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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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Region X MedicationAdministration September 2006 CEAdenosine - AdenocardCardizem - DiltiazemAspirin 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 & treat

cause -

drugs not

recommended

SVT


Normal Sinus Rhythm

P 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® - 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

  • 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/ml

2 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/ml

5 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


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