Answer: Treatment of paroxysmal supraventricular tachycardia (PSVT) including that associated with accessory bypass tracts (Wolff-Parkinson-White syndrome); when clinically advisable, appropriate vagal maneuvers should be attempted prior to adenosine administration; not effective in atrial flutter, atrial fibrillation, or ventricular tachycardia

Paroxysmal supraventricular tachycardia (Adenocard®): I.V. (rapid - over 1-2 seconds, via peripheral line): 6 mg; if not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed; maximum single dose: 12 mg.

Follow each I.V. bolus of adenosine with normal saline flush.

High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.

ANSWER:  50% Magnesium Sulfate Injection, USP must be diluted to a concentration of 20% or less prior to I.V. infusion (typically 1-2 gm diluted in 50-100ml NSS). Rate of administration should be slow and cautious, to avoid producing hypermagnesemia. The 50% solution also should be diluted to 20% or less for intramuscular injection in infants and children. The adverse effects of parenterally administered magnesium usually are the result of magnesium intoxication. These include flushing, sweating, hypotension, depressed reflexes, flaccid paralysis, hypothermia, circulatory collapse, cardiac and central nervous system depression proceeding to respiratory paralysis. Magnesium intoxication is manifested by a sharp drop in blood pressure and respiratory paralysis. Disappearance of the patellar reflex is a useful clinical sign to detect the onset of magnesium intoxication. In the event of overdosage artificial ventilation must be provided until a calcium salt can be injected intravenously to antagonize the effects of magnesium.

Answer:  The United States Pharmacopeia (USP) is the official public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States. USP sets standards for the quality of drug products and works with healthcare providers to help them meet the standards. Chapter 797 will affect anyone or any facility that handles injectables and other products that require sterility. This includes injections, aqueous bronchial and nasal inhalations, baths and soaks for live organs and tissues, irrigations for wounds and body cavities, ophthalmic drops and ointments, and tissue implants. USP 797 went through its final revision approval in December. The new standard becomes official June 1, 2008.

Please contact JDJ Consulting for assistance in meeting these standards.

Answer: All of the volatile inhalation anesthestics and one muscle relaxant, Succinycholine.

Remember, JDJ Consulting offers annual MH drills to all current clients.

http://www.fda.gov/bbs/topics/NEWS/2008/NEW01858.html

http://www.fda.gov/cder/drug/InfoSheets/HCP/fluoroquinolonesHCP.htm

http://www.fda.gov/cder/drug/infopage/fluoroquinolones/default.htm

Contact JDJ Consulting for additional information.

Answer: Give 300 mg diluted in a volume of 20 to 30 ml of 5% dextrose in water via IV push. For recurrent ventricular fibrillation/pulseless ventricular tachycardia, a 2nd dose of 150 mg IV may be given. Do not exceed 2g total in any 24h period.

JDJ writes: Federal DEA requirements for all facilities with controlled substances:

Code of Federal Regulations

Section 1304.11 Inventory Requirements

(a) General requirements. Each inventory shall contain a complete and accurate record of all controlled substances on hand on the date the inventory is taken, and shall be maintained in written, typewritten, or printed form at the registered location. An inventory taken by use of an oral recording device must be promptly transcribed. Controlled substances shall be deemed to be “on hand” if they are in the possession of or under the control of the registrant, including substances returned by a customer, ordered by a customer but not yet invoiced, stored in a warehouse on behalf of the registrant, and substances in the possession of employees of the registrant and intended for distribution as complimentary samples. A separate inventory shall be made for each registered location and each independent activity registered, except as provided in paragraph (e)(4) of this section. In the event controlled substances in the possession or under the control of the registrant are stored at a location for which he/she is not registered, the substances shall be included in the inventory of the registered location to which they are subject to control or to which the person possessing the substance is responsible. The inventory may be taken either as of opening of business or as of the close of business on the inventory date and it shall be indicated on the inventory.

(b) Initial inventory date. Every person required to keep records shall take an inventory of all stocks of controlled substances on hand on the date he/she first engages in the manufacture, distribution, or dispensing of controlled substances, in accordance with paragraph (e) of this section as applicable. In the event a person commences business with no controlled substances on hand, he/she shall record this fact as the initial inventory.

(c) Biennial inventory date. After the initial inventory is taken, the registrant shall take a new inventory of all stocks of controlled substances on hand at least every two years. The biennial inventory may be taken on any date which is within two years of the previous biennial inventory date.

Answer: Methemoglobinemia

Extra Credit: What is the treatment for methemoglobinemia?

Answer: Methylene Blue

Contact  JDJ Consulting for dosing guidelines.

Answer: Reconstitute a 1gm vial and then add to 250ml NSS. Infuse over at least 60 minutes.

Extra credit: What will occur if Vancomycin is run too rapidly?

Answer: 

Red man syndrome may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities. If this should occur, slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume. Reactions are often treated with antihistamines and steroids.

Answer: Date, time, MD signature, drug name, strength, dose, route, schedule and if prn, the order must include the indication for use.