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Street Level PharmacologyAuthored By:ARIELLE Gonzales, FP-C David Berry, FP-C, CCPRey Ramirez, BSN, CFRNShane Brown, FP-C Teresa NystromTom McClendon, CFRN

Objectives

1. Explain drug choice in association with case studies

2. Identify dose, indications, and contraindications for ground level medications

3. Compare and contrast dysrhythmias4. Compare and contrast analgesics

Medications1. Aspirin 2. Activated Charcoal3. Adenosine 4. Albuterol5. Amiodarone6. Atropine7. Diazepam8. Midazolam9. Dextrose10. Diphenhydromine11. Dopamine 12. Epinephrine 13. Glucogon

14. Furosimide15. Ipotroprium Bromide16. Lidocain17. Magnesium Sulfate18. Naloxone19. Fentanyl20. Morphine21. Nytroglicerin22. Oxygen23. Sodium Bicarb24. Vasopressin25. Zofran

Case Study 1

You are dispatched to the scene of a 65 year old man complaining of sudden onset chest pain. On your arrival your patient is complaining of 10/10 crushing midsternal chest pain and appears diaphoretic and pale.

Vitals 1

• BP 120/84• HR 84 and regular • RR 18 and regular• SpO2 96% on room air

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History and Assessment 1 OPQRST

• Onset- sudden • Provocation- physical activity• Quality- pressure like • Radiation- no • Severity- 10/10• Time- 60min

History and AssessmentSAMPLE (1 of 2)

• Signs and symptoms- GCS 15, PERRLA, the patient is complaining of feeling dizzy but denies having a headache, the patient is complaining of feeling nauseated but denies vomiting, no noted or reported syncope, the patient sates that he feels short of breath, breath sounds are clear

History and Assessment SAMPLE (2 or 2)

• Allergies- NKDA• Medications- lisinoprill, plavix, “baby” asprin• Past pertinent history- CVA two years ago,

hypertension• Last oral intake- sandwich two hours ago• Events leading up to- sitting on couch

watching TV began to feel pain, as pain progressed the patients wife called 911

http://www.learntheheart.com/assets/1/7/Inferior-STEMI-4.jpg

Treatment 1 (1 of 2)

• IV x2 large bore if possible

• Normal Saline Open

• Aspirin – Dose?

Treatment 1 (2 of 2)

• Nitroglycerin – Dose?

• Analgesic – Medication and Dose?

• Zofran – Dose?

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Aspirin- Acetylsalicylic Acid (ASA)

• Mechanism of action in patients with ischemic cardiac conditions: Makes platelets less sticky… What does that mean?

• Prehospital Indications: all patients with suspected AMI

• Absolute Contraindications: hypersensitivity, < 18 years old, Internal bleeding

Sublingual Nitroglycerin (NTG)

• Mechanism of action: vasodilatation

• Prehospital Indications: ischemic cardiac conditions– chest pain– CHF with pulmonary edema

NTG (1 of 2)

• Absolute Contraindications:– hypersensitivity, – hypotension, – paricardial tamponade, – increased intra-cranial pressure,– hypovolemia/sever anemia, – use of erectile dysfunction drugs within 24-

48hrs

NTG (2 of 2)

What do you do if the patient experiences: a throbbing headache, flushing, dizziness,

or burning under the tongue?

Analgesic

• Mechanism of Action: opioid receptor agonist in the CNS

• Prehospital Indication: pain, pulmonary edema

• Absolute Contraindications: hypersensitivity,Hypotension, myasthenia gravis, respiratory depression

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Zofran- Ondansetron

• Mechanism of Action: Serotonin receptor agonist- what does that mean?

• Prehospital Indications: nausea and/or vomiting

• Absolute Contraindications: hypersensitivity, prolonged QT interval syndrome

Case Study 1 ProgressionAfter the first dose of Nitroglycerine the patient becomes hypotensive, 80/40, and you begin to see occasional PVCs on the monitor. The patient progresses to this rhythm with a pulse:

http://static.wikidoc.org/f/fe/IVR-EKG.jpg

Progressive Treatment

• Oxygen- titrate to SpO2

• Continue Fluids

• Initiate Pacing

• Dopamine- What dose?

Atropine

Dopamine (1 of 2)

• Mechanism of Action: agonist of alpha 1, beta and dopaminergic receptors - what does that mean?

• Prehospital Indications: – Cardiogenic shock– Other forms of shock– Bradycardia when pacing is unavailable– What about renal failure?

Dopamine (2 of 2)

• Contraindications: – Tachydysrhythmias,– Pheochromocytoma,– Phenytoin use

** Note: Reduced Effects with Beta Blocker Use**

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How to Mix/Calculate

Given: Concentration 400mg of Dopamine/ 250ml of D5W. You have a 60gtts and wantto give 10mcg/kg/min. How many

drips/min:

45kg patient?90kg patient?50kg patient?

Cardiac Case Study 1 CPR

The patient becomes pulseless and apneic, and CPR is initiated. EKG reveals:

http://static.wikidoc.org/f/fe/IVR-EKG.jpg

Treatment During CPR

• The patient is shocked x1 at 200J initially and then again at the end of every round of CPR with no rhythm change

• Epinephrine – what dose?

• Antidysrhythmic – Which one and What dose?

Epinephrine (1 of 2)

• Mechanism of Action: alpha and beta agonist – What does that mean?

• Prehospital Indications: severe bronchospasms, bronchospasms unresponsive to albuterol, anaphylaxis, cardiac arrest, symptomatic bradicardia after other treatments

• Contraindications: hydrocephalus

Amiodarone

• Mechanism of Action: Prolongs Repolarization by increasing potassium permeability - What does that mean?

• Prehospital Indication: pulseless VT/VF refractory to shock, unstable VT

• Absolute Contraindication: hypersensitivity, Bradycardia, congestive heart failure

If the rhythm converts…

Hang a drip!

What is the dose?How do you mix it?

How many drips/min?

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Lidocaine

• Mechanism of Action: Inhibits Sodium Channels delaying depolarization - How is that different from Amiodarone?

• Prehospital Indication: symptomatic ventricular dysrhythmias, sustained VT, pulseless VT/VF, anesthetic

• Absolute Contraindication: hypersensitivity, Wolf Parkinson White Syndrome (WPW), Bradycardia

If the rhythm converts…

Hang a drip!

What is the dose?How do you mix it?

How many drips/min for a 45kg patient?

Magnesium Sulfate

• Mechanism of Action: inhibition of calcium influx a neuromuscular junctions

• Prehospital Indications: VT/VT without a pulse that is unresponsive to lidocain, torsads, pre-term contractions, asthma

• Absolute Contraindications: bradycardia, hypocalcemia, hypermagnesemia, anuria

Case Study 2 (1 of 2)

You are dispatched to the scene of a 21 year old unresponsive male patient at a local restaurant. On your arrival your patient is unresponsive and laying on the floor, the patient is breathing shallow. The patient’s friend advises that they were eating when the patient began to complain of shortness of breath, “he became worse and worse until he passed out.”

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Picture of the patient

http://www.resus.com.au/wp-content/uploads/2012/06/Screen-Shot-2012-06-22-at-11.18.46-AM.png

Case Study 2 (2 of 2)

Vitals 2

• BP 80/40• HR 130 • RR 10• SpO2 84% on room air

Treatment 2

• O2- BVM assist with 25 lpm• Albuterol- BVM assist - What dose?• Ipatroprium Bromide- BVM assist – What

dose?• Epinephrine – What dose?• IV initiation with NS open• Diphenhydramine – What dose?

Respiratory Pharmacology Albuterol

• Mechanism of Action: sympathomimetic, beta 2 selective adrenergic bronchodilator

• Prehospital Indications: emphysema, asthma, bronchitis, bronchoconstriction

• Absolute Contraindications: hypersensitivity, MAO inhibitors

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Ipatropium Bromide

• Mechanism of Action: inhibition of muscarinic acytilcholine receptors in the bronchi

• Prehospital Indications: asthma, bronchitis, emphysema, bronchospasms

• Absolute Contraindications: hypersensitivity

Epinephrine

Beta 2 effects of epinephrine cause bronchodilation, alpha effects increase blood pressure.

Diphenhydromine

• Mechanism of Action: Histamine antagonist

• Prehospital Indications: allergic reactions, dystonic reactions, motion sickness, anti-emetic

• Absolute Contraindications: hypersensativity

Should We Fly this Patient?

Case Study 3 (1 of 2)

You are called to the scene of a 21 year old man who is having a seizure. You arrive on scene and find the patient laying in bed alert and verbal with his hands pulled in and clamped (carpal pedal spasms). The patient is hyperventilating. You reach down to check a pulse and find that the patient is tachycardic with a strong bounding pulse.

Case Study 3 (2 of 2)

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Vitals 3

• BP 130/90• HR 220• RR 26• SpO2 100% on room air

Treatment 3

• IV• Vasalva• Adenosine – What dose?

Adenosine

• Mechanism of Action: inhibiting adenylyl cyclase – What does that mean?

• Prehospital Indications: SVT

• Absolute Contraindications: Hypersensitivity, Bradycardias, Sick Sinus Syndrome, Drug induced tachycardia

Case Study 4 (1 of 2)

You are called to the scene of a 35 year old female with an altered mental status. On your arrival the patient is found vomiting and lethargic. The patient mumbles “I just want to die”. The patient is a known drug abuser and there are several empty pill bottles near the patient that are prescribed to the person who called 911, the patients mother.

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Case Study 4 (2 of 2) Vitals 4

SpO2: 93% on Room AirBP: 80/50HR: 50RR: 9

Treatment 4

• IV x 2• NS or LR• Dextrose – What dose?• Narcan – What dose?• Glucagon – What dose?• Sodium Bicarb – What dose?

Dextrose

• Mechanism of Action: Increase serum blood glucose levels

• Prehospital Indications: hypoglycemia

• Absolute Contraindications: none in the presence of hypoglycemia

Narcan

• Mechanism of Action: narcotic antagonist

• Prehospital Indications: narcotic overdose

• Absolute Contraindications: hypersensitivity

Glucagon

• Mechanism of Action: hormone produced by the pancreases that releases glucose, release of cAMP

• Prehospital Indications: hypoglycemia, Beta Blocker overdose

• Absolute Contraindications: hypersensitivity

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Activated Charcol Sodium Bicarb

• Mechanism of Action: Serum alkalization

• Prehospital Indications: antidote for tricycle antidepressants

• Absolute Contraindications: any patient that does not meet established criteria

Case Study 5

You are called to the scene of a 68 year old female complaining of shortness of breath. You arrive on scene to find the patient alert and verbal with 2-3 word dyspnea. The patient advises you that her CHF is acting up.

Vitals 5

SpO2 92% on 2lpm via N/CBP 140/80HR 104RR 22

Treatment 5

• CPAP• NS• NTG – What dose?• Analgesic – Which one and what dose?• Lasix – What dose?

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Lasix

• Mechanism of Action: loop diuretic –What does that mean?

• Prehospital Indications: pulmonary edema of a cardiac nature, hypertensive emergency (AMI, APE)

• Absolute Contraindications: hypotension, tall peaked T waves, hypovolemia

Case Study 6

You are called to the scene of a 19 year old female who is having a seizure. You arrive to find the patient in a tonic state.

Vitals 6

SpO2 unable to get a readingBP unable to get a readingHR palpable tachycardiaRR 6 irregular

Treatment 6

• Protect the patient• Protect the airway- BVM assist if possible• Benzodiazepine – Which one and what

dose?

Diazepam (Valium)

• Mechanism of Action: Inhibition of polysynaptic pathways in the spinal cord

• Prehospital Indications: anxiety, seizures, sedation, skeletal muscle relaxation

• Absolute Contraindications: hypersensitivity, CNS depression

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Midazolam

• Mechanism of Action: enhances the effects of the neurotransmitter GABA

• Prehospital Indications: Seizures, muscle spasms

• Absolute Contraindications: hypersensitivity, CNS depression

References

(n.d.). Retrieved from Drugs.com: http://www.drugs.com/New Mexico State EMS Buraeu. (2012, September).

Medication Formulary. Santa Fe, New Mexico, UnitiedStates.

U.S. Department of Health and Human Services. (2015, November 19). U.S. Food and Drug Administration. Retrieved from FDA: http://www.fda.gov/?pwsID=JNP-Shop

Illustration References

http://static.wikidoc.org/f/fe/IVR-EKG.jpghttp://www.resus.com.au/wp-content/uploads/2012/06/Screen-Shot-2012-06-22-at-11.18.46-AM.png