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More drug cards
2014-03-13 21:08:57
Paramedic Drug

Paramedic Drug cards
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  1. Calcium Chloride
    • Class: Electrolyte (anion)
    • Mechanism of Action: Increases cardiac contractile state (positive inotropic effect). May enhance ventricular automaticity
    • Indications: Hypocalcemia, hyerkalemia, hypermagnesemia, beta blocker and calcium channel blocker toxicity
    • Contraindications:  Hypercalcemia, V-Fib, Digitalis toxicity
    • Adverse reactions/Side Effects: Syncope, cardiac arrest, dysrhythmia, bradycardia, hypotension, asystole, peripheral vasodilation, nausea, vomiting, metallic taste, tissue necrosis at injection site, coronary and cerebral artery spasm
    • Drug Interactions: May worsen dysrhythmias secondary to digitalis toxicity.  may antagoinze the effects of calcium channel blockers.  Do not mix or infuse immediately before or after sodium bicarbonate without intervening flush
    • How Supplied: 10% solution in 10 mL (100mg/mL) ampules, vials, and prefilled syringes
    • Dosage and Administration:  Adult: Ca+ channel bloker overdose and hyperkalemia: 500mg to 1,000mg (5-10mL of 10% solution) IV push, may repeat as needed.  Peds:  Ca+ channel blocker overdose and hyperkalemia: 20mg/kg (0.2ml/kg) slow IV/IO push.  Max 1g dose, may repeat in 10 mins
    • Duration of Action:  Onset: 1-3 mins  Peak Effect: variable  Duration: 20-30 mins, but may persist for 4 hours (dose dependent)
    • Special Considerations:  Pregnancy Safety: Category C.  Do not use routinely in cardiac arrest.  comparable dose of 10% calcium gluconate is 15-30mL.  Central venous administration is preferred route in peds if available
  2. Digoxin (Lanoxin)
    • Class: Inotropic agent, cardiac glycoside
    • Mechanism of Action: Rapid-acting cardiac glycoside with direct and indirect effects: Increase force of myocardial contraction, increase refractory period of AV node, and increase total peripheral resistance
    • Indications: Congestive heart failure, re-entry SVT, ventricular rate control in atrial flutter and atrial fibrillation
    • Contraindications: V-Fib, V-tach, digitalis toxicity, hypersensitivity to digoxin
    • Adverse reactions/Side Effects: Fatigue, HA, blurred yellow or green vision, seizures, confusion, bradycardia, dysrhythmia, N/V, anorexia, skin rash
    • Drug Interactions: Amiodarone, verapamil, and quinidine may increase serum digoxin concentrations by 50-70%.  Concurrent use of digoxin and verapamil may lead to severe heart block.  Diuretics may potentiate cardiac toxicity
    • How Supplied: 0.25 mg/mL vials
    • Dosage and administration: Adult: Loading dose 4-6 mcg/kg over 5 mins, 2nd and 3rd boluses of 2-3 mcg/kg to follow at 4-8 hr intervals.  Peds: Not recommeneded
    • Duration of Action:  Onset: 5-30 mins, Peak Effect: 30-120, Duration: Several days
    • Special Considerations: Pregnancy Safety: Category C.  Patient recieving IV digoxin must be on a monitor.  Patients with known renal failure are prone to developing digitalis toxcitiy.  Hypokalemia, hypomagnesemia, and hypercalcemia potentiate digitalis toxicity.  Use carefully in patients with WPW
  3. Norepinephrine Bitartrate (Levophed)
    • Class: Sympathomimetic, vasopressor
    • Mechanism of Action: Potent alpha-agonist resulting in intense peripheral vasoconstriction, positive chronotropic and increased inotropic effect (from 10% beta effect) with increased cardiac output.  Alpha-adrenergic acticity resulting inperipheral vasoconstriction and beta-adrenergic activity leading to inotropic stimulation of the heart and coronary artery vasodilation
    • Indications: Cardiogenic shock, unresponsive to fluid resuscitation, significant hypotension (less the 70)
    • Contraindications: Hypotensive patients with hypovolemia, pregnancy (relative)
    • Adverse reactions/Side Effects: HA, anxiety, dizziness, restlessness, dyspnea, braycardia, hypertension, dysrhythmias, chest pain, peripheral cyanosis, cardiac arrest, N/V, urniary retention, renal failure, decreased blood flow to the GI tract, kidneys, skeletal muscle, and skin, tissue necrosis from extravasation
    • Drug Interactions: Can be deactivated by alkaline solutions,  Sympathomimetic and phosphodiesterase inhibitors may exacerbate dysrhythmias.  Bretylium may potentiate the effects of catecholamines
    • How Supplied: 1 mg/mL vials
    • Dosage and administration: Adult: Dilute 8mg in 500mL of D5W or 4mg in 250mL of D5w (16mcg/mL).  Infuse by IV piggyback at 0.1-0.5 mcg/kg/min titrated to response (average dose for 70 kg pt 7-35 mcg/min)  Peds: Begin at 0.1-2 mcg/kg/min IV infusion, adjust rate to achieve desired change in blood pressure and systemic perfusion. Titrated to pt response.
    • Duration of Action:  Onset: 1-3 min, Peak Effect: Variable, Duration: 5-10 mins and lasts only 1 min after infusion is discontinued
    • Special Considerations: Pregnancy Safety: Category C. May cause fetal anoxia when used in pregnancy.  infuse norepi through large, stable vein to avoid extravasation and tissue necrosis.  Often used with low-dose dopamine to spare decreased renal and mesenteric blood flow.  Drug or poison-induced hypotension may require higher doses to achieve adequate perfusion.
  4. Insulin
    • Class: Antidiabetic, hormone
    • Mechanism of Action: Allows glucose transport into cells of all tissues, converts glycogen to fat, produces intracellular shift of K+ and Mg to reduce elevated serum levels of these electroyltes
    • Indications: Not used in emergency prehospital setting.  DKA or other hyperglycemic state, hyperkalemia (insulin and D50 used together), nonketotic hyperosmolar coma
    • Contraindications: Hypoglycemia, hyperkalemia
    • Adverse Reactions/Side Effects:  Weakness, fatigue, confusion, HA, seizure, coma, tachycardia, nausea, hypokalemia, hypoglycemia, diaphoresis, itching, swelling, redness
    • Drug Interactions: Incompatible in solutions with all other drugs.  corticosteroids, dobutaminie, epi, and thiazide diuretics decrease the hypoglycemic effects of insulin. Alcohol and salicylates may potentiate the effects of insulin
    • How Supplied:  30-70 units/mL vials
    • Dosage and Administration:  Adjust to gluc level.  STANDARD DOSE FOR DIABETIC COMA: Adult:  10-25 units SC/IM/IV followed by infusion of 0.1 unit/kg/hr  Peds: 0.1-0.2 unit/kg/hr SC/Im/IV followed by an infusion of 50 units/250mL (0.2 unit/mL, at a rate of 0.1-0.2 unit/kg/hr
    • Duration of Action:  Onset:  Minutes.  Peak Effect:  Approx 1 hr (short acting), 3-6 hr (intermediate), 5-8 hr (long acting,  Duration:  6-8 hr (short acting), 24 hrs (intermediate)  36 hrs (long acting)
    • Special Consideration: Pregnancy Safety Category B:  Insulin is the frug of choice for control of diabetes in prenancy.  Usually requires refrideration.  Most rapid absorption if injected in abdominal wall, next most rapid absorption if injected in the arm, slowest absorption if injected into the thigh.
  5. Glucagon (GlucaGen)
    • Class:  Hyperglycemic agent, pancreatic hormone, insulin antagonist
    • Mechanism of Action:  Increases blood glucose levels by stimulating glycogensis.  Unknown mechanism of stabilizing cardiac rhythm in beta blocker overdose.  Minimal positive inotropic and chronotropic response.  Decrease gastrointestinal motility and secretions
    • Indications;  Altered LOC when hypoglycemia is suspected.  May be used as a reversal agent in beta blocker and calcium channel blocker overdoses.
    • Contrainidcations:  Hyperglycemia, hypersensitivy
    • Adverse reactions/Side Effects:  Dizziness, HA, hypertension, tachycardia, N/V, rebound hypoglycemia
    • Drug Interactions: Incompatible in solution with most other substances. No significant drug interactions with other emergency meds
    • How supllied:  1mg powder in vials (requires reconstitution with diluent provided)
    • Dosage and administration:  Adult:  Hypoglycemia 0.5-1mg IM, may repeat in 7-10 min.  Calcium channel blocker/ beta blocker overdose: 3-10mg IV slowly over 3-5 mins initially; followed by a 3-5mg/hr infusion as needed.  Peds: Hypoglycemia 0.03-0.1 mg/kg IM/IO/SQ/ slow IV may repeat in 20 mins.  Max dose 1mg.  Calcium Channel/beta blocker overdose: 0.05-0.15 mg/kg IV/IO over 3-5 mins initially, followed by a 0.05-0.1 mg/kg/hr infusion as necessary
    • Duration of Action:  Onset: 1 min, Peak Effect: 5-20 mins, Duration: 60-90 mins
    • Special Considerations:  Pregnancy Category B.  Ineffective if glycogen stores depleted.  Should always be used in conjunction with D50 whenever possible.  If patient does not respond to 2nd dose to glucagon, D50 must be used.
  6. Lorazepam (Ativan)
    • Class:  Benzodiazepine, short/intermediate acting sedative, anticonvulsant, schedule IV drug
    • Mechanism of Action:  Anxiolytic, Anticonvulsant, and sedative effect, suppresses propagation of seizure activity produced by foci in cortex, thalamus, and limbic areas
    • Indications:  Initial control of status epilepticus or severe recurrent seizures, severe anxiety, sedation
    • Contraindication:  Acute narrow angel glaucoma, coma, shock, suspected drug abuse
    • Adverse reactions/ Side Effects:  Dizziness, drowsiness, CNS depression, HA, sedation, resp depression, apnea, hypotension, braycardia
    • Drug interactions:  May precipitate CNS depression if already taking CNS depressant meds
    • How supplied:  2 and 4 mg/mL vials and tubex syringes
    • Dosage and Administration:  Note: When given IV/IO, must  be diluted with equal volume of sterile water or saline.  When given IM dont dilute  Adult:  2-4 mg slow IM/IV at 2 mg/min, may be repeated in 15-20 mins.  Max dose of 8 mg.  For sedation 0.05 mg/kg up to 4 mg IM.  Peds: 0.05-0.2 mg/kg slow IV/IO/IM over 2 mins.  May be repeated once in 5-20 min.  Max does of 0.2 mg/kg
    • Duration of Action:  Onset: 1-5 mins. Peak Effect:  Variable.  Duration:  6-8 hrs
    • Special Consideration:  Pregnancy Category D.  Monitor resp rate and blood pressure during administration.   Have advanced airway equipment readily available.  Inadvertent arterial injection may result in vasospasm and gangrene.  Lorazepam expires in 6 weeks when not refridgerated.
  7. Dexamethasone Sodium Phosphate (Decadron)
    • Class:  Corticosteroid, adrenal glucocorticoid
    • Mechanism of Action:  Suppresses acute and chronic inflammation, immunosuppressive effects
    • Indications:  Anaphylaxis, asthma, spinal cord injury, croup, elevated ICP (prevention and treatment), as an adjunct in the treatment of shock
    • Contraindications:  Hypersensitivty, use caution is suspected sepsis
    • Adverse Reactions/Side Effects:  HA, restlessness, euphoria, psychoses, pulmonary TB, hypertension, peptic ulcer, N/V, GI bleeding, edema, hyperglycemia, immunosuppresion, sodium water retention.  None from single dose
    • Drug Interactions:  Calcium, metaraminol
    • How supplied:  100mg/5mL vials or 20mg/1mL vials
    • Dosage and Administration:  Adult:10-100 mg IV (1mg/kg slow IV bolus). Considerable variance through medical control. Peds: 0.25-1.0 mg/kg IV/IO/IM.  Given one tie with max dose of 16 mg
    • Duration of Action:  Onset: Hours    Peak Effect:  8-12 hrs      Duration:  24-72 hrs
    • Special Consideration:  Pregnancy safety category C.  Protect meds from heat.  Toxicity and side effects with long-term use.
  8. Diazepam (Valium and others)
    • Class: Benzodiazepine, long-acting, sedative-hypontic, anticonvuslant, schedule IV drug
    • Mechanism of Action:  Potentiates effects of inhibitory neurotransmitters.   Raises the seizure threshold.  Induces amnesia and sedation
    • Indications:  Acute anxiety states, and agitation, acute alcohol withdrawl, muscle relaxant, seizure activity, sedation for medical procedures (eg intubation,  ventilated oatients, cardioversion), may be helpful in acute symptomatic cocaine overdose 
    • Contraindications:  Hypersensitivty, narrow-angle glaucoma, mysathenia gravis, resp insufficiency, coma, head injury
    • Adverse Reactions/Side Effects: Dizziness, drowsiness, confusion, HA, resp depression, hypotension, reflex tachycardia, N/V, muscle weakness, tissue necrosis, ataxia, thromosis, phlebitis
    • Drug Interactions:  Incompatible with most drugs, fluids
    • How supplied:  5mg/mL prefilled syringes, ampules, vials, and tubex syringes
    • Dosage and Administration:  Adult:  Seizure activity: 5-10 mg IV every 10-15 mins PRN (5mg over 5 mins (max dose of 30mg).  Premedication for cardioversion: 5-15 mg IV over 5-10 min.  Peds:  Seizure activity: 0.2-0.5 mg/kg slow IV every 2-5 mins up to 5mg (max dose of 10mg/kg)  Rectal diazepam: 0.5mg/kg via 2" rectal catheter and flush with 2-3mL air after administration
    • Duration of action:  Onset: 1-5 min    Peak Effect: 15 mins    Duration: 20-50 mins
    • Special Considerations:  Pregnancy safety category D.  Short acting for anticonvulsant effect.  Reduce dose by 50% in elderly patients
  9. Dobutamine Hydrochloride (Dobutrex)
    • Class:  Symathomimetic, inotropic agent
    • Mechanism of Action: Synthetic catecholamine.  Increased myocardial contractility, stroke volume, and increased cardiac output.  Minimal chronotropic activity.  Increases renal blood flow.  
    • Indications: Cardiogenic shock, CHF, left ventricular dysfunction, often used in conjunction with other drugs
    • Contraindications: Tachydysrhythmias, severe hypotension, idiopathic hypertrophic subaortic stenosis (IHSS), suspected or known poison/drug induced shock
    • Adverse reactions/Side effects: HA, dyspnea, tachycardia, hypertension, chest pain, dysrhythmias, PVC's, N/V
    • Drug interactions:  Incompatible with sodium bicarb and furosemide.   Beta blockers may blunt inotropic efects
    • How supplied: 12.5mg/mL vials. 250mg/250mL D5W (1000mcg/mL)
    • Dosage and administration: ADULT: IV infusion at 2-20 mcg/kg/min titrated to desired effect.  Max dose of 40mcg/kg/min.  Peds:  IV infusion at 2-20 mcg/kg/min titrated to desired effects
    • Duration of action: Onset:  2 mins   Peak Effect: 10mins    Duration:1-2 min after being discontinued
    • Special Considerations: Pregnancy safety: Category B.  Monitor blood pressure closely.  Titrate dose to maintain a HR increase of no greater than 10% of baseline.  May increase infarct size in patients with MI.  Elderly patients may have a significantly decreased response
  10. Naloxone Hydrochloride (Narcan)
    • Class: Opioid antagonist
    • Mechanism of Action: Competitive inhibition at narcotic receptor sites.  Reverses resp depression secondary to opiate drugs.  Completely inhibits the effects of morphine.  
    • Indications:  Opiate overdose, complete or partial reversal of CNS and resp depression induced by opioids, decreased LOC, coma of unknown origin.  narcotic agonist for the following, morphine, heroin, dilaudid, methadone, demerol, paregoric, fentanyl, oxycodone, codeine, darvon.  Narcotic, agonist and antagonist for the following: stadol, talwin, nubain
    • Contraindications:  Use with caution in narcotic-dependent pts.  Use with caution in neonates of narcotic-addicted mothers.
    • Adverse reactions/Side Effects:  Restlessness, seizures, dyspnea, pulmonary edema, tachycardia, hypertension, dysrhythmias, cardiac arrest, N/V, withdrawal symptoms in opioid-addicted pts, daiphoresis
    • Drug interactions:  Incompatible with bisulfite and alkaline solutions
    • How Supplied:  0.4mg/mL and 1mg/mL ampules and vials
    • Dosage and Administration:  ADULT: 0.4-2mg IM/IV/IO/SQ/ET; minimum single dose recommended 2mg.  Repeat at 5-min intervals to a max dose of 10mg.  PEDS:  0.1mg/kg/dose IV/IM/IO/SQ every 2 mins as needed, if no response in 10 mins give another dose of 0.1mg/kg/dose
    • Durations of Action: ONSET: less then 2mins      PEAK EFFECT: Variable      DURATION: 30-60mins
    • Special Considerations:  Preg safety category C.  Assist ventilations prior to administration to avoid sympathetic stimulation.  Seizures without causal relationship have been reported.  May not reverse hypotension.  Use caution when administration to narcotic addicts (potential violent behavior)  Half-life of narcan is often shorter the the half-life of narcotics; repeat dosing may be required
  11. Metaproterenol Sulfate (Alupent)
    • Class:  Beta-2 adrenergic agonist, bronchodilator
    • Mechanism of Action:  Acts directly on bronchial smooth muscle causing relaxation of the bronchial tree and peripheral vasculature
    • Indications: Bronchial asthma, reversible bronchospasm secondary to bronchitis, COPD
    • Contraindications: Tachydysrhythmia, hypersensitivity, tachycardia caused by digitalis toxicity
    • Adverse reactions/Side Effects:  Nervousness, tremor, HA, anxiety, cough, paradoxical bronchospam, hypertension, CP, tachydyrhythmias, palpitations, cardiac arrest, diarrhea, N/V, backache, skin reactions, sweating
    • Drug Interactions:  Other sympathomimetics may exacerbate cardiovascular effects.  MAOIs may potentiate hypotensive effects.  Beta blockers may antagonize metaproterenol.
    • How Supplied:  Metered-dose inhaler: 0.65/mg/spray (15-mL inhaler). Solution: 5% solution in bottles of 10 and 30 mL with calibrated dropper.  Alupent inhalation solution unit-dose vial 0.4% or 0.6%
    • Dosage and administration:  ADULT: MDI 2-3 inhalations every 3-4 hrs (2 min between inhalations).  Inhalation solution 5%:Via nebulizer 0.2-0.3 mL of a 5% solution diluted in 2.5mL saline.  PEDS: MDI:  Not recommended. Inhalation solution 5%: age 6-12 years: 0.1-0.2 mL of a 5% solution diluted in 3mL saline.
    • Duration of Action:  ONSET: 1 min after inhalation.    PEAK EFFECT: 45 min    DURATION: 3-6 hrs
    • Special Consideration:  Preg Safety category C.  Monitor for hypotension and tachycardia.  Use with caution in pts with coronary artery disease, seizures, hypertension, and diabetes mellitus
  12. Mannitol
  13. Streptokinase (Streptase)
    • Class: Thrombolytic
    • Mechanism of Action: Combines with plasminogen to produce an activator complex that converts free plasminogen to proteolytic enzyme, plasmin.  Plasmin degrades fibrin threads and fibrinogen, causing clot lysis.
    • Indications: Acute evolving MI, massive PE,arterial  thrombosis and embolism, to clear intraventricular cannula
    • Contraindications: Hypersensitivity, active bleeding, recent CVA, prolonged cardiopulmonary resuscitation, intracranial and intraspinal neoplasm, arteriovenous malformation, recent surgery or significant trauma (particularly head trauma),severe uncontrolled hypertension
    • Adverse Reactions/Side Effects: Intracranial hemorrhage, bronchospastic hemoptysis, ARDS, reperfusion dysrhythmias, hypotension, MI, GI bleeding, hematuria, ABD pain, bleeding from other sites, allergic reactions
    • Drug Interactions: Aspirin, heparin,and other  anticoagulants may increase risk of bleeding as well as improve outcome
    • How supplied:250,000, 750,000, and 1.5 milion unit powder (requires reconstitution before administration)
    • Dosage and Administration: NOTE: Reconstitute by slowly adding 5 mL of sodium chloride or D5W directing stream to side of vial instead of into powder.  Gently roll and tilt vial for reconstitution; dilute slowly to 45 mL total.  ADULT: 500,000-1.5 million IU diluted to 45 mL IV over 1 hr.  PEDS: Safety not established
    • Duration of Action: Onset: 10-20 mins (fibrinolysis, 10-20 mins; clot lysis, 60-90 mins)  Peak Effect: Variable     Duration of Action: 3-4 hrs (prolonged bleeding times up to 24 hrs)
  14. Sodium Bicarbonate
    • Class:  Systemic hydrogen ion buffer, alkalizing agent
    • Mechanism of Action:  Buffers metabolic acidosis and lactic acid buildup in the body caused by anaerobic metabolism secondary to severe hypoxia by reacting with hydrogen ions to form water and CO2
    • Indications:  Metabolic acidosis during cardiac arrest, tricyclic antidepressant, aspirin and phenobarbital overdose, hyperkalemia, crush injuries
    • Contraindications: Metabolic and resp alkalosis, hypokalemia, electrolyte imbalance due to severe vomiting and diarrhea
    • Adverse Reactions/Side Effects:  Hypernatremia, metabolic alkalosis, tissue sloughing, cellulitis, or necrosis at injection site, seizures, fluid retention, hypokalemia, electrolyte imbalances, tetany, sodium retention, peripheral edema
    • Drug Interactions:  Increases the effects of amphetamines.  Decreases the effects of benzos, tricyclic antidepressants.  May deactivate sympathomimetics (dopamine, epi, norepi)
    • How supplied:  1mEq/mL of an 8.4% solution in 10 and 50mL vials and prefilled syringe.  0.5 mEq/mL of a 4.2% solution in 2.5, 5 and 10 mL prefilled syringes
    • Dosage and Administration:  ADULT: 1mEq/kg slow IV/IO push may repeat at 0.5 mEq/kg every 10 mins.  PEDS: 1mEq/kg slow IV/IO push (dilute in small children to 4.2%)
    • Duration of Action: ONSET: Seconds   PEAK EFFECT: 1-2 mins   DURATION: 10 mins
    • Special Considerations: Preganacy Safety Category C.  Repeat as needed in tricyclic antidepressant overdose until QRS narrows.  Must be used in conjunction with effective ventilation and chest compressions in cardiac arrest  Avoid contact with other medications, may precipitate or inactivate them.  Always flush IV line well before and after injecting.  Use with caution in pts with CHF and renal disease due to high sodium concentration.  Monitor pt closely for signs and symptoms of fluid overload.
  15. Vasopressin (Pitressin)
    • Class:  Vasopressor
    • Mechanism of Action:  Stimulation of smooth muscle receptors.  Potent vasoconstrictor when given in high doses
    • Indications:  Alternative vasopressor to the first or second dose of epi in cardiac arrest, alternative to epi in asystole, PEA
    • Contraindications:  Use with caution in pts with coronary artery disease, epilepsy, or heart failure
    • Adverse Reactions/Side Effects:  Dizziness, HA, bronchial constriction, MI, CP, angina, cardiac dysrhythmia, decreased cardiac output, abd cramps, diarrhea, N/V, paleness, sweating
    • Drug interactions: None reported
    • How supplied:  20 units/mL vials
    • Dosage and Administration:  ADULT: 40 U one-time dose IV/IO to replace the first or second dose of epi in cardiac arrest.  0.02-0.04 U/min continuous.  PEDS: 0.4-1 unit/kg IV/IO to a max of 40 units to replace the first or second dose of epi
    • Duration of Action:  ONSET: Immediate    PEAK EFFECT: Variable     Duration: Variable
    • Special Considerations:  Pregnancy Safety Category C.  May increase peripheral vascular resistance and provoke cardiac ischemia and angina
  16. Verapamil Hydrochloride (Isoptin, Calan) 
    • Class: Calcium Channel Blocker
    • Mechanism of Action:  Slow calcium channel blocker that selectively blocks the transmembrane influx of calcium ions into arterial smooth muscles and myocardial cells.  Prolongs AV nodal refractory period.  Reduces systemic vascular resistance and selective vasodilation of peripheral arteries.  Dilates coronary arteries and arterioles.
    • Indications:  Paroxysmal supraventricular tachycardia, A-flutter, A-fib with RVR, re-entry SVT
    • Contraindications: WPW, Lown-Ganong-levine syndrome, 2nd or 3rd degree AV block (without functioning pacemaker), hypotension, cardiogenic shock, severe left ventricular dysfunction (ejection fraction less than 30%), wide complex tachycardias, children younger than 12 months of age, A-fib
    • Adverse Reactions/Side Effects: Dizziness, HA, pulmonary edema, sinus arrest, asystole, AV blocks, bradycardia, hypotension, N/V, constipation
    • Drug interactions: Increases the serum concentration of digoxin. Beta-adrenergic blockers may have additive negative inotropic and chronotropic effects.  Antihypertensives may potentiate hypotensive effects.
    • How supplied: 2.5mg/mL vials
    • Dosage and administration:  ADULT: 2.5-5 mg IV bolus over 2 min (3 mins in elderly) Repeat dose of 5-10 mg may be given every 15-30 mins to max dose of 20mg.  PEDS: 0.01-0.02 mg/kg/dose IV, IO push over 2 mins.  Repeat dose in 30 mins if not effective.  NOTE: not to be used in children younger than 12 months of age
    • Duration of Action: ONSET: 2-5 mins      PEAK: Variable     Duration: 30-60 mins
    • Special Considerations: Pregnancy Safety category C.  Closely monitor pts vital signs.  Be prepared to resuscitate.  Atrio-ventricular block or asystole may occur because of slowed atrio-ventricular condition
  17. Meperidine Hydrochloride (Demerol)
    • Class: Opioid analgesic, schedule II drug
    • Mechanism of Action: Synthetic opioid analgesic whose effects on the CNS and smooth muscle organs are similar to morphine, primarily acting as an analgesic and a sedative
    • Indications:  Analgesia for moderate to severe pain
    • Contraindications: Hypersensitivity, to narcotics, diarrhea caused by poisoning, MAIO use, during labor or delivery of a premature infant, undiagnosed abd pain or head injury
    • Adverse Reactions/Side Effects: Seizures, confusion, sedation, dysphoria, HA, hallucinations, increased ICP, resp depression, apnea, hypotension, orthostatic hypotension, syncope, bradycardia, dysrhythmias, N/V, constipation, sweating
    • Drug Interactions: Do not give concurrently with MAOIs (even with a dose in the last 14 days).  Exacerbation CNS depression when given with other CNS depressants.
    • How Supplied: 50mg/mL and 100mg/mL prefilled syringes and Tubex syringes. 
    • Dosage and Administration: ADULT: 50-100 mg IM, SC.  25-50 mg slow IV.  PEDS: 1-2 mg/kg/dose IV, IO, IM, SC
    • Duration of Action: ONSET: IM: 10-45 mins; IV: immediate     PEAK: 30-60 mins     DURATION: 2-4 hrs
    • Special Considerations: Pregnancy Safety Category C.  Use with caution in pts with asthma and COPD.  May aggravate seizures in pts with known compulsive disorders.  Naloxone should be readily available as an antagonist.
  18. Fentanyl Citrate (Sublimaze)
    • Class:  Opioid analgesic, schedule II narcotic
    • Mechanism of Action:  Binds to opiate receptors, producing analgesia and euphoria.  
    • Indications:  Pain management, anesthesia adjunct
    • Contraindications: Known hypersensitivity.  Use with caution in tramatic brain injury
    • Adverse reactions/Side Effects:  Confusion, paradoxical excitation, delirium, drowsiness, CNS depression, sedation, resp depression, apnea, dyspnea, dysrhythmias, bradycardia, tachycardia, hypotension, syncope, N/V, abd pain, dehydration, fatigue
    • Drug Interactions: Increased resp effects when given with other CNS depressants
    • How supplied:  50 mcg/mL ampules and Tubex syringes
    • Dosage and Administration:  ADULT: 50-100 mcg (1 mcg/kg) IM or IV, or IO slow push (over 1-2 mins) to a max of 150 mcg.  PEDS: 1-2 mcg/kg IM, IV, or slow IO push (over 1-2 mins).  The safety and efficacy in children younger that 2 years has not been established
    • Duration of Action:  ONSET:  1-3 mins   PEAK:3-5 mins      DURATION: 30-60 mins
    • Special Considerations:  Pregnancy safety category C.  Chest wall rigidity possible with a high dose rapid infusion.  A dose of 100 mcg of fentanyl citrate is equivalent to 10 mg of morphine or 75 mg or meperidine
  19. Clopidogrel (Plavix)
    • Class:  Thienopyridine antiplatelet
    • Mechanism of Action:  Inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa complex
    • Indications: STEMI, moderate to high risk NSTEMI, acute coronary syndrome, substitute for aspirin with pts unable to take aspirin
    • Contraindications: Active GI bleeding, intracranial hemorrhage, known hypersensitivty 
    • Adverse Reactions/Side Effects: severe neutropenia, thrombotic thrombocytopenic purpura (TTP), GI hemorrhage, cerebral hemorrhage, angioedema, Steven-Johnson syndrome, rash, flu-like symptoms
    • Drug Interactions: Should not be taken with proton pump inhibitors (omeprazole and similar drugs), use with caution with other anticoagulants
    • How Supplied: 75mg and 300mg tablets
    • Dosage and Administration:  ADULT: loading dose of 300-600mg PO.  PEDS: Not recommended 
    • Duration of Action:  ONSET: Rapid     PEAK: 1 hr     DURATION: 7-10 days
    • Special Considerations: Pregnancy Safety Category:B.  Often given with other anticoagulants in ACS and MI
  20. Nitropaste (Nitro-Bid Ointment)
    • Class: Vasodilator
    • Mechanism of Action: Smooth muscle relaxant acting on vasculature, bronchial, uterine, intestinal smooth muscle.  Dilation of arterioles and veins in the periphery.  Reduces preload and afterload, decreasing workload of the heart and thereby myocardial oxygen demand
    • Indications: Acute angina pectoris, CP associated with AMI, hypertension, CHF, pulmonary edema
    • Contraindications: Hypotension, hypovolemia, intracranial bleeding or head injury, previous administration of ED meds
    • Adverse Reactions/Side Effects: HA, dizziness, weakness, reflex tachycardia, syncope, hypotension, N/V, dry mouth, muscle twitching, diaphoresis 
    • Drug Interactions: Additive effects with other vasodilators
    • How Supplied: 20-60 g tubes of 2% nitro with measuring applicators. Transdermal units of varying doses
    • Dosage and Administration: ADULT: Paste- apply 1/2"-3/4" (1-2 cm), 15-30mg, cover with wrap and secure with tape.  MAX of 5" (75mg) per application.  Transdermal: Apply unit to intact skin (usually on chest wall).  PEDS: Not recommended
    • Duration of Action:  ONSET: 30 mins      PEAK: Variable       DURATION: 18-24 hrs
    • Special Considerations:  Pregnancy Safety category C. Not of great value in prehospital arena.  Wear gloves when applying paste.  Store paste in a cool place with tube tightly capped.  Erratic absorption rates quite common
  21. Midazolam Hydrochloride (Versed)
    • Class: Benzodiazepine, short/intermediate acting, schedule IV drug
    • Mechanism of Action: Reversibly interacts with gamma-amino butyric acid (GABA) receptors in CNS causing sedative, anxiolytic, amnesic and hypnotic effects
    • Indications: Sedation for medical procedures (intubation, ventilated pts, cardioversion)
    • Contraindications: Acute narrow angle glaucoma, shock, coma, alcohol intoxication, overdose, depressed vital signs, concomitant use with barbiturates, alcohol, narcotics, or other CNS depressants
    • Adverse Reactions/Side Effects: HA, somnolence (sleepiness), resp depression, resp arrest, apnea, hypotension, cardiac arrest, N/V, pain at injection site
    • Drug Interactions:  Should not be used in pts who have taken CNS depressants
    • How Supplied:  1mg/mL and 5mg/mL
    • Dosage and Administration:  ADULT: 2-2.5 mg slow IV (over 2-3 mins).  May be repeated to a max of 0.1mg/kg    PEDS: 0.1-0.3mg/kg IV/IO (max single dose 10mg)
    • Duration of Action:  ONSET: 1-3 mins (dose dependent)     PEAK: Variable     DURATION: 2-6 hrs (dose dependent)
    • Special Considerations:  Pregnancy Safety Category D.  Administer immediately prior to intubation procedure.  Requires continuos monitoring or resp and cardiac function.  Decrease dose by 50% in pts with hepatic and renal dysfunction
  22. Oral Glucose (Insta-Glucose)
    • Class: Hyperglycemic, carbohydrate
    • Mechanism of Action: After absorption in the GI tract, glucose is distributed to the tissues providing an increase in circulating blood glucose levels.
    • Indications: Conscious patients with suspected hypoglycemia
    • Contraindications: Decreased levels of consciousness, N/V
    • Adverse Reactions/Side Effects: N/V
    • Drug Interactions: NONE
    • How Supplied: Paste and gels in various forms
    • Dosage and Administration: ADULT: 15-45 g PO in pts with an intact gag reflex and the ability to manage their own secretions.  PEDS:5-45 g PO in pts with an intact gag reflex and the ability to manage their own secretions
    • Duration of Action: ONSET 10 mins        PEAK: Variable      DURATION: Variable
    • Special Consideration: Must be swallowed. Glucose is not absorbed sublingually or buccally.  Check a glucometer reading before administering oral glucose and repeat at least 10 mins after
  23. Oxygen
    • Class: Naturally occurring atmospheric gas
    • Mechanism of Actions: Reverses hypoxemia
    • Indications: Confirmed or expected hypoxemia, ischemic chest pain, resp insufficiency, prophylactically during air transport, confirmed or suspected carbon monoxide poisoning, all other causes or decreased tissue oxygenation, decreased level or consciousness
    • Contraindications: Certain pts with COPD will not tolerate O2 concentrations over 35%. Hyperventilation
    • Adverse Reactions/Side Effects: Decreased LOC (COPD pts), decreased resp drive in COPD pts, dry mucus membranes
    • Drug Interactions: NONE
    • How Supplied: O2 cylinders (usually green and white) of 100% compressed O2 gas
    • Dosage and administration: ADULT: Cardiac arrest and CO poisoning: 100%, Hypoxemia: 10-15 L/min via NRB.  COPD: 0-2 L/min via nasal cannula or 28-35% Venturi mask. Be prepared to provide ventilatory support if higher concentrations of O2 are needed.  PEDS: Same as for adult with exception of premature infants
    • Duration of Action:  ONSET: Immediate      PEAK: Not applicable     DURATION: Less than 2 mins
    • Special Consideration: Be familiar with liter flow and each type of delivery device used.  Supports combustion.
  24. Oxytocin (Pitocin)
    • Class: Pituitary hormone
    • Mechanism of Action: Increases uterine contractions
    • Indications: Postpartum hemorrhage after infant and placental delivery
    • Contraindications: Presence of second fetus, unfavorable fetal position
    • Adverse Reactions/Side Effects: Coma, seizures, anxiety, subarachnoid hemorrhage, hypertension, tachycardia, dysrhythmias, CP, N/V, painful uterine contractions, uterine rupture
    • Drug Interactions: Other vasopressors may potentiate hypotension
    • How Supplied: 10 units/mL solution
    • Dosage and Administration: ADULT: IM administration: 10 units IM following delivery of the placenta.  IV administration: Mix 10-40 units in 1,000 mL of nonhydrating diluent.  Infused at 20-40 milliunits/min.  Titrated to severity of bleeding and uterine response.  PEDS: Not applicable
    • Duration of Action: ONSET: IM; 3-5 mins, IV; immediate        PEAK: Variable        DURATION: IM; 30-60 mins, IV; 20 mins after infusion is stopped
  25. Phenobarbital (Luminal)
    • Class: Barbiturate, long-acting, anticonvulsant, schedule IV drug
    • Mechanism of Action: Generally unknown but believed to reduce neuronal excitability by increasing the motor cortex threshold to electrical stimulation
    • Indications: Prevention and treatment of seizure activity, status epilepticus
    • Contraindications: Pts with porphyria, history of sedative or hypnotic addiction, severe liver or resp disease
    • Adverse Reactions/Side Effects: Coma, drowsiness, HA, vertigo, paradoxic excitation,  CNS depression, ataxia, bronchospasm, larygngospasm, resp depression, hypotension, bradycardia, syncope, N/V
    • Drug Interactions: Effects potentiated by other CNS depressants, anticonvulsants, and MAOI's. Incompatible with all other drugs.  Flush line before and after use
    • How Supplied: 30 mg/mL, 60 mg/mL, 65 mg/mL, 130 mg/mL, ampules and vials and Tubex syringes
    • Dosage and Administration: ADULT: 100-250 mg slow IV or IM.  May repeat as needed in 20-30 mins.  PEDS: 10-20 mg/kg slow IV/IO/IM.  Repeat as needed in 20-30 mins
    • Duration of Action: ONSET: 3-30 mins      PEAK: 30 mins     DURATION: 4-6 hrs
    • Special Consideration:  Pregnancy Safety Category D.  Potential for abuse.  Carefully monitor vital signs.  Use with caution in pts with pulmonary, cardiovascular, hepatic, or renal insufficiency.  Elderly more likely to experience side effects, consider decreasing dose to 75% of the usual dose.  Use large, stable vein for injection.
  26. Procainamide Hydrochloride (Pronestyl)
    • Class:Antidysrrthmic 
    • Mechanism of Action:  Suppresses phase 4 depolarization in normal ventricular muscle and Perkinje fibers, reducing ectopic pacemaker's automaticity, suppresses intraventricular conduction
    • Indications: Stable monomorphic ventricular tachycardia with normal QT interval, reentry SVT uncontrolled by vagal maneuvers and adenosine, stable wide complex tachycardia of unknown origin, A-Fib with RVR in pts with WPW
    • Contraindications: Torsades de pointes, 2nd and 3rd degree heart block, preexisting QT prolongation, digitalis toxicity, tricyclic antidepressant overdose
    • Adverse Reactions/Side Effects: Confusion, seizures, hypotension, bradycardia, relex tachycardia, ventricular dysrhymias, AV blocks, asystole, widening of PR, QRS, and Q-T intervals, N/V
    • Drug Interactions: Increase plasma levels of amiodarone, and quinidine
    • How Supplied: 100 mg and 500 mg vials
    • Dosage and Administration: ADULT: Recurrent V-Fib & pulseless V-Tach; 20mg/min slow IV infusion (max of 17mg/kg).  In urgent situations, up to 50mg/min may be administered (max of 17mg/kg).  Other indications; 20mg/min slow IV infusion until any one of the following occur: dysrhythmia suppression, hypotension, QRS widens by >50% of its pretreatment width, or total dose of  17 mg/kg has been given.  Maintenance dose: 1-4mg/min (diluted in D5W or normal saline).  Reduce dose in presence of renal insufficiency.  PEDS: Loading dose 15mg/kg IV/IO over 30-60 mins
    • Duration of Action: ONSET: 10-30 mins       PEAK: Variable      DURATION: 3-6 hrs
    • Special Considerations: Pregnancy Safety Category C.  Potent vasodilation and negative inotropic effects.  Hypotension may occur with rapid infusion.  Administer cautiously to pts with asthma or digitalis-induced dysrhythmias
  27. Terbutaline Sulfate (Brethine)
    • Class: Beta-2 adrenergic agonist, bronchodilator
    • Mechanism of Action: Selective beta-2 adrenergic receptor activity resulting in relaxation of smooth muscle of the bronchial tree and peripheral vasculature with minimal cardiac effects
    • Indications: Bronchial asthma, reversible bronchospasm associated with exercise, chronic  bronchitis, emphysema
    • Contraindications: Hypersensitivity, tachydysrhythmias 
    • Adverse Reactions/Side Effects: CNS stimulation, HA, seizure, restlessness, apprehension, wheezing, coughing, bronchospasm, bradycardia, tachycardia, ST wave changes, PVC's, PAC's, chest pain
    • Drug Interactions: Cardiovascular effects exacerbated by other sympathomimetics.  MAOI's may potentiate dysrhythmias. Beta blockers may antagonize terbutaline
    • How Supplied: 1mg/mL vials
    • Dosage and Administration: ADULT: 0.25 mg SC may repeat in 15-30 mins to max dose of 0.5 mg in a 4 hr period.  PEDS: Not recommended for children younger than 12 years old. 0.25 mg SC may repeat in 15-30 mins to a max dose of 0.5 mg in a 4 hr period 
    • Duration of Action:  ONSET: 5-10 mins      PEAK: Variable     DURATION: 1.5-4 hrs
    • Special Considerations:  Pregnancy Safety Category B.  Carefully monitor vital signs.  Use with caution in pts with cardiovascular disease, seizure disorder, hypotension, and diabetes.  Pts should receive O2 before and during administration
  28. Sodium Nitrate
    • Class: Antidote cyanide poisoning adjunct 
    • Mechanism of Action: Reacts with hemoglobin to form methemoglobin, which reacts with cyanide and chemically binds with it to prevent toxic effects
    • Indications: Cyanide poisoning
    • Contraindications: None in the emergency setting
    • Adverse Reactions/Side Effects: Hypotension, tachycardia, fainting, N/V
    • Drug Interactions: None in the emergency setting
    • How Supplied: 3% solution (30mg/mL) vial
    • Dosage and Administration: ADULT: 300mg (10ML of a 3% solution) slow IV push over 5 mins or dilute 300mg in 100mL of saline and infuse slowly.  PEDS: 10mg/kg (0.33mL/kg of a 10% solution) IV/IO over 3-5 mins
    • Duration of Action: ONSET: 2-10 mins     PEAK: varies      DURATION: 30 mins-2 hrs
    • Special Considerations: Pregnancy Safety Category C.  Potent vasodilator causes significant hypotension if given too rapidly.  Monitor BP closely.  Look for signs of methemoglobinemia (cyanosis, vomiting, shock and coma)
  29. Metoprolol Tartrate (Lopressor)
    • Class: Beta-blocker, beta-1 selective, antihypertensive, antidysrhythmic
    • Mechanism of Action: Decreases heart rate, conduction velocity, myocardial contractility, and cardiac output.  Used to control ventricular response in SVT (PSVT, A-Fib, A-flutter).  Considered 2nd line agent after adenosine, diltiazem or digitalis derivative  
    • Indications: PSVT, A-flutter, A-fib, reduces myocardial ischemia and damage in pts with AMI
    • Contraindications: Heart failure, 2nd or 3rd degree block, 1st degree block if PR interval is greater than or equal to 0.24 sec, sick sinus syndrome, cardiogenic shock, bradycardia
    • Adverse Reactions/Side Effects: Weakness, dizziness, depression, bronchospasm, wheezing, dyspnea, bradycardia, pulmonary edema, CHF, AV blocks, hypotension, heart failure, nausea, indigestion
    • Drug Interactions: Metoprolol may potentiate antihypertensive effects when given to pts taking calcium channel blockers or MAOI's.  Catecholamine-depleting drugs may potentiate hypotension.  Sympathomimetic effects may be antagoinized.  Signs of hypoglycemia may be masked 
    • How Supplied: 1mg/mL ampules and vials
    • Dosage and Administration:  ADULT: 5mg slow IV push at 5 min intervals to a total of 15 mg.  PEDS: Safety not established
    • Duration of Action: ONSET: 1-2 mins       PEAK: 5-10 mins      DURATION: 3-4 hrs
    • Special Considerations:  Pregnancy Safety Category C.  Metoprolol must be given slow IV over 5 mins.  Concurrent IV administration with IV calcium channel blocker such as verapamil or diltiazam can cause severe hypotension.  Metoprolol should be used with caution in pts with liver or renal dysfunction, hypotension and COPD
  30. Benzocaine Spray (Hurricane)
    • Class: Topical anesthetic
    • Mechanism of Action: Stabilizes neuronal membrane, which blocks the initiation and conduction of nerve impulses
    • Indications: Used as a lubricant and topical anesthetic to facilitate passage of diagnostic and treatment devices.  Suppresses the pharyngeal and tracheal gag reflux
    • Contraindications: People with known hypersensitivity to benzocaine
    • Adverse Reaction/Side Effects: Methomeglobinemia has been reported on extremely rare occasions following the use of benzocaine 
    • Drug Interactions: No significant interactions found or known
    • How Supplied: Multi-dose aerosol can of 20%
    • Dosage and Administration: ADULT: 0.5-1 second spray, repeat as needed.  PEDS: 0.25-0.5 seconds spray, repeat as needed
    • Duration of Action: ONSET: Immediate     PEAK: 30 secs     DURATION: 15 mins
    • Special Considerations: Pregnancy Safety Category C.  Topical use only; not for ocular use or injection