10 Golden Rules for Administering Drug Safety 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Administer the right drug Administer the right drug to the right pt. Administer the right dose Administer the right drug by the right route Administer the right drug at the right time Teach your pt. about the drug he is receiving Take a complete pt. drug history Find out if the pt. has any allergies Be aware of potential drug-drug or drug-food interaction Document each drug you administer

11 rights 1. Right drug 2. Right dose 3. Right time 4. Right route 5. Right patient 6. Right action 7. Right preparation 8. Right order 9. Right approach 10. Right arm 11. Right documentation Intake output 10 u 1 pint 1 tsp 1 tbsp 1 cup 1 glass 1 gallon 1 Li 1 oz 1 ml 1 mg 1 gm 1 kg 1 kg 1 ml 500 ml 5 ml 15ml 180 ml 240 ml 4 Li 1000 ml 30 ml 15 gtts 1000 ugtts 1000 mg 1000 gm 2.2 pounds

Fluid intake -Oral fluids -Ice chips

-Foods that tend to become liquids @ room temperature - Tube feedings -Parenteral fluid -IV medications -Blood transfusions -Catherter or tube irrigatns Output -

Urinary output Vomitus @ liquid feces Diaphoresis Tube drainage Wound drainage @ draining fistula

ECG placement of chest V1 - 4th ICS (R) sternum V2 4th ICS (L) sternum V3 between V2 @ V4 V4 5th ICS medclavicular line V5 4h ICS (L) anterior axillary line V6 5th ICS (L) midaxillary line Upper and lower limbs placement (R) arm red (R) foot black Red Yellow Green Brown Black violet

(L) arm yellow (L) fllt - green

ECG interpretation Lead 1, AVL, V5, V6 Lead II, III, AVF V1 & V2 V3 & V4 Defibrillation; VF, pulse less VT - Manual / automated - Monophasic / biphasic - Paddles / adhesive pads Paddle position Ant electrodes: Apex electrodes: Energy Rest 1st shock 2nd shock 3rd shock

Leteral wall Inferior wall Septal wall Anterior wall

@ upper (R) of the sternum placed to the (L) of the nipple w/ center @ MAL

200 J 200-300 J 360 J

Procedure: 1. Safety first 2. Apply gel

3. 4. 5. 6. 7.

Turn on defibrillator Select energy level Charge the capacitor Position paddle Deliver shock

Chant a. Im going to shock on three one Im clear (check if youre not in contact directly) b. Tow youre clear (shock that everyone is not in contact w/ pt) c. Three everybodys clear (re-check that no one else is in contact w/ pt.) (S S S E S L S A S) Shock Epinephrine Lidocaine Shock Atropine Shock Cardioversion for VT, atrila flutter, SVT, Supra VT Electrode placement RA (R) arm white white to (R) LA (L) arm black red to ribs LL (L) leg white black is what is left

Intravenous fluids Color Solution Orange D5NM Red D5W Green .9 NaCl Blue Plain LR (lactated ringers) Yellow D5 .9 NaCl Pink D5LR Light green D5NR Light blue D5 0.3 NaCl D5IMB

composition D5 0.3 NaCl 1L + 20 mEq KCl

D5W 1 L 335cc + 335 cc 0.9 NaCl

D5W 1l 335 cc + 335 CC 0.9 NaCl D5 0.15 NaCl 1L + 20 mEq KCl

Moss green White

Mannitol Dopamine D5 0.2 NaCl D5 0.45 NaCl D10 0.9 NaCl

D5W 1l 250cc + 250 cc 0.9 NaCl D5W 500cc + 500cc 0.9 NaCl D5 0.3 NaCl 500cc 50cc + 50 cc D5w

Drugs Given alone Aminophylline Ampicillin Ampotheracin Dextran Diazoxide Digoxin Photosensitivity Diazepam Epinephrine Furosemide Hydralizine

Diazepam Fusosemide Mannitol Phenobarbital Penothiazine pherytoin

Metronidazole Multivitamins Nitroprusside Terbutaline

Cold sensitive Metoclopromide

phenobarbital

Incompatible with IV heparin Aminoglycoside Ampicillin Barbiturates (flush w/ IVF 30 ml before giving meds) Can be diluted in D5W Epinephrine Dopamine Levanteranol NA nitro prusside

Drug stability Acyclovir Albumin Amikacin Amphothericin Chloramphenicol Expiration in hours Soln @ conc of 50 mg/ml @ 1530 C Discard unused portion Stable @ controlled room temp W/ water for injection 24 hrs @ room temp. Expiration under ref

23-32 C 1 wk protect from light 2-30 days

Ceftriaxone Cefuroxime Ciprofloxacin Cyclophosphamide Cytobine Hydrocortisone -mix o vial -dry pack Imiperom

6 C @ room temp 24 C @ room temp Photosensitive 24 C @ room temp Room temp -Unused soln discarded after 3 days -Use immediately H2O for injection w/in 1 hr only isotonic NaCl: 10 hrs Unused soln discarded Single used 48 hrs after mixing @ room temp. Single used Stable @ controlled room temp 4 hrs after reconstitution 3 days @ 25 C 24 hrs @ room temp. 4 wks. @ room temp. Multidose vial stableupto 14 days @ room -1 hr after reconstitution

24 hrs. 98 hrs 6 days 98 hrs.

Lipids Methotrexate Methyl pre + Na Metronidazole Netilmycin Omeprazole Oxacillin Piperacillin/tazocin Streptomycin Suxamethorium Urosyn/ampicillin -sulbactam Sancomycin Vincristine

14 days Single dose

Different techniques in giving drugs A. Thru soluset 1. 2. 3. 4.

Chloramphenicol Pen G Cloxacillin Cefepine ( 2gm)

5. 6. 7. 8.

Ceftriaxone Clindamycin Meroperom (pedia) Impenem (pedia)

B. Mixed w/ D5W 1. Azithromycin + 250 cc D5W 2. Imepenem + 100 cc PNSS 3. Aminophylline + 250 cc D5W

4. Gatifloxacin + 250 cc D5W 5. Ceftriaxone (pedia)

C. OB pt. 1. MgSO4 w/ soluset 2. Duvadilan (macroset) Mannitol D. IV infusion

3. Nicardipine (w/_ soluset) + 900 D5W

1. Ciprofloxacin (micro/macro) 2. Metronidazole macroset E. No skin testing / Required run test (10-15 mins. Macroset) 1. Azithromycin + 250 cc D5W 2. Moxifloxacin 3. Gatifloxacin + 250cc D5W 4. Levofloxacin Blood sample Lavander top (w/ Heparin) -CBC, Hgt, Hct, bld typing, typhidot Red top (w/o heparin) -bld chem. -Serum K, Na, Ca Black top (w/ heparin) -ESR (erythrocyte sedimentation rate) Blue top -PT (Prothrombine time) Greed top -Ammonia Orange Top -sputum GS, C/S Nasogastric Tube French # : 5 Gray 8 Blue 10 Black 12 white 14 Green 16 Orange 18 - Red

Suction Catheter French # : 10 Black 12 - White 14 Green 16 Orange 18 Red Indwelling Foley Catheter French # : 14 Green 16 Orange 18 Red

24 Blue Straight Catheter French # : 14 Green 16 Orange

IV Catherter Gauge # : 18 Green 20 Pink 22 Blue 24 Yellow

Glassgow Coma Scale Sub Scale Eye opeing Description Spontaneously To Speech To Pain Do not open Oriented Confused Inappropriate Speech Unintelligible Speech No Verbalization Obey Command Localized Pain Withdraw Dicorticate Deceribrate No motor Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Verbal Response

Motor Response

Interpretation of results 15-14 conscious 13-11 lethargy 10-8 stuporous 7-4 coma 3 deep coma

Conscious Lethargy Stupor Coma

awake drowsy or sleepy awake by pain (vigorously) stimulation light (+) painful stimulation Deep (-) painful stimulation

Conscious Lethargy Stuporous Comatose

Verbal (+) (+) (-) (-)

Tactile (+) (+) (-) (-)

Pain (+) (+) delayed (+) (-)

Muscle streght Grade 0/5 1/5 2/5 3/5 4/5 5/5 Tendon reflex O 1+ 2+ 3+ 4+ Absent Hypoactive Normal Hyperactive without clonus Clonus with movement no muscle movement visible muscle movement but no movement at joint movement at the joint but not against gravity movement against gravity but not against added resistance movement against resistance but less than normal normal strength

Activity

Respiration

Circulation

Consciousness

O2 saturation

Able to move 4 extremities Able to move 2 extremities Not able to move extremities voluntarily Able to breathe & cough Dyspnea or limited breathing Apnec BP + 20% of pre-anesthetic level BP + 21-49% of pre-anesthetic level BP + 50% of pre-anesthetic level Fully awake Arousable on calling Not responding Maintain o@ sat. >92% in room temp. Needs O2 to maintain O2 sat. >90% O2 sat. <90% worth O2 supplement

2 1 0 2 1 0 2 1 0 2 1 0 2 1 0

Stages of decubitus ulcer a. Redness o Compensatory mechanism b. Epidermis / Dermins

o o

Ulceration, pit-like Platelet clog (defence mechanism)

c. Subcutaneous o Foul smell d. Muscles / Bones Burns Classification 1st degree: 2nd degree: 3rd degree: 4th degree: Stages of burns 1st stage: 2nd stage: 3rd stage: shock / fluid accumulation -1st 48 hrs., IVC ISC diuretic / fluid remobilization -after 48 hrs., ISC IVC recovery -5th day onwards

epidermis, reddish, painful dermis, moist surface, with vesicle, painful subcutaneous layer, pearly white, no pain muscle & bones, blackish / charred, no pain

a. Major born injuries Partial thickness injury greater than 25% body surface area (>20% in children <10 y/o & adults >40 y/o) >10 % BSA, full thickness (children & adult) Involvement of face, eyes, feet, perineum b. Moderate burn injuries >15% - <25% BSA in adult, partial thickness (10% - 20% BSA In children <10y/o and adult >40 y/o) c. Minor burn injuries <15% BSA in adult (10% in children or elderly person) <2% BSA full thickness

Rule of 9 Adult Face, head, neck Anterior trunk Posterior trunk Left arm Right arm Left leg Right leg 9% 18% 18% 9% 9% 18% 18%

Genitalia

1%

Fluid replacement Types of fluids a. Colloids: blood, plasma expanders b. Electrolytes: lactated ringers c. Non-electrolytes: D5W Formulas Evans Formula C: 1ml x % burns x BW in kg E: 1ml X % burns x BW in kg N: 2000ml D5W

Brookes formula C: 0.5ml x % burns x BW in kg E: 1.5m; x % burns x BW in kg N 2000 ml D5W

Parkland formula (2-3 degree burn above 25% TBSA) 4ml LR x wt in kg x % TBSA 1st 24 hours - 1st 8 hrs. 50% of IV infusion - 2nd 8 hrs. 25% of IV infusion - 3rd 8 hrs. 25% of IV infusion

Functional use of space 1. Intimate zone (0-1 ft.) a. Visual distortion occurs b. Best for assessing breath & other body odors 2. Personal distance (1 to 4 ft.) a. Perceived as an extension of the self similar to a bubble b. Voice is moderate c. Body odors in apparent d. Most of the physical assessment occurs oat this distance 3. Social distance ( 4 to 12 ft.) a. Used for impersonal business transactions b. Perceptual information much less detailed c. Much of the interview occurs at this distance 4. Public distance (12ft +) a. Interaction with others impersonal b. Speakers voice must be projected c. Subtle facial expression imperceptible

Significance of elevation & depressed WBS count Types Nuetrophils Lymphocytes increase Bacterial infection, burns ,stress, inflammation Viral infection, some leukemias Decrease Radiation exposure, drug toxicity, vit. B deficiency, SLE Prolonged illness, immunosuppression, tx w/ cortisol

Monocytes

Eusinophils Basophils

viral or fungal infection, TB, some leukemias, other chronic disease Allergic reactions, parasitic infection, autoimmune disease Allergic reactions, leukemias, cancers, hypothyroidism

Bone marrow depression, tx w/ cortisol Drug toxicity, stress Pregnancy, ovulation, hyperthyoidism

Trauma T1-T4 Fracture T5-T9 T10-T12 liver, spleen, kidney, injuries pneumothorax, hemothorax

ruptured thoracic aorta, trachea or esophagus

Neurologic assessment Alcohol Encelopathy, endocrinpathy, electrolytes Insulin Opiods Uremia Trauma Infection Psychogenic Seizure, syncope

Serum Osmolality 2 (Na x K) + BUN = FBS 2.8 18 Normal value = 280-300 Creatine clearance Male = 140 (age x wt. kg) 70 x crea (mmol) 88.4 male cea x 0.85

Female =

Stages of renal failure 1 - >90 2 60-89

3 30-59 4 15-29 5 - <15 Cardiac enzymes & proteins Normal value CPK 25-2000 u/L CK-MB 0.9 mg/ml or 3% CK-ISO E2 of total CPK LDH 0-280 u/L LDH-1 20%-36% of total LDH <LDH 2

LDH-2

32-50% of total LDH > LDH-1

SGPT SGOT Myoglobin Trop I Trop T

<48 u/L <42 u/L 0-85g/ml 0.0 -0.1 mg/ml <0.18 mg/ml

Onset 3-8 hrs. prior to MI 6-10 hrs. prior to MI 2-5 days LDH-1 > LDH 2 12-24 hrs. prior to MI LDH-1 > LDH-2 12-48 hrs. prior to MI 8-12 hrs. 8-12 hrs. 1-2 hrs. 3-6 hrs. 3-5 hrs

Peak 16-30 hrs. 24 hrs.

Return to normal 4 days 72 hrs. 10 days 48 hrs

48 hrs.

18-30 hrs. 18-30 hrs. 4-8 hrs. 12-24 hrs. 24 hrs

12 hrs. 4-6 days 10-15 days

Killip classification of MI Killiop class I II Clinical presentation No signs of pulmonary or venous congestion Moderate heart failure or presence of bibasal rales, S3 gallop, tachypnea, or sighs of right heart failure including venous (JVP ) & hepatic congestion Severe heart failure, rales > 50 % of lung fields of pulmonary edema Shock with systolic pressure <90 mmHg & evidence of peripheral cyanosis, mental confusion & oliguria Expected hosp mortality 0-5 % 10-20 %

III

35-45 %

IV

85-95%

ABG interpretation FiO2 for age: (104-(age in years x 0.43))

1. (PaO2) = 713 x (present FiO2) PCO2) 0.8 2. (AaO2) = PO2 I (PaO2) 3. Desired FiO2 = FiO2 for age + PCO2 II (AaO2) 0.8 713 Pediatric advance life support Rapid cardiopulmonary assessment 1. Physical examination 2. Classification of physiologic status 3. Initial mgt. priorities Respiratory failure Tachypnea - Airway - ventilation - Breathing oxygenation A. Airway Clear Maintainable (positioning, suctioning) Unmaintainable w/ intubation B. Breathing Rate Effort/mechanics Skin color & temperature a. Potential (respiratory failure) i. Recognize caregiver ii. Position iii. O2 iv. NPO v. Pulse vi. Cardiac monitor b. Problem (respiratory failure) i. Separate to caregiver ii. Control airway iii. 100% FiO2 iv. Ventilation

x 100%

SHOCK -tachycardia Oxygenation Circulation perfusion

1. Circulation a. LOC b. Color c. Effort d. Temperature e. Capillary refill time LOC o o o o

f. g. h. i.

Heart rate Characteristic of pulse BP Urine output (1.2 ml/kg/hr)

Awake Voice (responsive to) Pain (responsive to) unresponsive

a. early shock increase HR poor system perfusion compensatory mechanism i. non-invasive (cannula/face mask) b. late signs weak pulse (central) altered mental status decrease urine output hypotension decompensation i. invasive (intubation/CPAP) Cardiac Pulmonary Failure - global deficit of ventilation, oxygenation and circulation Physical Status Classification o stable o respiratory failure potential probable o shock 100% FiO2 Vascular access 20cc/kg Re-assess o CP failure o CP arrest

Resuscitation Fluids Uses : Volume replacement Delivery f medication Fluid of choice: PNSS PLRS Drug delivery Drug must reach central circulation Central venous access is not required Intravascular

Intra-asseous needle: >6 years distal tibia (near medial malleolus) < 6 years proximal tibia Indication CP arrest Shock (decompensation) Intractable seizures

Drugs given through ET! LEAN Lidocaine Epinephrine Atropine Naloxone Resuscitation Drugs 1. Epinephrine Indication: Cardiac arrest Sympatomatic bradycardia unresponsive to ventilation & O2 administration Hypotension not r/t volume depletion

1:1000 (ampule) ET 1:10000 (0.1 epinephrine + 0.9 PNSS) IV/IO Endotrachial delivery
drug diluted in 3-5 cc PNSS instill via suction catheter

instill direcly positive pressure breaths

flush 3-5 cc PNSS

Epinephrine doses Indication Bradicardia

IV/IO dose 0.01 mg/kg

ET dose 0.1 mg/kg

0.1 ml/kg (1:10000) 1 mlg/kg (1:1000) Asystole / VT Same Same VT Same Same 2. Atropine sympatomatic bradycardia (no pulse) requires support of oxygenation & ventilation Dose: 0.02 mg/kg 0.01 mg (minimum dose) 0.5 mg (maximum dose) 3. Na bicarbonate (1meq/kg) aocumented acidosis when serum alkalinition required 4. Naloxone dose: narcotic induced respiratory depression 0.1 mg/kg for infants & children from birth to 5 y/o of age or upto 20 kg of body wt.

5. Ca Chloride hypocalrcemia, hyperlakemia, hypermagnesemia, Ca channel blocker overload Inotropics Dobutamine normotensive cardogenic shock Dopamine decrease dose improve renal, spastic blood increase dose - hypotension Drip 1. Epinephrine (PNSS) 0.6 x body wt. (kg) mg to add to diluents to make 100 ml volume 1 ml / hr delivers 0.1 mg/kg/min eg: Wt = 10 kg 0.3 mg/kg/min 0.6 x 10 kg = 6 mg = 6 cc + 94 cc PNSS x 3 cc/hr 2. Dopamine / Dobutamine (DW) 6 x body wt (kg) = mg to add to diluents to make 100 ml volume eg : wt = 10 kg 5 mg/kg/min 6 x 10 kg = 60 mg (shock: 40 mg/amp) = 1.5ml + 98.5 ml DW X 5 cc/hr eg: 20 kg x 0.6 = 12 mg = 12 cc + 88 cc PNSS dilute by facto of 10 (/10) infusion rate: 1 ml/hr increase by factor of OI (x10) 10 cc /hr

Trauma in pediatric pt. Head Extremity Abdomen Spine 59 % 26 % 12 % 2%

Cause of death 1. Airway compromise 2. Unrecognized hemorrhage

trauma

shock

hypoxia

hypotension

increase ICP

cerebral perfusion

ABC in trauma Airway Breathing Circulation Disability (rapid brief neurologic assessment) Exposure (body temperature)