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Region X Medication Administration September 2006 CE Adenosine - Adenocard Cardizem - Diltiazem Aspirin Nitroglycerin - PowerPoint PPT Presentation


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Region X Medication Administration September 2006 CE Adenosine - Adenocard Cardizem - Diltiazem Aspirin Nitroglycerin Morphine Narcan - Naloxone Valium - Diazepam Versed . Based on 2005 SOP S Hopkins, RN, BSN. Region X Medications. Medications discussed in the following format:

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based on 2005 sop s hopkins rn bsn

Region X MedicationAdministration September 2006 CEAdenosine - AdenocardCardizem - DiltiazemAspirin Nitroglycerin MorphineNarcan - NaloxoneValium - Diazepam Versed

Based on 2005 SOP

S Hopkins, RN, BSN

region x medications
Region X Medications
  • Medications discussed in the following format:
    • action/indication
    • contraindication
    • special considerations
    • dosing
    • side effects
adenosine adenocard
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 vs tachycardic rates
Normal vs Tachycardic Rates

NSR

Sinus

Tach -

ID & treat

cause -

drugs not

recommended

SVT

slide6

Normal Sinus Rhythm

P waves present with normal PR interval

PSVT -

absence of

P waves

Narrow

complexed

tachycardia -

absence of

P waves

adenosine
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
adenosine8
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)
adenosine9
Adenosine

place both

syringes in IV

line to give

draw up draw up saline med & flush as

adenosine flush quickly as

possible

diltiazem cardizem
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 cardizem11
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
Atrial Fibrillation

Normal Sinus Rhythm

Atrial Fibrillation

diltiazem cardizem15
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 cardizem16
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
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
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
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
nitroglycerin20
Nitroglycerin
  • Avoid concomitant use if viagra or viagra-type drug was used in past 24 hours
  • patient may develop a non-reversible hypotension
    • viagra® - sildenafil
    • levitra®
    • 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
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 d22
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
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
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
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
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
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
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 d29
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/ml

2 ml ampule

valium diazepam
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
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 d32
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
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/ml

5 ml total vial

versed cont d
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 d35
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 d36
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
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
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
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 140
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
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 242
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 243
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 244
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
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
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
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
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
ad