2. PARAMEDIC MEDICATIONS.pdf

Toxicological Medication Activated Charcoal

Activated Charcoal (Actidose®)

Type:

Toxicological agent

Mechanism of Action (What the drug does in the body):

This drug is given to patients’ who have ingested a poison. It binds and absorbs toxins in the gatrointestinal system. Activated charcoal is often given with a cathartic, such as sorbitol, to speed the passage of the bound toxin through the GI tract (In other words, it rushes the poison out via diarrhea).

Indications (When to give the drug):

Ingested poison and drug overdose

Contraindications (When NOT to give the drug):

Altered level of consciousness, whether actual or potential unless the airway is protected via an endotracheal tube.

Ingestion of heavy metals or caustic substances.

Precautions: If you need to induce vomiting with syrup of ipecac, activated charcoal will be more effective if given after the patient has vomited.


Black stools, N/V, abdominal cramping, constipation except when given with a cathartic agent

Supplied:

Plastic bottle is the most common with either 25 grams or 50 grams per container

Dosage and Route:

Adults: 1 gm/kg by mouth (PO)

Pediatrics: 1 gm/kg by mouth (PO)

Toxicological Medication Activated Charcoal

If activated charcoal is kept as a powder, mix with a glass of water to create a slurry. It is best to administer charcoal in an opaque container and straw so that the patient does not see the mixture.

Cardiac Medications Adenosine

Adenosine (Adenocard®)

Type: Cardiac antidysrhythmic Mechanism of Action (What the drug does in the body): Adenosine is an endogenous nucleoside (naturally found in the cells of the body) that acts to slow conduction through the AV node and on sinus pacemaker cells without reducing the force of contraction. It is recommended as the drug of choice to treat PSVT; however, adenosine is neither effective nor recommended for atrial flutter or atrial fibrillation. Due to the extremely short half-life of adenosine, intravenous access should be in a large vein above the diaphragm if possible (Antecubital). Half-Life (How long until the drug reduces from the initial dosage by half): 10 seconds Indications (When to give the drug): PSVT Wolff-Parkinson-White Syndrome (short PR interval with delta waves)

Cardiac Medications Adenosine

Contraindications (When not to give the drug): Hypersensitivity (allergic) Sick sinus syndrome Second or third degree AV blocks Side Effects (Undesirable things that happen in addition to the therapeutic benefit): Flushing Shortness of breath Lightheadedness Brief periods of asystole, bradycardia, and ventricular ectopy Headache Chest Pain Palpitations Supplied: 3 mg/ml in either vials or pre-filled syringes Precautions:

• May precipitate bronchospasm in asthmatics • Caffeine, theophylline and aminophylline block the effects of adenosine • Dipyradimole (antiplatelet drug) increases the potency of adenosine—most authorities

recommend reducing the dosage Dosage and Route: Adults: 6 mg rapid IVP to be immediately followed by a syringe-pushed 20 ml bolus of NS May repeat twice at 12 mg to a maximum of 30 mg. Peds: 0.1 mg/kg (max. of 6 mg dosage for the bolus) May repeat once at 0.2 mg/kg

Respiratory Medication

Albuterol (Proventil®)

Mechanism of Action (How the drug works):

Albuterol causes the bronchioles to dilate by activating the beta-2 receptors in the lungs. Recall that the beta-receptors are a component of the sympathetic nervous system.


Bronchoconstriction (evidenced by wheezing or a “silent chest”) secondary to: Emphysema, chronic bronchitis, asthma, and pneumonia

Contraindications (When NOT to give the drug):

Hypersensitivity


Side Effects (Undesirable things that happen in addition to the therapeutic benefit):

Restlessness Tachycardia

Nervousness Muscle tremors

Dysrhythmias

Supplied:

Nebulizer use: 0.5% multidose vial; 0.083% (2.5mg) in 3 cc single dose unit

Metered Dose Inhaler: 90 mcg / spray

Dosage:

For single dose unit – place the entire contents into a nebulizer unit and set the oxygen at 6 liters/min (non-humidified).

Multidose vial – 2.5 mg (0.5ml) mixed with 3 mL of normal saline into a nebulizer unit and set the oxygen at 6 liters/min (non-humidified).

Respiratory Medication Alupent

Alupent® (metaproterenol)

Type:

Beta – 2 Agonist


Albuterol causes the bronchioles to dilate by activating the beta-2 receptors in the lungs. Recall that the beta-receptors are a component of the sympathetic nervous system.


Bronchoconstriction (evidenced by wheezing or a “silent chest”) secondary to: Emphysema, chronic bronchitis, asthma, and pneumonia.

Contraindications (When not to give the drug):

Hypersensitivity (allergic)

Respiratory Medication Alupent

Ischemic heart disease


Restlessness Tachycardia

Nervousness Muscle tremors

Dysrhythmias

Supplied:

MDI:

0.65/mg/spray (15- ml inhaler)

Solution:

0.6% (2.5 ml dose); 5% (0.3 ml dose)

Precautions:

Cardiac dysrhythmias associated with tachycardia Hyperthyroidism Hypertension

Dosage and Route:

MDI

Adult: 2-3 inhalations q 3-4 hr (2 min between inhalations);

maximum dose of 12 inhalations/day

Pediatric: Not recommended

Nebulizer

15 mg via small volume nebulizer with 6 liters/min non-humidified oxygen

Solution

Adult: 5-15 inhalations of 5% solution

Pediatric: Not recommended

Cardiac Medication Amiodarone

Amiodarone (Cordarone®)

Type:

Cardiac antidysrhythmic


Amiodarone is used to convert both atrial and ventricular dysrhythmias. Due to its ability to be used in both areas of the heart, it is an ideal agent for pre-hospital use. It prolongs the duration of the action potential and the effective refractory period. Amiodarone decreases AV conduction velocity and sinus node function, thereby slowing the heart rate. In addition, it possesses the ability to inhibit both alpha and beta effects. By blocking the sympathetic receptors the heart rate, force of contraction, and conduction velocity will all be reduced.

Half-Life (Time it takes for the drug to lose half of the initial dose):

More than 30 days


Cardiac Medication Amiodarone

Atrial Tachycardia Ventricular Tachycardia

Atrial Flutter Refractory Ventricular Fibrillation

Atrial Fibrillation


None in cardiac arrest with VF or VT.

High degree AV blocks (2nd degree Type II or 3rd degree)

Sinus node dysfunction

Marked bradycardia.

Cardiogenic Shock


Hypotension

Bradycardia

Supplied:

150 mg / 3 ml ampule (50 mg/ml)

Dosage and Route:

Cardiac arrest – 300 mg IVP (2 ampules)

Tachycardias – 150 mg IV infusion over 10 minutes. May repeat once.

Note: A maintenance infusion may be given at 1 mg/min but this is typically reserved for hospital use.

Antipyretic Aspirin Antiplatelet

Aspirin (ASA)

Type:

Anti-platelet, Anti-pyretic


Aspirin inhibits the formation of Thromboxane A-2, which is a chemical that activates platelets and causes localized vasoconstriction. In the pre-hospital setting aspirin is administered to reduce the mortality associated with an acute myocardial infarction.


Acute myocardial infarction (possible or known)



Children

Bleeding disorders


Nausea/Vomiting Heart burn

G.I. discomfort

Supplied:

“Baby Aspirin” – 81 mg tablets

Aspirin – Varying doses (should not exceed 350 mg)

Precautions:

Should not be used in the pediatric setting due to its association with Reye’s syndrome

Dosage and Route:

Adults: 160 – 325 mg by mouth (P.O.)

Antipyretic Aspirin Antiplatelet

Note: Have the patient chew the aspirin to enhance absorption from the sublingual and buccal mucous membranes. When the patient reports an “allergy” to ASA, question the patient further to determine if a true allergy exists (urticaria, edema, itching, hypotension, dyspnea, wheezing, etc.)

Cardiac Medications Atropine

Atropine Sulfate

Type: Cardiac antidysrhythmic Mechanism of Action (What the drug does in the body): Atropine inhibits the effect of acetylcholine (neurotransmitter) in the parasympathetic nervous system (feed-or-breed system). It is given during symptomatic bradycardia to block the effect of the vagus nerve. If you block the effect of the vagus nerve, than the sympathetic nervous system will dominate (i.e. increased heart rate, increased conduction velocity, etc.). When administered for organophosphate or nerve gas poisoning, it helps to reverse the S.L.U.D.G.E. effect. Half-Life (How long the drug is in the therapeutic range): 2-6 hours Indications (When to give the drug): Symptomatic bradycardia (rate-dependant PVC’s, diaphoresis, altered LOC, hypotension) Asystole

Cardiac Medications Atropine

Organophosphate poisoning Nerve gas poisoning Contraindications (When not to give the drug): Tachycardia (except when associated with organophosphate or nerve gas poisoning) Narrow-angle glaucoma Hypersensitivity Side Effects (Undesirable things that happen in addition to the therapeutic benefit): Flushing Dizziness Tachydysrhythmias Nausea Headache Increased myocardial oxygen demand Palpitations Supplied: 1 mg / 10 ml prefilled syringe 8 mg / 20 ml vial Precautions:

• Do not administer a dosage less than 0.5 mg to adults and 0.1 mg for pediatrics—may result in a paradoxical (reverse) effect

• Is not considered effective for 2nd degree type II or 3rd degree AV blocks, and if used, may reduce conduction thereby slowing the heart rate. Some protocols still allow atropine to be administered for these AV blocks with discretion exercised by the medical director.

Dosage and Route: Adults: Symptomatic bradycardia – 0.5 – 1.0 mg IVP every 3-5 minutes as needed. Maximum 0.04 mg/kg. (usually around 3-4 mg). Asystole – 1.0 mg IVP or 2-3 mg diluted in 10 ml of saline administered via ET Tube. Maximum 0.03-0.04 mg/kg. Organophosphate/Nerve Gas poisoning – 2-5 mg IVP every 5-15 minutes to dry Secretions. No maximum – doses as high as 1 gram have been given for severe cases Peds: Symptomatic bradycardia: 0.02 mg/kg (max. of 0.5 mg dosage for child and 1.0 mg for adolescent in a single bolus). May repeat once only. Organophosphate/Nerve Gas poisoning – 0.05 mg IVP every 5-15 minutes to dry Secretions Asystole – efficacy is not established (no strong evidence to say it works)

Miscellaneous Medications Diphenhydramine

Diphenhydramine (Benadryl®)

Type: Anti-histamine Mechanism of Action (What the drug does in the body): Benadryl antagonizes the effects of histamine. Antihistamines prevent the physiological actions of histamine by preventing them from reaching H1 and H2 receptor sites. Benadryl has sedative and anticholinergic properties making it suitable to use as a sedative and an anti-emetic in the oral form. Half-Life (How long until the drug reduces from the initial dosage by half): 2.5 – 7 hours Indications (When to give the drug): Allergic reactions Anaphylaxis – second line treatment Dystonic reactions associated with phenothiazine overdoses (i.e. haldol) P.O. – nighttime sleep aid and motion sickness Contraindications (When not to give the drug): Acute attacks of asthma Side Effects (Undesirable things that happen in addition to the therapeutic benefit): Drowsiness Dry mouth Dizziness Headache Anorexia (decreased appetite) Supplied: 10 mg / ml or 50 mg / ml vials or prefilled syringes Precautions:

• Use cautiously in patients with severe liver disease • Elderly patients tend to have more adverse reactions – consider reducing the dosage

Dosage and Route: Adults: 25 – 50 mg IV or IM Peds: 1-2 mg/kg not to exceed 50 mg/day

Cardiac – Electrolyte Calcium Chloride

Calcium Chloride

Type:

Mineral / Electrolyte


Helps with myocardial muscle contraction and is effective in reversing overdoses on Calcium channel blockers & Magnesium Sulfate. Increases myocarcial force of contraction.


Overdose of Calcium channel blockers Hypocalcemia Hyperkalemia


NEVER use with Sodium Bicarbonate in the same IV site or tubing. A precipitate will form. Flush the IV line well if giving these drugs via the same route.

Precautions:

Use with caution on patients receiving Digitalis

Supplied:

1 gram/l0ml (10% solution)

Dosage and Route:

Adult – 2-4 mg/kg for hypocalcemia SLOW IVP

8-16 mg/kg (0.5 – 1.0 gram) for calcium channel blocker overdose SLOW IVP

Miscellaneous Dexamethasone

Dexamethasone (Decadron®)

Type:

Steroid


Dexamethasone is a synthetic steroid that works to reduce the inflammatory response. It is chemically related to the natural hormones—glucocorticoid and mineralocorticoid—released by the adrenal glands. It is useful in the treatment of allergic reactions due to its intense anti-inflammatory activity. This drug is also used for cerebral edema and/or spinal trauma; however, these uses are controversial.


3 - 4.5 hours


Miscellaneous Dexamethasone

Anaphylaxis

Asthma

COPD – emphysema, chronic bronchitis


None in the emergency setting


Euphoria Headache

Hyperglycemia Muscle weakness

Hypertension GI bleeding

Supplied:

4, 10, 20 or 24 mg/ml vials ranging from 1 – 30 ml

10 mg / 1 ml prefilled syringe

10 mg / 1 ml ampule

Precautions:

Onset of action is 4 – 8 hours making it an unsuitable agent for first-line treatment Cushing’s syndrome may occur – monitor and note any abnormalities

Dosage and Route:

Adults:

- 4 – 24 mg IV/IM for allergic reactions

- 30 mg/kg may be ordered for spinal cord injury

Peds: 0.5 – 1.0 mg/kg IV

Metabolic Medication Dextrose

Dextrose

Type:

Monosaccharide


Dextrose is a sugar compound that is metabolized into glucose to provide energy for metabolic needs.


Hypoglycemia


Stroke hemorrhage or ischemic with a normal blood glucose level (may worsen neurological outcome)

Metabolic Medication Dextrose

Delirium tremens with subsequent dehydration


Phlebitis (use larger veins) Thrombosis (use larger veins)

Hyperglycemia Hypokalemia

Alkalosis

Possible necrosis and sloughing if tissue infiltration occurs

Supplied:

Dextrose 50% D50- 25 grams in 50 ml

Dextrose 25% D25 - 12.5 grams in 50 ml or 6.25 grams in 25 ml

Dextrose 10% D10 - 2.5 grams in 25 ml

Precautions:

Establish intravenous access in a large vein, preferably in the antecubital area, to avoid possible thrombophlebitis Ensure patent IV prior to administration to avoid infiltration If IV infiltrates, immediately stop administration, apply cold pack to area and discontinue non-patent IV (Follow local protocol on treatment and documentation). Contact medical control ASAP.

Dosage and Route:

Adults: 25 grams intravenously only (Dextrose 50%)

Peds: (< 8 years of age) 2 – 4 ml/kg slow IV push (Dextrose 25%)

Neonate: 5 ml/kg slow IV push (Dextrose 10%)

Note: If you don’t have Dextrose 25%, empty half of the Dextrose 50% syringe and replace the 25 ml discarded with 25 ml of normal saline. To make Dextrose 10% dilute Dextrose 50% with normal saline at a 4:1 concentration.

CNS Depressant Diazepam

Diazepam (Valium®)

Type:

Benzodiazepine


Diazepam is a central nervous depressant that is effective in stopping seizure activity. It is also effective as a sedative to facilitate electrical cardioversion, intubation or anxiolysis (stopping anxiety).


Seizure activity including status epilepticus

Premedication for cardioversion

To facilitate intubation

Acute anxiety

CNS Depressant Diazepam


Neonates

Alcohol intoxication

Hypersensitivity


Altered mental status Bradycardia

Respiratory depression Hypotension

Blurred vision Nausea/Vomiting

Supplied:

Multiple packaging methods

10 mg / 2 ml vials

Precautions:

Establish IV in larger veins (i.e. antecubital) to avoid possible irritation (phlebitis) of smaller veins Do not mix diazepam with any other drug

Dosage and Route:

Adults: 5 – 10 mg IV push

Peds: 0.1 – 0.3 mg/kg IV push or if unavailable, 0.5 mg/kg rectally

Note: To administer diazepam rectally use a tuberculin syringe WITHOUT THE NEEDLE. Insert the syringe loaded with the correct dosage 3-5 cm into the rectum with the patient in a supine position. Once you have administered the entire dose hold the buttocks closed or tape them together.

Cardiac Medication Diltiazem

Diltiazem (Cardizem®)

Type:

Calcium channel blocker


Diltiazem inhibits the influx of calcium through the slow channels in the myocardium and arterial smooth muscle tissue. Through this inhibition SA and AV conduction is slowed, coronary arteries and peripheral arteries are dilated, and the force of contraction is reduced.


2 Hours


Atrial fibrillation with rapid ventricular response (to control rate)

Atrial flutterwith rapid ventricular response (to control rate)

Atrial tachycardia refractory to adenosine

Cardiac Medication Diltiazem


- Hypersensitivity

- Hypotension (BP<90 systolic)

- Wide complex tachycardias, including V.Tach

- Sick sinus syndrome

- 2nd or 3rd degree AV blocks

- Active AMI


Hypotension AV blocks

Headache Bradycardia

Angina Flushing

Syncope N/V

Supplied:

25 mg / 5 ml in a special prefilled syringe. Half of the syringe contains the lyophilized powder separate from the sterile saline. Twinsting the plunger of the syringe into place causes the powder and the saline to mix.

Precautions:

May reduce the force of contraction significantly in patient’s with CHF PVC’s may result during conversion from atrial tachycardia but are generally transient

Dosage and Route:

Adults: 0.25 mg / kg IV slowly over 2 minutes ( average dosage – 15 mg small adult; 20 mg medium adult; 25 mg large adult). May be followed by 0.35 mg / kg in 15 minutes.

Peds: Not recommended

Cardiac Medication Dopamine

Dopamine (Intropin ®)

Type:

Positive Chronotrope, Inotrope and Vasoconstrictor


Stimulates a wide array of responses based on the dosing range.

1-2 mcg/Kg/min dilation of renal, mesenteric, & cerebral arteries

5-10 mcg/Kg/min predominantly Beta-l effects with mild alpha effects

10-20 mcg/Kg/min Both alpha and beta-l effects

20mcg/Kg/min Alpha effects predominate. If we were to give a dose above 20 mcg/Kg/min, the vasoconstriction would put more of a load (afterload) on an already failing heart.


Cardiogenic Shock

Neurogenic Shock

Non-Traumatic Hypotension

Contraindications (When not to give the drug)::

Cardiac Medication Dopamine

Hypovolemia without volume resuscitation

Pheochromacytoma (tumor of the adrenal gland)

Tachydysrhythmias

Precautions:

May result in or worsen (exacerbate) supraventricular or ventricular dysrhythmias

May increase myocardial oxygen demand.

May cause or worsen pulmonary congestion

Tissue necrosis if IV infiltrates


Nausea/Vomiting Angina

Tachycardia Palpitations

Hypertension Dyspnea

Supplied:

Prefilled syringes or ampules 200mg, 400 mg, or 800 mg in 5-10 ml

Premixed IV Solution – 800 mg/500 ml or 400 mg/250 ml

Dosage and Route:

Adult: 5-20mcg/Kg/min titrated UP to desired effect via IV DRIP (INFUSION) only. Desired effects include:

systolic BP 90 -100mm Hg improved LOC improved tissue perfusion improved urinary output

Mixed as follows: 400mg in 250mlof NS = 1600mcg/ml

800mg in 250ml of NS = 1600mcg/ml

400 mg in 500ml of NS = 800 mcg/ml

Note: For cardiogenic shock it may be desirable to limit the upper limit of the drug to 15 mcg/kg/min.

Cardiac Medication Epinephrine Respiratory Medication

Epinephrine (Adrenaline®)


Stimulates the sympathetic nervous system via the alpha and beta receptors with the following effects:

Cardiovascular

• increased systemic vascular resistance • increased arterial blood pressure • increased heart rate (+ chronotropic effect) • increased coronary & cerebral blood flow • increased myocardial contraction (+inotropic effect) • increased myocardial oxygen demand (NOT GOOD!) • increased automaticity

Respiratory

• Bronchodilator


Asystole

Ventricular Fibrillation (pulseless V. Tach)

Pulseless Electrical Activity (PEA)

Anaphylaxis

Asthma



None during cardiac arrest or severe anaphylactic shock


Tachyarrhythmias Anxiousness

Palpitations Angina

Headache Myocardial Infarction

Hypertension

Precautions:

Underlying cardiovascular Disease

Pregnancy

Hypertension

Tachyarrhythmias

Hyperthyroidism

Protect from sunlight

Can be deactivated by alkaline solutions

Supplied:

Prefilled Syringes: 1mg in 10ml (1:10,000 solution) (IV/ET/IO use)

1 mg in 1ml (1:1000 solution) (SC use)

Ampules: 1 mg in 1ml (1:1000 solution) (SC use)

Multidose Vial: 30 mg in 30 ml (SC/IV/ET/IO use)

Dosage and Route:


Cardiac Arrest: (Standard dose) 1 mg every 3-5 min

(High Dose): 0.1 mg/kg every 3-5min IVP

*All IV push (IVP) medications given during cardiac arrest are to be followed by a 20ml fluid flush

Asthma Attack: (Mild-moderate) 0.3 mg – 0.5 mg subcutaneously (Severe) 0.3-1.0 mg SLOW IVP* Anaphylaxis:

(Mild-moderate) 0.3 mg – 0.5 mg subcutaneously (Severe) 0.3-1.0 mg SLOW IVP*

*The entire 1.0 mg may not be needed. Monitor your patient closely. CONSULT YOUR PROTOCOLS.

Refractory Bradycardia:

When atropine, pacing and dopamine are ineffective in increasing a bradycardic rhythm, an epi infusion is administered at 2-10 mcg/min.

*Epinephrine can also be given via the Endotracheal tube (ET); however, the dose must be 2 -2.5 times greater than the amount given IVP.

*Epinephrine drips (infusions) are occasionally used in the field setting. This infusion can be set up as follows:

1.0mg (1:1000 solution) injected into a 250ml bag of normal saline yielding a concentration of 4mcg/ml. The Epi is infused at l mcg/min & titrated to effect.

Cardiac Medication Furosemide

Furosemide (Lasix®)

Type:

Loop Diuretic

Venous Dilator


Initially (within approximately 5 minutes), furosemide will cause venous dilation and subsequent blood pooling. This helps to send less blood to the right ventricle, and therefore, less blood is circulated through the lungs. The hope with this action is to decrease the pulmonary edema by having less blood filter through the lungs. In approximately 15-20 minutes furosemide causes diuresis at the Loop of Henle in the kidneys. It inhibits sodium from being reabsorbed into the body; consequently, more sodium is excreted. Since water follows sodium, the result is increased diuresis.


Cardiac Medication Furosemide

Pulmonary edema


Hypersensitivity (allergic) to sulfa derivatives

Hyponatremia


Tinnitus (ringing in the ears)

Nausea/Vomiting

Hypotension (rare)

Supplied:

Vials or pre-filled syringes containing 20 mg, 40 mg, 60 mg, 80 mg, or 100 mg

Precautions:

Furosemide is an ototoxic agent (hurts the ears) and should be administered slowly Inactivated by sunlight

Dosage and Route:

Adults: 0.5 – 1.0 mg/kg slow IVP or a standard dose of 40 – 80 mg may be used

Note: If patient is currently taking prescribed oral diuretic, double the DAILY dose. (example: Mr. Smith is prescribed Lasix 20 mg to be taken three times a day. His daily dose is 60 mg; therefore, he should receive 120 mg IVP.

Metabolic Medications

Glucagon (Glucogen®)

Type: Hormone; Insulin antgonist Mechanism of Action (What the drug does in the body): Glucagon is a protein produced by the alpha cells in the pancreas. When used in the pre-hospital setting it is typically given intramuscularly. This is helpful when you have a hypoglycemic patient in whom you cannot establish an IV. Glucagon accelerates the breakdown of glycogen in the liver, which leads to an increase in glucose. The liver must have glycogen stored for this medication to work; therefore, this drug probably won’t help those suffering from chronic hypoglycemia, starvation or adrenal insufficiency. Half-Life (How long until the drug reduces from the initial dosage by half): 3 – 10 minutes Indications (When to give the drug): Hypoglycemia when administration of D50 is not possible Beta blocker overdose Contraindications (When not to give the drug): Known hypersensitivity (Beef or pork proteins) Side Effects (Undesirable things that happen in addition to the therapeutic benefit): Nausea / Vomiting Allergic reactions: urticaria, respiratory distress, hypotension, and edema. Supplied: Powder 1 mg to be reconstituted with sterile saline Concentration after mixing: 1mg / 1 ml Precautions:

• History of insulinoma (tumor of the pancreas) or pheochromocytoma (tumor of the adrenal glands)

• History of renal or hepatic disease Dosage and Route: Hypoglycemia Adult: 0.5-1 mg IM, SQ; repeat in 20 min prn Pediatric: 0.03-0.1 mg/kg/dose (not to exceed 1 mg) q 20 min IM, SQ, IV, prn

Beta Blocker Overdose: (Manifestations of beta-blocker poisoning include bradycardia, hypotension, decreased cardiac output, cardiogenic shock, and asystole.) Adult: 3-10 mg IV bolus followed by 2-5 mg/h infusion


Ipratropium bromide (Atrovent®)

Type:

Parasympatholytic (inhibits the parasympathetic nervous system) bronchodilator


This agent is an anticholenergic that is chemically related to atropine, hence the beginning of the trade name atro-vent. It works directly on the smooth muscle of the bronchioles by inhibiting acetycholine (e.g. smooth muscle relaxant).


1.5 – 2 hours



Bronchoconstriction secondary to:

- asthma

- emphysema

- chronic bronchitis

- pneumonia


Hypersensitivity to atropine


- Headache - Tachycardia

- Coughing - Dry mouth

- Drying of bronchial secretions

Supplied:

Single dose unit: 0.5 mg / 2.5 ml

MDI

Precautions:

Ipratropium should not be used as the first line treatment for an acute incident of bronchospasm. A beta agonist is preferred followed by this agent if needed. May worsen narrow angle glaucoma

Dosage and Route:

Adults: 0.5 mg placed into a nebulizer unit to be administered at 6 liters/min or 2 inhalations of the metered dose inhaler (MDI).

Peds: 125 – 250 mcg placed in a nebulizer to be administered at 6 liters/min or 1-2 inhalations of the MDI.

Cardiac Medication

Isoproterenol (Isuprel®)

Type:

Pure beta agonist


Isuprel is a potent sympathomimetic that is exclusively a beta-1 receptor agonist. By activating the Beta-1 receptors the result is:

Increased force of contraction (Positive inotropic effect)

Increased heart rate (Positive chronotropic effect)

Increased electrical conduction (Positive dromotropic effect)

Increased automaticity

Vasodilator


Refractory, symptomatic bradycardia (after pacing/atropine, dopamine and epinephrine have failed or are inappropriate)


Hypotension

Acute myocardial infarction

Cardiac arrest

Tachycardia dysrhythmias


Flushing Shortness of breath

Angina Tremors

Cardiac Medication

Chest Pain Palpitations

Hypotension

Supplied:

Prefilled syringes – 1 mg in 5 – 10 cc

Ampules – 1 mg in 5-10 cc

Precautions:

Increases myocardial oxygen demand May precipitate ventricular irritability (PVC’s, V. Tach, V. Fib) May be deactivated by alkaline solutions

Dosage and Route:

Adults: 2 – 20 mcg/min IV infusion only

Application: Mixing isoproterenol is a matter of protocols or personal preference. One suggested method is to mix 1 mg in 250 cc’s of normal saline. Using a mini-drip solution set (60 gtts/ml), start your infusion at 30 drops/min (30 cc/hour). Titrate the dosage as needed (15 gtts/min or 15 cc/hour = 1 mg) to increase the heart rate to normal limits. Do not exceed the maximum dosage of 20 mcg/min.

Cardiac Medication Lidocaine

Lidocaine (Xylocaine®)

Type:



Lidocaine suppresses ventricular irritability that is secondary to cardiac ischemia (low blood flow). It decreases the excitability of the ventricular muscle and conduction tissue. Additionally, it raises the threshold for ventricular fibrillation, which means that the patient will be less likely to go back into V. fib.

Half-Life (How long until the drug reduces its dosage by half)

10 – 15 minutes



Malignant PVC’s that are a result of ischemia

> 6 per minute Multifocal (multiple forms/shapes)

R on T phenomenon Runs of V. tach (3 or > in a row)

Couplets (Salvos)

Ventricular Tachycardia

Ventricular Fibrillation

Post-Conversion from V. Tach/V. Fib



Sick sinus syndrome

Second or third degree AV blocks

PVC’s associated with bradycardia (treat the rate – not the rhythm)

Idioventricular (Ventricular escape rhythm)


Paresthesia

Tinnitus

Heart Blocks

Bradycardia (uncommon)

Supplied:

1% solution – 100mg/10 ml (IVP)


4% solution – 1 gram/25 ml (IV maintenance drip only)



Precautions:

Excessive doses generally result in CNS side effects including paresthesia, altered LOC, grand mal seizure The liver metabolizes lidocaine; consequently, patients with decreased hepatic function (>70, cirrhosis, chronic alcoholic) tend to reach toxic levels when a maintenance infusion is administered. The initial bolus is given at the normal dosing regimen, but the maintenance drip should be reduced by 50%.

Dosage and Route:

Adults: 1 – 1.5 mg/kg (maximum 3 mg/kg) IVP

Peds: 1 mg/kg (may be repeated once) IVP

Note: Lidocaine can be administered via the endotracheal tube but the dosage is increased to 2-2.5 times the IV dose. The increase in dosage is needed as some of the drug will not reach the alveoli, which is the site of drug passage into the circulation.

Once the bolus is given and the rhythm converts to something that does not condraindicate the use of lidocaine, a maintenance infusion needs to be established.

Maintenance drip dosage:

Adult – 2-4 mg/min (mix 1 gram in 250 ml with a microdrip set and run at 30-60 gtts/min (30-60 cc/hour)

Pedi – 20 – 50 mcg/kg/min (mix 300 mg in 250 ml of saline and use a microdrip set. 1 drop/kg/min = 20 mcg/kg/min)


Lidocaine (Xylocaine®)

Type:



Lidocaine suppresses ventricular irritability that is secondary to cardiac ischemia (low blood flow). It decreases the excitability of the ventricular muscle and conduction tissue. Additionally, it raises the threshold for ventricular fibrillation, which means that the patient will be less likely to go back into V. fib.


10 – 15 minutes



Malignant PVC’s that are a result of ischemia

> 6 per minute Multifocal (multiple forms/shapes)

R on T phenomenon Runs of V. tach (3 or > in a row)

Couplets (Salvos)

Ventricular Tachycardia

Ventricular Fibrillation

Post-Conversion from V. Tach/V. Fib



Sick sinus syndrome

Second or third degree AV blocks

PVC’s associated with bradycardia (treat the rate – not the rhythm)

Idioventricular (Ventricular escape rhythm)


Paresthesia

Tinnitus

Heart Blocks

Bradycardia (uncommon)

Supplied:






Precautions:

Excessive doses generally result in CNS side effects including paresthesia, altered LOC, grand mal seizure The liver metabolizes lidocaine; consequently, patients with decreased hepatic function (>70, cirrhosis, chronic alcoholic) tend to reach toxic levels when a maintenance infusion is administered. The initial bolus is given at the normal dosing regimen, but the maintenance drip should be reduced by 50%.

Dosage and Route:

Adults: 1 – 1.5 mg/kg (maximum 3 mg/kg) IVP

Peds: 1 mg/kg (may be repeated once) IVP

Note: Lidocaine can be administered via the endotracheal tube but the dosage is increased to 2-2.5 times the IV dose. The increase in dosage is needed as some of the drug will not reach the alveoli, which is the site of drug passage into the circulation.

Once the bolus is given and the rhythm converts to something that does not condraindicate the use of lidocaine, a maintenance infusion needs to be established.

Maintenance drip dosage:

Adult – 2-4 mg/min (mix 1 gram in 250 ml with a microdrip set and run at 30-60 gtts/min (30-60 cc/hour)

Pedi – 20 – 50 mcg/kg/min (mix 300 mg in 250 ml of saline and use a microdrip set. 1 drop/kg/min = 20 mcg/kg/min)

Mineral Magnesium Sulfate

Magnesium Sulfate (MgSO4)

Type:

Mineral


Magnesium is an important factor for enzymatic reactions in the body and plays an important role in neurochemical transmission and muscular excitability. This agent prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine released from the nerves that synapse with muscles. Magnesium does NOT affect the fetus or mother when used for eclampsia. It acts as a CNS depressant and stimulates peripheral vasodilation. The drug is metabolized solely by the kidneys.


Eclampsia

Mineral Magnesium Sulfate

Refractory ventricular fibrillation

Hypomagnesemia

Torsades de pointes


Renal failure

Significant hypotension


Hypotension

Altered level of consciousness

Hypermagnesemia (too much magnesium in the blood)

Supplied:

Vial and prefilled syringe – 5 grams/10 ml

Precautions:

Be alert for signs of hypermagnesemia: Hypotension Diaphoresis Flaccid paralysis Hypothermia Hyporeflexia May produce fatal paralysis at toxic levels, so monitor patient closely.

Dosage and Route:

Eclampsia:

4 grams diluted in 100 – 250 ml of saline and infused over 5-10 minutes

Refractory Ventricular Fibrillation or Torsades de pointes:

1-2 grams diluted in 100 ml of saline and infused over 1–2 minutes

Cardiac Medication Morphine Sulfate Opiate

Morphine Sulfate (M.S.)

Type:

Opiate derivative


Morphine acts on pain receptors in the brain to reduce or eliminate the sensitivity to pain. Additional effects include venous dilation (venous pooling), CNS depression and decreased myocardial oxygen demand. It is a schedule II narcotic, thus it is a “controlled medication”.


2.5 – 3 hours


Severe pain

Acute myocardial infarction

Pulmonary edema


Undiagnosed abdominal pain

Cardiac Medication Morphine Sulfate Opiate

Head trauma

Alcoholic intoxication Hypersensitivity

Status epilepticus Bronchial asthma

Delerium tremens


Nausea/Vomiting Respiratory depression

Hypotension Decreased level of consciousness

Miosis (constricted pupils) Anxiety

Supplied:

Morphine comes packaged in a variety of ways but the most common for pre-hospital use is the prefilled syringe containing 10 mg/10 ml.

Precautions:

Give slowly when administering intravenously—rapid injection increases the incidence of adverse reactions (harmful side effects). Morphine has the capacity to elevate cerebrospinal fluid pressure. This effect is more pronounced in the head trauma patient. Do not give M.S. to patients suffering from asthma or COPD as even therapeutic doses and simultaneous increase in airway resistance may cause apnea.

Dosage and Route:

Adults:

2 – 5 mg IVP for chest pain

1 – 3 mg IVP for pulmonary edema

5 – 10 mg IVP for severe pain (maximum dosage depends on local protocols)

Peds: 0.1 mg/kg (max. of 10 mg dosage)

Note: Morphine may be administered intramuscular or subcutaneously

Cardiac Medication Nitroglycerine

Nitroglycerin (Nitrostat®)

Type:

Vasodilator


Nitroglycerin dilates both arteries and veins, but it has a more pronounced effect on the venous side. By increasing the venous capacitance the preload is reduced, which serves to decrease the work of the heart. A decrease in the arteries results in a decreased afterload further reducing the workload. Nitroglycerin may also produce coronary vasodilation in arteries that are not significantly calcified. Pain relief during an acute myocardial infarction (AMI) is due to the reduced workload—not by directly acting on pain receptors.


Cardiac Medication Nitroglycerine

Chest pain secondary to angina or AMI

Pulmonary edema


Viagra use within 24 hours

Hypotension (systolic <90 mm/Hg)

Increased intracranial pressure


Reflex tachycardia Headache

Flushing Nausea/Vomiting

Dizziness

Supplied:

Tablet or spray – 0.4 mg per dose (1/150th of a grain)

Precautions:

Nitroglycerin is inactivated by heat, light air and moisture and must be stored in a brown bottle or opaque metered spray device The shelf life is 3 months after opening the bottle Alcohol increases the vasodilation associated with nitroglycerin. Be alert for the development of hypotension and treat accordingly.

Dosage and Route:

Adults: 1 tablet or spray sublingually. May be repeated in 3 – 5 minutes to a maximum of 3 doses.

Cardiac Medications Procainamide

Procainamide (Pronestyl®)

Type: Cardiac antidysrhythmic Mechanism of Action (What the drug does in the body): This drug is a class Ia antidysrhythmic (Vaughn-Williams classification system) that decreases the excitability of the myocardium and prolongs the effective refractory period. It works on both atrial and ventricular tissue in contrast to lidocaine, which is only effective for ventricular tissue. Procainamide also slows the speed of conduction in the atria and ventricles thereby effectively slowing the heart rate. Half-Life (How long until the drug reduces from the initial dosage by half): 3 hours Indications (When to give the drug): Refractory ventricular fibrillation/Pulseless ventricular tachycardia PVC’s refractory to lidocaine Stable ventricular tachycardia that is refractory to lidocaine Contraindications (When not to give the drug): Hypotension High-grade AV blocks (2nd degree and 3rd degree) Digitalis toxicity Hypersensitivity Tricyclic antidepressant overdose Side Effects (Undesirable things that happen in addition to the therapeutic benefit): Hypotension AV block Bradycardia or reflex tachycardia N/V Flushing QRS widening CNS depression Supplied: 1 gram in 10 ml vial 1 gram in 2 ml vial Precautions:

• Use with caution in patients with a history of CHF • Procainamide is eliminated in the urine so use with caution for patient’s with renal

failure • Stop administration of the infusion if:

o QRS widens by 50% or greater o Hypotension develops o Arrhythmia is suppressed o Maximum dose of 17 mg/kg is infused

Cardiac Medications Procainamide

Dosage and Route: Adults: 30 mg/min via IV infusion. If conditions are urgent, use 50 mg/min as per current ACLS guidelines. If the patient converts and no contraindications exist, establish a maintenance infusion at 1-4 mg/min. Mix 1 gram in 250 ml of normal saline (4:1), connect a micro-drip set, and run at 15-60 drops per minute (15-60 cc/hour) Peds: 15 mg/kg IV/IO administered over a 30-60 minute period.

Cardiac Medications Vasopressin

Vasopressin (Pitressin®)

Type: Hormone; Vasoconstrictor/Vasopressor Mechanism of Action (What the drug does in the body): Vasopressin (anti-diuretic hormone) occurs naturally in the body and is secreted from the pituitary gland in response to hypotension or low blood volume states. It acts on adrenergic receptor sites (alpha-1) to produce vasoconstriction. Half-Life (How long until the drug reduces from the initial dosage by half): 10-20 minutes Indications (When to give the drug): Ventricular fibrillation as an alternative to epinephrine (may be followed by epinephrine in refractory v-fib) Contraindications (When not to give the drug): Chronic nephritis Ischemic heart disease (relative contraindication) Side Effects (Undesirable things that happen in addition to the therapeutic benefit): Chest pain Abdominal discomfort Diaphoresis N/V Tremors bronchoconstriction (evidenced by wheezing) Supplied: 20 units/ml vials Precautions:

• Pediatric and geriatric patients are at an increased risk for hyponatremia and water intoxication.

• Use with caution in the presence of asthma, epilepsy, migraine, CAD, and CHF. Dosage and Route: Adults: 40 units IVP

Verapamil (Isoptin®) Type:

Calcium channel blocker


Verapamil inhibits the influx of calcium through the slow channels in the myocardium and arterial smooth muscle tissue. Through this inhibition SA and AV conduction is slowed, coronary arteries and peripheral arteries are dilated, and the force of contraction is reduced. Therapeutic effects are seen within minutes after bolus administration (85-90% of patients).


1.5 - 5 Hours


Atrial fibrillation with rapid ventricular response (to control rate)

Atrial flutter with rapid ventricular response (to control rate)

Atrial tachycardia refractory to adenosine


- Hypersensitivity

- Wolff-Parkinson syndrome (Short PR interval with Delta waves)

- Hypotension (BP<90 systolic)

- Wide complex tachycardias, including V.Tach

- Sick sinus syndrome

- 2nd or 3rd degree AV blocks

- Active AMI


Hypotension AV blocks

Headache Bradycardia

Angina Flushing

Syncope N/V

Supplied:

Vials: 5 mg / 2 ml available in 2, 4 or 5 milliliters

Ampules: 5 mg / 2 ml available in 2 or 4 milliliters

Precautions:

• May reduce the force of contraction significantly in patient’s with CHF • PVC’s may result during conversion from atrial tachycardia but are generally

transient • Hepatic and renal failure will significantly increase the half-life. Many protocols

suggest reducing the dosage by half in those patients with liver and/or kidney failure

Dosage and Route:

Adults: 2-5 mg IV slowly over 2 minutes. May be repeated at double the initial dose to a maximum of 30 mg. Acute hypotension secondary to verapamil can be treated by shock positioning, IV fluids, and intravenous administration of calcium chloride.

Peds: Not recommended for paramedics to use in the field but may be used in the hospital

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