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EMT-

Paramedic

Medications

Community College of Aurora October 2008

Z:\Phase I files\Pharmacology Presentations\EMT-P Medications with Total Information revised 10.08.doc Page 2

CCA Paramedic Program

Medication List

Analgesics

1. fentanyl citrate

2. morphine sulfate

Anesthetics

3A. lidocaine

4. tetracaine

Anticoagulants/Thrombolytics

5. aspirin

Anticonvulsants

6A. diazepam

7A. midazolam hydrochloride

Antihistamines

8. diphenhydramine

Antiemetics

9. metoclopramide

10. zofran

Antipsychotics & Neuroleptics

6B. diazepam

11. haloperidol lactate

12. metoclopramide

7B. midazolam hydrochloride

Neuromuscular blockers

N/A

Cardiac

13. adenosine

14. amiodarone

3B. lidocaine

15. procainamide

Central Nervous System Medications

16A. atropine sulfate

17. dopamine

18. epinephrine

Dietary Supplements

19. calcium chloride

20. dextrose 50%

21. magnesium sulfate

22. sodium bicarbonate

Diuretics

23. furosemide

Endocrines

24. glucagon

Poisoning & OD medications

25. activated charcoal

16B atropine sulfate

26. naloxone

Respiratory medications

27. albuterol sulfate

28. ipratropium

29. oxygen

30. phenylephrine

31. racemic epinephrine

Steroids & Anti-inflammatories

32. methylprednisolone

Vasoactives

33. nitroglycerin

34. vasopressin

Analgesic

Medications


fentanyl citrate (Sublimaze)

CLASS: Analgesic medications

SUB-CLASS: Narcotic analgesic

DESCRIPTION: Fentanyl is a potent synthetic narcotic agonist analgesic with

pharmacologic actions qualitatively similar to those of morphine and

meperidine, but whose action is more prompt and less prolonged.

ONSET: Immediate, with peak effect in 3 – 5 minutes

DURATION: 30 – 60 minutes

ADVERSE CNS: Sedation, diaphoresis,

REACTIONS: convulsions with high doses CV: Hypotension, bradycardia, circulatory

depression, cardiac arrest Respiratory: Laryngospasm,

bronchoconstriction, respiratory depression or arrest Other: Muscle

rigidity especially muscles of respiration after rapid IV infusion

INDICATIONS: To induce sedation during rapid sequence intubation procedure

To control severe pain

CONTRAINDICATIONS: Patient who have received MAO inhibitors within 14 days,

myasthenia gravis. Use with caution in head injuries,

increased intracranial pressure, elderly, debilitated, COPD

and other respiratory problems, liver and kidney failure,

bradydysrhythmias.

DRUG INTERACTIONS: Alcohol and other CNS depressants potentiate its effects.

MAO inhibitors may precipitate hypertensive crisis.

DOSAGE AND Adult: 25 – 100mcg IV over 2-3 minutes, q 1 – 2

ADMINISTRATION: hours as needed to control pain

Pediatric: Children over 2 years 2 mcg/kg slow IV/IM

SPECIAL CONSIDERATIONS:

Pregnancy safety: Category C

Monitor vital signs and observe patient for signs of skeletal and thoracic muscle (depressed

respirations) rigidity and weakness.

Duration of respiratory depressant effect may be considerably longer than narcotic

analgesic effect. Have immediately available oxygen, resuscitative and intubation

equipment, and an opioid antagonist such as naloxone.


morphine sulfate (Astramorph/PF and others) CLASS: Analgesic medications SUB-CLASS: Narcotic analgesic DESCRIPTION: Morphine sulfate is a natural opium alkaloid that acts on opiate receptors

in the brain providing both analgesia and sedation. Morphine is one of the most potent analgesics known, yet its hemodynamic properties make it extremely useful in managing patients with acute MI and pulmonary edema. Its vasodilatory effects increase peripheral venous capacitance and reduce venous return. This reduces the cardiac workload and decreases myocardial demand, thus reducing infarct size in acute MI.

ONSET: Immediate for IV; 15-30 min IM/SC DURATION: 2-7 hours ADVERSE REACTIONS: CNS: Respiratory depression; CV: Bradycardia, syncope, orthostatic

hypotension, allergic reaction; Overdosage: Severe respiratory depression or arrest, pulmonary edema, coma, hypotension, bradycardia, cardiac arrest

INDICATIONS: To relieve moderate to severe pain To reduce venous return in acute MI and acute pulmonary edema CONTRAINDICATIONS: Hypersensitivity to narcotics, hypovolemia, hypotension,

head injury or undiagnosed abdominal pain, volume depleted or severely hypotensive, bronchial asthma, chronic pulmonary disease, severe respiratory depression, pulmonary edema secondary to chemical irritants. Use with caution in very old, very young, or debilitated patients.

DRUG INTERACTIONS: CNS depressants, sedatives, barbiturates, alcohol, benzodiazepines, and TCAs may potentiate the CNS depressant effects. Use MAO inhibitors cautiously due to potential for hypertensive crisis. Phenothiazines may antagonize analgesia.

DOSAGE AND Adult pain: 2.5 – 15mg slow IV over 1 – 5 min q 3 – 30 minutes ADMINISTRATION: titrated to effect Pediatric pain: 0.05 – 0.1mg Adult venous return: 1 – 2mg q 6 – 10 min Pediatric venous return: Not used SPECIAL CONSIDERATIONS: Pregnancy safety: Category B (if not used for prolonged periods or in high doses at

term); narcotics rapidly cross the placenta Dosage for elderly or debilitated patients is lower than for adult. Before administering the drug, note respiratory rate, depth, and rhythm and size of pupils.

Respirations of 12/min or below and miosis are signs of toxicity. Withhold drug and report to physician.

Observe patient closely to be certain pain relief is achieved. Elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial expression may

indicate need for analgesia. Differentiate among restlessness as a sign of pain and the need for medication, restlessness

associated with hypoxia, and restlessness caused by morphine induced CNS stimulation (a paradoxic reaction that is particularly common in women and elderly patients).

Monitor vital signs at regular intervals. Nausea and orthostatic hypotension most often occur in ambulatory patients or when a

supine patient assumes the head up position or in patients not experiencing severe pain. Naloxone should be readily available


Anesthetic

Medications


lidocaine (Xylocaine)

CLASS: Anesthetic

SUB-CLASS: Local anesthetic

DESCRIPTION: Denver Protocols: Used as a local anesthetic to reduce somatic pain during

intraosseous fluid administration.

ONSET: Under 3 minutes

DURATION: 10-20 minutes

ADVERSE CNS: chest heaviness, With high doses: Convulsions, respiratory

REACTIONS: depression and arrest CV: Hypotension, bradycardia, conduction disorders

including heart block, cardiovascular collapse, cardiac arrest

INDICATIONS: Denver Protocols: Given following intraosseous insertion to patients over

8 years of age

CONTRAINDICATIONS: Hypersensitivity to lidocaine, supraventricular rhythms, Stokes-

Adams syndrome, second or third degree AV block in the

absence of a pacemaker, SVT, untreated sinus bradycardia. Use

with caution in liver or renal disease, CHF, marked hypoxia,

respiratory depression, hypovolemia, shock, myasthenia gravis,

debilitated patient, the elderly, family history of malignant

hyperthermia.

DRUG INTERACTIONS: Barbiturates decrease lidocaine activity. Cimetidine, beta

blockers, and quinidine increase the pharmacologic effects of

lidocaine. Phenytoin increases its cardiac depressant effects.

Procainamide compounds neurologic and cardiac effects.

DOSAGE AND Denver Protocols: 0.5 mg/kg IO bolus, slowly,

ADMINISTRATION: maximum dose is 50 mg


Pregnancy safety: Category B

Only lidocaine hydrochloride injection without preservatives that is specifically labeled for IV use

should be used for IV injection or infusion. The role of lidocaine in advanced AHA guidelines. Prophylactic lidocaine should not be used.

Lidocaine is now considered second line therapy behind amiodarone, procainamide, and sotalol.


tetracaine (Pontacaine)

CLASS: Anesthetic medications

SUB-CLASS: Topical ophthalmic anesthetic

DESCRIPTION: Denver Protocols: Tetracaine inhibits conduction of nerve impulses

from sensory nerves. It is used for rapid, brief,

superficial anesthesia.

ONSET: Within 30 seconds

DURATION: 10 - 15 minutes

ADVERSE None pertinent to EMS

REACTIONS:

INDICATIONS: Short term relief from eye pain or irritation

Patient comfort before eye irrigation

CONTRAINDICATIONS: Open injury to the eye – hypersensitivity to tetracaine

DRUG INTERACTIONS: Incompatible with mercury or silver salts often found in

ophthalmic products

DOSAGE AND Adult: 1 – 2 drops

ADMINISTRATION: Pediatric: Same as adult



Can cause epithelial damage and systemic toxicity

Not recommended for prolonged use


Anticoagulant/

Thrombolytic

Medications


aspirin (ASA, Bayer, Ecotrin, St. Joseph, others) CLASS: Anticoagulant/thrombolytic medications SUB-CLASS: Analgesic; antipyretic; nonsteroidal anti-inflammatory drug; platelet inhibitor DESCRIPTION: Aspirin is an anti-inflammatory agent and an inhibitor of platelet function. The

major actions of aspirin appear to be associated primarily with inhibiting the formation of prostaglandins involved in the production of inflammation, pain, and fever. As an antiplatelet agent, aspirin (but not other salicylates) powerfully inhibits platelet aggregation by blocking the formation of thromboxane A2, which causes platelets to aggregate and arteries to constrict.

ONSET: 5-30 minutes DURATION: 1-4 hours ADVERSE REACTIONS: CNS: Dizziness, confusion; ENT: Tinnitus; GI: Stomach irritation, heartburn or

indigestion, nausea/vomiting GI bleeding; Hypersensitivity: Anaphylactic shock, urticaria, bronchospasm,

anaphylactic shock, laryngeal edema INDICATIONS: To inhibit clot formation in the presence of chest pain suggestive of an acute

myocardial infarction. To inhibit clot formation associated with thrombotic CVA. CONTRAINDICATIONS: Hypersensitivity to salicylates including methyl salicylates (oil of

wintergreen), active ulcer disease, and asthma. Use with caution in patient with allergies to other NSAIDS, and those who have other bleeding disorders.

DRUG INTERACTIONS: Anticoagulants increase risk of bleeding. Oral hypoglycemic

agents increase hypoglycemic activity with aspirin doses greater than 2 g/day.

DOSAGE AND Adult MI: 160 – 325mg PO (chewable) ADMINISTRATION: SPECIAL CONSIDERATIONS: Pregnancy safety: Category D Baby aspirin is preferred in the emergency setting because it can be chewed and swallowed. In adults, a sensation of fullness in the ears, tinnitus, and decreased or muffled gearing are the most

frequent symptoms associated with chronic salicylate overdosage. Potential for toxicity is high in elderly chronic aspirin users because they have less serum protein to

bind salicylate and also are less able to excrete it. Discontinue use with onset of ringing or buzzing in the ears, impaired hearing, dizziness, or GI

discomfort or bleeding, and report to physician. Avoid other medications containing aspirin unless directed by physician, because of danger of

overdosing.


Anticonvulsant

Medications


diazepam (Valium, and others) CLASS: Benzodiazepine medications SUB-CLASS : Sedative-hypnotic; anticonvulsant; benzodiazepine; antianxiety DESCRIPTION: Diazepam is a benzodiazepine whose exact mechanism is unknown, but

many believe it appears to act at both limbic and subcortical levels of the CNS. It is principally used for its anticonvulsant properties by suppressing the spread of seizure activity through the motor cortex of the brain.

ONSET: IV: 1-5 minutes IM: 15-30 minutes DURATION: (IV) 15 minutes-1 hour (IM) 15 minutes-1 hour ADVERSE CNS: Drowsiness, confusion, paradoxic rage, dizziness, REACTIONS: vertigo, EEG changes, tardive dyskinesia CV: Hypotension, tachycardia,

cardiovascular collapse Other: throat and chest pain, laryngospasm INDICATIONS: To eradicate seizure activity To manage acute anxiety Premedication prior to counter shock or TCP CONTRAINDICATIONS: Hypersensitivity to diazepam, shock, coma, acute alcohol

intoxication, depressed vital signs, obstetrical patients, infants less than 30 days. Use with caution in patients with psychoses, mental depression, myasthenia gravis, impaired hepatic or renal function, and in individuals who are known to abuse drugs or be addiction prone. Use IV diazepam with extreme caution in the elderly, the very ill, and patients with COPD

DRUG INTERACTIONS: Alcohol, CNS depressants, and anticonvulsants can

potentiate CNS depression. Cimetidine increases diazepam plasma levels and toxicity. Diazepam may decrease the antiparkinsonian effects of levodopa and increase phenytoin levels. Smoking decreases it sedative and antianxiety effects.

DOSAGE AND Adult seizure: 5 - 10mg IV/IM ADMINISTRATION: Pediatric seizure: 0.5 – 2 mg/kg slow IV or IM

Adult anxiety: 2-5 mg IM Pediatric anxiety: 0.5-2 mg IM Adult cardioversion TCP: 5 – 15mg IV; 5 – 10 min prior to

procedure Pediatric cardioversion: 0.2 – 0.5 mg/kg IV

SPECIAL CONSIDERATIONS: Pregnancy safety: Category D IM administration should be made deep into large muscle mass. To prevent swelling, irritation, venous thrombosis, and phlebitis, give direct IV by injecting

drug slowly, taking at least 1 minute for each 5mg. Flumazenil is an effective benzodiazepine antagonist and should be available in case

respiratory depression or other complications ensue.


midazolam hydrochloride (Versed) CLASS: Benzodiazepine medications SUB-CLASS: Sedative DESCRIPTION: Midazolam HCI is a short acting parenteral benzodiazepine with CNS

depressant, muscle relaxant, anticonvulsant, and anterograde amnestic effects.

ONSET: 3 - 5 minutes IV 15 minutes IM 6-14 minutes intranasal DURATION: Less than 2 hours IV 1-6 hours IM ADVERSE CNS: excessive sedation REACTIONS: CV: Hypotension Eye: pin-point pupils Respiratory: respiratory arrest INDICATIONS: To induce sedation and amnesia prior to cardioversion and other painful

procedures. CONTRAINDICATIONS: Hypersensitivity to benzodiazepines, acute narrow angle

glaucoma, shock, coma, and acute alcohol intoxication. Use with caution in patients with COPD, chronic renal failure, CHF, and in the elderly.

DRUG INTERACTIONS: Alcohol, CNS depressants, and anticonvulsants potentiate

CNS depression. Cimetidine increases midazolam plasma levels and toxicity. Midazolam may decrease the antiparkinsonian effects of levodopa and increase phenytoin levels. Smoking decreases it sedative and antianxiety effects.

DOSAGE AND Adult: 1 – 2.5mg slow IV ADMINISTRATION: 0.07-0.08 mg/kg IM (usual dose is 5mg)

Pediatric: Loading dose 0.05 – 0.2mg/kg IV 0.10-0.15 mg/kg IM Intranasal: 3 mg

SPECIAL CONSIDERATIONS: Pregnancy safety: Category D Inject IM drug deep into a large muscle mass, not the deltoid. During IV infusion, inspect injection site for redness, pain, swelling, and other signs of

extravasation. If the patient is premedicated with a narcotic agonist analgesic, the conscious sedation

period may be marked by hypotension. Anterograde amnesia (dose related) correlates well with degree of drowsiness and is about

the same as that for lorazepam. Most patients do no recall induction. In the obese patient, half life is prolonged. Therefore the duration of effects is prolonged. Overdose symptoms include somnolence, confusion, sedation, diminished reflexes, coma,

and untoward effects on vital signs. Have resuscitative equipment and flumazenil available prior to administering midazolam.


Antihistamine

Medications


diphenhydramine (Benadryl)

CLASS: Antihistamine medications

SUB-CLASS: Antihistamine

DESCRIPTION: Diphenhydramine is an antihistamine with significant anticholinergic

activity. It is useful for treating allergic reaction and anaphylaxis. High incidence of drowsiness, but GI side effects are minor. Diphenhydramine competes for H1 – receptor sites on effector cells, thus blocking histamine release. Its effects in parkinsonism and drug-induced extrapyramidal symptoms are apparently related to its ability to suppress central cholinergic activity and to prolong action of dopamine by inhibiting its reuptake and storage. It does not inhibit gastric secretion but has strong antiemetic effect.

ONSET: 15 – 30 minutes

DURATION: Under 10 minutes

ADVERSE CNS: Drowsiness, REACTIONS: CV: Palpitations, tachycardia, mild hypotension or hypertension,

cardiovascular collapse; Hypersensitivity: anaphylactic shock

INDICATIONS: Moderate to severe allergic reactions (after epinephrine use)

Anaphylaxis

Acute extrapyramidal reactions

CONTRAINDICATIONS: Hypersensitivity to diphenhydramine. Use with caution in

patients with asthma, COPD, glaucoma, and bladder

obstruction, as all of these conditions can be exacerbated by

its administration.

DRUG INTERACTIONS: May have additive effect with alcohol or depressants. MAO

inhibitors may prolong and intensify anticholinergic effects

of antihistamines.

DOSAGE AND Adult: 25 – 50mg slow IV/IM

ADMINISTRATION: Pediatric: 2 – 5 mg/kg slow IV/IO/IM



May cause CNS stimulation in children.


Antiemetic

Medications


metoclopramide (Reglan, Clopra, Maxolon, Reclomide,

Octamide) CLASS: Antiemetic medications SUB-CLASS: Antiemetic, phenothiazine

DESCRIPTION: Metoclopramide is a potent central and peripheral dopamine receptor

antagonist. It is structurally related to procainamide but has little antidysrhythmic or anesthetic activity. The exact mechanism of action is not clear but it appears to sensitize GI smooth muscle to effects of acetylcholine by direct action.

ONSET: IM : 10 – 15 minutes

IV: 1 – 3 minutes DURATION: 1 – 3 hours ADVERSE CNS: Mild sedation (50% of patients), REACTIONS: extrapyramidal symptoms (acute dystonia type); CV: SVT, bradycardia,

AV block INDICATIONS: To relieve severe nausea and vomiting CONTRAINDICATIONS: Sensitivity to metoclopramide, allergy to sulfite agents,

history of seizure disorders, concurrent use of drugs that can cause extrapyramidal symptoms, pheochromocytoma, mechanical GI obstruction or performation, history of breast cancer. Use with caution in patients with CHF, hypokalemia, renal dysfunction, GI hemorrhage history of porphyria

DRUG INTERACTIONS: Alcohol and other CNS depressants add to sedation.

Anticholinergics and opiate analgesics may antagonize effect on GI motility. Phenothiazines may potentiate extrapyramidal symptoms. Hypertension may occur when metoclopramide is administered to patient taking MAO inhibitors.

DOSAGE AND Adult: 10 mg slow IVP over 1 –2 minutes ADMINISTRATION: 10-20 mg IM Pediatric: 1-2 mg/kg IVP over 1 –2 minutes or IM SPECIAL CONSIDERATIONS: Pregnancy safety: Category B Extrapyramidal symptoms are most likely to occur in children, young adults, and the

elderly, and with high dose treatment of vomiting associated with cancer chemotherapy. Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors. Have diphenhydramine available as an antidote.

Metoclopramide is photosensitive and should be protected from light during storage


ondanestron (Zofran) CLASS: Antiemetic medications SUB-CLASS: Antiemetic, Seratonin antagonist DESCRIPTION: Brady textbook: Blocks the serotonin receptors in the CTZ, the stomach, and the small intestines. It is very effective in the treatment of nausea and vomiting associated with chemotherapy, and unlike the dopamine antagonists, it dose not cause extrapyramidal effects like dystonia and ataxia. Its most common side effects are headache and diarrhea. Denver protocols: Is a selective 5-HT3 receptor antagonist. Mechanism of action has not been fully characterized. It is not certain whether ondansetron’s antiemetic action is mediated centrally, peripherally, or in both sites. ONSET: 30 minutes DURATION: 6-8 hours ADVERSE Constipation, or diarrhea, headache. and light-headedness REACTIONS: INDICATIONS: To relieve nausea and vomiting CONTRAINDICATIONS: Patients with known hypersensitivity to ondansetron DRUG INTERACTIONS: Unavailable DOSAGE AND Adult: 4 mg SLOW IV push over 2-5 minutes (may also be ADMINISTRATION: given IM) Pediatric: (1-12 years of age)

Under 40 kg: 0.1 mg/kg SLOW IV push over 2-5 minutes (may also be given IM) Over 40 kg: 4 mg SLOW IV push over 2-t minutes (may also be given IM)

SPECIAL CONSIDERATIONS: Pregnancy safety: Category B Use with caution while performing tasks requiring alertness such as driving


Antipsychotic

& Neuroleptic

Medications


diazepam (Valium, and others) CLASS: Benzodiazepine medications SUB-CLASS : Sedative-hypnotic, anticonvulsant, antianxiety DESCRIPTION: Diazepam is a benzodiazepine whose exact mechanism is unknown, but

many believe it appears to act at both limbic and subcortical levels of the CNS. It is principally used for its anticonvulsant properties by suppressing the spread of seizure activity through the motor cortex of the brain.

ONSET: IV: 1-5 minutes IM: 15-30 minutes DURATION: (IV) 15 minutes-1 hour (IM) 15 minutes-1 hour ADVERSE CNS: Drowsiness, confusion, paradoxic rage, dizziness, REACTIONS: vertigo, EEG changes, tardive dyskinesia CV: Hypotension, tachycardia,

cardiovascular collapse Other: throat and chest pain, laryngospasm INDICATIONS: To eradicate seizure activity To manage acute anxiety Premedication prior to counter shock or TCP CONTRAINDICATIONS: Hypersensitivity to diazepam, shock, coma, acute alcohol

intoxication, depressed vital signs, obstetrical patients, infants less than 30 days. Use with caution in patients with psychoses, mental depression, myasthenia gravis, impaired hepatic or renal function, and in individuals who are known to abuse drugs or be addiction prone. Use IV diazepam with extreme caution in the elderly, the very ill, and patients with COPD

DRUG INTERACTIONS: Alcohol, CNS depressants, and anticonvulsants can

potentiate CNS depression. Cimetidine increases diazepam plasma levels and toxicity. Diazepam may decrease the antiparkinsonian effects of levodopa and increase phenytoin levels. Smoking decreases it sedative and antianxiety effects.

DOSAGE AND Adult seizure: 5 - 10mg IV/IM ADMINISTRATION: Pediatric seizure: 0.5 – 2 mg/kg slow IV or IM

Adult anxiety: 2-5 mg IM Pediatric anxiety: 0.5-2 mg IM Adult cardioversion TCP: 5 – 15mg IV; 5 – 10 min prior to

procedure Pediatric cardioversion: 0.2 – 0.5 mg/kg IV

SPECIAL CONSIDERATIONS: Pregnancy safety: Category D IM administration should be made deep into large muscle mass. To prevent swelling, irritation, venous thrombosis, and phlebitis, give direct IV by injecting

drug slowly, taking at least 1 minute for each 5mg. Flumazenil is an effective benzodiazepine antagonist and should be available in case

respiratory depression or other complications ensue.


haloperidol lactate (Haldol) CLASS: Antipsychotic & neuroleptic medications SUB-CLASS: Antipsychotic, phenothiazine DESCRIPTION: Haloperidol is a potent long acting antipsychotic agent with

pharmacologic actions similar to those of the phenothiazines but with a higher incidence of extrapyramidal effects and less hypotensive and relatively low sedative activity. While its exact mechanism is unclear, it appears to block the dopamine receptors in the brain associated with mood and behavior.

ONSET: IM: 30 – 45 minutes DURATION: 6 - 70 hours ADVERSE CNS: Extrapyramidal reactions, REACTIONS: grand mal seizures, exacerbation of psychotic symptoms. CV:

Tachycardia, ECG changes, hypotension, hypertension (with over dosage), hypoglycemia Respiratory: respiratory depression

INDICATIONS: To manage acute psychotic disorders CONTRAINDICATIONS: Parkinson’s disease, parkinsonism, seizure disorders, coma,

severe alcoholism, severe mental depression, CNS depression, thyrotoxicosis. Use with caution in elderly or debilitated patients or those with urinary retention, glaucoma, severe cardiovascular disorders, patients receiving anticonvulsant, anticoagulant, or lithium therapy

DRUG INTERACTIONS: CNS depressants, opiates, and alcohol may increase CNS

depression. Haloperidol may antagonize the activity of oral anticoagulants. Anticholinergics may increase intraocular pressure. Methyldopa may precipitate dementia.

DOSAGE AND Adult: 2 – 5mg IM ADMINISTRATION: Pediatric: 0.05 – 0.15mg PO in 2 – 3 divided doses SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Haloperidol should be administered by deep IM injection into a large muscle. Have the patient recumbent at time of parenteral administration and for about 1 hour after

injection. Assess for orthostatic hypotension. In emergency situations where the patient’s behavior poses an immediate risk to rescuers

and bystanders, the initial IM injection may be given through the patient’s clothing in order to minimize needle stick injuries.

Extrapyramidal or dystonic reactions are common with Haloperidol. Parenteral diphenhydramine should be administered.


midazolam hydrochloride (Versed) CLASS: Benzodiazepine medications SUB-CLASS: Sedative DESCRIPTION: Midazolam HCI is a short acting parenteral benzodiazepine with CNS

depressant, muscle relaxant, anticonvulsant, and anterograde amnestic effects.

ONSET: 3 - 5 minutes IV 15 minutes IM 6-14 minutes intranasal DURATION: Less than 2 hours IV 1-6 hours IM ADVERSE CNS: excessive sedation REACTIONS: CV: Hypotension Eye: pin-point pupils Respiratory: respiratory arrest INDICATIONS: To induce sedation and amnesia prior to cardioversion and other painful

procedures. CONTRAINDICATIONS: Hypersensitivity to benzodiazepines, acute narrow angle

glaucoma, shock, coma, and acute alcohol intoxication. Use with caution in patients with COPD, chronic renal failure, CHF, and in the elderly.

DRUG INTERACTIONS: Alcohol, CNS depressants, and anticonvulsants potentiate

CNS depression. Cimetidine increases midazolam plasma levels and toxicity. Midazolam may decrease the antiparkinsonian effects of levodopa and increase phenytoin levels. Smoking decreases it sedative and antianxiety effects.

DOSAGE AND Adult: 1 – 2.5mg slow IV ADMINISTRATION: 0.07-0.08 mg/kg IM (usual dose is 5mg)

Pediatric: Loading dose 0.05 – 0.2mg/kg IV 0.10-0.15 mg/kg IM Intranasal: 3 mg

SPECIAL CONSIDERATIONS: Pregnancy safety: Category D Inject IM drug deep into a large muscle mass, not the deltoid. During IV infusion, inspect injection site for redness, pain, swelling, and other signs of

extravasation. If the patient is premedicated with a narcotic agonist analgesic, the conscious sedation

period may be marked by hypotension. Anterograde amnesia (dose related) correlates well with degree of drowsiness and is about

the same as that for lorazepam. Most patients do no recall induction. In the obese patient, half life is prolonged. Therefore the duration of effects is prolonged. Overdose symptoms include somnolence, confusion, sedation, diminished reflexes, coma,

and untoward effects on vital signs. Have resuscitative equipment and flumazenil available prior to administering midazolam.


metoclopramide (Reglan, Clopra, Maxolon, Reclomide,

Octamide) CLASS: Antipsychotic & Neuroleptic medications SUB-CLASS: Antipsychotic, phenothiazine

DESCRIPTION: Metoclopramide is a potent central and peripheral dopamine receptor

antagonist. It is structurally related to procainamide but has little antidysrhythmic or anesthetic activity. The exact mechanism of action is not clear but it appears to sensitize GI smooth muscle to effects of acetylcholine by direct action.

ONSET: IM : 10 – 15 minutes

IV: 1 – 3 minutes DURATION: 1 – 3 hours ADVERSE CNS: Mild sedation (50% of patients), REACTIONS: extrapyramidal symptoms (acute dystonia type); CV: SVT, bradycardia,

AV block INDICATIONS: To relieve severe nausea and vomiting CONTRAINDICATIONS: Sensitivity to metoclopramide, allergy to sulfite agents,

history of seizure disorders, concurrent use of drugs that can cause extrapyramidal symptoms, pheochromocytoma, mechanical GI obstruction or performation, history of breast cancer. Use with caution in patients with CHF, hypokalemia, renal dysfunction, GI hemorrhage history of porphyria

DRUG INTERACTIONS: Alcohol and other CNS depressants add to sedation.

Anticholinergics and opiate analgesics may antagonize effect on GI motility. Phenothiazines may potentiate extrapyramidal symptoms. Hypertension may occur when metoclopramide is administered to patient taking MAO inhibitors.

DOSAGE AND Adult: 10 mg slow IVP over 1 –2 minutes ADMINISTRATION: 10-20 mg IM Pediatric: 1-2 mg/kg IVP over 1 –2 minutes or IM SPECIAL CONSIDERATIONS: Pregnancy safety: Category B Extrapyramidal symptoms are most likely to occur in children, young adults, and the

elderly, and with high dose treatment of vomiting associated with cancer chemotherapy. Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors. Have diphenhydramine available as an antidote.

Metoclopramide is photosensitive and should be protected from light during storage


Neuromuscular

Blocking

Medications


Neuromuscular

Blocking

Medications

No

medications

addressed within this

category


Cardiac

Medications


Classes of Antidysrhythmics • Class I

Are sodium channel blockers. They are further divided

into sub classes (Ia, Ib, Ic) based on the extent of

sodium channel blockade.

- Ia = Have no effect on conduction velocity

- Ib = Have little to no effect on conduction velocity

- Ic = Profoundly slow conduction and are only for

control of life threatening ventricular

dysrhythmias.

• Class II

Beta blocking agents, which reduce adrenergic

stimulation of the heart.

• Class III

Potassium channel blockade, which increases

contractility

• Class IV

Calcium channel blockers. Depresses the myocardial

and smooth muscle contraction, decreases automaticity,

and in some cases decreases conduction velocity.

adenosine (Adenocard) CLASS: Cardiac system medications SUB-CLASS: Miscellaneous antidysrhythmic DESCRIPTION: Adenosine is a naturally occurring nucleoside that is present in all body cells.

Adenosine slows conduction time through the AV node, can interrupt the reentry pathways through the AV and SA nodes, and can restore normal sinus rhythm in patients with PSVT, including PSVT associated with Wolff-Parkinson-White syndrome.

ONSET: Immediate DURATION: 20 seconds ADVERSE REACTIONS: CV: palpitations, atrial fibrillation or flutter, chest pain, hypotension

Respiratory: Shortness of breath/dyspnea, chest pressure, hyperventilation INDICATIONS: To convert PSVT to a sinus rhythm in patients refractory to common vagal

maneuvers. CONTRAINDICATIONS: Hypersensitivity to adenosine, second or third degree AV block,

sinus node disease, symptomatic bradycardia except in patients with a functioning pacemaker. Use with caution in COPD and asthma.

DRUG INTERACTIONS: IV adenosine has been effectively administered in the presence of other

cardioactive drugs, such as quinidine, beta adrenergic blocking agents,

calcium channel blocking agents, and ACE inhibitors, without change

in the adverse reaction profile. The effects of adenosine are

antagonized by methylxanthines such as caffeine and theophylline. In

the presence of methylxanthines, larger doses of adenosine may be

required or adenosine may not be effective. Adenosine effects are

potentiated by dipyridamole. Because the primary effect of adenosine

is to decrease conduction through the AV node, higher degrees of heart

block may be produced in the presence of carbamazepine. DOSAGE AND Adult: 6mg rapid IV over 1 – 3 seconds, followed by a 20 mL

ADMINISTRATION: saline flush; elevate extremity

Adult: If no response is observed after 1 – 2 min, administer a 12mg

Repeat: repeat dose in the same manner; may repeat once more in 1 – 2

min (max single dose: 12mg)

Pediatric: Initial dose 0.1mg/kg; may be doubled once (max first dose:

6mg); rapid IV bolus, followed by a 5 mL saline flush

SPECIAL CONSIDERATIONS: Pregnancy safety: Category C The solution must be clear at time of use. Since it contains no preservatives, discard used portion. Monitor ECG, B/P, and heart rate q 15 – 30 seconds for several minutes after administration. Inform your patient that facial flushing and transient symptoms may occur.


amiodarone (Cordarone) CLASS: Cardiac system medications SUB-CLASS: Antidysrhythmic (Class III antidysrhythmic) DESCRIPTION: Amiodarone is a unique antidysrhythmic. Totally unrelated to other

antidysrhythmics, it acts directly on all cardiac tissues. It is thought to prolong the duration of the action potential and refractory period without significantly affecting the resting membrane potential.

ONSET: Within minutes DURATION: Variable ADVERSE REACTIONS: CV: Bradycardia, hypotension (IV), sinus arrest, cardiogenic shock, CHF,

dysrhythmias; AV block INDICATIONS: To treat life threatening ventricular and supraventricular dysrhythmias,

particularly atrial fibrillation. CONTRAINDICATIONS: Hypersensitivity to amiodarone, cardiogenic shock, severe

sinus bradycardia, or advanced AV block unless a pacemaker is available, episodes of bradycardia which have caused syncope. Use with caution in patients with severe liver disease, during pregnancy, nursing mothers, and in children.

DRUG INTERACTIONS: amiodarone significantly increases digoxin levels and

enhances pharmacologic effects and toxicities of disopyramide, procainamide, quinidine, flecainide, and lidocaine. It also enhances the anticoagulant effects of oral anticoagulants. Calcium channel blockers and beta blockers may potentiate sinus bradycardia, sinus arrest, or AV block. Ritonavir may increase cardiotoxicity. Additional interactions include fentanyl, cyclosporine, cholestyramine, and cimetidine.

DOSAGE AND Adult: 300mg IV push (diluted in 20 – 30 mL NS or D5W) ADMINISTRATION: Pulseless arrest: Consider repeating 150mg IV push in 3 – 5 min (max cumulative dose 2g IV in 24 hours) Adult wide 150mg rapid IV infusion over first 10 min; complex repeat q 10 min as needed; or by slow tachycardia: infusion 360mg IV over 6 hours; maintenance infusion 540mg IV over 18 hours (0.5mg/min) Pediatric arrest: 5mg/kg rapid IV bolus

Pediatric tach: Loading dose 5mg/kg IV over 20 – 60 min (max dose 15mg/kg/day) SPECIAL CONSIDERATIONS: Pregnancy safety: Category D During IV infusion, carefully monitor B/P and slow the infusion if significant hypotension occurs.

Bradycardia should be treated by slowing the infusion or discontinue it if necessary. Be alert to signs of pulmonary toxicity: progressive dyspnea, fatigue, cough, pleuritic pain, fever. Auscultate chest periodically or when patient complains of respiratory symptoms. Check for

diminished breath sounds, rales, pleuritic friction rub, and observe breathing pattern. Drug induced pulmonary function problems must be distinguished from CHF or pneumonia.


lidocaine (Xylocaine) CLASS: Cardiac system medications SUB-CLASS: Antidysrhythmic (Class Ib) DESCRIPTION: Lidocaine has cardiac actions similar to those of procainamide and quinidine but

has little effect on myocardial contractility, AV and intraventricular conduction, cardiac output, and systolic arterial pressure in equivalent doses. It exerts antidysrhythmic action (class Ib) by suppressing automaticity (decreased phase 4 diastolic depolarization) in the HIS-Purkinje system and by elevating electrical stimulation threshold of the ventricles during diastole.

ONSET: Under 3 minutes DURATION: 10-20 minutes ADVERSE CNS: chest heaviness, With high doses: Convulsions, respiratory

depression and arrest REACTIONS: CV: Hypotension, bradycardia, conduction disorders including heart

block, cardiovascular collapse, cardiac arrest INDICATIONS: To convert ventricular tachycardia & ventricular fibrillation in cardiac arrest Stable Wide complex ventricular tachycardia CONTRAINDICATIONS: Hypersensitivity to lidocaine, supraventricular rhythms, Stokes-

Adams syndrome, second or third degree AV block in the absence of a pacemaker, SVT, untreated sinus bradycardia. Use with caution in liver or renal disease, CHF, marked hypoxia, respiratory depression, hypovolemia, shock, myasthenia gravis, debilitated patient, the elderly, family history of malignant hyperthermia.

DRUG INTERACTIONS: Barbiturates decrease lidocaine activity. Cimetidine, beta

blockers, and quinidine increase the pharmacologic effects of lidocaine. Phenytoin increases its cardiac depressant effects. Procainamide compounds neurologic and cardiac effects.

DOSAGE AND Adult 1 – 1.5mg/kg IV bolus or ET; consider repeat in ADMINISTRATION: Cardiac arrest: 3 – 5 min(max dose 3mg/kg); a single dose of

1.5mg/kg is acceptable; for refractory VT/VF, and additional bolus of 0.5 – 0.7mg/kg can be given; repeat in 5 – 10 min if necessary

Adult infusion: 2 – 4mg/min Adult stable VT: Initial loading dose of 1 – 1.5mg/kg IV; if needed,

give 0.5 – 0.75mg/kg in 5 – 10 min (max dose 3mg/kg); after conversion start a lidocaine drip (2 – 4mg/min)

Pediatric Cardiac arrest: 1mg/kg IV/IO or ET Pedi. Infusion: 20 – 50mcg/kg/min

Pedi. Stable VT: Initial loading dose of 1mg/kg IV/IO, followed by an infusion of 20 – 50mcg/kg/min

SPECIAL CONSIDERATIONS: Pregnancy safety: Category B Only lidocaine hydrochloride injection without preservatives that is specifically labeled for IV use

should be used for IV injection or infusion. The role of lidocaine in advanced AHA guidelines. Prophylactic lidocaine should not be used.

Lidocaine is now considered second line therapy behind amiodarone, procainamide, and sotalol.


procainamide (Pronestyl) CLASS: Cardiac system medications

SUB-CLASS: Class Ia antidysrhythmic

DESCRIPTION: Procainamide is an amide analog of procaine hydrochloride with cardiac actions similar

to those of quinine. It is a class Ia antidysrhythmic agent that depresses the excitability

of the myocardium to electrical stimulation, and reduces conduction velocity in the

atria, ventricles, and His-Purkinje system. Procainamide increases the duration of the

refractory period, especially in the atria. It also produces a slight change in contractility

of cardiac muscle and cardiac output.


DURATION: 3 – 6 hours

ADVERSE CNS: Dizziness, psychosis CV: Severe hypotension, pericarditis, ventricular

REACTIONS: fibrillation, AV block, tachycardia, flushing GI: Nausea, vomiting, diarrhea, anorexia

Hematologic: Thrombocytopenia Hypersensitivity: Fever, muscle and joint pain,

angioneurotic edema, maculopapular rash, pruritus Other: Pleuritic pain, pleural

effusion, erythema, skin rash, myalgia

INDICATIONS: To convert refractory ventricular fibrillation and pulseless ventricular tachycardia to

sinus rhythm.

CONTRAINDICATIONS: Hypersensitivity to procainamide, myasthenia gravis, complete AV

block, second and third degree AV block unassisted by pacemaker.

Use with caution in patients with hypotension, cardiac enlargement,

CHF, MI, coronary occlusion, ventricular dysrhythmia from digitalis

intoxication, hepatic or renal insufficiency, electrolyte imbalance,

bronchial asthma.

DRUG INTERACTIONS: Increases effects of skeletal muscle relaxants

Increases plasma NAPA (active metabolites) concentrations with

cimetidine, ranitidine, beta blockers, amiodarone, trimethoprim, and

quinidine

DOSAGE AND Adult: 20 - 30mg/min slow IV infusion in recurrent VF/pulseless VT

ADMINISTRATION: (up to 50mg/min may be given in urgent situations) (max total

17mg/kg; or 1g which ever comes first)

Pediatric: Loading dose 15 mg/kg IV/IO; infuse over 30 –60 min



Procainamide has potent vasodilating and inotropic effects

Rapid injection may cause procainamide induced hypotension

Carefully monitor vital signs and ECG (a small amount of QRS widening is expected)

Routine use in combination with other drugs that prolong the QT interval is not recommended

Administer cautiously to patients with asthma, digitalis induced dysrhythmias, AMI, or cardiac, hepatic, or

renal insufficiency


Central

Nervous System

Medications


atropine sulfate CLASS: Central nervous system medications SUB-CLASS: Parasympatholytic DESCRIPTION: Atropine sulfate exerts its effects on the autonomic nervous system. It is a competitive

antagonist that selectively blocks all muscarinic responses to acetylcholine (Ach). ONSET: 2 – 4 minutes DURATION: 4 hours ADVERSE CV: Both supine and postural hypotension, syncope, bradycardia, increased frequency

of PVCs and other dysrhythmias, exacerbation of digitalis induced dysrhythmias Other: Respiratory depression

REACTIONS: INDICATIONS: Hemodynamically significant bradycardia; Asystole; PEA with absolute bradycardia;

Organophosphate or nerve gas poisoning Bronchospastic pulmonary disorders CONTRAINDICATIONS: No contraindications in the prehospital setting. Use with caution in

patients with narrow angle glaucoma, acute MI and tachycardia DRUG INTERACTIONS: Amantadine, antihistamines, TCAs, quinidine, disophyramide,

procainamide can add to the anticholinergic effects of atropine. Levodopa effects are decreased. Methotrimeptrazine may precipitate extrapyramidal effects. Phenothiazine antipsychotic effects are decreased (decreased absorption).

DOSAGE AND Adult bradycardia: 0.5 – 1.0mg IV; q 3 – 5 min for desired response ADMINISTRATION: (max dose 3mg or 0.04mg/kg which ever is greater)

Adult arrest: 1mg IV, 2 mg ET; q 3 – 5 min (max dose 3mg or 0.04mg/kg which ever is greater)

Adult 2 - 5mg IV q 5 – 15 min to dry secretions (repeat as Anticholinergic: needed); then q 1 – 4 hours for at least 24 hours Pediatric brady: 0.02mg/kg IV, IO, ET; min dose 0.1mg; maximum

single dose of 0.5mg for child and 1mg for an adolescent; may q in 5 min for a max total dose 1mg for a child and 2mg for an adolescent

Pediatric arrest: Efficacy has not been established Pediatric 0.05mg/kg IV; may be repeated q 20 min until Anticholinergic: atropine effect is observed; then 1 – 4 hours for at least

24 hours SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Smaller doses of atropine are indicated for the elderly. Monitor vital signs. Pulse is a sensitive indicator of patient’s response to atropine. Be alert to changes in

quality, rate, and rhythm of pulse and respiration and to changes in blood pressure. Initial paradoxic bradycardia following IV atropine usually lasts only 1 – 2 minutes. It most likely occurs

when IV is administered slowly (more than a minute) or when small doses (less than 0.5 mg) are used. Atropine may actually worsen the bradycardia associated with Mobitz II and complete AV block. In these

cases, use transcutaneous pacing. Always rule out hypoxia as the cause for bradycardia in infants and small children. Atropine is indicated

only after oxygen and epinephrine fail.


dopamine (Intropin) CLASS: Central nervous system medications SUB-CLASS: Sympathomimetic DESCRIPTION: Dopamine is a naturally occurring neurotransmitter and immediate

precursor of norepinephrine. Its major cardiovascular effects are produced by direct action on alpha and beta adrenergic receptors and on specific dopaminergic receptors in mesenteric and renal vascular beds. Its positive inotropic effect on myocardium increases cardiac output with increase in systolic and pulse pressure and little or no effect on diastolic pressure.

ONSET: Less than 5 minutes DURATION: Less than 10 minutes ADVERSE CV: Hypotension, ectopic beats, tachycardia, anginal pain,

vasoconstriction REACTIONS: (indicated by disproportionate rise in diastolic pressure), INDICATIONS: Hemodynamically significant hypotension in the absence of hypovolemia CONTRAINDICATIONS: Patients with pheochromocytoma (adrenal gland tumor),

tachydysrhythmias, ventricular fibrillation. Use with caution in patients with history of occlusive vascular disease (e.g., Buerger’s or Raynaud’s disease), cold injury, diabetic endarteritis, or arterial embolism.

DRUG INTERACTIONS: Llike all catecholamines, dopamine is deactivated by

alkaline solutions such as sodium bicarbonate. MAO inhibitors increase the alpha adrenergic effects of dopamine and cause headache, hyperpyrexia, and hypertension. Phenytoin may decrease dopamine action and actually cause hypotensive effects. Beta blockers will antagonize its cardiac effects just as alpha blockers will antagonize peripheral vasoconstriction.

DOSAGE AND Adult: Low dose 2 – 4mcg/kg/min (dopaminergic) ADMINISTRATION: Moderate dose 5 – 10mcg/kg/min (cardiac) High dose 10 – 20mcg/kg/min (vasopressor) Pediatric: 2 – 20mck/kg/min titrated to patient response SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Before initiation of dopamine therapy, hypovolemia should be corrected. IV infusion rate and guidelines for adjusting rate of flow are in relation to changes in blood

pressure. Microdrip or another reliable metering device should be used for accuracy of flow.

Infusion rate must be continuously monitored for free flow, and care must be taken to avoid extravasation, which can result in tissue sloughing and gangrene.

Protect dopamine from light. Discolored solutions should not be used. Monitor B/P, pulse, and peripheral pulses every 5 minutes. Precise measurements are

essential for accurate titration of dosage.


epinephrine (Adrenalin) CLASS: Central nervous system medications SUB-CLASS: Sympathomimetic DESCRIPTION: Epinephrine is a naturally occurring catecholamine obtained from animal adrenal

glands, but is also prepared synthetically. Acting directly on both alpha, beta1, and beta2 adrenergic receptors, it is the most potent activator of alpha receptors.

ONSET: SQ: 3-10 minutes; IV, ET: Less than 2 minutes DURATION: SQ: 20 – 30 minutes; IV: 5-10 minutes ADVERSE CNS: cerebrovascular accident, syncope REACTIONS: CV: Precordial pain, palpitations, hypertension, MI, tachydysrhythmias including VF INDICATIONS: To restore cardiac rhythm in cardiac arrest For treatment of allergic reactions and bronchospasm Profound bradycardia CONTRAINDICATIONS: Hypersensitivity to epinephrine (not an issue especially in emergencies,

the dose should be lowered or given slowly in non-cardiac arrest patients with heart disease, narrow-angle glaucoma, hemorrhagic-traumatic-cardiogenic shock, cardiac dilatation, cerebral arteriosclerosis, coronary insufficiency, dysrhythmias, organic heart or brain disease, during second stage of labor. Use with caution in the elderly or debilitated, hypertension, diabetes mellitus, hyperthyroidism, Parkinson’s disease, tuberculosis, in patient with long standing bronchial asthma and emphysema with heart disease, in children less than 6 years of age.

DRUG INTERACTIONS: Epinephrine may increase hypotension in circulatory collapse or

hypotension caused by phenothiazines. It has additive toxicities with other sympathomimetics. Alpha and beta adrenergic blocking agents antagonize the effects of epinephrine. Epinephrine is pH dependent and can be deactivated when administered with highly alkaline solutions such as bicarbonate.

DOSAGE AND Adult arrest: 1mg (10 mL 1:10,000) IV push; q 3 – 5 minutes ADMINISTRATION: Adult bradycardia: 30mg in 250 mL of normal saline or D5W; run at 100

mL hour = 0.1mcg/kg/min Adult anaphylaxis Mild 0.3 – 0.5mg (1:1,000) SQ Adult anaphylaxis: Severe 0.5 – 1.0mg (1:10,000) IV Pediatric arrest: 1

st dose 0.01mg/kg (1:10,000) IV, IO, or ET

Pediatric brady: 0.1mcg/kg/min IV, IO; calculate dose by 0.6 x body weight (in kg) equals number of mg diluted to total 100mL; then 1 mL/hr delivers 0.1mcg/kg/min

Pediatric anaphy: Mild 0.01mg/kg SQ (1:1,000) Pediatric anaphy: Severe 0.01mg/kg (1:10,000) IV Bronchospasm: 0.3 – 0.5mg (1:1,000) SQ (Not in textbook) Pediatric broncho: 0.01mg (1:1,000) SQ (Not in textbook) SPECIAL CONSIDERATIONS: Pregnancy safety: Category C A tuberculin syringe may ensure greater accuracy in measurement of parenteral doses. Epinephrine injection should be protected from exposure to light at all times. Carefully aspirate before injecting epinephrine. Inadvertent IV injection of usual SC doses can result in

sudden hypertension and possibly cerebral hemorrhage. Vascular constriction from rapid repeated injections may cause tissue necrosis. Rotate injection sites and

observe for signs of blanching. Isoproterenol should not be used concurrently with epinephrine. A 4 hours interval should elapse before a

change is made from one drug to the other.


Dietary

Supplement

Medications


calcium chloride CLASS: Dietary supplement medications SUB-CLASS: Electrolyte DESCRIPTION: Calcium chloride provides elemental calcium in the form of the cation

Ca++

. Calcium is necessary for may physiologic activities. It is an essential element for regulating the excitation threshold of nerves and muscles, for blood clotting mechanisms, maintenance of renal function, and body skeleton and teeth. Calcium causes significant increase in myocardial contractility and in ventricular automaticity.

ONSET: Immediate DURATION: Dose dependent (effects may persist for 4 hours after IV administration) ADVERSE CNS: Tingling sensation, fainting Skin: Sensation of heat waves with

rapid IV REACTIONS: (peripheral vasodilation), pain and burning at IV site, necrosis and

sloughing ( with extravasation) CV: Hypotension, bradycardia, cardiac dysrhythmias, cardiac arrest, severe venous thrombosis

INDICATIONS: Hyperkalemia (except when associated with digitalis toxicity) Hypocalcemia (e.g., after multiple blood transfusions) Calcium channel blocker toxicity Hypermagnesemia CONTRAINDICATIONS: VF, hypercalcemia, and positive digitalis toxicity. Use with

caution in patients taking digoxin as it may precipitate toxicity.

DRUG INTERACTIONS: Calcium may worsen dysrhythmias secondary to digitalis

May antagonize the peripheral vasodilatory effects of calcium channel blockers

DOSAGE AND Adult: 2 – 4mg/kg of 10% solution slow IV; may be ADMINISTRATION: repeated if needed

Pediatric: 20mg/kg IV/IO of 10% solution slow IV; may repeat in 10 min if necessary

SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Calcium may produce vasospasm in coronary and cerebral arteries Do not use routinely in cardiac arrest Hypertension and bradycardia may occur with rapid administration Monitor heart rate during administration


dextrose 50%

CLASS: Dietary supplement medications

SUB-CLASS: Carbohydrate

DESCRIPTION: Dextrose is the principle form of glucose (sugar) used by the body to

create energy. Since serious brain injury can occur in prolonged

hypoglycemia, the rapid administration of the glucose is essential.

ONSET: Less than 1 minute

DURATION: Depends upon the degree of hypoglycemia

ADVERSE CV: thrombophlebitis tissue necrosis

REACTIONS: CNS: Wernicke’s encephalopathy, Korsakoff’s psychosis

INDICATIONS: To increase blood sugar levels in documented hypoglycemia

CONTRAINDICATIONS: There are no major contraindications to the IV

administration of dextrose 50% in a patient with

documented or suspected hypoglycemia. Use with caution

in patients with increased intracranial pressure as the added

glucose may worsen the cerebral edema.

DRUG INTERACTIONS: None in the emergency setting

DOSAGE AND Adult: 25g slow IV; may be repeated once

ADMINISTRATION: Pediatric: 2 mL/kg of 25% solution IV



Always ensure a patent IV line before administering dextrose 50% as severe tissue necrosis

may occur with extravasation of this solution.

Report and record blood glucose levels before and after administering this solution.

Avoid extravasation.


magnesium sulfate CLASS: Dietary supplement medications SUB-CLASS: Electrolyte DESCRIPTION: Magnesium sulfate is an essential element in many biochemical processes that

occur within the body. It acts as a physiologic calcium channel blocker and blocks neuromuscular transmission. Hypomagnesemia can cause cardiac dysrhythmias, including refractory VF. It also can result in symptoms of cardiac insufficiency and sudden cardiac death.

ONSET: IV: Immediate IM: 1 hour DURATION: 30 minutes ADVERSE CNS: Sedation, circulatory collapse Respiratory: Respiratory paralysis REACTIONS: INDICATIONS: To reverse refractory ventricular fibrillation and pulseless ventricular

tachycardia To reverse Torsade de pointes To provide prophylaxis following acute myocardial infarction To manage seizures caused by eclampsia CONTRAINDICATIONS: Patients with myocardial damage, heart block, shock, persistent

hypertension, hypocalcemia. Use with caution in patients with impaired renal function, digitalized patients, concomitant use of other CNS depressants or neuromuscular blocking agents.

DRUG INTERACTIONS: Neuromuscular blocking agents add to respiratory depression and

apnea. If administered in conjunction with digitalis, cardiac conduction abnormalities can occur.

DOSAGE AND Adult arrest: 1 – 2g diluted in 10 mL IV ADMINISTRATION: Pediatric arrest: 25-50 mg/kg IV/IM

Adult Torsades: 1 – 2g in 50 – 100 mL over 5 – 60 min; follow with – 0.5 – 1.0g/hr IV

Pediatric Torsades: 25-50 mg/kg IV/IM Prophylaxis AMI: 1 – 2g IV over 5 – 30 minutes Preeclamptic seizures: 2-4 g IV/IM in adults only Bronchoconstriction: 1 – 2g IV over 5 – 30 minutes (Not in textbook) SPECIAL CONSIDERATIONS: Pregnancy safety: Category B Administer magnesium slowly to minimize side effects. Verify correct IV concentration when administering to infants & children. Early indicators of magnesium toxicity include cathartic effect, profound thirst, feeling of warmth, sedation,

confusion, depressed deep tendon reflexes, and muscle weakness. Before each repeated parenteral does, patellar reflex should be tested. Depression or absence of reflexes is a

useful index of early magnesium intoxication. Calcium chloride or calcium gluconate should be available as an antidote if serious side effects occur. Newborns of mothers who received parenteral magnesium sulfate within a few hours of delivery should be

observed for signs of toxicity, including respiratory and neuromuscular depression. The role of magnesium in the management of refractory bronchospasm remains controversial.


sodium bicarbonate CLASS: Dietary supplement medications SUB-CLASS: Electrolyte; Buffer; Alkalizing agent DESCRIPTION: Sodium bicarbonate is a short acting, potent, systemic antacid. Given IV,

it immediately raises the pH of blood plasma by buffering excess hydrogen ions. In a short time, the plasma alkali reserve is increased and excess sodium and bicarbonate ions excreted in urine, thus rendering the urine less acidic.

ONSET: Immediate absorption (onset less than 15 minutes) DURATION: 1 –2 hours

ADVERSE Metabolic: May produce paradoxical acidosis that can depress cerebral REACTIONS: and cardiac function, extracellular alkalosis, electrolyte imbalance

(hypernatremia) CV: May induce malignant arrhythmias, severe tissue damage if extravasated

INDICATIONS: Known preexisting bicarbonate responsive acidosis To alkalinize the urine to enhance excretion of drug overdose (TCAs,

barbiturates) Known hyperkalemia CONTRAINDICATIONS: There are no absolute contraindications to using sodium

bicarbonate in the above situations. When administered in large quantities, it can cause a metabolic alkalosis.

DRUG INTERACTIONS: Most catecholamines and vasopressors can be deactivated

by alkaline solutions like sodium bicarbonate. When administered with calcium chloride, a precipitate may form that will clog the IV line.

DOSAGE AND Adult: 1 mEq/kg IV; repeat with 0.5 mEq/kg 1 10 min ADMINISTRATION: Pediatric: Same as adult; infuse slowly and only if

ventilations are adequate SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Infusion should be stopped immediately if extravasation occurs. Severe tissue damage has

followed tissue infiltration. Always flush the IV line following sodium bicarbonate administration, especially in cardiac

arrest.


Diuretic

Medications


furosemide (Lasix) CLASS: Diuretic medications SUB-CLASS: Loop diuretic DESCRIPTION: Furosemide is a rapid acting potent sulfonamide loop diuretic and

antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. Its exact mode of action is not clearly defined. It inhibits reabsorption of sodium and chloride primarily in the Loop of Henle and also in proximal and distal renal tubes.

ONSET: Diuretic effects within 5 – 30 minutes Vascular effects within 5 – 10 minutes DURATION: 6 hours ADVERSE CV: Postural hypotension, acute hypotensive episodes, circulatory

collapse REACTIONS: Fluid and electrolyte imbalances: Hypovolemia, dehydration,

hyponatremia, hypokalemia, hypochloremia metabolic alkalosis, hypomagnesemia, hypocalcemia (tetany)

INDICATIONS: Pulmonary edema associated with CHF CONTRAINDICATIONS: Hypersensitivity to furosemide or sulfonamides, increasing

oliguria, anuria, fluid and electrolyte depletion state, hepatic coma, pregnancy. Use with caution in infants, elderly patients, hepatic cirrhosis, nephritic syndrome, cardiogenic shock associated with acute MI, history of gout, patients receiving digitalis glycosides or potassium depleting steroids.

DRUG INTERACTIONS: Other diuretics enhance the diuretic effects of furosemide.

There is an increased risk of digoxin toxicity because of hypokalemia. Nondepolarizing neuromuscular blocking agents prolong neuromuscular blockage. Corticosteroids can potentiate hypokalemia. Furosemide decreases lithium elimination and increases its toxicity. It blunts the hypoglycemic effects of insulin. NSAIDs may attenuate diuretic effects.

DOSAGE AND Adult: 40 – 120mg slow IV over 1 – 2 min ADMINISTRATION: Pediatric: 1mg/kg (max 6mg/kg total dose) SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Protect syringes from light once they are removed from package. Verify correct IV concentration and rate when administering to neonates, infants, and

children. Patients receiving the drug parenterally should be observed carefully, and B/P and vital

signs closely monitored. Sudden death from cardiac arrest has been reported. Close observation of the elderly patient is particularly essential during period of brisk

diuresis. Sudden alteration of fluid and electrolyte balance may precipitate significant adverse reactions.

Furosemide should not be administered through the same IV line as amrinone as it will cause a precipitate to from in the line.


Endocrine

Medications


glucagon (GlucaGen)

CLASS: Endocrine medications

SUB-CLASS: Hormone DESCRIPTION: Glucagon is a natural polypeptide hormone produced by alpha cells of the

Islets of Langerhans in the pancreas. When released it causes a breakdown of stored glycogen to glucose and inhibits the synthesis of glycogen from glucose. Both actions increase the blood levels of glucose.


DURATION: 60 – 90 minutes

ADVERSE CV: Hypotension; hyperglycemia

REACTIONS:

INDICATIONS: To increased blood glucose levels in hypoglycemia without IV access

To reverse the effects of beta blocker toxicity

CONTRAINDICATIONS: Hypersensitivity to glucagon or proteins. Use with caution

in patients with a history of cardiovascular or renal disease.

DRUG INTERACTIONS: None in the emergency setting.

DOSAGE AND Adult hypoglycemia: 1mg IM/SQ; may repeat in 5 – 20 min

ADMINISTRATION: Pediatric hypoglycemia: 0.1 mg/kg IM/SC/IV if patient is>10kg

1.0 mg/kg IM/SC/IV if patient is<10kg

Adult beta blocker: 50 – 150mg/kg over 1 min

Pediatric beta blocker: 50 – 150mg/kg over 1 min



After reconstitution of dry powder, use solution immediately.

Glucagons will form a precipitate in saline solutions and solutions with pH of 3 – 9.5. glucagon should be

considered incompatible in syringe with any other drug.

Patient usually awakens from hypoglycemic coma 5 – 20 minutes after glucagons injection. As soon as

possible after patient regains consciousness, PO carbohydrate should be given.

After recovery from hypoglycemia reaction, symptoms such as headache, nausea, and weakness.

Most emergency departments and EMS services do not carry enough glucagon for a severe adult beta block

overdose. A kit with an adequate quantity of the drug could e kept with a supervisor unit in case it is

needed.


Poisoning & O.D.

Medications


activated charcoal (Aqua, Actidose, Liqui-Char)

CLASS: Poisoning & O.D. medications

SUB-CLASS: Adsorbent

DESCRIPTION: Activated charcoal is a fine black powder that adsorbs many drugs and

chemicals. It acts by binding (adsorbing) toxic substances, thereby

inhibiting their GI adsorption, enterohepatic circulation, and thus

bioavailability.

ONSET: Immediate

DURATION: Continual while in the GI tract

ADVERSE GI: Vomiting following rapid ingestion of high doses, abdominal

cramping,

REACTIONS: constipation (diarrhea from sorbitol additive)

INDICATIONS: To treat acute ingested poison.

CONTRAINDICATIONS: Poisonings by cyanide, mineral acids, caustic alkalis,

organic solvents, iron, ethanol, and methanol.

DRUG INTERACTIONS: Syrup of ipecac (adsorbed by activated charcoal, and will

result in vomiting of the charcoal)

DOSAGE AND Adult: 1gm/kg orally




Charcoal is frequently administered to pregnant patients and the potential benefit vs. risk is

very high. Since charcoal remains within the GI tract, its risk to the fetus is virtually

eliminated, unless the charcoal and other stomach content are aspirated.

Activated charcoal may also be known as “AC”

Is relatively insoluble in water

May blacken feces

Must be stored in a closed container

Different charcoal preparations may have varying adsorptive capacity

Does not adsorb all drugs and toxic substances (e.g., phenobarbital, ASA, cyanide, lithium,

iron, lead, arsenic)


atropine sulfate CLASS: Poisoning & OD Medications SUB-CLASS: Parasympatholytic DESCRIPTION: Atropine sulfate exerts its effects on the autonomic nervous system. It is a competitive

antagonist that selectively blocks all muscarinic responses to acetylcholine (Ach). ONSET: 2 – 4 minutes DURATION: 4 hours ADVERSE CV: Both supine and postural hypotension, syncope, bradycardia, increased frequency

of PVCs and other dysrhythmias, exacerbation of digitalis induced dysrhythmias Other: Respiratory depression

REACTIONS: INDICATIONS: Hemodynamically significant bradycardia; Asystole; PEA with absolute bradycardia;

Organophosphate or nerve gas poisoning Bronchospastic pulmonary disorders CONTRAINDICATIONS: No contraindications in the prehospital setting. Use with caution in

patients with narrow angle glaucoma, acute MI and tachycardia DRUG INTERACTIONS: Amantadine, antihistamines, TCAs, quinidine, disophyramide,

procainamide can add to the anticholinergic effects of atropine. Levodopa effects are decreased. Methotrimeptrazine may precipitate extrapyramidal effects. Phenothiazine antipsychotic effects are decreased (decreased absorption).

DOSAGE AND Adult bradycardia: 0.5 – 1.0mg IV; q 3 – 5 min for desired response ADMINISTRATION: (max dose 3mg or 0.04mg/kg which ever is greater)

Adult arrest: 1mg IV, 2 mg ET; q 3 – 5 min (max dose 3mg or 0.04mg/kg which ever is greater)

Adult 2 - 5mg IV q 5 – 15 min to dry secretions (repeat as Anticholinergic: needed); then q 1 – 4 hours for at least 24 hours Pediatric brady: 0.02mg/kg IV, IO, ET; min dose 0.1mg; maximum

single dose of 0.5mg for child and 1mg for an adolescent; may q in 5 min for a max total dose 1mg for a child and 2mg for an adolescent

Pediatric arrest: Efficacy has not been established Pediatric 0.05mg/kg IV; may be repeated q 20 min until Anticholinergic: atropine effect is observed; then 1 – 4 hours for at least

24 hours SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Smaller doses of atropine are indicated for the elderly. Monitor vital signs. Pulse is a sensitive indicator of patient’s response to atropine. Be alert to changes in

quality, rate, and rhythm of pulse and respiration and to changes in blood pressure. Initial paradoxic bradycardia following IV atropine usually lasts only 1 – 2 minutes. It most likely occurs

when IV is administered slowly (more than a minute) or when small doses (less than 0.5 mg) are used. Atropine may actually worsen the bradycardia associated with Mobitz II and complete AV block. In these

cases, use transcutaneous pacing. Always rule out hypoxia as the cause for bradycardia in infants and small children. Atropine is indicated

only after oxygen and epinephrine fail.


naloxone (Narcan) CLASS: Poisoning & O.D. medications

SUB-CLASS: Narcotic antagonist

DESCRIPTION: Naloxone is an analog of oxymorphone which is a pure narcotic antagonist with

essentially free of agonistic (morphine-like) properties. Thus it produces no

significant analgesia, respiratory depression, psychotomimetic effects, or miosis

when administered in the absence of narcotics and possesses more potent

narcotic antagonist action. Naloxone competes for and displaces narcotic

molecules from opiate receptors in the brain.

ONSET: Within 2 minutes IV, 2-10 minutes IM/ET

DURATION: 20 - 120 minutes

ADVERSE Excessive dosage in narcotic depression: Reversal of analgesia, increased B/P,

REACTIONS: Too rapid reversal: Nausea, vomiting, sweating, tachycardia

INDICATIONS: To reverse the effects of narcotic analgesics

To manage coma of unknown origin

CONTRAINDICATIONS: Patients with hypersensitivity to naloxone and in patients whose

respiratory depression is due to nonopioid drugs. Use with

caution in patients who are known or suspected narcotic addicts.

This includes newborn infants of mothers with known or

suspected narcotic dependence.

DRUG INTERACTIONS: Naloxone may cause withdrawal symptoms in narcotic addicts.

Use only enough to reverse respiratory depression.

DOSAGE AND Adult: 0.4 – 2.0mg IM/IV, may be repeated in 2-3 min

ADMINISTRATION: intervals to a maximum of 10 mg

Pediatric:

0.01mg/kg (IV, IO, ET), 2-2.5 times dose IV dose for ET administration



Naloxone may be given rapidly by direct IV.

Protect drug from excessive light.

Duration of action of some narcotics may exceed that of naloxone. Monitor the patient closely.

Monitor respirations and other vital signs.

The goal of prehospital naloxone therapy is to reverse any respiratory depression. Large, one time

boluses can induce an opiate withdrawal reaction that can be difficult to manage.


Respiratory

System

Medications


albuterol (Proventil, Ventolin) CLASS: Respiratory system medications

SUB-CLASS: Sympathomimetic

- Bronchodilator

DESCRIPTION: Albuterol is a relatively selective beta2 adrenergic. The prime action of beta adrenergic

drugs is to stimulate adenyl cyclase, the enzyme that catalyzes the formation of cyclic-

3’, 5’ adenosine monophosphate (cyclic AMP) from adenosine triphosphate (ATP).

The cyclic AMP causes relaxation of the smooth muscles of the bronchial tree,

decreasing airway resistance, facilitating mucus drainage, and increasing vital capacity.

It exerts minimal effects on beta1 or alpha receptors.

ONSET: 5-15 minutes

DURATION: 3-6 hours after inhalation

ADVERSE CNS: Tremors, anxiety, dizziness, seizures, headache,

REACTIONS: CV: Palpitations, tachycardia, hypertension Respiratory: Bronchospasm, cough,

wheezing

INDICATIONS: Relief of bronchospasm in patients with reversible obstructive airway disease (asthma,

chronic bronchitis, emphysema) and acute attacks of bronchospasm.

CONTRAINDICATIONS: Never use for patients with a known hypersensitivity to the drug.

DRUG INTERACTIONS: Other sympathomimetics aerosol bronchodilators or epinephrine should

not be used concomitantly with albuterol. Albuterol should be

administered with extreme caution to patients being treated with MAO

inhibitors or TCAs, since the action of albuterol on the vascular system

may be potentiated. Beta receptor blocking agents and albuterol inhibit

the effect of each other. Since albuterol may lower serum potassium,

care should be taken in patients also using other drugs that lower serum

potassium as the effects may be additive.

DOSAGE AND Adult solution: 2.5mg (0.5 mL of 0.5% solution) diluted to 3 mL with

ADMINISTRATION: 0.9% NS; administer over 5 – 15 min; 3 – 4 times/day

by nebulizer

Pedi. solution: 0.15 mg/kg diluted in 2.5 – 3.0 mL of 0.9% NS as

needed



Your patient may be taking albuterol in an oral form. The most common adverse effect associated with oral

drug is fine tremor in fingers, which may interfere with precision handwork.

Expect children 2 – 6 years old to be more prone to symptoms of CNS stimulation.

Significant subjective improvement in pulmonary functions should occur within 60 – 90 minutes after drug

administration. Reevaluate your patient’s condition often and repeat albuterol therapy when needed.


ipratropium (Atrovent) CLASS: Respiratory system medications

SUB-CLASS: Parasympatholytic

- Bronchodilator

DESCRIPTION: Ipratropium is an anticholinergic agent, chemically related to atropine. Given in

a nebulized form, it acts directly on the smooth muscle of the bronchial tree by

inhibiting acetylcholine at receptor sites. By blocking parasympathetic action, it

dilates the bronchial smooth muscle and decreases secretions.

ONSET: 5-15 minutes

DURATION: 4-6 hours

ADVERSE Eye: blurred vision (especially if sprayed into eye),

REACTIONS: Respiratory: Cough, hoarsensess, exacerbation of symptoms, drying of bronchial

secretions

INDICATIONS: Relief of bronchospasm in patients with reversible obstructive airway disease

(asthma, chronic bronchitis, emphysema) and acute attacks of bronchospasm.

CONTRAINDICATIONS: Hypersensitivity to atropine or its derivatives. It should not be

used as the primary treatment for acute episodes of

bronchospasm. Use with caution in pregnancy and nursing

mothers.

DRUG INTERACTIONS: None reported

DOSAGE AND Note: When used in combination with beta agonists, the beta

agonist

ADMINISTRATION: is always administered first with a 5 min wait before

administering ipratropium.

Adult: 500 mcg in 2.5 – 3.0 mL NS via nebulization

Adult MDI: 1 – 2 inhalations

Pediatric: Same as adult (over 12 years of age)



Monitor respiratory status. Auscultate lungs before and after inhalation.

Treatment failure should be reported to physician.

Ipratropium is almost always administered in conjunction with a beta adrenergic agent such as

albuterol.


oxygen

CLASS: Respiratory system medications

SUB-CLASS: Naturally occurring atmospheric gas

DESCRIPTION: Oxygen is an odorless, tasteless, colorless gas necessary for life. Oxygen

enters the body through the respiratory system and is transported to the

cells by hemoglobin, found in red blood cells. Oxygen is required for the

efficient breakdown of glucose into a usable energy from. The

administration of enriched oxygen increases the oxygen concentration in

the alveoli, which subsequently increases oxygen saturation of available

hemoglobin.

ONSET: Immediately

DURATION: Less than 2 minutes

ADVERSE High concentration oxygen may cause decreased LOC and respiratory

depression

REACTIONS: depression in patients with chronic carbon dioxide retention

INDICATIONS: To manage any situation in which hypoxia is suspected.

CONTRAINDICATIONS: There are no contraindications to oxygen. Use with caution

in patients with chronic obstructive pulmonary disease who

may have hypoxic drive.

DRUG INTERACTIONS: None significant

DOSAGE AND Adult: 100% for hypoxia



Pregnancy safety: N/A

Oxygen vigorously supports combustion


phenylephrine (Neo-Synephrine)

CLASS: Respiratory system medications

SUB-CLASS: Nasal decongestant

DESCRIPTION: Used for topical nasal administration, phenylephrine primarily exhibits

alpha-adrenergic stimulation. This stimulation can produce moderate to

marked vasoconstriction and subsequent nasal decongestion.


DURATION: 3 – 6 hours

ADVERSE

REACTIONS: CV: Palpitation, tachycardia, bradycardia, extrasystoles, hypertension,

precordial pain

INDICATIONS: Prior to nasotracheal intubation to induce vasoconstriction of the nasal

mucosa.

CONTRAINDICATIONS: None in the emergency setting

DRUG INTERACTIONS: Avoid administration into the eyes as it will cause dilation of

pupils.

DOSEAGE AND Adult:Instill 2 drops of 1% solution in the nostril prior

to attempting nasotracheal intubation.

ADMINISTRATION:

Pediatric: Same as adult.




racemic epinephrine (microNEFRIN) CLASS: Respiratory system medications SUB-CLASS : Sympathomimetic DESCRIPTION: Racemic epinephrine is slightly different chemically from the epinephrine

compounds that have been discussed previously. Compounds that differ only in their chemical arrangement are called isomers. This particular form is frequently used in children to treat croup. Racemic epinephrine stimulates both alpha and beta adrenergic receptors, with a slight preference for the beta2 receptors in the lungs. This results in bronchodilation and a decrease in mucus secretion. It also has some effect in relieving the subglottic edema associated with croup when administered by inhalation.

ONSET: Within 5 minutes DURATION: 1 – 3 hours ADVERSE CNS: Restlessness, tremors, anxiety, nervousness, dizziness, headache REACTIONS: CV: Tachycardia, hypertension, palpitation, angina, dysrhythmias

Respiratory: Bronchial edema/inflammation, paradoxical bronchospasm INDICATIONS: To relieve subglottic edema in croup. CONTRAINDICATIONS: Hypersensitivity to the drug, those with potential for

tachydysrhythmias and hypertension, epiglottitis. DRUG INTERACTIONS: None noted. DOSAGE AND Adult solution: Dilute 0.25 – 0.75 mL of a 2.25 solution in 2 ADMINISTRATION: mL saline, via nebulization

Pediatric: Same as adult SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Monitor vital signs prior to, during, and following administration. Many patients will experience rebound worsening 30 – 60 minutes after the initial

treatment and the effects of the drug have worn off. For this reason, transport all patients to the hospital. Hospitals have the policy that all children who have received racemic epinephrine will be admitted for at least 24 hours for observation.


Steroid & anti-

inflammatory

Medications


methylprednisolone (Solu-Medrol) CLASS: Steroid & anti-inflammatory medications SUB-CLASS : Steroid, glucocorticoid DESCRIPTION: Methylprednisolone is an intermediate acting synthetic adrenal

corticosteroid with similar glucocorticoid activity but considerable fewer sodium and water retention effects than hydrocortisone. Like the other steroids, its pharmacologic actions are vast and complex and, in medicine, have a wide range of uses.

ONSET: 1 - 2 hours (These IV time frames are not available in your resources) DURATION: 8 - 24 hours (These IV time frames are not available in your resources) ADVERSE CV: CHF, hypertension REACTIONS: Endocrine: hyperglycemia INDICATIONS: To reduce the inflammatory process in allergic reactions such as

anaphylaxis, asthma and COPD To reduce cerebral edema CONTRAINDICATIONS: None in the treatment of acute anaphylaxis. Use with

caution in patients with GI bleeding, diabetes mellitus, severe infection

DRUG INTERACTIONS: Furosemide and thiazide diuretics may increase potassium

loss. Phenytoin, phenobarbital, isoniazid, and rifampin may decrease the effectiveness of methylprednisolone and increase the metabolism of steroids.

DOSAGE AND Adult: 25 - 250mg IV/IM except for spinal cord injury where ADMINISTRATION: the initial dose is 30mg/kg IV bolus followed by an IV

infusion of 5.4mg/kg/hr for 23 hours Pediatric: 1 – 2mg/kg IV SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Give IM injection deep into large muscle (not deltoid). Verify correct IV concentration and rate of administration in infants and children. Most EMS agencies do not carry enough methylprednisolone for high dose steroid therapy

for spinal cord injuries. Systems that encounter, or are apt to encounter, spinal injuries should give consideration to preparing spinal injury packs with enough drug to handle a 220 pound adult.


Vasoactive

Medications


nitroglycerin (Nitrostat and others)

CLASS: Vasoactive Medications

SUB-CLASS: Nitrate

DESCRIPTION: Nitroglycerin is an organic nitrate and potent vasodilator with antianginal, anti-

ischemic, and antihypertensive effects. It relaxes vascular smooth muscle by

unknown mechanism, resulting in dose related dilation of both venous and

arterial blood vessels. It also promotes peripheral pooling of blood, reductions

of peripheral resistance, and decreased venous return to the heart.

ONSET: 1-3 minutes

DURATION: 20-30 minutes

ADVERSE CNS: Headache, vertigo, dizziness, faintness

REACTIONS: CV: Postural hypotension, palpitations, tachycardia (sometimes with

paradoxical bradycardia), increase in angina, syncope, and circulatory collapse

INDICATIONS: To increase coronary artery perfusion and relieve chest pain in angina and acute

myocardial infarction.

To reduce preload in acute pulmonary edema.

CONTRAINDICATIONS: Hypersensitivity, idiosyncrasy, or tolerance to nitrates. Patients

taking sildenafil (Viagra), severe anemia, head trauma, increased

ICP, glaucoma. Do not administer to shock patients.

DRUG INTERACTIONS: Alcohol and antihypertensive agents may compound the

hypotensive effects. It may cause orthostatic hypotension when

used in conjunction with beta blockers. Patients taking sildenafil

are at risk for severe cardiac event.

DOSAGE AND Adult: 0.3 - 0.4mg SL; may repeat twice

ADMINISTRATION: Pediatric: Not recommended



Approximately 50% of all patients experience mild to severe headaches following administration.

Postural hypotension may occur even with small doses of nitroglycerin.

Use with caution in patients who have taken sildenafil in the last 6 hours as hypotension can result.


vasopressin (Pitressin) CLASS: Vasoactive Medications SUB-CLASS: Hormone, vasopressor DESCRIPTION: Vasopressin is a polypeptide hormone extracted from animal posterior

pituitaries. It possesses pressor and antidiuretic principles, but is relatively free of oxytocic properties. Vasopressin produces concentrated urine by increasing tubular reabsorption of water, thus preserving up to 90% water. It may increase sodium and decrease potassium reabsorption but plays no causative role in edema formation. It acts by direct stimulation of smooth muscle V1 receptors.

ONSET: Immediate DURATION: Variable

ADVERSE Adverse reactions are infrequent with low doses Large doses: hypertension,

bradycardia, minor arrhythmias, premature atrial contractions, heart block, peripheral vascular collapse, coronary insufficiency, MI

REACTIONS: hypertension, bradycardia, minor arrhythmias, premature atrial contractions,

heart block, peripheral vascular collapse, coronary insufficiency, MI INDICATIONS: To increase peripheral vascular resistance during CPR (as an alternative to

epinephrine) or after epinephrine has been used. CONTRAINDICATIONS: Chronic nephritis accompanied by nitrogen retention, ischemic

heart disease, PVCs, advanced arteriosclerosis, during first stage of labor. Use with caution in patients with epilepsy, migraine, asthma, heart failure, angina pectoris, any state in which rapid addition to extracellular fluid may be hazardous, vascular disease, preoperative and postoperative polyuric patients, renal disease, goiter with cardiac complications, elderly and children.

DRUG INTERACTIONS: Alcohol, demeclocycline, epinephrine, heparin, lithium,

phenytoin may decrease antidiuretic effects of vasopressin. Gaunethidine, neostigmine increase vasopressor actions. Chlorpamidede, clofibrate, carbamazepine, thiazide diuretics may increase antidiuretic activity.

DOSAGE AND Adult arrest: 40 U IV push one time ADMINISTRATION: P ediatric: Not recommended SPECIAL CONSIDERATIONS: Pregnancy safety: Category C Conclusive evidence supporting the use of vasopressin in cardiac arrest is lacking. Its use in

refractory VF is class IIb (acceptable). Its use in asystole, PEA, or prolonged cardiac arrest is indeterminate (neither recommended nor forbidden).

It may useful in septic shock. It is a class IIb when used with standard therapy (inotropic agents and vasoconstrictor drugs commonly used) is inadequate.


Generic Name Trade Name Page #

activated charcoal Aqua, Actidose, Liqui-Char 46

adenosine Adenocard 28

albuterol Proventil, Ventolin 50

amiodarone Cordarone 29

aspirin ASA, Bayer, Ecotrin, St. Joseph 10

atropine sulfate N/A 33, 47

calcium chloride N/A 37

dextrose 50% N/A 38

diazepam Valium 12, 20

diphenhydramine Benadryl 15

dopamine Intropin 34

epinephrine Adrenalin 35

fentanyl citrate Sublimaze 4

furosemide Lasix 42

glucagon GlucaGen 44

haloperidol lactate Haldol 21

ipratropium Atrovent 51

lidocaine Xylocaine 7, 30

magnesium sulfate N/A 39

methylprednisolone Solu-Medrol 56

metoclopramide Reglan, Clopra, Maxolon, Reclomide,

Octamide 17, 23

midazolam hydrochloride Versed 13, 22

morphine sulfate Astramorph 5

naloxone Narcan 48

nitroglycerin Nitrostat 58

ondanestron Zofran 18

oxygen N/A 52

phenylephrine Neo-Synephrine 53

procainamide Pronestyl 31

racemic epinephrine MicroNEFRIN 54

sodium bicarbonate N/A 40

tetracaine Pontocaine 8

vasopressin Pitressin 59

albuterol (proventil, ventolin) and class… · z:\phase i files\pharmacology presentations\emt-p...

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