ED Medication Review

ADENOSINE
- dose and common route: 6 mg IV or 12 mg IV
- MOA: acts on the AV node to slow conduction and inhibit reentry pathways; used for PSVT
- safety and monitoring: pt on cardiac monitor, saline bolus at bedside, O2 on pt, double tailed extension c rapid flush and raised arm following administration
- contraindications: HTN crisis, pt c S/S of MI, only to be used in pregnant pts when clearly indicated
- AE: dizziness, numbness, tingling, HA, CP, flushing, hypotension, N/V, dyspnea, and throat, neck, or jaw discomfort

AMIODARONE
- dose and common route IV for ventricular arrhythmias: 150 mg over 10 min, then 360 mg over next 6 hr, then 540 mg over next 18 hr, then 0.5 mg/min infusion until started PO
- MOA: prolongs action potential and refractory period, inhibits adrenergic stim; slows sinus rate, increases PR and QT intervals, and decreases PVR (vasodilation)
- safety and monitoring: pt on cardiac monitor, assess for pulm toxicity/ARDS, SECOND NURSE CHECK (order, calc, and pump), administer c in-line filter
- AE: ototoxicity, ARDS, HF, bradycardia, hypotension, N/V, peripheral neuropathy, tremors

ATIVAN (lorazepam)
- dose and common route: 2-4 mg IV or IM, for status epilepticus may be repeated after 10-15 min
- MOA: depresses CNS, likely by potentiating GABA
- safety and mointoring: geriatric pts more prone to CNS reactions and falls; if given IV, dilute with equal amount sterile water, D5W, or NS for injection
- AE: apnea and cardiac arrect (with rapid IV use), dizziness, drowsiness/lethargy, resp depression

ATROPINE
- dose and common route: IV adults 0.5-1 mg, may repeat PRN q5min, not to exceed 2mg q3-5 min
- MOA: inhibits action of acetylcholine at postganglionic sites located in smooth muscle, secretory glands, and CNS (antimuscarinic activity); GI and GU tract motility are decreased at larger doses
- safety and mointoring: IV push over 1 min (slow admin >1 min may cause paradoxical bradycardia); cardiac monitoring
- CI: acute-closure glaucoma, acute hemorrhate, obstructive disease of the GI tract; (caution: safety not established in pregnancy and older adults have increased sensitivity to adverse reactions)
- SE/AE: tachycardia, blurred vision, dry mouth, urinary hesitancy, drowsiness

BENADRYL (diphenhydramine)
- dose and common route: PO (adults and children >12 yr) 25-50 mg q4-6hr, not >300 mg/day; IM or IV (adults) 25-50 mg q4hr, not >400 mg/day, when given IV, rate not to exceed 25 mg/min
- MOA: antagonizes effects of histamine at the H1-receptor sites; doesn't bid to or inactivate histamine; significant CNS depressant and anticholinergic properties
- safety and mointoring: on the BEERS list for geriatriac population (increased risk sedation, confusion, delirium)
- CI: acute asthma attack (may thicken bronchial secretions --> airway obstruction); lactation; known ETOH intolerance
- SE/AE: blurred vision, anorexia, dry mouth, constipation, drowsiness, dizziness

CALCIUM CHLORIDE
- dose and common route: for hypocalcemia, IV 500-1000 mg q6hr for adults; cardiac arrest and Ca antagonist toxicity, 2-4 mg/kg, may repeat in 10 min if needed; tetany, 1g over 10-30 min, may repeat after 6 hr; NOT to be administered IM; IV push administered at max rate of 50-100 mg/min, pt should remain recumbent for 30-60 min after IV administration, S/S rapid infusion: tingling, warm sensation, and metallic taste, halt if sx occur and resume after subsided
--> in arrest situations, use of CaCl is now limited to pts c hyperkalemia, hypocalcemia, and CCB toxicity
- MOA: electrolyte essential for nervous, muscular, and skeletal systems; acts as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscle; essential for bone formation and blood coagulation
--> may be used in emergency tx of hyperkalemia and hypermagnesemia and adjunt in cardiac arrest or CCB agent toxicity
- safety and monitoring: monitor BP, pulse, and ECG (may cause arrhythmias or transient increase or decrease in BP, especially in geriatric population or pts c HTN); S/S toxicity/OD: N/V, anorexia, thirst, severe constipation, paralytic ileus, and bradycardia
- CI: hypercalcemia, renal calculi, and vfib; caution with digitalis glycosides and renal or cardiac disease
- SE/AE: cardiac arrest, arrhythmias, constipation, phlebitis

- dose and common route: in hypocalcemia in adults, 1-2 g IV initially, then 1-2 g q6h PRN or as continuous infusion of 5.4-21.5 mg/kg/hr; in cardiac arrest and CCB toxicity in adults 500-800 mg IV (max 3 g/dose); in tetany in adults, 1-3 g IV until a response occurs; NOT to be administered IM, causes severe tissue necrosis and sloughing; IV administration max rate of 200 mg/min in adults of 100 mg/min in pediatric pts. Rapid administration may cause tingling, sensation of warmth, and metallic taste; halt infusion if sx occur, resume at slower rate when sx subside.
- MOA: electrolyte maintains cell membrane and capillary permeability, acts as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscle; essential for bone formation and blood coagulation
--> used IV in emergency tx of hyperkalemia and hypermagnesemia and adjunct in cardiac arrest or CCB toxicity
- safety and monitoring: monitor BP, pulse, and ECG frequently during parenteral therapy, may cause vasodilation c resulting hypotension, bradycardia, arrhythmias, and cardiac arrest; transiet increases in BP may occur during IV administration, especially in geriatric pts or in pts with HTN; measure serum Ca q4-6 hr during intermittent infusion and q1-4 hr with continuous infusion
- CI: hypercalcemia, renal calculi, neonates recieving ceftriaxone (increased risk of death, possibly r/t precipitation of drug which can deposit in organs or lead to embolic events); caution in renal or cardiac disease
- SE/AE: cardiac arrest, arrhythmias, constipation, phlebitis

CARDIZEM (diltiazem) - CCB
- indications: HTN, angina pectoris and vasospastic (Prinzmetal's) angina, SVT and RVR in aflutter or afib
- dose and common route: in adults, 0.25 mg/kg IV, may repeat in 15 min at 0.35 mg/kg, may follow with continuous infusion at 10 mg/hr (range 5-15 mg/hr) for up to 24 hr
- MOA: inhibits transport of Ca into myocardial and vascular smooth muscle cells, resulting ininhibition of excitation-contraction coupling and subsequent contraction
- safety and monitoring: monitor ECG continuously during administration, report bradycardia or prolonged hypotension; monitor I&O, assess for signs of HF (peripheral edema, rales/crackles, dyspnea, wt gain, JVD)
- CI: 2nd or 3rd degree AV block (unless artificial pacemaker in place); SBP <90; recent MI or pulmonary congestion; concurrent use of rifampin (reduces Cardizem effectiveness)
- SE/AE: arrhythmias, HF, peripheral edema, Stevens-Johnson Syndrome, flushing

COMPAZINE (prochlorperazine)
- indications: mgmt of N/V; tx of psychoses or anxiety
- dose and common route: as antiemetic for adults, PO 5-10 mg 3-4x/day, IM 5-10 mg q3-4hr, IV 2.5-10 mg (not to exceed 40 mg/day); as antipsychotic for adults, PO 5-10 mg 3-4x/day, IM 10-20 mg q2-4 hr upt to 4 doses, IV 2.5-10 mg up to 40 mg/day
--> IV administration, give at 1 mg/min, not to exceed 5 mg/min
- MOA: alters the effects of dopamine in the CNS; possesses significant anticholinergic and alpha-adrenergic blocking activity; depresses the chemoreceptor trigger zone (CTZ) in the CNS
- safety and monitoring: monitor BP (and orthostatic VS), ECG, HR, and respiratory rate before and during dosage adjustment (may cause Q-wave and T-wave changes in ECG); monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, HTN or hypotension, pallor, fatigue, severe muscle stiffness, loss of bladder control)
- CI: angle-closure glaucoma, bone marrow depression, severe liver or cardiovascular disease, children <2 y/o or <9.1 kg; caution in diabetes mellitus, resp disease, CNS tumors, epilepsy
- SE/AE: blurred vision, dry eyes, constipation, dry mouth, agranulocytosis, neuropleptic malignant syndrome, EPS reaction, pink or reddish-brown discoloration of urine

DILAUDID (hydromorphone)
- dose and common route: IV, IM, or subcut for adults >50 kg 1.5 mg q3-4 hr PRN, for adults and children <50 kg 0.015 mg/kg q3-4 hr, both doses may be increased; PO adults >50 kg 4-8 mg q3-4hr; antitussive for adults and children >12 yr, 1 mg q3-4hr
--> IV rate, administer slowly over 2-3 min (rapid admin may lead to increased resp depression, hypotension, and circulatory collapse)
- MOA: binds to opiate receptors in the CNS; alters perception of and response to painful stimuli while producing generalized CNS depression; suppresses the cough reflex via a direct central action
- safety and monitoring: assess BP, pulse, and respiration before and during administration; may cause sleep-related breathing disorders (central sleep apnea, sleep-related hypoxemia)
- CI: severe respiratory depression (in abscence of resuscitative equipment), paralyic ileus; caution in head trauma, IICP, severe pulmonary disease, seizure disorder
- SE/AE: hypotension, bradycardia, flushing, constipation, urinary retention, confusion, sedation, respiratory depression, physical and/or psychological dependence, tolerance

DOPAMINE
- dose and common route: IV adults for dopaminergic effects (renal vasodilation) 1-5 mcg/kg/min continuous infusion, for beta adrenergic effects (cardiac stimulation) 5-15 mcg/kg/min, for alpha-adrenergic effects (increased PVR) >15 mcg/kg/min
- MOA: small doses (0.5-3 mcg/kg/min) stimulate dopaminergic receptors, providing renal vasodilation; larger doses (2-10 mcg/kg/min) stimulate dopaminergic and beta1-adrenergic receptors, producing cardiac stimulation and renal vasodilation; doses >10 mcg/kg/min stimulate alpha-adrenergic receptors and may cause renal vasoconstriction
- safety and monitoring: volume expanders should generally be attempted prior to initiating dopamine; administer into large vein; SECOND NURSE CHECK of original order, dose calculations, and pump settings; monitor BP, HR, pulse pressure, ECG, and urine output continuously (outside of regularly provided ER capabilities, but also helpful to monitor pulmonary capillary wedge pressure (PCWP), CO, and CVP); palpate peripheral pulses and assess appearance of extremities routinely
- CI: tachyarrhythmias, pheochromocytoma; caution in: hypovolemia, MI, occlusive vascular disease
- SE/AE: arrhythmias, hypotension, angina, piloerection, N/V, irritation at IV site, HA, dyspnea; med will cause extravasation outside of venous circulation, may cause necrosis and sloughing of tissue

DECADRON (dexamethasone)
- indications: used systemically and locally in wide variety of chronic disease including: inflammatory, allergic, hematologic, endocrine, neoplastic, dermatologic, autoimmune, mgmt of cerebral edema, diagnostic agent in adrenal disorder (dx of Cushing's syndrome); unlabeled use: administration to high-risk mothers for prevention of RDS in neonates, adjunct mgmt of N/V from chemo, tx of airway edema prior to extubation
- dose and common route: PO IM IV for adults as an anti-inflammatory (0.75-9 mg daily, given q6-12 hr), airway edema or extubation (0.5-2 mg/kg/day divded q6hr, give 24 hr pre and post-extubation), cerebral edema (10 mg IV, then 4 mg IM or IV q6hr until maximal response achieved, then switch to PO)
--> IV administration, administer over 1-4 min if dose is <10 mg
- MOA: supresses inflammation and the normal immune response; supresses adrenal function at chronic doses of 0.75 mg/day
- safety and monitoring: monitor for bloody or guaiac-positive stools; stopping med suddenly may result in adrenal insufficiency (anorexia, N/V, weakness, fatigue, dyspnea, hypotension, hypoglycemia; notify HCP immediately, may be life-threatening)
- CI: active untreated infections (may be used in tx of TB meningitis), known ETOH or bisulfite hypersensitivity or intolerance, lactation or OB (safety not established)
- SE/AE: HTN, edema, acnea, decreased wound healing, ecchymoses, hirsutism, petechiae, adrenal suppression, peptic ulceration, anorexia or increased appetite N/V, thromboembolism, muscle wasting, osteoporosis, depression, euphoria, hallucinations, cushingoid appearance (moon face, buffalo hump)

FOSPHENYTOIN
- indications: seizure tx/prevention when use of phenytoin not feasible
- dose and common route: for status epilepticus 15-20 mg PE (phenytoin sodium equivalents)/kg; non-emergent and maintenance dosing for adults and children >16 y/o: IV or IM loading dose of 10-20 mg PE/kg, maintenance dose of 4-6 mg PE/kg/day starting 12 hr after loading dose, given in 2-3 divided doses
--> IV administration, rate of <150 mg PE/min in adults
- MOA: limits seizure propagation by altering ion transport, may decrease synaptic transmission; fosphenytoin is rapidly converted to phenytoin, which is responsible for its pharmacologic effects
- safety and monitoring: seizure precautions (seizure pads, suction equipment prepared); assess location, duration, frequency, and characteristics of seizure activity; monitor BP, ECG, and respiratory function continuously during administration and at med peak (15-30 min after administration)
- CI: sinus brady, SA block, 2nd or 3rd degree AV block; prior acute hepatotoxicity due to fosphenytoin or phenytoin; caution in hepatic or renal impairment
- SE/AE: hypotension, tachycardia, acute generalized exanthematous pustulosis, DRESS, Stevens-Johnson syndrome, toxic epidermal necrolysis, pruritis, ataxia, dizziness, drowsiness, nystagmus, angioedema, suicidal ideation, depression

EPINEPHRINE
- indications: severe allergic reactions (subcut, IM, IV); hypoension associated c septic shock (IV); upper airway obstruction and croup (INH; racemic epinephrine); adjunt in localization/prolongation of anesthesia
- dose and common route: for anaphylaxis on adults and children >/= 30 kg 0.3-0.5 mg subcut or IM or 0.1-0.25 mg IV, repeat q10-15 min PRN; during CPR for adults, 1 mg q3-5min; for bradycardia in adults, 2-10 mcg/min continuous infusion; for children, INH, 0.25-0.5 mL or 2.25% racemic epi diluted c 3 mL NS
--> for anaphylaxis via IM route, administer to anterolateral thigh, through clothing if necessary, massage after administration to enhance absorption and decrease local vasoconstriction; avoid gluteal injection, as this may not be effective for anaphylaxis
--> concentration for IV push administration is 1:10,000 (or 0.1 mg/mL; dilute 1 mg (1 mL) of a 1:1,000 solution in 9 mL of NS to prepare a 1:10,000 solution); give IV push dose over at least 1 min (unless during CPR), follow each dose with 20 mL IV saline flush
--> concentration of IM injection is 1:1,000 (1 g/1,000 mL)
--> racemic epi for INH is 2.25%, to be diluted with 3 mL NS for nebulizer
- MOA: results in accumulation of cyclic adenosine monophosphate (cAMP) at beta-adrenergic receptors; affects both beta1 (cardiac)-adrenergic receptors and beta2 (pulmonary)adrenergic receptor sites; produces bronchodilation; also has alpha-adrenergic agonist properties, which result in vasoconstriction; inhibits the release of mediators of immediate hypersensitivity reactions from mast cells
- safety and monitoring: SECOND NURSE CHECK original order, dose calculations, concentration, route, and pump settings; assess IV site for extravasation (cold, hard, pallid appearance), change infusion site if blanching occurs; observe for paradoxical bronchospasm (wheezing), if occurs, stop med and notify HCP
- CI: caution in: cardiac disease (angine, tachycardia, MI), HTN, hyperthyroidism, Parkinson's, pheochromocytoma, diabetes, cerebral arteriosclerosis, glaucoma; OB - use only if potential maternal benefit outweights potential risks to fetus (may decrease placental bloodflow --> increase risk fetal hypoxemia)
- SE/AE: angina, arrhythmias, HTN, tachycardia, hyperglycemia, N/V, nervousness, restlessnes, tremor, HA, paradoxical bronchospasm (c excessive use of inhalers), pulmonary edema

ETOMIDATE
- indications: induction of general anesthesia
- dose and common route: 0.2-0.6 mg/kg (usual dose 0.3 kg/kg); administer over 30-60 seconds, titrate to disired level of sedation
- MOA: hypnotic CNS depressant without analgesic activity; acts on the CNS to stimulate gamma-aminobutyric acid (GABA) receptors and, in doing so, depresses the reticular activating system
- safety and monitoring: monitor resp status (SpO2, etCO2), HR, BP, and EKG throughout etomidate therapy; anticipate apnea, maintain patent airway (suction and intubation equipment prepared)
- CI: prolonged infusion not recommended (supresses cortisol production), OB (may affect child's brain development when used during 3rd trimester); caution in pts undergoing severe stress (may require supplemental corticosteroids); caution in children <10 y/o (safety not established) and in children <3 y/o (may affect brain development)
- SE/AE: arrhythmias, HTN or hypotension, apnea, laryngospasm, postop N/V, transient skeletal muscle movements

FENTANYL
- indications: analegia; induction/maintenance of anesthesia (or adjunt to general anesthesia)
- dose and common route: sedation/analgesia in adults and children >12 y/o 0.5-1 mcg/kg/dose, may repeat after 30-60 min
--> IV push given undiluted over 1-3 min, administer doses >5 mcg/kg over 5-10 min
- MOA: binds to opiate receptors in the CNS, alterating response to and perception of pain; produces CNS depression
- safety and monitoring: monitor resp rate, SpO2, and BP frequently; resp depressant effects may last longer than analgesia
- CI: caution with diabetes, head trauma/IICP, or severe renal, pulmonary, cardiac, or hepatic disease; chronic OB tx c opioids during pregnancy may result in neonatal abstinence syndrome, during lactation, may cause infant sedation and/or resp depression
- SE/AE: arrhythmias, bradycardia, hypotension, confusion, apnea

FLUMAZENIL
- indications: complete/partial reversal of benzodiazepines
- dose and common route: for suspected benzo OD in adults, 0.2 mg IV, additional 0.3 mg may be given 30 sec later, further doses of 0.5 mg may be given at 1 min intervals up to total dose of 3 mg (usual required dose 1-3 mg )
--> IV administration: give over 15-30 sec in large vein, not to exceed 0.5 mg/min in adults
- MOA: flumazenil is a benzodiazepine derivative that antagonizes the CNS depressant effects of benzodiazepine compounds; has no effect on CNS depression from other causes (i.e., opioids, ETOH, barbiturates, or general anesthetics)
- safety and monitoring: place pt on seizure precautions; assess LOC and resp status before and during therapy; observe pt for at least 2 hr after administration for appearance of resedation
- CI: pts recieving benzo for life-threatening problems (status epilepticus or IICP); serious cyclic antidepressant OD
- SE/AE: N/V, seizures, dizziness

- give SLOWLY; may be able to give with benadryl to decrease SE of anxiety?