Pharmacology Book

PHARMACOLOGY
AND DRUG ADMINISTRATION

for Imaging Technologists
This page intentionally left blank
PHARMACOLOGY
AND DRUG ADMINISTRATION
for Imaging Technologists
SECOND EDITION
Steven C. Jensen, RT(R),

PhD Director, Radiologic Sciences
Program College of Applied Sciences
and Arts Southern Illinois University—
Carbondale
Carbondale, Illinois
Michael P. Peppers, RPh, PharmD

Clinical Pharmacist
Des Peres
Hospital St. Louis,
Missouri
11830 Westline Industrial Drive
St. Louis, Missouri 63146
PHARMACOLOGY AND DRUG ADMINISTRATION FOR ISBN-13: 978-0-323-03075-5

IMAGING TECHNOLOGISTS, SECOND EDITION ISBN-10: 0-323-03075-0
Copyright © 2006, 1998 by Mosby, Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the respon-
sibility of the practitioner, relying on their own experience and knowledge of the patient, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Authors
assumes any liability for any injury and/or damage to persons or property arising out or related to
any use of the material contained in this book.
The Publisher
ISBN-13: 978-0-323-03075-5
ISBN-10: 0-323-03075-0
Acquisitions Editor: Jeanne Wilke

Developmental Editor: Rebecca Swisher
Publishing Services Manager: Julie
Eddy Project Manager: Joy Moore
Design Project Manager: Bill Drone
Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife, Cathy,
for your love, support, intelligence, beauty, and patience.
To Jordan and Emily

for making me laugh and reminding
me what this life is all about.
And to my parents, Bob and Joan,

for teaching me the value of hard work
and dedication to family.
S.J.
To my mother, Carol Eaton,

for all your countless hours of work and love when
providing for three children in the hardest of times.
To my stepfather, Jim Eaton,

for coming into our lives when you did.
To my brother, Martin Peppers,

and sister, Joan Denman,
for just being there in times of need.
And to my twin daughters, Brooke and Brittany,

for whom there is no greater love than
the love this father has for them!
M.P.
Reviewers
JULIE A. BENSON, MHA, MN, ARNP LEONARD L. NAEGER, BS, MS, PhD, RPh
Tacoma Community College Professor of Pharmacology
Tacoma, Washington St. Louis College of Pharmacy
St. Louis, Missouri
DEANNA BUTCHER, MA, RT(R)
Program Director PAULA PATE-SCHLODER, MS, RT(R)(CV)(CT)(VI)
St. Luke’s Associate Professor
College Sioux College Misericordia
City, Iowa Dallas, Pennsylvania
RICHARD R. ESPINOSA, RPh, PharmD MARY SEBACHER, MEd, RT(R)
Department Chair for Allied Health Clinical Assistant Professor
Sciences and Associate Professor University of Missouri––Columbia
Austin Community Columbia, Missouri
College Austin, Texas
ERICA KOCH WIGHT, MEd, RT(R)(M)(QM)
DIANE H. GRONEFELD, MEd, RT(R)(M) Program Director and Assistant Professor
Associate Professor University of Alaska––Anchorage
Northern Kentucky University Anchorage, Alaska
Highland Heights, Kentucky
RAY WINTERS, MS, RT(R)(CT)
LINDA M. HOMOLKA, BA, RT(R) Associate Professor and Chair of
Medical Imaging Instructor Radiologic Sciences
Owens State Community Arkansas State University
College Toledo, Ohio Jonesboro, Arkansas
JEANNEAN HALL ROLLINS, MRC, RT(R)(CV)
Associate Professor, Radiologic Sciences
Arkansas State University
Jonesboro, Arkansas
vii
Preface
Our intent in writing this textbook is to help

students in the medical imaging professions OUR MISSION
better understand the importance of
pharmacologic principles and practices in The mission of Pharmacology and Drug
patient care. Some technologists do not Administration for Imaging Technologists is to
become fully aware of their role in “real”
patient care until they actually begin practicing
their profession.
The strengths of this textbook for both
student and instructor are:
●
Clear and understandable content
●
Measureable learning objectives at the
beginning of every chapter
●
A “Key Terms” list at the beginning of
every chapter
●
Interesting and entertaining “Did you know?”
boxes throughout the text
●
“Alert!” symbols to draw attention
to adverse drug reactions or toxic
effects
●
Learning exercises and sample quiz/test
questions at the end of each chapter
●
Online instructor’s materials including teaching
strategies, supplemental activities, student
handout materials, and test questions.
(NEW!)
A pharmacology textbook is never “finished.”
There are always new drugs, contrast media,
radionuclides, and techniques on the market
and new information available about existing
products. The available information seems
endless, and it is a tremendous challenge to
acquire enough knowledge to be a safe
practitioner. We have made every effort to
make the content very current by including
discussions of contemporary and traditional
medications and contrast media, common
problems, up-to-date regulations, legal issues
for technologists administering drugs, and
emergency pharmacology. Particular attention has
been paid to intravenous introduction of
contrast media, drug nomenclature, and the
physiologic processes responsible for drug
actions.
ix
focus on essential information that

technologists need to know for safe
administration of drugs; to clearly present this
complex subject so readers can easily
understand this material; and to provide a
consistent, practical format and design with
illustrations and tables that will aid readers in
comprehension.
Nothing teaches the imaging technologist
more about pharmacology than actually giving
medications to the patient. Students should
approach each encounter with a patient as an
opportunity to learn. As a student or practicing
technologist, you should accept it as a
personal challenge to learn about each
medication (contrast agent, radionuclide, and
so on) ordered for a patient under your care
and to understand why the medication is given
in that particular situation. Because
pharmacology is a rapidly changing and dynamic
field, we recommend that you be exposed to
supplemental drug information, such as package
inserts or current drug handbooks. We
encourage you to develop the habit of seeking
up- to-date and timely information to
supplement this book to provide specific details
that cannot be covered in a textbook.
PATIENT CARE
In working with patients, you will quickly learn
that medication administration is one of the
most challenging components of your role as a
technologist. A technologist who develops the
knowledge and skills needed to competently
administer medications is highly visible and will
gain the respect of both patients and
colleagues in the health care system. Both the
responsibilities and the personal rewards are
great.
We welcome your suggestions or
comments on this book so that we may
continue to provide a clear and useful
exposition of introductory pharmacology in
future editions.
Steven C. Jensen
Michael P. Peppers
Preface
xi
Acknowledgments
I wish to acknowledge the mental stimulation and opened doors for me that were otherwise
I have received from the many students who closed. I acknowledge my emergency
have asked challenging questions throughout medicine/ critical care preceptors, Joseph
my 30 years as a teacher at Southern Illinois Barone, PharmD, and Wesley Byerly, EMT-P,
University, Morehead State University, Western PharmD, for instilling in me the importance of
Wisconsin Technical Institute in Lacrosse, never quitting in my quest for information and the
Wisconsin, and Mercy Hospital in Cedar Rapids, importance of maintaining compassion and human
Iowa. The support of my professional feelings for the patient, no matter what the
colleagues, especially Robert Broomfield, Eric circumstance. I wish to thank all the nurses,
Matthews, Michael Grey, Rosanne Szekely, Karen doctors, and pharmacists at Mineral Area
Having, Scott Collins, and Don Borst at Regional Medical Center in Farmington,
Southern Illinois University has been Missouri, for their support and trust when
invaluable. I am grateful for the help of the allowing me to become involved with their
edito- rial, production, and design staff at patients at the clinical level. I wish to notably
Elsevier/Mosby and specifically thank Jeanne thank Marie LaRose, RN, and Perry Bramhall,
Wilke and Rebecca Swisher for their DO, for being instrumental catalysts to my
professionalism, attention to detail, and clinical career in the rural environment; in many
extreme patience. As always, I owe a special ways I wish I were still there working with you.
debt of gratitude to my children, Jordan and Emily, A special acknowledg- ment is due for Henry
for their constant love and good humor and for Cashion, RT(R), Director of Mineral Area
allowing me time away from them to complete Regional Medical Center School of Radiologic
this book. Finally, my portion of this book could Technology. Henry has an enthusiasm and
not have been completed without the passion for making certain that his students
dedication, expertise, and abilities of my wife, are armed with the necessary skills to take care
Catherine. She has the knack of making the of patients. He is years ahead of many when it
complex simple and the simple enjoyable. Her comes to practical, clinical education for the
proofreading and editing skills are evident radiologic technologies. In the 5 years that I had
throughout the text and online instructor the honor of teaching for his program, it became
materials. very apparent to me that Henry is an individual
S.J. with high standards of ethical conduct. Henry,
your students are some of the brightest that I
I wish to acknowledge all the patients I have have ever had the pleasure of teaching, and it
had the honor of treating, consulting for, and was an honor working with you. (It is with great
laughing and crying with over my years of clinical honor that I have now been able to see those
practice; you have taught me things that no very students out in clinical practice over the
textbook could possibly offer! I am also most recent 10 years.) My portion of this
grateful to David Rush, PharmD, and Rusty textbook would not have been written without
Ryan, PharmD, for helping me break through your foresight.
difficult barriers early in my educational
years; you had faith in my abilities M.P.
xi
Contents
1 The Role of the Imaging Professional, 1

Therapeutic Index, 46
Key Terms, 1 Adverse Effects, 48
Objectives, 1 Drug-Drug Interactions, 49
Introduction, 2 Conclusion, 49
Historical Perspective, 2 Learning Exercises, 50
Ethical and Legal Implications, 3
Standard of Care, 3 5 Drug Classifications, 54
HIPAA, 7
Key Terms, 54
Conclusion, 8
Objectives, 54
Learning Exercises, 9
Introduction, 54
Cardiac Medications, 54
2 Principles of Pharmacology, 12
Anticoagulant, Antiplatelet, and
Key Terms, 12 Thrombolytic Medications, 56
Objectives, 12 Analgesic Medications, 56
Introduction, 12 Antihistamine Medications, 58
Drug Nomenclature, 12 Endocrine Medications, 58
Legend Drugs, 13 Central Nervous System Medications,
The Legal Prescription, 13 59 Antiinfective Agents, 60
Controlled Substances, 15 Chemotherapy Agents, 60
Herbal Products, 16 Herbal Products, 60
Charting, 17 Conclusion, 61
Drug References, 22 Learning Exercises, 62
6 Classification, Chemistry, and
3 Biopharmaceutics and Pharmacology of Contrast Agents,
Pharmacokinetics, 30 64
Key Terms, 30 Key Terms, 64
Objectives, 30 Objectives, 64
Introduction, 30 Radiopaque Contrast Media, 64
Biopharmaceutics, 30 Pharmacology of Iodinated Radiopaque
Pharmacokinetics, 34 Contrast Media, 64
Conclusion, 38 Osmolality, Osmolarity, and Osmotic
Learning Exercises, 39 Activity, 65
Intravascular Radiopaque Contrast
4 Pharmacodynamics, 43 Media, 66
Key Terms, 43 Enteral Radiopaque Contrast Media,
Objectives, 43 72 Paramagnetic Contrast Agents, 73
Introduction, 43 Ultrasound Microbubble Agents, 75
Mechanism of Action, 43 Conclusion, 76
Drug-Response Relationships, 46 Learning Exercises, 77
Half-life, 46
xiii
Contents
7 Pharmacodynamics of Infection Prevention and Control,

Radiopaque Contrast Media, 81 134 Medical Asepsis, 136
Key Terms, 81 Employer Responsibilities, 142
Objectives, 81 Conclusion, 143
Iodinated Radiopaque Contrast Media, 81 Learning Exercises, 144
Diagnostic Pharmacodynamics, 81
Adverse Pharmacodynamics, 82 10 Anxiety, Phobia, and Conscious
General Adverse Reactions, 89 Sedation, 147
Paramagnetic Agent Adverse Reactions, Key Terms, 147
90 Ultrasound Microbubble Agent Objectives, 147
Adverse Introduction, 147
Reactions, 91
Conscious Sedation, 148
Screening, 91
Agents Used for Conscious Sedation, 149
Drug-Drug Interactions, 91 Barbiturates, 149
Barium Sulfate, 93 Benzodiazepines, 150
Conclusion, 94 Opiate Analgesics, 152
Learning Exercises, 95 Conclusion, 152
8 Routes of Drug Administration, 100
Key Terms, 100 11 Pharmacology of
Objectives, 100 Emergency Medications,
Introduction, 100 155
Oral Route, 102 Key Terms, 155
Sublingual and Buccal Routes, 102 Objectives, 155
Topical Route, 102 Introduction, 155
Rectal Route, 103 Cardiorespiratory Arrest, 155
Parenteral Route, 103 Emergency Medications for
Charting, 114 Cardiorespiratory Arrest, 156
Chest Tubes and Lines, 116 Other Cardiac Emergency
General Administration Guidelines, 117 Medications, 171
Learning Exercises, 121 Conclusion, 171
9 Infection Prevention and Control, 126
Key Terms, 126 Answer Section, 175
Objectives, 126
Introduction, 126 Bibliography, 181
Microbiology of Infections, 126
Fundamentals of Infection, 128
Hepatitis, HIV, and Tuberculosis,
132
xiv
The Role of the Imaging
Professional 1
OBJECTIVES KEY TERMS
At the conclusion of this chapter, you should be able to: accredited program
1. Discuss the standards of care in the medical imaging professions. educational standard
2. List sources of information on standards of care. HIPAA
3. Determine the legal ramifications of drug administration and liability
venipuncture for imaging professionals in your state. medical malpractice
4. Locate the policies for drug administration and venipuncture at medical negligence
the hospital or clinic where you are most often assigned. professional standard
5. Define HIPAA and discuss the importance of following HIPAA guidelines. scope of practice
standard of care
The physician opens the lead-lined door and steps into the brightly
lit hallway. The act and its required effort were harder this time . . .
it always is when one must face the family.
In the waiting room, the physician sees that the hospital
chaplain has arrived and offers an all-too-familiar glance before
turning to the parents. Their faces are ashen, yet it’s their eyes
the physician dislikes the most. For without a word being said, the
dire nonverbal messages had been conveyed. “No, your daughter
is not dead,” the physician says. “During the examination,
however, she experienced complications. She is now in a coma.”
What? How? Why? These are questions that demand answers;
questions that must be answered with compassion. Both the
questions and answers will never end.
“She had a seizure and went into cardiac arrest,” the physician
explains. “We got her back, and now hope that she’ll respond
further. You may see her for a few minutes. She is on a machine
that assists her breathing. We’re doing everything we can.”
The kidney exam was necessary; her RLQ pain and workup tests
confirmed it. The IV line was established. The questionnaire was
completed. The patient’s history of hay fever and asthma, as well as
the evening hour, called for nonionic contrast. The risks were
known. Radiology personnel were ready for everything . . . except
for the physician’s response time.
Continued
1
Pharmacology and Drug Administration for Imaging Technologists
The injection went smoothly, and the ER physician returned to

her exceptionally busy night of accident victims and coughing
infants. Following the initial film, the young female patient and
the radiologic technologist (RT) were talking about the previous
night’s award show on television. Then the grand mal hit.
Its intensity peaked so rapidly that the RT had to grab the girl to
keep her from vibrating off the table. The reaction tray was nearby,
but the telephone was 10 feet away. “The emergency room is just
down the hall,” thought the technologist. “And the ordering ER
physician knows where we are.”
The patient’s strength was immense. Her gurgled sounds were
worse in the technologist’s ears. The RT’s calls for help were
smothered by the enclosed room. “The ‘crash cart’ is just outside the
door,” she mumbled. “So what! I wouldn’t know what to give her
anyway.”
Then the tremors ceased as quickly as they had begun,
being replaced by stillness and quiet. The RT raced to the
telephone, calling the code.
INTRODUCTION
The preceding recreation of an actual event creates extreme
discomfort for most imaging professionals. What would you do in
this case? In most states, medications must be prescribed by
physicians or dentists. A technologist, however, may administer
various drugs for diagnostic procedures once they are prescribed.
These include medications for sedation and pain management,
contrast media, and emergency drugs for reactions to contrast. Too
often, the technologist (diagnostic, nuclear medicine, angiography,
computed tomography, ultrasound, radiation therapy, or magnetic
resonance imaging) is asked to administer these dangerous, often
life-threatening drugs with little or no training in drug actions, dose
calculation, methods of administration, or emergency drug therapy
techniques.
? DID YOU KNOW?

HISTORICAL PERSPECTIVE
The first court award for x- For decades, it was the responsibility of the imaging technologist to
ray burns occurred in 1899, assist the radiologist or other physician in the administration of drug
immediately after the x-ray
therapy. Seldom, if ever, did the technologist actually inject contrast
film was introduced to
medicine. At present, x-ray
media, sedatives, or other drugs without a physician present. The
film is still the predominant physician then remained with the patient, or within the immediate
modality in medical vicinity, for the duration of the examination. Times have changed. It
imaging, not to mention the is now common practice for technologists to complete examinations
most litigated. The median requiring administration of drugs to patients in settings where the
award for a medical physician is never present or within hailing range. As drug
malpractice case in the administration responsibilities have shifted more within the scope of
United States is a sobering practice of imaging professionals, emergency drug treatment therapies
$1.2 million. have remained only within the knowledge base of the physician.
2
Professional
The Joint Review Committee on Education in Radiologic

Technology (JRCERT) Standards for an Accredited Educational Program
in Radiologic Sciences, which reviews and assesses radiography and
radiation therapy educational practices, identifies pharmacology, patient
care, and medical ethics and legal issues as required content areas for
the accredited program. The JRCERT uses the American Society of
Radiologic Technologists (ASRT) Professional Curriculum (2002) to
develop and update its guidelines and standards for educational
programs. These standards now include venipuncture techniques as
part of the approved curriculum. In 1991, venipuncture was added to
the ASRT’s scope of practice description for radiographers (see
box).
Resolution 91-4.04. Be it resolved, that the ASRT adopt the

following position statement on venipuncture: “Radiologic
technologists be permitted to perform venipuncture to include the
administration of contrast media, radiopharmaceuticals and/or IV
medications where state statutes and/or institutional policy permits.”
The Joint Review Committee on Education Programs in

Nuclear Medicine Technology identifies intravenous (IV) injections
(venipuncture) as a component of the nuclear medicine technologists’
scope of practice. The Standards of this committee specifically states:
“The nuclear medicine technologist shall be able to . . . prepare
and, where permitted, administer radiopharmaceuticals and other
agents used in conjunction with nuclear medicine procedures to
patients by intravenous, intramuscular and subcutaneous injections,
aerosol and oral methods.”
The American College of Radiology (ACR) provided additional
support for the inclusion of venipuncture in the job descriptions of
imaging technologists in 1987 with resolution number 27. In this
resolution the ACR identifies the injection of contrast material and
diagnostic levels of radiopharmaceuticals as part of the
responsibilities of certified and licensed radiologic technologists.
ETHICAL AND LEGAL IMPLICATIONS

Review of the literature has identified conflicting information
regarding which states allow technologists to perform venipuncture.
Contact your state department of health or nuclear safety for current
information concerning licensure or certification. For a listing of all
state radiographer certification contacts and e-mail addresses, see
www.hsrd.ornl.gov/nrc/ special/StateIR.pdf.
STANDARD OF CARE
Medical negligence is the failure to do something that a reasonable per-
3
son of ordinary prudence would do in a certain situation, and
medical
4
Professional
malpractice is a breach of duty to adhere to a standard of care. In

both cases, a standard of care is applied to measure the competence
of the professional. The traditionally recognized standard of care
required that the medical professional practice his or her profession
? DID YOU KNOW?

with the average degree of skill, care, and diligence exercised by
members of the same profession practicing in the same or similar
locality in light of the present state of medical and surgical
Pauscher v. Iowa Methodist practice. In essence, the practice of medical professionals was held
Medical Center (408 N.W. 2d
to a regional standard.
355, 358 [Iowa 1987]) was a
case brought against a
Medicine has rapidly become more diverse and specialized. As
hospital for wrongful death. communication methods (i.e., electronic) have evolved, the law has
The hospital insisted that it been adapted in most courts to disregard the previously described
was unnecessary to inform a geographic considerations and to set the standard as that of a
patient that intravenous reasonable specialist practicing in the same field. Therefore, no
pyelogram (IVP) tests result matter where he or she practices, an individual practicing in the
in death for only 1 in imaging sciences must maintain the same level of competence as a
100,000 people. When the reasonable imaging practitioner in the same specialty. ASRT Practice
patient died from the test, Standards may be found at www.asrt.org. The hospital situation
her family sued and won. described in the box provides another recent, real-world
example; names and hospital locations have been
removed to protect those involved.
HOSPITAL ADMITS FATAL MISTAKE THAT POISONED PATIENT

A woman who underwent surgery for a brain to
aneurysm was mistakenly injected with a
highly toxic antiseptic solution and died,
hospital officials have admitted. (Patient’s
name), 69, had the operation (date) at
(hospital) and died Tuesday after amputation
and other extreme attempts to keep her
alive.
“We’re just so sorry and so devastated
this happened,” (administrator) said Tuesday.
“It’s a very unfortunate error that we all feel
horrible about.”
Hospital officials have apologized, issued
a detailed staff memorandum detailing
what happened, retrained staff, and
changed procedures in an effort to
prevent similar mistakes.
“We have offered our heartfelt apologies
to the family of the patient and are doing
everything we can to help them in this time
of grief, but perhaps the only way we can
make our apology real is to do everything
we can to prevent medical errors in our
system.”
At the end of (patient’s name) operation,
a technician (technologist) was supposed
5
inject a harmless marker dye used for
x-rays into a leg artery. Instead, the
syringe was filled with chlorhexidine,
a toxic antiseptic used to clean the
skin.
“The cleansing solution basically
acted as a poison, which caused
widespread damage to the organs of
her body,” (administrator) said.
The damage “couldn’t be
remedied or reversed, even
through aggressive treatment,” he
added.
Over the next 2 weeks the
patient’s health deteriorated as
she underwent a leg amputation
and suffered a stroke and multiple
organ failure, leading to death.
Immediately after the operation,
“things were looking good, but in
reality when that plunger was
pushed, my mother’s fate was
sealed,” (patient’s son) told a
local television reporter.
A hospital staff memo, issued on
behalf of (administrator) before
(patient) died, said she had been the
victim of “an avoidable mistake that
caused massive chemical injury.”
(Administrator), the hospital’s quality
chief, said that “while no single
person is responsible, all of us are
responsible.”
6
Professional
HOSPITAL ADMITS FATAL MISTAKE THAT POISONED PATIENT—CONT’D

Everyone involved in the mistake was taken
version that was better at killing germs. The
off duty and retrained, along with the entire
marker dye is also clear. The syringe was
medical staff, hospital officials said. The
filled from an unlabeled cup containing the
technician (technologist) and others involved,
antiseptic.
who were not identified, are now back at
(Administrator) said procedures have been
work.
changed to ensure that the two solutions are
A hospital investigation concluded the
never put on the same table during a
issue was not carelessness but a system
procedure. The liquid antiseptic “now comes
that allowed two clear solutions to be confused.
as a swab on a stick,” making an accidental
(Hospital) had recently switched from a
injection impossible, he said.
brown iodine antiseptic to a colorless
Liability and propose appropriate

When the new principle is applied to imaging professionals, the content for each area. The
liability issues increase as radiographers, nuclear medicine educational essentials and
technologists, radiation therapists, and sonographers, depending on the curriculum
the limitations of state statutes and regulations, cross specialization
lines and practice in fields in which they have limited education and
experience. Some states permit radiographers to perform nuclear
medicine and sonographic studies as well as therapeutic procedures,
allow nuclear medicine technologists to perform sonographic studies,
and permit sonographers to swing back and forth across lines of
specialization. Many members of these groups hold credentials in more
than one field and are thereby qualified to cross lines and meet the
standards of the specialties in which they practice. However, a large
percentage are trained on the job with limited direction and
supervision.
Individuals with limited education and experience who practice
as those with the appropriate education and experience are
expected to perform in the same manner as qualified personnel. A
radiographer performing nuclear medicine studies is held to the
standard of a nuclear medicine technologist and not to that of a
radiographer practicing nuclear medicine. Health care facilities that
require employees to perform procedures beyond the employee’s
educational expertise are ultimately liable for the employee, but
the employee also remains personally liable for all professional
activity.
Educational Standard
The educational requirements that determine the standard of care
are generally those recognized by the profession as appropriate for
the field. In radiography, nuclear medicine, radiation therapy, and
sonography, educational standards have been developed that
define what an accredited program must do to educate students.
Curriculum guides for the imaging sciences also define specific areas
of study (e.g., pharmacology and drug administration techniques)
7
? DID YOU KNOW?

Think the new equipment for magnetic resonance imaging (MRI) is just
what your patient needs? Maybe not, if he is like the plaintiff with panic
disorder in Curtis v. RI Imaging Services II (148 Or App 607, 941 P2d
602 [Oregon 1997]). Curtis sued for psychological injuries sustained when
an imaging provider failed to explain the claustrophobic effects of MRI
scanners and never obtained a history of his asthma condition before his
examination.
8
Professional
guides are periodically reviewed and revised by the ASRT and

JRCERT to meet the changing needs of the profession.
In cases of litigation, these educational requirements are
reviewed to determine whether a person practicing in a certain field
has the req- uisite education. Attorneys may also review the
continuing education (CE) requirements and the information
available in scholarly journals and other periodicals to determine the
standard of practice for a certain professional field.
The educational standard should be met by all personnel
practicing in the field of medical imaging. Technologists and
therapists should obtain and maintain certification or registration in
their areas of expertise. Likewise, it is imperative that each
professional understand the standard for the field in which he or she
practices and maintain currency in the field by attending CE
programs and reading published articles and professional materials.
Any professional who does not keep current and maintain continuing
education places himself or herself at greater risk for both making
mistakes and being liable for them.
Professional Standard
The standard established to determine the appropriate professional
practice is generally the standard recognized by the discipline’s
national professional organization. The professional standard may
be in the form of a scope of practice, or a series of guidelines set
forth to determine what these health care specialists should and
should not do under certain circumstances. Individuals practicing in
these fields should be familiar with these professional
requirements and should upgrade their knowledge of professional
practice as the standards change and develop.
Professionals who become stagnant or refuse to change the
? DID YOU KNOW?
way they practice may be personally liable if they fail to meet the
recommended standards of the profession. Many believe that if
they learned a procedure in school, it is the right thing to do.
Patients who refuse
treatment should sign a Reminder: just because something was learned in school does not
“refusal of consent” form. mean it is still appropriate practice 10 or 20 years later. People
Broek v. Park Nicollet Health expect their physicians to be current in their practice, and the same
Services (Case No. C9-02- is expected of medical imaging specialists.
1611 [Minnesota 2003]) The imaging sciences are changing rapidly and dramatically. It
involved a man with a heart is incumbent on those who practice in these specialized fields to
muscle disease who ignored remain current. The courts generally do not consider inadequate
his physician’s advice to time and money as good reasons for being unprepared for changes
have regular examinations. in a field. Hospitals should maintain library facilities containing
Seven years after his last professional journals from many health care disciplines and offer in-
echocardiogram, he died of service programs for employees. Public libraries carry the same or
cardiac arrest while playing
similar periodicals, and educational programs are required to
racquetball. His widow filed
maintain library resources, which are usually available to members of
a wrongful death suit that
was eventually thrown out, the profession.
but not before everyone The standard of care recognized by the law should be the level
spent a small fortune in legal of care that a patient can expect and receive when entering a health
fees. care facility for professional service. When the technologist is
9
expected to perform
procedures not found
in the professional
scope of practice, the
1
0
Professional
Providers, payors, and

technologist is ethically responsible to refuse to perform the insurers must educate and
procedures and lobby the employer for training in these procedures. train their staffs to be in
The facility should then provide documentation that the employees compliance with the new
providing these services have met minimum qualifications needed to requirements, then
perform them. perform ongoing compli-
ance monitoring and apply
appropriate sanctions
HIPAA when necessary. Providers,
The Health Insurance Portability and Accountability Act of 1996 unlike insurers, also must
(HIPAA) was the result of efforts by the Clinton Administration and deal with family members,
con- gressional proponents to reform health care. The goals and friends,
objectives of this legislation were to streamline industry
insufficiencies, reduce paperwork, make it easier to detect and
prosecute fraud and abuse, and enable workers in all professions to
change jobs, even if they (or family members) had preexisting
medical conditions. The HIPAA legislation had four primary
objectives, as follows:
1. Ensure health insurance portability by eliminating “job–
lock” caused by a preexisting medical condition.
2. Reduce health care fraud and abuse.
3. Enforce standards for health information.
4. Guarantee security and privacy of health information
(the imaging technologist’s primary concern with
HIPAA).
At the risk of oversimplification, this rule requires providers,
insurers, and payors to determine eligibility and claims processing
through electronic data interchange (EDI) transactions. EDI has been
commercially available since the 1980s, and many large
companies have created orders, sent invoices, and issued or
received payments with their electronic trading partners. EDI is
essentially a set of specific rules gov- erning how information will be
packaged to transfer payments elec- tronically from one electronic
trading partner to another.
The imaging technologist’s primary concern when dealing with
HIPAA compliance is patient confidentiality. Technologists must be
extremely careful when transferring patient information both inside
and outside the radiology department and clinical facility. At no time
may a patient’s identity or examination results be made public. This
is of particular concern to student technologists because
educational programs may require film critiques or pathology reports as
part of the curriculum. Do not include patient or hospital identification
on images submitted for these courses. Because of the extremely
sensitive nature of HIPAA guidelines, it is recommended that all
student and staff technologists participate in approved hospital or
clinic in-service training at each facility attended or where they are
employed. Many hospitals and clinics have been providing training
at a centralized location in more densely populated geographic
areas.
Achieving HIPAA compliance, particularly for health care providers,
is not easy and is costly to the provider and payor organizations.
1
1
?
DID YOU KNOW?
Have you ever had a problem obtaining your medical records? Whom do
they really belong to: the patient, the hospital, the physician, the
insurance company? Medical records actually belong to both the patient
and the clinician. The clinician (or facility) has primary custodial owner-
ship, but the patient has proprietary rights. This means the patient has
the right to reasonable access to those records, including having them
transferred or seeing their contents.
1
2
Professional
and outside visitors in the course of performing daily business. These

daily visitors, along with security challenges from Internet hackers, e-
mail viruses, and the physical size of some organizations, make the
protection of individually identifiable patient information a major
challenge in itself. As with most federally mandated programs, there
are no provi- sions for the recovery of HIPAA compliance
implementation costs or the ongoing costs to train new staff and
monitor compliance after initial implementation. Many health care
experts believe that more institutions will close as a result of not being
able to achieve HIPAA compliance for a variety of reasons. Currently,
some experts are estimating the costs of
achieving initial HIPAA compliance at more than $66 billion.
CONCLUSION
Although most states have a required certificate or licensure law,
the majority of these laws do not specifically address venipuncture or
drug administration by imaging technologists. Whether technologists in
these “silent states” are protected against litigation on the basis of
regional custom and tradition may be determined by the legal
system. Those states with no licensure or certification laws
completely expose the imaging technologist or physician and the
clinical site to legal scrutiny. Is the inclusion of a particular task in
national accrediting guidelines sufficient protection against
litigation, or are states responsible for this protection through specific
statutory terminology? For example, is the “scope of practice” as
defined by professional organizations legally protected in states
where regulations conflict with national accredita-
tion standards?
Although imaging technologists have always been instructed to
protect patient confidentiality, they are now mandated to do so by
the federal legislation known as HIPAA.
The number of technologists performing venipuncture and
subsequent pharmaceutical administration is increasing, which
also increases the possibility of litigation against technologists. It is
incumbent on the medical imaging community to address these
issues pro- ductively through increased levels of education and
documented clinical competence. This book addresses these issues
by providing the imaging student with the background necessary to
understand drug actions and classifications, administration routes
and techniques, and emergency medication procedures.
1
3
Learning Exercises
Abbreviations
Spell out each of the abbreviations below.
1. JRCERT:
2. ASRT:
3. HIPAA:
True-False
Circle T for true or F for false.
1. T F The American College of Radiology does not include the

injection of contrast material and diagnostic levels of
radiopharmaceuticals as part of the responsibilities of certified or
licensed radiologic technologists.
2. T F It is common for technologists to administer drugs to

patients without a physician present.
3. T F Scope of practice is a series of guidelines set forth to

determine what health care specialists should and should not
do under certain circumstances.
4. T F In a legal liability case the courts generally recognize

inadequate time and financial resources as legitimate reasons
for not being familiar with changes in your specialty.
5. T F The number of technologists performing venipuncture is

increasing.
10
Professional
6. T F A radiographer performing nuclear medicine studies will

not necessarily be held to the standard of a nuclear medicine
technologist rather than to that of a radiographer practicing nuclear
medicine.
7. T F If a health care facility requires an employee to perform

procedures beyond that employee’s educational expertise,
the employee is actually liable for all professional activity.
8. T F Some technologists practice across different lines of

specialization, but they must hold credentials in each area of
specialization.
9. T F All state laws referring to nuclear medicine technologists

have statements authorizing these technologists to perform
venipuncture.
10. T F The Joint Review Committee on Educational Programs in

Nuclear Medicine Technology does not identify venipuncture as
a component of nuclear medicine technologists’ scope of
practice.
Discussion Questions
1. Do you know what your state law allows medical imaging
technologists to perform when administering drugs to
patients?
2. What is the standard of care for your specialty?
3. In an emergency situation, what are your responsibilities?

What are your limitations?
4. How would you have handled the situation described at

the beginning of the chapter?
9
Professional
5. Do you fully understand HIPAA guidelines as they pertain to

you in the imaging department?
6. What are the differences between medical negligence and

medical malpractice?
7. Does your clinical facility have written guidelines

concerning appropriate personnel responsible for
venipuncture and drug administration?
8. Does your clinical facility assume liability for technologists

who administer drugs that result in adverse reactions or
death?
9. If the clinical facility does not assume the liability expressed

in the previous question, do the imaging technologists
continue to administer drugs?
10. How will you handle a future situation in which you are asked
to administer drugs by venipuncture knowing that you are not
allowed to do so under state statutes or clinical policy?
11
2 Principles of Pharmacology
KEY TERMS OBJECTIVES

AHFS Drug Information At the conclusion of this chapter, you should be able to:
Bureau of Narcotics and 1. Define pharmacology.
Dangerous Drugs 2. Discuss the significance of the various names assigned to drugs.
(BNDD) 3. Differentiate between legend and over-the-counter drugs.
charting 4. List the seven components of a valid prescription.
controlled 5. Define controlled substance and identify the method by which
substance controlled substances are classified.
schedule 6. Explain the significance of and methods involved in the charting of
Drug Enforcement Agency drugs and drug dosages given to patients.
(DEA) 7. Provide examples of questions found on patient drug histories
Drug Interaction Facts and informed consent forms.
drug references 8. List at least five references used by health professionals to answer
Drugs in Pregnancy and drug- related questions.
Lactation
Facts and Comparisons
Food and Drug
Administration (FDA)
Handbook on Injectable
Drugs
Hansten’s Drug
Interactions INTRODUCTION
informed Pharmacology is the study of drugs in living systems. It
consent LD50 encompasses the understanding of all medication effects, whether
legend drugs diagnostic, therapeutic, or adverse. Drugs have led to the control or
narcotic cure of many medical disorders. However, drugs have also been
patient history responsible for many unwanted illnesses and deaths over the years.
pharmacology All students of pharmacology must remember that medications
Physician’s Desk Reference can be very helpful but can also cause serious harm to patients. No
(PDR) one should prescribe or administer medication without knowledge
therapeutic index and comprehension of pharmacologic data. As a medical
professional, you should learn all that you can about the potential
poisons that will be placed into your patient. This book is designed
to teach important principles surrounding the pharmacologic
agents used frequently in the radiologic sciences.
DRUG NOMENCLATURE
A drug has many names given to it before it becomes available for
use. These names include chemical name, code number, generic
name, and trade or proprietary (brand) name. Most health care
workers and the general public are familiar with the generic name
12
Professional
and the brand

name.
13
Principles of Pharmacology
The other names are used primarily for research and manufacturing pur-
poses. Because of the length of these other names, the U.S. Food
and Drug Administration (FDA), the federal agency responsible for
? DID YOU KNOW?
protecting the public against fraudulent claims by manufacturers or Two thirds of cancer deaths
merchants of foods or drugs, allows the name to be shortened for can be prevented by healthy
ease of memory. The shortened version is the generic drug name and is lifestyle choices. The
the official name given to the active chemical ingredient contained American Cancer Society
in a particular drug product. recommends the following
Every medication has a generic name. A brand name is given seven choices:
to the drug by the particular manufacturer. Each manufacturer uses 1. Cut out tobacco.
a different brand name for its version of the generic drug. In 2. Hold the fat.
essence, the brand name is used as a marketing tool. The original 3. Opt for high-fiber fruits,
generic drug is developed by one company. The developing vegetables, and grains.
4. Drink alcohol only in mod-
company then acquires a patent for exclusive rights to manufacture
eration.
and sell the generic drug as its brand drug for a specified number of 5. Make regular visits to
years. After the patent expires, other companies may produce the physician.
same generic drug under different brand names. 6. Exercise daily.
For the sake of discussion, this book refers to drugs by their generic 7. Safeguard skin from the sun.
names. In some instances the brand name may be listed, but it
appears in parentheses after the generic name.
LEGEND DRUGS
?
Medications that require a prescription are called legend drugs.
These all have a written legend (or caption) on the package stating, DID YOU KNOW?
“CAU- TION: Federal Law prohibits dispensing without a
prescription.” Radiopaque contrast agents and other medications There are more than 1000
administered in the radiology department fall into the category of chemicals in a cup of coffee.
legend drugs. The imaging technologist must therefore know what Of these, only 26 have been
constitutes a legal prescription before dispensing or administering tested, and half caused cancer
drugs or diagnostic agents ordered. in rats.
THE LEGAL PRESCRIPTION

A valid prescription or order for a drug includes at least the
following seven components:
? DID YOU KNOW?
1. Patient name, room number or address, and identification Before 1906, patent
numbers medicines and remedies were
2. Drug name (generic or brand) sold by medicine men in
3. Dosage (in proper units of measure for particular drug) traveling wagon shows,
4. Dosage form (e.g., tablet, injection, solution) drugstores, and mail-order
5. Route of administration (e.g., oral, parenteral, rectal) houses and by “doctors,”
6. Date order is written real or self-titled. Such
7. Prescriber’s signature products were not required
to list ingredients on the
Fig. 2-1 shows a proper hospital order sheet to be used in pre-
label, so many contained
scribing medication.
drugs such as opium,
A prescription, or order for a medication, is a legal document morphine, heroin, chloral
admissible in a court of law. An important note for consideration is that hydrate, and alcohol. Many
a verbal order does not necessarily constitute a valid prescription. persons (especially infants) were
reportedly injured, became
addicted, or died as a result of
13
the dangerous ingredients or their quantities in these preparations.
14
Fig. 2-1 Physician’s order sheet.
15
A “verbal order” is one that is transcribed, by a certified medical

professional, to an order form or prescription form at the verbal order of
the prescriber. If that prescriber does not sign that verbal order, the
prescription is neither legal nor valid. It is thus in the best
interests of all involved either not to take verbal orders or to have
in place a written protocol (discussed in detail in later chapters) that
has been accepted as proper and standard medical care for all
patients admitted to the radiology department. The protocol should
be signed by all prescribers and department managers, then placed in
a safe filing system for retrieval. It should be updated at least annually.
By preparing such a document, the imaging professional can
safeguard his or her legal rights in the event of unscrupulous
activity, which unfortunately can occur.
CONTROLLED SUBSTANCES should store the drugs

under double lock and key
Medications that have a high potential for abuse are generally
(a locked cabinet inside a
placed into one of five controlled substance schedules. Drugs of
locked room) and should
this nature include the narcotic pain relievers, such as morphine,
require two signatures for
meperidine, codeine, hydromorphone, hydrocodone, pentazocine,
removing the medication
propoxyphene, methadone, fentanyl, alfentanyl, and other opiate
from the
analogs. Also included are the sedative-hypnotic and antianxiety
drugs, such as chloral hydrate and the benzodiazepines (e.g.,
diazepam, lorazepam, midazolam, temazepam, halazepam,
flurazepam, triazolam, oxazepam, chlordiazepoxide). Stimulant
medications such as cocaine and amphetamines are also classified
as controlled substances.
All controlled substances have a stamp placed on the outside
of the container to show the drug’s assigned schedule. The schedules
used in the United States are C-I, C-II, C-III, C-IV, and C-V. The “C”
stands for “controlled substance,” and the Roman numeral describes
the potential for abuse; the lower the Roman numeral, the greater
the potential for abuse. Table 2-1 describes the potential for abuse
and other factors for controlled substances in the C-I through C-V
schedules.
Schedule C-I drugs are illegal for patient use in the United
States. To acquire these drugs, an institution must be registered with
the federal Drug Enforcement Agency (DEA) as either a
manufacturer or a researcher of narcotic and dangerous drugs.
Schedule C-II drugs are legal for prescription use in patients
and have the highest potential for abuse. Generally, these drugs
cause marked euphoria with mind-altering effects. Potent narcotics
such as morphine and strong stimulants such as amphetamine fall
into this category. There are strict regulations regarding the control
and monitoring of drugs in this schedule. Each and every dosage unit
must be accounted for; if counts are inaccurate by as little as one
dosage unit, a report must be filed with the state agency, such as
the Bureau of Narcotics and Dangerous Drugs (BNDD), responsible
for controlling these medications. Anyone who has the
responsibility to dispense or administer this schedule of medication
16
? DID YOU KNOW?

The Food and Drug Act of 1906 designated The United States
Pharmacopeia and The National Formulary as official standards and
empowered the federal government to enforce them. Drugs were required
to comply with the standards of strength and purity professed for them,
and labels had to indicate the type and amount of morphine or other
narcotic ingredients present.
17
Table 2-1 Controlled Substance Schedules

Schedule Description/Examples
C-I High abuse potential. No currently accepted medical use in the

United States. Safety for use not acceptable, even under
medical supervision.
Heroin, opium, lysergic acid diethylamide (LSD),
marijuana (“pot”), crack cocaine, methamphetamine
(“ice”), peyote buttons, mescaline
C-II High abuse potential. Accepted medical uses under medical

supervision. May lead to severe psychological and/or
physical dependence.
Cocaine HCl flakes, morphine, meperidine, hydromorphone,
fentanyl, sufentanyl, oxymorphone, oxycodone,
secobarbital, pentobarbital
C-III High abuse potential, but less so than C-I and C-II. Accepted
medical use under medical supervision. Moderate to low
psychological and/or physical dependence.
Acetaminophen with codeine, butalbital with caffeine and aspirin
C-IV Abuse potential lower than C-III. Accepted medical use

under medical supervision. Limited and low psychological
and/or physical dependence.
Diazepam, lorazepam, oxazepam, midazolam, temazepam,
chloral hydrate, chlorazepate
? DID YOU KNOW?

C-V Abuse potential lower than C-IV. Accepted medical use. Some
states allow over-the-counter purchasing, provided that the phar-
International control of drugs macist has the patient sign a register. Limited psychological
legally began in 1912 when and/or physical dependence.
the first “Opium Acetaminophen with codeine cough syrup, diphenoxylate with
Conference” was held at The atropine sulfate tablets
Hague. Inter- national
treaties were drawn up
legally obligating govern- supply bin. All drugs should be accounted for at the beginning and
ments to (1) limit to medical end of each employee shift. Two employees should verify the count of
and scientific needs the every C-II drug in the bin. The count should agree with the previous
manufacturing of and trade shift count, minus any medications that have been administered to
in medicinal opium, (2) patients. If the count is not correct, an investigation must take place
control the production and immediately to determine why.
distribution of raw opium, and Schedules C-III, C-IV, and C-V drugs are also legal for
(3) establish a system of
prescription use. Although these medications have high potential for
governmental licensing to
control the manufacture of
abuse, they are less addictive than the C-I and C-II drugs. In the
and trade in drugs covered health care setting, these medications should also be verified in
by the convention. count at the beginning and end of each shift. Storing them under
double lock and key is also recommended.
HERBAL PRODUCTS
Self-treatment using herbal products has become relatively common
in the current health care market. From weight loss to depression,
their
18
scope can be somewhat broad, and herbal self-treatment can be

associated with dangers that the consumer frequently does not
understand. Medical professionals should not overlook the
possibility that their patients are using these products. On taking
accurate medication histories, practitioners should ask about at
least the following herbal products, since they have documented
pharmacologic effects associated with them:
Black cohosh, coenzyme Q10, danshen, dong quai, ephedra
(Ma Huang), garlic, Ginkgo biloba, ginseng, glucosamine,
grapefruit juice extract, guarana, kava kava, St. John’s wort.
Various adverse effects as well as serious drug-drug
interactions can affect the cardiovascular, gastrointestinal, and
central nervous systems when these herbal products are taken in
excess or when the product is not standardized with regard to
content. For example, many weight loss products historically
contained Ma Huang (ephedra alka- loids), which can lead to
serious hypertension, cardiac dysrhythmias, and death (ephedra
alkaloid is very potent and can be similar to the amphetamine class
of drugs).
CHARTING
The patient chart is a legal medical record belonging to the
hospital. Charting should tell an accurate, chronologic history of
events as they occur under the supervision of medical
professionals. Members of all medical disciplines rely on the
accuracy and input of others when looking through the chart. As an
imaging technologist, you should respect this document and comply
with the institutional procedures when entering information into
the chart. This document is retained when the patient is
discharged and will be used for various functions, such as patient
and insurance billing, auditing, research, epidemiology,
readmission information, and legal affairs. Most medical records or
charts are arranged in a format to include a summary sheet, legal
consents and advance directives, a history and physical
examination sheet, a problem list, physician orders, progress notes,
graphic records (e.g., blood and urine results), laboratory tests, and
consultations. Most hospitals use a problem-oriented medical record
(POMR) format. Figs. 2-2 through 2-11 show various forms and
records that use the POMR format.
The imaging technologist is responsible for placing various
documents into the medical record. These include the specific radi-
ologic procedure and medication orders, informed consents for the
various procedures and medications, patient history regarding
radiologic procedures, patient assessment during and after
procedures, and any medication administration performed. (Routes
and techniques of drug administration are discussed in detail in
later chapters.) Nursing and physician charting forms can be
modified to fit the radiology department. Figs. 2-12 and 2-13
provide examples of important documents that should be in the
19
radiology department chart.
20
Fig. 2-2 Chart summary sheet.
Fig. 2-3 Problem list.
18
Fig. 2-4 Patient history and physical examination forms.
19
Fig. 2-5 Patient progress notes.
Fig. 2-6 Consultation report.
Fig. 2-7 Laboratory test record. WBC, White blood cell count; RBC, red blood cell count;
HBG, hemoglobin; Hct, hematocrit; BUN, blood urea nitrogen.
20
Fig. 2-8 Clinical record.
21
Fig. 2-9 Kardex treatment/activity record.
DRUG REFERENCES
All health care professionals should have a library of useful drug
references to help answer any questions that may arise. For most
pharmacologic questions, a combination of the following references
can be used.
22
Fig. 2-10 Medication Kardex.
Fig. 2-11 Narcotic inventory form.
23
Example of a Patient History Prior to Radiologic Exam
1. Have you ever been given intravenous dye (contrast)? YES NO

2. Have you ever had a bad reaction to intravenous dye (contrast)? YES NO
3. Have you ever had a bad reaction to iodine? YES NO
4. Do you have any allergies to medicine or vitamins? YES NO
(IF YES TO #4, PLEASE DESCRIBE )
5. Do you have any allergies to iodine? YES NO
6. Do you have any allergies to food? YES NO
7. Do you have any other allergies whatever? YES NO
8. Are you pregnant or is there a possibility of pregnancy? YES NO
9. Do you suffer from sickle-cell anemia? YES NO
10. Do you feel frightened when placed in small spaces? YES NO
11. Do you have diabetes? YES NO
12. Do you have heart disease (describe )? YES NO
13. Do you have uncontrolled high blood pressure? YES NO
14. Do you have thyroid problems? YES NO
15. Do you have any kidney or bladder problems? YES NO
16. Please list all medications you are currently taking.
Fig. 2-12 Patient history.
Example of a Patient Informed Consent Prior to Radiologic Exam with a

Radiopaque Intravenous Contrast Agent
Patient Consent for Intravenous Radiopaque Contrast Enhanced CT Scan
Patient name: Age: Room:

Your physician, , has asked the Radiology Department to perform a
test that requires the use of a radiopaque contrast agent to help in diagnosing a health problem that you
may have. This test will require that the Radiology Department inject a dye (contrast media) into your
vein. This dye contains iodine. If you have any known allergy to iodine or if you have ever had a reaction
of any sort following a procedure requiring x-rays, CT scans, or MRI exams, then you must notify the
technologist of this fact. If you are pregnant or could possibly be pregnant, you must notify the
technologist.
This test and the drugs used in this test have been associated with some adverse effects, including
nausea, vomiting, facial flushing, a feeling of warmth all over the body, rashes, hives, metallic taste in the
mouth, allergic reactions, shock, and death. Although reactions are treatable and rare, they can occur.
I have read and understand the above information. I understand that the possible reactions that can
occur include anything from nothing to death. Knowing such, I do give my consent for the Radiology
Department to perform this test.
/ /
(signature/date) (signature of relative/date)
Procedure explained by:
/
(radiologist's or technologist's signature/date)
Fig. 2-13 Informed consent.
24
expensive and is generally

Physician’s Desk Reference (PDR) is a general reference that supplied through hospital-
is simply a compilation of various package inserts put out by wide contracts.
pharmaceutical manufacturers. Only the FDA-approved uses and
labeling are allowed to be printed. Manufacturers pay for their drugs
to be listed in this reference. The PDR is a good reference for
finding phone numbers of the major pharmaceutical companies,
which are a valuable resource for information. It is important to note
that the PDR does not necessarily contain current information on all
drugs. In fact, it does not contain all drugs. However, the PDR is a
highly recommended reference because most physicians use it. The
PDR is updated once per year. This reference is also available online
at www.pdr.net, on CD-ROM, and through handheld personal digital
assistant (PDA) technology.
Facts and Comparisons is available in loose-leaf and bound
ver- sions, on CD-ROM, and online. The loose-leaf three-ring binder
is recommended because the quarterly updates provided can be
easily inserted into the manual. This reference is moderately
extensive and concisely written, with multiple tables. The format of the
text is good for quick reference, ease of use, and comprehensiveness.
For a complete list of electronic databases provided by this
reference, you can log on to www.factsandcomparisons.com.
American Hospital Formulary Service (AHFS) Drug Information is
one of the most comprehensive reference books with regard to drug
information. It is updated quarterly and published in full text
yearly. Many pharmacists consider this book, along with Facts and
Comparisons, as the reference to consult for almost all questions
regarding approved and nonapproved uses for drugs. The book is
extensively referenced under separate cover; however, the
references are available only on request because of the sheer volume
of text required for them. Online data can be accessed at
www.ashp.org/ahfs/.
Handbook on Injectable Drugs is a comprehensive textbook
that discusses physical and chemical stability of injectable drugs
when combined with one another in the same intravenous tubing
or syringe. All hospital and infusion pharmacies should maintain and
update this book for questions regarding parenteral drug products
(the parenteral route bypasses the gastrointestinal tract).
Drug Interaction Facts and Hansten’s Drug Interactions are
invaluable in determining whether a drug-to-drug interaction may
occur when combination therapy is used. These references are
available at www.factsandcomparisons.com.
Drugs in Pregnancy and Lactation is highly recommended in
any practice that deals with pregnant patients or women who
breast-feed their children.
Other drug reference sources that should not be overlooked
include the pharmacist, poison control centers, and computer drug
information sources such as MicroMedex Drug Information, Iowa
Drug Information Service, Medline, and Epocrates. Of all the
references, MicroMedex is probably the most complete for intense
and rapid information gathering; however, it is extremely
25
? DID YOU KNOW?

The multibillion-dollar pharmaceutical industry is constantly screening
substances with potential marketability as new drugs. Prospective drugs
may take years and huge amounts of money to progress through the
following FDA testing sequence:
A. Animal studies, to ascertain:
1. Toxicity
a. Acute toxicity: as determined by LD50 (dose lethal to 50% of
animals); also known as median lethal dose
b. Subacute toxicity
c. Chronic toxicity
2. Therapeutic index: ratio of median lethal dose to median effective
dose
3. Modes of absorption, distribution, metabolism, and excretion
B. Human studies
1. Phase I: initial pharmacologic evaluation
2. Phase II: limited controlled evaluation
3. Phase III: extended clinical evaluation
26
Learning Exercises
Abbreviations
1. AHA:
2. AHFS:
3. BNDD:
4. DEA:
5. FDA:
6. PDR:
27
7. POMR:
True-False
1. T F Pharmacology includes the understanding of all

diagnostic, therapeutic, or adverse effects of medications in
living systems.
2. T F Not all medications have a generic name.
3. T F Legend drugs do not require a prescription.
4. T F Radiopaque drugs are considered legend drugs.
5. T F The expiration date of a drug is considered one of the

seven vital components of a valid prescription or order.
6. T F Controlled substances should be verified in count at the

beginning and end of each shift.
7. T F Schedule C-V drugs are illegal for patient use in the

United States.
8. T F The therapeutic index is the ratio of the median lethal

dose to the median effective dose.
9. T F Imaging technologists are not required to place informed

consent forms in the patient’s chart.
10. T F A prescription for a medication is a legal document

admissible in a court of law.
11. T F Manufacturers pay to have their drugs listed in the

Physician’s Desk Reference (PDR).
Review Questions
1. Controlled substances in the United States are categorized
into schedules C-I through C-V. For what does the “C”
stand?
27
2. Does a C-I drug have a greater or lesser potential for abuse

than a C-V drug?
3. What are the two general phases of the FDA prospective drug-
testing sequence?
4. What are four useful drug references available to help with

most pharmacologic questions?
5. What are at least five of the documents the imaging technologist

is responsible for placing into the patient’s medical record
(chart)?
6. What are the seven components of a valid drug prescription?
28
Multiple-Choice Questions
Place a check before the letter of the correct answer.
1. What is the official name given to the active ingredient found

in a particular drug product?
a. Generic name
b. Trade name
c. Code name
d. Chemical
2. What government agency is responsible for protecting the

public against fraudulent claims by drug manufacturers?
a. Drug Enforcement Agency
b. Food and Drug Administration
c. Bureau of Narcotics and Dangerous Drugs
d. American Hospital Association
3. What is the term for medications that require a prescription?

a. Narcotics
b. Amphetamines
c. Nonproprietary drugs
d. Legend drugs
4. Which of the following controlled substance schedules

contains drugs with the highest potential for abuse?
a. C-I
b. C-II
c. C-IV
d. C-V
5. Which of the following terms describes the study of drugs in

living systems?
a. Biology
b. Physiology
c. Pharmacology
d. Pharmacokinetics
6. To whom does the patient chart actually belong?

a. Patient
b. Hospital
c. Physician
d. Insurance company
29
3 Biopharmaceutics
and Pharmacokinetics

absorption At the conclusion of this chapter, you should be able to:
active transport 1. Define the key words used in describing biopharmaceutics
biopharmaceutics and pharmacokinetics.
buccal 2. List the dosage forms used to deliver drug therapy.
capsule
3. Discuss the manner in which drugs are absorbed,
compressed suppositories distributed, metabolized, and eliminated in the body.
dissolution
dosage form
emulsion
inserts
lipophilicity
liquid
parenteral
passive diffusion INTRODUCTION
pharmacokinetics
solution For a drug to produce pharmacologic effects in the body, it must
sublingual first reach the site of action. The process required for a drug to reach
suspension the site of action is best described using biopharmaceutic and
tablet pharmacokinetic principles. Think of it this way: in order to enjoy
troche your vacation, you have to get there first. Biopharmaceutics and
pharmacokinetics are analogous to what you pack, which car you
take (sports car or minivan), the gas you buy on the way, and the
road you take to get there. If we keep this analogy in mind, some
of the “rough spots in the road” will be easier to understand.
BIOPHARMACEUTICS
Biopharmaceutics is the area of pharmacology that focuses on the
method for achieving effective drug administration. Drugs are
placed into vehicles by the manufacturing process. A drug vehicle is
a substance into which a drug is compounded for initial delivery
into the body. A dosage form—solid, liquid, gas, or any combination
of these— is the combination of both the drug and the vehicle used
to deliver the drug. A dosage form must be capable of releasing its
contents so that the drug can be delivered to the site of action.
Dosage Forms
Solid dosage forms used for oral administration include tablets,
capsules, and troches (Box 3-1).
30
Biopharmaceutics and Pharmacokinetics
Tablets
BOX 3-1 SOLID DOSAGE FORMS
? DID YOU KNOW?
Compressed The bathroom medicine cabi-

Sugar coated net is one of the worst places to
Film coated keep medicines. The heat
Enteric coated and moisture of the
bathroom are
Multiple compressed just the conditions required to
Controlled release alter the chemistry of
Effervescent medications, making them
Buccal or sublingual weaker, possibly ineffective,
and in some cases, toxic. A
Capsules cool, dry area away from
Hard gelatin sunlight and children is
Soft gelatin optimal.
Troches
Lozenge
Pastille
Suppositories or inserts
Rectal
Vaginal
A tablet generally consists of an active ingredient (drug),

various fillers and disintegrators, dyes, flavoring agents, and an
outside coating. Fillers help the powdered mass to maintain form when
compressed in the manufacturing process. Disintegrators aid in
chemical disintegration when subjected to fluids or temperature
changes. The disintegration process is required for the solid to
become a solution before absorption across a biologic membrane. If
something is not done to make it dissolve, the solid will come out in
the same lump as initially used. Dyes and flavoring agents help make
the dosage form palatable. The coating may help with palatability and
aid in the drug-releasing process.
Various types of tablets are produced to aid in the delivery of
medication, as follows:
●
Compressed tablets are compacted with no special coating; they
are subject to chemical degradation from the environment.
●
Sugar-coated tablets have a thin layer of sugar coating designed
to mask bad taste and to protect the active ingredients from
chemical oxidation.
●
Film-coated tablets have a thin coating of material other than
sugar. This type of coating serves the same function as a sugar
coating but is less expensive to manufacture.
●
Enteric-coated tablets are designed to pass through the gastric area
and release the active ingredients into the small intestine. This
technology is used to prevent the strongly acidic contents of the
31
stomach from chemically destroying the activity of a drug. Enteric
coating is
32
also used to prevent gastric upset by a drug known to cause

significant local irritation in the stomach.
●
Multiple-compressed tablets and controlled-release tablets are
both designed to mask taste, protect contents against chemical
oxidation, and allow for periodic release of contents in a
controlled manner throughout the gastrointestinal (GI) transit.
Many drugs used for maintenance therapy, such as cardiovascular,
pulmonary, antiepilep- tic, and antirheumatic medications, are
formulated this way to allow for once-daily or twice-daily dosing to
improve patient compliance.
●
Effervescent tablets contain sodium bicarbonate and an organic acid
such as citrate or tartrate. These tablets liberate carbon dioxide and
disintegrate into an effervescent solution in the presence of water.
●
Buccal or sublingual tablets, such as nitroglycerin, are designed
to disintegrate in the buccal or sublingual space and become
absorbed through the buccal or sublingual vasculature.
Capsules generally consist of either a hard or a soft gelatin
shell that encloses the active ingredient. A hard gelatin capsule is a
two-piece shell made from calcium alginate, methylcellulose, and
gelatin. A soft gelatin capsule is a one-piece shell made from
similar material. Capsules are designed to mask taste, allow for ease
of swallowing, and contribute to a controlled-release mechanism.
The capsule must dissolve so that the active ingredient may be
released.
Troches are generally in the form of lozenges or pastilles. These are
solids that contain medicine in a hard sugar or glycerinated gelatin
base designed to dissolve slowly in the mouth. Topical oral
antifungals and anesthetics are most often placed in this dosage form
so that continued contact will be made between the medication and
the oral mucosa.
Compressed suppositories or inserts are solid dosage forms
generally designed for vaginal or rectal delivery. On contact with
the mucosa and in the presence of body temperature, these dosage
forms melt away to release the medicinal agent.
Liquid dosage forms include solutions, emulsions, and suspen-
sions (Table 3-1); these are used to administer medication by
virtually all routes conceivable.
Table 3-1 Liquid Dosage Forms
Dosage form Description
Solution A homogenous mixture of solid, liquid, or gas dissolved in

another liquid. The solute (drug) is dispersed in the solvent
(vehicle).
Emulsion A dosage form consisting of two immiscible* liquids. One liquid

appears as globules uniformly dispersed throughout the other liq-
uid. Generally, an emulsifying agent is required to maintain
glob- ular stability.
Suspension A solid medication dispersed throughout a liquid medium. A

sus- pending agent is generally added to help maintain
uniform dis- persion. Suspensions generally require agitation
33
(shaking) before administration.
*
Not susceptible to being mixed.
34
Parenteral dosage forms are given by injection under or

through one or more layers of skin or mucous membrane. This route
includes subcutaneous, intradermal, intrathecal, intracisternal,
intramuscular, intravenous, and intraarterial administration. The
parenteral route requires that the drug preparation be exceptionally
free from all con- taminants because the protective skin barrier is being
bypassed. The parenteral drug vehicle is usually a solution, a
suspension, or an emulsion. Gas dosage forms are typically used for
oxygen therapy, anesthe-
? DID YOU KNOW?
sia, and aerosol inhalers. Oxygen is in gaseous form at room Abraham Lincoln’s mother
temperature and requires no dispersing agent. Most anesthetics are died when the family dairy
also gaseous at room temperature. The inhalers usually contain a cow ate poisonous
liquified medication dispersed in a gas propellant, such as a mushrooms and Mrs. Lincoln
fluorinated hydrocarbon; on inhaler actuation, the fluorinated drank the milk.
hydrocarbon gas disperses the liquified medication to the bronchial
system.
Disintegration and Dissolution

Medication is absorbed in either liquid or gaseous solution.
? DID YOU KNOW?
Therefore, any solid or semisolid drug must first enter into one of Some manufacturers put sur-
these solution forms before becoming absorbed across a cellular prising things in their
membrane. A medication in solid form will generally require more medications that have little
time to enter the body than the same medication in liquid form. Fig. to do with the drug’s primary
3-1 depicts the process of solid drug absorption, and Table 3-2 shows purpose. With over-the-
the relative rapidity of absorption of various dosage forms. counter (OTC) analgesics
such as aspirin,
Disintegration and dissolution are generally considered to constitute
acetaminophen, and ibupro-
the beginning of the pharmacokinetic process. fen, for example, you may
find one brand has two
DISINTEGRATION different choices, such as
Granules “Super-sonic Pain Killer” and
Tablet “Super-sonic Pain Killer
P.M.” The only difference is
Smaller that the original has caffeine
particles and the “P.M.” version does
not. It pays to read labels.
DISSOLUTION
Solution
ABSORPTION of drug
solution in small intestine
35
Fig. 3-1 Process of solid drug absorption.
36
Table 3-2 Absorption

of Dosage Forms
PHARMACOKINETICS
Dosage Form Absorption Immediately on medication administration, a drug begins to
undergo the pharmacokinetic process. Pharmacokinetics consists of
Solutions Fastest
the process of how a drug is absorbed, distributed, metabolized,
Suspensions
Powders
and eliminated throughout the body. These parameters determine the
Capsules onset, duration, and extent of drug action.
Tablets
Coated
Absorption
tablets Prior to systemic action, a drug must either undergo the
Enteric-coated absorption process or be administered by direct intravenous
tablets Slowest injection, thus bypass- ing the need for absorption. Numerous
anatomic sites, including GI tract, lungs, mucous membranes, eyes,
skin, muscle, and subcutaneous tissues, can be used for systemic
drug absorption.
For absorption to occur, the physiochemical properties of the drug
and the vehicle must be compatible with the site for
administration. Rate and extent of drug absorption depend on
dissolution properties of the dosage form (previously discussed),
surface area at the site, blood flow to the site, concentration of
drug at the site, acid-base properties surrounding the absorbing
surface, lipophilicity (attraction to fat) of the drug, and compatibility
with other chemicals or drugs.
Surface area. A large surface area allows for better
? DID YOU KNOW?

absorption than does a smaller area. Pulmonary alveoli and GI
rugae give rise to some of the largest surface areas for absorption in
the human body. One could compare this concept to the distance
Good News/Bad News between two points. As the eagle flies, it may be 5 miles from point
The Good News: Some anal- A to point B. If you are driving in the mountains from point A to
gesic formulas, such as Alka- point B, however, you may zigzag back and forth on many curves
Seltzer and Bromo-Seltzer, and actually drive 25 miles. Similarly, with lungs and intestines, all
are liquid (disintegrated) the “ins” and “outs” add surface area.
when they enter the body.
This does shorten the time Blood flow. A large amount of blood supplies these sites.
between administration and
Blood must be flowing to the absorbing surface during the absorptive
onset of action (pain relief).
process to allow entry into the systemic circulation. Altered blood
The Bad News: These flow, such as occurs in cardiovascular shock, may change the drug
formulas contain large
absorption profile. Consequently, a patient who is in shock
amounts of sodium, which
generally requires medication delivered through the intravenous
makes them effervescent,
and they are not a good route.
choice for patients with
sodium-restricted diets. Concentration. Passive diffusion is the most common means
by which drugs traverse cellular membranes. Drugs in solution tend
to move from an area of higher concentration to an area of lower
concentration. In effect, the concentration of drug at the administration
site will influence both rate and extent of absorption (Fig. 3-2).
Exceptions to this rule include drugs that use an active
transport (carrier transport) system to facilitate movement across
membranes (e.g., ferrous ions). An active transport system generally
37
contains a carrier
protein to which a
drug attaches. The
protein complex
actively moves the
drug across the
membrane, then
releases it on the
postab- sorptive side.
This is like a
piggyback ride, with
the protein doing all
the
38
* *
* * * *
* * * * *
* * * *
* * * * *
* * * *
* *
Drug (*) in Cell Drug (*) in

high membrane low
concentration concentration
Fig. 3-2 Drug absorption via passive diffusion. The movement of drug across a
cellular membrane generally occurs in the direction of highest concentration pushing
toward the area where the lowest concentration exists.
work. Active transport can effectively move a drug from an area of low
concentration to an area of higher concentration (Fig. 3-3).
Acid-base properties. After dissolution, the acid-base

properties of the medium used for the drug affect the extent of
absorption across membranes. A neutrally charged, or nonionized,
particle crosses a cell membrane better than does a charged, or
ionized, particle. Most drugs are either weak acids or weak bases.
Weak acids are nonionized in acidic mediums (media) and ionized
when in alkaline media. Thus, a weak acid crosses barriers best
when in an acid medium.
Aspirin, which is a weak acid (acetylsalicylic acid), provides a
good example of this concept. When aspirin arrives at the stomach,
it enters an acidic environment where gastric juices have a pH of
1.0 to
2.0. Thus, the acidic aspirin is in an acidic environment, which makes
* * *
*— *— * * * *
* * * *
*— *— * * * * *
*— *— * * * *
* * *
*— *— * * * *
*— *— * * * *
Drug (*) in high Cell Drug (*) in high

concentration membrane concentration.
attaches toa Carrier protein ( —)
carrier protein ( —) has released drug
on side of highest
concentration.
Fig. 3-3 Drug absorption via active transport. In active (carrier) transport, the
movement of drug across a cellular membrane can occur in the direction of lowest
39
concentration pushing toward the area where the highest concentration exists.
40
it nonionized. This creates an easy pathway through the membrane

for the drug to enter the blood. However, when a weak acid is in
an alkaline environment, it becomes ionized, which hinders it
from passing across cellular membranes. When the aspirin enters the
blood (a slightly alkaline pH of 7.4), it becomes more ionized
because its pH no longer matches its environment. Therefore, it
will not cross from the blood back over into the stomach (Fig. 3-4).
Lipophilicity. The human cell has a double layer of lipid (fat)

through which a drug usually must penetrate for absorption to
occur. Drugs with good lipid solubility will cross lipid-layered
membranes readily. Water-soluble drug forms will not; however,
they must have some affinity for (attraction to) water, or they
cannot dissolve and be transported by blood and other body fluids.
Exceptions to this rule occur when the human cell uses active
transport, a small-pore system, or pinocytosis (process by which
extracellular fluid is taken into a cell) to allow access across the
membrane.
Compatibility. Some drugs may interact with other chemicals

to form insoluble precipitates. When such an interaction occurs,
absorption is significantly decreased. This concept is frequently used
in radiologic imaging. For example, barium is extremely toxic when
administered intravenously. However, barium does not cross GI
membranes well because it forms an insoluble complex (precipitate) in
that medium. Thus, barium is safely used as an oral GI radiopaque
agent.
A weak acid drug in... A weak basic drug in...

acid media basic media acid media basic media
+- + -
-
+- - +
- + +
-
+- +
Nonionized Ionized Ionized Nonionized
-
Membranes
+ +
-
+ +-
+
-+ - -
GI tract +
-
+ +-
-
- +
Bloodstream
B
Fig. 3-4 Effect of pH on drug ionization and transport. A, Effects of pH on drug
molecules. B, Effects of pH on the transport of drug molecules through
41
membranes. GI, Gastrointestinal.
42
Distribution
Once a drug is absorbed into the bloodstream, it is immediately distrib-
uted throughout the body by the circulation of the blood. Distribution
is defined as the transport of a drug in body fluids from the bloodstream
to various tissues of the body and ultimately to its site of action.
As an analogy, use two aspirin and trace their itinerary as if
they were travelers going on vacation. First, the two aspirin are
ingested and begin to dissolve as soon as they contact the water
and saliva in the mouth. So far, two travelers have left home with
their bags. The moment they get in the car, they become excited
about their upcoming excur- sion. Soon they are at the airport, just
as the aspirin are in the stomach. The absorption that takes place in
the acidic environment of the stomach is analogous to going through
the security systems at the airline gate. As soon as the aspirin enter the
bloodstream, it is like stepping onto a jet going 500 mph and letting
passengers parachute into all the small towns and big cities across
the country. In other words, the drug goes every- where the blood
goes (with two exceptions, as discussed later). Drug molecules are
now present throughout the body just as passengers are located all
over the country, but there is still one problem. The drugs must get
into certain cells to have their desired effect. This is analogous to
being forced through security systems one more time to get back into
the cities. The drugs must permeate a cell membrane to get in, just
as they had to permeate a cell membrane to get out (of the
stomach).
Several factors affect distribution, as follows:
1. Cardiac output: amount of blood pumped by the heart
per minute.
2. Regional blood flow: amount of blood supplied to a
specific organ or tissue.
3. Drug reservoirs: drug accumulations that are bound to
specific sites, such as plasma, fat tissue, and bone
tissue.
The body has two barriers to distribution made up of biologic
membranes: the blood-brain barrier and the placental barrier. As
one might expect, these barriers have both advantages and
disadvantages. With a central nervous system infection, for example,
it would be desir- able to have an antibiotic that could cross the blood-
brain barrier. With an expectant mother who did not know she was
pregnant, however, it would be undesirable for certain drugs to cross
the placental barrier and affect the unborn child.
Metabolism
Drugs are taken because a certain effect is desired. However, we do not
usually want that effect to be permanent. Metabolism, also called bio-
transformation, chemically changes a drug into a metabolite that can be
excreted from the body. The liver is primarily responsible for this task,
although the plasma, kidneys, lungs, and intestinal mucosa also play a role.
Drugs usually undergo one or both of the following types of chem-
ical reactions in the liver:
43
1. Oxidation, hydrolysis, or reduction: gaining an electron
to decrease positive valence.
44
2. Conjugation: transforms a drug from a lipid-soluble

substance that can cross biologic membranes to a water-
soluble substance that can be excreted through the biliary
tract.
Several factors contribute to prolonged drug metabolism,
including liver disease, immature metabolizing enzyme systems,
degenerating enzyme function, severe cardiovascular dysfunction,
and renal problems.
If drug metabolism is delayed, cumulative drug effects may
appear as symptoms of an overdose even though a usual dose was
administered.
One more phenomenon needs to be discussed with regard to
metabolism. Drugs that are administered orally normally travel first
to the liver before entering the general circulation. This first-pass
metabolism may cause significant deterioration (metabolism) of the
active drug, thus rendering the drug inactive. Thus, some drugs need
to be administered through an alternative route to ensure the proper
desired action at the intended site.
Excretion
Drug molecules, whether they are intact or metabolized,
eventually must be removed from the body. This elimination is
primarily accom- plished by the kidneys. They filter the blood and
remove unbound, water-soluble compounds. This is one reason why
drug testing is often done on urine.
The intestines may also eliminate drug compounds. After metabo-
lism by the liver, a metabolite may be secreted into the bile, passed into
the duodenum, and eliminated in the feces.
The third mechanism of excretion is the respiratory system. Gases
or volatile liquids that are administered through the respiratory
system usually are eliminated by the same route.
Breast milk, sweat, and saliva also contain certain drug
compounds but are not the body’s predominant mechanisms for
elimination.
CONCLUSION
Drugs undergo various phases of action best described using
biophar- maceutical and pharmacokinetic concepts. Biopharmaceutics
involves the designing of proper vehicles and dosage forms into
which a drug should be placed. The various dosage forms include
solids, liquids, and gases. Drugs must undergo dissolution before
absorption across cellular membranes. Various physiochemical
factors, including surface area of the administration site, acid-base
chemistry, concentration of drug and blood flow at the absorbing
surface, and lipophilicity of the drug, may affect drug absorption.
Drugs are primarily absorbed via passive diffusion but may undergo
active transport via protein carrier or may use a pore system or
undergo pinocytosis for absorption. Once absorbed, a medication is
distributed to body tissues, where it elicits activity. Drugs are
45
primarily metabolized by the liver and excreted by the kidneys.
46
Learning Exercises
Review Questions
1. Which dosage form is generally absorbed fastest, and which is

absorbed slowest?
2. What are three factors that affect drug distribution throughout the
body?
3. What are three primary means of drug elimination?
4. Define lipophilicity.
5. What are at least four factors controlling the rate and extent of
drug absorption?
39
6. What are the differences and similarities between drug

absorption via passive diffusion and drug absorption via active
transport?
Fill-in-the-Blank Questions
1. The and the are two drug dis-
tribution barriers the body has that are made of biologic
membranes.
2. is another name for metabolism.
3. is the area of pharmacology that focuses on
the method for achieving effective drug administration.
4. includes the processes of how a drug is
absorbed, distributed, metabolized, and eliminated throughout the
body.
5. The most common way drugs traverse cellular membranes is
.
6. can move a drug from an area of low
concentration to an area of higher concentration.
7. Medications must go through disintegration and
in order to be absorbed across a cell membrane.
Matching
Match the following terms with the appropriate descriptive phrases.
a. Compressed tablets
b. Sugar-coated tablets
c. Film-coated tablets
d. Enteric-coated tablets
e. Capsules
f. Troches
g. Compressed suppositories
h. Parenteral dosage forms
1. Lozenges or pastilles; topical oral antifungals.

2. Less expensive to manufacture than sugar coating.
3. Subject to chemical degradation from the environment.
40
4. Hard or soft gelatin encloses the active ingredient.
5. Mask taste and protect active ingredients from chemical
oxidation.
41
Pharmacology and Drug Administration for Imaging Technologists Biopharmaceutics and Pharmacokinetics
6. Release medicinal agent on contact with mucosa and melting.

7. Release active ingredients into the small intestine.
8. Injection under or through one or more layers of skin or
mucous membrane.
1. What is the term for the substance into which a drug is

compounded for initial delivery into the body?
a. Drug dose
b. Drug vehicle
c. Drug suspension
d. Drug filler
2. How are drugs eliminated from the body?

a. Metabolism
b. Ionization
c. Excretion
d. Both a and c
3. What is the term for the most common means by which drugs
traverse cell membranes?
a. Active transport
b. Passive diffusion
c. Lipophilicity
d. Cellular absorption
4. What is the general term for lozenges or pastilles?

a. Capsules
b. Tablets
c. Troches
d. Inserts
5. What is the term for the process of how a drug is absorbed,

distributed, metabolized, and eliminated in the body?
a. Pharmacodynamics
b. Biopharmaceutics
c. Pharmacokinetics
d. Cellular diffusion
6. Which of the following dosage forms is designed to mask taste,

allow for easy swallowing, and contribute to controlled release
of the drug?
a. Troches
b. Tablets
c. Pastilles
d. Capsules
42
7. Which of the following drug dosage forms consists of two

immiscible liquids?
a. Solution
b. Emulsion
c. Suspension
d. Parenteral
8. Which of the following drug dosage forms is a mixture of solid,

liquid, or gas dissolved in another liquid?
a. Solution
b. Emulsion
c. Suspension
d. Parenteral
42
specific receptor sites that
produces a physiologic
response, usually
predictable.
Pharmacodynamics
OBJECTIVES
At the conclusion of this chapter, you should be able to:
1. List and describe the three mechanisms of drug action.
2. Explain the differences between agonistic and antagonistic drug responses.
3. Recognize and interpret a serum concentration-time profile.
4. Discuss the significance of a drug’s half-life of elimination.
5. Cite and define terms associated with negative responses to drug action.
INTRODUCTION
After absorption and distribution, a drug reaches its site of action to pro-
duce an effect. Pharmaco refers to drugs, and dynamics refers to
what happens when two things meet and interact—that is, the drugs
and your body. In essence, pharmacodynamics is the study of how the
effects of a drug are manifested. Various terms are used in
pharmacodynamics, including mechanism of action, onset of action,
therapeutic effect, adverse effect, toxicity, termination of action, side
effect, and allergic reaction.
MECHANISM OF ACTION
The method by which a drug elicits effects is known as the
mechanism of action. Drugs produce effects through drug-receptor
interactions (stimulation or blockade), drug-enzyme interactions, or
nonspecific drug interactions.
Drug-Receptor Interactions
Receptors are specific biologic sites located on a cell surface or within a
cell (Fig. 4-1). Receptors can be thought of as “keyholes” into which spe-
cific keys (drugs) may fit. Drugs have specific affinity (attraction) for their
specific receptors. Strong affinity for a receptor allows a drug to elicit an
agonist, antagonist, or mixed agonist/antagonist interaction. The organ on
or in which the desired effect occurs is generally called the target
organ. The target organ can represent any organ or system in the
body.
An agonist is a drug or natural substance with an affinity for
43
4
KEY TERMS
adverse effect affinity agonist
allergic reaction antagonist
drug-drug interaction duration of action enzyme
half-life of elimination mechanism of action minimum effective
concentration onset of action
peak serum concentration pharmacodynamics receptor
serum concentration-time profile
side effect target organ
termination of action therapeutic effect therapeutic range toxic
level
toxicity
44
? DID YOU KNOW?

Drug
When screening for drug use,

it is important to know that
there is a finite amount of
time after drug ingestion Cell receptor sites
that the drug or any of its
metabolites can be
detected. Some of the more
Fig. 4-1 Drug-receptor interaction at target organ. Site configuration on drug
common drugs and detection resembles configuration of receptor on target organ. A drug with affinity for a particular
times include the following: receptor will attach to the receptor and produce an agonistic, antagonistic, or mixed
●
Cocaine: 2-4 days (10-20 agonistic/antagonistic response.
days with heavy use)
●
Amphetamines: 1-2 days
●
Heroin: 1-2 days A drug agonist simply stimulates or enhances the body’s natural response
●
Morphine: 1-2 days to stimulation. An example of such activity is seen with the use of
●
Phencyclidine (PCP): 1-8 days epinephrine in a patient suffering acute bronchospasm secondary
●
Alcohol: 3-10 hours to anaphylaxis. Epinephrine will stimulate a beta-2 (2) receptor in the
●
Benzodiazepines: up to 6 lungs to cause bronchodilation. The 2 receptor is normally
weeks with heavy use
stimulated by endogenous epinephrine, known as adrenaline, but the
Hydromorphone: 1-2 days
patient may not have enough of his or her own epinephrine to prevent
●
Tetrahydrocannabinol (THC):
severe respiratory distress when suffering acute anaphylaxis.
●
6-11 weeks with heavy use

●
Propoxyphene: 6-48 hours Administration of epinephrine, a 2-receptor agonist, can enhance the
●
Methadone: 2-3 days normal physiologic function of the 2 receptor to stimulate
●
Codeine: 1-2 days bronchodilation. No new function was developed; a normal
●
Barbiturates: up to 6 weeks physiologic/biologic function was simply enhanced. Using the lock-
and-key analogy, the endogenous epinephrine “key” plugs into the
receptor site “lock” to open the door for bronchodilation to occur.
? DID YOU KNOW?

The problem in acute anaphalaxis is that not enough keys are
available to unlock enough doors to allow bronchodilation to stop
the crisis. The epinephrine given to the patient is like pouring many
Lead poisoning has been new keys into the bloodstream to unlock many more doors.
blamed for contributing to Drugs with antagonist activity will block receptors for which
the fall of the Roman they have affinity. The normal physiologic/biologic function carried
Empire. Women became
out by the receptor cannot ensue; the door cannot be opened because
infertile by drinking wine
from vessels with lead that
the key- hole is blocked. In the previous example, a patient with
had dissolved in the wine, severe anaphylaxis may have worsening respiratory distress if
and the Roman upper classes given the drug propranolol, a 2-receptor blocker. Propranolol acts
died out within a couple of as an antagonist to the normal function of the 2 receptor in the
centuries. The Romans used lungs.
lead as a sweetening agent Breaking the words “agonist” and “antagonist” into their parts
and as a cure for diarrhea. helps to keep the two from being confused. The agonist enhances a
It added up to massive, self- response. The word antagonist is agonist with the prefix “ant” added,
inflicted poisoning. which means against. So antagonists diminish the response either of
endogenous agonists or other drugs. Box 4-1 provides a more
complete list of definitions.
Drug-Enzyme Interactions
Enzymes occur throughout body systems and are generally consid-
ered catalysts responsible for initiating biochemical reactions.
44
Pharmacodynamics
Many enzymes begin
working after
becoming attached to
a particular sub-
strate; this is
analogous to a drug
attaching to a
receptor. A drug-
enzyme
45
BOX 4-1 DRUG-RECEPTOR INTERACTION

TERMS
affinity Propensity of a drug to bind or attach itself to a given
receptor site.
efficacy (intrinsic activity) Drug’s ability to initiate biologic activity as
a result of such binding.
agonist A drug that combines with receptors and initiates a
sequence of biochemical and physiologic changes; possesses
both affinity and efficacy.
antagonist An agent designed to inhibit or counteract effects
produced by other drugs or undesired effects caused by cellular
components during illness.
competitive antagonist An agent with an affinity for the same
receptor site as an agonist; the competition with the agonist for the
site inhibits the action of the agonist; increasing the
concentration of the agonist tends to overcome the inhibition.
Competitive inhibition responses are usually reversible.
noncompetitive antagonist An agent that combines with
different parts of the receptor mechanism and inactivates the
receptor so that the agonist cannot be effective regardless of its
concentration. Noncompetitive antagonist effects are considered to
be irreversible or nearly so.
partial agonist An agent that has affinity and some efficacy but that
may antagonize the action of other drugs that have greater efficacy.
Antagonists may share some structural similarities with their
agonists.
interaction occurs when a drug resembles the substrate to which an

enzyme usually attaches. Stimulation or blockade of the enzyme
will then occur as a result of the drug, thus producing a
pharmacodynamic reaction.
An example of this type of pharmacodynamic reaction is seen
with nerve gas (as used in chemical warfare). Some nerve gases act
to “tie up” (or block) acetylcholinesterase enzyme.
Acetylcholinesterase enzyme metabolizes acetylcholine, a
neurotransmitter responsible for nerve stimulation. Inhibition of
acetylcholinesterase enzyme allows acetylcholine to accumulate,
reaching toxic levels in the nervous system. After reaching toxic
levels, acetylcholine will produce marked nausea and vomiting,
massive diarrhea, profuse sweating, pulmonary edema, and seizures.
This will progress until the drug effects on acetly- cholinesterase are
stopped.
Another example, seen more frequently in medicine, is the
cytochrome P450 enzyme interactions with various medications.
Cytochrome P450 enzyme is responsible for metabolism of many
med-
ications. Any interference with this enzyme can lead to decreased
metabolism with concomitant drug accumulation. Cimetidine, an antiul-
cer medication, is one drug that antagonizes cytochrome P 450 very
46
Pharmacodynamics
strongly. Theophylline, an antiasthma medication, is one drug that

requires
47
the enzyme for metabolism. Combining cimetidine and theophylline

can and does lead to theophylline poisoning, if not closely monitored.
Since theophylline poisoning can rapidly become fatal, it should be
apparent why it is important to understand drug-enzyme
interactions.
Nonspecific Drug Interactions

Finally, some drugs may elicit pharmacologic effects through
nonspecific pharmacodynamics. For example, ointments and
emollients may physically block underlying tissues from the outside
environment. The radiopaque contrast media, discussed in later
chapters, elicit their desired effects through the radiopaque iodine
contained within their structure. Some drugs penetrate cell membranes
or accumulate within a cell or cavity so that interference with
normal cell biochemical function occurs.
DRUG-RESPONSE RELATIONSHIPS
Two other terms need to be introduced at this point: efficacy and
potency. Efficacy is the degree to which a drug is able to produce
the desired effect (how great the effect will be). Potency is the relative
concentration required to produce that effect (how much drug is
needed). For example, if drug A produces a reduction in pain from
severe to mild, and if drug B reduces pain from severe to none at
all, drug B is more efficacious. If drug C and drug D both provide
total pain relief, but you must take 5000 mg of drug C and only 200
mg of drug D, then drug D is more potent. The dynamics of these
two phenomena are related to receptor-drug interaction.
After drug administration, the amount that reaches and remains
in the systemic circulation depends on the rates and extent of
absorption, distribution, metabolism, and elimination. Fig. 4-2 is a
graphic representation of response once drugs are administered; it
shows what happens over time, as indicated by the serum
concentrations of a drug: the serum concentration-time profile (Box
4-2).
HALF-LIFE
The time required for the current serum drug concentration to decline
by 50% is termed the biologic half-life, or half-life of elimination. The
half- life of elimination generally remains stable for each particular
drug, unless metabolism and excretion are altered (as in septic shock).
The drug dosage does not generally alter the half-life of elimination.
However, a few drugs, such as phenytoin, aspirin, and alcohol, may
have alterations in their respective half-lives of elimination when
dosages overwhelm the biologic capacity for metabolism. Fig. 4-3
uses theophylline, an antiasthma drug, to illustrate the concept of
half-life of elimination.
THERAPEUTIC INDEX
48
Pharmacodynamics
The therapeutic index is a measure of the relative safety of a drug.
It is a ratio between the following two mathematical factors:
49
20
Peak serum concentration Toxic level
18
16
14
Therapeutic
12 range
Absorption
Elimination
10
8
Minimal effective
6 concentration
4
2
0
2 3 4 5 6 7 8 9 10 11 12
Administration
of drug
Onset Duration of action Termination
of of
action action
Fig. 4-2 Drug serum concentration-time profile.
BOX 4-2 SERUM CONCENTRATION-TIME PROFILE TERMS

onset of action or latent period Interval between the time a drug is
administered and the first sign of its effect.
termination of action Point at which a drug effect is no longer seen.
duration of action Period from onset of drug action to the time
when response is no longer perceptible.
minimum effective concentration Lowest plasma concentration that
produces the desired drug effect.
peak serum concentration Highest plasma concentration attained
from a dose.
toxic level Plasma concentration at which a drug produces toxic
effects.
therapeutic range Range of plasma concentrations that produce the
desired drug effect without toxicity (the range between minimal
effective concentration and toxic level).
●
Lethal dose (LD50): the dose at which a drug is lethal to 50%
of the population.
●
Effective dose (ED50): the dose required to produce a therapeu-
tic effect in 50% of the population.
The therapeutic index (TI) is calculated with the following formula:
LD50
TI =
ED50
50
Pharmacodynamics
• 10.0 mg/L
Half-life of elimination = 8 hr
• 5.0 mg/L
• mg/L
2.5 1.25 mg/L
•
•
0 8 16 24 32 40
Time (hr)
Fig. 4-3 Half-life of elimination of theophylline. Theophylline is an antiasthma
drug that exhibits a half-life of elimination of about 8 hours in most individuals.
Therefore, it will take 8 hours for a serum theophylline concentration of 10 mg/L
to decline to 5 mg/L, provided no more theophylline enters the body. It will then
take another 8 hours to decline to 2.5 mg/L, another 8 hours to decline to 1.25
mg/L, and so on. A drug requires approximately four to five half-lives of
elimination to be completely cleared from the body.
The closer the calculation is to 1, the more dangerous the drug. If

it takes a lethal dose to obtain a therapeutic effect, you may kill
your patient at the same time you are trying to cure him.
? DID YOU KNOW?

ADVERSE EFFECTS
A side effect is generally considered a predictable pharmacologic
Cocaine is detectable with action on body systems other than the action intended. Side effects
hair tests and is included in the can be either “good” or “bad,” depending on the situation. Any
standard set of substances unwanted effect is an adverse effect. For example, hydroxyzine is a
tested. Hair tests generally use strong antihistamine medication that can be used to prevent
the most recent 1.5 inches of itching. Two side effects of this drug are antiemetic activity and
growth. This provides a anxiety relief, both of which may be considered good but not the
detection period of
primary drug function. Meperidine (Demerol) causes frequent nausea
approximately 90 days.
and vomiting, which are adverse effects. The good side effects of
hydroxyzine will lessen the adverse effects of meperidine while
simultaneously relieving anxiety often associated with pain.
However, another side effect of hydroxyzine is constipation, which
could lead to impaction and a severely adverse outcome. Thus, all
adverse effects need to be considered, and an acceptable ratio
between the good and adverse effects should be sought for all drug
therapy.
Toxicity is also an extension of pharmacologic action and is
directly related to dose: the higher the dose, the greater the toxic effects.
This is an area of concern for medical imaging technologists as well
as for you as a consumer. Remember that a normal dose may
51
become toxic if
metabolism or
elimination is
impaired.
52
Pharmacodynamics
An allergic reaction results from an immune-mediated

response by the body against the drug and is not necessarily related
to dose. Both toxic and allergic effects are adverse.
? DID YOU KNOW?
Absolutely no drugs are completely safe. All have potential to Poppy seeds contain both
cause side, adverse, toxic, and allergic effects in the human body. morphine and codeine and
In some cases the effects are immediately noticed; other cases can cause false-positive
require weeks to manifest the effects. Patients should never be given results for opiates in urine
a medication without proper, systematic, and critical thought. tests. Ingestion of a poppy
Even water has killed those who have overdosed on it! seed bagel can produce an
opiate level of about 250
ng/ml 3 hours later.
DRUG-DRUG INTERACTIONS
A drug-drug interaction occurs when two or more drugs act in
?
unison to produce additive agonist, synergistic, or antagonist
responses. Many drugs will alter the metabolism of other drugs, thus DID YOU KNOW?
leading to accumulation and possible toxicity. Some drugs, such as the
sedative-hypnotics, will synergize with others in their class. Concerned parents often
Synergism means that two drugs act together to give a pharmacologic give their children doses of
response that is greater than the additive response expected. Alcohol drugs for a variety of reasons
plus diazepam (Valium) is a good example of a synergistic (e.g., cold medicines,
combination. The sedative properties of either drug alone may not antibiotics). One of the
make a person comatose at small doses. When alcohol is taken with factors that concern physi-
diazepam, however, the patient may experience severe central cians, pharmacists, and
pharmaceutical companies
nervous system depression with a comatose state. Another type of
is the therapeutic index for
drug-drug interaction is chemical incompatibility. pediatric patients. Some drugs
When two drugs with different chemical composition are placed require an adult dose to
together, they may precipitate to an insoluble complex or may achieve the therapeutic
chemically destroy their activity. effect. However, children’s
kidneys and livers are not
fully mature and are not able
CONCLUSION to handle the adult dose. Any
Pharmacodynamics is the study of the way drugs act on the body. Drugs medication given to a child
produce effects through drug-receptor stimulation or blockade, should be responsibly and
drug- enzyme interactions, and nonspecific drug interactions. Drugs carefully considered.
do not confer any new biologic functions; they simply enhance or
block existing functions. The serum concentration-time profile helps
to illustrate onset of action, minimum effective and toxic
concentrations, peak serum concentration, half-life of elimination,
and duration of action. No drug is considered absolutely safe; all
can exhibit adverse and potentially toxic effects. Likewise, all drugs
have the potential to interact with other drugs to cause either
beneficial or adverse outcomes.
49
Learning Exercises
True-False
1. T F The plasma concentration at which a drug no longer pro-

duces serious adverse effects is known as the toxic level.
2. T F The therapeutic index is a measure of the relative

effectiveness of a drug.
3. T F Drugs have a specific affinity for their specific receptors

on a cell surface or within a cell.
4. T F Half-life is the time required for the current serum

concentration to double.
5. T F The half-life of elimination generally remains stable for most

drugs.
6. T F Some drugs are completely safe.
7. T F Efficacy is the degree to which a drug is able to produce

the desired effect.
8. T F The latent period is the point at which a drug effect is

no longer seen.
9. T F Side, adverse, and toxic effects of drugs always are

manifested immediately.
10. T F Radiopaque contrast media elicit their desired effects

through the radiopaque iodine contained in their structure.
1. Generally thought to be catalysts responsible for changes in
biochemical reactions, occur throughout the body
systems.
2. A is a predictable pharmacologic action on
body systems other than the action intended.
3. When two drugs are combined and cause a pharmacologic
response that is greater than it would have been if the drugs
had been given individually, this is known as .
50
Pharmacodynamics
4. The method by which a drug elicits effects is known as the

.
5. The organ in which the occurs is generally
called the target organ.
6. A occurs when a drug resembles the substrate
to which an enzyme usually attaches.
7. After drug administration the amount that reaches and remains
in the systemic circulation depends
on ,
, , and .
8. Any unwanted effect from a drug is termed .
9. Both toxic and allergic effects are known as .
10. A occurs when two or more drugs act in
unison to produce additive agonist, synergistic, or antagonist
responses to each other.
1. What term is defined as the study of the manner in which drug

effects are manifested?
a. Pharmacokinetics
b. Pharmacodynamics
c. Affinity
d. Toxicity
2. Drugs produce effects through mechanisms of action termed

drug- receptor stimulation or blockade, nonspecific drug
interactions, or which of the following?
a. Drug-drug interactions
b. Physiologic/biologic processes
c. Drug-enzyme interactions
d. Pharmacologic effect
3. What is the term for specific biologic sites located on a cell

surface or within a cell that attract certain drugs?
a. Target organs
b. Organelles
c. Receptors
d. Keys
51
4. Which of the following is true of drugs with antagonistic activity?

a. They stimulate receptors for which they have affinity.
b. They block receptors for which they have affinity.
c. They destroy receptors for which they have affinity.
d. They have no effect on receptors for which they
have affinity.
5. What is the term for the catalysts responsible for initiating

changes in biochemical reactions?
a. Proteins
b. Agonistic drugs
c. Substrates
d. Enzymes
6. What is the mechanism by which radiopaque contrast media

elicit their desired effects through the radiopaque iodine contained
within their structure?
a. Drug-enzyme interaction
b. Drug-drug interaction
c. Nonspecific drug interaction
d. Serum-drug interaction
7. What is the term for a predictable extension of pharmacologic

action into body systems other than those intended?
a. Toxic effect
b. Side effect
c. Adverse effect
d. Allergic effect
8. Which of the following are depicted on the plasma

concentration graph?
a. Onset of action
b. Toxic concentrations
c. Half-life of elimination
d. All of the above
52
Pharmacodynamics
Review Questions
1. Using the serum concentration-time profile, what is the
significance of toxic serum concentration?
2. What are the three mechanisms of drug action?
3. When does a drug-drug interaction occur, and what does it produce?
4. What is the relationship between dose and toxic effect?
53
5 Drug Classifications

acetaminophen At the conclusion of this chapter, you should be able to:
analgesic 1. Identify major drug classifications.
antianxiety 2. Identify drug names and how they fit into the drug classifications.
antiarrhythmic 3. Acquire a basic understanding of the actions of certain drugs by
antibiotic knowing their classification.
anticoagulant
antidepressant
antidiabetic
antifungal
antihistamine
antihypertensive INTRODUCTION
antiplatelet
The imaging technologist needs at least a basic understanding of
antipsychotic
drug classification as patients report to the radiology setting. Learning
antiseizure (anticonvulsant)
a few basic drug classes allows the technologist to assimilate a quick
antiviral
snapshot of the patient’s medical condition. This chapter briefly
chemotherapy
outlines some common drug classifications along with intended uses.
digoxin
For a more complete understanding of drug class effects, the
diphenhydramine
reader is encouraged to review the specialized references discussed
diuretic
in Chapter 2.
epinephrine
hydroxyzine thyroid
insulin CARDIAC MEDICATIONS
lorazepam
Cardiac medications encompass a broad class of agents used to
metformin
treat cardiovascular pathology.
midazolam
Antiarrhythmic (or antidysrhythmic) medications are those
naloxone
drugs that affect the electrical conduction system of the
narcotic
myocardium. The actions of these medications differ among the
thrombolytic
individual drugs. As a group, however, they act to block the sinoatrial
thyroid
(SA) node, atrioventricular (AV) node, His-Purkinje system (bundle
warfarin
of His and Purkinje fibers), or the electrical membrane current
within the myocardial cell. Antiarrhythmics do this by blocking
various electrolyte channels, such as those for sodium, calcium, and
potassium, or by blocking the beta receptors located within the
myocardium. The ultimate goal for this class of medications is to
suppress excess electrical conduction within the cardiac system and
thus decrease arrhythmia (dysrhythmia) production. Common drugs in
this class include lidocaine, procainamide, fle- cainide,
disopyramide, mexilitine, moricizine, amiodarone, atenolol,
metoprolol, acebutolol, esmolol, labetolol, sotalol, propafenone, dilti-
54
Pharmacodynamics
azem, verapamil,
adenosine,
ibutilide,
dofetilide, and
digoxin.
55
Drug Classifications
Antihypertensive medications assist in lowering the blood the bloodstream, thus
pressure to safe, long-term goals. These drugs also affect heart decreasing the overall
failure in a positive way by decreasing the pressure against which pressure within the vessels.
the heart must pump. This allows the failing heart to pump more Overuse or improper use
efficiently without “tiring out.” Many studies are now confirming can lead to dehydration
the positive long-term effects that some antihypertensives have on and kidney failure. Some
the duration of life. Various actions within this class can occur of
between the drugs. Generally, patients with severe and difficult
hypertension will require more than one antihypertensive, each of
which affects blood pressure through different mechanisms.
Antihypertensives generally lower the blood pressure by causing
vasodilation, decreased heart rate, decreased sympathetic nerve
outflow from the central nervous system, decreased sodium and water
retention, or inhibition of the renin-angiotensin- aldosterone
system (see Chapter 11) or through direct vasodilatory effects on
the blood vessels. Antihypertensive drugs include verapamil,
diltiazem, nifedipine, nicardipine, amlodipine, nisoldipine, captopril,
enalopril, fosinopril, lisinopril, trandolapril, ramipril, quinapril,
moex- ipril, perindopril, valsartan, olmesartan, candesartan,
telmisartan, propranolol, acebutolol, atenolol, metoprolol, labetolol,
nadolol, pen- butolol, bisoprolol, pidolol, furosemide,
bumetanide, torsemide hydrochlorothiazide, chlorothiazide,
amiloride, sprionolactone, eprenolone, metolazone, hydralazine,
isosorbide mononitrate, isosorbide dinitrate, bosentan, prazocin,
terazosin, minoxidil, clonidine, guanethidine, methyldopa, and
reserpine.
Heart failure medications encompass a variety of classes, but
for simplicity, we discuss only those drugs for which a positive
inotropic effect (increased force of contraction) is needed. Digoxin
is used for increasing the force of myocardial contraction in the
failing heart. By stimulating a release of calcium from the
sarcoplasmic reticulum, digoxin leads to a greater contractile force
from each cardiac muscle. Digoxin is also used to block the AV node
in the heart so that patients with atrial fibrillation do not
experience too many adverse beats from the atrium to the ventricle.
Dobutamine, milrinone, dopamine, norepinephrine, and epinephrine
are intravenous medications that can be used to increase the force of
contraction in a failing heart as well. Dopamine, norepinephrine, and
epinephrine also have vasoactive properties to help increase blood
pressure. When patients are prescribed one of these five medications,
they are generally much less stable, and acute problems can occur
rapidly.
Lipid-lowering medications are used to lower the serum
choles- terol levels and to assist in long-term life enhancement for
patients with coronary syndromes or hypercholesterolemia. The more
common lipid- lowering drugs include lovastatin, simvastatin,
pravastatin, ezetimibe, fluvastatin, atorvastatin, gemfibrozil,
colestipol, cholestyramine, and niacin.
Diuretics are frequently referred to a “water pills.” These
medications are designed to eliminate excess fluid and sodium from
55
?
DID YOU KNOW?
The first known heart medicine was discovered in an English garden. In
1799, physician John Ferriar noted the effect of dried leaves of the common
foxglove plant, Digitalis pur- purea, on heart action. Still used in heart
medications, digitalis slows the pulse and increases the force of heart con-
tractions and the amount of blood pumped per heartbeat.
56
the more common diuretics include hydrochlorothiazide, chlorthali-

done, furosemide, torsemide, bumetanide, acetazolamide, amiloride,
chlorothiazide, ethacrynic acid, spironolactone, triamterene, metalo-
zone, and indapamide.
ANTICOAGULANT, ANTIPLATELET,
AND THROMBOLYTIC MEDICATIONS
Patients receiving any of the anticoagulant, antiplatelet, or thrombolytic
medications are at risk for bleeding. In some cases, such as with
the thrombolytics, severe bleeding can to lead to hemorrhagic
stroke. Therefore, the imaging technologist should know about the
signs and symptoms of an evolving stroke so that it can be reported
quickly if patients are taking one of these medications.
Anticoagulant medication is frequently used in patients who
have either a history of blood clot formation or the potential to
develop blood clots. Warfarin is an oral medication used to prevent
the absorption of vitamin K from the intestinal tract, thus preventing
the formation of the blood-clotting factors responsible for the
propagation of a blood clot. Heparin, enoxaparin, deltaparin,
fundoparinox, bivalirudin, lep- irudin, and argatroban are
examples of medications that affect the activity of thrombin in
various ways to inhibit clot formation.
Antiplatelet medication is generally used in patients who have
experienced an acute ischemic event to either their heart or their
brain in the past. Since platelets are one of the initial instigators of
blood clot formation, cardiologists and neurologists will prescribe
antiplatelet drugs to prevent that portion of the coagulation cascade.
Aspirin, clopi- dogrel, and dipyridamole are some of the most
common oral medications for inhibiting platelet effects.
Eptifibatide, abciximab, and tirofiban are the most frequently
used intravenous medications for inhibiting platelet function.
Thrombolytic medication is used to actively break up a newly
formed clot, such as found in patients with acute myocardial
infarction, acute stroke secondary to blood clot, or lower leg
ischemia. Alteplase, retaplase, streptokinase, tenecteplase, and
urokinase are the most frequently used medications in this class. If a
patient has recently been given an agent in this class, the patient is at
very high risk for bleeding internally and externally. Use caution with all
intravenous (IV) sites. Do not start an IV line in these patients without
physician orders and close supervision.
ANALGESIC MEDICATIONS
Analgesic medications are prescribed more frequently than any
other medication on the market. The drugs are used to treat both
acute and chronic pain syndromes, such as arthritis, headache,
muscle sprains, cancer pain, surgical and traumatic pain, nerve
pain, and in some cases, anxiety. The many subclasses of pain
medications are beyond the scope of this textbook. However,
57
common subclasses include the
58
narcotics, nonsteroidal antiinflammatory drugs, muscle relaxants, and

acetaminophen.
Narcotic medications stimulate central nervous system receptors
known as opioid receptors and cause a decrease in the perception
of pain. These are very potent analgesics and are associated with
the potential for physical and psychological addiction. The narcotic
class of analgesic is generally highly controlled by the local and
federal enforcement agencies to prevent misappropriation into the
community. The narcotics are also dangerous in that respiratory
depression can rapidly occur to the point of respiratory arrest if the
dose is too great. The technologist should keep this concept in mind
if patients are being treated with narcotic medications. If
respiratory arrest occurs, naloxone is the drug of choice (given
intravenously, intramuscularly, or endotracheally) to reverse
immediately the respiratory depressant effects of narcotic agents.
Examples of common narcotic medications include morphine,
meperidine, fentanyl, hydromorpone, hydrocodone, codeine,
oxycodone, alfentanyl, remifentanyl, tramadol, pentazocine,
nalbuphine, and butorphanol.
Nonsteroidal antiinflammatory drugs (NSAIDs) are used to
treat pain associated with inflammation, such as in arthritis,
vasculitis, muscle tears, broken bones, and surgical incision or
trauma wounds. These drugs relieve pain by inhibiting the
production and release of various chemical mediators responsible
for stimulating a nociceptor (pain receptor). Some NSAIDs can also
cause platelet dysfunction and thus place the patient at risk for
bleeding. Ulceration of the stomach and kidney failure are common
adverse effects from this class of medication. Common NSAIDs
include ibuprofen, naproxen, nabumetone, diclofenac, ketorolac,
? DID YOU KNOW?
indomethacin, fenoprofen, rofecoxib, celocoxib, and valdecoxib. Aspirin went on sale as the
Aspirin is technically in a class of its own but has actions similar to first pharmaceutical drug in
the NSAID class. 1899, after Felix Hoffman, a
Muscle relaxants are used to treat pain associated with muscle German chemist at the drug
spasms. These drugs are often used in ailments such as whiplash, company Bayer, successfully
spinal cord injury with spastic muscles, and muscular strains or modified salicylic acid, a
sprains. Importantly, if a patient is acutely ill, these medications may compound found in willow
affect the way the patient breathes simply by decreasing the strength of bark, to produce aspirin.
the external muscles of respiration (e.g., intercostals) and the
diaphragm. Common muscle relaxants include cyclobenzaprine,
baclofen, diazepam, lorazepam, clonazepam, alprazolam,
methocarbamol, and metaxalone.
Acetaminophen is probably the most common analgesic in use
today. It is contained in almost all pain medication combinations and
is in a subclass by itself. It is not fully known just how
acetaminophen elicits its effects, but some believe that it acts by
inhibiting prostaglandins in the central nervous system that are
responsible for pain production. Acetaminophen is a low-potency
pain reliever and must not exceed 4000 mg per day because it is
associated with severe liver damage at high doses. Long-term use of
high doses can also cause renal and cardiac damage.
59
ANTIHISTAMINE MEDICATIONS
Antihistamines are medications used to block histamine from
producing adverse effects such as itching, inflammation, respiratory
distress, and overall allergic reactions. Common antihistamines
include hydroxyzine (Vistaril, Atarax) and diphenhydramine
(Benadryl). The newest form of antihistamine is much less sedating,
but not typically used in radiologic science; these drugs include
fexofenadine (Allegra), lorata- dine (Claritin), and cetirizine
(Zyrtec). Antihistamines in general are quite sedating and may lead
to respiratory depression when used in combination with analgesic
medications.
ENDOCRINE MEDICATIONS
Diabetes and hypothyroidism are two common endocrine problems
for which patients frequently receive drug treatment.
Antidiabetic medication is required for patients who have
difficulty maintaining proper balance between blood sugar and
tissue sugar. Some patients are termed insulin dependent (diabetes
mellitus type 1) because they have little or no circulating
endogenous insulin. Diabetic patients who have sufficient
circulating endogenous insulin but poor receptor sensitivity to the
insulin are termed non–insulin dependent (diabetes mellitus type
2).
There are several types of insulin, including ultrashort acting, short
acting, intermediate acting, long acting, and ultralong acting.
Regardless of the type of insulin, the technologist should remember
that patients taking insulin may require regular meals so that blood
sugar does not drop to dangerously low values, which can lead to
seizure activity and a comatose state. The technologist should
ensure that all diabetic patients are aware of the time constraints
from sitting in the radiology suite when meals are planned around
the insulin given (even if the insulin was given hours earlier). Non–
insulin-dependent diabetic patients may require oral medications to
assist the endogenous insulin to function appropriately. Common
drugs in this category include glimeprimide, glipizide, glyburide,
rosiglitazone, pioglitazone, nateglinide, and metformin.
Technologists need to always be aware of patients receiving
metformin because this drug should be held before and for at least
48 hours after receiving a radiopaque contrast agent. If metformin is
not held, the patient is put at increased risk for severe metabolic
acidosis secondary to metformin metabolite accumulation, in the event
renal dysfunction is caused by the radiopaque contrast agent.
Thyroid medication is used to treat hypothyroidism that is
either primary because of a lack of endogenous thyroid hormone
production or secondary to removal or obliteration of the thyroid
gland. Thyroid hormone is a basic regulator of many metabolic
processes in the body; either a lack or and an excess of this hormone
can present as many different types of pathology. Common
60
hormone preparations designed to
61
secondary to
enhance thyroid function include levothyroxine, thyroxine, liothyronine, claustrophobia when
and desiccated thyroid. Common preparations designed to block undergoing computed
or inhibit thyroid function include methimazole and tomography (CT) and
propylthiouracil. magnetic resonance
imaging (MRI) scans.
These medications gener-
CENTRAL NERVOUS SYSTEM MEDICATIONS ally act on the limbic
Many drugs have direct effects on the central nervous system (CNS). system in the brain by
We believe the CNS medications described and listed here are most enhancing the effect of
important to understand from the perspective of the imaging
technologist.
Antiseizure (anticonvulsant) medications are used to prevent
and to treat seizure disorders. Some patients require multiple
antiseizure medications to prevent frequent attacks, which can
become fatal if the patient loses the ability to oxygenate for long
periods. Goals of treatment for these medications are to stop the
seizure activity and to prolong the interval between each seizure
event. Examples include phenytoin, fos- phenytoin, ethotoin,
metphenytoin, diazepam, clonazepam, lorazepam, valproic acid,
divalproex, topiramate, carbamazepine, oxcarbazine, phenobarbital,
amobarbital, pentobarbital, secobarbital, ethosuximide,
methsuximide, felbamate, gabapentin, lamotrigine, tiagabine,
zon- isamide, and levetiracetam.
Antipsychotic medications are used to treat psychotic
episodes and disorders such as schizophenia, paranoid behaviors,
hallucinations, delusions, bipolar affective disorder, acute
agitation, antisocial behaviors, and mania. These medications
generally take weeks to months to reach their full effects, so you
may have patients with some paranoid delusions while presenting to
your radiology department. Keep in mind that this may be part of
their normal behavior as well as new-onset CNS pathology. Some
common antipsychotic medications include haloperidol, valproic
acid, divalproex, olanzapine, clozapine, quetiapine, aripiprazole,
chlorpromazine, fluphenazine, triflupromazine, loxapine, mesoridazine,
thioridazine, amoxepine, perphenazine, risperi- done, ziprasidone,
thiothixine, and pimozide.
Antidepressant medications act are use to treat clinical depression
that results from neurotransmitter deficiencies. These drugs
usually enhance the CNS levels of serotonin and norepinephrine,
which ultimately elevates the depressed mood into a more normal
state. As with antipsychotic medications, antidepressants require
weeks of therapy to become fully active. Common antidepressants
include amitripty- line, nortriptyline, desipramine, imipramine,
protriptyline, trim- ipramine, amoxapine, maprotiline,
isocarboxazid, tranylcypromine, sertraline, citalopram, escitalopram,
fluoxetine, venlafaxine, mirtazap- ine, trazadone, buproprion, and
nefazodone.
Antianxiety medications are used for treating acute and
chronic anxiety states. Radiologic technologics frequently encounter
this class because patients require sedatives to alleviate the anxiety
62
? DID YOU KNOW?

More than 100 year ago, the felt hat makers of England used mercury to
stabilize wool. Most of these workers eventually became poisoned by the
fumes, as demonstrated by the Mad Hatter in Lewis Carroll’s Alice in
Wonderland. Breathing mercury’s fumes over a long period of time will
cause erethism, a disorder characterized by nervousness, irritability, and
strange personality changes.
63
the sedative neurotransmitter gamma-aminobutyric acid and in

some cases, serotonin. Drugs in this class include diazepam,
lorazepam, midazolam, alprazolam, chlordiazepoxide,
clonazepam, and bus- pirone.
to cure leukemia.
? DID YOU KNOW?

One of the primary medica-
tions of the Lewis and Clark
journey was mercurial salts.
They were administered for
a number of reasons in a
variety of forms. One of the
most popular methods of
administration was through
Dr. Benjamin Rush’s famed
pills called
“Thunderclappers.” So much
mercury was consumed by
the Corps of Discovery that
modern archaeologists can
trace the route of Lewis and
Clark by finding their camp-
sites, based on the excessive
mercury deposits in the soil
(left by normal human excre-

tory functions).
? DID YOU KNOW?

The rosy periwinkle plant,
found in Madagascar, is used
64
ANTIINFECTIVE AGENTS clarithromycin, azithromycin), lincosamides (clindamycin), and
nitroimidazoles (metronidazole).
Antibiotics are
Antifungals include amphotericin B, fluconazole, voriconazole,
therapeutic agents
caspofungin, clotrimazole, flucytosine, itraconazole, miconazole,
used to kill or
keto- conazole, nystatin, and terbinazine.
suppress pathologic
Antiviral agents include acyclovir, famciclovir, ganciclovir, ribavirin,
microorganisms
valacyclovir, valganciclovir, rimantidine, foscarnet, and interferon.
responsible for causing
infectious diseases.
Antifungals are CHEMOTHERAPY AGENTS
agents used to kill
Chemotherapy drugs are extremely toxic compounds designed to
mycotic (fungal)
kill off rapidly growing (e.g., cancerous) cells of the human body by
organisms, and
altering or destroying the various stages in cellular division. These
antivirals are used to
agents are toxic to all cells that are in a growth stage, not only
suppress and limit the
cancerous cells. Special precautions should be taken with all
spread or shedding of
chemotherapy patients so that no medication touches the unexposed
viruses that invade
skin of a health care worker. Coming into physical contact with these
the human body.
medications can put the health care worker at risk of serious side
Generally, these three
effects, including the stimulation of a cancerous condition. Even
medication subclasses
coming into contact with bodily fluids into which the chemotherapy
act at the cellular
is secreted, such as urine, can pose a potential threat to the
level to destroy,
clinician. Universal precautions and special gloves and gowns should be
inhibit, or suppress
worn when dealing with chemotherapy. Examples include
the cell wall,
adriamycin, etoposide, vincristine, VP-16, cyclophosphamide,
enzymatic activity,
bleomycin, flurouracil, doxirubucin, paclitaxel, docetaxel, methotrex-
or ribosomal or
ate, and nitrogen mustard.
deoxyribonucleic acid
(DNA) function of an
invading HERBAL PRODUCTS
microorganism.
See Chapter 2.
Antibiotics
include the
penicillins (oxacillin,
cloxacillin, nafcillin,
ampicillin, ticarcillin,
piperacillin),
cephalosporins
(cefazolin, cefuroxime,
ceftriaxone,
cefpodoxime,
cefotetan,
cefamandole, cefaclor,
cefalexin, cefadroxil,
ceftazidime, cefipime),
carbapenams
(meropenam,
imipenam,
ertapenam),
tetracyclines
(tetracycline,
minocycline,
doxycycline),
macrolides
(erythromycin,
65
CONCLUSION
This brief overview provides some common drug classes used to
treat many patients; the examples listed are simply those seen most
often in a hospital setting. Specialized reference sources must be
available to the imaging technologist for complete listings and
understanding; no text can encompass all the needed information for
complete mastery of information.
66
Learning Exercises
True or False
1. T F Midazolam is an opiate analgesic.
2. T F Etoposide is in the chemotherapy class of drugs.
3. T F Diphenhydramine can be used for allergic reactions.
4. T F Fluconazole is one example of an antiviral agent.
5. T F Acyclovir is one example of an antifungal agent.
6. T F Antihistamines block histamines from causing allergic reac-

tions.
7. T F Enalapril is an antihypertensive medication.
Fill-in-the Blank Questions

1. Special precautions should be taken with all
patients so that no medication touches the unexposed skin of a
health care worker.
2. are medications use to block histamine from
producing adverse effects such as itching, inflammation,
respiratory distress, and overall allergic reactions.
3. medications stimulate central nervous system
receptors known as opioid receptors and cause a decrease in the
perception of pain.
4. are frequently referred to a “water pills.”
5. is probably the most common analgesic in use
today.
62
1. Which of the following is not considered an analgesic agent?

a. Morphine
b. Fentanyl
c. Ibuprofen
d. Naloxone
e. Naproxen
2. Which of the following medications is a chemotherapy agent?

a. Lorazepam
b. Etoposide
c. Codeine
d. Acetaminophen
3. Which of the following medications should be held for at least

48 hours before administration of radiocontrast dye?
a. Metformin
b. Acetaminophen
c. Midazolam
d. Enalapril
4. Which of the following medications is used primarily to make

the heart beat stronger (positive inotropic action)?
a. Acyclovir
b. Adriamycin
c. Digoxin
d. Haloperidol
e. None of the above
5. Which of the following medications might be used for a patient

who is hallucinating and suffering acute agitation secondary to
underlying psychosis?
a. Methimazole
b. Haloperidol
c. Dobutamine
d. Diphenhydramine
e. All of the above
6. Which of the following medications would most likely be used to

treat an acute allergic reaction?
a. Diphenhydramine
b. Propylthiouracil
c. Digoxin
d. Dobutamine
e. Celocoxib
63
6 Classification, Chemistry, and
Pharmacology of Contrast Agents

anion At the conclusion of this chapter, you should be able to:
barium 1. Define radiopaque contrast media (ROCM).
sulfate cation 2. Discuss the importance of iodine in ROCM.
diatrizoate meglumine 3. Differentiate between osmolarity, osmolality, and osmotic activity.
diatrizoate sodium 4. Identify and discuss the three categories of intravascular ROCM.
enteral 5. Cite the advantages and disadvantages of the three forms of
iocetamic acid enteral ROCM.
iodine 6. Define the uses for the paramagnetic contrast agents and the
ionic ultrasound microbubble agents.
nonionic
osmolality
osmolarity
osmotic activity
paramagnetic
contrast
agent RADIOPAQUE CONTRAST MEDIA
parenteral Radiopaque contrast media (ROCM) are high-density
radiopaque contrast pharmacologic agents used to visualize low-contrast tissues in the
media (ROCM) body, such as the vasculature, kidneys, gastrointestinal (GI) tract,
ratio-1.5 media and biliary tree.
ratio-3.0 media The most frequently prescribed ROCM are iodine and barium.
triiodinated benzoic acid The atomic number of iodine is 53, and the atomic number of barium
ultrasound microbubble is 56. Each has a much higher atomic number and mass density than
agent the low- contrast tissues listed above. When an iodinated compound
fills a blood vessel or when barium fills a portion of the GI tract,
these internal organs become visible on a radiograph. Low-
kilovoltage techniques (below 80 kilovoltage peak [kVp]) are usually
selected to produce high- contrast radiographs of the blood vessels or
genitourinary tract. Higher- kilovoltage operation (above 90 kVp) is
used in GI examinations not only to reveal the presence of the organ,
but also to penetrate the contrast media to see the walls and inner
structures.
PHARMACOLOGY OF IODINATED RADIOPAQUE CONTRAST

MEDIA
ROCM are available in parenteral and enteral, ionic and nonionic,
and high-osmolality and low-osmolality forms. With the exception
of barium, ROCM used for roentgenography are derivatives of
64
triiodinated
benzoic acid (Fig.
6-1).
65
Classification, Chemistry, and Pharmacology of Contrast Agents
Iodine
Side group
Side group
Iodine
Iodine
COOH
Fig. 6-1 Triiodinated benzoic acid.
Iodine molecules contained within ROCM are effective photon

absorbers in the human body. The iodine molecules essentially do
not allow as many photons to pass through for projection onto the
radiographic film. Thus, iodine molecules are responsible for the
silhouette images projected. Radiopacity elicited by ROCM is a direct
function of the percentage of iodine (except in the case of barium
sulfate) in the molecule and the concentration of media present. In
the case of barium sulfate, barium acts as iodine.
OSMOLALITY, OSMOLARITY, AND OSMOTIC ACTIVITY

Before the intravascular ROCM are discussed, you must first understand
the concepts of osmolality, osmolarity, and osmotic activity. Osmosis is
the movement of water across a semipermeable membrane. The
membrane must be more permeable to water than to the solute,
and there must be a greater concentration of solute on one side so
that water is drawn across the membrane to the side of higher
solute concentration to equilibrate the solute concentrations.
Osmolality controls the distribution and movement of water
between body compartments. The terms osmolality and osmolarity are
often used interchangeably in reference to osmotic activity;
however, because one measures in weight and the other measures
in volume, they define different measurements. Osmolality is the
number of mil- liosmoles per kilogram of water (mOsm/kg), or the
concentration of molecules per weight of water. Osmolarity is the
number of millios- moles per liter of solution (mOsm/L), or the
concentration of molecules per volume of solution. Sometimes the
difference between the two measurements is insignificant. In the
case of plasma, there are a number of solutes (e.g., proteins,
glucose, lipids), so the difference between osmolality and osmolarity
becomes more significant.
Simply stated, a highly osmotic agent will attract water so that
a dilutional effect can occur to equilibrate pressures between two
permeable or semipermeable membranes. Fig. 6-2 illustrates the
effects of osmotically active particles in solution. Highly osmotic
substances, such as ROCM, placed into the bloodstream will cause
fluid from outside the bloodstream (extravascular space) to be
drawn into the bloodstream (intravascular space). This effectively
65
dilutes osmotic particles
66
Osmotically
active
Semipermeable
particles in H 2O membrane
solution
H2O H2O
H2O
H2O H2O
H2O
A Intravascular
Extravascular B C
space space
Fig. 6-2 A, Normal intravascular osmolality or osmolarity. B, Intravascular hyperosmolality or
hyperosmo- larity. C, Intravascular hypoosmolality or hypoosmolarity.
? DID YOU KNOW?

until osmotic pressures equilibrate between the intravascular and
extravascular spaces. Ultimately, this results in both a dilution of normal
A study reported that whole intravascular constituents (e.g., albumin, electrolytes, sugar) and
(4%) milk is an effective, an increase in intravascular hydrostatic (fluid) pressures. These
low- attenuation oral contrast osmotic influences contribute to the adverse cardiac and renal
agent for upper GI computed effects experienced with ROCM.
tomography (Radiology
211:870-
875, 1999). INTRAVASCULAR RADIOPAQUE CONTRAST MEDIA
Intravascular (i.e., intravenous or intraarterial) ROCM are used to
add density to vascular structures. Increased density of the media
alters the attenuation of x-rays passing through the area, thus
enhancing the anatomic image on the radiographic film.
Categories
Three broad categories of intravascular ROCM exist: high-osmolality
ionic, low-osmolality nonionic, and low-osmolality ionic ROCM.
Generally, ionic ROCM exist in salt forms consisting of sodium and
meglumine (see Tables 6-1 and 6-3), whereas nonionic ROCM are
supplied as nonsalt forms (see Table 6-2).
High-osmolality ionic ROCM, such as those listed in Table 6-1,
contain three iodine atoms per molecule and dissociate into two
osmotically active particles when injected into the bloodstream.
These particles consist of one radiopaque anion (negatively charged
particle) and one cation (positively charged particle) for every three
iodine atoms in solution. These ionic ROCM are referred to as ratio-
1.5 media because the ratio of iodine atoms to osmotically active
particles is 3:2 (Fig. 6-3). The newer low-osmolality nonionic ROCM,
such as those listed in Table 6-2, contain three iodine atoms per
67
molecule and do not
dissociate in
solution. These exist
as one osmotically
active particle for
every
68
Table 6-1 High-Osmolality Ionic Intravascular Radiopaque Contrast Media

Contrast medium (brand name) Percentage of iodine
MEGLUMINE SALTS
Diatrizoate meglumine 30% 14.1
(Hypaque Meglumine 30%)
(Reno-M-Dip)
(Urovist Meglumine DIU/CT)

(Angiovist 282)
(Hypaque Meglumine 60%)
(Reno-M-60)

(Diatrizoate Meglumine 76%)
Iodamide meglumine 24% 11.1

(Renovue-Dip)
Iodamide meglumine 65% 30.0

(Renovue-65)
Iodipamide meglumine 10.3% 5.1

(Chlorografin Meglumine)
Iodipamide meglumine 52% 25.7

(Chlorografin Meglumine)
Iothalamate meglumine 30% 14.1

(Conray 30)
Iothalamate meglumine 43% 20.2

(Conray 43)
Iothalamate meglumine 28.2

60% (Conray)
SODIUM SALTS
Diatrizoate sodium 25% 15.0
(Hypaque Sodium 25%)
Diatrizoate sodium 50% 30.0

(Hypaque Sodium 50%)
(Urovist Sodium 300)
Iothalamate sodium 54.3% 32.5

(Conray 325)
Iothalamate sodium 66.8% 40.0

(Conray 400)
Iothalamate sodium 80% 48.0

(Angio Conray)
Continued
69
Table 6-1 High-Osmolality Ionic Intravascular Radiopaque Contrast

Media—cont’d
Contrast medium (brand name) Percentage of iodine
COMBINED MEGLUMINE AND SODIUM SALTS

Diatrizoate meglumine 28.5% 31.0
Diatrizoate sodium 29.1%
(Renovist II)

(Renovist)

(Hypaque-M 75%)

(Angiovist 292) (MD-60)
(Renografin-60)

(Hypaque-M 90%)

(Angiovist 370)
(Hypaque-76)
(MD-76)
(Renografin-76)
Iothalamate meglumine 52.0% 40.0

Iothalamate sodium 26.0%
(Vascoray)
three iodine atoms and are thus referred to as ratio-3.0 media

because the ratio of iodine to osmotically active particles is 3:1 (Fig.
6-4).
The newer low-osmolality ionic ROCM, such as those listed in
Table 6-3, consist of six iodine atoms per molecule and dissociate
into two osmotically active particles. These are also considered to
be ratio-3.0 media because there are six iodine atoms and two
dissoci- ated particles per molecule for a ratio of 6:2, which equals
3:1 (Fig. 6-5).
Visipaque (iodixanol) is the only isosmolar contrast medium
available in the United States. With an osmolality equal to blood
(similar ratios of sodium and calcium), it offers a high degree of
patient safety and comfort. This contrast agent is approved for use
in children over one year of age and is safe for most intravascular
procedures such as coronary angiography, CT, IVP and venography.
70
Table 6-2 Low-Osmolality

( Diatrizoate
anion ( Sodium
cation Nonionic Intravascular
Radiopaque Contrast Media
)
Osmotically active
radiopaque anion
)
Osmotically
active cation
Contrast medium Percentage
(brand name) of iodine
with 3 iodine
atoms Iohexol 43.36
(Omnipaque)
O Iopamidol 26% 12.8
( –)
C O + (Isovue-128)
Na(+) Iopamidol 41% 20.0
(Isovue-200)
I I ( Sodium
particle
(Isovue-M 200)
Iopamidol 61% 30.0
O
H H
O
) (Isovue-300)
CH3 C N N C CH3 (Isovue-M 300)

Iopamidol 76% 37.0
(Isovue-370)
I
Ioversol 34% 16.0
(Optiray 160)
( Diatrizoate
particle Ioversol 51% 24.0
(Optiray 240)
) Ioversol 68% 32.0
Diatrizoate sodium (Optiray 320)
Fig. 6-3 Representation of ratio-1.5 ionic ROCM. Diatrizoate sodium contains one Metrizamide 48.25
osmotically active anion and one osmotically active cation, for a total of two osmotically (Amipaque)
active particles when in solution. Diatrizoate sodium contains three iodine (I) atoms per
every two osmotically active particles to constitute a ratio of 3:2, which equals 1.5.
CH2OH
O
Osmotically active HO
radiopaque particle
with 3 iodine atoms OH
O NH
C
(No cation
No anion
Table 6-3 Low-Osmolality
I I
) Ionic Intravascular
Radiopaque Contrast Media
O O
CH3 Contrast medium Percentage
H
N N (brand name) of iodine
CH3 C C CH3
COMBINED MEGLUMINE
I AND SODIUM SALTS
Ioxaglate
Metrizamide meglumine 39.3% 32.0
Fig. 6-4 Representation of ratio-3.0 nonionic ROCM. Metrizamide contains one Ioxaglate sodium
osmotically active particle when in solution. It does not dissociate into cations and 19.6%
anions. Metrizamide contains three iodine (I) atoms per every osmotically active parti- (Hexabrix)
cle to constitute a ratio of 3:1, which equals 3.0.
71
Osmotically active
Osmotically active
radiopaque ion
radiopaque ion
with 3 iodine
with 3 iodine
atoms
atoms
COOH
CONCH3
HOH2C I I I I
HOHC H O O
CH N C N CO CH2 CO NCCH3
N
HOH2C H CH3
I I
H
Ioxaglate
Fig. 6-5 Representation of ratio-3.0 ionic ROCM. Ioxaglate contains two osmotically
active ions when in solution. Iotriol contains a total of six iodine atoms per every two
osmotically active particles to constitute a ratio of 6:2, which equals 3.0.
Distribution
Intravascular ROCM consist of large molecules with molecular
weights between 600 and 1700 and with poor lipid (fat) solubility.
Consequently, intravascular ROCM do not cross cellular membranes
well and are primarily distributed into the bloodstream.
In general, the various intravascular ROCM provide immediate
contrast-enhanced visibility to (1) veins and arteries after rapid injection
or (2) heart and major thoracic vessels when instilled
intravascularly into the heart chambers. Urinary tract visibility is
enhanced within 15 minutes of rapid intravenous (IV) injection or
within 30 minutes of starting a slow IV infusion in patients with
normal renal function. Urinary tract visibility may be significantly
delayed or may not occur in patients with renal dysfunction or
failure. (See Figs. 6-6 and 6-7.)
Tight endothelial junctions forming a blood-brain barrier
prevent significant distribution of ROCM into the normal central
nervous system. A small amount of ROCM may be distributed into
the cerebrospinal fluid through the choroid plexus. ROCM will be
distributed into brain tumors and can be used to define tumors that
lack a blood-brain barrier; pathologic tissues often contain
membranes that are less obstructive, and thus more permeable, to
ROCM. Contrast enhancement of the brain may require up to 40
minutes for the ROCM to reach the site. In general, when
intravascular ROCM are used to visualize tissue compartments,
time is allowed for the ROCM to distribute into them.
Excretion
Intravascular ROCM are excreted primarily via the kidneys; they are
72
concentrated in the kidneys and subsequently opacify the entire
renal system. Generally, renal parenchyma is opacified first,
followed by the tubular structures, renal calyces, and pelvis, and
ending with the ureter and bladder. In normal renal function, up to
100% of an intravascular
73
Fig. 6-6 Urogram.
Hepatic Splenic
artery artery
Left renal
artery
Right renal
artery Abdominal
aorta
Right common
iliac artery
Fig. 6-7 Abdominal aortogram.
dose is excreted in 24 hours. A very small percentage may be

excreted into the intestines through the hepatic-biliary system.
Several days may be required for complete excretion in patients
with renal impair- ment. Consequently, these patients have much
lower to no opacification in the kidneys because up to 50% of the
ROCM may be eliminated via the hepatic-biliary system, thus
opacifying the biliary and GI tracts.
74
One IV ROCM, iodamide meglumine, is eliminated principally

by the hepatic-biliary system and is thus used primarily for
cholecystography and cholangiography. This agent generally has
been replaced by other ROCM with the use of safer imaging
methods such as ultrasonography and computed tomography (CT).
ENTERAL RADIOPAQUE CONTRAST MEDIA

Enteral ROCM are used to diagnose and evaluate disorders of the GI
system. These agents may also be used to help define the cardiac
shadow. Enteral ROCM can be broken down into the categories of
aqueous solutions, suspensions, and tablets.
Solutions
Diatrizoate meglumine and diatrizoate sodium solutions are used for
oral or rectal administration to aid in the diagnosis of GI tract
disorders. Generally, these solutions are used when barium sulfate
suspension is potentially harmful, such as in GI perforation. The
high osmolality of these agents causes significant osmotic action
within the GI tract. This leads to significant dilution of the iodine as
well as a profuse diarrhea, systemic hypovolemia, dehydration,
and electrolyte imbalance. Iodine dilution leads to less definitive
diagnostic studies; this, along with the adverse effect profile of
iodine, is why barium sulfate is often the preferred diagnostic GI
agent. The diatrizoate compounds are preferred over barium
sulfate for CT because of less artifact production.
Radiodensity (radiopacity) occurs immediately in the
esophagus and stomach after oral administration but may take 15 to
90 minutes for the duodenum. Immediate radiodensity occurs in the
rectum and colon following rectal administration.
Gastrointestinal ROCM are not absorbed through the GI wall
and are thus distributed solely into the GI lumen. These agents are
excreted by the GI tract into the feces.
Suspensions
Barium sulfate is an ROCM suspension used for oral or rectal
administration to aid in the diagnosis of GI tract disorders. Barium is
radiodense in the same manner as iodine. Radiodensity occurs
immediately in the esophagus and stomach after oral administration
but may take 15 to 90 minutes for the duodenum. Immediate
radiodensity occurs in the rectum and colon following rectal
administration (Fig. 6-8).
Barium sulfate is generally the preferred GI ROCM because it
provides a more thorough visualization of structures, especially
the mucosa, without extensive local adverse effects. Barium
sulfate may produce significant artifact in CT evaluation of the GI
tract and thus is not the preferred agent for this radiologic
examination.
Barium sulfate is not absorbed through the GI wall and thus is
distributed solely into the GI lumen. It is excreted by the GI tract
75
into the feces.
76
Tablets
Iocetamic acid (Cholebrine) is an oral ROCM used for opacifying the
gallbladder. Absorption varies from person to person, but the
gallbladder can generally be visualized approximately 10 to 15
hours after oral administration (Fig. 6-9).
Most of the iocetamic acid is excreted into the urine 48 hours
after administration. Some is excreted via the biliary system into the
feces.
Fig. 6-8 Barium-filled large intestine.
Fig. 6-9 Oral cholecystogram.
77
PARAMAGNETIC CONTRAST AGENTS

Magnetic resonance imaging (MRI) basically measures the return of
transiently excited protons back to a state of equilibrium in
biologic tissues exposed to radio frequencies while the patient is
placed in a strong magnetic field. The paramagnetic contrast agents
consist of heavy metal chelates, such as gadolinium, iron, and manganese,
that reduce both the longitudinal, or spin-lattice, time (T1) and the
transverse, or spin-spin relaxation, time (T2) of nearby water
protons. This results in an enhanced image when exposed to a
strong magnetic field in the MRI scan (Figs. 6-10 and 6-11).
Gadolinium Compounds
Gadolinium compounds rapidly distribute into intracellular and
extravascular spaces. The gadolinium compounds include
gadodiamide (Omniscan), gadoteridol (ProHance), gadoversetamide
(OptiMARK), gadobutrol (Gadovist), gadopentetate dimeglumine
(Magnevist), and gadoterate meglumine (Dotram). These agents
have a high osmolality that is approximately 1960 mOsm/kg H2O.
These agents are particularly useful in identifying central
nervous system lesions such as spinal neoplasms, spinal disease,
primary brain tumors, intracranial metastases, acoustic neurinomas,
active multiple sclerosis, pituitary adenomas, and meningeal
disease. Gadopentetate salts also have potential use in renal,
hepatic, myocardial, and muscu- loskeletal imaging. In addition, by
using fat suppression techniques to assist with resolution,
gadopentetate salts may have a role in MRI of very obese
individuals.
Iron Compounds
Ferumoxides are compounds that contain iron particles that are
highly paramagnetic. These agents remain in the bloodstream for long
periods. Agents in this class include ferumoxtran-10 (Combidex),
iron oxide
Fig. 6-10 Abdominal CT scan with contrast. L, Liver; K, kidney; PV, portal vein; P,
78
pan- creas; CT, celiac trunk; SV, splenic veins; TC, transverse colon; SP, spleen.
79
(Clariscan), and ferumoxytol. These agents have a low osmolality that

is approximately 340 mOsm/kg H2O.
These iron-containing agents are useful in identifying hepatic
lesions and lesions associated with lymphatic tissues. Studies are
investigating their use in angiography because some of these com-
pounds are taken up by macrophages that reside in unstable
coronary plaque.
Manganese Compounds
Mangafodipir trisodium (Teslascan) is a compound containing man-
ganese metal that is highly paramagnetic with a high affinity to
hepatic cells. This product is therefore used primarily to identify
can- cers that have hepatocytes in their matrix. Because of its
toxicity, mangafodipir is chelated with a biologic ligand to
decrease its toxic profile.
ULTRASOUND MICROBUBBLE AGENTS

Ultrasound technology is beginning to develop more contrast tech-
niques to assist in delineating differences among the black and gray
scales that used to be the standard (Figs. 6-12 and 6-13). Now,
with color Doppler imaging, newer contrast agents, called
ultrasound microbubble agents, have been designed to enhance
ultrasound imaging. Octafluoropropane is a gas that comes
prepared in either a lipid (fat) or an albumin microsphere. These
microspheres are essentially an emulsion of gas with acoustic
properties that enhance left myocardial ventricular cavity while Fig. 6-11 MRI of spinal
improving the visualization of endocardial bor- ders in patients cord with bulging disk
undergoing echocardiography. These microspheres have an acoustic (arrow).
impedance lower than blood, thus enhancing the blood backscatter
against a darker myocardium. Perflutren (Definity) is the lipid
version, and octafluoropropane albumin microspheres (Optison) is the
albumin version.
Fig. 6-12 Abdominal ultrasound (note fetal face).
80
Fig. 6-13 Abdominal ultrasound with contrast.
CONCLUSION
Radiopaque contrast media (ROCM) are diagnostic agents of high
density, most of which contain iodine molecules. The iodine is an
integral component because it produces radiopacity. ROCM are
divided into various chemical categories and dosage forms. Newer
products have now become available for MRI and ultrasound. The
MRI agents are generally compounds that contain gadolinium, iron,
or manganese, whereas the ultrasound agents are encapsulated in
a lipid or albumin microsphere. All products have potential adverse
effects associated with them. The imaging professional is
encouraged to receive updates on new products as they become
available.
81
Learning Exercises
Abbreviations
Spell out the abbreviations below.
1. ROCM:
2. MRI:
True-False
1. T F All ROCM used for roentgenography are derivatives of

triiodinated benzoic acid.
2. T F Radiopaque contrast media are high-density pharmacologic

agents used to visualize low-contrast tissues in the body.
3. T F Radiopaque contrast media are not available in enteral

form; they are available in parenteral form only.
4. T F Ionic ROCM exist in salt form, and nonionic ROCM exist in

nonsalt form.
5. T F Diatrizoate solutions are used for oral or rectal

administration to aid in the diagnosis of gastrointestinal tract
disorders.
6. T F Barium sulfate is absorbed through the gastrointestinal wall.
7. T F Iocetamic acid is an oral ROCM used for opacifying the gall-

bladder.
8. T F Octafluoropropane is an ultrasound microbubble agent.
77
9. T F Paramagnetic agents are used in radiology for MRI.
78
1. Most radiopaque contrast media used for roentgenography are

derivatives of which of the following?
a. Barium sulfate
b. Triiodinated benzoic acid
c. Lead oxide
d. Iocetamic acid
2. What is the term for the concentration of osmotically active particles

in solution?
a. Osmosis
b. Osmolality
c. Osmotic activity
d. Osmolarity
3. What is the term for a negatively charged particle?

a. Electron
b. Cation
c. Anion
d. Proton
4. Why is barium sulfate not used during computed tomography

examinations?
a. Danger of electrical shock
b. Creation of image artifacts
c. Nonvisualization of the mucosa
d. Insufficient kilovoltage to penetrate the contrast medium
5. If the kidneys are functioning normally, what percentage of an

intravascular ROCM dose is excreted in a 24-hour period?
a. 100%
b. 75%
c. 50%
d. 25%
6. To visualize the gallbladder, ROCM are administered most often

in which of the following forms?
a. Suspensions
b. Solutions
c. Injections
d. Tablets
79
7. After injection of an intravascular ROCM, visualization of the

kidneys should begin within what period of time?
a. 5 to 10 minutes
b. 15 to 30 minutes
c. 30 to 45 minutes
d. 1 hour
8. Which of the following is not a paramagnetic agent?

a. Gadodiamide (Omniscan)
b. Ferumoxtran-10 (Combidex)
c. Mangafodipir trisodium (Teslascan)
d. Perflutren (Definity)
1. A charged particle is known as an anion, and a
charged particle is known as a cation.
2. A will attract water so that a dilutional effect
can occur to equilibrate pressures between two permeable or
semipermeable membranes.
3. density of the ROCM alters the attenuation of
x-rays, thus enhancing the anatomic image on the radiographic film.
4. is an integral component of ROCM because
radiopacity is produced by this element.
5. ROCM are excreted primarily via the kidneys
and are concentrated in the kidneys.
6. ROCM consist of large molecules, with
molecular weights ranging from 600 to 1700 and with poor lipid
solubility.
7. Mangafodipir trisodium (Teslascan) is a compound containing
manganese metal that is highly with a high
affinity to hepatic cells.
8. Octafluoropropane is a gas that comes prepared in either a
an microsphere.
Review Questions
1. What is the difference between ratio-1.5 media and ratio-3.0 media?
80
2. Why is iodine used so extensively in ROCM?
3. Why do intravascular ROCM tend to remain in the bloodstream?
4. Why is iodamide meglumine used primarily for cholecystography

and cholangiography?
5. What are the three broad categories of intravascular ROCM?
6. When are diatrizoate solutions most often used?
7. What are the names of the major iron-containing paramagnetic

agents?
8. What are the microbubble agents generally used for in radiologic

science?
80
shadow is projected onto
the radiographic film.
Pharmacodynamics of Radiopaque
Contrast Media
OBJECTIVES
1. List the diagnostic pharmacodynamic effects of radiopaque contrast
media (ROCM).
2. Describe the adverse pharmacodynamic effects of ROCM.
3. Discuss examples of screening methods used to evaluate patients
before introduction of ROCM.
4. Identify specific drug-drug interactions with ROCM that can cause
adverse effects.
5. Describe the adverse effects seen after administration of the
paramagnetic agents and ultrasound microbubble agents.
IODINATED RADIOPAQUE CONTRAST MEDIA

Pharmacodynamics, as outlined in Chapter 4, is the study of the actions
or the outcome elicited by drugs when the site of action is
reached. Pharmacodynamic effects can be therapeutic, diagnostic,
or adverse. Diagnostic effects of intravascular radiopaque contrast
media (ROCM) are a function of the iodine contained within them.
Adverse effects elicited by ROCM depend at least partially on their
serum or tissue iodine concentration and osmolality and their
calcium-chelating, anticoagulant, and immune system–stimulating
abilities.
DIAGNOSTIC PHARMACODYNAMICS
Serum iodine concentration must be within the range of 280 to
370 mg/ml for a normal x-ray film to reflect the vascular lumen. To
achieve this high iodine concentration, the ROCM must contain a
large propor- tion of iodine (see Chapter 6 for iodine
concentrations) and must be injected intravascularly at a rate equal
to or greater than blood flow. If the contrast medium is injected
slowly, the cardiovascular system will significantly dilute the iodine
concentration before imaging. Rapid intravascular injection thus
helps to limit the early dilutional effects on the iodine by the
cardiovascular system. High concentrations of iodine
pharmacodynamically prevent the penetration of photons so that a
81
7
KEY TERMS
acetylcysteine
acute renal failure (ARF) anaphylaxis anticoagulation
antigen-antibody complex baroreceptors
chelate chemoreceptors decompensated
thyrotoxicosis fenoldopam mast cells oliguric
pulseless electrical activity (PEA)
serum iodine concentration sodium bicarbonate thyroid storm
vasovagal reaction
82
For computed tomography (CT) or digital subtraction

angiography (DSA), the serum iodine concentration needs only to be
between 2 and 8 mg/ml. Thus, either a less concentrated iodine
contrast medium or a slower intravascular infusion will produce
adequate pharmacodynamic action for these imaging procedures.
ADVERSE PHARMACODYNAMICS
Serious adverse effects from ROCM do occur. An estimated one of
every 20,000 to 40,000 patients receiving ROCM dies as a result of
these effects. Although the odds of death appear low, they become
very real if it happens to you or your patient. Thus, it is paramount
that the technologist understand adverse effects so that proper
actions can be insti- tuted as rapidly as possible.
Osmolality Effects
As discussed in Chapter 6, the intravascular ROCM contain a higher
osmolar weight than the normal bloodstream. Various physiologic
effects are elicited by intravascular administration of high-
? DID YOU KNOW? osmolality ROCM. Intravascular administration of ROCM will cause a
transient rise in intravascular osmotic pressure. Fluid from surrounding
Contrast agents used in mag- tissues is then drawn into the vascular lumen to dilute the osmotically
netic resonance imaging active particles. This occurs to equalize pressure between
(MRI) are usually paramagnetic intravascular and extravascular spaces (see Fig. 6-2). These osmotic
agents designed to enhance forces or effects will cause fluid extraction from red blood cells
the T1 and T2 relaxation (RBCs), endothelium, and the extravascular space.
times of hydrogen nuclei. When fluid is extracted from the RBCs, they shrink and
These agents have been become less pliable. Endothelium water loss also results in
developed for intravenous,
endothelial shrink- ing. The movement of tissue water into the
oral, and inhalation
intravascular space as a result of osmotic forces causes short-term
administration. Most are
introduced intravenously. extravascular fluid decreases with resultant increased intravascular
Gado- linium 3 (Gd3),
contents. In other words, there is less fluid outside the vessels and
which has seven unpaired more fluid inside the vessels. This action is thought to be
electrons, has the strongest responsible for vasodilation and flushing experienced by most
relaxation rate properties and patients receiving intravascular ROCM.
has proven effective in Shortly after injection, the cardiovascular system circulates
demonstrating various types and dilutes the hyperosmolar ROCM, washing it downstream,
of lesions. Because of its high eventually producing an intravascular hypoosmolar state in
toxicity, it is administered in a comparison to the extravascular space. In other words, the extra
complex with DTPA (dieth- particles inside the vessels are moved away in the current of the
ylenetriaminepentaacetic blood supply, as in a river. When that happens, the fluid on the
acid) (GD-DTPA) to ensure outside of the vessels no longer needs to dilute the fluid on the
detoxifi- cation.
inside of the vessels. The extravascular space becomes hyperosmolar
because of dehydration, resulting in yet another fluid shift from the
intravascular space back to the extravascular or tissue space. This
continues until an osmolar equilibrium is reached between
intravascular and extravascular spaces. These intravascular-
extravascular osmotic shifts produced by ROCM may be partially
responsible for adverse renal effects induced by these agents.
Initial increases in renal vessel fluid volume, caused by
82
Pharmacodynamics of Radiopaque Contrast Media
hyperosmolar fluid
shifts, are followed
by a prolonged
decrease in renal
blood flow,
83
ROCM. PEA is a heart

which ultimately leads to tissue ischemia (decreased oxygen) with rhythm disturbance
resultant damage. In addition, the urine becomes hyperosmolar characterized by electrical
when the ROCM is excreted into it; this will cause an osmotic impulses without cardiac
diuresis, which can result in dehydration of the patient. con-
Hyperosmolar ROCM injection into the carotid arteries results
in intraarterial osmotic pressure changes significant enough to
stimulate baroreceptors and chemoreceptors located at the
bifurcation of the aortic arch and carotid arteries. These receptors
cause the autonomic nervous system to slow down the heart rate
(bradycardia) and produce a drop in aortic pressure. If this occurs,
the patient may faint or lose consciousness. This type of reaction has
been referred to as a vasovagal reaction (Fig. 7-1, A); the vagus
nerve is stimulated by transient vascular hypertension. When a
vasovagal event occurs, the patient becomes symptomatically
hypotensive as a result of moderate to severe bradycardia
produced by vagus nerve stimulation.
Intravascular osmotic fluid shifts can also result in acute heart
failure in patients who already have chronic congestive heart failure
(Fig. 7- 1, B). Signs and symptoms of acute-on-chronic heart failure
(acute heart failure superimposed on chronic heart failure) generally
include respiratory difficulty with pulmonary edema and may
include tachycardia or bradycardia, hypertension or hypotension,
cardiac dysrhythmias, cardiorespiratory arrest, and death.
A failing heart has trouble pumping all the fluid that is presented to
it. When osmotic shifts of fluid occur intravascularly, the heart is
presented with an increased load, or burden, to pump. The cardiac output
then drops as the heart continues to fail. Baroreceptors located in the
aortic arch and carotid arteries then send signals to the central nervous
system (CNS) that ultimately cause the release of counterregulatory
hormones such as vasopressin, adrenaline, renin, angiotensin I,
angiotensin II, and aldosterone. These hormones act to increase the
blood pressure by causing fluid retention and vasoconstriction; the
goal of the body is to preserve brain function in a state of perceived
decreased blood pressure and nutrient (oxygen) supply. Unfortunately,
this cycle becomes detrimental to outcome because the heart is
already burdened. Vasoconstriction will increase the force against which
the heart has to pump, thus causing the heart to work harder and fail
quicker. The fluid retention causes an increased volume presenting to
the heart for circulation, thus leading to a greater load of fluid, which
is a burden to a failing heart. In these patients, it is therapeutic to use
diuretics, such as furosemide, to excrete fluid from the body, and cardiac
stimulators, such as dobutamine, to increase the strength of the
heart. Fig. 7-1, B, briefly outlines this effect.
Chelation Effects
ROCM can chelate (bind to) calcium ions in the cardiovascular
system after injection. Calcium chelation may be one
pharmacodynamic mechanism by which adverse heart rhythms, such
as pulseless electrical activity (PEA), cardiac arrest, and sudden
death, occur in a minority of patients receiving intravascular
84
?
DID YOU KNOW?
Contrast agents are being used in ultrasonography using micro- aggregated
albumin. Albumin resembles air bubbles and is being used especially in
the determination of fallopian tube patency and during echocardiography.
85
CNS
Vagus nerve fires

and causes HR
Carotid artery
(bradycardia), which
ultimately leads to
BP and fainting
BP stimulates firing of
baroreceptors and
chemoreceptors
Aorta
CNS
Vasopressin
(ADH) release Vasoconstriction (angiotensin II,
vasopressin, epinephrine)
Workload
Burden
CHF
Angiotensin II
Baroreceptors
Angiotensin- Chemoreceptors
I
converting
enzyme Lung
(ACE) Failing
heart
Angiotensin
Adrenal gland
I
1. Releases epinephrine
2. Is acted on by angiotensin II
Fluid return to cause release of aldosterone,
Workload which leads to Na+ and H2O
Burden retention by the kidney
CHF
Kidney
Angiotensin Renin
I Angiotensinogen
B
Fig. 7-1 A, Vasovagal reaction. HR, Heart rate; BP, blood pressure. B, Congestive heart
failure (CHF) with osmotic load added. ADH, Antidiuretic hormone.
traction. In other words, the heart monitor shows electrical activity,

but the heart is not pumping. Cardiac arrest means that the heart has
ceased to pump effectively blood to maintain life. Sudden death is
84
usually the result of a heart rhythm (ventricular tachycardia and/or

fibrillation) that cannot sustain life.
85
Anticoagulation Effects
High-osmolality ROCM can cause some anticoagulation (blood thin-
ning) to occur. This can theoretically result in bleeding and bruising
episodes. Low-osmolality ROCM do not appear to produce
anticoagulant effects.
Immune System–Like Effects

The immune system is highly complex and consists of various
components, including physical barriers (e.g. skin, gastric acid,
duodenal alkali, respiratory cilia) and biochemical defenses (e.g.,
inflammation, lysosymes, complement proteins, immunoglobulins).
The biochemical defenses are thought to have a role in the
immediately life-threatening reaction mimicking an anaphylactic
reaction that can occur with ROCM. Importantly, this reaction is
not absolutely characterized as “anaphylaxis,” but more
appropriately is anaphylactoid in nature. To understand this
distinction, we must first understand what true anaphylaxis entails.
Anaphylaxis is an immediately life-threatening, systemic
hypersensitivity reaction. Patients suffering anaphylaxis may exhibit
any combination of nausea, vomiting, diarrhea, hives, rash,
flushing, cyanosis, pallor, lightheadedness, unconsciousness,
seizures, stridor, wheezing, respiratory distress, bronchospasm,
laryngeal edema, cardiac dysrhythmias, marked hypotension,
vascular collapse, and cardiorespiratory arrest. Anaphylaxis is often
fatal if treatment is not immediate. Within minutes of exposure to a
foreign substance, acting as an antigen, a complex forms with an
endogenous antibody known as immunoglobulin E (IgE) and located
on a mast cell.
Mast cells are connective tissue cells that contain the
chemicals histamine, leukotriene (also known as “slow-reacting
substance of anaphylaxis” [SRS-A]), eosinophil chemotactic factor,
neutrophil chemotactic factor, kininogenase, arylsulfatase A,
exglycosides, prostaglandin, thromboxane, platelet-activating factor
(PAF), monohy- droxyeicosatetraenoic acid (HETE), and
hydroperoxyeicosatetraenoic acid (HPETE). Mast cells are located in
skin, synovium, and mesentery; around large and small blood
vessels; in the mucosa of the respiratory tract; and in the subserosal
and submucosal layers of the gastrointestinal tract.
Anaphylaxis is generally referred to as a type I
hypersensitivity reaction, which requires a first-time exposure to the
antigen (i.e., the foreign substance) at some time in the patient’s
history. The first exposure results in the substance forming an
antigen-antibody complex that “sensitizes” the mast cells to future
events (Fig. 7-2, A). An immediate reaction does not occur at this
point. It is the second exposure to the same substance that causes
IgE to stimulate the “sensitized” mast cell to release its dangerous
chemicals. In combination, these chemicals cause the life-threatening
effects described earlier. This type of reaction is common in patients
who are allergic to bee stings; the first sting poses no threat, but
weeks or years later a second sting may be fatal.
86
IGE
Allergen
First
exposure
Mast cell Sensitizer
IGE
Allergen
Second
exposure
A Degranulation
ROCM
allergen
First
exposure
B Mast cell
Degranulation
1. Histamine
2. SRSA
3. Others
Blood vessels
Vasodilation
BP
Flushing
Warmth
Shock
Lungs HR
Swelling
Edema
C Bronchoconstriction
Fig. 7-2 A, Anaphylactic reaction. IGE, Immunoglobulin E (IgE). B, Anaphylactoid
reaction. C, Anaphylaxis effects. SRSA, Slow-reacting substance of anaphylaxis
(leukotriene); HR, heart rate; BP, blood pressure.
87
preventing renal
ROCM may cause what is termed anaphylactoid reactions (Fig. 7- dysfunction after
2, B). This type of reaction clinically mimics the anaphylactic radiocontrast
reaction, but no prior exposure to ROCM is necessary to “sensitize” administration: half-normal
the mast cell. On first exposure to the ROCM, mast cells may release saline (0.45% normal saline
their chemicals to cause an anaphylaxis-like, or anaphylactoid, [NS]), fenoldopam,
adverse effect. Therefore, a history of previous exposure is not acetylcysteine, and
relevant to the possibility of anaphylactoid reaction. This reaction is sodium bicarbonate.
just as lethal as anaphylaxis (Fig. 7- 2, C). For this reason, a medical
imaging technologist needs a functional understanding of emergency
procedures.
The biochemical pathways for anaphylactoid reactions are not
well known at this time. Up to 40% of patients who have had an
anaphylactoid event as a result of ROCM in the past may have one
again. However, it is controversial whether to administer
prophylactic medications such as antihistamines and
corticosteroids to such patients.
Renal Dysfunction
ROCM are responsible for approximately 10% of all acute renal
failure (ARF) events and are the third most common cause of
hospital-acquired ARF. Reported incidences are 2% after
angiography, 2% to 25% after intravenous pyelography (IVP), and
50% to 100% in patients who have renal nephropathy caused by
diabetes.
Patients with ROCM-induced ARF generally present with a
mild, reversible, nonoliguric (i.e., urine output greater than 400 ml/day)
event of short duration. The serum creatinine concentration (a renal
function test) begins to rise in the first 24 hours after
administration of intravenous (IV) ROCM, peaks in 2 to 4 days, and
normalizes in 7 to 10 days.
Oliguric ARF does occur in some patients. Urine output does
not exceed 400 ml/day in these patients. The renal failure may not
be reversible, and the serum creatinine does not normalize.
The pharmacodynamic mechanisms for ROCM-induced ARF are
theorized to include direct renal tubular toxicity, renal ischemia due to
the osmotic fluid shifts discussed earlier, intratubular obstruction
from precipitated proteins or uric acid and calcium oxalate
crystals, toxic oxygen radicals, and least likely, immunologic
factors.
Patients at risk for ARF after IV administration of ROCM are
those with preexisting renal compromise, diabetes with
concomitant renal dysfunction, or possibly dehydration.
Diabetes alone was historically considered a high risk but is
now considered high risk only if concomitant renal dysfunction exists.
Diabetic patients with serum creatinine levels greater than 4.5 mg/dl
have been reported to experience a 100% incidence of ARF after ROCM
administration. Dehydration before ROCM injection is not a major risk
factor, provided the patient is hydrated after the examination.
(Dehydration alone can result in significant ARF if not treated.)
Four drugs are used in radiology patients to assist in
88
? DID YOU KNOW?

The normal daily intake of iodine to the human body is
{1/10,000} gram (g). There is only {1/100} g of iodine in the total body at
any time. During an intravenous pyelogram using 150 ml of Conray 60, 42
g of iodine are injected. This is 420,000 times the normal daily intake.
During the same examination, using 200 ml of Optiray 320, 64 g of iodine
are added to the bloodstream—640,000 times normal daily intake!
89
Half-normal saline or normal saline. Many studies have been

performed to assess the outcomes for prophylaxis against ROCM-
induced renal dysfunction. Most conclude that hydration is the most
important preventive measure that one can perform to prevent this
adverse effect, provided the patient’s cardiac condition can withstand
it. Generally, it is best to begin hydrating the patient with either NS
or 0.45% NS infusion at 1 to 1.5 ml/kg/hr 12 hours before the test
and to continue the hydration for at least 24 hours after the test.
Fenoldopam. Fenoldopam is a relatively new agent for

treating hypertensive emergencies. This medication has potent
vasodilatory effects through stimulation of the dopamine-1 receptor
(see Chapter 10 for receptor physiology). Fenoldopam has also been
shown to increase and preserve renal blood flow through dopamine-
1 receptor stimulation. Some studies have shown favorable results
with fenoldopam in preventing renal dysfunction in some patients
receiving ROCM, although the largest studies have proved to be
inconclusive beyond using saline alone. We include fenoldopam here
because of its frequent use currently in some parts of the United
States.
Fenoldopam must be titrated starting at 0.03 microgram per
kilogram body weight per minute (g/kg/min) and
progressing to
0.1 g/kg/min starting 1 to 2 hours before angiography and
continuing for at least 6 hours total. Titration should be performed
at 15- to 20- minute intervals by increasing the dose by 0.03 to 0.05
g/kg/min to a final dose of 0.1 g/kg/min. Fenoldopam should be
stopped or held and the physician notified if the systolic blood
pressure falls below 99 mm Hg. Fenoldopam is very short acting,
with an elimination half-life of 5 minutes, because most is
eliminated by the kidneys after the liver metabolizes it to a
conjugated form.
Major adverse effects include significant hypotension,
hypokalemia, increased intraocular pressure (worsening glaucoma),
tachycardia, flushed face, nausea, and headache. Fenoldopam is
generally mixed as 10 mg/250 ml NS or 5% dextrose in water
(D5W) to yield a 40-g/ml concentration for infusion. Compatibility
with other products is unknown, and thus a separate IV line should
be used for infusion.
Acetylcysteine (N-acetylcysteine, Mucomyst). Because of

the possibility of direct toxicity from oxygen radicals resulting from
administration of ROCM, investigators have begun using the
antioxidant properties of acetylcysteine to prevent renal
dysfunction. The studies are conflicting; show good success,
whereas others are inconclusive. Because of the relative safety of
this product, however, many are using acetylcysteine as an adjunctive
agent in hopes that it will prevent some renal insults.
Acetylcysteine is available as a 10% or 20% (100 or 200 mg/ml)
respiratory nebulization solution and as an IV form. The
88
nebulization solution is the form used for prophylaxis at 600 mg
orally, beginning 12 hours before the procedure and continuing every
12 hours for a total
89
of four doses (2 days). Adverse effects include nausea and vomiting

because the drug has a very putrid sulf-hydryl smell and a taste
mimicking that of rotten eggs. Some clinicians will try masking the
smell and taste by placing the liquid into a beverage such as juice
or soda. However, nothing really covers this quality very well, and
patients should be forewarned to hold their nostrils for several
minutes to assist in swallowing the dose. The mechanism of action
for acetylcysteine is not fully known, but it is thought to be an
oxygen radical scavenger and possibly a vasodilator in the renal
tissue.
Sodium bicarbonate. The acidic environment produced in the

renal tubular urine is thought to produce a medium for the
production of toxic, free ionic radicals. This theory is supported by
the fact that these radicals are not produced in the less acidic
bloodstream. This theory led investigators to study the effects of
sodium bicarbonate IV solution as a possible prophylactic strategy
against the development of renal failure secondary to ROCM. A recent
study did find that sodium bicarbonate (154 mEq added to D5W
1000 ml) did result in significantly better outcomes compared
with D5NS alone. The doses used were
3 ml/kg/hr for 1 hour before ROCM administration, followed by
1 ml/kg/hr throughout the procedure and continued at 1 ml/kg/hr for
a total 6 hours after the procedure.
Thyroid Storm
A rare but potentially fatal adverse pharmacodynamic effect that
has occurred after administration of iodine-rich ROCM is thyroid
storm. This generally occurs in patients who have decompensated
thyrotoxicosis, a condition in which the body becomes unable to
tolerate thyroid hormones. In these patients, iodine from ROCM
can cause the thyroid to produce or liberate amounts of thyroid
hormone that exceed the body’s tolerance level. It is important to
note this does not imply that the serum thyroid hormone levels are in
excess of normal values, but rather that they are in excess of the
patient’s ability to tolerate them.
Signs and symptoms of thyroid storm include fever,
tachycardia (rapid heart rate), diaphoresis (sweating), agitation,
nervousness, and emotional instability. Untreated, thyroid storm can
lead to congestive heart failure, refractory pulmonary edema,
cardiovascular collapse, coma, and death within 24 hours.
As an imaging professional, it may not be your responsibility to
diagnose thyroid storm, but you can always help refresh the memory
of those with whom the responsibility lies. Keep in mind that thyroid
storm can have a fatal outcome.
GENERAL ADVERSE REACTIONS

General adverse effects of ROCM that may or may not be related to
any of the adverse effects mentioned earlier include nausea, vomiting,
90
flushing with a generalized feeling of warmth, rhinitis, lacrimation,
sneezing, itching, rash, angioedema, generalized edema, cramps,
excessive
91
salivation, salivary gland swelling, diaphoresis, retching and

choking, metallic taste in mouth, decreased white blood cells, chills,
fever, and disseminated intravascular coagulation (DIC).
Adverse CNS effects may include nervousness, confusion,
anxiety, headaches, dizziness, tremors, agitation, and seizures. At
the site of injection, the patient may have thrombophlebitis, pain,
burning, sting- ing, numbness, bruising, necrosis, and sloughing of
tissue (if extravasation occurs).
ROCM can lead to sickling of RBCs as a result of osmotic fluid
shifts in patients with sickle cell anemia, to ARF in patients with
multiple myeloma (cancer of serum proteins), to hypertensive
crisis in patients with pheochromocytoma (adrenal gland tumor
that releases large amounts of adrenaline), and to intractable
seizures in patients with subarachnoid hemorrhage.
ROCM do cross the placental barrier and should not be used in
pregnant women unless benefits greatly exceed risks.
PARAMAGNETIC AGENT ADVERSE REACTIONS

Gadolinium Compounds
Adverse effects that may be seen after the use of the gadolinium
compounds, such as gadodiamide (Omniscan), gadoteridol
(ProHance), gadoversetamide (OptiMARK), gadobutrol (Gadovist),
gadopentetate dimeglumine (Magnevist), and gadoterate meglumine
(Dotram), include a significant increase in serum iron concentrations
up to 4 hours after injection. This is secondary to RBC hemolysis and
will generally correct itself in 24 hours.
Cardiovascular events may occur in less than 1% of patients
and include vasovagal reactions, hypotension, hypertension,
? DID YOU KNOW?

syncope, tachycardia, pallor, chest pain, and cardiac arrest. CNS
adverse effects can include dizziness, paresthesias, drowsiness,
weakness, thirst, headache (most frequent adverse effect), and
Dr. Werner Forssman was seizures (in patients with previous history). Gastrointestinal adverse
experimenting with cardiac effects can include general gastric pain, nausea, vomiting, sialorrhea
catheterization techniques in
(excessive salivation), xeros- tomia (too little salivation), and
the late 1930s. Finding no
dysgeusia (bad taste in mouth). Renal dysfunction has not been
willing human subjects, he
cut down to his own brachial reported, but caution is advised in renal- impaired patients.
artery nine separate times Anaphylaxis has been reported in less than 1% of patients. Skin
and introduced a urinary rashes, urticaria, and pruritus can occur. Ocular pain and visual field
catheter into his own heart. defects, as well as excessive lacrimation and conjunctivitis, have
The medical community occurred. Rarely, throat irritation, rhinorrhea, sneezing, dyspnea,
thought he was insane and cough, and anaphylaxis have been reported.
banned him from all teaching
and medical appoint- ments. Ferumoxide Compounds
In 1956, Dr. Forssman was Adverse effects that may be seen after the use of the ferumoxide
awarded the Nobel Prize. compounds (iron compounds), such as ferumoxtran-10
(Combidex), iron oxide (Clariscan), and ferumoxytol, include
hypotension if infused too rapidly; it is recommended not to exceed
25 to 30 ml/hr. Rare cases of hypertension, dysrhythmias, and
tachycardia have been reported. Increased serum iron
92
concentration can
occur in some
patients to an
93
insignificant amount; however, in those with iron overload, caution

is advised. Rapid infusion has been associated with acute lumbar
pain. Nausea, abdominal pain, skin rash, and shortness of breath
can occur.
Manganese Compounds
Adverse effects from the manganese compounds, such as
mangafodipir trisodium (Teslascan), may include chest pain and “more
forceful heartbeat,” peripheral vasodilation (flushing), headache,
dizziness, lightheadedness, nausea, dyspepsia, vomiting, and
abdominal pain.
ULTRASOUND MICROBUBBLE AGENT ADVERSE REACTIONS

Adverse effects include QT prolongation on the electrocardiogram
in up to 30% of patients administered perflutren (Definity).
Dizziness, ventricular dysrhythmias, and chest pain occur infrequently
with either octafluoropropane albumin microspheres (Optison) or
perflutren. Headache is the adverse effect reported most often by
patients who received either agent. Nausea, dyspnea, rash,
flushing, and back pain may also be seen. Anaphylaxis has been
reported in numerous patients receiving the albumin microsphere
octafluoropropane.
SCREENING
In light of all the serious adverse effects that can occur by injection
of intravascular ROCM, the imaging technologist should use a
screening method that includes the assessment of patient medical
history and current renal function status. Questions that should be
answered before administering intravascular ROCM include at least
those listed in Box 7-1.
DRUG-DRUG INTERACTIONS
Many patients requiring intravascular ROCM administration have an
indwelling IV catheter through which other medications are to be
infused. Occasionally, an IV drug may be required to improve
visualization in a vascular bed or to counteract severe adverse effects
that may result from ROCM. For example, vasodilators are used to
improve delivery of ROCM to small arteries that may be
inaccessible otherwise. Vasoconstrictors are administered to decrease
delivery of ROCM to normal vascular beds in order to help visualize
beds that are not normal and are supplying a tumor. Vascular beds
within a tumor may not respond to vasoconstrictors as normal
vessels do, because they lack elasticity and receptor density;
therefore, ROCM will be specifically delivered to the tumor vessels
when vasoconstrictors are used. These adjunct medications are
generally injected immediately before ROCM injection. Drug-drug
interactions in the form of chemical incompatibilities may occur
94
between ROCM and these adjunct drugs.
Chemical incompatibilities that produce insoluble precipitates can
theoretically lead to occlusion of IV catheters and possibly a chemically
95
BOX 7-1 QUESTIONS TO BE ANSWERED BEFORE

ADMINISTRATION OF ROCM
1. History of allergies to medications?
2. History of intolerance to iodine?
3. History of adverse reactions to radiopaque contrast media?
4. History of asthma or breathing difficulties?
5. History of cardiac disease?
a. Congestive failure
b. Cardiac dysrhythmias
c. Hypertension
d. Hypotension
6. History of renal disease?
a. Chronic renal failure
b. Acute renal failure
c. Current blood urea nitrogen (BUN) concentration (renal
function test)
d. Current serum creatinine concentration (renal function test)
7. Current medications?
8. History of diabetes?
9. History of sickle cell anemia (in black patients)?
10. History of multiple myeloma?
11. Is the patient pregnant (females)?
12. Current central nervous system trauma?
induced embolism that can occlude small vessels in its path. The
sever- ity can range from mild to death, depending on which vessel
is occluded. Thus, it is paramount that the technologist understand
which drug-ROCM combinations are known to cause this
phenomenon and how to circumvent the problem.
Diatrizoate meglumine, diatrizoate sodium, ioxaglate, and
iothalamate are the more active ROCM with regard to forming
precipitates with other IV drugs (Table 7-1). Iopamidol and iohexol
have not been found to interact chemically with the medications
listed in Table 7-1. Other medications tested and found to cause no
precipitate with the ROCM listed include prostaglandin E1,
nitroglycerin, vasopressin, epinephrine hydrochloride,
pheniramine maleate, benzylpenicillin sodium, ampicillin sodium,
chloramphenicol sodium succinate, lidocaine hydrochloride,
heparin sodium, urokinase, and hydrocortisone sodium succinate.
If two incompatible drugs must be administered to a patient, it
is recommended that physiologic saline (0.9% sodium chloride) be
used to flush the IV catheter before each drug. If the chemical
compatibility between two drugs is not known, it is prudent to
assume that they are incompatible and administer a physiologic
saline flush between doses. In any case, it is probably safest to
flush the IV line between doses of two drugs, regardless of known
compatibility data.
96
Table 7-1 ROCM and Common Intravenous Drugs Forming Precipitates*

Contrast medium Intravenous drugs
Diatrizoate meglumine  Papaverine hydrochloride (smooth muscle relaxant)

Phentolamine mesylate (antiadrenergic)
Diphenhydramine hydrochloride (antihistamine)
Cimetidine hydrochloride (stomach antacid)
Diazepam (sedative and tranquilizer)
Meperidine hydrochloride (narcotic analgesic)
Protamine sulfate (heparin antagonist)
Diatrizoate sodium  Papaverine hydrochloride

Phentolamine mesylate
Diphenhydramine hydrochloride
Meperidine hydrochloride
Protamine sulfate
Ioxaglate  Tolazoline hydrochloride (peripheral

vasodilator) Gentamicin sulfate
(aminoglycoside antibiotic) Papaverine
hydrochloride
Phentolamine mesylate
Diphenhydramine hydrochloride
Cimetidine hydrochloride
Protamine sulfate
Iothalamate  Phentolamine mesylate

*
These radiopaque contrast media (ROCM), when mixed with any of the listed intravenous drugs,
may form precipitates that may occlude intravenous catheters or produce chemically induced
emboli.
Other drug-drug interactions that many fear include the possibility least one case of barium
of an increase in seizure activity when phenothiazine antinauseants are sulfate aspiration.
used after intrathecal administration of ROCM. Also, the use of
ROCM in patients who take antihypertensive medications may lead
to prolonged and exaggerated hypotensive effects.
BARIUM SULFATE
Enteral barium sulfate can cause both gastrointestinal (GI) and respiratory
adverse effects. In the GI tract, barium sulfate produces an insoluble pre-
cipitate with calcium to form barium fecaliths, which can lead to consti-
pation, intestinal obstruction, ulceration, and perforation as a result of
impaction of the colon. Surgical intervention may be required to remove
them. Distention, cramping, and diarrhea may also occur. Rarely, chem-
ically induced appendicitis has occurred in patients who retain barium
in the appendix. If intestinal perforation occurs, large amounts of
barium can cause intestinal infarction, desiccation, severe peritonitis, and
death. Aspiration of barium sulfate into the lungs generally does
not cause harm, provided the amount aspirated is small. Large
aspirates may lead to pneumonitis and nodular granulomas of both
lung tissue and lymph nodes. Asphyxiation and death have been
reported in at
97
? DID YOU KNOW?

In 1910, a Bonn gastroenterol- ogist, Paul Krause, found by accident that
barium sulfate was surprisingly nontoxic and an almost-ideal gastrointesti-
nal contrast agent. It quickly became the standard, replacing the
expensive, toxic bis- muth salts. (Barium sulfate is nontoxic, fine–grained,
and inexpensive.)
98
CONCLUSION
Radiopaque contrast media have various pharmacodynamic actions
that are important for the imaging technologist to comprehend.
Diagnostic effects rely on adequate ROCM concentrations at the
site. Adverse effects and drug-drug interactions caused by ROCM are
generally mild but can be life threatening. The competent
imaging professional will strive to understand such reactions.
99
Learning Exercises
Abbreviations
1. DSA:
2. PEA:
3. ARF:
True-False
1. T F Low-osmolality radiopaque contrast media can cause anti-

coagulation to occur.
2. T F Radiopaque contrast media do cross the placental barrier.
3. T F Intravascular administration of ROCM will cause a

transient decrease in intravascular osmotic pressure.
4. T F Sometimes, ROCM do cause serious adverse effects.
5. T F When a vasovagal event occurs, the patient becomes

symptomatically hypertensive as a result of moderate to
severe bradycardia.
6. T F Calcium chelation may be one pharmocodynamic

mechanism by which adverse heart rhythms, cardiac arrest,
and
95
sudden death occur in a minority of patients receiving

intravascular ROCM.
7. T F High-osmolality ROCM can cause some anticoagulation,

which can result in bleeding and bruising.
8. T F Even without immediate treatment, anaphylaxis is seldom

fatal.
9. T F Decompensated thyrotoxicosis is a condition in which the

body becomes unable to tolerate thyroid hormones.
10. T F ROCM are responsible for approximately 10% of all acute

renal failure (ARF) events and are the third most common cause
of hospital-acquired ARF.
1. To visualize the vascular lumen with normal x-ray exposure, the

blood iodine concentration must be within which of the
following ranges?
a. 150 to 200 mg/ml
b. 220 to 260 mg/ml
c. 280 to 370 mg/ml
d. 400 to 480 mg/ml
2. What is the term for a heart rhythm disturbance characterized by

electrical impulses without cardiac contraction?
a. Pulseless electrical activity
b. Chelation
c. Tachycardia
d. Fibrillation
3. What is the term for an immediately life-threatening systemic

hypersensitivity reaction?
a. Tachycardia
b. Stridor
c. Anaphylaxis
d. Hypotension
4. Radiopaque contrast media are responsible for approximately

what percentage of all acute renal failure (ARF) events?
a. 5%
b. 10%
c. 50%
d. 75%
96
5. In oliguric ARF, urine output does not exceed what amount?

a. 100 ml/day
b. 200 ml/day
c. 300 ml/day
d. 400 ml/day
6. When a patient is assessed before introduction of a radiopaque

contrast medium, it is vitally important to evaluate the medical
history and which of the following?
a. Current renal function status
b. Mode of medium introduction
c. Injection site
d. Subsequent diagnostic tests
7. Thyroid storm generally occurs in patients who have which of

the following?
a. Tachycardia
b. Decompensated thyrotoxicosis
c. Hypothyroidism
d. Congestive heart failure
8. What is the percentage of ARF cases after ROCM angiography?

a. 1%
b. 2%
c. 10%
d. 25%
9. The pharmacodynamic mechanisms for ROCM-induced ARF are

theorized to include which of the following?
a. Direct renal tubular toxicity
b. Renal ischemia
c. Intratubular obstruction
d. All of the above
10. Which of the following can result from large amounts of barium
sulfate being aspirated?
a. Death
b. Pneumonitis
c. Granulomas of lung tissue and lymph nodes
d. All of the above
11. Which of the following is not an agent used to protect the

kidneys from ROCM-induced renal dysfunction?
a. Fenoldopam
b. Phentolamine
c. Acetylcysteine
d. Sodium bicarbonate
97
1. An immediately life-threatening systemic hypersensitivity

reaction is known as .
2. A is a sensory nerve cell activated by
chemical stimuli.
3. ROCM can lead to sickling of red blood cells as a result of
osmotic fluid shifts in patients who have .
4. ROCM cross and should not be used in preg-
nant women unless benefits far exceed risks.
5. Patients at risk for after intravascular ROCM
administration include those with preexisting renal
compromise, diabetes with concomitant renal dysfunction, or
dehydration.
6. Signs and symptoms of include fever,
tachycardia, diaphoresis, agitation, nervousness, and emotional
instability.
7. Because of the serious effects that can occur by injection of
intravascular ROCM, the imaging technologist should use a
screening method that includes and .
8. are used to improve delivery of ROCM to
small arteries that may be inaccessible otherwise.
9. Because of the possibility of direct toxicity from oxygen
radicals resulting from administration of ROCM, investigators
have begun using the antioxidant properties of to prevent
renal dysfunction.
10. Acetylcysteine is available as a or
respiratory nebulization solution and as an
intravenous form.
11. is a relatively new agent for treating
hypertensive emergencies, but it has been used for
prophylaxis against ROCM-induced renal dysfunction.
98
Review Questions
1. Why is a history of previous exposure to a drug or ROCM not
enough to predict the possibility of a hypersensitivity reaction?
2. What should be done to ensure safe administration of two or

more incompatible drugs? What should be done if information on
drug- drug compatibility is not available?
3. What drugs are being used for protection against ROCM-induced

renal dysfunction, and how are they theorized to work?
4. List the major adverse effects seen with the paramagnetic agents and
ultrasound microbubble agents.
99
8
Routes of Drug Administration

anesthetic At the conclusion of this chapter, you should be able to:
antecubital space 1. List and define the “five rights” of drug administration.
antihistamine
2. Cite the advantages and disadvantages of the various routes
antiseptic
of medication administration.
aqueous solution
3. Identify the landmarks for the administration of medications by
aqueous suspension
the intramuscular route.
aspiration
4. Identify specific procedures used to maintain patient safety during
astringent
the preparation and administration of medications.
bacteriostatic
5. Recognize common abbreviations and symbols related to
buccal
medication administration.
butterfly set
6. Identify the most commonly used veins for intravenous injections.
central venous line
7. Demonstrate the procedure used for venipuncture.
dorsogluteal
8. List the symptoms of extravasation.
emollient
9. Identify the universal precautions that must be taken by the technologist
endotracheal tube
performing venipuncture.
extravasation (infiltration)
10. List all information placed in the patient’s medical record following
gauge (needle)
drug administration.
intradermal
11. Differentiate between and describe the uses of endotracheal tubes
intramuscular
and central venous lines.
intravenous
keratinized
lipodystrophy
oral
parenteral
pulmonary arterial INTRODUCTION
line rectal
subcutaneous Before giving a patient any medication (drug), the medical imaging
sublingual technologist should always adhere to the five rights of drug administra-
topical tion (Box 8-1).
venipuncture Note that the patient has the right to refuse medication. The
ventrogluteal imaging technologist should never force a patient to take a drug
or drugs. Consult the patient’s physician immediately on refusal.
The following common sense reminders can help ensure that
the right patient receives the right drug in the right amount at the right
time via the right route. Check the drug name carefully by always
reading the label on the container three times: once when the
container is removed from the shelf, again when the drug is removed
from the container, and a third time when the container is replaced.
Since it is now common for drug companies to prepare contrast in
“prefilled” syringes, be sure to
100
Routes of Drug
Administration
BOX 8-1 FIVE RIGHTS OF DRUG ADMINISTRATION

●
Right patient
●
Right drug
●
Right amount
●
Right time
●
Right route
and parenteral routes.

check the name on the prefilled syringe as it is taken from the General principles
package to ensure that it matches the name on the outside of the associated with each route
package. Also, remember that the names of different drugs may of administration are
sound similar (e.g., Renografin vs. Gastrografin). Never use a drug discussed here.
that is unlabeled or expired. Always check the label for the drug’s
expiration date. Under no circumstances should an expired drug be
used. To prevent error, it is good practice never to administer a
drug someone else has prepared. If you must prepare a drug for
another health professional to administer, always show the
container to the individual who will administer the drug before you
hand him or her the medication. If an error is made, everyone
involved is responsible! Make sure you have done everything right
for your patient.
Dose measurement must be done carefully and accurately to
ensure that the right amount is used. Inaccurate measurements can lead
to significant toxicity. When you are preparing to administer an
injectable drug, it is also important to select the right size and type
of syringe and needle. Some medication may require a large-bore
needle because of medication viscosity or the need for rapid
injection.
Check the patient’s wristband for proper identification and ask for
his or her name to ensure that you are administering the drug to
the right patient. If the wristband does not coincide with the name
given, do not administer the drug. If the patient does not state his or
her name as written on the wristband, do not administer the drug.
Keep in mind that confused patients may answer to any name given.
Make the patient verbalize his or her name before you state the
name. If he or she is too young to speak or is unable to speak, ask a
parent or someone present to identify the patient. Last, address the
patient by name before administering the drug.
The right time for administering a drug is usually indicated by
the physician or practitioner responsible for ordering the drug. As a
general rule, the medical imaging technologist does not determine the
time but should administer the drug at the time specified.
The physician usually specifies the route by which the drug
should be administered. The technologist must be familiar with
medical terminology to ensure that the drug is administered by the
right route.
Drugs may be administered by the oral, sublingual, topical, rectal,
101
?
DID YOU KNOW?
In the United States, the eld- erly hospitalized patient is prescribed an
average of 9.1 drugs per day. In Canada, 7.1 drugs are prescribed daily, and
Israel follows with 6.3 per day, New Zealand with 5.8 per day, and
Scotland with 4.6 per day.
102
Pharmacology and Drug Administration for Imaging Technologists Routes of Drug
Administration
ORAL ROUTE
The oral route is the most common method of drug administration.
Oral administration is the safest, most economical, and most
convenient way of giving medication. Therefore, it is the preferred
route unless some distinct advantage is to be gained by using
another route or a contra- indication to oral administration is present.
Most drugs undergo absorption in the small intestine; few are
absorbed in the stomach and colon (see Chapter 3). Drug effects
are generally slower and less efficient when a drug is given orally
rather than parenterally. When receiving drugs by the oral route,
the patient must be conscious and the head should be elevated to
aid in swallowing.
A major advantage of the oral route is that it allows for the
easiest retrieval of a drug in overdose situations. Until a drug is
dissolved and absorbed, it may be retrieved by lavage or catharsis or
may be adsorbed to block absorption. The parenteral route does not
allow for this.
Disadvantages of oral administration of certain drugs are that
(1) they may have an objectionable odor or taste or may be bulky
to swallow, (2) they may harm or discolor the teeth, (3) they may
irritate the gastric mucosa, causing nausea and vomiting, (4) they
may be aspirated by a seriously ill or uncooperative individual, (5)
they may be destroyed by digestive enzymes, and (6) they may be
inappropriate for some patients, such as those who must be given
nothing by mouth.
SUBLINGUAL AND BUCCAL ROUTES

Sublingual administration is performed by placing the drug under
the tongue for dissolution and absorption. The thin epithelium and
network of capillaries on the underside of the tongue permit drug
absorption. Drugs administered by this route will gain access to the
general circulation without traversing the liver or being affected by
? DID YOU KNOW?

gastric and intestinal enzymes. Thus, the drug potency may be
enhanced. This also applies to buccal administration, in which a
tablet is held in the mouth in the pocket between gums and cheek
Anytime a drug is
for local dissolution and absorption. Nitroglycerin tablets and
administered to a patient,
relevant information must morphine sulfate solution are two examples of drugs commonly
be recorded on the patient’s administered by the sublingual and buccal routes.
chart to document the event. The number of drugs that can be given sublingually or buccally
The name and dosage of the is limited (e.g., nitroglycerin tablets). The drug must dissolve readily,
drug, route of adminis- and the patient must be able to cooperate. The patient must
tration, date, time, and site understand that the drug is not to be swallowed and that taking a
of injection (if the drug is drink must be avoided until the drug has been absorbed. However,
administered parenterally) usually little harm is done if a sublingual drug is inadvertently
should be included. swallowed. It is unclear, in some cases, whether a drug is absorbed
under the tongue or actually swallowed and absorbed in the
intestinal tract.
103
TOPICAL ROUTE
The topical route of
drug administration
involves the
application of a drug
directly onto the skin
or mucous
membrane. The drug
is diffused
104
Routes of Drug
Administration
through the skin or membrane and absorbed into the bloodstream.

These medications are applied for the following effects:
1. Astringent: resulting in vasoconstriction, tissue
contraction, and decreased secretions and sensitivity, thereby
counteracting inflammatory effects.
2. Antiseptic or bacteriostatic: to inhibit growth and development
of microorganisms (e.g., Betadine, Bactroban).
3. Emollient: for a soothing and softening effect to overcome
dry- ness and hardness (e.g., lanolin).
4. Cleansing: for the removal of dirt, debris, secretions, or
crusts (e.g., Hibiclens).
5. Anesthetic: to remove the sensation of pain (e.g., benzocaine).
6. Antihistamine: for manifestations caused by allergic
reactions (e.g., Benadryl cream).
Topical medications may be applied in the form of a lotion,
tinc- ture (alcoholic solution), ointment or cream, foam, spray, gel, wet
dress- ing, tampon, bath, or soak. The effectiveness of medicinals
applied to the skin for local effect is limited by the fact that highly
specialized layers of skin resist penetration of many (not all) foreign
substances to protect the internal body environment. Topical
absorption is increased when the skin is thin or macerated, when
there is increased drug concentration, when there is prolonged
contact of the drug with the skin, or when the drug is combined
with a solvent-penetrant. The mucous membranes absorb drugs
much more readily because they are not keratinized. Keratin is a
scleroprotein that is the principal constituent of the epidermis, hair,
nails, and the organic matrix of the enamel of the teeth.
RECTAL ROUTE
Rectal administration of certain preparations can be used advanta-
geously when the stomach is nonretentive or traumatized, when
the medicine has an objectionable taste or odor, or when it can be
changed by digestive enzymes. This route is also a reasonably
convenient and safe method of giving drugs when the oral method
is unsuitable, as when the patient is a small child or is unconscious.
Use of the rectal route avoids irritation of the upper
gastrointestinal tract and may promote higher bloodstream drug titers
because venous blood from the lower part of the rectum does not traverse
the liver. The sup- pository drug vehicle is often superior to the
retention enema vehicle because the drug is released at a slow but
steady rate to ensure a prolonged effect. Disadvantages of the retention
enema are unpredictable retention of drug and the possibility of fluid
passing above the lower rectum to be absorbed into the portal
circulation, where metabolism can be extensive.
PARENTERAL ROUTE
The term parenteral means to be administered by injection. The four
most common methods by which drugs are administered
103
parenterally are intradermal, subcutaneous, intramuscular, and
intravenous (Table 8-1).
104
Routes of Drug
Administration
Table 8-1 Suggested Injection Guidelines

Volume injected (ml)
Route Common areas Region Needle sizes* Average Range† Examples of medications by this route
Intradermal (intra- Skin (corium) Inner aspect of midforearm or 26 or 27 gauge  3⁄8 in 0.1 0.001 to Tuberculin, allergens, local
cutaneous) scapula 1.0 anesthetics
Subcutaneous Beneath the Lateral upper arms; thighs; 25 to 27 gauge  1⁄2 to 0.5 0.5 to Epinephrine (non-oily), insulin,
5
skin abdominal fat pads except ⁄8 in‡ 1.5 some narcotics, tetanus toxoid,
the 1-in area around vaccines, vitamin B12, heparin
umbilicus and tissue over
bone; upper back, upper hips
Intramuscular Gluteus Dorsogluteal 20 to 23 gauge  2 to 4 1 to 5 Most intramuscular and Z-

medius 11⁄2 to 3 track injections
Gluteus Ventrogluteal in‡ 1 to 4 1 to 5 All intramuscular medications
minimus 20 to 23 gauge 
Vastus Anterolateral 11⁄2 to 3 1 to 4 1 to 5 Almost all intramuscular
lateralis midthigh in‡ medications
Deltoid Upper arm below shoulder 22 to 25 gauge  0.5 0.5 to 2 Vaccines, absorbed tetanus
5
⁄8 to 1 in‡
23 to 25 gauge 
5
⁄8 to 1 in‡ toxoid, most narcotics,
epinephrine, sedatives,
vitamin B12, lidocaine
Intravenous Cephalic and Dorsum of hand and 18 to 23 gauge  1 1 to 10 0.5 to 50 Antibiotics, vitamins, fluids and
forearm; bolus basilic veins antecubital fossa to 11⁄2 in (or more electrolytes, antineoplastics,
by conti- vasopressors, corticosteroids,
nuous aminophylline, blood products
infusion)
*
Needles used for withdrawing medication from a container should be changed before injecting medication drawn (1) from ampules, because irritating medication may cling to
needle (filter-needles should be used to withdraw medication from ampules), and (2) from vials, because needles are dulled after insertion through rubber tops; disposable needles
are thus labeled “for one-time use only.”
†
Administration of the largest volumes listed here should be avoided if possible by dividing the dose and using different sites or by using another route in consultation with prescriber.
‡
See text for discussion of factors influencing choice of needle length.
Routes of Drug
Administration
The medical imaging technologist may also witness intraarterial

injections with certain medical procedures.
Parenteral administration of drugs includes all forms of drug
injection into body tissues or fluids using a syringe and needle or
catheter and container. Drugs given parenterally must be sterile,
readily soluble and absorbable, and relatively nonirritating.
Parenteral administration can be the most hazardous route by which
to give a drug. Administering medication by this route requires
specialized knowledge, aseptic technique, and manual skill to
ensure safety and therapeutic effectiveness. Aseptic technique,
accurate drug dosage, and proper technique and rate of injection at
the proper site of injection are all essential to avoid- ing harm, such
as lipodystrophy (atrophy or hypertrophy of subcutaneous fat
tissue), abscess, necrosis, skin sloughing, nerve injuries, prolonged
pain, and periostitis. An injected drug acts rapidly and is
irretrievable. Thus, an error in dosage, method, or site is not easily
corrected.
Table 8-2 Commonly Used Weights and Measures

Metric Apothecary Household
WEIGHT
1 kg* 2.2 pounds
1000 mg = 1 gram* gr xv
60 mg* (occasionally seen

as 65 mg) gr î
30 mg 1 g (mcg) = 0.001 mg gr ss (one half)
VOLUME
4 quarts 1 gallon
1000 ml* = approx 1 liter = Approx 1 qt 1 quart

1000 cc
500 ml Approx 1 pint (1⁄2 qt) 16 ounces

z
240 or 250 ml 3 viii (8 1 cup or 1 glass
fluidounces)†
= approx 1⁄2 pint
z
30 ml* = approx 30 cc 3 î (1 fluidounce) 2 tbsp
Approx 16 ml = approx 3 iv (4 fluidrams) 1 tbsp

16 cc
Approx 8 ml 3 îî (2 fluidrams) 2 tsp
4 to 5 ml 3 î (1 fluidram) 1 tsp
1 ml* = approx 1 cc Minims xv or xvi Minims cannot be

compared with drops
*
These equivalents may be committed to memory for ready application to dosage problems.
105
†
Note the small difference in the symbols for fluidounce and fluidram.
106
Routes of Drug
Administration
Most methods of parenteral administration may be performed

by the technologist, but some are usually performed only by a physician
or a nurse. Knowledge of, and strict adherence to, agency policy is
imperative. (See Table 8-2 for common weights and measures.)
? DID YOU KNOW? Intradermal (ID) Method

Intradermal or intracutaneous injection means that the injection is
The blood urea nitrogen made into the upper layers of the skin almost parallel to the skin surface
(BUN) and creatinine levels (Fig. 8-1).
in a patient’s blood are The amount of drug given is small, and absorption is slow. The
indicators of renal function.
ID method is used mostly in testing for allergic reactions and for
Elevated levels of these
substances may
giving small amounts of a local anesthetic. In testing for allergic
contraindicate the use of reactions, minute amounts of the solution to be tested are injected
intravascular radiopaque just under the outer layers of skin. The medial surface of the
contrast media (ROCM), forearm and the skin of the back are sites frequently used. These
which could cause further injections are best made with a fine, short needle (26 or 27 gauge)
stress on renal function. and a small-barrel syringe, such as a tuberculin syringe (Fig. 8-2).
Imaging technologists should
check a patient’s chart for Subcutaneous (SC) Method
this information and bring it Small amounts of drug in solution are given subcutaneously
to the attention of the radiol- (beneath the layers of skin, yet above the muscle), usually by
ogist before administering means of a 25- gauge (or thinner) needle and syringe. The needle is
such contrast media.
inserted through the skin with a quick movement, but the injection
is made slowly and steadily (Fig. 8-3). The technologist should slightly
withdraw the plunger of the syringe (aspirate) before injecting the
drug to make sure that a blood vessel has not been entered. If a red
streak is observed as the plunger is withdrawn, the operator should
assume that a vessel has been tapped. It is then necessary to
reposition or replace the needle and possibly the syringe and
contents. If this simple precaution is not observed, an SC injection
immediately turns into an intravenous or intraarterial injection;
either of which can be extremely dangerous to the patient (e.g., air
embolism, hematoma, extravasation).
Fig. 8-1 Intradermal injection method. The needle penetrates epidermis and goes into
dermis but not subcutaneous tissue. (Note that the skin is not pinched up.)
107
Routes of Drug
Administration
Fig. 8-2 Syringe types. These syringes are used to accurately measure varying
amounts of liquids and liquid medications. The syringe at the bottom is known as a
tuberculin syringe and is graduated in 0.01 cc (ml). It is a syringe of choice for
administration of very small amounts. The 2-cc syringe is typically used to give a
drug subcutaneously or intramuscularly. It is graduated in 0.1 cc. The larger syringes
are used when a larger volume of drug is to be administered intramuscularly or
intravenously; for withdrawing blood for laboratory testing; or for obtaining urine
specimens from urinary catheters (20-cc syringes may be preferred for the last
two uses).
The angle of insertion should usually be 45 to 60 degrees (but

can vary between 30 and 90 degrees), depending on needle length and
depth of fat pads. Insertion should be made on the fat pads of the
abdomen, the outer surface of the upper arm, the anterior surface of
the thigh, or occasionally the lower abdominal surface (when heparin is
ordered). In these locations there are fewer large blood vessels, and
sensation is less keen
Fig. 8-3 Subcutaneous injection method. The skin surface has been cleansed, and
the syringe is held at the angle at which the needle will penetrate subcutaneous
tissue. The left hand is used to pinch the arm gently but firmly. When the needle has
been inserted into the subcutaneous tissue, the tissue of the arm is released, and
the solution is steadily injected. Based on the patient’s condition or the
107
medication to be injected, judgment may dictate a different angle or an alternate

approach to pinching up the skin.
108
Routes of Drug
Administration
than on the medial surfaces of the extremities. Massage of the part after
SC injection tends to increase the rate of absorption but should be
avoided after injection of some drugs, such as heparin, to minimize
bruising as the drug spreads through the tissues. Disposable syringes
and needles contribute to aseptic safety of the procedure but also to
cost and problems of storage and disposal. Subcutaneously injected
medicines are limited to drugs that are highly soluble and nonirritating
and to solutions of limited volume (ideally no more than 1 ml).
Irritating drugs given subcutaneously can result in the formation
of sterile abscesses and necrotic tissue, especially if injections are
made repeatedly in the same site. Care should be exercised to avoid
contamination and to rotate sites. SC injections are not effective in
individuals with sluggish peripheral circulation (e.g., the patient in
shock).
Intramuscular (IM) Method

Deeper injections are made into muscular tissue, through the skin
and subcutaneous tissue, when a drug is too irritating to be given
subcutaneously, although irritation may also occur with some drugs
given intramuscularly. Larger doses can be given by IM injection (up
to 5 ml) than by SC injection. In cases of circulatory collapse (i.e.,
shock), intravenous (IV) injection is preferred over the delayed
absorption through the SC, IM, or ID route.
A drug may be given intramuscularly in an aqueous solution,
an aqueous suspension, or a solution or suspension of oil.
Suspensions form a supply of drug in the tissue and result in slow,
gradual absorption. Two disadvantages sometimes encountered
when preparations in oil are used are that the patient may be
sensitive to the oil and the oil may not be absorbed. In the latter
case, incision and drainage of the oil may be necessary. Fortunately,
?
few drugs are formulated in oil.
DID YOU KNOW? Criteria for selection of a safe IM injection site include distance
from large, vulnerable nerves, bones, and blood vessels and from
Nonionic iodinated contrast bruised, scarred, or swollen previous injection or infusion sites. The
media have proved to be less type of needle used for IM injection depends on the site of the
likely to cause an adverse injection, the condition of the tissues, the size of the patient, and the
reaction than ionic contrast nature of the drug to be injected. Needles from 1 to 11⁄2 inches in
media. Nonionic contrast
length are common. The usual gauge is 21 to 23; the larger the
media do not dissociate into
number, the finer the needle (Fig. 8-4). Fine needles can be used for
ionic particles when
introduced to the thin solutions and heavier needles for suspensions and oils. Needles
bloodstream as do the ionic for injection into the deltoid area should be 5⁄8 to 1 inch in length,
types of media. This results in the gauge again depending on the material to be injected. The
a lesser osmotic effect on deltoid can readily absorb up to 2 ml of drug. For many IM injections,
the cells, which lowers the the gluteal muscles are preferred because of fewer nerve end- ings and
occurrence of adverse less discomfort. The needle must be long enough to avoid depositing
reactions. the solution of drug into the subcutaneous or fatty tissue. The depth of
insertion depends on the amount of subcutaneous tissue and will
vary with the weight of the patient.
It is essential to locate the appropriate landmarks to determine the
areas safe for injections (see Table 8-1 and Fig. 8-5). IM injections
109
may be given into
such clearly defined
areas of musculature
as the gluteal region
of the lower back
(provides slowest
absorption), the deltoid
area,
110
Routes of Drug
Administration
Fig. 8-4 Parts of the needle and various needle gauges.
and the anterolateral thigh. At first it seems to most students that

the fleshy part of the buttock is a logical IM site. It is not, however,
because underneath, centrally, and running diagonally to this site is
the sciatic nerve, which, if damaged, can result in permanent leg
paralysis. Every attempt must be made to avoid this area.
There are now two acceptable ways to map appropriate IM sites
in the gluteal region. The formerly used method of dividing the
gluteus medius into imaginary quadrants and injecting into the
upper outer quadrant is out of favor because it does not necessarily
prevent an injection into the sciatic nerve, especially if its course
runs abnormally.
The technologist can best locate the dorsogluteal site (the muscle
underneath is the gluteus medius) by asking the patient to lie
facedown and exposing the entire area so that the landmarks and the
injection site can be clearly located. The proper site for this
injection is outlined by an imaginary diagonal line drawn from the
area of the greater trochanter of the femur to the posterior iliac
spine. The injection should be given at any point between that
imaginary straight line and below the curve of the iliac crest (see
Fig. 8-5, A).
The ventrogluteal site can be made accessible with the
patient lying in a supine or side-lying position. This site is used for IM
injections in either children or adults and could be used more often.
To locate it on the left side, the technologist should palpate for the
left greater trochanter with the right palm, point the right index finger
to the anterior superior iliac spine, and extend the middle finger
toward the iliac crest. The injection should be made into the
center of the V formed between the index and middle fingers (see
111
Fig. 8-5, B). The left hand is used to detect landmarks in the right
hip.
112
Routes of Drug
Administration
D
Fig. 8-5 Intramuscular injection sites. A, Dorsogluteal site, located anterior to
the diagonal line from the trochanter to the posterior iliac spine. An injection near the
middle of the buttocks may result in an injury to the sciatic nerve. The needle is
inserted with a quick firm movement, entering perpendicular to the skin. After
aspiration, to make certain the needle is not in a blood vessel, the solution is
injected slowly and steadily. B, Ventrogluteal intramuscular injection site. The V
fans out from the greater trochanter between the anterior iliac spine and iliac crest.
The injection site (O) is cen- tered at the base of the triangle. C, Vastus lateralis
(midlateral thigh) intramuscular injection site—a handsbreadth below the greater
trochanter and a handsbreadth above the knee and halfway between the front and
side of the thigh. D, Mid-deltoid intramuscular injection site—below the acromion
and lateral to the axilla.
113
Routes of Drug
Administration
The mid-deltoid area is the muscular area in the arm formed by the
rectangle bounded on the top by the edge of the shoulder and on
the bottom by the beginning of the axilla (see Fig. 8-5, D). The
deltoid muscle has a considerably higher blood flow than the other
IM injection sites and, for rapid onset, is the area of choice for
many small-volume (2 ml or less) medications.
The vastus lateralis is a muscular area in the upper outer leg.
The potential area for injection is a long rectangular area just lateral
to the frontal plane of the thigh. Its top boundary is found about
one handsbreadth below the greater trochanter, and the bottom
boundary is about one handsbreadth above the knee (see Fig. 8-5,
C). This area can accommodate volumes of medication the same
size as the gluteus medius and is distant from any major blood
vessels or nerves. However, injection here may be more painful than
in the buttocks.
For the IM injection, the needle and syringe assembly is held as
if it were a dart while the other hand stretches the skin of the
injection site taut. If the muscle mass underlying the injection site is
inadequate to accommodate the length of the needle, the flesh
may instead be pinched up before needle insertion. The injection
should be made perpendicular to the skin surface, from a distance
of about 2 inches, in one quick motion. If possible, the needle
should not be inserted to its full depth, and a small portion of
needle should be left accessible above the skin so that the needle
might be retrieved should it break, a very rare occurrence. As in SC
injection, it is necessary to make certain that the needle is not in a
blood vessel, thus causing the unintended deposit of medication
into the bloodstream instead of muscle tissue. This is ascertained
by pulling out the plunger slightly after the needle is in place in the
tissue (aspiration). A slight pinkish tinge to the medication may be
seen close to the needle hub, or a small amount of blood may enter
the barrel of the syringe, if the needle is in a blood vessel rather
than in tissue. If this is the case, both needle and medication-
filled syringe should be withdrawn and discarded before con-
tinuing. In certain cases, injection of oily or particulate medicines
or bacteria by such an inadvertent intravascular administration
could result in a serious emergency situation.
Contrary to popular belief, needle puncture of the skin is not
always the prime source of discomfort associated with injections,
although a dull needle such as one that has been inserted through a
vial’s rubber stopper will certainly contribute to pain. Also, it is not the
length of the needle that causes pain, but the diameter; a 3-inch
needle will hurt no more than a 5⁄8-inch needle if the diameter is
similar. Except for the psychological aspect of anxiety about
needles, most injection pain is thought to occur (1) from stretching
of tissue (pain receptors in the skin) as it accommodates the volume
of the drug; (2) from irritation from the drug itself; (3) from
unsteadiness in the injector’s technique, which results in jiggling of
the needle during overly slow insertions;
(4) during aspiration; (5) while the injector is reaching for the
111
antiseptic swab at completion; or (6) from wet antiseptic on the
skin during insertion. Firm pressure applied to the needle-tissue
juncture with an
112
Routes of Drug
Administration
? DID YOU KNOW?

antiseptic swab will prevent discomfort as the needle is withdrawn.
Massaging the site acts to disperse the medication and may also
reduce discomfort.
There is a very good reason
to start an IV line with a Intravenous (IV) Method
catheter versus a butterfly Direct injection into a vein (intravenously) is warranted when “immedi-
set. One frequent cause of
ate” effects of a drug or fluid are desired. Most emergency drugs,
litigation arises when contrast
media is injected without a
sterile saline and dextrose solutions (dehydration), chemotherapy
venous access line already in drugs, and radiopaque contrast media (ROCM; imaging
place. Once the patient has examinations) are introduced through the IV route.
developed anaphylaxis, it is
extremely difficult to insert Intravenous injection sites. The most common IV injection
an IV line. We believe that the sites are the basilic or cephalic veins on the back of the hand, the
standard of care requires that basilic vein on the medial, anterior forearm and elbow or the
intravenous or intraarterial cephalic vein on the lateral, anterior forearm and elbow (Fig. 8-6).
contrast media be used only The anterior recess of the elbow where these veins are located is often
in patients who have IV lines referred to as the antecubital space.
in place. A note stating that
there was difficulty starting an Intravenous equipment. The winged-tip or butterfly set is
IV line in a patient already in
the most common IV needle used by imaging technologists for the
shock is a strong admission of
negligence and will not be introduction of contrast. These needles vary from 1⁄4 to 11⁄4 inches
overlooked by an alert in length and 18 to 27 gauge in diameter. Most have 6 to 12 inches
attorney for the plaintiff. of tubing attached, extending from the needle to the syringe hub
(Fig. 8-7). Some imaging procedures may require a slower “drip
infusion” technique. For these procedures, a bag or bottle of liquid
containing a diluted percentage of the prescribed drug is hung from
an IV pole or stand (Fig. 8- 8). A catheter extending from the bag is
attached to the needle after
Radial
vein
Anterior
Superficial Right Forearm
dorsal veins
Dorsal Posterior Basilic

venous Right Hand vein
arch
Median vein
of forearm
Basilic
vein
Cephalic Median
vein cubital
vein
Basilic Cephalic
vein vein
Fig. 8-6 Veins most accessible for venipuncture.
113
Routes of Drug
Administration
Fig. 8-7 Intravenous (IV) administration needles. Top, Butterfly needle. Bottom,
Over-needle catheter.
insertion at the injection site. ALERT! To avoid an air embolism,

make sure that all air bubbles are out of the catheter before
releasing the “drip” infusion.
Intravenous procedure. The following sequence should be used

when performing venipuncture:
1. Wash your hands thoroughly.
2. Introduce yourself and thoroughly check the patient’s identification.
3. Explain the procedure. Make sure the patient understands.
Obtain feedback.
Fig. 8-8 IV fluid packaging. After removing cap, remove diaphragm carefully to
avoid contamination. With tubing clamped off, insert drip chamber firmly into
access port. Invert bottle or bag and suspend from pole. Pinch drip chamber to draw
fluid into chamber. Fill chamber about half full.
113
4. Prepare the drug and all required supplies for administration.

5. Put on disposable gloves.
6. Determine the most appropriate site for venipuncture, and cleanse
it with an alcohol swab using a circular motion while moving
from the injection site outward. Cleansing a second time may
be warranted.
7. Apply a tourniquet 3 to 4 inches above the site of injection.
The patient may open and clench the fist to make the veins
more identifiable.
8. To stabilize the vein and to keep it from rolling, place your
thumb directly below the injection site and gently pull the skin
toward the fingers of the patient.
9. Hold the needle with the bevel facing upward. If using a
butterfly set, pinching the wings together assists in stability.
10. Insert the needle at a 15- to 20-degree angle through the skin.
Gently advance it into the vein. You will feel a subtle “pop” as
the needle enters the vein, and you should see a backflow of
blood into the tubing.
11. Release the tourniquet and inject the drug. Taping the needle
in place during injection will keep it from dislodging.
12. Remove the needle quickly, and apply gentle pressure to the
injection site with an alcohol swab.
13. Dispose of the syringe and needle in a labeled “sharps” container.
14. Chart all pertinent information.
Fig. 8-9 illustrates the venipuncture technique through seven steps.
During and after venipuncture, it is important to watch
carefully for drug and blood leakage into the tissues surrounding
the vein. This infiltration or extravasation can be very painful and is
often quite serious for the patient. If extravasation does occur,
remove the needle immediately, apply pressure to the injection
site, and apply a warm, moist cloth to relieve the pain. Important:
Do not continue to inject the drug! If the drug was potentially
corrosive or caustic, a physician should be contacted immediately.
Hospital or clinic policy may dictate that an “incident report” be
filed for extravasations, especially those involving contrast media or
corrosive drugs.
If venipuncture is to be reattempted, seek an alternate
injection site and be sure to use a new needle to avoid
contamination.
CHARTING
Relevant information must be recorded on a patient’s medical
record whenever a drug is administered. Refer to Chapter 2 for more
detailed information on charting. The following information must be
included:
1. Name of drug
2. Dose of drug
3. Route of drug administration
4. Date of administration
114
Routes of Drug
5. Time of administration Administration
6. Injection site (if administered parenterally)
115
Fig. 8-9 Venipuncture procedure. A, Step 1: Make patient comfortable. B, Step 2: Cleanse site with alcohol swab. C and D,
Step 3: Isolate vein and prepare for insertion. E, Step 4: Insert needle. F, Step 5: Remove tourniquet and inject drug.
Continued
If starting an IV line, be sure to chart the number of injection

attempts.
Imaging technologists are being held increasingly accountable for
proper charting and documentation of drug and contrast media
administration. If errors or problems occur during the introduction
of a drug,
116
Routes of Drug
Administration
Fig. 8-9, cont’d G, Step 6: Remove needle after injection. H, Step 7: Apply pressure until bleeding stops, and apply bandage.
? DID YOU KNOW?

or if the patient experiences any adverse effects, a full explanation
should be documented in the chart. Technologist errors associated with
Surgical teams must now drug administration are often litigated.
schedule a “time out” before
an operation to make sure
CHEST TUBES AND LINES
that the right procedure is
being performed in the right Medical imaging technologists may often come in contact with
place on the right patient. patients who have endotracheal tubes, central venous lines, or
pulmonary arterial lines. A general understanding of the actual
placement of these devices and their use is important.
Endotracheal Tubes (Intubation)

Endotracheal (ET) tubes are used primarily to assist the patient through
a number of respiratory problems. Indications for use of ET tubes
include the following:
●
Mechanical ventilation and oxygen delivery necessitated by
oxygen debt (e.g., airway obstruction, shock, poor gas exchange in
lungs)
●
Concerns about aspiration of stomach contents
●
Upper airway obstruction
●
Administration of epinephrine during advanced cardiac life support
(ACLS)
The inhaled air must be adequately humidified because the
normal humidifying function of the upper respiratory tract is
bypassed. Inhaled air must also be protected from contamination as
much as possible. Suctioning of secretions through the tube is
required because normal expulsion of these secretions is impossible.
Since a patient with an ET tube in place cannot talk, means must be
arranged to assist with communication.
Central Venous Lines

Central venous (CV) lines, also known as central venous catheters
117
and venous access devices,
are catheters inserted into
a large vein to
118
Routes of Drug
Administration
administer drugs, manage fluid volume, transfuse and analyze

blood, and monitor pressures within the heart.
CV catheters vary in size and composition and are used in both
short-term and long-term patient care. They are available as percutaneous
catheters (subclavian insertion), totally implanted access ports
(Infusa Port, Port-a-Cath, Mediport), peripherally inserted central
catheters (PICC lines), and externally tunneled catheters. Implantable
ports are desired when access is required intermittently over a long
period.
Regardless of the style used, the goal is to position the catheter
tip in a central vein, usually the superior vena cava, 2 to 3 cm
above the right atrial junction. Because of its size, the superior
vena cava reacts less to infusions of caustic IV fluids.
The most common insertion site for CV catheters is the
subclavian vein. Other common sites include the internal jugular and
femoral veins.
Pulmonary Arterial Lines

Pulmonary arterial (PA) lines are commonly called Swan-Ganz catheters,
after their inventors. PA lines are actually specialized CV lines that
incorporate a small electrode at the distal end used to monitor pul-
monary arterial pressures. PA lines are used to estimate left ventricular
end-diastolic pressure (LVEDP). Because catheter placement in the
left ventricle creates major physiologic consequences, the safest
way to assess left-sided heart pressure is to estimate its value by
monitoring right-sided heart and pulmonary pressures.
Complications and Patient Care

Central venous access devices can improve and extend quality of
life for many patients, but the potential for complications demands
the attention of all members of the health care team. Examples of
complications include catheter dislodgment and occlusions resulting
from the accumulation of blood clots or drug residue.
Care must be exercised when handling patients with CV lines.
Assessing the patient before performing imaging procedures is essential
to avert the possibility of line displacement. Although recognition
of problems related to tubes and line use is not specifically identified in
the technologist’s scope of practice, an implied responsibility certainly
exists.
GENERAL ADMINISTRATION GUIDELINES

The following guidelines are recommended for distributing or
administering drugs to patients. Accurate and full identification of
the patient before giving medications ensures that the right person
receives the right medication. Remember the five “rights” of drug
administration (see Box 8-1).
1. When preparing or giving medicines, focus all your attention on
the task. Do not permit yourself to be distracted while working
with medicines.
117
2. Make certain that you have a written order for every medication
for which you assume the responsibility of administration. (Verbal
and
118
Routes of Drug
Administration
telephone orders should be written out and signed by the

prescriber as soon as possible. These orders should be used only
in limited circumstances and not for the convenience of the
prescriber.)
3. Make a habit of reading the label of the medicine and
comparing it to the requisition carefully at least three times: first,
when removing the drug from the supply drawer or medication
cart; second, when placing the medication in a cup or syringe;
and third, just before administering it to the patient, before
the container is discarded.
4. Never give a medicine from an unlabeled container or from one
on which the label is not legible.
5. If you must calculate in some way the dosage for a client from
the preparation on hand and you are uncertain of your calcula-
tion, verify your work on paper by having some other responsi-
ble person (instructor, lead technologist, pharmacist) check it.
Whenever the result of a calculation calls for more than two
units of a drug to make a dose, double-check the calculation. It
is highly unusual for more than two units of a drug to be
administered in a single dose.
6. When measuring liquids, hold the container so that the line
indi- cating the desired quantity is on a level with the eye. The
quantity is read when the lowest part of the concave surface of
the fluid (meniscus) is on this line.
7. Dosage forms such as tablets, capsules, and pills should be
handled so that the fingers do not come into contact with the
medicine. Use the cap of the container to guide or lift the
medicine into the medicine glass or container that you will be
taking to the patient.
8. Avoid wasting medicines. Medicines tend to be expensive; a
single capsule may cost the patient several dollars.
9. When pouring liquid medicines, hold the bottle so that the
liquid does not run over the side and obscure the label. Wipe
the rim of the bottle with a clean piece of tissue before
replacing the stopper or cover.
10. When preparing an injection, always label the syringe
immediately. Keep the vial with the syringe, and do not rely on
memory to determine what solution is in which syringe.
11. Never administer medication prepared by another person. In
doing so, you accept the responsibility for accuracy, dose,
correct medication, and so forth. If the person who prepared
the medication has made an error, you are accountable for any
harm done to the patient.
12. If a patient expresses doubt or concern about a medication or
the dosage of a medication, reassure the patient as well as
yourself by rechecking to make certain that there is no error,
before the medication is administered. You may need to
recheck the order, the label on the medicine container, or the
patient’s chart. The patient should be able to talk about
whatever feelings caused the doubt or concern, thus providing
119
the opportunity for the patient to exercise some control over
the environment.
120
Routes of Drug
Administration
13. Assist weak or helpless patients to take their medications. Do so

as patiently and unhurriedly as possible.
14. Remain with the patient until the medicine has been taken.
Most patients are very cooperative about taking medicines
immediately when the drugs are provided. However, some are
more ill than they appear and may forget, or may lose the ability,
to take the dose provided.
15. Stay with the patient receiving IV medication for a least 5
minutes, and monitor closely for adverse effects. (In the case
of contrast agents, remain with the patient for a minimum of
60 minutes.)
16. Do not leave a tray or cart of medicines unattended.
17. Never chart a medicine as having been given until it has been
administered. The name of the drug, the dosage, the time of
administration, and the route of administration should be
noted on the medication record in the chart. In the recording of
parenteral medications, the site of injection is always
included. The patient’s response to the medication (adverse as
well as intended) should be recorded in the progress notes.
18. Acquire full understanding of common abbreviations and
symbols related to medication administration (Table 8-3).
Table 8-3 Common Abbreviations and Symbols Related to

Medication Administration
Abbreviation Unabbreviated form Meaning
a ante before
ac ante cibum before meals
ad lib ad libitum freely
AM ante meridiem morning
bid bis in die twice each day
c
 cum with
cap capsule capsule
cc, cm3 cubic centimeter cubic centimeter (ml)
clt client client
D/C or DC discontinue terminate
elix elixir elixir
g, gm gram 1000 milligrams
gr grain 60 milligrams
gtt guttae drops
h, hr hora hour
hs hora somni at bedtime
IM intramuscular into a muscle
IV intravenous into a vein
IVPB IV piggyback secondary IV line
kg kilogram 2.2 lb
KVO keep vein open very slow infusion rate
L left left
L liter liter
g, mcg microgram one millionth of a gram
Continued
121
Table 8-3 Common Abbreviations and Symbols Related to Medication

Administration—cont’d
Abbreviation Unabbreviated form Meaning
mg milligram one thousandth of a gram

mEq milliequivalent number of grams of solute
dissolved in 1 ml of a normal
solution
min or m minim minim (1⁄15 or 1⁄16 ml)
ml, mL milliliter one thousandth of a liter
ng nanogram one billionth of a gram
o no or none no or none
OD oculus dexter right eye
OS oculus sinister left eye
os os mouth
OTC over-the-counter nonprescription drug
OU oculus uterque each eye
pc post cibum after meals
PM post meridiem after noon
PO per os by mouth, orally
prn pro re nata according to necessity
pt patient patient
q quaque every
qd quaque die every day
qh quaque hora every hour
q4h, q4˚ every 4 hours every 4 hours around
clock qid quater in die four times each day
qod quaque aliem die every other day
qs quantum satis sufficient quantity
® right right
Px receipt take

s sine without
SL sub linguam under the tongue
SOS si opus sit if necessary
ss semis a half
stat statim at once
SC, SQ subcutaneous into subcutaneous tissue
tbsp tablespoon tablespoon (15 ml)
tid ter in die three times a day
TO telephone order order received over telephone
tsp teaspoon teaspoon (4 to 5 ml)
U unit a dosage measure for
insulin, penicillin, heparin
VO verbal order order received verbally
¯i, ¯i¯i one, two one, two (as in “gr,” “gr “)
3 dram 4 or 5 ml
z
3 ounce or fluid ounce ounce (30 milliliters)
 times as in two times a week
> greater than greater than
< less than less than
= equal to equal to
, increase or increasing increase or increasing
,  decrease or decreasing decrease or decreasing
122
Routes of Drug
Administration
Learning Exercises
Abbreviations
1. SC:
2. IM:
3. IV:
4. CV:
5. PA:
6. PICC:
123
Fill-in-the-Blank
1. is the accidental injection of IV fluid or
medication into the tissues surrounding the vein.
2. The anterior elbow (the bend) is known as the .
3. Checking for backflow, immobilizing the needle at the injection
site, and stopping the injection immediately if the patient
complains of discomfort are three ways to minimize the
possibility of
.
4. The two most common replacement fluids for dehydrated patients
are and a 5% solution of .
5. A hypodermic needle with wings attached for ease of placement
is called a .
True-False
1. T F Only when a drug is initially administered to a patient

should relevant information be recorded in the patient’s chart.
2. T F If you administer medication prepared by another person

and that person has made an error, you are accountable for
any harm done to the patient resulting from that error.
3. T F It is acceptable practice to record medication

administration in patients’ charts before the actual event to
clear the paperwork out of the way and concentrate on the
task.
4. T F It is not the diameter of a needle but the length and depth

of insertion that cause pain.
5. T F Intramuscular injections should be made perpendicular to

the skin surface from a distance of about 2 inches, in one quick
motion.
6. T F The mid-deltoid area is the muscular area in the arm

formed by the rectangle bounded on the top by the edge of the
shoulder and on the bottom by the beginning of the axilla.
7. T F Intramuscular injections are given when a drug is too

irritating to be given subcutaneously.
8. T F Intradermal injections are given beneath the layers of skin

and above the muscle.
124
Routes of Drug
Administration
9. T F Elevated levels of blood urea nitrogen and creatinine in a

patient’s blood may contraindicate the use of intravascular
ROCM.
10. T F The veins most often used for initiating IV lines are found
in the anterior forearm, the posterior hand, the radial aspect of
the wrist, and the antecubital space.
1. What is the term for the administration of drugs placed under

the tongue?
a. Sublingual
b. Topical
c. Parenteral
d. Subcutaneous
2. Which of the following statements expresses the correct

relation between lumen diameter and gauge number?
a. As the diameter increases, the gauge number stays
the same.
b. As the diameter increases, the gauge number increases.
c. As the diameter decreases, the gauge number increases.
d. As the diameter decreases, the gauge number decreases.
3. During intramuscular injections, it is necessary to determine if

the needle is in a blood vessel. What is the term for the slight
pulling of the syringe plunger to check for this dangerous
problem?
a. Injection
b. Aspiration
c. Extravasation
d. Infiltration
4. Which of the following would not be considered one of the

“five rights” of drug administration?
a. Right time
b. Right place
c. Right patient
d. Right drug
5. The abbreviation qh means that the drug should be delivered

at what intervals?
a. Daily
b. Every 4 hours
c. Hourly
d. Every 2 hours
125
6. What is the term for injections made into the upper layers of
skin, almost parallel to the skin surface?
a. Intramuscular
b. Intravenous
c. Topical
d. Intradermal
7. Tuberculin, allergens, and local anesthetics are best delivered

by which route of injection?
a. Subcutaneous
b. Intradermal
c. Intramuscular
d. Intravenous
8. What is the term for a medication applied to the skin in order

to decrease the number of microorganisms?
a. Astringent
b. Emollient
c. Antiseptic
d. Cleansing agent
9. When a drug is injected subcutaneously, what should be the

angle of needle insertion?
a. 20 degrees
b. 45 to 60 degrees
c. 90 degrees
d. 120 degrees
10. What does the term parenteral mean?

a. Administration of a drug by mouth
b. Administration of a drug by injection
c. Assessment of patient history
d. Acquisition of consent for minors
Review Questions
1. What are the guidelines for administering drugs intramuscularly
to patients?
2. What are two acceptable ways for a technologist to map

appropriate IM sites in the gluteal region? (Describe in detail.)
126
Routes of Drug
Administration
3. What steps may be taken to locate an acceptable vein for venipuncture?
4. What should be done if a radiopaque contrast medium infiltrates

the tissues?
5. When an immediate response to a medication is critical, how

should the drug be delivered?
6. What precautions should be taken when disposing of used

syringes and needles?
7. What information should be placed in the patient’s chart after

administration of ROCM?
8. What is the most common insertion point for a central venous

catheter? Why?
127
9
Infection Prevention and Control

bacteria At the conclusion of this chapter, you should be able to:
biohazard 1. Define medical asepsis, disinfection, and sterilization.
disinfection
2. List four factors involved when pathogenic organisms are transferred
fomite
from person to person.
fungi
3. State five examples of personal hygiene that help in preventing the
hepatitis B virus (HBV)
spread of infection.
host
4. Demonstrate techniques for effective handwashing.
human immunodeficiency
5. Describe the correct method of linen disposal using medical
virus (HIV)
asepsis principles.
infection cycle
6. Demonstrate steps used in discarding disposable equipment in the
medical
clinical area.
asepsis
7. Name the agent used for disinfecting equipment in the radiology department.
microorganisms
8. State the importance of following “universal precautions” in the
nosocomial
clinical setting.
pathogen
9. Define hepatitis, HIV, and tuberculosis and discuss their relevance to
protozoa
the modern health care worker.
reservoir
sterilization
surgical asepsis
universal precautions
vector INTRODUCTION
viruses
With the onset of AIDS, this century’s “bubonic plague,” the
expansion of education and training on how to recognize and deal
with job- related dangers is an absolute necessity. No medical or
dental program is complete without up-to-date content in this area.
Disease transmission from patient to patient and from patient to
operator is now a life- threatening hazard. This chapter discusses
the preventive procedures necessary to maintain the health of
patients and professionals and prevent crises. The term “infection
control” is outdated; the measures currently practiced actually
represent infection prevention and control.
MICROBIOLOGY OF INFECTIONS
Some basic microbiologic terms must be defined to avoid confusion
in discussing infection prevention and control. Organisms that are
too small to be seen without the aid of a microscope are called
microorganisms. For the purposes of this discussion, microorganisms
are categorized as bacteria, viruses, protozoa, and fungi. Within each
126
Routes of Drug
Administration
of these
127
their own environment

“categories” are many different types and mutations. There are (cysts), which is resistant
also some microorganisms that are more like “kissing cousins” to to chemical and physical
bacteria: rickettsiae, chlamydiae, and mycoplasmas. changes. This allows them
Bacteria are unicellular microorganisms that can be spherical to survive outside the host
(cocci, meaning “berry”), rod shaped (bacilli, meaning “little staff”), spi- organism.
ral (spirochetes, which are corkscrew shaped), or comma shaped
(vib- rios, curved rods), which can grow together to form S shapes.
Bacteria can reproduce by cell division about every 20 minutes,
giving them the ability to develop huge numbers very quickly. Some
also have the ability to produce a highly resistant form known as
an endospore. This is a resting, nonactive state. Because they are not
active (i.e., not reproduc- ing or metabolizing), endospores have no
activity to be disrupted by a chemical or physical agent. Therefore,
they are extremely resistant to much of the environment, to
chemical agents, and to physical procedures applied to them.
Bacteria can remain viable for years and then germinate when the
environment becomes favorable to them. Some bacteria are
capable of producing an endotoxin that is toxic to mam- mals. This
endotoxin is responsible for producing the high fevers associated
with a bacterial infection.
Viruses are perhaps the simplest form of life. They cannot live
outside a living cell because they are missing some of the
components absolutely necessary for their own reproduction.
Viruses use the organelles and metabolic functions of the host cell
to produce new viruses. When the reproduction phase is complete,
the new viral particles are released from the host, often by
bursting the host cell, which leads to cell death. One of the
interesting properties of viruses is that they must find a compatible
receptor site on the host cell. Have you ever had a cold sore? This
lesion is caused by herpes simplex, a virus. The interesting fact is
that herpesvirus is found on soft tissue that is not attached to bone.
One can have herpes lesions on the lips, face, or genital mucosa,
but they do not appear on the gum tissue that covers the bone,
even though this tissue is exposed to millions of virulent viral cells.
The reason is because there are no compatible receptor sites.
There are two major medical concerns about viruses: (1) the
limited pharmacotherapeutic drugs available and (2) the ability of
viruses to mutate. Our advanced medical field still depends
predominantly on the patient’s own immune system to fight viral
infections.
Protozoa are unicellular and colonial organisms that exhibit
characteristics typical of animal life. All classes of protozoa are thought
to contain some species that cause disease in humans. These
diseases can be transmitted through contact with contaminated
feces, either directly or by mechanical transmission (e.g., from
flies). They can also be transmitted through insect bites, such as
malaria from mosquitoes, or directly from person to person, as with
trichomoniasis, a protozoan sexually transmitted disease (STD).
Protozoa are classified according to their motility (amoeba-like,
flagellate, ciliar, or nonmotile). Some protozoa are able to form
128
?
DID YOU KNOW?
Pathogens can leave the human body through a variety of means. The skin,
mucous membranes, respiratory tract, gastrointestinal tract, surgical tubes
and drains, urine, blood, and breaks in the skin allow pathogens to exit the
body and infect susceptible hosts.
DID YOU KNOW?

?
Each time you come in contact with patients, if you do not wash your
hands, or if you do not remove or change gloves, the patient’s infectious
organisms have just relocated to the control panel or console you are about
to touch. Think about it.
129
Fungi (Eumycetes) are familiar in many forms and sizes, such

as lichen, mushrooms, toadstools, puffballs, molds, and yeasts.
Some of these are pathogenic (disease causing). Some nonpathogenic
forms may be equally dangerous because of allergic reactions. Fungal
diseases are called mycoses; the drug Mycostatin (nystatin) is used
as an antifungal agent (myco, fungal; statin, stopping reproduction).
Fungi live on dead or decaying matter, need an abundant amount of
moisture and oxygen, and grow best at room temperature. Warm,
humid environments will accelerate their growth, and they grow
well in environments that contain sugar or are slightly acidic. Fungi
reproduce through spore formation, which is more like seed
production than the types of bacterial spores discussed earlier. Aside
from their negative effects, fungi are also widely used industrially for
such products as antibiotics, cheese, bread, beer, and wine.
Microorganisms are present throughout the life cycle. Those
capable of causing disease are called pathogens (Table 9-1). Some
microorganisms live within the human body. Bacteria are found on
the skin (staphylococci). Enormous numbers of bacteria are found in
the feces. Many live in the saliva and mucus, some of which are
capable of causing severe illness. The presence of pathogens is only
one of the necessary components for disease or infection; the other
factors are discussed in the following section. Removing any one of
these components will break the chain of infection. This knowledge is
the basis for infection prevention and control procedures: finding a
way to break the chain (Fig. 9-1).
FUNDAMENTALS OF INFECTION
The presence of microorganisms alone does not necessarily mean
an infection will ensue. The process is interdependent on the
following factors:
1. A pathogenic organism in sufficient quantity and virulence
to pose a threat
2. Reservoirs in which the offending organism can thrive and
mul- tiply
3. A portal of exit through which the pathogen leaves one host
4. A mode of transport (e.g., hands, air, water droplets,
vectors, fomites)
5. A portal of entry through which the pathogen enters
another host
6. A susceptible host
Quantity and Virulence

Not all microbes are pathogenic. Also, some that are normally
benign can become pathogenic given the right circumstances. One
bacterial cell, one lone virus, or one protozoan probably will not
cause any ill effect. However, some normally benign microbes can
become deadly pathogens in large enough numbers with
susceptible hosts. The link can be broken by infection control
procedures that involve simple handwashing to sterilization,
128
disinfection, and antiseptic techniques.
129
Table 9-1 Examples of Common Human Pathogens

System Disease Classification Mode of transmission Name
Respiratory tract Whooping cough Bacterium Airborne Bordetella pertussis

Pneumonia, Fungus Airborne Candida albicans
thrush
Diphtheria Bacterium Airborne Corynebacterium diphtheriae
Flu Virus Airborne, droplets Influenza virus
Tuberculosis Bacterium Airborne, droplets Mycobacterium tuberculosis
Mumps Virus Airborne Mumps virus
Pneumonia, sinus Bacterium Airborne Streptococcus pneumoniae
infections
Strep throat Bacterium Airborne Streptococcus pyogenes
Gastrointestinal Amebic Protozoan Food, water Entamoeba
tract dysentery histolytica
Giardiasis Protozoan Food, water Giardia lamblia
Poliomyelitis Virus Food, water Poliovirus
Salmonellosis Bacterium Food, water Salmonella species
(food infection)
Shigellosis Bacterium Food, water Shigella species
(bacillary
dysentery)
Genitourinary tract Cystitis, nephritis Bacterium Contact Escherichia coli

Genital herpes Virus Sexual contact Herpes simplex type 2
Gonorrhea Bacterium Sexual contact Neisseria gonorrhoeae
Cystitis, nephritis Bacterium Contact Proteus species
Syphilis Bacterium Sexual contact Treponema pallidum
Vaginitis Protozoan Sexual contact Trichomonas vaginalis
Skin Fever blisters Virus Contact, predisposition Herpes simplex

type 1
Measles Virus Airborne, contact Measles virus
Boils, wound Bacterium Contact Staphylococcus
infections aureus
Ringworm Fungus Contact, Tinea capitis
predisposition
Athlete’s foot Fungus Contact, Tinea pedis
predisposition
Blood Lyme disease Bacterium Vectors (ticks) Borrelia

burgdorferi
Serum hepatitis Virus Contaminated Hepatitis B
serum
AIDS Virus Mixing of human HIV
fluids
Leptospirosis Bacterium Food, water, Leptospira
contact
Malaria Sporozoan Vectors Plasmodium species
(mosquitoes)
Typhoid fever Bacterium Food, water Salmonella typhi
AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus.
130
Pathologic Reservoir of
organism infection
Susceptible Portal of
host
Infection
exit
Cycle
Portal of Mode of
entry transportation
Fig. 9-1 The infection cycle.
These measures are aimed at reducing the number of pathogens or

rendering present microbes nonpathogenic.
Reservoir
Microorganisms must live and grow somewhere. Hosts who have
developed infections or disease from these microbes and manifest
clinical symptoms are those seen as patients. Common sense leads
the health care worker to be careful around people who look or act
sick or diseased. It is easy to practice wise infection control measures
when potential harm is perceived. However, some pathogens live in
the bodies of seemingly healthy individuals without causing readily
apparent symptoms. These people may develop the disease after an
appropriate incubation period, or they may be immune and may never
develop the disease at all. These persons are most likely to pose a
problem to health care workers. The classic example is the person
who has been infected with HIV and has no symptoms. An individual
? DID YOU KNOW?
may even have a negative blood test if the incubation period has not
been sufficiently long to develop the marker for the test. Interestingly,
Physicians were listed
the actual microbial count in the blood is often higher during the
number one as the health incubation period than at any other time. In short, patients are the
professionals least likely to most infectious during the time that they are asympto- matic.
wash their hands between Carelessness usually occurs with a “healthy” patient, who may not be as
patient contacts. In the healthy as he or she appears. Reservoirs may also be something
same study, radiologic other than a person. Contaminated food and water, human and
technologists were number animal waste, and insect toxins and wastes have all been identified and
two on the list. linked to major epidemics. This link in the chain of infection is what
motivates health care facilities to ensure optimal “housekeeping”
procedures.
Portal of Exit
The portal of exit is the way the infection leaves one host before
entering another. What do you think are the most common portals? If
131
you said “body fluids,”
you are correct. Some
of these fluids are
often overlooked.
132
growing beard. As often

Blood is an obvious major exit portal. However, saliva, semen, happens because of stress, the
sputum, and the water droplets and mucus “shot out” into the bride had developed a cold
atmosphere with the force of a bullet from a sneeze or cough must sore (herpes simplex) on her
also be considered. lip. The next day she had
several more lesions on her
Mode of Transport face. During close and
continued contact, the viral
There are four main routes of transmission for infection, as follows: fluid, which has enormous
1. Direct contact. One host comes in direct contact (touches) with
another. STDs are good examples of this mode. The infected
mucous membrane of one host comes in contact with the mucous
membrane of a susceptible host. For example, a technologist
touches the skin of a patient with scabies.
2. Fomite (indirect contact). An object that has been in contact
with pathogenic organisms is a fomite. Think about what might
be a fomite in the radiology department: the x-ray table, the CT
or MRI patient couch, the chin rest on the chest board, the
calipers, posi- tioning sponges, the ultrasound transducer, the
gamma camera surface, a mishandled syringe or needle, or even
the patient’s chart. The worst (and most often forgotten) fomite
is the pillowcase not changed after each patient.
People have no idea how often they touch different things
without thinking. Certainly, microbiologists and infection control
specialists understand the role that hands play in transferring
infection from one person to another. It is not only about self-
protection, but also about protecting the next person or patient
contacted. Careless technique can increase patient-to-operator
contamination as well as patient-to-patient contamination. Studies
have shown that people, especially health care workers, are not
diligent about washing their hands after bathroom use. Contemplate
the number of patients and staff using the restroom each day. Just
how clean is that “exit” door handle?
3. Vector (indirect contact). An animal or insect that transmits an
infectious microorganism to a new host is a vector. Mosquitoes
that transmit malaria, ticks that transmit Lyme disease, and
now birds that transmit West Nile disease are just a few vectors
with which the technologist should be familiar.
4. Airborne (indirect contact). Contamination is spread by water
droplets or dust. Coughing, sneezing, or even speaking propels
droplets into the air, sometimes with the force and speed of a
bullet.
Portal of Entry
The portal of entry is the path through which a pathogen can enter
the body of the susceptible host. Open wounds are portals for
pathogens that might otherwise not cause infection. This does not
need to be a large wound; it can be as small as a minor skin
abrasion.
Although rather simplistic, the following true anecdote should
help you better appreciate daily health care routines:
A young couple went on their honeymoon. The groom had a heavy, fast-
133
? DID YOU KNOW?

Biopsies and other surgical procedures are no longer performed only in a
surgical or angiography suite. It is becoming increasingly common for MRI,
CT, mammography, sonography, and even nuclear medicine technologists
to be involved with surgical procedures. A working knowledge of surgical
asepsis has never been more important in these areas.
134
amounts of virulent virus, was spread by lip-to-lip and lip-to-cheek

contact. This did not necessarily mean that she would become infected.
However, two more factors were present: (1) she was “run down” from stress
and fatigue (thus the first lesion) and (2) she had open portals of entry
where the groom’s whiskers had abraded her skin.
The respiratory, intestinal, and reproductive tracts are also suscep-
tible portals. Actually, any mucous membrane is susceptible,
including the eyes. Dental professionals are now routinely wearing
protective eyewear. They have reported eye infections, such as with
streptococcus, from saliva splatter. Medical professionals have even
greater concern because of the potential for blood splatter to the
eyes.
Susceptible Host
Susceptible hosts are persons who have reduced resistance to
infection or who undergo overwhelming exposure. Patients are
particularly at risk because in addition to the primary problem that
caused their hospital- ization, they may develop a secondary infection.
They are around other reservoirs of microbes different from their
own, have lowered resistance, often have extra portals of entry,
come in contact with a whole new set of fomites, and may be
needlessly exposed by careless health care workers who do not
wash their hands enough.
In addition, these patients may be exposed to particularly virulent
strains of microorganisms. Staphylococcus aureus is an example of a
relatively benign microbe evolving into a deadly threat. One of the
most life- threatening infections is a hospital-acquired
staphylococcal (“staph”) infection. These organisms have been so
? DID YOU KNOW?

exposed to antimicrobial agents that they have mutated into strains
that are resistant to chemical agents. One can sterilize equipment that
is contaminated, but one cannot sterilize a patient’s arm. These
One of the reasons patients hospital-acquired infections are called nosocomial. They also pose a
are asked what their threat to health care workers. Thousands of health care workers are
temperature was and how
infected with the hepatitis B virus (HBV) each year; as many as 2% of
often they have taken it is to
those infected die. This particular strain of hepatitis is highly infectious,
help determine if an
infection is bacterial or viral. requires intensive treatment, and may lead to lifelong health prob-
Although this is not an lems. In 1991 the Occupational Safety and Health Administration
absolute, bacterial infections (OSHA) published regulations requiring health care employers to
are often associated with provide HBV immunizations to employees, as well as procedures and
high fevers and viral equipment to prevent the transmission of HIV and other bloodborne
infections with low fevers. diseases to which employees are exposed. There is also a strain labeled
hepatitis D that “pig- gybacks” on HBV. The most distressing fact is that
hepatitis B is preventable with immunization, and therefore hepatitis
D is also preventable. No health care worker should be without this
immunization.
HEPATITIS, HIV, AND TUBERCULOSIS

In addition to HBV, human immunodeficiency virus (HIV) and
tuberculosis (TB) are common concerns for all health care
135
professionals. The
information about
these infections is
constantly changing
but needs to be
addressed. Although
universal precautions
were created to deal
with prevention of
transmission of HIV
and HBV, TB is
surfacing again with
136
reported tracing the

increased virulence. Much of the information in this section is origin of HIV to a single
derived from the most current publications of the Centers for virus found in a
Disease Control and Prevention (CDC) (www.cdc.gov). subspecies of equatorial
West African chimpanzee.
Viral Hepatitis
There are five types of hepatitis viruses, plus a few unknown strains.
These viruses are more or less related by their source and route of
transmission. The primary source of hepatitis A virus (HAV) and hepatitis
E virus (HEV) is feces. The oral-fecal route is the primary route of
transmission. Their course of infection is acute. Immune globulin can
be used for either pre- exposure protection or postexposure treatment.
There is also a vaccine for HAV prevention. HBV, hepatitis C virus
(HCV), and hepatitis D virus (HDV) are bloodborne viruses and can
cause chronic infection. Their primary route of transmission is
percutaneous and mucosal exposure. HBV can be prevented by
receiving the hepatitis B vaccine. Once exposed, treatment includes
hepatitis B immune globulin (HBIG) and the hepatitis B vaccine. As
mentioned, hepatitis D can also be prevented by the HBV vaccine.
HDV is dependent on HBV to duplicate; therefore, if HBV is not
present, neither is HDV. Persons with chronic HBV may develop HDV
as a superinfection even if the two are not contracted at the same
time. Co- infection with both HBV and HDV has different effects
than with HBV alone. There are no preventive treatments for HCV or
HEV at present.
Human Immunodeficiency Virus

The first known case of HIV was in 1959, but the medical
community as a whole did not really become aware of HIV until the
late 1970s or early 1980s. Rare types of pneumonia, cancer, and
other diseases were being reported in disproportionate numbers in
California and New York among homosexual men. The condition was
first labeled acquired immunodeficiency syndrome (AIDS) because
of the conditions being observed. Opportunistic infections such as
Kaposi’s sarcoma and Pneumocystis carinii pneumonia were
increasing. Microorganisms that did not cause an infection in healthy
people were causing death in persons with a compromised immune
system. The virus reduces the host’s resistance to infection because
it destroys T lymphocytes (infection- fighting cells). The progression
of HIV is a story of irony. In brief, T lymphocytes are the body’s
defense against infection. The AIDS virus uses the T lymphocyte as its
host cell to replicate. When the virus is released, the T cell dies. More
new virus in the blood signals the body to send more T cells. The
additional T cells provide more places for the AIDS virus to
replicate. The T cells are supposed to kill the virus, but the virus uses
the T cells to reproduce and then kills the T cell.
The term AIDS is now used to refer to the stage when persons
who are HIV positive have developed additional illnesses from
opportunistic microorganisms. In 1982 the virus was discovered and
initially named “HTLV” (human T cell lymphotrophic virus). The
name was later changed to HIV. In 1999, international scientists
137
? DID YOU KNOW?

Some health departments provide free immunizations for newborns, and
hepatitis B is now available as part of that program.
138
To clarify terminology, “HIV” is the name of the virus. Persons

who have positive results from blood tests for HIV are “HIV
positive.” In recent years, there have been rumors and statements
that persons who are HIV positive do not necessarily develop AIDS.
This is certainly mis- leading. Not all people who are HIV positive
have AIDS because the illness has not progressed to that stage. At
present, the outcome of contracting HIV is ultimately AIDS and
death.
HIV is primarily transmitted through infected blood and blood
products and through reproductive fluids. Although the virus has
been found in tears, sweat, and saliva, no cases of transmission
through those fluids has been documented. The case can be made
for inadequate amount of microorganisms in those fluids.
Tuberculosis
TB is no longer really a problem, or is it? There are 8 million new
cases of TB in the world each year and 3 million deaths. TB
increased by 20% in the United States between 1985 and 1992. An
? DID YOU KNOW? estimated 10 to 15 million persons in the United States are infected
with Mycobacterium tuberculosis. TB has increased as HIV has
Scientists have identified increased. The greatest problem to health care workers is the
only 4000 different viruses, a increase in multidrug-resistant outbreaks in hospitals and prisons.
fraction of the estimated Many prisons employ full-time health care staff.
400,000 believed to exist on TB is spread by airborne particles known as droplet nuclei.
earth. Merely coughing can transmit the infection. This information should
underline the need for all health care providers to be well educated
in universal procedures and institutional policies. The unknown is the
greatest danger.
INFECTION PREVENTION AND CONTROL

Removing any one of the six factors described earlier will stop the infec-
tion cycle (see Fig. 9-1). This discussion concentrates on techniques
used by the health care worker to stop transmission from the
reservoir to the susceptible host because this is the predominant factor
they can control. However, it is important to note that the imaging
technologist who works when his or her resistance is low as a result of
fatigue, stress, a low-grade infection, or trauma increases personal
susceptibility as a host.
Universal Precautions
In 1983 the CDC published “Guidelines for Isolation Precautions in
Hospitals,” which directly addressed the issue of body fluid and
bloodborne pathogens. In 1987 the CDC revised the
recommendations by publishing “Recommendations for Prevention
of HIV Transmission in Health-Care Settings.” This document changed
the recommendations to state that blood and body fluid precautions
should be consistently used for all patients regardless of their
bloodborne infection status; that is, precautions should be universal.
The recommendations were to protect the health care worker from
139
the transmission of
HIV, HBV, and other
bloodborne
pathogens. It should
be stressed that the
term “universal”
refers to universal
treatment of blood
and certain body
fluids, requiring them
to be treated the same,
regardless of the
patient’s apparent
infectious
140
state. It does not refer to “universal protection” from transmission of all

diseases. Droplet, airborne, and contact transmission of infections such
as influenza, TB, and methicillin-resistant Staphylococcus aureus
may or may not be addressed with “universal precautions.”
This CDC document was again revised in a 1988 publication
that clarified such issues as which body fluids should be treated as
potentially infectious, HBV immunization of health care workers, special
settings, use of protective barriers, specific guidelines for “sharps,” and
waste management. Universal procedures apply to blood or any other
body fluids that contain visible blood, as well as to semen and vaginal
secretions. These procedures also apply to tissues and the following
fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and
amniotic. However, these procedures do not apply to feces, nasal
secretions, sputum, tears, sweat, urine, or vomitus. Remember,
however, that universal precautions were created to deal with HIV and
HBV only, so this in no way indicates that these fluids are not
contaminated with other pathogens.
The rest of this chapter focuses on general procedures and how
to adapt them to your setting. These recommendations are factual
and clearly written but will work only if put to actual use. The key to
effective protection is a consistent approach to all contact with all
body substances of all patients at all times (Box 9-1).
The authors quote directly from the CDC guidelines throughout
this discussion, as indicated by the different text format.
BOX 9-1 UNIVERSAL PRECAUTIONS

1. Gloves should be worn when you are in contact with
blood, body fluids containing visible blood, mucous
membranes, or nonintact skin.
2. Gloves should be worn when you are handling items or
touching surfaces soiled with blood or body fluids or when
performing venipuncture or other vascular access
procedures.
3. Gloves should be changed after contact with each patient.
4. Masks and protective eye shields should be worn during
procedures that can generate droplets of blood or other
body fluids, to prevent exposure of mucous membranes of
the mouth, nose, and eyes to infection.
5. Gowns should be worn during procedures that can result
in the splashing of blood or other body fluids.
6. Hands and other skin surfaces should be thoroughly
washed immediately after contamination with blood or
body fluids.
7. Needles should not be recapped, purposely bent or broken,
or removed from syringes.
8. Needles and syringes must be disposed of in puncture-
resistant containers in the immediate work area.
9. Mouthpieces, Ambu bags, and ventilation devices should
be used rather than mouth-to-mouth resuscitation.
10. Health care workers with oozing or open sores should refrain
141
MEDICAL ASEPSIS
A great deal of infection control and prevention is common sense.
Consider the following analogies from daily life. If you don’t want to
get paint splatter on your furniture, you cover it. If you don’t want to get
dirt on your hands when you garden, wear gloves. If you don’t want
to breathe drywall dust, wear a mask. If you can’t clean all the
little crevices in the broiler pan, cover it with aluminum foil before
you use it. These common practices are all barriers.
Barrier techniques are the front line of medical asepsis. You cannot
get your hands truly clean by washing, even if you use a hand
brush; wear gloves. You do not want blood to splatter on you, so
you wear a gown, mask, gloves, and protective eyewear.
Additionally, masks and eyewear can keep droplet and airborne
pathogens away from the mucous membrane of your nose, mouth,
and eyes. Using gloves also reduces the potential for spread of
nosocomial infections from direct contact with antibiotic-resistant
staphylococci. The authors make these statements with the
understanding that “using” means using properly.
“Sterilization and Disinfection (www.cdc.gov)

Standard sterilization and disinfection procedures for patient-care equipment
currently recommended for use in a variety of health-care settings—including
hospitals, medical and dental clinics and offices, hemodialysis centers,
emergency-care facilities, and long-term nursing-care facilities—are adequate to
sterilize or disin- fect instruments, devices, or other items contaminated with
blood or other body fluids from persons infected with blood-borne pathogens
including HIV.
Instruments or devices that enter sterile tissue or the vascular system
of any patient or through which blood flows should be sterilized before
reuse. Devices or items that contact intact mucous membranes should be
sterilized or receive high-level disinfection, a procedure that kills
vegetative organisms and viruses but not necessarily large numbers of
bacterial spores. Chemical germicides that are registered with the U.S.
Environmental Protection Agency (EPA) as “sterilants” may be used either for
sterilization or for high-level disinfection depending on contact time.”
Handwashing and Gloving

Handwashing is a major part of any infection control system. It is a
critical step by itself and also the first step in the “gloving” process. You
know to wash your hands after removing gloves. It is also wise to wash
hands before putting on gloves. You know you should wash your hands
after using the restroom, sneezing, coughing, or blowing your nose.
Other times to wash hands that you may not have thought of include
the following:
●
After you write in charts with pencils or pens that may be
contaminated by all who have used them.
●
Between patients because of all the contact with contaminated items
(e.g., doorknobs, film cassettes).
●
After touching your contaminated barriers, as in removing a gown
or taking off your mask and glasses.
142
●
Even after touching the arm of a patient.
See Fig. 9-2 for handwashing
technique.
143
Fig. 9-2 Handwashing technique. A, Step 1: Use a no-touch sensor faucet whenever possible. Water temperatures will
typically be preset. B, Step 2: Holding hands lower than the elbows, completely wet the hands and the lower arms under
running water. C, Step 3: Use a no-touch soap dispenser to deposit a generous amount of soap to the hands. D, Step 4:
Interlock fingers and rub the palms and the back of the hands to lather well. Do this for at least 20 to 30 seconds,
moving the hands in a circular motion to contact all skin surfaces. E, Step 5: Rinse wrists and hands thoroughly under
running water. Water should drain from wrists to fingertips. F and G, Step 6: If a no-touch hand dryer or blower is not
available, use a paper towel to dry hands and wrists thoroughly. Do not move paper towel up and down the arm and
hand continuously. Move from fingers to wrist or wrist to fingers (prevents recontamination of skin). H, Step 7: Use a paper
towel on the door handle. Open door from the handwashing area and deposit the towel in a receptacle outside the room.
144
Many clinical facilities use alcohol-based hand rubs in place of

handwashing. Although these hand rubs have proved effective in reduc-
ing nosocomial infections and are extremely convenient, they do
not kill certain bacteria and can never replace handwashing and
gloving when hands are severely contaminated or when contacting
body fluids or feces. Many of the alcohol-based rubs are flammable.
Some facilities have removed hand-rub dispensers from their premises
because of this problem. Considerable care should be taken when
using these products in areas where flame or extreme heat is in use.
“Gloves should be worn:
●
for touching blood and body fluids requiring universal precautions,
mucous membranes, or nonintact skin of all patients, and
●
for handling items or surfaces soiled with blood or body fluids to
which universal precautions apply.”
Although these CDC guidelines are written for a phlebotomist,
you must remember that you become a “phlebotomist” when you are
injecting patients during specific imaging procedures.
“Gloves should be changed after contact with each patient. Hands
and other skin surfaces should be washed immediately or as soon as patient
safety permits if contaminated with blood or body fluids requiring universal
precautions. Hands should be washed immediately after gloves are
removed. Gloves should reduce the incidence of blood contamination of
hands during phlebotomy, but they cannot prevent penetrating injuries
caused by needles or other sharp instruments. Institutions that judge
routine gloving for all phle- botomies is not necessary should periodically
reevaluate their policy. Gloves should always be available to health care
workers who wish to use them for phlebotomy. In addition, the following
general guidelines apply:
1. Use gloves for performing phlebotomy when the health care
worker has cuts, scratches, or other breaks in his/her skin.
2. Use gloves in situations where the health care worker judges that
hand contamination with blood may occur, e.g., when performing
phlebotomy on an uncooperative patient.
3. Use gloves for performing finger and/or heel sticks on infants and children.
4. Use gloves when persons are receiving training in phlebotomy.
General infection control practices should further minimize the
already minute risk for salivary transmission of HIV. These infection control
practices include the use of gloves for digital examination of mucous
membranes and endotracheal suctioning, handwashing after exposure to
saliva, and minimiz- ing the need for emergency mouth-to-mouth
? DID YOU KNOW?
resuscitation by making mouthpieces and other ventilation devices
available for use in areas where the need for resuscitation is predictable.”
Eighteen million courses of Gloves should be put on last and removed last. Remove the
antibiotics are prescribed for first glove down to the fingertips. Then, grasp the opening of the
the common cold in the
second glove at the wrist with the gloved fingertips of the first hand,
United States each year.
Unfortunately, colds are
turning the second glove inside out to make a “baggie” for the first
caused by viruses. Fifty glove. Discard in an appropriate container.
million unnecessary antibi-
otics are prescribed for viral
Masks, Protective Eyewear, and Gowns
respiratory infections. Most imaging procedures do not involve exposure to blood. However,
certain procedures may pose a great risk of blood splatter to the technol-
145
ogist, including arteriograms, cardiac catheterizations, severe trauma, and

orthopedic surgical procedures. Masks, protective eyewear, and
gowns should be worn during these procedures.
Good Housekeeping
Housekeeping is another area requiring practical common sense.
Each department should have a written set of protocols to follow for
the different situations that arise. Much of the cleaning in the
radiology department may be done at night by the housekeeping
staff, but that does not relieve the technologist from responsibility.
One of the technologist’s primary duties is to clean the patient
table, couch, or cart between examinations.
Every piece of equipment that comes in contact with the
patient, such as the chest stand or gamma camera, must also be
cleaned after each use.
Hospital protocol will most likely determine what protocols to use.
However, some general principles follow:
1. Always clean from the least contaminated area toward the more
contaminated area and from the top down.
2. Use the most effective but surface-appropriate disinfectant
possible. Household bleach (sodium hypochlorite) is still one of
the most effective disinfectants. Although appropriate for the
metal patient table, bleach is not typically used with the film or
cassette because of potential chemical reaction with the film
emulsion. Bleach is also inappropriate for cloth or vinyl articles.
3. Use barriers where disinfectant chemicals are inappropriate.
You cannot wash the control panel with a disinfectant.
However, you could put some plastic wrap over the panel if
needed.
The following information is from CDC guidelines:
“Medical devices or instruments that require sterilization or
disinfection should be thoroughly cleaned before being exposed to the
germicide, and the manufacturer’s instructions for the use of the germicide
should be followed. Further, it is important that the manufacturer’s
specifications for compatibility of the medical device with chemical
germicides be closely followed. Information on specific label claims of
commercial germicides can be obtained by writing to the Disinfectants
Branch, Office of Pesticides, Environmental Protection Agency, 401 M
Street, SW, Washington, D.C. 20460. Studies have shown that HIV is
inactivated rapidly after being exposed to commonly used chemical
germicides at concentrations that are much lower than used in practice.
Embalming fluids are similar to the types of chemical germicides that have
been tested and found to completely inactivate HIV. In addition to
commercially available chemical germicides, a solution of sodium
hypochlorite (household bleach) prepared daily is an inexpensive and effective
germicide. Concentrations ranging from approximately 500 ppm (1:100
dilution of household bleach) sodium hypochlorite to 5,000 ppm (1:10
dilution of household bleach) are effective depending on the amount of
organic material (e.g., blood, mucus) present on the surface to be cleaned
and disinfected. Commercially available chemical germicides may be more
compatible with certain medical devices that might be corroded by
repeated exposure to
146
sodium hypochlorite, especially to the 1:10 dilution.”
147
Handling Linens and Uniforms

Soiled hospital linens, uniforms, and “scrubs” are considered
fomites. Proper aseptic technique must be strictly observed when
dealing with these objects. Stains may not be apparent, but any
contact with patient body fluids or feces should make personnel
wary of contamination. Never use linens for more than one
patient. When disposing of linens or scrubs, handle them as little as
possible. Do not shake, neaten, fold, or tuck used linens. Gently
fold them toward the middle and immediately dispose of the loose
bundle in the appropriate container or bin.
A protective gown should be worn over the uniform or scrubs
when working with trauma patients or with patients who may be
emitting body fluids or fecal material. To protect all who must
handle contaminated linens (technologists, sanitation workers,
laundry personnel), contaminated materials should be placed in a
clearly labeled bag or box and taped or tied shut. Labels such as
“blood contamination,” “urine contamination,” or “fecal
contamination” should be applied to the container in bold, clearly
visible lettering. Most hospitals provide bags already labeled
“biohazard.” Any object dropped on the hospital floor is con-
sidered contaminated; there is no “10-second rule” in this setting.
Anything touching the floor should be disposed of immediately or rester-
ilized if not disposable. A general rule of thumb is, “If you don’t know
it is uncontaminated (sterile, clean, aseptic), do not use it or wear it.”
Contaminated Waste Disposal

The hospital should have policies and procedures for disposing of
all items. These are not optional; such policies are regulated by both
OSHA and the EPA. Some departments may require the separation
of glass, plastic, and paper into clearly labeled, covered
Fig. 9-3 Top,
Biohazardous waste
containers, whereas others may place all disposable items in the
container. Bottom, same bag or box. Recent regulations demand that objects
Biohazard label. contaminated with blood or body fluids be discarded in a suitable
container and marked with the biohazard symbol (Fig. 9-3). If your
department does not have a written set of procedures, you should
inquire about them.
? DID YOU KNOW? Bandages and dressings should be handled with gloves and
should be placed directly into waterproof bags, which should be
About 90,000 people die sealed before discarding.
each year from infections Always wear gloves when assisting patients with bedpans or
that they contracted while in uri- nals. Be sure to empty them at once, unless a specimen is needed.
the hospital. Rinse them well, and discard or put them in the proper place to be
sterilized unless they are to be reused immediately by the same
patient.
Handling Sharps
Handling needles, scalpels, and other types of “sharps” is the
primary mode of occupational transmission of HIV and HBV in
health care settings. Some items, such as surgical instruments, are
sterilized, usually in a central sterilization unit. Other items, such as
148
needles, are
disposable. You should
know hospital policies
concerning disposal of
these items (Fig. 9-4).
Needlesticks and
sharps injuries are by
far the major mode of
149
occupational transmission of HIV. This, however, is not the only

risk. The following discussion is taken largely from CDC guidelines.
Bloodborne Virus Transmission to Health Care Personnel

Injuries from needles and other sharp devices used in health care
and laboratory settings are associated with the occupational
transmission of more than 20 pathogens. HBV, HCV, and HIV are the
most commonly transmitted pathogens during patient care (Table 9-
2).
“Prevention
All health-care workers should take precautions to prevent injuries caused
by needles, scalpels, and other sharp instruments or devices during
procedures; when cleaning used instruments; during disposal of used
needles; and when handling sharp instruments after procedures. To prevent
needlestick injuries, needles should not be recapped, purposely bent or
broken by hand, removed from disposable syringes, or otherwise
manipulated by hand. After they are used, disposable syringes and
needles, scalpel blades, and other sharp items should be placed in
puncture-resistant containers for disposal; the puncture- resistant
containers should be located as close as practical to the use area.
Table 9-2 Infections Transmitted by “Sharps” Injuries* Fig. 9-4 Top, Puncture-proof
Infection Patient Care Laboratory/autopsy containers for needle and
syringe disposal. Bottom,
Blastomycosis X Sharps label.
Cryptococcosis X
Diphtheria X
Ebola X
Gonorrhea X
Hepatitis B X X
Hepatitis C X X
Herpes X
HIV X X
Leptospirosis X
Malaria X
Mycobacterium tuberculosis X X
Rocky Mountain spotted fever X

Scrub typhus X
Streptococcus pyogenes X
Syphilis X
Toxoplasmosis X
*
During patient care and/or during laboratory testing or autopsy.
150
Large-bore reusable needles should be placed in a puncture-resistant container

for transport to the reprocessing area.
Management of Exposures
You can do everything right, and something beyond your control can still
go wrong. If an exposure occurs, the following guidelines apply:
If a health-care worker has a parenteral (e.g., needlestick or cut) or
mucous-membrane (e.g., splash to the eye or mouth) exposure to blood or
other body fluids or has a cutaneous exposure involving large amounts of
blood or prolonged contact with blood—especially when the exposed skin is
chapped, abraded, or afflicted with dermatitis—the source patient should be
informed of the incident and tested for serologic evidence of HIV infection
after consent is obtained. Policies should be developed for testing source
patients in situations in which consent cannot be obtained (e.g., an
unconscious patient).
If the source patient has AIDS, is positive for HIV antibody, or refuses
the test, the health-care worker should be counseled regarding the risk of
infection and evaluated clinically and serologically for evidence of HIV
infection as soon as possible after the exposure. The health-care worker
should be advised to report and seek medical evaluation for any acute
febrile illness that occurs within 12 weeks after the exposure. Such an
illness—particularly one characterized by fever, rash, or lymphadenopathy
—may be indicative of recent HIV infection. Seronegative health-care
workers should be retested 6 weeks postexposure and on a periodic basis
thereafter (e.g., 12 weeks and 6 months after exposure) to determine
whether transmission has occurred. During this follow- up period—especially
the first 6-12 weeks after exposure, when most infected persons are
expected to seroconvert—exposed health-care workers should follow U.S.
Public Health Service (PHS) recommendations for preventing trans-
mission of HIV.
No further follow-up of a health-care worker exposed to infection as
described above is necessary if the source patient is seronegative unless
the source patient is at high risk of HIV infection. In the latter case, a
subsequent specimen (e.g., 12 weeks following exposure) may be obtained
from the health-care worker for antibody testing. If the source patient cannot
be identified, decisions regarding appropriate follow-up should be
individualized. Serologic testing should be available to all health-care
workers who are concerned that they may have been infected with HIV.
If a patient has a parenteral or mucous-membrane exposure to blood
or other body fluid of a health-care worker, the patient should be informed
of the incident, and the same procedure outlined above for management
of exposures should be followed for both the source health-care worker
and the exposed patient.”
EMPLOYER RESPONSIBILITIES
The employer is responsible to provide a working environment that
is as safe as possible. Your employer must provide you with the
mechanisms to protect yourself and your patients. The following
CDC guidelines address this issue:
“Implementation of Recommended Precautions
Employers of health-care workers should ensure that policies exist
for:
151
1. Initial orientation and continuing education and training of all

health- care workers—including students and trainees—on the
epidemiology, modes of transmission, and prevention of HIV and
other blood-borne infections and the need for routine use of
universal blood and body- fluid precautions for ALL patients.
2. Provision of equipment and supplies necessary to minimize the risk
of infection with HIV and other blood-borne pathogens.
3. Monitoring adherence to recommended protective measures.
When monitoring reveals a failure to follow recommended
precautions, counseling, education, and/or re-training should be
provided, and, if necessary, appropriate disciplinary action should
be considered. Professional associations and labor organizations,
through continuing education efforts, should emphasize the need for
health-care workers to follow recommended precautions.”
CONCLUSION
Not much has changed in the area of “universal precautions” since
the 1987 CDC publication and 1988 update. In 1996 the CDC
published new guidelines known as “standard precautions,” which
synthesize the major features of “body substance isolation” (BSI) and
universal precautions to prevent transmission of a variety of
organisms. See www.cdc.gov/ ncidod/hip/BLOOD/UNIVERSA.htm,
www.cdc.gov/ncidod/hip/ISOLAT/ isopart1.htm, and
www.cdc.gov/ncidod/hip/ISOLAT/isopart2.htm for further updates.
However, there are many changes in every other area of
medicine. It is your personal and professional responsibility to keep
up with these changes through reading, researching, and continuing
education.
152
Learning Exercises
Abbreviations
1. CDC:
2. HBV:
3. OSHA:
4. EPA
True-False
1. T F Infectious organisms too small to be seen with unaided

human vision are called microorganisms and include bacteria,
viruses, protozoa, and fungi.
2. T F Some pathogens aid in digestion and skin preservation.
3. T F The human body is the most common reservoir of

infection; however, secondary sources include contaminated
food or water and any damp, warm place that is not regularly
144
cleaned.
145
4. T F Since technologists are exposed to many pathogens during

the day, the technologist who works when his or her resistance is
low because of fatigue, stress, or a low-grade infection has increased
susceptibility as a host.
5. T F Three routes of transmission of infection are direct and

involve transport of organisms by means of fomites, vectors, and
airborne contamination.
6. T F When treating patients with serious diseases, the symptoms

will be readily apparent to you. You should take extra safety
precautions with these patients.
7. T F Proper handwashing is important after handling dressings or

touching open wounds, but not necessarily before these actions.
8. T F Radiologic technologists, along with physicians, are often

offenders when it comes to not washing their hands between
patients.
1. Microorganisms causing infectious diseases are classified as

which of the following?
a. Lytic
b. Endogenous
c. Pathogenic
d. Nosocomial
2. Which of the following is not a type of indirect disease transmission?

a. Vector
b. Fomite
c. Aerosol
d. Touching
3. The common cold is an example of an infection by which of the

following?
a. Bacteria
b. Virus
c. Fungus
d. Protozoa
4. What term best describes the absolute removal of all life forms?
a. Disinfection
b. Medical asepsis
c. Antisepsis
d. Sterilization
146
5. A health care worker is accidentally punctured with a

contaminated needle. This type of transmission is known as which
of the following?
a. Iatrogenic
b. Vector
c. Fomite
d. Nosocomial
6. What is the most common means of spreading infection?

a. Improperly disposed of contaminated waste
b. Instruments improperly sterilized
c. Soiled linen
d. Human hands
7. What is the term for objects that have been in contact with
pathogenic organisms?
a. Fomites
b. Pathogens
c. Microbes
d. Viruses
Review Questions
1. Why is it never good practice to recap needles?
2. What are five of the 10 universal precautions issued by the CDC?
146
Anxiety, Phobia, and Conscious
Sedation 10
OBJECTIVES KEY TERMS
At the conclusion of this chapter, you should be able to: analgesic
1. Describe the basic terms anxiety, panic disorder, and phobia. antianxiety
2. Understand basic reasons for patient fear when undergoing anxiety
radiologic procedures. barbiturate
3. Understand the critical difference between conscious sedation benzodiazepine
and general anesthesia. claustrophophia
4. Describe the various mechanisms of action of all the medications used conscious sedation
for sedation. fentanyl
5. Know the adverse effects of conscious sedation medications. flumazenil
6. Know the antidotes for reversing respiratory depression after general anesthesia
administration of conscious sedation medications. meperidine
methohexital
midazolam
morphine
naloxone
opiate analgesic
panic disorder
phenobarbital
INTRODUCTION phobia
Anxiety and phobia are important considerations in patients thiopental
presenting to the radiology suite for computed tomography (CT) and
magnetic resonance imaging (MRI) scans. Thus, a basic
understanding of the following disorders will assist the imaging
technologist in performing safe and accurate scanning:
●
Anxiety may cause a patient to experience an unpleasant state of ten-
sion forewarning danger. This can be very painful and persistent if
the cause is unknown.
●
Panic disorder occurs as a sudden, unexpected, intense attack of
apprehension sometimes accompanied by physical symptoms such as
agitation, tachycardia, hypertension, cardiac dysrhythmias, and
shortness of breath. There is a general feeling of impending
doom even though the danger is not real.
●
Phobia is a psychological condition that consists of irrational fear
leading to avoidance. Claustrophobia, the fear of tight and
enclosed spaces, is one example of such phobia.
Investigators studied the 4.3% of patients who experienced
psychological distress severe enough to require halting an MRI
procedure. The majority were found to have had similar minor
anxiety reactions in
147
the past. Symptoms included nervousness, fear, palpitations,

choking sensations, and fear of dying. Less than 1% had a previous
psychiatric illness, suggesting that a previous psychatric diagnosis is
not required for a patient to experience this reaction.
Anxiety was precipitated by two major sources: (1) the
?
physical conditions of the MRI and (2) emotional turmoil. The
DID YOU KNOW? physical conditions were such that the patient was unable to see
outside the tube or to move while in the tube. Equally distressing was
Methylphenidate (Ritalin) is the unbearable noise of “metal being crunched.” Emotional turmoil
a medication prescribed for resulted from the fear of what the MRI might show (e.g., brain
individuals (usually children) tumor, cancer). These anxiety reactions have also been described in
who have an abnormally high other procedures, such as cardiac catheterization, gastroscopy,
level of activity or attention- uroscopy, dental procedures, and intensive care unit stay.
deficit hyperactivity disorder A basic physiologic response is seen with the anxious and
(ADHD). According to the
agitated patient. This response includes a decreased pain threshold,
National Institute of Mental
tachycardia, palpitations, chest pain, tachypnea, dyspnea, muscular
Health, about 3-5% of the
general population has the weakness, numbness, paresthesias, gastrointestinal (GI) distress
disorder, which is (cramping, pain, nausea, vomiting), and headaches. If severe enough,
characterized by agitated anxiety can theoretically cause a compromised organ to fail
behavior and an inability to because of the excessive physiologic strain.
focus on tasks.
Methylphenidate also is
occasionally prescribed for CONSCIOUS SEDATION
treating narcolepsy. Conscious sedation is a drug-induced relaxation allowing the patient
Methylphenidate is a central to tolerate unpleasant procedures. The patient remains conscious,
nervous system (CNS) but sedated, and in some cases amnestic (loss of memory) at the
stimulant. It has effects time of the procedure. With the proper amount of sedation, the
similar to, but more potent
patient remains cooperative, is able to respond purposefully to
than, caffeine and less
potent than amphetamines.
verbal com- mands and tactile stimulus, maintains airway with
It has a notably calming adequate cardiorespiratory function, and has reduced anxiety and
effect on hyperactive apprehension toward the procedure.
children and a “focusing” It is paramount the clinician realize that the only difference
effect on those with ADHD. between conscious sedation and general anesthesia, requiring mechan-
ical ventilation, is the dose of sedative. All the sedatives used for
conscious sedation can completely incapacitate a patient’s own
ability to breathe if the dose is too high.
The following should be performed before considering
conscious sedation:
1. Obtain an accurate history, physical examination, height, and
weight.
2. Assess heart and lungs and document airway patency.
3. Acquire a list of all the patient’s medications, including over-
the- counter drugs, herbal medications, alcohol, and illicit drugs.
4. List all known allergies to food and medication.
5. Know when the patient’s last oral intake of medication, fluid, or food
occurred.
6. List all known abnormalities of organ function.
Before administering any of the conscious sedation
medications, the following should be available:
148
Anxiety, Phobia, and Conscious Sedation
1. Oxygen source and pulse oximeter to monitor oxygen saturation

throughout procedure.
2. Suction equipment.
3. Airway equipment and means for providing positive-pressure
ventilation (e.g., bag mask, ventilator).
4. Emergency resuscitation equipment and medications.
5. Pharmacologic reversal agents, including flumazenil and naloxone.
6. Intravenous (IV) equipment to maintain IV access throughout
procedure.
7. A cardiac monitor is strongly advised.
8. A crash cart generally has all that is required to complete 1
through 7 above.
AGENTS USED FOR CONSCIOUS SEDATION

Medications used in the radiology department for conscious
sedation consist primarily of the barbiturate, benzodiazepine
(antianxiety agents), and opiate analgesic classes of drugs (see
Chapter 5).
Antianxiety medications alleviate the anxiety that is secondary to
claustrophobia when undergoing CT and MRI. These medications
generally act on the limbic system in the brain by enhancing the
effect of the sedative neurotransmitter gamma-aminobutyric acid
(GABA) and by blocking stimulation in the limbic and cortical
systems of the brain.
Analgesic medications are frequently used in combination
with the antianxiety drugs for conscious sedation. By combining the
opiate (narcotic) analgesics, a synergistic action takes place to
relieve the painful anxiety caused by the procedure. Opiate
analgesics stimulate central nervous system (CNS) receptors known
as opioid receptors and cause a decrease in the perception of pain.
Examples of common narcotic medications used for conscious
sedation include morphine, meperidine, and fentanyl.
The combination of antianxiety and opiate medications is
especially dangerous because of the synergistic effects on
respiration. Respiratory depression can rapidly occur to the point
of respiratory arrest if the dose of either of these agents is too great.
Should a respiratory arrest occur, naloxone, 0.4 to 2 mg given
intravenously (IV), intramuscularly (IM), or endotracheally, is the
drug of choice to immediately reverse the respiratory depressant
effects of the opiates. To reverse the effects of the antianxiety drugs,
flumazenil, 0.2 to 1 mg given IV, is the drug of choice.
BARBITURATES
Mechanism of Action
Barbiturates include medications such as thiopental,
methohexital, and phenobarbital. These agents decrease cortical
brain activity by facilitating the inhibitory neurotransmitter GABA
and depress cerebral cortex activity by blocking excitatory
neurotransmitters such as glutamic acid and acetylcholine. The
149
barbiturates are capable of
150
producing all levels of anesthesia, from conscious sedation to

complete anesthesia.
Thiopental
Thiopental is used mostly in the surgical suite to induce full
anesthesia. It can also be used rectally for pediatric conscious
sedation before MRI studies. Generally, thiopental is given through
a female-type urinary catheter inserted rectally. The dose for
infants is 50 mg/kg for patients under 6 months of age, 35 mg/kg for
ages 6 to 12 months, and 25 mg/kg (not to exceed 700 mg total) for
ages greater than 12 months. The onset of action is approximately 30
minutes, with a sleep duration of about 45 minutes. With the
advent and use of midazolam, thiopental for children has fallen out
of favor over the years.
Major adverse effects include bronchospasm (secondary to
histamine release), hypotension with rebound tachycardias, apnea
(breathing stops), respiratory depression, paradoxical excitation and
agitation, GI upset (nausea, vomiting, diarrhea), and exacerbation of
porphyria. Rarely, fatal exfoliative dermatitis (Stevens-Johnson
syndrome) has occurred.
Methohexital
Methohexital is extremely rapid in onset and very short in duration. It
is used mostly for brief procedures, such as cardioversions and
electro- convulsive therapy (ECT), and for anesthesia induction.
Methohexital also is used as a rectal preparation for pediatric
conscious sedation before CT studies. The dose for rectal use in
pediatrics is 25 mg/kg 15 minutes before CT. The child will sleep for
up to 90 minutes (range 20 to 90 minutes). The dose for adults
undergoing these short procedures is 1 mg/kg IV (note that this drug
has ultrashort action in adults and would not be a good choice for
procedures requiring more than 5 minutes of sedation).
Major adverse effects mirror those of thiopental. Thus, the
same monitoring parameters would apply.
Phenobarbital
Occasionally, phenobarbital, 30 mg orally, may be given to an adult
patient the night before and the morning of the scheduled radiographic
study to keep the patient calm.
Again, the adverse effects can mirror those of the other
barbiturates and should be monitored as well.
BENZODIAZEPINES
Mechanism of Action
All benzodiazepines have the propensity to be used used for
conscious sedation. However, the one most frequently used in
current practice is midazolam because of its rapid onset (2 to 15
minutes) and short duration of action (up to 90 minutes).
Benzodiazepines cause selective CNS depression, muscle relaxation,
151
antianxiety, anticonvulsant, and seda-
152
be involved with its

tive-hypnotic activities. These agents also facilitate the inhibitory administration.
neurotransmitter GABA and block stimulation and arousal in the
limbic and cortical systems of the brain. In addition, the
benzodiazepines cause some amnesia surrounding the immediate
events (antegrade amnesia) and block reflexes. These agents have
excellent absorption through the entire GI tract. Benzodiazepines
also have conscious sedation action that is longer acting than with
the barbiturates; patients may feel a “hangover” effect after the
procedure.
Adverse reactions. As a class, the benzodiazepines can cause

excessive drowsiness, hiccups (midazolam), lassitude, decreased
dexterity, dry mouth, GI upset (nausea, vomiting, cramping, consti-
pation), headache, blurred vision, amnesia, paradoxical excitation,
hallucinations, and choreiform spasmodic movements. These
agents can also cause severe respiratory depression from both CNS
depression and weakness in the external skeletal muscles used for
respiration. The benzodiazepines can lead to cardiovascular
collapse secondary to extreme hypotension, third-degree heart
block, and respiratory depression when administered too rapidly
by the IV route; extreme caution is advised.
Midazolam
Midazolam is probably the most widely used benzodiazepine for
conscious sedation. It is very predictable and quick in onset with
a short duration of action. It was shown to decrease anxiety and
improve the outcome of MRI by decreasing motion artifact.
Midazolam is given to pediatric patients by either the intranasal or the
rectal route at 0.2 to 0.5 mg/kg (maximum 20 mg) 15 minutes before
procedure. Likewise, the same dose can be swallowed by using
midazolam syrup. For more intense procedures such as endoscopy or
fluroscopy, midazolam can be given IV slowly, as follows:
Children 6 months to 0.05 to 0.1 mg / kg IV at rate of
1 5 years old: mg/min
Children 6 to 12 years old: 0.025 to 0.4 mg/kg IV at rate of 1
mg/min Greater than 12 years old: 0.035 to 0.07 mg/kg at rate of
1 mg/min
It is generally recommended to start at the lower dosage end and repeat
a dose that is 25% of the initial dose every 2 to 5 minutes if needed
to maintain sedation. Midazolam takes effect in 2 to 15 minutes and
lasts up to 90 minutes. It is generally recommended not to exceed 10
mg for conscious sedation. When given IV in combination with
narcotic analgesics, it is wise not to exceed 2 mg per dose.
Midazolam has been associated with respiratory depression and
apnea, so monitoring with a pulse oximeter is paramount.
Other benzodiazepines are not discussed because they are
more likely to be given orally the night before a test. The student is
encouraged to review specialized pharmacology texts if needed.
Midazolam is one benzodiazepine that must be given immediately
before the test, and thus the imaging professional is more likely to
153
? DID YOU KNOW?

Soldiers disease is a term for morphine addiction. The Civil War produced
over 400,000 morphine addicts.
154
OPIATE ANALGESICS
Mechanism of Action
Opiate analgesic medications stimulate the CNS opioid receptors to
decrease pain perception. When used in combination with the
antianxiety medications (e.g., midazolam), the opiates (e.g.,
fentanyl, morphine, meperidine) allow for decreased pain and
anxiety.
Adverse reactions. As a class, the opiate analgesics can cause

excessive drowsiness, GI upset (nausea, vomiting, constipation),
urinary retention, dizziness, headache, lightheadedness, histamine
release, confusion, hallucinations, hypotension, and respiratory
depression. Generally, a lower dose can be used when antianxiety
medications are used in conjunction with opiate analgesics.
The three main opiates used for conscious sedation include
morphine, meperidine, and fentanyl. Morphine is dosed 0.08 to 0.15
mg/kg IV in adults and 0.1 mg/kg IV in pediatric patients. Meperidine
is dosed 1 to 3 mg/kg IV in adults and is not recommended for
children. Fentanyl is dosed at 1 to 5 micrograms (g)/kg IV in adults
and 1 to 5 g/kg IV in pediatric patients. Fentanyl may also be
prescribed in children at 5 to 20 g/kg transmucosally (oral route).
CONCLUSION
Conscious sedation is frequently required to decrease patient
anxiety and pain associated with medical procedures. The
administration of these medicinal agents improves the outcome of
the procedure. However, the imaging technologist must not forget
the inherent dangers associated with these type of medications.
Before administering one of the agents discussed in this chapter, it
is highly recommended to acquire certification in basic life support
so that cardiopulmonary resuscitation (CPR) can begin without
delay should the patient suffer cardiorespiratory arrest. All patients
should be monitored closely with a heart monitor and pulse oximetry,
and the machines used for the procedure will need to be
compatible for such monitoring.
155
Learning Exercises
True-False
1. T F Midazolam is a barbiturate.
2. T F Methohexital is a benzodiazepine.
3. T F Opiate-induced respiratory depression can be treated with

naloxone.
4. T F Flumazenil is the antidote for midazolam overdose.
5. T F Benzodiazepines can cause drowsiness, hallucinations,

and amnesia.
6. T F Combining opiates with benzodiazepines may produce

synergistic effects.
1. medications stimulate
central nervous system receptors known as opioid receptors to
decrease pain perception.
2. As a class, the can cause excessive drowsiness,
hiccups (midazolam), lassitude, decreased dexterity, dry mouth,
gastrointestinal upset (nausea, vomiting, cramping,
constipation), headache, blurred vision, amnesia, paradoxical
excitation, hallucinations, and choreiform movements.
3. is a drug-induced relaxation
allowing the patient to tolerate unpleasant procedures.
4. occurs as a sudden, unexpected, intense attack
of apprehension sometimes accompanied by physical symptoms
such as agitation, tachycardia, hypertension, cardiac
dysrhythmias, and shortness of breath.
153
1. Which of the following is not an opiate analgesic?

a. Midazolam
b. Meperidine
c. Morphine
d. Fentanyl
e. All the above are opiate analgesics.
2. Which of the following is considered an antidote?

a. Meperidine
b. Flumazenil
c. Barium sulfate
d. Naloxone
e. Both b and d
3. What is the major difference between conscious sedation and

general anesthesia?
a. Conscious sedation only uses the opiate medication to
sedate the patient.
b. The dose of medication used to sedate.
c. The use of benzodiazepine medication.
d. There is no difference between conscious sedation and
general anesthesia.
e. All of the above.
4. Which of the following should be immediately available before

initiating conscious sedation to a patient?
a. Oxygen
b. Emergency cart
c. Flumazenil
d. Naloxone
e. All of the above
154
cardiorespiratory arrest. A
full
Pharmacology of Emergency
Medications
OBJECTIVES
1. Define cardiac arrest and respiratory arrest.
2. State the basic steps involved in managing a patient in cardiac arrest
in the radiology department.
3. Define CPR, ACLS, BLS, and Code Blue.
4. Identify the most commonly used emergency medications for cardiac
arrest.
5. Describe the coloration of outdated cardiac drugs found in the drug
box or cart.
INTRODUCTION
Patients are frequently transported to the radiology department
under the direct care and supervision of the imaging technologist.
Eventually, the technologist will have to deal with a patient
experiencing an acute life-threatening condition requiring emergency
action. Therefore, technologists should have a basic understanding
of life-threatening emergencies that can occur in the radiology
suite. Since this book deals primarily with pharmacology, emergency
conditions not treated by drug intervention, such as choking,
seizures, fainting, shock, and diabetic emergencies, are not
discussed in this chapter. These conditions may be life threatening,
and the technologist should be skilled in recognizing and providing
treatment. The most common emergency in the radiology department
requiring drug therapy is cardiorespiratory arrest. This condition and
the drugs used to treat it are discussed in detail.
CARDIORESPIRATORY ARREST
Cardiac arrest is a condition in which the heart ceases to pump
blood adequately to the rest of the body. A respiratory arrest is a
condition in which the patient becomes unable to breathe; thus the
body is inade- quately oxygenated. If not treated promptly, a
respiratory arrest will progress to a full cardiac arrest, known as
155
11
KEY TERMS
advanced cardiac life support (ACLS)
alpha receptors amiodarone antidiuretic hormone
(ADH)
atropine
basic life support (BLS) beta receptors
cardiac arrest cardiopulmonary
resuscitation (CPR) Code Blue dopamine epinephrine lidocaine
metabolic acidosis muscarinic receptor neuromuscular blocker normal
sinus rhythm (NSR) paralytic
premature ventricular contractions (PVCs)
respiratory arrest return of spontaneous
circulation (ROSC) sodium bicarbonate vasopressin ventricular
fibrillation
156
cardiac arrest becomes lethal if immediate intervention does not

occur. Management of cardiac arrest requires a systematic
approach.
The American Heart Association (AHA) states that the highest
survival rate after cardiac arrest occurs in patients who receive
cardiopulmonary resuscitation (CPR) within 4 minutes and who are
additionally provided medications through advanced cardiac life
support (ACLS) within 8 minutes. Time is life! The patient with no
blood circulation for more than 4 minutes will likely have brain
damage. If spontaneous circulation is not restored within 8
minutes, the patient will probably die. For these reasons, the
technologist cannot rely solely on other medical professionals to
provide care to patients experiencing a life-threatening emergent
condition. A medical imaging technologist can call for help and
then begin basic life support (BLS), as outlined by the AHA or
American Red Cross, until assistance arrives. Every technologist
should be certified in BLS. However, prudence would dictate the
technologist be prepared for the possibility that the emergency team
may be delayed or may need extra assistance. Therefore, familiarity
with advanced life support procedures and medications is
recommended.
ACLS is a set of guidelines developed by the AHA for use in
managing a patient undergoing cardiac arrest. Specific treatment
methods are outlined in the ACLS guidelines and can be used for
treating victims of cardiac arrest. These protocols are especially
helpful for health care professionals who are occasionally
confronted with a cardiac arrest patient. When a clinical dilemma
of this magni- tude and urgency occurs, inexperienced personnel
require guidelines or protocols that can be quickly and easily
consulted so that the correct treatment steps can be initiated.
The technologist should also be familiar with emergency pager
systems so that emergency assistance can be summoned swiftly and
efficiently. Generally, a standardized phrase such as Code Blue or a
fic- titious physician’s name such as “Dr. Stat” is used to summon an
emergency team to the area where immediate assistance is
required. Each medical facility has its own procedure to call for
emergency assistance. It is the professional duty of the medical
imaging technologist to know this procedure clearly.
EMERGENCY MEDICATIONS FOR CARDIORESPIRATORY

ARREST
Preparation made in advance of any emergency is critical. In
addition to life support skill, personnel should be familiar with the
emergency medication box or cart (Fig. 11-1).
The technologist should check the emergency medication box
(or cart) at least monthly to ensure that all drugs are present, are in
adequate supply, and have not expired. The box should also be
checked and restocked after each emergency use. Medical imaging
technologists should become familiar with the contents, drug
156
Pharmacology of Emergency Medications
names, location of drugs within the box, proper uses, and
pharmacology. Acquiring this knowledge and expertise allows the
technologist to predict accurately
157
? DID YOU KNOW?

Small amounts of
epinephrine are included in
many dental anesthetic
preparations. Clini- cians who
administer these preparations
without aspirating may
inadvertently inject into a
small vessel. This places epi-
nephrine into the
bloodstream of a patient with
normal cardiovascular
activity. Epinephrine in this
Fig. 11-1 Emergency cart with situation causes a number
defibrillator.
of unnerving reactions, such
as heart palpitations, cold
sweats, and a sense of
doom.
which drug will most likely be needed and thus rapidly acquire it
for the emergency team. This assists in swift and efficient handling of
emergency situations.
Epinephrine (Adrenaline)
Epinephrine is currently one of the most valuable, potentially
lifesaving therapeutic agents available to cardiac arrest victims. This
drug is the pharmaceutical equivalent of adrenaline, produced by the
adrenal gland.
Pharmacodynamics. Epinephrine elicits sympathomimetic

(mimics the sympathetic nervous system) effects on various organ
systems by attaching to and stimulating the alpha-1 (1), alpha-2
(2), beta-1 (1), and beta-2 (2) receptors. Table 11-1 outlines the
various effects that can occur when these receptors are stimulated by
epinephrine. The effects of epinephrine on the various receptors are
dose dependent. Low doses generally result in a predominance of
beta receptors, whereas higher doses result in a predominance of
alpha receptors. In cardiac arrest, epinephrine is primarily given in
doses sufficient to stimulate 1 receptors so that arterioles (small
blood vessels) can constrict. This produces a marked increase in
blood pressure. When combined with chest compressions,
epinephrine is used to cause a return of spontaneous circulation
(ROSC).
158
Although it is thought that 1 receptors play no role in ROSC,
epinephrine stimulation of these receptors in various organ
systems may contribute to increasing and sustaining blood
pressure. In the myocardium, 1-receptor stimulation leads to
increased force of contraction, rate, and cardiac output. 1-receptor
stimulation in the kidneys
159
Table 11-1 Pharmacodynamic Effects of the Adrenergic Receptors*

Receptor Effects
Alpha-1 (1) Increases blood pressure; dilates pupils; decreases ability

to urinate and defecate
Alpha-2 (2) Decreases blood pressure (when stimulated in the

brain); causes constipation
Beta-1 (1) Increases heart rate, cardiac output, and dysrhythmias;

causes fat to break down (lipolysis); releases renin
hormone from the kidneys (may lead to increased blood
Beta-2 (2) Decreases blood pressure; opens airways; causes

constipation; inhibits uterine contractions; increases
glucose production; releases insulin; contracts
skeletal muscle
pressure)
Dopamine Vasodilation of renal, coronary, intracerebral, and mesenteric
blood vessels
*
The effects listed are seen when the receptor is stimulated; if more than one receptor is stimu-
lated at any given moment, the effects seen may be mixed.
causes release of the hormone renin, which eventually helps produce

a potent vasoconstrictive substance in the blood, angiotensin II.
Angiotensin II in turn stimulates the adrenal gland to secrete the
hormone aldosterone, which travels to the kidneys, where it acts to
facilitate salt and water retention. The process is collectively
known as the renin-angiotensin-aldosterone system and ultimately
leads to increased blood pressure when activated.
Epinephrine also stimulates 1 receptors in the posterior pitu-
itary gland (located at the base of the brain) to cause release of
antidiuretic hormone (ADH, vasopressin), which is also a potent
vasoconstrictor and water preserver. Again, the combination of
vasoconstriction and water preservation leads to an increase in
blood pressure.
Pharmacokinetics. Epinephrine has an onset of action of 1 to

2 minutes, with a duration of action of 2 to 10 minutes. Once inside
tissues, epinephrine is rapidly metabolized and inactivated by the
enzymes catechol-O-methyltransferase (COMT) and monoamine
oxidase (MAO). The resulting sulfate and glucuronide metabolites of
epinephrine are excreted in the urine.
Indications. Epinephrine is indicated as first-line treatment

for cardiorespiratory arrest and is used as such in ventricular
fibrillation, asystole, and pulseless electrical activity (PEA). Other
uses include treatment of anaphylactic or anaphylactoid reactions
and acute bronchospasm. Table 11-2 lists the available epinephrine
preparations used for cardiac arrest.
160
Table 11-2 Common Parenteral Forms of Emergency Medications

Drug Route* Concentration Volume
Epinephrine IM, IV, 1.0 mg/ml (1:1000) 1 ml ampule

SC, ET, IO 1.0 mg/ml (1:1000) 1 ml vial
1.0 mg/ml (1:1000) 30 ml vial
0.1 mg/ml (1:10,000) 10 ml syringe
0.01 mg/ml (1:100,000)† 5 ml syringe
Dopamine IV 0.8 mg/ml (800 g/ml) 250 and 500 ml bag

1.6 mg/ml (1600 g/ml) 250 and 500 ml bag
40 mg/ml (40,000 g/ml) 5, 10, 20 ml vial
80 mg/ml (80,000 g/ml) 5, 20 ml vials
80 mg/ml (80,000 g/ml) 10 ml syringe
160 mg/ml (160,000 g/ml) 5 ml vials
Atropine IV, ET, IO 0.05 mg/ml 5 ml syringe

0.10 mg/ml 10 ml syringe
0.30 mg/ml 1, 30 ml vial
0.40 mg/ml 1, 20, 30 ml vial
0.80 mg/ml 0.5 ml syringe
Lidocaine (for direct IV IV, ET, IO 10 mg/ml 5 ml syringe

administration) 10 mg/ml 20, 30, 50 ml vial
20 mg/ml 5 ml syringe
Lidocaine (for IV admixture) IV 40 mg/ml 25, 50 ml vials

40 mg/ml 25, 50 ml syringe
100 mg/ml 10 ml vial
200 mg/ml 10 ml vial
Lidocaine in D5W IV 2 mg/ml 500, 1000 ml bag

(premixed IV infusion) 4 mg/ml 250, 500 ml bag
8 mg/ml 250, 500 ml bag
Sodium bicarbonate IV, IO 0.5 mEq/ml 5, 10 ml syringe

0.9 mEq/ml 50 ml syringe
1.0 mEq/ml 10, 50 ml syringe
Vasopressin IV, IM 20 units/ml (40 unit vial)
Amiodarone IV 150 mg/3 ml vial, 900 mg/18 ml vial

*
ET, Endotracheal; IO, intraosseous (generally used in pediatrics).
†1:100,000 concentration; 5-ml syringe is a pediatric formulation.
D5W, 5% dextrose in water.
Dosage and administration. Conventional ACLS guidelines

recommend epinephrine 0.5 to 1.0 mg (0.01 to 0.015 mg/kg) every 5
to 10 minutes, followed immediately by 20-ml normal saline (NS)
flush as needed to attain ROSC. Five to 10 ml of a 1:10,000 solution is
equivalent to 0.5 to
1.0 mg. Some medication carts will carry a 30-ml vial of a 1:1000 ml
solution, which is equivalent to 1 mg/ml. In the pediatric patient, 0.01
mg/kg to 0.015 mg/kg should be used.
161
Over the past several years, the AHA has revised its guidelines
to include adult epinephrine doses greater than 1 mg after the first
round of medication fails to attain ROSC. Doses greater than 1 mg
are considered “high dose.” High-dose epinephrine at 0.2 mg/kg
is considered appropriate if the patient fails to respond to the
initial 1-mg dose. Epinephrine may be administered intravenously
? DID YOU KNOW?

through a periph-
eral or central vein, down the endotracheal tube (intrapulmonary
administration), intraosseously (into the bone lumen) in pediatrics,
Before beginning invasive or by intracardiac injection into the left ventricle. Intracardiac
procedures or injecting injection is not widely practiced at this time because myocardial
patients with contrast necrosis can result. The intraosseous (IO) and endotracheal (ET) routes
agents, you should obtain a are important to keep in mind; many practitioners forget about
thorough medical history, these routes in the excitement of an actual emergency. IO
including information about
injection is very effective in pediatric patients. ET administration is
any existing cardiac
dysrhythmias (arrhythmias),
very effective in both pediatric and adult patients.
and assess baseline vital Endotracheal administration is generally performed when no
signs. An irregular cardiac intravenous (IV) access is available. To perform this technique, the
rhythm in a patient with a medication should be diluted to a total volume of 10 ml, squirted
cardiovascular condition (e.g., down the ET tube, then followed by at least three rapid ventilations
coronary artery disease) or via bag-valve mask. These rapid ventilations serve to disperse the
who has had a myocardial medication over the large surface area of the lung so that systemic
infarction or open- heart absorption can take place. This technique has been documented
surgery can quickly progress to be effective at delivering epinephrine to the systemic circulation
to a cardiac arrest. during cardiac arrest.
Adverse effects. Major adverse effects seen with epinephrine

consist of cardiac dysrhythmias, including ventricular fibrillation,
through 1-receptor stimulation in the heart. Epinephrine may also
lead to increased ischemia in an already-damaged heart because
the oxygen demand exceeds the oxygen supply in cardiorespiratory
arrest. In cardiac arrest, however, the benefits generally outweigh
the risks. If the patient survives the cardiac arrest, hypertension
and dysrhythmias should be expected. Other major adverse effects
include a sense of nervousness, headache, and muscle twitching
(fasciculations).
Stability. Epinephrine products are unstable when exposed to

light for long periods and may turn pink or brown. Discolored
solutions should not be used because they may be ineffective.
Checking your medication stock frequently can help to avoid this
problem.
Vasopressin (Pitressin)
Vasopressin is the pharmaceutical equivalent to endogenous ADH.
Studies of post–cardiac arrest patients have shown that survivors
had higher serum levels of vasopressin in their body after the insult
compared with those who died. Vasopressin has been shown to
increase blood flow to vital organs and improve oxygen delivery to
the cerebral area in laboratory studies.
162
According to the newest ACLS guidelines, vasopressin is now

standard therapy as an alternative to epinephrine. Because of a
recent large clinical trial, many in the field now consider
vasopressin as first-line therapy for all patients who undergo
cardiac arrest with the initial rhythm of asystole. A significant
improvement in survival was documented in patients who
received vasopressin as first-line therapy for asystole compared
with those who received only epinephrine. Also, those who received
both vasopressin and epinephrine for asystole did better than those
receiving either drug alone. Vasopressin and epinephrine were equal
in outcomes when used for ventricular fibrillation or pulseless
electrical activity. However, vasopressin is currently recommended
in patients with shock-resistant ventricular fibrillation after epi-
nephrine has failed and in those with circulatory shock (e.g.,
sepsis).
Pharmacodynamics. Vasopressin has potent vasoconstrictive

and water retention effects that ultimately lead to an increase in
systemic blood pressure. The onset for vasoconstriction effects is
immediate, whereas the water retention occurs within
approximately 20 minutes. These actions occur even in the acidotic
state, which is a benefit to patients with metabolic acidosis
secondary to the cardiac arrest. Vasopressin causes water retention
by the renal tubules and results in a concentrated urine as urine
volume declines. At vasoconstrictive doses (40 units), vasopressin
stimulates a vasopressin-1 receptor in the smooth muscle, increasing
the availability of calcium from the sarcoplasmic reticulum to allow
for increased smooth muscle contraction, and thus causing
vasoconstriction.
Pharmacokinetics. Vasopressin has an onset of action within 3

minutes, with maximum effects occurring up to 20 minutes after
injection. It is rapidly destroyed by the liver and the kidneys, resulting
in a plasma half-life of 10 to 20 minutes.
Indications. Vasopressin is currently recommended as an

alternative to epinephrine in shock-resistant ventricular fibrillation
and for cardiovascular shock.
Dosage and administration. Vasopressin is administered to

patients in cardiac arrest via direct IV push at 40 units for one dose
every 20 minutes per ACLS guidelines. However, many clinicians
are now advocating vasopressin 40 units every 3 minutes for two
doses when treating asystolic cardiac arrest.
Adverse effects. Vasopressin can cause circumoral pallor,

sweating, nausea and vomiting, tremor, abdominal cramps, and
pounding headache at doses much lower than used for cardiac
arrest. Higher doses may cause hypertension, cardiac dysrhythmias
(bradycardia, premature atrial contractions, heart block),
163
myocardial ischemia, and myocardial infarction.
164
Stability. Commercially prepared vasopressin injections are

stable until the expiration date listed on the product. Vasopressin
injection is stable at temperatures ranging from 15˚ to 30˚ C.
Dopamine (Intropin)
?
Dopamine is the pharmaceutical equivalent of endogenous dopamine.
DID YOU KNOW? Endogenous dopamine is a precursor to norepinephrine and
epinephrine naturally produced by the body.
In an article in 1998, The
Journal of the American Pharmacodynamics. Dopamine has dose-dependent effects on the
Medical Association claimed various sympathetic (adrenergic) nervous system receptors. At low
that adverse drug reactions doses, dopamine primarily stimulates the dopamine receptors in the
may cause more than renal, coronary, intracerebral, and mesenteric arteries. This leads to
100,000 deaths a year in the arteriolar vasodilation with increased blood flow to the respective
United States alone. organs. At moderate doses, dopamine will also begin stimulating
the 1 receptors to
cause increases in contractility, force of contraction, and stroke
volume in the myocardium. This effectively increases cardiac output in
patients in shock or with congestive heart failure. At high doses,
dopamine begins stimulating alpha receptors. When high doses are used,
the net effects are a combination of dopamine receptor and 1-, 1-,
and 2-receptor stimulation; no 2-receptor stimulation occurs. At
very high doses, the primary pharmacodynamic effects seen are
those associated with
1-receptor stimulation.
Pharmacokinetics. Dopamine has an onset of action of 2 to 4

minutes, with a duration of action of less than 10 minutes. Renal
vasodilation with increased urine output may take up to 20
minutes. Dopamine is metabolized to homovallinic acid (HVA),
norepinephrine, and other chemicals by the enzymes COMT and
MAO. The resulting metabolites of dopamine are excreted in the
urine. A small fraction of dopamine is excreted unchanged in the
urine.
Indications. Dopamine is indicated for treating hypotension

secondary to congestive heart failure, myocardial infarction,
trauma, sepsis, and overt heart failure. Dopamine is also used to
increase urine output in patients with renal failure. In cardiac arrest,
dopamine is used as second-line therapy, after epinephrine and fluids
have failed to attain ROSC. Dopamine is also used to support blood
pressure further after successful ROSC in cardiac arrest victims.
Dosage and administration. Dopamine is administered by IV

infusion through a controlled delivery device such as an electronic
pump. The appropriate total dose should be diluted in either NS or
5% dextrose in water (D5W). Low-dose dopamine is considered to
be less than 5 g/kg/min. Intermediate dosing is between 5 and 10
g/kg/min. High-dose dopamine is generally considered to be any
dose above 10 g/kg/min.
165
Generally, dopamine is used as the premixed solution. Table 11-
2 lists available dopamine preparations. If mixing the solution
is
166
parasympathetic nervous
required, then an easy method is by placing 800 mg into 500 ml of system on the heart
either D5W or NS and attaching a microdrip (60 drops/ml while allowing the
calibration) tubing set to the infusion bag. This gives a total sympathetic nervous
concentration of 1600 system to function
g/ml. An average 70-kg patient would then require approximately unopposed; keep in mind
700 g/min (10 g/kg/min) for 1-receptor effects to increase that the parasympathetic
blood pressure. This calculates to be 42,000 g/hr (700 g/min for nervous system and the
60 minutes), which is approximately 26 ml/hr of the 1600-g/ml sympathetic nervous
solution. By using the microdrip tubing, the technologist can easily system generally
titrate the drip rate to 26 drops/min, which is equal to 26 ml/hr. counterregulate
(Note: If macro-
drip tubing [calibrated at 15 drops/ml] is used, the drip rate per
minute is equal to ml/hr divided by 4; approximately 6.5 drops/min
= 26 ml/hr.)
Adverse effects. Dopamine produces dose-dependent adverse

effects. Hypotension occurs with low doses. Hypertension, cardiac
dysrhythmias, headache, nausea, vomiting, angina pectoris, and tachy-
cardia may occur with high doses. If dopamine extravasates into
surrounding tissues, necrosis may occur. Gangrene of the
extremities has occurred with high-dose infusions in patients with
diabetes or vascular occlusive diseases. Phenytoin (Dilantin) may
interact with dopamine and cause hypotension, bradycardia, and
seizures.
Stability. Dopamine is generally stable for up to 24 hours

when placed into solution. Commercially prepared solutions are
stable until the expiration date listed on the product. Dopamine
products are unstable when exposed to light for long periods and
should be protected from light when in storage. Discolored
solutions should not be used because they may be ineffective.
Checking the medication stock frequently can help to avoid this
problem. Dopamine is incompatible with sodium bicarbonate, iron
salts, and oxidizing agents.
Atropine
Atropine is an antimuscarinic agent frequently used in patients
experiencing cardiac arrest.
Pharmacodynamics. Atropine competitively inhibits the action of

acetylcholine or other cholinergic stimuli at the muscarinic
receptors in the parasympathetic nervous system. Box 11-1 lists the
various effects that occur when muscarinic receptors are stimulated in
the parasympathetic nervous system; the competitive inhibition of
these receptors by atropine generally yields the opposite effect.
Atropine is used in the setting of cardiac arrest when a patient
exhibits bradycardia (slow heart rate) on the cardiac monitor. When
the heart rate falls to 40 beats/min or less, the emergency medical
team will use atropine to competitively block the muscarinic
receptors in the myocardium. This blunts the effects of the
167
? DID YOU KNOW?

Tobacco smoke contains over 4,000 chemicals, including at least 50 that
cause, initiate, or promote cancer such as tar, ammonia, carbon monoxide,
oxides of nitrogen, and ben- zopyrene.
168
BOX 11-1 EFFECTS OF MUSCARINIC (CHOLINERGIC)

RECEPTORS WHEN STIMULATED*
Pupillary constriction (miosis)
Decreased heart rate (bradycardia)
Decreased heart conduction velocity
Decreased heart contractility
Arteriolar vasodilation
Bronchial smooth muscle
contraction Bronchial gland
secretions Gastrointestinal
peristalsis Gastrointestinal
secretions Gastrointestinal
sphincter relaxation Salivation
Urinary bladder
contraction Urinary
sphincter relaxation Sweat
gland secretion Glycogen
synthesis
*
Atropine generally blocks these effects and may lead to the opposite reactions.
each other in almost all tissues and organs. The sympathetic

nervous system will thus stimulate the 1 receptors with the
neurotransmitter norepinephrine, resulting in increased heart rate,
contractility, and conduction velocity. In addition, if epinephrine or
dopamine is currently in use, their actions on the 1 receptors of the
heart will be enhanced following atropine administration.
Pharmacokinetics. Atropine has an onset of action of 2 to 4

minutes after IV administration. Atropine is absorbed through the
oral, intramuscular, and pulmonary routes; however, the IV and ET
(pulmonary) routes are the only accepted routes for cardiac arrest
victims. Atropine distributes well throughout the body and will lead
to side effects in the parasympathetic nervous system. Atropine is
metabolized by the liver to tropic acid, tropine, tropic acid esters, and
glucuronide conjugates. The half-life of elimination for atropine is 2
to 3 hours. Atropine and its metabolites are eliminated principally
in the urine, but some may be excreted by pulmonary exhalation.
Indications. Atropine is indicated for cardiac arrest patients

with hemodynamically significant bradycardia, first-degree
atrioventricular block, and ventricular asystole (flat line). Atropine
may also be used when attempts at intubation lead to vagal nerve
(a parasympathetic nerve) stimulation resulting in symptomatic
bradycardia.
Dosage and administration. Atropine should be given via rapid IV

push at doses ranging from 0.5 to 1.0 mg every 3 to 5 minutes until
the
169
desired heart rate is achieved. Ventricular asystole generally requires

at least 1.0 mg. A cumulative dose of 3.0 mg generally should not
be exceeded, since this will lead to complete vagus nerve
blockade. Pediatric patients require 0.02 mg/kg, with a minimum
dose of 0.1 mg and a maximum single dose of 0.5 mg in children
and 1.0 mg in adolescents; the cumulative maximum dose for
children is 1.0 mg and for adolescents is 2.0 mg.
If atropine is given via slow IV push, a paradoxical action may
occur leading to a further decrease in heart rate that could be lethal. If
the IV route is unavailable, either the ET or the IO route can be
used. The technique for ET administration is the same as for
epinephrine, discussed earlier.
Adverse effects. Serious adverse effects of atropine include a

worsening of myocardial ischemia or extension of infarct zone,
ventricular fibrillation, and ventricular tachycardia. A paradoxical
slowing of heart rate may occur with low doses of atropine and in
patients who receive the drug by slow IV push. Less severe adverse
effects include dry mouth, blurred vision, constipation, urinary
retention, pupillary dilation (mydri- asis), headache, nervousness,
progression of angle-closure glaucoma, drowsiness, weakness,
dizziness, flushing, insomnia, nausea, vomiting, gastrointestinal
bloating, bad taste in mouth, mental confusion, and central nervous
system excitement.
Stability. Commercially prepared atropine injections are stable

until the expiration date listed on the product. Atropine products
are unstable when exposed to light for long periods and should be
protected from light when in storage. Atropine is incompatible with
sodium bicarbonate, norepinephrine, metaraminol bitartrate,
methohexital, and pentobarbital.
Lidocaine (Xylocaine)
Lidocaine is one of the most frequently used antidysrhythmic
(antiarrhythmic) drugs for patients experiencing cardiac arrest.
Pharmacodynamics. The myocardium has an extensive

electrical conduction system that works in coordination with the
parasympathetic and sympathetic nervous systems. Chemical
electrolytes such as sodium, calcium, magnesium, and potassium
play an integral role in the electrical activity of the conduction
system of the heart. An improper balance of these electrolytes can
lead to life- threatening cardiac dysrhythmias. Lidocaine
pharmacologically blocks sodium channels, thus blocking sodium
electrolytes, which affects the myocardial ventricles. This
mechanism of action allows lidocaine to terminate premature
ventricular contractions (PVCs) and convert a ventricular
tachycardia to a slower, more stable cardiac rhythm, such as
normal sinus rhythm (NSR). If multiple PVCs and ventricular
tachycardia were allowed to continue in the cardiac
170
arrest patient, a severe decrease in cardiac output could lead to

the patient’s death.
Pharmacokinetics. Lidocaine has an onset of action of 30 to 90

seconds following IV administration and 10 minutes after
intramuscular (IM) administration. Lidocaine reaches significant
serum levels only when absorbed via the IV, IM, and pulmonary
routes. This drug distributes rapidly out of the bloodstream and into
tissues throughout the body after IV administration. Lidocaine requires a
steady serum concentration between
1.5 and 6.0 g/ml to maintain therapeutic action. For this reason and
because of its rapid distribution out of the bloodstream into tissues, lido-
caine usually requires two bolus doses approximately 10 minutes
apart initially, followed by a continuous IV drip to maintain its serum
concentration in the therapeutic range. It is metabolized by the
liver to monoethylglycinexylidide (MEGX) and glycinexylidide (GX).
These metabolites are active in producing pharmacologic effects.
Lidocaine has a half-life of elimination of 80 to 108 minutes in normal
individuals, but this may be as long as 7 hours in patients with heart
failure. Lidocaine and its metabolites are eliminated primarily by the
kidneys.
Indications. Lidocaine is indicated for treating ventricular

dysrhythmias in heart attack or cardiac arrest. After cardiac
arrest, lidocaine is primarily used to treat ventricular tachycardia. It
can be used to treat ventricular fibrillation when direct-current
electrical shock (i.e., defibrillation) has failed. If defibrillation is
successful in converting the heart rhythm to NSR, lidocaine should
be used as a follow-up measure to stabilize the heart.
Dosage and administration. Lidocaine is administered as an

initial IV bolus dose of 1.0 mg/kg body weight (the usual adult dose
is 50 to 100 mg) and repeated every 5 to 10 minutes as needed to
suppress ventricular dysrhythmias. The total, cumulative bolus
dose should not exceed 3 mg/kg. Patients with congestive heart
failure should receive only 50% of the total dose to avoid toxicity.
Lidocaine is available in a prepared syringe for emergency use.
(Lidocaine can also be effectively administered by ET tube and the IO
route; the techniques are the same as for epinephrine.)
Immediately after the first bolus dose of lidocaine, an IV drip at the
rate of 2 mg/min should be started; in pediatric patients, the
infusion rate should be 20 g/kg/min. Patients with congestive
heart failure should receive only 50% of the total dose to avoid
toxicity. A lidocaine infusion can be prepared by adding 1 g (1000
mg) of lidocaine to 250 ml NS or D5W for a concentration of 4
mg/ml; the IV pump rate then required to give a 2-mg/min infusion
is 30 ml/hr; for pediatrics, dosage calculation should be based on 20
g/kg/min. Table 11-2 lists other lidocaine preparations that can
be used.
171
Adverse effects. Adverse effects of lidocaine usually occur
when it is infused too rapidly to a conscious patient, when excessive
doses are
172
will cause hypotension;

used, or when a drug-drug interaction occurs. Mild lidocaine thus, if the patient has
toxicity includes drowsiness, confusion, nausea, dizziness, gait hypotension, it is strongly
disturbances (ataxia), ringing in the ears (tinnitus), numbness
(paresthesias), and muscle twitching (fasciculations). Severe
toxicity includes psychosis, seizures, and respiratory depression.
Stability. Commercially prepared lidocaine injections are

stable until the expiration date listed on the product. Lidocaine
products are unstable when exposed to excessive heat (greater
than 40˚ C). Preparations made by adding lidocaine to D5W or NS
are stable for 24 hours at room temperature. Lidocaine may
adversely affect the action of dopamine, epinephrine, norepinephrine,
and isoproterenol. It is best to administer lidocaine through a
separate IV line, if possible.
Amiodarone
Amiodarone is an antidysrhythmic agent used in patients
experiencing cardiac arrest. Amiodarone use has become more
frequent over the years because it contains actions that mimic all
classes of antidysrhythmic medications. Therefore, amiodarone is a
relatively good choice in emergency situations when the exact
focus of rhythm disturbance is unknown and when a patient has a
heart condition.
Pharmacodynamics. Amiodarone suppresses dysrhythmias by

various mechanisms, including sodium channel blockade (see lido-
caine discussion), beta-receptor blockade, calcium channel
blockade, and membrane stabilization. These actions result in delayed
repolariza- tion of cardiac cells by prolonging the action potential
and the refractory period in myocardial cells.
Pharmacokinetics. Amiodarone is distributed extensively in many

tissues, with an elimination half-life as long as 58 days. Because of
rapid distribution into multiple tissues, amiodarone must be given by
an initial bolus, followed by a continuous IV drip, in patients with
cardiac arrest. When the patient stabilizes, the drug can be
converted to oral therapy. Amiodarone is metabolized by the liver
to the metabolite N- desethylamiodarone. Both amiodarone and N-
desethylamiodarone are excreted in the urine.
Indications. Amiodarone is recommended for pulseless

ventricular tachycardia, shock-resistant ventricular fibrillation,
polymorphic ventricular tachycardia, and wide-complex
tachycardia, as well as for rate control in atrial fibrillation or flutter.
Dosage and administration. For pulseless ventricular

tachycardia or shock-resistant ventricular fibrillation, amiodarone
should be administered by IV push as a 300 mg/30 ml D5W solution.
A second dose of 150 mg/30 ml D5W may be given in 3 to 5 minutes
if no effect has occurred. It is important to note that amiodarone
173
? DID YOU KNOW?

With the remote location of some radiology departments, there may be
work shifts when you find yourself alone with a patient or at a great
distance from other medical personnel. When using contrast agents, or when
you sense the patient is having difficulty breathing or exhibits the first
signs of cardiac distress, ask for assistance from others, or keep an open
line of electronic communication between you and the trauma center or
nursing floor.
174
recommended to administer this bolus over a 10-minute period. If

amiodarone is effective, a continuous IV drip containing 450
mg/250 ml D5W should be set to infuse at 1 mg/min for 6 hours,
then 0.5 mg/min for at least 18 hours over a minimum of 24 hours.
In the event that a higher dose is required, the maximum daily dose
should not exceed 2200 mg.
Adverse effects. The most frequent adverse effect seen with

IV amiodarone is hypotension. Other cardiac effects may include
dysrhythmia production. Long-term use can lead to pulmonary
fibrosis (reported within 6 hours of initiation) and hypothyroidism.
Stability. Commercially prepared amiodarone injections are
? DID YOU KNOW?

stable until the expiration date listed on the product. Amiodarone
injection is stable at temperatures ranging from 20˚ to 30˚ C when
protected from light. Once diluted in D5W, the drug does not need
Cocaine was the first local protection from light and should be discarded after 24 hours. This
anesthetic; being used as medication loses approximately 10% of its potency when placed in a
such from about 1884 polyvinyl chloride bag; thus, a glass bottle or polyolefin bag is
onwards. recommended for preparing IV drips of more than 2 hours.
Amiodarone is incompatible with many medications, including
aminophylline, cefamandole, cefazolin, mezlocillin, heparin, and
sodium bicarbonate. Either a separate IV line should be used or the
line should be flushed with NS before amiodarone injection.
Sodium Bicarbonate
Sodium bicarbonate is a strong alkalinizing agent. Its use for
treating cardiac arrest has been carefully scrutinized, but it is still
frequently used in select patients.
Pharmacodynamics. Sodium bicarbonate is an alkalinizing

agent that dissociates into its chemical components to liberate
bicarbonate
3 ion (HCO ). The human body has many chemical
buffers to maintain the acid-base homeostasis of its tissues.
Bicarbonate serves as a principal component of one of the main
buffer systems, the bicarbonate–carbonic acid buffer system. The
pulmonary and renal systems are major contributors to this system.
The following basic description shows how the bicarbonate–carbonic
acid buffer system functions clinically in the event of cardiac arrest–
induced acidosis. (The student is referred to advanced literature for
a more complete understanding of physiologic buffer systems.)
If the body is producing too much acid through metabolic
processes (i.e., metabolic acidosis), the lungs will increase
carbonic acid excretion by increasing respiratory rate in patients
who are capable of breathing; carbonic acid is excreted into the
atmosphere by the lungs. The kidney will 3
also retain HCO  to help
buffer the acid produced. These two mechanisms effectively
maintain the acid-base balance of the body. If the patient is
incapable of breathing3 rapidly enough or the amount of HCO  is
significantly depleted, excessive acid may
175
increase in the body and lead to clinical acidosis, which can be

severely detrimental to health.
During cardiorespiratory arrest, the patient generally cannot
adequately ventilate. The body then begins a process of respiration
known as anaerobic (without oxygen) respiration to help supply
?
energy to tissues. Anaerobic respiration is a very ineffective way of
supplying energy to tissues. The end product of anaerobic DID YOU KNOW?
respiration is lactic acid. When lactic acid accumulates to critical
levels, the body undergoes extreme metabolic acidosis. This can Despite the fact that
be lethal in cardiorespiratory arrest patients. A combination of federal spending on the
sodium bicarbonate and artificial respiration is used to combat drug war increased from
severe acidosis in cardiorespiratory arrest. IV sodium bicarbonate is $1.65 billion in 1982 to
used to restore HCO3 body stores depleted during clinical $17.7 billion in 1999, more
deterioration of the patient. than half of the students in
Administering sodium bicarbonate to a severely acidotic the United States in 1999
patient may actually make the tissue acidosis worse and thus may tried an illegal drug before
be more detrimental to the patient. This paradox may occur because they graduated from high
during the metabolism of sodium bicarbonate, a CO2 molecule school. Additionally, 65%
(acidic com- have tried cigarettes by
pound) is liberated as well as an HCO3 ion; the CO2 molecule may 12th grade and 35% are
distribute more rapidly into tissue than the HCO3 ion, thus current smokers, and
producing a severe acidosis before the HCO3:CO2:H equilibrium. 62% of 12th graders and
For this rea- 25% of 8th graders in 1999
son, sodium bicarbonate is no longer recommended as an absolute; report having been drunk
it at least once.
is recommended only if the physician deems it necessary based on
clinical factors.
Pharmacokinetics. Specific pharmacokinetic data are not

relevant to the use of sodium bicarbonate in cardiac arrest
patients. Determination of bicarbonate need is guided by serum3
pH,
HCO , and partial pressure of carbon dioxide (PCO2). These measures
are expressed chemically in the body by the the Henderson-
Hasselbach equation, as
follows:
log [HCO3 ]
pH = 6.1 
0.032  PCO2
where: log
pH = Potential of hydrogen ion
= 1
H+
6.1 = A constant
[HCO 3] = Concentration of bicarbonate in mEq/L
Indications. Sodium bicarbonate may be used for treating

severe metabolic or respiratory acidosis.
Dosage and administration. Sodium bicarbonate is usually

administered via rapid IV infusion push during cardiac arrest. In
176
pediatric cardiac arrest, this medication can be delivered by IO
injection. In adult cardiac arrest patients, 1 mEq/kg may be given
initially, followed by 0.5 mEq/kg every 10 minutes during continued
arrest. Adequate ventilation must be performed in addition to sodium
bicarbonate, since ventilation
177
is an important mechanism for correcting severe metabolic

acidosis. Children should receive the pediatric formula at an initial
dose of 1 mEq/kg via slow IV push. Using the adult formulation or
rapid IV push in small children or neonates can lead to hypertonicity
because of the high sodium concentration. If arterial blood gas
values are available, the dose of sodium bicarbonate should be
calculated using the following formula:
Sodium bicarbonate (mEq) = 0.3  Body weight (kg)  Base deficit
Base deficit is equal to the normal serum HCO  minus the measured
3
serum HCO 3.
Adverse effects. Extravasation of IV sodium bicarbonate can

lead to cellulitis, tissue necrosis, ulceration, and tissue sloughing.
Metabolic alkalosis can occur with excessive doses or in patients
with renal dysfunction. Metabolic alkalosis can cause ionized cal-
cium to decrease, resulting in irritability and muscle tetany.
Metabolic alkalosis may also decrease oxygen release from
hemoglobin, resulting in tissue hypoxia, anaerobic respiration, and
lactic acid production. The high sodium content of this medication
can lead to osmotic fluid shifts with resultant increases in
intravascular fluid. Congestive heart failure may then occur.
Finally, serum potassium concentrations may decrease because of
ion shift during sodium bicarbonate therapy.
Stability. Commercially prepared sodium bicarbonate

injections are stable until the expiration date listed on the product.
Sodium bicarbonate injection is stable at temperatures ranging
from 15˚ to 30˚ C. This medication is incompatible with many
medications, including calcium salts, epinephrine, dopamine, and
lidocaine. Either a separate IV line should be used or the line should
be flushed with NS before sodium bicarbonate injection.
Neuromuscular Blockers
The neuromuscular blockers, also called paralyzing agents, should
be used only by clinicians skilled in intubation technique.
Frequently, in the setting of a cardiorespiratory arrest, a quick-onset
paralyzing drug is required to relax all skeletal muscles so that the
patient can be rapidly intubated. If a patient is unsuccessfully
intubated after receiving a paralytic, the patient will have
essentially no ability to contract the skeletal muscles required for
respiration. So that the technician can at least know which drug to
? DID YOU KNOW? locate when called for by the physician, common neuromuscular
blockers or paralytics include succinyl- choline, vecuronium,
Five times as many deaths pancuronium, atracurium, cisatracurium, rocuro- nium, and
are caused by the mivacurium. Generally, these agents are used in conjunction with a
negligence of physicians as sedative, such as midazolam or lorazepam, to intu- bate patients
caused by firearms. rapidly if they do not breathe on their own within 8 minutes of
beginning CPR and ACLS.
178
OTHER CARDIAC EMERGENCY MEDICATIONS

This chapter describes medications generally used as first-line agents for
treating cardiorespiratory arrest. The student is encouraged to use
one of the reference books mentioned in Chapter 2 to learn about
other potential drugs of use, including procainamide, digoxin,
adenosine, magnesium, calcium, isoproterenol, verapamil, diltiazem,
metoprolol, propranolol, labetalol, norepinephrine, dobutamine,
milrinone, nitroglycerin, and nitroprusside.
CONCLUSION
Cardiorespiratory arrest is a clinical dilemma that eventually will
con- front all medical professionals who work in or around a hospital
setting. Even those who work in the clinic setting may see this life-
threatening situation. Death usually ensues if medications are not
administered within the first 8 minutes of arrest. It is obvious that all
medical professionals should become familiar with at least the
treatment that is initially required to save a patient’s life. This
chapter gives the imaging technologist a good overview of the major
medications used in the first few minutes of cardiorespiratory arrest.
By understanding the pharmacologic principles behind the
medications, the radiologic technologist can at least summon help
and have the medication cart out, open, and ready for use by the
emergency team. This may be one of the most important functions
you ever perform for your patients. Understanding the concepts
presented in this chapter could be the difference between life and
death for your patient.
179
Learning Exercises
Abbreviations
1. ACLS:
2. ADH:
3. BLS:
4. AHA:
5. CPR:
True-False
1. T F Cardiac arrest is a condition in which the heart ceases to

pump blood adequately to the rest of the body.
172
2. T F ACLS is a set of guidelines developed by the AHA for use in

managing the patient undergoing cardiopulmonary arrest.
3. T F Technologists should check the emergency medication box

at least twice a year to ensure that all drugs are present, are in
adequate supply, and have not expired.
4. T F When combined with chest compressions, epinephrine is

used to cause a return of spontaneous circulation (ROSC).
5. T F Dopamine is indicated for treating hypotension secondary

to congestive heart failure, myocardial infarction, trauma, sepsis,
and overt heart failure.
6. T F Dopamine is administered by intramuscular injection.
7. T F A patient’s cardiovascular history has no effect on the

administration of ROCM.
8. T F Extravasation of IV sodium bicarbonate can lead to tissue

necrosis.
1. The highest survival rate after cardiac arrest occurs in patients

who receive CPR within what time frame?
a. 4 minutes
b. 6 minutes
c. 8 minutes
d. 10 minutes
2. Epinephrine is the pharmaceutical equivalent to which of the fol-

lowing?
a. Renin
b. Adrenaline
c. Aldosterone
d. ADH
3. The antidiuretic hormone known as which of the following is a

potent vasoconstrictor?
a. Adrenaline
b. Xylocaine
c. Nitroglycerin
d. Vasopressin
173
4. What is the term for a drug that inhibits the postganglionic

parasympathetic receptors?
a. Antimuscarinic
b. Cholinergic
c. Sympathetic
d. Antidysrhythmic
e. Both a and b
5. What is the drug of choice when a patient exhibits bradycardia

on the cardiac monitor?
a. Dopamine
b. Epinephrine
c. Atropine
d. Sodium bicarbonate
e. None of the above
6. Which of the following is a strong alkalinizing agent given after

cardiac arrest?
a. Epinephrine
b. Sodium bicarbonate
c. Atropine
d. Calcium
7. Dopamine should be delivered only by which of the following?

a. Intramuscular injection
b. Intraosseous injection
c. Intravenous injection
d. Endotracheal injection
8. Which drug is administered to convert a premature ventricular

contraction to normal sinus rhythm?
a. Lidocaine
b. Sodium bicarbonate
c. Atropine
d. Epinephrine
Review Questions
1. In detail, what are the steps to be taken when an intravenous pyelo-
gram patient suffers a cardiac arrest?
2. What are the pharmacodynamic effects of alpha versus beta receptors?
174
Answer Section
Chapter 1 10. Discuss the different answers with your fellow

Abbreviations students.
1. JRCERT: Joint Review Committee on Education
in Radiologic Technology
2. ASRT: American Society of Radiologic
Technologists
3. HIPAA: Health Insurance Portability and
Accountability Act
True-False
1. F 6. F
2. T 7. T
3. T 8. F
4. F 9. F
5. T 10. F
Discussion Questions
1. Because of the ever-changing legislative
statutes within states, it is beyond the scope of
this textbook to list current laws. Contact your
state professional society regarding the most
current restrictions.
2. Again, standards of care vary from state to
state and even vary within states. Check with
your professional society to verify the
standard of care in your region concerning
administration of pharmaceuticals.
3. The hospital and department policy manuals
should outline in detail your responsibilities
and limitations during a patient crisis. If they
do not, all parties involved in resolving the
crisis may be open to litigation.
4. There is no “correct” answer here. Discuss the
situation with your fellow students and
professor. What will your clinical facility allow
you to do?
5. Begin with your state professional organization.
Quickly involve state legislators elected from
your district.
6. Negligence is the failure to do something that a
reasonable person of ordinary prudence would
do in a certain situation. Malpractice is a
breach of duty to adhere to a standard of care.
7. Check your departmental policy manual.
8. Make sure that you are covered—in writing.
9. Yes or no? If they do continue to administer
drugs, do they truly understand the
ramifications?
175
CHAPTER 2
Abbreviations
1. AHA: American Hospital Association
2. AHFS: American Hospital Formulary Service
3. BNDD: Bureau of Narcotics and Dangerous Drugs
4. DEA: Drug Enforcement Agency
5. FDA: Food and Drug Administration
6. PDR: Physician’s Desk Reference
7. POMR: problem-oriented medical record
True-False
1. T 7. F
2. F 8. T
3. F 9. F
4. T 10. T
5. F 11. T
6. T
Review Questions
1. Controlled substance
2. Greater
3. Animal studies and human studies
4. PDR, Facts and Comparisons, AHFS Drug
Information, Handbook on Injectable Drugs, Drug
Interaction Facts, Hansten’s Drug Interactions,
Drugs in Pregnancy and Lactation
5. Medication name, date, dosage, route, and time;
technologist’s initials should also be recorded.
6. Patient’s name, date order is written,
medication name, dosage, route, frequency of
dosage, and prescriber’s signature.
1. a 4. a
2. b 5. c
3. d 6. b
CHAPTER 3
Review Questions
1. Fastest: solutions; slowest: enteric-coated tablets
2. Cardiac output, regional blood flow, drug reservoirs
3. Kidneys, intestines, respiratory system
4. An affinity (attraction) for fat
5. Nature of absorbing surface through which drug
must go; blood flow to site of administration;
solubility of drug; pH; drug concentration; and
dosage form.
176
Answer Section
6. Passive diffusion is the random movement of a Fill-in-the-Blank Questions

substance from a region of higher
concentration to a region of lower concentration 1. Generally thought to be catalysts responsible
until equilibrium is established at the membrane. for changes in biochemical reactions, enzymes
The majority of drugs are transported by this occur throughout the body systems.
mechanism. Active transport is conducted by 2. A side effect is a predictable pharmacologic action
“carriers” that form complexes with drug on body systems other than those intended.
molecules on one surface of the membrane, 3. When two drugs are combined and cause a
carry them through the membrane, and then let pharmacologic response that is greater than it
them go. The ionic forms of most drugs do not would have been if the drugs had been given
readily enter cells and therefore require active individually, this is known as synergism.
transport. Active transport is usually more rapid 4. The method by which a drug elicits effects is
than passive diffusion. known as the mechanism of action.
5. The organ in which the desired effect occurs is
Fill-in-the-Blank Questions generally called the target organ.
1. The blood-brain barrier and the placental barrier 6. A drug-enzyme interaction occurs when a drug
are two drug distribution barriers the body has resembles the substrate to which an enzyme
that are made of biologic membranes. usually attaches.
2. Biotransformation is another name for metabolism. 7. After drug administration the amount that reaches
3. Biopharmaceutics is the area of pharmacology and remains in the systemic circulation
that focuses on the method for achieving effective depends on the rate and extent of absorption,
drug administration. distribution, metabolism, and elimination.
4. Pharmacokinetics includes the processes of how 8. Any unwanted effect from a drug is termed adverse.
a drug is absorbed, metabolized, distributed, 9. Both toxic and allergic effects are known as adverse.
and eliminated throughout the body. 10. A drug-drug interaction occurs when two or
5. The most common way drugs traverse cellular more drugs act in unison to produce additive
membranes is passive diffusion. agonist, synergistic, or antagonist responses.
6. Active transport can move a drug from an area of Multiple-Choice Questions
low concentration to an area of higher
concentration. 1. b 5. d
7. Medications must go through disintegration and 2. c 6. c
dissolution in order to be absorbed across a cell 3. c 7. b
membrane. 4. b 8. d
Matching Review Questions

1. f 5. b 1. Dosage was well above that required for peak drug
2. c 6. g performance.
3. a 7. d 2. Drug-receptor interactions, drug-enzyme interac-
4. e 8. h tions, and nonspecific drug interactions.
3. When two or more drugs act in unison;
Multiple-Choice Questions produces additive agonist, synergistic, or
1. b 5. c antagonist responses.
2. d 6. d 4. The higher the dose, the greater the toxic
3. b 7. b effects; dose may become toxic if metabolism or
4. c 8. a elimination is impaired.
CHAPTER 4 CHAPTER 5
True-False True-False
1. F 6. F 1. F 5. F
2. F 7. T 2. T 6. T
3. T 8. F 3. T 7. T
4. F 9. F 4. F
5. T 10. T
176 177
Answer Section
the kidneys and are concentrated in the

Fill-in-the-Blank Questions kidneys.
1. One should take special precaution with all
chemotherapy patients so that no medication
touches the unexposed skin of a health care
worker.
2. Antihistamines are medications used to block
histamine from producing adverse effects, such
as itching, inflammation, respiratory distress,
and overall allergic reactions.
3. Narcotic (or Opiate) medications stimulate
central nervous system receptors known as
opioid receptors and cause a decrease in the
perception of pain.
4. Diuretics are frequently referred to as “water pills.”
5. Acetaminophen is probably the most common
analgesic currently in use.
1. d 4. c
2. b 5. b
3. a 6. a
CHAPTER 6
Abbreviations
1. ROCM: radiopaque contrast media
2. MRI: magnetic resonance imaging
True-False
1. F 5. T
2. T 6. F
3. F 7. T
4. T 8. T
9. T
1. b 5. a
2. d 6. d
3. c 7. b
4. b 8. d
1. A negatively charged particle is known as an
anion, and a positively charged particle is known as
a cation.
2. A highly osmotic agent will attract water so that
a dilutional effect can occur to equalize
pressures between two permeable or
semipermeable membranes.
3. Increased density of the ROCM alters the
attenuation of x-rays, thus enhancing the
anatomic image on the radiographic film.
4. Iodine is an integral component in ROCM because
radiopacity is produced by this element.
5. Intravascular ROCM are excreted primarily via
177
6. Intravascular ROCM consist of large molecules,

with molecular weights ranging from 600 to 1700
and with poor lipid solubility.
7. Mangafodipir sodium (Teslascan) is a compound
containing manganese that is highly paramagnetic
with a high affinity to hepatic cells.
8. Octafluoropropane is a gas that comes prepared
in either a lipid (fat) or an albumin microsphere.
Review Questions
1. Ratio of iodine atoms to osmotically active particles
is 3:2 in ratio-1.5 media and 3:1 in ratio-3.0
media.
2. Because it absorbs x-ray photons, thus enhancing
contrast.
3. Large molecules that cannot cross cell membranes.
4. Excreted by the hepatobiliary system.
5. High-osmolality ionic ROCM, low-osmolality non-
ionic ROCM, and low-osmolality ionic ROCM.
6. When barium sulfate suspension is potentially
harmful, such as in GI perforation, or when com-
puted tomography is being used because of less
artifact production.
7. Major iron-containing paramagnetic agents include
ferumoxtran-10 (Combidex), iron oxide (Clariscan),
and ferumoxytol.
8. Microbubble agents include octafluoropropane
albumin (Optison) and perflutren (Definity).
CHAPTER 7
Abbreviations
1. DSA: digital subtraction angiography
2. PEA: pulseless electrical activity
3. ARF: acute renal failure
True-False
1. F 6. T
2. T 7. T
3. F 8. F
4. T 9. T
5. F 10. T
1. c 6. a
2. a 7. b
3. c 8. b
4. b 9. d
5. d 10. d
11. b
1. An immediately life-threatening systemic hypersen-
sitivity reaction is known as anaphylaxis.
(Anaphylactoid reaction or anaphylactic reaction is
also correct.)
Answer Section
2. A chemoreceptor is a sensory nerve cell 6. PICC: peripherally inserted central venous

activated by chemical stimuli. catheter
3. ROCM can lead to sickling of red blood cells as
a result of osmotic fluid shifts in patients who Fill-in-the-Blank Questions
have sickle cell anemia. 1. Extravasation (infiltration) is the accidental injection
4. ROCM cross the placental barrier and should of IV fluid or medication into the tissues
not be used in pregnant women unless benefits surrounding the vein.
far exceed risks. 2. The anterior elbow (the bend) is known as the
5. Patients at risk for acute renal failure (or ARF) antecubital space.
after intravascular ROCM include those with 3. Checking for backflow, immobilizing the needle
preexisting renal compromise, diabetes with at the injection site, and stopping the injection
concomitant renal dysfunction, or dehydration. immediately if the patient complains of
6. Signs and symptoms of thyroid storm include discomfort are three ways to minimize the
fever, tachycardia, diaphoresis, agitation, possibility of extravasation (infiltration).
nervousness, and emotional instability. 4. The two most common replacement fluids for dehy-
7. Because of the serious effects that can occur by drated patients are saline and a 5% solution of
injection of intravascular ROCM, the imaging dextrose.
technologist should use a screening method 5. A hypodermic needle with wings attached for
that includes the assessment of patient medical ease of placement is called a butterfly.
history and current renal function status.
8. Vasodilators are used to improve delivery of True-False
ROCM to small arteries that may be
1. F 6. T
inaccessible otherwise.
2. T 7. T
9. Because of the possibility of direct toxicity
3. F 8. F
from oxygen radicals resulting from
4. F 9. T
administration of ROCM, investigators have
5. T 10. T
begun using the antioxidant properties of
acetylcysteine. Multiple-Choice Questions
10. Acetylcysteine is available as a 10% (100
1. a 6. d
mg/ml) or 20% (200 mg/ml) respiratory
2. c 7. b
nebulization solution and as an intravenous
3. b 8. c
form.
4. b 9. b
11. Fenoldopam is a relatively new agent for
5. b 10. b
treating hypertensive emergencies, but it has
been used as prophylaxis against ROCM-induced Review Questions
renal dysfunction.
1. (a) Injection site should at a considerable
Review Questions distance from large nerves, bones, and blood
vessels and from bruised, scarred, or swollen
1. Mast cells may respond to the first exposure
previous injection sites; (b) the proper needle
with anaphylaxis.
length and gauge should be selected based on
2. Assume incompatibility and flush line with
injection site, tissue condition, size of patient, and
saline to prevent drug-drug contact.
the type of drug to be injected;
3. Acetylcysteine: free-radical scavenger, vasodila-
(c) hold needle and syringe assembly as if it were
tion; feneldopam: renal artery dilation; NS/hydra-
a dart, and make the injection perpendicular to
tion: hydration; sodium bicarbonate: hydration,
the skin surface from a distance of about 2
decrease free radicals.
inches, in one quick motion; (d) aspirate to
4. See text.
determine proper needle location (not in a blood
CHAPTER 8 vessel); (e) inject medication; (f) massage site to
Abbreviations disperse the drug.
2. Ask patient to lie facedown to expose the dorso-
1. SC: subcutaneous
gluteal site for identification of landmarks
2. IM: intramuscular
(greater trochanter of femur to posterior iliac
3. IV: intravenous
spine) for injection anywhere along this imaginary
4. CV: central venous
line, or ask patient to lie on either side; to locate
5. PA: pulmonary arterial landmarks on the left side, the technologist should
178 palpate for the 179
Answer Section
blood, body fluids containing visible blood,

left greater trochanter with the right palm, point the mucous
right index finger to the anterior superior iliac
spine, and extend the middle finger toward the
iliac crest—and inject into the center of the V
formed between the index finger and the middle
finger (use left hand to detect landmarks in the
right hip).
3. After proper application of a tourniquet 3 to 4
inches above the injection site, locate the basilic or
cephalic veins on the back of the hand, the
basilic vein on the medial anterior forearm and
elbow, or the cephalic vein on the lateral
anterior forearm and elbow.
4. Remove the needle immediately, apply pressure
to the injection site, and apply a warm, moist
cloth to relieve the pain.
5. Intravenous injection.
6. Dispose of the syringe and needle in a labeled
“sharps” container. Do not recap or touch the
needle.
7. Name of the drug, dose, route of drug
administration, date of administration, time of
administration, and injection site (document
number of attempts).
8. The subclavian vein due to ease of access.
CHAPTER 9
Abbreviations
1. CDC: Centers for Disease Control and Prevention
2. HBV: hepatitis B virus
3. OSHA: Occupational Safety and Health Adminis-
tration
4. EPA: Environmental Protection Agency
True-False
1. T 5. F
2. F 6. F
3. T 7. F
4. T 8. T
1. c 6. d
2. d 7. a
3. b
4. d
5. c
Review Questions
1. During recapping, it is very easy to be distracted
or slip and puncture your finger or hand with the
contaminated needle. Simply throw the entire
needle and syringe away in a clearly marked
“sharps” disposal box.
2. (a) Gloves should be worn when in contact with
179
membranes, or nonintact skin; (b) gloves should

be worn when handling items or touching
surfaces soiled with blood or body fluids and when
performing venipuncture and other vascular
access procedures; (c) gloves should be
changed after contact with each patient; (d)
masks and protective eye shields should be worn
during procedures that can generate droplets of
blood or other body fluids, to prevent exposure
of mucous membranes of the mouth, nose, and
eyes to infections; (e) gowns should be worn
during procedures that can result in the splashing
of blood or other body fluids; (f) hands and other
skin surfaces should be thoroughly washed
immediately after contamination with blood or
body fluids; (g) needles should not be recapped,
purposely bent or broken, or removed from syringes;
(h) needles and syringes must be disposed of in
puncture-resistant containers in the immediate work
area; (i) mouthpieces, Ambu bags, and ventilation
devices should be used rather than mouth-to-mouth
resuscitation; (j) health care workers with oozing or
open sores should refrain from direct contact
and handling of patient care equipment or items.
CHAPTER 10
True-False Questions
1. F 4. T
2. F 5. T
3. T 6. T
1. Opiate analgesic (or narcotic analgesic) medications
stimulate central nervous system receptors known as
opioid receptors to decrease pain perception.
2. As a class, the benzodiazepines can cause
excessive drowsiness, hiccups (midazolam),
lassitude, decreased dexterity, dry mouth,
gastrointestinal upset (nausea, vomiting, cramping,
constipation), headache, blurred vision, amnesia,
paradoxical excitation, hallucinations, and
choreiform movements.
3. Conscious sedation is a drug-induced relaxation
allowing the patient to tolerate unpleasant procedures.
4. Panic disorder occurs as a sudden, unexpected,
intense attack of apprehension sometimes accom-
panied by physical symptoms such as agitation,
tachycardia, hypertension, cardiac dysrhythmias,
and shortness of breath.
Multiple Choice Questions

1. a
2. e
3. b
4. e
Answer Section
CHAPTER 11 basic life support (BLS) by using proper

Abbreviations cardiopulmonary resuscitation. In addition, the
1. ACLS: advanced cardiac life support technologist should prepare in advance by checking
2. ADH: antidiuretic hormone the emergency medication box (or cart) to be
3. BLS: basic life support certain that all medications and supplies are fresh.
4. AHA: American Heart Association This is recommended to be done at least once
5. CPR: cardiopulmonary resuscitation every month. Replace any outdated medications
or supplies. Make certain that there are adequate
True-False quantities of medications and supplies, restocking if
1. T 5. T necessary. Finally, become familiar with the
2. T 6. F pharmacology of emergency drugs, their locations
3. F 7. F within the box, and their proper use.
4. T 8. T 2. Alpha-1 (1): increases blood pressure, dilates
pupils, decreases ability to urinate and defecate.
Multiple-Choice Questions Alpha-2 (2): decreases blood pressure (when
1. a 5. c stimulated in the brain), causes constipation.
2. b 6. b Beta-1 (1): increases heart rate, cardiac
3. d 7. c output, and dysrhythmias; causes fat to break
4. e 8. a down (lipolysis); releases renin hormone from
the kidneys (may lead to increased blood
Review Questions pressure).
1. Call for help. Become familiar with the Beta-2 (2): decreases blood pressure, opens
emergency paging system of the institution so airways, causes constipation, inhibits uterine
that a swift summons for help can be done. State contractions, increases glucose production,
the location where help is needed. Repeat the releases insulin, contracts skeletal muscle.
summons at least three times before hanging up These effects are seen when the receptor is
the paging system. Imme- diately after hanging up stimulated; if more than one receptor is
the paging system, initiate stimulated at any given moment, the effects
seen may be mixed.
180 181
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183
INDEX
Note: Page numbers followed by f indicate figures; t,

Alpha receptors, 158t. See also Adrenergic receptors.
tables; b, boxes.
dopamine and, 162, 163
A American College of Radiology, on
imaging technologist venipuncture
Abbreviations and symbols, in drug
practice, 3
administration, 119-120t
American Heart Association, 156, 160
Absorption, drug. See Drugs, absorption of.
American Society of Radiologic Technologists
Access ports, in intravenous administration, 117
venipuncture practice standards of, 3,
Accredited program, 3, 5
3b website of, 4
Acetaminophen, 16t, 57 Amiodarone, 54, 167
Acetylcholine, 45, 149
dosage of, 167-168
atropine and, 163, 164b
drug interactions with, 168
Acetylcholinesterase, 45
hypotension with, 167-168
Acetylcysteine, 88-89
parenteral forms of, 159t
Acetylsalicylic acid. See
Amphetamines, 15, 44b
Aspirin.
Ampules, 104t
Acid-base balance
Anaerobic respiration, 169
in drug absorption, 35-36, 36f Analgesics, 56-57, 149. See also Aspirin; Narcotic
sodium bicarbonate and, 168- pain relievers.
169
Anaphylaxis, 85, 86f
Acidosis, metabolic, 168, 169
from albumin microsphere octafluoropropane, 91
ACLS, 156
epinephrine for, 44
Acquired immunodeficiency syndrome. See
gadolinium compounds and, 90
AIDS. Active transport, in drug absorption, 34-
standard of care and, 112b
35, 35f Activity/treatment record, 22f
Anesthetics, 103
Acute renal failure
Angiography
intravascular ROCM and, 87
acute renal failure and, 87
prophylaxis against, 88-89 digital subtraction, serum iodine concentration for, 82
ADH, 158
Anion, 66
heart failure with osmotic load and, 83,
Antagonist drug reaction, 44, 45b
84f Adrenaline. See Epinephrine.
Antecubital space, 112
Adrenergic receptors, 157-158,
Antianxiety drugs, 59-60, 149
158t atropine and, 163-164
Antiarrhythmic drugs, 54
dopamine and, 158t, 162
Antibiotics, 60
epinephrine and, 157-158
Anticoagulant drugs, 56
Advanced cardiac life support, 156
Anticonvulsants, 59
Adverse effect, 48
Antidepressants, 59
Aerosol inhalers, 33
Antidiabetic drugs, 58
Agonist drug reaction, 43-44, 45b
Antidiuretic hormone. See ADH.
AHA (American Heart Association), cardiac arrest
Antifungals, 60
guidelines by, 156
Antigen-antibody complex, 85
epinephrine in, 160
Antihistamines, 58, 103
AHFS (American Hospital Formulary Service)
Antihypertensive drugs, 55
Drug Information, 25
radiopaque contrast media and, 93
AIDS, 129t, 133, 134. See also Human immunodeficiency
Antiplatelet drugs, 56
virus (HIV).
Antipsychotic drugs, 59
exposure management with, 142
Antiseizure drugs, 59
Albumin, in sonography, 75, 76, 83b, 91
Antiseptic agents, 103
Alcohol, 44b
Antivirals, 60
diazepam and, 49
Anxiety, patient, 147-148
half-life of elimination and, 46
Aortogram, abdominal, 71f
Alfentanyl, 15, 57
Appendicitis, from barium sulfate, 93
Allergic reaction, 49. See also Anaphylaxis.
185
Index
Arrhythmia, cardiac, 54, 83-84

C
Asepsis, medical, 136, 137f, 138-143
Aspiration Calcium chelation, and intravascular
barium sulfate and, 93 ROCM, 83
injection, 106, 111 Capsules, 32
Aspirin, 35-36, 56, 57 Cardiac arrest, 84, 155
half-life of elimination and, 46 acidosis from, 168-
ASRT, 3, 3b, 4 169 arrhythmia and,
Assessment, patient, 91, 92b 160b
Astringent agents, 103 Cardiac medications, 54-56, 156-171, 159t
Asystole Cardiorespiratory arrest, 155-156
atropine for, 165 amiodarone for, 167-168
epinephrine for, 158, 161 atropine for, 163-165
vasopressin for, 161 dopamine for, 162-163
Atropine, 163, 164 epinephrine for, 157, 158-160
adverse effects of, 165 lidocaine for, 165-166
dopamine with, 164 sodium bicarbonate for, 169-170
dosage for, 164-165 treatment for, 156
drug interactions with, 164 vasopressin for, 160-161
epinephrine with, 164 Cardiovascular system, and intravascular
indications for, 164 ROCM, 83-85, 84f
and muscarinic drug receptors, 163, 164b Catheter IV infusion, 112-113, 113f
parenteral forms of, 159t air embolism and, 113
vagus nerve blockade with, 165 central lines in, 116-117
Cation, 66
B Centers for Disease Control and
Bacteria, 127 Prevention infection control precautions
Bacteriostatic agents, 103 of, 142-143 isolation precautions of,
Barbiturates, 44b, 149-150 134-135, 136
Barium, 36, 64, 65 website of, 133,
Barium sulfate, 72, 93b 143 Central nervous
adverse effects with, 93 system
Baroreceptors, 83 antihypertensive agents and, 55
Barrier protection equipment, 136, 138- intravascular ROCM and, 70-71, 83
139 Basilic vein, 112, 112f Central venous lines, 116-117
Benzodiazepines, 15, 16t, 44b, 150-151 Cephalic vein, 112, 112f
adverse reactions with, 151 Chart summary sheet, 18f
Beta receptors Charting, 17, 102b, 114-116, 119
adrenergic stimulation of, 157-158, Chemotherapy agents, 60
158t antiarrhythmics and, 54 Chest tubes, 116
drug-receptor interactions and, 44 in drug administration, 160
Bicarbonate. See Sodium bicarbonate. Chloral hydrate, 15, 16t
Biliary system, and intravascular Chlordiazepoxide, 15, 59-60
ROCM, 71 Chlorhexidine, 4b
Biohazardous waste, 140f, 140-141, 141f Cholangiography, 71
Biopharmaceutics, 30 Cholebrine. See Iocetamic acid.
Blood urea nitrogen, 106b Cholecystography, 71
Blood vessels, by low-kilovoltage oral, 73f
technique, 64 Cimetidine, 45, 46
Blood-borne pathogen management ROCM precipitates with, 93t
controls, 142-143 Circulatory collapse, intravenous
Blood-brain barrier, 37 injection with, 108
pathologic tissue and, 71 Claustrophobia, 147
Body fluids, 130-131 Clinical record, 21f
Body substance isolation. See CNS
Universal precautions. antihypertensive agents and, 55
Bradycardia, from vasovagal event, 83, 84f intravascular ROCM and, 70-71, 83
Butterfly set, 112, 113f, 115f Cocaine, 15, 16t, 44b, 48b
Code Blue, 156
Codeine, 15, 16t, 44b
186 poppy seeds and,
49b
Index
Colon, by rectal ROCM, 72, 73f
187
Index
atropine with, 164

Computed tomography (CT)
abdomen by, 74f
gastrointestinal tract by, 72
serum iodine concentration for, 82
Confidentiality, patient, 7-8
Congestive heart failure
dopamine for, 162
lidocaine and, 166
osmotic load and, 83,
84f
sodium bicarbonate and, 170
Conscious sedation, 148-149, 152
Consent
contrast media form for, 24f
refusal of, 6b
Consultation form, 20f
Contaminated waste, 140f, 140-141, 141f
Continuing education, 6
Contrast media, 108b. See also
Paramagnetic contrast agents;
Radiopaque contrast media (ROCM);
Ultrasound microbubble agents.
consent form for, 24f
Controlled substances, 15
schedules for, 15-16, 16t
Creatinine level, and intravascular ROCM, 87,
106b CT, 72, 74f, 82
CV lines, 116-117
Cytochrome P 450, 45
D
DEA, 15
Decompensated thyrotoxicosis,
89 Diabetes
dopamine and, 163
Diatrizoate meglumine, 67t, 68t, 72
intravenous drug precipitates with, 93t
Diatrizoate sodium, 67t, 68t, 69f, 72
Diazepam, 15, 16t, 57, 59-60
alcohol and, 49
ROCM precipitates with, 93t
Digital subtraction angiography, serum iodine
concentration for, 82
Digoxin, 54, 55
Diphenhydramine, 58
Disinfection, 139
Disseminated intravascular coagulation (DIC),
and radiopaque contrast media, 89-90
Dissolution, 33f
Diuretic drugs, 55-
56
for congestive heart failure, 83
Dobutamine, 55, 83
Dopamine, 55, 162
and adrenergic receptors, 158t, 162
adverse effects of, 163
187
Index
excretion of, 38
Dopamine half-life of elimination for,
(Continued) 46 herbal products and, 17
dosage for, legend, 13
162-163 mechanism of action by, 43
drug interactions with, minimum effective concentration for, 47b,
163 indications for, 162 47f patents for, 13
lidocaine and, 167 prescription for, 13, 15
parenteral forms serum concentration-time profile of, 46, 47b, 47f
of, 159t sodium
bicarbonate and,
170 stability of,
163
Dorsogluteal IM drug site,
109, 110f Dosage forms,
30-33, 31b, 32t
absorption of, 34t
weights and measures for, 105t
Drug administration, 100-101, 117-
119 abbreviations and symbols in,
119-120t aspiration in IM or
subcutaneous, 106, 111 buccal, 102
endotracheal tube route in, 160
by imaging technologists, 2, 3, 3b, 100-101,
101b medication withdrawal for, 104t
oral, 102
parenteral, 103, 104t, 105-114
rectal, 103
routes of delivery and, 38, 102-103,
105-109, 111-114, 160
sublingual, 102
suspensions in, 108
topical, 102-103
Drug Enforcement Agency, 15
Drug Interaction Facts, 25
Drug receptors, 43-44, 44f,
45b adrenergic, 158t
muscarinic,
164b Drug
references,
22, 25
Drug-drug interaction, 49, 91-92
Drug-enzyme interactions, 44-46
Drugs, 12-13. See also specific classes of
drugs. absorption of, 33, 33f, 34, 34t
acid-base properties in,
35-36, 36f active
transport in, 34-35, 35f
affinity and, 43, 45b
lipophilicity in, 34,
36 passive diffusion
in, 34, 35f
receptors in, 43-44,
44f, 45b.
See also Beta receptors.
administration of. See Drug
administration. biotransformation
of, 37-38
distribution of, 37
duration of action for,
47b, 47f efficacy of,
45b, 46
188
Index
Drugs (Continued)
Flumazenil, dosage for, 149
side effects of,
Flurazepam, 15
48
Fomite, 131
therapeutic index for, 46-48
Food and Drug Administration,
Drugs in Pregnancy and Lactation, 25
13 Fungi, 128
DSA, serum iodine concentration for, 82
Furosemide, 55-56, 83
Duodenum, by enteral ROCM, 72
G
E
Gadolinium compounds, 74, 82b
Echocardiography, by gas emulsion, 75-76, 83b
adverse effects with, 90
Gamma-aminobutyric acid (GABA),
Educational standard, 5, 6
59-60, 149
patient confidentiality and, 7
Gastrointestinal tract
Effective dose, for drugs, 47
by enteral ROCM, 72, 73f
Efficacy, of drugs, 45b, 46
by high-kilovoltage technique, 64
Electronic data interchange, 7
Genitourinary tract, by low-kilovoltage
Emboli
technique, 64
air, intravenous catheter infusion and, 113
Gloving, 136, 138
chemically induced, 91-92
Emergency assistance paging system, 156 H
Emergency cart, 156, 157f
Emergency pharmacology action, 155 Halazepam, 15
Emollients, 46, 103 Half-life of drug elimination, 46
Emulsion, 32t Handbook on Injectable Drugs, 25
Endotoxin, 127 Handwashing, 136, 137f, 138
Endotracheal tubes, 116 Hansten’s Drug Interactions, 25
in drug administration, Health Insurance Portability and
160 Enema, retention, 103 Accountability Act, 7, 8
Enzymes, 44 Health records, 7, 7b, 8, 114-116, 119
Ephedra, 17 Hemorrhage, subarachnoid, radiopaque contrast
Epinephrine, 55, 157, 158 media and, 90
and adrenergic receptors, 157-158, Henderson-Hasselbach equation, 169
158t adverse effects of, 157b, 160 Hepatic-biliary system, and
for anaphylaxis, 44 intravascular
atropine with, 164 ROCM, 71
dosage for, 159 Hepatitis B virus (HBV), 132, 133, 133b,
high dosage of, 140 sharps-injury transmission of, 141t
160 indications for, Hepatitis viruses, 132, 133
158 Herbal products, 16-17
lidocaine and, 167 Herpes simplex, 127, 129t, 131-132
parenteral forms of, 159t High-osmolality ionic ROCM, 66, 67-68t, 69f
sodium bicarbonate and, 170 anticoagulation and, 85
stability of, 160 HIPAA, 7, 8
versus vasopressin, 161 Hospital linens, 140
Esophagus, by enteral ROCM, 72 Hospital order sheet,
ET (endotracheal tube) drug 14f Hospital problem
administration, 160 list, 18f
Eumycetes, 128 Housekeeping, in infection control, 139
Exposure management, 142 Human immunodeficiency virus
Extravasation, 114 (HIV), 133-134, 140-141
exposure management with,
F 142 prevention against, 142-
143
Facts and Comparisons, 25
saliva and, 134, 138
FDA, 13
sharps-injury transmission of, 141t
Fenoldopam, 88
Hydrocodone, 15, 57
Fentanyl, 15, 16t, 149
Hydromorphone, 15, 16t, 44b
dosage for, 152
Hydroxyzine, 48, 58
Ferumoxides, 74
Hyperosmolar ROCM, vagus nerve
adverse reactions with, 90-91
189
Index
stimulation by, 83
Hypersensitivity reaction, type I, 85
190
Index
saline flush between, 92

I in venipuncture practice, 3, 3b
ID, 104t, 106, 106f
IM. See Intramuscular (IM) injection.
Imaging technologist
basic life support and, 156
conscious sedation by, 148-149,
152
drug administration by, 2, 3,
3b, 100-101, 101b. See
also Drug administration.
educational curriculum of, 5-6
patient confidentiality and, 7
microorganism reservoirs and, 130b
Immune system, 85
Infection, 128, 130f, 130-131
cycle of, 130f
exposure management and, 142
portal of entry for, 131-132
prevention controls against, 142-
143 sharps-injury transmission of,
141t
Informed consent form, radiology, 24f
Insoluble precipitates, 36
Insulin, 58
Intracutaneous injection, 104t, 106
Intradermal injection, 104t, 106, 106f
Intramuscular (IM) injection, 104t, 108-
109,
110f, 111-112
aspiration and, 111
Intraosseous (IO) injection, 160
Intravenous injection, 104t, 112-114,
115-116f
drip infusion in, 112-113, 113f
air embolism and, 113
central lines in, 116-117
saline flush with, 92
in fatal mistake, 4-5b
ROCM standard of care and, 112b
in scope of practice, 3, 3b
thrombolytic agents and, 56
Intravenous pyelogram, 87b
mortality and, 4b
IO injection, 160
Iocetamic acid, 72
Iodamide meglumine, 67t, 71
Iodine, as contrast agent, 46, 64-65,
65f, 72, 87b, 108b
Iothalamate, 67t, 68t
intravenous drug precipitate with, 93t
Ioxaglate, 69t, 70f
Iron compounds, 74, 90-91
dopamine and, 163
IV medications, 113f. See also
Intravenous injection; Radiopaque
contrast
media (ROCM).
191
Index
Low-osmolality ionic ROCM, 68, 69t, 70f
J Low-osmolality nonionic
ROCM, 66, 68, 69f, 69t
Joint Review Committee on Education in
Radiologic Technology, 3 M
Joint Review Committee on Education Ma Huang, 17
Programs in Nuclear Medicine Magnetic resonance imaging, 73-74, 75f
Technology, intravenous contrast agents for, 73-75, 82b, 90-91
injection practice of, 3 Mangafodipir, 75, 91
JRCERT, 3 Mast cells, 85
Median lethal dose, 25b, 47
K Medical asepsis, 136, 137f, 138-
Keratin, 103 143 Medical malpractice, 2b, 3-4
Key terms, 1, 12, 30, 43, 54, 64, 81, Medical records, 7, 7b, 8, 114-116, 119
100, 126, 147, 155 Medication. See Drugs.
Kilovoltage technique, with contrast media, Medication record form, 23f
64 Meperidine, 15, 16t, 48, 149
dosage for, 152
L
Laboratory Metabolic acidosis, 168, 169
test Metabolism, of drugs, 37-38
record, Metformin, 58
20f LD50,
25b, 47
Legend drugs, 13
Lethal
dose,
median,
25b, 47
Leukotrien
e, 85
Liability, 5
Lidocaine,
54, 165,
166
adverse
effects
of, 166-
167
dosage
for, 166
drug
interactions
with, 167
indications
for, 166
parenteral
forms of,
159t sodium
bicarbonate
and, 170
stability of,
167
Lipid-based
solution
in
sonograp
hy, 75,
76, 91
Lipid-lowering drugs, 55
Lipodystrophy, 105
Lipophilicity, 34, 36
Lorazepam, 15, 16t, 57, 59-60
192
Index
Methadone, 15, 44b

Oxazepam, 15, 16t
Methohexital, 150
Oxycodone, 16t, 57
atropine and, 165
Metrizamide, 69f, 69t
P
MicroMedex Drug Information, 25
Microorganisms, 126-127 PA lines, 117
reservoirs of, 128, 130 Pain, and needle injections, 111-
Midazolam, 15, 16t, 59-60, 150-151 112 Panic disorder, 147
apnea with, 151 Paralytic agents, 170
dosage for, 151 Paramagnetic contrast agents, 73-75, 82b, 90-91
Mid-deltoid IM drug site, 110f, 111 Parenteral dosage forms, 33, 104t
Milrinone, 55 Passive diffusion, in drug absorption, 34, 35f
Minimum effective concentration, for drugs, 47b, 47f Pathogens, 128, 129t
Morphine, 15, 16t, 44b, 149 portals of entry for, 131-132
dosage for, 152 reservoirs of, 130
poppy seeds and, Patient chart, 7b, 17, 102b, 114-116, 119
49b Patient confidentiality, 7-8
Multiple myeloma, and radiopaque Patient history, 17, 19f
contrast media, 90 radiologic, 5b, 24f, 92b, 160b
Muscle relaxant drugs, 57 Patient progress notes, 20f
Myocardial infarction Patient screening, for radiology services, 91, 92b
atropine and, 165 Patients, infection exposure management with,
dopamine for, 162 142 PDR, 25
from vasopressin, 161 Peak serum concentration, 47b, 47f
Pentazocine, 15, 57
N Pentobarbital, 16t, 59
Naloxone, 57 atropine and, 165
dosage for, 149 Perflutren, 75-76, 91
Narcotic inventory form, 23f Peritonitis, from barium sulfate, 93
Narcotic pain relievers, 15, 16t, 57, 152 pH
in conscious sedation, 149, 152 in drug transport, 35-36, 36f
Needles, 108, 109f, 113f in Henderson-Hasselbach equation, 169
for medication withdrawal, 104t Pharmacodynamics, 43
pain and, 111-112 Pharmacokinetics, 34
Negligence, 3 Pharmacology, 12
venous access line and, 112b and herbal products, 17
Neuromuscular blockers, 170 Phenobarbital, 150
Nonsteroidal antiinflammatory drugs (NSAIDS), 57 Phenothiazine, and ROCM, 93
Norepinephrine, 55, 59 Phenytoin, 59
atropine and, 165 dopamine and, 163
lidocaine and, 167 half-life of elimination and, 46
Nosocomial infection, 132 Pheochromocytoma, and radiopaque contrast media, 90
NSR (normal sinus rhythm), 165 Phlebotomy, 138
Nuclear medicine technologists. See also Imaging Phobia, 147
technologist. Physical Examination form, 19f
pharmaceutical agents practice by, 3 Physician’s Desk Reference,
Nystatin, 128 25 Physician’s order sheet,
14f Pinocytosis, 36
O Placental barrier, 37
radiopaque contrast media across, 90
Octafluoropropane, 75-76
Positive inotropic effect, 55
Potency, of drugs, 46
Ointments, 46
Prescription, for legend drugs, 13, 15
Oliguric, 87
Professional standard, 6
Onset of action, for drugs, 47b, 47f
Propoxyphene, 15, 44b
Opiates. See Analgesics; Narcotic pain relievers.
Propranolol, 44, 55
Osmolality, 65
Protein carrier transport, for drug
Osmolarity, 65
absorption, 34-35, 35f
Osmotic activity, 65, 66f
Protozoa, 127
of radiopaque contrast media, 65-66
193
Index
Pulmonary arterial lines, 117 Scope of practice (Continued)

Pulseless electrical activity (PEA), 83-84, 158 and standard of care, 6-7
treatment of, 161 venipuncture practice in, 3, 3b
“Scrubs,” 140
R Secobarbital, 16t, 59
Radiologic patient history form, 24f Sepsis, vasopressin for, 161
Radiologic technologist. See also Imaging technologist. Serotonin, 59, 60
conscious sedation by, 148-149, 152 Serum concentration-time profile, 46, 47b, 47f
drug administration by, 2, 3, 3b, 100-101, 101b Serum creatinine, and intravascular
microorganism reservoirs and, 130b ROCM, 87, 106b
Radiopaque contrast media (ROCM), 64-65, 66, 81 Serum iodine concentration
acute renal failure from, 87 for computed tomography, 82
adverse effects with, 82-85, 87, 89-90 for contrast x-ray, 81
anaphylactoid reaction from, 86f, 87 Sharps control, 140-142, 141f
bradycardia from, 83 in universal precautions, 135b
calcium chelation with, 83 Shock
consent form for, 24f dopamine for, 162
contraindications to, 90, intravenous injection with, 108,
106b dehydration and, 82-83 112b vasopressin for, 161
disseminated intravascular coagulation from, 89-90 Sickle cell anemia, and radiopaque
drug interactions with, 91-92, 93t contrast media, 90
enteral, 72 Sodium bicarbonate, 168, 169
hydration with, 88 adverse effects of, 169, 170
intravascular, 66, 68, 70-71 amiodarone and, 168
categories of, 66, 67-68t, 68, 69t atropine and, 165
ionic, 108b. See also High-osmolality dopamine and, 163
ionic ROCM. dosage of, 169-170
metformin and, 58 parenteral forms of, 159t
multiple myeloma and, 90 ROCM with, 89
osmotic activity of, 65-66, 82, 108b Sodium hypochlorite, 139
screening questions before, 91, 92b Solution, 32t
sickle cell anemia and, 90 Sonography. See Ultrasound.
vasovagal reaction with, 83 Spinal cord, by magnetic resonance
in venipuncture practice, 3, 3b imaging, 75f
Radiopharmaceuticals, in venipuncture Standard of care, 4, 6
practice, 3, 3b IV catheter and,
Ratio-1.5 media, 66, 112b liability and, 5
69f litigation and, 6
Ratio-3.0 media, 66, 68, 69f, 70f scope of practice and, 6-7
Rectum, by rectal ROCM, 72, 73f Standard precautions. See Universal precautions.
Red blood cells (RBCs), and radiopaque Staphylococcus aureus, 129t, 132
contrast media, 82 universal precautions and, 135
Refusal of consent, 6b “Sterilants,” 136
Regulatory agencies, for controlled substances, 15 Sterilization, 139
Renal system Stomach, by enteral ROCM, 72
by intravascular ROCM, 71 Subcutaneous injection, 104t, 106-108, 107f
intravascular ROCM and, 82-83, 87. aspiration and, 106
See also Acute renal failure. Sudden death, 84
Renin-angiotensin-aldosterone system, 84f, 157-158 Suppositories, 32, 103
Respiratory arrest, 155 Suspension, 32t
ROCM. See Radiopaque contrast media (ROCM). Suspension IM drug administration,
ROSC (return of spontaneous circulation), 157-158 108 Swan-Ganz catheters, 117
RT. See Radiologic technologist. Synergism, 49
Syringes, 107f
S
SC, 104t, 106-108, 107f T
Scope of practice, 2, 3 Tablets, 31-32
liability and, 5 Target organ, 43
litigation and, 6
194
Illustration Credits
Telephone orders, 13, 15, 117-118

Vasopressin (Continued)
Temazepam, 15, 16t
indications for, 161
Termination of action, for drugs, 47b, 47f
parenteral forms of, 159t
Theophylline, 45-46 Vasovagal reaction, 83, 84f
half-life of elimination of,
with gadolinium compounds, 90
48f Therapeutic index, 46-48
Vastus lateralis IM drug site, 110f,
Therapeutic range, for drugs, 47b, 47f
111 Vector, for infection, 131
Thiopental, 150
Venipuncture, 113-114, 115-116f
Thrombolytic drugs, 56
in radiologic education, 3, 3b
Thyroid medication, 58-59
veins in, 112, 112f
Thyroid storm, 89
Venous access devices, 116-117
Thyrotoxicosis, decompensated, 89 Ventricular fibrillation, 84
Toxic level, of drugs, 47b, 47f amiodarone for, 167
Toxicity, 48 from atropine, 165
Treatment, refusal of, 6b
epinephrine and, 158, 160
Treatment record forms,
lidocaine for, 166
22f Triazolam, 15
vasopressin for, 161
Triiodinated benzoic acid, 64, 65f
Ventrogluteal IM drug site, 109,
Troches, 32
110f Verbal orders, 13, 15, 117-118
Tuberculin syringe, 107f
Vials, for medication, 104t
Tuberculosis, 129t, 134
Viruses, 127
sharps-injury transmission of, 141t
Vital sign record forms, 21f
universal precautions and, 135
Tumor, brain, by intravascular ROCM, 71 W
Warfarin, 56
U Water retension
Ultrasound, abdomen by, 75f epinephrine in, 158
Ultrasound microbubble agents, 75-76, 83b vasopressin in, 161
adverse effects with, 91 Website
Uniforms, 140 for AHFS Drug Information, 25
Universal precautions, 134-135, 135b for Centers for Disease Control and
standard precautions and, 143 Prevention, 133, 143
Urinary tract, and intravenous ROCM, 70, for Facts and Comparisons, 25
70f Urogram, 70f for Physician’s Desk Reference, 25
for practice standards, 4
V for radiology certification information, 3
Vasopressin, 158, 160-162 X
adverse effects of, 161
X-ray
dosage for, 161
contrast, serum iodine concentration for,
heart failure with osmotic load and, 83, 84f
81 malpractice litigation and, 2b
192 195
Illustration Credits
Illustration Credits Figs. 9-3, A, and 11-1: From Kowalczyk N, Donnett K:

Integrated patient care for the imaging professional, St
Figs. 6-6, 6-7, 6-8, and 6-9: From Ballinger PW, Frank
Louis, 1996, Mosby.
ED: Merrill’s atlas of radiographic positions and
Figs. 3-1, 3-4, 4-2, and 8-5: From McKenry LM, Salerno
radiologic procedures, ed 10, St Louis, 2003, Mosby.
E: Mosby’s pharmacology in nursing, ed 21, St Louis,
Figs. 2-1, 2-2, 2-3, 2-4, 2-5, 2-6, 2-7, 2-8, 2-9, 2-10, 2-11,
2003, Mosby.
and 8-4: From Edmunds MW: Introduction to clinical
pharmacology, ed 4, St Louis, 2003, Mosby.
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PHARMACOLOGY

AND DRUG ADMINISTRATION

Steven C. Jensen, RT(R),

Michael P. Peppers, RPh, PharmD

PHARMACOLOGY AND DRUG ADMINISTRATION FOR ISBN-13: 978-0-323-03075-5

Copyright © 2006, 1998 by Mosby, Inc.

Acquisitions Editor: Jeanne Wilke

Printed in the United States of America

To Jordan and Emily

And to my parents, Bob and Joan,

To my mother, Carol Eaton,

To my stepfather, Jim Eaton,

To my brother, Martin Peppers,

And to my twin daughters, Brooke and Brittany,

Our intent in writing this textbook is to help

focus on essential information that

1 The Role of the Imaging Professional, 1

7 Pharmacodynamics of Infection Prevention and Control,

The injection went smoothly, and the ER physician returned to

? DID YOU KNOW?

The Joint Review Committee on Education in Radiologic

Resolution 91-4.04. Be it resolved, that the ASRT adopt the

The Joint Review Committee on Education Programs in

ETHICAL AND LEGAL IMPLICATIONS

malpractice is a breach of duty to adhere to a standard of care. In

? DID YOU KNOW?

HOSPITAL ADMITS FATAL MISTAKE THAT POISONED PATIENT

HOSPITAL ADMITS FATAL MISTAKE THAT POISONED PATIENT—CONT’D

Liability and propose appropriate

? DID YOU KNOW?

guides are periodically reviewed and revised by the ASRT and

Providers, payors, and

and outside visitors in the course of performing daily business. These

1. T F The American College of Radiology does not include the

2. T F It is common for technologists to administer drugs to

3. T F Scope of practice is a series of guidelines set forth to

4. T F In a legal liability case the courts generally recognize

5. T F The number of technologists performing venipuncture is

6. T F A radiographer performing nuclear medicine studies will

7. T F If a health care facility requires an employee to perform

8. T F Some technologists practice across different lines of

9. T F All state laws referring to nuclear medicine technologists

10. T F The Joint Review Committee on Educational Programs in

2. What is the standard of care for your specialty?

3. In an emergency situation, what are your responsibilities?

4. How would you have handled the situation described at

5. Do you fully understand HIPAA guidelines as they pertain to

6. What are the differences between medical negligence and

7. Does your clinical facility have written guidelines

8. Does your clinical facility assume liability for technologists

9. If the clinical facility does not assume the liability expressed

KEY TERMS OBJECTIVES

and the brand

THE LEGAL PRESCRIPTION

Fig. 2-1 Physician’s order sheet.

A “verbal order” is one that is transcribed, by a certified medical

CONTROLLED SUBSTANCES should store the drugs

? DID YOU KNOW?

Table 2-1 Controlled Substance Schedules

C-I High abuse potential. No currently accepted medical use in the

Drug () in Cell Drug () in

Drug () in high Cell Drug () in high