Medications

The drug chapter: safety checks, vasopressors, arrest drugs, RSI, rate control, sedation, psych, antidotes and the rest.

Medications

With medications, #1 is

• Always ask about allergies before giving any medication. Once it's in the body, you cannot take it back. Always ask for allergies. Although all medications deserve your undivided attention, you need to be extra careful with insulins, opioids, blood thinners, blood pressure meds, and any medication that you are giving to a pediatric patient.

Blood Thinners

o Before giving, you need to know the reason for administration. Is it for atrial fibrillation, a PE or DVT, for a stent, or for DVT prophylaxis? o Do you need to have baseline coags? Ideally, yes. Even for DVT prophylaxis. It helps assess for any undiagnosed coagulation disorders. o Are they going to surgery any time soon? If they are, always consult with the provider to ensure it is safe to continue. They would have to take into consideration the risks of thrombotic events and potential bleeding. o Are they currently bleeding from anywhere? Ask about blood in their stool (black or red), blood in vomitus (red or coffee ground) and assess for significant bruising throughout their body. If this patient is going to be admitted to the hospital, they should have had a CBC, what is the HGB/HCT.

Insulins

o What is the Point of Care Glucose? It needs to be recent, no more than 30-45 minutes old. o Is the patient insulin naive? If so, ensure the provider is aware and recheck a Point of Care Glucose based on the onset and peaks. Also monitor for signs of hypoglycemia such as diaphoresis, confusion, tachycardia and so forth. o Do you know how to treat hypoglycemia? Review hypoglycemia in section on Common Conditions

Blood Pressure Lowering Medications

o Always check the blood pressure before administering. If it is on the lower side, notify your provider before administration to ensure they still want it. If it is less than 90(even sbp 100), never administer. Notify your provider first. o Be mindful of orthostatics. If your patient has to get up, do it slowly. Have them sit at the edge of the bed for a few minutes first, then stand slowly with you always present. o See below for more on specific BP lowering meds.

IV Opioids

o Always give very slowly. Never give Fast IV Push. If needed dilute with normal saline in order to give it more slowly and in a controlled manner. o Double verify dosing. Be mindful of the dosing in elderly and pediatrics. o Are they on a monitor? Have they ever had IV opioids before? Is oxygen equipment readily available if needed? For peds, always double check the dosing with a buddy nurse. o See Below for more on specific IV opioids used for pain. Again, always ask for help if you do not know something or if you feel unsure about anything, especially when it comes to medications.

Vasopressors

Vasopressors, also commonly known as pressors, are potent medications that constrict blood vessels, ultimately, increasing blood pressure with the goal of restoring tissue perfusion in very hypotensive patients. Besides vasoconstriction, they can also affect heart contractility, and heart rate. Epinephrine also affects the lungs. 1) Alpha Receptors (Found in blood vessels- vascular smooth muscle cells) a) Cause Vasoconstriction when stimulated, with an ultimate increase in blood pressure. 2) Beta 1 Receptors (Found in the heart) a) Cause an increase in the strength of contraction of the heart (positive inotropic effect) and an increase in heart rate when stimulated (positive chronotropic effect). 3) Beta 2 Receptors (Found in bronchial smooth muscle of the lungs) a) Cause bronchodilation when stimulated b) It can also cause vasodilation 4) V1 Receptors (Found in smooth muscle cells of blood vessels) a) Cause vasoconstriction when stimulated

Caution with Vasopressors

Although vasopressors can save a patient's life, they come with many possible and deadly complications. 2. Never Bolus vasopressors Complications • Increase Risk for Arrhythmias • Cardiac, Organ and Peripheral Ischemia • Tissue Necrosis from Extravasation • Rapid Increase in Bp Now lets talk about specific vasopressors and why they are used in shock (to help increase the bp and ultimately help increase the perfusion to organs).

Norepinephrine (Levophed)

• Potent Alpha Agonist with Slight Beta 1 o Increase blood pressure through vasoconstriction o Help the heart squeeze/contract a little better and faster • Can be started peripherally in emergencies (Peripheral infusion should be no more than 1-2 hours. Advocate for a central line). • Known as the "workhorse" vasopressor because it is often the first line vasopressor used for many issues. o Pressor of choice for septic shock. It can also be used as the first line agent for neurogenic, cardiogenic and obstructive shock when needed. ▪ Also used in hypovolemic shock, however, only when the patient has been appropriately volume resuscitated (fluids, blood products). • Onset: within 1-2 minutes • Concentration: 4mg in 250ml of NS (it can also be 8mg in 250, or up to 16mg in 250) • Range and Titration Range from facility to facility (Fill out with your own facilities protocol) o Start Dose: o Titrate By: o Range/Max:

Vasopressin

• Potent V1 Agonist o Increases BP • Second Line Agent in Septic Shock, added on after Norepinephrine (Levophed) o After constantly titrating Levophed up and are near the max dose, notify the provider and suggest vasopressin be added. You'll notice a big difference in the bp and in perfusion. • Onset: Up to 15 minutes • Do not Titrate o Start it and leave it alone o Rate: 0.04U/min • Concentration o 20 Units in 100ml of NS (or 50 Units in 250Ml of NS)

Epinephrine

• Alpha, Beta 1, Beta 2 • Vasoconstriction, Increases HR and contraction, Bronchodilation • Vasopressor of choice with anaphylactic shock and in shock states where the heart rate is low (bradycardia patients) as it will help bring the heart rate and bp up together ▪ Added on after Levophed and vasopressin in septic patients • Onset: within 1 minute • Concentration: 1mg in 250 ml or 4mg in 250 ml • Range and Titration Range from facility to facility (Fill out with your own facilities protocol) ▪ Start Dose: ▪ Titrate By: ▪ Range/Max: • Dirty Epinephrine Drip ▪ In Emergencies when the patient is about to code, I've had providers order a "Dirty Epi Drip." Essentially you get 1mg of epi(an amp from the crash cart), and you inject it into a 1L NS bag(label it of course). This 1L of NS with 1mg of Epi is then administered "wide open" to the patient. • The point of this is to give you enough time to stabilize the patient and then place them on an actual drip. • You should not be doing this unless your provider explicitly states they want this and your preceptor is with you. • Push Dose Epi ▪ You should also be aware that your provider may admin a push dose of Epinephrine to your patient in an emergency to bring their bp up so they don't code. It will be approximately 10 mcg. It is not in our scope to administer this but it is nice to know about it. • Epinephrine is used in a variety of ways including during Cardiopulmonary Arrest, as a Push Dose Pressor, as a Vasopressor and even in laceration repairs.

Phenylephrine (Neosynephrine)

• Pure Alpha o Only vasoconstriction o Be mindful that if you only increase the BP, if too high, the body may try to bring the BP down by decreasing the heart rate. (Can cause bradycardia so be careful with bradycardic patients) • Typically an add on vasopressor when the others have not worked. It is also used with anaphylaxis to help vasoconstrict and bring the BP back up. • Onset: within 1 minute • Concentration: 20mg in 250ml or 50mg in 250 ml of NS • Can also be used as a push dose vasopressor just like Epinephrine o Its typical dose for adults will be 100-200 mcg. Just like with Epi, it is not in our scope to push this, it must be the provider. • Range and Titration Range from facility to facility (Fill out with your own facilities protocol) o Start Dose: o Titrate By: o Range/Max: • Dopamine o Alpha, B1, and Effects on the Kidneys ▪ Dose dependent. It can be difficult to know what it effects it will have • For this reason, at least in the ER, it's not really used, since we can use levophed and epinephrine, and we know what we are getting with those two since their effects are more predictable. ▪ Typically on lower doses it increases blood flow to the kidneys and on higher doses it causes vasoconstriction and an increase in heart/contraction o Onset: within 5 minutes o Concentration: 400mg in 250ml of NS o Range and Titration Range from facility to facility (Fill out with your own facilities protocol) ▪ Start Dose: ▪ Titrate By: ▪ Range/Max:

Dobutamine

• Beta 1, Beta 2 and Alpha Agonist o Primary effect is on Beta 1, especially on helping the heart contract better o Since beta 2 can also cause vasodilation, it often counteracts the effects of Alpha. It can, at times, cause more vasodilation and lead to hypotension after starting the infusion. • It's main use will be in Cardiogenic Shock from heart failure • Onset: Up to 10 minutes • Concentration: 500mg in 250ml of NS • Range and Titration Range from facility to facility (Fill out with your own facilities protocol) o Start Dose: o Titrate By: o Range/Max:

General Vasopressor Tips

• Start norepinephrine peripherally in emergency situations! • Pressors are typically compatible with each other. • Always have your next bag ready to go! Never let the bag run dry. • You must learn how to make a Levophed, an Epi and a vasopressin drip for emergency situations or when pharmacy is not available. • You do not titrate vasopressin. • They all suck in severe acidosis, except vasopressin. • Tidy Up! Label all your lines at the patient and by the pump! • Do not bolus! Ever. (After titrating, give them time to work) • Set your BP's to take Q5Minutes, or quicker! So you can keep an eye on how the patient is responding. • If you are starting a second pressor, you better be asking for an Arterial Line to closely monitor the BP. • Ask for a central line. • Keep an eye on mcg/min vs mcg/kg/min.

ALS Medications

Cardiac Arrest Medications

Epinephrine

Indication: Used during cardiac arrest for rhythms such as: • Asystole • Pulseless Electrical Activity (PEA) • Ventricular Fibrillation (V-Fib) • Pulseless Ventricular Tachycardia (V-Tach) Purpose: Epinephrine is a vasoconstrictor and inotropic agent. It improves coronary and cerebral perfusion during cardiac arrest, increasing the likelihood of achieving ROSC (Return of Spontaneous Circulation). Dose: • 1 mg IV/IO every 3–5 minutes during cardiac arrest

Calcium Chloride

Purpose: Calcium plays a vital role in myocardial cell membrane stability and cardiac contractility. It is administered during cardiac arrest when specific underlying conditions are suspected. Indications: • Hyperkalemia: High potassium levels can lead to life-threatening arrhythmias. Calcium chloride helps stabilize cardiac cell membranes, reducing the risk of arrhythmias. • Hypocalcemia: Replaces low calcium levels that can impair cardiac function. • Calcium Channel Blocker Overdose: Helps reverse the effects on cardiac and smooth muscle by improving conduction, contractility, and counteracting vasodilation. Adult Dose: • 1 gram IV/IO (10 mL of a 10% calcium chloride solution)

Sodium Bicarbonate

Purpose: Used during cardiac arrest to treat severe metabolic acidosis, which can impair both cardiac function and cellular metabolism. By correcting the acidosis, sodium bicarbonate may help improve the likelihood of achieving ROSC (Return of Spontaneous Circulation). Adult Dose: • 50 mEq IV/IO (50 mL of an 8.4% sodium bicarbonate solution)

Amiodarone

Purpose: An antiarrhythmic used during cardiac arrest for: • Ventricular Fibrillation (V-Fib) • Pulseless Ventricular Tachycardia (V-Tach) Amiodarone works by prolonging the action potential and refractory period of cardiac cells. In V-Fib and pulseless V-Tach, the ventricles are irritable and firing chaotically. By extending the refractory period, amiodarone helps stabilize the myocardium and reduce excitability. Adult Dose: • First dose: 300 mg IV/IO • Second dose (if needed): 150 mg IV/IO Post-ROSC: • If ROSC is achieved, initiate a continuous infusion of amiodarone to help maintain rhythm stability.

Lidocaine

Purpose: An antiarrhythmic used during cardiac arrest for: • Ventricular Fibrillation (V-Fib) • Pulseless Ventricular Tachycardia (V-Tach) Lidocaine works by blocking sodium channels in cardiac cells, which slows conduction and helps stabilize the cardiac cell membrane. How it works: During an action potential, depolarization begins with sodium influx. The faster this occurs, the more excitable or irritable the cell becomes. By slowing the influx of sodium, lidocaine helps calm the myocardium and reduce excitability. Adult Dose: • Initial dose: 1 to 1.5 mg/kg IV/IO • Repeat dose (if needed): 0.5 to 0.75 mg/kg IV/IO

Magnesium Sulfate

Purpose: Used during cardiac arrest to treat Torsades de Pointes (polymorphic ventricular tachycardia). Magnesium supports proper function of ion channels in cardiac cell membranes. When magnesium is low or imbalanced, it can lead to Torsades, a specific form of ventricular tachycardia. Adult Dose: • 2 grams IV/IO Post-conversion: • If effective, a magnesium infusion should be initiated to maintain rhythm stability.

Narcan (Naloxone)

Purpose: Used for the reversal of suspected opioid overdose. Opioid overdose can lead to respiratory depression, which, if untreated, may progress to respiratory arrest and cardiac arrest. Adult Dose: • 0.4 to 2 mg IV/IO/IN/IM • If the patient is without a pulse, give 2 mg IV push • If reversal is successful, a continuous infusion should be considered. Note: High doses can sometimes lead to flash pulmonary edema, which is associated with poor outcomes.

Dextrose

Purpose: Used for the treatment of hypoglycemia. Adult Dose: • 25 g IV (50 mL of a 50% dextrose solution) • If the patient responds, continue to monitor glucose levels closely. • If needed, start a D5 or D10 infusion to maintain blood glucose levels.

IV Fluids

Types: • Normal Saline (NS) • Lactated Ringer's (LR) Purpose: May be used during cardiac arrest to help replenish intravascular volume, support perfusion, and improve the chances of achieving ROSC (Return of Spontaneous Circulation).

Other ALS Medications

Atropine

Purpose: Used to treat symptomatic bradycardia by blocking parasympathetic (vagal) stimulation of the heart. This enhances conduction through the AV node, increasing heart rate. Adult Dose: • 1 mg IV every 3–5 minutes • Maximum total dose: 3 mg Important Note: Atropine may be ineffective in patients with 3rd-degree AV block. While a provider may still order it, you should be preparing for more definitive interventions, such as transcutaneous pacing.

Adenosine

Purpose: Used for the treatment of Supraventricular Tachycardia (SVT). Adenosine has a very short half-life (~10 seconds) and works by blocking conduction through the AV node. This brief interruption allows the SA node to regain control and restore normal rhythm. Administration: • Must be given as a rapid IV push, immediately followed by a 20 mL normal saline flush, to ensure the medication reaches the heart quickly before it is metabolized. Adult Dose: • First dose: 6 mg IV push • Second dose (if needed): 12 mg IV push

Rapid Sequence Intubation Medications

Sedative before Paralytic! Always. The main sedative used is Etomidate, while the two main paralytics are Rocuronium and Succinylcholine. • Etomidate o Primary Sedative used as it is hemodynamically stable and has a fast onset. It will not lower blood pressure or increase the heart rate. o Onset: 10-30 seconds. Duration: 5-10 minutes. o Dosing: Commonly 0.3mg/kg o Side Effects ▪ Besides respiratory depression(which is fine since the patient is getting intubated), it can cause myoclonus (seizure like jerking movements), although it is typically self limiting and will go away on its own. Just nice to know about it. • Succinylcholine o Paralytic commonly used as it works fast and does not last long. In Rapid Sequence Intubation when a patient needs to be intubated in a safe yet rapid manner, a paralytic that works fast is ideal. If the intubation is unsuccessful and or there are complications, it is beneficial that it wears off fast so the patient can regain the ability to breathe on their own which reduces potential prolonged hypoxia and gives the team time to come up with alternative techniques such as video laryngoscope or even calling the anesthesia team for assistance if available. o Onset: 30-60 seconds. Duration: up to 10 minutes o Dosing is typically 1.5mg/kg o Side Effects ▪ The key disadvantage of succs is that it can cause hyperkalemia so it is avoided in renal patients, burns, crush injuries, rhabdomyolysis and any condition where hyperkalemia would be a concern. ▪ It can also cause malignant hyperthermia • Rocuronium o Paralytic used when Succs is not ideal. Although it typically does not have contraindications like succs, it is not primary used due to its longer onset and duration. o Onset: up to 2 minutes. Duration: up to 60 minutes o Dosing is typically 1mg/kg o Side Effects ▪ Although no major contraindication, be prepared to handle unsuccessful intubations due to its prolonged duration of 1 hour. Have BVM with NPA/OPA readily available or even a supraglottic airway. ( Even supplies needed for emergency cric). ▪ If needed, the reversal agent is Sugammadex. • Ketamine o Although not commonly used as a sedative for intubation, it still has important uses. Key points of ketamine include that patients typically maintain their respiratory drive, it has bronchodilatory effects, can increase heart rate and blood pressure, and it has analgesic properties. Therefore, it can be a good option for when asthmatics or COPD patients need to be intubated. Also useful for high risk Awake Intubations. o Onset: 30-60 seconds. Duration: 10-20 minutes o Dosing for RSI is typically 1.5mg/kg o Side Effects ▪ It is not used as often as it comes with the risk of laryngospasm, increased cerebral edema and as a result of increasing the heart rate, it can place further strain on a weakened heart.

Heart Rate Medications

• Intravenous Diltiazem(Cardizem): o A calcium channel blocker used to lower heart rate. Used primarily IV in the ER with Atrial Fibrillation with a rapid ventricular response. At times, providers may also use it for SVT. o Dosing: 0.25mg/kg. Typically for adults most providers will just order around 20mg IV ▪ Usually followed by 30mg PO tablet to help control the heart rate longer. o Admin and Side Effects: Don't Push It. Give it slowly over two minutes. Cycle the bp right before it, during and after to ensure it did not drop a significant amount. ▪ If the BP is already low beforehand, do not give it until you talk to the provider about it. Perhaps start a liter of NS prior to administration of Diltiazem. If the BP is low, and you give it, it will only make it go lower. (They may tell you that the BP will go up after the heart rate comes down due to better filling of the ventricles and so forth but if the BP is already low beforehand, don't administer until the BP is addressed first). • Intravenous Metoprolol o A beta blocker used to lower heart rate. Typically used intravenously for atrial fibrillation with a rapid ventricular response. o Dosing: 2.5-5 mg slow IV. Can be repeated. If it works, typically followed by a PO dose of 50mg for longer heart rate control. o Side Effects ▪ Like with cardizem, do not administer if the BP is low, address the BP first. ▪ Should not be used with patients who have asthma or COPD due to possibility of bronchoconstriction • Intravenous Esmolol o A beta blocker to lower heart rate. Typically used as an infusion/drip. I have only used it for bringing the BP down in aortic dissections and for bringing the HR down in Afib RVR. ▪ It slows the HR down, therefore decreasing cardiac output and BP. ▪ Useful in Dissection because you don't just want to give a med that will only lower the BP, the body will respond to this by increasing the HR and contractility, which will make the dissection worse. Esmolol helps with both bringing the HR down and BP. o Fast on fast off. Onset within 1 minute and duration of only up to 9-10 minutes. o The infusion will typically require a loading dose followed by 50mcg/kg/min, titrating by 50mcg/kg/min q 5-10mins, max of 200mcg/kg/min o (Please verify drips/infusions start rates, titrations, and max with your own facilities protocols) • Intravenous Amiodarone o An antiarrhythmic that prolongs the action potential which can help restore normal sinus rhythm or rate control by reducing the heart rate. Used for arrhythmias such as Ventricular tachycardia, Ventricular fibrillation and atrial fibrillation o During cardiac arrest as with ventricular fibrillation or pulseless ventricular tachycardia ▪ Dosing: 300mg IV push, if needed followed by a second dose of 150mg o With atrial fibrillation or with a stable ventricular tachycardia ▪ Loading Dose of 150mg IV over 10 minutes ▪ Followed by an infusion of 1mg/min over 6 hours (typically 360 mg) ▪ Then 0.5mg/kg infusion over 18 hours (typically 540 total) o Considerations ▪ It can cause hypotension, bradycardia and QT prolongation. ▪ If bradycardia is an issue, communicate with the team as it should not be used. ▪ If your patient is hypotensive or on the lower side, discuss with the team. Set your BPs to repeat q5 minutes after starting drip/infusion for 30 minutes to assess how your patient responds. ▪ Although typically not a concern in the ER, long term use can cause pulmonary, liver and thyroid toxicity.

Sedation and Analgesia for Mechanically Ventilated patients

• Propofol o A sedative hypnotic used for sedation of intubated mechanically ventilated patients. o A key feature of propofol is that it has a fast onset and short duration. "Fast on, Fast off." This makes it great for most patients especially neuro pts as an accurate neuro assessment can be obtained relatively quick after stopping the infusion. ▪ Onset within 1 minute, duration up to 10 minutes. Except if it has been administered long term, allow up to 30 minutes for effects to fully wear off. o Range of 5-50mcg/kg/min (have seen higher ranges), with typical start of 5mcg/kg/min, titrated by 5mcg Q10 minutes. Some patients may need to be titrated or started with higher doses to maintain appropriate sedation, if so, ensure your provider is aware and provides an order to do so (since you may be going outside the set protocol). Please review your facilities start dose, titration dose and interval and max range. o Considerations ▪ It will cause respiratory depression and hypotension. Your pt is intubated so respiratory depression is not an issue typically. For hypotension, cycle BPs Q5 mins initially after starting infusion to ensure you closely monitor how your patient responds. If propofol drops the BP and is not maintaining adequate sedation, another agent should be used such as versed. (Sometimes providers want to use propofol for sedation for its fast off properties and may add a vasopressor such as Levophed to maintain the BP). ▪ Change the tubing every 12 hours to prevent bacterial growth. ▪ Do not let the bottle run empty! Ever! Your patient will wake up and try to take the ET Tube out. ▪ Propofol Infusion Syndrome: Extremely rare. Associated with high doses and prolonged use. Key characteristics are cardiovascular collapse and arrhythmias • Versed(Midazolam) o Used as an infusion for sedation of intubated patients when pts are hemodynamically unstable (low bp:since prop can drop the bp significantly). o Onset is within 5 minutes and duration can be up to an hour. If the infusion has been long term, the duration may be significantly longer. o For dosing, please review your organization's protocol. o Considerations ▪ Main issue is respiratory depression, if pt is intubated, typically not an issue. ▪ At higher prolonged doses, it can cause hypotension. However, typically not as severe as propofol. ▪ Reversal Agent: Flumazenil/Romazicon • Fentanyl o Used as an infusion for pain management (opioid analgesic) for intubated patients. It is used in combination with Versed and or Propofol as either of those do not have any effects on pain. o For dosing, please review your organization's protocol. o Considerations ▪ As with any opioid it can cause respiratory depression. With intubated patients, it is not an issue. ▪ (When giving it for pain in non-intubated patients please dilute and give slow. If given fast, it will cause respiratory depression, hypotension and chest wall rigidity.) • Precedex o An alpha 2 agonists with mild sedative properties. Used when a mild/slight sedation is desired. The patient keeps their own respiratory drive and usually wakes up with physical stimulation. o Onset is within 10 minutes. With duration, patients wake up almost immediately after discontinuing, but may feel drowsy for 1-2 hours. o Considerations ▪ It can cause bradycardia and hypotension, especially when a loading dose is given prior to starting the infusion. • This has happened quite a bit in the past when I have used precedex. If it does, stop the infusion, call the team and be prepared to administer IV fluids or atropine or a vasopressor as needed. (Typically after stopping it and giving a bolus of NS, the effects go away even by the team the team arrives)

Psych Medications for Acute Agitation

• Medications ordered to help calm/sedate these patients will vary from provider to provider, but they should keep in mind the cause of the agitation. Antipsychotics should be administered when schizophrenia, bipolar or delirium are suspected as the cause of the agitation, while benzodiazepines can be used when the agitation is as a result of alcohol withdrawal and intoxication with uppers (meth, PCP etc). o You'll find that in violent patients where rapid sedation is needed, both types of medications are ordered. You'll come across the phrase B52. Stands for Benadryl 50mg, Haldol 5mg and Lorazepam 2mg. (There are providers that may order Olanzapine 5-10mg instead of the haldol). In acute agitation, these medications are going to be given Intramuscularly (IM). It is very difficult to place an IV on a patient that is combative and that is the perfect recipe for a needle stick injury. o Benadryl: Although an antihistamine, it does have sedative effects and it helps prevent EPS symptoms from administering Haldol (or Olanzapine) o Haldol: A first generation antipsychotic commonly used for agitation. A key potential side effect of haldol is that it can cause QT Prolongation and in susceptible patients that can lead to Torsades De Pointes. o Lorazepam: A benzodiazepine, a sedative. One of its many uses includes administration for acute agitation in combination with other medications like Haldol. A key side effect is respiratory depression. o KEY NURSING POINT: After giving medications, you must be very vigilant and closely monitor the patient. When these drugs are combined together, their potential for adverse effects intensify. These adverse effects include respiratory depression and ECG changes. As soon as you are able to safely do so, place the patient on the monitor spo2, ecg, BP, RR, Capno. If your combative verbal patient suddenly goes quiet, please be alarmed and go to assess and place on the monitor. This is very important when you've had to redose patients multiple times, all the medications can suddenly take effect together and cause respiratory depression. ▪ After the patient is sedated, do not lag in performing or obtaining the ordered tests. Do them while the patient is sedated. These include the ECG, going to CT, drawing labs, giving additional medications and so forth. ▪ With that in mind, if a patient is not cooperative and may become violent, do not attempt any intervention that may lead to personal injury such as lab draw. Discuss with the provider the potential for injury and if need be, state that you feel unsafe performing a task on a patient who may move and or cause injury to you. If the patient is borderline, discuss the use of PO medications while offering the patient food. When they take effect and the patient is more cooperative, then you can safely perform interventions. • Other Medications include Olanzapine, Ziprasidone, Droperidol, Versed and Ketamine. Again, unless your facility has specific guidelines or protocols for acute agitation, the medications of choice for acute violent behavior will be provider choice. Your job is to ensure your safety and the patients safety. o Olanzapine: A second generation antipsychotic that can be used for acute agitation. Common first dose is 5-10 mg IM. Side effects include hypotension, QT prolongation and oversedation (closely monitor when combining with other medications). o Ziprasidone: A second generation antipsychotic that can be used for acute agitation. Common first dose is 10-20mg. The Key Issue with Ziprasidone is its potential for QT Prolongation and ultimate torsades de pointes. As with haldol, careful use of it in patients with ecg/cardiac issues. o Droperidol: An antipsychotic that can be used for acute agitation. Common dose is 5-10mg IM. Key side effect is QT prolongation and as a result deadly rhythms. o Midazolam: A benzodiazepine with strong sedative properties that can be used for acute violent behavior. Dosing is 2.5-5mg IM. Key side effects include respiratory depression, oversedation and hypotension. o Ketamine: A dissociative anesthetic with potent sedative properties. I've typically seen ketamine ordered for the very severe violent patients who've typically come back positive with multiple substances on the tox screen like PCP and meth. The dosing Intramuscularly may seem like a lot, it is 4-5mg/kg IM(Intramuscular). Key side effects include emergence reactions (confusion when waking up), increase in HR and BP, and in rare occasions laryngospasm(may have to intubate). Nursing Key Point: Closely monitor your patients after administering any of these medications. Watch out for oversedation, respiratory depression, hypotension and QT prolongation. Place on the cardiac monitor with continuous SPO2, BP, RR, HR, ECG and even end tidal CO2. In emergency situations with acute agitation, these medications are going to be given IM.

Antidotes

• Acetaminophen- Acetylcysteine • Digoxin-Digoxin Immune Fab • Benzodiazepine-Flumazenil • Heparin-Protamine Sulfate • Organophosphates-Atropine and Pralidoxime • Anticholinergics-Physostigmine • Warfarin- Vitamin K / FFP / Prothrombin Complex Concentrate • Ethylene Glycol and Methanol – Fomepizole • Aspirin – Sodium Bicarbonate and Dialysis • Insulin – Glucose

Other Important Medications

• Thrombolytics (TPA or TNK): Given to break up a blood clot. In the ER, used for Ischemic Strokes within 4.5 hours of symptom onset, for pulmonary embolisms and if PCI is unable for STEMIs, it may be used. o Contraindications: Include active bleeding, recent surgery, uncontrolled hypertension, recent trauma, bleeding issues like hemophilia, recent ischemic stroke, use of blood thinners, history of brain bleed, known brain lesions (aneurysms, Cancer), elevated INR or PTT. o Nursing Considerations: Monitor closely for signs of bleeding such a sudden drop in BP, Hematuria, melena and a change in mental status. If these changes occur, you must communicate promptly with the team. For example, if the patient received thrombolytics for an ischemic stroke and now their mentation suddenly worsened, it could signal an intracranial hemorrhage and the must obtain a repeat head ct to rule out or confirm. No invasive procedures or IV sticks after giving thrombolytics, so place if possible 2 good working IVs prior to administration. • Heparin o Used to prevent clots from growing, allowing the body to naturally break them down. o Common Indications: DVT (Deep Vein Thrombosis, PE (Pulmonary Embolism), Atrial Fibrillation (when rapid anticoagulation is needed) o Before Starting get baseline PTT / Coags, Hgb & Hct, Check for signs of bleeding (e.g., melena, hematuria) o Risk vs. benefit: Sometimes given even if there's bleeding risk, depending on clinical urgency. o Heparin Bolus + Drip: Start with Heparin bolus (dose per protocol), Follow with continuous infusion, Repeat PTT at ordered intervals (often every 6 hours) until therapeutic, Therapeutic PTT goal: ~60–90 seconds (check your hospital's range) o Nursing Considerations: Monitor for bleeding (Drop in BP or Hgb, Bruising, petechiae, Blood in urine or stool), Avoid unnecessary pokes or procedures, Antidote is protamine sulfate, Double-check pump settings and titration protocols, DOUBLE CHECK WITH A SECOND NURSE. • Calcium Gluconate o Stabilizes the cardiac membrane, reducing heart irritability from potassium, helping prevent arrhythmias o 1 gram over 10 minutes o If hyperkalemia is causing instability and arrhythmias, I've seen up to 3 grams given initially. • Glucagon o If IV access is not available and or staff is having a difficult time obtaining IV access, Intramuscular Glucagon can be given to help bring glucose levels up. It acts on the liver to help release glucose stores. o Again, for hypoglycemia, only administered IM when there is no IV access for an Amp of D50 (I have only done this once or twice in my whole career so not very common) o A very common side of effect of glucagon is nausea and vomiting. Keep this in mind and be prepared to deal with the vomiting and any airway issues it may cause. (Turn them so they do not aspirate) o (Glucagon is also given for beta blocker OD. It will also cause nausea and vomiting. Give an antiemetic with it) • Phenobarbital o Used for alcohol withdrawal when lorazepam isn't enough. Enhances GABA activity to calm the CNS and reduce overexcitability. o How It's Given: IV administration over 10–15 minutes, Typically mixed in 50–100 mL of NS, Do NOT exceed 60 mg/min infusion rate. ( Check your facility's protocol for exact dosing and infusion instructions.) o Controlled substance, so if you don't use it, do not forget to waste it. • NS vs LR o LR: Contains Na, Cl, K, Ca, and lactate. Commonly used in burns and trauma. o NS: Contains only Na and Cl. Sodium (Na+): 154 mEq/L. Chloride (Cl−): 154 mEq/L. Compatible with blood products. Has a high level of chloride, so large amounts of fluid resuscitation can lead to Hyperchloremic Metabolic Acidosis, so it worsens acidosis in very large amounts, which is why providers may choose LR when high levels of fluids are expected, think DKA, burns and trauma. • Hypertonic Saline o 3% Hypertonic Saline is used to correct severe hyponatremia. Also given for cerebral edema and increased ICP. ▪ Nursing: If correcting hyponatremia, is must be done slowly to prevent osmotic demyelination syndrome. Central line is preferred but can be given via large bore IV. Monitor chemistry Q 2-4 hours for serum sodium and electrolyte shifts, fluid balance and neuro status. o 23.4% hypertonic saline is a last resort emergency medication used for impending brain herniation, used for emergent ICP reduction. It is a very small dose of 10-20 mls (Pls double verify dose before giving). Should be given via central line. With these patients, also monitor for electrolyte shifts and fluid balance changes. Of course, ensure ICP decreases and if not, you are promptly communicating with the team. BUT, please double verify dose. • Mannitol o Mannitol is another last resort medication for increasing ICP and impending brain herniation. Its an osmotic diuretic that pulls water from brain tissue, making more space within the skull and therefore lowering ICP. Always use a filter as mannitol can crystallize. Monitor serum osmolality, electrolytes, renal function, and for fluid overload. • IV Opioid for Pain (Give slowly, never give IV push) o Morphine: Common dose in adults is 2-4mg. Can cause respiratory depression and hypotension. Do not give in hypotensive patients. In elderly, closely watch for respiratory depression. Dilute with normal saline to give slowly if possible. Onset within 10 minutes, peak around 20 minutes, can last up to 4 hours. Avoided in renal patients, as the kidneys clear morphine. If given to renal patients, morphine may accumulate and lead to severe effects such as prolonged sedation, respiratory depression and hypotension. (Do be aware providers will still order it for renal patients sometimes.) o Fentanyl: Common dose in adults is 25-100 mcg. Fast onset and short duration, with minimal effects on BP. When a patient is hypotensive, morphine is contraindicated, so patients tend to get fentanyl. Renal patients can still get fentanyl instead of morphine. Onset within 2 minutes, peak is 5-10 minutes, duration up to an hour. Give slowly and watch closely for respiratory depression. If you push this fast, it can lead to chest wall rigidity, so give it slowly! o Dilaudid (Hydromorphone): 10x stronger than morphine. Double verify dose. Give slowly and dilute if possible to ensure slow administration. Common dosing in adults can range from 0.1mg to 0.5mg. DOUBLE VERIFY DOSE. Onset within 5 minutes, peak of around 20 minutes, duration of up to 4 hours. Watch for respiratory depression, oversedation and hypotension. DOUBLE VERIFY DOSE. o Nursing: Monitor respiratory rate, sedation level, and BP. Give slowly and be extra cautious in elderly or opioid-naive patients. Have naloxone available. • Octreotide o Used primarily when variceal bleeding is suspected as it helps reduce portal hypertension, which helps decrease the amount of bleeding. This effect is also useful post treatment/fixing to help prevent rebleeding. You will typically give a bolus/push then start an infusion at a set rate. IV bolus: often 50 mcg, Followed by continuous infusion: 25–50 mcg/hr (Dose and protocol vary by institution) • Aspirin o Given for patients presenting with chest pain and possible ACS (Acute Coronary Syndrome). An antiplatelet, essentially helps by preventing the clot from getting bigger. For adults, the typical dose will be 324mg. ▪ Ensure the patient is not allergic and there are no signs of acute bleeding. ▪ If allergic, Plavix should be given. It is also an antiplatelet that helps prevent the clot from getting bigger. • Nausea Medications o Ondansetron: Typically 4 mg. Either IV or ODT. Onset within 10 minutes typically. Main issue is that it can cause Qt prolongation (rare but be aware of it). So if you are giving other medications that also have QT issues like Haldol, you must keep a close eye on it and even ask if an ECG should be obtained prior to administration. (Remember: Qt prolongation can lead to torsades) o Metoclopramide: Used over Zofran in nausea in patients with diabetes/DKA as it helps with gastroparesis and improves gastric mobility/emptying. Common adult dosing I have seen ordered by providers is 10mg. (Give slowly because if you push it fast, patients can feel anxious and restless- if this happens providers will order Diphenhydramine/benadryl). • Headache Cocktail o Compazine OR Reglan with Benadryl and Toradol (Always give the Compazine and or Reglan slowly, if you push it, patients will feel like they are crawling out of their skin.) (I've seen the providers do acetaminophen instead of Toradol).

Updated 12 Sep 2026