Ch. 15 Emergency Medications Flashcards by Derek Ross

Class:
Analgesic, antipyretic
Action:
Increases pain threshold by inhibiting cyclooxygenase and reduces fever by acting on the hypothalamus.
Has no anti-inflammatory properties or effect on platelets.
Indications:
Fever, pain relief
Contraindications:
Hypersensitivity and use caution in patients with liver disease.
Onset/Duration:
* Onset: 10-30 min PO
* Duration: 3-4 hours PO
Dose/route:
* Adult: 325-1000 mg PO every 4-6 hr
* Peds: 15 mg/kg PO/PR every 4-6 hr
Side Effects:
Nausea/vomiting, hepatotoxicity

Acetaminophen (APAP)

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Class: Carbonic anhydrase inhibitor, diuretic
Mechanism of action
a. Inhibits hydrogen ion excretion in the renal tubules
Indications
a. AMS (treatment and prophylaxis)
b. Prevention of HACE
Contraindications
a. Hypersensitivity to acetaZOLAMIDE or sulfa
b. Known hypokalemia or hyponatremia
c. Renal or liver dysfunction
d. Should not be used for the treatment of HAPE
Adverse reactions/side effects include:
a. Fluid and electrolyte imbalance
b. Metabolic acidosis
c. Seizures
d. Nausea
e. Vomiting
Drug interactions
a. Increased risk of severe acidosis and CNS toxicity with high-dose aspirin
b. Use caution with diuretics, anticonvulsants.
c. May potentiate the effects of hypoglycemics
d. Increased risk of renal calculus formation with sodium bicarbonate administration
Dosage and administration
a. Adult
i. 250 mg orally every 12 hours
b. Pediatric
i. 2.5 mg/kg orally every 12 hours
ii. Maximum: 250 mg/dose
Duration of action
a. Onset: 1 to 1.5 hours
b. Peak effect: 2 to 4 hours
c. Duration: 4 to 12 hours
Special considerations
a. Pregnancy safety: Category C

AcetaZOLAMIDE (Diamox, Diamox Sequels)

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Acetic Acid (vinegar)
1. Class: Otic anti-infective, irrigating solution
2. Mechanism of action
a. Provides an acidic medium during irrigation of the ear that minimizes bacterial and fungal promulgation
b. Stabilizes nematocyst discharge in jellyfish found outside the United States
c. Decreases pain
3. Indications
a. Otitis externa
b. Pain control for envenomation by jellyfish from outside the United States
4. Contraindications
a. Hypersensitivity
b. Perforated tympanic membranes
c. May increase nematocyst discharge for US jellyfish and should be used only outside the United States
5. Adverse reactions/side effects
a. Skin irritation
b. Sensitivity
c. Stinging sensation
6. Drug interactions
a. None currently identified
7. Dosage and administration
a. Adult and pediatric
i. Position the patient on the side with the affected ear uppermost.
ii. Instill 4 to 6 drops into the external ear, and repeat every 2 to 3 hours.
iii. For jellyfish stings outside the US, rinse the area with vinegar for 30 seconds to limit the discharge of unfired nematocysts remaining on the skin.
8. Duration of action
a. Onset: 5 minutes
b. Peak effect: 45 to 90 minutes
c. Duration: 2 to 3 hours
9. Special considerations
a. Pregnancy safety: Category C
b. Safety and efficacy have not been established in children younger than 3 years.

Acetic Acid (vinegar)

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Class:
Misc. antidysrhythmic, endogenous nucleoside
Action:
Decreases electrical conduction through the AV node without causing negative inotropic effects.
It also acts on the SA node and vagal nerve terminals to decrease HR.
Indications:
Supraventricular tachycardia (SVT/PSVT)
Contraindications:
Hypersensitivity, bradycardia, drug induced tachycardia, 2nd or 3rd degree heart blocks, A-Fib, A-Flutter,
V-Tach, WPW with A-Fib/flutter.
Onset/Duration:
* Onset: Immediate
* Duration/half-life: 10 seconds
Dose/Route:
* Adult: 6 mg rapid IV/IO push followed by 20 cc saline flush.
o May repeat in 1-2 min at 12 mg rapid IV push followed by 20 cc saline flush. May repeat
twice.
* Peds: 0.1mg/kg (max 6mg) IV/IO followed by 5-10 cc saline flush.
o May repeat in 1-2 min at 0.2 mg/kg (max 12mg) IV/IO followed by 5-10 cc saline flush.
Side Effects:
Dizziness, headache, shortness of breath, hypotension, flushing, palpitations, chest pain,
nausea/vomiting
Note:
Methylxanthine classified stimulants (caffeine & theophylline) usage will antagonize adenosine

Adenosine (Adenocard)

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Class:
Sympathomimetic, bronchodilator, beta-2 agonist
Action:
Sympathomimetic that is selective for Beta-2 adrenergic receptors.
Relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating adrenergic
receptors of sympathetic nervous system.
Indications:
Asthma, bronchospasms, reversible obstructive airway disease, anaphylaxis, hyperkalemia
Contraindications:
Hypersensitivity, caution with pts with cardiac dysrhythmias
Onset/Duration:
* Onset: 5-8 min
* Duration: 2-6 hours
Dose/Route:
* Adult/Peds: 2.5 mg diluted in 3 mL of Normal Saline, repeat as needed
Side Effects:
Tremors, tachycardia, hypertension, anxiety, nausea, headache, palpitations, cough, dizziness.
Note:
Albuterol may precipitate angina & cardiac dysrhythmias.
Use with caution in pt’s with cardiovascular disorder, diabetes, seizure disorder, hyperthyroidism.
Beta blockers may antagonize albuterol.

Albuterol (Proventil)

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Class:
Class III antidysrhythmic
Action:
Prolongs duration of the action potential and prolongs the refractory period, also may have beta
adrenergic receptor and calcium channel blocking activity.
Works on both the ventricles and the atria
Indications:
V-Fib, hemodynamically unstable V-Tach, treatment for some stable atrial rhythms
Contraindications:
CHF, cardiogenic shock, bradycardia, 2nd or 3rd degree heart blocks with no pacemaker present,
hypersensitivity to amiodarone or iodine
Onset/Duration:
* Onset: within minutes
* Duration: Variable but considered 30 – 45 days
Dose/Route:
* Adult:
o Pulseless V-Tach/V-Fib arrest - 300mg IV/IO may repeat once at 150mg IV/IO.
o V-Tach with a pulse 150mg IV drip over 10 minutes up to max of 2.2g in 24 hours
* Peds:
o Pulseless V-Tach/V-Fib arrest - 5mg/kg IV/IO.
o V-Tach with a pulse 5mg/kg IV drip over 20-60 minutes with a max of 15mg/kg/day.
Side Effects:
Bradycardia, hypotension, headache, CHF, abnormal liver/thyroid functions. In rare cases can cause
pulmonary fibrosis

Amiodarone (Cordarone)

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Class: Adsorbent, antidote
2. Mechanism of action
a. Adsorbs ingested toxic substances from the GI tract
3. Indications
a. Most oral poisonings and medication overdoses in the alert patient
b. Can be used after evacuation of poisons
4. Contraindications
a. Known hypersensitivity
b. Unprotected airway
c. Absence of a gag reflex
d. Ileus
e. Intestinal obstruction
f. Do not use after ingestion of petroleum distillates, hydrocarbons, heavy metals, acids or alkalis (corrosives), alcohols, iron, lithium, solvents.
g. Use caution in patients experiencing abdominal pain of unknown origin.
5. Adverse reactions/side effects
a. Emesis
b. Constipation
c. Black stools
d. Diarrhea
e. Bowel obstruction
6. Drug interactions
a. Bonds with and inactivates whatever it is mixed with
b. Moderate interactions with acetylcysteine, citalopram, digoxin, dyphylline, methotrexate, and theophylline
7. Dosage and administration
a. Adult and pediatric older than 1 year
i. 25 to 100 g orally or via NG tube
b. Pediatric younger than 1 year
i. 1 g/kg orally or via NG tube
8. Duration of action
a. Onset: Immediate
b. Peak effect: Depends on GI function
c. Duration: Will act until excreted
9. Special considerations
a. Pregnancy safety: Category C
b. Shake vigorously before use.
c. Contact medical direction before administering in cases of acetaminophen overdose.

Activated Charcoal (Insta-Char, Actidose-Aqua, Liqui-Char)

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Class:
Analgesic, nonsteroidal anti-inflammatory drug (NSAID), antipyretic, and antiplatelet
Action:
Inhibits prostaglandins involved in the production of inflammation, pain and fever.
Dilates peripheral vessels and inhibits platelet aggregation by blocking the formation of thromboxane
A2.
Indications:
Acute coronary syndrome (ACS) such as myocardial infarction, ischemic chest pain or angina, and given
for mild to moderate pain or fever.
Contraindications:
GI bleeding, hemorrhagic stroke, active gastric ulcers, bleeding disorders, asthma, hypersensitivity to
salicylates, children
Onset/Duration:
* Onset: 15-30 min
* Duration: 4-6 hours
Dose/Route:
* Adult: Mild pain/fever – 325-650 mg PO every 4 hours.
o ACS – 2 to 4 baby chewable aspirin, 162-324 mg OR 1 adult aspirin, 325mg PO.
* Peds: Not indicated in pre-hospital setting
Side Effects:
Stomach irritation, GI bleeding, nausea/vomiting
Note:
Children under 12 should not be given Aspirin as they may develop Reye’s syndrome.

Aspirin (Salicylate)

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Class:
Anticholinergic, Parasympatholytic
Action:
Inhibits actions of acetylcholine (mostly at muscarinic receptor sites) causing decreased salivation and
bronchial secretions, increased heart rate and decreased gastric motility.
Indications:
Hemodynamically unstable bradycardia, organophosphate or nerve gas poisoning
Contraindications:
Tachycardia, hypersensitivity, avoid use with hypothermic pts, caution in pts with an active MI and
hypoxia
Onset/Duration:
* Onset: Rapid
* Duration: 2-6 hours
Dose/Route:
* Adult:
o Bradycardia – 1 mg IV/IO q 3-5 min up to max total of 3 mg
o Organophosphate poisoning – 1 to 5mg IV/IM/IO repeated 3-5 min until cessation of
bronchial secretions
* Peds:
o Bradycardia NOT responding to Epi- 0.02mg/kg IV/IO (min dose of 0.1 mg and max single
dose 0.5 mg) with maximum total of 1 mg for a child and 3 mg for an adolescent.
o Organophosphate peds < 12 yrs old - 0.05mg/kg IV/IM/IO may be repeated every 20-30
mins until cessation of bronchial secretions.
Side Effects:
Tachycardia, paradoxical bradycardia if given too slow or too small of dose, mydriasis (dilated pupils),
dysrhythmias, headache, nausea/vomiting, headache, dizziness, flushed, anticholinergic effects (dry
mouth/nose/skin, blurred vision, urinary retention, constipation)
Note:
Effects of atropine may be potentiated by antihistamines, procainamide, quinidine, antipsychotics,
antidepressants, and thiazides.

Atropine Sulfate

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Class
a. Topical anesthetic
Mechanism of action
a. Prevents impulse transmission along sensory nerve fibers and at nerve endings
Indications
a. Topical anesthetic
b. Suppresses the pharyngeal and tracheal gag reflex
Contraindications
a. Hypersensitivity
Adverse reactions/side effects
a. Signs of methemoglobinemia
b. Headache, light-headedness, shortness of breath
c. Anxiety, fatigue, and tachycardia
Drug interactions
a. Rare and sometimes fatal cases of methemoglobinemia related to the topical or oromucosal benzocaine products
b. Nitrites and nitrates may induce methemoglobin formation.
Dosage and administration
a. Adult
i. 0.5- to 1-second spray
ii. Repeat as needed.
b. Pediatric
i. 0.25- to 0.5-second spray
ii. Repeat as needed.
Duration of action
a. Onset
i. Immediate
b. Peak effect
i. Less than 5 minutes
c. Duration
i. 15 to 20 minutes
Special considerations
a. Pregnancy safety: Category C
b. Quantity in a single spray varies among different manufacturers.
c. Potentially dangerous to use in the mouth and throat

Benzocaine Spray (Hurricane)

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Antagonize the effects of epinephrine on beta adrenergic receptors
Beta-1 selective blockers
a. Cardioselective beta blockers
b. Slow the heart rate and force of contraction
c. Safer for use in patients with lung diseases
Nonselective beta blockers
a. Antagonize beta-1 and beta-2 receptors.
b. Decrease heart rate and force of contraction.
c. Cause some degree of bronchoconstriction.
d. Contraindicated in patients with asthma and should be used with caution in patients with COPD

Beta Blocking Agents

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Class
a. Loop diuretic
Mechanism of action
a. A potent loop diuretic with a rapid onset and short duration of action
b. Inhibits the reabsorption of sodium and chloride in the ascending limb of the loop of Henle
Indications
a. Pulmonary edema, heart failure
Contraindications
a. Hypersensitivity to bumetanide, furosemide, or sulfonamides
b. Hypovolemia, anuria, acid-based imbalance, electrolyte imbalance, hepatic coma
c. Use with caution in patients with hepatic cirrhosis, ascites, or diabetes.
Adverse reactions/side effects
a. Dehydration
b. Dizziness
c. Headache
d. Hypotension
e. ECG changes due to electrolyte depletion
f. Nausea/vomiting
g. Itching (liver disease)
h. Fatigue
Drug interactions
a. NSAIDs reduce the effects of diuretics.
b. May increase risk of lithium poisoning
c. Antihypertensives can cause further hypotension.
Dosage and administration
a. Adult
i. 0.5 to 1 mg IV slowly over 1 to 2 minutes or IM
b. Pediatric
i. Not recommended for children younger than 12 years.
Duration of action
a. Onset
i. Immediate
b. Peak effect
i. 15 to 30 minutes
c. Duration
i. 3 to 6 hours
Special considerations
a. Pregnancy safety: Category C
b. Bumetanide does not have the vasodilatory effects of furosemide.
c. Diuretic potency is about 40 times greater than furosemide.

Bumetanide (Bumex)

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Class:
Electrolyte, hypertonic solution
Action:
It is an essential element for regulating the excitation threshold of nerves and muscles, normal cardiac
contractility, and blood coagulation.
Indications:
Hyperkalemia, hypocalcemia, hypermagnesemia, calcium channel blocker overdose
Contraindications:
V-Fib during cardiac resuscitation, digitalis toxicity, hypercalcemia
Onset/Duration:
* Onset: 5-15 min
* Duration: Dose dependent but may last up to 4 hours
Dose/Route:
* Adult: 1-2 g (10-20 ml) slow IV of 10% solution
* Peds: 20 mg/kg slow IV of 10% solution
Side Effects:
Bradycardia, hypotension, Metallic taste in mouth, local necrosis if given IM or IV infiltration

Calcium Chloride

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Class
a. Antiulcer, H2 blocker
Mechanism of action
a. Blocks the effects of histamine at H2 receptors of gastric parietal cells
Indications
a. Gastric or duodenal ulcers
b. GERD
c. Adjunct in treating hives and/or itching
Contraindications
a. Known hypersensitivity to cimetidine or other H2 blockers
Adverse reactions/side effects
a. Headache
b. Dizziness
c. Diarrhea
d. Muscle aches
e. Skin rashes
f. Fatigue
Drug interactions
a. Inhibition of specific liver enzymes may result in increased plasma levels of certain drugs.
Dosage and administration
a. Adult
i. 400 mg orally four times daily
ii. Maximum is 1,200 mg/day
b. Pediatric
i. Use is not recommended.
ii. 20 to 40 mg/kg per day in divided doses
Duration of action
a. Onset
i. 60 minutes
b. Peak effect
i. 45 to 90 minutes
c. Duration
i. 4 to 5 hours
Special considerations
a. Pregnancy safety: Category B
b. Can be given orally or IV in conjunction with diphenhydrAMINE for urticaria

Cimetidine (Tagamet)

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Class
a. Corticosteroid, adrenal glucocorticoid, anti-inflammatory agent
Mechanism of action
a. Suppresses acute and chronic inflammation
b. Immunosuppressive effects
Indications
a. Anaphylaxis
b. Acute exacerbation of bronchial asthma
c. AMS
d. HACE
e. Spinal cord injury
f. Croup
g. Elevated ICP
h. Adjunct in treatment of shock
i. COVID-19
Contraindications
a. Documented hypersensitivity
b. Systemic fungal infection
c. Preterm infants
Adverse reactions/side effects
a. Headache
b. Restlessness
c. Nervousness
d. Increased appetite
e. Insomnia
f. Sodium and water retention
g. None from a single dose
Drug interactions
a. Simultaneous use with ASA and NSAIDs increases the risk of GI bleeding and ulceration.
b. Hypokalemia when used concurrently with diuretics
c. Echinacea may reduce its effectiveness.
Dosage and administration
a. Adult
i. AMD treatment: Give 4 mg IM, IV, or orally every 6 hours
ii. HACE: 8 mg IM, IV, or orally, followed by 4 mg IM, IV, or orally every 6 hours
iii. Bronchospasm: 0.6 mg/kg IM, IV, or orally (16 mg maximum)
b. Pediatric
i. AMS, HACE treatment: 0.15 mg/kg IM, IV, or orally every 6 hours (4 mg/dose maximum)
ii. For croup: 0.6 mg/kg orally, IM, IV, or IO given once (16 mg maximum)
iii. For asthma: 0.6 mg/kg IM, IV, or IO every 24 hours (16 mg maximum)
Duration of action
a. Onset
i. 4 to 8 hours
b. Peak effect
i. 6 to 12 hours
c. Duration
i. 24 to 72 hours
Special considerations
a. Pregnancy safety: Category C
b. Administer IV/IO doses slowly.
c. Steroids can mask infection.
d. Can increase blood glucose levels
e. Hydrocortisone succinate is preferred over methylPREDNISolone and dexamethasone.
f. High doses of glucocorticoids or prolonged use can result in many adverse reactions and side effects.
g. It should not be used for AMS or HACE prevention in children.

Dexamethasone Sodium Phosphate (Decadron)

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Class
a. Electrolyte
Mechanism of action
a. Mineral component of bones and teeth
b. Cofactor in enzymatic reactions
c. Essential for neurotransmission, blood clotting, and contraction of cardiac, smooth, and skeletal muscles
Indications
a. Topical use in hydrofluoric acid burn management
b. Hypocalcemia
c. Hyperkalemia
d. Beta blocker and calcium channel blocker toxicity
Contraindications
a. Known hypersensitivity
b. Digoxin toxicity
c. Hypercalcemia
d. Suspected severe hypokalemia
Adverse reactions/side effects
a. Syncope
b. Cardiac arrest
c. Dysrhythmias
d. Hypotension
e. Asystole
f. Peripheral vasodilation
g. Hypotension
h. Nausea/vomiting
i. Metallic taste
j. Tissue necrosis at injection site
k. Coronary and cerebral artery spasm
Drug interactions
a. Severe bradycardia
b. May antagonize the effects of calcium channel blockers
c. Incompatible with most medications
d. Flush the IV/IO line before and after its administration.
Dosage and administration
a. Adult
i. 1.5 to 3 g (15 to 30 mL of 10% solution) slow IV/IO push over 5 minutes
b. Pediatric
i. 60 mg/kg slow IV/IO push over 10 minutes
ii. May repeat if documented or suspected clinical indication persists
c. Adult and pediatric hydrofluoric acid burn management
i. Apply generous amounts of topical gel.
ii. Leave in place for at least 20 minutes.
Duration of action
a. Onset
i. 1 to 3 minutes
b. Peak effect
i. Immediate
c. Duration
i. 30 minutes to 2 hours
Special considerations
a. Pregnancy safety: Category C
b. Constant ECG and vital sign monitoring is essential.
c. Central venous administration is the preferred route in pediatrics.
d. Do not administer by either the IM or subcutaneous routes.

Calcium Gluconate

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Class:
Carbohydrate, hypertonic solution
Action:
A monosaccharide, which provides calories for metabolic needs, spares body proteins and loss of
electrolytes
Indications:
Hypoglycemia.
If protocol allows also for altered ALOC, coma, and seizure of unknown origin
Contraindications:
Intracranial hemorrhage, increased intracranial pressure, known or suspected stroke in the absence of
hypoglycemia
Onset/Duration:
* Onset: 1 min
* Duration: Variable depending on degree of hypoglycemia
Dose/Route:
* Adult: 12.5-25 g slow IV (25-50 ml 50% dextrose; 125-250 ml 10% dextrose)
* Peds: 0.5-1 g/kg (2-4 ml/kg) IV of 25% dextrose
* Neonates: 0.5-1 g/kg (2-4 ml/kg) IV of 10% dextrose
Side Effects:
Hyperglycemia, thrombophlebitis
Note:
If given through infiltrated IV, will cause tissue necrosis so use large vein and flush with saline to ensure
IV patency.
D50 may cause Wernicke’s encephalopathy in thiamine deficient patient (alcoholics and malnourished
pts) so if these conditions are suspected, administer 100 mg Thiamine IV prior to administering D50.

Dextrose 50%, 25%, 10%

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Class:
Benzodiazepine
Action:
Increases the activity of the inhibitory neurotransmitter GABA, thereby producing a sedative effect,
relaxing skeletal muscles, and raising the seizure threshold.
Indications:
Seizure activity, acute anxiety, skeletal muscle relaxation, sedation for pacing/ cardioversion, acute
alcohol withdrawal
Contraindications:
Hypersensitivity, respiratory depression, head injury w/ CNS depression, shock, and coma.
Use with caution in pts with acute substance abuse.
Onset/Duration:
* Onset: 1-5 min IV and 15-30 min IM
* Duration: 15-60 min IV and 15-60 min IM
Dose/Route:
* Adult:
o Seizures – 5 to 10 mg IV over 2 mins every 10-15 min as needed & a max of 30 mg.
o Premedication for pacing/ cardioversion – 5-15 mg IV 10 minutes prior to
* Peds:
o Ages 30 days to 5 yrs – 0.2-0.5 mg slow IV push over 2 mins every 2-5 min to a max of 5 mg.
o Peds 5 yrs or older – 1 mg slow IV push over 2 mins every 2-5 min with a max of 10 mg.
Side Effects:
Respiratory depression, altered LOC, hypotension, amnesia, confusion, nausea, vomiting, blurred vision

Diazepam (Valium)

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Class:
Calcium channel blocker
Action:
Inhibits calcium ion influx through slow channels into the cell of myocardial and arterial smooth muscle.
Slows SA and AV nodal conduction.
Dilates coronary arteries and arterioles thus inhibits coronary artery spasms.
Indications:
A-Fib and A-Flutter, multifocal atrial tachycardia, SVT/PSVT refractory to Adenosine.
Contraindications:
Hypersensitivity, 2nd and 3rd degree heart block, hypotension, cardiogenic shock, ventricular rhythms,
sick sinus syndrome, Wolf-Parkinson-White syndrome, AMI, V-Tach.
Onset/Duration:
* Onset: 2-5 min
* Duration: 1-3 hours
Dose/Route:
* Adult: 15-20 mg IV (0.25mg/kg) over 2 min, may be repeated in 15 min at 20-25 (0.35mg/kg) mg IV
over 2 min.
o Maintenance infusion 5-15 mg/hr titrated to HR.
* Peds: Not recommended in the prehospital setting
Side Effects:
Headache, dizziness, hypotension, 1st and 2nd degree heart block, bradycardia, palpitations, CHF, chest
pain, ventricular rhythms.
Note:
Use caution with renal/liver impaired pt’s and those taking beta blockers.

Diltiazem (Cardizem)

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Class:
Antihistamine
Action:
Blocks histamine H1 receptor sites thereby inhibiting actions of histamine release.
Indications:
Allergic reactions, anaphylaxis, acute extrapyramidal reaction (dystonia)
Contraindications:
Hypersensitivity, pt’s taking MAO inhibitors, caution with narrow-angle glaucoma, newborns and nursing
mothers.
Onset/Duration:
* Onset: 5-15 min with max effects in 1-3 hrs
* Duration: 6-12 hrs
Dose/Route:
* Adult: 25-50mg IV/IM/PO with a max of 400 mg/day
* Peds: 1 mg/kg IV/IM/PO with a max of 300 mg/day
Side Effects:
Drowsiness, palpitations, hypotension, tachycardia or bradycardia, disturbed coordination, dry
mouth/throat, thickening of bronchial secretions.
Note:
Use with caution in CNS depressed pts and pts with lower respiratory tract diseases such as asthma.

Diphenhydramine (Benadryl)

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Class:
Sympathomimetic, vasopressor
Action:
Acts primarily on alpha-1 and beta-1 adrenergic receptors.
At low doses (2-5 mcg/kg/min), it may act on dopaminergic receptors causing renal, mesenteric, and
cerebral vascular dilation.
At moderate doses (5-10 mcg/kg/min), dopamine stimulates mostly beta 1 receptors causing increased
cardiac contractility and output.
At high doses (10-20 mcg/kg/min) dopamine has mostly alpha-1 stimulation effects causing peripheral
arterial and venous constriction.
Indications:
Hemodynamically significant hypotension in the absence of hypovolemia such as in cardiogenic shock,
neurogenic shock, septic shock.
Second line pharmacological treatment for bradycardia after atropine.
Contraindications:
Hypovolemia, trauma, tachydysrhythmias, V-Fib, pt’s with pheochromocytoma.
Onset/Duration:
* Onset: 2-4 min
* Duration: 10-15 min
Dose/Route:
* Adult: 2-20 mcg/kg/min IV drip and titrate to desired effect
* Peds: Same as adult
Side Effects:
Tachycardia, hypertension, anxiety, headache, nausea/vomiting, increased myocardial oxygen demand,
mydriasis, dose-related tachydysrhythmias

Dopamine (Intropin)

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Class
a. Adrenergic, inotropic agent
Mechanism of action
a. Synthetic catecholamine
i. Simulates beta-1 receptors with minor stimulation of beta-2 and alpha-1 receptors
b. Increases myocardial contractility and stroke volume
c. Increases renal blood flow secondary to increased cardiac output
Indications
a. Heart failure with a SBP of 70 to 100 mm Hg and no signs of shock
Contraindications
a. Known hypersensitivity
b. Suspected or known poison/drug-induced shock
c. SBP less than 10 mm Hg and signs of shock
d. Idiopathic hypertrophic subaortic stenosis
Adverse reactions/side effects
a. Headache
b. Dyspnea
c. Tachycardia
d. Hypertension
e. Chest pain
f. Dysrhythmias
g. Nausea/vomiting
Drug interactions
a. Incompatible with sodium bicarbonate and furosemide
b. Beta blockers may blunt the inotropic effects.
Dosage and administration
a. Adult
i. IV infusion at 2 to 20 mcg/kg/min titrated to desired effect
b. Pediatric
i. IV infusion at 2 to 20 mcg/kg/min titrated to desired effect
Duration of action
a. Onset
i. 2 minutes
b. Peak effect
i. 10 minutes
c. Duration
i. 1 to 2 minutes after infusion discontinued
Special considerations
a. Pregnancy safety: Category B
b. BP and hemodynamic monitoring recommended.
c. Titrate dose to maintain a heart rate increase of no greater than 10% of baseline.
d. May increase infarct size in patients with MI
e. May precipitate or exacerbate ventricular ectopy
f. Older patients may have a significantly decreased response.
g. Patients may become hypotensive from the vasodilatory effect.

DOBUTamine Hydrochloride (Dobutrex)

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Class
a. Antiemetic, antipsychotic
Mechanism of action
a. Produces marked tranquilization and sedation
b. Reduces motor activity and anxiety
c. Possesses adrenergic-blocking, antifibrillatory, antihistaminic, and anticonvulsive properties
Indications
a. Chemical restraint
b. Acute delirium or psychosis
Contraindications
a. Known hypersensitivity
b. Known or suspected prolonged QT interval
c. Use with extreme caution in patients with bradycardia, cardiac disease, concurrent MAOI therapy, or use of Class I and Class III antidysrhythmics or other drugs.
Adverse reactions/side effects
a. QT interval prolongation
b. VT
c. TdP
d. Cardiac arrest
e. Mild to moderate hypotension
f. Hypertension
g. Tachycardia
h. Dizziness
i. Drowsiness
j. Restlessness
k. Anxiety
l. Dysphoria
m. Hyperactivity
n. Hallucinations
o. Extrapyramidal symptoms
Drug interactions
a. Potentiates CNS depressants
b. Reduces pressor effect of epinephrine
Dosage and administration
a. Adult
i. 2.5 mg slow IV or 5 mg IM
b. Pediatric
i. Not routinely recommended
Duration of action
a. Onset
i. 3 to 10 minutes IV/IM
b. Peak effect
i. 30 minutes IV/IM
c. Duration
i. 2 to 4 hours IV/IM
Special considerations
a. Pregnancy safety: Category C
b. Cases of QT prolongation and/or TdP
c. Closely monitor vital signs and ECG.
d. Monitor the QT interval with a 12-lead ECG if feasible.
e. Document the QT interval and relay findings to the receiving facility staff.

Droperidol (Inapsine)

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Class:
Sympathomimetic
Action:
Endogenous catecholamine that directly stimulates both alpha-1, beta-1 and beta-2 adrenergic
receptors.
The effects this will have on the heart include increased contractile force, increased rate, and increased
cardiac output.
Epinephrine is also a potent vasoconstrictor as well as a bronchodilator.
Other effects include slowing of gastric motility, miosis, and pale skin.
Indications:
Anaphylaxis, cardiac arrest, asthma, bradycardia (first line in peds), shock not caused by hypovolemia,
severe hypotension accompanied with bradycardia when pacing and atropine fail.
Contraindications:
Hypovolemic shock. Caution should be used in patients with known cardiovascular disease or pts > 45
y/o
Onset/Duration:
Onset: 1-2 min IV, 5-10 mins SQ
Duration: 5-10 min IM
Dose/Route:
* Adult:
o Cardiac arrest – 1 mg (0.1mg/1mL) IV/IO every 3-5 min with no max.
o Anaphylaxis/asthma – 0.3-0.5 mg SQ/IM (1mg/1mL). If no response, some protocols give
0.3-0.5 mg IV (0.1mg/1mL).
o Post cardiac arrest or for bradycardia with severe hypotension –2-10 mcg/min IV drip and
titrate to effect.
* Peds:
o Cardiac arrest – 0.01 mg/kg (0.1mg/1mL) IV/IO max of 1 mg every 3-5 mins.
o Anaphylaxis/asthma – 0.01 mg/kg (1mg/1mL) SQ/IM with a max single dose 0.3 mg.
Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors, dyspnea
Note: Always use epinephrine 1mg/1mL when given SQ/IM and 0.1mg/1mL when given IV/IO. Giving
concurrently with alkaline solutions such as sodium bicarbonate will cause crystallization of fluid.

Epinephrine (Adrenalin)

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Class: Sympathomimetic Action: Racemic Epinephrine is an inhaled version of epinephrine that is used as a bronchodilator and as an antinflammatory to treat laryngeal/tracheal swelling and edema. Its actions are the same as epinephrine but since it is inhaled it has both systemic and localized effects. Indications: Laryngotracheobronchitis (croup), asthma, bronchospasms, laryngeal edema Contraindications: Hypertension, epiglottitis. Use caution in patients with known cardiovascular disease or in pts > 45 y/o. Onset/Duration: * Onset: 5 min * Duration: 1-3 hrs Dose/Route: * Adult: 0.5mL (2.25%) in 5mL NS over 15 min * Peds: All doses given via aerosolized neb. o For pts < 6 months – 0.25 ml (2.25%) diluted in 3 ml NS. o For pts > 6 months – 0.5 ml (2.25%) diluted in 3 ml NS. Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors

Epinephrine, Racemic (Micronefrin)

Class: Anesthetic, non-barbiturate hypnotic Action: Etomidate is a very potent drug that acts on the reticular activating system to produce a short-acting anesthesia with amnesic properties. Etomidate has very little effect on respiratory drive which makes it ideal for certain procedures. Indications: Premedication prior to procedures such as endotracheal intubation, synchronized cardioversion, conscious sedation for bone dislocation relocation. Contraindications: Hypersensitivity, labor and delivery Onset/Duration: * Onset: < 1 min * Duration: 5-10 min Dose/Route: * Adult: 0.3mg/kg IV over 30-60 sec, limited to one dose * Peds: >10 years- 0.3mg/kg IV over 30-60 sec with a max dose of 20 mg Side Effects: Hypotension, hypertension, dysrhythmias, hypoventilation, nausea/vomiting, cortisol suppression Note: Primarily used for Rapid Sequence Intubation/induction (RSI) in the prehospital setting

Etomidate (Amidate)

1. Class a. Antiulcer, H2 blocker 2. Mechanism of action a. Inhibits the volume and concentration of gastric secretions 3. Indications a. GI ulcer b. Suspected upper GI bleeding c. GERD d. As an adjunct in the treatment of urticaria and/or pruritus 4. Contraindications a. Known hypersensitivity to famotidine or other H2 blockers 5. Adverse reactions/side effects a. Constipation b. Diarrhea c. Rhabdomyolysis d. Seizures e. Pneumonia f. Agitation g. Vomiting h. Headache i. Dizziness j. Vitamin B12 deficiency k. Prolonged QT interval l. Confusion, hallucinations, disorientation, agitation, and seizures in older adults 6. Drug interactions a. Decreased absorption of iron b. Decreased effects of ketoconazole, naproxen, pseudoephedrine c. Increased action of metformin 7. Dosage and administration a. Adult i. 20 mg IV, 20 mg orally twice daily b. Pediatric i. 0.25 mg/kg/dose every 12 hours IV (20 mg/dose maximum) ii. 0.5 mg/kg orally (40 mg/dose maximum) 8. Duration of action a. Onset i. 60 minutes b. Peak effect i. 1 to 3 hours c. Duration i. 10 to 12 hours 9. Special considerations a. Pregnancy safety: Category B b. Fewer adverse effects and drug interactions and a longer duration of action than cimetidine c. Can be given orally or IV

Famotidine (Pepcid)

Class: Synthetic Opioid analgesic Action: Combines with the receptor sites in the brain to produce potent analgesic effects. Indications: Pain and sedation, sedation for invasive airway procedures Contraindications: Hypersensitivity to opiates, hypotension, head injury, respiratory depression, cardiac dysrhythmias, myasthenia gravis Onset/Duration: * Onset 1-2 min IV * Duration 30-60 min Dose/Route: * Adult: 0.5 – 2 mcg/kg IV/IN/IM over 2 mins, q 5 min, max single dose of 100 mcg, max total dose of 300 mcg. * Peds: 0.5 – 1 mcg/kg IV/IN/IM over 2 mins, q 5 min, max single dose of 100 mcg, max total dose of 3 mcg/kg. Side Effects: Respiratory depression, hypotension or hypertension, bradycardia, nausea/vomiting, and rigidity of chest wall muscles

Fentanyl (Sublimaze)

Class: Loop diuretic Action: Furosemide is a potent diuretic that inhibits the reabsorption of sodium and chloride in the proximal tubule and loop on Henle. IV doses can also reduce cardiac preload by increasing venous capacitance. Indications: Pulmonary edema (CHF) with SBP > 90, hypertensive emergencies, hyperkalemia Contraindications: Anuria, hypersensitivity, hypovolemia, hypokalemia Onset/Duration: * Onset: 15-20 min IV * Duration: 2 hrs Dose/Route: * Adult: 20-40 mg IV over 1-2 min. If no response double dose up to 2 mg/kg over 1-2 min. Most services allow up to a max of 40-80 mg IV. * Peds: 1 mg/kg/dose IV over 1-2 min with a total max of 6 mg/kg Side Effects: Tinnitus and hearing loss (if given too quickly), hypotension, hypokalemia, hyponatremia, hypocalcemia, hyperglycemia Note: Must give slowly or may cause permanent hearing problems.

Furosemide (Lasix)

1. Dissolve blood clots and restore blood flow. 2. Can be given with other agents to maintain vessel patency after the clot is dissolved

Fibrinolytic Agents

Class a. Hyperglycemic agent, pancreatic hormone, insulin antagonist 2. Mechanism of action a. Increases blood glucose level b. Unknown mechanism of stabilizing cardiac rhythm in beta blocker overdose c. Minimal positive inotropic and chronotropic responses d. Decreases GI motility and secretions 3. Indications a. Altered mental status when hypoglycemia is suspected b. Antidote for symptomatic bradycardia caused by beta blocker or calcium channel blocker overdoses 4. Contraindications a. Known hypersensitivity, pheochromocytoma, hyperglycemia, insulinoma 5. Adverse reactions/side effects a. Dizziness/headache b. Hypotension c. Tachycardia d. Nausea/vomiting e. Rebound hypoglycemia 6. Drug interactions a. Incompatible in solution with most other substances b. No significant drug interactions with other emergency medications 7. Dosage and administration a. Adult i. Hypoglycemia: 1 mg IM/IN; repeat dose until symptoms have resolved. ii. Calcium channel blocker or beta blocker overdose: 5 mg slowly via IV push; repeat in 5 to 10 minutes. b. Pediatric i. Hypoglycemia: 1 mg IM/IN (≥ 20 kg or 5 years) otherwise 0.5 mg ii. Calcium channel blocker or beta blocker overdose: 1 mg (25 to 40 kg) or 0.5 mg (less than 25 kg) slowly via IV push every 5 minutes 8. Duration of action a. Onset i. 1 minute b. Peak effect i. 5 to 20 minutes c. Duration i. 60 to 90 minutes 9. Special considerations a. Pregnancy safety: Category B b. Ineffective if glycogen stores are depleted c. Document reassessment of vital signs and mental status after administration.

Glucagon

1. Class a. Hyperglycemic, carbohydrate 2. Mechanism of action a. Increases circulating blood glucose levels 3. Indications a. Conscious patients with suspected hypoglycemia 4. Contraindications a. Known hypersensitivity b. Decreased level of consciousness c. Nausea/vomiting 5. Adverse reactions/side effects a. Nausea/vomiting 6. Drug interactions a. None 7. Dosage and administration a. Adult i. 25 g orally b. Pediatric i. 0.5 to 1 g/kg orally ii. Maximum dose: 25 g 8. Duration of action a. Onset i. 10 minutes b. Peak effect i. Variable c. Duration i. Variable 9. Special considerations a. Must be swallowed b. Check a glucometer reading before administering and repeat 10 minutes after administration. c. Document reassessment of vital signs and mental status after administration.

Glucose, Oral (Insta-Glucose)

1. Block the bindings of fibrinogen to glycoprotein IIb/IIIa receptors, thereby inhibiting platelet aggregation

Glycoprotein IIb/IIIa Inhibitors

Class a. Tranquilizer b. Antipsychotic 2. Mechanism of action a. Antagonizes dopamine-1 and dopamine-2 receptors in the brain b. Depresses the reticular activating system and inhibits release of hypothalamic and hypophyseal hormones 3. Indications a. Acute psychotic episodes or agitated/violent behavior b. Anxiety 4. Contraindications a. Documented hypersensitivity b. Severe CNS depression c. Neuroleptic malignant syndrome d. Poorly controlled seizure disorder e. Parkinson disease f. Agitation secondary to shock and hypoxia 5. Adverse reactions/side effects a. Seizures b. Sedation c. Confusion d. Restlessness e. Extrapyramidal reactions f Dystonia g. Respiratory depression h. Hypotension/orthostatic hypotension i. Tachycardia j. Constipation, dry mouth, nausea, vomiting, drooling, blurred vision k. Risk of QT interval prolongation, TdP, and sudden death from off-label IV administration of higher than the recommended dose 6. Drug interactions a. Enhanced CNS depression and hypotension in combination with alcohol b. Additive effect with antihypertensive medications c. Antagonizes amphetamines and epinephrine d. Other CNS depressants may potentiate its effects. 7. Dosage and administration a. Adult i. Chemical restraint: 5 mg IV or 10 mg IM ii. Anxiety: 5 mg IV b. Pediatric i. Chemical restraint: Ages 6 to 12 years: 1 to 3 mg IM (0.15 mg/kg maximum) 8. Duration of action a. Onset i. 5 to 10 minutes IV ii. 10 to 20 minutes IM b. Peak effect i. 30 to 45 minutes c. Duration i. Variable (generally 12 to 24 hours) 9. Special considerations a. Pregnancy safety: Category C b. Continuous cardiac monitory is required if administering IV. c. Monitor the QT interval with a 12-lead ECG if feasible.

Haloperidol (Haldol)

1. Class a. Medical gas 2. Mechanism of action a. Reduces airflow resistance within the bronchial tree in patients with obstructive lung disease b. May reduce the work of breathing and improve pulmonary gas exchange efficiency 3. Indications a. Persistent or severe bronchospasm 4. Contraindications a. None 5. Adverse reactions/side effects a. May reduce the effectiveness of coughing 6. Drug interactions a. Unknown 7. Dosage and administration a. Adult and pediatric i. Normoxic patients: 80% helium and 20% oxygen ii. Hypoxemic patients: 70% helium and 30% oxygen or 60% helium and 40% oxygen iii. Helium/oxygen mixture fills a reservoir bag attached to a nonrebreathing mask. 8. Duration of action a. Onset i. Immediate b. Peak effect i. Minutes c. Duration i. Eliminated within a few breaths 9. Special considerations a. Pregnancy safety: Not classified b. The lower the helium percentage, the less effective. c. It should not be routinely administered to children with respiratory distress.

Helium Gas Mixture (Heliox)

1. Class a. Antihypertensive, vasodilator 2. Mechanism of action a. Relaxes arteriolar, but not venous, smooth muscle b. Lowers BP 3. Indications a. Pregnancy-induced hypertension lasting more than 15 minutes with associated preeclampsia symptoms 4. Contraindications a. Known hypersensitivity, CAB, mitral valve rheumatic heart disease b. Use with caution in patients with stroke, known renal disease, or hypotension. 5. Adverse reactions/side effects a. Headache, nausea, flushing, hypotension, palpitations, tachycardia, dizziness, and angina b. Paresthesia, numbness, and tingling 6. Drug interactions a. MAOIs b. Synergistic effects if given simultaneously with other antihypertensives c. NSAIDs may diminish the antihypertensive effects. 7. Dosage and administration a. Adult i. 5 mg IV; may repeat 10 mg after 20 minutes ii. Goal to reduce MAP by 20% to 25% b. Pediatric i. Not usually indicated in the prehospital setting 8. Duration of action a. Onset i. 5 to 20 minutes b. Peak effect i. 10 to 80 minutes c. Duration i. 2 to 12 hours 9. Special considerations a. Pregnancy safety: Category C b. Not recommended for long-term use during pregnancy c. Usually lowers DBP more than SBP

HydrALAZINE (Apresoline)

1. Class a. Corticosteroid, adrenal glucocorticoid 2. Mechanism of action a. Anti-inflammatory b. Immunosuppressive with salt-retaining actions 3. Indications a. Shock with history of adrenal insufficiency or long-term steroid dependence i. Anaphylaxis, asthma, and COPD 4. Contraindications a. Known hypersensitivity b. Systemic fungal infections c. Premature infants 5. Adverse reactions/side effects a. Headache b. Vertigo c. Heart failure d. Hypertension e. Fluid retention f. Nausea 6. Drug interactions a. Simultaneous use with ASA and NSAIDs increases the risk of GI bleeding and ulceration. b. Concurrent use with diuretics increases potassium loss and can result in hypokalemia. 7. Dosage and administration a. Adult i. 2 mg/kg IV/IM (100 mg maximum) ii. IM administration preferred. b. Pediatric i. Consult medical direction 8. Duration of action a. Onset i. 1 hour b. Peak effect i. Variable c. Duration i. 8 to 12 hours 9. Special considerations a. Pregnancy safety: Category C b. Steroids can mask infection. c. Can increase blood glucose levels d. High doses of glucocorticoids or prolonged use can result in many adverse reactions and side effects. e. Hydrocortisone succinate is preferred. f. Patients with adrenal insufficiency may have an emergency dose of hydrocortisone.

Hydrocortisone Sodium Succinate (Solu-Cortef)

1. Class a. Synthetic opioid analgesic b. Schedule II drug 2. Mechanism of action a. Opioid agonist-analgesic of opioid receptors b. Inhibits ascending pain pathways c. Increases the pain threshold d. Produces analgesia, respiratory depression, and sedation 3. Indications a. Management of acute moderate to severe pain 4. Contraindications a. Known hypersensitivity b. MAOI use during the previous 14 days c. GI obstruction d. Administer with caution in: i. Older adults ii. Patients with a GCS score less than 15 iii. Patients with hypotension, hypoxia, signs of hypoventilation, head injury, or concomitant use of CNS depressants 5. Adverse reactions/side effects a. Dizziness/headache b. Drowsiness/weakness c. Hypotension d. Syncope e. Apnea 6. Drug interactions a. MAOIs b. SSRIs c. Concurrent use with other CNS depressants can induce severe respiratory and/or CNS depression. 7. Dosage and administration a. Adult and pediatric i. 0.015 mg/kg IM, IV, or IO ii. Maximum initial dose: 2 mg iii. Maximum cumulative dose: 4 mg 8. Duration of action a. Onset i. Variable IM ii. 5 minutes IV iii. 15 to 30 minutes oral b. Peak effect i. Variable IM ii. 10 to 20 minutes IV iii. 30 to 60 minutes oral c. Duration i. 2 to 3 hours 9. Special considerations a. Pregnancy safety: Category C b. 5 to 7 times more potent than morphine, with a shorter duration of analgesia c. Respiratory depression is managed with naloxone. d. Document pain severity using a scare of 0 to 10 before and after administration and on arrival.

HYDROmorphone (Dilaudid)

Class: Vitamin, antidote Action: Active form of Vitamin B12 used to treat known or suspected cyanide poisoning. Indications: Known or suspected cyanide poisoning Contraindications: Hypersensitivity Onset/Duration: * Onset: Rapid * Duration: > 24 hrs Dose/Route: * Adult: 5 g IV infusion over 15 min. Can repeat 5 g IV infusion over 2 hrs up to 10 g total. * Peds: 70 mg/kg IV infusion over 15 min. Side Effects: Hypertension, headache, nausea, photophobia, red-colored urine and skin Note: The vial should be repeatedly inverted or rocked, not shaken, for at least 60 sec prior to administration. Use vented IV administration tubing.

Hydroxocobalamin (Cyanokit)

1. Class a. NSAID, nonopioid analgesic 2. Mechanism of action a. Inhibits prostaglandin synthesis b. Reduces swelling, pain, and fever 3. Indications a. Acute pain management b. Antipyretic 4. Contraindications a. Known ASA/NSAID hypersensitivity b. ASA-sensitive asthma c. Significant renal function impairment d. Pregnancy e. Known peptic ulcer disease f. Active intracranial hemorrhage or GI bleeding g. Thrombocytopenia h. Coagulation defects i. Proven or suspected necrotizing enterocolitis j. Perioperative pain in the setting of coronary artery bypass graft surgery 5. Adverse reactions/side effects a. Headache, dizziness, drowsiness, fatigue, restless sleep b. Thirst/sweating c. Tingling or numbness in hands and feet d. Tinnitus e. Blurred vision and eye irritation f. Fluid retention g. Nausea/vomiting h. Frequent urination 6. Drug interactions a. Additive risk for bleeding if given in combination with other agents that affect hemostasis b. Alfalfa, anise, and bilberry may enhance adverse effects. c. May diminish the antihypertensive effect of HydrALAZINE d. May diminish the diuretic effect of loop, thiazide, and thiazide-like diuretics e. TCAs may enhance the NSAID antiplatelet effects. f. May increase bleeding time in patients taking anticoagulants. 7. Dosage and administration a. Adult i. Give 10 mg/kg orally for patients older than 6 months. ii. Maximum dose: 800 mg b. Pediatric i. Febrile seizures: 10 mg/kg orally, if able to swallow ii. Maximum dose: 600 mg 8. Duration of action a. Onset i. 30 to 60 minutes b. Peak effect i. 1 to 2 hours c. Duration i. 6 to 8 hours 9. Special considerations a. Increased risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease b. Increased risk of heart failure

Ibuprofen (Advil, Motrin)

1. Class a. Anticholinergic, bronchodilator, short-acting antimuscarinic agent 2. Mechanism of action a. Antagonizes the action of acetylcholine on bronchial smooth muscle 3. Indications a. Persistent bronchospasm b. COPD exacerbation c. Toxic inhalation (in conjunction with albuterol) 4. Contraindications a. Hypersensitivity to ipratropium, atropine, alkaloids, or peanuts b. Use with caution in patients with urinary retention, narrow-angle glaucoma, cardiovascular disease, or hypertension. 5. Adverse reactions/side effects a. Headache/dizziness b. Nervousness c. Tremor d. Dyspnea e. Worsening COPD symptoms f. Hypertension g. Tachycardia h. Palpitations i. Flushing j. MI k. Dry mouth, nausea, vomiting, GI distress 6. Drug interactions a. Potential for additive anticholinergic effects when administered with other antimuscarinic or anticholinergic medications 7. Dosage and administration a. Adult and pediatric i. 0.5 mg nebulized ii. Up to three doses iii. In conjunction with albuterol 8. Duration of action a. Onset i. 5 to 15 minutes b. Peak effect i. 1.5 to 2 hours c. Duration i. 4 to 6 hours 9. Special considerations a. Pregnancy safety: Category B b. Shake well before use. c. It should not be given to children with bronchiolitis in the prehospital setting.

Ipratropium Bromide (Atrovent)

1. Class a. Secondary alcohol 2. Mechanism of action a. Antiseptic b. Antiemetic 3. Indications a. Nausea and vomiting 4. Contraindications a. None 5. Adverse reactions/side effects a. None in adults 6. Drug interactions a. None 7. Dosage and administration a. Adult i. Allow the patient to inhale the vapor from an isopropyl alcohol wipe three times every 15 minutes as tolerated. b. Pediatric i. Consult medical direction regarding use in this patient population. 8. Duration of action a. Onset i. Within 10 minutes b. Peak effect i. Variable c. Duration i. Variable 9. Special considerations a. None

Isopropyl Alcohol

1. Class a. Analgesic, general anesthetic, dissociative anesthetic b. Schedule III drug 2. Mechanism of action a. Blocks pain receptors and minimizes spinal cord activity 3. Indications a. Procedural sedation b. Management of agitated or violent behavior c. Pain control 4. Contraindications a. Known hypersensitivity b. Infants younger than 3 months of age c. Pregnancy d. Angina e. Heart failure f. Symptomatic hyperthyroidism g. Known or suspected schizophrenia h. Conditions where hypertension would be hazardous to a patient’s care i. Use with caution in any patient with the potential for increased ICP. 5. Adverse reactions/side effects a. Hypertension b. Hallucinations c. Nausea/vomiting d. Nystagmus e. Bronchodilation f. Tachycardia g. Increased secretions h. Hypersalivation i. Laryngospasm j. Respiratory depression k. Mild to moderate elevations in BP and heart rate 6. Drug interactions a. Ketamine may enhance the CNS depressant effects of alcohol, cannabis, opioids, barbiturates, and nondepolarizing neuromuscular blockers. b. St. John’s wort can reduce its effectiveness. 7. Dosage and administration a. Adult i. Procedural sedation: Give 1 to 2 mg/kg IV push over 1 to 2 minutes. ii. Moderate pain control: 0.5 mg/kg IN (maximum initial dose: 55 mg; maximum total dose: 100 mg) iii. Severe to excruciating pain control: 0.25 mg/kg IM/IV/IO (maximum initial dose: 25 mg; maximum total dose: 100 mg) iv. Chemical restraint: 2 mg/kg IV or 4 mg/kg IM b. Pediatric i. Procedural sedation: 1 to 2 mg/kg IV/IO push over 1 to 2 minutes ii. Chemical restraint: 1 mg/kg IV or 3 mg/kg IM 8. Duration of action a. Onset i. 30 seconds b. Peak effect i. 30 seconds to 5 minutes c. Duration i. 10 to 15 minutes 9. Special considerations a. Pregnancy safety: Category N (not classified) b. Dissociative anesthetic c. Shorter acting and less toxic that PCP d. Some patients may experience an emergence reaction after the full duration of the medication’s effect, which may last a few hours.

Ketamine (Ketalar)

1. Class a. NSAID, nonopioid analgesic 2. Mechanism of action a. Potent analgesic that inhabits prostaglandin synthesis b. Does not have any sedative or anxiolytic properties 3. Indications a. Acute management of moderate to severe pain 4. Contraindications a. NSAID or ASA allergy b. ASA-sensitive asthma c. Renal insufficiency d. Pregnancy e. Known peptic ulcer disease f. Hypotension g. Women who are in active labor or breastfeeding h. Significant renal impairment i. Previous or current GI bleeding j. Intracranial bleeding k. Coagulation defects l. Patients at high risk of bleeding m. Use with caution in older patients due to a higher risk of renal and fatal GI adverse reactions. 5. Adverse reactions/side effects a. Drowsiness b. Dizziness/headache c. Sedation d. Bronchospasm e. Dyspnea f. Edema g. Vasodilation h. Hypotension/hypertension i. GI bleeding j. Diarrhea k. Dyspepsia l. Nausea 6. Drug interactions a. May increase bleeding time in patients taking anticoagulants b. TCAs may enhance the NSAID antiplatelet effects. 7. Dosage and administration a. Adult i. Moderate discomfort: 30 mg IM in adults who are not pregnant ii. Severe to excruciating discomfort: 15 mg IV in adults who are not pregnant b. Geriatric i. Moderate discomfort: 1 mg/kg IM (maximum dose: 30 mg) c. Pediatric (2 to 16 years) i. Moderate discomfort: 1 mg/kg IM (maximum dose: 30 mg) ii. Severe to excruciating discomfort: 0.5 mg/kg IV (maximum dose: 15 mg) iii. Febrile seizures: 1 mg/kg IV (maximum dose: 15 mg) if unable to swallow 8. Duration of action a. Onset i. 10 minutes b. Peak effect i. 1 to 2 hours c. Duration i. 2 to 6 hours 9. Special considerations a. Pregnancy safety: Category C b. Use caution if pain is possibly from a traumatic source. c. Document pain severity using a scale of 0 to 10 before and after administration and on arrival at the receiving facility.

Ketorolac Tromethamine (Toradol)

1. Class a. Sympathomimetic, bronchodilator, short-acting beta-2 adrenergic agonist 2. Mechanism of action a. Stimulates beta-2 receptors 3. Indications a. Treatment of acute bronchospasm in patients with reversible obstructive airway disease (COPD/asthma) b. Bronchospasm prophylaxis in patients with asthma 4. Contraindications a. Known hypersensitivity to the drug, other sympathomimetics, or peanuts b. MAOI use within 14 days c. Angioedema, tachydysrhythmias, and severe cardiac disease d. Avoid administration with other drugs that prolong the QT interval. e. Use with caution in patients with cardiac dysrhythmias and cardiovascular disorders. 5. Adverse reactions/side effects a. Headache, anxiety, dizziness, restlessness b. Hallucinations c. Throat irritation d. Tachycardia e. Hypertension/hypotension f. Dysrhythmias g. Angina h. Nausea/vomiting i. Dyspepsia j. Tremors k. Hypokalemia l. Hyperglycemia 6. Drug interactions a. Increased actions of bronchodilators, TCAs, MAOIs, and other adrenergic drugs b. Increased risk of QT prolongation when administered with other QT-prolonging drugs 7. Dosage and administration a. Adult i. 1.25 mg in 3 mL NS administered by nebulizer over 5 to 15 minutes and repeated as necessary b. Pediatric i. 0.63 to 1.25 mg in 3 mL NS administered by nebulizer over 5 to 15 and repeated as necessary 8. Duration of action a. Onset i. 5 to 15 minutes b. Peak effect i. 60 to 90 minutes c. Duration i. 6 to 8 hours 9. Special considerations a. Pregnancy safety: Category C

Levalbuterol (Xopenex)

1. Class a. Antidysrhythmic (Class Ib), anesthetic 2. Mechanism of action a. Cardiac i. Inhibits recovery after repolarization ii. Decreases myocardial excitability and conduction velocity b. Local anesthetic c. May decrease ICP response during laryngoscopy 3. Indications a. Alternative to amiodarone in patients with cardiac arrest from: i. VT, VF ii. Stable monomorphic VT iii. Stable polymorphic VT with normal baseline QT interval when ischemia is treated with electrolyte balance is corrected b. Can be used for stable polymorphic VT with baseline QT interval prolongation if TdP is suspected c. Can be used as a local anesthetic for various procedures 4. Contraindications a. Hypersensitivity to lidocaine or amide-type local anesthetics, second- or third-degree AV block b. Prophylactic use in AMI is contraindicated. 5. Adverse reactions/side effects a. Drowsiness b. Confusion c. Seizures d. Slurred speech e. Hypotension f. Dysrhythmias g. Cardiac arrest h. Nausea/vomiting 6. Drug interactions a. Apnea induced with succinylcholine may be prolonged by high doses of lidocaine. b. Cardiac depression may occur in conjunction with administration of IV phenytoin. c. Procainamide may exacerbate the CNS effects. d. Metabolic clearance is decreased in patients with liver disease and patients taking beta blockers. 7. Dosage and administration a. Adult i. Cardiac arrest: Initial does: 1 to 1.5 mg/kg IV/IO. Repeat dose: 0.5 to 0.75 mg/kg IV/IO repeated in 5 to 10 minutes. Maximum total dose: 3 mg/kg. Maintenance infusion: 1 to 4 mg/min ii. Stable VT and stable regular wide-complex tachycardia: Initial does: 1 to 1.5 mg/kg IV/IO. Repeat dose: 0.5 to 0.75 mg/kg IV/IO repeated in 5 to 10 minutes. Maximum total dose: 3 mg/kg. Maintenance infusion: 1 to 4 mg/min iii. Local anesthetic dose varies depending on the procedure and anatomic location. b. Pediatric i. IV/IO dose: 1 mg/kg IV/IO push ii. Maintenance IV/IO infusion: 20 to 50 mcg/kg/mins. Repeat bolus dose if infusion started more than 15 minutes after initial bolus dose. iii. ET dose: 2 to 3 mg/kg iv. RSI: 1 to 2 mg/kg IV/IO v. Local anesthetic dose varies depending on the procedure and anatomic location. 8. Duration of action a. Onset i. 1 to 5 minutes b. Peak effect i. 5 to 10 minutes c. Duration i. 10 to 20 minutes 9. Special considerations a. Pregnancy safety: Category B b. Reduce the maintenance infusion in the presence of impaired liver function or left ventricular dysfunction. c. Discontinue the infusion immediately if signs of toxicity develop.

Lidocaine Hydrochloride (Xylocaine)

1. Class a. Benzodiazepine, sedative-hypnotic, anticonvulsant b. Schedule IV drug 2. Mechanism of action a. Anxiolytic, anticonvulsant, and sedative effect b. Suppresses propagation of seizure activity produced by foci in the cortex, thalamus, and limbic areas c. Inhibits GABA receptors in the CNS, reducing neuron excitability 3. Indications a. Uncontrolled shivering associated with hyperthermia/heat exposure b. Active seizures c. Anxiety/sedation d. Chemical restraint 4. Contraindications a. Documented hypersensitivity b. Neurologic or respiratory depression c. Acute narrow-angle glaucoma d. Sleep apnea e. Shock f. Suspected drug abuse 5. Adverse reactions/side effects a. Dizziness b. Drowsiness c. CNS depression d. Apnea e. Hypotension f. Bradycardia 6. Drug interactions a. Concomitant use with other CNS depressants may cause respiratory depression, hypotension, profound sedation, and death. b. Individuals taking passionflower or St. John’s wort may experience hand tremors, dizziness, and muscular fatigue. c. Motherwort can potentiate the sedative effects and may result in coma. 7. Dosage and administration a. When given IV/IO, must be diluted with an equal volume of sterile water or sterile saline b. Adult i. Anxiety/sedation: 0.1 mg/kg IV slowly over 2 minutes (maximum single dose: 4 mg); 4 mg IM ii. Shivering associated with hyperthermia/heat exposure: 1 mg IV/IO, may repeat once in 5 minutes; or 2 mg IM, may repeat once in 10 minutes iii. Chemical restraint: 2 mg IV or 4 mg IM c. Pediatric i. Seizures: 0.1 mg/kg IV/IO slowly over 2 minutes (maximum single dose: 4 mg) ii. Shivering associated with hypothermia/heat exposure: 0.1 mg/kg IV/IM/IO (maximum single dose: 1 mg) iii. Chemical restraint: 0.05 mg/kg IV (maximum dose: 2 mg) or 0.05 mg/kg IM (maximum dose: 4 mg) 8. Duration of action a. Onset i. 2 to 5 minutes IV ii. 15 to 30 minutes IM b. Peak effect i. Less than 15 minutes IV ii. 2 to 3 hours IM c. Duration i. 6 to 8 hours IV/IM 9. Special considerations a. Pregnancy safety: Category D b. Monitor respiratory rate and BP during administration. c. Have advanced airway equipment readily available. d. Consider decreasing the dose by 50% in patients older than 60 years.

Lorazepam (Ativan)

1. Class a. Electrolyte, Class V antidysrhythmic 2. Mechanism of action a. Depresses the CNS, blocks peripheral neuromuscular transmission, and produces anticonvulsant effects b. Decreases the amount of acetylcholine released at the endplate by motor nerve impulses, slows the rate of SA node impulse formation in the myocardium, and prolongs conduction time c. Promotes calcium, potassium, and sodium movement in and out of cells and stabilizes excitable membranes d. Induces uterine relaxation e. Can cause bronchodilation after beta agonists and anticholinergics have been administered 3. Indications a. Management of TdP b. Severe bronchoconstriction with impending respiratory failure c. Seizure during the third trimester of pregnancy or in the postpartum patient 4. Contraindications a. Known hypersensitivity, heart block, myocardial damage, diabetic coma, hypermagnesemia, hypercalcemia b. Use with caution in patients with known renal insufficiency. 5. Adverse reactions/side effects a. Drowsiness b. CNS depression c. Respiratory depression/tract paralysis d. Vasodilation e. Possible hypotension and bradycardia with rapid administration f. Decreased deep tendon reflexes. 6. Drug interactions a. May enhance the effects of other CNS depressants b. Serious changes in overall cardiac function may occur with cardiac glycosides. 7. Dosage and administration a. Adult i. Severe hypertension lasting more than 15 minutes with associated preeclampsia symptoms: Give 4 g of a 20% solution IV/IO over 20 minutes, followed by 1 g/h IV/IO, if available. ii. Seizure activity associated with pregnancy greater than 20 weeks’ gestation: Give 4 g of a 50% solution IV/IO over 10 to 20 minutes, followed by 1 g/h IV/IO, if available. iii. Cardiac arrest due to hypomagnesemia or TdP: Give 1 to 2 g IV/IO iv. TdP with pulse or AMI with hypomagnesemia: Loading dose of 1 to 2 g in 50 to 100 mL of D5W or NS over 5 to 60 minutes IV. Follow with 0.5 to 1 g/h IV. v. Status asthmaticus: 1 to 2 g IV over 15 to 30 minutes vi. Severe bronchoconstriction/impending respiratory failure: 40 mg/kg IV over 10 to 15 minutes (2 g maximum) b. Pediatric i. Pulseless VT with TdP: 25 to 50 mg/kg IV/IO bolus of a 50% solution (2 g maximum) ii. TdP with pulses or hypomagnesemia: 25 to 50 mg/kg IV/IO of a 50% solution over 10 to 20 minutes (2 g maximum) iii. Status asthmaticus: 25 to 50 mg/kg IV/IO of a 50% solution over 15 to 30 minutes (2 g maximum) 8. Duration of action a. Onset i. Immediate b. Peak effect i. Variable c. Duration i. 30 minutes 9. Special considerations a. Pregnancy safety: Category D b. To treat magnesium toxicity: i. Stop the infusion. ii. Give calcium gluconate 1 g IV in cases of impending respiratory arrest. iii. Support the patient’s ventilatory effort. c. Do not abbreviate magnesium sulfate to avoid confusion with morphine sulfate.

Magnesium Sulfate

1. Class a. Osmotic diuretic 2. Mechanism of action a. Promotes the movement of fluid from the intracellular space to the extracellular space b. Decreases cerebral edema and ICP c. Promotes urinary excretion of toxins 3. Indications a. Reduction of ICP in managing neurologic emergencies b. Promotes diuresis for excretion of toxic substances and metabolites 4. Contraindications a. Known hypersensitivity, hypotension, pulmonary edema b. Severe pulmonary congestion c. Electrolyte abnormalities d. Severe dehydration e. Intracranial bleeding f. Heart failure g. Use with caution in patients with impaired renal function (fluid overload can result). 5. Adverse reactions/side effects a. Headache, confusion, blurred vision b. Tachycardia c. Chest pain d. Heart failure e. Hypotension/hypertension f. Hypokalemia/hyperkalemia g. Hyponatremia/hypernatremia h. Nausea/vomiting i. Masking or worsening dehydration j. Rebound increases in ICE. k. Injection site reaction 6. Drug interactions a. Many b. May precipitate digitalism toxicity when given concurrently c. Avoid use of other diuretics in combination, if possible. d. Concomitant administration may potentiate renal toxicity. e. Avoid use with salicylates and NSAIDs. f. Use with nitrates can cause hypotension. 7. Dosage and administration a. Adult i. Give 0.5 to 1 g/kg IV infusion over 5 to 10 minutes through an in-line filter. ii. Additional doses of 0.25 to 2 g/kg can be given every 4 to 6 hours as needed. b. Pediatric i. Consult medical direction. 8. Duration of action a. Onset i. 1 to 3 hours for diuretic effect ii. 15 minutes for reduction of ICP b. Peak effect i. Variable c. Duration i. 4 to 6 hours for diuretic effect ii. 3 to 8 hours for reduction of ICP 9. Special considerations a. Pregnancy safety: Category C b. May crystallize at low temperatures c. Usage and dosages in emergency care are controversial. d. Be sure to have ventilatory support available.

Mannitol (Osmitrol)

1. Class a. Opioid analgesic b. Synthetic opioid c. Schedule II drug 2. Mechanism of action a. Synthetic opioid analgesic b. Primarily acts as an analgesic and a sedative 3. Indications a. Analgesia for moderate to severe pain 4. Contraindications a. Known hypersensitivity b. Diarrhea caused by poisoning c. Patients who have taken an MAOI during the previous 14 days d. During labor or delivery for a premature infant. e. Administer with caution to patients with: i. A GCS score less than 15 ii. Hypotension iii. Hypoxia after maximal supplemental oxygen therapy iv. Signs of hypoventilation f. Decrease the dose for patients with hepatic or renal insufficiency. 5. Adverse reactions/side effects a. Seizures b. Confusion c. Sedation d. Headache e. Hallucinations f. Increased ICP g. Respiratory depression h. Apnea i. Hypotension/orthostatic hypotension j. Syncope k. Dysrhythmias l. Nausea/vomiting m. Constipation n. Sweating 6. Drug interactions a. Additive CNS depression with TCAs, alcohol, or other CNS depressants 7. Dosage and administration a. Adult i. 50 to 100 mg IM ii. 25 to 50 mg slowly IV/IO b. Pediatric i. Not recommended 8. Duration of action a. Onset i. 10 to 15 minutes IM ii. Within 1 minute IV b. Peak effect i. Within 60 minutes IM ii. 5 to 7 minutes IV c. Duration i. 2 to 4 hours IV 9. Special considerations a. Pregnancy safety: Category C b. Use with caution in patients with asthma and COPD. c. May aggravate seizures in patients with known convulsive disorders d. Has a shorter duration of action than morphine e. Effects are reversible with naloxone. f. Document pain severity using a scale of 0 to 10 before and after administration and on arrival.

Meperidine Hydrochloride (Demerol)

1. Class a. Corticosteroid, synthetic glucocorticoid, anti-inflammatory agent 2. Mechanism of action a. Highly potent synthetic glucocorticoid that suppresses acute and chronic inflammation b. Potentiates vascular smooth muscle relaxation by beta adrenergic agonists c. Has few to no mineralocorticoid properties 3. Indications a. Allergic reaction b. Anaphylaxis c. Acute bronchospastic disease management d. Shock with a history of adrenal insufficiency or long-term steroid dependence 4. Contraindications a. Known hypersensitivity b. Serious untreated infections c. Premature infants d. Use with caution in patients with: i. GI bleeding ii. Heart failure iii. Hypertension iv. Recent AMI v. Renal disease vi. Seizure disorder vii. Cushing disease 5. Adverse reactions/side effects a. Depression b. Euphoria c. Headache d. Restlessness e. Seizure f. Nausea/vomiting g. Peptic ulcer h. Fluid retention i. Hypernatremia j. Hyperkalemia 6. Drug interactions a. Hypoglycemic responses to insulin and hypoglycemic agents may be blunted. 7. Dosage and administration a. Adult i. Bronchospasm: 2 mg/kg IV/IO/IM (maximum dose: 125 mg) ii. Shock with history of adrenal insufficiency or long-term steroid dependence: 2 mg/kg IV (maximum dose: 125 mg) b. Pediatric i. For status asthmaticus, anaphylaxis: 2 mg/kg IV/IO/IM loading dose (maximum dose: 60 mg) ii. Maintenance dose: 0.5 mg/kg IV every 6 hours or 1 mg/kg IV every 12 hours up to 120 mg/day 8. Duration of action a. Onset i. 1 to 2 hours b. Peak effect i. Variable c. Duration i. 8 to 24 hours 9. Special considerations a. Pregnancy safety: Category C b. Steroids can mask infection. c. Can increase blood glucose levels d. Hydrocortisone succinate is preferred. e. High doses or prolonged use can result in many adverse reactions and side effects.

MethyIPREDNISolone Sodium Succinate (Solu-Medrol)

1. Class a. Antiemetic, direct-acting cholinergic agonist, prokinetic agent 2. Mechanism of action a. Blocks dopamine and serotonin receptors in the chemoreceptor trigger zones of the CNS b. Sensitizes tissues to acetylcholine c. Increases upper GO motility but not secretions d. Increases lower esophageal sphincter tone 3. Indications a. Nausea/vomiting 4. Contraindications a. Known hypersensitivity to metoclopramide or procainamide b. GI hemorrhage, mechanical obstruction, or perforation c. History of seizures, tardive dyskinesia, or a dystonic reaction d. Pheochromocytoma e. Parkinson disease f. Administration with other drugs that can cause extrapyramidal symptoms 5. Adverse reactions/side effects a. Nausea/vomiting b. Headache c. Fatigue d. Rash e. Dystonic reaction f. Confusion g. AV block h. Bradycardia i. Hallucinations j. Laryngospasm 6. Drug interactions a. Increased sedation risk when used with CNS depressants, antihistamines, anticholinergics, MAOIs b. May decrease the effects of dopamine agonists c. Can increase the rate or extent of ASA absorption because of accelerated gastric emptying 7. Dosage and administration a. Adult i. 10 mg IV/IM b. Pediatric i. Older than age 2 and weight greater than 12 kg: 0.1 mg/kg IM or 0.1 mg/kg ii. May repeat once in 20 to 30 minutes if no relief iii. Maximum 10 mg/dose IV 8. Duration of action a. Onset i. 1 to 3 minutes (IV), 30 to 60 minutes b. Peak effect i. Immediate (IV) c. Duration i. 1 to 2 hours 9. Special considerations a. Pregnancy safety: Category B b. Geriatric patients should receive the lowest dose that is effective. i. They are at a greater risk for adverse effects.

Metoclopramide (Reglan)

1. Class a. Benzodiazepine, anticonvulsant, antianxiety agent, anxiolytic, sedative-hypnotic b. Schedule IV drug 2. Mechanism of action a. Inhibits GABA receptors in the CNS b. Causes sedative, anxiolytic, amnesic, and hypnotic effects 3. Indications a. Uncontrolled shivering associated with hyperthermia/heat exposure b. Active seizures c. Chemical restraint d. Severe respiratory distress e. Sedation for medical procedures f. Poisoning/overdose care 4. Contraindications a. Documented hypersensitivity b. Neurologic or respiratory depression c. Acute narrow-angle glaucoma d. Sleep apnea e. Shock f. Alcohol intoxication g. Overdose h. Depressed vital signs i. Concomitant use with barbiturates, alcohol, opioids, or other CNS depressants 5. Adverse reactions/side effects a. Headache b. Somnolence c. Respiratory depression/arrest d. Hypotension e. Cardiac arrest f. Nausea/vomiting g. Pain at the injection site 6. Drug interactions a. Concomitant use with other CNS depressant may cause respiratory depression, hypotension, profound sedation, and death. b. Motherwort can potentiate midazolam’s sedative effects and may result in coma. c. St. John’s wort and green tea can reduce its effectiveness. d. Mango and grapefruit juice may potentiate its effects. 7. Dosage and administration a. Adult i. Shivering associated with hyperthermia/heat exposure: 2.5 mg IV/IN/IO, may repeat once in 5 minutes; or 5 mg IM, may repeat once in 10 minutes ii. Seizures: If vascular access is available, 0.1 mg/kg IV/IO slowly over 2 minutes (maximum single dose: 4 mg); if access is not available, 0.2 mg/kg (maximum: 10 mg) IM or IN iii. Chemical restraint: 5 mg IV, IM, or IN iv. Severe respiratory distress: 2 to 5 mg IV v. Procedural sedation: 0.1 to 0.3 mg/kg IV (maximum single dose: 10 mg) vi. Poisoning/overdose care: 0.1 mg/kg in 2-mg increments via slow IV push over 1 to 2 minutes (maximum single dose: 5 mg) b. Pediatric i. Shivering associated with hyperthermia/heat exposure: 0.1 mg/kg IV/IO or 0.2 mg/kg IN/IM (maximum single dose: 1 mg). A 5 mg/mL concentration is recommended for IN/IM administration. ii. Seizures: If vascular access is available, 0.1 mg/kg IV/IO slowly over 2 minutes (maximum single dose: 4 mg); if access is not available, 0.2 mg/kg (maximum: 10 mg) IM or IN iii. Chemical restraint: 0.05 to 0.1 mg/kg IV, or 0.1 to 0.15 mg/kg IM, or 0.3 mg/kg IN (maximum dose: 5 mg) vi. Poisoning/overdose care: 0.1 mg/kg in 2-mg increments via slow IV push over 1 to 2 minutes (maximum single dose: 5 mg) or 0.2 mg/kg IN (maximum single dose: 4 mg) 8. Duration of action a. Onset i. Immediate IV/IN ii. 15 minute IM b. Peak effect i. 3 to 5 minutes IV/IN ii. 30 to 60 minutes IM c. Duration i. Less than 2 hours IV/IN ii. 1 to 6 hours IM 9. Special considerations a. Pregnancy safety: Category D b. Requires careful monitoring of respiratory and cardiac function c. Reduce the dose by 50% in patients older than 60 years.

Midazolam Hydrochloride (Versed)

1. Class a. Inotrope 2. Mechanism of action a. Increases myocardial contractility b. Has a direct dilating effect on vascular smooth muscle c. Does not possess beta adrenergic properties 3. Indications a. Heart failure in postoperative cardiovascular surgical patients b. Shock with high systemic vascular resistance 4. Contraindications a. Known hypersensitivity b. Reduce the dose in patients with renal dysfunction 5. Adverse reactions/side effects a. Headache b. Nausea/vomiting c. Hypotension d. Hypokalemia e. Bronchospasm f. SVT g. Ventricular dysrhythmias 6. Drug interactions a. Synergistic with catecholamines 7. Dosage and administration a. Consult medical direction or follow the dosing ordered by the sending physician. 8. Duration of action a. Onset i. 5 to 15 minutes b. Peak effect i. Unknown c. Duration i. 3 to 6 hours 9. Special considerations a. Pregnancy safety: Category C b. Hemodynamic monitoring is required. c. Closely monitor BP and heart rate.

Milrinone (Primacor)

1. Class a. Opioid analgesic b. Schedule II drug 2. Mechanism of action a. Alleviates pain through CNS action b. Suppresses the fear and anxiety centers in the brain c. Depresses brainstorm respiratory centers d. Increases peripheral venous capacitance and decreases venous return e. Decreases preload and afterload, which decreases myocardial oxygen demand 3. Indications a. Management of acute pain 4. Contraindications a. Known hypersensitivity b. Patients who have taken an MAOI during the previous 14 days c. Paralytic ileus d. Toxin-mediated diarrhea e. Heart failure due to chronic lung disease f. Head injuries g. Brain tumors h. Delirium tremens i. Seizure disorders j. During labor when premature birth is anticipated k. Acute or severe bronchial asthma l. Upper airway obstruction m. Administer with caution to patients with: i. A GCS score less than 15 ii. Hypotension iii. Hypoxia after maximal supplemental oxygen therapy iv. Signs of hypoventilation 5. Adverse reactions/side effects a. Confusion b. Sedation c. Headache d. CNS depression e. Respiratory depression f. Apnea g. Bronchospasm h. Dyspnea i. Hypotension/orthostatic hypotension j. Syncope k. Bradycardia l. Tachycardia m. Nausea/vomiting n. Dry mouth 6. Drug interactions a. Additive effects with other CNS depressants b. MAOIs may cause paradoxical excitation. 7. Dosage and administration a. Adult i. Moderate discomfort: 0.1 mg/kg IM (maximum dose: 15 mg) ii. Severe to excruciating discomfort: 0.1 mg/kg slow IV/IO (maximum dose: 10 mg) iii. STEMI: Initial dose: 2 to 4 mg slow IV (over 1 to 5 minutes) Repeat dose: 2 to 8 mg at 5- to 15-minute intervals iv. NSTEMI/unstable angina: 1 to 5 mg slow IV push only if symptoms are not relieved by nitrates, provided additional therapy is used to manage the underlying ischemia. b. Pediatric i. 0.1 to 0.2 mg/kg per dose IV/IO/IM (maximum dose: 5 mg) 8. Duration of action a. Onset i. Immediate b. Peak effect i. 20 minutes c. Duration i. 2 to 4 hours 9. Special considerations a. Pregnancy safety: Category C b. Safety in neonates has not been established. c. Use with caution in older patients, those with asthma, and those susceptible to CNS depression. d. The effects are reversible with naloxone. e. Document pain severity using a scale of 0 to 10 before and after administration and on arrival. f. Do not abbreviate to avoid confusion with magnesium sulfate.

Morphine Sulfate (Roxanol, MS Contin)

1. Class a. Opioid antagonist, opioid reversal agent, antidote 2. Mechanism of action a. Competitive inhibition at opioid receptor sites; reverses respiratory depression and sedation secondary to opioids 3. Indications a. Complete or partial reversal of CNS and respiratory depression induced by opioids or synthetic opioids 4. Contraindications a. Known hypersensitivity or allergy b. Use with caution in opioid-dependent patients c. Use with caution in neonates of opioid-addicted mothers 5. Adverse reactions/side effects a. Restlessness b. Seizures c. Dyspnea d. Pulmonary edema e. Hypertension/hypotension with rapid administration f. Dysrhythmias g. Diaphoresis h. Nausea/vomiting i. Withdrawal symptoms in opioid-addicted patients 6. Drug interactions a. Incompatible with bisulfite and alkaline solutions 7. Dosage and administration a. Adult i. Initial dose 0.4 to 2 mg IV/IO/IM/ET tube or up to a dose of 4 mg IN b. Pediatric i. Initial dose 0.1 mg/kg IV/IO/IM/IN/ET tube ii. Maximum dose: 2 mg IV/IM/ET tube or 4 mg IN 8. Duration of action a. Onset i. Less than 2 minutes, IV ii. 2 to 10 minutes IM/IN b. Peak effect i. Less than 2 minutes, IV ii. 2 to 10 minutes IM/IN c. Duration i. 20 to 120 minutes, IV/IM/IN 9. Special considerations a. Pregnancy safety: Category C b. Repeat dosing may be required. c. It is generally not beneficial in patients with cardiac arrest. d. Provide ongoing airway support as needed until the patient has adequate respiratory effort. e. Administration can be titrated until adequate respiratory effort is achieved if given with a syringe IV, IM, IN, or ET tube. i. When administered IN, divide doses equally to give a maximum of 1 mL per nostril. f. Administration can result in onset opioid withdrawal. g. Very high doses may be required when managing novel opioid overdoses. h. If administered to the patient before EMS arrival, obtain information on the dose and route through which it was administered and bring the devices with the patient.

Naloxone Hydrochloride (Narcan, EVZIO)

1. Class a. Calcium channel blocker 2. Mechanism of action a. Inhibits movement of calcium ions across cell membranes b. Inhibits cardiac and vascular smooth muscle contraction c. Does not prolong AV nodal conduction 3. Indications a. HAPE prevention and treatment b. Pregnancy-induced hypertension lasting more than 15 minutes with associated preeclampsia symptoms 4. Contraindications a. Known hypersensitivity to calcium channel blockers b. Cardiogenic shock c. Immediate-release preparation for urgent or emergent hypertension 5. Adverse reactions/side effects a. Headache/dizziness b. Nervousness c. Weakness d. Mood changes e. Dyspnea f. Cough/wheezing g. Heart failure h. MI i. Ventricular dysrhythmias j. Hypotension k. Syncope l. Nausea, abdominal discomfort, diarrhea 6. Drug interactions a. Beta blockers may potentiate NIFEdipine’s effects. b. Effects of theophylline may be increased. c. Antihypertensives may potentiate the hypotensive effects. 7. Dosage and administration a. Adult i. HAPE prevention and treatment: 30 mg of the extended-release preparation orally every 12 hours or 20 mg of the extended-release preparation orally every 8 hours ii. Pregnancy-induced hypertension: 10 mg orally and may repeat 10 to 20 mg orally every 20 minutes, twice, for persistent, severe hypertension with preeclampsia symptoms. Goal is to reduce MAP by 20% to 25%. b. Pediatric i. Data are unavailable. 8. Duration of action a. Onset i. 15 to 30 minutes b. Peak effect i. 1 to 3 hours c. Duration i. 6 to 8 hours 9. Special considerations a. Pregnancy safety: Category C b. Can be used for HAPE treatment when descent is impossible or delayed and reliable access to supplemental oxygen or portable hyperbaric therapy is unavailable c. Hypotension is less common when the extended-release preparation is used but may develop when the medication is given to patients with intravascular volume depletion. d. Reassess vital signs every 10 minutes during transport.

NIFEdipine (Procardia, Adalat, Nifedical)

1. Class a. Vasodilator, nitrate, antianginal 2. Mechanism of action a. Smooth muscle relaxant b. Dilated peripheral arterioles and veins c. Reduces peripheral vascular resistance, preload, and afterload, decreasing the heart’s workload and myocardial oxygen demand 3. Indications a. Ischemic-type chest pain b. Acute and symptomatic hypertension c. Heart failure d. Pulmonary edema 4. Contraindications a. Known hypersensitivity b. Hypotension c. Hypovolemia d. Intracranial bleeding or head injury e. Pericardial tamponade f. Severe bradycardia or tachycardia g. RV infarction h. Previous administration of sildenafil or vardenafil within 24 hours or tadalafil within 48 hours i. Use with caution in patients with: i. Hepatic disease ii. Anemia iii. Diabetes mellitus iv. Pregnancy v. Breastfeeding 5. Adverse reactions/side effects a. Headache b. Dizziness c. Weakness d. Reflex tachycardia e. Syncope f. Hypotension g. Nausea/vomiting h. Dry mouth i. Muscle twitching j. Diaphoresis 6. Drug interactions a. Increased hypotensive effect with alcohol, beta blockers, calcium channel blockers, antihypertensives, benzodiazepines, phenothiazines, and other vasodilators b. Incompatible with other drugs given IV c. Hawthorn increases NTG levels. 7. Dosage and administration a. Adult i. SL: 0.3 to 0.4 mg; may repeat in 3 to 5 minutes to a maximum of 3 doses ii. Spray: 1 or 2 sprays; may repeat in 3 to 5 minutes to a maximum of 3 doses iii. NTG IV: 12.5 to 25 mcg bolus (if no SL or spray is given), then begin 10 mcg/min infusion, increase by 10 mcg/min every 3 to 5 minutes until symptom response or desired effect (maximum dose: 200 mcg/min) b. Pediatric i. Not recommended 8. Duration of action a. Onset i. 1 to 3 minutes b. Peak effect i. 5 to 10 minutes c. Duration i. 20 to 30 minutes SL ii. 1 to 10 minutes after discontinuation of IV infusion 9. Special considerations a. Pregnancy safety: Category C b. Hypotension is more common in older patients. c. If a 12-lead ECG shows an inferior wall infarct, rule out RV infarction via right-side 12-lead ECG before administering NTG. d. It must be kept in an airtight container. e. IV NTG must be administered only with an infusion pump direct from the bottle with a vented IV set and non-polyvinyl chloride tubing. f. The active ingredient may have stinging effect when administered.

Nitroglycerin (Nitrostat, Nitrolingual Pumpspray, NitroQuick, Nitro-Bid, Tridil)

1. Class a. Antihypertensive, vasodilator 2. Mechanism of action a. Arterial and venous vasodilator that reduces afterload b. Decreases BP and increases cardiac output 3. Indications a. Heart failure b. Acute and symptomatic hypertension 4. Contraindications a. Known hypersensitivity b. Hypotension c. Decreased cerebral perfusion d. Heart failure with reduced peripheral vascular resistance 5. Adverse reactions/side effects a. Confusion b. Restlessness c. Flushing d. Dizziness e. Headache f. Palpitations g. Dysrhythmias h. Hypotension i. Methemoglobinemia j. Cerebrovasodilation leading to increased ICP 6. Drug interactions a. Additive effects with ganglionic blocking agents b. General anesthetics c. Other antihypertensives d. Sympathomimetics 7. Dosage and administration a. Consult medical direction or follow the dosing ordered by the sending physician. 8. Duration of action a. Onset i. Immediate b. Peak effect i. Rapid c. Duration i. 1 to 10 minutes 9. Special considerations a. Pregnancy safety: Category C b. Light sensitive c. Keep the drug reservoir and tube covered with an opaque material. d. Can cause cyanide toxicity

Nitroprusside (Nitropress)

1. Class a. Gaseous analgesic and anesthetic 2. Mechanism of action a. Exact mechanism is unknown. 3. Indications a. Analgesia in the patient who can self-administer this medication 4. Contraindications a. Known hypersensitivity b. Impaired level of consciousness c. Head injury d. Inability to follow or comply with instructions e. Decompression illness f. Significant respiratory compromise g. Suspected abnormal air-filled cavities h. Maxillofacial trauma or facial burns. i. Relative contraindications include: stroke history, hypotension, pregnancy, known cardiac conditions, and known vitamin B12 deficiency. 5. Adverse reactions/side effects a. Light-headedness b. Headache c. Dizziness d. Confusion e. Nausea/vomiting f. Hallucination 6. Drug interactions a. Can potentiate the effects of CNS depressants 7. Dosage and administration a. Adult i. Self-administered ii. Assess the patient’s ability to self-administer after the initial dose. b. Pediatric i. Same as adult 8. Duration of action a. Onset i. 2 to 5 minutes b. Peak effect i. 2 to 5 minutes c. Duration i. 2 to 5 minutes 9. Special considerations a. Pregnancy safety: Category C b. Some EMS agencies prohibit use inside ambulances because of the risk of rescuer exposure. c. It is nonflammable and nonexplosive. d. It is ineffective in 20% of the population. e. Document pain severity using a scale of 0 to 10 before and after administration and on arrival at the receiving facility.

Nitrous Oxide 50:50 (Nitronox)

1. Class a. Sympathomimetic, vasopressor 2. Mechanism of action a. Produces constriction of resistance and capacitance vessels b. Increases systemic BP and coronary artery blood flow c. Acts on beta-1 receptors d. In lower doses, the cardiac-stimulant effect predominates e. In larger doses, the vasoconstrictor effect predominates 3. Indications a. First-line vasopressor in neurogenic shock b. Hypotension unresponsive to IV/IO fluid resuscitation 4. Contraindications a. Known hypersensitivity b. Hypotension caused by hypovolemia c. Pregnancy (relative) 5. Adverse reactions/side effects a. Headache b. Anxiety, dizziness, restlessness, dyspnea c. Hypertension, dysrhythmias, chest pain, peripheral cyanosis, cardiac arrest d. Nausea/vomiting e. Urinary retention, renal failure f. Tissues necrosis from extravasation g. Decreased blood flow to the GI tract, kidneys, skeletal muscle, and skin 6. Drug interactions a. TCAs can markedly increase response to pressors. b. Concomitant use of sympathomimetics may result in additive cardiovascular effects. c. Alpha adrenergic effects can be blocked during concurrent administration of phenothiazines. d. Inactivated by alkaline solutions 7. Dosage and administration a. Adult i. 0.1 to 0.5 mcg/kg/min IV/IO infusion titrated to effect b. Pediatric i. Begin at 0.05 to 0.1 mcg/kg/min IV infusion. ii. Adjust rate to achieve desired change in BP and systemic perfusion. iii. Maximum infusion rate: 2 mcg/kg/min 8. Duration of action a. Onset i. Immediate b. Peak effect i. Less than 1 minute c. Duration i. 1 to 2 minutes 9. Special considerations a. Pregnancy safety: Category C b. Correct hypovolemia before administering. c. Use an infusion pump and administer through a large, stable vein to avoid extravasation and tissue necrosis. d. Close monitoring of the IV/IO site and vital signs is essential. e. Drug or poison-induced hypotension may require higher doses to achieve adequate perfusion. f. Lower mortality rate for patients in cardiogenic or septic shock than those treated with DOPamine.

Norepinephrine Bitartrate (Levophed, Levarterenol)

1. Class a. Synthetic hormone, antidiarrheal 2. Mechanism of action a. Decreases visceral blood flow b. Inhibits the release of serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide 3. Indications a. Treatment of active GI bleeding during transport 4. Contraindications a. Known hypersensitivity 5. Adverse reactions/side effects a. Nausea/vomiting b. Bloating c. Dizziness d. Headache e. Dysrhythmias f. Pain and irritation at the injection site 6. Drug interactions a. Decreases cycloSPORINE levels 7. Dosage and administration a. Consult medical direction or follow the dosing ordered by the sending physician. 8. Duration of action a. Onset i. 30 minutes b. Peak effect i. 30 minutes c. Duration i. Up to 12 hours 9. Special considerations a. Pregnancy safety: Category B

Octreotide (Sandostatin)

1. Class a. Second-generation antipsychotic, antimanic agent 2. Mechanism of action a. Exact mechanism has not been determined. b. May act through a combination of dopamine and serotonin type 2 receptor site antagonism 3. Indications a. Agitated or violent patients experiencing a behavioral emergency b. Chemical restraint 4. Contraindications a. Documented hypersensitivity b. Use with caution in patients who: i. Have dehydration or heat exposure ii. Are taking medications with anticholinergic effects c. Impaired core body temperature regulation may occur. d. Use with caution in patients with a history of seizures or urinary retention. 5. Adverse reactions/side effects a. Drowsiness b. Dry mouth c. Difficulty speaking d. Slurred speech e. Unsteady gait f. Headache g. Depression h. Insomnia i. Extrapyramidal symptoms (dose-dependent) 6. Drug interactions a. Additive effects with alcohol and other CNS depressants. b. Concurrent use of IM/IV benzodiazepines and olanzapine IM is not recommended. c. Ginkgo may potentiate effects. 7. Dosage and administration a. Adult i. Chemical restraint: 10 mg IM b. Pediatric i. Limited data are available for pediatric use. ii. Chemical restraint: Ages 6 to 11 years: 5 mg IM Ages 12 to 18 years: 10 mg IM 8. Duration of action a. Onset i. 15 to 30 minutes IM b. Peak effect i. 15 to 45 minutes IM c. Duration i. Variable 9. Special considerations a. Pregnancy safety: Category C b. Patients are at risk for severe sedation or delirium after each injection. i. Must be observed for at least 3 hours with access to emergency response services. ii. Risk is significant when administered concomitantly with benzodiazepines.

Olanzapine (Zyprexa)

1. Class a. Selective serotonin receptor (5-HT3) antagonist, antiemetic. 2. Mechanism of action a. Blocks the action of serotonin. b. Does not affect dopamine receptors. 3. Indications a. Prevention and control or nausea or vomiting. 4. Contraindications a. Known hypersensitivity to ondansetron or other 5-HT3 receptor antagonists b. Known or suspected long QT syndrome c. Coadministration with apomorphine 5. Adverse reactions/side effects a. Headache b. Malaise c. Syncope d. Wheezing e. Bronchospasm f. Dysrhythmias g. ECG changed h. Palpitations i. Constipation j. Diarrhea k. Hives/skin rash l. Serotonin syndrome 6. Drug interactions a. Avoid administration with other drugs that prolong the QT interval. b. Serotonin syndrome can occur with simultaneous use of several drugs. 7. Dosage and administration a. Adult i. Antiemetic: 4 mg IV/SL or orally or 4 mg SL of the orally disintegrating tablet formulation ii. Vomiting associated with AMS: 4 mg IV, SL, or orally every 6 hours iii. Stimulant poisoning/overdose: 8 mg slow IV over 2 to 5 minutes or 4 to 8 mg IM or 8 mg orally disintegrating tablet b. Pediatric i. Ages 6 months to 14 years: Antiemetic: 0.15 mg/kg IV or orally ii. Maximum dose: 4 mg 8. Duration of action a. Onset i. 30 minutes b. Peak effect i. 1.3 hours (oral) ii. 10 minutes (IV) c. Duration i. 3 to 6 hours 9. Special considerations a. Pregnancy safety: Category B b. ECG monitoring is recommended for patients who have electrolyte abnormalities, heart failure, or bradydysrhythmias, or who are also receiving other medications that cause QT prolongation. c. It can be sedating in very young children.

Ondansetron Hydrochloride (Zofran, Zofran ODT, Zuplenz)

1. Class a. Intranasal decongestant, vasoconstrictor, topical sympathomimetic 2. Mechanism of action a. Stimulates alpha adrenergic receptors in the arterioles of the nasal mucosa to produce vasoconstriction 3. Indications a. Epistaxis in a patient experiencing facial trauma 4. Contraindications a. Known hypersensitivity b. Severe hypertension 5. Adverse reactions/side effects a. Rebound nasal congestion b. Nasal mucosa irritation 6. Drug interactions a. May diminish the vasoconstricting effects of alpha-1 agonists b. May enhance the hypertensive effects of sympathomimetics 7. Dosage and administration a. Adult i. 2 to 3 sprays in each nare b. Pediatric i. 1 to 2 sprays in each nare 8. Duration of action a. Onset i. Immediate b. Peak effect i. 5 minutes c. Duration i. Up to 5 hours 9. Special considerations a. Pregnancy safety: Category B

Oxymetazoline (Afrin, Dristan 12-Hour, Vicks Sinus-12 Hour)

1. Class a. Pituitary hormone, uterine vasoconstrictor 2. Mechanism of action a. Binds to oxytocin receptor sites on the surface of uterine smooth muscle b. Increases the force and frequency of uterine contractions c. Causes dilation of vascular smooth muscle, thereby increasing renal, coronary, and cerebral blood flow 3. Indications a. Postpartum hemorrhage due to uterine atony after infant and placental delivery 4. Contraindications a. Known hypersensitivity b. Presence of a remaining fetus c. Unfavorable fetal position d. Anticipated nonvaginal delivery e. Fetal distress when delivery is not imminent f. Prolonged use in severe toxemia 5. Adverse reactions/side effects a. Coma b. Seizures c. Anxiety d. Hypotension e. Dysrhythmias f. Nausea/vomiting g. Anaphylaxis h. Painful uterine contractions i. Electrolyte disturbances j. Maternal intracranial hemorrhage 6. Drug interactions a. Can cause severe, persistent hypertension if administered with vasopressors b. Synergistic effect with black cohosh, cotton root, squaw vine, and cinnamon 7. Dosage and administration a. Adult i. IM administration: 10 units IM after delivery of placenta ii. IV/IO administration: Mix 10 to 40 units in 1,000 mL of a compatible IV solution infused at 10 to 15 drops/min, titrated to the severity of bleeding and uterine response. b. Pediatric i. Not appliable 8. Duration of action a. Onset i. 3 to 5 minutes IM ii. Within 1 minute IV/IO b. Peak effect i. 40 minutes IM ii. Unknown IV/IO c. Duration i. 2 to 3 hours IM ii. 1 hour after IV/IO infusion is stopped 9. Special considerations a. Pregnancy safety: Category C b. Closely monitor vital signs, including fetal heart rate and uterine tone

Oxytocin (Pitocin)

1. Class a. Nondepolarizing neuromuscular blocking agent, cholinergic receptor antagonist 2. Mechanism of action a. Binds to the receptor for acetylcholine at the neuromuscular junction b. Relaxes skeletal muscle 3. Indications a. Adjunct to provide skeletal muscle relaxation and facilitate tracheal intubation and ventilation 4. Contraindications a. Known hypersensitivity to pancuronium or a bromide hypersensitivity b. Inability to control the airway and/or support ventilation with oxygen and positive pressure c. Neuromuscular disease d. Hepatic or renal failure e. Use with extreme caution in patients with pulmonary disease, such as COPD. 5. Adverse reactions/side effects a. Bronchospasm b. Angioedema c. Hypotension d. Edema e. Tachycardia f. Flushing g. Weakness h. Hypersalivation i. Itching/hives j. Prolonged neuromuscular block k. Risk of respiratory depression due to relaxation of the intercostal muscles and diaphragm 6. Drug interactions a. Calcium channel blockers may prolong neuromuscular blockade. b. Positive chronotropic drugs may potentiate tachycardia. c. Coadministration of opioids may enhance neuromuscular blockade and produce an increased degree of respiratory depression, hypotension, or sedation. 7. Dosage and administration a. Adult i. 0.06 to 0.1 mg/kg via slow IV initially, followed by incremental doses of 0.01 mg/kg at 25- to 60-minute intervals as needed to maintain muscle relaxation b. Pediatric i. Consult medical direction. 8. Duration of action a. Onset i. 2 to 3 minutes b. Peak effect i. Paralysis in 4 minutes c. Duration i. 35 to 45 minutes 9. Special considerations a. Pregnancy safety: Category C b. Does not provide sedation of analgesia and will not stop neuronal seizure activity. c. If the patient is conscious, explain the effect of the medication before administration. d. Always sedate the patient before administration. e. Intubation and ventilatory support must be readily available. f. Doses should be calculated based on ideal body weight. g. Anaphylactic and anaphylactoid-type adverse reactions, including fatalities, have been reported in association with neuromuscular blocker use.

Pancuronium Bromide (Pavulon)

1. Class a. Adrenergic, alpha agonist, nasal vasoconstrictor 2. Mechanism of action a. Stimulates alpha adrenergic receptors in the arterioles of the nasal mucosa to produce vasoconstriction 3. Indications a. Epistaxis b. To reduce bleeding during nasotracheal intubation 4. Contraindications a. Known hypersensitivity b. Use with extreme caution in geriatric patients with preexisting cardiovascular disease. 5. Adverse reactions/side effects a. Tremors b. Palpitations c. Hypertension 6. Drug interactions a. Exaggerated adrenergic effects if given with, or up to 21 days after, MAOI administration b. Hypertensive effects may be potentiated by TCAs, guanethidine, methyldopa, and atropine-like drugs. 7. Dosage and administration a. Adult i. Two sprays in the selected nare before nasotracheal tube insertion 8. Duration of action a. Onset i. Seconds b. Peak effect i. 30 minutes c. Duration i. 30 minutes to 4 hours 9. Special considerations a. Pregnancy safety: Category C b. Each bottle is for single-patient use

Phenylephrine (Neo-Synephrine)

1. Class a. Antidote 2. Mechanism of action a. Potassium iodide (KI) can help block radioactive iodine from being absorbed by the thyroid gland. i. Reduces the risk of thyroid cancer ii. Does not keep radioactive iodine from entering the body and cannot reverse health effects 3. Indications a. Environmental radiation emergency to block uptake of radioactive iodine isotopes in the thyroid and reduce thyroid cancer risk 4. Contraindications a. Known iodine hypersensitivity b. Hyperthyroidism c. Respiratory failure 5. Adverse reactions/side effects a. Skin rash b. Salivary gland swelling c. Iodism 6. Drug interactions a. Use with caution in patients taking drugs that may increase serum potassium levels, such as ACE inhibitors. b. NSAIDs may cause potassium retention. 7. Dosage and administration a. Consult medical direction. 8. Duration of action a. Onset i. Data unavailable b. Peak effect i. Data unavailable c. Duration i. About 24 hours 9. Special considerations a. Pregnancy safety: Category D b. EMS providers may be asked to assist public health agencies in distribution and administration in a mass-casualty incident involving radiation release or exposure. c. Adults older than 40 years should not take KI without public health or emergency management official acknowledgment. d. Adults older than 40 years have the lowest chance of developing thyroid cancer or injury after contamination with radioactive iodine and are more likely to have allergic reactions or adverse effects.

Potassium Iodide (Pima Syrup, SSKI, ThyroSafe, ThyroShield)

1. Class a. Cholinesterase reactivator, antidote 2. Mechanism of action a. Binds to organophosphates and breaks their alkyl phosphate-cholinesterase bonds b. Restores the activity of acetylcholinesterase. 3. Indications a. Antidote in treating poisoning by organophosphate pesticides and related nerve gases 4. Contraindications a. Known hypersensitivity b. Reduce the dose in: i. Patients with impaired renal function ii. Older adults with hypertension iii. Patients with myasthenia gravis 5. Adverse reactions/side effects a. Dizziness, drowsiness, headache, neuromuscular blockage, seizure, laryngospasm, hyperventilation, apnea, tachycardia, cardiac arrest, nausea, muscle rigidity/weakness, rash, pain at injection site b. Especially in geriatric patients, excessive doses may cause severe systolic and diastolic hypertension, neuromuscular weakness, headache, tachycardia, and visual impairment. c. An overdose may cause profound neuromuscular weakness and subsequent respiratory depression in children. 6. Drug interactions a. Avoid using concurrently with succinylcholine, morphine, aminophylline, theophylline, and other respiratory depressants. 7. Dosage and administration a. Consult with medical direction. b. Dosage recommendations vary depending on the degree of exposure and patient age and weight. c. May be provided in a single-dose vial, prefilled syringes, or auto-injectors i. Commercially available auto-injectors contain 600 mg. 8. Duration of action a. Onset i. Minutes b. Peak effect i. 10 to 20 minutes IM ii. 5 to 15 minutes IV c. Duration i. Variable 9. Special considerations a. Pregnancy safety: Category C b. Slow IV infusion prevents tachycardia, laryngospasm, and muscle rigidity. c. Consider drawing a blood sample before administration for the hospital to run pretreatment levels. d. A dose should be administered shortly after the nerve agent or organophosphate poisoning exposure. e. Cardiac monitoring should be considered in all cases of severe organophosphate poisoning.

Pralidoxime (2-PAM, Protopam)

1. Class a. Class Ia antidysrhythmic 2. Mechanism of action a. Inhibits recovery after repolarization b. Direct membrane depressant that decreases conduction velocity, prolongs the refractory period, decreases automaticity, and reduces repolarization abnormalities 3. Indications a. Stable monomorphic VT with normal QT interval b. Reentry SVT uncontrolled by vagal maneuvers and adenosine if BP is stable c. Stable wide-complex tachycardia of unknown origin d. AF with a rapid ventricular rate in patients with Wolff-Parkinson-White syndrome 4. Contraindications a. Known hypersensitivity to procainamide or other ingredients b. TdP c. Second- and third-degree heart AV block d. Systemic lupus erythematosus e. Preexisting QT prolongation f. Digitalis toxicity g. TCA overdose h. Administer with caution to patients with: i. Asthma or digitalis-induced dysrhythmias ii. Myasthenia gravis iii. Cardiac, hepatic, or renal insufficiency 5. Adverse reactions/side effects a. Can induce or worsen cardiac dysrhythmias b. Anorexia c. Nausea/vomiting d. Confusion e. Seizures f. Severe hypotension g. Widening of PR, QRS, and QT intervals 6. Drug interactions a. Additive effect with other antidysrhythmic agents b. Use with beta agonists may be associated with adverse cardiovascular effects, including QT interval prolongation. 7. Dosage and administration a. Adult i. Recurrent VF/pulseless VT: 20 mg/min slow IV infusion until the dysrhythmia is suppressed ii. Maximum total dose: 17 mg/kg iii. In urgent situations, up to 40 mg/min may be administered, up to a total dose of 17 mg/kg iv. Other indications: 20 mg/min slow IV infusion unto dysrhythmia suppression, hypotension, QRS widens by more than 50% of its pretreatment width, or a total dose of 17 mg/kg has been given. v. Maintenance infusion: 1 to 4 mg/min vi. In the presence of cardiac, hepatic, or renal dysfunction, reduce the maximum total dose to 12 mg/kg and the maintenance infusion to 1 to 2 mg/min. b. Pediatric i. Not recommended in the prehospital setting 8. Duration of action a. Onset i. 10 to 30 minutes b. Peak effect i. Variable c. Duration i. 3 to 6 hours 9. Special considerations a. Pregnancy safety: Category C b. Hypotension may occur with rapid infusion.

Procainamide Hydrochloride (Pronestyl)

1. Class a. Antiemetic, first-generation (typical) anti-psychotic, phenothiazine 2. Mechanism of action a. Depresses the brain’s chemoreceptor trigger zone b. Moderate anticholinergic and alpha adrenergic receptor blocking effects c. Alpha-1 adrenergic receptor blockade produces sedation, muscle relaxation, and cardiovascular effects. 3. Indications a. Nausea and vomiting 4. Contraindications a. Documented hypersensitivity to phenothiazines b. Concurrent use of large amounts of CNS depressants leading to sedation c. Concomitant use of anticholinergic medications d. Preexisting cardiac conduction abnormalities e. Poorly controlled seizure disorder f. Narrow-angle glaucoma g. Prostatic hypertrophy h. Past or current history of tardive dyskinesia i. Subcortical brain damage j. Pediatric surgery k. Children younger than age 2 years 5. Adverse reactions/side effects a. Drowsiness b. Dizziness c. Headache d. Blurred vision e. Tachycardia f. Hypotension g. Prolonged QT interval h. Extrapyramidal symptoms 6. Drug interactions a. Increased risk of respiratory depression when used with other medications that cause respiratory depression. 7. Dosage and administration a. Adult i. 5 to 10 mg IV/IM b. Pediatric i. Older than age 2 years and weight greater than 12 kg: 0.1 mg/kg slow IV or deep IM ii. Maximum dose: 10 mg 8. Duration of action a. Onset i. 10 to 20 minutes IM ii. Rapid IV b. Peak effect i. 30 to 60 minutes IV c. Duration i. 3 to 4 hours IM/IV 9. Special considerations a. Pregnancy safety: Category C b. Use during pregnancy only if the potential maternal benefit outweighs the fetal risk. c. Contraindicated for use in breastfeeding women d. The label carries an FDA black box warning for children younger than age 2 years.

Prochlorperazine (Compazine)

1. Class a. Phenothiazine, antiemetic, antihistamine 2. Mechanism of action a. H1 receptor antagonist b. Blocks the action of histamine c. Possesses sedative, antimotion, antiemetic, and anticholinergic activity d. Potentiates the effects of opioids to induce analgesia 3. Indications a. Nausea and vomiting 4. Contraindications a. Known hypersensitivity to any phenothiazines b. Concurrent use of large amounts of CNS depressants c. Reye syndrome d. Lower respiratory symptoms e. Children younger than 2 years f. Use with caution, if at all, in patients with a history of sleep apnea, acute or chronic respiratory impairment, or seizure disorders. 5. Adverse reactions/side effects a. Headache b. Dizziness c. Drowsiness d. Confusion e. Restlessness f. Wheezing g. Chest tightness h. Thickening of bronchial secretions i. Palpitations j. Bradycardia k. Reflex tachycardia l. QT prolongation m. Postural hypotension n. Diarrhea, nausea, vomiting 6. Drug interactions a. Additive with other CNS depressants b. Increased extrapyramidal effects with MAOIs 7. Dosage and administration a. Adult i. 12.5 to 25 mg deep IM b. Pediatric i. Older than age 2 years: 0.25 to 0.5 mg/kg deep IM 8. Duration of action a. Onset i. 20 minutes b. Peak effect i. 30 to 60 minutes c. Duration i. 4 to 6 hours 9. Special considerations a. Pregnancy safety: Category C b. Convulsions and sudden death have been reported when used with children. c. Do not administer if haloperidol or droperidol with be or has been given. d. Monitor the QT interval with a 12-lead ECG if feasible. e. Document the QT interval and relay the findings to the receiving facility staff. f. Deep IM injection is the recommended route of administration.

Promethazine Hydrochloride (Phenergan)

1. Class a. Topical ophthalmic anesthetic 2. Mechanism of action a. Produces local anesthesia by blocking sodium ion channels 3. Indications a. Induction of topical anesthesia before eye irrigation in the management of a chemical injury to the eye 4. Contraindications a. Known hypersensitivity b. Known or suspected trauma that may have results in intraocular injury c. Use with caution in patients with cardiac disease or hyperthyroidism. 5. Adverse reactions/side effects a. Temporary stinging, burning, and conjunctival redness 6. Drug interactions a. Data unavailable 7. Dosage and administration a. Adult and pediatric i. 1 to 2 drops in the affected eye(s) 8. Duration of action a. Onset i. 15 to 60 seconds b. Peak effect i. 30 to 120 seconds c. Duration i. 10 to 20 minutes 9. Special considerations a. Pregnancy safety: Category C b. Each bottle is for single-patient use. c. The corneal epithelium may become dry during use. d. Instruct the patient not to rub, touch, or wipe the affected eye because the affected eye will be insensitive to touch for as long as 20 minutes after use.

Proparacaine Ophthalmic (Alcaine, Ophthaine)

1. Class a. Short-acting general anesthetic, sedative-hypnotic 2. Mechanism of action a. Produces a rapid and brief state of general anesthesia 3. Indications a. Maintenance of sedation in mechanically ventilated patients 4. Contraindications a. Hypovolemia b. Known sensitivities, including to soybean oil, peanuts, and eggs 5. Adverse reactions/side effects a. Seizure b. Apnea c. Dysrhythmias d. Hypotension/hypertension e. Rash/itching f. Injection site reactions g. Involuntary muscle movement 6. Drug interactions a. Increased anesthetic or sedative effects when combined with alcohol, antihistamines, opioids, and combinations of opioids and sedatives b. Avoid mixing with medications that cannot pass through lipids. c. Simultaneous use with fentanyl can cause profound bradycardia in pediatric patients. 7. Dosage and administration a. Consult medical direction or follow the dosing ordered by the sending physician. 8. Duration of action a. Onset i. Less than 1 minute b. Peak effect i. 1 minute c. Duration i. As long as the infusion is running 9. Special considerations a. Pregnancy safety: Category B b. It has no analgesic properties. c. Use with caution in patients: with difficult airways. d. Have emergency airway equipment readily available. e. Avoid rapid administration in older patients to avoid hypotension and airway obstruction. f. Carefully monitor vital signs and oxygenation. g. Use a large, stable vein to avoid injection during transport because noxious stimuli may arouse patients. h. Infusion may need to be increased during transport because noxious stimuli may arouse patients.

Propofol (Diprivan)

1. Class a. Phosphodiesterase-5 enzyme inhibitor 2. Mechanism of action a. Inhibits phosphodiesterase enzyme 5 in lung tissue 3. Indications a. HAPE prevention 4. Contraindications a. Known hypersensitivity b. Coadministration with nitrates c. Significant cardiovascular disease 5. Adverse reactions/side effects a. Headache b. Nasal congestion c. Flushing d. Epistaxis e. Erythema f. Diarrhea g. Skin rash h. Tinnitus 6. Drug interactions a. Can potentiate the hypotensive effects of nitrates, alpha blockers, antihypertensives, or alcohol b. Increased risk of side effects when taken with grapefruit juice and grapefruit products 7. Dosage and administration a. Adult i. HAPE prevention: Give 50 mg orally every 8 hours b. Pediatric i. Data unavailable 8. Duration of action a. Onset i. 20 minutes b. Peak effect i. 30 to 120 minutes c. Duration i. 4 hours 9. Special considerations a. Pregnancy safety: Category B

Sildenafil (Revatio, Viagra)

1. Class a. Systemic hydrogen ion buffer, alkalizing agent 2. Mechanism of action a. Reacts with hydrogen ions to form water and carbon dioxide, correcting metabolic acidosis b. Increases blood and urinary pH by releasing a bicarbonate ion, which in turn neutralizes hydrogen ion concentrations 3. Indications a. Management of cardiac arrest in which either hyperkalemia or TCA overdose is suspected b. QRS prolongation in known or suspected TCA overdose c. Crush syndrome 4. Contraindications a. Documented hypersensitivity b. Known metabolic or respiratory alkalosis c. Hypokalemia d. Hypernatremia e. Hypocalcemia f. Use with caution in patients with heart failure and renal disease due to high sodium concentration it produces. 5. Adverse reactions/side effects a. Electrolyte imbalance, heart failure, and pulmonary edema b. Tremors, twitching, and seizures caused by alkalosis 6. Drug interactions a. Increases the effects of amphetamines b. Decreases the effects of benzodiazepines and TCAs c. May deactivate sympathomimetics 7. Dosage and administration a. Adult i. 1 mEq/kg slow IV/IO push b. Pediatric i. 1 mEq/kg slow IV/IO push (4.2% concentration recommended for infants younger than 1 month) ii. Consult medical direction for repeat dosing orders. 8. Duration of action a. Onset i. Seconds b. Peak effect i. Less than 15 minutes c. Duration i. 1 to 2 hours 9. Special considerations a. Pregnancy safety: Category C b. Monitor the patient closely for signs and symptoms of fluid overload. c. Ensure the patient has adequate airway and ventilatory support. d. May precipitate or inactivate other medications e. Flush the IV line well before and after injecting sodium bicarbonate. f. Extravasation may lead to tissue sloughing, cellulitis, and necrosis at the injection site.

Sodium Bicarbonate

1. Class a. Depolarizing neuromuscular blocker b. Skeletal muscle relaxant 2. Mechanism of action a. Ultra-short-acting depolarizing skeletal muscle relaxant that mimics acetylcholine 3. Indications a. Adjunct to provide skeletal muscle relaxation and facilitate tracheal intubation and ventilation 4. Contraindications a. Known hypersensitivity b. Inability to control the airway or support ventilation with oxygen and positive pressure c. Renal failure d. Muscular dystrophy and other neuromuscular diseases e. Paraplegia/quadriplegia f. Penetrating eye injuries g. Prolonged immobilization h. Stroke with residual motor dysfunction i. History of malignant hyperthermia j. Acute injury after multisystem trauma, major burns, known or suspected hyperkalemia, or extensive muscle injury that may result in hyperkalemia k. Use with caution if a difficult airway is anticipated. 5. Adverse reactions/side effects a. Apnea b. Respiratory depression c. Dysrhythmias d. Cardiac arrest e. Excessive salivation f. Prolonged muscle rigidity g. Rhabdomyolysis h. Malignant hyperthermia i. Hyperkalemia j. Increased intracranial, intraocular, and intragastric pressure 6. Drug interactions a. Coadministration with CNS depressants may cause profound sedation, coma, respiratory depression, hypotension, or death. b. Oxytocin, beta blockers, and organophosphates may potentiate its effects. c. Diazepam may reduce its duration of action. 7. Dosage and administration a. Adult i. 1 to 1.5 mg/kg rapid IV b. Pediatric i. 1 to 1.5 mg/kg for children ii. 2 mg/kg for infants 8. Duration of action a. Onset i. 45 to 60 seconds b. Peak effect i. 1 to 3 minutes c. Duration i. 4 to 6 minutes 9. Special considerations a. Pregnancy safety: Category C b. Doses should be calculated based on ideal body weight. c. If the patient is conscious, explain the effects of the drug before administration. d. Appropriate sedation and analgesia should be provided to any conscious patient before initiating neuromuscular blockade. e. Time management is crucial. f. Postintubation sedation and analgesia should be readily available.

Succinylcholine Chloride (Anectine)

1. Class a. Phosphodiesterase-5 enzyme inhibitor 2. Mechanism of action a. Inhibits phosphodiesterase enzyme 5 in lung tissue b. Relaxes pulmonary vascular smooth muscle cells 3. Indications a. HAPE prevention 4. Contraindications a. Known hypersensitivity b. Coadministration with nitrates c. Stevens-Johnson syndrome d. Exfoliative dermatitis 5. Adverse reactions/side effects a. Headache b. Nasal congestion c. Back pain d. Flushing e. Epistaxis f. Erythema g. Diarrhea h. Skin rash i. Tinnitus 6. Drug interactions a. Can potentiate the hypotensive effects of nitrates, alpha blockers, antihypertensives, or alcohol b. Increased risk of side effects when taken with grapefruit juice and grapefruit products 7. Dosage and administration a. Adult i. HAPE prevention: Give 10 mg orally twice daily b. Pediatric i. Date unavailable 8. Duration of action a. Onset i. 30 to 45 minutes b. Peak effect i. 2 hours c. Duration i. Up to 36 hours 9. Special considerations a. Pregnancy safety: Category B

Tadalafil (Cialis, Adcirca)

1. Class a. Topical ophthalmic anesthetic 2. Mechanism of action a. Produces local anesthesia by blocking sodium ion channels b. Stops cellular depolarization and prevents the action potential development of nerve impulses at the ophthalmic pain nerve cell membrane 3. Indications a. Induction of topical anesthesia before eye irrigation in the management of a chemical injury to the eye 4. Contraindications a. Known hypersensitivity b. Known or suspected trauma that may have resulted in intraocular injury 5. Adverse reactions/side effects a. Blurry vision b. Transient stinging, burning, and conjunctival redness 6. Drug interactions a. Monitor closely for methemoglobinemia signs if coadministered with methemoglobin-inducing drugs. 7. Dosage and administration a. Adult and pediatric i. 1 to 2 drops in the affected eye(s) 8. Duration of action a. Onset i. Immediate b. Peak effect i. 15 to 30 seconds c. Duration i. 10 to 20 minutes 9. Special considerations a. Pregnancy safety: Not classified b. Each bottle is for single-patient use. c. Instruct the patient not to rub, touch, or wipe the affected eye for as long as 20 minutes after use.

Tetracaine Ophthalmic Solution (Pontocaine)

1. Class a. Vitamin 2. Mechanism of action a. Combines with adenosine triphosphate to form thiamine pyrophosphate 3. Indications a. Adjunctive therapy that should precede the administration of dextrose 50% or glucagon in an adult patient if alcoholism or malnourishment is suspected 4. Contraindications a. Known hypersensitivity 5. Adverse reactions/side effects a. Vasodilation b. Hypotension c. Weakness d. Sweating e. Itching f. Hives g. Nausea h. Feeling of warmth 6. Drug interactions a. Unstable in alkaline solutions 7. Dosage and administration a. Adult i. 100 mg as a very slow IV/IO bolus over 5 minutes or 100 mg deep IM b. Pediatric i. Consult medical direction 8. Duration of action a. Onset i. Hours b. Peak effect i. 3 to 5 days c. Duration i. Data unavailable 9. Special considerations a. Pregnancy safety: Category A

Thiamine Hydrochloride (Vitamin B1)

1. Class a. Hemostatic agent, antifibrinolytic agent, plasminogen inhibitor 2. Mechanism of action a. Inhibits the activation of plasminogen b. Reduces the conversion of plasminogen to plasmin c. Clotting factors and circulating platelet plugs can form a seal and reduce bleeding. 3. Indications a. Blunt or penetrating trauma less than 3 hours from onset with hemodynamic compromise, bleeding 4. Contraindications a. Known hypersensitivity b. Mechanism of injury more than 3 hours prior to EMA care c. Subarachnoid hemorrhage d. History of PE, DVT, or other thromboembolic disorder e. Reduce the dose in patients with renal insufficiency 5. Adverse reactions/side effects a. Fatigue b. Headache c. Dizziness d. Abdominal and back pain e. Joint pain f. Musculoskeletal pain g. Anemia h. Rapid infusion may cause hypotension. i. May increase the risk of thromboembolic disorders 6. Drug interactions a. Hormonal contraceptives and clotting factor complexes increase the risk of thromboembolic disorders. 7. Dosage and administration a. Adult i. 1 g IV infusion over 10 minutes b. Pediatric i. Not recommended. 8. Duration of action a. Onset i. Unknown b. Peak effect i. Unknown c. Duration i. 7 to 8 hours 9. Special considerations a. Pregnancy safety: Category B b. Must be mixed into an infusion bag, typically 100 mL of NS

Tranexamic Acid (Cyklokapron, Lysteda)

1. Class a. Nondepolarizing neuromuscular blocking agent, cholinergic receptor antagonist 2. Mechanism of action a. Neuromuscular agent with an intermediate duration of action that competes with acetylcholine for receptors at the motor endplate, resulting in neuromuscular blockade 3. Indications a. Adjunct to provide skeletal muscle relaxation and facilitate tracheal intubation and ventilation 4. Contraindications a. Known hypersensitivity to vecuronium or bromide b. Inability to control the airway or support ventilation with oxygen and positive pressure c. Neuromuscular disease d. Acute narrow-angle glaucoma e. Penetrating eye injuries f. Newborns g. Hepatic or renal failure 5. Adverse reactions/side effects a. Hypersensitivity reactions associated with histamine release b. Itching c. Weakness d. Prolonged neuromuscular blockade e. Excessive salivation 6. Drug interactions a. Additive effects if administered with or following an opioid, sedative, or anesthetic agent 7. Dosage and administration a. Adult i. 0.08 to 0.1 mg/kg IV push over 1 minute ii. Maintenance dose within 20 to 45 minutes: 9.01 to 0.015 mg/kg IV push every 12 to 15 minutes as needed to maintain muscle relaxation b. Pediatric i. 0.1 to 0.3 mg/kg IV/IO 8. Duration of action a. Onset i. 3 to 5 minutes b. Peak effect i. Varies c. Duration i. 20 to 35 minutes 9. Special considerations a. Pregnancy safety: Category C b. Vecuronium does not provide sedation or analgesia and will not stop neuronal seizure activity. c. If the patient is conscious, explain the effect of the medication before administering it. d. Always sedate the patient before administration. e. Intubation and ventilatory support must be readily available. f. Doses should be calculated based on ideal body weight. g. Anaphylactic and anaphylactoid-type adverse reactions, including fatalities, have been reported in association with neuromuscular blocker use.

Vecuronium Bromide (Norcuron)

1. Class a. Calcium channel blocker 2. Mechanism of action a. Slows AV node conduction b. Shortens the refractory period of accessory pathways c. Acts as a negative inotrope and vasodilator 3. Indications a. Stable narrow-QRS tachycardia if the rhythm persists despite vagal maneuvers or adenosine or if the tachycardia is recurrent b. To control the ventricular rate in patients with AF or atrial flutter without preexcitation 4. Contraindications a. Known hypersensitivity b. Wolff-Parkinson-White syndrome, Lown-Ganong-Levine syndrome c. Second- or third-degree AV block, sick sinus syndrome, or other sinus node disease without an artificial pacemaker present d. Hypotension, cardiogenic shock, severe left ventricular dysfunction, wide-complex tachycardias e. Children younger than age 12 months f. Use with extreme caution in patients receiving oral beta blockers. 5. Adverse reactions/side effects a. Dizziness, headache, dysrhythmias, nausea/vomiting b. Can decrease myocardial contractility 6. Drug interactions a. Increases the serum concentration of digoxin b. Simultaneous administration with IV beta blockers can produce severe hypotension. c. Antihypertensives may potentiate the hypotensive effects. d. May potentiate the activity of depolarizing and nondepolarizing neuromuscular blocking agents e. Increased risk of sudden cardiac death when given concurrently with erythromycin f. St. John’s wort can reduce its effectiveness. 7. Dosage and administration a. Adult i. 2.5 to 5 mg IV bolus over 2 minutes (3 minutes in older patients) ii. Repeat dose of 5 to 10 mg may be given every 15 to 30 minutes to a maximum total dose of 20 mg. iii. Alternative dosing: 5 mg IV bolus every 15 minutes to a total dose of 30 mg b. Pediatric i. Consult medical direction. 8. Duration of action a. Onset i. 2 to 5 minutes b. Peak effect i. Variable c. Duration i. 10 to 20 minutes 9. Special considerations a. Pregnancy safety: Category C b. Carefully monitor BP, heart rate, and ECG before, during, and after administration. c. AV block or asystole may occur because of slowed AV conduction.

Verapamil Hydrochloride (Isoptin, Calan)

1. Class a. Second-generation antipsychotic 2. Mechanism of action a. Blocks synaptic reabsorption of serotonin and norepinephrine b. Binds to alpha adrenergic receptors, dopamine receptors, and serotonin receptors 3. Indications a. For the management of agitated or violent patients experiencing a behavioral emergency b. Anxiety (palliative care) 4. Contraindications a. Known hypersensitivity b. History of QT prolongation c. Use of any drugs that prolong the QT interval d. Recent AMI e. Uncompensated heart failure f. Use with caution in patients with impaired renal function 5. Adverse reactions/side effects a. Dizziness b. Headache c. Extrapyramidal symptoms d. Orthostatic hypotension e. Suicide attempt f. Bradycardia g. Prolonged QT interval 6. Drug interactions a. Avoid simultaneous administration with drugs that prolong the QT interval. b. CNS depressants increase its effects. 7. Dosage and administration a. Adult i. Chemical restraint: 10 mg IM ii. Anxiety (palliative care): 20 mg IM b. Pediatric i. Limited data available for pediatric use ii. Chemical restraint: Ages 6 to 11 years: 5 mg IM Ages 12 to 18 years: 10 mg IM 8. Duration of action a. Onset i. 10 minutes IM b. Peak effect i. 60 minutes c. Duration i. Unknown 9. Special considerations a. Pregnancy safety: Category C b. Monitor the QT interval with a 12-lead ECG if feasible. c. Document the QT interval and relay the findings to the receiving facility staff.

Ziprasidone (Geodon)

1. Class a. Colloid, blood modifier agent, volume expander 2. Mechanism of action a. Oncotically similar to human plasma b. Causes the body to shift approximately 3.5 times the amount administered into the intravascular space 3. Indications a. Hypovolemia 4. Contraindications a. Hypersensitivity b. Patients at risk of hypervolemia c. Use with caution in patients with renal insufficiency or anemia. 5. Adverse reactions/side effects a. Nausea/vomiting b. Itching/hives c. Abdominal pain d. Angioedema e. Dysrhythmias f. Bronchospasm 6. Drug interactions a. None currently identified 7. Dosage and administration a. Infusion rate is adjusted to the patient’s requirements. 8. Duration of action a. Onset i. 15 to 30 minutes b. Peak effect i. Unknown c. Duration i. 24 hours 9. Special considerations a. Pregnancy safety: Category C b. Administered with 0.9% NS, D5W, or sodium lactate

Albumin (Albumarc, Albutein, Flexbumin)

1. Class a. Diluent or solvent 2. Mechanism of action a. Works as a solvent or dilutional agent 3. Indications a. Used for diluting or dissolving drugs for IV, IM, or subcutaneous injections based on the drug manufacturer’s recommendations 4. Contraindications a. Hypersensitivity to benzyl alcohol due to use as a preservative 5. Adverse reactions/side effects a. None noted if used according to the manufacturer’s recommendations 6. Drug interactions a. None noted 7. Dosage and administration a. According to the drug manufacturer’s recommendations 8. Duration of action a. Not applicable 9. Special considerations a. Pregnancy category: C b. Due to the presence of a benzyl alcohol additive, other dilutional agents should be used if available. c. Solution should be made approximately isotonic before use.

Bacteriostatic Water

1. Class a. Artificial colloid 2. Mechanism of action a. A sugar-containing colloid used as an intravascular volume expander b. Remains in the intravascular compartment for approximately 12 hours 3. Indications a. Hypovolemic shock 4. Contraindications a. Known hypersensitivity b. Heart failure, renal failure, or known bleeding disorders 5. Adverse reactions/side effects a. Rash, itching, dyspnea, chest tightness, mild hypotension b. Incidence is very low, and reactions are generally mild. c. Increased bleeding time has also been reported due to the interference of dextran with platelet function. 6. Drug interactions a. Should not be administered to patients receiving anticoagulants because it significantly slows blood clotting. 7. Dosage and administration a. Titrate according to the patient’s physiologic response. 8. Duration of action a. 8 to 12 hours 9. Special considerations a. In the management of burn shock, it is essential to follow standard fluid resuscitation regimens to prevent possible circulatory overload.

Dextran

1. Class a. Artificial colloid 2. Mechanism of action a. A starch-containing colloid used as an intravascular volume expander b. Increases intravascular volume by virtue of its colloid osmotic pressure 3. Indications a. Hypovolemic shock, especially burn shock b. Septic shock 4. Contraindications a. No significant contraindications when used in the management of life-threatening hypovolemic states 5. Adverse reactions/side effects a. Nausea/vomiting b. Mild febrile reactions c. Chills, itching, urticaria d. Rare severe anaphylactic reactions 6. Drug interactions a. Should not be administered to patients who are receiving anticoagulants b. Patients allergic to corn may be allergic to hetastarch 7. Dosage and administration a. Titrated according to the patient’s physiologic response 8. Duration of action a. 24 to 36 hours 9. Special considerations a. Pregnancy Safety: Category C

Hetastarch (Hespan)

1. Class a. Isotonic crystalloid solution 2. Mechanism of action a. Replaces water and electrolytes 3. Indications a. Hypovolemic shock b. Keep open IV, hypoperfusion 4. Contraindications a. Heart failure or renal failure b. Avoid use in patients with crush injuries/compartment syndrome. 5. Adverse reactions/side effects a. Rare with therapeutic dosages 6. Drug interactions a. Few in the emergency setting 7. Dosage and administration a. Hypovolemic shock: titrate according to the patient’s physiologic response b. Hypoperfusion: 20 mL/kg IV/IO over 15 minutes; repeat as needed. 8. Duration of action a. Short-term therapy 9. Special considerations a. None

Lactated Ringer (Hartmann) Solution

1. Class a. Natural colloid 2. Mechanism of action a. Protein-containing colloid that remains in the intravascular compartment b. Increases intravascular volume by attracting water from other fluid compartments by virtue of its colloid osmotic pressure 3. Indications a. Hypovolemic shock, especially burn shock b. Hypoproteinemia (low-protein states) 4. Contraindications a. No significant contraindications when used to treat life-threatening hypovolemic states 5. Adverse reactions/side effects a. Chills, fever, hives, nausea, vomiting 6. Drug interactions a. Solutions should not be mixed with or administered through the same administration sets as other IV fluids. 7. Dosage and administration a. Titrate according to the patient’s hemodynamic response. b. In the management of shock secondary to bums, the physician’s orders regarding the administration rate must be closely followed. c. The medical control physician uses standard formulas to determine the correct rate of IV administration. 8. Duration of action a. 24 to 36 hours 9. Special considerations a. Do not use if the solution is cloudy or if sedimentation is seen.

Plasma Protein Fraction (Plasmanate)

1. Class a. Electrolyte, nutrition 2. Mechanism of action a. Replenishes electrolyte and nutrients 3. Indications a. Ordered and customized to each patient based on needs identified from lab work 4. Contraindications a. Vary based on the specific mixture 5. Adverse reactions/side effects a. Vary based on the specific mixture 6. Drug interactions a. Vary based on the specific mixture 7. Dosage and administration a. Vary based on the specific mixture

Total Parenteral Nutrition (TPN; varies based on mixture)

1. Class a. Hypotonic dextrose-containing solution 2. Mechanism of action a. Provides nutrients in the form of dextrose as well as free water 3. Indications a. IV access for emergency drugs b. Dilution of concentrated drugs for IV infusion 4. Contraindications a. Should not be used as a fluid replacement for hypovolemic states 5. Adverse reactions/side effects a. Rare with therapeutic doses 6. Drug interactions a. Should not be used with phenytoin (Dilantin) or amrinone (Inocor) 7. Dosage and administration a. Usually administered through a minidrip (60 drops/mL) set at a TKO rate 8. Duration of action a. Short-term therapy 9. Special considerations a. D5W should not be administered simultaneously with blood through the same IV administration set because of the possibility of hemolysis.

5% Dextrose in Water

1. Class a. Hypertonic dextrose-containing solution 2. Mechanism of action a. Provides nutrients in the form of dextrose as well as free water 3. Indications a. Neonatal resuscitation b. Hypoglycemia 4. Contraindications a. Should not be used as a fluid replacement for hypovolemic states 5. Adverse reactions/side effects a. Rare with therapeutic dosages 6. Drug interactions a. Should not be used with phenytoin (Dilantin) or amrinone (Inocor) 7. Dosage and administration a. Infusion rate is usually dependent on the patient’s condition. 8. Duration of action a. Short-term therapy 9. Special considerations a. None

10% Dextrose in Water

1. Class a. Hypotonic crystalloid solution 2. Mechanism of action a. Replaced free water and electrolytes 3. Indications a. Patients with diminished renal or cardiovascular function for whom rapid rehydration is not indicated 4. Contraindications a. Cases in which rapid rehydration is indicated 5. Adverse reactions/side effects a. Rare with therapeutic dosages 6. Drug interactions a. Few in the emergency setting 7. Dosage and administration a. The specific situation and patient condition will dictate the rate at which one-half normal saline is administered. 8. Duration of action a. Short-term therapy 9. Special considerations a. None

0.45% Sodium Chloride

1. Class a. Hypertonic crystalloid solution 2. Mechanism of action a. Osmotic effect allows fluid to cross the blood-brain barrier, reducing the amount of fluid in the cranial cavity and decreasing the ICP. 3. Indications a. Traumatic brain injuries b. Fluid resuscitation in severe sepsis c. Hyponatremia 4. Contraindications a. Hypotension b. Use with caution in pediatric patients because their sodium levels shift rapidly. c. Rapid increases can cause significant neurologic complications. 5. Adverse reactions/side effects a. Increases sodium levels b. Seizures c. Neurologic deficits 6. Drug interactions a. None currently identified 7. Dosage and administration a. Infusion rate will depend on the specific situation being treated. 8. Duration of action a. Onset i. Rapid b. Peak effect i. Unknown c. Duration i. Unknown 9. Special considerations a. Should be administered through a central line due to its high osmolarity and tonicity

3% Sodium Chloride (Hypertonic Saline)

1. Class a. Hypertonic dextrose-containing crystalloid solution 2. Mechanism of action a. Replaces free water and electrolytes and provides nutrients in the form of dextrose 3. Indications a. Heat exhaustion, diabetic disorders b. KVO solution in patients with impaired renal or cardiovascular function 4. Contraindications a. Should not be used when rapid fluid resuscitation is indicated 5. Adverse reactions/side effects a. Rare with therapeutic dosages 6. Drug interactions a. Should not be used with phenytoin (Dilantin) or amrinone (Inocor) 7. Dosage and administration a. Infusion rate will depend on the specific situation being treated. 8. Duration of action a. Short-term therapy 9. Special considerations a. None

5% Dextrose in 0.45% Sodium Chloride

1. Class a. Hypertonic dextrose-containing crystalloid solution 2. Mechanism of action a. Replaces free water and electrolytes and provides nutrients in the form of dextrose 3. Indications a. Heat-related disorders b. Freshwater drowning c. Hypovolemia d. Peritonitis 4. Contraindications a. Should not be administered to patients with impaired cardiac or renal function 5. Adverse reactions/side effects a. Rare with therapeutic dosages 6. Drug interactions a. Should not be used with phenytoin (Dilantin) or amrinone (Inocor) 7. Dosage and administration a. Infusion rate will depend on the specific situation being treated. 8. Duration of action a. Short-term therapy 9. Special considerations a. None

5% Dextrose in 0.9% Sodium Chloride

1. Class a. Hypertonic dextrose-containing crystalloid solution 2. Mechanism of action a. Replaces water and electrolytes and provides nutrients in the form of dextrose 3. Indications a. Hypovolemic shock b. Hemorrhagic shock c. Some instances of acidosis 4. Contraindications a. Should not be administered to patients with decreased renal or cardiovascular function 5. Adverse reactions/side effects a. Rare with therapeutic dosages 6. Drug interactions a. Should not be used with phenytoin (Dilantin) or amrinone (Inocor) 7. Dosage and administration a. Infusion rate will depend on the specific situation being treated. 8. Duration of action a. Short-term therapy 9. Special considerations a. None

5% Dextrose in Lactated Ringer Solution