High Yield NSGY Pharm

High Yield NSGY Pharm

Drugs for LP

Try not to, but if you must you can use one of these on the floor without ICU team.
DRUG
DOSE AND ROUTE
USE FOR
Lido with epi
Needle-site pain, especially if anticipate you will try multiple levels as the bottle in LP kits has a very small volume adequate for only one level. Order this and ask nurse to get it ready on every single patient but don't open unless needed
Fentanyl
25 mg IV for normal sized adult 
can go up to 50 mg IV for large people (>100kg)
If no access, same doses intranasally will work
Ativan (Lorazepam)
0.5mg-1mg PO  or 0.5mg-1.0mg IV
Ketamine
0.3 mg/kg max of 35 mg over 15 minutes in an NS bag
only use if in the ICU; key is to push it slow to not cause laryngospasm! This rate is slow and likely will be ok on the floor.

Drugs for MRI

MRI will frequently page you that a patient is freaking out/ in too much pain to sit still for an MRI.
Return the call immediately and dose one of the following drugs.
Remember rules for conscious sedation at PUH only allow you to dose 1 at a time w/o ICU presence and certainly with just an MRI nurse (see below).
TIP: if you know a pt is likely to freak out or be in too much pain to stay still, order one of the drugs below PRN and specify in comments to use in MRI if needed (save yourself a page).
NOTE: when ordering any of these drugs which may depress respiration, there is no harm in playing it safe and just putting the patient on a cardiac monitor with pulse ox. This is something that can easily go into the scanner with the patient, no reason not to do it.
DRUG
DOSE AND ROUTE
USE FOR
Valium
5mg PO, 2.5mg IV
Anxiety / Agitation / claustrophobia
Dilaudid
0.2mg IV (0.5 if large / non-opioid ideally, naive only if "<65")
Pain
Ativan
0.5mg-1mg PO  or 0.5mg-1.0mg IV
Anxiety / Agitation / claustrophobia
Zyprexa (olanzapine)
start w/ 2.5 P.O. if geriatric / small / TBI 
up 5.0mg ODT/IM if excessive agitation / large 
up to 10mg max
Agitation

Anticoagulants / Antiplatelets

 
Drug
MOA
Dosing
Reversal
Notes
Aspirin
COX1 inhibitor
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Plavix (clopidogrel)
P2Y12 receptor antagonism
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Brillinta (ticagrelor)
P2Y12 receptor antagonism
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Effient (prasugrel)
P2Y12 receptor antagonism
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Integrellin (eptifibatide)
Gp IIb/IIIa inhibition
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Pradaxa (dabigatratan)
direct thrombin inhibition
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Idarucizumab
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Eliquis (apixaban)
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Xarelto (rivaroxaban)
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Reversal Agents x Drugs

Reversal Agent
Contents / Mechanism
Drugs reversed
Labs affected
NOTES
Vitamin K
FFP
tPA (2nd line)
#2 option for tPA reversal
4 Factor PCC (K Centra)
Xarelto (rivaroxaban)
Cryoprecipitate
fibrinogen, vWF, fibronectin
Factor 7, AT-III
tPA
Fibrinogen
tPA depletes fibrinogen (contained in cryo)
Protamine
TXA
tPA (2nd line)
#2 option for tPA reversal
Tranexamic acid
TXA protocol for cSDH medical management
  • TAX 650 mg PO BID for 14 days, 28 tabs
  • Atorvastatin 40 mg daily until follow up
 
 

ICP Controls

Drug
Dosing
Notes
Mannitol
0.5- to 1-g/kg bolus for ICP reduction
- can also act as a free radical scavenger and decrease blood viscosity resulting in a transient elevation of CBF.
 

    Analgesics

    Tylenol

    Drug
    Dosing
    Notes
    APAP
    1g q6H
    unless liver concerns or patient is also on Norco (which has tylenol), no reason to not max someone in pain out on standing 4g of tylenol daily

    Narcotics / Narcotic Drips

    Drug
    Dosing
    Notes
    Oxy IR
    5.0 for mod 4-6 pain
    10 for severe 7-10 pain
    2.5 is a baby dose sometimes effective
    For discharge Rx: generally, ordering 5mg tabs x 28 will be the most painless for you, as more will require insurance authorization.
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    Drips (ok for floor)

    Drug
    Dosing
    Notes
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    NSAIDs

    Drug
    Dosing
    Notes
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    Muscle relaxers

    Drug
    Dosing
    Notes
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    Neuropathic pain

    Drug
    Dosing
    Notes
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    Topical

    Drug
    Dosing
    Notes
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    Other

    Drug
    Dosing
    Notes
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    Antiseizure medicines (ASMs) / Antiepileptic Drugs (AEDs)

    ❗
    AEDs are not harmless and should be thoughtfully prescribed. 2008 meta-analysis of 199 RCTs of 11 AEDs showed risk of suicidality 2x as high
    https://www.nejm.org/doi/full/10.1056/NEJMoa0909801

    Keppra

    • does NOT have significant hepatic enzyme interaction
    • consider giving instead of fospheny in < 80 year-olds if complex meds list

    Phenobarbital

    • MOA in trauma: decreased cerebral metabolic rate (less synaptic transmission), shunt blood from normal perfusion to reduced CBF, decreased nitrogen excretion, higher intracerebral glucose, glucagon energy stores

    Benzo-diazepenes

    MOA: GABA A receptor activators → Cl- ion channel gets activated → anion influx and hyperpolarization → anxiolysis, amnesia, sedation, hypnosis, anticonvulsant
    Drug
    Dosing
    Use
    Alprazolam (Xanax)
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    Clonazepam (Klonopin)
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    Diazepam (Valium)
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    duration of AED effect: 15-30 min
    Lorazepam (Ativan)
    0.5 - 1.0 mg PO for anxiolysis
    0.1 mg/kg (up to 2mg) for seizures
    duration of AED effect: 12-24 hrs
    Midazolam (Versed)
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    Baclofen

    Mechanism: GABA B activation → muscle spasticity
    • inhibitory NT
    • blocks monosynaptic/polysynaptic reflexes

    Neurostimulation

    Drug
    MOA
    Dosing
    Notes
    Amantadine
    NMDA antagonist
    50-100 bid to TID
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    Anti-hypertensives