Emergency Medications

Emergency Medications
Chapter 12 Emergency Medications 1

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.

Emergency Medications Names Effects Indications Routes of administration Dosages for the medications administered

Emergency Medications (cont’d) Actions Contraindications Complications Side Effects Interactions

Introduction Paramedics must have a comprehensive understanding of all medications they might administer. Pharmacology is one of the more difficult subjects to master. 5

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 6

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. 7

AHA Classification of Recommendations and Level of Evidence
A treatment should be administered. Class IIa It is reasonable to administer treatment. Class IIb Treatment may be considered. 8

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 9

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 10

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. 11

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. 12

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 13

Radio Communications Become familiar with terminology related to medications and medication administration. Be familiar with common medical abbreviations. 14

Radio Communications 15

Radio Communications 16

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 17

Medication Listings Name of medication Class And other common names
How the medication is classified compared to other medications 18

Medication Listings Mechanism of action Indications Contraindications
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 19

Medication Listings Adverse reaction/side effects Drug interactions
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 20

Medication Listings How supplied Dosage and administration
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 21

Medication Listings Duration of action Special considerations Onset
Peak effect Duration Special considerations 22

Activated Charcoal (EZ-Char, Actidose, Liqui-Char)
Mechanism of action Absorbs toxic substances from the gastrointestinal tract Indications Most oral poisonings/ medication overdoses Contraindications Oral administration to comatose patients Adverse reactions If aspirated, can induce fatal form of pneumonitis Bowel obstruction Considerations Mix contents well before administration. Does not absorb cyanide, lithium, iron, lead, or arsenic 23

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 24

Albuterol (Proventil, Ventolin)
Mechanism of action Results in smooth-muscle 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 25

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. 26

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. 27

Amyl Nitrite Mechanism of action Indications Contraindications
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 28

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 29

Atenolol (Tenormin) Mechanism of action Indications Contraindications
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 30

Atropine Sulfate Mechanism of action Indications Contraindications
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. 31

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 32

Bumetanide (Bumex) Mechanism of action Indications Contraindications
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 33

Calcium Chloride Mechanism of action Indications Contraindications
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. 34

Calcium Gluconate Mechanism of action Indications Contraindications
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 35

Clopidogrel (Plavix) Mechanism of action Indications Contraindications
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 36

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. 37

Dextrose Mechanism of action Indications Contraindications
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 38

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. 39

Digoxin (Lanoxin) Mechanism of action Indications Contraindications
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 40

Diltiazem (Cardizem) Mechanism of action Indications Contraindications
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. 41

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 42

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. 43

Dolasetron (Anzemet) Mechanism of action Indications Contraindications
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 chemotherapy-induced nausea and vomiting. 44

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 dose-dependent 45

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 46

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. 47

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 48

Etomidate (Amidate) Mechanism of action Indications Contraindications
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. 49

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 high-dose rapid infusion 50

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, seizure-prone patients Adverse reactions Seizures, dizziness, agitation, confusion, headache, visual disturbances Considerations Pregnancy safety: Category C Not recommended in combined drug overdoses 51

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 third-degree 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. 52

Furosemide (Lasix) Mechanism of action Indications Contraindications
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. 53

Glucagon (GlucaGen) Mechanism of action Indications Contraindications
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 54

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 55

Heparin Sodium Mechanism of action Indications Contraindications
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. 56

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 57

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. 58

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 59

Insulin Mechanism of action Indications Contraindications
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. 60

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. 61

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, dose-related tachycardia, palpitations Considerations None 62

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. 63

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. 64

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. 65

Lidocaine Hydrochloride (Xylocaine)
Mechanism of action Decreases automaticity Indications Alternative to amiodarone in cardiac arrest from ventricular tachycardia Contraindications Hypersensitivity, second- or third-degree 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. 66

Lorazepam (Ativan) Mechanism of action Indications Contraindications
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. 67

Magnesium Sulfate Mechanism of action Indications Contraindications
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 68

Mannitol (Osmitrol) Mechanism of action Indications Contraindications
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. 69

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 70

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. 71

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 72

Metoprolol Tartrate (Lopressor)
Mechanism of action Decreases heart rate Indications PSVT, atrial flutter, atrial fibrillation Contraindications Heart failure, second- or third-degree AV block Adverse reactions Weakness, dizziness, depression, bronchospasm Considerations Pregnancy safety: Category C Metoprolol must be given slow IV over 5 minutes 73

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. 74

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. 75

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. 76

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 77

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 78

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 79

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 80

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. 81

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 82

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 83

Oral Glucose (Insta-Glucose)
Mechanism of action Provides an increase in circulating blood glucose levels Indications Conscious patients with suspected hypoglycemia Contraindications Decreased level of consciousness, nausea, vomiting Adverse reactions Nausea, vomiting Considerations Must be swallowed. Glucose is not absorbed sublingually or buccally. 84

Oxygen Mechanism of action Indications Contraindications
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. 85

Oxytocin (Pitocin) Mechanism of action Indications Contraindications
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. 86

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. 87

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. 88

Phenytoin (Dilantin) Mechanism of action Indications Contraindications
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. 89

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 90

Procainamide Hydrochloride (Pronestyl)
Mechanism of action Suppresses intraventricular conduction Indications Stable monomorphic ventricular tachycardia with normal QT interval Contraindications Torsades de pointes, second- and third- degree heart atrioventricular block Adverse reactions Confusion, seizures, hypotension, bradycardia Considerations Pregnancy safety: Category C Potent vasodilation and negative inotropic effects 91

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 92

Propofol (Diprivan) Mechanism of action Indications Contraindications
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. 93

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 third-degree 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. 94

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. 95

Sodium Bicarbonate Mechanism of action Indications Contraindications
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 96

Sodium Nitrate Mechanism of action Indications Contraindications
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 97

Sodium Thiosulfate Mechanism of action Indications Contraindications
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 98

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 99

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. 100

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. 101

Thiamine (Betaxin) Mechanism of action Indications Contraindications
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. 102

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 103

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 104

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. 105

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. 106

IV Solutions (Colloids and Crystalloids)
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 107

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. 108

Dextran Mechanism of action Indications Contraindications
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. 109

Hetastarch (Hespan) Mechanism of action Indications Contraindications
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. 110

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 111

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 112

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 113

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 114

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 115

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 116

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 117

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 118

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. 119

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. 120

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.

Emergency Medications

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Emergency Medications

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