SUCCINYLCHOLINE (Anectine)

Class: Neuromuscular blocker, depolarizing

Action: Competes with the acetylcholine receptor of the motor end plate on the muscle cell, resulting in muscle
paralysis.
Indications: To induce neuromuscular blockade for the facilitation of ET intubation.
Contraindications: Malignant hyperthermia, burns, trauma. Use with caution in children, cardiac disease, hepatic
disease, renal disease, peptic ulcer disease, cholinesterase-inhibitor toxicity, pseudocholinesterase deficiency, digitalis
toxicity, glaucoma, hyperkalemia, hypothermia, rhabdomyolysis, myasthenia gravis.
Precautions: IV administration results in neuromuscular blockade in 0.5 to 1 min. IM administration results in
neuromuscular blockade in 2 to 3 min. IV administration in infants and children can potentially result in profound
bradycardia and, in some cases, asystole. The incidence of bradycardia is greater after the second dose. Occurrence of
bradycardia can be reduced with the pretreatment of atropine. Succinylcholine can have a significantly prolonged effect
in the setting of poisoning with nerve gas agents and organophosphate pesticides. Pregnancy class C
Side effects: Anaphylactoid reactions, respiratory depression, apnea, bronchospasm, cardiac arrhythmias, malignant
hyperthermia, hypertension, hypotension, muscle fasciculation, postprocedure muscle pain, hypersalivation, rash.
Dosage/Route: Adult – IV: 0.6 mg/kg IV, IO (range 0.3-1.1 mg/kg)
IM: 3-4 mg/kg (max dose: 150 mg)
Pediatric – IV: Adolescents and older children, 1 mg/kg IV, IO
Small children and infants: 2mg/kg IV, IO
IM: 3-4 mg/kg (max dose: 150 mg)

ATROPINE SULFATE
Class: Anticholinergic (antimuscarinic)
Action: Competes reversibly with acetylcholine at the site of the muscarinic receptor. Receptors affected, in order from
the most sensitive to the least sensitive, include salivary, bronchial, sweat glands, eye, heart, and GI tract.
Indications: Symptomatic bradycardia, asystole or PEA, nerve agent exposure, organophosphate poisoning.
Contraindications: Acute MI, myasthenia gravis, GI obstruction, closed-angle glaucoma, known sensitivity to
atropine, belladonna alkaloids, or sulfites. Will not be effective for infranodal (type II) AV block and new third-degree
block with wide QRS complex.
Precautions: Half-life is 2.5 hours. Pregnancy class C, possibly unsafe in lactating mothers.
Side effects: Decreased secretions resulting in dry mouth and hot skin temperature, intense facial flushing, blurred
vision or dilation of the pupils with subsequent photophobia, tachycardia, restlessness. Atropine may cause paradoxical
bradycardia if the dose administered is too low or if the drug is administered too slowly.
Dosage/route: Symptomatic Bradycardia:
Adult – 0.5 mg IV, IO every 3-5 min (max dose: 3 mg)
Adolescent – 0.02 mg/kg (min: 0.1 mg/dose, max: 1 mg/dose) IV, IO up to a total dose of 2 mg
Pediatric – 0.02 mg/kg (min: 0.1 mg/dose, max: 0.5 mg/dose) IV, IO up to a total dose of 1 mg
Asystole/PEA:
1 mg IV, IO every 3-5 min (max dose: 3mg). May be administered via ET tube at 2-2.5 mg diluted
in 5-10 ml of water or normal saline.
Nerve Agent or Organophosphate poisoning:
Adult – 2-4 mg IV, IM; repeat if needed every 20-30 min until symptoms dissipate. In severe cases,
the initial dose can be as large as 2-6 mg administered IV. Repeat doses of 2-6 mg can be
administered IV, IM every 5-60 min.
Pediatric – 0.05 mg/kg IV, IM every 10-30 min PRN until symptoms dissipate.
Infants <15 lb – 0.05 mg/kg IV, IM every 5-20 min PRN until symptoms dissipate.
ROCURONIUM (Zemuron)
Class: Neuromuscular blocker, nondepolarizing
Action: Antagonizes acetylcholine at the motor end plate, producing skeletal muscle paralysis.
Indications: To induce neuromuscular blockade for the facilitation of ET tube intubation.
Contraindications: Known sensitivity to bromides. Use with caution in heart disease, liver disease.
Precautions: Onset of action is 2-8 min. Duration of action is 31 min. Pregnancy class B.
Side effects: Muscle paralysis, apnea, dyspnea, respiratory depression, sinus tachycardia, urticardia.
Dosage/route: Adult – 0.6 to 1.2 mg/kg IV, IO
Pediatric (older than 3 mos.) – 0.6 mg/kg IV, IO

VECURONIUM (Norcuron)
Class: Neuromuscular blocker, nondepolarizing
Action: Antagonizes acetylcholine at the motor end plate, producing skeletal muscle paralysis.
Indications: To induce neuromuscular blockade for the facilitation of ET tube intubation.
Contraindications: Known sensitivity to bromides. Use with caution in heart disease, liver disease.
Precautions: Pregnancy class C.
Side effects: Muscle paralysis, apnea, dyspnea, respiratory depression, sinus tachycardia, urticardia.
Dosage/route: Adult – 0.08 to 0.1 mg/kg IV, IO
Pediatric – Dosage is individualized

ATRACURIUM (Tracrium)
Class: Neuromuscular blocker, nondepolarizing
Action: Antagonizes acetylcholine at the motor end plate, producing muscle paralysis.
Indications: Neuromuscular blockade for the facilitation of ET tube intubation.
Contraindications: Cardiac disease, electrolyte abnormalities, dehydration, known sensitivity.
Precautions: Do not give by IM injection. Pregnancy class C.
Side effects: Flushing edema, urticardia, pruritus, bronchospasm and/or wheezing, alterations in HR, decreased BP.
Dosage/route: Adult – 0.4 to 0.5 mg/kg IV, IO; repeat with 0.08 to 0.1 mg/kg every 20-45 min PRN.
Pediatric – Older than 2 yrs: Same as adult dosing.
Younger than 2 yrs: 0.3 to 0.4 mg/kg IV, IO

PANCURONIUM (Pavulon)
Class: Neuromuscular blocker, nondepolarizing
Action: Antagonizes acetylcholine at the motor end plate, producing skeletal muscle paralysis.
Indications: To induce neuromuscular blockade for the facilitation of ET tube intubation.
Contraindications: Known sensitivity to bromides. Use with caution in heart disease, renal disease.
Precautions: Pregnancy class C.
Side effects: Muscle paralysis, apnea, dyspnea, respiratory depression, cutaneous flushing, sinus tachycardia.
Dosage/route: Adult – 0.04 to 1 mg/kg IV, IO; repeat dosing is 0.01 mg/kg every 25-60 min.
Pediatric – Same as adult dosing.
MIDAZOLAM (Versed)
Class: Benzodiazepine, Schedule C-IV
Action: Binds to the benzodiazepine receptor and enhances the effects of the brain chemical (neurotransmitter) GABA.
Benzodiazepines act at the level of the limbic, thalamic, and hypothalamic regions of the CNS to produce short-acting
CNS depression (including sedation, skeletal muscle relaxation, and anticonvulsant activity.
Indications: Sedation, anxiety, skeletal muscle relaxation.
Contraindications: Acute-angle glaucoma, pregnant women, known sensitivity.
Precautions: Patients receiving midazolam require frequent monitoring of vital signs and pulse oximetry. Be prepared
to support patient’s airway and ventilation. Pregnancy class D.
Side effects: Respiratory depression, respiratory arrest, hypotension, nausea/vomiting, headache, hiccups, cardiac
arrest.
Dosage/route: Sedation:
Adult – Healthy and <60 yrs: Some patients require as little as 1 mg IV, IO. No more than 2.5 mg
should be given over a 2 min interval. If additional sedation is required, continue to
administer small increments over 2 min periods (max dose: 5 mg). If the patient has also
received a narcotic, he or she will typically require 30% less midazolam than the same
patient not given the narcotic.
>60 yrs and debilitated or chronically ill patients: This group of patients has a higher risk
of hypoventilation, airway obstruction, and apnea. The peak clinical effect can take
longer in these patients; therefore dose increments should be smaller, and the rate of
injection should be slower. Some patients require a dose as small as 1 mg IV, IO, and no
more than 1.5 mg should be given over a 2 min period. If additional sedation is required,
additional midazolam should be given at a rate of no more than 1 mg over a 2 min period
(max dose: 3.5 mg). If the patient has also received a narcotic, he or she will typically
require 50% less midazolam than the same patient not given the narcotic.
Continuous infusion: Continuous infusions can be required for prolonged transport of
intubated, critically ill, and injured patients. After an initial bolus dose, the adult patient
will require a maintenance infusion dose of 0.02 go 0.1 mg/kg/hr (1-7 mg/hr).
Pediatric (weight-based) – Pediatric patients typically require higher doses of midazolam than do
adults on the basis of weight (in mg/kg). Younger pediatric patients (<6 yrs) require higher doses
(in mg/kg) than older pediatric patients. Midazolam takes approx. 3 min to reach peak effect,
therefore wait at least 2 min to determine effectiveness of drug and need for additional dosing.
12-16 yrs: Same as adult dosing. Some patients in this age group require a higher dose
than used in adults, but rarely does a patient require more than 10 mg.
6-12 yrs: 0.025 to 0.05 mg/kg IV, IO up to a total dose of 0.4 mg/kg. Exceeding 10 mg as
total dose usually is not necessary.
6 mos to 5 yrs: 0.05 to 0.1 mg/kg IV, IO up to a total dose of 0.6 mg/kg. Exceeding 6 mg
as a total dose usually is not necessary.
Younger than 6 mos: Dosing recommendations for this age group is unclear. Because this
age group is especially vulnerable to airway obstruction and hypoventilation, use small
increments with frequent clinical evaluation. Dose: 0.05 to 0.1 mg/kg IV, IO.
FLUMAZENIL (Romazicon)
Class: Benzodiazepine receptor antagonist, antidote
Action: Competes with benzodiazepines for binding at the benzodiazepine receptor, reverses the sedative effects of
benzodiazepines.
Indications: Benzodiazepine oversedation
Contraindications: Cyclic antidepressant overdose, life-threatening conditions that require treatment with
benzodiazepines such as status epilepticus and intra cranial hypertension, known sensitivity to flumazenil or
benzodiazepines. Use with caution where there is the possibility of unrecognized benzodiazepine dependence and in
patients who have a history of substance abuse or who are known substance abusers.
Precautions: Monitor for signs of hypoventilation and hypoxia for approx 2 hrs. If the half-life of the benzodiazepine
is longer than flumazenil, an additional dose may be needed. May precipitate withdrawal symptoms in patients
dependent on benzodiazepines. Flumazenil has not been shown to benefit patients who have overdosed on multiple
drugs. Pregnancy class C.
Side effects: Resedation, seizures, dizziness, pain at injection site, nausea/vomiting, diaphoresis, headache, visual
impairment.
Dosage/route: Adult – Initial dose is 0.2 mg IV, IO over a 15 sec period. If the desired effect is not observed after
45 sec, administer a second 0.2 mg does, again over a 15 sec period. Doses can be repeated a total
of four times until a total dose of 1 mg had been administered
Pediatric – Children older than 1 yr, 0.01 mg/kg IV, IO given over a 15 sec period. May repeat in
45 sec and then every minute to a max cumulative dose of 0.05 mg/kg or 1 mg, whichever is the
lower dose.

ETOMIDATE (Amidate)
Class: Hypnotic, anesthesia induction agent
Action: Although the exact mechanism is unknown, etomidate appears to have GABA-like effects.
Indications: Induction for rapid sequence intubation and pharmacologic-assisted intubation, induction of anesthesia.
Contraindications: Known sensitivity. Use in pregnancy only if the potential benefits justify the potential risk to the
fetus. Do not use during labor and avoid in nursing mothers.
Precautions: Etomidate is used to prepare a patient for orotracheal intubation. Both personnel and equipment must be
present to manage the patient’s airway before administration. Pregnancy class C.
Side effects: Hypotension, respiratory depression, pain at the site of injection, temporary involuntary muscle
movements, frequent nausea/vomiting on emergence, adrenal insufficiency, hyperventilation, hypoventilation, apnea of
short duration, hiccups, laryngospasm, snoring, tachypnea, hypertension, cardiac arrhythmias.
Dosage/route: Adult – 0.2 to 0.6 mg/kg slow IV, IO (over 30-60 sec). A typical adult intubating dose of etomidate
is 20 mg slow IV. Consider less (e.g., 10 mg) in the elderly or patients with cardiac conditions.
Pediatric – Older than 10 yrs: Same as adult dosing.
Younger than 10 yrs: Safety has not been established.
KETAMINE (Ketalar)
Class: General anesthetic
Action: Produces a state of anesthesia while maintaining airway reflexes, heart rate, and blood pressure.
Indications: Pain and as anesthesia for procedures of short duration.
Contraindications: Patients in whom a significant elevation in blood pressure would be hazardous (hypertension,
stroke, head trauma, increased intracranial mass or bleeding, MI). Use with caution in patients with increased ICP or
increased intraocular pressure (glaucoma) and patients with hypovolemia, dehydration, or cardiac disease (especially
angina and CHF).
Precautions: Pregnancy class C.
Side effects: Emergence phenomena, hypertension and sinus tachycardia, hypotension and sinus bradycardia, other
cardiac arrhythmias (rare), respiratory depression, apnea, laryngospasm and other forms of airway obstruction (rare),
tonic and clonic movements, vomiting.
Dosage/route: IV, IO:
Adult – 1 to 4.5 mg/kg IV, IO. 1-2 mg/kg produces anesthesia usually within 30 sec that typically
lasts 5-10 min.
Pediatric – 0.5 to 2 mg IV, IO over a 1 min period.
IM:
Adult – 6.5 to 13 mg/kg IM. 10 mg/kg IM is capable of producing anesthesia within 3-4 min with
an effect typically lasting 12-25 min. In adults, concomitant administration of 5-15 mg of diazepam
reduces the incidence of emergence phenomena.
Pediatric – 3 to 7 mg IM.