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New Hampshire AEMT Pharmacology New Hampshire Division of Fire Standards & Training and Emergency Medical Services Special Thank you! Jeanne Erickson, NREMT-I Christopher Rousseau, NREMT-I AEMT Medications Activated Charcoal Epinephrine – cardiac Epinephrine – anaphylaxis Dextrose Atropine Narcan Ipratropium Albuterol Aspirin Nitroglycerin Glucagon Oral Glucose Nitrous Oxide Oxygen Objectives Understand basic pharmacological definitions Understand the normal actions of the body Look at the forms in which the medications may be found Know how to calculate drug dosages Become competent in methods of drug administration State which medications are approved for Intermediate use Know the dosages, uses, side effects, contraindications of approved meds Objectives Review the specific anatomy and physiology pertinent to pharmacology. Discuss the standardization of drugs. Differentiate among the chemical, generic (nonproprietary), and trade (proprietary) names of a drug. List the four main sources of drug products. Describe how drugs are classified. List the authoritative sources for drug information. Discuss special consideration in drug treatment with regard to pregnant, pediatric and geriatric patients. Discuss the AEMT responsibilities and scope of management pertinent to the administration of medications. List and describe general properties of drugs. List and describe liquid, solid, and gas drug forms. List and differentiate routes of drug administration. Objectives Differentiate between enteral and parenteral routes of drug administration. Describe mechanisms of drug action. List and differentiate the phases of drug activity, including the pharmaceutical, pharmacokinetic, and pharmacodynamic phases. Describe pharmacokinetics, pharmacodynamics, theories of drug action, drug-response relationship, factors altering drug responses, predictable drug responses, iatrogenic drug responses, and unpredictable adverse drug responses. Discuss considerations for storing drugs. List the components of a drug profile. List and describe drugs which the AEMT may administer in a pharmacological management plan according to local protocol. Discuss procedures and measures to ensure security of controlled substances the AEMT may administer. Objectives Review of the following medical emergencies and the related NH Patient Care Protocols Drug Chemical agents used in the diagnosis, treatment, or prevention of disease. Pharmacology The study of drugs and their interactions with the body. Drugs are NOT magical. They cannot alter the body systems qualitatively, only quantitatively Names Chemical Name Generic Name A name suggested by the manufacture and confirmed by the U.S. Adopted Name Council Official Name Most detailed, chemical description FDA’s official name Brand Name A manufacturer’s trade name or proprietary name As an example: Epinephrine Chemical Name: Generic name: epinephrine Official name: 4-(1-hydroxy-2-methylamino-ethyl)benzene1,2-diol epinephrine Brand name: Adrenalin, EpiPen® Source Plants Animal Insulin (bovine & porcine) Mineral Purple foxglove = digitalis Deadly nightshade Atrope belladonna plant = Atropine Calcium Chloride, magnesium sulfate Laboratory (synthetic) Fentanyl Reference Materials USP (United States Pharmacopoeia) PDR (Physician’s Desk Reference) Drug Information Monthly Prescribing Reference AMA (American Medical Association) Drug Evaluation Drug Profile Names Classifications Mechanism of action Indications Pharmacokinetics Side effects/adverse reactions Contraindications Dosages How supplied Special considerations Drugs and the Law Pure Food & Drug Act of 1906 Harrison Narcotic Act of 1914 Federal Food, Drug & Cosmetic Act of 1938 Durham-Humphrey Amendments Comprehensive Drug Abuse Prevention & Control Act of 1970 Over-the-counter (OTC) medication State laws Local Standards Drug Schedules Schedule I: No acceptable medical indications Schedule ll: Accepted medical indication, but high abuse potential, may lead to severe dependence Schedule lll: Less abuse potential, may lead to moderate or low physical dependence Schedule lV: Less abuse potential then lll, limited psychological and/or physical dependence Schedule V: Even lower abuse potential Special considerations in drug therapy Pregnant patients Before using any drug during pregnancy, the expected benefits should be considered against the possible risks to the fetus The FDA has established a scale (Categories A, B, C, D, and X) to indicate drugs that may have documented problems in animals and/ or humans during pregnancy Many drugs are unknown to cause problems in animals and/ or humans during pregnancy Pregnancy causes a number of anatomical and physiological changes Drugs may cross the placenta or through lactation Special considerations in drug therapy Pediatric patients Based on the child's weight or body surface area Special concerns for neonates Length-based resuscitation tape Geriatric patients The physiological effects of aging can lead to altered pharmacodynamics and pharmacokinetics Scope of Management AEMT’s are held responsible for safe and therapeutically effective drug administration AEMT’s are personally responsible - legally, morally, and ethically - for each drug they administer Scope of Management-continued AEMT’s are responsible for: Use correct precautions and techniques Observe and document the effects of drugs Keep their knowledge base current to changes and trends in pharmacology Establish and maintain professional relationships Understand the pharmacology of their approved drugs Perform evaluation to identify drug indications and contraindications Seek drug reference literature Take a drug history from their patients including OTC Review of the Nervous System Patient’s Rights Right Right Right Right Right Right medication dose time route patient documentation Actions of Drugs Pharmacokinetics – study of how drugs enter the body, reach their site of action & are eliminated Pharmacodynamics – study of drug’s action on a body Can act by binding to a receptor site Can act by changing physical properties Can act by chemically combining with other substances Can act by altering a normal metabolic pathway Pharmacokinetics Absorption Distribution Biotransformation Elimination Absorption Liberation - Release of drug from pill, tablet, capsule Dissolving of active drug in GI fluids Absorption – the process by which drug enters the blood stream; is influenced by several factors: Route of administration Circulatory status Absorption Speed of absorption (in order) Intravenous / Intraosseous Transtracheal (ETT) Sublingual Rectal Intramuscular Subcutaneous Oral Distribution Distribution – once in circulatory system, the drug is distributed to body’s tissues From intravascular to interstitial spaces Some drugs bind to serum proteins & have a delayed onset & longer duration Dependent on circulatory status Brain is protected from most drugs by blood brain barrier Biotransformation Biotransformation (AKA Metabolism)– many drugs are inactive when given & have to be converted to active form Done in the blood or by the target tissue Results in chemical variations called metabolites Some drugs are active on administration, are utilized, then biotransformed into an inactive metabolite for excretion Elimination Elimination – either in its original form or as a metabolite, excreted by: The kidneys, liver, intestines and the lungs Varies with the drug & general health: Adversely affected by shock, poor renal, hepatic or respiratory status The slower the rate of elimination, the longer the drug stays in the body Actions of Drugs Drug Receptors – proteins on surface of cells that, when activated, cause cell to behave in desired manner ie. Epinephrine effect on target cells in lungs Agonists are drugs that bind to receptor to cause desired response Antagonists are substances that bind to same receptor & block the desired biochemical response Pharmacodynamics Drug Receptor Interactions Agonist Antagonist Affinity Efficacy Types of receptors Beta Alpha Other definitions you need to know Agonist: drug that binds to a receptor and causes it to initiate the expected response Antagonist: drug that binds to a receptor but does not cause it to initiate the expected response Receptor Sites Factors altering drug responses Age Body mass Sex Environmental milieu Time of administration Pathologic state Genetic factors Psychological factors Drug Routes Enteral PO Orogastric/naogastric SL Buccal Rectal Parenteral IV ET IO Umbilical IM SQ Inhalation/nebulized Topical Transdermal Nasal Instillation Intradermal Drug Forms Pills/tablets: compressed Powders: Suppositories: drug mix with wax-like base (melts) Capsules: gelatin container, dissolves in GI Solutions: generally water based Tinctures: an alcohol solution w/ non-volatile drug Suspensions: solid does not dissolve Emulsions: suspension w/ oily substance in solvent Spirits: Volatile drug in alcohol Elixirs: alcohol & water, often flavored Syrups: sugar, water & drug Gas: Action of Drugs Bind to a receptor site Change the physical properties of cells Chemically combine with other chemical Alter the normal metabolic pathway Responses to Drug Administration Allergic reaction: hypersensitivity Idiosyncrasy: unique to the individual; different than seen or expected in the general population Cross tolerance: tolerance of a drug after admin of a different drug. Morphine & other opioids Tachyphylaxis: rapid tolerance. Typically w/ sympathetic agonists (decongestant & bronchodilation agents) Cumulative Effects: increased effects with several doses Drug interaction: one drug alters the response to another Synergism: 2 drugs given give greater response than their sum. 1+1=3 Unpredictable adverse responses Anaphylaxis Delayed reaction Tolerance Drug dependence Summation (addition or additive effect) Potentiation Interference Predictable Responses Desired action Side effects Body Substance Isolation Equipment Always take appropriate body substance isolation measures to reduce your risk of exposure during medication administration Drug Storage Storage considerations Temperature Light Moisture Shelf Life Security Accountability Logs Needle Handling Precautions Minimize the tasks performed in a moving ambulance Balance the safety needs with the need to transport in a timely manner Immediately dispose of used sharps in a sharps container Recap needles only as a last resort Learn the one-handed recapping maneuver Definitions Metric System – system of weights & measures widely used in science & medicine Based on units of 10 Apothecary System – antiquated system of measures & weights used in early medicine Weights & Measures Metric System has 3 basic units of measurements For Mass: the gram (G) For Length: the meter (M) For Volume: the liter (L) All metric units are derived from these 3 base units Conversion between Prefixes Weights & Measures – Metric Kilogram(kg)= 1,000 grams Gram (gm) = 1,000 milligrams Decigram (dl)= 100 mg or 0.1 gm Milligram (mg)= 1,000 micrograms or 0.001 gm Microgram (mcg or μg)= 1/1,000,000 or 0.000001 1 Liter (l)= 1,000 milliliters (ml) ml = cc Weights & Measures – Apothecary 1 grain = 60 milligrams ¼ grain = 15 milligrams Household 1 teaspoon = 5 ml 1 tablespoon = 15 ml 1 ounce = 30 ml 8 ounces = 240 ml 1 quart = 946 ml Weights & Measures You need to know how to Add, subtract, multiply & divide decimals Convert from liters <-> milliliters, etc. Calculate dosages If in doubt, carry a calculator, find a chart Have your partner double check you It’s better to double check than to make a mistake!!! Buy & use medication math calculation books Drug Calculations Desired Dose – quantity of medication that the physician wants administered Usually expressed in mg, gm or gr. Concentration of Drug on Hand – amount of drug present in the vial or ampoule or syringe Expressed in mg., gm. Or gr. Per volume unit i.e. 10 mg / 2 ml Volume of Drug on Hand – the amount of fluid within the vial or ampoule Expressed in ml or cc Drug Calculations Medication Dose Volume administered = Volume on hand x Desired Dose Concentration on Hand Or use the fraction / ratio format Concentration on hand expressed as a fraction Desired dose expressed as a fraction 100 mg 1 ml = 75 mg x ml x = 75 100 100x = 75 100 x = 0.75 ml 100x = 75 100 Drug Calculations Converting Pounds to Kilograms: Weight in Pounds Kilograms 2.2 = Weight in OR 3 a.m. rule: Divide wt in pounds by 2 and subtract 10% of the result = Weight in Kilograms Medications via Inhalation Route Broncholdiator (beta angonist) Equipment oxygen nebulizer adapters Administering Indications Techniques Precautions General principals Parenteral Administration Subcutaneous Intramuscular Intravenous bolus Intraosseous Sublingual Equipment: syringes, needles, ampules, vials, prefilled syringes, others Subcutaneous Injection Intramuscular Injection Sublingual Route Intravenous Bolus Prefilled / Preloaded Syringes Intravenous Med Administration Pt’s Rights Right medication Right dose Right time Right route Right patient Right documentation Prepare the equipment Check the label Check the expiration date Prefilled / Preloaded Syringes Confirm prefilled syringe label (name, dose, and expiration date) Assemble the prefilled syringe Remove the pop-off caps and screw together Reconfirm indication, drug, dose, and route of administration Administer appropriately via the indicated route Properly dispose of the needle and syringe Intravenous Med Administration Select administration port Port closest to the patient Cleanse Pinch the tubing upstream from the port Intravenous Med Administration Administer the medication Flush the line Re-assess the patient Re-adjust the rate QUESTIONS