Rocky Mountain EMS Special Skills Drug Review

1. Rocky Mountain EMS Special Skills Drug Review Laura Kay MD EMS Medical Director

2. We have gathered here together….. Goals • Familiarity with new drugs • Familiarity with new scope of practice • Familiarity with your first name!!!! Lets Get Started! Hold your applause please

3. GP llb/llla Inhibitors

4. GP llb/llla Inhibitors • GENERIC NAME: Abciximab, Eptifibatide, Tirofiban • TRADE NAME: ReoPro, Integrilin, Aggrastat • TYPE OF DRUG: Platelet aggregation inhibitor • MECHANISM OF ACTION: GP llb/llla inhibitors bind to the intact platelet GPIIb/IIIa receptor, which is a member of the integrin family of adhesion receptors and the major platelet surface receptor involved in platelet aggregation. GP llb/llla inhibitors inhibit platelet aggregation by preventing the binding of fibrinogen, von Willebrand factor, and other adhesive molecules to GPIIb/IIIa receptor sites on activated platelets.

5. GP llb/llla Inhibitors • PHARMACOKINETICS: Following intravenous bolus administration, free plasma concentrations of GP llb/llla inhibitors decrease rapidly with an initial half-life of less than 10 minutes and a second phase half-life of about 30 minutes, probably related to rapid binding to the platelet GPIIb/IIIa receptors. Platelet function generally recovers over the course of 48 hours (2, 3), although GP llb/llla inhibitors remains in the circulation for 15 days or more in a platelet-bound state. • PREHOSPITAL INDICATIONS: Used with heparin and aspirin to prevent acute cardiac ischemia following percutaneous transluminal angioplasty (PTCA) in patients at high risk for reclosure of affected arteries

6. GP llb/llla Inhibitors • CONTRAINDICATIONS: 1. Hypersensitivity to this drug or murine protein 2. GI or GU bleeding 3. CVA within 2 years 4. Bleeding disorders 5. Intracranial neoplasm, arteriovenous malformations or aneurysm 6. Platelet count > 100,000/ mm3 7. Recent surgery 8. Aneurysm 9. Uncontrolled severe hypertension 10. Vasculitis

7. GP llb/llla Inhibitors • PRECAUTIONS / INCOMPATIBILITIES: • Therapy with GP llb/llla Inhibitors requires careful attention to all potential bleeding sites (including catheter insertion sites, arterial and venous puncture sites, cutdown sites, needle puncture sites, and gastrointestinal, genitourinary, and retroperitoneal sites). • Arterial and venous punctures, intramuscular injections, and use of urinary catheters, nasotracheal intubation, nasogastric tubes and automatic blood pressure cuffs should be minimized. When obtaining intravenous access, non-compressible sites (e. g., subclavian or jugular veins) should be avoided. Saline or heparin locks should be considered for blood drawing. Vascular puncture sites should be documented and monitored. Gentle care should be provided when removing dressings. • SIDE EFFECTS: • Minor bleeding • TOXIC EFFECTS: • Intercranial Hemorrhage • OVERDOSE THERAPY: Turn off infusion and any other blood thinners. Control excess bleeding with direct pressure.

8. Administration Abciximab Adults: IV 250 mcg (0.25 mg)/kg bolus 10-60 minutes prior to PTCA, followed by 10 mcg/min continuous infusion for 12 hours. Integrilin Acute coronary syndrome: Adults: IV bolus 180 mcg/kg as soon as diagnosed, then IV continuous 2 mcg/kg/min until discharge or CABG up to 72 hours. May decrease infusion rate to 0.5 mcg/kg/min if undergoing PCI. Continue infusion for 20-24 hours post procedure, allowing up to 96 hours of treatment. PCI in patients without acute coronary syndrome: Adults: IV bolus 135 mcg/kg given immediately before PCI, then 0.5 mcg/kg/min x 20-24 hours. Aggrastat Adults: IV 0.4 mcg/kg/min x 30 minutes, then 0.1 mcg/kg/min. Give ½ dose in renal disease

9. Fibrinolytics

10. Fibrinolytics I. GENERIC NAME: Reteplase, Streptokinase, Alteplase, Urokinase II. TRADE NAME: Retavase, Kabikinase, TPA, Abbokinase III. TYPE OF DRUG: Thrombolytic agent IV. MECHANISM OF ACTION: Thrombolyticsaction is based on a protease enzyme that directly catalyzes the cleavage of plasminogen to form plasmin. Plasmin then directly degrades the fibrin matrix of the thrombus. V. PHARMACOKINETICS: Thrombolytics pharmacokinetic profile has not been extensively studied in humans. The time to onset of effect ranges from 30-60 minutes. VI. PREHOSPITAL INDICATIONS: 1. Management of acute myocardial infarction

11. Fibrinolytics • CONTRAINDICATIONS: 1. Active internal bleeding 2. History of CVA 3. Recent intracranial or intraspinal surgery or trauma 4. Intracranial neoplasm 5. Arteriovenous malformation 6. Aneurysm 7. Known bleeding diathesis 8. Severe uncontrolled hypertension • PRECAUTIONS / INCOMPATIBILITIES: 1. Heparin, vitamin K antagonists or drugs that alter platelet function

12. Fibrinolytics • SIDE EFFECTS: • Hematologic: Bleeding • Bronchospasm • Hypotension • Reperfusion dysrhthmia • TOXIC EFFECTS: • Excessive bleeding • OVERDOSE THERAPY: • Do not administer second dose if there is excessive bleeding. Control excess bleeding with direct pressure.

13. Administration Retaplase Adults: IV bolus: First bolus 10 U administered over 2 minutes followed by second bolus 10 U 30 minutes later. Streptokinase Lysis of coronary artery thrombi: Adults: IC 20,000 IU, then 2000 IU/min over 1 hour as IV infusion. Arteriovenous cannula occlusion: Adults: IV infusion 250,000 IU/2 ml solution into the occluded limb of cannula run over ½ hour. Clamp for 2 hours, aspirate contents, flush with NaCl solution and reconnect. Thrombosis/embolism/DVT/pulmonary embolism: Adults: IV infusion 250,000 IU over ½ hour, then 100,000 IU/hr for 72 hours for deep-vein thrombosis. 100,000 IU/hr over 24-72 hour for pulmonary embolism. 100,000 IU/hr x 24-72 hours for arterial thrombosis or embolism. Acute evolving transmural MI: Adults: IV infusion 1,500,000 IU diluted to a volume of 45 ml, give within 1hour. Intracoronary infusion 20,000 IU by bolus, then 2,000 IU/min x 1 hr, for a total dose of 140,000 IU

14. Administration TPA Adults > 65 kg: IV a total of 100 mg. 6-10 mg given IV bolus over 1-2 minutes; 60 mg given over the first hour, 20 mg given over the second hour and 20 mg given over the third hour. Or 1.25 mg/kg given over 3 hours for smaller patients. Accelerated Infusion: Adults: IV bolus 15 mg, then 0.75 mg/kg over ½ hour; 0.5 mg/kg over 1 hour. Urokinase Lysis of pulmonary emboli: Adults: IV 4400 IU/kg/hr x 12-24 hours, not to exceed 200 ml; then IN heparin, then anticoagulants Coronary artery thrombosis: Adults: INSTILL 6000 IU/min into occluded artery for 1-2 hours after giving IV bolus of heparin 2500-10,000 U. May also give as IV infusion 2 million-3 million U over 45-90 minutes. Venous catheter occlusion: Adults: INSTILL 5000 IU into line, wait 5 minutes, then aspirate, repeat aspiration attempts every 5 minutes x ½ hour. If the occlusion has not been removed, cap the line and wait ½-1 hour, then aspirate. May need 2nd dose if still occluded.

15. General Anesthetics

16. PROPOFOL • GENERIC NAME: Propofol • TRADE NAME: Diprivan, Disoprofol, “Milk of Amnesia” • TYPE OF DRUG: General anesthetic • MECHANISM OF ACTION: Propofol produces dose-dependent CNS depression but its’ action is unknown. • PHARMACOKINETICS: Rapid onset typically within 40 seconds after IV. • PREHOSPITAL INDICATIONS: • 1. Sedation in mechanically ventilated patients • 2. Induction or maintenance of anesthesia

17. PROPOFOL • CONTRAINDICATIONS: • Hypersensitivity • Hyperlipidemia • PRECAUTIONS / INCOMPATIBILITIES: • Respiratory depression or severe respiratory disorders • Cardiac dysrhythmias • Elderly, pregnancy, labor and delivery, lactation, children • Administer propofol alone. Do not mix with other agents before using. • ADMINISTRATION: • Initiate at 5mcg/kg/min over 5 minutes, q5 minutes, until desired effect. • Maintain sedation as follows: • Children >3 years: 0.125-0.3mg/kg/min (7.5-18 mg/kg/hr) • Adults: 0.1-0.2 mg/kg/min (6-12 mg/kg/hr) • Elderly: 0.05-0.1 mg/kg/min (3-6 mg/kg/hr)

18. PROPOFOL • SIDE EFFECTS: • GI: Nausea, vomiting, abdominal cramping • Cardiovascular: Bradycardia, hypotension, asystole • Respiratory: Apnea, cough, hiccups • Integumentary: Flushing, phlebitis, hives, burning/stinging at injection site • TOXIC EFFECTS: • Asystole • Apnea • OVERDOSE THERAPY: • Discontinue drug • Administer vasopressor agents or anticholinergics and artificial ventilation

19. ETOMIDATE • GENERIC NAME: Etomidate • TRADE NAME: Amidate, Hypomidate • TYPE OF DRUG: General anesthetic; non-analgesic hypnotic • MECHANISM OF ACTION: Thought to be depression of activity in the brain stem reticular system, acting on the GABA receptor sites. • PHARMACOKINETICS: Given SIVP, onset about 1 minute and duration of about 5 minutes +/- 2 minutes depending on dose. Hepatic metabolism. • PREHOSPITAL INDICATIONS: • Facilitation of endotracheal intubation as part of an RSI protocol.

20. ETOMIDATE • CONTRAINDICATIONS: Known hypersensitivity. • PRECAUTIONS / INCOMPATIBILITIES: • Possible abortive agent - consider alternative agent if patient is pregnant. • Increased risk of vomiting when used in conjunction with opiates. • ADMINISTRATION: • Adults: 0.3mg/kg (0.2-0.6mg/kg) SIVP over 30-60 seconds, in large vein if possible. • Pediatrics: Consult MCEP prior to administration. • SIDE EFFECTS: • Transient injection site pain, reduced by using large vein and slow administration. • Transient skeletal muscle movements. • Transient decrease in cerebral blood flow, thus possible cerebral hypoxia. • Hyper/hypoventilation, apnea or laryngospasm • Bradycardia (very rare) • Hyper/hypotension. • Nausea, vomiting and or hiccups

21. ETOMIDATE • TOXIC EFFECTS: All reported serious cardiovascular or respiratory effects have been associated with rapid administration. • OVERDOSE THERAPY: • Provide supportive care as indicated by patient presentation.

22. FENTANYL • GENERIC NAME: Fentanyl • TRADE NAME: Actiq, Fentanyl, Fentanyl Oralet, Sublimaze • TYPE OF DRUG: Narcotic analgesic • MECHANISM OF ACTION: Fentanyl inhibits ascending pain pathways in the CNS, increases pain threshold and alters the perception of pain by binding to opiate receptors. • PHARMACOKINETICS: Onset is generally immediate if given IV, with peak effects within 3-5 minutes and a duration of ½ -1 hour. IM onset is usually within 7-8 minutes, peak in 30 minutes and a duration of effects of 1-2 hours. • PREHOSPITAL INDICATIONS: • Pre and postoperatively • Adjunct to general anesthetic

23. FENTANYL • CONTRAINDICATIONS: • Hypersensitivity to opiates • Myasthenia gravis • PRECAUTIONS / INCOMPATIBILITIES: • Respiratory depression or severe respiratory disorders • Increased intracranial pressure • Seizure disorders • Cardiac dysrhythmias • Elderly, pregnancy or lactation • Give IM/IV injection slowly to prevent rigidity • ADMINISTRATION: • Anesthetic: Adults: IV 2-50 mcg/kg every 2-3 minutes as required • Preoperatively: Adults: IM 0.05-0.1 mcg/kg every 30-60 minutes before surgery • Postoperatively: Adults: IM 0.05-0.1 mcg/kg every 1-2 hours as required • Pediatrics: Consult MCEP

24. FENTANYL • SIDE EFFECTS: • Cardiovascular: Bradycardia, arrest • Respiratory: Depression, arrest, laryngospasm • TOXIC EFFECTS: • Bradycardia • Cardiac arrest • Respiratory depression or arrest • Laryngospasm • OVERDOSE THERAPY: • Monitor and support ventilation and respiration • Administer Naloxone PRN • Support other vital signs

25. THIOPENTAL • GENERIC NAME: Thiopental • TRADE NAME: Pentothal, thiopental sodium • TYPE OF DRUG: General anesthetic, barbiturate • MECHANISM OF ACTION: Thiopental acts in the reticular-activating system to produce anesthesia; it also raises seizure threshold. • PHARMACOKINETICS: Given IV, onset is within 30-40 seconds. • PREHOSPITAL INDICATIONS: • Short, general anesthesia • Narcoanalysis • Induction anesthesia before other anesthetics

26. THIOPENTAL • CONTRAINDICATIONS: • Hypersensitivity • Status asthmaticus • Hepatic or intermittent porphyrias • PRECAUTIONS / INCOMPATIBILITIES: • Severe cardiovascular disease • Renal or liver disease • Hypotension • Myxedema • Myasthenia gravis • Asthma • Increased intracranial pressure • Pregnancy • ADMINISTRATION: • General anesthetic: Adults: IV 50-75mg given at 20-40 second intervals • Induction: Adults: IV 50-100 mg or 3-5 mg/kg • Pediatrics: consult MCEP

27. THIOPENTAL • SIDE EFFECTS: • Cardiovascular: Myocardial depression, dysrhythmias • Respiratory: Respiratory depression, bronchospasm • Integument: Shivering • TOXIC EFFECTS: • Myocardial depression • Dysrhythmias • Respiratory depression • Bronchospasm • OVERDOSE THERAPY: • It is generally agreed that respiratory depression or arrest due to unusual sensitivity to thiopental sodium or overdosage is easily managed if there is no concomitant respiratory obstruction. If the airway is patent, any method of ventilating the lungs (that prevents hypoxia) should be successful in maintaining other vital functions. Since depression of respiratory activity is one of the characteristic actions of the drug, it is important to observe respiration closely. Should laryngeal spasm occur, it may be relieved by one of the usual methods, such as the use of a relaxant drug or positive pressure oxygen. Endotracheal intubation may be indicated in difficult cases.

28. PENTOBARBITAL • GENERIC NAME: Pentobarbital • TRADE NAME: Nembutal, pentobarbital sodium • TYPE OF DRUG: Sedative/hypnotic barbiturate • MECHANISM OF ACTION: Pentobarbital depresses activity in brain cells, primarily in the reticular activating system in the brain stem. It selectively depresses neurons in the posterior hypothalamus and limbic structures, with a sedative and hypnotic effect. • PHARMACOKINETICS: The onset of action is 1 minute for IV administration and 10-15 minutes for IM administration. The duration of effect in IV form is about 15 minutes; 1-2 hours for IM. It is cleared by both the liver and the kidneys. • PREHOSPITAL INDICATIONS: • Sedation • Preoperative medication • Increased intracranial pressure • Insomnia

29. PENTOBARBITAL • CONTRAINDICATIONS: • Hypersensitivity or addiction to barbiturates • Pregnancy • Respiratory depression • Severe liver or renal impairment • Porphyria • Uncontrolled pain • PRECAUTIONS / INCOMPATIBILITIES: • Anemia • Lactation • Hepatic or renal disease • Hypertension • Elderly • Acute or chronic pain • IM administration: Inject deep in large muscle mass to prevent tissue sloughing and abscesses. • ADMINISTRATION: • Adults: IV dosage is 1-3 mg/kg, at a rate no greater than 50 mg/minute. • IM dosage is the same, but no more than 5 mL should be administered at any one IM site. • Pediatrics: Consult MCEP

30. PENTOBARBITAL • SIDE EFFECTS: • CNS: Lethargy, drowsiness, hangover, CNS depression • Integumentary: Rash, Stevens-Johnson syndrome • Respiratory: Respiratory depression, apnea, laryngospasm, bronchospasm • Hematologic: Agranulocytosis, thrombocytopenia, megaloblastic anemia • TOXIC EFFECTS: • CNS depression • Stevens-Johnson syndrome • Respiratory depression • Apnea • Laryngospasm • Bronchospasm • Agranulocytosis • Thrombocytopenia • Megaloblastic anemia (long-term treatment) • OVERDOSE THERAPY: • Ensure ventilations and respirations • Monitor and support vital signs • Hemodialysis

31. Paralytics

32. Neuromuscular Agents Depolarizing • GENERIC NAME: Succinylcholine • TRADE NAME: Anectine • TYPE OF DRUG: Neuromuscular blocker (depolarizing-ultra short) • MECHANISM OF ACTION: Succinylcholine inhibits transmission of nerve impulses by binding with cholinergic receptor sites, antagonizing action of acetylcholine. It also causes release of histamine. • PHARMACOKINETICS: Given IV, onset is generally in 1 minute, with peak effects in 2-3 minutes and a duration of 6-10 minutes. Onset is 2-3 minutes given IM. • PREHOSPITAL INDICATIONS: • Facilitation of endotracheal intubation

33. SUCCINYLCHOLINE • CONTRAINDICATIONS: • Hypersensitivity • Malignant hyperthermia • Decreased plasma pseudocholinesterase • Penetrating eye injuries • Acute narrow-angle glaucoma • PRECAUTIONS / INCOMPATIBILITIES: • Pregnancy, lactation, children < 2 years • Cardiac, neuromuscular or respiratory disease • Severe burns • Fractures • Electrolyte imbalances • Dehydration • Collagen diseases • Glaucoma or eye surgery • Elderly or debilitated patients • Deep IM injection, preferably high in deltoid muscle

34. SUCCINYLCHOLINE • ADMINISTRATION: • Adults: 1.0 - 1.5 mg/kg • Pediatrics: Consult MCEP

35. SUCCINYLCHOLINE • SIDE EFFECTS: • Cardiovascular: Sinus arrest, dysrhythmias • Respiratory: Prolonged apnea, bronchospasm, cyanosis, respiratory depression • Hematologic: Myoglobulinemia • TOXIC EFFECTS: • Sinus arrest, Dysrhythmias • Prolonged apnea, Bronchospasm, Cyanosis • Respiratory depression • Myoglobulinemia • Malignant hyperthermia • OVERDOSE THERAPY: • Edrophonium or neostigmine (dangerous and rarely used) • Atropine • Monitor vital signs • May require mechanical ventilation

36. Neuromuscular Agents Non-Depolarizing • GENERIC NAME: Rocuronium, Pancuronium, Atracurium, Cistracurium, Doxacurium, Vecuronium • TRADE NAME: Zemuron, Pavulon, Tracrium, Nimbex, Nuromax, Norcuron • TYPE OF DRUG: Neuromuscular blocker (nondepolarizing) • MECHANISM OF ACTION: These agents inhibit transmission of nerve impulses by binding with cholinergic receptor sites, antagonizing action of acetylcholine.

37. Neuromuscular Agents Non-Depolarizing • PHARMACOKINETICS • Atracurium: Given IV, onset is generally within 2 minutes, with a duration of effects between 20-60 minutes. • Cistacurium: Given IV, onset is generally within 1-3 minutes, with peak effects in 2-5 minutes and a duration of 30-40 minutes. • Doxacurium: Onset is generally within 3-16 minutes when administered IV. Duration of effects is variable, 1-5 hours. • Pancuronium: Given IV, onset is generally within 30-45 seconds, with peak effects in 3-5 minutes. • Rocuronium: Onset in 1-3 minutes with a duration of ½ hour. • Vecuronium: Given IV onset is generally within 15 minutes, peak effects in 3-5 minutes and a duration of effects between 45-60 minutes. • PREHOSPITAL INDICATIONS: • Facilitation of endotracheal intubation • Maintenance of skeletal muscle relaxation during mechanical ventilation, surgery or general anesthesia

38. Neuromuscular Agents Non-Depolarizing • CONTRAINDICATIONS: • Hypersensitivity • PRECAUTIONS / INCOMPATIBILITIES: • Pregnancy, lactation, children < 2 years • Cardiac, neuromuscular or respiratory disease • Electrolyte imbalances • Dehydration • Do not administer IM • Burns • Asthma • Renal or hepatic disease • Obesity • Malignant hyperthermia • Hypothermia

39. Neuromuscular Agents Non-Depolarizing • SIDE EFFECTS: • Respiratory: Prolonged apnea, bronchospasm, cyanosis, respiratory depression • TOXIC EFFECTS: • Prolonged apnea • Bronchospasm • Cyanosis • Respiratory depression • OVERDOSE THERAPY: • Edrophonium or neostigmine • Atropine • Monitor vital signs • May require mechanical ventilation

40. Administration Rocuronium Adults: IV 1.2 mg/kg Pediatrics: Consult MCEP Pancuronium Adults: IV 0.04-0.1 mg/kg, then 0.01 mg/kg every ½-1 hour. Pediatrics: Consult MCEP Atracurium Adults: IV bolus 0.3-0.5g/kg, then 0.08-0.10 mg/kg 20-45 minutes after the first dose if needed for prolonged procedures. Pediatrics: Consult MCEP

41. Administration Cistacurium Adults: IV 0.15-0.2 mg/kg. Pediatrics: Consult MCEP Doxacurium Adults: IV initial dose 0.025-0.08 mg/kg. Maintenance doses 0.005-0.01 mg/kg may be necessary after 1 hour. Pediatrics: Consult MCEP Vecuronium Adults: IV 0.08-0.10 mg/kg, then 0.01-0.015 mg/kg for maintenance of paralysis Pediatrics: Consult MCEP

42. DANTROLENE • GENERIC NAME: Dantrolene • TRADE NAME: Dantrium, Dantrium Intravenous • TYPE OF DRUG: Direct acting skeletal muscle relaxant • MECHANISM OF ACTION: Dantrolene interferes with the intracellular release of calcium from the sarcoplasmic reticulum that is necessary to initiate muscle contraction. It also slows catabolism in malignant hyperthermia. • PHARMACOKINETICS: The meanbiologichalf-life of Dantrium after intravenousadministration is variable, between 4 to 8 hours under most experimental conditions. • PREHOSPITAL INDICATIONS: • Malignant hyperthermia • Spasticity in multiple sclerosis • Stroke • Spinal cord injury • Cerebral palsy

43. DANTROLENE • CONTRAINDICATIONS: • Hypersensitivity • Compromised pulmonary function • Active hepatic disease • Impaired myocardial function • PRECAUTIONS / INCOMPATIBILITIES: • Peptic ulcer, renal or hepatic disease • Stroke or seizure disorder • Diabetes mellitus • Pregnant, lactating or elderly

44. DANTROLENE • ADMINISTRATION: • IV after diluting 20 mg/60 ml sterile H2O for injection without bacteriostatic agent (333 mcg/ml). Shake until clear and give by rapid IV push. Follow by prescribed dosages immediately. • Malignant hyperthermia: • Adults: IV 1 mg/kg. May repeat to a total dose of 10 mg/kg. • Prevention of malignant hyperthermia: • Adults: IV 2.5 mg/kg prior to anesthesia • Pediatrics: Consult MCEP

45. Dantrolene • SIDE EFFECTS: • CNS: Dizziness, weakness, fatigue, drowsiness or seizures • Hematological: Eosinophilia • GI: Hepatic injury, nausea • TOXIC EFFECTS: • Seizures • Eosinophilia • Hepatic injury • OVERDOSE THERAPY: • Supportive therapy • Dialysis

46. Beta Blockers • Hypertension: Inhibition of the renin system, decreased cardiac output, dimunition of tonic sympathetic efferent nerve pathways • Angina: Blocks catecholamine induced increases in HR, SBP, and force-velocity (speed and strength) relationships of contraction. • Antiarrythmic: Exerts not only beta blockade but also a quinidine effect of membrane action potential stabilization

47. Beta Blockers • GENERIC NAME: Propranolol, Labetalol, Esmolol, Metoprolol • TRADE NAME: Inderal, Normodyne, Trandate, Brevibloc, Lopressor • TYPE OF DRUG: Antihypertensive, antianginal • MECHANISM OF ACTION: Propranolol is a nonselective beta-blocker with negative inotropic, chronotropic and dromotropic properties. • PHARMACOKINETICS: Given IV, onset is generally within 2 minutes, with peak effects in 15 minutes and a duration of 3-6 hours. • PREHOSPITAL INDICATIONS: • Supraventricular dysrhythmias • Chronic stable angina pectoris • Hypertension • Migraine • MI prophylaxis

48. Beta Blockers • CONTRAINDICATIONS: • Hypersensitivity • Cardiac failure • Cardiogenic shock • 2nd or 3rd degree heart block • Reactive Airway Disease • Sinus bradycardia or sick sinus syndrome • CHF • PRECAUTIONS / INCOMPATIBILITIES: • Diabetes mellitus • Pregnancy, lactation or children • Renal or hepatic disease • Hyperthyroidism • COPD • Myasthenia gravis • Peripheral vascular disease • Hypotension • CHF

49. Beta Blockers • SIDE EFFECTS: • Respiratory: Bronchospasm • Cardiovascular: CHF • Hematologic: Agranulocytosis, thrombocytopenia • EENT: Laryngospasm • TOXIC EFFECTS: • CHF • Agranulocytosis • Thrombocytopenia • Laryngospasm

50. Administration Propranolol Dysrhythmias: Adults: IV bolus 0.01-0.1 mg/kg, give 1 mg/min. May repeat in 2 minutes. May repeat every 4 hours thereafter. Labetalol Hypertensive crisis: Adults: IV infusion 0.2-1 mg/kg q 10 min or 0.4-1 mg/kg/hr infusion. Stop infusion at desired response. Repeat every 6-8 hours as needed. Esmolol Adults: IV loading dose 500 mcg/kg/min over 1 minute; maintenance 50 mcg/kg/min for 4 minutes. If there is no response in 5 minutes give 2nd loading dose. Then increase infusion to 100 mcg/kg/min for 4 minutes. If there is no response, repeat the loading dose, then increase maintenance infusion by 50 mcg/kg/min (maximum of 200 mcg/kg/min). Titrate to patient response. Metoprolol Myocardial infarction: Adults: (early treatment) IV bolus 5 mg every 2 minutes x 3, then 50 mg.