Quick Recall – Need to Know Drugs/Management

This section acts as an aide memoir.  Please check doses and facts before using on real patients….

Resus:

  • Adrenaline:
    • Anaphylaxis 0.5mg IM 1:1000 or 10mcg/kg (0.01ml/kg) Paediatric 1:1000
    • ALS: 1mg 1:10000 or 0.1ml/kg 1:10000 (Paediatrics)
    • IV Bolus: 25-50mcg.
    • Infusion:  6mg in 100ml.  1ml/hr = 1mcg/min. Dose 1-20mcg/min (1-20ml/hr). Kids 0.1-0.5 mcg/kg/min
    • Croup: 5ml 1:1000 in Nebuliser all ages.
  • Atropine 10-20mcg/kg Paediatrics, 600-1200mcg up to 3mg in Adults. In cholinergic od 1.2mg and double dose every 2-3min  aim sbp>80, hr>80
  • RSI and Post Drugs
    • Suxamethonium 1-2 mg/kg (2mg preferable in neonates/infants)
    • Rocuronium 1.2mg.kg
    • Cisatucurium 10mg for paralysis post RSI.
    • Ketamine:  1-4mg/kg
    • Midazolam: 0.2mg/kg. Infusion: 100mg in 100ml NS, 1-10mg/hr
    • Morphine: 2-5-10mg.  Infusion: 120mg in 120ml NS.  1-20mg/hr
    • Fentanyl: 1-2mcg/kg.  Infusion: 25-250mcg/hr
    • Propofol: 1.5-3mg/kg.  Infusion: 4mg/kg/hr maximum.
    • Thiopentone 3-5mg/kg
  • RSI Equipment
    • ETT formula: Size Age/4 +4;  Depth Age/2+12
    • Vent settings:
      • Obstructive: Permissive hypercapnoea (pH>7.1).  SIMV, TV 4-8ml/kg, I:E prolonged (quick insp flow rate), PEEP 0-5, FiO2 titrates to SpO2 >92%, RR Low -10.  Plateau pressure <30.
      • Lung protective: SIMV, TV 6-8ml/kg, Insp flow 60-80L/min, RR 14-16 (maintain normal CO2), Aim Sats 88-95% and PaO2 55-80 by adjusting PEEP.  Aim plateau pressure <30 and peak pressure <35.
    • NIV:
      • IPAP 8-10 cmH20 (Max 10-16), EPAP 2-4cm H2O (Max 8-10)
      • Increasing IPAP increases ventilation (i.e. dec CO2).  increasing EPAP improves atelectasis and recruits.
      • Contraindications: Obtunded, uncooperative, vomiting risk, facial trauma/burns, pt refusal, facial, oesophageal/gastric surgery, pneumothorax.
  • Pressor’s
    • Noradrenaline 6mg in 100ml 5%D.  Infusion 1-20mcg/min
    • Metaraminol: 0.5-5mg stat.  Infusion 15-100mg titrating to BP
    • Phenylephrine: 0.1-0.5mg
  • Asthma
    • Salbutamol 5mg nebs.
    • Ipatropium (atrovent) 0.5mg nebs
    • Steroid Hydrocortisone 100mg (4mg/kg) IV Prednisolone 50mg (1mg/kg)
    • Magnesium 10mmol over 20min (0.1-0.2 mmol/kg)
    • IV Salbutamol: 10mg in 100ml, 0-10ml/hr (5 mcg/kg/min for one hour as a load, followed by 1-2 mcg/kg/min)
    • NIV
    • Pads consider aminophylline: 10mg/kg loading dose over 1/24.
  • Status Epilepticus
    • 1st Line:  Midazolam 0.1mg/kg (0.3 mg/kg Buccal), Diazapam 0.1-0.3mg/kg
    • 2nd Line: Phenytoin 20mg/kg.  Phenobarbitone 20mg/kg (neonates).  Levetiracetem 20mg/kg
    • 3rd Line: Intubation/Paralysis – Thiopentone/Propofol/Midazolam infusion
  • Electrolyte:
    • Hyperkalaemia
      • 10% Calcium Gluconate 10-30ml IV or 10% CaCl 5-10ml IV
      • Insulin 10-20 units, Dextrose 25g – 50ml
      • Salbutamol 5-10mg neb
      • Resonium 15-30g
      • IVF, frusemide (if ok kidneys).
    • Hyponatraemia
      • Correct slowly 0.5mmol/hr max 10mmol/24hrs.  Avoid hypertonic saline – may need free water if  Na rising too quickly with NS.
      • Seizures Benzo as above + rapid administration for hypertonic saline
        • 4ml/kg 3% Saline over 15-30min may need to rpt.
  • Sepsis
    • END-POINTS to quote in management qn:
      • MAP >65mmHg, HR< 100, UO >50ml/kg/hr, SpO2 >93%, Avoid acidosis, Conscious state.
    • lung protective strategies if intubated/ARDS
    • Antibiotics:
      • Unknown source: Gentamicin 4-7mg/kg, Flucloxacillin 2g
      • Neutropaenia: Piperacillin-tazobactem 4.5g +/- Gentamicin 4-7mg/kg +/- Vancomycin 25mg/kg (If indwelling device)
  • Antibiotics:
    • Pneumonia
      • Mild: Amoxicillin 1g 8/24 or Doxycyline 100mg BD
      • Mod: IV Benzylpenicillin 1.2g & Doxycyline 100mg
      • Severe:  Ceftriaxone 1g IV and Azithrmocyin
      • Kids >5yo with suspected mycoplasma: Clarithromycin 7.5mg/kg (avoid doxy <8yo)
      • Aspiration: Add metronidazole 500mg IV or Broad spectrum: Tazocin.  Cefempime if penicillin hypersens.
    • Endophthalmitis: Cirpofloxacin 750mg + Vancomycin 1g.
    • Meningitis: Dexamethasone 10mg (0.15mg/kg) + Ceftriaxone 4g
    • Epidural abscess:  Gent + Vanc
    • Encephalitis: Aciclovir 10mg/kg (20mg/kg if <5)
    • Endocarditis: Gent + Benylpenicillin + Vanc
    • Cholecystitis and ascending cholangitis:  Gentamicin 5mg/kg + Ampicillin 2g (Ceftriaxone if can’t have gent or HS to penicillin).  Add in Metronidazole to cover anaerobes.
    • Peritonitis:  Amp + Gent + Metronidazole (Ceftriaxone + Flagyl alternative)
    • SBP: Ceftriaxone 2g
    • PD:  Gent + Cephazolin via PD bag.
    • Osteomyelitis/Septic arthritis – Flucloxacillin 2g (50mg/kg) (diabetic foot = Tazocin)
    • Cellulitis: Mild Flucloxacillin 500mg QID, Severe: Flucloxacillin 2g IV 6/24
    • Necrotising skin infections:  Merepenem 1g, Vancomycin 1g, Clindamycin 600mg.
    • Pyelonephritis: Gent 5mg/kg + Ampicillin 1.2g
    • STI: Ceftriaxone 500mg IV/IM + Azithromycin 1g oral rpt in 1 week. (add in Metronidazole if ?PID)
  • Head Injury – Neuroprotective strategy.
    • Intubate rapidly, consider pre-treatment, avoid Sux
    • Sedation +/- paralysis
    • Head up, loosen collar/avoid impedance of drainage
    • Avoid hypotension – Aim MAP>80mHg
    • Avoid hypoxia. SpO2 >95%, Avoid PEEP.
    • Euglycaemia, Avoid hyperthermia.
    • Seizure prevention/prophylaxis – Keppra 1g loading.
    • Aim PCO2 35.  Avoid acidosis/hyperventilation.  Aim normal pH.
    • Mannitol 1g/kg
    • Early NSURG referral and ICU management
  • Permissive/Minimal Volume resuscitation/Massive Transfusion
    • Massive transfusion = 1/2 blood volume in 4 hrs or whole blood volume in 24hrs.  (Kids = 40ml/kg)
    • Permissive hypotension SBP 80-100/Cerebral and tissue perfusion.  Contraindicated in head injury.
    • Avoid hypothermia/coagulopathy/acidosis
    • Aim pH>7.2, Temp >36, Lactate <4, iCa >1.1, Platelet >50, Fibrinogen >1, INR <1.5 APTT< 1.5 normal.
  • Correct Coagulopathy
    • FFP 1-2 units, Prothrombinex 50U/kg
    • Vit K
  • Cardiac
    • SVT:  Adenosine 6mg, 12mg IV.  Diltazem 12-20mg IV over 2min.  Paeds 0.1mg/kg inc by 0.1mg/kg each dose.  Synchronised cardioversion (1-2J/kg in kids)
    • Atrial Fibrillation
      • Rate Control:
        • Metoprolol 25-50mg oral or 1-10mg 2-5min up to 10mg IV
        • Digoxin 250mcg o/IV rpt in 6/24
        • Verapamil 1mg/min IV up to 15mg or 180 to 360mg CR
      • Rhythm Control
        • Synchronised Cardioversion
        • Amiodarone infusion 5mg/kg over 30min then infusion 900mg/24hrs.
        • Flecanide 50-100mg oral or 2mg/kg IVI over 30min (need normal LV and no CAD)
        • Sotalol 1-2mg IV or 80-160mg oral.
      • Anticoagulation if CHADS > 2 (long term) or onset >48hrs for 3ks before cardioversion.
    • Conscious VT: Amiodarone 5mg/kg over 20min.  Lignocaine 100mg loading then infusion. Synchronised Cardioversion +/- sedation
    • Torsades: Synchronised cardioversion, Mg 10mmol, Correct electrolytes K >4.5, Chronotherapy eg. Adrenaline/Isoprenaline/Atropine reduced QTc, Overdrive pacing – normally captures at >100 BPM.
    • Bradycardia: 300-600mcg up to 3mg.  Adrenaline 2-10mcg/min, Pacing.
      • Calcium channel blocker = High dose insulin therapy 1unit/kg insulin + Dextrose.  Monitor K
      • Betablocker = Glucagon 5mg IV q10
  • Thrombolysis
    • STEMI:  Tenectaplase 10000Units (if >90kg)
    • Pulmonary Embolism: Alteplase 10mg bolus followed by 90mg infusion over 2/24
      • Massive PE = SBP <90 persistent, cardiac arrest, bradycardia (+shock)
      • Submassive = No shock, RV dysfn, myocardial necrosis
    • Stroke: 0.9mg/kg – 10% Bolus then rest over 2/24
    • Absolute contraindications: Active bleeding/bleeding diasthesis, Closed head injury or facial trauma within 3/12, Suspected dissection, any intracranial haemorrhage (anytime), ischaemic stroke within 3/12, known structual intracranial malformation or malignancy
    • Relative Contraindications: Anticoagulation, Surgery within 3/52, non compressible vascular puncture, GI bleeding/active peptic ulcer, prolonged CPR, Ischaemic stroke >3/12 ago, pregnancy, HTN >180
  • Toxicology
    • Paracetamol: 200mg/kg or 10g. NAC 150mg/kg over 1/24 then 50mg/kg 4/24 then 100mg/kg 16/24
    • Na Channel Blockade: 1-2ml/kg of NaHCO3 8.4% repeat every 2-3min. Intubation, hyperventilation. Aim restoration of perfusion and ph>7.5
    • Ca Channel Blocker/Betablocker: Atropine 0.5mg up to 3, Adrenaline 50mcg bolus, Calcium Gluconate 10% 30ml (if CaCB), Pace, High dose insulin therapy – 1unit/kg insulin then 1unit/kg/hr infusion, Dextrose (MONITOR K & BSL), Intubate and decontaminate (MDAC/WBI).
  • Paediatrics
    • Croup:  Mild/Mod Prednisolone 1mg/kg, Dexamethasone 0.15mg/kg oral.  Severe Nebulised adrenaline 5ml 1:1000 and IV dexamethasone 0.6mg/kg.
    • THE MISFITS (Sick Neonate) = Trauma (NAI), Heart (Congenital/Hypovol), Endocrine (BSL/Thyroid/CAH), Metabolic (Na/Ca/Glucose), Inborn errors, Seizures, Forumal errors, Intestinal disasters (Volvulus, NEC, Intussusception) Toxins, Sepsis.
    • Sepsis
      • <1mo: Cefotaxime 50mg/kg and Benzylpenicillin 50mg/kg
      • >1mo Ceftriaxone 50mg/kg and Flucloxacillin 50mg/kg
      • Noradrenaline 0.15mg/kg or Adrenaline 0.1-0.2mcg/kg/min
  • Pregnancy
    • Pre-eclampsia/Eclampsia
      • Mild >140SBP and DBP>90 + Protein, Severe: SBP>160/>110, HELLP, Neuro, GI, Large Protien
      • Mx BP (<140/90): Labetalol 10-20mg rpt q10min or infusion.  Hydralazine 5-10mg bolus every q20
      • Mg: 4g IV then infusion.
    • PPH
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s