1. Pharmacology
Gimme ‘da DRUGS, man!

2. Case
During the transport of an ACS patient, you notice that after giving nitroglycerin, their blood pressure drops to s*&#! (S*&#! = 50/palp). As you wonder “how did nitroglycerin drop it that low” you give a fluid bolus but also grab the Dopamine. “How does Dopamine work? How do I give it? What are the side effects?” You ponder, noticing a bit late that your patient has been unconscious for the past 10 seconds, in V-fib. Things just went from S*&#! to F*&#!...

3. Pharmacology Terms
Generic Name/Trade Name: different names depending on who is making it. Examples: acetaminophen/Tylenol, fentanyl/Sublimaze, hydromorphone/Dilaudid.
Mechanism of Action: how it works in the body
Pharmacokinetics – how it is absorbed, distributed, and eliminated from the body
Dosage/Route – how much and where (oral, rectal, nasal, IV, IM, subcutaneous)
Indications/Contraindications – what its used for, what will prevent you from giving it.
Adverse effects – things that might go wrong if you give it

4. Drug Metabolism
Therapeutic levels – range of serum levels in which drug will have its predicted value
LD50 – level at which drug will kill 50% of the patients given the drug
Metabolism – how the body transforms the drug to make it inert and ready for removal
Excretion – how the drug exits the body
Liver/fecal
Kidney/urine
Combination

5. The Six Rights Right Drug Right Patient Right Dose Right Time
Think Mass Casualty situations
Right Dose
Have a reference handy
Right Time
Right Route
Right Documentation
Time, who gave it, what happened!!

6. How does a drug work? Receptor
A protein made by the cell, nestled in the cell wall that acts as a signal sentinel.
Acts in response to this signal in a certain way
Usually by a second messenger system
The structure of the receptor is such that it can be stimulated, overstimulated, or blocked from acting.
The second messengers cause the production of enzymes

7. How does a drug work? Stimulate a receptor Block a receptor
epinephrine, dopamine, Narcotics, Benzos, succinylcholine, albuterol
Block a receptor
lidocaine, aspirin, Narcan, Vecuronium, atropine, adenosine, amiodarone, diphenhydramine
Directly effect body chemistry/osmolarity
electrolytes, bicarb, NaCl, mannitol
Act as an enzyme or catalyst
tPA, thiamine, cyanocobalamin
Block an enzyme
Act as substrate for a chemical reaction
Mucomyst, nitroglycerin, oxygen, glucose
Kill Bugs - antibiotics

8. Autonomic Nervous System
Sympathetic
Alpha (1, 2)
Constricts blood vessels, dilates pupils
Beta
1 – increases heart rate
2 – dilates bronchioles, arterioles
Parasympathetic
Muscarinic
Relaxes smooth muscle (except bronchioles)
Decreases heart rate, electrical conduction
Constricts pupils

9. Other Nervous System Receptors
GABA
Causes a decrease in neuronal activity
Opioid
Block pain reception in the spinal cord
Causes euphoria (mu receptor)
Acetylcholine
Allows for transmission of nerve impulse to a muscle group – contracts muscle
Dopamine
Poorly understood, neuronal signaling and cognition

10. The EMT formulary Aspirin (Ecotrin, Bayer)
Action: Thromboxane A2 inhibitor, causes platelet function inhibition
Dosage: 324mg oral chewed
Indications: Cardiac chest pain
Contraindications: Allergy, GI bleeding
Side Effects – bleeding, GI upset

11. EMT Formulary
Nitroglycerin (EMT can assist patient with his/her own, AEMT and medic can give without prior Rx)
Effect: vasodilator, chest pain reliever
Dosage: 0.4mg sublingual Q 15 min x3
Indications: chest pain
Contraindications: hypotension, allergy
Side Effects: Headache, hypotension, syncope, cardiac arrest

12. EMT formulary Albuterol (Proventil)
Effect: Dilates smooth muscle in bronchioles (B2)
Dosage: 1-2 puffs per MDI PRN (max three doses); AEMTs and Medics – 1 ampule neb prn, max 3
Indications: Asthma or COPD exacerbations
Contraindications: none
Side Effects: jitteriness, tachycardia, arrhythmia, sweating, anxiety

13. EMT formulary Epinephrine (EpiPen, EpiPen Jr)
Effect: A1, A2, B1, B2 receptor agonist – vasocontricts, relaxes bronchiole smooth muscle, increases heart rate
Dosage: EMTs: EpiPen (0.3ml) or EpiPen Jr (0.15ml)
Dosage: AEMTs: 0.3ml 1:1000 IM, or 0.15ml for 15-30kg
Dosage: Medics: as above, or mg iv 1:10,000 for anaphylaxis, 0.1mg/kg, max 1mg IV Q5 min for arrest
Indications: Anaphylaxis, severe asthma (medical control), cardiac arrest
Contraindications – none
Side Effects: arrhythmia, hypertension, MI, jitteriness

14. EMT Formulary
Oxygen
Effects: acts as a metabolic substrate for respiration, energy production
Dosage: 2-15lpm via NC (max 6lpm), or oxymask
Indications: hypoxia, respiratory distress, stroke like syndromes
Contraindications: open flame
Side Effects: hyperoxia indicated in free radical formation and increased cell damage.

15. AEMT formulary (State Mandated)
Dextrose/Glucagon
Reviewed in Diabetic Emergencies Lecture
Diphenhydramine (Benadryl)
Reviewed in Anaphylaxis Lecture
Naltrexone (Narcan)
Effects: opioid receptor antagonist
Dosage: 0.4mg IV Q5 min until desired effect, max 2mg
Indications: altered mental status, narcotic OD
Contraindications: alert patient
Side Effects: pain, agitation, vomiting, injury to EMT if patient not restrained.

16. AEMT formulary Benzodiazepines (diazepam/Valium; medazolam/Versed)
Effects: GABA receptor agonist – increase seizure threshold, sedating effects
Dosage: Valium (long acting) .1-.2mg/kg IV, IM or PR (gel) max 5-10mg x1 dose
Versed (medium acting) mg/kg max 4mg x1
Indications :Seizures, acute severe agitation, bath salts
Contraindications: respiratory depression, sedation, high risk airway, allergy
Side Effects: miosis, respiratory depression, need for intubation

17. AEMT formulary Narcotics (morphine; fentanyl)
Effects: opioid agonist – provides pain relief
Dosage: Morphine 0.1mg/kg IV/IM max 10mg for pain
Fentanyl – mcg/kg iV max 50mcg x1 SLOW
Medical control for any further dosing
Indications: acute traumatic pain, cardiac pain (morphine only)
Contraindications: abdominal pain, allergy, respiratory depression or altered mental status
Side Effects: Chest Wall Rigidity syndrome, respiratory depression, hypotension

18. Paramedic Formulary Zofran
Effect: Reduction of nausea through inhibition of serotonin 5-HT3 receptor
Dosage: 4mg IV/ODT for Adults and Children 6 and older
2mg IV/ODT children 2-6
1mg IV children 6 months-2 years
Indications: nausea and vomiting
Contraindications: allergies
Side effects: may prolong QT, headache

19. Paramedic Formulary Phenergan
Effects: reduces nausea and vomiting via dopamine receptor antagonism
Dosage: 25mg IM for adults only. Pediatric use not permitted
Indication: nausea and vomiting
Contraindication: sedation, allergy
Side Effects: respiratory depression, extrapyramidal symptoms (dystonic reaction), anxiety, hypotension

20. Paramedic Formulary Haldol
Effects: sedation and reduction of psychotic symptoms via dopamine receptor antagonism
Dosage: 2.5mg-5mg IM/2mg IV
Indication: acute psychosis, severe agitation, second line to maxing out your benzos for bath salts.
Contraindications: allergies, prolonged QT syndrome
Side Effects: sedation, Torades de Pointe, ventricular tachycardia, dystonia.

21. Paramedic Formulary Ketamine
Effect: produces dissociative state through limbic system interaction
Dosage: 1-2mg/kg IV or 3-4mg/kg IM
Indications: induction agent
Contraindications: Theoretical – increased ICP, increased IOP, allergy
Side effects: laryngospasm, emergence reactions, excessive drooling

22. Paramedic Formulary Paralytics (Rocuronium/Vecuronium)
Effect: inhibits release of acetylcholine at the neuromuscular junction causing paralysis
Dosage: Vecuronium: 0.1mg/kg IV
Rocuronium: 1mg/kg IV
Indications: paralytic agent for RSI
Contraindications: difficult airway, insuffient expertise in airway management
Adverse Reactions: death

23. Paramedic Formulary Solu-Medrol
Effects: corticosteroid - reduces inflammation and immunity through multiple messengers and interactions
Dosage: 1mg/kg IV, max 125mg IV
Indications: asthma, COPD, anaphylaxis
Contraindications: allergy
Side Effect: hyperglycemia, jitteriness, immunosuppression, renal impairment, GI bleeding

24. Paramedic Formulary Vasopressin
Effect: hormone – constricts blood vessels and improves cardiac contractility
Dosage; 40 units x1 dose in lieu of first epi for cardiac arrest.
Indications: cardiac arrest
Contraindications: none
Side effects: none in prehospital setting

25. Paramedic Formulary Lidocaine
Effects: Sodium Channel Blockade, inhibiting nerve conduction for pain, and delaying ventricular automaticity
Dosage: V-tach/V-fib – 1mg/kg IV x1
IO needle pain – flush IO tubing with lidocaine and push through with first normal saline flush
Indications – v-tach/v-fib, IO injection site pain
Contraindications: allergy
Side effects: complete heart block, ventricular arrest, seizures

26. Paramedic Formulary MARK I Kit
Effects: Reverses the effects of organophosphate poisons
Dosage : 1 kit, repeat in 5 min as needed
Contains: Atropine 1mg
2-PAM Chloride 600mg
Indications: organophosphate poisoning, WMD event
Contraindications: none in this setting
Side Effects: blurred vision, headache, dizziness, nausea, tachycardia

27. Paramedic Formulary Magnesium Sulfate
Effect: relaxes smooth muscles in bronchioles, uterus, stabilizes cardiac membranes
Dosage: 1-2 gm IV in adults over 20 minutes for asthma (medical control required), 1-2gm IV push for Torsades
Indications: severe asthma, Torsades, preterm labor
Contraindications: hypermagnesemia
Side Effects: paralysis, respiratory depression

28. Paramedic Formulary Amiodarone
Effect: Antiarrhythmic – multiple mechanisms
Dosage: 150mg IV for V-tach, 300mg IV for V-fib arrest
Indications: V-tach, V-fib
Contraindications: allergy, AV block, pregnancy, breastfeeding
Side Effects: lung fibrosis, AV block, Torsades with other QT prolonging medications

29. Paramedic Formulary Atropine
Effect: antagonizes muscarinic receptors in parasympathetic nervous system
Dosage: 0.5mg-1mg IV
Indication: Symptomatic Bradycardia
Contraindications: none
Side Effects: dry mouth, tachycardia, jitteryness

30. Paramedic Formulary Hydroxocobalamin
Effect: reverses cyanide toxicity by combining with cyanide to make Vitamin B12
Dosage:5gm IV
Indications: cyanide Toxicity
Contraindications: caution for hemodialysis patients
Side Effects: none

31. Paramedic Formulary Tetracaine
Effect: anaesthetizes eye nerve ending through sodium channel blockade
Dosage: 1-2 gtts per eye, repeat PRN
Indications: eye trauma
Contraindications: allergy to agent, open globe
Side Effects: increasing tearing. Burning

32. Paramedic Formulary Adenosine Effects: AV nodal blocking agent
Dosage: mg/kg up to 6mg IV RAPID push, max 12mg
Indications: SVT
Contraindications: wide complex tachycardia with abberancy, WPW
Side Effect: asystole (short lived), increased HR with WPW.