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S/B/E Pharmacology Crystalloids: Isotonic y y y y y Normal Saline/ Lactated Ringer s Action: Fluid remains primarily in the intravascular space, increasing intravascular volume Type of Shock: Used for initial volume replacement in most types of shock Nursing Implications: Monitor pt closely for circulatory overload. LR should not be used in pts with liver failure. What to Watch for: Fluid volume overload. Low hemoglobin and hematocrit levels b/c of dilution by overexpansion intravascular compartment.

Colloids (Volume Expanders) Hetastarch (Hespan) y y y Action: Made from starch and acts as volume expander; is at least as effective as albumin; can exert osmotic effect for up to 36 hr Type of Shock: All types of shock except cardiogenic and neurogenic shock Nursing Implications: May be 50% less costly than albumin. Use cautiously in pts with heart failure, renal failure, or bleeding disorders (due to antiplatelet effect).

Albumin y y y Action: Can increase plasma colloid osmotic pressure; rapid volume expansion Type of Shock: All types of shock except cardiogenic and neurogenic shock Nursing Implications: Monitor for circulatory overload. Mild side effects of chills, fever, and uriticaria may develop. More expanders than other colloids.

Dextran y y y Action: Hyperosmotic glucose polymer; has similar degrees of volume expansion with dextran 40 and dextran 70; longer duration of action with dextran 70 Type of Shock: Limited use b/c of side effects including reducing PLT adhesion, diluting clotting factors Nursing Implications: Increases risk of bleeding. Important to monitor pt for allergic reactions and acute renal failure.

Inotrope y y y An agent that affects myocardial contractility Contractility describes the strength of contraction. Contractility is said to increase when preload is not changed yet the heart contracts more forcefully. Positive inotropes causes increased contractility: Epinephrine, Norepinephrine (Levophed), Isoproterenol (Isuprel), Dopamine (Intropin), Dobutamine (Dubutrex), digitalis-like drugs, Calcium, and Milrinone (Primacor) Negative inotropes causes decreased contractility, such as Barbiturates, alcohol, calcium channel blockers, B-adrenergic blockers, and conditions (acidosis) Many positive inotropes affect preload and afterload

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Chronotrope y y y A chronotrope is an agent that affects heart rate. Positive chronotropes cause an increase in heart rate (eg, epinephrine, isuprel). Negative chronotropes cause a decrease in the heart rate. Examples of negative chronotropes are betablockers and rate control calcium channel blockers (eg, diltiazem).

Preload y Preload is defined as the blood volume remaining in the ventricles at the end of diastole or ventricular end diastolic volume (VEDV). Preload influences the amount of end diastolic stretch on the myocardial muscle fibers. Venous blood return to the heart is influenced not only by actual blood volume in the venous system but also by venous tone or compliance, which is the relaxation and contraction in the smooth muscle walls of the veins. Preload enhancers are vasopressors and volume expanders (eg, normal saline). Preload reducers are vasodilators and diuretics.

Afterload y y Afterload is the pressure that the ventricles must pump against to overcome the resistance to systolic ejection. Afterload is determined primarily by the arterial tone or pressure (ie, blood pressure). A simplistic way to think of afterload is blood pressure. Patients with systemic hypertension have increased left ventricular afterload, and in pulmonary hypertension, the right ventricular afterload is increased. The most influential factors in afterload are systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). The SVR and PVR are derived parameters that are influenced by many factors. Medications that increase both right ventricular (RV) and left ventricular (LV) afterload are vasopressors (eg, norepinephrine). Medications that decrease RV and LV afterload are arterial vasodilators (eg, hydralazine).

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Dobutamine (Dobutrex) y y y y y y Classification: Inotropics, adrenergic, beta1 agonist Action: Stimulates beta1 adrenergic receptors (myocardial) to increase contractility but with relatively minor effect on heart rate. Indication: Increased cardiac output in short-term treatment of cardiac decompensation caused by depressed contractility, such as during refractory heart failure Type of Shock: Used in cardiogenic shock with severe systolic dysfunction. Used in septic shock with normal CO that is not meeting increase metabolic demands Hemodynamic Effects: Decrease SVR/ PAWP, Increase CO/ Stroke volume/ CVP, Increase/decrease HR Nursing Implications: -Before starting therapy, give a plasma volume expander to correct hypovolemia and a cardiac glycoside. Do not administer in same line with NaHCO3. Give through a central venous catheter or large peripheral vein using an infusion pump. Watch for irritation and infiltration (notify provider of pain or discomfort at insertion site); extravasation can cause tissue damage and necrosis. Change IV sites regularly to avoid phlebitis.-Monitor HR, BP (hypotentsion may worsen, requiring addition of a vesopressor), monitor for tachydysrhythmias. -B/C drug increases AV node conduction, patients with atrial fibrillation may develop a rapid ventricular rate. Continuously monitor ECG, BP, Pulmonary artery

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wedge pressure, cardiac output, and urine output. Monitor electrolyte levels, drug may lower potassium level. Monitor BUN, Creatinine, and PT Drug may lower platelet count. Adverse Reactions: -anaphylaxis, asthma attack, shortness of breath, hypertension, increased heart rate, headache. Overdose S &S: anorexia, nausea, tremor, vomiting, palpitations, headache, shortness of breath, chest pain, hypertension, tachydysrhythmias, myocardial ischemia, ventricular fibrillation, hypotension. Cautions: Use cautiously in patients with hypertension because drug may increase pressor response. Drugs: Dobutrex Remember: FAIL -Failure (heart) -Angina, arrhythmia- undesirable effect- Increases contractility, BP- Look for an increase in cardiac and urine output

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Dopamine (Intropin) y y Classification: Inotropics Action: Positive Inotropic effects (increased myocardial contractility, increased automaticity, increased atrioventricular conduction. Low doses: increased blood flow to renal, mesenteric, and cerebral circulation. High doses: can cause progressive vasoconstriction.- Precursor to epinephrine and norepinephrine. Hemodynamic effects from release of norepinephrine Indications: Treats cardiogenic shock and correct hemodynamic imbalances; to improve perfusion to vital organs; to increase cardiac output; to correct hypotension Type of shock: Cardiogenic shock (Increases MAP, Increases HR, Increases MVO2) Hemodynamic Effects: Increased HR, CO, BP 3 Dosing levels: 2-5ug/kg/min (low dose) minimal alpha effects, causes more splanchnic dilation, improving renal blood flow (a dopaminergic response). 5-10ug/kg/min (medium dose) beta effects start to predominate for a positive inotropic effect. 10-20ug/kg/min (high dose) may cause vasoconstriction, alpha effects more prevalent, increases BP. Nursing Implications:-Correct hypovolemia, -administer via central line (infiltration leads to tissue sloughing), - do not administer in same line with NaHCO3, -Monitor for tachydysrhythmias, -monitor for peripheral vasoconstriction at moderate to high doses (ex. Paresthesias, coldness in extremities). After drug is stopped watch for closely for sudden drop in BP (taper dosage slowly to evaluate stability of BP), Acidosis decreases effectiveness of drug, -check urine output often (if urine flow decreases w/o hypotension, notify prescriber b/c dosage may need to be reduced), -Observe pt for adverse reactions (drug may need to be stop), -If diastolic pressure rises disproportionately w/ a significant decrease in pulse pressure, decrease infusion rate, and watch carefully for further evidence of predominant vasoconstrictor activity, unless such an effect is desired, -During infusion monitor ECG,BP, CO, central venous pressure, pulmonary artery wedge pressure, pulse rate, urine output, and color and temp of limbs. Adverse Reactions: anaphylactic reactions, asthmatic episodes, ventricular arrhythmias (high doses), Overdose S&S: Excessive BP elevation Interactions: Alpha and beta blockers (may antagonize dopamine effects. Monitor pt closely), Ergot Alkaloids (may cause extremely high BP, avoid using together), Inhaled anesthetics (may increase risk of arrhythmias or hypertension, MAO inhibitors (may cause fever, headache, HTN crisis), Oxytocics, Phenytoin (may cause severe HTN and cardiac arrest, Tricyclic antidepressants (may decrease pressor response) Effects on lab test results: may increase catecholamine, glucose, and urine urea levels

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Black Box Warning: Watch infusion site carefully for extravasation; if it occurs, stop infusion immediately and call prescriber. To prevent sloughing and necrosis in ischemic areas, you may need to infiltrate area with 5 to 10 mg phentolamine in 10 to 15 ml normal saline solution.

Epinephrine (Adrenalin) y y y y y Classification: Vasopressors, Bronchodilators, Antiasthmatics, Adrenergic Action: Low doses: B-adrenergic agonist (increases inotropic and chronotropic cardiac activity, bronchial dilation, peripheral vasodilation). High doses: a-adrenergic agonist (peripheral vasoconstriction) Indications: Anaphylaxis, Bronchospasm, Topical vasoconstrictor, Cardiac Arrest Types of Shock: Low doses: Cardiogenic shock combined w/ afterload reduction, Anaphylactic shock. High doses: Cardiac arrest, pulseness ventricular tachycardia, ventricular fibrillation, asystole Hemodynamic Effects: Low dose: increases HR, Contractility, CO, Decreases SVR. High dose: Increases stroke volume and SVR, Increases systolic/decreases diastolic BP, widened pulse pressure, Increases CVP/PAWP Nursing Implications: -Correct hypovolemia if appropriate, -monitor for HR >110 beats/min, -monitor for dyspnea, pulmonary edema, - monitor chest pain, dysrhythmias secondary to increase MVO2, - monitor for renal failure secondary to ischemia, -monitor BP,HR, and ECG when therapy starts and frequently thereafter. If BP increases sharply, give rapid acting vasodilators such as nitrates and alpha blockers to counteract the marked pressor effect of large doses. Adverse Reactions: Cerebral hemorrhage, stroke, shock, ventricular fibrillation Overdose S&S: Precordial distress, vomiting, headache, dyspnea, HTN, peripheral vascular constriction, pulmonary edema, cerebral hemorrhage Interactions: -Alpha blockers (may cause hypotension), Levodopa (may enhance risk of arrhythmias, monitor ECG), MAO inhibitors (may increase risk of HTN, monitor BP). Effects on Lab Test Results: may increase BUN, GLUCOSE and lactic acid levels.

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Norepinephrine (Levophed) y y y y y y Classification: Vasopressors Action: B1-Adrenergic agonist (Cardiac stimulation), a-Adrenergic agonist (peripheral vasoconstriction), Renal/splanchnic vasoconstriction Indications: Produces vasoconstriction and myocardial stimulation, which may be required after adequate fluid replacement in the treatment of severe hypotension and shock. (Restores BP in acute hypotension) Types of Shock: Cardiogenic shock after myocardial infarction, Septic shock: works by increasing vascular tone Hemodynamic Effects: increases BP, MAP, CVP/PAWP,SVR, increases/decreases CO Nursing Implications: Used for hypotension unresponsive to adequate fluid resuscitation, Administer via a central line (infiltration leads to tissue sloughing), Monitor for dysrhythmias secondary to increased MVO requirements Adverse Reactions: Bradycardia, severe hypertension, arrhythmias, asthma attacks, anaphylaxis Overdose S&S: Headache severe hypertension, reflex bradycardia, increased peripheral resistance, decreased cardiac output Interactions: Alpha blockers, atropine, MAO

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Vasopressin (Pitressin) y y y y y y y y Classification: Hormone Action: Antidiuretic hormone, nonadrenergic, vasoconstrictor. Alters the permeability of the renal collecting ducts allowing reabsorption of water. Indications: Vasodilatory shock Types of Shock: Shock states (most commonly septic shock) refractory to other vasopressors Hemodynamic Effects: Increases MAP, Urine Output, Decreases need for other vasopressors Nursing Implications: Usually administer low doses, monitor hemodynamic pressures, urine output Adverse Reactions: arrhythmias, cardiac arrest, myocardial ischemia, decreased cardiac output, bronchoconstriction, anaphylaxis Overdose S&S: Water intoxication

Phenylephrine (Neo-Synephrine) y y y y y y y y Classification: Vasopressors Action: Constricts blood vessels by stimulating alpha-adrenergic receptors Indications: Management of hypotension associated with shock that may persist after adequate fluid replacement Types of Shock: Neurogenic shock Hemodynamic Effects: increases HR,BP,SVR, increases/decreases CO Nursing Implications: Monitor for reflex bradycardia, headache, restlessness. Monitor for renal failure secondary to decreased renal blood flow. Administer via central line (infiltration leads to tissue sloughing) Adverse Reactions: bradycardia, arrhythmias, asthmatic episodes, anaphylaxis Overdose S&S: Ventricular extrasystoles, short paroxysms of ventricular tachycardia, sensation of fullness in the head, tingling of the extremities

Sodium Nitroprusside (Nipride) y y y Classification: Antihypertensives, Vasodilators Action: Arterial and venous vasodilation, decreased preload/afterload Indications: To lower BP quickly in hypertensive emergencies, to produce controlled hypotension during anesthesia, to reduce preload and afterload in cardiac pump failure or cardiogenic shock (may be used with or without dopamine) Types of Shock: Cardiogenic shock with increased SVR Hemodynamic Effects: Decreases CVP/PAWP, BP. Increases/Decreases CO Nursing Implications: Continuously monitor BP, Protect solution from light (wrap infusion bottle with opaque covering), Administer with D5W only, Monitor for cyanide toxicity (tinnitus, hyperreflexia, confusion, seizures) Adverse Reactions: increased ICP, bradycardia, methemoglobinemia, thiocyanate toxicity, cyanide toxicity Overdose S&S: Hypotension, acidosis, cyanide or thiocyanate toxicity

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Nitroglycerin (Tridil) y y y y y y y Xigris y y y y y y y y Classification: Anti-infective, Recombinant human activated protein C Action: Anticoagulant effect by inhibiting factor Va/Villa, Profibrinolytic and anti-inflammatory properties Indications: To reduce the risk of death in patients with severe sepsis from acute organ dysfunction Types of Shock: Septic Shock Hemodynamic Effects: none Nursing Implications: Monitor for signs of bleeding. Monitor hemoglobin, platelets, PT, PTT Adverse Reactions: Hemorrhage Effects on Lab Test Results: May prolong PT and PTT Classification: Antianginals, Nitrates Action: Venodilation, Dilates coronary arteries (decreased preload and MVO) Types of Shock: Cardiogenic Shock Hemodynamic Effects: Decreased SVR and BP Nursing Implications: Continuously monitor BP, reflex tachycardia. Use glass bottles for storage Adverse Reactions: dizziness, headache, hypotension, tachycardia Overdose S&S: Vasodilation, decreased CO, venous pooling, hypotension, methemoglobinemia

H-2 Receptor Blockers y y y y y Classification: Antiulcer Agents Action: Inhibit histamine action on H2-receptors, which are found on the gastric parietal cells and prevent gastrin secretion, thus decreasing acid production Indications: upper GI bleeding, Heartburn, acid indigestion, and GERD. Gastric and duodenal ulcer therapy Adverse Effects: Diarrhea, dysrhythmias Nursing Implications: Give oral drug before eating or with food; give at bedtime for adequate coverage. Teach to avoid alcohol. Smoking may decrease effectiveness

Corticosteroids y Action: Suppresses the inflammatory and immune systems by inhibiting synthesis of chemical mediators (prostaglandins, leukotrienes, and histamine). Decreases inflammation, which then reduces swelling, warmth, redness, and pain. Indications: To decrease inflammation, to suppress graft rejection. Asthma, COPD, respiratory distress syndrome in infants, Inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, Addison s disease, hormone replacement, cancer therapy. Adverse Effects: Peptic ulcers, GI bleeding, edema, Osteoporosis, hyperglycemia, delayed wound healing, muscle wasting, fluid and electrolyte disturbances, Cushing s syndrome Nursing Implications: Check fluid balance and potassium and glucose levels. Warn client to take as prescribed and not to discontinue therapy suddenly. Daily doses need to be increased during stress. Asses for Cushing s syndrome. Check stools for occult blood

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Diphenhydramine (Benadryl) y y y y y y Classification: Antihistamines Action: Competitively block the H1-receptor sites on effector cells and impede histamine- mediated responses. Second generation causes less drowsiness. Indications: Prevent and treat allergies and allergic reactions. Allergic transfusion reactions. Decrease itching and pruritis. May be used with epinephrine in the management of anaphylaxis. Type of Shock: Anaphylactic Shock Adverse Effects: Dry mouth, Drowisness Nursing Implications: Take with food or milk to reduce GI distress. Instruct pt to take drug 30 minutes before travel to prevent motion sickness. Advise use of sunblock (Photosensitivity). Warn pt not to take this drug with any other products that contain diphenhydramine b/c of increased adverse effects. Effects on Lab Tests Results: May decrease hemoglobin level and hematocrit. May decrease granulocyte and platelet counts. May prevent, reduce, or mask positive result in diagnostic skin test. Overdose S&S: Dry mouth, fixed or dilated pupils, flushing, GI symptoms

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Classification: Low-Molecular Weight Heparin Action: Accelerates formation of antithrombin III-thrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin. Indications: Prevention of thrombus formation Adverse Effects: hemorrhage, thrombocytopenia, angioedema, anaphylaxis Nursing Implications: Instruct pt not to take aspirin, naproxen, or ibuprofen w/o consulting health care provider while on Lovenox therapy. Instruct pt to watch for signs of bleeding or abnormal bruising and to notify precriber immediately if any occur. Monitor PLT counts regularly (pts with a normal coagulation won t need close monitoring of PT or PTT). Avoid IM injections of other drugs to prevent or minimize hematoma. Never give Lovenox IM. Overdose S&S: Hemorrhagic complications Effects on Lab Test Results: May increase ALT and AST levels. May decrease hemoglobin level. May decrease platelet count

Thorazine y y y y y y y Classification: Antiemetics Action: A piperidine phenothiazine that may block postsynaptic dopamine receptors in the brain Indications: Drug of choice to suppress shivering in Heatstroke Adverse Reactions: Neuroleptic malignant syndrome, leukopenia, arganulocytosis, aplastic anemia, thrombocytopenia Nursing Implications: Have pt report signs of urine retention or constipation. Tell pt to wear sunblock. No alcohol while taking drug. Overdose S&S: CNS depression, somnolence, coma, hypotension, extrapyramidal symptoms, agitation, restlessness, seizures, fever, dry mouth, ileus, ECG changes, cardiac arrhythmias. Effects of Lab Test Results: May decrease hemoglobin level and hematocrit. May increase liver function test values and eosinophil count. May decrease granulocyte, PLT, and WBC counts.

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Calcium Gluconate y y y y y Classification: Mineral and electrolyte replacements/ supplements Action: Replaces calcium and maintains calcium levels Indications: Hypocalcemia, Hyperkalemia, Dietary Supplement, Hyperphosphatemia, Management of magnesium intoxication Adverse Reactions: Cardiac arrest, arrhythmias, constipation, hemorrhage Nursing Implications: Tell pt to report anorexia, nausea, vomititng, constipation, abdominal pain, dry mouth, thirst, or polyuria. Warn pt that in the meal before he takes calcium, he shouldn t have rhubarb, spinach, bran and whole grain cereals or dairy products. Monitor calcium levels. Overdose S&S: stupor, confusion, coma, hypercalcemia, delirium

y CroFab y y

Classification: Antivenin Action: CroFab is a venom-specific antibody fragment (Fab) that works by binding and neutralising venom toxins, facilitating their redistribution away from target tissues and their elimination from the body Indications: Pit viper antivenin is a medicine used to treat the bites of certain poisonous snakes called pit vipers (crotalids), which are native to North America. This particular pit viper antivenin is made from the blood of sheep and is used to treat the bites of the following types of pit viper: the Western Diamondback, Eastern Diamondback, and Mojave rattlesnakes, and the Copperhead snake or Water Moccasin. Adverse Reactions: Coagulopathy is a complication noted in many victims of viper envenomation that arises due to the ability of the snake venom to interfere with the blood coagulation cascade (characterized by decreased fibrinogen, decreased platelets, and elevated prothrombin time, occurred in approximately half of patients studied). Monitor for signs and symptoms of an acute allergic reaction (e.g., urticaria, pruritus, erythema, angioedema, bronchospasm with wheezing or cough, stridor, laryngeal edema, hypotension, tachycardia) and treated with appropriate emergency medical care (e.g., epinephrine, intravenous antihistamines and/or albuterol). Contraindications/Precautions: Product contains mercury in the form of thimerosal (0.11 mg of mercury per vial). Use is contraindicated in patients that have a known hypersensitivity to papaya or papain, prior hypersensitivity to CroFab or any other sheep-derived products. Pregnancy category C.

Activated Charcoal y y y y y Classification: Antidotes, Adsorbents Action: Binds drugs and chemicals in the GI tract. Decreased intestinal absorption of drugs or chemicals in the overdose situation. Indications: Acute management of many oral poisonings following emesis/lavage Adverse Reactions: Black stools, constipation, diarrhea, vomiting Nursing Implications: Warn pt that stools will be black until all the charcoal has passed through the body. Instruct pt to drink 6 to 8 glasses of liquid per day b/c drug can cause constipation. Don t aspirate or allow pt to aspirate charcoal powder, this may result in death. Give after emesis is complete b/c activated charcoal absorbs and inactivates ipecac syrup. For best effect, give within 30 mins after poison ingestion. Don t give with ice cream, milk or sherbet, these decrease adsorptive capacity of activated charcoal. If pt vomits shortly after administration, repeat dose. Give drug at least 2 hrs before or 1 hr after other drugs.

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N-acetylcysteine (Mucomyst) y y y y Classification: Antidotes Action: Decreases the buildup of a hepatotoxic metabolite in acetaminophen over dosage Indications: Antidote for the management of potentially hepatotoxic over dosage of acetaminophen (administer within 24 hours of ingestion) Adverse Reactions: Bronchospasm, nausea, vomiting, rash, allergic reactions (primarily with IV), including anaphylaxis, angioedema

Fluid Bolus

Parkland formula Fluid Requirements for the first 24hrs= TBSA burned(%) x Wt (kg) x 4mL (Lactated Ringer s solution). Give 1/2 of total requirements in first 8 hours, 1/4 of total in second 8hrs, and 1/4 of total in third 8hrs (ex. For a 70kg. pt. with 50% TBSA burn: 4ml x 70kg x 50% TBSA burn=14,000ml = 14L in 24hr  of total in first 8hr = 7000ml (875 ml/hr)  of total in second 8hr = 3500ml (436 ml/hr)  of total in third 8hr = 3500ml (436 ml/hr) (Table 25-12 pg. 497)  Parkland (Baxter): FIRST 24hrs- (Crystalloids) LR solution: 4ml/kg/% TBSA burn; given first 8hrs; given each next 8hrs. SECOND 24hrs.- (Colloids) 20%-60% of calculated plasma volume (Glucose in water) Amount to replace estimated evaporative losses (Table 25-11 pg. 497)  Of the formulas used for fluid replacement, the Brooke and Parkland (Baxter) formulas are the most commonly used. It is important to remember that all formulas are estimates and must be titrated based on the pts physical response. For example, pts with inhalation injury may have greater than normal fluid requirements. This formula is widely used in North America because it is easy to calculate and monitor using the pts weight, and it provides a reliable method of fluid replacement for most pts. y y Silver sulfadiazine (Silvadene, Flumazine) y y y y Classification: Anti-Infectives (Topical), Sulfonamides Action: Bactericidal action against organisms found in Burns Indications: Prevention and Treatment of wound sepsis in pts with 2nd and 3rd degree burns Adverse Effects: leukopenia, burning, itching, pain, rash, skin discoloration, skin necrosis

Sulfamylon (Mafenide, Acetate) y Classification: