Based on 2005 SOP S Hopkins, RN, BSN

1. Region X MedicationAdministration September 2006 CEAdenosine - AdenocardCardizem - DiltiazemAspirin Nitroglycerin MorphineNarcan - NaloxoneValium - Diazepam Versed Based on 2005 SOP S Hopkins, RN, BSN

2. Region X Medications • Medications discussed in the following format: • action/indication • contraindication • special considerations • dosing • side effects

3. 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

4. Normal Conduction System

5. Normal vs Tachycardic Rates NSR Sinus Tach - ID & treat cause - drugs not recommended SVT

6. Normal Sinus Rhythm P waves present with normal PR interval PSVT - absence of P waves Narrow complexed tachycardia - absence of P waves

7. 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

8. 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)

9. Adenosine place both syringes in IV line to give draw up draw up saline med & flush as adenosine flush quickly as possible

10. 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

11. 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

12. Atrial Fibrillation Normal Sinus Rhythm Atrial Fibrillation

13. Atrial Fibrillation Criteria

14. Normal Sinus Rhythm vs Atrial Fibrillation

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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?

43. 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

44. 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

45. 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?

46. 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

47. 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?

48. 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