dr. zohair alaseri, md frcpc, emergency medicine frcpc, critical care medicine intensivest and...

Dr. Zohair Alaseri, MDFRCPc, Emergency MedicineFRCPc, Critical Care MedicineIntensivest and Emergency Medicine ConsultantDirector, Department of Emergency MedicineKing Khalid University HospitalChairman Disaster Committee King Saud University Hospitals, Riyadh, KSA

Emergency Medications

Life support medicationsLife support medications Main indicationsMain indications Main contraindicationsMain contraindications DosagesDosages Major side effect and precautionsMajor side effect and precautions


VasopressorsEpinephrine

The single most useful drug currently available for the The single most useful drug currently available for the treatment of cardiac arrest. treatment of cardiac arrest.

It raises both aortic systolic and aortic diastolic It raises both aortic systolic and aortic diastolic pressures, resulting in higher coronary and cerebral pressures, resulting in higher coronary and cerebral perfusion pressures. perfusion pressures.


Dose 1.0 mg IV(0.014 mg/kg) in a 70-kg Dose 1.0 mg IV(0.014 mg/kg) in a 70-kg person. person.

The endotracheal dosage is 2 to 3 mg. The endotracheal dosage is 2 to 3 mg.

Subsequent doses are administered every 3 to 5 Subsequent doses are administered every 3 to 5 minutes. minutes.

Clinical trials show no difference in survival to hospital discharge with Clinical trials show no difference in survival to hospital discharge with high-dosage epinephrine.high-dosage epinephrine.



It also works in cases ofIt also works in cases of Anaphylactic shock Anaphylactic shock Sever asthmatic attackSever asthmatic attack



Epinephrine Precautions Precautions

may cause may cause myocardial ischemiamyocardial ischemia anginaangina increased myocardial oxygen demandincreased myocardial oxygen demand

Do not mix or give with alkaline solutionsDo not mix or give with alkaline solutions


Vasopressin has been shown to be an effective has been shown to be an effective

alternative to epinephrine in both animal alternative to epinephrine in both animal and human studies.and human studies.


a peptide hormone normally released from a peptide hormone normally released from the posterior pituitary gland in response to the posterior pituitary gland in response to HypovolemiaHypovolemia HypotensionHypotension increased plasma osmolarity. increased plasma osmolarity.

potent vasoconstrictorpotent vasoconstrictor

Vasopressin


Vasopressin Dosing Dosing

One time dose of 40 units onlyOne time dose of 40 units only May be substituted for epinephrineMay be substituted for epinephrine Not repeated at any timeNot repeated at any time May be given down the endotracheal tubeMay be given down the endotracheal tube

DO NOTDO NOT double the dose double the doseDilute in 10 mLDilute in 10 mL of NS of NS


AntidysrhythmicsAmiodarone Amiodarone is considered a class III Amiodarone is considered a class III

antidysrhythmic antidysrhythmic In a recent trial, amiodarone administered to In a recent trial, amiodarone administered to

patients with persistent V Fib improved patients with persistent V Fib improved survival to hospital admission.survival to hospital admission.


Main Side effects Main Side effects bradycardia and hypotension. bradycardia and hypotension.

AntidysrhythmicsAmiodarone


The 300-mg bolus in cardiac arrestThe 300-mg bolus in cardiac arrest

(1 mg/min) over 6 hours followed by 540 (1 mg/min) over 6 hours followed by 540 mg (0.5 mg/min) over the next 18 hours. mg (0.5 mg/min) over the next 18 hours.

If breakthrough VT or VF occurs, give If breakthrough VT or VF occurs, give another bolus of 150 mg over 15 to 30 another bolus of 150 mg over 15 to 30 minutes. minutes.

AntidysrhythmicsAmiodarone


Atropine

Atropine acts as a competitive antagonist of Atropine acts as a competitive antagonist of acetylcholine (ACh) at the muscarinic acetylcholine (ACh) at the muscarinic receptor. receptor.


The maximum vagolytic dosage in healthy The maximum vagolytic dosage in healthy human volunteers is 0.04 mg/kg (3 mg in a human volunteers is 0.04 mg/kg (3 mg in a 70-kg person). 70-kg person).

Based on the available data, a dose of 0.04 Based on the available data, a dose of 0.04 mg/kg should be used in asystolemg/kg should be used in asystole

AtropineEmergency Medications

Calcium ChlorideCalcium administration is likely to be beneficial in Calcium administration is likely to be beneficial in

cases of cases of

HyperkalemiaHyperkalemia HypocalcemiaHypocalcemia Calcium channel blocker toxicity. Calcium channel blocker toxicity.


Infusion dosageInfusion dosage

If required, 4 mg/kg of calcium chloride (0.04 If required, 4 mg/kg of calcium chloride (0.04 ml/kg of 10% solution) may be ml/kg of 10% solution) may be administered every 10 minutes. administered every 10 minutes.

Calcium Chloride


Oxygen

Indications Indications

Any suspected cardiopulmonary emergencyAny suspected cardiopulmonary emergency

Note: Note: Pulse oximetry should be Pulse oximetry should be monitoredmonitored


Oxygen Dosing Dosing

Nasal ProngsNasal Prongs 1 to 6 lpm1 to 6 lpm 24 to 44%24 to 44%

Venturi MaskVenturi Mask 4 to 8 lpm4 to 8 lpm 24 to 40%24 to 40%

Partial Partial Rebreather Rebreather MaskMask

6 to 10 lpm6 to 10 lpm 35 to 60%35 to 60%

Bag MaskBag Mask 15 lpm15 lpm up to 100%up to 100%

DeviceDevice Flow RateFlow Rate Oxygen %Oxygen %


Oxygen

Precautions Precautions Pulse oximetry inaccurate in:Pulse oximetry inaccurate in:

Low cardiac output Low cardiac output VasoconstrictionVasoconstrictionHypothermiaHypothermia

NEVER NEVER rely on pulse oximetry!rely on pulse oximetry!


Magnesium Sulfate Indications Indications

Cardiac arrest associated with torsades de Cardiac arrest associated with torsades de pointes or suspected hypomagnesemic statepointes or suspected hypomagnesemic state Refractory VFRefractory VF VF with history of ETOH abuseVF with history of ETOH abuse ventricular arrhythmias due to digitalis ventricular arrhythmias due to digitalis

toxicity, tricyclic overdosetoxicity, tricyclic overdose


Magnesium Sulfate Dosing Dosing

1 to 2 g (2 to 4 mL of a 50% solution) diluted 1 to 2 g (2 to 4 mL of a 50% solution) diluted in 10 mL of D5W IVin 10 mL of D5W IV


Magnesium Sulfate Precautions Precautions

Occasional fall in blood pressure with rapid Occasional fall in blood pressure with rapid administrationadministration Use with caution if renal failure is Use with caution if renal failure is

presentpresent


Sodium Bicarbonate Indications Indications

Class I if known preexisting hyperkalemiaClass I if known preexisting hyperkalemia TCA, ASA overdoseTCA, ASA overdose Class III (not useful or effective) in hypoxic Class III (not useful or effective) in hypoxic

lactic acidosis or hypercarbic acidosis (eg, lactic acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation)cardiac arrest and CPR without intubation)


Sodium Bicarbonate Dosing Dosing

1 mEq/kg IV bolus1 mEq/kg IV bolus Repeat half this dose every 10 minutes thereafterRepeat half this dose every 10 minutes thereafter

PrecautionPrecaution CaCa KK NaNa H2oH2o AlkalosisAlkalosis


Aspirin

Indications Indications Administer to all patients with ACS, Administer to all patients with ACS,

Give as soon as possibleGive as soon as possible Blocks formation of thromboxane A2, Blocks formation of thromboxane A2,

which causes platelets to aggregatewhich causes platelets to aggregate


Aspirin

Dosing Dosing 160 to 325 mg tablets160 to 325 mg tablets

Preferably chewedPreferably chewedMay use suppositoryMay use suppository

Higher doses may be harmfulHigher doses may be harmful


Aspirin

Precautions Precautions

Relatively contraindicated in patients with Relatively contraindicated in patients with active ulcer disease or asthmaactive ulcer disease or asthma


Nitroglycerine

IndicationsIndications Chest pain of suspected cardiac originChest pain of suspected cardiac origin Unstable anginaUnstable angina CHFCHF Hypertensive EmergenciesHypertensive Emergencies


Nitroglycerine

Dosing Dosing Sublingual RouteSublingual Route

• 0.3 to 0.4 mg; repeat every 5 minutes0.3 to 0.4 mg; repeat every 5 minutesAerosol SprayAerosol Spray

• Spray for 0.5 to 1.0 second at 5 Spray for 0.5 to 1.0 second at 5 minute intervalsminute intervals

IV InfusionIV Infusion• Infuse at 10 to 20 µg/min and titrateInfuse at 10 to 20 µg/min and titrate


Nitroglycerine

CIsCIs BP <90 mm HgBP <90 mm Hg RV infarctionRV infarction Limit BP drop to 10% if patient is Limit BP drop to 10% if patient is

normotensivenormotensive Sever tachycardiaSever tachycardia


Morphine Sulfate

Dosing Dosing 1 to 3 mg IV (over 1 to 5 minutes) every 5 1 to 3 mg IV (over 1 to 5 minutes) every 5

to 10 minutes as neededto 10 minutes as needed


Morphine Sulfate

Precautions Precautions Administer slowly and titrate to effectAdminister slowly and titrate to effect May compromise respirationMay compromise respiration Causes hypotension in volume-depleted Causes hypotension in volume-depleted

patientspatients


Beta Blockers Dosing Dosing

EsmololEsmolol0.5 mg/kg over 1 minute, followed by 0.5 mg/kg over 1 minute, followed by

continuous infusion at 0.05 mg/kg/mincontinuous infusion at 0.05 mg/kg/minTitrate to effectTitrate to effect

Esmolol has a short half-life (<10 minutes)Esmolol has a short half-life (<10 minutes)


Labetalol

For Hypertensive emergencies and For Hypertensive emergencies and pheochromocytomapheochromocytoma

10 mg labetalol IV push over 1 to 2 minutes10 mg labetalol IV push over 1 to 2 minutesMay repeat or double labetalol every 10 May repeat or double labetalol every 10

minutes to a maximum dose of 150 mgminutes to a maximum dose of 150 mggive initial dose as a bolus, then start give initial dose as a bolus, then start

labetalol infusion 2 to 8 µg/minlabetalol infusion 2 to 8 µg/min


Beta BlockersPrecautions Precautions Concurrent IV administration with IV calcium channel Concurrent IV administration with IV calcium channel

blockersblockers bronchospastic diseases, bronchospastic diseases, cardiac failurecardiac failure cardiac conductioncardiac conduction

Monitor cardiac and pulmonary status during Monitor cardiac and pulmonary status during administrationadministration

May cause myocardial depressionMay cause myocardial depression


Heparin

Indications Indications For use in ACS, PE, DVTFor use in ACS, PE, DVT

Inhibits thrombin generation by factor Xa Inhibits thrombin generation by factor Xa inhibition and also inhibit thrombin inhibition and also inhibit thrombin indirectly by formation of a complex with indirectly by formation of a complex with antithrombin IIIantithrombin III


Heparin

DosingDosing By protocolBy protocol


Heparin CIsCIs

active bleedingactive bleeding recent intracranialrecent intracranial intraspinal or eye surgeryintraspinal or eye surgery severe hypertensionsevere hypertension bleeding disordersbleeding disorders gastroinintestinal bleedinggastroinintestinal bleeding

DO NOTDO NOT use if platelet count is below 100 000 use if platelet count is below 100 000


Glycoprotein IIb/IIIa Inhibitors

IndicationsIndicationsMI with planned PCI within 24 hoursMI with planned PCI within 24 hoursMust use with heparinMust use with heparin

• Binds irreversibly with plateletsBinds irreversibly with platelets

• Platelet function recovery requires Platelet function recovery requires 48 hours48 hours


Fibrinolytics

IndicationsIndications For Acute Ischemic StrokeFor Acute Ischemic Stroke Hemodynamiclly unstable PEHemodynamiclly unstable PE For AMI in adultsFor AMI in adults

ST elevation or new or presumably ST elevation or new or presumably new LBBB; new LBBB;

Time of onset of symptoms < 12 hoursTime of onset of symptoms < 12 hours


Fibrinolytics

Dosing Dosing For fibrinolytic use, all patients should have For fibrinolytic use, all patients should have

2 peripheral IV lines2 peripheral IV lines1 line exclusively for fibrinolytic 1 line exclusively for fibrinolytic

administrationadministration


Fibrinolytics Dosing for AMI Patients Dosing for AMI Patients

Alteplase, recombinant (tPA)Alteplase, recombinant (tPA)Accelerated InfusionAccelerated Infusion

• 15 mg IV bolus15 mg IV bolus• Then 0.75 mg/kg over the next 30 minutesThen 0.75 mg/kg over the next 30 minutes

– Not to exceed 50 mgNot to exceed 50 mg• Then 0.5 mg/kg over the next 60 minutesThen 0.5 mg/kg over the next 60 minutes

– Not to exceed 35 mgNot to exceed 35 mg3 hour Infusion3 hour Infusion

• Give 60 mg in the first hour (initial 6 to 10 mg is given as Give 60 mg in the first hour (initial 6 to 10 mg is given as a bolus)a bolus)

• Then 20 mg/hour for 2 additional hoursThen 20 mg/hour for 2 additional hours

Fibrinolytics Dosing for AMI Patients Dosing for AMI Patients

Anistreplase (APSAC)Anistreplase (APSAC)– Reconstitute 30 units in 50 mL of sterile waterReconstitute 30 units in 50 mL of sterile water– 30 units IV over 2 to 5 minutes30 units IV over 2 to 5 minutes

Reteplase, recombinantReteplase, recombinant• Give first 10 unit IV bolus over 2 minutesGive first 10 unit IV bolus over 2 minutes• 30 minutes later give second 10 unit IV bolus over 2 minutes30 minutes later give second 10 unit IV bolus over 2 minutes

StreptokinaseStreptokinase• 1.5 million IU in a 1 hour infusion1.5 million IU in a 1 hour infusion

Tenecteplase (TNKase)Tenecteplase (TNKase)• Bolus 30 to 50 mgBolus 30 to 50 mg


Dopamine

Indications Indications Second drug for symptomatic Second drug for symptomatic

bradycardia (after atropine)bradycardia (after atropine) Use for hypotension (systolic BP 70 to Use for hypotension (systolic BP 70 to

100 mm Hg) with S/S of shock100 mm Hg) with S/S of shock


Dopamine

• 5 to 20 µg/kg per minute 5 to 20 µg/kg per minute


Dopamine DO NOTDO NOT mix with sodium bicarbonate mix with sodium bicarbonate


Diltiazem IndicationsIndications

To control ventricular rate in atrial To control ventricular rate in atrial fibrillation and atrial flutterfibrillation and atrial flutter

Use after adenosine to treat refractory Use after adenosine to treat refractory PSVT in patients with narrow QRS PSVT in patients with narrow QRS complex and adequate blood pressurecomplex and adequate blood pressure


Diltiazem

Dosing Dosing Acute Rate ControlAcute Rate Control

15 to 20 mg (0.25 mg/kg) IV over 2 15 to 20 mg (0.25 mg/kg) IV over 2 minutesminutes

Maintenance InfusionMaintenance Infusion5 to 15 mg/hour, titrated to heart rate5 to 15 mg/hour, titrated to heart rate


Adenosine

Indications Indications

First drug for narrow-complex PSVTFirst drug for narrow-complex PSVT


Adenosine

Dose Dose

IV Rapid PushIV Rapid Push Initial bolus of 6 mg given rapidly over 1 to Initial bolus of 6 mg given rapidly over 1 to

3 seconds followed by normal saline bolus 3 seconds followed by normal saline bolus of 20 mL; then elevate the extremityof 20 mL; then elevate the extremity

Repeat dose of 12 mg in 1 to 2 minutes if Repeat dose of 12 mg in 1 to 2 minutes if neededneeded


Adenosine

Precautions Precautions

Less effective in patients taking theophyllinesLess effective in patients taking theophyllines


Dobutamine Indications Indications

Increases Inotropy Increases Inotropy


Dobutamine

DosingDosing Usual infusion rate is 2 to 20 µg/kg per Usual infusion rate is 2 to 20 µg/kg per

minuteminute


Dobutamine

Precautions Precautions Avoid when systolic blood pressure <100 Avoid when systolic blood pressure <100

mm Hg with signs of shockmm Hg with signs of shock

DO NOT mix with sodium bicarbonateDO NOT mix with sodium bicarbonate


Norepinephrine

Indications Indications For severe shock and hemodynamic For severe shock and hemodynamic

significant hypotensionsignificant hypotension


Norepinephrine

Dosing Dosing 0.5 to 1 mcg/min titrated to improve 0.5 to 1 mcg/min titrated to improve

blood pressure (up to 30 mcg/min)blood pressure (up to 30 mcg/min)DO NOTDO NOT administer is same IV line as administer is same IV line as

alkaline infusionsalkaline infusions


Agent Receptor type

alpha Beta 1 Beta 2 Dopamine

Norepinephrine

++++ ++++ +/++ none

Epinephrine +++ ++++ +++ none

Dopamine ++/+++ ++++ ++ ++++

Dobutamine + ++++ ++ none

Phenylephrine ++++ none none none

Catecholamines

TREATMENTTREATMENT

SEDATIVES IV DOSE (mg/kg)

ONSET(min)

Effect on BP

Effect on ICP

Midazolam 0.2 – 0.4 1 – 2 Minimal Minimal

Etomidate 0.2 – 0.4 < 1 Minimal/

Thiopental 2 – 5 < 1

Ketamine 1 – 2 1 Minimal/

Propofol 2 – 3 < 1

IV Induction agent

RSI

Indications for Pretreatment Agents in RSIRSI

Children under 10 years old 0.02 mg/kg

1.5 mg/kg

3 μg/kg

Lidocaine:

Atropine:

Fentanyl:

Drug Indications IV dose

Patients with elevated intracranial pressure (ICP) or penetrating globe injury who are receiving succinylcholine; reactive airway disease

Elevated ICP, intracranial hemorrhage, berry aneurysm, ischemic heart disease, aortic dissection

Agent Dose (mg/kg) Onset (min)Duration (min)

Succinylcholi 1.5 1 3–5

Pancuronium 0.1 2–5 40–60

Vecuronium 0.1 3 30–35

0.25 1 60–120

Atracurium 0.5 3 25–35

Mivacurium 0.15 2–3 15–20

Rocuronium 1.0 1–1.5 30–110

RSIParalytic Agents


Naloxone

Indications Indications Respiratory and neurologic depression due Respiratory and neurologic depression due

to opiate intoxication unresponsive to to opiate intoxication unresponsive to oxygen and hyperventilationoxygen and hyperventilation


Naloxone

Dosing Dosing

0.4 to 2 mg IVP every 2 minutes0.4 to 2 mg IVP every 2 minutes Use higher doses for complete narcotic Use higher doses for complete narcotic

reversalreversal Can administer up to 10 mg in a short Can administer up to 10 mg in a short

time (10 minutes)time (10 minutes)


Observe forObserve for acute pulmonary edema opioid withdrawal seizures

Naloxone


In summary

There are some medications you need to know them in detail

Life support medication Airway management medicationes Anti ischemic medications


Thank you


dr. zohair alaseri, md frcpc, emergency medicine frcpc, critical care medicine intensivest and...

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