17776369 drug study on emergency drugs

Name of the Drug Dosage/Route Action/Classification Indication/ Contraindications

Adverse Effects/ Side Effects Nursing Responsibilities

Generic Name: epinephrine

Brand Name:Injection, OTC nasal solution: Adrenalin Chloride

Ophthalmic solution: Epifrin, Glaucon

Insect sting emergencies: EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. Auto-Injector (delivers 0.15 mg IM for children)OTC solutions for

nebulization: AsthmaNefrin, microNefrin, Nephron, S2

Cardiac arrest: 1 mg IV of 1:10,000 solution q 3-5 min; double dose if administering via ET tube

Anaphylaxis: 0.1- 1 mg SQ or IM of 1:1000 solution.

Asthma: 0.1-0.3 mg SQ or IM of 1:10,000 solution

Refractory bradycardia and hypotension: 2-10ug/min

Action:Stimulates beta receptors in lung.

Relaxes bronchial smooth muscle.

Increases vital capacity BP, HR, PR

Decreases airway resistance.

Classification:

Beta2 Adrenergic Agonists

Indications:o Asthmao Bronchitiso Emphysemao All cardiac arrest,

anaphylaxiso Used for

symptomatic bradycardia.

o Relief of bronchospasm occurring during anesthesia

o Exercised-induced bronchospasm

Contraindications:Contraindicate in patients with angle-closure glaucoma, shock (other than anaphylactic shock), organic brain damage, cardiac dilation, arrhythmias, coronary insufficiency, or cerebral arteriosclerosis. Also contraindicated in patient receiving general anesthesia with halogenated hydrocarbons or cyclopropane and in patients in labor (may delay second stage)

Some products containing sulfites and are contraindicated in patients

Adverse Effects:

nervousness, tremor, vertigo,

pain, widened pulse pressure,

hypertension nausea

Side Effects:headache

Monitor V/S. and check for

cardiac dysrhythmias

Drug increases rigidity and

tremor in patients with

Parkinson’s disease

Epinephrine therapy

interferes with tests for

urinary catecholamine

Avoid IM use of parenteral

suspension into buttocks. Gas

gangrene may occur

Massage site after IM

injection to counteract

possible vasoconstriction.

Observe patient closely

for adverse reactions. Notify

doctor if adverse reaction

develop

If blood pressure increases

sharply, rapid-acting

vasodilators such as nitrates or

alpha blockers can be given to

counteract

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with sulfite allergies except when drug is used for serious allergic reactions or in other emergency situations.

In conjunction with local anesthesia, epinephrine is contraindicated for use in finger, toes, ears, nose, and genitalia.

Use cautiously with long-standing bronchial asthma and emphysema, who have developed degenerative heart disease and in those with hyperthyroidism, CV disease, hypertension, psychoneurosis, or diabetes.

In pregnant woman, drug is contraindicated.

In breast feeding do not use the drug or stop breast feeding.

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Generic Name: lidocaine

Brand Name: Xylocaine

1-1.5 mg/kg IVP or ETT (double dose if giving via ET tube), may repeat q 5-10 min. max3 mg/kg; If conversion successful start an infusion of 2-4 mg/min

Action:

Decrease cardiac excitability,

cardiac contraction is delayed

in the atrium and ventricle

Classification: Antiarrythmic and Anesthetic

Indications: Decrease cardiac excitability, cardiac contraction is delayed in the atrium and ventricle

Contraindications:Contraindicated in patients hypersensitive to amide-type local anesthetics and in those with Adams –Stoke syndrome. Wolff-Parkinsons-White Syndrome, or severe degrees of SA, AV, or intraventricular block in the absence of pacemaker.

Adverse Effects:

CNS: Confusion, tremor,

lethargy, somnolence, stupor,

restlessness anxiety,

hallucinations, nervousness,

seizure. CV: hypotension,

bradychardia, new or

worsened arrhythmias EENT:

tinnitus, blurred or double

vision.

Respiratory: Respiratory

depression and arrest

Skin: soreness at injection site

Other: anaphylaxis,

Side Effects:

sensation of cold, vomiting

Monitor EKG, BP, pulse, rhythm, continuously.

Monitor serum lidocaine levels throughout theraphy; therapreutic range 1.5-5 mcg/ml

Monitor intake and output

Do not mix in the same syringe with amphoterin B or cefazolin

Administer Lidocaine TIV.

In case of circulatory

depression have dopamine

available

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Generic Name: furosemideBrand Name:

Apo-Furosemide

Furoside

Lasix

Lasix Speacial

Novosemide

Uritol

0.5-1 mg/kg slow IVP over 1-2 min, may repeat once at 2 mg/kg slow IVP over 1-2 mins.

Action:inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle

Classification: Loop Diuretics

Indications:Edema associated with CHF

Cirrhosis with ascites or renal dysfunction

For hypertension or in combination with other antihypertensive medications.

ICP, nephritic syndrome, hepatic cirrhosis

Contraindications:

Contraindicated to patients hypersensitive to drug or any of its components and in those with anuria.

Use cautiously in patient with hepatic cirrhosis.

Patients with allergies to sulfonamides may also be allergic to furosemide.

In pregnant woman, use only if benefits outweighs the risk to the fetus.

In breast feeding woman, do not use drug.

Adverse Effects:vertigo, headache, paresthesia, orthostatic hypotension, thrombophlebitis, abdominal pain, Hypokalemia, anemia, muscle spasm

Monitor serum glucose, and electrolyte

D iet- K+ for all except aldactone

I ntake and Output, daily weight

U ndesirable effects; Fluid and electrolyte imbalance

R eview HR, BP and electrolytes

E lderly-Careful T ake with or after

meals and in AMI ncrease risk of

orthosthatic hypotension; move slowly

C ancel alcohol

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Generic Name: digoxin

Brand Name:Lanoxin, Digoxin, Lanoxicap

Adults: For rapid digitalization, give 0.4 to 0.6 mg I.V. initially, followed by 0.1 to 0.3 mg I.V. every 4 hours, as needed and tolerated, for 24 hours.

Children: digitalizing dose is based on child’s age and is given in three or more divided doses over the first 24 hours. First dose is 50% of total dose; subsequent dose are given q 4 to 8 hours as needed and tolerated.

Children age 10 years and older: For rapid digitalization, give 8 to 12 mcg/kg I.V. over 24 hours, divided as above, Maintenance dose is 25% to 35% of total digitalizing dose, given daily as a single dose.

Children ages 5 to 10: For rapid digitalization, give 15 to 30 mcg/kg I.V. over 24 hours divided as above. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Action: Inhibits the sodium-potassium ATP phase.

Classification: Cardiac Glycosides

Indications:V-fib, V-flutter, CHF, pulmonary edema, atrial fibrillation and or flutter, and paroxysmal atrial contractions

Contraindications:Contraindicated in patients hypersensitive to the drug or any of its components and in those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure.

Use cautiously in patients with acute MI, in complete Av block, sinus bradycardia, PVCs,, chronic constrictive pericarditis, hyperthropic cardiomyopathy, renal insufficiency, severe pulmonary disease, or hypothyroidism.

Adverse Effects:CNS: hallucinations, paresthesia, stupor, vertigo.CV: Arrythmias, heart failure, hypotension.EENT: blurred vision, diplopia, light flashes, photophobia, yellow-green halos around visual images.GI: anorexia, diarrhea, nausea, vomiting.

Side Effects:CNS: agitation, dizziness, fatigue, generalized weakness, headache, malaise.GI: Nausea

Monitor K+, Mg++, ECG, liver/renal function tests, drug level (therapeutic level 0.5-2.0 mg/ml, toxicity is >2.0 mg/ml).

Before each dose assess apical pulse for full minute, record and report changes in rate or rhythm.

Withhold drug and contact provider if pulse is < 60/min. or >100 (adults) or < 110/minute (children) Weigh dailyMonitor I&O and signs of CHF

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Children ages 2 to 5: For rapid digitalization: give 25 to 35 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 25% to 35% of total digitalizing dose, divided and given in two or three equal portions daily.

Infants ages 1 month to 2 years: For rapid digitalization. Give 30 to 50 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 25% to 35% of the total digitalizing dose, divided and given in two or three equal portions daily.

Neonates: for rapid digitalization, give 20 to 30 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 25% to 30% of the total digitalizing dose, divided and given in two or three equal portions daily.

Premature Infants: For rapid digitalization, give 15 to 25 mcg/kg I.V. over 24 hours, divided as above. Maintenance dose is 20% to 30% of the total digitalizing dose, divided and given into two or three equal portions daily.

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Generic Name: Sodium Bicarbonate

Brand Name: Arm and Hammer Pure Baking Soda, Citrocarbonate, Soda Mint

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

Action: Neutralizes gastric acid

Decrease pepsin activity Classification: Alkalizing Agent, Buffer, Antacid, electrolyte

Indications: o Hyperacidityo Peptic ulcero Hyperkalemiao Tricyclic

antidepressant ODo Shock associated

with severe diarrhea, dehydration, uncontrolled DM

o Reflux esophagitis

Contraindications:Contraindicated in patients with metabolic or respiratory alkalosis; patients who are losing chlorides from vomiting or continuous GI suction; patients taking diuretics known to produce hypochloremia alkalosis; and patients with hypocalcemia in which alkalosis may produce tetany, hypertension, seizures, or heart failure. Oral sodium bicarbonate is contraindicated in patients with acute ingestion of strong mineral acids.

Adverse Effects:GI: Gastric distention, belching, flatulence.Metabolic: metabolic alkalosis, hypernatremia, hypokalemia, hyperosmolarity (with overdose).Other: Pain and irritation at injection site.

Monitor urinary pH, calcium, electrolytes and phosphate levels. Record amount and consistency of stools. Clients on low-sodium diets should evaluate sodium contents of antacids.

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Generic Name: Dopamine HCl.

Brand Name:Intropin; Revimine

Adults: initially, 1 to 5 mcg/kg/minute by I.V. infusion. Adjust dose to desired hemodynamic or renal response, increase by 1 to 4 mcg/kg/minute at 10 to 30-minute intervals.

ActionStimulates dopaminergic and alpha and beta receptors of the sympathetic nervous system. Action is dose-related; large doses can cause mainly alpha stimulation.

Classification: Inotropic, vasopressor

Indications: To treat shock and correct hemodynamic imbalances, improve perfusion of vital organs, to increase cardiac output, and to correct hypotension.

Contraindications:Contraindicated in patient with uncorrected tachyarrhythmias, pheocromocytoma, or ventricular fibrillation.- Use cautiously in patients with occlusive vascular disease, cold injuries, diabetic endarteritis, and arterial embolism; in pregnant woman; with a history of sulfite sensitivity; and in those taking MAO inhibitor.

Adverse Effects: Cv: anginal pain, arrythmias, bradycardia, conduction disturbances ectopic breasts,hypertension, hypotension, palpitations, tachycardia, vasoconstriction, widening of QRS complex.

GI: vomiting.

GU: azotemiaRespiratory: asthma attacks, dyspnea

Skin: necrosis,piloerection, tissue sloughing with extravasation.

Other: anaphylaxis.

Side Effects:CNS: headache GI: nausea

Blood is not a substitute for blood or fluid volume deficit. If deficit occurs, replace fluid deficit first before giving meds.

During infusion, frequently monitor ECG, BP, cardiac output, CVP, pulmonary artery wedge pressure, pulse rate, urine output, and color and temperature of the limbs.

If diastolic pressure rises disproportionately, decrease perfusion rate and watch out carefully for further signs of vasoconstriction unless such action is desired.

Observe for adverse reaction.

Check for urine output. If urine flow is decrease without hypotension, notify physician.

After drug is stopped, Tamper dosage slowly to evaluate stability of blood pressure. Acidosis decrease effectiveness of dopamine.

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Name of the Drug Dosage/Route/Timing Action/Classification Indication/ Contraindications


GenericNitroglycerinBrandNitrostat

0.3-0.4 mg SL q 5 min, max 3 doses.

Action:Relaxes the vascular smooth system Myocardial oxygen consumption left ventricular workload arterial BP venous return

ClassificationAntianginal, Nitrate, Vasodilator, Coronary

Indication:Angina pectorisCHF associated with AMI Cardiac load reducing agent Hypertensive Crisis

Contraindication:Contraindicated in patients hypersensitive to nitrates and in those with early MI. (S.L. form), severe anemia, increase ICP angle-closure glaucoma, IV nitroglycerine is contraindicated in patients with hypovolemia, hypotension, orthostatic hypotension, cardiac tamponade restrictive cardiomyopathy, constrictive pericarditis.

Adverse EffectsCV: orthostatic hypotension, flushing, fainting.EENT: sublingual burning.Skin: Cutaneous vasodilation, contact dermatitis (patch)Side EffectsCNS: headache, throbbing, dizziness, weakness.GI: nausea, vomiting.Skin: Rash

Record characteristics and precipitating factors of anginal pain. Monitor BP and apical pulse beforeadministration and periodically after dose. Have client sit or lie down if taking drug for the first time. Client must have continuing EKG monitoring for IV administration Cardioverter/ defibrillator must not be discharged through paddle electrode overlyingNitro-Bid ointment or the Transderm-Nitro Patch. Assist with ambulating if dizzy.

Instruct to take at first sign of anginal pain. May be repeated q 5 minutes to max. of 3 doses. If the client doesn’t experience relief, advise to seek medical assistance

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immediately.



GenericAtrophine Sulfate

BrandIsopto Atropine

Bradycardia: 0.5 -1 mg IV (may give via ETT at double dose) q 3-5 min, max 0.04 mg/kgCardiac arrest: 1 mg q 3-5 min, max 0.04 mg/kg

Nerve gas and organophosphate symptoms, may repeat in 2 mg increments q 3 min tiltrated to relief symptoms.

Actioncholinergic receptor sites so response to acetylcholine is decreased

ClassificationAnticholinergics

IndicationAs an anti-sialagogue for preanesthetic medication to prevent or reduce secretions of the respiratory tract To restore cardiac rate and arterial pressure during anesthesia, when vagal stimulation produced by intra-abdominal surgical traction causes a sudden decrease in pulse rate and cardiac action To lessen the degree of atrioventricular (A-V) heart block when increased vagal tone is a major factor in the conduction defect, as in some cases due to digitalis To overcome severe carotid sinus reflex Antidote for cardiovascular collapse from the injudicious use of a cholinergic drug.

ContraindicationContraindicated in patients hypersensitive to drug and those with acute angle closure glaucoma, obstructive uropathy, obstructive disease

Adverse EffectsCNS: restlessness, ataxia, disorientation, hallucinations, delirium, coma, insomnia, agitation, confusion.CV: tachycardia, angina, arrhythmias, flushing.EENT: photophobia, blurred vision, mydriasis.GI: dry moth, constipation, vomiting.GU: urine retention.Hematologic: leukocytosisOther: anaphylaxis

Side EffectsCNS: headache, excitement.CV: palpitationsGI: thirst, nausea.

Monitor VS. Report HR Monitor for constipation, oliguria. Atrophine could result in CNS stimulation (confusion, excitement) or drowsiness Instruct to take 30 mins before meals Eat foods high in fiber and drink plenty fluids. Avoid OTC antihistamines. Instruct client not to drive a motor vehicle or participate in activities requiring alertness. Advise to use hard candy, ice chips, etc. for dry mouth.

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of GI tract, paralytic elius, toxic magacolon, intestinal atony, unstable CV status in acute hemorrhage, asthma, or myasthenia gravis. Also contraindicated in pregnant women.

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GenericDobutamine Hydrochloride

BrandDobutrex

Adults individualized: 2.5-15 mcg/kg/min.

Rate of administration and duration of therapy depend on the response of client as determined by HR, presence of activity, BP and urine flow

ActionEnhancing the force of myocardial contraction HR, CO, and SV with minor effects to HR. elevated ventricular filling pressure and helps AV node conduction

ClassificationInotropic, Adrenergic

Indication Short term treatment of cardiac decompensation in organic heart disease of cardiac surgical pressures.

ContraindicationContraindication in patients hypersensitive to drug or any of its components and in those with idiopathic hypertrophic subaortic stenosis.

Adverse EffectsCV: angina, hypertension, hypotension, increased heart rate, nonspecific chest pain, phlebitis, PVCs.GI: nausea and vomiting.Respiratory: asthma attacks, shortness of breath.Others: anaphylaxis.

Side EffectsCNS: headacheMusculoskeletal: mild leg crams or tingling sensation.

Monitor CVP to assess vascular volume and cardiac pumping efficiency.

(Elevated CVP may indicate disruption on CO, as in pump failure or Pulmonary edma; low CVP may indicate hypovolemia) Monitor ECG and BP continuously during drug administration Record I&O Monitor glucose in diabetes patients

Drug is administered IV to improve cardiac function thus increasing BP and improving urine output. Report any chest pain, increase SOB, headaches or IV site pain.

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GenericMorphine Sulfate

BrandImmediate-release tablets: MSIRTimed-release: Kadian, M-Eslon (CAN), MS Contin, Oramorph SROral solution: MSIR, Rescudose, Roxanol, Roxanol TRectal suppositories: RMSInjection: Astramorph PF, Duramorph, Epimorph (CAN)Preservative-free concentrate for microinfusion devices for intraspinal use: Infumorph

ADULTSOralOne-third to one-sixth as effective as parenteral administration because of first-pass metabolism; 10–30 mg q 4 hr PO. Controlled-release: 30 mg q 8–12 hr PO or as directed by physician; Kadian: 20–100 mg PO daily–24-hr release system; MS Contin: 200 mg PO q 12 hr.SC and IM10 mg (5–20 mg)/70 kg q 4 hr or as directed by physician.IV2.5–15 mg/70 kg of body weight in 4–5 mL water for injection administered over 4–5 min, or as directed by physician. Continuous IV infusion: 0.1–1 mg/mL in 5% dextrose in water by controlled infusion device.Rectal10–30 mg q 4 hr or as directed by physician.EpiduralInitial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If adequate pain relief is not achieved within 1 hr,

ActionPrincipal opium alkaloid; acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins).

ClassificationOpioid agonist analgesic

IndicationRelief of moderate to severe acute and chronic pain

Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia, and reduce anesthetic dosage

Analgesic adjunct during anesthesia

Component of most preparations that are referred to as Brompton's cocktail or mixture, an oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer patients

Intraspinal use with microinfusion devices for the relief of intractable pain

Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edemaContraindication

Contraindicated with hypersensitivity to opioids;

Adverse EffectCNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of cough reflex

CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope

Dermatologic: Pruritus, urticaria, Respiratory: laryngospasm, bronchospasm, edema

GI: Nausea, vomiting, anorexia, biliary tract spasm; increased colonic motility in patients with chronic ulcerative colitis

AssessmentHistory: Hypersensitivity to opioids; diarrhea caused by poisoning; labor or delivery of a premature infant; biliary tract surgery or surgical anastomosis; head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression; acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction; pregnancy; lactation

Physical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious sounds; bowel sounds, normal output; urinary frequency,

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incremental doses of 1–2 mg may be given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous infusion, initial dose of 2–4 mg/24 hr is recommended. Further doses of 1–2 mg may be given if pain relief is not achieved initially.IntrathecalDosage is usually one-tenth that of epidural dosage; a single injection of 0.2–1 mg may provide satisfactory pain relief for up to 24 hr. Do not inject > 2 mL of the 5 mg/10 mL ampule or > 1 mL of the 10 mg/10 mL ampule. Use only in the lumbar area. Repeated intrathecal injections are not recommended; use other routes if pain recurs. For epidural or intrathecal dosing, use preservative-free morphine preparations only.

PEDIATRIC PATIENTSDo not use in premature infants.SC or IM0.05–0.2 mg/kg (up to 15 mg per dose) q 4 hr or as directed by physician.

GERIATRIC PATIENTS

diarrhea caused by poisoning until toxins are eliminated; during labor or delivery of a premature infant (may cross immature blood–brain barrier more readily); after biliary tract surgery or following surgical anastomosis; pregnancy; labor (respiratory depression in neonate; may prolong labor).

Use cautiously with head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression, hypoxia, hypercapnia (may decrease respiratory drive and increase airway resistance); lactation (wait 4–6 hr after administration to nurse the baby); acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction.

GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency

Respiratory: Respiratory depression,

apnea, circulatory depression, respiratory arrest, shock, cardiac arrest

Side EffectsGI: dry mouth, constipation.Skin: Tissue irritation and induration (SC injection).Other: sweating,physical tolerance and dependence, psychological dependence

voiding pattern, normal output; ECG; EEG; thyroid, liver, kidney function tests

InterventionsCaution patient not to chew or crush controlled-release preparations.

Dilute and administer slowly IV to minimize likelihood of adverse effects.

Tell patient to lie down during IV administration.

Keep opioid antagonist and facilities for assisted or controlled respiration readily available during IV administration.

Use caution when injecting SC or IM into chilled areas or in patients with hypotension or in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored.Reassure patients that they are unlikely to become addicted; most patients who receive opioids for medical reasons do not develop dependence syndromes

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OR IMPAIRED ADULTSUse caution. Respiratory depression may occur in the elderly, the very ill, those with respiratory problems. Reduced dosage may be necessary.EpiduralUse extreme caution; injection of < 5 mg in the lumbar region may provide adequate pain relief for up to 24 hr.IntrathecalUse lower dosages than recommended for adults above.

Teaching points

Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, tranquilizers, over-the-counter drugs.

Swallow controlled-release preparation (MS Contin, Oramorph SR) whole; do not cut, crush, or chew them.

Do not take leftover medication for other disorders, and do not let anyone else take your prescription.

These side effects may occur: Nausea, loss of appetite (take with food, lie quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness and visual acuity).

Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.

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17776369 drug study on emergency drugs

Documents

nursing responsibilities monitor

indication contraindications indications

equal portions daily

increased intracranial pressure

biliary tract surgery

decrease cardiac excitability

acute abdominal conditions

total digitalizing dose