Transcript Region X Medication Administration September 2006 CE Adenosine

Region X Medication
Administration
September 2006 CE
Adenosine - Adenocard
Cardizem - Diltiazem
Aspirin
Nitroglycerin
Morphine
Narcan - Naloxone
Based on
Valium - Diazepam
2005 SOP
Versed
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
draw up
as
adenosine
place both
syringes in IV
line to give
draw up saline med & flush
flush
quickly as
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:
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–
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–
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heartburn
GI bleeding
81 mg each
nausea, vomiting
tablet
wheezing
prolonged bleeding time with high dosage
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 viagratype 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
0.4mg
gr 1/150
dizziness
tachycardia
postural syncope (pass out when attempting to
stand
– nausea and vomiting
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:
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–
–
–
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 narcoticdependent 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
1 mg/ml
2 ml ampule
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
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
5 mg/ml
3-4 times more potent than valium
5 ml total
vial
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
®
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?
– SVT
• Is the patient stable or unstable?
• Evaluate blood pressure and level of
consciousness to best determine
stability
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