Chapter 12 Emergency Medications National EMS Education Standard

Chapter 12 Emergency Medications

National EMS Education Standard Competencies Pharmacology Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies and improve the overall health of the patient.

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 • Actions • Contraindications • Complications • Side Effects • Interactions (cont’d)

Introduction • Paramedics must have a comprehensive understanding of all medications they might administer. − Pharmacology is one of the more difficult subjects to master.

Introduction • Paramedics have to make quick decisions about: − When to administer medications − What medications to administer − When administering certain medications would be harmful to the patient

Introduction • Pharmacology is constantly changing. − Stay up to date on the latest pharmacologic information. • State and regional EMS systems have the right to include medications and indications. − Always follow local protocols.

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

Pregnancy Category Ratings for Drugs • Category A − Possibility of fetal harm appears to be remote • Category B − Either: • Animal studies have not demonstrated a fetal risk but there are no controlled studies in women or • Animal reproductive studies have shown an adverse effect that was not confirmed in controlled studies on women in the first trimester

Pregnancy Category Ratings for Drugs • Category C − Drugs in this category should be given only if the potential benefit justifies the risk to the fetus. • Category D − There is positive evidence of human fetal risk, but the benefits for pregnant women may be acceptable despite the risk.

Pregnancy Category Ratings for Drugs • Category X − The risk of using the drug in pregnant women clearly outweighs any possible benefit. − The drug is contraindicated in women who are or may become pregnant.

Federal “Controlled Substance Act of 1970” Schedule Summary • The legal foundation of the government’s fight against abuse of drugs and other substances. − Consolidation of many laws regulating the manufacture/distribution of controlled substances − Enforced by the DEA

Radio Communications • Become familiar with terminology related to medications and medication administration. • Be familiar with common medical abbreviations.

Radio Communications

Radio Communications

Drug Dosage Calculations • Desired dose − Quantity of a medication that is to be administered • Concentration − Amount of medication that is present in vial • Volume − Amount of fluid medication is dissolved in • Yield − The amount of drug in 1 m. L

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 • Contraindications − 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

Medication Listings • How supplied − How the manufacturer packages the medication for distribution and sale • Dosage and administration − Typical or average volume of the medication to be administered and the route of introduction

Medication Listings • Duration of action − Onset − Peak effect − Duration • Special considerations

Activated Charcoal (EZ-Char, Actidose, Liqui-Char) • Mechanism of action • Adverse reactions − Absorbs toxic substances from the gastrointestinal tract − If aspirated, can induce fatal form of pneumonitis − Bowel obstruction • Indications − Most oral poisonings/ medication overdoses • Contraindications − Oral administration to comatose patients • Considerations − Mix contents well before administration. − Does not absorb cyanide, lithium, iron, lead, or arsenic

Adenosine (Adenocard) • Mechanism of action − 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 • Contraindications − Bronchoconstrictive or bronchospastic lung disease • Adverse reactions − Generally short duration and mild • Considerations − Evaluate elderly for signs of dehydration

Albuterol (Proventil, Ventolin) • Mechanism of action − Results in smoothmuscle relaxation in the bronchial tree • Indications − Treatment of bronchospasm in patients with COPD/asthma) • Contraindications − Hypersensitivity reactions to albuterol • Adverse reactions − 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 r. TPA, Activase) • Mechanism of action − Restores perfusion • Indications − Acute myocardial infarction, STEMI, massive pulmonary emboli, acute ischemic cerebrovascular accident • Contraindications − Active internal bleeding − Recent surgery • Adverse reactions − Intracranial bleeding, reperfusion dysrhythmias, chest pain, hypotension, GI bleeding, nausea, abdominal pain • Considerations − Monitor vital signs closely. − Observe for bleeding.

Amiodarone (Cordarone, Pacerone) • Mechanism of action − Delays repolarization and increases the duration of action potential • Indications − Ventricular fibrillation • Contraindications − Known hypersensitivity to amiodarone or iodine − Cardiogenic shock • Adverse reactions − Dizziness, fatigue, malaise − Congestive heart failure • Considerations − Pregnancy safety: Category D − Monitor patient for hypotension.

Amyl Nitrite • Mechanism of action − Converts hemoglobin to methemoglobin to prevent toxic effects • Indications − Cyanide poisoning • Contraindications − None in emergency settings • Adverse reactions − Headache, dizziness, weakness • Considerations − Pregnancy safety: Category X − Highly flammable

Aspirin (ASA, Bayer, Ecotrin, St. Joseph, and Others) • 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 • Adverse reactions − Bronchospasm, anaphylaxis, wheezing in allergic patients, prolonged bleeding • Considerations − Pregnancy safety: Category D − Not recommended in pediatric population

Atenolol (Tenormin) • Mechanism of action − Decreases heart rate, myocardial contractility, and cardiac output • Indications − To reduce myocardial ischemia and damage in acute myocardial infarction patients • Contraindications − Heart failure, cardiogenic shock, bradycardia • Adverse reactions − Dizziness, bronchospasm, bradycardia • Considerations − Pregnancy safety: Category D − Atenolol must be given slowly IV over 5 minutes − Should be used with caution in patients with liver or renal dysfunction and COPD

Atropine Sulfate • Mechanism of action − Increases heart rate in life-threatening bradydysrhythmias • Indications − Hemodynamically unstable bradycardia • Contraindications − Tachycardia, hypersensitivity • Adverse reactions − Drowsiness, confusion, headache, tachycardia, palpitations • Considerations − Pregnancy safety: Category C − Moderate doses may cause pupillary dilation.

Benzocaine Spray (Hurricane) • Mechanism of action − Stabilizes neuronal membrane, which blocks the initiation and conduction of nerve impulses • Indications − Suppresses pharyngeal and tracheal gag reflex • Contraindications − People with known hypersensitivity to benzocaine • Adverse reactions − Methemoglobinemia has been reported on extremely rare occasions. • Considerations − Pregnancy safety: Category C − Topical use only; not for ocular use or injection

Bumetanide (Bumex) • Mechanism of action − Inhibits the reabsorption of sodium and chloride in the ascending limb of the loop of Henle • Indications − Pulmonary edema, congestive heart failure • Contraindications − Hypersensitivity to bumetanide or sulfonamides • Adverse reactions − Dizziness, headache, orthostatic hypotension • Considerations − Pregnancy safety: Category C

Calcium Chloride • Mechanism of action − Increases cardiac contractile state • Indications − Hypocalcemia, hyperkalemia, hypermagnesemia • Contraindications − Hypercalcemia, ventricular fibrillation, digitalis toxicity • Adverse reactions − Syncope, cardiac arrest, dysrhythmia, bradycardia • Considerations − Pregnancy safety: Category C − Do not use routinely in cardiac arrest.

Calcium Gluconate • Mechanism of action − Counteracts the toxicity of hyperkalemia • Indications − Hyperkalemia, hypocalcemia • Contraindications − Ventricular fibrillation, digitalis toxicity, hypercalcemia • Adverse reactions − Syncope, cardiac arrest, dysrhythmia, bradycardia • Considerations − Pregnancy safety: Category C − Do not administer by IM or SQ

Clopidogrel (Plavix) • Mechanism of action − Inhibits platelet aggregation • Indications − Acute coronary syndrome − Substitute for aspirin in patients unable to take aspirin • Contraindications − Active GI bleeding, intracranial hemorrhage • Adverse reactions − Severe neutropenia − Hemorrhaging • Considerations − Pregnancy safety: Category B − Often given with other anticoagulants

Dexamethasone Sodium Phosphate (Decadron) • Mechanism of action − Suppresses acute and chronic inflammation • Indications − Anaphylaxis, asthma, spinal cord injury • Contraindications − Hypersensitivity, use caution in suspected systemic sepsis • Adverse reactions − Headache, restlessness, euphoria, psychoses • Considerations − Pregnancy safety: Category C − Protect medication from heat. Toxicity and side effects occur with long-term use.

Dextrose • Mechanism of action − Rapidly increases serum glucose levels • Indications − Hypoglycemia, altered level of consciousness • Contraindications − Intracranial hemorrhage • Adverse reactions − Cerebral hemorrhage − Cerebral ischemia − Pulmonary edema • Considerations − Pregnancy safety: Category C

Diazepam (Valium and Others) • Mechanism of action − Raises the seizure threshold; induces amnesia and sedation • Indications − Acute anxiety states and agitation, acute alcohol withdrawal • Contraindications − Hypersensitivity, narrow-angle glaucoma • Adverse reactions − Dizziness, drowsiness, confusion, headache • Considerations − Pregnancy safety: Category D − Short duration for anticonvulsant effect − Reduce dose by 50% in elderly patients.

Digoxin (Lanoxin) • Mechanism of action − Increases force of myocardial contraction • Indications − Congestive heart failure, reentry SVTs, ventricular rate control in atrial flutter and atrial fibrillation • Contraindications − Ventricular fibrillation, ventricular tachycardia, digitalis toxicity • Adverse reactions − Fatigue, headache, blurred yellow or green vision, seizures • Considerations − Pregnancy safety: Category C − Patient receiving IV digoxin must be on a monitor

Diltiazem (Cardizem) • Mechanism of action − Reduces myocardial oxygen demand • Indications − Controls rapid ventricular rates • Contraindications − Hypotension − Sick sinus syndrome • Adverse reactions − Dizziness, weakness, headache, dyspnea • Considerations − Pregnancy safety: Category C − Use with caution in patients with renal or hepatic dysfunction.

Diphenhydramine (Benadryl) • Mechanism of action − Blocks cellular histamine receptors • Indications − Symptomatic relief of allergies, allergic reactions, and anaphylaxis • Contraindications − Asthma, glaucoma, pregnancy, hypertension • Adverse reactions − Drowsiness, sedation, seizures • Considerations − Pregnancy safety: Category B − Not used in infants

Dobutamine Hydrochloride (Dobutrex) • Mechanism of action − Increased myocardial contractility, stroke volume, and increased cardiac output • Indications − Cardiogenic shock, CHF • Contraindications − Tachydysrhythmias, severe hypotension • Adverse reactions − Headache, dyspnea, tachycardia, hypertension, chest pain • Considerations − Pregnancy safety: Category B − Monitor blood pressure closely.

Dolasetron (Anzemet) • Mechanism of action − Selectively blocks the action of serotonin • Indications − Prevention and control of nausea or vomiting • Contraindications − Use caution in patients with cardiac dysrhythmias or electrolyte abnormalities • Adverse reactions − ECG changes, dysrhythmias, anaphylactic reaction, headache, hypotension • Considerations − Pregnancy safety: Category B − Injectable form should not be used in patients with chemotherapyinduced nausea and vomiting.

Dopamine Hydrochloride (Intropin) • Mechanism of action − Increases myocardial contractility and stroke volume • Indications − Cardiogenic and septic shock, hypotension with low cardiac output states • Contraindications − Hypovolemic shock, pheochromocytoma, tachydysrhythmias • Adverse reactions − Headache, anxiety, dyspnea, dysrhythmias • Considerations − Pregnancy safety: Category C − Effects are dosedependent

Epinephrine (Adrenalin) • Mechanism of action − Blocks histamine receptors • Indications − Cardiac arrest, symptomatic bradycardia • Contraindications − Hypertension, hypothermia, pulmonary edema • Adverse reactions − Nervousness, restlessness, headache, tremor • Considerations − Pregnancy safety: Category C − May cause syncope in asthmatic children

Epinephrine Racemic (Micronefrin) • Mechanism of action − Reduces airway resistance • Indications − Bronchial asthma, prevention of bronchospasm, croup • Contraindications − Hypertension, underlying cardiovascular disease, epiglottitis • Adverse reactions − Headache, anxiety, fear, nervousness, respiratory weakness • Considerations − May cause tachycardia and other dysrhythmias − Monitor vital signs.

Eptifibatide (Integrilin) • Mechanism of action − Prevents the aggregation of platelets • Indications − Unstable angina and NSTEMI (ACS) being managed medically • Contraindications − Any prior intracranial hemorrhage, known malignant intracranial neoplasm, suspected aortic dissection • Adverse reactions − Cerebral hemorrhage, pulmonary hemorrhage, hypotension, GI bleeding • Considerations − Pregnancy safety: Category B − Must be administered only with an infusion pump direct from bottle with a vented IV set

Etomidate (Amidate) • Mechanism of action − Short-acting hypnotic • Indications − Premedication for tracheal intubation or cardioversion • Contraindications − Hypersensitivity, labor/delivery • Adverse reactions − Apnea of short duration, respiratory depression, hypoventilation, hyperventilation • Considerations − Pregnancy safety: Category C − Carefully monitor vital signs.

Fentanyl Citrate (Sublimaze) • Mechanism of action − Produces analgesia and euphoria • Indications − Pain management, anesthesia adjunct • Contraindications − Known hypersensitivity. Use with caution in traumatic brain injury. • Adverse reactions − Confusion, paradoxical excitation, delirium, drowsiness • Considerations − Pregnancy safety: Category C − Chest wall rigidity possible with a highdose rapid infusion

Flumazenil (Romazicon) • Mechanism of action − Reverses the sedative effects of benzodiazepines • Indications − Reversal of respiratory depression and sedative effects from benzodiazepine • Contraindications − Hypersensitivity, tricyclic antidepressant overdose, seizureprone patients • Adverse reactions − Seizures, dizziness, agitation, confusion, headache, visual disturbances • Considerations − Pregnancy safety: Category C − Not recommended in combined drug overdoses

Fosphenytoin (Cerebyx) • Mechanism of action − Elevates the excitability threshold of the cell, reducing its response to stimuli • Indications − Status epilepticus, seizure disorder • Contraindications − Bradycardia, Adams. Stokes syndrome, second- or thirddegree AV blocks • Adverse reactions − Severe hypotension, bradycardia, dysrhythmias • Considerations − Pregnancy safety: Category D − Use with caution in patients with hepatic and renal impairment and diabetic, elderly, and debilitated patients.

Furosemide (Lasix) • Mechanism of action − Causes increased urine output • Indications − CHF, pulmonary edema, hypertensive crisis • Contraindications − Hypovolemia, anuria, hypotension • Adverse reactions − Dizziness, headache, ECG changes, weakness • Considerations − Pregnancy safety: Category C − Ototoxicity, deafness, and projectile vomiting can occur with rapid administration.

Glucagon (Gluca. Gen) • Mechanism of action − Increases blood glucose level • Indications − Altered level of consciousness when hypoglycemia is suspected • Contraindications − Hyperglycemia, hypersensitivity • Adverse reactions − Dizziness, headache, hypertension, tachycardia • Considerations − Pregnancy safety: Category B − Should be used in conjunction with 50% dextrose whenever possible

Haloperidol Lactate (Haldol) • Mechanism of action − Inhibits central nervous system catecholamine receptors • Indications − Acute psychotic episodes • Contraindications − Parkinson's disease, depressed mental status • Adverse reactions − Seizures, sedation, confusion, restlessness • Considerations − Pregnancy safety: Category C − Treat hypotension secondary to haloperidol with fluids and norepinephrine, not epinephrine

Heparin Sodium • Mechanism of action − Affects clotting factors IX, XII, plasmin; does not lyse existing clots • Indications − Acute myocardial infarction, prophylaxis and treatment of thromboembolic disorders • Contraindications − Hypersensitivity, active bleeding • Adverse reactions − Pain, anaphylaxis, shock, hematuria • Considerations − Pregnancy safety: Category C − Heparin does not lyse existing clots.

Hydrocortisone Sodium Succinate (Solu-Cortef) • Mechanism of action − Anti-inflammatory; immunosuppressive with salt-retaining actions • Indications − Shock due to acute adrenocortical insufficiency, anaphylaxis, asthma, and COPD • Contraindications − Systemic fungal infections, premature infants • Adverse reactions − Headache, vertigo, pulmonary tuberculosis • Considerations − Pregnancy safety: Category C − May be used in status asthmaticus as a second-line drug

Hydroxocobalamin (Cyanokit) • Mechanism of action − Binds with cyanide to prevent its toxic effects • Indications − Treatment of known or suspected cyanide poisoning • Contraindications − None in the emergency setting • Adverse reactions − Hypertension, allergic reactions, GI bleeding, nausea, vomiting • Considerations − Pregnancy safety: Category C − Make sure to reassess the patient’s airway, oxygenation, and hydration during administration.

Hydroxyzine (Atarax, Vistaril) • Mechanism of action − Potentiates effects of analgesics • Indications − Controls nausea and vomiting in anxiety reactions and motion sickness • Contraindications − Hypersensitivity, early pregnancy • Adverse reactions − Drowsiness, agitation, ataxia, dizziness, headache, weakness • Considerations − Pregnancy safety: Category C − Should be administered by IM injection only

Insulin • Mechanism of action − Allows glucose transport into cells of all tissues • Indications − Not used in emergency prehospital setting • Contraindications − Hypoglycemia, hypokalemia • Adverse reactions − Weakness, fatigue, confusion, headache • Considerations − Pregnancy safety: Category B − Insulin is the drug of choice for control of diabetes in pregnancy.

Ipratropium (Atrovent) • Mechanism of action − Inhibits interaction of acetylcholine at receptor sites of bronchial smooth muscle • Indications − Persistent bronchospasm, COPD exacerbation • Contraindications − Hypersensitivity to ipratropium, atropine, alkaloids, peanuts • Adverse reactions − Headache, dizziness, nervousness, fatigue • Considerations − Pregnancy safety: Category B − Shake well before use.

Isoetharine (Bronchosol, Bronkometer) • Mechanism of action − Relaxes smooth muscle of bronchioles • Indications − Acute bronchial asthma, bronchospasm • Contraindications − Use with caution in patients with diabetes, hyperthyroidism, and cardiovascular and cerebrovascular disease. • Adverse reactions − Nervousness, doserelated tachycardia, palpitations • Considerations − None

Ketorolac Tromethamine (Toradol) • Mechanism of action − Potent analgesic • Indications − Short-term management of moderate to severe pain • Contraindications − Allergy to salicylates or other nonsteroidal anti-inflammatory drugs • Adverse reactions − Drowsiness, dizziness, headache, sedation • Considerations − Pregnancy safety: Category C − Use with caution in elderly patients due to higher risk of renal and fatal GI adverse reactions.

Labetalol (Normodyne, Trandate) • Mechanism of action − Blood pressure reduction without reflex tachycardia • Indications − Moderate to severe hypertension • Contraindications − Bronchial asthma, congestive heart failure, cardiogenic shock • Adverse reactions − Fatigue, weakness, depression, headache, dizziness • Considerations − Pregnancy safety: Category C − Blood pressure, pulse rate, and ECG should be monitored continuously.

Levalbuterol (Xopenex) • Mechanism of action − Relaxation of bronchial tree and peripheral vasculature • Indications − Treatment of acute bronchospasm in patients with reversible obstructive airway disease • Contraindications − Hypersensitivity to drug and other sympathomimetics • Adverse reactions − Headache, anxiety, dizziness, restlessness, hallucinations • Considerations − Pregnancy safety: Category C − Use with caution in patients with cardiac dysrhythmias and cardiovascular disorders.

Lidocaine Hydrochloride (Xylocaine) • Mechanism of action − Decreases automaticity • Indications − Alternative to amiodarone in cardiac arrest from ventricular tachycardia • Contraindications − Hypersensitivity, second- or thirddegree AV block in the absence of an artificial pacemaker • Adverse reactions − 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.

Lorazepam (Ativan) • Mechanism of action − Anxiolytic, anticonvulsant, and sedative effect • Indications − Initial control of status epilepticus or severe recurrent seizures • Contraindications − Acute narrow-angle glaucoma, shock • Adverse reactions − Dizziness, drowsiness, CNS depression, headache • Considerations − Pregnancy safety: Category D − Monitor respiratory rate and blood pressure during administration.

Magnesium Sulfate • Mechanism of action − Reduces striated muscle contractions • Indications − Seizures of eclampsia, torsades de pointes, hypomagnesemia • Contraindications − Heart block, myocardial damage • Adverse reactions − Drowsiness, CNS depression, respiratory depression • Considerations − Pregnancy safety: Category A − Recommended that the drug not be administered in the 2 hours before delivery, if possible

Mannitol (Osmitrol) • Mechanism of action − Decreases cerebral edema and intracranial pressure • Indications − Cerebral edema • Contraindications − Hypotension, pulmonary edema, severe dehydration, intracranial bleeding, CHF • Adverse reactions − Headache, confusion, seizures, pulmonary edema • Considerations − Pregnancy safety: Category C − May crystallize at low temperatures; store at room temperature − Have ventilatory support available.

Meperidine Hydrochloride (Demerol) • Mechanism of action − Primarily acts as an analgesic and a sedative • Indications − Analgesia for moderate to severe pain • Contraindications − Hypersensitivity to narcotics • Adverse reactions − Seizures, confusion, sedation, dysphoria, headache • Considerations − Pregnancy safety: Category C − Use with caution in patients with asthma and COPD

Metaproterenol Sulfate (Alupent) • Mechanism of action − Acts directly on bronchial smooth muscle causing relaxation • Indications − Bronchial asthma, COPD • Contraindications − Tachydysrhythmia, hypersensitivity, tachycardia caused by digitalis toxicity • Adverse reactions − Nervousness, tremor, headache, anxiety • Considerations − Pregnancy safety: Category C − Monitor for hypotension and tachycardia.

Methylprednisolone Sodium Succinate (Solu-Medrol) • Mechanism of action − Suppresses acute and chronic inflammation • Indications − Acute spinal cord trauma, anaphylaxis, bronchodilator for unresponsive asthma • Contraindications − Premature infants, systemic fungal infections • Adverse reactions − Depression, euphoria, headache, restlessness, seizure • Considerations − Pregnancy safety: Category C − Not effective if time of spinal cord injury greater than 8 hours

Metoprolol Tartrate (Lopressor) • Mechanism of action − Decreases heart rate • Indications − PSVT, atrial flutter, atrial fibrillation • Contraindications − Heart failure, secondor third-degree AV block • Adverse reactions − Weakness, dizziness, depression, bronchospasm • Considerations − Pregnancy safety: Category C − Metoprolol must be given slow IV over 5 minutes

Midazolam Hydrochloride (Versed) • Mechanism of action − Causes sedative, anxiolytic, amnesic, and hypnotic effects • Indications − Sedation for medical procedures • Contraindications − Acute narrow-angle glaucoma, shock, coma, alcohol intoxication • Adverse reactions − Headache, somnolence, respiratory depression • Considerations − Pregnancy safety: Category D − Administer immediately prior to intubation procedure.

Morphine Sulfate (Roxanol, MS Contin) • Mechanism of action − Alleviates pain through CNS action • Indications − Severe CHF, acute cardiogenic pulmonary edema • Contraindications − Head injury, exacerbated COPD, depressed respiratory drive • Adverse reactions − Confusion, sedation, headache, CNS depression • Considerations − Pregnancy safety: Category C − Morphine rapidly crosses the placenta.

Nalbuphine Hydrochloride (Nubain) • Mechanism of action − Activates opiate receptor • Indications − Chest pain with acute MI, acute pain • Contraindications − Head injury, undiagnosed abdominal pain, diarrhea from poison, hypovolemia, hypotension • Adverse reactions − Headache, dizziness, vertigo, seizure • Considerations − Pregnancy safety: Category B − Use with caution in patients with impaired respiratory function.

Naloxone Hydrochloride (Narcan) • Mechanism of action − Reverses respiratory depression secondary to opiate drugs • Indications − Opiate overdose, complete or partial reversal of central nervous system and respiratory depression induced by opioids • Contraindications − Use with caution in narcotic-dependent patients • Adverse reactions − Restlessness, seizures, dyspnea, pulmonary • Considerations − Pregnancy safety: Category C

Nifedipine (Procardia, Adalat) • Mechanism of action − Inhibits movement of calcium ions across cell membranes • Indications − Hypertensive crisis, angina pectoris • Contraindications − Compensatory hypertension, hypotension • Adverse reactions − Headache, dizziness, nervousness, weakness, mood changes • Considerations − Pregnancy safety: Category C − Have beta blocker available for control of reflex tachycardia

Nitroglycerin (Nitrostat, Nitro-Bid, Tridil) • Mechanism of action − Smooth muscle relaxant acting on vasculature, bronchial, uterine, intestinal smooth muscle • Indications − Acute angina pectoris, ischemic chest pain • Contraindications − Hypotension, hypovolemia, intracranial bleeding or head injury • Adverse reactions − Headache, dizziness, weakness, reflex tachycardia • Considerations − Pregnancy safety: Category C − Hypotension more common in the elderly

Nitropaste (Nitro-Bid Ointment) • Mechanism of action − Smooth muscle relaxant • Indications − Acute angina pectoris • Contraindications − Hypotension, hypovolemia, intracranial bleeding or head injury • Adverse reactions − Headache, dizziness, weakness • Considerations − Pregnancy safety: Category C − Not a great value in prehospital arena

Nitrous Oxide 50: 50 (Nitronox) • Mechanism of action − Exact mechanism unknown • Indications − Moderate to severe pain, anxiety, apprehension • Contraindications − Impaired level of consciousness, head injury • Adverse reactions − Lightheadedness, drowsiness, respiratory depression • Considerations − Pregnancy safety: Category C − Nitrous oxide increases the incidence of spontaneous abortion.

Norepinephrine Bitartrate (Levophed) • Mechanism of action − Potent alpha-agonist resulting in intense peripheral vasoconstriction • Indications − Cardiogenic shock, unresponsive to fluid resuscitation • Contraindications − Hypotensive patients with hypovolemia • Adverse reactions − Headache, anxiety, dizziness • Considerations − Pregnancy safety: Category C. − May cause fetal anoxia when used in pregnancy

Ondansetron Hydrochloride (Zofran) • Mechanism of action − Blocks action of serotonin • Indications − Prevention and control of nausea or vomiting • Contraindications − Known allergy to ondansetron • Adverse reactions − Headache, malaise, wheezing • Considerations − Pregnancy safety: Category B

Oral Glucose (Insta-Glucose) • Mechanism of action • Adverse reactions − Provides an increase in circulating blood glucose levels − Nausea, vomiting • Indications − Conscious patients with suspected hypoglycemia • Contraindications − Decreased level of consciousness, nausea, vomiting • Considerations − Must be swallowed. Glucose is not absorbed sublingually or buccally.

Oxygen • Mechanism of action − Reverses hypoxemia • Indications − Confirmed or expected hypoxemia, ischemic chest pain • Contraindications − Certain patients with COPD will not tolerate oxygen concentrations over 35%. • Adverse reactions − 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.

Oxytocin (Pitocin) • Mechanism of action − Increases uterine contractions • Indications − Postpartum hemorrhage after infant and placental delivery • Contraindications − Presence of second fetus, unfavorable fetal position • Adverse reactions − Coma, seizures, anxiety • Considerations − Pregnancy safety: Category C − Monitor vital signs including fetal heart rate and uterine tone closely.

Pancuronium Bromide (Pavulon) • Mechanism of action − Binds to the receptor for acetylcholine at the neuromuscular junction • Indications − Induction or maintenance of paralysis after intubation to assist ventilations • Contraindications − Hypersensitivity, inability to control airway and/or support ventilations with oxygen and positive pressure • Adverse reactions − Weakness, prolonged neuromuscular block, bronchospasm • Considerations − Always sedate the patient before administering.

Phenobarbital (Luminal) • Mechanism of action − Generally unknown but believed to reduce neuronal excitability • Indications − Prevention and treatment of seizure activity, status epilepticus • Contraindications − Patients with porphyria, history of sedative or hypnotic addiction • Adverse reactions − Coma, drowsiness, headache, vertigo, paradoxic excitation • Considerations − Pregnancy safety: Category D − Potential for abuse − Carefully monitor vital signs.

Phenytoin (Dilantin) • Mechanism of action − Promotes sodium efflux from neurons • Indications − Prophylaxis and treatment of major motor seizures • Contraindications − Hypersensitivity, bradycardia • Adverse reactions − Ataxia, agitation, dizziness, headache, drowsiness • Considerations − Pregnancy safety: Category D − Carefully monitor vital signs.

Pralidoxime (2 -PAM, Protopam) • Mechanism of action − Acts as an antidote to organophosphate and pesticide poisonings • Indications − As an antidote in the treatment of poisoning • Contraindications − Reduce dose in patients with impaired renal function, and patients with myasthenia gravis • Adverse reactions − Dizziness, drowsiness, headache, neuromuscular blockade • Considerations − Pregnancy safety: Category C − Slow IV infusion prevents tachycardia, laryngospasm, muscle rigidity

Procainamide Hydrochloride (Pronestyl) • Mechanism of action − Suppresses intraventricular conduction • Indications − Stable monomorphic ventricular tachycardia with normal QT interval • Contraindications − Torsades de pointes, second- and thirddegree heart atrioventricular block • Adverse reactions − Confusion, seizures, hypotension, bradycardia • Considerations − Pregnancy safety: Category C − Potent vasodilation and negative inotropic effects

Promethazine Hydrochloride (Phenergan) • Mechanism of action − H-1 receptor antagonist; blocks action of histamine • Indications − Nausea/vomiting, motion sickness, sedation for patients in labor • Contraindications − Coma, central nervous system depression from alcohol, barbiturates, or narcotics • Adverse reactions − Headache, dizziness, drowsiness, confusion, restlessness, wheezing • Considerations − Pregnancy safety: Category C − Convulsions and sudden death when used with children

Propofol (Diprivan) • Mechanism of action − Produces rapid and brief state of general anesthesia • Indications − Anesthesia induction/ maintenance, sedation for mechanically ventilated patients • Contraindications − Hypovolemia, known sensitivity • Adverse reactions − Seizure, apnea, dysrhythmias, asystole, hypotension, hypertension • Considerations − Pregnancy safety: Category B − Avoid rapid administration in elderly patients to avoid hypotension and airway obstruction.

Propranolol Hydrochloride (Inderal) • Mechanism of action − Reduces chronotropic, inotropic, and vasodilator response to beta-adrenergic stimulation • Indications − Hypertension, angina pectoris • Contraindications − Sinus bradycardia, second- or thirddegree AV block • Adverse reactions − Weakness, depression, fatigue, anxiety, dizziness, bronchospasm • Considerations − Pregnancy safety: Category C − Closely monitor patient during administration. − Use with caution in elderly patients. − Atropine should be readily available.

Rocuronium Bromide (Zemuron) • Mechanism of action − Produces skeletal muscle paralysis • Indications − Rapid sequence intubation • Contraindications − Known sensitivity to bromides. Use with caution in heart and liver disease. • Adverse reactions − Bronchospasm, wheezing, rhonchi, respiratory depression, apnea • Considerations − Pregnancy safety: Category B − Decrease doses for patients with renal disease. − Sedate patient before administering.

Sodium Bicarbonate • Mechanism of action − Buffers metabolic acidosis and lactic acid buildup • Indications − Metabolic acidosis during cardiac arrest, tricyclic antidepressant, aspirin • Contraindications − Metabolic/respiratory alkalosis, hypokalemia, electrolyte imbalance • Adverse reactions − Hypernatremia, metabolic alkalosis, tissue sloughing, cellulitis • Considerations − Pregnancy safety: Category C − Repeat as needed in tricyclic antidepressant overdose until QRS narrows

Sodium Nitrate • Mechanism of action − Reacts with hemoglobin to form methemoglobin, which reacts with cyanide • Indications − Cyanide poisoning • Contraindications − None in the emergency setting • Adverse reactions − Hypotension, tachycardia, fainting, nausea, vomiting • Considerations − Pregnancy safety: Category C − Potent vasodilator causes significant hypotension if given too rapidly

Sodium Thiosulfate • Mechanism of action − Converts cyanide to the less toxic thiocyanate, which is then excreted in the urine • Indications − Cyanide poisoning • Contraindications − None in the emergency setting • Adverse reactions − Diarrhea • Considerations − Pregnancy safety: Category C − If response to treatment is inadequate, repeat sodium nitrite and sodium thiosulfate

Streptokinase (Streptase) • Mechanism of action − Combines with plasminogen to convert free plasminogen to the proteolytic enzyme, plasmin • Indications − Acute myocardial infarction, massive pulmonary emboli, arterial thrombosis/ embolism, to clear intraventricular cannula • Contraindications − Hypersensitivity, active bleeding, recent cerebral vascular accident • Adverse reactions − Intracranial hemorrhage, bronchospastic hemoptysis, ARDS • Considerations − Pregnancy safety: Category C

Succinylcholine Chloride (Anectine) • Mechanism of action − Ultra-short-acting depolarizing skeletal muscle relaxant • Indications − Rapid-sequence intubation • Contraindications − Acute narrow-angle glaucoma, penetrating eye injuries, malignant hyperthermia • Adverse reactions − Apnea, respiratory depression, bradydysrhythmia, tachydysrhythmia • Considerations − Pregnancy safety: Category C − If the patient is conscious, explain the effects of the drug before administration.

Terbutaline Sulfate (Brethine) • Mechanism of action − Relaxation of bronchial tree and peripheral vasculature with minimal cardiac effects • Indications − Bronchial asthma, bronchospasm associated with exercise • Contraindications − Hypersensitivity, tachydysrhythmias • Adverse reactions − CNS stimulation, headache, seizure, restlessness, apprehension • Considerations − Pregnancy safety: − Category B − Monitor vital signs.

Thiamine (Betaxin) • Mechanism of action − Combines with ATP to form thiamine pyrophosphate coenzyme • Indications − Coma of unknown origin, delirium tremens, beri, Wernicke encephalopathy • Contraindications − None • Adverse reactions − Anxiety, dyspnea, respiratory failure, vasodilation • Considerations − Pregnancy safety: Category A − Rapid or large IV doses may cause respiratory difficulties, hypotension, and vasodilation.

Tirofiban Hydrochloride (Aggrastat) • Mechanism of action − Inhibits aggregation of platelets • Indications − Acute coronary syndrome • Contraindications − Trauma or major surgery within the past 30 days • Adverse reactions − 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

Vasopressin (Pitressin) • Mechanism of action − Stimulation of smooth muscle receptors • Indications − Alternative vasopressor to the first or second dose of epinephrine in cardiac arrest • Contraindications − Use with caution in patients with coronary artery disease, epilepsy, or heart failure. • Adverse reactions − Dizziness, headache, bronchial constriction, MI, chest pain, angina • Considerations − Pregnancy safety: Category C − May increase peripheral vascular resistance and provoke cardiac ischemia and angina

Vecuronium Bromide (Norcuron) • Mechanism of action − Neuromuscular agent that results in neuromuscular blockade • Indications − Rapid-sequence intubation • Contraindications − Acute narrow-angle glaucoma, penetrating eye injuries • Adverse reactions − Weakness, prolonged neuromuscular block, bronchospasm, apnea • Considerations − Pregnancy safety: Category C − If patient is conscious, explain the effect of the medication before administration and always sedate the patient before using vecuronium.

Verapamil Hydrochloride (Isoptin, Calan) • Mechanism of action − Prolongs AV nodal refractory period, dilates coronary arteries and arterioles • Indications − Paroxysmal supraventricular tachycardia, atrial flutter, and atrial fibrillation with rapid ventricular response • Contraindications − Wolff-Parkinson-White syndrome, Lown. Ganong-Levine syndrome • Adverse reactions − Dizziness, headache, pulmonary edema • Considerations − Pregnancy safety: Category C − Closely monitor patient’s vital signs.

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

Plasma Protein Fraction (Plasmanate) • Mechanism of action − Increases intravascular volume • Indications − Hypovolemic shock, especially burn shock • Contraindications − No major contraindications • Adverse reactions − Chills, fever, urticaria (hives), nausea, and vomiting • Considerations − Do not use if the solution is cloudy or if you see sedimentation.

Dextran • Mechanism of action − Sugar-containing colloid used as an intravascular volume expander • Indications − Hypovolemic shock • Contraindications − Patients with congestive heart failure, renal failure, or known bleeding disorders • Adverse reactions − 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.

Hetastarch (Hespan) • Mechanism of action − A starch-containing colloid used as an intravascular volume expander • Indications − Hypovolemic shock, especially burn shock; septic shock • Contraindications − No major contraindications • Adverse reactions − Nausea, vomiting, mild febrile reactions, chills, itching, and urticaria • Considerations − Pregnancy safety: Category C − Patients allergic to corn may be allergic to hetastarch.

Lactated Ringer’s (Hartmann’s Solution) • Mechanism of action − Replaces water and electrolytes • Indications − Hypovolemic shock; keep open IV • Contraindications − Should not be used in patients with congestive heart failure or renal failure • Adverse reactions − Rare in therapeutic dosages • Considerations − None

5% Dextrose in Water (D 5 W) • Mechanism of action − Provides nutrients in the form of dextrose as well as free water • Indications − For dilution of concentrated drugs for intravenous infusion • Contraindications − Should not be used as a fluid replacement for hypovolemic states • Adverse reactions − Rare in therapeutic dosages • Considerations − Should not be used with phenytoin or amrinone

10% Dextrose in Water (D 10 W) • Mechanism of action − Provides nutrients in the form of dextrose as well as free water • Indications − Neonatal resuscitation, hypoglycemia • Contraindications − Should not be used as a fluid replacement for hypovolemic states • Adverse reactions − Rare in therapeutic dosages • Considerations − None

0. 9% Sodium Chloride (Normal Saline) • Mechanism of action − Replaces water and electrolytes • Indications − Heat-related problems (heat exhaustion, heat stroke), freshwater drowning, hypovolemia • Contraindications − Should not be used in patients with congestive heart failure • Adverse reactions − Rare in therapeutic dosages • Considerations − None

0. 45% Sodium Chloride (½ Normal Saline) • Mechanism of action − Replaces free water and electrolytes • Indications − Patients with diminished renal or cardiovascular function for which rapid rehydration is not indicated • Contraindications − Cases in which rapid rehydration is indicated • Adverse reactions − Rare in therapeutic dosages • Considerations − None

5% Dextrose in 0. 45% Sodium Chloride (D 5½NS) • Mechanism of action − Replaces free water and electrolytes and provides nutrients in the form of dextrose • Indications − Heat exhaustion, diabetic disorders • Contraindications − Should not be used when rapid fluid resuscitation is indicated • Adverse reactions − Rare in therapeutic dosages • Considerations − None

5% Dextrose in 0. 9% Sodium Chloride (D 5 NS) • Mechanism of action − Replaces free water and electrolytes and provides nutrients in the form of dextrose • Indications − Heat-related disorders, freshwater drowning • Contraindications − Should not be given to patients with impaired cardiac or renal function • Adverse reactions − Rare in therapeutic dosages • Considerations − None

5% Dextrose in Lactated Ringer’s (D 5 LR) • Mechanism of action − Replaces water and electrolytes and provides nutrients in the form of dextrose • Indications − Hypovolemic shock, hemorrhagic shock • Contraindications − Should not be administered to patients with decreased renal or cardiovascular function • Adverse reactions − Rare in therapeutic dosages • Considerations − None

Summary • Paramedics are required to know the names, class, mechanism of action, adverse reactions and side effects, interactions, indications, contraindications, complications, routes of administration, dose, and specific administration considerations for many emergency medications and intravenous fluids. • Individual states have the authority to include additional medications, which may be taught by your local training agency.

Summary • Because paramedics must make quick decisions about when to administer medications, what medications to administer, and when administering certain medications would be harmful to the patient, it is critically important they develop a solid understanding of the information in this chapter and stay up to date on the latest pharmacologic information.

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