Short duration of CPR and low adrenaline dosage correlate with immediate and long-term success of CPR. It is an alkalizing agent used to buffer acids present in the body during periods of metabolic acidosis. 2% slowly. Do not administer with other medications in same IV line. It provides bicarbonate to assist the buffer system in reducing the effects of acidosis. The standard dosage is 1 mg/kg of body weight as the initial dose followed by 0. NWRETAC Combined EMS Guidelines Approved January 1, 2018. Sodium bicarbonate (SB) administration has been considered an important part of treatment for severe metabolic acidosis in cardiac arrest, because, based on pathophysiologic considerations, normalization of extracellular and intracellular pH was considered a meaningful endpoint of resuscitation. This indicates that long-term CPCR success is inversely correlated with increasing amounts of sodium-bicarbonate infused. 9 to 10 grams (1 to 2½ teaspoonfuls) in a glass of cold water after meals.
Administration and Dosage. Sodium Bicarbonate. 5 grams (5 teaspoonfuls) a day. Most commonly used antacids contain less soluble agents, given alone or in combination. Acids are increased when body tissues become hypoxic due to cardiac or respiratory arrest. New research changes drug and treatment therapies daily. Food and Drug Administration (FDA) to increase the availability of Sodium Bicarbonate Injection. 44 Xylometazoline HCL (Otrivin). 5mEq/L), altering the resting potential gradient, as Sodium influx is decreased and Potassium influx increases.
Sodium Bicarbonate (NaHCO3) DESCRIPTION. Aspirin Poisoning Overview. Although Calcium Chloride Pharmacologic properties: Calcium is a cation that essential for neurotransmission, bone formation, enzymatic reactions and muscle (including cardiac) contraction. In lactic acidosis and diabetic ketoacidosis, the organic anion can regenerate bicarbonate when Florida Regional Common EMS Protocols Drug Summary Section Table of Contents 5. Experimental tricyclic antidepressant toxicity: a randomized, controlled comparison of hypertonic saline solution, sodium bicarbonate, and hyperventilation. When used for this purpose, it is said to belong to the group of medicines called antacids. Care should be taken if patient is already using an inhalant due to possible development of severe paradoxical airway resistance with repeated excessive use. 3 reasons to use ketamine for prehospital analgesia. For medication administration, document dosage, route of administration, time of Bicarb Sodium bicarbonate EMS Coordinator Hall County Fire Services Table of .
Medical grade sodium bicarbonate is also used for preparation of dialysate solution. During Hyperkalemia, a greater amount of Potassium is found extracellular (>5. 4% and 4. ” Sodium bicarbonate Sotalol Streptokinase Succinylcholine Tenecteplase Tetracaine Thiamine Tiroﬁ ban Vasopressin Vecuronium Verapamil DRUG IDENTIFICATION GUIDE The Emergency Drug Index is a list of commonly prescribed medications that are used in prehospital care; it is not intended to be a complete guide to all emergency medi- Sodium bicarbonate is an antacid used to relieve heartburn and acid indigestion. At each clinical setting, physicians and other providers should evaluate drug, equipment, and training needs. sodium bicarbonate, Furosemide, calcium chloride). 5-1. • Narcan – it is not necessary that the patient be awake and alert. 4% solution and add 25 ml of NS from IV bag, each ml will contain 0.
5% Acetylsalicylic Acid, aspirin, ASA EMT Administration Proparacaine Hydrochloride Ophthalmic Before 1986, sodium bicarbonate was routinely used during CPR, even without knowledge of the patient’s acid-base status. Federal Government. Clinically, this means an eGFR of less than 30 ml/min; an eGFR of100 ml/min is considered “healthy. 3. Solutions are offered in concentrations of 4. 0%, 7. MEDICATION 15 Epinephrine (1:10,000) Pharmacologic properties: Epinephrine is a sympathomimetic which stimulates both Alpha and Beta adrenergic receptors. To view the price of the Prehospital Pathophysiology is a new monthly column that provides an opportunity for EMS providers of all Crush Injuries and Compartment Syndrome. Find patient medical information for Sodium Bicarbonate Oral on WebMD including its uses, side effects and safety, interactions, pictures, warnings and user ratings.
Brown TC. Sodium chloride can reduce some types of bacteria in certain body secretions, such as saliva. Calculating medications when given a dosage range and a per kg dose: A. Calculate weight in kilos and multiply by the prescribed dosage (e. Adult: 1 mEq/kg IV. Following administration of controlled medications, EMS personnel shall follow their individual department's policy on the correct accounting, disposal, and restocking of these medications. Usual Adult Dose for Urinary Alkalinization An alkalizing agent used to buffer acids present in the body during and after severe hypoxia. Tricyclic Whilst an infusion of sodium bicarbonate was used due to ongoing prolongation of the patient’s QRS and for practical reasons, boluses of sodium bicarbonate are thought to be more effective as they lead to rapid shifts in concentration of free drug due to the effect on binding to plasma and tissue proteins. Symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest.
Insulin therapy may obviate the need for bicarbonate therapy since it will promote glucose utilization and decrease the production of ketoacids. SODIUM BICARBONATE . DOSAGE Adult: 1 mEq/kg IV (8. … Calcium chloride should not be administered in the same infusion with sodium bicarbonate, since calcium will combine with sodium bicarbonate to form an insoluble precipitate (calcium carbonate). Guidelines for Use of Sodium Bicarbonate Recommended Neonatal Dose, Route, and Interval Dosage based on base deficit: HCO3 needed (mEq) = 0. Indications Sodium Bicarbonate Injection, USP is a sterile, nonpyrogenic, hypertonic solution of sodium bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and systemic alkalizer. When given to chronic opioid patients, withdrawal symptoms may present. Quick and Dirty Guide to Crush Injuries. 2), 19, 20 which may be an associated feature in ARF.
EMS Drug Formulary EMS personnel must be familiar with a number of drugs and other agents in their routine work. Tricyclic antidepressant overdose is poisoning caused by excessive medication of the tricyclic antidepressant (TCA) type. Prolongs Phase 3 of the Action Potential 3. In cases where the EKG indicates moderate to severe hyperkalemia, administer 1 g IV Calcium Chloride (must use separate IV line or stop Sodium Bicarbonate if running) and administer 10‐20 mg nebulized Albuterol Administer slowly because bicarbonate solution is hyperosmotic. MEDICATION 29 SODIUM BICARBONATE Pharmacologic properties: Sodium bicarbonate is an endogenous anion that reacts with hydrogen ions to form water and carbon dioxide. The cause is believed to be sodium bicarbonate dissociating into carbon dioxide and water; carbon dioxide rapidly crosses the blood-brain barrier, but bicarbonate does not, leading to CNS acidosis. Crush injuries occur when a crushing force is applied to a body area. Next Update: August 2018. Calcium chloride should be given with extreme caution, and in reduced dosage, to persons taking digitalis because it increases ventricular irritability Anticholinesterase Overdosage.
Sodium Bicarbonate may interact with other drugs. Multichannel blocker-Sodium, potassium, calcium channel, noncompetitive Alpha/Beta-Blocker This statement provides current recommendations about the use of emergency drugs for acute pediatric problems that require pharmacologic intervention. 2%, 5. May be deactivated by alkaline solutions (e. Sodium Bicarbonate 1mEq/kg IVP, max dose of 100mEq, for hypotension (SBP 90mmHg or less), seizure, and/or a QRS widening greater than 0. Hospira’s sodium bicarbonate prefilled syringes come in a variety of sizes and concentrations. Aspirin is another name for acetylsalicylic acid, a common pain reliever (also called an analgesic). 5% and 8 How to use 12-lead EKG, scene size-up to assess tricyclic antidepressant overdose A combination of history findings, scene clues and EKG interpretation skills help paramedics quickly identify a Sodium bicarbonate ear drops are used to soften dry or hardened earwax. .
Sodium Bicarbonate in 1000 cc Normal Saline and infuse at 100‐150 cc/hour. May decrease arterial oxygen tension acutely by causing bronchodilation in areas of lung with poor blood perfusion. 04 mg/kg). II. Sodium bicarbonate administration in conjunction with epinephrine was reported to increase survival as early as 1968, with more recent studies demonstrating similar results. (1989) 5161-S172 S161 Elsevier Scientific Publishers Ireland Ltd. In cardiac arrest, indicated for treatment of suspected hyperkalemia (history of renal failure or diabetes). Its effect is to raise the serum pH. Its effects are to increase systemic vascular resistance, arterial blood pressure, coronary and cerebral blood flow, heart rate and contractility.
Calcium chloride should be given with extreme caution, and in reduced dosage, to persons taking digitalis because it increases ventricular irritability I've recently discovered that Austin-Travis EMS has a protocol for its HazMat paramedics to administer nebulized sodium bicarb for chlorine gas inhalation (although for the life of me I can no longer find a link to their protocol manual). ARE INTER-CENTER DIFFERENCES IN EMS-MANAGEMENT AND SODIUM-BICARBONATE ADMINISTRATION IMPORTANT FOR THE OUTCOME OF CPR? Use Sodium Bicarbonate sparingly. 3 x Wt (kg) x base deficit (mEq/L) Administer half of calculated dose, and then assess need for remainder Usual dosage: 1-2mEq/kg of the 4. Initial, 300 mg IV push; if necessary, a supplemental dose of 150 mg IV by rapid infusion may be considered 2. 3/1/2016. There is no substitution for Sodium Bicarbonate. 5mEq/kg IVP, max dose of 50mEq 6. Children up to 6 years of age—Dose must be determined by your doctor. Administration of sodium bicarbonate may inactivate simultaneously administered catecholamines; it will create an insoluble precipitate if mixed with calcium chloride.
The earliest known uses of the drug can be traced back to the Greek 12/12/2011 OCMCA EMS Advisory 005 Duplicate Refusal Protocols 12/12/2011 OCMCA EMS Advisory 004 Narcotic Wasting and Witness Signature 10/18 /2011 OCMCA EMS Advisory 003 Valium and Fentanyl Shortages Drug Profiles Table of Contents [Revised 09-17-2015] ABCIXIMAB Oxytocin Acetylsalicylic Acid, aspirin, ASA Phenylephrine Nasal Spray 0. It has no significant action on plasma K in the first 60 minutes after administration. 5 mg/kg every 10 minutes for the duration of the cardiac arrest. Bicarbonate combines with excess acids (usually lactic acid) present in the body to form a weak, volatile acid. S. PALS Medications for Cardiac Arrest and Symptomatic Arrhythmias DRUG DOSAGE (PEDIATRIC) REMARKS Sodium bicarbonate Infuse slowly and only if ventilation is B. 10 per pound. Refer to Handtevy System infusion instructions for dosage. ALS units may remain in service even if Sodium Bicarbonate is not available.
If we were looking at an apples-to-apples dosage rate for pH control, this would indicate a savings of $0. Your doctor also may prescribe sodium bicarbonate to make your blood or urine less acidic in certain conditions. What follows is a description of drugs or agents used by LCEMS personnel. 11. 20. Calcium chloride should not be administered in the same infusion with sodium bicarbonate, since calcium will combine with sodium bicarbonate to form an insoluble precipitate (calcium carbonate). ACTIONS An alkalizing agent used to buffer acids present in the body during and after severe hypoxia. Child: 1 mEq/kg IV. Do not mix with isoproterenol as it results in exaggerated response.
This document is a tool to be used by the pre-hospital providers that operate in the Bernaillo County system. 5 mEq/kg. Sodium bicarbonate injection, USP is a sterile, nonpyrogenic, hypertonic solution of sodium bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and systemic alkalizer. Tell your doctor all prescription and over-the-counter medications and supplements you use. 2 Albuterol (Proventil®, Ventolin®) 5. Sodium Bicarbonate 8. EMS providers know well the daily tragedies represented by the following three cases, where young or otherwise healthy individuals succumb to sudden and unexpected illness or injury. Alkalosis Sodium and water retention Pain and irritation at infusion site. In the following two circumstances this is particularly important.
Early aggressive treatment of patients suspected of having a crush injury is crucial. It is the initial drug of choice for treating bronchoconstriction and hypotension resulting from anaphylaxis and all forms of cardiac arrest. 03. Formula changes to allow for continued administration of Atropine and Dextrose during this drug shortage. This acid is broken down into CO2 and H2O. Refer to appropriate PRACTICE PARAMETER for specific dosages. 3, 7, 12, 16 It may be indicated in severe metabolic acidosis (pH <7. Renal Failure and Dialysis Patients: What the EMS Provider Should Know sodium bicarbonate and beta agonists cause a reduction in serum potassium levels. 5 mg/min for 18h The main concern with using sodium bicarbonate: The sodium load from baking soda can cause fluid retention, particularly edema and nephrotic syndrome in people with compromised kidneys or chronic kidney disease (CKD).
Description . Rapid infusion of sodium bicarbonate to correct metabolic acidosis has led to paradoxical CNS acidosis in animal studies. may become more susceptible to Sodium and potassium bicarbonates are nontoxic primary alkalizing agents for the prevention and treatment of cancer, liver disease, Type I & Type II diabetes, Lupus, heart disease, pharmacological toxicosis, vascular surgery operation, tonsillar herniation due to cerebral edema, lactic acid toxicosis, and hyponatremia or low salt or loss of salts due to excessive or over-exercise. Interactions: Flush IV line between administrations of Calcium Chloride and Sodium Bicarbonate to avoid precipitation. During pregnancy, Sodium Bicarbonate should only be used if DOSAGE. Side Effects. 1 Rev. Quizlet flashcards, activities and games help you improve your grades. I rank Sodium Bicarbonate 22 on my list of 33 drugs.
Maintenance after return of spontaneous circulation, 1 mg/min for 6h, then 0. Waste 25 ml of 8. Can precipitate or inactivate other drugs. Plasma osmolality Treatment of acute metabolic acidosis by alkali therapy is usually indicated to raise and maintain the plasma pH to greater than 7. Bicarbonate does not improve the ability to defibrillate. Each time you use the drops, allow the solution to remain in your ear for 5-10 minutes. Effectively increases the blood pH. 4% Sodium Bicarbonate . In Stock and Going FAST.
Sodium Bicarbonate 244 Resuscitation, 17 Suppl. 4% Page 2 of 2 1/99 Neonatal Dosage: 1 mEq/kg IV or IO of 4. provide high quality Emergency Medical Services with cutting edge technolgy and the most recent practices and standards of the EMS community. This practice was changed due to the potential adverse effects of buffer therapy and due to the clinical studies that failed to demonstrate any advantage of using sodium bicarbonate during cardiac arrest [58–60]. Sodium chloride is the chemical name for salt. 2. Introduction. INDICATIONS GD-054-PHS-EMS: Drug Profile for Sodium Bicarbonate 8. 1.
g. Stimulates alpha, beta1, and beta2 adrenergic receptors in dose related fashion. Pharmacologic properties: Sodium bicarbonate is an endogenous anion that reacts with hydrogen ions to form water and carbon dioxide. 03-0. 46 Medicine and pharmacology is a constantly changing science and not all therapies are clearly established. Repeat every 15 minutes at 0. INDICATIONS Acidosis associated with prolonged down time in cardiac arrest Tricyclic antidepressant overdose CONTRAINDICATIONS Alkalosis 5. It is used in cooking, as a cleaning agent or in tooth paste. Administer until max dosage is reached : or: RR greater than 12/min.
0 mg rapid IV push or via ET every 3-5 minutes to a total dose of 3 mg if symptoms profound (0. I rate it above calcium partly because it links me more closely with Johnny and Roy, and more importantly because it can be used for tricycliate overdose, and for crush injuries (I have never used it for these indications). Information about drug Sodium bicarbonate combination includes cost of the drug and the type of drug - tablet, capsule, syrup, cream, gel, ointment, liquid or injection. Sodium bicarbonate is an endogenous anion that reacts with hydrogen ions to form water and carbon dioxide. Due to the current critical shortage of Sodium Bicarbonate Injection, USP in the United States (US) market, Athenex Pharmaceutical Division, LLC (Athenex) is coordinating with the U. If hypotension and seizures persist, or if the QRS becomes greater than 0. However, sodium bicarbonate may be used in cases with documented metabolic acidosis after effective ventilation has been established. Midazolam (preferred), * *Medication is optional* MEDICATION ( Refer to the protocols for specific dosages ) Amiodarone or Lidocaine - Premix and Bolus Adenosine Albuterol Sulfate Aspirin clark county ems system emergency medical care protocols effective: june 1, 2017 (replaces march 29, 2017 version) po box 3902 – las vegas, nv 89127 REVISED FORMULARY 2010 Page 6 INTRODUCTION The new State approved Prehospital and Interfacility drug protocols have been developed by the Division of EMS in Sodium Bicarbonate IV (dilute 1:1 with NS if <1year) 1mEq/mL 1mEq/kg 50mEq *Administer 1mL/kg then reassess, if patient still with altered level of consciousness, continue 1mL/kg doses until maximum of 5mL/kg; for patients >24 kg, administer 125mL D10 and reassess, if patient still symptomatic then GD-030-PHS-EMS: Drug Profile for Atropine Sulfate Page 2 of 3 5/13/03 Incompatibilities/Drug Interactions: Sodium bicarbonate (relative) Adult Dosage: Symptomatic Bradycardia: 0. 2% concentration over at least 30 minutes Alabama Department of Public Health, Office of EMS Paramedic Medication Formulary ADPH OEMS State Approved Paramedic Medication Formulary – Version 2018.
o Do not mix with sodium bicarbonate Dose: o Use as a premixed bag of 400mg/250ml D5W or put 400mg in 250ml NS; titrate to patient response Low dose o 1-5 mcg/kg/min continuous infusion Moderate dose (cardiac doses) o 5-10 mcg/kg/min continuous infusion High dose (vasopressor doses) o 10-20 mcg/kg/min Rice County Emergency Medical Services Drug Formulary Class Class III Antiarrhythmic Effect 1. " Bicarb concentrate is. Sometimes they are associated with internal organ rupture, major fractures, and hemorrhagic shock. 2. Administering sodium bicarbonate may be 7000 MEDICATIONS NWRETAC Combined EMS Guidelines Approved July 1, 2016. 3 Amiodarone Hydrochloride (Cordarone®) EMS DIVISION 29. However, the dose is usually not more than 19. Most side effects are dosage related. Sodium bicarbonate , also known as baking soda, is used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid.
DOSAGE ADULT: 50 Grams . 5 mEq of sodium bicarbonate Routes of Administration: IV bolus; IV infusion Flush IV line between administrations of Calcium Chloride and Sodium Bicarbonate to avoid precipitation. 34 Sodium Bicarbonate 8. It may be used to treat the symptoms of stomach or duodenal ulcers. NaHCO 3 has been recommended in textbooks for many years. Sodium Bicarbonate Injection is administered by the intravenous route preferably via a central line. Calcium Chloride Indication: 1) Ionized hypocalcemia 2 Beta-blockers may inhibit the effects. The main complication as a result of these electrical disturbances are lethal arrhythmias, which is why Hyperkalemia is so important to suspect. Sodium Bicarbonate; Descriptions.
Listing a study does not mean it has been evaluated by the U. EMS DIVISION 15. For sodium bicarbonate effervescent powder: To relieve heartburn or sour stomach: Adults and teenagers—3. -Pulseless VT or VF: 1. Also infusions may lead to renal Emergency Medical Services Providers” Sepsis Protocol is a new addition to The Maryland Medical Protocols for EMS Providers. Sodium Chloride - Side Effects, Dosage, Interactions SODIUM BICARBONATE Antidepressant OD Cardiac arrest : 1 mEq/kg IV or IO : For crush injury, consider additional 1 mEq/kg added to 1L NS using second IV line Assure adequate ventilation. As an antagonist to such anticholinesterases as neostigmine, pyridostigmine, and ambenonium, which are used in the treatment of myasthenia gravis, PROTOPAM (pralidoxime chloride) may be given in a dosage of 1000 to 2000 mg intravenously followed by increments of 250 mg every five minutes. McCabe JL, Cobaugh DJ, Menegazzi JJ, Fata J. 1 Adenosine Triphosphate (Adenocard®) 5.
-mg/kg) B. Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. Revised: January 1, 2017 SODIUM BICARBONATE Description Sodium bicarbonate is an alkalotic solution, which neutralizes acids found in the body. With the increased use of ketamine by the military medics and emergency departments is it time for more widespread use of ketamine by civilian EMS? • Sodium Bicarbonate products in ABBOJECT syringes. While indication, contraindication, drug doses, and other relevant information are included in If it is rapidly released, without a dump of Sodium Bicarbonate via IV, it can be fatal. Tricyclic antidepressant overdosage: experimental studies on the management of circulatory complications. SODIUM BICARBONATE CLASS Alkalinizing agent (buffer) ACTION Binds free hydrogen ions to form carbonic acid. SODIUM BICARBONATE. 4% Prefilled Syringes 50 mL is a sterile, nonpyrogenis, hypertonic solution of sodium bicarbonate (NaHCO3) in water for injection for administration by the intravenous route as an electrolyte replenisher and systemic alkalizer.
Sodium bicarbonate is commonly known as baking soda. Sodium Bicarbonate in Cardiopulmonary Resuscitation (SB CAT) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Administration should be guided by arterial blood gases and pH data, when available. We had a guy He was alert and talking, lifted the house, he was dead in 10-12 seconds due to the compartment syndrome in his legs. 13 . 10 seconds 5. In the myocardium, it increases the force of contraction and augments cardiac output. Sodiumbicarbonate is effective only when administered with adequate ventilation and oxygenation. Side Effects: Bradycardia, arrhythmias, syncope, nausea, vomiting, cardiac arrest.
FireEMS Blogs Network. Use three or four drops twice daily for 3-5 days. IM dosing is the preferred route of administration. 8/15/2016. Sodium Bicarbonate Drug Card (Paramedic) study guide by mggallo includes 10 questions covering vocabulary, terms and more. Ann Emerg Med 1998; 32:329. The sodium bicarbonate solution in dialysis clinics is often referred to as "Bicarb Concentrate. ” Dosage of Sodium Bicarbonate depends on the condition being treated and the weight of the patient. Dosage of Sodium Bicarbonate Injection is determined by the severity of the acidosis, appropriate laboratory determinations, and the patient's age, weight and clinical condition.
However, as we discovered above, we will use much more sodium bicarbonate to make an adjustment in pH than we would using in sodium carbonate. Hyponatremia and hypernatremia are common findings in the inpatient and outpatient settings. 12 seconds, administer additional Sodium Bicarbonate 0. This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information Find patient medical information for Sodium Bicarbonate Intravenous on WebMD including its uses, side effects and safety, interactions, pictures, warnings and user ratings. EMS providers can expect a sudden increase in If sodium bicarbonate is used to treat diabetic ketoacidosis, the initial dosage is 50 mEq sodium bicarbonate in 1 L of appropriate IV solution to be given once. Medscape - Cardiac arrest and metabolic acidosis dosing for sodium bicarbonate, frequency-based adverse effects, comprehensive interactions, contraindications, pregnancy & lactation schedules, and cost information. 14 This was reaffirmed in 2005 when Pittsburgh researchers found that EMS systems administering NaHCO3 with epinephrine within minutes of resuscitation demonstrated a higher The main concern with using sodium bicarbonate: The sodium load from baking soda can cause fluid retention, particularly edema and nephrotic syndrome in people with compromised kidneys or chronic kidney disease (CKD). Sodium disorders are associated with an increased risk of morbidity and mortality. Note: Routine initial use of sodium bicarbonate in cardiac arrest is not recommended.
2% CLASS Buffer, Alkalinizing agent, Antacid. Emergency Medical Programs Common Drugs 6 | Page Do not administer with sodium bicarbonate or it may Section I: EMS Field Medications 3 DIETARY SUPPLEMENTS Sedative Hypnotics Diphenhydramine (Benadryl) Etomidate (Amidate) Midazolam (Hypnovel, Versed) Calcium Salts [Chloride, Gluconate] Dextrose, 25%, 50% Sodium Bicarbonate [NaHCO 3] Thiamine [Vitamin B 1] ENDOCRINE SYSTEM AGENTS Antidiabetic Agents Insulin, injectable Hormone & Synthetic However, the soluble nature of sodium bicarbonate has made it less desirable, as larger doses can lead to systemic alkalosis and high sodium load, which can be problematic in patients with systolic cardiac dysfunction or renal insufficiency. sodium bicarbonate dosage ems
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