The RN in the intensive care unit has been administering ondansetron (Zofran) to a patient every 4-6 hours for nausea.
The RN notices that the patient has developed Q-T prolongation per the cardiac monitor.
Suddenly, the patient develops a wide-complex arrhythmia and is quickly determined to be in Torsades de Pointes. What is the 1st line drug for treatment?

Choice A rationale:

Fever is not a common side effect of metformin. While it's possible for a minority of patients to experience a mild fever as their bodies adjust to the medication, it's not considered a typical or expected adverse effect.

Fevers typically occur due to infections or inflammation, and metformin does not directly cause either of these processes.

If a patient taking metformin develops a fever, it's crucial to rule out other potential causes, such as infections or other medications, before attributing it to metformin.

Choice B rationale:

Insomnia is also not a common side effect of metformin. In fact, some studies have suggested that metformin may even have a positive effect on sleep quality in some individuals.

While sleep disturbances can occur with any medication, they are not specifically associated with metformin.

If a patient experiences insomnia while taking metformin, it's essential to consider other potential factors, such as stress, anxiety, or other medications, that could be contributing to sleep problems.

Choice C rationale:

Bitter or metallic taste is a very common side effect of metformin, experienced by approximately 30-40% of patients. This taste disturbance is thought to be caused by metformin's interaction with taste receptors on the tongue.

The taste is often described as metallic, bitter, or similar to the taste of pennies.

While it can be unpleasant, it's generally not considered a serious side effect and does not usually require discontinuation of the medication.

Some strategies to manage the metallic taste include: Taking metformin with meals or snacks to mask the taste.

Chewing sugar-free gum or sucking on hard candy after taking the medication. Rinsing the mouth with water or mouthwash after taking the medication.

Switching to an extended-release formulation of metformin, which may have a less pronounced metallic taste.

Choice D rationale:

Seizures are a rare but serious side effect of metformin.

They are most likely to occur in patients with underlying kidney problems or those taking certain other medications that can interact with metformin.

If a patient taking metformin experiences a seizure, it's critical to seek immediate medical attention.

Choice A rationale:

Dopamine was once considered a first-line vasopressor for cardiogenic shock. However, recent studies have shown that it is associated with increased mortality compared to norepinephrine.

Dopamine has dose-dependent effects on dopamine receptors, beta receptors, and alpha receptors. At low doses (1-5 mcg/kg/min), it primarily stimulates dopamine receptors, leading to renal vasodilation and increased urine output. At moderate doses (5-10 mcg/kg/min), it stimulates beta receptors, resulting in increased heart rate and contractility. At high doses (>10 mcg/kg/min), it stimulates alpha receptors, causing vasoconstriction.

The main concern with dopamine is its potential to cause arrhythmias, particularly at higher doses. This is due to its effects on beta receptors, which can increase heart rate and myocardial oxygen demand.

Additionally, dopamine can cause tachyphylaxis, meaning that its effects can diminish over time, requiring higher doses to achieve the same effect.

Choice B rationale:

Norepinephrine is a potent alpha-adrenergic agonist that causes vasoconstriction, leading to an increase in blood pressure. It has minimal effects on beta receptors, so it is less likely to cause tachycardia and arrhythmias compared to dopamine.

Norepinephrine also has some inotropic effects, meaning that it can increase the strength of contraction of the heart muscle.

Studies have shown that norepinephrine is associated with improved survival rates in patients with cardiogenic shock compared to dopamine.

It is generally well-tolerated, with the most common side effects being hypertension and peripheral vasoconstriction.

Choice C rationale:

Epinephrine is a potent alpha- and beta-adrenergic agonist that causes vasoconstriction, increased heart rate, and increased contractility.

It is typically used as a second-line agent in cardiogenic shock, after norepinephrine has failed to achieve adequate blood pressure.

Epinephrine can cause significant tachycardia and arrhythmias, so it should be used with caution in patients with underlying heart disease.

Choice D rationale:

Vasopressin is a hormone that causes vasoconstriction by acting on V1 receptors in vascular smooth muscle. It is sometimes used as an adjunct to norepinephrine in patients with refractory cardiogenic shock.

Vasopressin has the potential to cause coronary vasoconstriction, so it should be used with caution in patients with coronary artery disease.