Transcript Chapter 12: Emergency Medications

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 mL
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 rTPA, 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, AdamsStokes 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
(GlucaGen)
• 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, XI, 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, coma,
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, beriberi,
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, LownGanong-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
(D5W)
• 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 (D10W)
• 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 (D5½NS)
• 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 (D5NS)
• 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 (D5LR)
• 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.
Credits
• Chapter opener: © Jones & Bartlett Learning.
Courtesy of MIEMSS.
• Backgrounds: Orange—© Keith Brofsky/
Photodisc/Getty Images; Red—© Margo
Harrison/ShutterStock, Inc.;Gold—Jones & Bartlett
Learning. Courtesy of MIEMSS; Lime—©
Photodisc.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by the
American Academy of Orthopaedic Surgeons.