2011/01/07

DOSAGES:

METRIC OR MADNESS?

Adrenaline: 1:1000

10
VITAL LIFE SAVING EMERGENCY MEDICATIONS

% Dextrose 50% gm vs mg vs mcg

ADRENALINE 1:1000 DOF DOSAGES

Everything metric is:- volume = litre mass = gram g 1:1000 = 1gram/ 1000mls = 1000mg / 1000 mls = 1mg/ml so why not say so in the first place?

DEXTROSE 50%
Percentages mean out of 100 50% = 50 grams / 100 mls = 50 x 1000 mg / 100 mls = 500mg/ml so take any % dose and add a 0 afterwards to obtain the mg/ml. Why not simply write the mg/ml dose? DOF dosing description

DRUG CALCULATIONS
Dose required X Volume (ml) X Weight (Kg) X Administration Set X 60(hour) Dose in stock

TRY THIS

You are requested to set up an infusion of Midazolam in an intubated 75kg female patient in the Emergency Department at 0.03mg/kg/min using a 10 drop per ml administration set and a 100ml Normal Saline vacolitre. You have 2 x 15mg/3ml ampoules of midazolam. How many drops per minute will you require?

ml = millilitres Kg = kilograms Administration set = drops/ml 60 minutes, if hourly infusion rate required. Dose in stock + dose requires must have same units

Dose required Volume (ml) (Kg) Administration Set D i dXV l ( l) X Weight W i ht (K ) X Ad i i t ti S t X 60 Dose in stock 0.03(mg) x 75(kg) x 100 (mls) x 10 drops min x kg x 30 (mg) x mls = 75 drops /min = 1 drop per second practically

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TRY THIS

REVERSE INFUSION

You are requested to sep up an infusion of Adrenaline in a shocked 50kg male patient during a resuscitation at 5mcg per minute, using a syringe infusion driver, utilising a 50ml syringe. You have a 1mg/ml ampoule of adrenaline, 200ml normal saline vacolitre. The infusion driver can only be set to run at ml/hour.

At the bedside you find a 100kg patient receiving a Dopamine infusion. The nurse informs you that it is running at 30ml per hour through the pressure infusion device. You wish to know how many mcg/kg/min the machine has been set to so as to calculate if the patient is receiving an adequate dose of drug. She can only tell you that a single ampoule of 200mg /10ml has been diluted into the 200ml Normal Saline vacolitre. What is the original prescribing dose?

Dose required Volume (ml) (Kg) Administration Set D i dXV l ( l) X Weight W i ht (K ) X Ad i i t ti S t X 60 Dose in stock 5 (mcg) x 50 (mls) x 60 (min) min x 1000 (mcg) = 15mls per hour

Dose required X Volume (ml) X Weight (Kg) X Administration Set X 60mins Dose in stock D i t k Dose required = Present Rate x Dose in stock Weight x Volume x 60 Dose required (mcg/kg/min) = 30 (mls) x 200 x 1000 (mcg) 1 hour 60 mins x 100 (kg) x 200 (mls) Dose required = 5 mcg/kg/min

ADRENALINE
Pharmacology The administration of epinephrine causes increases in:
(a) Systemic vascular resistance

ADRENALINE
Pharmacokinetics (1) IV administered epinephrine has an extremely rapid onset of action. (2) Is rapidly inactivated by the liver (3) Subcutaneous administration of epinephrine results in slower absorption due to local vasoconstriction. (4) Local massage will hasten absorption. (5) Topically applied nebulizer within the respiratory tract, adrenaline has vasoconstrictor properties which result in reduction of mucosal and submucosal edema. It also has bronchodilator properties which reduce airway smooth muscle spasms.

(b) Systemic arterial pressure (c) Heart rate (positive chronotropic effect) (d) Contractile state (positive inotropic effect) (e) Myocardial oxygen requirement (f) Cardiac automaticity (g) AV conduction (positive dromotropic effect)

Causes a reduction with bronchodilation by relaxing smooth muscles in the bronchial tree (bronchial dilation)

ADRENALINE
Indications:

ADRENALINE
Precautions

Cardiac arrest?
Do not mix with sodium bicarbonate as this deactivates epinephrine.

Acute severe allergic reaction / anaphylaxis

Adrenaline causes a dramatic increase in myocardial oxygen consumption.

Life threatening bronchial asthma

Its use in the setting of an acute MI should be restricted to cardiac arrest.

Respiratory stridor - Croup Severe epistaxis

IV adrenaline 1:1,000 should not be administered to any patient with a pulse. Always read the label for ampoule strength e.g. 1:1000 or 1:10 000

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ADRENALINE
Adult:

DOSE IN CARDIAC ARREST

ADRENALINE:
Adult: not indicated Pediatric:

DOSE FOR BRADYCARDIA

Administer 1 mg (1:10,000) IV every 4minutes, if at all. Paediatric:

IV/IO: administer 0.01 mg/kg (0.1 ml/kg) of 1:10,000; repeat every 4 minutes g g( g) of 1:10,000; , ; repeat p y 4 mins IV/IO: 0.01 mg/kg (0.1 ml/kg) every ET tube: 0.1 mg/kg of 1:1,000, diluted with 5 ml of Ringer Lactate; repeat every 4 minutes Neonate: IV/IO: Administer 0.01 mg/kg (0.1 m/kg) of 1:10,000; repeat every 5 minutes ET tube : 0.1mg/kg of 1:1000, diluted with 3ml Ringer Lactate; repeat every 5 mins ET tube: 0.1 mg/kg of 1:1,000, diluted with 5 ml of Ringer Lactate; repeat every 4 minutes Neonate: IV/IO: administer 0.01 mg/kg (0.1 ml/kg) of 1:10,000; repeat every 4 minutes ET tube: 0.1 mg/kg of 1:1000, diluted with 3 ml of Ringer Lactate

ADRENALINE:

DOSE FOR ANAPHYLAXIS / ASTHMA

ADRENALINE:
Adult: not indicated

DOSE FOR CROUP

FOR ANAPHYLACTIC SHOCK ONLY Adults -immediate Adrenaline : 0.5mg (0.5ml) of 1:1,000 IM into anterior lateral thigh; repeat every 3-5 minutes as required. Paediatric - -immediate Adrenaline : 0.3mg (0.3ml) of 1:1,000 IM into anterior lateral thigh; 3-5 l t l thi h repeat t every 3 5 minutes i t as required. i d If IV/IO access available, dilute 1ml of 1:1000 with 9mls normal saline and administer 1ml of the 1:10 000 every 30 60seconds until clinical improvement. Always monitor the patients pulse and blood pressure during IV/IO administration of adrenaline. Do not administer 1:1000 adrenaline to a patient with palpable pulses.

Paediatric: administer 2.5 ml of adrenaline 1:1,000 via nebulizer. Repeat as necessary.

ADRENALINE AUTO- INJECTOR

a) Indications Severe allergic reaction with respiratory distress or mild allergic reaction with history of life-threatening allergic reaction b) Adverse Effects Tachycardia Angina Headache Nausea/ vomiting Dizziness Hypertension Nervousness/Anxiety Tremors .

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ASPIRIN
a) Pharmacology Platelet inhibitor Anti-inflammatory b) Pharmacokinetics Blocks platelet aggregation c) Indications Chest pain when acute myocardial infarction is suspected. d) Contraindications Known hypersensitivity e) Adverse Effects Heartburn Nausea and vomiting Wheezing f) Precautions GI bleeding and upset. Do not use double strength 500mg DISPIRN g) Dosage Adult: 300 mg orally / sublingual / chewed

ASPIRIN
d) Contraindications None in the presence of anaphylaxis e) Preparations Adrenaline Auto-injector (single or multi-dose) only Adult: 0.3 0 3 mg Pediatric: 0.15 mg f) Dosage Patients 3 years of age or greater: Adult Auto-injector: 0.3 mg IM Patients less than 3 years of age: Pediatric Auto-injector: 0.15 mg IM

SALBUTAMOL
Pharmacology Synthetic sympathomimetic amine (a type of stimulant) Stimulates beta-2 adrenergic receptors of the bronchioles Little effect on blood pressure Little cardiac effects Main effect is bronchodilation. It may cause some vasodilation as evidenced by headache or flushing. b) Pharmacokinetics Bronchodilation begins within 5 to 15 minutes after inhalation. Peak effect occurs in 30 minutes c) Indications To reverse bronchospasm To reverse hyperkalemia

SALBUTAMOL
Contraindications Known hypersensitivity Adverse Effects Tachycardia, palpitations, peripheral vasodilation, tremors, and nervousness, headache, sore throat, nausea, and vomiting Precautions Bronchospasm may worsen in rare situations due to patient tolerance or hypersensitivity. If respirations worsen, consider discontinuing use. Should be used with caution in patients with hyperthyroidism or coronary artery disease. Use with caution when administering to patients taking MAO inhibitors or tricyclic antidepressants which may be potentiated by Albuterol.

SALBUTAMOL
Dosage Bronchospasm Adult: 5 mg by nebulized aerosol connected to 6-8 lpm of oxygen; repeat every 10 mins. Pediatric: nebulised aerosol connect to 6-8 lpm of oxygen (a) Age >2 : 2.5 mg by nebulized aerosol (b) Age < 2 year: 1.25 mg by nebulized aerosol Hyperkalemia Adult: 20 mg by nebulized aerosol connected to 6-8 lpm of oxygen

SALBUTAMOL
Dosage: Pressurised metered dose inhaler pMDi with spacer Adults: 8 sprays into spacer every 20 minutes up to 4 hours Paediatrics: 4 sprays into spacer every 20 minutes up to 4 hours

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ATROPINE SULFATE
Pharmacology Parasympatholytic - vagolytic action Anticholinergic - accelerates the heart rate

ATROPINE SULFATE
Contraindications Known hypersensitivity Dysrhythmias in which enhancement of conduction may accelerate the ventricular rate and cause decreased cardiac output (e.g. atrial fibrillation, atrial flutter, or PAT with block) Relative Contraindications (Weigh risk/benefits.): AV block at His-Purkinje level (second-degree Type II AV Block and third-degree AV Block) Suspected acute myocardial infarction or ischemia Glaucoma e) Adverse Effects Excessive doses of atropine can cause delirium, restlessness, disorientation, tachycardia, coma, flushed and hot skin, ataxia, blurred vision, dry mucous membranes. Ventricular fibrillation and tachycardia have occurred following IV administration of atropine. f) Precautions Not clinically significant

) Pharmacokinetics b) Accelerated heart rate within minutes of IV injection Peak effect is seen within the first 15 minutes. Atropine disappears rapidly from the blood. c) Indications Symptomatic bradycardia Organophosphate poisoning Nerve agent poisoning Asystole no longer since 2010.

ATROPINE SULFATE
Dosage Bradycardia : Adult: 0.5-1 mg IV, repeated every 3 minutes. Minimum dose: 0.5mg Maximum 0.04 mg/kg = 3mg Pediatric: 0.02 mg/kg IV/IO; minimum dose 0.1 mg; maximum single dose Child (10 kg-25 kg), 0.5 mg; Adolescent (25-40 kg), 1 mg; EndoTracheal tube administration??; 0.03 mg/kg, dilute 5 mL; repeat once Organophosphate poisoning Adult: Administer 2,5 mg IV or IM every 5 minutes until signs of Atropinisation Pediatric: Administer 0.02 mg/kg IV /IO or IM every 5 minutes

ATROVENT (IPRATROPIUM)

a. Pharmacology Anticholinergic (parasympatholytic) brochodilator Brochodilator is site-specific, not systemic Most effective in combination with a beta-andrenergic brochodilator

b. Pharmacokinetics Improved pulmonary function in 15

c. Indications Allergic reactions/ anaphylaxis Bronchial asthma Reversible bronchospasms associated with chronic bronchitis and emphysema

ATROVENT (IPRATROPIUM)
Precautions to be used as a single agent must be used in combination with a beta-agonist. Dosage Adult: 0.5mg (2.5 mL) by nebulized aerosol connected to 6-8 lpm of oxygen in combination With Salbutamol 5 mg. Pediatric: 0.25mg (1.25ml) by nebulized aerosol is connected to 6 - 8 lpm of oxygen. If < 1 year of age: contraindicated If 1 year but less than 2 years: 0.25mg (1.25 mL) by nebulized aerosol If > 2 and older: 0.5mg (2.5 mL) by nebulized aerosol pMDi + appropriate spacer, together with salbutamol.

CALCIUM 10%
a) Pharmacology Increase cardiac contractile state, and ventricular automaticity Reverses cardiac arrhythmias due to hyperkalemia b) Pharmacokinetics Rapid onset of action with IV administration c) Indications Hyperkalemia Hypocalcemia To treat adverse effects caused by calcium channel blocker overdose Hypotension secondary to diltiazem administration.

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CALCIUM 10%
d) Contraindications Not indicated in cardiac arrest except when hyperkalemia, hypocalcemia, or calcium channel toxicity is highly suspected

CALCIUM 10%
Dosage: NB: depends if it is Calcium Chloride or Calcium Gluconate Adult: Administer CaCl = 0.5 -1 gm by slowly IV CaGlu = 1.5 3gm by slow IV

e) Adverse Effects Bradycardia may occur with rapid injection. f) Precautions Use with caution on patients taking digitalis, as calcium may increase ventricular irritability and precipitate digitalis toxicity. If given with sodium bicarbonate, calcium will precipitate.

Maximum dose: CaCl = 1 gm or 10 mls. Ca Glu = 3 gm or 30mls Administer 250 mg slow IV for hypotension following diltiazem administration. Pediatric: Administer 20 mg/kg (0.2 ml/kg) slow IV/IO at 50 mg/min Maximum dose 1 gram or 10 mls

DEXTROSE IV
a) Pharmacology Dextrose is a water-soluble monosaccharide found in corn syrup and honey. b) Pharmacokinetics (1) Dextrose restores circulating blood sugar and is rapidly utilized following IV injection. (2) Excess dextrose is rapidly excreted unchanged in the urine. c) Indications Correction of altered mental status due to low blood sugar (hypoglycemia) seizures and cardiac arrest d) Contraindications Known hyperglycemia e) Adverse Effects May worsen hyperglycemia

DEXTROSE IV
Dosage Adult: Administer 25 grams in 50 ml IV, usually 1 ampoule of 50% solution through free flowing vein. Paediatric: If < 2 months of age - Administer 510 ml/kg of Dextrose 10% IV/IO Dextrose 10% is prepared by mixing one part of D50W with four parts normal saline If > 2 months but < 2 years of age - administer 2-4 ml/kg of 25% dextrose IV/IO; 25% dextrose is prepared by mixing 50% Dextrose with an equal volume of normal saline If greater > 2 years of age - Administer 50% Dextrose 12 ml/kg IV/IO.

DIAZEPAM
a) Pharmacology Sedation, hypnosis, alleviation of anxiety, muscle relaxation, anticonvulsant activity Little cardiovascular effect b) Pharmacokinetics Onset of action is extremely rapid following IV administration. c) Indications Sustained and/or recurrent seizures, during seizures d) Contraindications Known hypersensitivity, head injury Should be used with caution in patients with altered mental status, hypotension, or acute narrow angle glaucoma

DIAZEPAM
Adverse Effects Lightheadedness, motor impairment, ataxia, impairment of mental and psychomotor function, confusion, slurred speech, amnesia Additive effect with ethanol f) Precautions Respiratory depression may occur with IV administration, especially if given too rapidly. Respiratory support may be required. Use with caution in pregnant patients, persons ingesting alcohol, or persons ingesting sedatives. g) Dosage: Adult: Administer 5mg 10mg IV slowly over 30 seconds. Repeat in 3 mins prn. Usual dose 0.15mg/kg. Max. Dose 30mg.

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LORAZEPAM
Drug of choice for grand-mal type seizing patients. Needs to be refrigerated at 4C, so might not always be available. Has an oily base, so requires free flowing IV access. If available, administer 4mg IV over 30 seconds in adults.

MIDAZOLAM
Good alternative for the actively seizing patient due to the multiple routes of administration; Intravenous: 5mg over 30 seconds, repeat every 3 minutes until the seizure terminates. Doses i excess of 20mg are not advised Intramuscular: 10-15mg as a single dose into the antero-lateral thigh; repeat in 5mins if necessary. Nasal : 10-15mg is squirted into the nasal cavity slowly as a single dose using a small syringe. Close the nostrils after administration. Buccal : 10mg undiluted, rubbed onto the inside cheek as a single dose. Rectal: 20mg. For rectal administration of the injection solution, attach a plastic applicator or plastic needle cap protector onto the end of a syringe and gently push the plastic applicator through the anus into the rectum before injecting contents. Remove immediately after administration. If the volume of medication to be Administered rectally is too small, water for injection may be added to increase the intended volume to 10ml.

MORPHINE SULFATE
Pharmacology (1) Decreases pain perception and anxiety (2) Relaxes respiratory effort (3) Causes peripheral dilation which decreases preload (4) Decreases left ventricular afterload ) Pharmacokinetics b) Binds with opiate receptors in the CNS, altering both perception and emotional response to pain Onset of action is in less than 5 minutes after IV dose and effects last 4-5 hours. Causes peripheral arterial and venous vasodilation c) Indications severe pain Acute myocardial infarction Burns Isolated injuries requiring pain relief Sedative for transcutaneous pacing

MORPHINE SULFATE
Relative Contraindications Head injury Multiple trauma COPD with compromised respiratory effort Hypotension Sensitivity to morphine, codeine, or other opioids e) Adverse Effects (1) Respiratory depression/arrest (2) Altered mental status (decreased level of consciousness) (3) Increased vagal tone due to suppression of sympathetic pathways (slowed heart rate) (4) Nausea and vomiting (5) Constricted pupils (pin-point) (6) Increased cerebral blood flow

MORPHINE SULFATE
Precautions Should be administered diluted, slowly and titrated to effect. 15mg/ml + 14mls normal saline = 1mg/ml Administer 1mg/ml every 30 seconds to effect. Vital signs should be monitored frequently. Hypotension is a greater possibility in volume-depleted patients.

CORTICOSTEROIDS
Range of product: Prednisolone / Methylprednisolone / Hydrocortisone / Dexamethazone Pharmacology: Anti inflammatory / membrane stabilisation Indications: Acute anaphylaxis / Allergies Acute A t asthma th Acute meningitis non HIV Acute epiglottitis adult Acute addisonian crisis Dose: Prednisolone 40-80mg orally Methylprednisolone 125mg IV Hydrocortisone 200mg IV Dexamethisone 10mg IV

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ANTIBIOTICS: CEFTRIAXONE
Pharmacology: Cephalosporin Antibiotic Metablosim: Excreted unchanged in urine (33% - 67%) and in bile Emergency Indication: Suspected Meningococcal septicaemia Severe Sepsis - severe sepsis or septic shock Contraindication /Precautions: Allergy to Cephalosporin Antibiotics Route of Administration Intravenous (IV) route is preferred Intramuscular (IM) route if IV access not available. Side Effects: Nausea and Vomiting, Skin Rash Dose: Adult 1gram Child 50mg/kg IV must be made up to 10ml using sterile water and dose administered over 2min. IM must be made up to 4ml using 1% Lignocaine and dose administered in lateral upper thigh