EMERGENCY MEDICATIONS

1. ACE INHIBITORS ( ANGIOTENSIN-CONVERTING ENZYME INHIBITORS )

     Anti hypertensive

    Common Agents : Captopril,enalapril,lisinopril,ramipril.
    Indications          : MI ,Hypertension,CHF,Heart failure w/o hypotension,ST Segment elevation,
                                left ventricular dysfunction after MI.
    Dose                  : see individual order and dosage
                                Usually not started in emergency department,but within 24 hrs after fibrinolitic
                                therapy has been completed and blood pressure has stabilized.
    Contraindication : Lactation,pregnancy,angioedema,hypersensitivity to ACE inhibitors,serum
                               serum potassium   >5 mEq/L.
    Side Effects        : Tachycardia,dizzines,headache,fatigue,hypotension,hyperkalemia.
    Precautions        : Reduce dose in renal failure.

2. ADENOSINE  (  Adenocard,adenosan ) Anti arrhythmic.
    Indication           : Narrow complex tachycardia and PSVT.
    Dose                  : 6 mg rapid intravenous push ( IVP )over 1-3 second followed by a 20 ml bolus of
                                normal saline. Give 12 mg by IVP in 1-2 minute if needed. A third dose of
                               12 mg IVP may be given in 1-2 minute,max 30 mg.
    Contraindication : Hypersensitivity,sick sinus syndrome,2nd or 3rd degree AV block (unless a
                                functional artificial pacemaker is present,drug or poison-induced tachycardia.
    Side Effects        : Flushing,dizzines,bronchospasm,chest pain or tightness,bradycardia,AV block,
                                asystole,ventricular ectopic beats,VF.
    Precautions        : Ineffective in treating Atrial fibrilation,atrial flutter,or VT. Avoid in patients with
                               receiving dipyridamole and in patients with ashtma or unstable angina.

3. AMIODARONE  (Cordorane,Pacerone ) Anti Arrhythmic
    Indications         :Wide and narrow complex tachycardia,polymorphic VT,shock refractory VF
                               or pulseless VT,SVT,PSVT.
    Dose                 : Cardiac arrest 300 mg (diluted in 20-30 mL D5W ) IVP,
                               Consider additional 150 mg IVP  in 3-5 min.Wide narrow complex tachycardia
                               (stable) 150 mg IVP over first  10 min ( 15 mg/min )-may repeat infusion
                               of 150 mg IVP every 10 min as needed. Slow infusion of 360 mg IV over
                               next 6 hr ( 1 mg /min ).Max.cumulative dose 2.2 g IV in 24 hr.
  Contraindications: Bradycardia,hypersensitivity,cardiogenic shock,2nd or 3rd degree AV Block.
  Side Effects        : Vasodilation,hypotension,visual impairment,hepatotoxicity,pulmonary toxicity,
                              CHF;may prolonge QT Interval.
  Precautions        : Avoid concurrent use with procainamide.Correct hypokalemia and
                             hypomagnesemia if possible before use. Draw up amiodarone through a large
                             gauge needle to reduce foaming.For slow or maintenance IV infusion,mix
                             medication only in glass bottle containing D5W and administer through an in-
                             line filter.          
                              
4. ASPIRIN   ( Acetylsalicylic Acid ) Antiplatelet.
   Indications       :  Acute coronary syndrome,symptoms suggestive or cardiac ischemia.
   Dose               :  162-325 mg PO non-enteric coated for antiplatelet effect.
                             Give within minutes of onset.
  Contraindications: Known allergy to aspirin,pregnancy.
  Side effects      : Anorexia,nausea,epigastric pain,anaphylaxis.
  Precautions      : Active ulcers and asthma,bleeding disorders or thrombocytopenia.

5. ATROPINE ( Antiarrhythmic,Anticholinergic )
    Indications     : Symptomatic sinus bradycardia,asystole,PEA with rate <60bpm,cholinergic
                           drug toxicity and mushroom poisoning ( Antidote )
    Dose             : Cardiac arrest 1mg IVP every 3-5 min (may give trough ET/endotracheal
                           tube ) at 2.0-3.0 mg diluted in 10 mL normal saline,max 0.03-0.04 mg/kg.
                           Bradycardia 0.5-1.0 mg IVP every 3-5 min,max 0.03-0.04mg/kg.

  Contraindications: A-fib,A-flutter (see Reading ECG),glaucoma,asthma.
  Side efffects    :Tachycardia,headache,dry mouth,dilated pupil,VF or VT.
  Precautions     : Use caution in myocardial ischemia and hypoxia.
                          Avoid in hypothermic bradycardia and in 2nd degree or 3rd degree AV Block.

 6. BETA BLOCKERS  ( Antihypertensive )
    Common agents: Atenolol,esmolol,labetalol,metoprolol,propanolol.
    Indications    : MI ,unstable angina,PSVT ,A-fb,A-flutter,HTN.
    Dose            : See individual order or dose
    Contraindications: HR < 60 bpm systolic BP <100 mmHg,2nd-3rd dgree AV Block,
                         Left ventricle failure.
    Side effects   : Hypotension,dizzzines,bradycardia,headache,nausea and vomiting.
    Precautions   : Concurrent use with calcium channel blockers,such as verapamil or
                          diltiazem can cause hypotension. Use cautions in patients with a history
                          of bronchospasm or cardiac failure.

7. CALCIUM CHLORIDE (Mineral/Electrolytes/calcium salt.
    Indications   : Hyperkalemia ,hypcalcemia,hypermagnesemia,
                         Antidote to calcium channel blockers and beta blockers,given prophylactically
                         with calcium channel blockers to prevent hypotension.
   Dose            : Hyperkalemia and antidote to calcium channel blockers 8-16 mg/kg
                         ( usually 5-10 mL ) slow IVP.May be repeated as needed.
                         Given prophylactically prior to IV calcium channel blockers 2-4 mg/kg
                         ( usually 2 mL ) slow IVP.
   Contraindications : Hypercalcemia,VF ,digoxin toxicity,renal calculi.
   Sise effects     : Bradycardia,asystole,hypotension,VF,nausea and vomiting.
   Precautions    : Incompatible with sodium bicarbonat.

 8.DIGOXIN IMMUNE FAB (Fragment Antigen Binding ) DIGIBIND=Antidote to

                      digoxin,digitoxin.

   Indications   : Symptomatic digoxin toxicity or acute ingestion of unknown amount of digoxin.
   Dose           : Dependent on serum digoxin level. one 40 mg vials binds to approximately 0.6
                        of digoxin,dose tipically administered over 30 min.
  Contraindications : Allergy only,otherwise none known.
  Side effects   ; Worsening of CHF ,A-fib ,hypokalemia,increased serum digoxin level.
  Precautions   : Allergy to sheep proteins or other sheep products.

9. DIGOXIN ( Lanoxin ) ( Inotropic,Antiarrhythmic)
    Indications  : To slow ventricular response in A-fib or A-flutter,as a positive inotrope
                         in CHF,pulmonary edema.May be used as an alternative drug for PSVT.
    Dose          :  loading dose of 10-15 microgram/kg.administer over 5 min.
                         Maintenence dose determined by body size and renal function.
    Contraindications : hypersensitivity,uncontrolled ventricular arrhythmia,AV Block,idiopatic
                         hypertrophic subaortic stenosis ( IHSS ),constrictive pericarditis.
    Side effects : Arrhythmias,particularly VF and AV Block,bradycardia,fatigue,nausea,
                        vomiting,blurred or yellow vision,headache,hypokalemia.
    Precautions : Avoid electrical cardioversion of stable patients.If the patients condition
                         is unstable use lower current settings such as 10-12 J. Use cautiously in
                         elderly patients. Monitor digoxin level,moniotor clinical sign of toxicity.

10. DILTIAZEM ( Cardizem ) Calcium Channel B locker )
      Indications : A-fib,A-flutter,PSVT refractory to adenosine with narrow QRS complex
                         and adequate BP.
      Dose         : 15-20 mg ( 0.25 mg/kg) IVP over 2 min. May repeat in 15 min at
                         20-25 mg ( 0.35mg/kg ) IVP over 2 min. Start maintenence drip
                         at 5-15 mg/hr and titrate to HR.
     Contraindications: Drug or poison induced tachycardia,wide complex tachycardia
                         of uncertain origin,rapid A-fib and A-flutter with Wolf- Parkinson-
                         White syndrome,sick sinus syndrome,2nd-3rd degree AV block.
     Side effects : Hypotension,bradycardia,chest pain,ventricular arrhythmias.
     Precautions : Severe hypotension,in patients receiving beta blockers,hepatic injury,
                         renal disease.

11. DOPAMINE ( INTROPIN )  Vasopressor,Inotropic.
     Indications : Symptomatic bradycardia and hypotension,cardiogenic shock.
     Dose         : Continuous infusion ( tritate to patient response):
                        Low dose 1-5 microgram/kg/min
                        Moderate dose 5-10 microgram/kg/min. ( cardiac dose )
                        High dose 10-20microgram/kg/min ( vasopressor dose )
                        Mix 400 mg/250 mL in normal saline,lactated Ringers solutions
                        or D5W (1600 microgram/mL ).
    Contraindications :Pheochromocytoma,uncorrected tachycardia,cardiogenic shock
                        with CHF.
    Side effects : Tachyarrhythmias,angina,hypotension,palpitations,vasoconstriction,
                        dyspnea,nausea and vomiting.
    Precautions : Hypovolemia,MI. Adjust dosage in elderly patients and in those with occlusive
                        vascular disease.Ensure adequate hydration prior to infusion. Taper slowly.
                        Do not mix with sodium bicarbonate.Use care with peripheral administration,
                        infiltration can cause tissue necrosis. Central line is prefered.


 12. EPINEPHRINE ( Adrenalin ) ( Adrenergic  Agonist )
      Indications : Cardiac arrest: PEA,asystole,pulseless VT,VF,severe hypotension,symptomatic
                          bradycardia,anaphylaxis,severe allergic reactions.
     Dose         : Cardiac arrest 1mg IVP ( 10 mL of 1:10.000 solution ) every 3-5 min,
                         follow each dose with 20 mL IV flush,higher dose up to 0.2 mg/kg may be
                         used if 1 mg dose fails. Give 2.0-2.5 mg diluted in 10 mL normal saline
                         if administering by ET Tube. For continuous infusion add 30 mg ( mL of
                        1 : 1000 solution ) to 250 mL normal saline or D5W,run at 100 mL/hr,
                        and tritate to response.
                        Profound Bradycardia or hypotension 2-10 microgram/min IV
                        ( add 1 mg of 1 : 1000 solution to 500 mL normal saline or D5W and infuse
                        at 1-5 mL/min.
                        Anaphylaxis/asthma  0.1-0.5 mg SC or IM   of 1 : 1000 solution every
                        5-15 min,may be followed by 1-4 micogram/min continuous infusion.
    Contraindications : Hypersensitivity to adrenergic amines,hypovolemic shock,coronary
                        insufficiency.
    Side effects : Angina,HTN,tachycardia,VT,VF,nervousness,restlessness,tremors,weakness,
                        headache,nausea.
    Precautions : Use caution in HTN and increasing heart rate ( may cause increased
                        myocardial oxyggen demand ).Higher doses can contribute to post arrest
                        cardiac impairment,but they may be requaired to treat poison or drug
                        induced shock.

 13. FIBRINOLYTIC AGENTS  (Thrombolytic,Fibrinolytic )
     Common agents :Alteplase (Activase,t-PA ),anistreplase (Eminase ),reteplase ( Revatase )
                        streptokinase (Streptase ),tenecteplase (TNKase ).
     Indications :Within  < 12 hr from onset of symptoms of acute MI
                        Alteplase is the only Fibrinolytic agent approved for acute ischemic stroke
                        and must be started < 3 hr from onset of symptoms.
     Dose         : See Dosage Fibrinoytic Agents
     Contraindications :Active internal bleeding within 21 days ( except menses ),
                       neuorvascular event within 3 month ,major surgery or trauma within 2 weeks,
                       aortic dissection,severe HTN,bleeding disorder,prolonged CPR,
                       lumbar punctur within 1 week.
    Side effects : Hypotension,reperfusion,arrhythmias,heart failure,headache,increased bleeding
                      time,deep or superficial hemorrhage,flushing,urticaria,anaphylaxis.
    Precautions : Use cautiously in patients with severe renal or hepatic disease.

14.FUROSEMIDE ( LASIX ) Diuretic,loop diuretic.
     Indications : CHF with acute pulmonary edema,hypertensive crisis,post arrest cerebral edema,
                        hepatic or renal disease.
     Dose         : 0.5-1.0 mg /kg slow IVP over 1-2 min,may repeat at 2 mg/kg slow IVP over
                        1-2 min.
    Contrindications : Hypersensitivity,uncontrolled electrolyte imbalance,hepatic coma,anuria,
                       hypovolemia.
    Precautions : Use cautiously in severe liver disease,accompanied by cirrhosis or ascites,
                        electrolyte depletion,diabetes mellitus,pregnancy,lactation,risk for ototoxicity,
                        with increased dose or rapid injection,Monitor electrolytes closely.

15. IBUTILIDE ( Corvert ) (AntiArrhythmic )
      Indications : SVT including A-fib and A- flutter,most effective for conversion of  A-fib or
                         A-flutter or short duration.
     Dose          : Patient more than 60 kg 1mg IVP over 10 min, may repeat same dose in 10 min.
                        Patient less than 60 kg  0.01 mg/kg IVP over 10 min,may repeat same dose  in
                        10 min.
     Contraindications : Known hypersensitivity,history of ventricular arrhythmias including
                        torsade de pointes.
     Side effects : Headache,nausea and vomiting.
     Precautions : Monitir ECG for 4-6 hr after administration,with defibrillator nearby.
                         Correct  electrolyte abnormalities prior to used.If A-fib > 48 hr,anticoagulation
                         is requaired before cardioversion with ibutilide.

16. ISOPROTERENOL ( Isuprel ) Sympathomimetic,Beta Adrenergic Agonist.
       Indications : Symptomatic bradycardia,refractory torsade de pointes unresponsive to
                          magnesium,bradycardia in heart transplant patients,bete blocker poisoning.
       Dose         : IV infusion : mix 1 mg /250 mL in normal saline,Lactate Ringer solution,or D5W,
                          run at 2-10 microgram/min,and tritate to patient response.
      Contraindications : Cardiac arrest,concurrent use with epinephrine ( can cause VF or VT ),
                         poison or drug induced shock ( exception : beta blocker poisoning ).
      Side effects : Anxiety,tachycardia,palpitations,skin flushing.
      Precautions : May increase myocardial ischemia,tachycardia,restlessness
                          High dose are harmfull except in beta blocker overdose.

17. LIDOCAINE ( Xylocaine ) Antiarrhytmic,Anesthetic.
      Indications : VF or pulseless VT,STABLE vt,wide complex tachycardia or uncertaine origin,
                          wide complex PSVT.
      Dose          : Cardiac arrest from VF or VT 1.0-1.5 mg/kg IVP or 2-4 mg/kg via ET tube.
                          may repeat 0,5-0.75 mg/kg IVP every 5-10 min. Max 3mg/kg.
                          Stable VT,Wide complex tachycardia of uncertaine origin use 0.5-0.75 mg/kg
                          and up to 1.0-1.5 mg/kg. May repeate 0.5-0.75 mg/kg every 5-10 min.
                          Max total dose 3.0 mg/kg. If conversion is succesfull,start an IV infusion of
                          1-4 mg/min in normal saline or D5W.
    Contraindications : Prophylactic use in acute MI,andvanced AV Block,hypotension,
                          Wolf-Parkinson-White Syndrome,hypersensitivity to amide-type local
                          anesthetics.
    Side effects   : Confusion,seizures,hypotension,bradycardia,cardiovascular collapse,
                           respiratory arrest.
    Precautions   : CHF,repiratory depression,shock. Reduce maintenence dose ( not loading dose )
                           in presence of impaired liver function or left ventricular dysfunction or in the elderly.
                           Stop infusion if sign of toxicity ( prolonge PR interval,QRS widening,or CNS
                           changes) develop.

18. MAGNESIUM SULFATE ( Electrolyte,Antiarrhythmic )
      Indications : Torsade de pointes,VF refractory to lidocaine,digoxin induced VT/VF.
      Dose         :  Cardiac arrest ( in hypomagnesemia or torsade de pointes )
                         1-2 g ( 2-4 mL of 50% solution ) diluted in 10 mL of D5W IVP.
                         Digoxin-induced VT or VF 1-2 g IVP.
                         Torsade de pointes ( non-cardiac arrest )load with 1-2 mixed in 50-100 mL
                         of D5W infused over 5-60 min IV,then infuse 0.5-1.0 g/hr IV ( titrate to control
                         torsade ).
                         Acute MI load with 1-2 g mixed in 50-100 mL of D5W over 5-60 min IV,
                         then infuse 0.5-1.0 g/hr IV for up to 24 hr.
     Contraindications : Hypermagnesemia,hypocalcemia,renal disease,AV block,toxemia of
                        pregnancy 2 hr prior to delivery.
     Side effects : Hypotension,bradycardia,cardiac arrest,respiratory depression,altered level of
                         consciousness ( LOC ),flushed skin,diaphoresis.
     Precautions : Renal insufficiency,occasional fall in BP with rapid administration.
                         Monitor serum magnesium level.

19.MORPHINE ( Opioid Agonist Analgesic )
     Indications : Chest pain unrelieved by nittroglicerin,CHF and dyspnea associated with
                        pulmonary edema.
     Dose         : 2-4 mg IVP over 1-5 min every 5-30 min.
     Contraindications : Hypersensitivity,heart failure due to chronic lung disease,respiratory
                        depression,hypotension.
    Side effects : Respiratory depression,hypotension,nausea and vomiting,bradycardia,
                        altered LOC,seizures.
    Precautions : Administer slowly and tritate to effect. Reverse with naloxone (0.4-2.0 mg IVP).
                        Use caution in cerebral edema and pulmonary edema with compromised respiration.
                       
20. NITROGLYCERINE ( Nitrostat,Nitrolingual Pumpspray )

                       Antianginal,Nitrate.

     Indications : Angina,CHF associated with acute MI,hypertensive crisis.
     Dose         : Sublingual route,0.3-0.4 mg ( 1 tablet ),repeat every 5 min,max 3 doses/15 min.
                        Aerosol, spray for 0.5-1.0 sec at 5 min interval ( provides 0.4 mg/dose ),
                        max 3 sprays/15 min.
                        If no sublingual or spray used ( IVP at 12.5-25.0 microgram )
                        IV infusion ; mix 25 mg/250 mL (100 microgram/mL) in D5W,run at 5-20
                        microgram/min and tritate to desired response.
    Contraindications : Hypersensitivity,systolic BP < 90 mmHg,severe bradycardia,or severe
                       tachycardia,sildenafil ( viagra ),tadalafil ( cialis ),vardenafil (levitra )
                       within 24hr,right ventricular infarction.
    Side effects : Hypotension with secondary tachycardia,syncope,headache,flushed skin.
    Precautions : Do not mix with other medications,tritate IV to maintain systolic BP >90 mmHg.
                        Mix only in glass IV bottles and infuse only through tubing provided by manufacturer,
                        standard polyvinyl chloride tubing can bind up to 80% of the medication,
                        making it necessary to infuse higher doses.

21. OXYGEN ( Gas )
      Indications : Cardiopulmonary  emergencies with shortness of breath and chest pain,cardiac
                         or respiratory arrest.
      Dose         : Nasal cannula 1-6 L/min ( 24%-44% oxygen )
                         Venturi mask  4-8 L/min ( 24%-40% oxygen )
                         Simple mask   5-8 L/min ( 40%-60% oxygen )
                         Partial rebreathing mask 6-15 L/min ( 35%- 60% oxygen )
                         Non rebreathing mask    6-15L/min  ( 60%-90% oxygen )
                         Bag valve mask                  15L//min ( up to 100% oxygen ) 
     Contraindications : Emphysema ( deliver < 35% oxygen unless severely hypoxic,hyperventilation.
     Side effects : Drying of respiratory mucosa,possible bronchospasm if oxygen is extremly
                         cold and dry.Oxygen supports combustion and can cause fuel a fire.
    Precautions : Respiratory arrest in patients with hypoxic drive. Patient needs an airway
                        and adequate ventilation before oxygen is effective.
 
22. PROCAINAMIDE ( Pronestyl ) Antiarrhythmic
      Indications : Reccurent VT or VF,PSVT,refractory to adenosine and vagal stimulation,
                         rapid A-fib with Wolf-Parkinson-White syndrome,stable wide complex
                         tachycardia of uncertaine origin,maintenance after conversion.
      Dose         : 20 mg/min IV infusion or up to 50 mg/min under urgent conditions,
                         max. 17mg/kg loading dose.
                         Maintenance IV infusion : mix 1 g/250 mL in normal saline or D5W,
                         run at 1-4 mg/min.
     Contraindications : 2nd and 3rd degree AV Block ( unless a functioning artificial pacemaker
                         is in place ),torsade de pointes,hypersensitivity.
     Side effects : Hypotension,widening QRS Complex,headache,nausea and vomiting,flushed skin
                         seizures,ventricular arrhythmias,AV block,cardiovascular collapse,arrest.
     Precautions : Monitor BP every 2-3min while administering procainamide.
                         If QRS width increase by 50% or more or of BP decreases to <90 systolic,
                         stop drug.
                         Reduce total dose to 12 mg/kg and maintenance infusion to 1-2 mg/min if cardiac
                         or renal dysfunction is present. Use cautiously in myasthenia gravis and in hepatic
                         or renal disease.

23. SODIUM BICARBONAT ( Alkalizing Agent,Buffer )
      Indications : Prolonged resuscitation with effective ventilation,hyperkalemia,diabetic ketoacidosis
                         cocaine toxicity,tricyclic anti depressan.diphenhydramine or acetylsalicylic acid
                         overdose,hypercarbic acidosis.
     Side effects : Hypokalemia,metabolic alkalosis,seizures,tetany.
     Precautioans : CHF,renal disease,cirrhosis,toxemia,concurrent corticosteroid therapy.
                         Not recommended for routine use in cardiac arrest patients because adequate
                         ventilation and CPR are the major "buffer agents'' in cardiac arrest.
                         Incompatible with many drugs,flush line before and after administration.

24. VASOPRESSIN ( Pitressin Synthetic ) Vasopressor,Hormone )
      Indications : Vasodilatory septic shock,an alternative to epinephrine in shock-refractory
                         VF and pulseless VT.
      Dose         : Cardiac arrest 40 units IVP single dose.
      Contraindications : Seizures,heart failure,asthma,coronary artery disease ( CAD ),migraine,
                         allergy to beef or pork protein,chronic renal failure with increased blood urea 
                         nitrogen (BUN )
     Side effects: Dizziness,headache,nausea and vomiting ,MI, chest pain,abdominal cramps,
                        diaphoresis,bronchocostriction,anaphylaxis,coma,convulsions.
     Precautions : CAD (may precipitate angina or MI ),renal impairment,potent peripheral
                         vasoconstrictor.

25. VERAPAMIL ( Calan ,Isoptin ) Calcium Channel Blocker,Antiarrhythmic,Antihypertensive.
      Indications : PSVT ( with narrow QRS and adequate BP ) refractory to adenosine,
                         rapid ventricular rates in A-fib,A-fultter,or MAT.
      Dose         : 2.5-5.0 mg slow IVP over 2 min,may give second dose if needed,of 5-10 mg IVP
                         in 15-30 min,max.dose 20 mg.
                         An alternativec second dose is 5 mg IVP every 15 min,max dose 30 mg.
     Contraindications :A-fb with Wolf-Parkinson-White syndrome,wide complex tachycardia of
                         uncertaine origin,2nd or 3rd degree AV Block,sick sinus syndrome,hypotension,
                         severe CHF,cardiogenic shock.
     Side effects : Hypotension,exacerbation of CHF with left ventricular dysfunction,bradycardia,
                         AV Block.
     Precautions : Concurrent beta blockers,CHF,impaired hepatic or renal function.
                          In geriatric patients administer dose slowly over 3 min.                           

                                          EMERGENCY SKILL


 DEFIBRILLATION

  MANUAL DEFIBRILLATION

AUTOMATIC EXTERNAL DEFIBRILLATION ( AED )

CARDIOVERSION

TRANSCUTANEOUS PACING.