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.
Indications (When to give the drug):
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.
Indications (When to give the drug):
Bronchoconstriction (evidenced by wheezing or a “silent chest”) secondary to: Emphysema, chronic bronchitis, asthma, and pneumonia
Contraindications (When NOT to give the drug):
Hypersensitivity
Respiratory Medication
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
Mechanism of Action (What the drug does in the body):
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.
Indications (When to give the drug):
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
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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
Indications (When to give the drug):
Cardiac Medication Amiodarone
Atrial Tachycardia Ventricular Tachycardia
Atrial Flutter Refractory Ventricular Fibrillation
Atrial Fibrillation
Contraindications (When not to give the drug):
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
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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.
Indications (When to give the drug):
Acute myocardial infarction (possible or known)
Contraindications (When not to give the drug):
Hypersensitivity (allergic)
Children
Bleeding disorders
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
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
Mechanism of Action (What the drug does in the body):
Helps with myocardial muscle contraction and is effective in reversing overdoses on Calcium channel blockers & Magnesium Sulfate. Increases myocarcial force of contraction.
Indications (When to give the drug):
Overdose of Calcium channel blockers Hypocalcemia Hyperkalemia
Contraindications (When not to give the drug):
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
Mechanism of Action (What the drug does in the body):
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.
Half-Life (Time it takes for the drug to lose half of the initial dose):
3 - 4.5 hours
Indications (When to give the drug):
Miscellaneous Dexamethasone
Anaphylaxis
Asthma
COPD – emphysema, chronic bronchitis
Contraindications (When not to give the drug):
None in the emergency setting
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
Dextrose is a sugar compound that is metabolized into glucose to provide energy for metabolic needs.
Indications (When to give the drug):
Hypoglycemia
Contraindications (When not to give the drug):
Stroke hemorrhage or ischemic with a normal blood glucose level (may worsen neurological outcome)
Metabolic Medication Dextrose
Delirium tremens with subsequent dehydration
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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).
Indications (When to give the drug):
Seizure activity including status epilepticus
Premedication for cardioversion
To facilitate intubation
Acute anxiety
CNS Depressant Diazepam
Contraindications (When not to give the drug):
Neonates
Alcohol intoxication
Hypersensitivity
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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.
Half-Life (Time it takes for the drug to lose half of the initial dose):
2 Hours
Indications (When to give the drug):
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
Contraindications (When not to give the drug):
- Hypersensitivity
- Hypotension (BP<90 systolic)
- Wide complex tachycardias, including V.Tach
- Sick sinus syndrome
- 2nd or 3rd degree AV blocks
- Active AMI
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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.
Indications (When to give the drug):
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
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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®)
Mechanism of Action (What the drug does in the body):
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
Indications (When to give the drug):
Asystole
Ventricular Fibrillation (pulseless V. Tach)
Pulseless Electrical Activity (PEA)
Anaphylaxis
Asthma
Cardiac Medication Epinephrine Respiratory Medication
Contraindications (When not to give the drug):
None during cardiac arrest or severe anaphylactic shock
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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 Medication Epinephrine Respiratory Medication
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
Mechanism of Action (What the drug does in the body):
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.
Indications (When to give the drug):
Cardiac Medication Furosemide
Pulmonary edema
Contraindications (When not to give the drug):
Hypersensitivity (allergic) to sulfa derivatives
Hyponatremia
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Respiratory Medication
Ipratropium bromide (Atrovent®)
Type:
Parasympatholytic (inhibits the parasympathetic nervous system) bronchodilator
Mechanism of Action (What the drug does in the body):
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).
Half-Life (Time it takes for the drug to lose half of the initial dose):
1.5 – 2 hours
Respiratory Medication
Indications (When to give the drug):
Bronchoconstriction secondary to:
- asthma
- emphysema
- chronic bronchitis
- pneumonia
Contraindications (When not to give the drug):
Hypersensitivity to atropine
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
- 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
Mechanism of Action (What the drug does in the body):
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
Indications (When to give the drug):
Refractory, symptomatic bradycardia (after pacing/atropine, dopamine and epinephrine have failed or are inappropriate)
Contraindications (When not to give the drug):
Hypotension
Acute myocardial infarction
Cardiac arrest
Tachycardia dysrhythmias
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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:
Cardiac antidysrhythmic
Mechanism of Action (What the drug does in the body):
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
Indications (When to give the drug):
Cardiac Medication Lidocaine
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
Contraindications (When not to give the drug):
Hypersensitivity (allergic)
Sick sinus syndrome
Second or third degree AV blocks
PVC’s associated with bradycardia (treat the rate – not the rhythm)
Idioventricular (Ventricular escape rhythm)
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
Paresthesia
Tinnitus
Heart Blocks
Bradycardia (uncommon)
Supplied:
1% solution – 100mg/10 ml (IVP)
2% solution – 100mg/5 ml (IVP)
4% solution – 1 gram/25 ml (IV maintenance drip only)
20% solution – 1 gram/5 ml (IV maintenance drip only)
Cardiac Medication Lidocaine
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)
Cardiac Medication Lidocaine
Lidocaine (Xylocaine®)
Type:
Cardiac antidysrhythmic
Mechanism of Action (What the drug does in the body):
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
Indications (When to give the drug):
Cardiac Medication Lidocaine
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
Contraindications (When not to give the drug):
Hypersensitivity (allergic)
Sick sinus syndrome
Second or third degree AV blocks
PVC’s associated with bradycardia (treat the rate – not the rhythm)
Idioventricular (Ventricular escape rhythm)
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
Paresthesia
Tinnitus
Heart Blocks
Bradycardia (uncommon)
Supplied:
1% solution – 100mg/10 ml (IVP)
2% solution – 100mg/5 ml (IVP)
4% solution – 1 gram/25 ml (IV maintenance drip only)
20% solution – 1 gram/5 ml (IV maintenance drip only)
Cardiac Medication Lidocaine
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
Mechanism of Action (What the drug does in the body):
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.
Indications (When to give the drug):
Eclampsia
Mineral Magnesium Sulfate
Refractory ventricular fibrillation
Hypomagnesemia
Torsades de pointes
Contraindications (When not to give the drug):
Renal failure
Significant hypotension
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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”.
Half-Life (How long until the drug reduces its dosage by half)
2.5 – 3 hours
Indications (When to give the drug):
Severe pain
Acute myocardial infarction
Pulmonary edema
Contraindications (When not to give the drug):
Undiagnosed abdominal pain
Cardiac Medication Morphine Sulfate Opiate
Head trauma
Alcoholic intoxication Hypersensitivity
Status epilepticus Bronchial asthma
Delerium tremens
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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.
Indications (When to give the drug):
Cardiac Medication Nitroglycerine
Chest pain secondary to angina or AMI
Pulmonary edema
Contraindications (When not to give the drug):
Viagra use within 24 hours
Hypotension (systolic <90 mm/Hg)
Increased intracranial pressure
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Mechanism of Action (What the drug does in the body):
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).
Half-Life (Time it takes for the drug to lose half of the initial dose):
1.5 - 5 Hours
Indications (When to give the drug):
Atrial fibrillation with rapid ventricular response (to control rate)
Atrial flutter with rapid ventricular response (to control rate)
Atrial tachycardia refractory to adenosine
Contraindications (When not to give the drug):
- 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
Side Effects (Undesirable things that happen in addition to the therapeutic benefit):
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
Top Related