EMS POCKET DRUGGUIDE

EDITOR

Patrick T. Gomella, MPH, NREMT-P

www.emsdrugbook.com

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Copyright © 2010 by Patrick T. Gomella, based on The Clinician’s Pocket Drug Reference © 2009 by Leonard G. Gomella. Published by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

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PREFACE xiMEDICATION KEY xiiiABBREVIATIONS xvii

I EMS FIELD MEDICATIONS 1Prehospital Drug Classification 1

Allergy 1Antidotes 1Cardiovascular (CV) Agents 1Central Nervous System Agents 2Dietary Supplements 3Endocrine System Agents 3Gastrointestinal Agents 3Hematologic Agents 3Musculoskeletal Agents 4OB/GYN Agents 4Pain Medications 4Respiratory Agents 5

II COMMONLY PRESCRIBED MEDICATIONS: 33CLASSIFICATION

Allergy 33Antidotes 33Antimicrobial Agents 33Antifungals 35Antiretrovirals 36Antineoplastic Agents 36Cardiovascular (CV) Agents 38Central Nervous System Agents 41Dermatologic Agents 42

iii

CONTENTS

Dietary Supplements 43Ear (Otic) Agents 44Endocrine System Agents 44Eye (Ophthalmic) Agents 45Gastrointestinal Agents 47Hematologic Agents 49Immune System Agents 50Musculoskeletal Agents 51OB/GYN Agents 51Pain Medications 53Respiratory Agents 54Urinary/Genitourinary Agents 56Wound Care 56Miscellaneous Therapeutic Agents 56Natural and Herbal Agents 57

III COMMONLY PRESCRIBED MEDICATIONS: 59GENERIC AND SELECTED BRAND DATA

IV COMMONLY USED MEDICINAL HERBS 323

V COMMON STREET DRUGS 337

VI TABLES 345Table VI-1 Comparison of Systemic Steroids 345Table VI-2 Topical Steroid Preparations 346Table VI-3 Comparison of Insulins 348Table VI-4 Commonly Used Oral Contraceptives 349Table VI-5 Some Common Oral Potassium Supplements 352Table VI-6 Common Multivitamins Available OTC 353Table VI-7 Antiarrhythmics: Vaughn Williams Classification 354Table VI-8 Cytochrome P-450 Isoenzymes and Common 355

Drugs They Metabolize, Inhibit, and InduceTable VI-9 SSRIs/SNRI/Triptan and Serotonin Syndrome 357Table VI-10 Weight Conversion Table 358

iv Contents

Table VI-11 Burn Management: Rule of “9’s” 359and Parkland Formula

Table VI-12 Adult Injury Severity Measures 360(Glasgow Coma Score and Revised Trauma Score)

Table VI-13 Pediatric Injury Severity Measures 362(Glasgow Coma Score and Pediatric Trauma Score)

Table VI-14 APGAR Scoring for Newborns 364Table VI-15 Bioterrorism Agents 365Table VI-16 List of Substances with a General Overview 370

of Prehospital Treatment and Specific Antidotes for Poisoning and Overdose

Table VI-17 Rapid Sequence Induction (RSI) Intubation 374Table VI-18 Cardiac Algorithms: ADULT 376Table VI-19 Cardiac Algorithms: PEDIATRIC 382

INDEX 387

ADULT EMERGENCY CARDIAC CARE MEDICATIONS

INSIDE BACK COVER AND BACK PAGE

Contents v

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EDITOR

Patrick T. Gomella, MPH, NREMT-PClass of 2013Jefferson Medical CollegeThomas Jefferson UniversityPhiladelphia, PennsylvaniaFirefighter/ParamedicConcordville Fire and Protective AssociationConcordville, Pennsylvania

ASSOCIATE EDITORS

Rex Mathew, MD, FACEPVice President for Emergency Medicine Clinical Operations Thomas Jefferson University HospitalsAssistant ProfessorDepartment of Emergency MedicineThomas Jefferson UniversityPhiladelphia, Pennsylvania

Matthew McMullan, BS, NREMT-P, CCEMT-P, FP-CParamedic/FirefighterMalvern Fire CompanyMalvern, Pennsylvania

David J. Schoenwetter, DO, PhP, FACEPMedical Director, Geisinger EMSMedical Director, Geisinger Life FlightAttending Physician, Emergency MedicineGeisinger Health SystemDanville, Pennsylvania

Jason P. Zielewicz, MS, NREMT-PPlatoon ChiefSusquehanna Health/Regional EMSSenior PartnerEMERGE Public Safety, LLC.Williamsport, Pennsylvania

EDITORS

vii

CONSULTING EDITORS

Aimee G. Adams, PharmDClinical Pharmacist Specialist, Ambulatory CareAdjunct Assistant ProfessorCollege of Pharmacy and Department of Internal MedicineUniversity of Kentucky HealthCareLexington, Kentucky

Judith A. Barberio, PhD, APN,C, ANP, FNP, GNPAssistant ProfessorCoordinator, Adult & Family Nurse Practitioner TracksRutgers, The State University of New JerseyCollege of NursingNewark, New Jersey

Leonard G. Gomella, MD, FACSThe Bernard W. Godwin, Jr, ProfessorChairman, Department of UrologyJefferson Medical CollegeAssociate Director of Clinical AffairsKimmel Cancer CenterThomas Jefferson UniversityPhiladelphia, Pennsylvania

Tricia L. Gomella, MDPart-Time Clinical Assistant Professor of PediatricsJohns Hopkins University School of MedicineBaltimore, Maryland

Steven A. Haist, MD, MS, FACPClinical ProfessorDepartment of MedicineDrexel University College of Medicine,Philadelphia, Pennsylvania

Nick A. Pavona, MDProfessor, Department of SurgeryBenjamin Franklin University Medical CenterChadds Ford, Pennsylvania

CONTRIBUTORS AND TECHNICAL REVIEWERS

Carol Beck, PhDAssistant Dean, Jefferson College of Graduate StudiesAssistant Professor, Department of Pharmacology and Experimental Therapeutics

Thomas Jefferson UniversityPhiladelphia, Pennsylvania

viii Editors

Shawn M. Maguire, BS, NREMT-BEmergency Medical TechnicianUniversity Ambulance ServicePennsylvania State UniversityUniversity Park, Pennsylvania

Glenn R. Oettinger, PharmDClinical Pharmacist, Emergency MedicineThomas Jefferson University HospitalPhiladelphia, Pennsylvania

Editors ix

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xi

PREFACE

I am pleased to present the first edition of the EMS Pocket Drug Guide. This guideis based on the popular Clinician’s Pocket Drug Reference and adapted for use inthe field by front-line EMS providers.

As an EMS provider, I found the many “pocket” drug guides available wereeither too large to carry while working or did not provide sufficient drug informa-tion beyond simply listing a name and classification. While knowing the drug classis useful for formulating a medically sound treatment plan for your patient, addi-tional drug-specific information is often necessary to tailor your treatment basedon the specific drugs your patient is currently prescribed. Recent data suggests that51% of insured Americans take at least one prescription drug for at least onechronic condition and over 20% of the US population take three or more medica-tions chronically. Knowing key drug information in the field is becoming moreessential as people begin to use more and more prescription medications.

This book provides several resources that can be accessed quickly to providethe best care possible. A section is devoted to descriptions of over 70 drugs com-monly used in the pre-hospital setting, followed by descriptions of about 1000 ofthe most commonly used prescription and over-the-counter medications. Knowingthe dosing commonly used for FDA approved and so called off label uses is helpfulin determining if an excessive dose was ingested. A section on commonly usedmedicinal herbs and supplements is also included as some of these can be veryclinically significant. A section dedicated to “street drugs” is also included forquick reference.

A key feature of this guide is the concise “must know” medication informationwith drug-specific EMS pearls, which includes signs and symptoms of overdoseand any specific overdose management. This guide is designed with sufficientdetail while maintaining its utility as a truly pocket drug reference. The book alsoincludes several reference charts and tables relevant to pre-hospital care.

I would like to thank Joe Morita and the entire production staff at McGraw-Hillfor their willingness to bring this book to the emergency service provider. Theopportunity to use the Clinician’s Pocket Drug Reference as a basis for the com-monly used medications and adapt this information for the EMS provider is appreci-ated. I would also like to thank my associate editors, consulting editors, contributors,and technical reviewers who were asked to provide input to the book often on veryshort notice. And lastly, my sincerest thanks go to my entire family, several of whom

helped with various aspects of this book, for their support and guidance during theprocess.

I encourage providers to take an active role and provide constructive feedbackabout this book. Please feel free to e-mail me with any suggestions, drugs or refer-ence charts you would like to see included in future editions.

Patrick T. Gomella, MPH, NREMT-PPhiladelphia, Pennsylvania

xii Preface

CONTROLLED SUBSTANCE CLASSIFICATIONMedications under the control of the US Drug Enforcement Agency (Schedules I–Vcontrolled substances) are indicated by the symbol [C]. Most medications are “uncontrolled” and do not require a DEA prescriber number on the prescription. Thefollowing is a general description for the schedules of DEA-controlled substances:

xiii

MEDICATION KEY

Medications are generally listed by prescribing class and the individual medica-tions are then listed in alphabetical order by generic name for both EMS fieldmediations (Section I) and the commonly prescribed medications (Section III).Some of the more frequently recognized trade names are listed for each medication(in parentheses after the generic name) or if available without prescription, notedas OTC (over-the-counter).

Generic Drug Name (Selected Common Brand Names)[Controlled Substance] [Drug Classification] WARNING:Summarized versions of the “Black Box” precautions deemed necessaryby the FDA. These are significant precautions and contraindications con-cerning the individual medication. Uses: This includes both FDA-labeledindications bracketed by ** and other “off-label” uses of the medication.Because many medications are used to treat various conditions based onthe medical literature and not listed in their package insert, we list com-mon uses of the medication in addition the official “labeled indications”(FDA approved) based on input from our editorial board Action: Howthe drug works. This information is helpful in comparing classes of drugsand understanding side effects and contraindications Dose: Adults. Whereno specific pediatric dose is given, the implication is that this drug is notcommonly used or indicated in that age group. Caution: [pregnancy/fetalrisk categories, breast-feeding (as noted below)] precautions concerningthe use of the drug in specific settings Contra: Contraindications Disp:Drug primary formulation or route (ie, IV, Tabs, and Susp) SE: Commonor significant side effects EMS: Important facts/information relevant toEMS providers in the field OD: Common symptoms of overdose andspecific treatment suggestions if available and appropriate

Schedule (C-I) I: All nonresearch use forbidden (eg, heroin, LSD, mescaline).

Schedule (C-II) II: High addictive potential; medical use accepted. No tele-phone call-in prescriptions; no refills. Some states require special prescription form(eg, cocaine, morphine, methadone).

Schedule (C-III) III: Low to moderate risk of physical dependence, high risk ofpsychologic dependence; prescription must be rewritten after 6 months or five refills (eg, acetaminophen plus codeine).

Schedule (C-IV) IV: Limited potential for dependence; prescription rules sameas for schedule III (eg, benzodiazepines, propoxyphene).

Schedule (C-V) V: Very limited abuse potential; prescribing regulations oftensame as for uncontrolled medications; some states have additional restrictions.

FDA FETAL RISK CATEGORIES

Category A: Adequate studies in pregnant women have not demonstrated a riskto the fetus in the first trimester of pregnancy; there is no evidence of risk in thelast two trimesters.

Category B: Animal studies have not demonstrated a risk to the fetus, but noadequate studies have been done in pregnant women.

orAnimal studies have shown an adverse effect, but adequate studies in pregnantwomen have not demonstrated a risk to the fetus during the first trimester of preg-nancy, and there is no evidence of risk in the last two trimesters.

Category C: Animal studies have shown an adverse effect on the fetus, but noadequate studies have been done in humans. The benefits from the use of the drugin pregnant women may be acceptable despite its potential risks.

orNo animal reproduction studies and no adequate studies in humans have been done.

Category D: There is evidence of human fetal risk, but the potential benefits fromthe use of the drug in pregnant women may be acceptable despite its potential risks.

Category X: Studies in animals or humans or adverse reaction reports, or both,have demonstrated fetal abnormalities. The risk of use in pregnant women clearlyoutweighs any possible benefit.

Category ?: No data available (not a formal FDA classification; included toprovide complete dataset).

xiv Medication Key

BREAST-FEEDING CLASSIFICATIONNo formally recognized classification exists for drugs and breast-feeding althoughthe FDA is considering developing one. This shorthand was developed for theClinician’s Pocket Drug Reference.

+ Compatible with breast-feedingM Monitor patient or use with caution± Excreted, or likely excreted, with unknown effects or at unknown

concentrations?/− Unknown excretion, but effects likely to be of concern− Contraindicated in breast-feeding? No data available

Medication Key xv

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xvii

* *: FDA-labeled indicationsbracketed by asterisks

#: drugs marked with this in Section Ihave additional information onprescription use included in thegeneric drug section (Section III)

÷: divided�: check or monitor↑ glucose: hyperglycemia↑ HR: increased heart rate

(tachycardia)↑: increase or increased↓ BM: bone marrow suppression,

myelosuppression↓ BP: hypotension↓ plt: decreased platelets

(thrombocytopenia)↓: decrease or decreased5-FU: 5-fluorouracil (chemotherapy

drug)5-HT: 5-hydroxytryptamineAA: African AmericanAB: abortionAb: antibodyabd: abdomen/abdominalABMT: autologous bone marrow

transplantationAbs: antibodiesac: before meals (Latin “ante cibum”)ACE: angiotensin-converting enzymeACEI: angiotensin-converting

enzyme inhibitor

ACLS: advanced cardiac life supportACS: acute coronary syndrome,

American Cancer Society,American College of Surgeons

ADH: antidiuretic hormoneADHD: attention-deficit

hyperactivity disorderADR: adverse drug reactionAE: adverse eventsAF: atrial fibrillationAHA: American Heart AssociationAl: aluminumALL: acute lymphocytic leukemiaALS: amyotrophic lateral sclerosisALT: alanine aminotransferase

(a liver enzyme)AMI: acute myocardial infarctionAML: acute myelogenous leukemiaamp: ampuleAMS: acute myocardial syndromeANC: absolute neutrophil countANS: autonomic nervous systemAPACHE: Acute Physiologic and

Chronic Health Evaluation; ICUillness severity scoring system

APAP: acetaminophen [N-acetyl-p-aminophenol]

aPTT: activated partialthromboplastin time

ARB: angiotensin II receptor blockerARDS: adult respiratory distress

syndrome

ABBREVIATIONS

ARF: acute renal failureASA 1-5: American Society of

Anesthesiology; 1-5 scoringsystem for anesthesia risk

ASA: aspirin (acetylsalicylic acid)ASAP: as soon as possibleAUB: abnormal uterine/vaginal

bleedingAUC: area under the curveAV: atrioventricularAVM: arteriovenous malformation

(blood vessel abnormality)b/c: becauseBB: beta blockersBCL: B-cell lymphomaBCL-ABL: a type of cancer genebid: twice a day (Latin “bis in die”)BiPAP: bilevel continuous airway

pressureBM: bone marrow; bowel movementBMT: bone marrow transplantationBOO: bladder outlet obstructionBP: blood pressureBPH: benign prostatic hypertrophybpm: beats per minuteBSA: body surface areaBUN: blood urea nitrogen (measure

of hydration and kidney function)BW: body weightC: constipationCa/Ca2+: calciumCA: cancerCABG: coronary artery bypass graftCAD: coronary artery diseaseCAP: community acquired pneumoniacaps: capsulecardiotox: cardiotoxicityCBC: complete blood countCCB: calcium channel blockerCF: cystic fibrosiscGMP: cyclic GMP, an intracellular

chemical

CHF: congestive heart failureCHI: closed head injuryCLA: cis-linoleic acidCLL: chronic lymphocytic leukemiaCML: chronic myelogenous leukemiaCMV: cytomegalovirusCNS: central nervous systemComps: complicationsCOMT: catechol-O-methyltransferaseContra: contraindicatedCOPD: chronic obstructive

pulmonary diseaseCOX: cyclooxygenaseCP: chest painCPAP: continuous positive airway

pressureCPK: creatine phosphokinaseCPP: central precocious pubertyCR: controlled releaseCrCl: creatinine clearanceCRF: chronic renal failureCV: cardiovascularCVA: cerebrovascular accident,

costovertebral angleCVD: cardiovascular diseaseCVH: common variable

hypergammaglobulinemiaCYP: cytochrome p 450 (CYP)

isoenzymes (such asCYP3A/CYP2D6/CYP1A2) areimportant in increasing ordecreasing the effects andmetabolism of many medications(See Table XXX)

D/C: discontinued/t: due tod: dayD: diarrheaD5LR: 5% dextrose in lactated

Ringer’s solutionD5NS: 5% dextrose in normal salineD5W: 5% dextrose in water

xviii Abbreviations

DBP: diastolic blood pressureDI: diabetes insipidusDisp: dispensed as, how the drug is

suppliedDKA: diabetic ketoacidosisdL: deciliterDM: diabetes mellitusDMARD: disease-modifying

antirheumatic drug; drugs definedin randomized trials to decreaseerosions and joint space narrowingin rheumatoid arthritis (eg, D-penicillamine, methotrexate,azathioprine)

DN: diabetic nephropathyDOT: directly observed therapy

(method used commonly in thetreatment of infectious diseasesuch as sexually transmitteddisease or TB)

dppr: dropperDVT: deep venous thrombosisDz: diseaseEC: enteric-coatedECC 2005: Emergency Cardiac Care

guidelines 2005ECC: emergency cardiac careECG: electrocardiogramED: Emergency department, Erectile

dysfunctionEGFR: epidermal growth factor

receptor (cancer cell marker that isa target for anti-neoplastic therapy)

ELISA: enzyme-linkedimmunosorbent assay(measurement method)

EMIT: enzyme-multipliedimmunoassay test

epi: epinephrineEPS: extrapyramidal symptoms

(tardive dyskinesia, tremors andrigidity, restlessness [akathisia],

muscle contractions [dystonia],changes in breathing and heartrate); a side effect of somemedications

ER: extended releaseesp: especiallyESRD: end-stage renal diseaseET: endotrachealEtOH: ethanolext/exts: extractsF/U: follow upFACEP: Fellow American College

of Emergency PhysiciansFACP: Fellow American College

of PhysiciansFACS: Fellow American College

of SurgeonsFDA: Food and Drug AdministrationFe: ironFSH: follicle-stimulating hormoneFxn: functiong: gramGABA: gamma-aminobutyric acidGAD: generalized anxiety disorderG-CSF: granulocyte colony

stimulating factorgen: generationGERD: gastroesophageal reflux

diseaseGF: growth factorGFR: glomerular filtration rateGH: growth hormoneGHB: gamma hydroxybutyrateGI: gastrointestinalGIST: gastrointestinal stromal tumorGLA: gamma-linoleic acidGM-CSF: granulocyte-macrophage

colony-stimulating factorGnRH: gonadotropin-releasing

hormonegt, gtt: drop, drops (Latin “gutta”)GTT: glucose tolerance test

Abbreviations xix

GU: genitourinaryGVHD: graft vs host diseaseh: hour(s)HA: headacheHCG human chorionic gonadotropinHCL: hairy cell leukemiaHct: hematocritHCTZ: hydrochlorothiazideHD: hemodialysisHDAC: histone deacetylaseHep: hepatitishepatotox: hepatotoxicityHER2: type of cancer geneHF: heart failureHFA: designation for type of

inhalation deviceHgb: hemoglobinHIT/HITTS: heparin-induced

thrombocytopeniaHIV: human immunodeficiency virusHMG-CoA: hydroxymethylglutaryl

coenzyme A (liver enzymeimportant in cholesterolmetabolism)

HPA: hypothalamic pituitary axisHPV: human papilloma virusHR: heart ratehs: at bedtime (Latin “hora somni”)HSV: herpes simplex virusHTN: hypertensionHx: history ofI&O: intake & outputI: iodineIBD: irritable bowel diseaseIBS: irritable bowel syndromeIBW: ideal body weightICP: intracranial pressureIFIS: intraoperative floppy iris

syndromeIg: immunoglobulinIGF-1/HGH: types of human growth

factors

IHSS: idiopathic sub aortic stenosisIM: intramuscularIN: intranasalInf: infusionInfxn: infectionInh: inhalationINH: isoniazidINR: international normalized ratioInsuff: insufficiencyIntravag: intravaginalIO: intraosseous infusion/injectionIOP: intraocular pressureISA: intrinsic sympathomimetic

activityIT: intrathecalITP: idiopathic thrombocytopenic

purpuraIV: intravenousIVP: intravenous pushJRA: juvenile rheumatoid arthritisK/K+: potassiumKVO: keep vein openL/d: liters per dayLA: long actingLDL: low-density lipoproteinLFT: liver function testLH: leuteinizing hormone LHRH: luteinizing hormone releasing

hormoneLi: lithium (lithium is used to treat

manic depression)Liq: liquidLMW: low molecular weight (usually

refers to a type of heparin)LOAD: mnemonic for pretreatment

for rapid sequence intubationLidocaine, Opioids, Atropine,Defasciculating agent

LOC: loss of consciousness, level ofconsciousness

LSD: lysergic acid diethylamideLVD: left ventricular dysfunction

xx Abbreviations

LVEF: left ventricular ejectionfraction

LVSD: left ventricular systolicdysfunction

MAC: Mycobacterium aviumcomplex (typical bacterialinfection in HIV orimmunocompromised patients)

maint: maintenanceMAO/MAOI: monoamine

oxidase/inhibitor (class of drugused typically to treat depression)

MDI: multidose inhalerMDS: myelodysplasia syndromemeds: medicationsmEq: milliequivalentMg/Mg2+: magnesiumMI: myocardial infarction, mitral

insufficiencymL: milliliterMMR: measles mumps rubellaMMRV: measles-mumps-rubella

vaccineMoAb: monoclonal antibody mod: moderateMRSA: methicillin-resistant

Staphylococcus aureusMS: multiple sclerosisMSSA: methicillin-sensitive

Staphylococcus aureusMTT: monotetrazoliumMTX: methotrexate (chemotherapy

agent)MyG: myasthenia gravisN/A: no applicable, not appropriateN/V/D/C: nausea, vomiting, diarrhea,

constipationN/V/D: nausea, vomiting, diarrheaN/V: nausea and vomitingN: nauseaNa/Na2+: sodiumNA: narrow angle

NAG: narrow angle glaucomaNBC: nuclear, biological, and

chemicalneb: nebulizernephrotox: nephrotoxicityneurotox: neurotoxicityng: nanogramNG: nasogastricNHL: non-Hodgkin lymphomanl: normalNMDA: N-methyl-D-aspartateNNRTI: nonnucleoside reverse

transcriptase inhibitor (class ofdrugs to treat HIV infections)

NO: nitric oxideNPO: nothing by mouth

(Latin “nil per os”)NRTI: nucleoside reverse

transcriptase inhibitor (class ofdrugs to treat HIV infections)

NS: normal salineNSAID: nonsteroidal

antiinflammatory drugNSCLC: non small cell lung cancerNSS: normal saline solutionNYHA: New York Heart AssociationOAB: overactive bladderOCD: obsessive-compulsive disorderOCP: oral contraceptive pill (birth

control pills)OD: overdoseODT: orally disintegrating tabletsoint: ointmentOJ: orange juiceOK: recommended or acceptableophthal: ophthalmicOTC: over the counterototox: ototoxicityP: phosphorusPABA: para-amino benzoic acidPAT: paroxysmal atrial tachycardiapc: after eating (Latin “post cibum”)

Abbreviations xxi

PCa: cancer of the prostatePCI: percutaneous coronary

interventionPCN: penicillinPCP: phencyclidinePCP: Pneumocystis jiroveci

(formerly carinii) pneumonia (a type of infection common in HIVinfected or immunocompromisedpatients)

PCWP: pulmonary capillary wedgepressure

PDE5: phosphodiesterase type 5;drugs used to treat conditions suchas erectile dysfunction, e.g.,sildenafil, interfere with thisenzyme

PDGF: platelet-derived growth factorPE: pulmonary embolus, physical

examination, pleural effusionPEA: pulseless electrical activityPFT: pulmonary function testpg: picogramPh +: a type of genetic abnormality

(Philadelphia chromosome)Photosens: photosensitivityPID: pelvic inflammatory diseaseplt: plateletPMDD: premenstrual dysphoric

disorderPMH: past medical historyPO: by mouth (Latin “per os”)PPD: purified protein derivativePR: by rectumPrep: preparationPRG: pregnancyPRN: as needed (Latin “pro re nata”)PSVT: paroxysmal supraventricular

tachycardiapt: patientPT: prothrombin time (to measure

anticoagulant drug warfarin)

PTCA: percutaneous transluminalcoronary angioplasty

PTH: parathyroid hormonePTT: partial thromboplastin timePUD: peptic ulcer diseasepulm: pulmonaryPVC: premature ventricular

contractionPVD: peripheral vascular diseasePWP: pulmonary wedge pressurePx: preventionq: every (Latin “quaque”)q_h: every__hours (Latin

“quaque_hora”)q_min: every__minuteqd: every dayqh: every hourqhs: every hour of sleep

(before bedtime)qid: four times a day

(Latin “quater in die”)qod: every other dayqowk: every other weekqwk: every weekRA: rheumatoid arthritisRAAS: rennin-angiotensin

aldosterone systemRAS: renal artery stenosisRBBB: right bundle branch blockRBC: red blood cell(s)RCC: renal cell carcinomaRDA: recommended dietary allowanceRDS: respiratory distress syndromeresp: respiratoryRLS: restless leg syndromeROSC: recovery of spontaneous

circulationRSI: rapid sequence

intubation/inductionRSV: respiratory syncytial virusRT: radiation therapyRT: reverse transcriptase

xxii Abbreviations

RTA: renal tubular acidosisRUQ: right upper quadrantRx: prescription or therapy

(Latin “recipe”)Rxn: reactionS/Sxs: signs and symptomss: second(s)SBP: systolic blood pressureSCI: spinal cord injurySCLC: small cell lung cancerSCr: serum creatinineSDV: single dose vialSE: side effectSIADH: syndrome of inappropriate

antidiuretic hormoneSL: sublingualSLE: systemic lupus erythematosusSLUDGE: mnemonic for

organophosphate poisoningsymptoms: Salivation,Lacrimation, Urination,Defecation, Gastrointestinalmotility, Emesis

SMX: sulfamethoxazoleSNRIs: serotonin-norepinephrine

reuptake inhibitors (class of drugsused to treat depression, e.g.,venlafaxine)

SOAP ME: mnemonic for rapidsequence induction/intubation:Suction, Oxygen, AirwayEquipment (including arescue/backup airway device ortechnique), Pharmacology,Monitoring Equipment

SOB: short of breathsoln: solutionsp: speciesSPAG: small particle aerosol

generatorSQ: subcutaneousSR: sustained release

SSRI: selective serotonin reuptakeinhibitor (class of drugs used totreat depression, e.g., sertraline)

SSS: sick sinus syndromestat: immediately (Latin “statim”)supl: supplement or suppliedsupp: suppositorySusp: suspensionSVT: supraventricular tachycardiaSx: symptomsynd: syndromeSz: seizuretab/tabs: tablet/tabletstach: tachycardiaTB: tuberculosisTBI: traumatic brain injuryTCA: tricyclic antidepressant (class

of drugs commonly used to treatdepression, e.g., amitriptyline)

TCP: transcutaneous pacingTD: transdermal TFT: thyroid function testTIA: transient ischemic attacktid: three times a day

(Latin “ter in die”)tinc: tinctureTMP: trimethoprim

(type of antibiotic)TMP–SMX: trimethoprim–

sulfamethoxazole (2 types ofantibiotic)

TNF: tumor necrosis factortox: toxicityTPA: tissue plasminogen activatortri: trimesterTSH thyroid stimulating hormonetsp: teaspoonTTP: thrombotic thrombocytopenic

purpura (rash due to low platelets)TTS: transdermal therapeutic systemTx: treatmentUC: ulcerative colitis

Abbreviations xxiii

ULN: upper limits of normalUPA: unsaturated pyrrolizidine

alkaloidsURI: upper respiratory infectionUTI: urinary tract infectionV: vomitingvag: vaginalVF: ventricular fibrillationVIPOMA: type of tumor that secretes

vasoactive intestinal peptide (VIP)vit: vitaminVRE: vancomycin-resistant

Enterococcus

VT: ventricular tachycardiaw/: withw/in: withinw/o: withoutwgt/wt: weightWHI: Women’s Health Initiativewk: weekWNL: within normal limitsWPW: Wolff–Parkinson–White

syndromeXR: extended releaseZE: Zollinger–Ellison (syndrome)Zn: zinc

xxiv Abbreviations

This section is designed as a rapid reference for those drugs commonly administeredin the field and is representative of general principles for these useful EMS medica-tions. Specific administration and dosing guidelines given are typical for pre-hospitalprotocols. Review your local protocol and make hand written corrections if differentguidelines given. A summary of the most recent 2005 American Heart AssociationCardiac Care medications are included as a quick reference table inside the backcover of this book.

I EMS Field Medications

PREHOSPITAL DRUG CLASSIFICATION ALLERGYAntihistaminesDiphenhydramine

(Benadryl)

ANTIDOTESActivated Charcoal

(SuperChar, Actidose,Liqui-Char Activated)

AtropineAtropine/Pralidoxime

[2-PAM] (DuoDote,NAAK, Mark-1)

Albuterol (Proventil,Ventolin, Volmax)

Amyl NitriteCalcium Salts (Chloride,

Gluconate)Cyanide Antidote Kit

(See Amyl Nitrate,Sodium Nitrite, andSodium Thiosulfate)

Flumazenil (Romazicon)

Hydroxocobalamin(Vitamin B12)

Naloxone (Narcan)Pralidoxime (2-PAM,

Protopam)Sodium NitriteSodium Thiosulfate

CARDIOVASCULAR (CV) AGENTSAngiotensin-Converting Enzyme (ACE) InhibitorsCaptopril (Capoten,

others)Enalapril (Vasotec)

Antiarrhythmic AgentsAdenosine (Adenocard)Amiodarone (Cordarone,

Pacerone)Atropine

Lidocaine (AnestaconTopical, Xylocaine,others)

Magnesium Sulfate (Various)

Procainamide(Pronestyl, PronestylSR, Procanbid)

1

2 EMS Pocket Drug Guide

CENTRAL NERVOUS SYSTEM AGENTS

Anesthetic Agents, General

Calcium Channel AntagonistsDiltiazem (Cardizem,

Cardizem CD,Cardizem SR, CartiaXT, Dilacor XR, Diltia XT, Taztia XT,Tiamate, Tiazac)

Verapamil (Calan,Isoptin, Verelan)

Bumetanide (Bumex) Furosemide (Lasix) Mannitol (Osmitrol, others)

Diuretics

Inotropic/Pressor AgentsDobutamine (Dobutrex)Dopamine (Intropin)Epinephrine (Adrenalin,

Sus-Phrine, EpiPen,EpiPen Jr, others)

Isoproterenol (Isuprel)Norepinephrine

(Levophed)

Phenylephrine, Nasal(Neo-Synephrine,nasal)

Nitroglycerin (Nitrostat,Nitrolingual, Nitro-BidOintment, Nitro-Bid IV,Nitrodisc, Transderm-Nitro, others)

Vasodilators

Ketamine (Ketalar)

Antianxiety AgentsLorazepam (Ativan) Diazepam (Valium,

Diastat)

Anticonvulsants

Diazepam (Valium, Diastat)

Lorazepam (Ativan, others)

Midazolam (Hypnovel,Versed)

AntipsychoticsHaloperidol (Haldol) Ziprasidone (Geodon)

Section I: EMS Field Medications 3

DIETARY SUPPLEMENTS

Sedative Hypnotics

Diphenhydramine(Benadryl)

Etomidate (Amidate) Midazolam (Hypnovel,Versed)

Calcium Salts [Chloride,Gluconate]

Dextrose, 25%, 50%

Sodium Bicarbonate[NaHCO3]

Thiamine [Vitamin B1]

ENDOCRINE SYSTEM AGENTS

Antidiabetic Agents

Insulin, injectable

Hormone & Synthetic Substitutes

Dexamethasone(Decadron)

Glucagon (GlucaGen)

Oxytocin (Pitocin) Vasopressin (Pitressin)

GASTROINTESTINAL AGENTS

Antiemetics

Ondansetron (Zofran,Zofran ODT)

Promethazine(Anergan, Phenergan)

Metoclopramide(Reglan, Clopra,Octamide)

HEMATOLOGIC AGENTS

Anticoagulants

Heparin

Antiplatelet Agents

Aspirin (Bayer, Ecotrin,St. Joseph’s)

Antithrombotic Agents

Alteplase, Recombinant[tPA] (Activase) (See tissue plasmino-gen activator)

Streptokinase (Streptase,Kabikinase)

4 EMS Pocket Drug Guide

OB/GYN AGENTS

Miscellaneous Ob/Gyn Agents

Magnesium Sulfate (Various)

Oxytocin (Pitocin)

Terbutaline (Brethine,Bricanyl)

PAIN MEDICATIONS

Local Anesthetics

Tetracaine (Pontocaine)

Narcotic Analgesics

Fentanyl (Sublimaze)Hydromorphone

(Dilaudid)Meperidine (Demerol)

Morphine (Avinza XR,Duramorph, Infu-morph, MS Contin,Kadian SR, OramorphSR, Palladone, Roxanol)

Nalbuphine (Nubain)

Nonnarcotic Analgesics

Aspirin (Bayer, Ecotrin, St. Joseph’s)

Nonsteroidal Anti-inflammatory Agents

Ketorolac (Toradol)

Miscellaneous Pain Medications

Nitrous Oxide (Nitronox, Entonox)

MUSCULOSKELETAL AGENTS

Muscle Relaxants

Diazepam (Diastat, Valium)

Neuromuscular Blockers

Pancuronium (Pavulon)Rocuronium (Zemuron)

Succinylcholine(Anectine, Quelicin,Sucostrin, others)

Vecuronium (Norcuron)

Section I: EMS Field Medications 5

# indicates additional information on prescription use inSection III.

Activated Charcoal (SuperChar, Actidose, Liqui-Char activated)[Adsorbent] Uses: Emergency poisoning by most drugs & chemicals (seeContra) Action: Adsorbent detoxicant Dose: Adults. 1 g/kg Peds. 1 g/kg Caution:[C, ?] May cause V (hazardous w/ petroleum & caustic ingestions); do not mix w/dairy Contra: Not effective for cyanide, mineral acids, caustic alkalis, organic sol-vents, iron, EtOH, methanol poisoning, Li; do not use sorbitol in pts w/ fructoseintolerance, intestinal obst, nonintact GI tracts; do not use in pts w/ depressed men-tal status unless via NG tube Disp: Powder, Liq, caps SE: Some Liq dosage formsin sorbitol base (a cathartic); V/D, black stools, constipation Notes: Charcoal w/sorbitol not OK in children <1 y; monitor for ↓ K+ & Mg2+; protect airway in lethargic/comatose pts Interactions: ↓ Effects if taken W/ ice cream, milk, sherbet; ↓ effectsOF digoxin & absorption of other oral meds, ↓ effects OF syrup of ipecac EMS:Contact Poison Control/Medical Command before administration; most effective ifgiven w/in 30 min of acute poisoning; only give PO to conscious pts; can be givenvia NG tube in conscious or unconscious pts; protect airway from aspiration; shakewell and can be mixed w/ ice/water (or fruit juice) to make more palatableAdenosine (Adenocard) [Antiarrhythmic/Nucleoside] Uses:PSVT (refractory to vagal maneuvers); including w/ WPW Action: Class IV

Respiratory Inhalants

Ipratropium (Atrovent HFA, Atrovent Nasal)

Miscellaneous Respiratory AgentsMagnesium Sulfate

(Various)Methylprednisolone

Succinate & Acetate(Solu-Medrol,Depot-Medrol)

Oxygen

RESPIRATORY AGENTS

BronchodilatorsAlbuterol (Proventil,

Ventolin, Volmax)Albuterol & Ipratropium

(Combivent, DuoNeb)Aminophylline

Epinephrine (Adrenalin,Sus-Phrine, EpiPen,EpiPen Jr, others)

Epinephrine, Racemic(microNefrin)

Isoproterenol (Isuprel)Metaproterenol

(Alupent, Metaprel)Terbutaline (Brethine,

Bricanyl)

6 Albuterol

antiarrhythmic; slows AV node conduction Dose: Adults. 6 mg rapid IVP, followed w/ saline flush, elevate extremity; may repeat at 12 mg in 1–2 min if no conversion,followed by another 12 mg if needed Peds. 0.1 mg/kg IV bolus; may repeat once in1–2 min at 0.2 mg/kg if no conversion Caution: [C, ?] pts w/ asthma Contra: 2nd- or3rd-degree AV block or SSS (w/o pacemaker); recent MI or cerebral hemorrhageDisp: Inj 3 mg/mL SE: Facial flushing, HA, dyspnea, chest pressure, ↓ BP Interac-tions: ↓ Effects W/ theophylline, caffeine, guarana; ↑ effects W/ dipyridamole; ↑ riskof hypotension & chest pain W/ nicotine; ↑ risk of bradycardia W/ BBs; ↑ risk of heartblock W/ carbamazepine; ↑ risk of ventricular fibrillation W/ digitalis glycosidesEMS: Administer in a large proximal vein; monitor BP, pulse and ECG during ther-apy, monitor resp status; ↑ risk of bronchospasm in asthmatics; max single dose is 12 mg; can cause momentary asystole when administered; not as effective in the pres-ence of methylxanthines and caffeine; discard unused or unclear solnAlbuterol# (Proventil, Ventolin, Volmax) [Bronchodilator/Adrenergic] Uses: Asthma; prevent exercise-induced bronchospasm; hyper-kalemia Action: β-Adrenergic sympathomimetic bronchodilator; relaxes bronchialsmooth muscle Dose: Adults. MDI: 2 sprays Neb: 1.25–5 mg (0.25–1 mL of 0.5%soln in 2–3 mL of NS) Peds. MDI: 2 sprays Neb: 0.05 mg/kg (max 2.5 mg) in 2–3 mLof NS Caution: [C, +] Disp: Tabs 2, 4 mg; XR tabs 4, 8 mg; syrup 2 mg/5 mL; 90 mcg/dose met-dose inhaler; soln for neb 0.083, 0.5% SE: Palpitations, tach, ner-vousness, GI upset Interactions: ↑ Effects W/ other sympathomimetics; ↑ CVeffects W/ MAOI, TCA, inhaled anesthetics; ↓ effects W/ BBs; ↓ effectiveness OFinsulin, oral hypoglycemics, digoxin EMS: Monitor HR, BP, S/Sxs bronchospasm &CNS stimulation (esp in children); instruct on proper use of inhaler; can use neb inO2 mask for handsfree use; causes transient ↑ in glucose and ↓ in K post inhalationAlbuterol & Ipratropium# (Combivent, DuoNeb) [Bronchodilator/Adrenergic, Anticholinergic] Uses: COPD,Bronchospasm Action: Combo of β-adrenergic bronchodilator & quaternary anti-cholinergic Dose: Adults & Children >1. Neb: 3 mg in 2–3 mL of NS, may repeatonce Caution: [C, +] Contra: Peanut/soybean allergy Disp: Met-dose inhaler;soln for neb (DuoNeb) SE: Palpitations, tach, nervousness, GI upset, dizziness,blurred vision Interactions: ↑ Effects W/ anticholinergics, including ophthalmicmeds; ↓ effects W/ herb jaborandi tree, pill-bearing spurge EMS: Combivent—MDI form, DuoNeb—nebulized form; determine if pt has a peanut allergy as thisis a contraindication; esp useful in bronchospasm w/ excess secretions; monitorHR, BP, S/Sxs bronchospasm & CNS stimulation (esp in children); instruct onproper use of inhaler; can use neb in O2 mask for handsfree use; causes transient ↑in glucose and ↓ in K post inhalation; may cause transient blurred vision/irritationAlteplase Recombinant [tPA] (Activase) (See tissue plasminogenactivator)Aminophylline [Bronchodilator/Xanthine Derivative] Uses:Asthma, COPD & bronchospasm Action: Relaxes smooth muscle (bronchi, pulm

Amyl Nitrite 7

vessels); stimulates diaphragm Dose: Adults. Acute asthma: Load 6 mg/kg IV, then0.4–0.9 mg/kg/h IV cont inf Peds. Load 6 mg/kg IV, then 1 mg/kg/h IV cont inf Cau-tion: [C, +] Uncontrolled arrhythmias, HTN, Sz disorder, hyperthyroidism, pepticulcers Disp: Tabs 100, 200 mg; PR tabs 100, 200 mg, soln 105 mg/5 mL, inj 25 mg/mLSE: N/V, irritability, tach, ventricular arrhythmias, Szs Interactions: ↓ Effects OFLi, phenytoin, adenosine; ↓ effects W/ phenobarbital, aminoglutethimide, barbiturates,rifampin, ritonavir, thyroid meds; ↑ effects W/ cimetidine, ciprofloxacin, erythromycin,INH, OCP, verapamil, tobacco, charcoal-broiled foods, St. John’s wort EMS: Very nar-row therapeutic range, determine pt history for other methylxanthine use (certain OTCcough medicines include methylxanthines); sudden ↑ BP may be a sign of toxAmiodarone (Cordarone, Pacerone) [Ventricular Antiarrhythmic/Adrenergic Blocker] WARNING: Liver tox, exac-erbation of arrhythmias and lung damage reported Uses: Recurrent VF or hemo-dynamically unstable VT, cardiac arrest w/ VF/VT, supraventricular arrhythmias,AF Action: Class III antiarrhythmic Dose: Adults. Life threatening ventriculararrhythmias: 150 mg over 10 min (15 mg/min) add 150 mg to 100 mL D5W andNS, followed by 1 mg/h over the next 6 h- total dose should not exceed 2.2 g Car-diac arrest: 300 mg IVP, may repeat once at 150 mg in 3–5 min Peds. 5 mg/kg IV/IOpush; max dose is 15 mg/kg Caution: [D, −] Contra: Sinus node dysfunction, 2nd-/3rd-degree AV block, sinus bradycardia (w/o pacemaker), iodine sensitivity Disp: Tabs 100, 200, 300, 400 mg; inj 50 mg/mL SE: Pulm fibrosis (w/ long-termuse), exacerbation of arrhythmias, prolongs QT interval; CHF, hypo/hyperthy-roidism, liver failure, corneal microdeposits, optic neuropathy/neuritis, peripheralneuropathy, photosens Interactions: ↑ Serum levels OF digoxin, quinidine, pro-cainamide, flecainide, phenytoin, warfarin, theophylline, cyclosporine; ↑ levels W/cimetidine, indinavir, ritonavir; ↓ levels W/ cholestyramine, rifampin, St. John’swort; ↑ cardiac effects W/ BBs, CCB EMS: May be used in place of lidocaine incardiac arrest; for loading dose, add 150 mg to 100 mL D5W or NS, infuse at a rateof 100 mL/10 min; monitor HR, BP; monitor ECG for increased PR and QRS &monitor lung sounds for drug induced pulm tox; may cause bradycardiaAmyl Nitrite [Nitrate Vasodilator] Uses: Tx of cyanide poisoningAction: Short-acting vasodilator, relaxes smooth muscle, & may help create cyan-methemoglobin to deactivate cyanides poisonous effects Dose: Adults & Peds.Amp (typically 0.3 mL) crushed and inhaled for about 30 s, may be repeatedq1–2min PRN until arrival at ED or if sodium nitrite is administered Caution:[C, ?] Contra: None in an emergency setting for acute cyanide poisoning; use cau-tion in pregnant pts, pts w/ chronic methemoglobinemia & in pts w/ a hypotensionrisk; Disp: 0.3 mL inhalant amp SE: N/V, hypotension, dizziness, flushing, skinrash, tach (some SEs related to the creation of methemoglobin) Interactions: ↑Risk of severe hypotension W/ PDE-5 inhibitors—ED drugs—(vardenafil, silde-nafil, tadalafil), EtOH, ASA, and CCBs EMS: Included in the commercially avail-able cyanide antidote kit (includes 12 amps of Amyl Nitrite); given by crushing

8 Aspirin

amp and holding in front of pts nose and mouth; this is a temporary Tx until an IVis established to administer sodium nitrite; is a drug that is commonly abusedbecause of its euphoric SEs (known as a “Popper”); related to nitroglycerinAspirin# (Bayer, Ecotrin, St. Joseph’s) [OTC] [Antipyretic,Analgesic/Salicylate] Uses: Angina; AMI Action: Prostaglandin inhibitorDose: Adults. Acute coronary synd: 160–325 mg PO ASAP (chewing preferred atonset) Caution: [C, M] Linked to Reye synd; avoid w/ viral illness in children Contra: Allergy to ASA, chickenpox/flu Sxs, synd of nasal polyps, angioedema, &bronchospasm to NSAIDs Disp: Tabs 325, 500 mg; chew tabs 81 mg; EC tabs 81,162, 325, 500, 650, 975 mg; SR tabs 650, 800 mg; effervescent tabs 325, 500 mg;supp 125, 200, 300, 600 mg SE: GI upset & erosion Interactions: ↑ Effects W/anticoagulants, ammonium chloride, antibiotics, ascorbic acid, furosemide, methio-nine, nizatidine, NSAIDs, verapamil, EtOH, feverfew, garlic, ginkgo biloba, horsechestnut, kelpware (black-tang), prickly ash, red clover; ↓ effects W/ antacids, acti-vated charcoal, corticosteroids, griseofulvin, NaHCO3, ginseng, food; ↑ effects OFACEI, hypoglycemics, insulin, Li, MTX, phenytoin, sulfonamides, valproic acid; ↓effects OF BBs, probenecid, spironolactone, sulfinpyrazone EMS: Baby aspirin ispreferred, enteric-coated aspirin should be avoidedAtropine [Antiarrhythmic/Anticholinergic] WARNING: Primaryprotection against exposure to chemical nerve agent and insecticide poisoning is thewearing of specially designed protective garments Uses: Preanesthetic; sympto-matic bradycardia & asystole, organophosphate (insecticide) and acetylcholinesterase(nerve gas) inhibitor antidote Action: Antimuscarinic; blocks acetylcholine atparasympathetic sites, cycloplegic Dose: Adults. Asystole or PEA: 1 mg IV/IO push.Repeat q3–5min (if asystole persists) to 3 mg max Bradycardia: 0.5–1.0 mg IVq3–5min as needed; max 3 mg; ET 2–3 mg in 10 mL NS Poisoning: 1–2 mg IV bolus,repeat q3–5min PRN to reverse effects Peds. Asystole or PEA: 0.01–0.03 mg/kg IVq2–5min, max 1 mg, min 0.1 mg Preanesthetic: 0.01 mg/kg/dose SQ/IV (max 0.4 mg)Poisoning: 0.05 mg/kg IV, repeat q10min PRN to reverse effects Caution: [C, +]Contra: tach, glaucoma Disp: Inj: 0.05, 0.1, 0.3, 0.4, 0.5, 0.8, 1 mg/mL AtroPenAutoInjector: 0.5, 1, 2 mg/dose MDI: 0.36 mg/inhal SE: Flushing, mydriasis, tach,dry mouth & nose, blurred vision, urinary retention, constipation, psychosis Interac-tions: ↑ Effects W/ amantadine, antihistamines, disopyramide, procainamide, quini-dine, TCA, thiazides, betel palm, squaw vine; ↓ effects W/ antacids, levodopa; ↓effects OF phenothiazines EMS: Use caution in pts w/ suspected MIs (use lowerdose); reflex bradycardia may occur if administered in small doses; may work in 2nd-degree, do not use in 3rd-degree heart block (use transcutaneous pacing); SLUDGEare Sxs of organophosphate/carbamate/nerve gas poisoning—personal safety is thepriority in cases of nerve or pesticide exposure; large doses may be required to treatS/Sxs of SLUDGE and is used in combination w/ valium and 2-PAMAtropine/Pralidoxime (2-PAM) (DuoDote) [Antiarrhythmic/Anticholinergic/Antidote] WARNING: For use by personnel w/

Atropine/Pralidoxime 9

appropriate training; wear protective garments; do not rely solely on medication;evacuation and decontamination as soon as possible Uses: Nerve agent andinsecticide poisoning Action: Atropine blocks effects of excess acetylcholine;pralidoxime reactivates acetylcholinesterase inactivated by organophosphorus poi-soning Dose: 1 inj in mid-lateral thigh; if Sxs progress or are severe, give 2 addi-tional injs Caution: [C, ?] Contra: None in life-threatening situations Disp:AutoInjector: 2.1 mg atropine/600 mg pralidoxime SE: Dry mouth, blurred vision,dry eyes, photophobia, confusion, HA, tach, flushing, urinary retention, constipa-tion, abd pain N/V, emesis Interactions: ↑ Effects W/ amantadine, antihistamines,disopyramide, procainamide, quinidine, TCA, thiazides, betel palm, squaw vine; ↑effects OF barbiturates; ↓ effects W/ antacids, levodopa; ↓ effects OF phenoth-iazines EMS: Personal safety is the priority in cases of nerve or pesticide expo-sure; pt should be receiving oxygen and be decontaminated to prevent furtherexposure; severe Sxs of poisoning include confusion, dyspnea w/ copious secre-tions, weakness & twitching, involuntary urination and defecation, convulsions,unconsciousness; give 1 pen for minor poisoning, give 2 additional pens for severe poisonings; can be used through clothes/NBC clothing; use an anticon-vulsant (diazepam—Adult 10 mg IV Peds 0.3 mg/kg IV, lorazepam—Adults 4 mgIV Peds 0.1 mg/kg IV) if Szs present; reassess q5min for Sxs resolution/worseningAtropine/Pralidoxime (2-PAM) (Nerve Agent Antidote Kit-NAAK; Mark 1 Injector Kit) (2 Injectors: 2 mg, Atropine; 600 mg, Pralidoxime) [Anticholinergic/Antidote] WARNING:Primary protection against exposure to chemical nerve agent and insecticide poison-ing is the wearing of specially designed protective garments Uses: Antidote fornerve agent or organophosphate poisoning (or similar poisoning) Action: Atropineblocks effects of excess acetylcholine; pralidoxime reactivates acetylcholinesteraseinactivated by organophosphorus poisoning Dose: Adults. Severe poisoning:(Severe resp distress, SLUDGE, agitation) 3 Mark 1 Kits (give 3 atropine then 3pralidoxime) max Pralidoxime dose is 1.8 g Moderate poisoning: (Resp distress,SLUDGE) 2 Mark 1 Kits (2 atropine and 1 pralidoxime) Mild/asymptomatic: NoMark 1 Kits but monitor for changes q5min Peds. Severe poisoning age 2–7: 1Mark 1 Kit Age 8–14: 2 Mark 1 Kits Contra: None in life-threatening emergencysetting Disp: AutoInjector 2.1 mg atropine/600 mg pralidoxime SE: Dry mouth,blurred vision, dry eyes, photophobia, confusion, HA, tach, flushing, urinary reten-tion, constipation, abd pain N/V, emesis Interactions: N/A for an emergency settingEMS: Personal safety is the priority in cases of nerve or pesticide exposure; ptshould be receiving oxygen and be decontaminated to prevent further exposure; canbe used through clothes/NBC clothing; severe Sxs of poisoning include confusion,dyspnea w/ copious secretions, weakness & twitching, involuntary urination anddefecation, convulsions, unconsciousness; use an anticonvulsant (diazepam—Adult10 mg IV Peds 0.3 mg/kg IV, lorazepam—Adults 4 mg IV Peds 0.1 mg/kg IV) ifSzs present; reassess q5min for Sxs resolution/worsening

10 Bumetanide

Bumetanide# (Bumex) [Diuretic/Loop] Uses: Edema from CHFand pulm edema Action: Loop diuretic; ↓ reabsorption of Na+ & Cl−, in ascendingloop of Henle & the distal tubule Dose: Adults. 0.5–1 mg IV/IM Caution: [D, ?]Pregnancy Contra: Anuria, hepatic coma, severe electrolyte depletion Disp: Tabs0.5, 1, 2 mg; inj 0.25 mg/mL SE: ↓ K+, ↓ Na+, ↑ Cr, ↑ uric acid, dizziness, ototoxInteractions: ↑ Effects W/ antihypertensives, thiazides, nitrates, EtOH, clofibrate;↑ effects OF Li, warfarin, thrombolytic drugs, anticoagulants; ↑ K+ loss W/ car-benoxolone, corticosteroids, terbutaline; ↑ ototox W/ aminoglycosides, cisplatin; ↓effects W/ cholestyramine, colestipol, NSAIDs, probenecid, barbiturates, pheny-toin EMS: High doses in the elderly may cause profound hypotension and CV col-lapse; more potent than furosemideCalcium Chloride [Calcium Supplement, Electrolyte] Uses: Ca2+

replacement, Ca2+ blocker tox, Mg2+ intox, ↑ K+ Action: Ca2+ supl/replacement Dose:Hypocalcemia, hyperkalemia, hypermagnesemia and CCB tox Adults. 5–10 mL10% soln IV PRN q5–10min Peds. 0.1–0.2 mL/kg 10% soln PRN q10min Caution:[C, ?] Contra: ↑ Ca2+ Disp: CaCl inj 10% = 100 mg/mL = Ca 27.2 mg/mL = 10-mLamp; Ca gluconate inj 10% = 100 mg/mL = Ca 9 mg/mL; tabs 500 mg = 45 mg Ca,650 mg = 58.5 mg Ca, 975 mg = 87.75 mg Ca, 1 g = 90 mg Ca; Ca gluceptate inj220 mg/mL = 18 mg/mL Ca SE: Bradycardia, cardiac arrhythmias, ↑ Ca2+

Interactions: ↑ Effects OF quinidine and digitalis; ↓ effects OF tetracyclines,quinolones, verapamil, CCBs, Fe salts, ASA, atenolol; ↓ Ca absorption W/ highintake of dietary fiber EMS: Preferred over calcium gluconate d/t higher Ca2+ con-centration; use caution to prevent extravasation (avoid small veins, inj slowly);incompatible w/ NaHCO3

Calcium Gluconate [Calcium Supplement, Electrolyte] Uses:Ca2+ replacement, Ca2+ blocker tox, Mg2+ intox, ↑ K+ Action: Ca2+ supl/replacementDose: Hypocalcemia, hyperkalemia, hypermagnesemia and CCB tox Adults.10–20 mL 10% soln IV PRN q5–10min Peds. 0.2–0.3 mL/kg 10% soln PRNq5–10min Caution: [C, ?] Contra: ↑ Ca2+ Disp: CaCl inj 10% = 100 mg/mL = Ca27.2 mg/mL = 10-mL amp; Ca gluconate inj 10% = 100 mg/mL = Ca 9 mg/mL;tabs 500 mg = 45 mg Ca, 650 mg = 58.5 mg Ca, 975 mg = 87.75 mg Ca, 1 g = 90 mgCa; Ca gluceptate inj 220 mg/mL = 18 mg/mL Ca SE: Bradycardia, cardiac arrhyth-mias, ↑ Ca2+ Interactions: ↑ Effects OF quinidine and digitalis; ↓ effects OF tetra-cyclines, quinolones, verapamil, CCBs, Fe salts, ASA, atenolol; ↓ Ca absorption W/high intake of dietary fiber EMS: Calcium chloride is preferred; use caution to pre-vent extravasation (avoid small veins, inj slowly); incompatible w/ NaHCO3

Captopril# (Capoten, Others) [Antihypertensive/ACEI] Uses:HTN, CHF Action: ACE inhibitor Dose: Adults. 25 mg PO (sublingual) Caution:[C (1st tri); D (2nd & 3rd tri) +]; unknown effects in renal impair Contra: Hxangioedema, bilateral RAS Disp: Tabs 12.5, 25, 50, 100 mg SE: Rash, proteinuria,cough, ↑ K+ Interactions: ↑ Effects W/ antihypertensives, diuretics, nitrates,probenecid, black catechu; ↓ effects W/ antacids, ASA, NSAIDs, food; ↑ effects