Region X MedicationAdministration

September 2006 CEAdenosine - AdenocardCardizem - Diltiazem

Aspirin Nitroglycerin

MorphineNarcan - NaloxoneValium - Diazepam

Versed

Based on 2005 SOP

S Hopkins, RN, BSN

Region X Medications

• Medications discussed in the following format:– action/indication– contraindication– special considerations– dosing– side effects

Adenosine (Adenocard®)• Classified as an antiarrhythmic

• Slows conduction time thru AV node without negative effects on contractility; decreases heart rate at SA node & vagal nerve terminals

• To slow increased heart rate in stable narrow-complexed PSVT

• Does not convert atrial fibrillation, atrial flutter, or ventricular tachycardia

• If given in VT, may cause deterioration including hypotension

Normal Conduction System

Normal vs Tachycardic Rates

NSR

Sinus Tach - ID & treatcause - drugs notrecommended

SVT

Normal Sinus RhythmP waves present with normal PR interval

PSVT - absence of P waves

Narrow complexed tachycardia - absence of P waves

Adenosine• Dosing via large bore IV

– IV to be started in antecubital area preferably right

– 1st dose:

• 6 mg rapid IVP immediately followed with 20ml normal saline flush

– 2nd dose if needed given after 1-2 minutes (dosages are not cumulative)

• 12 mg immediately followed by 20ml normal saline flush

• Both syringes should be simultaneously in 2 IV ports; raise arm for brief period after given

• Run monitor strip during administration

Adenosine• Transient side effects include flushing, chest pressure or

tightness, brief periods of asystole, bradycardia, or ventricular ectopy.– Warn patient that the drug may make them feel “funny” for just a

few minutes

• Less effective (larger dose necessary - medical control order) in patients taking theophylline (for asthma) or caffeine

• More sensitive (smaller dose necessary - medical control order) in patients taking dipyridamole (persantine) or carbamazepine (Tegretol)

Adenosine

place both

syringes in IV

line to give

draw up draw up saline med & flush as

adenosine flush quickly as

possible

Diltiazem (Cardizem®)• Calcium channel blocker

– Slows SA and AV node conduction– Vasodilates arterioles which causes a decrease in peripheral

vascular resistance which decreases blood pressure

• Used to slow the ventricular rate of rapid atrial fibrillation and atrial flutter

• Do not use in wide complexed tachycardias or WPW (Wolff-Parkinson-White)

• Do not use if severe hypotension present

Diltiazem - Cardizem• At a rapid rate, patients are expected to have some signs and

symptoms they may be very aware of but are being tolerated• Drug to be given when the heart rate produces signs and

symptoms that indicate the patient is not tolerating the rapid rate (difficult to predetermine a number on the heart rate that causes symptoms - typically 150 - 180)– shortness of breath– chest pressure– decreasing blood pressure– feeling of lightheadedness

Atrial Fibrillation

Normal Sinus Rhythm Atrial Fibrillation

Atrial Fibrillation Criteria

Normal Sinus Rhythm vs Atrial Fibrillation

Diltiazem - Cardizem• Onset is 3 minutes with a peak effect of 7 minutes• Goal is to slow down a rapid heart rate; goal does not

have to be a heart rate <100 • Rhythm does not convert risk of stroke when atrial fib is present• Carefully monitor heart rate and blood pressure during

administration• Dosage: 0.25 mg/kg IVP over 2-5 minutes• Typical dose is 20 mg to slow the rate - may not need

full calculated dose to accomplish goal

Diltiazem - Cardizem• To assemble:

– Keep syringe upright and remove cap

– Insert plunger rod and turn slowly clockwise

– While turning rod, center stopper advances moving fluid thru membrane into upper chamber

– When all fluid is in upper chamber, rod will function as a plunger

– Roll syringe to mix medication and fluid

– Expel excess air & use

Aspirin® - Acetylsalicylic acid

• Inhibits platelet aggregation (clot formation) and acts as an antiinflammatory agent

• Reduces ACS mortality, reinfarction, and nonfatal strokes

• Given to patients presenting with a possible acute coronary syndrome

• Avoid use in patients allergic to aspirin

• Often avoided in patients with active ulcer disease or asthma

Aspirin

• 324 mg (4 - 81 mg baby aspirin) chewed– chewing breaks drug down faster & enhances faster

absorption

• Side effects:– heartburn– GI bleeding– nausea, vomiting– wheezing– prolonged bleeding time with high dosage

81 mg each tablet

Nitroglycerin

• Potent vasodilator, relaxes vascular smooth muscle

• Reduces cardiac workload

• Dilates coronary arteries

• Given to patients presenting with acute coronary syndrome & pulmonary edema

• Avoid use in patients who are already hypotensive

Nitroglycerin Avoid concomitant use if viagra or viagra-type

drug was used in past 24 hours patient may develop a non-reversible hypotension

viagra® - sildenafillevitra®cialis® - tadalafil

Will need to tactfully ask for use of a viagra type drug and may or may not get a truthful response

Nitroglycerin cont’d• Dosage 0.4 mg sl

– onset of action 1-3 minutes sl; peaks 5-10 minutes sl; duration 20-30 minutes sl

– highly recommended to have IV established first!

• May be repeated every 5 minutes• Monitor blood pressure while using• If 2 doses do not change the pain level, begin morphine

administration• If mouth is dry, should offer the patient a sip of water first

so the pill may dissolve

Nitroglycerin cont’d

• Side effects:– headache– hypotension– dizziness– tachycardia– postural syncope (pass out when attempting to

stand– nausea and vomiting

0.4mg gr 1/150

Morphine• Opioid narcotic analgesic

• Used to reduce pain and anxiety in acute coronary syndrome and during conscious sedation for intubation.

• Reduces pain, anxiety and dilates blood vessels to reduce blood return to the heart in pulmonary edema.

• Avoid use in hypotensive patients

• Effects may be enhanced in presence of other depressant drugs (ie: alcohol)

Morphine cont’d• Dosage - Conscious Sedation, ACS, Pulmonary

Edema, Burns, Pain Management :– 2 mg slow IVP, titrated in 2 mg increments every

3 minutes to 10 mg maximum

• Side effects:– hypotension (monitor B/P)– respiratory depression– constricted pupils– altered mental state

Morphine Use in SOP’s• Pain Management SOP

– morphine 2mg slow IVP– may repeat every 3 minutes in 2 mg increments– 10 mg maximum

• Acute Abdominal Pain SOP– No use of morphine without medical control orders– This specific SOP supercedes the more generic one

(ie: pain management) when the patient specifically complains about abdominal pain

Narcan® (Naloxone)• Narcotic antagonist• Reverses effects of narcotics - respiratory

depression• Effective for:

– morphine, demerol, heroin, paregoric, dilaudid, codeine, percodan, fentanyl, methadone

– synthetic drugs like: nubain, talwin, stadol, darvon

• May cause narcotic withdrawal in narcotic-dependent patient

Narcan cont’d• Prior to administration, have enough help

available should the patient regain consciousness and become extremely agitated

• Consider using enough to just reverse the respiratory depression (discuss with medical control if considering use of less than 2 mg)

• Effects of narcan may be short acting; monitor patient for return of effects of the narcotic (ie: respiratory depression)

Patient “Speedballing”• A patient may combine heroin use with cocaine use

• Administration of narcan will reverse sedative effects of heroin but may cause the stimulating effects of cocaine to be overwhelming - you will have a very agitated and possibly uncontrollable patient to deal with

• If speedballing suspected, contact medical control for possible lower dose just to increase respiratory rate but not full arousal of patient

Narcan cont’d• Dosage:

– 2 mg IVP– Can be repeated at 2 mg every 5 minutes to a

maximum of 10 mg– Purpose is to reverse respiratory depression and improve a

decreased level of consciousness!

• Side effects (usually rare):– hypo or hypertension, ventricular dysrhythmias, nausea &

vomiting– may trigger withdrawal in the drug dependent patient possibly

causing seizures

1 mg/ml2 ml ampule

Valium® (Diazepam)• Relatively short acting sedative,

hypnotic, anticonvulsant

• Used to relax skeletal muscles, reduce chest wall discomfort when using a TCP, stop active seizure activity

• Will stop a current seizure but does not prevent future seizure activity

• A BVM should be available when using Valium

Valium® cont’d• Incompatible with many other medications; flush

IV tubing well before and after using• Valium crosses the placental barrier so delivered

infant may have respiratory depression if used on mother just prior to delivery

• Effects may be enhanced when mixed in the presence of other CNS depressant drugs including alcohol

Valium® cont’d

• Dosage:– pain control with TCP : 2 mg increments slow

IVP to maximum 10 mg– seizures &/or agitation: 5 mg slow IVP or 10 mg

rectally/IM; 5 mg increments to maximum 10 mg– peds seizures or control of shivering during rapid

cooling: 0.2 mg/kg IVP/IO• 0.5 mg/kg if administered rectally

Versed® (Midazolam)• Potent but short acting benzodiazepine

• Used as a sedative and hypnotic

• 3-4 times more potent than valium

• Used to premedicate patient during conscious sedation for intubation and prior to synchronized cardioversion attempts of unstable tachycardia

• This medication has no effect on pain levels

• Duration is dose dependent & patient specific

5 mg/ml5 ml total vial

Versed® cont’d• Cautious use when used with other CNS depressants

taken by patient– alcohol– barbiturates– narcotics

• Always have BVM reached and ready for use when administering Versed due to respiratory depressant effect

• Often may need to bag patient few minutes after use of Versed until they lighten up enough to breathe without prompting

Versed® cont’d• Dosage:

– Conscious sedation:• 2 mg IVP initially

• If not sedated in 60 seconds, repeat 2mg IVP every minute until sedated

• Maximum total dosage 10 mg

• Contact medical control if additional sedation is required

– Synchronized cardioversion• 2 mg slow IVP

• Repeat 1 mg as needed to sedate

Versed® cont’d• Side effects:

– respiratory depression (supported with BVM; reversed with Midazolam IVP)

– headache

– amnesia

– hypotension

– cough, laryngospasm, bronchospasm

– nausea & retching

– dyspnea

– drowsiness

– bradycardia, tachycardia

Controlled Substances

• Morphine, valium and versed are considered controlled substances

• These medications need to be protected and stored in a tamper proof environment over and above their packaging

• Baggies and seals available thru CMC EMS office

Case Scenario #1

• A 67 year-old patient calls due to pounding in their chest for the past 3 hours

• They are now also complaining of lightheadedness and dizziness especially when standing

• No significant past history or medications

• Vital signs: B/P 102/64; P - 180; R - 20

Case Scenario #1 cont’d• What is your interpretation of the EKG?

• Is the patient stable or unstable?

• Evaluate blood pressure and level of consciousness to best determine stability

– SVT

Case Scenario #1• What intervention is appropriate?• IV to be established in antecubital area• Adenosine 6 mg rapid IVP followed immediately with 20 ml

normal saline IVP• Warn patient they may feel a little funny for just a few

minutes• Run a rhythm strip while administering the drug• Reevaluate how the patient feels, vital signs and EKG• If needed, administer 12 mg Adenosine rapid IVP with

another 20 ml normal saline IVP

Case Scenario #2• You are called to care for a 87 year old patient

who complains of heart palpitations, a rapid heart beat, and fatigue

• What is the rhythm?

Lead II

Case Scenario #2

• Patient is in rapid atrial fibrillation

• Vital signs: B/P 104/70; P - irregular 150; R - 20

• What treatment is appropriate for this patient?

Case Scenario #2 Determine if the patient is stable or unstable

Consider Diltiazem 0.25 mg/kg slow IVP (20 mg is an average dose) if patient stable and symptomatic

Carefully watch blood pressure (hypotension is a common response)

How much of the drug is necessary?

Enough to lower the pulse rate. The pulse rate does not need to get below100. Also, the rhythm will not convert - just slow down

Case Scenario #2• During administration of cardizem, what is the

patient’s new rhythm?

• Controlled atrial fibrillation - now is the time to reassess the patient’s vital signs and subjective complaints

Case Scenario #3• You needed to perform a synchronized

cardioversion on a 72 year-old patient for an unstable tachycardia

• You have administered a total of 6 mg of versed

• Your patient is now unresponsive; respiratory rate is 4/minute; heart rate remains tachycardic

• What prompted the change in LOC?

• What is your plan of action?

Case Scenario #3 cont’d• The patient is responding as expected to the versed -

they are sedated!

• The patient is sufficiently sedated so synchronized cardioversion should proceed quickly

• Immediately after cardioversion, the patient should be reassessed and respirations supported with a BVM until they lighten up and can support their own respirations

• There is no need for intubation at this point yet

Case #4

• You have responded to the scene of a 67 year old patient who complains of chest pain radiating down the left arm accompanied with feelings of nausea

• Vital signs: B/P 142/84; P - 88; R - 18

• No allergies, no medications

• You elect to treat this patient following the Acute Coronary Syndrome

• What are your assessment & treatment plans?

Case #4 cont’d• During history taking, what is important to

know prior to initiating ACS treatment?• Use of viagra or viagra-type drug in the past

24 hours– these drugs could cause irreversible

hypotension when mixed with nitroglycerin• Prior to nitroglycerin monitor that the blood

pressure remains over 100 systolic