2CaseDuring 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*!...
3Pharmacology TermsGeneric 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 bodyPharmacokinetics – how it is absorbed, distributed, and eliminated from the bodyDosage/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
4Drug MetabolismTherapeutic levels – range of serum levels in which drug will have its predicted valueLD50 – level at which drug will kill 50% of the patients given the drugMetabolism – how the body transforms the drug to make it inert and ready for removalExcretion – how the drug exits the bodyLiver/fecalKidney/urineCombination
5The Six Rights Right Drug Right Patient Right Dose Right Time Think Mass Casualty situationsRight DoseHave a reference handyRight TimeRight RouteRight DocumentationTime, who gave it, what happened!!
6How 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 wayUsually by a second messenger systemThe structure of the receptor is such that it can be stimulated, overstimulated, or blocked from acting.The second messengers cause the production of enzymes
7How does a drug work? Stimulate a receptor Block a receptor epinephrine, dopamine, Narcotics, Benzos, succinylcholine, albuterolBlock a receptorlidocaine, aspirin, Narcan, Vecuronium, atropine, adenosine, amiodarone, diphenhydramineDirectly effect body chemistry/osmolarityelectrolytes, bicarb, NaCl, mannitolAct as an enzyme or catalysttPA, thiamine, cyanocobalaminBlock an enzymeAct as substrate for a chemical reactionMucomyst, nitroglycerin, oxygen, glucoseKill Bugs - antibiotics
9Other Nervous System Receptors GABACauses a decrease in neuronal activityOpioidBlock pain reception in the spinal cordCauses euphoria (mu receptor)AcetylcholineAllows for transmission of nerve impulse to a muscle group – contracts muscleDopaminePoorly understood, neuronal signaling and cognition
10The EMT formulary Aspirin (Ecotrin, Bayer) Action: Thromboxane A2 inhibitor, causes platelet function inhibitionDosage: 324mg oral chewedIndications: Cardiac chest painContraindications: Allergy, GI bleedingSide Effects – bleeding, GI upset
11EMT FormularyNitroglycerin (EMT can assist patient with his/her own, AEMT and medic can give without prior Rx)Effect: vasodilator, chest pain relieverDosage: 0.4mg sublingual Q 15 min x3Indications: chest painContraindications: hypotension, allergySide Effects: Headache, hypotension, syncope, cardiac arrest
12EMT 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 3Indications: Asthma or COPD exacerbationsContraindications: noneSide Effects: jitteriness, tachycardia, arrhythmia, sweating, anxiety
13EMT formulary Epinephrine (EpiPen, EpiPen Jr) Effect: A1, A2, B1, B2 receptor agonist – vasocontricts, relaxes bronchiole smooth muscle, increases heart rateDosage: EMTs: EpiPen (0.3ml) or EpiPen Jr (0.15ml)Dosage: AEMTs: 0.3ml 1:1000 IM, or 0.15ml for 15-30kgDosage: Medics: as above, or mg iv 1:10,000 for anaphylaxis, 0.1mg/kg, max 1mg IV Q5 min for arrestIndications: Anaphylaxis, severe asthma (medical control), cardiac arrestContraindications – noneSide Effects: arrhythmia, hypertension, MI, jitteriness
14EMT FormularyOxygenEffects: acts as a metabolic substrate for respiration, energy productionDosage: 2-15lpm via NC (max 6lpm), or oxymaskIndications: hypoxia, respiratory distress, stroke like syndromesContraindications: open flameSide Effects: hyperoxia indicated in free radical formation and increased cell damage.
15AEMT formulary (State Mandated) Dextrose/GlucagonReviewed in Diabetic Emergencies LectureDiphenhydramine (Benadryl)Reviewed in Anaphylaxis LectureNaltrexone (Narcan)Effects: opioid receptor antagonistDosage: 0.4mg IV Q5 min until desired effect, max 2mgIndications: altered mental status, narcotic ODContraindications: alert patientSide Effects: pain, agitation, vomiting, injury to EMT if patient not restrained.
16AEMT formulary Benzodiazepines (diazepam/Valium; medazolam/Versed) Effects: GABA receptor agonist – increase seizure threshold, sedating effectsDosage: Valium (long acting) .1-.2mg/kg IV, IM or PR (gel) max 5-10mg x1 doseVersed (medium acting) mg/kg max 4mg x1Indications :Seizures, acute severe agitation, bath saltsContraindications: respiratory depression, sedation, high risk airway, allergySide Effects: miosis, respiratory depression, need for intubation
17AEMT formulary Narcotics (morphine; fentanyl) Effects: opioid agonist – provides pain reliefDosage: Morphine 0.1mg/kg IV/IM max 10mg for painFentanyl – mcg/kg iV max 50mcg x1 SLOWMedical control for any further dosingIndications: acute traumatic pain, cardiac pain (morphine only)Contraindications: abdominal pain, allergy, respiratory depression or altered mental statusSide Effects: Chest Wall Rigidity syndrome, respiratory depression, hypotension
18Paramedic Formulary Zofran Effect: Reduction of nausea through inhibition of serotonin 5-HT3 receptorDosage: 4mg IV/ODT for Adults and Children 6 and older2mg IV/ODT children 2-61mg IV children 6 months-2 yearsIndications: nausea and vomitingContraindications: allergiesSide effects: may prolong QT, headache
19Paramedic Formulary Phenergan Effects: reduces nausea and vomiting via dopamine receptor antagonismDosage: 25mg IM for adults only. Pediatric use not permittedIndication: nausea and vomitingContraindication: sedation, allergySide Effects: respiratory depression, extrapyramidal symptoms (dystonic reaction), anxiety, hypotension
20Paramedic Formulary Haldol Effects: sedation and reduction of psychotic symptoms via dopamine receptor antagonismDosage: 2.5mg-5mg IM/2mg IVIndication: acute psychosis, severe agitation, second line to maxing out your benzos for bath salts.Contraindications: allergies, prolonged QT syndromeSide Effects: sedation, Torades de Pointe, ventricular tachycardia, dystonia.
21Paramedic Formulary Ketamine Effect: produces dissociative state through limbic system interactionDosage: 1-2mg/kg IV or 3-4mg/kg IMIndications: induction agentContraindications: Theoretical – increased ICP, increased IOP, allergySide effects: laryngospasm, emergence reactions, excessive drooling
22Paramedic Formulary Paralytics (Rocuronium/Vecuronium) Effect: inhibits release of acetylcholine at the neuromuscular junction causing paralysisDosage: Vecuronium: 0.1mg/kg IVRocuronium: 1mg/kg IVIndications: paralytic agent for RSIContraindications: difficult airway, insuffient expertise in airway managementAdverse Reactions: death
23Paramedic Formulary Solu-Medrol Effects: corticosteroid - reduces inflammation and immunity through multiple messengers and interactionsDosage: 1mg/kg IV, max 125mg IVIndications: asthma, COPD, anaphylaxisContraindications: allergySide Effect: hyperglycemia, jitteriness, immunosuppression, renal impairment, GI bleeding
24Paramedic Formulary Vasopressin Effect: hormone – constricts blood vessels and improves cardiac contractilityDosage; 40 units x1 dose in lieu of first epi for cardiac arrest.Indications: cardiac arrestContraindications: noneSide effects: none in prehospital setting
25Paramedic Formulary Lidocaine Effects: Sodium Channel Blockade, inhibiting nerve conduction for pain, and delaying ventricular automaticityDosage: V-tach/V-fib – 1mg/kg IV x1IO needle pain – flush IO tubing with lidocaine and push through with first normal saline flushIndications – v-tach/v-fib, IO injection site painContraindications: allergySide effects: complete heart block, ventricular arrest, seizures
26Paramedic Formulary MARK I Kit Effects: Reverses the effects of organophosphate poisonsDosage : 1 kit, repeat in 5 min as neededContains: Atropine 1mg2-PAM Chloride 600mgIndications: organophosphate poisoning, WMD eventContraindications: none in this settingSide Effects: blurred vision, headache, dizziness, nausea, tachycardia
27Paramedic Formulary Magnesium Sulfate Effect: relaxes smooth muscles in bronchioles, uterus, stabilizes cardiac membranesDosage: 1-2 gm IV in adults over 20 minutes for asthma (medical control required), 1-2gm IV push for TorsadesIndications: severe asthma, Torsades, preterm laborContraindications: hypermagnesemiaSide Effects: paralysis, respiratory depression
28Paramedic Formulary Amiodarone Effect: Antiarrhythmic – multiple mechanismsDosage: 150mg IV for V-tach, 300mg IV for V-fib arrestIndications: V-tach, V-fibContraindications: allergy, AV block, pregnancy, breastfeedingSide Effects: lung fibrosis, AV block, Torsades with other QT prolonging medications
30Paramedic Formulary Hydroxocobalamin Effect: reverses cyanide toxicity by combining with cyanide to make Vitamin B12Dosage:5gm IVIndications: cyanide ToxicityContraindications: caution for hemodialysis patientsSide Effects: none
31Paramedic Formulary Tetracaine Effect: anaesthetizes eye nerve ending through sodium channel blockadeDosage: 1-2 gtts per eye, repeat PRNIndications: eye traumaContraindications: allergy to agent, open globeSide Effects: increasing tearing. Burning
32Paramedic Formulary Adenosine Effects: AV nodal blocking agent Dosage: mg/kg up to 6mg IV RAPID push, max 12mgIndications: SVTContraindications: wide complex tachycardia with abberancy, WPWSide Effect: asystole (short lived), increased HR with WPW.