Vimala Colaco

Atropine• Treatment of sinus pulseless electrical activity,

bradycardia, or asystole.. Neonates and children: 0.02mg/kg

intratracheal (max: 0.5mg); may repeat5min later, one time

Cardiac pacing is required in neonates with ventricular rates of 50 beats/min or experience heart failure after birth. to increase the heart rate temporarily until pacemaker placement can be arranged

Preoperative medication to inhibit secretions and salivation

• Antidote to organophosphate poisoning. 0.02–0.05 mg/kg every 10–20min until atropine effect is

seen then q1–4h for at least 24hr.

Cautions: gastrointestinal obstruction, thyrotoxicosis, and tachycardia.

Adverse events: Tachycardia, palpitations, delirium, ataxia, dry hot skin, tremor, urinary retention

EpinephrineIndications: Treatment of cardiac arrest,

bronchospasm, anaphylactic reaction For asystole or for failure Epinephrine

(0.1–0.3mL/kg of a 1:10,000 solution, intravenously or intratracheally) is given to respond to 30sec of combined resuscitation. The dose may be repeated every 5 min

Routes- IV, intratracheal, continuous infusion and nebulisation

Adverse events: Tachycardia, hypertension, nervousness,

restlessness, irritability, headache, tremor, weakness, nausea, vomiting, acute urinary retention.

Peripheral soft tissue damage if they extravasate from peripheral lines into the local tissues

Hydrocortisone• Indications: Status asthmaticus, shock

[50mg/kg/dose 4h],Treatment of adrenal insufficiency, congenital adrenal hyperplasia,

• Caution: Abrupt withdrawal -acute adrenal insufficiency.

• Adverse events: Hypertension, hyperglycemia, hypokalemia, euphoria, insomnia, headache, Cushing syndrome, peptic ulcer, cataracts, immunosuppression, skin and muscle atrophy, acne, edema.

Status asthmaticus

Oxygen inhalation + adrenaline/terbutaline inj

inhalation salbutamol+ ipratropium and hydrocortisone (10mg/kg)

improve

continue terbutaline inj[20-30min]

hydrocortisone 5mg/kg 6-8 hrly

loading dose theophylline

if not

Anaphylactic shockConsider when compatible history of severe allergic-type reaction with respiratory difficulty and/or hypotension especially if skin changes present

Oxygen treatment when available

Stridor, wheeze, respiratory distress or clinical signs of shock [1]

Adrenaline (epinephrine) [2,3] 1:1000 solution0.5 mL (500 micrograms) IM

Repeat in 5 minutes if no clinical improvement

Antihistamine (chlorphenamine)10-20 mg IM/or slow IV

IN ADDITION

For all severe or recurrent reactions and patients with asthma give

Hydrocortisone 100-500 mg IM/or slowly IV

If clinical manifestations of shock do not respond to drug treatment give 1-2 litres IV fluid. [4] Rapid infusion or one repeat dose may be necessary

Dopamine• Indication: hypotension and shock• 1–20μg/kg/min IV• Adverse events: Tachycardia, ectopic beats,

ventricular arrhythmias, tissue necrosis with extravasation, vasoconstriction, gangrene of extremities, excess urine output (doses <5μg/kg/min), oliguria (doses 10μg/kg/min).

Dose microgm/kg/min

Strengthens contractions

throughout dose range

1-5

Increases renal blood flow

Low/intermediate doses

5-15

Vasocontriction High dose 15-25

FurosemideIndications: Pulmonary edema-cardiac

failure, SIADH, reduction of ICT in combination with mannitol, broncho-pulmonary dysplasia

Adverse events: Dehydration, electrolyte loss, hyperuricemia, photosensitivity, ischemic hepatitis, hypercalciuria, renal stones, ototoxicity (IV infusion rate >4mL/min), gastrointestinal intolerance

Heart failure. It inhibits the reabsorption of sodium and chloride in the distal tubules and the loop of Henle.

Acute diuresis should be given intravenous or intramuscular furosemide at an initial dose of 1–2mg/kg, which usually results in rapid diuresis

.Chronic furosemide therapy is then prescribed at a dose of 1–4mg/kg/24hr given between one and four times a day

Careful monitoring of electrolytes is necessary with long-term furosemide therapy because of the potential for significant loss of potassium.

Potassium chloride supplementation is usually required unless the potassium-sparing diuretic spironolactone is given concomitantly.

When furosemide is administered every other day, dietary potassium supplementation may be adequate to maintain normal serum potassium levels

Digoxin• Indications :Treatment of systolic heart

failure and supraventricular tachyarrhythmias• Cautions: Contraindicated in AV block,

idiopathic hypertrophic subaortic stenosis,or constrictive pericarditis

• Adverse events: Anorexia, nausea, vomiting, diarrhea, feeding intolerance,bradycardia, arrhythmias, lethargy, depression, vertigo, blurred vision, diplopia, photophobia, yellow or green vision

The drug crosses the placenta, and therefore a fetus with heart failure(secondary to arrhythmia) can be treated by administering digoxin to the mother.

The kidney eliminates digoxin, so dosing must be adjusted according to the patient'srenal function.

Digoxin in heart failureRapid digitalization of infants and children in

heart failure may be carried out intravenously. The recommended schedule is to give half the total digitalizing dose immediately and the succeeding two one-quarter doses at 12hr intervals later.

Maintenance digitalis therapy is started approximately 12hr after full digitalization. The daily dosage is divided in two and given at 12hr .The dosage is one quarter of the total digitalizing dose

Slow digitalization –patient not critically ill or initiation of a maintenance digoxin schedule without a previous loading dose .full digitalization in 7–10 days

Monitoring: • Dosing should be guided by measuring serum

digoxin concentrations: therapeutic: 0.8–2ng/mL; toxic: >2–2.5ng/mL.

• DLIS - elevate digoxin levels, so pretreatment digoxin levels can be obtained and subtracted from treatment levels or samples can be run through a free-level filter to remove DLIS before assay.

• Check post-distribution levels (drawn at least 6–8hr post dose) at steady-state (2–4 wk) or if ECG or clinical signs of toxicity. Check ECG, serum electrolytes, calcium, and magnesium.

Digoxin Immune FabTreatment of digitalis intoxication from

digoxin Dose is based on amount of digoxin ingested

or estimated total body load based on post-distributive serum concentration

Adverse events: Worsening of heart failure or atrial fibrillation, hypokalemia, facial swelling, and redness.

Naloxone• Indication: opiate excess(overdose,

poisoning).• Neonates and children: 0.1mg/kg IV (max

dose: 2mg). If no response, repeat q 2–3min until desired effect. May give by continuous IV infusion

• Adverse effects May precipitate acute opiate withdrawal. Duration of effect of many opiates may be longer than naloxone requiring individualized naloxone dosing.

Phenytoin• Indications: Anticonvulsant and

antiarrhythmic.• Status epilepticus: mg/kg IV Loading

doseMaintenance dose

Neonates 15-20 5

Children 15-18 .5-6yr 8-10

7-9yr 6-8

10-16yr 6-7

Cautions: Infuse slowly IV; variable oral bioavailability;

chewable tablet most consistent. Must shake oral suspension very well before use.

Certain disease states (renal failure, acute head trauma) may lead to imbalance between free and protein-bound drug.

Fosphenytoin has advantages over the older formulation - it is water soluble, less irritating after IV injection, and well absorbed after intramuscular injection

• Adverse effects: Lethargy, dizziness, nystagmus, hypotension, hirsutism, gingival hyperplasia, rash, Stevens-Johnson syndrome, hepatitis, thrombophlebitis.

• Drug interactions: May increase metabolism of certain hepatically

cleared drugs; griseofulvin, corticosteroids, cyclosporin;

Highly protein boundand may cause displacement interaction.

• Monitoring: Phenytoin concentrations: therapeutic 8–20μg/mL.

PhenobarbitoneIndications: anticonvulsant,sedative,

hypnotic, anesthetic, hyperbillubinemiaAnticonvulsant loading dose Children:15 -20mg/kg PO, IV.

Maintenance dose Neonates: 3–4mg/kg, Children: 5–

6mg/kg/24hr PO, IV, q12–24h.

• Cautions: Dose titrated to desired effect. Administer IV =30mg/min

• Adverse effects: Hypotension, drowsiness, respiratory depression, paradoxical hyperactivity

• Drug interactions: May increase metabolism of many hepatically

cleared drugs; griseofulvin, corticosteroids. Certain drugs may interfere with phenobarbital

metabolism: valproic acid, chloramphenicol, felbamate.

.

Potassium chlorideIndications: - Hypokalemia < 2.5meq/l, cardiac rhythm disturbances 40mEq/L @ 0.6 mEq/kg/hr under

continuous EEG monitoring - Tachyarrhythmias – chronic use of

digoxin[max 100m mol)

Chloride responsive metabolic alkalosis , as a component of mantainance fluids[10/20 meq/l], bronchopulmonary dysplasia ( with hydrochlorothiazide), supplementation (with furosemide in heart failure with digoxin), nonketotic hyperosmolar coma

Adverse effects : Hyperkalemia, gastritis

Sodium bicarbonate• Presence of a severe metabolic

acidosis(1mEq/kg,) as documented by arterial blood gas analysis and during a prolonged resuscitation when it may be given every 10 min during the arrest

• Symptomatic hyperkalemia(>7meq/L), hypermagnesemia, tricyclic antidepressant drug intoxications, or with adverse events due to sodium channel blocking agents

• Alkalinization of urine with sodium bicarbonate increases effectiveness of aminoglycosides against in the urinary tract

Alkali therapy may result in hypernatremia, skin slough from infiltration, increased serum osmolarity, hypocalcemia, hypokalemia,

Liver injury when oncentrated solutions are administered rapidly through an umbilical vein catheter wedged in the liver

Calcium gluconateHyperkalemia- counteracts the potassium-

induced increase in myocardial irritability Calcium gluconate 10% solution, 1.0mL/kg IV, over 3–5 min

Neonatal tetany consists of intravenous injections of 5–10mL of a 10% solution of calcium gluconate at the rate of 0.5–1mL/min while the heart rate is monitored.

Symptomatic hypocalcemia in neonates, calcium gluconate is given at a dose of 100–200mg/kg (1–2mL/kg of a 10% solution).dose may be repeated every 6–8hr until the calcium level stabilizes

Alternatively, intravenous infusion can be given

Adverse effects :hypercalcemia