❤️ Exam 6
The heart and the kidney: cardiovascular drugs, then diuretics, IV fluids and the antidotes.
Modules 10–11 · 50 questions · 28 drugs · 16 concepts
Module 10: Cardiovascular Disorders Part 2
What is the pharmacological treatment plan for acute coronary syndrome?🚨 DANGER
Immediate treatment of ACS is ASPIRIN (162 to 325 mg CHEWED), NITROGLYCERIN, oxygen if SpO2 is under 90%, and morphine for pain not relieved by nitrates - the classic MONA, given in the order Aspirin, Nitro, Oxygen if needed, Morphine last. Then add a P2Y12 inhibitor, an anticoagulant, a beta blocker, a high-intensity statin, and an ACE inhibitor, and arrange REPERFUSION.
- ASPIRIN FIRST AND FAST. Chewed, not swallowed whole, so it is absorbed in minutes. It is the single intervention with the largest mortality benefit. The textbook lists immediate treatment as supplemental oxygen, aspirin, and nitroglycerin.
- NITROGLYCERIN: sublingual every 5 minutes up to 3 doses, checking blood pressure before each. HOLD if systolic BP is under 90, if the heart rate is under 50 or over 100, in right ventricular/inferior MI, or if the patient has taken a PDE-5 INHIBITOR (sildenafil or vardenafil within 24 hours, tadalafil within 48) - that combination causes catastrophic hypotension.
- REPERFUSION IS THE PRIORITY IN STEMI: primary PCI within 90 minutes of first medical contact, or a fibrinolytic (alteplase, tenecteplase) within 30 minutes of arrival if PCI is not available within 120 minutes. The textbook lists thrombolytics such as tPA with heparin, angioplasty with stents, or bypass surgery.
- DUAL ANTIPLATELET THERAPY: aspirin plus a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel), continued for about 12 months after stenting. Plus an anticoagulant (heparin, enoxaparin, or bivalirudin) during the acute phase.
- Within 24 hours if no contraindication: a BETA BLOCKER (reduces oxygen demand and mortality; hold if in acute heart failure, bradycardic, or hypotensive), a HIGH-INTENSITY STATIN (atorvastatin 80 mg regardless of the lipid panel), and an ACE INHIBITOR (especially with reduced ejection fraction, anterior MI, or diabetes).
- Oxygen ONLY if SpO2 is under 90% or the patient is dyspneic. Routine oxygen in a normoxic patient may cause harm. Morphine is now last-line, for pain refractory to nitrates, because it blunts P2Y12 absorption. Nursing: continuous ECG monitoring, serial troponins and 12-lead ECGs, two large-bore IVs, bed rest, and continuous assessment for arrhythmia, heart failure, and bleeding after fibrinolytics.
| Drug | Why | Nursing catch |
|---|
| Aspirin 162-325 mg CHEWED | Antiplatelet; biggest mortality benefit | Chew it. Give it first. Ask about true aspirin allergy |
| Nitroglycerin SL q5min x3 | Vasodilation, reduces preload and chest pain | Check BP before EACH dose. NEVER with a PDE-5 inhibitor. Hold if SBP under 90 or right ventricular MI |
| Oxygen | Only if SpO2 under 90% or dyspneic | Routine oxygen in a normoxic patient can be harmful |
| Morphine | Pain and anxiety refractory to nitrates | Now last-line: monitor BP and respirations |
| P2Y12 inhibitor: ticagrelor, prasugrel, clopidogrel | Dual antiplatelet therapy | Bleeding risk; hold before CABG per protocol |
| Heparin or enoxaparin | Prevents clot extension | Monitor aPTT and platelets (HIT) |
| Beta blocker within 24 h | Lowers oxygen demand and mortality | Hold in acute decompensated HF, bradycardia, hypotension |
| High-intensity statin, ACE inhibitor | Plaque stabilization; remodeling prevention | Start regardless of the lipid panel |
| PCI within 90 min OR fibrinolytic within 30 min | REPERFUSION - the definitive treatment | Time is muscle. Screen fibrinolytics for bleeding contraindications |
MONA greets everyone, but ASPIRIN goes first and REPERFUSION is what actually saves the muscle.
Which medications cause a reduction in heart rate?⭐ HIGH YIELD
BETA BLOCKERS (metoprolol, atenolol, propranolol, carvedilol), NON-DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS (diltiazem, verapamil), DIGOXIN, AMIODARONE, ADENOSINE, and IVABRADINE. Also alpha-2 agonists (clonidine, dexmedetomidine), cholinesterase inhibitors (donepezil), and opioids.
- The first four are the ones tested: beta blockers, diltiazem and verapamil, digoxin, and amiodarone. All are negative chronotropes.
- COMBINING a beta blocker WITH diltiazem or verapamil is the classic dangerous pairing: additive bradycardia, heart block, and reduced contractility. Watch for it on a medication list.
- ADENOSINE causes a dramatic, transient asystole (a few seconds of flatline) as it converts SVT. Give it as a RAPID IV PUSH (6 mg, then 12 mg) as close to the heart as possible, immediately followed by a rapid saline flush, with the patient on a monitor and a code cart nearby. Warn the patient they will feel a moment of chest pressure and impending doom.
- DIGOXIN: take an APICAL pulse for a FULL MINUTE and HOLD for a rate under 60 in adults (under 70 in children, under 90 to 110 in infants). Toxicity signs are nausea, vomiting, anorexia, visual changes (yellow-green halos), confusion, and arrhythmias. HYPOKALEMIA potentiates toxicity. Antidote is digoxin immune Fab (DigiFab).
- Before giving ANY of these: check the apical heart rate and blood pressure and hold per parameters. The standard hold is HR under 60.
- IVABRADINE slows the SA node only, without affecting contractility or blood pressure. It is used in heart failure when the heart rate stays above 70 on a maximally tolerated beta blocker. Non-drug causes of bradycardia to consider in the differential: increased intracranial pressure, hypothyroidism, hypothermia, hyperkalemia, athletic conditioning, and vagal stimulation (suctioning, straining, vomiting).
Beta blockers, dilTIAZem and verapamil, digoxin, amiodarone, adenosine. Apical pulse, full minute, hold under 60.
What are the treatment options for atrial fibrillation?⭐ HIGH YIELD
Three goals: RATE control (beta blocker, diltiazem or verapamil, digoxin), RHYTHM control (amiodarone, flecainide, propafenone, sotalol, dofetilide, or electrical cardioversion/ablation), and ANTICOAGULATION to prevent stroke (a DOAC such as apixaban or rivaroxaban, or warfarin), based on the CHA2DS2-VASc score.
- ANTICOAGULATION IS THE PART THAT SAVES LIVES. Blood pools in the fibrillating atria, forms clot, and embolizes to the brain. Rate control makes the patient feel better; anticoagulation prevents the stroke.
- CHA2DS2-VASc scores stroke risk: Congestive heart failure, Hypertension, Age 75+ (2 points), Diabetes, prior Stroke/TIA (2 points), Vascular disease, Age 65-74, Sex category female. A score of 2 or more in men, or 3 or more in women, means anticoagulate.
- DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin for most patients: no routine monitoring, fewer food and drug interactions, less intracranial bleeding. WARFARIN is still required for mechanical heart valves and moderate-to-severe mitral stenosis.
- THE CARDIOVERSION RULE: if the atrial fibrillation has lasted MORE THAN 48 HOURS or the duration is unknown, the patient needs 3 weeks of therapeutic anticoagulation before cardioversion, or a transesophageal echocardiogram to rule out atrial thrombus. Then anticoagulate for at least 4 weeks after. Cardioverting a clot-filled atrium throws a stroke.
- Rate control targets a resting ventricular rate under about 100 to 110. Digoxin is a weak rate-control agent that works at rest but not with activity; it is used in heart failure or when the blood pressure will not tolerate a beta blocker or CCB. AMIODARONE is the most effective rhythm-control drug but the most toxic: pulmonary fibrosis, hepatotoxicity, thyroid dysfunction (both hyper and hypo), corneal deposits and vision loss, blue-gray skin discoloration, photosensitivity, and heart block. It requires baseline and periodic chest imaging, LFTs, TSH, and eye exams, and it raises digoxin and warfarin levels.
- UNSTABLE atrial fibrillation (hypotension, altered mental status, chest pain, acute heart failure) means IMMEDIATE SYNCHRONIZED CARDIOVERSION, not drugs. Long-term definitive options are catheter ablation and left atrial appendage occlusion.
| Goal | Options |
|---|
| Rate control | Beta blockers (metoprolol, esmolol); diltiazem or verapamil; digoxin (in HF or hypotension) |
| Rhythm control | Amiodarone, flecainide, propafenone, sotalol, dofetilide; synchronized cardioversion; catheter ablation |
| Anticoagulation (stroke prevention) | DOACs: apixaban, rivaroxaban, dabigatran, edoxaban. Warfarin (INR 2-3) for mechanical valves or mitral stenosis |
| UNSTABLE patient | IMMEDIATE synchronized cardioversion |
Rate, Rhythm, Ribbon-thin blood. The anticoagulant is what prevents the stroke.
Review the definitions of inotropy and chronotropy. Identify examples of positive chronotropes, negative chronotropes, positive inotropes, and negative inotropes.⭐ HIGH YIELD
INOTROPY is the FORCE of contraction; CHRONOTROPY is the RATE. POSITIVE INOTROPES: digoxin, dobutamine, dopamine, epinephrine, milrinone. NEGATIVE INOTROPES: beta blockers, diltiazem, verapamil. POSITIVE CHRONOTROPES: atropine, epinephrine, dopamine, isoproterenol. NEGATIVE CHRONOTROPES: beta blockers, diltiazem, verapamil, digoxin, amiodarone, adenosine.
- DIGOXIN IS THE ONE TO REMEMBER because it splits: POSITIVE inotrope (harder squeeze) but NEGATIVE chronotrope (slower rate). That combination is exactly what heart failure with atrial fibrillation needs.
- Beta blockers and non-dihydropyridine CCBs are negative on BOTH counts, which is why they are held for bradycardia and hypotension, avoided together, and avoided in acute decompensated heart failure.
- Cardiac output = heart rate x stroke volume. Positive inotropes raise the stroke volume side. Positive chronotropes raise the rate side. Push either one too far and myocardial oxygen demand outruns supply.
- DOBUTAMINE is the pure inotrope of cardiogenic shock: it increases contractility and cardiac output but can LOWER blood pressure through beta-2 vasodilation, so it is often paired with a vasopressor.
- ATROPINE is the first-line positive chronotrope for symptomatic bradycardia (1 mg IV, repeat every 3 to 5 minutes to a maximum of 3 mg), followed by transcutaneous pacing, dopamine, or epinephrine.
- MILRINONE is a phosphodiesterase-3 inhibitor: an 'inodilator' that increases contractility AND vasodilates, used in acute decompensated heart failure. It causes hypotension and arrhythmias. In heart failure, chronic beta blockade is beneficial despite being a negative inotrope, because it protects the heart from chronic sympathetic overdrive. Start LOW and titrate SLOWLY, and never start a beta blocker during acute decompensation.
| POSITIVE (increases) | NEGATIVE (decreases) |
|---|
| INOTROPY (force) | digoxin, dobutamine, dopamine, epinephrine, norepinephrine, milrinone, calcium | beta blockers, diltiazem, verapamil, flecainide, high-dose propofol |
| CHRONOTROPY (rate) | atropine, epinephrine, dopamine, isoproterenol, dobutamine, theophylline | beta blockers, diltiazem, verapamil, DIGOXIN, amiodarone, adenosine, ivabradine, clonidine |
Digoxin: squeezes HARDER, beats SLOWER. Everything that slows the rate also weakens the squeeze, except digoxin.
Compare dihydropyridine and non-dihydropyridine calcium channel blockers. Identify examples of medications in each class.⭐ HIGH YIELD
DIHYDROPYRIDINES (the -DIPINES: amlodipine, nifedipine, felodipine, nicardipine, clevidipine) are VASCULAR-selective: they dilate arteries to lower blood pressure and have little effect on the heart. NON-DIHYDROPYRIDINES (verapamil and diltiazem) are CARDIAC-selective: they slow the heart rate, slow AV conduction, and reduce contractility.
- That difference drives every clinical decision. If you want to lower blood pressure, reach for a -dipine. If you want to slow the ventricular rate in atrial fibrillation or SVT, reach for diltiazem or verapamil.
- The textbook's version: calcium channel blockers treat hypertension because they relax smooth muscle and cause vasodilation, and they treat arrhythmias because they increase the refractory period of the AV node, decreasing the ventricular response and the heart rate. Diltiazem is indicated for angina, hypertension, and supraventricular tachycardias.
- DIHYDROPYRIDINE side effects come from vasodilation: PERIPHERAL EDEMA (especially ankles, and it does NOT respond to diuretics), headache, flushing, dizziness, and REFLEX TACHYCARDIA. Short-acting immediate-release nifedipine is avoided in hypertension because the reflex tachycardia can precipitate an MI.
- NON-DIHYDROPYRIDINE side effects come from cardiac suppression: bradycardia, AV block, hypotension, and worsening heart failure (the textbook notes diltiazem can worsen heart failure because of its negative inotropic effect). VERAPAMIL causes severe CONSTIPATION.
- DO NOT COMBINE a non-dihydropyridine with a beta blocker: additive bradycardia, heart block, and reduced contractility. AVOID both in heart failure with reduced ejection fraction. Amlodipine is the CCB that IS considered safe in heart failure.
- BOTH classes: avoid GRAPEFRUIT JUICE (CYP3A4 inhibition raises levels and causes hypotension), do not crush extended-release forms, check BP and apical pulse before dosing, and rise slowly. Verapamil raises digoxin levels. Nicardipine and clevidipine are IV dihydropyridines used as titratable drips for hypertensive emergency.
| Dihydropyridine (-dipine) | Non-dihydropyridine |
|---|
| amlodipine, nifedipine, felodipine, nicardipine, clevidipine, nimodipine | verapamil, diltiazem |
| Acts on VESSELS (vascular smooth muscle) | Acts on the HEART (SA and AV node, myocardium) |
| Lowers BP by vasodilation; little effect on rate | Slows heart rate, slows AV conduction, reduces contractility |
| Uses: hypertension, angina, Raynaud's; nimodipine for subarachnoid hemorrhage vasospasm | Uses: atrial fibrillation and SVT rate control, angina, hypertension |
| Adverse: ANKLE EDEMA, headache, flushing, REFLEX TACHYCARDIA | Adverse: bradycardia, AV block, worsening heart failure; verapamil causes CONSTIPATION |
| Amlodipine is safe in heart failure | AVOID in heart failure with reduced EF and with beta blockers |
-DIPINE dilates the PIPEs. Verapamil and diltiazem talk to the HEART.
💉 AdenosineHIGH ALERT
Antidysrhythmic, Endogenous nucleoside
What it is for
PSVT, as a diagnostic aid to assess myocardial perfusion defects in CAD, Wolff-Parkinson-White syndrome Unlabeled: Wide-complex tachycardia diagnosis
How it works
Slows conduction through AV node, can interrupt reentry pathways through AV node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT)
Watch for
CNS: Light headedness, dizziness, arm tingling, numbness, headache; seizures CV: Chest pain, pressure, atrial tachydysrhythmias, sweating, palpitations, hypotension, facial flushing, AV block, cardiac arrest, ventricular dysrhythmias, atrial fibrillation GI: Nausea, metallic taste RESP: Dyspnea …
Teaching
- To report facial flushing, dizziness, sweating, palpitations, chest pain; usually transient; chest pressure may occur immediately after administration
- To report IV discomfort
- Pregnancy/breastfeeding: to advise prescriber if pregnancy is planned or suspected or if breastfeeding; do not breastfeed
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 AmiodaroneHIGH ALERTBLACK BOX
Antidysrhythmic (class III), Iodinated benzofuran derivative
What it is for
Hemodynamically unstable ventricular tachycardia, supraventricular tachycardia, ventricular fibrillation not controlled by first-line agents
How it works
Prolongs duration of action potential and effective refractory period, noncompetitive α- and β-adrenergic inhibition; increases PR and QT intervals, decreases sinus rate, decreases peripheral vascular resistance
Watch for
CNS: Headache, dizziness, involuntary movement, tremors, peripheral neuropathy, malaise, fatigue, ataxia, paresthesias, insomnia, confusion, hallucinations CV: Hypotension, bradycardia, HF, dysrhythmias EENT: Corneal microdeposits, dry eyes ENDO: Hypo/hyperthyroidism GI: Nausea, vomiting, diarrhea …
Teaching
- To take this product as directed; to avoid missed doses; not to use with grapefruit juice; not to discontinue abruptly, not to use other drugs, herbs without prescriber a …
- To use sunscreen or stay out of sun to prevent burns; that dark glasses may be needed for photophobia
- To report side effects immediately; more common at high dose and longer duration
- That skin discoloration is usually reversible
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Atenolol/metoprololHIGH ALERTBLACK BOX
Antihypertensive, antianginal, β-Blocker, β1-, β2-blocker (high doses)
What it is for
Hypertension, angina pectoris; suspected or known MI (IV use); MI prophylaxis
How it works
Competitively blocks stimulation of β-adrenergic receptor within vascular smooth muscle; produces negative chronotropic activity (decreases rate of SA node discharge, increases recovery time), slows conduction of AV node …
Watch for
CNS: Insomnia, fatigue, dizziness, mental changes, memory loss, depression, lethargy, drowsiness, strange dreams CV: Profound hypotension, bradycardia, HF ENDO: Hypo- and hyperglycemia GI: Nausea, diarrhea, vomiting, constipation GU: Impotence, decreased libido, urinary frequency MS: Back …
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 CaptoprilBLACK BOX
Antihypertensive, Angiotensin-converting enzyme (ACE) inhibitor
What it is for
Hypertension, HF, left ventricular dysfunction after MI, diabetic nephropathy, proteinuria, acute MI, hypertensive emergency/urgency,
How it works
Selectively suppresses reninangiotensin-aldosterone system; inhibits ACE; prevents conversion of angiotensin I to angiotensin II
Watch for
CNS: Fever, chills, dizziness, drowsiness, fatigue, headache, insomnia, weakness CV: Hypotension, postural hypotension, tachycardia, angina GI: Loss of taste, increased LFTs GU: Impotence, dysuria, nocturia, proteinuria, nephrotic syndrome, acute reversible renal failure, polyuria, oliguria …
Teaching
- To take 1 hr prior to or 2 hr after meals; not to discontinue product abruptly; if dose is missed, take as soon as remembered but not if almost time for next dose; not to …
- Not to use OTC products (cough, cold, or allergy) unless directed by prescriber; to avoid salt substitutes, high-potassium or high-sodium foods
- To adhere to dosage schedule, even if feeling better
- To use cautiously in hot weather, make sure fluids are adequate
🔗 Full card in the drug guide
💉 Digoxin (What are the signs/symptoms and risk factors for toxicity?)HIGH ALERT
Cardiac glycoside, inotropic, antidysrhythmic, Digoxin preparation
What it is for
Heart failure, atrial fibrillation/flutter, paroxysmal supraventricular tachycardia (PSVT) treatment/prophylaxis
How it works
Inhibits the sodium-potassium ATPase pump, which makes more calcium available for contractile proteins, thereby resulting in increased cardiac output (positive inotropic effect); increases force of contractions …
Watch for
CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations CV: Dysrhythmias, hypotension, bradycardia, AV block EENT: Blurred vision, yellow-green halos, photophobia, diplopia GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea
Teaching
- Not to stop product abruptly; about all aspects of product; to take exactly as ordered; how to monitor heart rate
- To avoid OTC medications, herbal remedies because many adverse product interactions may occur; not to take antacid within 2 hr of this product
- To notify prescriber of loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred or yellow vision, rash, depression, toxicity
- About the toxic symptoms of this product; when to notify prescriber
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 LosartanBLACK BOX
Antihypertensive, Angiotensin II receptor (type AT1) antagonist
What it is for
Hypertension, alone or in combination; nephropathy in type 2 diabetes; proteinuria; stroke prophylaxis for hypertensive patients with left ventricular hypertrophy
How it works
Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II; selectively blocks the binding of angiotensin II to the AT1 receptor found in tissues
Watch for
CNS: Dizziness, insomnia, anxiety, confusion, abnormal dreams, migraine, tremor, vertigo, headache, malaise, depression, fatigue CV: Angina pectoris, 2nd-degree AV block, cerebrovascular accident, hypotension, MI, dysrhythmias EENT: Blurred vision, burning eyes, conjunctivitis GI: Diarrhea …
Teaching
- To avoid sunlight or to wear sunscreen if in sunlight; that photosensitivity may occur
- To comply with dosage schedule, even if feeling better; not to discontinue abruptly; not to share with others
- To notify prescriber of mouth sores, fever, swelling of hands or feet, irregular heartbeat, chest pain
- That excessive perspiration, dehydration, vomiting, diarrhea may lead to fall in B/P; to consult prescriber if these occur
🔗 Full card in the drug guide
💉 MilrinoneHIGH ALERT
Inotropic/vasodilator agent, Bipyridine phosphodiesterase inhibitor
What it is for
Short-term management of advanced heart failure that has not responded to other medication
How it works
Positive inotropic agent; increases contractility of cardiac muscle with vasodilator properties; reduces preload and afterload by direct relaxation on vascular smooth muscle
Watch for
CNS: Headache CV: Ventricular dysrhythmias, hypotension, chest pain, PVCs, palpitations, angina, ventricular tachycardia HEMA: Thrombocytopenia MISC: Inj site reactions
Teaching
- To report angina, palpitations immediately during infusion
- To report headache, which can be treated with analgesics
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Nifedipine/amlodipine
Calcium channel blocker, antianginal, antihypertensive, Dihydropyridine
What it is for
Chronic stable angina pectoris, variant angina, hypertension
How it works
Inhibits calcium ion influx across cell membrane during cardiac depolarization; relaxes coronary vascular smooth muscle; dilates coronary arteries; increases myocardial oxygen delivery in patients with vasospastic angina …
Watch for
CNS: Headache, fatigue, drowsiness, dizziness, anxiety, depression, weakness, insomnia, light-headedness, paresthesia, tinnitus, blurred vision, nervousness, tremor, flushing CV: Dysrhythmias, edema, hypotension, palpitations, tachycardia GI: Nausea, vomiting, diarrhea, gastric upset, constipation …
Teaching
- To avoid hazardous activities until stabilized on product, dizziness is no longer a problem
- To limit caffeine consumption; to avoid alcohol products
- To avoid OTC products unless directed by prescriber; give without regard to meals, not to use with grapefruit juice
- That empty tab shells may appear in stools and are not significant
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Nitroglycerin
Antianginal, Nitrate, vasodilator
What it is for
Acute angina and prevention of angina; acute coronary syndrome and MI; heart failure with pulmonary congestion; hypertension during surgery.
How it works
Turns into nitric oxide in the vessel wall, which relaxes smooth muscle. Veins dilate first, so less blood comes back to the heart — preload drops and the heart has less work to do. At higher levels arteries dilate too, and it opens the coronary arteries directly.
Watch for
CNS: Headache (very common, expected, and a sign it is working), dizziness, fainting. CV: Hypotension, reflex tachycardia, flushing. GI: Nausea, vomiting. INTEG: Contact dermatitis under a patch. MISC: Tolerance with continuous use.
Teaching
- Sit or lie down before taking it — it drops blood pressure and people faint standing up.
- Sublingual tablet: one dose, then call 911 if the pain is not gone in five minutes, then up to two more doses five minutes apart while help is coming. Newer teaching calls EMS after the first dose.
- A tingling or burning under the tongue and a headache mean the tablet is still potent. No headache at all can mean the supply has gone stale.
- Store sublingual tablets in the original glass bottle, tightly capped, away from heat and light, and honor the expiration date. Older nursing teaching says replace six months after opening.
🔗 Full card in the drug guide
💉 ProcainamideHIGH ALERTBLACK BOX
Antidysrhythmic (class IA), Procaine HCl amide analog
What it is for
Life-threatening ventricular dysrhythmias
How it works
Depresses excitability of cardiac muscle to electrical stimulation and slows conduction velocity in atrium, bundle of His, and ventricle; increases refractory period
Watch for
CNS: Headache, dizziness, confusion, psychosis, restlessness, irritability, weakness, depression CV: Hypotension, heart block, cardiovascular collapse, arrest, torsades de pointes GI: Nausea, vomiting, anorexia, diarrhea, hepatomegaly, pain, bitter taste HEMA: SLE syndrome, agranulocytosis …
Teaching
- That wax matrix may appear in stools
- Not to discontinue without provider’s approval
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Ranolazine
Antianginal, Piperazine derivative
What it is for
Chronic angina pectoris
How it works
Antianginal, antiischemic; unknown, may work by inhibiting portal fatty-acid oxidation
Watch for
CNS: Headache, dizziness, hallucinations CV: Palpitations, QT prolongation, orthostatic hypotension EENT: Tinnitus GI: Nausea, vomiting, constipation, dry mouth MISC: Peripheral edema RESP: Dyspnea
Teaching
- To avoid hazardous activities until stabilized on product, dizziness no longer a problem
- To avoid OTC drugs, grapefruit juice, products prolonging QTc (quiNIDine, dofetilide, sotalol, erythromycin, thioridazine, ziprasidone or protease inhibitors, diltiaZEM, …
- To comply with all areas of medical regimen
- To take as directed; not to skip dose, not to double dose
🔗 Full card in the drug guide
💉 Verapamil/diltiazemHIGH ALERT
Calcium channel blocker; antihypertensive; antianginal, antidysrhythmic (class IV), Diphen
What it is for
Chronic stable, vasospastic, unstable angina; dysrhythmias, hypertension, supraventricular tachycardia, atrial flutter or fibrillation Unlabeled uses: Prevention of migraines
How it works
Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle; dilates coronary arteries; decreases SA/AV node conduction; dilates peripheral arteries
Watch for
CNS: Headache, drowsiness, dizziness, anxiety, depression, weakness, insomnia, confusion, light-headedness, asthenia, fatigue CV: Edema, HF, bradycardia, hypotension, palpitations, AV block, dysrhythmias GI: Nausea, diarrhea, gastric upset, constipation, increased LFTs GU: Impotence, gynecomastia …
Teaching
- To increase fluids, fiber to counteract constipation
- How to take pulse, B/P before taking product; to keep record or graph
- To avoid hazardous activities until stabilized on product, dizziness no longer a problem
- To limit caffeine consumption; to avoid alcohol products
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Atorvastatin
Antilipidemic, HMG-CoA reductase inhibitor (statin)
What it is for
As adjunct for primary hypercholesterolemia (types Ia, Ib), elevated triglyceride levels, prevention of CV disease by reduction of heart risk in those with mildly elevated cholesterol, heterozygous familial hypercholesterolemia in pediatric patients …
How it works
Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis; high doses lead to plaque regression
Watch for
CNS: Headache, asthenia, insomnia EENT: Lens opacities GI: Abdominal cramps, constipation, diarrhea, flatus, heartburn, dyspepsia, liver dysfunction, pancreatitis, nausea, increased serum transaminase GU: Impotence, UTI INTEG: Rash MISC: Hypersensitivity …
Teaching
- That compliance is needed for positive results to occur, not to skip or double doses
- That blood work and eye exam will be necessary during treatment
- To report blurred vision, severe GI symptoms, headache, muscle pain, and weakness; to avoid alcohol
- That previously prescribed regimen will continue: low-cholesterol diet, exercise program, smoking cessation
🔗 Full card in the drug guide
💉 Cholestyramine
Antilipemic, Bile acid sequestrant
What it is for
Primary hypercholesterolemia (esp. type IIa/IIb hyperlipoproteinemia), pruritus associated with biliary obstruction
🔗 Full card in the drug guide
💉 Ezetimibe
Antilipemic; cholesterol absorption inhibitor
What it is for
Hypercholesterolemia, homozygous familial hypercholesterolemia (HoFH), homozygous sitosterolemia
How it works
Inhibits absorption of cholesterol by the small intestine, causes reduced hepatic cholesterol stores
Watch for
CNS: Fatigue, dizziness, headache GI: Diarrhea, abdominal pain MISC: Chest pain MS: Myalgias, arthralgias, back pain, myopathy, rhabdomyolysis RESP: Pharyngitis, sinusitis, cough, URI EENT: Sinusitis, nasopharyngitis SYST: Angiedema
Teaching
- That compliance is needed
- That risk factors should be decreased: high-fat diet, smoking, alcohol consumption, absence of exercise
- To notify prescriber if pregnancy suspected, planned, or if breastfeeding
- To notify prescriber if unexplained weakness, muscle pain present
🔗 Full card in the drug guide
💉 Gemfibrozil
Antilipemic, Fibric acid derivative
What it is for
For use as an adjunct to diet for the treatment of hyperlipoproteinemia and for hypertriglyceridemia including type IV (elevated triglycerides, VLDL) and type V (elevated triglycerides, chylomicrons …
How it works
Inhibits biosynthesis of VLDL, decreases triglycerides, production in the liver increases HDL
Watch for
CNS: Fatigue, vertigo, headache, paresthesia, dizziness GI: Dyspepsia, diarrhea, abdominal pain, nausea, vomiting HEMA: Leukopenia, anemia, eosinophilia, thrombocytopenia INTEG: Rash, urticaria, pruritus MS: Myopathy, rhabdomyolysis
Teaching
- That compliance is needed for positive results; not to double or skip dose, to take missed dose as soon as remembered unless almost time for next dose
- To minimize risk factors: high-fat diet, smoking, alcohol consumption, absence of exercise
- To notify prescriber of diarrhea, nausea, vomiting, chills, fever, sore throat, muscle cramps, abdominal cramps, severe flatulence, tendon pain
- To avoid driving, hazardous activities if dizziness, blurred vision occur
🔗 Full card in the drug guide
💉 Niacin (vitamin B3/nicotinic acid)
Vit B3, antihyperlipidemic, Water-soluble vitamin
What it is for
Pellagra, hyperlipidemias (types 4, 5), peripheral vascular disease that presents a risk for pancreatitis
🔗 Full card in the drug guide
Module 11: Diuretics, IV Fluids, & Treatment of Poisoning
What are the different pharmaceutical classifications of diuretics? Give examples of drugs in each class.⭐ HIGH YIELD
Five classes: LOOP (furosemide, bumetanide, torsemide), THIAZIDE (hydrochlorothiazide, chlorthalidone, metolazone), POTASSIUM-SPARING (spironolactone, eplerenone, amiloride, triamterene), OSMOTIC (mannitol), and CARBONIC ANHYDRASE INHIBITORS (acetazolamide). They differ by where in the nephron they act, which determines potency and which electrolytes are lost.
- LOOP diuretics are the most POTENT. They block reabsorption in the loop of Henle and cause loss of sodium, potassium, calcium, and magnesium. Onset within 1 hour orally, peak in the first or second hour, duration 6 to 8 hours. Used for acute fluid overload and pulmonary edema, and they still work when the GFR is low. OTOTOXIC if pushed too fast IV - give furosemide no faster than 20 mg/min. Sulfa-allergic patients may need ethacrynic acid.
- THIAZIDES act near the distal tubule and are NOT effective for immediate diuresis - they are maintenance antihypertensives. They lose sodium and potassium but RETAIN CALCIUM (useful in osteoporosis, bad in hypercalcemia). They stop working when the GFR falls below about 30. They raise uric acid (gout), glucose, and lipids, and cause photosensitivity. HCTZ plus large amounts of licorice causes hyperkalemia per the textbook.
- POTASSIUM-SPARING agents are weak diuretics used mainly for their potassium-sparing and, for spironolactone, mortality benefit in heart failure. HYPERKALEMIA is the danger: no salt substitutes, no potassium supplements, and caution with ACE inhibitors and ARBs. Spironolactone also causes GYNECOMASTIA, menstrual irregularity, and hirsutism because it blocks androgen receptors; eplerenone does not.
- MANNITOL is an osmotic diuretic that pulls fluid out of cells and tissues by raising the osmotic pressure of the glomerular filtrate. It is used for increased INTRACRANIAL PRESSURE and cerebral edema, and for increased intraocular pressure. Give through an in-line FILTER, inspect for crystals (warm the bottle if crystallized), monitor serum osmolality and neuro status, and expect a transient rise in intravascular volume that can precipitate heart failure.
- ACETAZOLAMIDE is weak as a diuretic and causes metabolic ACIDOSIS with potassium loss. It is used for glaucoma, altitude sickness, and some seizure disorders.
- FOR ALL DIURETICS: daily weights at the same time on the same scale (1 kg equals about 1 liter), strict intake and output, monitor electrolytes and renal function, monitor for orthostatic hypotension and falls, and GIVE IN THE MORNING so the patient can sleep. Report weight gain over 3 pounds in a day. Loops and thiazides cause HYPOkalemia (encourage potassium-rich foods: bananas, oranges, potatoes, spinach). Potassium-sparing agents cause HYPERkalemia. Both matter enormously if the patient is also on digoxin, because hypokalemia potentiates digoxin toxicity.
| Class | Site of action | Examples | Key point |
|---|
| Loop | Loop of Henle | furosemide, bumetanide, torsemide, ethacrynic acid | MOST POTENT; loses K+, Ca++, Mg++; OTOTOXIC if pushed fast |
| Thiazide | Distal tubule | hydrochlorothiazide, chlorthalidone, metolazone | Maintenance HTN, not for acute overload; RETAINS calcium; raises uric acid and glucose |
| Potassium-sparing | Collecting duct | spironolactone, eplerenone, amiloride, triamterene | HYPERKALEMIA risk; spironolactone causes gynecomastia; HF mortality benefit |
| Osmotic | Glomerulus / proximal tubule | mannitol | Increased ICP and IOP; use a FILTER; watch for crystals and fluid overload |
| Carbonic anhydrase inhibitor | Proximal tubule | acetazolamide | Glaucoma, altitude sickness; causes metabolic ACIDOSIS |
Loops LOSE everything. Thiazides KEEP calcium. Spironolactone KEEPS potassium. Mannitol pulls water off the BRAIN.
What are the indications for hypotonic, isotonic, and hypertonic solutions?⭐ HIGH YIELD
ISOTONIC fluids stay in the vessels and expand blood volume - use for dehydration, hemorrhage, shock, and blood administration. HYPOTONIC fluids move water INTO cells - use for cellular dehydration, hypernatremia, and DKA after initial resuscitation. HYPERTONIC fluids pull water OUT of cells into the vessels - use for severe symptomatic hyponatremia and cerebral edema.
- ISOTONIC (same osmolality as plasma, about 275 to 295 mOsm/L): no fluid shift. Indications include hypovolemia, hemorrhage, vomiting and diarrhea, burns, shock, and as the only fluid compatible with blood products (0.9% NaCl). RISK: fluid overload, so monitor lungs, edema, jugular veins, and daily weights, especially in heart failure and renal failure.
- HYPOTONIC (lower osmolality): water leaves the vessels and enters cells, rehydrating them. Indications: hypernatremia, cellular dehydration, DKA maintenance after the initial isotonic bolus, and as a maintenance fluid. DANGER: it makes cells swell, so it is CONTRAINDICATED in increased intracranial pressure, head trauma, stroke, and neurosurgery (worsens cerebral edema), and in burns, trauma, and hypovolemia, where it can worsen hypotension and cause vascular collapse.
- HYPERTONIC (higher osmolality): water is pulled out of cells into the vascular space. Indications: severe symptomatic hyponatremia, cerebral edema and increased ICP, and third-spacing with hypovolemia. DANGER: fluid overload and pulmonary edema, cell shrinkage and dehydration, and phlebitis. Give slowly, on a PUMP, usually through a CENTRAL line, with frequent neuro checks and serum sodium.
- THE SODIUM CORRECTION RULE: correct sodium NO FASTER than about 8 to 10 mEq/L in 24 hours. Correcting too fast causes OSMOTIC DEMYELINATION SYNDROME (central pontine myelinolysis), which is permanent and devastating.
- For every IV fluid: assess lung sounds, edema, jugular venous distention, daily weight, strict intake and output, electrolytes, and mental status. Use an infusion pump for hypertonic solutions and for anyone at risk of overload.
- The direction of water movement is the whole concept: water always moves TOWARD the higher concentration of solute. Hypotonic fluid is dilute, so water leaves it and goes into the cell. Hypertonic fluid is concentrated, so it pulls water out of the cell.
| Tonicity | Water moves | Use for | Do NOT use in |
|---|
| ISOTONIC | Stays in the vascular space | Hypovolemia, hemorrhage, shock, vomiting/diarrhea, burns, blood administration (NS) | Heart failure, renal failure, cerebral edema (overload risk) |
| HYPOTONIC | Out of vessels INTO cells | Hypernatremia, cellular dehydration, DKA maintenance, maintenance fluid | Increased ICP, head trauma, stroke, burns, trauma, hypovolemia |
| HYPERTONIC | Out of cells INTO vessels | Severe symptomatic hyponatremia, cerebral edema/increased ICP, third-spacing | Dehydration, heart or renal failure; give slowly on a pump, central line preferred |
HypOtonic goes Out to the cells (they swell). HyperTonic pulls water back To the vessels (cells shrink). Isotonic stays put.
Give examples of IV fluids that are hypotonic, isotonic, and hypertonic.⭐ HIGH YIELD
HYPOTONIC: 0.45% NaCl (half normal saline), 0.33% NaCl, 0.225% NaCl, and D5W once the dextrose is metabolized. ISOTONIC: 0.9% NaCl (normal saline), lactated Ringer's, and D5W in the bag. HYPERTONIC: 3% and 5% NaCl, D10W, D5 in 0.45% NaCl, D5 in 0.9% NaCl, D5 in lactated Ringer's, and D50W.
- D5W IS THE TRICK QUESTION. It is ISOTONIC IN THE BAG (about 252 mOsm/L) but becomes HYPOTONIC IN THE BODY as soon as the dextrose is metabolized, leaving free water. That is why it is dangerous in head injury and increased ICP.
- Any 'D5 plus something isotonic' is HYPERTONIC: D5NS, D5 half-NS, and D5LR. Adding dextrose to an already isotonic solution pushes the osmolality above plasma.
- LACTATED RINGER'S is isotonic and contains sodium, chloride, potassium, calcium, and lactate (which the liver converts to bicarbonate). It is preferred for burns and large-volume resuscitation. Avoid in liver failure (cannot metabolize lactate), in hyperkalemia (it contains potassium), and NEVER with blood products (the calcium clots the line).
- 0.9% NORMAL SALINE is the only fluid that may be given with blood. Large volumes cause hyperchloremic metabolic acidosis.
- 3% NaCl is the hypertonic saline used for symptomatic hyponatremia and cerebral edema. It requires a pump, frequent sodium checks, and usually a central line and an ICU setting.
- Memory anchor: the number tells you the tonicity for saline. Below 0.9% is hypotonic, exactly 0.9% is isotonic, above 0.9% is hypertonic. For dextrose, 5% alone is isotonic in the bag, and anything higher (10%, 50%) is hypertonic.
| HYPOTONIC | ISOTONIC | HYPERTONIC |
|---|
| 0.45% NaCl (half NS) | 0.9% NaCl (NS) | 3% NaCl and 5% NaCl |
| 0.33% NaCl | Lactated Ringer's | D10W, D50W |
| 0.225% NaCl (quarter NS) | D5W (in the bag only) | D5 in 0.45% NaCl |
| D5W once dextrose is metabolized | Ringer's solution, Plasma-Lyte | D5 in 0.9% NaCl, D5 in LR |
Under 0.9 is hypo, 0.9 is iso, over 0.9 is hyper. D5W is iso in the bag and hypo in the body.
💉 Furosemide
Loop diuretic, Sulfonamide derivative
What it is for
Pulmonary edema; edema with HF, hepatic disease, nephrotic syndrome, ascites, hypertension
How it works
Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle
Watch for
CNS: Headache, fatigue, weakness, vertigo, paresthesias CV: Orthostatic hypotension, chest pain, ECG changes, circulatory collapse EENT: Loss of hearing, ear pain, tinnitus, blurred vision ELECT: Hypokalemia, hypochloremic alkalosis, hypomagnesemia, hyperuricemia, hypocalcemia, hyponatremia …
Teaching
- To discuss the need for a highpotassium diet or potassium replacement with prescriber
- To rise slowly from lying or sitting position because orthostatic hypotension may occur; teach fall prevention strategies
- To recognize adverse reactions that may occur: muscle cramps, weakness, nausea, dizziness; teach diabetic patients to monitor blood glucose carefully; blood glucose level …
- About the entire treatment regimen, including exercise, diet, stress relief for hypertension
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Hydrochlorothiazide
Thiazide diuretic, antihypertensive, Sulfonamide derivative
What it is for
Edema, hypertension, diuresis, HF; idiopathic lower extremity edema therapy Unlabeled: Diabetes insipidus, hypercalciuria, nephrolithiasis, premenstrual syndrome, renal calculus
How it works
Acts on distal tubule and ascending limb of loop of Henle by increasing excretion of water, sodium, chloride, potassium
Watch for
CNS: Drowsiness, paresthesia, depression, headache, dizziness, fatigue, weakness, fever CV: Irregular pulse, orthostatic hypotension, palpitations, volume depletion, allergic myocarditis EENT: Blurred vision ELECT: Hypokalemia, hypercalcemia, hyponatremia, hypochloremia, hypomagnesemia GI: Nausea …
Teaching
- To rise slowly from lying or sitting position to prevent postural hypotension
- To notify prescriber of muscle weakness, cramps, nausea, dizziness; hypokalemia is common; rash
- That product may be taken with food or milk
- To use sunscreen for photosensitivity
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 MannitolBLACK BOX
Diuretic, osmotic; GU irrigant, Hexahydric alcohol
What it is for
Edema; promotion of systemic diuresis in cerebral edema; decrease in intraocular/intracranial pressure; improved renal function in acute renal failure, chemical poisoning, urinary bladder irrigation, kidney transplant
How it works
Acts by increasing osmolarity of glomerular filtrate, which inhibits reabsorption of water and electrolytes and increases urinary output
Watch for
CNS: Dizziness, headache, confusion CV: Edema, thrombophlebitis, hypo/hypertension, tachycardia, angina-like chest pains, fever, chills, HF, circulatory overload ELECT: Fluid, electrolyte imbalances, electrolyte loss, dehydration, hypo/hyperkalemia GI: Nausea, vomiting …
Teaching
- To rise slowly from lying or sitting position
- About the reason for, method of treatment
- To report signs of electrolyte imbalance, confusion, pain at injection site, hearing loss, blurred vision
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Spironolactone/eplerenoneBLACK BOX
Potassium-sparing diuretic, Aldosterone antagonist
What it is for
Edema of HF, hypertension, diuretic-induced hypokalemia, primary hyperaldosteronism (diagnosis, shortterm treatment, long-term treatment), edema of nephrotic syndrome, cirrhosis of liver with ascites
How it works
Competes with aldosterone at receptor sites in distal tubule, thereby resulting in the excretion of sodium chloride and water and the retention of potassium and phosphate
Watch for
CNS: Headache, confusion, drowsiness, lethargy, ataxia ELECT: Hyperchloremic metabolic acidosis, hyperkalemia, hyponatremia ENDO: Impotence, gynecomastia, irregular menses, amenorrhea, postmenopausal bleeding, hirsutism, deepening voice, breast pain GI: Diarrhea, cramps, bleeding, gastritis …
Teaching
- To avoid foods with high potassium content: oranges, bananas, salt substitutes, dried apricots, dates; to avoid potassium salt substitutes
- That drowsiness, ataxia, mental confusion may occur; to observe caution when driving
- To notify prescriber of cramps, diarrhea, lethargy, thirst, headache, skin rash, menstrual abnormalities, deepening voice, breast enlargement
- To take in am to prevent sleeplessness
Antidote / reversal: 1
🔗 Full card in the drug guide
Dextran 40🚨 DANGER
Dextran 40 is a low-molecular-weight COLLOID plasma volume EXPANDER. It stays in the vascular space and pulls interstitial fluid in with it, so it expands blood volume by MORE than the volume infused. Used for hypovolemic shock and to improve microcirculation and prevent thrombosis.
- IT INTERFERES WITH BLOOD TYPING AND CROSSMATCHING. DRAW THE TYPE AND CROSSMATCH SPECIMEN BEFORE STARTING THE INFUSION. This is the number one nursing point.
- It has ANTIPLATELET and antithrombotic effects: it coats platelets and reduces blood viscosity, so it INCREASES BLEEDING RISK. Monitor for bleeding, and avoid in thrombocytopenia and active hemorrhage.
- ANAPHYLAXIS can occur, sometimes with the first few milliliters. Stay with the patient and infuse the first 5 to 10 minutes slowly with close observation. Keep emergency equipment available.
- RENAL FAILURE is a real risk, especially in dehydrated patients: dextran is filtered by the kidney and can cause osmotic nephrosis and tubular obstruction. Ensure adequate hydration, monitor urine output hourly, and monitor BUN and creatinine.
- Because it is a volume expander, it can cause FLUID OVERLOAD and pulmonary edema. Monitor lung sounds, jugular veins, and daily weights. Contraindicated in severe heart failure and severe renal disease with oliguria or anuria.
- Dextran 70 is the higher-molecular-weight version used mainly for volume expansion; dextran 40 is preferred when improving microcirculatory flow is the goal. Colloids (dextran, albumin, hetastarch) stay in the vessels and expand volume more efficiently than crystalloids (NS, LR), but they cost more and carry these specific risks.
Dextran pulls fluid IN, but draw the crossmatch FIRST and watch for bleeding and kidneys.
Dextrose in water 5%🚨 DANGER
Dextrose 5% in water (D5W) is ISOTONIC IN THE BAG but functionally HYPOTONIC IN THE BODY, because the dextrose is metabolized within minutes leaving free water that shifts into cells. It provides free water and about 170 calories per liter, and is used as a maintenance fluid, a drug diluent, and to treat hypernatremia and free water deficit.
- DO NOT GIVE D5W IN HEAD INJURY, INCREASED ICP, STROKE, OR NEUROSURGERY. The free water shifts into brain cells and worsens cerebral edema. This is the most tested fact about D5W.
- Do not use it as a resuscitation fluid in hypovolemia or shock. Only about a tenth of it stays in the vascular space, so it will not restore blood pressure. Use an isotonic crystalloid.
- NEVER give D5W with blood products - it causes red cell hemolysis. Only 0.9% normal saline may run with blood.
- The 170 calories per liter are not nutrition. They protect against ketosis and spare a little protein, but a patient on D5W alone is being starved.
- Monitor for hyponatremia and water intoxication with prolonged or rapid infusion: headache, nausea, confusion, lethargy, and seizures. Also monitor blood glucose in diabetic patients, because the dextrose load raises glucose.
- Do not use it in a patient who is already at risk for fluid overload, and do not use plain D5W in a hypoglycemic emergency - the concentration is far too low. Use D50W.
D5W: isotonic in the bag, hypotonic in the vein, and poison for a swollen brain.
Dextrose in water 50%🚨 DANGER
Dextrose 50% in water (D50W) is a HYPERTONIC concentrated sugar solution given IV PUSH as the emergency treatment for SEVERE HYPOGLYCEMIA in a patient who is unconscious, NPO, seizing, or otherwise unable to swallow. One 50 mL prefilled syringe contains 25 grams of dextrose.
- Give it through a LARGE-BORE IV in a LARGE VEIN, preferably a central line, and push SLOWLY. It is extremely hypertonic (about 2,525 mOsm/L) and is a VESICANT: extravasation causes tissue necrosis and sloughing.
- Verify IV PATENCY and blood return before pushing. Assess the site during and after. If extravasation occurs, stop, aspirate, elevate, and follow the institutional extravasation protocol.
- In an unconscious patient with no IV access, give GLUCAGON 1 mg IM or subcutaneously instead. Never put anything in the mouth of a patient who cannot protect their airway.
- GIVE THIAMINE FIRST OR CONCURRENTLY in a patient with alcohol use disorder or malnutrition. A glucose load without thiamine can precipitate WERNICKE ENCEPHALOPATHY.
- Recheck the blood glucose in 15 to 20 minutes and repeat if still low. Once the patient is awake and able to swallow, give a complex carbohydrate plus protein snack, because the effect of D50 is short-lived and rebound hypoglycemia is common - especially with a long-acting insulin or sulfonylurea on board.
- Monitor for rebound HYPERglycemia and for hypokalemia (glucose drives potassium into cells). Continue to monitor closely for 24 hours per the textbook, and notify the provider and the oncoming nurse. D50 is also used in hyperkalemia treatment (with insulin, to drive potassium into cells) and in some pediatric protocols at lower concentrations (D10 or D25) because D50 is too concentrated for small veins.
D50 is the syringe for the unconscious diabetic. Big vein, slow push, thiamine first in an alcoholic, and feed them when they wake up.
💉 Potassium chlorideHIGH ALERT
Electrolyte, mineral replacement, Potassium
What it is for
Prevention and treatment of hypokalemia
How it works
Needed for the adequate transmission of nerve impulses and cardiac contraction, renal function, intracellular ion maintenance
Watch for
CNS: Confusion CV: Bradycardia, cardiac depression, dysrhythmias, arrest; peaking T waves, lowered R, depressed RST, prolonged P-R interval, widened QRS complex GI: Nausea, vomiting, cramps, pain, diarrhea, ulceration of small bowel GU: Oliguria INTEG: Cold extremities, rash
Teaching
- To add potassium-rich foods to diet: bananas, orange juice, avocados, whole grains, broccoli, carrots, prunes, cocoa after product is discontinued
- To avoid OTC products: antacids, salt substitutes, analgesics, vitamin preparations unless specifically directed by prescriber; to avoid licorice in large amounts because …
- To report hyperkalemia symptoms (lethargy, confusion, diarrhea, nausea, vomiting, fainting, decreased output) or continued hypokalemia symptoms (fatigue, weakness, polyur …
- To dissolve powder or tablet completely in ≥120 mL water or juice
🔗 Full card in the drug guide
Sodium chloride 0.9%⭐ HIGH YIELD
Sodium chloride 0.9% (normal saline, NS) is an ISOTONIC crystalloid that stays in the vascular space and expands blood volume. It is used for hypovolemia, dehydration, hemorrhage, shock, hyponatremia, DKA resuscitation, and it is the ONLY solution compatible with BLOOD PRODUCTS.
- THE BLOOD RULE: only 0.9% NaCl may be hung with blood. Lactated Ringer's contains calcium and clots the line; dextrose solutions cause hemolysis.
- It is also the standard flush for IV lines and the standard diluent for many IV medications, and it is used for irrigation and for nasal and wound care.
- It contains 154 mEq/L each of sodium and chloride, which is MORE chloride than plasma. Large volumes cause HYPERCHLOREMIC METABOLIC ACIDOSIS and can worsen kidney injury, which is why balanced solutions like lactated Ringer's and Plasma-Lyte are often preferred for large-volume resuscitation.
- FLUID OVERLOAD is the main risk. Use cautiously and monitor closely in heart failure, renal failure, cirrhosis, and older adults: assess lung sounds for crackles, jugular venous distention, peripheral edema, dyspnea, and daily weights. Report a weight gain over 2 to 3 pounds in a day.
- It can also cause HYPERNATREMIA with excessive use. Monitor serum sodium, chloride, and bicarbonate along with intake and output.
- 0.9% is the reference point for tonicity: below 0.9% is hypotonic, 0.9% is isotonic, above 0.9% is hypertonic.
Normal saline is the default and the ONLY fluid that runs with blood. Watch the lungs for overload.
Sodium chloride 3%🚨 DANGER
Sodium chloride 3% is HYPERTONIC saline. It pulls water OUT of cells and into the vascular space. It is used for SEVERE SYMPTOMATIC HYPONATREMIA (seizures, coma, altered mental status) and for CEREBRAL EDEMA with increased intracranial pressure.
- THE CORRECTION RATE IS THE WHOLE SAFETY ISSUE: raise the serum sodium NO FASTER than about 8 to 10 mEq/L in 24 hours (some sources say 6 to 8 in high-risk patients). Correcting too quickly causes OSMOTIC DEMYELINATION SYNDROME (central pontine myelinolysis), which produces permanent quadriparesis, dysarthria, dysphagia, and locked-in syndrome.
- Administer on an INFUSION PUMP, slowly, ideally through a CENTRAL LINE, in an ICU or monitored setting. Peripheral administration causes phlebitis, pain, and infiltration; assess the site frequently.
- Check SERUM SODIUM FREQUENTLY, often every 2 to 4 hours during active correction, along with neurologic status.
- Monitor for FLUID OVERLOAD as water is pulled into the vasculature: crackles, dyspnea, jugular venous distention, bounding pulse, hypertension, and headache. Contraindicated or used with extreme caution in heart failure and renal failure.
- Watch for cellular dehydration on the other side: thirst, dry mucous membranes, restlessness, and rising sodium above the target.
- The signs the patient needs it are neurologic: hyponatremic seizures, obtundation, and coma. Asymptomatic chronic hyponatremia is corrected slowly with fluid restriction, not with 3% saline.
3% saline pulls water off the brain, but raise sodium too fast and you destroy the pons. 8 to 10 mEq in 24 hours, no more.
💉 Acetylcysteine
Mucolytic; antidote—acetaminophen, Amino acid l-cysteine
What it is for
Acetaminophen toxicity; bronchitis; cystic fibrosis; COPD; atelectasis
How it works
Decreases viscosity of secretions by breaking disulfide links of mucoproteins; serves as a substrate in place of glutathione, which is necessary to inactivate toxic metabolites with acetaminophen overdose
Watch for
CNS: Dizziness, drowsiness, fever, chills CV: Edema, flushing tachycardia EENT: Rhinorrhea, pharyngitis GI: Nausea, stomatitis, vomiting, anorexia INTEG: Urticaria, rash, clamminess, pruritus RESP: Bronchospasm, chest tightness, cough, dyspnea MISC: Anaphylaxis, angiedema, unpleasant odor
Teaching
- That foul odor and smell may be unpleasant
- To clear airway for inhalation
- To report vomiting because dose may need to be repeated
- Provide adequate hydration
🔗 Full card in the drug guide
Ammonium chloride🚨 DANGER
Ammonium chloride is an ACIDIFYING agent. Given IV or orally, it supplies hydrogen and chloride ions to treat severe METABOLIC ALKALOSIS and HYPOCHLOREMIA that have not responded to sodium chloride and potassium chloride replacement. It is also used to acidify urine.
- CONTRAINDICATED IN HEPATIC IMPAIRMENT AND RENAL FAILURE. The liver converts ammonium to urea; if it cannot, AMMONIA ACCUMULATES and causes hepatic encephalopathy, and the failing kidney cannot excrete the acid load. Monitor for confusion, asterixis, and altered mental status.
- AMMONIA TOXICITY presents as pallor, sweating, irregular breathing, bradycardia, twitching, seizures, and coma. Stop the infusion and notify the provider immediately.
- Give IV doses SLOWLY and DILUTED. Rapid infusion causes pain, irritation at the site, and toxicity. It is an IRRITANT - monitor the site.
- Monitor: serum electrolytes, chloride, bicarbonate, pH and arterial blood gases, ammonia level, and liver and kidney function. Correcting alkalosis too fast can flip the patient into acidosis.
- Because it acidifies urine, it can be used adjunctively in some poisonings and to enhance excretion of certain drugs, and it will alter the excretion of other drugs (it speeds elimination of weak bases like amphetamines and slows elimination of weak acids).
- GI side effects with oral use are common: nausea, vomiting, and gastric irritation. Give with food. Think of it as the mirror image of sodium bicarbonate: bicarb treats acidosis, ammonium chloride treats alkalosis.
Ammonium chloride ACIDIFIES. The liver has to handle the ammonia, so never give it in liver failure.
Dimercaprol🚨 DANGER
Dimercaprol (BAL in Oil, British Anti-Lewisite) is a CHELATING agent for heavy metal poisoning: ARSENIC, GOLD, and MERCURY, and LEAD when combined with edetate calcium disodium. It binds the metal into a stable complex that the kidneys excrete.
- IT IS PREPARED IN PEANUT OIL, so it is CONTRAINDICATED IN PEANUT ALLERGY. Always ask. This is the classic exam point.
- GIVE BY DEEP INTRAMUSCULAR INJECTION ONLY - never IV. The injections are notoriously PAINFUL; rotate sites and consider local comfort measures. Use the Z-track technique.
- In severe LEAD ENCEPHALOPATHY, dimercaprol is given FIRST, about 4 hours before edetate calcium disodium, because giving EDTA first can mobilize lead into the brain and worsen encephalopathy.
- ALKALINIZE THE URINE to protect the kidneys: the dimercaprol-metal complex breaks down in acidic urine and releases free metal into the tubules. Maintain hydration and monitor renal function.
- Expected adverse effects, usually dose-related and transient: HYPERTENSION AND TACHYCARDIA (peak 15 to 30 minutes after the dose), burning of the lips, mouth, and throat, a feeling of constriction in the chest, lacrimation, salivation, rhinorrhea, nausea and vomiting, headache, and paresthesias. Fever occurs in about 30% of children.
- Contraindicated in hepatic impairment (except postarsenical jaundice) and used with caution in G6PD deficiency (hemolysis) and in renal impairment. Do NOT use it for IRON, CADMIUM, or SELENIUM poisoning - the resulting complexes are more toxic than the metal itself. Do not give iron supplements during therapy - the dimercaprol-iron complex is toxic. Wait 24 hours after the last dose.
BAL is in PEANUT oil, deep IM, and it goes in FIRST for lead encephalopathy. Never for iron.
Edetate calcium disodium🚨 DANGER
Edetate calcium disodium (calcium EDTA, Calcium Disodium Versenate) is the CHELATING agent for LEAD POISONING. It exchanges its calcium for lead and the lead-EDTA complex is excreted in the urine. Given IV or deep IM.
- DO NOT CONFUSE IT WITH EDETATE DISODIUM (Na2EDTA). Edetate disodium has no calcium, binds the patient's OWN serum calcium, and causes FATAL HYPOCALCEMIA, tetany, arrhythmias, and cardiac arrest. Deaths have occurred from this exact mix-up. Read the label twice.
- NEPHROTOXICITY is the dose-limiting toxicity: acute tubular necrosis. Ensure adequate HYDRATION and URINE FLOW before and during therapy, monitor urine output hourly, and monitor BUN, creatinine, and urinalysis daily. Do not give if the patient is anuric.
- In LEAD ENCEPHALOPATHY, give DIMERCAPROL FIRST, about 4 hours before the EDTA, because EDTA alone can redistribute lead into the brain and worsen the encephalopathy. Avoid rapid IV infusion in encephalopathy because it raises intracranial pressure; the IM route is preferred there.
- IM injections are painful; procaine is often added to the solution. Rotate sites.
- Monitor serum lead levels, calcium, zinc, iron, and other trace metals - EDTA chelates them too. Rebound of the blood lead level occurs after therapy stops as lead moves out of bone, so repeat courses are often needed. Other adverse effects: fever, chills, malaise, myalgia, headache, GI upset, hypotension, and transient elevation of transaminases.
- THE REAL TREATMENT IS REMOVING THE SOURCE. Chelation does not undo neurologic damage. Identify and eliminate the lead exposure (old paint, contaminated water, occupational or hobby exposure), report to public health, and screen other children in the home. Succimer (DMSA) is the oral chelator used for less severe lead poisoning.
Calcium EDTA has the calcium it needs. Plain disodium EDTA steals the patient's and stops the heart.
💉 FlumazenilBLACK BOX
Antidote: benzodiazepine receptor antagonist, Imidazobenzodiazepine derivative
What it is for
Reversal of sedative effects of benzodiazepines
How it works
Antagonizes actions of benzodiazepines on CNS, competitively inhibits activity at benzodiazepine recognition site on GABA/benzodiazepine receptor complex
Watch for
CNS: Dizziness, agitation, emotional lability, confusion, seizures, somnolence, panic attacks CV: Hypertension, palpitations, cutaneous vasodilation, dysrhythmias, bradycardia, tachycardia, chest pain EENT: Abnormal vision, blurred vision, tinnitus GI: Nausea, vomiting, hiccups SYST: Headache …
Teaching
- Not to use with alcohol or other medications for at least 24 hr
- That sedation may occur after treatment
- To avoid hazardous activities, driving until effects are known
- That amnesia may continue
🔗 Full card in the drug guide
💉 Glucagon
Antihypoglycemic
What it is for
Hypoglycemia, used to temporarily inhibit movement of GI tract as a diagnostic test
🔗 Full card in the drug guide
💉 InsulinHIGH ALERT
Antidiabetic, Intermediate-acting human insulin
What it is for
Type 1 and type 2 diabetes, usually twice daily, often paired with a short-acting insulin at meals.
How it works
Regular insulin bound to protamine so it dissolves slowly out of the injection site. Same action as any insulin once absorbed — it just arrives over hours instead of minutes, which is what gives basal-ish coverage.
Watch for
ENDO: Hypoglycemia (classically in the afternoon or overnight, at the peak), weight gain. INTEG: Lipodystrophy, injection site reaction.
Teaching
- The cloudy one. Roll it gently between the palms to mix — do not shake, shaking makes foam and breaks up the suspension.
- Subcutaneous only. NPH must never go IV.
- Onset roughly one to two hours, peak around four to twelve. Plan a snack near the peak, and know that an overnight dose puts the peak in the middle of the night.
- When mixing with regular: air into NPH first, then air into regular, then draw regular up first. Clear before cloudy.
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Naloxone
Opioid antagonist, antidote, Thebaine derivative
What it is for
Respiratory depression induced by opioids, opiate agonist overdose Unlabeled: Pruritus (opiate induced)
How it works
Competes with opioids at opiate receptor sites
Watch for
CV: Rapid pulse, ventricular tachycardia, fibrillation, hypo/hypertension GI: Nausea, vomiting CNS: Headache, seizures MS: Pain INTEG: Injection site reactions MISC: Withdrawal symptoms in those dependent EENT: Nasal dryness
Teaching
- When patient is lucid, about the reasons for, expected results of product; for nasal administration, teach family, caregivers correct use, use of autoinjector
- Opioid emergency:
- Teach patient and family increased sleepiness, coma, trouble breathing are a sign of overdose; discuss family’s use of this product for overdose
🔗 Full card in the drug guide
💉 Sodium bicarbonate
Alkalinizer, NaHCO3
What it is for
Acidosis (metabolic), cardiac arrest, alkalinization (systemic/urinary), antacid, salicylate poisoning Amyotrophic lateral sclerosis (ALS)
How it works
Orally neutralizes gastric acid, which forms water, NaCl, CO2; increases plasma bicarbonate, which buffers H+ ion concentration; reverses acidosis IV
Watch for
CNS: Irritability, headache, confusion, stimulation, tremors, twitching, hyperreflexia, tetany, weakness, seizures of alkalosis CV: Irregular pulse, cardiac arrest, water retention, edema, weight gain GI: Flatulence, belching, distention META: Metabolic alkalosis MS: Muscular twitching, tetany …
Teaching
- Not to take antacid with milk because milk-alkali syndrome may result; not to use antacid for >2 wk
- To notify prescriber if indigestion accompanied by chest pain; trouble breathing; diarrhea; dark, tarry stools; vomit that looks like coffee grounds; swelling of feet/ank …
- About sodium-restricted diet; to avoid use of baking soda for indigestion
- sodium phenylbutyrate/taurursodiol (Rx)
🔗 Full card in the drug guide
Nothing matched that. Try a shorter word.
Where this came from. Drug cards are pulled from your own drug guide, which was fact-checked against FDA labeling. The concept answers were written for this guide from your course textbook,
Pharmacology (WTCS, 2e), so they should match your lectures. Check anything that contradicts what your instructor said — they write the exam.