UNDERSTANDING CODE DRUGS
http://rnbob.tripod.com/codedrugs.htm
OXYGEN
· Essential in cardiac arrest and emergency cardiac care
· Expired air = 16-17% oxygen
· Must given supplemental oxygen @ FIO2 of 100%
· Give to all patients with acute chest pain that may be due to cardiac ischemia, suspected hypoxemia of any cause and cardiopulmonary arrest
· Do not withhold from patients with COPD
· Nasal cannula, masks, positive pressure devices, volume ventilators
· Major precaution: ADEQUATE VENTILATION - ensure by measuring end tidal CO2 and pulse oximeter
MEDICATION / INDICATION/DOSAGES / NURSING CONSIDERATIONS /Adenosine
(slows conduction through AV node and interrupts AV node reentry pathways)
Half-life= 1 seconds
1 vial = 6mg / PSVT including PSVT associated with WPW syndrome: 6mg rapid IVP over 1-3 seconds then 2ml flush; if no response, repeat 12mg dose in 1-2min / · Side effects include- flushing, dyspnea, chest pain resolving within 1-2 min
· Transient sinus bradycardia, ventricular ectopy or even a brief period of asystole
· * Interaction with theophylline, methylxanthines, and dipyridamole may require dose adjustment or another drug
Amrinone- rapid acting inotropic. vasodilator similar to dobutamine
Mix in NSS / CHF refractory to diuretics, vasodilators and conventional inotropics; Load with 1mcg/kg then 2-15 mcg/kg/min / · Monitor for tachyarrhythmias
· Do not mix with dextrose solutions
Atropine
(parasympatholytic)
1mg atropine= 10ml bristojet / Symptomatic bradycardia: 0.5- 1.0mg I.V. push q. 3-5 min, not to exceed a total dose of 0.04mg/kg
Asystole or PEA: 1mg I.V push q. 3-5min, not to exceed total dose of 0.04mg/kg
Relative bradycardia- HR wnl but insufficient to meet demands / · Don’t give less than 0.5mg per dose because the possible paradoxical effect may further slow heart rate
· Use cautiously in presence of MI
· If given via ET tube: dilute 1-2mg in 10ml sterile water or saline- follow with 1ml flush of NSS
· Enhances SA node automaticity and AV conduction via direct vagolytic action
Beta Blockers-
· Propranolol
· Metoprolol
· Atenolol
· Esmolol / Recurrent VT, VF or rapid PSVT refractory to other therapies
Angina, atrial flutter and fibrillation / · Reduce HR, BP, myocardial contractility, myocardial oxygen consumption
· Slows AV conduction
· Administer slowly IV
· Monitor for CHF, bronchospasm
Bretylium
(Adrenergic neuronal blocking and antifibrillatory agent)
Vial = 50mg
Mix 1Gm/25D5W for drip
(1mg/min = 15cc on pump) / VF or pulseless VT unresponsive to defibrillation, epinephrine and lidocaine: 5mg/kg IV push; if arrhythmia persists increase to 1mg/kg repeated every 5-10min to MAX dose of 35mg/kg
Stable VT or stable wide-complex tachycardia of uncertain origin: 5-10mg/kg over 8-1min; to MAX dose of 35 mg/kg over 24 hrs; if loading dose converts arrhythmia, start infusion @ 2 mg/min (30cc on pump) / · Not a first-line drug
· May cause severe hypotension
· May induce projectile vomiting
· Follow boluses with 2ml saline flush
· Treat hypotension with IV fluids, supine position, Trendelenburg position, norepinephrine may be required since may be refractory to epinephrine
· Hypertension and tachycardia are transient due to initial stimulation of norepinephrine release
· Use with caution in arrhythmias induced by digitalis toxicity
Calcium Chloride
(increases myocardial contractile function- positive inotropic effect modulated by effect on SVR + or -)
10ml bristojet = 1Gm
(1ml= 100mg) / Hyperkalemia, hypocalcemia, after multiple transfusions or Calcium channel blocker toxicity: 8-16mg/kg of 10% solution; repeat if necessary / · May cause slowing of HR
· May precipitate digitalis toxicity
· * Precipitates with Na Bicarb
Digoxin / atrial fib/flutter; CHF. Slows heart rate, increases force of contraction and refractory period of AV node / Monitor for nausea, visual disturbances, atrial or junctional tachycardias, PVCs, heart blocks; K+
Dobutamine- catecholamine- sympathomimetic-inotropic vasoactive- alpha and beta effects
1mg/kg/min = 1cc if 6Xwt in Kg/100cc D5W / Pulmonary congestion ; low cardiac output; hypotension; septic shock
- 2-2mcg/kg/min / · Avoid alkaline solutions (Bicarb)
· Monitor for tachycardia, hypertension and ventricular ectopy
· Side effects include headache, nausea, tremor and hypokalemia
Dopamine-
catecholamine-vasoconstrictor
(dopaminergic, beta and alpha receptors)
Premix= 400mg/250cc D5W in top drawer of crash cart / Hemodynamically significant hypotension:
low dose- 1-2 mcg/kg/min= cerebral, mesenteric and renal vasodilation; UOP increase; HR & BP unchanged
mid dose- 2-1mcg/kg/min= increased cardiac output
high dose- >10mcg/kg/min= increased SVR, PVR, preload secondary to renal, mesenteric, peripheral arterial and venous vasoconstriction
toxic dose- >20mcg/kg/min ischemic changes
Symptomatic bradycardia- add norepinephrine if > 20mcg/kg/min required / · Use lowest dose that produces desired effect
· Avoid in hypovolemia, high SVR, pulmonary congestion or increased preload
· Avoid Na Bicarb line
· Avoid extravasation
· MAO inhibitors potentiate effects
Epinephrine- catecholamine
(alpha & beta-adrenergic agonist)
1mg epi=
(10ml of a 1:10,00solution)
or
(1ml of a 1:100solution in multidose vial) / VF,pulseless VT,PEA, or asystole
-standard dosing: 1mg I.V. push q. 3-5min
-intermediate dosing: 2-5mg I.V.push over 3-5min
-escalating dosing: 1mg,3mg,5mg I.V. push 3 min apart
- high dosing: 0.1mg/kg I.V. push q 3-5min
Symptomatic bradycardia: continuous infusion @ 2-1mcg/min; titrate to hemodynamic response (not used as a first-line drug)
MIX 1mg(1ml of a 1:100solution) in 500ml NSS or D5W / · Each dose given peripherally should be followed by 20ml fluid flush to ensure delivery to central circulation
· If no IV access available, give 2- 2.5 times the dose via ET tube; follow with 10ml flush of NSS
· Intracardiac administration used only when no other route available
· Increases SVR, BP, cardiac electrical activity, coronary and cerebral blood flow, strength of myocardial contraction, automaticity and myocardial oxygen requirements
Heparin / Venous thrombosis and to prevent deep vein thrombosis and pulmonary embolism. Anticoagulant inhibits clotting of blood and fibrin clots. / Hemorrhage, prolonged PTT, GI bleeding, chills, fever, rhinitis, acute reversible thrombocytopenia.
Antidote: Protamine Sulfate.
Isoproterenol- sympathomimetic with pure beta- potent inotropic and chronotropic effects)
1mg/25D5W Standard / Temporary control of hemodynamically significant bradycardia after atropine, pacing, dopamine and epinephrine used; 2-10mcg/min / · Monitor for tachyarrhythmias and myocardial ischemia
· Contraindicated in digitalis toxicity
Lasix
(diuretic) / Pulmonary Edema
- 20-4mg IVP / · Monitor K+, dehydration and hypotension; electrolytes
Lidocaine
(Antiarrhythmic)
100mg = 10ml bristojet
1GM/25D5W= Premix drip in first drawer of crash cart / VF or pulseless VT refractory to electrical countershocks and epinephrine: initially, 1-1.5mg/kg I.V. push; repeat q. 3-5min to max of 3mg/kg
Stable VT or stable wide-complex tachycardia of uncertain origin: repeat doses of half the original dose
If lidocaine successfully converts the VF/VT; begin a continuous infusion @ 2-4mg/min
(1mg=15cc on pump) / · Use 2-2.5 times the IV dose when given via ET tube; followed by 1ml saline flush
· If toxic symptoms develop (slurred speech, altered LOC, muscle twitching and seizures), stop the drug or reduce the dose
· Do NOT give this drug if PVCs occur with bradycardia or escape rhythm
· No longer recommended for VF/VT prophylaxis in acute MI
· * Suppresses ventricular arrhythmias and elevates the fibrillation threshold (less likely to occur)
Magnesium
(physiological calcium channel blocker and blocks neuromuscular transmission)
5Gm/10ml bristojet / Torsades de points: Drug of Choice: up to 5- 1gms have been used
Acute MI with hypomagnesemia: intermittent or continuous infusion 0.5- 1.gm/hr
VF/VT with hypomagnesemia: 1-2Gms diluted in 1ml D5W given IVP over 1-2 min / Monitor for flushing, sweating, bradycardia and hypotension; also if toxicity may see depressed reflexes, flaccid paralysis, circulatory collapse, respiratory paralysis and diarrhea
Morphine
(increases venous capacitance and reduces SVR, relieving pulmonary congestion- decreasing intramyocardial wall tension and myocardial oxygen requirements) / Pulmonary Edema or Ischemic chest pain; 1 to 3 mg slow IV over 1 to 5 min until desired effect achieved / · Monitor for respiratory depression, hypotension, bradycardia, decreased LOC
· Have Narcan available for reversal
Neuromuscular blockers / To relax skeletal muscle; manage patients on ventilators / May need to provide sedatives/ analgesic.
Nitroglycerin
(vasodilator)
50mg/25D5W / Angina Pectoris; dosing titration to effect / Monitor for headache, hypotension, syncope, faintness
Norepinephrine
(catecholamine- potent alpha (arterial and venous vasoconstriction) with minimal beta (increase contractility) effect
MIX 8mg/250cc D5W or NSS
(32mcg/ml) / Refractory SHOCK
Hemodynamically significant hypotension refractory to other sympathomimetics (septic and neurogenic shock)
- Start with 0.5-1.mcg/min and titrate to effect / · Increase BP by increasing SVR and thereby diminishing cardiac output (increases myocardial oxygen demand, causes myocardial ischemia)
· Needs A-line for monitoring BP
· Also monitor CO, PCWP, PA pressures
· Contraindicated in hypovolemia
· Extravasation leads to necrosis- phentolamine infiltration minimizes sloughing
Potassium chloride / Low serum K+, low Cl -; digitalis toxicity. / Monitor K+ and Cl-. Monitor for signs of hyperkalemia (wide QRS complex, tall, peaked T waves, disappearing P wave and asystole. Watch for phlebitis, pain or redness at IV site.
Procainamide
(suppresses ventricular ectopy and slows intraventricular conduction)
Vial= 500mg
MIX 1Gm/25D5W for drip
(1mg/min = 15cc on pump) / Persistent cardiac arrest due to VF
PVCs or recurrent VT
Dosing: 20-30mg/min until:
1) arrhythmia suppressed
2) hypotension occurs
3) PR or QRS widens by 50% of its original width
or MAX dose of 17mg/kg has been given
……..if effective, start drip @ 1-4mg/min / · Monitor BP closely during administration; may cause precipitous hypotension; infuse cautiously in acute MI
· Contraindicated in patients with preexisting long QT intervals or torsades de points
· * Hypokalemia and hypomagnesemia may exacerbate arrhythmias
Sodium Bicarbonate
Bristojet= 8.4% 50meq/50ml / Pre-existing metabolic acidosis or prolonged cardiopulmonary arrest with abnormal ABG not corrected by CPR and ventilation: 1 meq/kg IV bolus then ½ dose in 1min prn / · Monitor ABGs
· Monitor for hypernatremia or hyperosmolarity
Sodium Nitroprusside
(vasodilator)
50mg/25D5W or NSS / Severe Hypertension; 0.5- 8.0mcg/kg/min / · Monitor for hypotension
· Toxicity includes tinnitus, visual blurring, altered mental status, nausea, abdominal pain, hyperreflexia, and seizures
Thrombolytics
Streptokinase
TPA / Acute MI with thrombosis; other types of thrombosis / Watch for coagulopathies, bleeding disturbances
Verapamil & Diltiazem
(Calcium channel blockers-direct negative chronotropic & negative inotropic effect) / Acute and preventive treatment of PSVTs, and slowing ventricular response in atrial flutter and fibrillation
Verapamil: 2.5-5mg IV bolus over 2 min; repeat dose 5-10mg in 15-3min then 5mg q 15 until desired response or total dose of 30mg given
Diltiazem: 0.25mg/kg (20mg for avg patient) IV over 2 min; may repeat 0.35mg/kg in 15 min; then infusion of 5-15mg/hr titrated to HR / Reduce oxygen demand; decreased SVR caused by vasodilatation of vascular smooth muscle (coronary vasodilation)
Versed / To relieve anxiety in ventilated patients; pre-op sedation or anesthesia induction. / Monitor for respiratory depression, apnea, laryngospasm, dyspnea, respiratory arrest, PVCs, amnesia, confusion, and visual disturbances. Have emergency equipment available.
CONVERSIONS
To change Pounds to Kilograms
2.2 pounds = 1 Kilogram
An easy way to calculate dosage in kilograms is simply to divide the weight of the patient in pounds by 2.2. This gives you the patient’s weight in kilograms.
Example
1. Patient’s weight is 16pounds.
160/2.2 = 72.7 kg
2. Patient’s weight is 44 pounds.
44/2.2 = 2kg
To convert to Milligrams per Kilogram
To calculate the dosage of a drug given in mg/kg, you multiply the number of milligrams needed times the patient’s weight in kilograms.
Example
If the patient is to receive a dose of 5 mg/kg of bretylium, multiply 5 times the patient’s weight in kilograms. The patients 44 pounds.
44/2.2 = 2kg Then
5mg/kg x 2kg = 10mg bretylium