Ch. 15 Emergency Medications Flashcards
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)
- 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)
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)
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)
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)
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)
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)
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)
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
- 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)
- 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
- 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)
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
- 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)
- 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)
- 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
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%
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)
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)
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)
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)
- 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)
- 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)
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)
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)
- Class
a. Antiulcer, H2 blocker - Mechanism of action
a. Inhibits the volume and concentration of gastric secretions - Indications
a. GI ulcer
b. Suspected upper GI bleeding
c. GERD
d. As an adjunct in the treatment of urticaria and/or pruritus - Contraindications
a. Known hypersensitivity to famotidine or other H2 blockers - 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 - Drug interactions
a. Decreased absorption of iron
b. Decreased effects of ketoconazole, naproxen, pseudoephedrine
c. Increased action of metformin - 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) - Duration of action
a. Onset
i. 60 minutes
b. Peak effect
i. 1 to 3 hours
c. Duration
i. 10 to 12 hours - 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)
- Dissolve blood clots and restore blood flow.
- 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
- Class
a. Hyperglycemic, carbohydrate - Mechanism of action
a. Increases circulating blood glucose levels - Indications
a. Conscious patients with suspected hypoglycemia - Contraindications
a. Known hypersensitivity
b. Decreased level of consciousness
c. Nausea/vomiting - Adverse reactions/side effects
a. Nausea/vomiting - Drug interactions
a. None - Dosage and administration
a. Adult
i. 25 g orally
b. Pediatric
i. 0.5 to 1 g/kg orally
ii. Maximum dose: 25 g - Duration of action
a. Onset
i. 10 minutes
b. Peak effect
i. Variable
c. Duration
i. Variable - 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)
- 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)
- Class
a. Medical gas - 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 - Indications
a. Persistent or severe bronchospasm - Contraindications
a. None - Adverse reactions/side effects
a. May reduce the effectiveness of coughing - Drug interactions
a. Unknown - 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. - Duration of action
a. Onset
i. Immediate
b. Peak effect
i. Minutes
c. Duration
i. Eliminated within a few breaths - 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)
- Class
a. Antihypertensive, vasodilator - Mechanism of action
a. Relaxes arteriolar, but not venous, smooth muscle
b. Lowers BP - Indications
a. Pregnancy-induced hypertension lasting more than 15 minutes with associated preeclampsia symptoms - Contraindications
a. Known hypersensitivity, CAB, mitral valve rheumatic heart disease
b. Use with caution in patients with stroke, known renal disease, or hypotension. - Adverse reactions/side effects
a. Headache, nausea, flushing, hypotension, palpitations, tachycardia, dizziness, and angina
b. Paresthesia, numbness, and tingling - Drug interactions
a. MAOIs
b. Synergistic effects if given simultaneously with other antihypertensives
c. NSAIDs may diminish the antihypertensive effects. - 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 - 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 - 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)
- Class
a. Corticosteroid, adrenal glucocorticoid - Mechanism of action
a. Anti-inflammatory
b. Immunosuppressive with salt-retaining actions - Indications
a. Shock with history of adrenal insufficiency or long-term steroid dependence
i. Anaphylaxis, asthma, and COPD - Contraindications
a. Known hypersensitivity
b. Systemic fungal infections
c. Premature infants - Adverse reactions/side effects
a. Headache
b. Vertigo
c. Heart failure
d. Hypertension
e. Fluid retention
f. Nausea - 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. - Dosage and administration
a. Adult
i. 2 mg/kg IV/IM (100 mg maximum)
ii. IM administration preferred.
b. Pediatric
i. Consult medical direction - Duration of action
a. Onset
i. 1 hour
b. Peak effect
i. Variable
c. Duration
i. 8 to 12 hours - 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)
- Class
a. Synthetic opioid analgesic
b. Schedule II drug - 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 - Indications
a. Management of acute moderate to severe pain - 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 - Adverse reactions/side effects
a. Dizziness/headache
b. Drowsiness/weakness
c. Hypotension
d. Syncope
e. Apnea - Drug interactions
a. MAOIs
b. SSRIs
c. Concurrent use with other CNS depressants can induce severe respiratory and/or CNS depression. - 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 - 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 - 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)
