Emergency Medications

ACE INHIBITORS (Angiotensin-converting Enzyme Inhibitors)

(Antihypertensive)

Captopril, enalapril, lisinopril, ramipril.

Indications: MI, hypertension (HTN), congestive heart failure (CHF), heart failure without hypotension, ST segment elevation, left ventricular dysfunction after MI.

Usually not started in emergency department, but within 24 hr after fibrinolytic therapy has been completed and blood pressure (BP) has stabilized.


ADENOSINE (Adenocard, Adenoscan) (Antiarrhythmic)

Indications: Narrow-complex tachycardias and PSVT.

Dose: 6 mg rapid intravenous push (IVP) over 1–3 sec followed by a 20-mL bolus of normal saline. Give 12 mg by IVP in 1–2 min if needed. A third dose of 12 mg IVP may be given in 1–2 min, max. 30 mg.


AMIODARONE (Cordarone, Pacerone) (Antiarrhythmic)
Indications: Wide- and narrow-complex tachycardia, polymorphic VT, shock-refractory VF or pulseless VT, SVT, PSVT.

Dose: Cardiac arrest 300 mg (diluted in 20–30 mL D5W) IVP; consider additional 150 mg IVP in 3–5 min. Wide- and narrowcomplex tachycardia (stable) 150 mg IVP over first 10 min (15 mg/min)—may repeat infusion of 150 mg IVP every 10 min as needed; slow infusion of 360 mg IV over next 6 hr (1mg/min); maintenance infusion of 540 mg over next 18 hr (0.5 mg/min).
Max. cumulative dose: 2.2 g IV in 24 hr.

NURSES RESPONSIBILITY

Draw up amiodarone through a large-gauge needle to reduce foaming. For slow or maintenance IV infusion, mix medication only in glass bottle containing D5W and administer through an in-line filter.

ASPIRIN (Acetylsalicylic Acid) (Antiplatelet)
Indications: Acute coronary syndrome, symptoms suggestive of cardiac ischemia.

Dose: 162–325 mg PO non-enteric coated for antiplatelet effect.

ATROPINE (Antiarrhythmic, Anticholinergic)
Indications: Symptomatic sinus bradycardia, asystole, PEA with rate 60 bpm, cholinergic drug toxicity and mushroom poisoning (antidote).

Dose: Cardiac arrest 1 mg IVP every 3–5 min (may give through endotracheal (ET) tube at 2.0–3.0 mg diluted in 10 mL normal saline, max. 0.03–0.04 mg/kg. Bradycardia 0.5–1.0 mg IVP every 3–5 min, max. 0.03–0.04 mg/kg.

BETA BLOCKERS (Antihypertensive)
Common Agents: Atenolol, esmolol, labetalol, metoprolol, propranolol.

Indications: MI, unstable angina, PSVT, A-fib, A-flutter, HTN.

CALCIUM CHLORIDE (Minerals/Electrolytes/Calcium Salt)
Indications: Hyperkalemia, hypocalcemia, hypermagnesemia; antidote to calcium channel blockers and beta blockers; given prophylactically with calcium channel blockers to prevent hypotension.

Dose: Hyperkalemia and antidote to calcium channel blocker 8–16 mg/kg (usually 5–10 mL) slow IVP, may be repeated as needed. Given prophylactically prior to IV calcium channel blockers 2–4 mg/kg (usually 2 mL) slow IVP.


DIGOXIN IMMUNE FAB (Fragment Antigen Binding) (Digibind)

(Antidote to Digoxin, Digitoxin)

Indications: Symptomatic digoxin toxicity or acute ingestion of unknown amount of digoxin.

Dose: Dependent on serum digoxin levels. One 40-mg vial binds to approximately 0.6 mg of digoxin. Dose typically administered over 30 min.

DIGOXIN (Lanoxin) (Inotropic, Antiarrhythmic)

Indications:To slow ventricular response in A-fib or A-flutter, as a positive inotrope in CHF, pulmonary edema. May be used as an alternative drug for PSVT.

Dose: Loading dose of 10–15 g/kg, administered over 5 min.

Maintenance dose determined by body size and renal function.

NURSES RESPOSIBILITIES
Avoid electrical cardioversion of stable patients. 
If the patient’s condition is unstable, use lower current settings such as 10–20 J. 
Use cautiously in elderly patients. 
Correct electrolyte abnormalities, monitor digoxin levels, monitor for clinical signs of toxicity.

DILTIAZEM (Cardizem) (Calcium Channel Blocker)

Indications: A-fib, A-flutter, PSVT refractory to adenosine with narrow QRS complex and adequate BP.

Dose: 15–20 mg (0.25 mg/kg) IVP over 2 min. May repeat in 15 min at 20–25 mg (0.35 mg/kg) IVP over 2 min. Start maintenance drip at 5–15 mg/hr and titrate to HR.

DOPAMINE (INTROPIN) (Vasopressor, Inotropic)

Indications: Symptomatic bradycardia and hypotension, cardiogenic shock.

Dose: Continuous infusions (titrate to patient response): Low dose 1–5 g/kg/min; moderate dose 5–10 g/kg/min (cardiac doses); high dose 10–20 g/kg/min (vasopressor doses). Mix 400 mg/250 mL in normal saline, lactated Ringer’s solution, or D5W (1600 g/mL).

NURSES RESPOSIBILITIES
Hypovolemia, MI. Adjust dosage in elderly patients and in those with occlusive vascular disease. Ensureadequate hydration prior to infusion. 
Taper slowly. 
Do not mix with sodium bicarbonate. 
Use care with peripheral administration; infiltration can cause tissue necrosis. 
Central line is preferred.

EPINEPHRINE (Adrenalin) (Adrenergic Agonist)

Indications: Cardiac arrest: PEA, asystole, pulseless VT, VF; severe hypotension; symptomatic bradycardia; anaphylaxis; severe allergic reactions.

Dose: Cardiac arrest 1 mg IVP (10 mL of 1:10,000 solution) every 3–5 min; follow each dose with 20 mL IV flush; higher doses (up to 0.2 mg/kg) may be used if 1-mg dose fails. Give 2.0–2.5 mg diluted in 10 mL normal saline if administering by ET tube. For continuous infusion add 30 mg (30 mL of 1:1000 solution) to 250 mL normal saline or D5W, run at 100 mL/hr, and titrate to response. Profound bradycardia or hypotension 2–10 g/min IV (add 1 mg of 1:1000 solution to 500 mL normal saline or D5W and infuse at 1–5 mL/min).

Anaphylaxis/asthma 0.1–0.5 mg SC or IM of 1:1000 solution every 5–15 min, may be followed by 1–4 g/min continuous infusion.

EPINEPHRINE

Side Effects: Angina, HTN, tachycardia, VT, VF, nervousness, restlessness, tremors, weakness, headache, nausea.

NURSES RESPOSIBILITIES
Use caution in HTN and increasing heart rate (may cause increased myocardial oxygen demand). Higher doses can contribute to postarrest cardiac impairment, but they may be required to treat poison- or drug-induced shock.

FIBRINOLYTIC AGENTS (Thrombolytic, Fibrinolytic)

Common Agents: Alteplase (Activase, t-PA), anistreplase (Eminase), reteplase (Retavase), streptokinase (Streptase), tenecteplase (TNKase).

Indications: Within 12 hr from onset of symptoms of acute MI. Alteplase is the only fibrinolytic agent approved for acute ischemic stroke and must be started 3 hr from onset of symptoms.

FUROSEMIDE (Lasix) (Diuretic, Loop Diuretics)

Indications: CHF with acute pulmonary edema, hypertensive crisis, postarrest cerebral edema, hepatic or renal disease.

Dose: 0.5–1.0 mg/kg slow IVP over 1–2 min, may repeat at 2 mg/kg slow IVP over 1–2 min.

NURSES RESPOSIBILITIES
Use cautiously in severe liver disease accompanied by cirrhosis or ascites, electrolyte depletion, diabetes mellitus, pregnancy, lactation, risk for ototoxicity with increased dose or rapid injection. 
Monitor electrolytes closely.

IBUTILIDE (Corvert) (Antiarrhythmic)

Indications: SVT, including A-fib and A-flutter; most effective for conversion of A-fib or A-flutter of short duration.

Dose: Patients ≥60 kg 1 mg IVP over 10 min, may repeat same dose in 10 min. Patients 60 kg 0.01 mg/kg IVP over 10 min, may repeat same dose in 10 min.

NURSES RESPOSIBILITIES
Precautions: Monitor ECG for 4–6 hr after administration, with defibrillator nearby. 
Correct electrolyte abnormalities prior to use. 
If A-fib 48 hr, anticoagulation is required before cardioversion with ibutilide.

ISOPROTERENOL (Isuprel) (Sympathomimetic, Beta-Adrenergic Agonist)

Indications: Symptomatic bradycardia, refractory torsade de pointes unresponsive to magnesium, bradycardia in heart transplant patients, beta blocker poisoning.

Dose: IV infusion: mix 1 mg/250 mL in normal saline, lactated Ringer’s solution, or D5W, run at 2–10 g/min, and titrate to patient response. In torsade de pointes titrate to increase heart rate until VT is suppressed.

LIDOCAINE (Xylocaine) (Antiarrhythmic, Anesthetic)

Indications: VF or pulseless VT, stable VT, wide-complex tachycardia of uncertain origin, wide-complex PSVT.

Dose: Cardiac arrest from VF or VT 1.0–1.5 mg/kg IVP (or 2–4 mg/kg via ET tube), may repeat 0.5–0.75 mg/kg IVP every 5–10 min, max. 3 mg/kg. Stable VT, wide-complex tachycardia of uncertain origin use 0.5–0.75 mg/kg and up to 1.0–1.5 mg/kg, may repeat 0.5–0.75 mg/kg every 5–10 min; max. total dose 3.0 mg/kg. If conversion is successful, start an IV infusion of 1–4 mg/min (30–50 g/kg/min) in normal saline or D5W.

NURSES RESPOSIBILITIES
 Reduce maintenance dose (not loading dose) in presence of impaired liver function or left ventricular dysfunction or in the elderly.
Stop infusion if signs of toxicity (prolonged PR interval, QRS widening, or CNS changes) develop.

MAGNESIUM SULFATE (Electrolyte, Antiarrhythmic)

Indications:Torsade de pointes, VF refractory to lidocaine, digoxin-induced VT/VF.

Dose: Cardiac arrest (in hypomagnesemia or torsade de pointes) 1–2 g (2–4 mL of a 50% solution) diluted in 10 mL of D5W IVP. Digoxin-induced VT or VF 1–2 g IVP. Torsade de pointes (non-cardiac arrest) load with 1–2 g mixed in 50–100 mL of D5W infused over 5–60 min IV, then infuse 0.5–1.0 g/hr IV (titrate to control torsade). Acute MI load with 1–2 g mixed in 50–100 mL of D5W over 5–60 min IV, then infuse 0.5–1.0 g/hr IV for up to 24 hr.

MORPHINE (Opioid Agonist Analgesic)

Indications: Chest pain unrelieved by nitroglycerin, CHF and dyspnea associated with pulmonary edema.

Dose: 2–4 mg IVP (over 1–5 min) every 5–30 min.

NURSES RESPOSIBILITIES

Administer slowly and titrate to effect. Reverse with naloxone (0.4–2.0 mg IVP). Use caution in cerebral edema and pulmonary edema with compromised respiration.

NITROGLYCERIN (Nitrostat, Nitrolingual Pumpspray) (Antianginal, Nitrate)

Indications: Angina, CHF associated with acute MI, hypertensive crisis.

Dose: Sublingual route, 0.3–0.4 mg (1 tablet), repeat every 5 min, max. 3 doses/15 min. Aerosol, spray for 0.5–1.0 sec at 5- min intervals (provides 0.4 mg/dose), max. 3 sprays/15 min. IVP at 12.5–25.0 g (if no sublingual or spray used). IV infusion: mix 25 mg/250 mL (100 g/mL) in D5W, run at 5–20 g/min, and titrate to desired response.

NURSES RESPOSIBILITIES
Do not mix with other medications; titrate IV to maintain systolic BP 90 mm Hg. Mix only in glass IV bottles and infuse only through tubing provided by manufacturer; standard polyvinyl chloride tubing can bind up to 80% of the medication, making it necessary to infuse higher doses.

OXYGEN (Gas)

Indications: Cardiopulmonary emergencies with shortness of breath and chest pain, cardiac or respiratory arrest.

Dose: Nasal cannula 1–6 L/min (24%–44% oxygen), Venturi mask 4–8 L/min (24%–40% oxygen), simple mask 5–8 L/min (40%–60% oxygen), partial rebreathing mask 6–15 L/min (35%–60% oxygen), nonrebreathing mask 6–15 L/min (60%–90% oxygen), bag-valve-mask 15 L/min (up to 100% oxygen).

PROCAINAMIDE (Pronestyl) (Antiarrhythmic)

Indications: Recurrent VT or VF, PSVT refractory to adenosine and vagal stimulation, rapid A-fib with Wolff-Parkinson-White syndrome, stable wide-complex tachycardia of uncertain origin, maintenance after conversion.

Dose: 20 mg/min IV infusion or up to 50 mg/min under urgent conditions, max. 17 mg/kg loading dose. Maintenance IV infusion: mix 1 g/250 mL (4 mg/mL) in normal saline or D5W, run at 1–4 mg/min.

NURSES RESPOSIBILITIES
Monitor BP every 2–3 min while administering procainamide. 
If QRS width increases by 50% or more, or if BP decreases to 90 systolic, stop drug. 
Reduce total dose to 12 mg/kg and maintenance infusion to 1–2 mg/min if cardiac or renal dysfunction is present. 
Use cautiously in myasthenia gravis and in hepatic or renal disease and with drugs that prolong QT interval (e.g., amiodarone, sotalol).

SODIUM BICARBONATE (Alkalizing Agent, Buffer)

Indications: Prolonged resuscitation with effective ventilation; hyperkalemia; diabetic ketoacidosis; cocaine toxicity; tricyclic antidepressant, diphenhydramine, or acetylsalicylic acid overdose; metabolic acidosis; shock associated with severe diarrhea.

Dose: 1 mEq/kg IVP, may repeat 0.5 mEq/kg every 10 min.

NURSES RESPOSIBILITIES
CHF, renal disease, cirrhosis, toxemia, concurrent corticosteroid therapy. 
Not recommended for routine use in cardiac arrest patients because adequate ventilation and CPR are the major “buffer agents” in cardiac arrest. Incompatible with many drugs; flush line before and after administration.

VASOPRESSIN (Pitressin Synthetic) (Vasopressor, Hormone)

Indications: Vasodilatory (septic) shock, an alternative to epinephrine in shock-refractory VF and pulseless VT.

Dose: Cardiac arrest 40 units IVP single dose.

VERAPAMIL (Calan, Isoptin) (Calcium Channel Blocker, Antiarrhythmic, Antihypertensive)

Indications: PSVT (with narrow QRS and adequate BP) refractory to adenosine, rapid ventricular rates in A-fib, A-flutter, or MAT.

Dose: 2.5–5.0 mg slow IVP over 2 min; may give second dose, if needed, of 5–10 mg IVP in 15–30 min, max. dose 20 mg. An alternative second dose is 5 mg IVP every 15 min, max. dose 30 mg.

NURSES RESPOSIBILITIES 
Concurrent oral beta blockers, CHF, impaired hepatic or renal function; may decrease myocardial contractility. 
In geriatric patients administer dose slowly over 3 min.