Dr. Zohair Alaseri, MD FRCPc, Emergency Medicine FRCPc, Critical Care Medicine Intensivest and Emergency Medicine Consultant Director, Department of Emergency.
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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
Emergency Medications
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.
Emergency Medications
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.
VasopressorsEpinephrine
Emergency Medications
It also works in cases ofIt also works in cases of Anaphylactic shock Anaphylactic shock Sever asthmatic attackSever asthmatic attack
VasopressorsEpinephrine
Emergency Medications
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
Emergency Medications
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.
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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.
Emergency Medications
Main Side effects Main Side effects bradycardia and hypotension. bradycardia and hypotension.
AntidysrhythmicsAmiodarone
Emergency Medications
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
Emergency Medications
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.
Emergency Medications
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.
Emergency Medications
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
Emergency Medications
Oxygen
Indications Indications
Any suspected cardiopulmonary emergencyAny suspected cardiopulmonary emergency
Note: Note: Pulse oximetry should be Pulse oximetry should be monitoredmonitored
Emergency Medications
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 %
Emergency Medications
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!
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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)
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
Aspirin
Precautions Precautions
Relatively contraindicated in patients with Relatively contraindicated in patients with active ulcer disease or asthmaactive ulcer disease or asthma
Emergency Medications
Nitroglycerine
IndicationsIndications Chest pain of suspected cardiac originChest pain of suspected cardiac origin Unstable anginaUnstable angina CHFCHF Hypertensive EmergenciesHypertensive Emergencies
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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)
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
Heparin
DosingDosing By protocolBy protocol
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
Dopamine
• 5 to 20 µg/kg per minute 5 to 20 µg/kg per minute
Emergency Medications
Dopamine DO NOTDO NOT mix with sodium bicarbonate mix with sodium bicarbonate
Emergency Medications
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
Emergency Medications
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
Emergency Medications
Adenosine
Indications Indications
First drug for narrow-complex PSVTFirst drug for narrow-complex PSVT
Emergency Medications
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
Emergency Medications
Adenosine
Precautions Precautions
Less effective in patients taking theophyllinesLess effective in patients taking theophyllines
Emergency Medications
Dobutamine Indications Indications
Increases Inotropy Increases Inotropy
Emergency Medications
Dobutamine
DosingDosing Usual infusion rate is 2 to 20 µg/kg per Usual infusion rate is 2 to 20 µg/kg per
minuteminute
Emergency Medications
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
Emergency Medications
Norepinephrine
Indications Indications For severe shock and hemodynamic For severe shock and hemodynamic
significant hypotensionsignificant hypotension
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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
Emergency Medications
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)
Emergency Medications
Observe forObserve for acute pulmonary edema opioid withdrawal seizures
Naloxone
Emergency Medications
In summary
There are some medications you need to know them in detail
Life support medication Airway management medicationes Anti ischemic medications
Emergency Medications
Thank you
Emergency Medications
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