Medic Drugs Light

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FlyingSheep
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260044
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Medic Drugs Light
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2014-03-19 12:05:38
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Medic Drugs - Light Version
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  1. Albuterol
    • Action: Beta-2 agonist
    • Indications: Patient requires beta-2 stimulation to relieve the bronchospasm component of bronchiolar obstruction
    • Contraindications: Ineffective when used with beta blockers; cautious use with marked tachycardia (highly unlikely) as there are beta-2 receptors in the cardiac muscle that may be stimulated by a beta-2 agonist and produce an increase in heart rate - this must be balanced against the relief of hypoxia-induced tachycardia.
    • Dose: For adults, typically 2.5mg per HFN although some protocols indicate that 5mg is the correct starting dose
    • Side Effects: Mostly contained to tremors and agitation (20%) with a few reports of actual tachycardia or palpitations (5%)
    • Delivery: Patients take prescription albuterol by either MDI or HFN under the trade name ProAir or Ventolin or Proventil; most perhospital services deliver albuterol via HFN.
    • Typically Supplied: Preloaded vial with twist-off top for easy and rapid distribution into the HFN chamber; some services may carry a multi-dose vial with an eye dropper for mixing with small saline packets in the HFN.
    • Other uses: Albuterol forces potassium from the bloodstream into the cells and is therefore, an adjunct in treatment of hyperkalemia however this method is somewhat slow and dosing is quite high (4 x in most protocols) compared with usual albuterol for bronchospasm - some protocols suggest the intubated patient can get albuterol dumped into the ET tube directly rather than nebulized.
  2. Amiodarone (Push Dose-Cardiac Arrest)
    • Action: Slows cardiac conduction via multiple mechanisms.
    • Indications: in VF / Pulseless VT cardiac arrest to avoid “re-fib”
    • Contraindications: none in cardiac arrest
    • Dose: for adults---300mg IVP with one repeat dose at 150mg; when ROSC is attained, start infusion of 1mg/min
    • Mix options: 
    • - 150mg in 100cc at 40gtts / minute with a microdrip set;
    • - 150mg in 250cc at 100gtts/min with a microdrip set;
    • - Remove 25cc from 100cc bag of NS then add 150mg; infuse at 30gtts/min with microdrip set
    • Side Effects: none pertinent in cardiac arrest
    • Delivery: rapid IV push (IV or IO)
    • Typically Supplied: vial of 150mg in 3cc
    • Other uses: dysrhythmia control (studied separately)
  3. Atropine
    • Action: Parasympathetic antagonist (aka anticholinergic) [parasympathetic breaks for heart rate, antagonist is a blocker, takes off break; increase heart rate]
    • Indications: Patient requires positive chronotrope due to symptoms related to heart rate in the setting of increased vagal/parasympathetic tone such as sinus bradycardia or 1st degree AV Block or 2nd Degree Type 1 (Mobitz I or Wenkebach)
    • Contraindications: AV Blocks that are not related to increased parasympathetic tone such as 2nd Degree Type II and 3rd Degree and High-Grade AV Block; possible benefit in 2nd Degree with 2:1 conduction (particularly if wide QRS) because those are not clearly either a Type I or Type II. Remember, 2nd Degree Type II and higher grade blocks do not respond to Atropine because the block is not related to parasympathetic tone yet the heart rate may increases from the Atropine and make the block more of a problem.
    • Dose: For adults, typically 0.5mg IVP; use length-based chart for peds patients and beware that there is a minimum dose to avoid a paradoxical. Watch for bradycardia effect in peds.
    • Delivery: Slow IV Push over 30-60 seconds; repeat if needed every 3-5 minutes up to a maximum dose of 3.0mg
    • Typically Supplied: Preloaded syringe of 1mg in 10cc so 0.1mg per cc (purple box) which gives a standard adult dose of 5cc
    • Other uses: Reversal of cholinergic effects of some nerve gas agents and organophosphate poisoning (insect killers) but these use require very large amount of Atropine (well over 3mg)(SLUDGE Salivation Lacrimation (tears) Urination Defecation Gastrointestinal Emesis)
  4. Calcium Chlorid
    • Action: calcium supplement
    • Indications: hypocalcemia, hyperkalemia, hypermagnesemia, calcium channel blocker overdose, beta blocker overdose
    • Contraindications: known or suspected digitalis toxicity—-contact medical control
    • Dose: 500 to 2000 mg over 5-10 minutes. Dosing varies by use and by specific service protocol. Online medical control is ALWAYS a good idea when using this medication.
    • Caution: avoid administration in uncertain or fragile veins (hand, foot) and watch closely for infiltration due to severe tissue damage possibility
    • Side Effects: hypotension and bradycardia (particularly with rapid administration) Delivery: IV very slow push
    • Typically Supplied: 100 mg / ml in a 10 cc preloaded syringe
  5. Epinephrine (Push Dose)
    • Action: Beta-1, Beta-2, Alpha 1 agonist (sympathetic agonist, sympathomimetic)
    • Indications: in cardiac arrest to support the effectiveness of CPR
    • Contraindications: none in cardiac arrest Dose: for adults--- 1mg IVP every 3-5 minutes (every 4 minutes for our class)
    • Side Effects: none pertinent in cardiac arrest
    • Delivery: rapid IV push (IV or IO) (via ETT if no other alternative but at dose of 2mg)
    • Typically Supplied: preloaded syringe with 1mg in 10cc
    • Other uses: we will separately study epinephrine for IV drip infusion (for chronotropic support or as a vasopressor) and for IM / SQ (in anaphylaxis)
  6. Epinephrine Drip
    • Action: beta and alpha agonist
    • Indications: positive chronotrope for symptomatic bradycardia; positive inotrope and vasoconstrictor
    • Contraindications: none pertinent
    • Caution: higher doses increases likelihood of ventricular tachycardia or fibrillation
    • Dose: 2-10 mcg / minute (30gtts / min to start)
    • Side Effects: increased myocardial oxygen demand
    • Delivery: IV drip infusion (pump desirable)
    • Typically Supplied: mixed on scene using 1mg in 250cc D5W or NS to yield 4mcg / cc
    • Note: More effects come from higher doses.
  7. Dextrose 50%
    • Action: elevate blood glucose
    • Indications: hypoglycemia
    • Contraindications: no absolute contraindications although USE CAUTION in cases with uncertain IV quality as D50 is tissue destructive if it infiltrates (if this happens, discontinue any infusion but leave the IV catheter in place for ED management of the extravasation)
    • Dose: 25 grams slow IV over 2-3 minutes (diluted to Dextrose 25% in infants and children in most cases—-consult Broselow or equivalent)
    • Side Effects: none (other than hyperglycemia)
    • Delivery: IV slow push
    • Typically Supplied: 25 gram preloaded (50cc) syringe
    • Other Uses: when insulin is used to treat hyperkalemia, D50 is given to counteract the hypoglycemic effect of the insulin
  8. Diazepam
    • Action: benzodiazepine
    • Indications: seizure control, sedation
    • Contraindications: None in the field setting other than to be aware of the likely respiratory depression in higher doses
    • Dose: 5 mg IV given over 1 minute; may repeat in 5 minutes or per protocol / online medical control
    • Side Effects: respiratory depression
    • Delivery: IV slow push (5 mg per minute)
    • Typically Supplied: 5 mg / ml in a 2 cc carpule
    • Other Names: Valium
  9. Dopamine
    • Action: beta and alpha agonist depending on dose
    • Indications: positive chronotrope for symptomatic bradycardia; positive inotrope
    • Contraindication: None pertinent Caution: higher doses increases likelihood of ventricular tachycardia or fibrillation
    • Dose: 5-10 mcg / kg / minute for beta effects; higher doses yield maximum beta 1 effects plus increasing alpha 1 effects
    • Side Effects: increased myocardial oxygen demand
    • Delivery: IV drip infusion (pump desirable) Typically Supplied: pre-mixed 400mg in 250cc D5W or NS (some other concentrations)
    • Other uses: vasopressor at higher doses
  10. Flumazenil (Romazicon)
    • Action: benzodiazepine antagonist
    • Indications: reduction in benzodiazepine effects from field sedation
    • Contraindications: seizure patients and patients with benzodiazepine dependence (precipitates withdrawal which can include seizures that could not be treated with benzodiazepines)
    • Dose: For reversal of benzodiazepines given for sedation: 0.2 mg IVP over 15-30 seconds; repeat in 1 minute up to 3.0 mg total (some protocols, like BHC, allow for increasing the dosage on the 2nd dose to 0.3mg and subsequent doses to 0.5mg). ANY time this medication is given, online medical control contact is prudent.
    • Side Effects: may precipitate benzodiazepine withdrawal and cause seizures
    • Delivery: IV slow push Typically Supplied: 0,5 mg in a 5 ml multi-dose vial
  11. Glucagon
    • Action: Elevate blood glucose.
    • Indications: Hypoglycemia
    • Contraindications: Pheochromocytoma (adrenal tumor that secretes catecholamines such as adrenaline).
    • Dose: 1mg IM
    • Side Effects: None for IM use .
    • Delivery: IM Typically Supplied: 2-part vial system for reconstituting or “emergency kit” containing a pre-filled syringe with sterile water
    • Other uses: for calcium-channel blocker and beta blocker overdose to mediate the myocardial depression (negative inotropic effects) of the beta blockers because glucagon causes an increase in calcium availability for myocardial contraction and thereby increases contractility by a mechanism other than beta 1 stimulation (the doses for this treatment are much higher and most EMS services won’t carry enough glucagon for this therapy…..also, beware of vomiting with high doses of IV glucagon and pretreat with ondansetron)
  12. Ipratropium
    • Action: Anticholinergic bronchodilator (vagus nerve uses acetylcholine as its neurotransmitter and thus it is called the cholinergic system).
    • Indications: Patient requires anticholinergic (parasympathetic antagonist) to relieve the bronchospasm component of bronchiolar obstruction.
    • Contraindications: Not a contraindication but ipratropium is not necessarily a fast-acting medication (also, there is NOT an issue with ipratropium via HFN for patients with a soy or peanut allergy -- that was the propellant in the older version of the MDI).
    • Dose: For adults, typically 2mg per HFN; frequently given as part of DuoNeb or Combivent (both are albuterol and ipratropium combined).
    • Side Effects: Dry mouth.
    • Delivery: Patients take prescription albuterol be either MDI or HFN under the trade name Atrovent; most prehospital services deliver ipratropium via HFN.
    • Typically Supplied: Preloaded vial with twist-off top for easy and rapid distribution into the HFN chamber; some services may carry a multi-dose vial with an eye dropper for mixing with small saline packets in the HFN; again, commonly given prehospital as part of the albuterol-ipratropium combination (Combivent, DuoNeb).
  13. Labetalol
    • Action: Beta blocker and alpha blocker.
    • Indications: Reduction in blood pressure via reduced chronotropy and inotropy and blockade of alpha receptor induced vasoconstriction.
    • Contraindications: Asthma / COPD (bronchial constriction) and bradycardia / AV Block as well as hypertension from amphetamine ingestion.
    • Dose: 20 mg IV over 1-2 minutes in 5 mg increments.
    • Side Effects: Bronchospasm, bradycardia.
    • Delivery: IV slow push.
    • Typically Supplied: 5 mg / ml multi-dose vial
    • Other Uses: Could be an adjunct in tachycardia although other beta blockers are more cardioselective.
    • Other Names: Normodyne, Trandate
  14. Lidocaine (Push Dose-Cardiac Arrest)
    • Action: slows cardiac conduction
    • Indications: in VF / Pulseless VT cardiac arrest to avoid “re-fib”
    • Contraindications: none in cardiac arrest
    • Dose: for adults---1 to 1.5mg/kg IVP repeated at half the initial dose every 5-10 minutes up to a maximum of 3mg/lg then followed by a drip after ROSC at 1-4 mg/min (pre-mixed drips at concentrations of 1g in 250cc or 2g in 250cc or equivalent)
    • Side Effects: none pertinent in cardiac arrest
    • Delivery: rapid IV push (IV or IO)
    • Typically Supplied: preloaded syringes of 100mg in 10cc
    • Other uses: dysrhythmia control (studied separately)
  15. Lorazepam (Ativan)
    • Action: Benzodiazepine.
    • Indications: Seizure control, sedation.
    • Contraindications: None for the field use although caution in respiratory depression.
    • Dose: 1-4 mg (varies by protocol and physician)
    • Side Effects: Respiratory depression.
    • Delivery: IV slow push 2 mg / minute (maximum rate).
    • Typically Supplied: 2 mg / ml or 4 mg / ml carpules or multi-dose vials.
  16. Midazolam (Versed)
    • Action: Benzodiazepine.
    • Indications: seizure control, sedation
    • Contraindications: none for its intended use although caution with respiratory depression
    • Dose: For IV dosing, use 2.5 mg given over 2 minutes repeated once after a 2-minute waiting period for a total of 5 mg—-however, online medical control contact is advisable when using this drug and orders may vary.
    • Side Effects: Respiratory depression.
    • Delivery: IV slow push (2.5 mg over 2 minutes)
    • Typically Supplied: Both 1 mg / ml in a 2 cc multi-dose vial and 5 mg / ml in a 2 cc multi-dose vial are commonly found in the field setting.
  17. Naloxone (Narcan)
    • Action: Opiate antagonist.
    • Indications: Reduction of effects of opiates / opioids such as heroin, morphine etc.
    • Contraindications: Relatively few in the field setting.
    • Dose: Titrated to improve respiratory effort (as opposed to full reversal of all effects) which usually is best achieved with small incremental doses such as 0.4 or 0.5 mg repeated as needed every 2-3 minutes (be aware that some sources suggest 0.05 mg increments).
    • Side Effects: None pertinent.
    • Delivery: IV slow push.
    • Typically Supplied: 2 mg / 2 cc preload.
  18. Oral Glucose Paste
    • Action: Elevate blood glucose.
    • Indications: Hypoglycemia in patients who can swallow and who can maintain their airway.
    • Contraindications: none
    • Dose: 1 tube with repeated doses as needed after 15-20 minutes.
    • Side Effects: None (other than hyperglycemia).
    • Delivery: Buccally (between cheek and gum)
    • Typically Supplied: 30-112 gram tube (various flavors and various vendors)
  19. Thiamine
    • Action: Vitamin B1
    • Indications: Correct thiamine deficiency (malnourished, chronic alcohol use) to prevent Korsakoff syndrome or to prevent / partially treat Wernicke’s encephalopathy
    • Contraindications: none
    • Dose: 100 mg IV (or IM)
    • Side Effects: none
    • Delivery: IV slow push
    • Typically Supplied: 100 mg / ml multi-dose vial.
  20. Vasopressin
    • Action: vasoconstriction independent of sympathetic system
    • Indications: in cardiac arrest to support the effectiveness of CPR
    • Contraindications: none in cardiac arrest
    • Dose: for adults--- 40 units IVP in place of the first or second dose of epinephrine (not repeated)
    • Side Effects: none pertinent in cardiac arrest
    • Delivery: rapid IV push (IV or IO) (via ETT if no other alternative and at same dose but diluted in 5-10cc NS or sterile water)
    • Typically Supplied: multi-dose vial of 20 units in 1cc
    • Other uses: use in cardiac arrest is per ACLS but “off-label”; typically used for control of diabetes insipidus; other off-label uses include as a vasopressor in vasodilatory shock
  21. Aspirin
    • Action: Anti-platelet action
    • Indication: Reduce formation of clots (does NOT break up clots that have formed—-those medications are thrombolytics) in acute stages of ACS
    • Contraindications: None in field use other than allergy to aspirin Dose: 324 mg (four tablets of 81 mg)
    • Side Effects: None in field use (chronic use may contribute to GI bleeding)
    • Delivery: Chewable in field use
    • Typically Supplied: 81 mg tablets
    • Note: Clopidogrel (Plavix) Ticlopidine (Ticlid) are common prescription meds with similar uses although many patients simply take enteric coated aspirin or “baby aspirin”
  22. Combivent & DuoNeb
    • Action: Bronchodilation
    • Indications: Patient requires beta-2 stimulation from albuterol to relieve the bronchospasm component of bronchiolar obstruction and may benefit from the anticholinergic effects of ipratropium (inhibition of bronchial constriction and mucous production)
    • Contraindications: Same as for each component (beta blockers may block albuterol effects and the primary side effect of albuterol is some increase in heart rate)
    • Dose: For adults--- one dose of either combination includes albuterol 2.5mg and ipratropium 0.5 mg; some protocols direct albuterol only as first therapy followed by combination while others utilize the combination as first-line therapy
    • Side Effects: Mostly contained to tremors and agitation (20%) with a few reports of actual tachycardia or palpitations (5%)
    • Delivery: Patients take prescription albuterol and ipratropium combinations such as Combivent and DuoNeb; EMS services carry
    • Typically Supplied: preloaded vial with twist-off top for easy and rapid distribution into the HFN chamber
  23. Dobutamine
    • Action: Pure beta positive ionotropy, beta 1-, beta 2-, and alpha 1-adrenoceptors
    • Indication: Used in heart failure patients, CHF. Makes the heart pump stronger by increasing cardiac output
    • Contraindication: Hypertrophy, stenosis
    • Caution: Higher doses increases likelihood of ventricular tachycardia or fibrillation.
    • Dose: 0.5-1.0 mcg/kg/min
    • Side Effects: Increased myocardial oxygen demand, tachycardia
    • Delivery: IV drip infusion (pump desirable)
    • Typically Supplied: 20ml single dose preload
    • Notes: Typically this medication is encountered by paramedics during inter
  24. Furosemide
    • Action: Diuretic (loop diuretic meaning it functions more effectively in patients with impaired renal function than other diuretics such as thiazide diuretics that inhibit reabsorption of salt)
    • Indications: Promotes diuresis
    • Contraindications: None in the field setting
    • Dose: Usually 40-80 mg
    • Side Effects: Few in the usual doses although sources list hyperglycemia; also tends to reduce potassium levels
    • Delivery: IV slow push (40 mg per minute max)
    • Typically Supplied: 100mg / 10cc vial
  25. Magnesium Sulfate
    • Action: Relaxes smooth muscle (such as found in bronchioles, uterus, blood vessels)
    • Indications: Bronchodilation when nebulizer medications are not effective
    • Contraindications: For prehospital uses, relatively few if any however use caution with rapid administration due to likely hypotension.
    • Dose: Varies with reason for use: 2g IV for bronchodilation, 4-5g IV for eclampsia, 1-2g IV for torsades de points—-consult protocols AND we suggest online medical control for any case requiring mag sulfate
    • Side Effects: Hypotension secondary to vasodilation; flushed skin
    • Typically Supplied: Various packaging but usually 0.5g / cc
    • Delivery: MUST BE DILUTED for IV to 20% solution or less (comes in 50% solution). No faster than 150mg / minute for patients not in cardiac arrest so 2g will take about 33 minutes to give at the maximum rate (10g in 100cc at 1.5cc / minute on an infusion pump). Over 2 minutes in cardiac arrest—-So, for 2g of mag (that’s 4cc), you would draw up 16cc of saline to make a total of 20cc of the now 10% solution and push that slowly over two minutes.
    • Other Uses: Correct low magnesium levels, treat pre-eclampsia or eclampsia, treat torsades de pointes
  26. Nitroglycerin
    • Action: Dilates veins and, to some extent, dilates arterioles
    • Indications: Reduce preload primarily (higher doses may reduce afterload although what constitutes “higher doses” is variable by patient).
    • Contraindications: Significant bradycardia or heart block (patient may not be able to increase HR to compensate for reduction in blood pressure following vasodilation). Recent use of phosphodiesterase-5 (PDE-5) inhibitors (sildenafil, tadalafil, or vardenafil), typically for erectile dysfunction. When nitrate administration becomes medically necessary, may administer nitrates only if 24 hours have elapsed after use of sildenafil (Viagra) or vardenafil (Levitra), and 48 hours after tadalafil /Cialis use. Hypotension (typically SBP <100 although some sources say <90)Impaired right ventricular function (RV is very preload sensitive because of its relatively small mass compared to the LV)—check for RVMI (one third of inferior wall MI).Dose: Usually 0.4mg SL repeated as needed (peak effect around 5 minutes and duration 10-15 minutes).
    • Side Effects: Headache is common and usually transient.
    • Delivery: SL (do not shake the spray bottle) or IV infusion (50mg in 250cc D5W started at 10 mcg / min which is 3cc / hr.
    • Typically Supplied: tablets or spray for SL use (patients may also have paste for topical administration to promote more consistent blood levels)
  27. Ondansetron
    • Actions: Blocks the stimulation of serotonin and vagal receptors that stimulate the vomiting reflex. This is not the same as a parasympathetic antagonist and ondansetron has no negative or positive chronotropic effects. 
    • Indications: nausea control 
    • Contraindications: None 
    • Dose: Usually 4-8 mg or 0.15 mg/kg 
    • Side Effects: few in the usual doses although some patients have experienced headache, diarrhea or constipation; some reports of prolonged QT leading to Torsades but these were with higher doses that are no longer recommended (16mg at a time or more) 
    • Delivery: IV slow push 
    • Typically Supplied: 4mg / 1cc vial
    • Other Names: Zofran
  28. Diazepam
    • Action: Benzodiazepine.
    • Indications: Seizure control, sedation.
    • Contraindications: Hone in the field setting other than to be aware of the likely respiratory depression in higher doses.
    • Dose: 5 mg IV given over 1 minute; may repeat in 5 minutes or per protocol / online medical control.
    • Side Effects: Respiratory depression.
    • Delivery: IV slow push (5 mg per minute)
    • Typically Supplied: 5 mg / ml in a 2 cc carpule.
    • Other Names: Valium.
  29. Diphenhydramine
    • Action: Antihistamine.
    • Indications: Reversal of histamine effects.
    • Contraindications: Hone specifically in field setting.  
    • Dose: 50 mg IV.
    • Side Effects: Drowsiness, dizziness.
    • Delivery: IV slow push (25 mg per minute).
    • Typically Supplied: 50 mg / ml vial.
    • Other Names: Benadryl.

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