg/kg (1:1000 solution) M. Vasopressin Vasopressin is indicated for the treatment of ventricular fibrillation that is refractory to defibrillation. It is found in the human body as endogenous antidiuretic hormone. When used as a cardiac emergency drug: noradrenergic peripheral vasoconstriction. When used as an emergency agent: coronary artery dilation during CPR & exhibits vasopressor effects. It is given to clients in cardiac arrest before or after epinephrine administration as a single 40 units IV/IO. Its an adjunct to epinephrine, can replace either the 1st/2nd epinephrine dose in the cardiac arrest algorithm. Contraindicated: in responsive clients who have coronary artery disease (clients with CAD but not in cardiac arrest) because vasopressin can induce myocardial ischemia and angina Pediatric Implications Vasopressin administration is not recommended for the treatment of pediatric cardiac arrest N. Sodium Bicarbonate Sodium bicarbonate is used to treat the metabolic acidosis that may accompany cardiac arrest and hyperkalemia & acidotic states related to specific drug overdose situations. The current standard in resuscitation is to give sodium bicarbonate only after adequate ventilation, chest compressions, IV fluids, and drug therapy fail to correct the acidotic state. It is given based on results of arterial blood gas analysis when acidosis is severe If a client has been in arrest for long period & blood gas analysis is not available, sodium bicarbonate may be ordered as part of the ongoing resuscitation attempt. o Sodium bicarbonate 1 mEq/kg IV; may be repeated at 0.5mEq/kg q 10 minutes as needed. Pediatric Implications If severe metabolic acidosis persists after attention has been directed at maintaining optimal ventilation and oxygenation, sodium bicarbonate may be given to pediatric client: 1 mEq/kg via the IV or IO route. Sodium bicarbonate is hyperosmolar: diluted from an 8.4% solution (1 mEq/ml) to a 4.2% solution (0.5mEq/ml) for infants younger than 3 months of age. Emergency Drugs for Neurosurgical Disorders A. Mannitol Its an osmotic diuretic, used in emergency & neurosurgical setting to treat cerebral edema & ICP, which may occur following head trauma, neurosurgery, and other types of intracranial pathology. Mannitol may be given as an IV bolus or via a continuous drip. o 1st dose mannitol l g/kg IV bolus of a 20%-25% solution. Subsequent dosing is highly variable and is influenced by serum osmolality. Mannitol is held when serum osmolality > 310-320. Mannitol is highly irritating to veins. o Use a filter needle because crystals may form in the solution & syringe and be inadvertently injected. o Different filter needles are used to draw up the mannitol and to administer the mannitol IV. o Carefully assess the clients neurologic status, monitor laboratory studies (include serum osmolality), and keep accurate I&O records to assess fluid volume status, because diuresis may be substantial. B. Methylprednisolone High-dose may be administered as an option to clients with traumatic spinal cord injuries. When used, a strict pharmacologic protocol must be initiated within 8 hours of acute spinal cord injury: o 30 mg/kg IV bolus mixed in 100 ml of normal saline solution over 15 minutes

o Follow by a maintenance infusion of 5.4 mg/kg/hr within 45 minutes of the bolus If the injury is < 3 hours old, continued for 23 hours If the injury is between 3 and 8 hours old, continue run for 48 hours. Contraindications: allergy to the drug, penetrating trauma to the spinal cord, HIV infection, severe infection, a spinal cord injury > 8 hours old, pregnancy, and uncontrolled diabetes mellitus. Adverse effects: transient hypertension with administration of the loading dose and elevation of blood during the infusion. o Monitor vital signs & blood sugar; perform frequent & accurate neurologic assessments pertinent to spinal cord injury. Clients who receive methylprednisolone may be at a higher infection risk. Emergency Drugs for Poisoning A. Naloxone Naloxone is an opiate antagonist. It reverses the effects of all opiate drugs (e.g. morphine, meperidine, codeine, propoxyphene, and heroin) by competitively binding to opiate receptor sites in the body. Naloxone is an antidote opiate drugs overdose, experiencing respiratory or cardiovascular depression, and for those brought to the ER in coma of unknown etiology (which may be drug induced). For actual / suspected opiate overdose: o Naloxone 0.4-2 mg IV q 2 minutes until the clients condition improves to an acceptable level o If there is no improvement within 10 minutes after 10 mg of the drug has been injected, non-opiate drugs or disease must be suspected. o Although naloxone should be administered IV in emergency situations, it also may be given via the IM, in IO or subQ routes if IV access is not readily obtainable. Because most opiate drugs have a longer duration of action than naloxone, monitor the client closely for signs and symptoms of recurrent opiate effects such as respiratory depression and hypotension. o Naloxone administration may be repeated several times or a continuous IV infusion may be ordered. Adverse effects: withdrawal symptoms in clients addicted to opiate drugs; pulmonary edema following naloxone administration in clients who have had an overdose of morphine Pediatric Implications For narcotic reversal in children, 0.01-0.1 mg/kg, repeating the drug as necessary up to 2 mg. Naloxone can be administered IV, IO, IM or subQ in children. B. Flumazenil Flumazenil is the reversal agent for the respiratory depressant and sedative effects of benzodiazepine (e.g., diazepam [Valium], midazolam [Versed], chlordiazepoxide [Librium]). It is administered to counteract the effects of benzodiazepines and to treat benzodiazepine overdose. Flumazenil does not reverse the CNS depressant effects of nonbenzodiazepine agents such as alcohol opiates, and barbiturates; and may not reverse amnesia induced by benzodiazepines. o 1st dose: Flumazenil 0.2 mg IV over 15 seconds. o 2nd dose: Flumazenil 0.3 mg IV over 30 seconds. o 3rd dose & subsequent doses of 0.5 mg IV q min until the desired clinical response is achieved OR until a total dose of 3 mg is given. o If sedation occurs again, Repeat doses at 20 min intervals (not to 1 mg at a time) to a total hourly dose of 3 mg IV. Careful assessment of respiratory rate & effort, blood pressure; and mental status. If the benzodiazepine is reversed too rapidly, clients may feel agitated, confused, & perceptual distortions Seizures are precipitated by benzodiazepine withdrawal, precautions must be implemented those who are at risk (e.g. long-standing benzodiazepine use/abuse or for those who have a known seizure disorder) C. Activated Charcoal Activated charcoal may be prescribed for poisoning to prevent absorption of toxins into the body Activated charcoal is prepared as slurry, given PO or via a gastric tube within 1 hour of ingestion The dose is dependent on the amount of poison ingested: o Adult & pediatric dose is 1-2 g/kg, up to 25-50 gm/dose. o Activated charcoal dosing may need to be repeated for salicylates, slow-release drug preparations, and Amanita phalloides (death cap mushrooms) poisoning

Vomiting is a common adverse reaction, use with extreme caution in client with an impaired gag reflex or altered level of consciousness, because there is risk of aspiration. Activated charcoal should not be given with milk products, because they decrease its adsorptive properties. It should not be given to clients who have ingested pesticides, hydrocarbons, alcohols, acids/alkalis, lithium, solvents and iron supplements. o A cathartic (a purgative resulting in bowel movements) may be ordered following administration of activated charcoal to speed elimination of the charcoal-toxin complex from the body. Charcoal produces black stools. Emergency Drugs for Shock Drugs should not be used to correct hypotension associated with hypovolemic shock ( blood/fluid volume);. Administration of fluids/blood products/both is the only acceptable means to treat hypovolemic shock. A. Dopamine Dopamine, a sympathomimetic agent, used to treat hypotension in shock (not hypovolemia shock). Dopamine is used to increase heart rate (beta1 effect) in bradycardic rhythms if atropine ineffective. o The dose range is 2 to 20 mcg/kg/min. Dopamine enhances cardiac output by increasing myocardial contractility, increasing HR (beta1 effect) and elevates BP thru vasoconstriction (alpha-adrenergic effect). Alpha effects predominate at higher doses vasoconstriction of renal, mesenteric, peripheral blood vessels. o Vasoconstriction poor organ & tissue perfusion decreased cardiac performance & urine output. The lowest effective dose of dopamine should be used. abrupt discontinuation can cause severe hypotension Dopamine 400-800 mg in 250 ml D5W IV by a volumetric infusion pump for precision in a central vein, Continuous monitoring heart, BP, vital signs and record intake and output as ordered. Adverse effects: tachycardia, dysrhythmias, myocardial ischemia, nausea, and vomiting. o The IV site must be assessed hourly for signs of drug infiltration; extravasations (escape into tissues) of dopamine can produce tissue necrosis that may necessitate surgical debridement and skin grafting. o If extravasations occur, injected phentolamine (Regitine) 5-10 mg in 10-15 ml of normal saline, in multiple areas around the site to reduce or prevent tissue damage. Drug interactions: Sodium bicarbonate will inactivate dopamine; do not infuse them in the same IV line. B. Dobutamine Dobutamine is a sympathomimetic drug with beta adrenergic activities: o Beta1 effects: enhance myocardial contraction (+ inotropic effect) & HR (+ chronotropic effect). o Beta2 effects: produce mild vasodilation. Blood pressure is elevated only through the increase in cardiac output. Dobutamine 2-20 mcg/kg/min IV via a volumetric infusion pump for precision. Dobutamine 250-1000 mg mixed in 250 ml of D5W or normal saline. Like dopamine, dobutamine administration should be tapered gradually as the clients condition warrants. Continuous cardiac & blood pressure monitoring are required Adverse effects: myocardial ischemia, tachycardia, dysrhythmias, headache, nausea, and tremors. o Carefully monitor I&O and assess for any signs/symptoms of myocardial ischemia (e.g. chest pain or development of dysrhythmias) C. Norepinephrine Norepinephrine is a catecholamine with extremely potent vasoconstrictor actions (alpha-adrenergic effect). It is used when dopamine and dobutamine have failed to produce adequate blood pressure. Like high-dose dopamine, peripheral vasoconstriction decrease organ and tissue perfusion & impair cardiac performance Norepinephrine 4-8 mg mix in 250 ml D5W or normal saline solution, infused at 0.5-30 mcg/min Continuous cardiac monitoring and precise blood pressure monitoring are required. The drug must be tapered slowly; abrupt discontinuation can result in severe hypotension. Adverse effects: myocardial ischemia, dysrhythmias, and impaired organ perfusion. o If extravasations occur, injected phentolamine (Regitine) 5-10 mg in 10-15 ml of normal saline, in multiple areas around the site to reduce or prevent tissue damage.

D. Epinephrine Epinephrine is used to treat anaphylactic shock (an allergic response of the most serious type) brought about by an antibody-antigen reaction. o Anaphylactic shock can be fatal if prompt treatment is not initiated. o Severe bronchoconstriction & hypotension resulting from cardiovascular collapse. Epinephrine is also indicated for an acute, severe asthmatic attack. Administration of epinephrine causes bronchodilation, enhance cardiac performance, and vasoconstriction For severe asthma and anaphylactic shock: o Epinephrine 0.2 to 0.5 mg IM or subQ (1:1000 solution) via a tuberculin syringe for accuracy IM is preferred over subQ, because the IM route has a more predictable pattern of absorption. o Epinephrine 0.1 to 0.25 mg IV over 5 to 10 minutes (1:10,000 solution). o Epinephrine administration can be repeated q 5-15 minutes if necessary. Adverse effects: excitability, fear, anxiety, restlessness, tachycardia, cardiac dysrhythmias, hypertension, and angina. o Clients given IV epinephrine must be on a cardiac monitor, with resuscitation equipment on the side Anaphylactic response may recur and necessitate repeated treatment. o For this reason, steroids (e.g. hydrocortisone Na succinate, prednisone, methylprednisolone) are ordered and are slowly tapered over days to weeks to prevent recurrence. For some clients (e.g. severe allergic responses to bee stings), the physician may prescribe an epinephrine kit or pen to be carried with the client for self-medication in the event of contact with the antigen. E. Albuterol A -adrenergic bronchodilator used to reverse bronchoconstriction in anaphylactic shock, asthma, COPD. In emergency situations, its administered via nebulizer (adults: 0.5 ml of 0.5% inhalation in 2.5 ml saline). Albuterol is also in metered-dose inhaler, client can self-administer a rescue dose during an acute episode of bronchospasm. The nurse should assess breath sounds before and after administration In severe bronchospasm, wheezing may not be audible. As the bronchospasm is relieved, wheezing may become more pronounced, indicating that the drug is producing the desired therapeutic effect. Assessment of the clients subjective feelings of respiratory distress b4 & after administration is important. Adverse effects: tachycardia, tremor, nervousness, cardiac dysrhythmias, and hypertension F. Diphenhydramine Hydrochloride Diphenhydramine, an antihistamine, is often administered with epinephrine to treat anaphylactic shock. Its effective for treating histamine-induced tissue swelling & pruritus common to severe allergic reactions. Adult dose: 25-50 mg IV/deep IM in emergencies. Oral pill & liquid forms for home setting emergencies, its self-administration during an allergic reaction prior to receiving medical assistance from the ER. Adverse effects: drowsiness, sedation, confusion, vertigo, excitability, hypotension, tachycardia, GI disturbances, and dry mouth G. Dextrose 50% Dextrose 50% is a [high-carbohydrate solution] to treat insulin-induced hypoglycemia or insulin shock. When insulin shock is known or suspected and the clients state of consciousness is impaired: o 50 ml of dextrose 50% is commonly ordered and given as an IV bolus. o Dextrose 50% is highly irritating to veins, should be given in large peripheral or central vein o Phlebitis can occur. Extravasation of the solution can cause tissue sloughing and necrosis. o Monitor the clients blood sugar carefully; hyperglycemia is common, especially after rapid injection. o Urine output should be accurately recorded, because osmotic diuresis can occur when blood sugar is elevated, and a hyperosmolar state can result. Pediatric Implications Glycogen stores in infants and children may be quickly depleted in stress states produced by severe illness. Because adequate amounts of glucose are essential to strong myocardial function, hypoglycemia must be corrected to provide the greatest chance for successful resuscitation.

After hypoglycemia is confirmed by finger/heel stick method of rapid blood glucose testing: o Dextrose 25% or less may be administered per physician order. o Because glucose is supplied in a 50% concentration, it must be diluted 1:1 in sterile water before administration to reduce its osmolality and prevent sclerosis of peripheral veins. o The standard dose is 0.5 to l g/kg IV or IO H. Glucagon Glucagon is a pancreas-produced hormone that elevates blood sugar by stimulating glycogen breakdown Glucagon, like dextrose 50%, is used to treat severe insulin-induced hypoglycemia or insulin shock. In an emergency when dextrose 50% is unavailable or cannot be administered IV: o Glucagon may be given subQ, IM, or IV. o Adults & children dose: 0.5 to 1 mg, can be repeated in 15 minutes for persistent coma. If the coma has not resolved after two doses, dextrose 50% must be administered. Adverse effects: nausea, vomiting, and hypersensitivity reaction bronchospasm & respiratory distress. Glucagon is an antidote for calcium channel blocker & beta-blocker over-dose; o Glucagon 3 mg IV followed by an IV infusion of 3 mg/hour. Emergency Drugs for Hypertensive Crises and Pulmonary Edema A. Labetalol Labetalol is an alpha & beta adrenergic blocker that acts by inhibiting the effects of the SNS Pharmacologic actions: lower heart rate, blood pressure, myocardial contractility, myocardial oxygen consumption, and reduce vasoconstriction that results from sympathetic nervous system stimulation. This agent is indicated for the acute management of clinically significant hypertension in the presence of ischemic and hemorrhagic stroke, as well as for hypertensive crisis. o Initial dose: labetalol 10-20 mg IV push over 2 minutes, can be repeat or double q 10 minutes until the desired clinical response is achieved, up to a maximum dose of 300 mg. o As an alternative approach, a continuous infusion of labetalol mixed with D5W over 2 mg/min until the target therapeutic response is attained. The continuous infusion is then stopped, but may be repeated every 6 to 12 hours if needed. Use a volumetric infusion pump for accurate continuous infusion medication delivery, cardiac monitoring, and frequent blood pressure measurement q 5 minutes during IV push dosing/continuous infusion. Adverse effects: hypotension, ventricular dysrhythmias, dizziness, and bronchospasm. Contraindicated: in clients with bronchial asthma or COPD because of the risk of bronchospasm; in clients with severe bradycardia or apparent heart failure. B. Nitroprusside Sodium Nitroprusside sodium is an IV agent used to reduce arterial blood pressure in hypertensive emergencies. The mechanism of action is immediate direct arterial and venous vasodilation. o Blood pressure increases as soon as drug administration is stopped. o Continuous and accurate blood pressure measurement is required. Nitroprusside sodium 50 mg mixed in 250 ml D5W. The typical dose range for adults: 0.25 to 5 mcg/kg/min, maximum dose is 10 mcg/kg/min. There are several important nursing considerations: o Nitroprusside sodium is rapidly inactivated by light; the IV bottle or bag must be wrapped with aluminum foil or another opaque material to protect the solution from degradation. Although a faint brown tint is typical, blue or brown discoloration of the solution indicates degradation and necessitates that the solution be discarded. o When nitroprusside sodium therapy is prolonged, or infused at the maximum dose of 10 mcg/kg/min for more than 10 minutes, clients are at risk for toxicity resulting from elevated serum thiocyanate or cyanide levels (byproducts of drug metabolism). Signs and symptoms: metabolic acidosis, profound hypotension, dyspnea, dizziness, vomiting. Serum thiocyanate levels should be monitored q 24 to 72 hours for infusions of > 3mcg/kg/min. Clients with renal failure are at a higher risk, because the metabolites are excreted in the urine. o Clients should be placed on an oral antihypertensive agent as soon as possible so that nitroprusside sodium can be tapered slowly.

C. Furosemide Furosemide, a loop diuretic that acts by excreting water, Na, Cl, Mg, H, & Ca and depletes K from the ascending loop of Henle and the proximal and distal tubules. Furosemide also has peripheral and renal vasodilating effects that can lower blood pressure. Furosemide is used for acute pulmonary edema from left ventricular dysfunction and hypertensive crisis. o Initial dose: Furosemide 0.5 to 1 mg/kg IV bolus over 1 to 2 minutes. For clients who take furosemide on a regular basis is higher (up to 2 mg/kg). The vasodilatory effects occur before diuresis begins and act to lower blood pressure. Central venous pressure is reduced thru a in venous return to the heart once vasodilation is achieved. Diuresis should start within 10 minutes of drug administration and may continue for approximately 6 hours. Adverse effects: severe hypovolemia, dehydration, and electrolyte disturbances (hypokalemia, hypomagnesemia, hyponatremia, and hypochloremia). o Clients on digitalis preparations are at an increased risk of digitalis toxicity from hypokalemia. o The clients fluid and electrolyte status must be carefully assessed before and after furosemide administration, including auscultation of breath sounds for rales, strict surveillance of I&O o An indwelling urinary catheter might be necessary. o Electrolyte & careful fluid replacement may be required during furosemide therapy to prevent physiologic consequences. o The nurse must also exercise caution in administering the drug to clients with sulfonamide sensitivity, because furosemide is a sulfonamide derivative and can produce an allergic reaction. Herbal: Furosemide Ginseng can inhibit efficacy. Licorice can promote potassium loss, enhancing the potential for severe hypokalemia. These herbs should not be taken concurrently with furosemide. D. Morphine Sulfate Like furosemide, morphine sulfate is also indicated for acute pulmonary edema, because it produces venous vasodilation that decreases cardiac preload (the amount of blood returning to the right ventricle). The net effect is a decrease in pulmonary venous congestion.