*Indications (CPFR Drugs, per PCPs)

Question 1

Albuterol:

A. Indication(s)

Answer 1

1. Wheezing, allergic reactions (as well as anaphylaxis per PPP p. 45), asthma, COPD ;
2. Suspected hyperkalemia;
3. Crush Injury Syndrome;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. 45, O-5*

Question 2

1. Ipratropium Bromide: Indication(s)

Answer 2

1.

• Bronchospasms secondary to asthma, COPD and reactive airway disease;

Memory Aid: Ipratropium bromide : bronchospasms;

Pierce County EMS Procedures and PCPs, Medication / IV Guide, p. O-31, June 2019

Question 3

1. Amiodarone: Indication(s)

Answer 3

1.

• Shock-Refractory VF / pVT (AHA ECC Handbook, p. 131 states, “VF / pVT Cardiac Arrest Unresponsive to CPR, Shock, and Vasopressor”);
• Polymorphic VT / wide complex tachycardia of uncertain origin;
• Control of hemodynamically-unstable VT when cardioversion is ineffective;
• Acceptable for termination of ectopic or multifocal atrial tachycardia with preserved LV function;
• Used for rate control in treatment of atrial fibrillation or flutter when other therapies are ineffective;
• Note: *Amiodarone administration should generally occur after the third defibrillation during a cardiac arrest.*
• Pierce County EMS Procedures and PCPs, Medication / IV Guide, p. O-7, June 2019​​*
• AHA ECC Handbook, Advanced Cardiovascular Life Support Drugs, p. 131, 2015*
• *Highlights of the 2020 AHA Guideline for CPR and ECC, Adult Cardiac Arrest Algorithm*

Question 4

Epinephrine:

A. Indication(s)

Answer 4

1. Allergic reactions;
2. Anaphylactic shock;
3. Status asthmaticus;
4. Croup;
5. Obstructive upper airway edema;
6. Bradycardia unresponsive to atropine, TCP, dopamine;
7. Hypotension;
8. Cardiac arrest (VF, pVT, PEA, asystole);
   * Pierce Co. EMS Procedures and PCPs, January 2019, p. O-23*

Question 5

Adenosine:

A. Indication(s)

Answer 5

1. Conversion of stable narrow-complex SVT to sinus rhythm;
2. Conversion of unstable narrow-complex reentry tachycardia to sinus rhythm;
3. Regular and monomorphic wide complex tachycardia, thought to be or previously defined to be reentry SVT;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-3*

Question 6

Etomidate:

A. Indication(s)

Answer 6

1. Induction agent for RSI (adults and pediatric patients >= 10 years old);
2. Cardioversion pre-sedation;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-26*

Question 7

Succinylcholine:

A. Indication(s)

Answer 7

1. Induction of paralysis during sequenced intubation (generally-speaking, for patients with an intact gag reflex);

Pierce Co. EMS Procedures and PCPs, June 2019, p. O-55

Question 8

Methylprednisolone:

A. Indication(s)

Answer 8

1. Mild (PPP p. 36) as well as moderate-to-severe asthma / COPD exacerbations;
2. Moderate-to-severe allergic reactions;
3. Moderate-to-severe angioedema;
4. Anaphylaxis;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. 36, O-39*

Question 9

Ondansetron:

A. Indication(s)

Answer 9

1. Nausea and / or vomiting (as well as to stave-off potential nausea / vomiting related to traumatic eye injuries and the use of oral Dexamethasone during the treatment of pediatric croup);

Pierce Co. EMS Procedures and PCPs, June 2019, Traumatic Emergencies, p. 26, Respiratory Emergencies, p. 37, O-49

Question 10

Dopamine:

A. Indication(s)

Answer 10

1. Symptomatic hypotension secondary to non-hypovolemic states;
2. *Low cardiac output states such as cardiogenic, anaphylactic, neurogenic or septic shock (additionally indicated for vasogenic shock and hypotension of unknown etiology);
3. Symptomatic bradycardia when atropine and TCP are ineffective;

Note: *These are components of “UV SCAN”, a Berdancronym for the blood pressure-related indications for the use of dopamine.

UV SCAN

U - Unknown-origin hypotension

V - Vasogenic Shock

S - Septic Shock

C - Cardiogenic Shock

A - Anaphylactic Shock

N - Neurogenic Shock

Pierce Co. EMS Procedures and PCPs, June 2019, Medical Emergencies, p. 41, O-21

Question 11

Lidocaine:

A. Indication(s)

Answer 11

1. Cardiac arrest from VF/VT;
2. Stable VT, wide-complex tachycardias of uncertain type, wide complex PSVT (indeterminate);
3. As anesthetic flush prior to IO infusion (conscious adult patients);
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-34*

Question 12

Diphenhydramine:

A. Indication(s)

Answer 12

1. Allergic reactions (“uncomplicated allergic conditions);
2. Anaphylaxis (as an adjunct to epinephrine);
3. Dystonic or extrapyramidal reactions;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-20*

Question 13

Magnesium Sulfate:

A. Indication(s)

Answer 13

1. Seizures due to pre-eclampsia, eclampsia;
2. Life threatening ventricular arrhythmias due to digitalis toxicity, tricyclic overdose;
3. Torsades de pointes;
4. Respiratory distress (asthma);
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-36*

Question 14

Glucagon:

A. Indication(s)

Answer 14

1. Blood glucose < 80, when unable to establish an IV;
2. Beta blocker or calcium channel blocker overdose;
3. Epinephrine-refractory anaphylaxis secondary to beta-blockade;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-28*

Question 15

Sodium Bicarbonate:

A. Indication(s)

Answer 15

1. Correct known hyperkalemia;
2. Correct known bicarbonate-responsive acidosis (e.g., diabetic ketoacidosis or *overdose of tricyclic antidepressant, aspirin, cocaine or diphenhydramine);
3. Prolonged resuscitation with effective ventilation (including upon return of spontaneous circulation after long arrest interval);
4. Crush Injury Syndrome;

Note: *Note: These are components of “TADA! Cocaine!”, a Berdancronym for overdoses producing bicarbonate-responsive acidosis.

TADA! Cocaine!

TA - Tricyclic Antidepressants

D - Diphenhydramine

A - Aspirin

Cocaine!

Pierce Co. EMS Procedures and PCPs, June 2019, p. O-53

Question 16

Dextrose:

A. Indications

Answer 16

1. Suspected hypoglycemia;
2. Coma of unknown origin;
3. Crush Injury Syndrome;
4. Routine IV administration;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-16*

Question 17

Diltiazem:

A. Indication(s)

Answer 17

1. Ventricular rate control in symptomatic atrial fibrillation or flutter;
2. Adenosine-refractory narrow complex reentry SVT;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-19*

Question 18

Nitroglycerine:

A. Indication(s)

Answer 18

1. Chest pain;
2. Congestive heart failure with pulmonary edema and adequate BP;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-46*

Question 19

Atropine:

A. Indication(s)

Answer 19

1. Symptomatic bradycardic rhythms associated with hypotension, decreased mentation, ventricular irritability (PVC’s), and chest pain (the AHA’s Adult Bradycardia with a Pulse Algorithm states to consider treating bradyarrhythmias causing 1. Hypotension, 2. Acutely altered mental status, 3. Signs of shock, 4. Ischemic chest discomfort, 5. Acute heart failure);
2. May be beneficial in AV nodal block, but not likely to be effective for type 2 second-degree or third-degree AV block, let alone PEA or asystole;
3. Organophosphate anticholinesterase poisoning;
4. Nerve Agent poisoning;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-9*
   * AHA ECC Handbook, 2015 Ed., p. 27-28*

Question 20

Naloxone:

A. Indication(s)

Answer 20

1. Respiratory depression secondary to narcotics, synthetic narcotic agents and related drugs;
2. Opiate overdoses such as Codeine, Darvon, Demerol, Dilaudid, Fentanyl, Heroin, Hydrocodone, Methadone, Morphine, Nubain, Oxycodone, Perdocan, Stadol, Talwin, etc;
3. Treatment of coma of unknown origin with apnea / hypoventilation, or in neonatal resuscitation;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-44*

Question 21

Calcium Chloride:

A. Indication(s)

Answer 21

1. Renal dialysis patients experiencing bradycardia secondary to hyperkalemia - exhibiting tall, peaked T waves, prolonged QRS complexes and low P waves;
2. Calcium channel blocker or beta blocker overdose;
3. Magnesium sulfate toxicity (antidote).
4. Crush Injury Syndrome hyperkalemia;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-11*

Question 22

Fentanyl:

A. Indication(s)

Answer 22

1. Severe pain;
2. Sequenced intubation;
   * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-27*

Question 23

1. Midazolam: Indication(s)

Answer 23

1.

• Anxiety (“acute anxiety states”, e.g., burns [p. 28], CIS [p. 30] and CPAP [p. 35-36]);
• Violent patients (p. 46);
• Excited Delirium Syndrome (p. 48);
• Seizures;
• Procedural sedation:
  
  • Synchronized cardioversion;
  • Post-intubation;

Pierce County EMS Procedures and PCPs, Traumatic Emergencies, p. 25, 28, 30, Respiratory Emergencies, p. 35-36, Behavioral Emergencies, p. 46, 48, Medication / IV Guide, p. O-40, June 2019​​

Question 24

1. Oral Glucose: Indication(s)

Answer 24

1.

• Symptomatic hypoglycemia;
• Altered mental status;

Note: These are components of “SHAMS”, a Berdancronym for conditions which indicate the use of oral glucose.

SHAMS

The indications for oral glucose are so general they should be considered a sham!

S - Symptomatic

H - Hypoglycemia

A - Altered

M - Mental

S - Status

• Pierce County EMS Procedures and PCPs, Medication / IV Guide, p. O-29, June 2019​​*
• Berdancronym*

Question 25

Acetaminophen: A. Indication(s)

Answer 25

1. Fever; 2. Pain management; * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-2*

Question 26

Afrin: A. Indication(s)

Answer 26

1. Preparation for nasotracheal intubation; 2. Control of epistaxis; * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-4*

Question 27

Aspirin: A. Indication(s)

Answer 27

1. Suspected ischemic chest pain; 2. Suspected acute coronary syndrome; * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-8*

Question 28

Cyanokit (Hydroxycobalamin): A. Indication(s)

Answer 28

1. Cyanide poisoning featuring the following signs: * Markedly altered level of consciousness; * Seizure; * Respiratory depression or arrest; * Cardiac dysrhythmia (other than sinus tachycardia); _Note: The Environmental Emergencies section of the PCPs states, "Treat for cyanide poisoning any person removed from or having high potential for unprotected exposure to fire gasses and smoke." (PPP. p. 42)_ *Pierce Co. EMS Procedures and PCPs, June 2019, p. 42, O-13*

Question 29

Diazepam: A. Indication(s)

Answer 29

1. Severe anxiety (e.g., burns [PPP p. 28], and CPAP [PPP p. 35-36]); 2. Violent patients (PPP. 46); 3. Excited Delirium Syndrome (PPP. 48); 4. Transcutaneous pacing procedural sedation; 5. Synchronized cardioversion procedural sedation; 6. Intubation post-sedation; 5. Seizures secondary to head trauma and alcohol withdrawal; 6. Status epilepticus; 7. Severe muscle spasm; * Pierce Co. EMS Procedures and PCPs, June 2019, p. 46, 48, O-17*

Question 30

Ibuprofen: A. Indication(s)

Answer 30

1. Pain management (e.g. back pain, ankle sprain); 2. Fever; * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-30*

Question 31

Ketamine: A. Indication(s)

Answer 31

1. Violent patients (PPP p. 46); 2. Excited Delirium Syndrome (PPP p. 48); 3. Sequenced intubation procedural sedation (pre- and post-procedure dissociative anesthesia); 4. Pain management (exclusive to "refractory pain" per PPP. p. 33-34); * Pierce Co. EMS Procedures and PCPs, June 2019, p. 33-34, 46, 48, O-32*

Question 32

1. Morphine Sulfate: Indication(s)

Answer 32

1. * Severe pain (e.g., burns, isolated extremity injuries, abdominal pain, myocardial infarction); _Note: These are components of "**BEAM"**, a Berdancronym for the types of pain for which morphine sulfate is indicated._ **BEAM** **B - B**urns **E - E**xtremity injuries, isolated **A - A**bdominal pain **M - M**yocardial Infarction * Pierce Co. EMS Procedures and PCPs, Medication / IV Guide, p. O-42, June 2019* * Berdancronym*

Question 33

Nitrous Oxide: A. Indication(s)

Answer 33

1. Severe pain due to fractures and burns (and any other cause when approved by the Base Station); ## Footnote *Pierce Co. EMS Procedures and PCPs, June 2019, p. O-48*

Question 34

1. Oxygen: Indication(s)

Answer 34

1. * Hypoxia; * Ischemic chest pain and / or stroke (if pulse oximetry \< 94%); * Respiratory insufficiency; * Apneic oxygenation for intubation; * Carbon monoxide poisoning; * Crush Injury Syndrome (CIS) / Traumatic Rhabdomyolysis (TR); *Pierce County EMS Procedures and PCPs, Traumatic Emergencies, p.30, Medication / IV Guide, p. O-50, June 2019*

Question 35

Rocuronium: A. Indication(s)

Answer 35

1. Induction of paralysis for sequenced intubation (generally performed "in patients with an intact gag reflex"); 2. Maintenance of paralysis after intubation ("to assist ventilation during prolonged transport"); * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-42*

Question 36

1. Sodium Chloride 0.9%: Indication(s)

Answer 36

1. * Mixing / dilution of medications; * To keep vein open (AKA KVO or TKO); * Fluid resuscitation: * Burns (thermal and electrical; p. 28-29); * Excited Delirium Syndrome (p. 48); * Shock * Due to status of pulse and blood pressure (i.e., Shock Index; p. 19); * Vasogenic shock (p. 41); * Anaphylactic shock (p. 44); * Neurogenic shock (p. 31); * Septic shock (Appendix DD); * Traumatic hypovolemic shock (p. 24); * Uncontrolled internal hemorrhage (p. 24); * TBI (p. 24); * Controlled hemorrhage with shock (p. 24); * Trauma (p. 24-26);​ * Traumatic cardiac arrest (p. 4); * CNS (p. 24-25); * Facial (p. 24-25); * Spinal (p. 25); * Neck (p. 26); * Chest (p. 26); * Abdominal (p. 26); * Femur / hip / pelvic fractire (p. 27); * HoTn of unknown origin (p. 41); * Cardiac arrest (traumatic: p. 4, ROSC: AHA ECC Handbook); * Childbirth (p. 51); * Vaginal bleeding (p. 53); * Asthma / COPD (p. 36); _Note: These are components of "BEST CVA", a Berdancronym for the general indications for fluid resuscitation with sodium chloride 0.9%._ **BEST CVA** **B - B**urns **E - E**xDs **S - S**hock **T - T**rauma **C - C**hildbirth / **C**ardiac arrest **V - V**aginal bleeding **A - A**sthma / COPD *Pierce Co. EMS Procedures and PCPs, p. Administrative Policy, p. 4, General Principles / Routine Care, p. 19, Traumatic Emergencies, p. 24-28, Respiratory Emergencies, p. 36, Medical Emergencies, p. 41, Environmental Emergencies, p. 44, Behavioral Emergencies, p. 48, OB / GYN Emergencies, p. 51, 53, Appendix DD, Medication / IV Guide, p. O-42, April 2020*

Question 37

Xylocaine 2% Jelly: A. Indication(s)

Answer 37

1. Nasal / oral endotracheal intubation; 2. Nasogastric tube placement; * Pierce Co. EMS Procedures and PCPs, April 2020, O-57*

Question 38

Drug-induced movement disorders including dystonia, akathisia, parkinsonism, bradykinesia, tremor and tardive dyskinesia.

Answer 38

1. Extrapyramidal symptoms (EPS); ## Footnote *https://en.wikipedia.org/wiki/Extrapyramidal\_symptoms*

Question 39

A drug-induced movement disorder featuring continuous spasms and muscle contractions.

Answer 39

1. Dystonia; * https://en.wikipedia.org/wiki/Extrapyramidal\_symptoms*

Question 40

Calcium Gluconate 10%: A. Indication(s)

Answer 40

1. Suspected hyperkalemia - ECG exhibiting tall, peaked T waves, prolonged QRS complexes and low P waves; 2. Calcium channel blocker or beta blocker overdose; 3. Magnesium sulfate toxicity (antidote); 4. Crush Injury Syndrome hyperkalemia; * Pierce Co. EMS Procedures and PCPs, June 2019, p. O-12*