Kee: Pharmacology, 8th Edition

Chapter 59: Adult and Pediatric Emergency Drugs

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Oxygen is classified as a drug, because it can have both beneficial and adverse effects on
the body, based on the amount and manner in which it is administered. Without oxygen,
brain death begins within 6 minutes. Inadequate oxygenation produces hypoxemia and
significant physiologic sequela to all body systems; therefore, oxygen is a first-line drug
for all emergency situations.

Adequate oxygenation may be all that is necessary to effectively treat physiologic

disturbances such as chest pain, bradycardia, and cardiac dysrhythmias. Pulse oximetry is
an essential monitoring tool that should be used in emergency situations to assess the
adequacy of oxygenation and guide further interventions.

EMERGENCY DRUGS FOR CARDIAC DISORDERS

In a resuscitation situation, the foundation of patient therapy is based upon proper

oxygenation and ventilation, performance of optimal CPR, and application of electrical
therapy according to established treatment algorithms and standards. Pharmacologic
agents are used as adjuncts in synchrony with these efforts when indicated to enhance the
likelihood of a successful outcome.

Aspirin is a frontline emergency drug used to decrease platelet aggregation in the

management of acute coronary syndromes and myocardial infarction. It is best
administered at the onset of chest pain.

The patient should be asked to chew the aspirin to speed absorption of the drug instead of
swallowing the tablet whole. For patients experiencing nausea and vomiting, an aspirin
rectal suppository can be given as an alternative.

Nitroglycerin dilates coronary arteries and improves blood flow to an ischemic

myocardium. It is therefore the treatment of choice for angina pectoris and myocardial
infarction. A focused medication history is essential prior to administration, even in
emergency situations, because nitroglycerin in combination with drugs for erectile
dysfunction causes profound hypotension that may be refractory to treatment when taken
within a 24- to 48-hour period.

Sublingual nitroglycerin is indicated for patients experiencing an acute anginal attack

who have a systolic blood pressure >90 mm Hg. The patient is taught to sit or lie down
and moisten 1 sublingual nitroglycerin tablet with saliva and then place it under the
tongue to allow it to dissolve slowly.

If the chest pain is not relieved, sublingual nitroglycerin may be repeated at 3- to 5minute intervals as long as the patients systolic blood pressure remains >90 mm Hg until
a total of 3 tablets has been taken.
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Patients prescribed the translingual aerosol preparation should be reminded that the spray
should not be inhaled. Instead, it should be sprayed onto or under the tongue. The patient
should be instructed not to swallow for approximately 10 seconds to allow absorption of
the drug. As with sublingual nitroglycerin, up to 3 doses may be taken within 15 minutes.

Hypotension is a common adverse effect of nitroglycerin, especially the first time a

patient takes nitroglycerin. Tachycardia or, uncommonly, bradycardia also may occur.

Morphine sulfate, a narcotic analgesic, is used to treat the chest pain associated with
AMI. It also is indicated for acute cardiogenic pulmonary edema. Morphine relieves pain,
dilates venous vessels, and reduces the workload on the heart. Because respiratory
depression and hypotension are common adverse effects, the drug must be administered
slowly and carefully titrated to achieve the desired therapeutic effects.

Atropine sulfate is the primary agent indicated for the treatment of hemodynamically
significant bradycardia and some types of heart block. Atropine acts to increase heart rate
by inhibiting the action of the vagus nerve.

Atropine sulfate is also used as an emergency drug to reverse the toxic effects of
organophosphate pesticide and nerve agent exposure, which include bradycardia and
excessive secretions.

Continuous cardiac and blood pressure monitoring is essential for the patient who
receives atropine sulfate. Significant adverse effects include cardiac dysrhythmias,
tachycardia, myocardial ischemia, restlessness, anxiety, mydriasis, thirst, and urinary
retention.

The definition of bradycardia is variable and age-specific for the pediatric population.
Knowledge of normal ranges is essential. Because cardiac output is dependent on heart
rate in infants younger than 6 months, bradycardia (heart rate <100 beats/min for infants)
must be treated.

Adenosine is the first-line drug of choice to treat paroxysmal supraventricular tachycardia

(PSVT), a sudden, uncontrolled, rapid rhythm that originates above the ventricles. The
goal is to convert PSVT to sinus rhythm.

A natural substance found in all body cells, adenosine slows impulse conduction through
the hearts AV node, interrupts dysrhythmia-producing reentry pathways, and restores a
normal rhythm in patients with PSVT.

Nursing considerations include continuous cardiac monitoring and frequent assessment of

vital signs. Though usually transient, ventricular ectopy, bradycardia, flushing, chest pain,
and dyspnea may occur. In addition, a short period of asystole may follow injection of
adenosine (up to 15 seconds). Spontaneous cardiac activity typically resumes.

Adenosine is contraindicated in patients with poison- or drug-related tachycardia, secondand third-degree heart block, and in patients with sick sinus syndrome, except those with
functioning pacemakers.

Diltiazem is a calcium channel blocker and is administered to treat PSVT and to slow the
ventricular response rate in atrial fibrillation or flutter. It is considered a second-line agent

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after adenosine. Diltiazem has less of a negative inotropic effect than other similar
calcium channel blockers, but it has strong negative chronotropic actions.

For ongoing control of the ventricular rate in patients with atrial fibrillation or flutter, a
continuous infusion of diltiazem is indicated, titrated according to the desired heart rate.

The nurse must carefully monitor blood pressure and heart rate and rhythm after
administering diltiazem. Arrhythmias, bradycardia, heart block, and hypotension may
develop.

Diltiazem can elevate serum digoxin levels, predisposing the patient to digitalis toxicity.
Simultaneous use of calcium channel blockers and beta blockers is contraindicated,
because their negative inotropic and negative chronotropic effects are synergistic, causing
myocardial depression and bradycardia.

The IV form of amiodarone is considered a first-line agent in the advanced cardiac life
support algorithms for the treatment of life-threatening ventricular dysrhythmias and
cardiac arrest. It has alpha- and beta-adrenergic blocking effects and acts on sodium,
potassium, and calcium channels. Significant adverse effects include hypotension and
bradycardia. The nurse should slow the infusion rate to prevent or treat these effects and
be prepared to administer IV fluids, vasopressors, and agents to increase heart rate. A
temporary pacemaker may be needed.

Lidocaine may be used to treat significant ventricular dysrhythmias such as frequent

premature ventricular contractions (PVCs), ventricular tachycardia, and ventricular
fibrillation as an alternative agent to amiodarone. Lidocaine exerts a local anesthetic
effect on the heart, thus decreasing myocardial irritability. Important nursing
considerations for the patient receiving lidocaine include continuous cardiac monitoring
and assessment for signs and symptoms of lidocaine toxicity. Because lidocaine is
metabolized by the liver, patients with hepatic impairment, heart failure, shock, and
advanced age are at higher risk for toxicity.

Procainamide is an antidysrhythmic agent prescribed for ventricular tachycardia, PVCs,

and rapid supraventricular dysrhythmias unresponsive to adenosine.

The nurse must monitor vital signs and the ECG with particular attention to heart rate and
rhythm, as well as blood pressure and the width of the QRS complex. Procainamide
administration can cause severe hypotension. Heart block, rhythm disturbances, and
cardiac arrest can occur.

Magnesium is an essential element in multiple enzymatic reactions in the body, including

function of the sodium-potassium adenosine triphosphatase (ATPase) pump. Its
physiologic effects can be likened to a calcium channel blocker with neuromuscular
blocking properties. Hypomagnesemia is associated with the development of atrial and
ventricular dysrhythmias.

The primary indications for emergency administration of magnesium sulfate are

refractory ventricular tachycardia, refractory ventricular fibrillation, cardiac arrest
associated with hypomagnesemia, and life-threatening ventricular dysrhythmias from
digitalis toxicity. It is also the drug of choice for the treatment of torsades de pointes.

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Hypotension is the most common adverse effect when magnesium is given by rapid IV
push. Other effects include mild bradycardia, flush, and sweating.

Epinephrine is a catecholamine with alpha- and beta-adrenergic effects. Emergency

cardiac indications for administration of epinephrine include profound bradycardia and
hypotension, asystole, pulseless ventricular tachycardia, and ventricular fibrillation.

Epinephrine is thought to improve perfusion of the heart and brain in cardiac arrest states
by constricting peripheral blood vessels. In addition, epinephrine increases the chances
for successful electrical countershock in ventricular fibrillation.

Nursing implications for patients receiving epinephrine include constant cardiac and
hemodynamic monitoring. Epinephrine can cause myocardial ischemia and cardiac
dysrhythmias.

Epinephrine should never be administered in the same site as an alkaline solution such as
sodium bicarbonate, because alkaline solutions inactivate epinephrine.

Vasopressin is indicated for the treatment of ventricular fibrillation that is refractory to

defibrillation. It is found in the human body as endogenous antidiuretic hormone. The
effects of vasopressin as a cardiac emergency drug include nonadrenergic peripheral
vasoconstriction. When used as an emergency agent, it appears to increase coronary
artery perfusion during CPR and to exhibit vasopressor effects.

Vasopressin is considered an adjunct to epinephrine and can replace either the first or
second epinephrine dose in the cardiac arrest algorithm.

Because vasopressin can induce myocardial ischemia and angina, it is contraindicated in

responsive patients who have coronary artery disease.

Sodium bicarbonate is prescribed to treat the metabolic acidosis that may accompany
cardiac arrest and the hyperkalemia and acidotic states related to specific drug overdose
situations.

The current standard in resuscitation is to give sodium bicarbonate only after adequate
ventilation, chest compressions, IV fluids, and drug therapy fail to correct the acidotic
state.

Important nursing considerations relevant to sodium bicarbonate include careful

monitoring of arterial blood gas analysis results. Sodium bicarbonate administration can
lead to metabolic alkalosis, which may be very difficult to reverse and have deleterious
physiologic effects.

EMERGENCY DRUGS FOR INTRACRANIAL HYPERTENSION

Mannitol is an osmotic diuretic used in emergency, trauma, critical care, and

neurosurgical settings to treat cerebral edema and increased intracranial pressure.
Mannitol is highly irritating to veins. The nurse must use a filter needle when

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administering mannitol, because crystals may form in the solution and syringe and be
inadvertently injected.

The nurse should carefully assess the patients neurologic status; monitor laboratory
studies, including electrolytes and serum osmolality, and keep accurate intake and output
records to assess fluid volume status, because diuresis may be substantial.

EMERGENCY DRUGS FOR POISONING

Naloxone is classified as an opiate antagonist. It reverses the effects of all opiate drugs by
competitively binding to opiate receptor sites in the body. Naloxone is indicated for
individuals who have taken an overdose of opiate drugs, those experiencing respiratory or
cardiovascular depression from therapeutic doses of opiates given in a health care setting,
and those brought to the emergency department in a coma of unknown etiology.

Because most opiate drugs have a longer duration of action than naloxone, the nurse must
monitor the patient closely for signs and symptoms of recurrent opiate effects such as
respiratory depression and hypotension. In this situation, naloxone administration may
need to be repeated several times or a continuous IV infusion ordered.

Nurses also must be on guard for combative or violent behavior following naloxone
administration, especially in patients who have overdosed on an illicit drug; having
security personnel available to stand by is prudent.

Flumazenil is the reversal agent for the respiratory depressant and sedative effects of
benzodiazepine medications. It is administered to counteract the effects of
benzodiazepines given as sedative or anesthetic agents, as well as to treat accidental or
intentional benzodiazepine overdose.

Nursing considerations include careful assessment of respiratory rate and effort, blood
pressure, and mental status.

If the benzodiazepine is reversed too rapidly, patients may have emergence reactions in
which they become agitated and confused and experience perceptual distortions. Because
seizures are precipitated by benzodiazepine withdrawal, seizure precautions must be
implemented for patients at risk

Activated charcoal may be prescribed for poisoning as a means to prevent absorption of

toxins into the body if the ingested substance is known to be affected by charcoal in the
GI tract.

Activated charcoal dosing may need to be repeated for certain types of poisoning,
particularly from agents such as salicylates, slow-release drug preparations, and Amanita
phalloides (death cap mushrooms), to name a few. Since vomiting is a common adverse
reaction, patients with an impaired gag reflex and/or an impaired mental status are at high
risk for aspiration after ingesting activated charcoal. To promote safety, these patients
may need intubation for airway protection followed by installation of the activated
charcoal via a gastric tube.

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EMERGENCY DRUGS FOR SHOCK

In hypovolemic shock, drugs should never be used as the primary therapy to correct the
hypotension associated with this condition. Administration of fluids or blood products or
both is the only acceptable initial means to treat hypovolemic shock.

Dopamine is a sympathomimetic agent often used to treat hypotension in shock states.

Dopamine may also be used to increase heart rate (beta1 effect) in bradycardic rhythms
when atropine has not been effective.

Dopamine enhances cardiac output by increasing myocardial contractility and increasing

heart rate (beta1 effect) and elevates blood pressure through vasoconstriction (alphaadrenergic effect). Alpha effects predominate at higher dosesvasoconstriction of renal,
mesenteric, and peripheral blood vessels occurs.

Patients must be weaned gradually from dopamine; abrupt discontinuation of the infusion
can cause severe hypotension.

The nurse must carefully document vital signs, the cardiac rhythm, and intake and output
as prescribed. Significant adverse effects include tachycardia, dysrhythmias, myocardial
ischemia, nausea, and vomiting.

The IV site must be assessed hourly for signs of drug infiltration; extravasation of
dopamine can produce tissue necrosis that may necessitate surgical debridement and skin
grafting.

Dobutamine is a sympathomimetic drug with beta-adrenergic activities. The beta1 effects

include enhancing the force of myocardial contraction and increasing heart rate. The beta2
effects produce mild vasodilation. Dobutamine is indicated in shock states when
improvement in cardiac output and overall cardiac performance is desired.

Dobutamine administration should be tapered gradually as the patients condition

warrants; abrupt discontinuation can precipitate clinical deterioration.

Continuous cardiac and blood pressure monitoring are required for patients receiving
dobutamine infusions. Adverse effects are dose-related and include myocardial ischemia,
tachycardia, dysrhythmias, headache, nausea, and tremors.

Norepinephrine is a catecholamine with extremely potent vasoconstrictor actions (alphaadrenergic effect). It is used in shock states, often when drugs such as dopamine and
dobutamine have failed to produce adequate blood pressure or as an alternative to
dopamine.

Continuous cardiac monitoring and precise blood pressure monitoring are required. The
drug must be tapered slowly; abrupt discontinuation can result in severe hypotension.

Adverse effects of norepinephrine include myocardial ischemia, dysrhythmias, and

impaired organ perfusion. Extravasation of norepinephrine causes tissue necrosis, so
attention to the IV site is essential.
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Epinephrine is the drug of choice in the treatment of anaphylactic shock. Anaphylactic

shock can be fatal if prompt treatment is not initiated. Severe bronchoconstriction and
hypotension resulting from cardiovascular collapse are its hallmarks.

Administration of epinephrine causes bronchodilation, enhanced cardiac performance,

and vasoconstriction to increase blood pressure. The patient who receives epinephrine
must be closely monitored for tachycardia, cardiac dysrhythmias, hypertension, and
angina.

The nurse should be alert to the possibility that the anaphylactic response may recur and
necessitate repeated treatment. For this reason, steroids are commonly ordered and are
slowly tapered over days to weeks to prevent recurrence.

Patient education should include strict avoidance of the agents responsible for the
anaphylactic reaction and follow-up care with a physician. For some patients, such as
those with severe allergic responses to bee stings, the physician may prescribe an
epinephrine kit or pen to be carried with the patient for self-medication in the event of
contact with the antigen.

Albuterol is a beta-adrenergic bronchodilator used to reverse bronchoconstriction in

anaphylactic shock, asthma, and COPD. In emergency situations, it is typically
administered via nebulizer.

The nurse should assess breath sounds before and after administration of albuterol;
effectiveness is evidenced by relief of bronchospasm. Adverse effects of albuterol include
tachycardia, tremor, nervousness, cardiac dysrhythmias, and hypertension.

Diphenhydramine, an antihistamine, is often administered with epinephrine to treat

anaphylactic shock. This agent is effective for treating the histamine-induced tissue
swelling and pruritus common to severe allergic reactions. Adverse effects include
drowsiness, sedation, confusion, vertigo, excitability, hypotension, tachycardia, GI
disturbances, and dry mouth.

Dextrose 50% is a concentrated, high-carbohydrate solution given to treat insulin-induced

hypoglycemia or insulin shock. The nurse must monitor the patients blood sugar
carefully; hyperglycemia is common, especially after rapid injection. Patient education
must be centered on teaching about diabetes, nutrition, physical activity, and insulin
administration.

Glucagon is a pancreas-produced hormone that elevates blood sugar by stimulating

glycogenolysis. Glucagon is indicated in the treatment of severe insulin-induced
hypoglycemia or insulin shock. Adverse effects from glucagon are uncommon but can
include nausea, vomiting, and a hypersensitivity reaction that may produce bronchospasm
and respiratory distress.

EMERGENCY DRUGS FOR HYPERTENSIVE CRISES AND PULMONARY EDEMA

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Labetalol is an alpha- and beta-adrenergic blocker that acts by inhibiting the effects of the
sympathetic nervous system. Its pharmacologic actions include lowering heart rate, blood
pressure, myocardial contractility, myocardial oxygen consumption, and reducing the
vasoconstriction that results from sympathetic nervous system stimulation. Labetalol is
indicated for the acute management of clinically significant hypertension in the presence
of ischemic and hemorrhagic stroke, as well as for hypertensive crisis.

Important nursing considerations during the administration of labetalol include the use of
an electronic infusion pump for accurate continuous infusion medication delivery, cardiac
monitoring, and frequent blood pressure measurement.

Serious adverse effects of labetalol administration include hypotension, bradycardia,

ventricular dysrhythmias, and bronchospasm. Dizziness is also a frequently reported
adverse reaction.

Nitroprusside sodium is an IV agent used to reduce arterial blood pressure in

hypertensive emergencies. The mechanism of action is immediate direct arterial and
venous vasodilation. Antihypertensive effects end when nitroprusside sodium is
discontinued; blood pressure increases as soon as drug administration is stopped.
Continuous and accurate blood pressure measurement is required.

Furosemide is classified as a loop diuretic that acts by inhibiting sodium and chloride
reabsorption from the ascending loop of Henle and the proximal and distal tubules. It
promotes the renal excretion of water, sodium, chloride, magnesium, hydrogen, and
calcium and depletes potassium.

Furosemide also has peripheral and renal vasodilating effects that can lower blood
pressure. The main indications for use of furosemide as an emergency drug are acute
pulmonary edema from left ventricular dysfunction and hypertensive crisis.

The most significant adverse effects of furosemide are severe hypovolemia, dehydration,
and electrolyte disturbances. Patients on digitalis preparations are at an increased risk of
digitalis toxicity from hypokalemia.

The nurse must also exercise caution when administering furosemide to patients with
sulfonamide sensitivity, because furosemide is a sulfonamide derivative and can produce
an allergic reaction.

Morphine sulfate is also indicated for acute pulmonary edema, because it produces
venous vasodilation that decreases cardiac preload. The net effect is a decrease in
pulmonary venous congestion.

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