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Chapter 11B: Critical Care Pharmacology : 

Chapter 11B: Critical Care Pharmacology Galveston College EMS Critical Care Paramedic 2009

Neurologic Drugs : 

Neurologic Drugs Inhibit aberrant electrical activity in brain Prevent, control seizures

Antiepileptics : 

Antiepileptics

Phenytoin Sodium (Dilantin)(1 of 5) : 

Phenytoin Sodium (Dilantin)(1 of 5) Class CNS agent Anticonvulsant Hydantoin Actions Thought to act on motor cortex Stabilizes seizure threshold Has antidysrhythmic properties also

Phenytoin Sodium (Dilantin)(2 of 5) : 

Phenytoin Sodium (Dilantin)(2 of 5) Indications Grand mal, complex seizure activity Contraindications Allergy to phenytoin Hypoglycemic seizures Cardiac dysrhythmias Bradycardia Heart blocks Sick-sinus syndrome

Phenytoin Sodium (Dilantin)(3 of 5) : 

Phenytoin Sodium (Dilantin)(3 of 5) Side effects Ataxia Slurred speech Confusion CNS depression Nystagmus Hypotension with rapid administration, gingival hyperplasia with prolonged use Tissue necrosis with extravasation

Phenytoin Sodium (Dilantin)(4 of 5) : 

Phenytoin Sodium (Dilantin)(4 of 5) Dose Adult 10–15 mcg/kg slow IVP over 30 minutes or one 1,000 mcg loading dose Maintenance dose: 4–8 mcg/kg slow IVP Pediatric 2 years of age 40-60–mcg/kg slow IVP 2-10 years of age 20-40 mcg/kg slow IVP 10 years of age 10-15 mcg/kg slow IVP

Phenytoin Sodium (Dilantin)(5 of 5) : 

Phenytoin Sodium (Dilantin)(5 of 5) Special considerations Incompatible with dextrose-containing IV solutions Do not administer faster than 50 mg/min Use cautiously in patients with hepatic or renal disease

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (1 of 4) : 

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (1 of 4) Class CNS agent Anticonvulsant Sedative-hypnotic Barbiturate Actions Inhibits nerve impulse transmission in the cerebral cortex via the ascending reticular activating system Depresses the CNS Exerts hypnotic effects Controls the spread of seizures by raising the threshold for motor cortex stimuli

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (2 of 4) : 

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (2 of 4) Indications Grand mal, complex partial seizures Eclampsia Need for sedation Contraindications Allergy to barbiturates Significant hepatic, respiratory, or renal disease Significant hypotension

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (3 of 4) : 

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (3 of 4) Side effects Sedation Bradycardia Hypotension Respiratory depression Nystagmus Confusion Ataxia Somnolence

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (4 of 4) : 

Phenobarbital Sodium (Luminal, Barbital, Solfoton) (4 of 4) Dose Adult 100–250 mg IV over 5 minutes Pediatric 10–20 mg/kg IV over 5 minutes Special considerations Monitor for respiratory depression Use cautiously in the elderly and patients with renal failure

Fosphenytoin Sodium (Cerebryx)(1 of 4) : 

Fosphenytoin Sodium (Cerebryx)(1 of 4) Class CNS agent Anticonvulsant Hydantoin Actions Thought to act on motor cortex Stabilizes seizure threshold Exhibits antidysrhythmic properties also

Fosphenytoin Sodium (Cerebryx)(2 of 4) : 

Fosphenytoin Sodium (Cerebryx)(2 of 4) Indications Grand mal, complex seizure activity Contraindications Allergy to phenytoin, hydantoin products Hypoglycemic seizures Cardiac dysrhythmias Bradycardia Heart blocks Sick-sinus syndrome

Fosphenytoin Sodium (Cerebryx)(3 of 4) : 

Fosphenytoin Sodium (Cerebryx)(3 of 4) Side effects Ataxia Slurred speech Confusion CNS depression Nystagmus Hypotension with rapid administration, gingival hyperplasia with prolonged use Tissue necrosis with extravasation

Fosphenytoin Sodium (Cerebryx)(4 of 4) : 

Fosphenytoin Sodium (Cerebryx)(4 of 4) Dose 15–20 mg PE/kg IV PE  phenytoin equivalents Maintenance dose: 4–6 mg PE/kg slow IVP Special considerations Use cautiously in patients with impaired hepatic, renal, or pulmonary function Do not administer faster than 100–150 mg PE/min Keep refrigerated before administering

Miscellaneous Neurologic Drugs : 

Miscellaneous Neurologic Drugs

Mannitol (Osmitrol)(1 of 4) : 

Mannitol (Osmitrol)(1 of 4) Class Electrolyte/water balance agents Osmotic duiuretic Actions Acts a hyperosmolar agent Draws interstitial fluid into the intravascular space Increases GFR Decreases sodium reabsorption Promotes water loss

Mannitol (Osmitrol)(2 of 4) : 

Mannitol (Osmitrol)(2 of 4) Indications Increased ICP Contraindications Hypotension Dehydration Acute pulmonary edema Anuria Known allergy

Mannitol (Osmitrol)(3 of 4) : 

Mannitol (Osmitrol)(3 of 4) Side effects Hypotension Dehydration Acidosis Electrolyte imbalances

Mannitol (Osmitrol)(4 of 4) : 

Mannitol (Osmitrol)(4 of 4) Dose 1.5–2 gm/kg IVP over 30–60 minutes Special considerations Use cautiously in patients with blood loss, hypotension, or dehydration Monitor urinary output closely Be alert for transient hypertension Use cautiously in patients with poor left ventricular function, renal disease

Methylprednisolone (Solu-Medrol, Medrol) (1 of 5) : 

Methylprednisolone (Solu-Medrol, Medrol) (1 of 5) Class Hormone and synthetic substitute Corticosteroid Glucocorticoid Anti-inflammatory Actions Acts as anti-inflammatory agent Exhibits immunosuppressive properties

Methylprednisolone (Solu-Medrol, Medrol) (2 of 5) : 

Methylprednisolone (Solu-Medrol, Medrol) (2 of 5) Indications Chronic and acute inflammation, swelling Bronchospasm Spinal cord injury Contraindications Suspected fungal infections Known hypersensitivity

Methylprednisolone (Solu-Medrol, Medrol) (3 of 5) : 

Methylprednisolone (Solu-Medrol, Medrol) (3 of 5) Side effects Edema Hypokalemia Hypotension, hypertension Hyperglycemia CHF Delayed wound healing

Methylprednisolone (Solu-Medrol, Medrol) (4 of 5) : 

Methylprednisolone (Solu-Medrol, Medrol) (4 of 5) Dose Spinal cord injury 30 mg/kg IV over 10–20 minutes Maintenance infusion: 5.4 mg/kg/hr for next 23 hours Bronchospasm 40–125 mg IV over 2 minutes

Methylprednisolone (Solu-Medrol, Medrol) (5 of 5) : 

Methylprednisolone (Solu-Medrol, Medrol) (5 of 5) Special considerations Use cautiously in patients with: Cushing’s syndrome GI ulcerations Diabetes Psychotic tendencies Monitor for hyperglycemia in nondiabetic patients

Dexamethasone (Decadron, Hexadryl, Dexasone) (1 of 4) : 

Dexamethasone (Decadron, Hexadryl, Dexasone) (1 of 4) Class Hormone and synthetic substitute Corticosteroid Glucocorticoid Actions Has potent anti-inflammatory properties Crosses blood-brain barrier Plays role in managing increased ICP

Dexamethasone (Decadron, Hexadryl, Dexasone) (2 of 4) : 

Dexamethasone (Decadron, Hexadryl, Dexasone) (2 of 4) Indications Adrenal insufficiency concomitant with: Mineralocorticoid use Inflammatory conditions Allergic states Collagen diseases Hematologic disorders Addisonian shock Neoplasm Rheumatic disorders Inflammatory GI diseases

Dexamethasone (Decadron, Hexadryl, Dexasone) (3 of 4) : 

Dexamethasone (Decadron, Hexadryl, Dexasone) (3 of 4) Contraindications Known allergy to the drug Systemic fungal infections Tuberculosis Varicella Side effects Edema Hypokalemia Hypotension, hypertension Hyperglycemia CHF Delayed wound healing

Dexamethasone (Decadron, Hexadryl, Dexasone) (4 of 4) : 

Dexamethasone (Decadron, Hexadryl, Dexasone) (4 of 4) Dose Adult 1–2 mg/kg Maintenance infusion: 1–1.5 mg/kg tapered dose over 4–6 hours Pediatric 0.5–1.0 mg/kg Special considerations Risk of CHF Use cautiously in patients with: Hepatic and renal disease GI ulceration Diabetes Seizure disorders Psychiatric disorders

Nimodipine (Nimotop)(1 of 4) : 

Nimodipine (Nimotop)(1 of 4) Class Cardiovascular agent Calcium channel blocker Actions Blocks calcium channels Relaxes smooth muscle Preferentially binds to cerebral arteries Achieves cerebral vasodilation

Nimodipine (Nimotop)(2 of 4) : 

Nimodipine (Nimotop)(2 of 4) Indications Vasospasm associated with SAH Contraindications Lactation

Nimodipine (Nimotop)(3 of 4) : 

Nimodipine (Nimotop)(3 of 4) Side effects Hypotension Tachycardia ECG abnormalities GI bleeding Peripheral edema

Nimodipine (Nimotop)(4 of 4) : 

Nimodipine (Nimotop)(4 of 4) Dose 60 mg PO or NG q 4 hours Administered within 96 hours of subarachnoid hemorrhage Continued for 21 consecutive days Special considerations Caution when administered with other calcium channel blockers

Pulmonary Drugs : 

Pulmonary Drugs Relieve bronchoconstriction Increase oxygen delivery to cells

Sympathomimetic Aerosols(1 of 3) : 

Sympathomimetic Aerosols(1 of 3) Albuterol (Proventil, Ventolin) Class Sympathomimetic Beta-adrenergic agonist Bronchodilator Actions Serves as beta-2 agonist Exhibits slight degree of beta-1, alpha properties Achieves bronchodilation Promotes insulin release Helps treat hyperkalemia

Sympathomimetic Aerosols(2 of 3) : 

Sympathomimetic Aerosols(2 of 3) Albuterol (Proventil, Ventolin) Indications Bronchospasm Hyperkalemia Contraindications Tachycardia Cardiac dysrhythmia Hypertension

Sympathomimetic Aerosols(3 of 3) : 

Sympathomimetic Aerosols(3 of 3) Albuterol (Proventil, Ventolin) Side effects Tachycardia Hypertension Cardiac dysrhythmia Anxiety Palpitations Nausea/vomiting Dilated pupils

Sympathomimetic Aerosols : 

Sympathomimetic Aerosols

Albuterol (Proventil, Ventolin) : 

Albuterol (Proventil, Ventolin) Dose Adult 2.5 mg in 3–5 mL of saline nebulized Pediatric 1.25 mg in 3–5 mL saline nebulized Special considerations Requires adequate tidal volume to distribute medication to distal airways

Ipratropium Bromide (Atrovent)(1 of 5) : 

Ipratropium Bromide (Atrovent)(1 of 5) Class Sympathomimetic Anticholinergic Bronchodilator Actions Blocks acetylcholine receptors on bronchial smooth muscle Decreases intracellular cyclic-GAMP Achieves bronchodilation

Ipratropium Bromide (Atrovent)(2 of 5) : 

Ipratropium Bromide (Atrovent)(2 of 5) Actions

Ipratropium Bromide (Atrovent)(3 of 5) : 

Ipratropium Bromide (Atrovent)(3 of 5) Indications Bronchoconstriction Contraindications Hypersensitivity Not to be used as first-line agent for bronchoconstriction

Ipratropium Bromide (Atrovent)(4 of 5) : 

Ipratropium Bromide (Atrovent)(4 of 5) Side effects Tachycardia Dry mouth Palpitations Nervousness Headache

Ipratropium Bromide (Atrovent)(5 of 5) : 

Ipratropium Bromide (Atrovent)(5 of 5) Dose Adult 500 mcg nebulized Pediatric 125–250 mcg nebulized Special considerations Often administered with albuterol

Levalbuterol Hydrochloride (Xopenex) (1 of 5) : 

Levalbuterol Hydrochloride (Xopenex) (1 of 5) Class Sympathomimetic Beta-adrenergic agonist Bronchodilator Actions Has chemical relationship with albuterol Exhibits higher specificity for beta-2 receptors Gives longer duration of action Achieves bronchodilation Facilitates mucus drainage Increases vital capacity

Levalbuterol Hydrochloride (Xopenex) (2 of 5) : 

Levalbuterol Hydrochloride (Xopenex) (2 of 5) Indications Bronchospasm Contraindications Hypersensitivity to levalbuterol or albuterol 6 years of age Pregnancy

Levalbuterol Hydrochloride (Xopenex) (3 of 5) : 

Levalbuterol Hydrochloride (Xopenex) (3 of 5) Side effects Nervousness Palpitations Dry mouth Headache Tachycardia

Levalbuterol Hydrochloride (Xopenex) (4 of 5) : 

Levalbuterol Hydrochloride (Xopenex) (4 of 5) Dose Adult 0.63–1.25 mg via nebulizer q 6–8 hours Pediatric 0.31–0.63 mg via nebulizer q 6–8 hours

Levalbuterol Hydrochloride (Xopenex) (5 of 5) : 

Levalbuterol Hydrochloride (Xopenex) (5 of 5) Special considerations Use cautiously in patients with: CVD CAD Dysrhythmias Convulsive disorders Hyperthyroidism Diabetes Adequate tidal volume needed to distribute medication to distal airways

Sympathomimetics (injection) : 

Sympathomimetics (injection)

Terbutaline (Brethaire, Brethine, Bricanyl) (1 of 4) : 

Terbutaline (Brethaire, Brethine, Bricanyl) (1 of 4) Class Sympathomimetic Beta-adrenergic agonist Bronchodilator Actions Stimulates beta-2 adrenergic receptors Results in: Bronchodilation Relaxed peripheral vasculature Relaxed uterine muscle

Terbutaline (Brethaire, Brethine, Bricanyl) (2 of 4) : 

Terbutaline (Brethaire, Brethine, Bricanyl) (2 of 4) Indications Bronchospasm Preterm labor Contraindications Known hypersensitivity Severe hypertension CAD Lactation Concurrent digitalis toxicity

Terbutaline (Brethaire, Brethine, Bricanyl) (3 of 4) : 

Terbutaline (Brethaire, Brethine, Bricanyl) (3 of 4) Side effects Tachycardia Hypertension Nervousness Palpitations Nausea/vomiting

Terbutaline (Brethaire, Brethine, Bricanyl) (4 of 4) : 

Terbutaline (Brethaire, Brethine, Bricanyl) (4 of 4) Dose Adult 0.25 mg SQ Repeat q 15 minutes Maximum dose: 0.5 mg in 4 hours Pediatric 0.005–0.01 mg/kg SQ Repeat if needed q 15–20 minutes Maximum dose: 0.4 mg Special considerations Monitor vital signs and cardiac monitor

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (1 of 4) : 

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (1 of 4) Class Skin and mucus membrane agent Anti-inflammatory Hormone and synthetic substitute Corticosteroid Glucocorticoid Mineral corticoid Actions Serves as short-acting synthetic steroid Acts as immunosuppressant Achieves anti-inflammatory effects

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (2 of 4) : 

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (2 of 4) Indications Chronic restrictive airway disease COPD Asthma Contraindications Idiopathic thrombocytopenic purpura Psychosis Cushing’s syndrome Acute hepatic dysfunction Age 2 years

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (3 of 4) : 

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (3 of 4) Side effects Hypertension Hyperglycemia Flushing Tachycardia Anaphylactoid reactions Weight gain Mental disturbance Thrombocytopenia Muscle wasting

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (4 of 4) : 

Hydrocortisone Sodium (A-Hydrocort, Solu-Cortef) (4 of 4) Dose Adult 100 mg IV q 6 hours Pediatric 1–2 mg/kg IV Special considerations Use cautiously in patients with: Diabetes Hepatitis Convulsive disorders Hypothyroidism Gastritis CHF Hypertension Renal insufficiency

Neuromuscular Blocking Agents : 

Neuromuscular Blocking Agents Used as adjunct agents to facilitate endotracheal intubation Paralyze skeletal muscle Used with sedative agents Render patient paralyzed, not unconscious

Depolarizing Agents (1 of 4) : 

Depolarizing Agents (1 of 4) Succinylcholine chloride (Anectine, Quelicin, Sucostrin) Class Sympathomimetic Skeletal muscle relaxant, depolarizing Actions Blocks cholinergic receptors on motor endplate Produces depolarization Achieves fasciculations Inhibits subsequent nerve impulse transmissions Achieves rapid onset Acts over short term

Depolarizing Agents (2 of 4) : 

Depolarizing Agents (2 of 4) Succinylcholine chloride (Anectine, Quelicin, Sucostrin) Indications RSI Contraindications Personal or family history of malignant hyperthermia Skeletal muscles myopathies Use cautiously in patients who: Are pediatric Have burns Are at risk for hyperkalemia

Depolarizing Agents (3 of 4) : 

Depolarizing Agents (3 of 4) Succinylcholine chloride (Anectine, Quelicin, Sucostrin) Side effects Respiratory paralysis Malignant hyperthermia Muscular fasciculations Rhabdomyolysis Increased intracranial, intragastric, and intraoccular pressures

Depolarizing Agents (4 of 4) : 

Depolarizing Agents (4 of 4) Succinylcholine chloride (Anectine, Quelicin, Sucostrin Dose Adult 1.0–1.5 mg/kg IV Pediatric 1.0–2.0 mg/kg IV Special considerations Be prepared for endotracheal intubation immediately after administering drug When intubation is unsuccessful, ventilatory assistance is required Eye care to prevent desiccation, abrasions Shelf life of 30 days after removal from refrigeration

Nondepolarizing Agents (1 of 4) : 

Nondepolarizing Agents (1 of 4) Vecuronium (Norcuron) Class Sympathomimetic Skeletal muscle relaxant, nondepolarizing Actions Blocks cholinergic receptors on motor endplate Does not result in muscle depolarization Achieves no fasciculations Inhibits nerve impulse transmissions

Nondepolarizing Agents (2 of 4) : 

Nondepolarizing Agents (2 of 4) Vecuronium (Norcuron) Indications Need for RSI Long-term paralysis after RSI Contraindications Known hypersensitivity

Nondepolarizing Agents (3 of 4) : 

Nondepolarizing Agents (3 of 4) Vecuronium (Norcuron) Side effects Similar to those for succinylcholine No fasciculations

Nondepolarizing Agents (4 of 4) : 

Nondepolarizing Agents (4 of 4) Vecuronium (Norcuron) Dose Defasciculating dose 0.1 mg/kg IV Paralyzing dose Adult 0.08–0.10 mg/kg IV Repeat q 1–2 hours Pediatric 0.1 mg/kg IV Repeat q 1–2 hours Special considerations Consider using sedative or analgesic to decrease cardiovascular side effects Be prepared for endotracheal intubation immediately after administering drug When intubation is unsuccessful, ventilatory assistance is required Eye care to prevent desiccation, abrasions

Pancuronium Bromide (Pavulon)(1 of 4) : 

Pancuronium Bromide (Pavulon)(1 of 4) Class Sympathomimetic Skeletal muscle relaxant, nondepolarizing Actions Blocks cholinergic receptors on motor endplate Does not result in muscle depolarization Achieves no fasciculations Inhibits nerve impulse transmissions Compared to other NMBAs, produces little histamine release Imparts less bronchospasm, hypotension

Pancuronium Bromide (Pavulon)(2 of 4) : 

Pancuronium Bromide (Pavulon)(2 of 4) Indications Need for RSI Long-term paralysis after RSI Contraindications Known hypersensitivity

Pancuronium Bromide (Pavulon) (3 of 4) : 

Pancuronium Bromide (Pavulon) (3 of 4) Side effects Similar to those for vecuronium Greater cardiovascular effects Tachycardia Ventricular ectopy

Pancuronium Bromide (Pavulon)(4 of 4) : 

Pancuronium Bromide (Pavulon)(4 of 4) Dose Adult 0.04–0.10 mg/kg IV Pediatric 0.04–0.1 mg/kg IV Special considerations Similar to those for vecuronium

Rocuronium Bromide (Zemuron)(1 of 4) : 

Rocuronium Bromide (Zemuron)(1 of 4) Class Sympathomimetic Skeletal muscle relaxant, nondepolarizing Actions Blocks cholinergic receptors on motor endplate Does not result in muscle depolarization Achieves no fasciculations Inhibits nerve impulse transmission

Rocuronium Bromide (Zemuron)(2 of 4) : 

Rocuronium Bromide (Zemuron)(2 of 4) Indications Need for RSI Long-term paralysis after RSI Contraindications Known hypersensitivity

Rocuronium Bromide (Zemuron)(3 of 4) : 

Rocuronium Bromide (Zemuron)(3 of 4) Side effects Similar to those for vecuronium Fewer cardiovascular side effects

Rocuronium Bromide (Zemuron)(4 of 4) : 

Rocuronium Bromide (Zemuron)(4 of 4) Dose Adult RSI 0.6 mg/kg IV Maintenance paralyzation 0.1–0.2 mg/kg IV q 1–2 hours Continuous infusion 0.01–0.012 mg/kg/min IV Pediatric (2 years) 0.6 mg/kg IV Special considerations Similar to those for vecuronium

Cistracurium Besylate (Nimbex)(1 of 4) : 

Cistracurium Besylate (Nimbex)(1 of 4) Class Sympathomimetic Skeletal muscle relaxant, nondepolarizing Actions Blocks cholinergic receptors on motor endplate Does not result in muscle depolarization Achieves no fasciculations Inhibits nerve impulse transmissions Has intermediate onset and duration compared to other NMBAs

Cistracurium Besylate (Nimbex)(2 of 4) : 

Cistracurium Besylate (Nimbex)(2 of 4) Indications Need for RSI Long-term paralysis after RSI Contraindications Known hypersensitivity

Cistracurium Besylate (Nimbex)(3 of 4) : 

Cistracurium Besylate (Nimbex)(3 of 4) Side effects Bradycardia Hypotension Flushing Bronchospasm

Cistracurium Besylate (Nimbex)(4 of 4) : 

Cistracurium Besylate (Nimbex)(4 of 4) Dose Adult 0.15 mg/kg to 0.20 mg/kg IV Maintenance infusion: 1–3 mcg/kg/min Pediatric 1–2 mcg/kg/min Special considerations Use cautiously in patients with: Electrolyte abnormalities Burns Neuromuscular disease Advanced age Decreased renal function Pregnancy

Analgesics : 

Analgesics Provide pain relief Have no real anxiolytic, sedative properties

Narcotic Analgesics : 

Narcotic Analgesics

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (1 of 4) : 

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (1 of 4) Class CNS agent Narcotic agonist Actions Acts as semisynthetic derivative structurally similar to morphine Exerts 8–10 times more potent analgesic effect Achieves more rapid onset Exhibits shorter duration of action Imparts less hypnotic action Has less tendency to produce nausea/vomiting Occupies opiate receptors

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (2 of 4) : 

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (2 of 4) Indications Pain Contraindications Known hypersensitivity to hydromorphone Intolerance to opiate agonists Lactation

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (3 of 4) : 

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (3 of 4) Side effects Respiratory depression Hypotension Bradycardia/reflex tachycardia Nausea/vomiting Constipation Euphoria Vertigo Sedation Drowsiness

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (4 of 4) : 

Hydromorphone Hydrochloride (Dilaudid, Dilaudid-HP) (4 of 4) Dose Adult 1–4 mg IV Repeat as needed Pediatric 0.015 mg/kg Repeat as needed Special considerations Naloxone as antidote for overdose

Morphine Sulfate (Duramorph, MS Contin) (1 of 4) : 

Morphine Sulfate (Duramorph, MS Contin) (1 of 4) Class CNS agent Narcotic agonist Actions Occurs naturally Arises as opium poppy derivative Binds with opiate receptors Produces mild vasodilation Decreases preload, afterload Decreases myocardial oxygen demand

Morphine Sulfate (Duramorph, MS Contin) (2 of 4) : 

Morphine Sulfate (Duramorph, MS Contin) (2 of 4) Indications Pain CHF Contraindications Allergy to opiates Decreased level of consciousness Hypotension Increased intracranial pressure Respiratory depression Convulsive disorder Ingested poisoning

Morphine Sulfate (Duramorph, MS Contin) (3 of 4) : 

Morphine Sulfate (Duramorph, MS Contin) (3 of 4) Side effects Respiratory depression Hypotension Localized allergic reaction with intravenous administration Nausea/vomiting Constipation Addiction with long-term use

Morphine Sulfate (Duramorph, MS Contin) (4 of 4) : 

Morphine Sulfate (Duramorph, MS Contin) (4 of 4) Dose Adult 2–10 mg IV over 1–2 minutes Repeat as needed Pediatric 0.05–0.1 mg/kg IV Maximum dose: 15 mg Repeat as needed Special considerations Be prepared to assist with ventilations or tracheal intubation if respiratory depression occurs Action potentiated when used with sedatives, hypnotics, or barbiturates Naloxone as antidote for overdose

Meperidine Hydrochloride (Demerol) (1 of 4) : 

Meperidine Hydrochloride (Demerol) (1 of 4) Class CNS agent Narcotic agonist Analgesic Actions Serves as synthetic opiate Acts at opiate receptor Exerts analgesic effects that mirror those of morphine at all dose ranges

Meperidine Hydrochloride (Demerol) (2 of 4) : 

Meperidine Hydrochloride (Demerol) (2 of 4) Indications Pain Contraindications Known hypersensitivity Seizure disorder

Meperidine Hydrochloride (Demerol) (3 of 4) : 

Meperidine Hydrochloride (Demerol) (3 of 4) Side effects Similar to those for morphine

Meperidine Hydrochloride (Demerol) (4 of 4) : 

Meperidine Hydrochloride (Demerol) (4 of 4) Dose Adult 25–100 mg IV over 1–2 minutes Repeat as needed Pediatric 0.5–1.0 mg IV over 1–2 minutes Repeat as needed Special considerations Naloxone as antidote for overdose

Fentanyl Citrate (Sublimaze, Duragesic) (1 of 4) : 

Fentanyl Citrate (Sublimaze, Duragesic) (1 of 4) Class CNS agent Narcotic agonist Analgesic Actions Serves as opioid analgesic Acts at opiate receptors Achieves 10 times greater potency than morphine Has short duration of action

Fentanyl Citrate (Sublimaze, Duragesic) (2 of 4) : 

Fentanyl Citrate (Sublimaze, Duragesic) (2 of 4) Indications Pain RSI Sedation Contraindications Similar to those for morphine Patient receiving MAOI within previous 14 days Myasthenia gravis Active labor and delivery

Fentanyl Citrate (Sublimaze, Duragesic) (3 of 4) : 

Fentanyl Citrate (Sublimaze, Duragesic) (3 of 4) Side effects Similar to those for morphine Vertigo Delirium Euphoria Bradycardia Hypotension

Fentanyl Citrate (Sublimaze, Duragesic) (4 of 4) : 

Fentanyl Citrate (Sublimaze, Duragesic) (4 of 4) Dose Adult 25–200 mcg IV over 1–2 minutes Pediatric 1–2 mcg/kg IV over 1–2 minutes Special considerations Use cautiously in patients with: Head injury Advanced age COPD Bradydysrhythmia Severe pulmonary, renal, or hepatic disease

Narcotic Agonists-Antagonists : 

Narcotic Agonists-Antagonists

Ketorolac Tromethamine (Toradol, Acular) (1 of 3) : 

Ketorolac Tromethamine (Toradol, Acular) (1 of 3) Class CNS agent NSAID Analgesic Antipyretic Actions Serves as peripherally acting analgesic Inhibits prostaglandin synthesis Indications Pain Moderate to severe

Ketorolac Tromethamine (Toradol, Acular) (2 of 3) : 

Ketorolac Tromethamine (Toradol, Acular) (2 of 3) Contraindications Active labor/delivery Evidence of NSAID reaction Nasal polyps Angioedema Bronchospasm Renal failure Bleeding risk Active peptic ulcer disease Concomitant use of other NSAIDs Side effects Drowsiness Vertigo Headache GI distress Nausea/vomiting

Ketorolac Tromethamine (Toradol, Acular) (3 of 3) : 

Ketorolac Tromethamine (Toradol, Acular) (3 of 3) Dose Adult 30 mg IV Repeat q 6 hours Maximum dose: 120 mg Consider 15 mg IV: Age 65 years Weight 50 kg Renal failure/impairment Pediatric 0.5 mg/kg IV Maximum dose: 15 mg Special considerations May increase: Methotrexate levels and toxicity Lithium levels and toxicity

Nalbuphine Hydrochloride (Nubain) (1 of 3) : 

Nalbuphine Hydrochloride (Nubain) (1 of 3) Class CNS agent Analgesic Narcotic agonist-antagonist Actions Serves as synthetic opioid Acts at opiate receptor like morphine

Nalbuphine Hydrochloride (Nubain) (2 of 3) : 

Nalbuphine Hydrochloride (Nubain) (2 of 3) Indications Pain Moderate to severe Need to slow labor Contraindications Avoid long-term use in pregnancy Fetal dependence

Nalbuphine Hydrochloride (Nubain) (3 of 3) : 

Nalbuphine Hydrochloride (Nubain) (3 of 3) Side effects Same as those for morphine Dose Adult 5–10 mg IV, as needed Pediatric 0.1–0.15 mg/kg IV, as needed

Sedatives and Hypnotics : 

Sedatives and Hypnotics Ideal when anxiolysis, sedation desired Not true analgesics

Benzodiazepines : 

Benzodiazepines

Midazolam Hydrochloride (Versed) (1 of 4) : 

Midazolam Hydrochloride (Versed) (1 of 4) Class CNS agent Benzodiazepine anticonvulsant Sedative-hypnotic Actions Acts at GABA receptors Increases receptor affinity to GABA Results in: Sedation Skeletal muscle relaxation Sleep, at high doses

Midazolam Hydrochloride (Versed) (2 of 4) : 

Midazolam Hydrochloride (Versed) (2 of 4) Indications Anxiety Need for sedation RSI Combativeness Contraindications Hypotension Decreased level of consciousness Hypoperfusion Alcohol intoxication Narrow-angle glaucoma

Midazolam Hydrochloride (Versed) (3 of 4) : 

Midazolam Hydrochloride (Versed) (3 of 4) Side effects Hypotension Tachy/bradycardia Respiratory depression Altered level of consciousness

Midazolam Hydrochloride (Versed) (4 of 4) : 

Midazolam Hydrochloride (Versed) (4 of 4) Dose Adult 1.0–2.5 mg IV over 1–2 minutes Pediatric 0.05–0.2 mg/kg IV over 2–3 minutes Special considerations Flumazenil 0.2–1.0 mg IV for benzodiazepine overdose Effects potentiated with combination analgesic/sedative/hypnotic therapy Be alert for respiratory depression

Diazepam (Valium)(1 of 4) : 

Diazepam (Valium)(1 of 4) Class CNS agent Benzodiazepine anticonvulsant Anxiolytic Actions Serves as benzodiazepine derivative Exhibits actions similar to midazolam

Diazepam (Valium)(2 of 4) : 

Diazepam (Valium)(2 of 4) Indications Anxiety Need for sedation RSI Combativeness Seizures Contraindications Hypersensitivity Respiratory, cardiovascular depression

Diazepam (Valium)(3 of 4) : 

Diazepam (Valium)(3 of 4) Side effects CNS, cardiovascular, respiratory depression

Diazepam (Valium)(4 of 4) : 

Diazepam (Valium)(4 of 4) Dose Adult 2–10 mg slow IVP, repeat as needed Pediatric 0.5–2.0 mg slow IVP, repeat as needed Special considerations Diastat available for rectal administration Flumazenil as antidote for overdose

Lorazepam (Ativan)(1 of 4) : 

Lorazepam (Ativan)(1 of 4) Class CNS agent Benzodiazepine Sedative-hypnotic Anxiolytic Actions Similar to those for midazolam Acts as most potent of benzodiazepines

Lorazepam (Ativan)(2 of 4) : 

Lorazepam (Ativan)(2 of 4) Indications Anxiety Need for sedation RSI Combativeness Contraindications Hypersensitivity Respiratory, cardiovascular depression

Lorazepam (Ativan)(3 of 4) : 

Lorazepam (Ativan)(3 of 4) Side effects Respiratory and cardiovascular depression Altered level of consciousness Dose Adult 0.5–2.0 mg slow IVP, repeat as needed Pediatric 0.03–0.05 mg/kg slow IVP Maximum dose: 4 mg

Lorazepam (Ativan)(4 of 4) : 

Lorazepam (Ativan)(4 of 4) Special considerations Similar to those for midazolam Flumazenil as antidote

Hypnotics : 

Hypnotics

Propofol (Diprivan)(1 of 4) : 

Propofol (Diprivan)(1 of 4) Class CNS agent General anesthesia Sedative-hypnotic Actions Exact mechanism of action unknown Thought to slow limbic system impulses Has rapid onset/half-life

Propofol (Diprivan)(2 of 4) : 

Propofol (Diprivan)(2 of 4) Indications Need for sedation Painful procedures Endotracheal intubation Mechanical ventilation Contraindications Known hypersensitivity Egg allergy

Propofol (Diprivan)(3 of 4) : 

Propofol (Diprivan)(3 of 4) Side effects Hypotension Decreased level of consciousness Respiratory depression Bradycardia Tachycardia Pain at injection site Acalculous cholecystitis with prolonged use

Propofol (Diprivan)(4 of 4) : 

Propofol (Diprivan)(4 of 4) Dose Adult 2–2.5 mg/kg IVP over 1 minute Maintenance infusion: 6–12 mg/kg/hour Pediatric (3 years) 2.5–3.5 mg/kg IV over 1 minute Maintenance infusion: 7.5–18 mg/kg/hour Special considerations Consider use of analgesic with propofol administration Discontinue infusion for assessment

Nonbarbiturate Hypnotic : 

Nonbarbiturate Hypnotic

Etomidate (Amidate)(1 of 4) : 

Etomidate (Amidate)(1 of 4) Class CNS agent General anesthesia Actions Exact mechanism of action unknown Thought to slow limbic system impulses Has rapid onset/half-life

Etomidate (Amidate)(2 of 4) : 

Etomidate (Amidate)(2 of 4) Indications RSI Need for anesthesia Contraindications Known allergy Pregnancy Adrenocortical function suppression

Etomidate (Amidate)(3 of 4) : 

Etomidate (Amidate)(3 of 4) Side effects Respiratory depression Bronchospasm Bruxism Vascular irritation Muscle rigidity

Etomidate (Amidate)(4 of 4) : 

Etomidate (Amidate)(4 of 4) Dose 0.1–0.3 mg/kg IV over 1 minute Special considerations No analgesic effects Side effects exacerbated with rapid administration

Narcotic/Benzodiazepine Antagonists : 

Narcotic/Benzodiazepine Antagonists

Naloxone Hydrochloride (Narcan)(1 of 4) : 

Naloxone Hydrochloride (Narcan)(1 of 4) Class CNS agent Narcotic antagonist Actions Acts as oxymorphone analog Exerts no opiate effects Blocks opiate receptors

Naloxone Hydrochloride (Narcan)(2 of 4) : 

Naloxone Hydrochloride (Narcan)(2 of 4) Indications Opioid overdose Contraindications Known hypersensitivity

Naloxone Hydrochloride (Narcan)(3 of 4) : 

Naloxone Hydrochloride (Narcan)(3 of 4) Side effects Hypertension Tachycardia Ventricular dysrhythmias Abrupt withdrawal symptoms in long-term narcotic users and abusers

Naloxone Hydrochloride (Narcan)(4 of 4) : 

Naloxone Hydrochloride (Narcan)(4 of 4) Dose Adult 0.4–2.0 mg IVP, IM, SQ q 2–3 minutes Maximum dose: 10 mg Pediatric 0.01 mg/kg IV, IM, SQ q 2–3 minutes Maximum dose: 10 mg Special considerations Be prepared for rapid withdrawal symptoms, including: Agitation Rhythm disturbance Pulmonary edema Cardiovascular collapse

Flumazenil (Mazicon, Romazicon)(1 of 4) : 

Flumazenil (Mazicon, Romazicon)(1 of 4) Class CNS agent Benzodiazepine antagonist Action Blocks GABA receptors in brain

Flumazenil (Mazicon, Romazicon)(2 of 4) : 

Flumazenil (Mazicon, Romazicon)(2 of 4) Indications Benzodiazepine OD Contraindications Known hypersensitivity Seizure history

Flumazenil (Mazicon, Romazicon)(3 of 4) : 

Flumazenil (Mazicon, Romazicon)(3 of 4) Side effects Hot flashes Pain at injection site Agitation Breakthrough seizures Elevated CNS response Anxiety

Flumazenil (Mazicon, Romazicon)(4 of 4) : 

Flumazenil (Mazicon, Romazicon)(4 of 4) Dose Adult 0.2 mg IV q minute, as needed Maximum dose: 1.0 mg Pediatric 0.01 mg/kg IV Maximum dose: 0.2 mg Special considerations Phenobarbitol for seizure control after Flumazenil use

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