10 Golden Rules for Administering Drug Safety

1. Administer the right drug2. Administer the right drug to the right pt.3. Administer the right dose4. Administer the right drug by the right route5. Administer the right drug at the right time6. Teach your pt. about the drug he is receiving7. Take a complete pt. drug history8. Find out if the pt. has any allergies9. Be aware of potential drug-drug or drug-food interaction10. Document each drug you administer

11 rights1. Right drug2. Right dose3. Right time4. Right route5. Right patient6. Right action7. Right preparation8. Right order9. Right approach10. Right arm11. Right documentation

Intake output

10 “u” - 1 ml1 pint - 500 ml1 tsp - 5 ml1 tbsp - 15ml1 cup - 180 ml1 glass - 240 ml1 gallon - 4 Li1 Li - 1000 ml1 oz - 30 ml1 ml - 15 gtts1 mg - 1000 ugtts1 gm - 1000 mg1 kg - 1000 gm1 kg - 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 RedV2 – 4th ICS (L) sternum YellowV3 – between V2 @ V4 GreenV4 – 5th ICS medclavicular line BrownV5 – 4h ICS (L) anterior axillary line BlackV6 – 5th ICS (L) midaxillary line violet

Upper and lower limbs placement(R) arm – red (L) arm – yellow(R) foot – black (L) fllt - green

ECG interpretationLead 1, AVL, V5, V6 Leteral wallLead II, III, AVF Inferior wallV1 & V2 Septal wallV3 & V4 Anterior wall

Defibrillation; VF, pulse less VT- Manual / automated- Monophasic / biphasic- Paddles / adhesive pads

Paddle positionAnt electrodes: @ upper (R) of the sternumApex electrodes: placed to the (L) of the nipple w/ center @ MAL

Energy Rest1st shock 200 J2nd shock 200-300 J3rd shock 360 J

Procedure:1. Safety first2. Apply gel

3. Turn on defibrillator4. Select energy level5. Charge the capacitor6. Position paddle7. Deliver shock

Chanta. I’m going to shock on three one I’m clear (check if you’re not in contact directly)b. Tow you’re clear (shock that everyone is not in contact w/ pt)c. Three everybody’s 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 ribsLL – (L) leg – white black is what is left

Intravenous fluidsColor Solution compositionOrange D5NM D5 0.3 NaCl 1L + 20 mEq KClRed D5WGreen .9 NaClBlue Plain LR (lactated ringer’s)Yellow D5 .9 NaCl D5W 1 L – 335cc + 335 cc 0.9 NaClPink D5LRLight green D5NRLight blue D5 0.3 NaCl D5W 1l – 335 cc + 335 CC 0.9 NaCl

D5IMB D5 0.15 NaCl 1L + 20 mEq KCl

Moss green MannitolWhite Dopamine

D5 0.2 NaClD5 0.45 NaClD10 0.9 NaCl

D5W 1l – 250cc + 250 cc 0.9 NaClD5W 500cc + 500cc 0.9 NaClD5 0.3 NaCl 500cc – 50cc + 50 cc D5w

Drugs Given aloneAminophyllineAmpicillinAmpotheracinDextranDiazoxideDigoxin

DiazepamFusosemideMannitolPhenobarbitalPenothiazinepherytoin

PhotosensitivityDiazepamEpinephrineFurosemideHydralizine

MetronidazoleMultivitaminsNitroprussideTerbutaline

Cold sensitiveMetoclopromide phenobarbital

Incompatible with IV heparinAminoglycosideAmpicillinBarbiturates (flush w/ IVF 30 ml before giving meds)

Can be diluted in D5WEpinephrineDopamineLevanteranolNA nitro prusside

Drug stabilityExpiration in hours Expiration under ref

Acyclovir Sol’n @ conc of 50 mg/ml @ 15-30 C

Albumin Discard unused portionAmikacin Stable @ controlled room temp 23-32 CAmphothericin W/ water for injection 24 hrs @

room temp.1 wk protect from light

Chloramphenicol 2-30 days

Ceftriaxone 6 C @ room temp 24 hrs.Cefuroxime 24 C @ room temp 98 hrsCiprofloxacin PhotosensitiveCyclophosphamide 24 C @ room temp 6 daysCytobine Room temp 98 hrs.Hydrocortisone-mix o vial

-dry pack

-Unused sol’n discarded after 3 days-Use immediately

Imiperom H2O for injection w/in 1 hr only isotonicNaCl: 10 hrs

Lipids Unused sol’n discardedMethotrexate Single usedMethyl pre + Na 48 hrs after mixing @ room

temp.Metronidazole Single usedNetilmycin Stable @ controlled room tempOmeprazole 4 hrs after reconstitutionOxacillin 3 days @ 25 CPiperacillin/tazocin 24 hrs @ room temp.Streptomycin 4 wks. @ room temp.Suxamethorium Multidose vial stableupto 14

days @ room Urosyn/ampicillin -sulbactam -1 hr after reconstitutionSancomycin 14 daysVincristine Single dose

Different techniques in giving drugs

A. Thru soluset1. Chloramphenicol2. Pen – G3. Cloxacillin4. Cefepine ( 2gm)

5. Ceftriaxone6. Clindamycin7. Meroperom (pedia)8. Impenem (pedia)

B. Mixed w/ D5W1. Azithromycin + 250 cc D5W2. Imepenem + 100 cc PNSS3. Aminophylline + 250 cc D5W

4. Gatifloxacin + 250 cc D5W5. Ceftriaxone (pedia)

C. OB pt.1. MgSO4 w/ soluset2. Duvadilan (macroset) Mannitol

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

D. IV infusion

1. Ciprofloxacin (micro/macro)2. Metronidazole – macroset

E. No skin testing / Required run test (10-15 mins. Macroset)1. Azithromycin + 250 cc D5W2. Moxifloxacin3. Gatifloxacin + 250cc D5W4. 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 – Gray8 – Blue10 – Black12 – white14 – Green16 – Orange18 - Red

Suction Catheter

French # : 10 – Black12 - White14 – Green16 – Orange18 – Red

Indwelling Foley Catheter

French # : 14 – Green16 – Orange18 – Red

24 – Blue

Straight Catheter

French # : 14 – Green16 – Orange

IV Catherter

Gauge # : 18 – Green20 – Pink22 – Blue24 –Yellow

Glassgow Coma Scale

Sub Scale Description ScoreEye opeing Spontaneously

To SpeechTo Pain

Do not open

4321

Verbal Response OrientedConfused

Inappropriate SpeechUnintelligible Speech

No Verbalization

54321

Motor Response Obey CommandLocalized Pain

WithdrawDicorticateDeceribrateNo motor

654321

Interpretation of results15-14 conscious13-11 lethargy10-8 stuporous7-4 coma3 deep coma

Conscious - awakeLethargy - drowsy or sleepyStupor - awake by pain (vigorously) stimulationComa - light (+) painful stimulation

Deep (-) painful stimulation

Verbal Tactile PainConsciousLethargyStuporousComatose

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

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

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

Muscle streght

Grade

0/5 no muscle movement1/5 visible muscle movement but no movement at joint2/5 movement at the joint but not against gravity3/5 movement against gravity but not against added resistance4/5 movement against resistance but less than normal5/5 normal strength

Tendon reflex

O Absent1+ Hypoactive2+ Normal3+ Hyperactive without clonus4+ Clonus with movement

Activity Able to move 4 extremitiesAble to move 2 extremitiesNot able to move extremities voluntarily

210

Respiration Able to breathe & coughDyspnea or limited breathingApnec

210

Circulation BP + 20% of pre-anesthetic levelBP + 21-49% of pre-anesthetic levelBP + 50% of pre-anesthetic level

210

Consciousness Fully awakeArousable on callingNot responding

210

O2 saturation Maintain o@ sat. >92% in room temp.Needs O2 to maintain O2 sat. >90%O2 sat. <90% worth O2 supplement

210

Stages of decubitus ulcer

a. Rednesso Compensatory mechanism

b. Epidermis / Dermins

o Ulceration, pit-likeo Platelet clog (defence mechanism)

c. Subcutaneouso Foul smell

d. Muscles / Bones

Burns

Classification1st degree: epidermis, reddish, painful2nd degree: dermis, moist surface, with vesicle, painful3rd degree: subcutaneous layer, pearly white, no pain4th degree: muscle & bones, blackish / charred, no pain

Stages of burns

1st stage: shock / fluid accumulation-1st 48 hrs., IVC – ISC

2nd stage: diuretic / fluid remobilization-after 48 hrs., ISC – IVC

3rd stage: recovery-5th day onwards

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 9% Anterior trunk 18% Posterior trunk 18% Left arm 9% Right arm 9% Left leg 18% Right leg 18% Genitalia 1%

Fluid replacement

Types of fluidsa. Colloids: blood, plasma expandersb. Electrolytes: lactated ringers’c. Non-electrolytes: D5W

Formulas Evan’s Formula

C: 1ml x % burns x BW in kgE: 1ml X % burns x BW in kgN: 2000ml D5W

Brooke’s formula

C: 0.5ml x % burns x BW in kgE: 1.5m; x % burns x BW in kgN 2000 ml D5W

Parkland formula(2-3 degree burn above 25% TBSA)

4ml LR x wt in kg x % TBSA1st 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 ½ ft.)a. Visual distortion occursb. Best for assessing breath & other body odors

2. Personal distance (1 ½ to 4 ft.)a. Perceived as an extension of the self similar to a bubbleb. Voice is moderatec. Body odors in apparentd. Most of the physical assessment occurs oat this distance

3. Social distance ( 4 to 12 ft.)a. Used for impersonal business transactionsb. Perceptual information much less detailedc. Much of the interview occurs at this distance

4. Public distance (12ft +)a. Interaction with others impersonalb. Speaker’s voice must be projectedc. Subtle facial expression imperceptible

Significance of elevation & depressed WBS count

Types increase DecreaseNuetrophils Bacterial infection, burns ,stress,

inflammationRadiation exposure, drug toxicity, vit. B deficiency, SLE

Lymphocytes Viral infection, some leukemias Prolonged illness, immunosuppression, tx w/ cortisol

Monocytes viral or fungal infection, TB, some leukemias, other chronic disease

Bone marrow depression, tx w/ cortisol

Eusinophils Allergic reactions, parasitic infection, autoimmune disease

Drug toxicity, stress

Basophils Allergic reactions, leukemias, cancers, hypothyroidism

Pregnancy, ovulation, hyperthyoidism

Trauma

T1-T4 Fracture ruptured thoracic aorta, trachea or esophagus

T5-T9 pneumothorax, hemothorax

T10-T12 liver, spleen, kidney, injuries

Neurologic assessment

AlcoholEncelopathy, endocrinpathy, electrolytesInsulinOpiodsUremiaTraumaInfectionPsychogenicSeizure, syncope

Serum Osmolality

2 (Na x K) + BUN = FBS2.8 18

Normal value = 280-300

Creatine clearance

Male = 140 – (age x wt. kg) 70 x crea (mmol)

88.4

Female = male cea x 0.85

Stages of renal failure

1 - >902 – 60-89

3 – 30-594 – 15-295 - <15Cardiac enzymes & proteins

Normal value Onset Peak Return to normalCPK 25-2000 u/L 3-8 hrs. prior to MI 16-30 hrs. 4 days

CK-MBCK-ISO E2

0.9 mg/ml or 3% of total CPK

6-10 hrs. prior to MI

24 hrs. 72 hrs.

LDH 0-280 u/L 2-5 days 10 daysLDH-1 20%-36% of total

LDH <LDH – 2LDH-1 >LDH – 2

12-24 hrs. prior to MI

- 48 hrs

LDH-2 32-50% of total LDH > LDH-1

LDH-1 >LDH-2

12-48 hrs. prior to MI

- 48 hrs.

SGPT <48 u/L 8-12 hrs. 18-30 hrs. -SGOT <42 u/L 8-12 hrs. 18-30 hrs. -

Myoglobin 0-85g/ml 1-2 hrs. 4-8 hrs. 12 hrs.Trop I 0.0 -0.1 mg/ml 3-6 hrs. 12-24 hrs. 4-6 daysTrop T <0.18 mg/ml 3-5 hrs 24 hrs 10-15 days

Killip classification of MI

Killiop class Clinical presentation Expected hosp mortalityI No signs of pulmonary or venous

congestion0-5 %

II Moderate heart failure or presence of bibasal rales, S3 gallop, tachypnea, or sighs of right heart failure including venous (JVP ) & hepatic congestion

10-20 %

III Severe heart failure, rales > 50 % of lung fields of pulmonary edema

35-45 %

IV Shock with systolic pressure<90 mmHg & evidence of peripheral cyanosis, mental confusion & oliguria

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 + PCO2II (AaO2) 0.8 x 100% 713

Pediatric advance life support

Rapid cardiopulmonary assessment

1. Physical examination2. Classification of physiologic status3. Initial mgt. priorities

Respiratory failureTachypnea

- 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. Positioniii. O2iv. NPOv. Pulse

vi. Cardiac monitor

b. Problem (respiratory failure)i. Separate to caregiver

ii. Control airwayiii. 100% FiO2iv. Ventilation

SHOCK-tachycardia

Oxygenation Circulation – perfusion

1. Circulationa. LOCb. Colorc. Effortd. Temperaturee. Capillary refill time

f. Heart rateg. Characteristic of pulseh. BPi. Urine output (1.2 ml/kg/hr)

LOCo Awakeo Voice (responsive to)o Pain (responsive to)o 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 Classificationo stableo respiratory failure

potential probable

o shock 100% FiO2 Vascular access 20cc/kg Re-assess

o CP failureo CP arrest

drug

instill via suction

catheter

flush 3-5 cc PNSS

positive pressure breaths

instill direcly

diluted in 3-5 cc PNSS

Resuscitation FluidsUses :

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!

LEANLidocaineEpinephrineAtropineNaloxone

Resuscitation Drugs

1. EpinephrineIndication:

Cardiac arrest Sympatomatic bradycardia unresponsive to ventilation & O2 administration Hypotension not r/t volume depletion

1:1000 (ampule) ET1:10000 (0.1 epinephrine + 0.9 PNSS) IV/IO

Endotrachial delivery

Epinephrine dosesIndication IV/IO dose ET doseBradicardia 0.01 mg/kg

0.1 ml/kg (1:10000)0.1 mg/kg1 mlg/kg (1:1000)

Asystole / VT Same SameVT Same Same

2. Atropine sympatomatic bradycardia (no pulse) requires support of oxygenation & ventilation

Dose:0.02 mg/kg0.01 mg (minimum dose)0.5 mg (maximum dose)

3. Na bicarbonate (1meq/kg) aocumented acidosis when serum alkalinition required

4. Naloxone narcotic induced respiratory depression

dose: 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

InotropicsDobutamine – normotensive cardogenic shockDopamine – decrease dose – improve renal, spastic blood

- increase dose - hypotension

Drip1. Epinephrine (PNSS)

0.6 x body wt. (kg) – mg to add to diluents to make 100 ml volume1 ml / hr delivers 0.1 mg/kg/min

eg: Wt = 10 kg 0.3 mg/kg/min0.6 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/min6 x 10 kg = 60 mg (shock: 40 mg/amp)

= 1.5ml + 98.5 ml DWX 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 59 % Extremity 26 %Abdomen 12 %Spine 2 %

Cause of death1. Airway compromise2. Unrecognized hemorrhage

ABC in trauma

AirwayBreathingCirculationDisability (rapid brief neurologic assessment)Exposure (body temperature)

trauma

hypoxia

increase ICP

cerebral perfusion

hypotension

shock