Chapter 12 Emergency Medications. National EMS Education Standard Competencies Pharmacology Integrates comprehensive knowledge of pharmacology to formulate

Chapter 12Chapter 12

Emergency Medications

National EMS Education Standard CompetenciesNational 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

IntroductionIntroduction

• Paramedics must have a comprehensive understanding of all medications they might administer.− Pharmacology is one of the more difficult

subjects to master.


• 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


• 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.

AHA Classification of Recommendations and Level

of Evidence


of Evidence

• Class I− A treatment should be administered.

• Class IIa− It is reasonable to administer treatment.

• Class IIb− Treatment may be considered.


of Evidence


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

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



• 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.



• 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.

Federal “Controlled Substance Act of 1970” Schedule Summary

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

Radio CommunicationsRadio Communications

• Become familiar with terminology related to medications and medication administration.

• Be familiar with common medical abbreviations.



Drug Dosage CalculationsDrug 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

Medication ListingsMedication Listings

• Name of medication− And other common names

• Class− How the medication is classified compared to

other medications


• Mechanism of action− 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


• Adverse reaction/side effects− 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


• How supplied− 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


• Duration of action− Onset

− Peak effect

− Duration

• Special considerations

Activated Charcoal (EZ-Char, Actidose, Liqui-Char)

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

Adenosine (Adenocard)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

Albuterol (Proventil, Ventolin)

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

Alteplase, Recombinant (Tissue Plasminogen Activator

or rTPA, Activase)

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.

Amiodarone (Cordarone, Pacerone)

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


Category D

− Monitor patient for hypotension.

Amyl NitriteAmyl Nitrite

• Mechanism of action− Converts hemoglobin

to methemoglobin to prevent toxic effects

• Indications− Cyanide poisoning

• Contraindications− None in emergency

settings

• Adverse reactions− Headache, dizziness,

weakness


Category X

− Highly flammable

Aspirin (ASA, Bayer, Ecotrin, St. Joseph, and Others)

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


Category D

− Not recommended in pediatric population

Atenolol (Tenormin)Atenolol

(Tenormin)

• Mechanism of action− 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


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

Atropine SulfateAtropine Sulfate

• Mechanism of action− Increases heart rate in

life-threatening bradydysrhythmias

• Indications− Hemodynamically

unstable bradycardia

• Contraindications− Tachycardia,

hypersensitivity

• Adverse reactions− Drowsiness,

confusion, headache, tachycardia, palpitations


Category C

− Moderate doses may cause pupillary dilation.

Benzocaine Spray (Hurricane)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.


Category C

− Topical use only; not for ocular use or injection

Bumetanide (Bumex)

Bumetanide (Bumex)

• Mechanism of action− 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


Category C

Calcium ChlorideCalcium Chloride

• Mechanism of action− Increases cardiac

contractile state

• Indications− Hypocalcemia,

hyperkalemia, hypermagnesemia

• Contraindications− Hypercalcemia,

ventricular fibrillation, digitalis toxicity

• Adverse reactions− Syncope, cardiac

arrest, dysrhythmia, bradycardia


Category C

− Do not use routinely in cardiac arrest.

Calcium GluconateCalcium Gluconate

• Mechanism of action− Counteracts the

toxicity of hyperkalemia

• Indications− Hyperkalemia,

hypocalcemia

• Contraindications− Ventricular fibrillation,

digitalis toxicity, hypercalcemia

• Adverse reactions− Syncope, cardiac

arrest, dysrhythmia, bradycardia


Category C

− Do not administer by IM or SQ

Clopidogrel (Plavix)

Clopidogrel (Plavix)

• Mechanism of action− 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


Category B

− Often given with other anticoagulants

Dexamethasone Sodium Phosphate (Decadron)

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


Category C

− Protect medication from heat. Toxicity and side effects occur with long-term use.

DextroseDextrose

• Mechanism of action− Rapidly increases

serum glucose levels

• Indications− Hypoglycemia, altered

level of consciousness

• Contraindications− Intracranial

hemorrhage

• Adverse reactions− Cerebral hemorrhage

− Cerebral ischemia

− Pulmonary edema


Category C

Diazepam (Valium and Others)

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


drowsiness, confusion, headache


Category D

− Short duration for anticonvulsant effect

− Reduce dose by 50% in elderly patients.

Digoxin (Lanoxin)Digoxin (Lanoxin)

• Mechanism of action− 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


Category C

− Patient receiving IV digoxin must be on a monitor

Diltiazem (Cardizem)Diltiazem (Cardizem)

• Mechanism of action− Reduces myocardial

oxygen demand

• Indications− Controls rapid

ventricular rates

• Contraindications− Hypotension

− Sick sinus syndrome

• Adverse reactions− Dizziness, weakness,

headache, dyspnea


Category C

− Use with caution in patients with renal or hepatic dysfunction.

Diphenhydramine (Benadryl)

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


Category B

− Not used in infants

Dobutamine Hydrochloride (Dobutrex)

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


Category B

− Monitor blood pressure closely.

Dolasetron (Anzemet)

Dolasetron (Anzemet)

• Mechanism of action− 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


Category B − Injectable form should

not be used in patients with chemotherapy-induced nausea and vomiting.

Dopamine Hydrochloride (Intropin)

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


Category C

− Effects are dose-dependent

Epinephrine (Adrenalin)

Epinephrine (Adrenalin)

• Mechanism of action− Blocks histamine

receptors

• Indications− Cardiac arrest,

symptomatic bradycardia

• Contraindications− Hypertension,

hypothermia, pulmonary edema

• Adverse reactions− Nervousness,

restlessness, headache, tremor


Category C

− May cause syncope in asthmatic children

Epinephrine Racemic (Micronefrin)

Epinephrine Racemic (Micronefrin)

• Mechanism of action− Reduces airway

resistance

• Indications− Bronchial asthma,

prevention of bronchospasm, croup

• Contraindications− Hypertension,

underlying cardiovascular disease, epiglottitis


fear, nervousness, respiratory weakness

• Considerations− May cause

tachycardia and other dysrhythmias

− Monitor vital signs.

Eptifibatide (Integrilin)

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


Category B

− Must be administered only with an infusion pump direct from bottle with a vented IV set

Etomidate (Amidate)Etomidate (Amidate)

• Mechanism of action− Short-acting hypnotic

• Indications− Premedication for

tracheal intubation or cardioversion


labor/delivery

• Adverse reactions− Apnea of short

duration, respiratory depression, hypoventilation, hyperventilation


Category C

− Carefully monitor vital signs.

Fentanyl Citrate (Sublimaze)

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


Category C

− Chest wall rigidity possible with a high-dose rapid infusion

Flumazenil (Romazicon)Flumazenil (Romazicon)

• Mechanism of action− Reverses the sedative

effects of benzodiazepines

• Indications− Reversal of respiratory

depression and sedative effects from benzodiazepine


tricyclic antidepressant overdose, seizure-prone patients

• Adverse reactions− Seizures, dizziness,

agitation, confusion, headache, visual disturbances


Category C

− Not recommended in combined drug overdoses

Fosphenytoin (Cerebyx)

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


Category D

− Use with caution in patients with hepatic and renal impairment and diabetic, elderly, and debilitated patients.

Furosemide (Lasix)

Furosemide (Lasix)

• Mechanism of action− Causes increased

urine output

• Indications− CHF, pulmonary

edema, hypertensive crisis

• Contraindications− Hypovolemia, anuria,

hypotension


ECG changes, weakness


Category C

− Ototoxicity, deafness, and projectile vomiting can occur with rapid administration.

Glucagon (GlucaGen)Glucagon (GlucaGen)

• Mechanism of action− Increases blood

glucose level

• Indications− Altered level of

consciousness when hypoglycemia is suspected

• Contraindications− Hyperglycemia,

hypersensitivity


hypertension, tachycardia


Category B

− Should be used in conjunction with 50% dextrose whenever possible

Haloperidol Lactate (Haldol)

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


Category C

− Treat hypotension secondary to haloperidol with fluids and norepinephrine, not epinephrine

Heparin SodiumHeparin Sodium

• Mechanism of action− Affects clotting factors

IX, XI, XII, plasmin; does not lyse existing clots


infarction, prophylaxis and treatment of thromboembolic disorders


active bleeding

• Adverse reactions− Pain, anaphylaxis,

shock, hematuria


Category C

− Heparin does not lyse existing clots.

Hydrocortisone Sodium Succinate (Solu-Cortef)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


Category C

− May be used in status asthmaticus as a second-line drug

Hydroxocobalamin (Cyanokit)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


Category C

− Make sure to reassess the patient’s airway, oxygenation, and hydration during administration.

Hydroxyzine (Atarax, Vistaril)

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


Category C

− Should be administered by IM injection only

InsulinInsulin

• Mechanism of action− Allows glucose

transport into cells of all tissues

• Indications− Not used in

emergency prehospital setting

• Contraindications− Hypoglycemia,

hypokalemia

• Adverse reactions− Weakness, fatigue,

confusion, headache


Category B

− Insulin is the drug of choice for control of diabetes in pregnancy.

Ipratropium (Atrovent)

Ipratropium (Atrovent)

• Mechanism of action− Inhibits interaction

of acetylcholine at receptor sites of bronchial smooth muscle

• Indications− Persistent

bronchospasm, COPD exacerbation


ipratropium, atropine, alkaloids, peanuts


nervousness, fatigue


Category B

− Shake well before use.

Isoetharine (Bronchosol, Bronkometer)

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

Ketorolac Tromethamine (Toradol)

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


Category C

− Use with caution in elderly patients due to higher risk of renal and fatal GI adverse reactions.

Labetalol (Normodyne, Trandate)

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


Category C

− Blood pressure, pulse rate, and ECG should be monitored continuously.

Levalbuterol (Xopenex)

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


dizziness, restlessness, hallucinations


Category C

− Use with caution in patients with cardiac dysrhythmias and cardiovascular disorders.

Lidocaine Hydrochloride (Xylocaine)

Lidocaine Hydrochloride (Xylocaine)

• Mechanism of action− Decreases

automaticity

• Indications− Alternative to

amiodarone in cardiac arrest from ventricular tachycardia


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.

Lorazepam (Ativan)

Lorazepam (Ativan)

• Mechanism of action− Anxiolytic,

anticonvulsant, and sedative effect

• Indications− Initial control of status

epilepticus or severe recurrent seizures

• Contraindications− Acute narrow-angle

glaucoma, coma, shock


drowsiness, CNS depression, headache


Category D

− Monitor respiratory rate and blood pressure during administration.

Magnesium SulfateMagnesium Sulfate

• Mechanism of action− Reduces striated

muscle contractions

• Indications− Seizures of

eclampsia, torsades de pointes, hypomagnesemia

• Contraindications− Heart block,

myocardial damage

• Adverse reactions− Drowsiness, CNS

depression, respiratory depression


Category A

− Recommended that the drug not be administered in the 2 hours before delivery, if possible

Mannitol (Osmitrol)Mannitol (Osmitrol)

• Mechanism of action− 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


Category C

− May crystallize at low temperatures; store at room temperature

− Have ventilatory support available.

Meperidine Hydrochloride (Demerol)

Meperidine Hydrochloride (Demerol)

• Mechanism of action− Primarily acts as an

analgesic and a sedative

• Indications− Analgesia for

moderate to severe pain


narcotics

• Adverse reactions− Seizures, confusion,

sedation, dysphoria, headache


Category C

− Use with caution in patients with asthma and COPD

Metaproterenol Sulfate (Alupent)

Metaproterenol Sulfate (Alupent)

• Mechanism of action− Acts directly on

bronchial smooth muscle causing relaxation


COPD

• Contraindications− Tachydysrhythmia,

hypersensitivity, tachycardia caused by digitalis toxicity

• Adverse reactions− Nervousness, tremor,

headache, anxiety


Category C

− Monitor for hypotension and tachycardia.

Methylprednisolone Sodium Succinate (Solu-Medrol)

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


Category C

− Not effective if time of spinal cord injury greater than 8 hours

Metoprolol Tartrate (Lopressor)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


Category C

− Metoprolol must be given slow IV over 5 minutes

Midazolam Hydrochloride (Versed)

Midazolam Hydrochloride (Versed)

• Mechanism of action− Causes sedative,

anxiolytic, amnesic, and hypnotic effects

• Indications− Sedation for medical

procedures


glaucoma, shock, coma, alcohol intoxication

• Adverse reactions− Headache,

somnolence, respiratory depression


Category D

− Administer immediately prior to intubation procedure.

Morphine Sulfate (Roxanol, MS Contin)

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


Category C

− Morphine rapidly crosses the placenta.

Nalbuphine Hydrochloride (Nubain)

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


vertigo, seizure


Category B

− Use with caution in patients with impaired respiratory function.

Naloxone Hydrochloride (Narcan)

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


narcotic-dependent patients

• Adverse reactions− Restlessness,

seizures, dyspnea, pulmonary


Category C

Nifedipine (Procardia, Adalat)

Nifedipine (Procardia, Adalat)

• Mechanism of action− Inhibits movement

of calcium ions across cell membranes

• Indications− Hypertensive crisis,

angina pectoris

• Contraindications− Compensatory

hypertension, hypotension


nervousness, weakness, mood changes


Category C

− Have beta blocker available for control of reflex tachycardia

Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)

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


hypovolemia, intracranial bleeding or head injury


weakness, reflex tachycardia


Category C

− Hypotension more common in the elderly

Nitropaste (Nitro-Bid Ointment)

Nitropaste (Nitro-Bid Ointment)

• Mechanism of action− Smooth muscle

relaxant

• Indications− Acute angina pectoris


hypovolemia, intracranial bleeding or head injury


weakness


Category C

− Not a great value in prehospital arena

Nitrous Oxide 50:50 (Nitronox)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


Category C

− Nitrous oxide increases the incidence of spontaneous abortion.

Norepinephrine Bitartrate (Levophed)

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


dizziness


Category C.

− May cause fetal anoxia when used in pregnancy

Ondansetron Hydrochloride (Zofran)

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


Category B

Oral Glucose (Insta-Glucose)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.

OxygenOxygen

• Mechanism of action− 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.

Oxytocin (Pitocin)

Oxytocin (Pitocin)

• Mechanism of action− Increases uterine

contractions

• Indications− Postpartum

hemorrhage after infant and placental delivery

• Contraindications− Presence of second

fetus, unfavorable fetal position

• Adverse reactions− Coma, seizures,

anxiety


Category C

− Monitor vital signs including fetal heart rate and uterine tone closely.

Pancuronium Bromide (Pavulon)

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


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.

Phenobarbital (Luminal)

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


Category D

− Potential for abuse


Phenytoin (Dilantin)

Phenytoin (Dilantin)

• Mechanism of action− Promotes sodium

efflux from neurons

• Indications− Prophylaxis and

treatment of major motor seizures


bradycardia

• Adverse reactions− Ataxia, agitation,

dizziness, headache, drowsiness


Category D


Pralidoxime (2-PAM, Protopam)

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


drowsiness, headache, neuromuscular blockade


Category C

− Slow IV infusion prevents tachycardia, laryngospasm, muscle rigidity

Procainamide Hydrochloride (Pronestyl)

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


Category C

− Potent vasodilation and negative inotropic effects

Promethazine Hydrochloride (Phenergan)

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


drowsiness, confusion, restlessness, wheezing


Category C

− Convulsions and sudden death when used with children

Propofol (Diprivan)Propofol (Diprivan)

• Mechanism of action− 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


Category B

− Avoid rapid administration in elderly patients to avoid hypotension and airway obstruction.

Propranolol Hydrochloride (Inderal)

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


Category C − Closely monitor

patient during administration.

− Use with caution in elderly patients.

− Atropine should be readily available.

Rocuronium Bromide (Zemuron)

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


Category B

− Decrease doses for patients with renal disease.

− Sedate patient before administering.

Sodium BicarbonateSodium Bicarbonate

• Mechanism of action− 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


Category C

− Repeat as needed in tricyclic antidepressant overdose until QRS narrows

Sodium NitrateSodium Nitrate

• Mechanism of action− Reacts with

hemoglobin to form methemoglobin, which reacts with cyanide



emergency setting

• Adverse reactions− Hypotension,

tachycardia, fainting, nausea, vomiting


Category C

− Potent vasodilator causes significant hypotension if given too rapidly

Sodium ThiosulfateSodium Thiosulfate

• Mechanism of action− Converts cyanide to

the less toxic thiocyanate, which is then excreted in the urine



emergency setting

• Adverse reactions− Diarrhea


Category C

− If response to treatment is inadequate, repeat sodium nitrite and sodium thiosulfate

Streptokinase (Streptase)

Streptokinase (Streptase)

• Mechanism of action− Combines with

plasminogen to convert free plasminogen to the proteolytic enzyme, plasmin


infarction, massive pulmonary emboli, arterial thrombosis/ embolism, to clear intraventricular cannula


active bleeding, recent cerebral vascular accident

• Adverse reactions− Intracranial

hemorrhage, bronchospastic hemoptysis, ARDS


Category C

Succinylcholine Chloride (Anectine)

Succinylcholine Chloride (Anectine)

• Mechanism of action− Ultra-short-acting

depolarizing skeletal muscle relaxant

• Indications− Rapid-sequence

intubation


glaucoma, penetrating eye injuries, malignant hyperthermia

• Adverse reactions− Apnea, respiratory

depression, bradydysrhythmia, tachydysrhythmia


Category C

− If the patient is conscious, explain the effects of the drug before administration.

Terbutaline Sulfate (Brethine)Terbutaline Sulfate (Brethine)

• Mechanism of action− Relaxation of

bronchial tree and peripheral vasculature with minimal cardiac effects


bronchospasm associated with exercise


tachydysrhythmias

• Adverse reactions− CNS stimulation,

headache, seizure, restlessness, apprehension


− Category B

− Monitor vital signs.

Thiamine (Betaxin)Thiamine (Betaxin)

• Mechanism of action− 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


Category A

− Rapid or large IV doses may cause respiratory difficulties, hypotension, and vasodilation.

Tirofiban Hydrochloride (Aggrastat)

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


Category B

− Must be administered only with an infusion pump direct from bottle with a vented IV set

− Severe spontaneous bleeding risk

Vasopressin (Pitressin)

Vasopressin (Pitressin)

• Mechanism of action− Stimulation of smooth

muscle receptors

• Indications− Alternative

vasopressor to the first or second dose of epinephrine in cardiac arrest


patients with coronary artery disease, epilepsy, or heart failure.


bronchial constriction, MI, chest pain, angina


Category C

− May increase peripheral vascular resistance and provoke cardiac ischemia and angina

Vecuronium Bromide (Norcuron)

Vecuronium Bromide (Norcuron)

• Mechanism of action− Neuromuscular agent

that results in neuromuscular blockade

• Indications− Rapid-sequence

intubation


glaucoma, penetrating

eye injuries

• Adverse reactions− Weakness, prolonged

neuromuscular block, bronchospasm, apnea


Category C

− If patient is conscious, explain the effect of the medication before administration and always sedate the patient before using vecuronium.

Verapamil Hydrochloride (Isoptin, Calan)

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


pulmonary edema


Category C

− Closely monitor patient’s vital signs.

IV Solutions (Colloids and Crystalloids)

IV Solutions (Colloids and Crystalloids)

• Colloids− 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

Plasma Protein Fraction (Plasmanate)

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.

DextranDextran

• Mechanism of action− 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.

Hetastarch (Hespan)

Hetastarch (Hespan)

• Mechanism of action− A starch-containing

colloid used as an intravascular volume expander


especially burn shock; septic shock

• Contraindications− No major

contraindications

• Adverse reactions− Nausea, vomiting,

mild febrile reactions, chills, itching, and urticaria


Category C

− Patients allergic to corn may be allergic to hetastarch.

Lactated Ringer’s (Hartmann’s Solution)

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


5% Dextrose in Water (D5W)

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


dosages

• Considerations− Should not be used

with phenytoin or amrinone

10% Dextrose in Water (D10W)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


dosages


0.9% Sodium Chloride (Normal Saline)

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


dosages


0.45% Sodium Chloride (½ Normal Saline)

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


dosages


5% Dextrose in 0.45% Sodium Chloride (D5½NS)

5% Dextrose in 0.45% Sodium Chloride (D5½NS)


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


dosages


5% Dextrose in 0.9% Sodium Chloride (D5NS)

5% Dextrose in 0.9% Sodium Chloride (D5NS)


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


dosages


5% Dextrose in Lactated Ringer’s (D5LR)

5% Dextrose in Lactated Ringer’s (D5LR)

• Mechanism of action− Replaces water and

electrolytes and provides nutrients in the form of dextrose


hemorrhagic shock

• Contraindications− Should not be

administered to patients with decreased renal or cardiovascular function


dosages


SummarySummary

• 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.

SummarySummary

• 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.

CreditsCredits

• 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.

Documents

Chapter 12 Emergency Medications. National EMS Education Standard Competencies Pharmacology Integrates comprehensive knowledge of pharmacology to formulate