adult ii 2015

Adult II 2015

Emergency Medications

National EMS Education Standard Competencies

Emergency Medications

• Names

• Effects

• Indications

• Routes of administration

• Dosages for the medications administered

National EMS Education Standard Competencies

Emergency Medications (cont’d)

• Actions

• Contraindications

• Complications

• Side Effects

• Interactions

AHA Classification of Recommendations and Level

of Evidence

• Class I

− A treatment should be administered.

• Class IIa

− It is reasonable to administer treatment.

• Class IIb

− Treatment may be considered.

AHA Classification of Recommendations and Level

of Evidence

• Class III

− Treatment should NOT be administered.

− It is harmful, not helpful.

• Class Indeterminate

− Research is either beginning or continuing on

this treatment.

− Cannot be recommended for or against

Medication Listings

• Name of medication

− And other common names

• Class

− How the medication is classified compared to

other medications

Medication Listings

• Mechanism of action

− The way a medication produces the intended

response

• Indications

− Circumstance that shows cause or warning of

disease


− Any condition that renders some particular line

of treatment improper or undesirable

Medication Listings

• Adverse reaction/side effects

− An abnormal or harmful effect to an organism

caused by exposure to a chemical

• Drug interactions

− Any potential effects a medication may have

when administered with or in the presence of

something else in the patient’s system

Adenosine (Adenocard)

• Classification:

• anti arrhythmatic, diagnostic

agent


− Slows conduction through

the AV node

− Can interrupt reentrant

pathways

− The drug of choice for

reentry SVT

• Indications

− Most forms of stable

narrow-complex SVT


− Bronchoconstrictive or

bronchospastic lung disease

• Adverse reactions

− Generally short duration and

mild

• Considerations

− Evaluate elderly for signs of

dehydration

− Dose:by rapid IV bolus only

given over 1_2 seconds

administered directly into a vein

or as proximal as possible ;

follow with a rapid saline flush .

Albuterol (Proventil, Ventolin)


− Results in smooth-

muscle relaxation in

the bronchial tree

• Indications

− Treatment of

bronchospasm in

patients with

COPD/asthma)


− Hypersensitivity

reactions to albuterol


− Often dose-related

and include

headache, fatigue,

lightheadedness,

irritability,

restlessness

• Considerations

− Pregnancy safety:

Category C

− May precipitate

angina pectoris and

dysrhythmias

Alteplase, Recombinant (Tissue Plasminogen Activator

or rTPA, Activase)

• Classification: Thrombolytic agent

• Mechanism of action− Restores perfusion

• Indications− Acute myocardial infarction,

STEMI, massive pulmonary emboli, acute ischemic cerebrovascular accident

• Contraindications− Active internal bleeding

− Recent surgery

Dose: 100mg IV over 2 hr, followed immediately by heparin therapy .


− Intracranial bleeding,

reperfusion

dysrhythmias, chest

pain, hypotension,

GI bleeding, nausea,

abdominal pain

• Considerations

− Monitor vital signs

closely.

− Observe for bleeding.

Amiodarone (Cordarone, Pacerone)

• Classification antiarrhythmatic

• Mechanism of action− Delays repolarization and

increases the duration of action potential

• Indications− Ventricular fibrillation

• Contraindications− Known hypersensitivity to

amiodarone or iodine

− Cardiogenic shock

Dose:1000mg IV over 24hours,150 mg loading dose over 10min,followed

− Over 6 hr at rate 1mg/min

− For maintenance infusion 540mg at 0.5 mg / min over 18 hr .


− Dizziness, fatigue,

malaise

− Congestive heart

failure

• Considerations


Category D

− Monitor patient

for hypotension.

Aspirin (ASA)

• Classification:

antiplatelet

• Mechanism of action− Prevents platelets from

clumping together and forming emboli

• Indications− New onset chest pain

suggestive of acute myocardial infarction

• Contraindications− Relatively contraindicated in

patients with active ulcer disease or asthma


− Bronchospasm,

anaphylaxis,

wheezing

in allergic patients,

prolonged bleeding

• Considerations


Category D

− Use cautiously with

impaired renal

function .

Atropine Sulfate

• Classification:

• Parasympathetic,Anticholinergic


− Increases heart rate in life-

threatening bradydysrhythmias

• Indications

− Hemodynamically unstable

bradycardia


− Tachycardia, hypersensitivity

Dose:

for bradycardia 0.4mg to1mg (up to

2 mg )IV every 1-2 hr as needed

.


− Drowsiness, confusion,

headache, tachycardia,

palpitations

• Considerations

− Pregnancy safety: Category

C

− Moderate doses may cause

pupillary dilation.

Calcium Gluconate

• Classification:

• Electrolytes


− Helps maintain cardiac

function

• Indications

− Hyperkalemia,

hypocalcemia


− Ventricular fibrillation,

digitalis toxicity,

hypercalcemia

− Dose :infusion slowly

,0.5ml-2ml/min, (500mg

/kg/day IV given in divided

Doses.


− Syncope, cardiac

arrest, dysrhythmia,

bradycardia

• Considerations


Category C

− Do not administer by

IM or SQ,stop infusion

if patient complains of

discomfort; resume

when symptoms

disappear .

Clopidogrel (Plavix)

• Classification:Antiplatelet


− Inhibits platelet aggregation by blocking Adenosine diphosphate receptors on platelets(ADP), preventing clumping of platelets.

• Indications

− Acute coronary syndrome

− Substitute for aspirin in patients unable to take aspirin

Dose: recent MI,stroke 75mg daily

ACS (Acute Coronary Syndrome )300mg PO loading dose , then 75mg/day with aspirin .


− Active GI bleeding, intracranial hemorrhage


− Severe neutropenia

− Hemorrhaging

• Considerations


B

− Often given with

other anticoagulants

Dexamethasone Sodium Phosphate (Decadron)

• Classification: corticosteroid

,Hormone


− Suppresses acute and

chronic inflammation

• Indications

− Anaphylaxis, asthma, spinal

cord injury,cerebral edema

associated with brain tumor

,craniotomy, or head injury .


− Hypersensitivity, use

caution in suspected

systemic sepsis


− Headache,

restlessness,

euphoria, psychoses

• Considerations


Category C

− Protect medication

from heat. Toxicity

and side effects occur

with long-term use.

Diazepam (Valium and Others)

• Classification :

• Benzodiazepine, Anxiolytic, Antiepileptic, Skeletal muscle relaxant (centrally acting ).

• Mechanism of action− Raises the seizure

threshold; induces amnesia and sedation

• Indications− Acute anxiety states and

agitation, acute alcohol withdrawal

• Dose :Status epilepticus5-10mg by slow IV. May repeat q 5-10 min to total dose 30mg .


− Hypersensitivity, narrow-

angle glaucoma

− Adverse reactions

− Dizziness, drowsiness,

confusion, headache

• Considerations


D

− Short duration for

anticonvulsant effect

− Reduce dose by 50%

in elderly patients.

Digoxin (Lanoxin)


Cardiac glycoside ,Cardiotonic


− Increases force of myocardial contraction

• Indications

− Congestive heart failure, reentry SVTs, ventricular rate control in atrial flutter and atrial fibrillation

• Dose:evaluate patient carefully

to determine the appropriate dose

loading dose 0.125-0.25mg IV, maintenance dose0.125-0.25mg /day PO .


− Fatigue, headache, blurred

yellow or green vision,

seizures

• Considerations


C

− Patient receiving IV digoxin

must be on a monitor

− Assessment for renal

function , serum K+, Mg++

level.


− Ventricular fibrillation, ventricular tachycardia, digitalis toxicity

Diltiazem (Cardizem)


• Calcium channel blocker, antianginal

,antihypertensive .


− Reduces myocardial oxygen

demand

• Indications

− Controls rapid ventricular

rates(Paroxysmal supra

ventriculartachycardia , atrial

fibrillation , atrial flutter.

Dose :direct IV bolus :0.25mg/Kg

(20mg for the average patient )

second bolus of 0.35mg /kg .

Continuous IV infusion 5-10 mg

/hr


− Dizziness, weakness,

headache, dyspnea

• Considerations


C

− Use with caution in patients

with renal or hepatic

dysfunction.


− Hypotension

− Sick sinus syndrome

Dobutamine Hydrochloride (Dobutrex)

• Classification:

Sympathomimetic ,Beta1 selective adrenergic agonist.

• Mechanism of action− Increased myocardial

contractility, stroke volume, and increased cardiac output

• Indications− Cardiogenic shock, CHF

• Dose :Administer only by IV infusion using an infusion pump

• 2.5mg -10mg /kg/min IV is ususl rate to increase cardiac output .


− Headache, dyspnea,

tachycardia, hypertension,

chest pain

• Considerations


B

− Monitor blood pressure

closely.


− Tachydysrhythmias, severe

hypotension

Dopamine Hydrochloride (Intropin)

• Classification:

• Sympathomimetic

Alpha –adrenergic agonist , Beta1-selective adrenergic agonist, Dopaminergic drug .

• Mechanism of action− Increases myocardial

contractility and stroke volume

• Indications

− Cardiogenic and septic shock, hypotension with low cardiac output states

− Dose :Administer only by IV infusion using an infusion pump

− Initially 2-5mcg/kg/min IV patients who more seriously ill,5mcg/kg/min up to a rate of 20-50mcg/kg/min.

• Adverse reactions− Headache, anxiety,

dyspnea, dysrhythmias

• Considerations− Pregnancy safety: Category

C

− Effects are dose-dependent

− Contraindications

− Hypovolemic shock, pheochromocytoma, tachydysrhythmias

Epinephrine (Adrenalin)

• Classification:Sympathomimetic ,Alpha-adrenergic agonist,Beta1-and beta2- adrenegic agonist ,cardiac stimulant .

• Mechanism of action− Blocks histamine

receptors

• Indications

− Cardiac arrest, symptomatic bradycardia

• Dode:cardiac arrest ;0.5IV during resuscitation q 5 min.


− Nervousness, restlessness,

headache, tremor

• Considerations


C

− May cause syncope in

asthmatic children


− Hypertension, hypothermia,

pulmonary edema

Furosemide (Lasix)

• Classification : loop diuretic


− Causes increased urine output

• Indications

− CHF, pulmonary edema, hypertensive crisis

Dose: in pulmonary edema 40 mg IV over 1-2 min.may be increased to 80mg IV given over 1-2 min if response unsatisfactory after 1 hour .

in hypertension 40mg bid. if needed additional anti hypertensive may be needed .


− Dizziness, headache, ECG

changes, weakness

• Considerations


C

− Ototoxicity, deafness, and

projectile vomiting can

occur with rapid

administration.


− Hypovolemia, anuria,

hypotension

Haloperidol Lactate (Haldol)


• Dopaminergic –blocking drug

Antipsychotic.


− Inhibits central nervous

system catecholamine

receptors

• Indications

− Acute psychotic episodes

Dose:IV unlabeled use for acute

situations2-25mg IV q hr at

arate of 5mg /min.


− Seizures, sedation,

confusion, restlessness

• Considerations


C

− Treat hypotension

secondary to haloperidol

with fluids and

norepinephrine,

not epinephrine


− Parkinson's disease,

depressed mental status

Heparin Sodium

• Classification :Anticogulant

• Mechanism of action− Inhibiting thrombus and clot

formation by blocking the conversion of prothrombin to thrombin and fibronogen to fibrin plasmin; does not lyses existing clots

• Indications− Acute myocardial infarction,

prophylaxis and treatment of thromboembolic disorders

− Dose:Adjust dose according

To cogulation tests. Dosage is adequate when PTT=1.5-3 times control value .


− Pain, anaphylaxis, shock,

hematuria

• Considerations


C

− Heparin does not lyse

existing clots.


− Hypersensitivity, active

bleeding

Hydrocortisone Sodium Succinate (Solu-Cortef)


• corticosteroid short acting ,glucocorticoid ,Adrenal cortical steroid, hormone.

• Mechanism of action− Anti-inflammatory;

immunosuppressive with salt-retaining actions

• Indications− Shock due to acute

adrenocortical insufficiency, anaphylaxis, asthma, and COPD.

− Dose: 100mg- 500mg initially and q 2-10h based on condition and response .


− Headache, vertigo,

pulmonary tuberculosis

• Considerations


C

− May be used in status

asthmaticus as a

second-line drug


− Systemic fungal infections,

premature infants

Lidocaine Hydrochloride (Xylocaine)

• Classification: Antiarrhythmatic ,local anesthetic .


− Decreases automaticity of ventricular cells , increase ventricular fibrillation threshold .

• Indications

− Alternative to amiodarone in cardiac arrest from ventricular tachycardia

− Dose :Arrhythmias, monitor ECG constantly ,give 50-100mg at rate of 25-50mg /min, 1/3 to 1/2the initial dose may be given after 5min if needed .do not exceed 200-300mgin 1 hr .


− Anxiety, drowsiness,

confusion, seizures

• Considerations

− Apnea induced with

succinylcholine may be

prolonged with high doses

of lidocaine.

− Exceedingly high doses can

result in coma or death.


− Hypersensitivity, second- or

third-degree AV block in the

absence of an artificial

pacemaker

Magnesium Sulfate

• Classification:

• Electrolyte Antiepileptic .

• Mechanism of action− Reduces striated muscle

contractions

• Indications− Seizures of eclampsia,

torsades de pointes, hypomagnesemia

• Dose:

• 1-4 gm of a 10%-20%solution .Do not exceed 1.5 ml/min of a10% solution. or 4-5 gm in 250ml of 5%dextrose. Do not exceed 3ml / min .


− Drowsiness, CNS

depression, respiratory

depression

• Considerations


A

− Recommended that

the drug not be

administered in the

2 hours before delivery, if

possible


− Heart block, myocardial

damage

Mannitol (Osmitrol)


• osmotic diuretic, diagnostic agent,


− Decreases cerebral edema and intracranial pressure

• Indications

− Cerebral edema

• Dose:

• In reduction of intracranial pressure and cerebral edema:1.5-2 gm/kg as a 15%-25% solution over 30-60min.Evidence of reduced pressure should be seen in 15 min.


− Headache, confusion, seizures, pulmonary edema

• Considerations

− Pregnancy safety: Category C

− May crystallize at low temperatures; store at room temperature

− Have ventilatory support available.


− Hypotension, pulmonary edema, severe dehydration, intracranial bleeding, CHF

Methylprednisolone Sodium Succinate (Solu-Medrol)

• Classification:

• corticosteroid,glucocorticoid , hormone.

• Mechanism of action− Suppresses acute and chronic

inflammation

• Indications− Acute spinal cord trauma,

anaphylaxis, bronchodilator for unresponsive asthma

• Dose:10-40mg IV administered over 1 min to several minutes .give subsequent dosesIVor IM.

• Warning :Rapid IV administration of large doses (more than0.5mg-1gm in less than 10-20min)has caused serious cardiac complications.


− Depression, euphoria,

headache, restlessness,

seizure

• Considerations


Category C

− Not effective if time of spinal

cord injury greater than

8 hours


− Premature infants, systemic

fungal infections

Midazolam Hydrochloride (Versed)

• Classification:

• Benzodiazepine (short acting )

• CNS depressant

• Mechanism of action− Causes sedative, anxiolytic,

amnesic, and hypnotic effects

• Indications− Sedation for medical

procedures.

− Continuous sedation of intubated and mechanically ventilated patients during treatment in critical care setting .


− Headache, somnolence,

respiratory depression

• Considerations


D

− Administer immediately

prior to intubation

procedure.


− Acute narrow-angle

glaucoma, shock, coma,

alcohol intoxication

Morphine Sulfate (Roxanol, MS Contin)

• Classification: Opoid agonist

analgesic .


− Alleviates pain

through CNS action

• Indications

− Severe CHF, acute cardiogenic

pulmonary edema

Dose :2.5mg -15mg /70kg of body

weight in 4-5ml water for

injection administered over 4-5

min. Continuous IV infusion 0.1-

1 mg /ml in 5% dextrose in

water by controlled infusion

device .


− Confusion, sedation,

headache, CNS depression

• Considerations


C

− Morphine rapidly crosses

the placenta.


− Head injury, exacerbated

COPD, depressed

respiratory drive

Naloxone Hydrochloride (Narcan)


• Opoid antagonist , Diagnostic

agent .


− Reverses respiratory

depression secondary to

opiate drugs

• Indications

− Opiate overdose, complete

or partial reversal of central

nervous system and

respiratory depression

induced by opioids

• Dose:

• Opoid overdose initial dose of 0.4 - 2 mg IV additional doses may be repeated at 2-3 min intervals. If no response after 10mg question the diagnosis .


− Use with caution in narcotic-dependent patients


− Restlessness, seizures, dyspnea, pulmonary

• Considerations


Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)

• Classification:

• Antianginal


− Smooth muscle relaxant acting on vasculature, with a resultant decrease in venous return and decrease in arterial BP ,which reduces myocardial oxygen cosumption .

• Indications

− Acute angina pectoris, ischemic chest pain

• Dose: Initial dose , 5mcg/min delivered through an infusion pump .inceased by 5mcg/min .if no response

• 20mcg/min.Once BP response is obtained reduce dose and llengthen dosage intervals. continually monitor response and titrate carefully .

• Adverse reactions− Headache, dizziness,

weakness, reflex tachycardia

• Considerations− Pregnancy safety:

Category C

− Hypotension more common in the elderly

• Contraindications− Hypotension, hypovolemia,

intracranial bleeding or head injury

Norepinephrine Bitartrate (Levophed)

• Classification:

• Sympathomimetic

• Alpha-adrenergic agonist ,Beta1adrenergic agonist , cardiac stimulant ,vasopresser.

• Mechanism of action− Potent alpha-agonist resulting in

intense peripheral vasoconstriction

• Indications− Cardiogenic shock,

unresponsive to fluid resuscitation

Dose :Add 4ml of the solution (1mg/ml)to 1000ml of 5% dextrose solution for a concentration of 4mcg base /ml

Initially give 8-12 mcg /min adjust dose gradually to maintain desired Bp .

• Adverse reactions− Headache, anxiety,

dizziness

• Considerations− Pregnancy safety: Category

C.

− May cause fetal anoxia when used in pregnancy

• Contraindications− Hypotensive patients with

hypovolemia

Ondansetron Hydrochloride (Zofran)

• Classification: Antiemetic

• Mechanism of action− Blocks action of serotonin

• Indications− Prevention and control of

nausea or vomiting

• Dose:

• Prevention of chemotherapy -induced nausea and vomiting three 0.15mg /kg doses IV first dose is given over 15 min, before 30min of starting the chemotherapy .


− Headache, malaise,

wheezing

• Considerations


Category B


− Known allergy to

ondansetron

Oxygen


− Reverses hypoxemia

• Indications

− Confirmed or

expected hypoxemia,

ischemic chest pain


− Certain patients with

COPD will not tolerate

oxygen concentrations

over 35%.


− Decreased level of

consciousness

(COPD patients),

decreased respiratory

drive in COPD

patients

• Considerations

− Be familiar with liter

flow and each type of

delivery device used.

Phenytoin (Dilantin)

• Classification:

• Antiepileptic , antiarrhythmic group Ib.

• Mechanism of action− Promotes sodium

efflux from neurons

− Effective in treating cardiac arrhythmias, especially those induced by digitalis.

• Indications− Prophylaxis and treatment

of major motor seizures

Dose:status epilepticus 10-15 mg /kg

by slow IV .for maintenance 100mg 6-8 hr .


− Ataxia, agitation, dizziness,

headache, drowsiness

• Considerations


D

− Carefully monitor vital signs.

− Contraindications

− Hypersensitivity,

bradycardia

Propofol (Diprivan)


− Produces rapid and brief state of general anesthesia

• Indications

− Anesthesia induction/ maintenance, sedation for mechanically ventilated patients

− Dose:Inducción anestésicaIV: 1 – 2,5 mg/kgMantenimiento anestésicoPerfusión IV: 50 – 150 mcg/kg/minSedaciónDosis de carga IV: 0,25 – 1 mg/kgMantenimiento IV:10 – 50 µg/kg/min


− Seizure, apnea, dysrhythmias, asystole, hypotension, hypertension

• Considerations

− Pregnancy safety: Category B

− Avoid rapid administration in elderly patients to avoid hypotension and airway obstruction.


− Hypovolemia, known sensitivity

Propranolol Hydrochloride (Inderal)

• Classification :• Beta-adrenergic blocker

(nonselective) antianginal,antiarrhythmic.

• Mechanism of action− Reduces chronotropic,

inotropic, and vasodilator response to beta-adrenergic stimulation

• Indications− Hypertension, angina

pectoris

− Dose : life threatening arrhythmias 1-3 mg IV with careful monitoring ,not to exceed 1mg /min .


− Weakness, depression, fatigue, anxiety, dizziness, bronchospasm

• Considerations


− Closely monitor patient during administration.

− Use with caution in elderly patients.

− Atropine should be readily available.


− Sinus bradycardia, second-or third-degree AV block

Sodium Bicarbonate


• Electrolyte , systemic alkalinizer,


− Buffers metabolic acidosis and lactic acid buildup

• Indications

− Metabolic acidosis during cardiac arrest.

Dose:for severe metabolic acidosis ,dose depends on blood CO2 content , PH, and patient clinical condition ,90-180mEq/L.IVduring first hour then adjust PRN.


− Hypernatremia, metabolic

alkalosis, tissue sloughing,

cellulitis

• Considerations


Category C

− Repeat as needed in

tricyclic antidepressant

overdose until QRS narrows


− Metabolic/respiratory

alkalosis, hypokalemia,

electrolyte imbalance

Tirofiban Hydrochloride (Aggrastat)

• Classification:

• Antiplatelet


− Inhibits aggregation of

platelets

• Indications

− Acute coronary syndrome

• Dose:

• 0.4mcg/kg/min infusion over

30min .then continue at rate

of 0.1 mcg/kg/min.


− Dizziness, pain, sweating, intracranial bleeding, CVA

• Considerations

− Pregnancy safety: Category B

− Must be administered only with an infusion pump direct from bottle with a vented IV set

− Severe spontaneous bleeding risk


− Trauma or major surgery

within the past 30 days

IV Solutions (Colloids and Crystalloids)

• Colloids

− Expand plasma volume

− Most often used in hypovolemic shock states

• Crystalloid solutions are used for:

− Electrolyte replacement

− A route for medication

− Short-term intravascular volume expansion

Dextran


− Sugar-containing

colloid used as an

intravascular volume

expander

• Indications

− Hypovolemic shock


− Patients with

congestive heart

failure, renal failure, or

known bleeding

disorders


− Rash, itching,

dyspnea, chest

tightness, and mild

hypotension

• Considerations

− In the management of

burn shock, it is

especially important to

follow standard fluid

resuscitation regimens

to prevent possible

circulatory overload.

adult ii 2015

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