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Maryland Protocols - Detailed > Medications > Flashcards

Medications Flashcards

1
Q

Acetaminophen - Indications (2)

A

Patients 3 months and above with:
(1) Mild to moderate discomfort
(2) Fever (Greater than 100.4F)

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2
Q

Acetaminophen - Contraindications (9)

A

(1) Head Injury
(2) Hypotension
(3) Administration of Acetaminophen within previous 4 hours
(4) Inability to swallow
(5) Respiratory Distress
(6) Persistent vomiting
(7) Known or suspected liver disease
(8) Allergy
(9) Patients <3 mos

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3
Q

Acetaminophen - Dosage

A

(1) < 3 mos: Not indicated
(2) 3mos to 2 years: (See Chart in protocols)
(3) 2-4 years: 160mg/5ml
(4) 5-12years: 320mg/10ml
(5) 13 years+ 640mg/20ml OR (x2) 325mg pill

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4
Q

Activated Charcoal - Pharmocokinetics

A

Absorbs poison and prevents toxins from entering body systems

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5
Q

Activated Charcoal - Indications

A

Poisoning by mouth

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6
Q

Activated Charcoal - Contraindications (2)

A

(1) Altered Mental Status
(2) Patients who have received an emetic

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7
Q

Activated Charcoal - Dosage

A

CONSULT

Adult: 1gm/kg PO

Pediatric: 1gm/kg PO

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8
Q

Adenosine - Pharmacology (5)

A

(1) Naturally occurring purine nucleoside
(2) Used to treat narrow complex tachycardia (SVT, PSVT)
(3) Slows conduction through the AV node
(4) No effect on ventricular contractility
(5) Causes peripheral vasodilation

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9
Q

Adenosine - Pharmokinetics

A

Onset of action is 5-20 seconds

Half life is 10 seconds

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10
Q

Adenosine - Indications (4)

A

(1) Slows the rate of arrow complex tachycardia
(2) Is only effective on SVT/PSVT
(3) No affect on VT. A-FIB. A-Flutter
(4) Stable wide complex tachycardia in pediatrics with caution

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11
Q

Adenosine - Contraindications (3)

A

(1) Hypersensitivity
(2) Hx of moderate to severe asthma or active bronchospasms
(3) Polymorphic or irregular wide complex tachycardia

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12
Q

Adenosine - Precautions ( 3)

A

(1) Effects antagonized by theophylline (Treats asthma and broncospasms)
(2) Effects enhanced by dipyridamole, digitalis, carbamazepine, calcium channel blockers and benzodiazepines
(3) Be prepared for up to 40 seconds of asystole

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13
Q

Adenosine - Dosage

A

ADULT:
(1) 6mg rapid IVP followed by a flush
(2) 12mg rapid IVP if no response within 2 minutes
(3) 12 mg rapid IVP if no response within 2 minutes

PEDIATRIC:
(1) 0.1mg/kg max 6mg rapid IVP followed by a flush
(2) 0.2 mg/kg max 12mg rapid IVP if no response within 2 minutes
(3) 0.2mg/kg max 12mg rapid IVP if no response within 2 mintues

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14
Q

Albuterol - Pharmacology

A

Stimulates Beta 2 adrenergic receptors of the bronchioles; bronchodilator

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15
Q

Albuterol - Pharmacokinetics (3)

A

(1) Bronchodilation begins within 5-15 minutes after inhalation
(2) Peak effect occurs 30-120 minutes
(3) Duration of action 3-4 hours

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16
Q

Albuterol - Indications (3)

A

(1) Signs and symptoms of respiratory distress
(2) Bronchospasms/wheezing associated with:
(A) Asthma
(B) COPD/emphysema
(C) Allergic reaction (Anaphylaxis)
(3) Hyperkalemia

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17
Q

Albuterol - Dosage

A

(1) Bronchospasms
(A) < 2yo 1.25mg nebulized
(B) 2yo+ 2.5mg nebulized
(2) Hyperkalemia CONSULT
Adult: 20mg nebulized
Pediatric: See dosing above

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18
Q

Amiodarone - Pharmacology

A

Slows duration and refractory period of action potential

Slows electrical conduction and impulse potential through the SA node and accessory pathways

Dilates blood vessels

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19
Q

Amiodarone - Pharmacokinetics

A

Primarily alters/blocks sodium and potassium ion permeability across the myocardial membrane, which stabilizes the ion channels and changes impulse conduction through the myocardium. Amiodarone also has some effects on beta receptors and calcium channels.

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20
Q

Amiodarone - Indications (4)

A

(1) Prevent recurrence of VF/VT after defibrillation and conversion
(2) Ventricular Tachycardia (VT)
(3) Ventricular Fibrillation (VF)
(4) Atrial Fib/Atrial Flutter with aberrancy (wide QRS) for HR> 130 and SBP >100

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21
Q

Amiodarone - Contraindications (9)

A

(1) 2nd degree or 3rd degree AV blocks
(2) Sensitivity
(3) Idioventricular escape
(4) Accelerated idioventricular
(5) Sinus bradycardia/arrest/block
(6) Hypotension
(7) Cardiogenic Shock
(8) Ventricular conduction defects
(9) Iodine hypersensitivity

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22
Q

Amiodarone - Adverse effects (3)

A

(1) Bradycardia
(2) Hypotension
(3) Prolonged QT Interval (increases risk of Torsades and VF)

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23
Q

Amiodarone - Dosing

A

Adult:
(1) W pulse: 150mg IV/IO (in 50-100ml) over 10 minutes.Repeat x1
(2) W/O pulse(VF/VT/Torsades after Mag): 300mg IV/IO. Repeat x1

Pediatric:
(1) W pulse: 5mg/kg IV/IO (in 50-100ml) over 20 minutes.
(2) W/O pulse: 5mg/kg IV/IO Max 300mg. Repeat (x2) Max total dose 15mg/kg

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24
Q

Aspirin - Pharmacology (2)

A

(1) Platelet Inhibitor
(2) Anti-inflammatory

Blocks platelet aggregation

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25
Q

Aspirin - Indications (2)

A

(1) Acute Coronary Syndrome
(2) ST Elevation MI (STEMI)

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26
Q

Aspirin - Contraindications (2)

A

(1) Hypersensitivity
(2) Patients who have received a full dose prior to EMS arrival

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27
Q

Aspirin - Dosing

A

ADULT: 324mg chewed

PEDIATRIC: Not Indicated

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28
Q

Atropine - Pharmacology (2)

A

(1) Parasympatholytic (vagolytic action) (Inhibits action of the vagus nerve)

(2) Anticholenergic ( Accelerates heart rate)

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29
Q

Atropine - Pharmacokinetics (4)

A

(1) Accelerated heart rate within minutes of IV injection
(2) Peak effect within 15 minutes
(3) Atropine disappears rapidly in the blood
(4) Excreted in the urine within first 12 hours

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30
Q

Atropine - Indications (3)

A

(1) Symptomatic bradycardia (If pacing unavailable or ineffective)
(2) Organophosphate Poisoning
(3) Nerve Agent Exposure

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31
Q

Atropine - Contraindications (3)

A

(1) Hypersensitivity
(2) Dysrhytmias in which enhancement of conduction may accelerate the ventricular rate and cause decreased cardiac output (a-fib, a-flutter, PAT with blocks)
(3) Relative contraindications:
(A) 2nd degree Type II or 3rd degree block CONSULT
(B) Acute MI or Ischemia
(C) Glaucoma

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32
Q

Atropine - Dosing

A

(1) Adult: Bradycardia 0.5-1mg IV/IO every 3-5 minutes, Max 0.04mg/kg
(2) Pediatric: Bradycardia 0.02mg/kg IV/IO max single dose 0.5mg. Repeat once
(3) Organophosphate Posioning:
(A) Adult: 2-4mg IVP or IM every 5-10 minutes
(B) Pediatric: 0.02mg/kg IVP/IO/IM every 5-10 minutes

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33
Q

Calcium Chloride - Pharmacology (2)

A

(1) Increases cardiac contractile state and ventricular automaticity

(2) Is useful in reversing arrhythmias due to hyperkalemia

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34
Q

Calcium Chloride - Pharmokinetics

A

Rapid onset following IV administration

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35
Q

Calcium Chloride - Indications (5)

A

(1) Hyperkalemia
(2) Hypocalcemia
(3) Treat adverse effects from calcium channel blocker overdose
(4) Hypotension secondary to diltiazem or verapamil
(5) Respiratory depression, decreased reflexes, flaccid paralysis and apnea following magnesium administration

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36
Q

Calcium Chloride - Contraindications (2)

A

(1) Not indicated in cardiac arrest except when hyperkalemia, hypocalcemia or calcium toxicity are highly suspected

(2) Patient currently taking Digoxin with suspected calcium channel blocker overdose

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37
Q

Calcium Chloride - Adverse effects (2)

A

(1) Bradycardia may occur following rapid IV injection

(2) Syncope, cardiac arrest, arrhythmias, bradycardia

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38
Q

Calcium Chloride - Precautions (3)

A

(1) Use with caution on patients taking digitalis as calcium may increase ventricular irritability and precipitate digitalis toxicity

(2) If given with sodium bicarbonate, calcium will precipitate

(3) Calcium salt may produce coronary and cerebral artery spasms

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39
Q

Calcium Chloride - Dosing

A

(1) Adult:
(A) Hyperkalemia, hypocalcemia, calcium channel blocker OD: 0.5-1gm SLOW IVP/IO over 10 minutes. Max 1 gram
(B) Hypotension following diltiazem/verapamil administration or respiratory depression, decreased reflexes, flaccid paralysis and apnea following magnesium administration: 500mg SLOW IVP/IO

(2) Pediatric: 20mg/kg SLOW IVP/IO (50mg/min) Max 1 gram

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40
Q

Dexamethasone - Indications (3)

A

(1) Moderate to severe asthma/COPD exacerbation

(2) Croup

(3) Anaphylaxis

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41
Q

Dexamethasone - Adverse effects (10)

A

(1) Headache
(2) Edema
(3) Vertigo
(4) Fluid retention
(5) Adrenal insufficiency with long term use
(6) HTN
(7) CHF
(8) Nausea and vomiting
(9) Dyspepsia
(10) Anaphylaxis

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42
Q

Dexamethasone - Contraindications (3)

A

(1) Hypersensitivity

(2) Known systemic fungal infection

(3) Premature infants

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43
Q

Dexamethasone - Dosing

A

(1) Adult: 10mg IV (preferred) or PO

(2) Pediatric:
(A) Asthma: 0.5mg/kg PO (preferred) or IV. Max 10mg
(B) Croup: 0.5 mg/kg PO/IM/IV Max 10mg

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44
Q

Dextrose - Pharmacology

A

A water-soluble monosaccharide found in corn syrup and honey

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45
Q

Dextrose - Pharmacokinetics (2)

A

(1) Restores circulating blood sugar and is rapidly utilized following IV administration

(2) Excess dextrose is rapidly excreted in the urine

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46
Q

Dextrose - Indications (1)

A

(1) Correction of altered mental status due to low blood sugar (hypoglycemia) seizures and cardiac arrest

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47
Q

Dextrose - Contraindications (1)

A

(1) Known hyperglycemia

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48
Q

Dextrose - Dosing

A

(1) Adult: Blood glucose < 70mg/DL 25grams in 50 ml or D10 in 50 ml blouses (x5 250mls) until normal mental status or blood glucose in 90mg/DL. Repeat (x1)

(2) <28 days - blood glucose less than 40mg/DL administer 2ml/kg D10W

(3) 28 days - 4 years: blood glucose less than 70mg/DL administer 2-4ml/kg D10W

(4) 5 years - 18 years: blood glucose less than 70 mg/DL administer 2-4ml/kg D10W

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49
Q

Diltiazem - Class/Actions

A

Class: Calcium channel blocker

Actions:
(1) Inhibits the movement of calcium ions across cardiac muscle cells
(2) Decreases conduction velocity and ventricular rate

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50
Q

Diltiazem - Indications

A

Symptomatic A-fib and A-flutter

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51
Q

Diltiazem - Contraindications (5)

A

(1) Hypotension (SBP < 100mmHg)
(2) Heart rate < 130bpm
(3) Second or third degree heart blocks
(4) Hypersensitivity
(5) < 18 yoa

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52
Q

Diltiazem - Dosing

A

Adult:
(A) 0.25mg/kg max of 20mg SLOW IVP over 2 minutes. Reassess then 0.35mg/kg max 25mg SLOW IVP over 2 minutes.
(B) Over 50 yo, borderline BP (100-120 systolic), renal failure or CHF consider 5-10mg administered over 2 mins.

Pediatric:
Contraindicated in patients under 18yo. Consult if needed.

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53
Q

Dipenhydramine - Pharmacology

A

Antihistamine

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54
Q

Dipenhydramine - Pharmacokinetics (4)

A

(1) Effect begins within 15 minutes
(2) Peak effect 1-4 hours
(3) Metabolized by the liver
(4) Half life 2-10 hours

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55
Q

Dipenhydramine - Indications (3)

A

(1) Allergic reaction
(2) Anaphylaxis
(3) Dystonic reactions

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56
Q

Dipenhydramine - Contraindications

A

Known allergy to Dipenhydramine

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57
Q

Dipenhydramine - Dosing

A

Adult: 25-50 mg SLOW IVP or IM

Pediatric: (greater than 6 months) 1 mg/kg SLOW IV or IM

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58
Q

Droperidol - Pharmacology

A

Antipsychotic

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59
Q

Droperidol - Pharmacokinetics

A

Onset of action within 10 minutes of IM administration

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60
Q

Droperidol - Indications

A

Moderate agitation (defined as behavior that puts the patient or clinician at risk of harm) due to suspected psychiatric (schizophrenia) or medical delirium

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61
Q

Droperidol - Contraindications (5)

A

(1) Children under 15 years of age
(2) Pregnancy
(3) Parkinson’s
(4) CNS depression or acute CNS injury
(5) Severe agitation (administer midazolam of ketamine)

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62
Q

Droperidol- Adverse Effects (3)

A

(1) Dystonic Reactions (administer Dipenhydramine)
(2) Hypotension and tachycardia
(3) Torsades de pointes

63
Q

Droperidol - Dosing

A

(1) Adult:
(A) 18-69: 2.5mg IM
(B) 69+: 1/25mg IM
(C) Consult for additional doses

(2) Pediatric:
(A) 13-18: 2.5mg IM
(B) < 13: Contraindicated
(C) Consult for additional doses

64
Q

Epinephrine - Pharmacology

A

(1) The administration of epinephrine causes increases in:
(A) Systemic vascular resistance
(B) Systemic arterial pressure
(C) Heart rate (+ Chronotropic effect)
(D) Contractile state (+ Inotropic effect)
(E) Myocardial oxygen requirements
(F) Cardiac automaticity
(G) AV Conduction (+ Dronotropic effect)

(2) Causes bronchial dilation by smooth muscle relaxation

65
Q

Epinephrine - Pharmacokinetics (5)

A

(1) IV epinephrine has an extremely rapid onset of action
(2) Is rapidly inactivated by the liver
(3) Subcutaneous administration of epi results in slower absorption
(4) Local massage will hasten absorption
(5) Topically applied nebulizer within the respiratory tract, epi has vasoconstrictor properties that result in reduction of mucosal and and submucosal edema. Bronchodilator properties that reduce smooth airway muscle spasms

66
Q

Epinephrine - Indications (6)

A

(1) Medical cardiac and pediatric trauma arrest
(2) Moderate to severe allergic reaction/anaphylaxis
(3) IV push epi is reserved for cardiac arrest
(4) Epi infusion (IV/IO) should be reserved for patients in shock refractory to fluid bolus of for patients in anaphylactic shock
(5) Severe asthma
(6) Respiratory strider (croup)

67
Q

Epinephrine - Contraindications (3)

A

(1) Hypertension
(2) Preexisting tachydysrhytmias with a pulse
(3) IV push Epi should not be used on any patient with a pulse

68
Q

Epinephrine - Adverse effects (7)

A

(1) Tachydysrhytmias
(2) Hypertension
(3) May induce early labor in pregnant women
(4) Headache
(5) Nervousness
(6) Decreased LOC
(7) Rebound edema may occur in 20-30 minutes after administration to croup patients

69
Q

Epinephrine - Precautions

A

(1) Do not mix with Sodium Bicarbonate as this deactivates Epi
(2) Epi causes a dramatic increase in myocardial oxygen consumption
(3) It’s use in the setting of an acute MI should be restricted to cardiac arrest
(4) CONSULT Medical consult must be obtained prior to administering to asthma patient’s with pregnancy or cardiac history. Consult not required for any patient with severe allergic reaction with respiratory distress.

70
Q

Epinephrine - Dosing (Cardiac Arrest and Bradycardia)

A

(1) Cardiac Arrest
(A) Adult: 1mg IVP/IO every 4mins to a max of 4mg. If arrest reoccurs following ROSC, max 2 additional doses.
(B) Ped/Neonate:
(1) Follow pediatric Epi Chart 0.01mg/kg. Every 4 mins for 4 total doses. If arrest reoccurs following ROSC, max 2 additional doses.
(2) ET administration: 0.01mg/kg diluted with 5ml LRs repeated every 4 mins for 4 doses. If arrest reoccurs following ROSC, administer 2 additional doses

(2) Bradycardia
(A) Adult: (Epi Infusion). 1 mg mixed in 100ml using a 60gtts. Start at 60gtts/min(1ml/min). If pressure remains below 90mmHg, obtain medical consult.
(B) Pediatric:
(1) Administer Epi 0.01mg/kg IV/IO. Repeat every 3-5mins (0.01mg/kg is equivalent to 0.1ml/kg)
(2) ET: Administer Epi 0.1mg/kg diluted with 5ml LRs repeating every 3-5 mins
(C) Neonate:
(1) Administer Epi 0.01mg/kg IVP/IO repeat every 3-5mins.
(2) ET: Administer 0.03mg/kg diluted with 1ml of LRs

71
Q

Epinephrine - Dosing (Allergic Reaction/Anaphylaxis/COPD/Asthma)

A

(1) Adult:
(A) Mild allergic reaction (with hx of life threatening allergic reaction), moderate allergic reaction or anaphylaxis: 0.5mg IM repeated every 5 mins to a total of 3 doses
(B) Patients who remain hypotensive or impending respiratory failure, administer Epi infusion.

(2) Pediatric:
(A) < 5yo, 0.15mg IM, repeat every 5 mins total 3 doses
(B) 5yo + 0.5 mg IM, repeat every 5 mins total 3 doses
(C) Pediatric Epi Infusion - See chart

72
Q

Epinephrine - Dosing (Croup)

A

(1) Adult: Not indicated
(2) Pediatric:
(A) 2.5ml of Epi 1mg/ml via nebulizer. Repeat x1 if no improvement
(B) Severe croup/imminent respiratory arrest: 0.01 mg/kg IM. Max 0.5mg IM
(C) Medical consult required for patient’s < 1yo

73
Q

Epinephrine - Dosing (Epinephrine Infusion)

A

(1) Add 1mg Epi in a 100ml bag of approved dilutent
(2) Use a Microdrip (60 drops/ml) for infusion administration
(3) Adult:
(A) Start at 1ml/min (60gtts) IV/IO
(B) Check BP every 5 mins. If MAP < 65mmHg or Systolic BP <90mmHg increase to a maximum rate of 2ml/min (120gtts)
(4) Pediatric:
(A) Follow pediatric dosing chart <50 kg
(B) BP Goals:
(1) 10yo+ systolic BP > 90mmHg
(2) < 10yo systolic BP 70 + (2x age)

74
Q

Fentanyl - Pharmacology (2)

A

(1) Synthetic opioid that binds with opiate receptors in the CNS that alters both perception and emotional response to pain

(2) Fentanyl is significantly more potent than morphine

75
Q

Fentanyl - Pharmacokinetics

A

Onset of action is within 2-3 mins and effects last 30 mins - 1 hour

76
Q

Fentanyl - Indications (2)

A

(1) Patient reports moderate to severe pain

(2) In the clinicians judgement, the patient would benefit from an opioid analgesic

77
Q

Fentanyl - Contraindications (3)

A

(1) Hypersensitivity

(2) Uncorrected respiratory distress or hypoxemia refractory to supplemental O2

(3) uncorrected hypotension (systolic BP<90mmHg)

78
Q

Fentanyl - Adverse Effects (6)

A

(1) Respiratory depression/arrest
(2) Altered mental status
(3) Increased vagal tone (slow HR)
(4) Constricted pupils
(5) Increased cerebral blood flow
(6) Chest wall rigidity if pushed too fast

79
Q

Fentanyl - Dosing

A

(1) Adult: IN (preferred) IV/IO/IM
(A) 1mcg/kg max 200mcg
(B) Reassess in 5-10mins. Administer second dose 1mcg/kg max 200mcg.
(C) Consult required for additional doses

(2) Pediatric: IN/IV/IO/IM
(A) 1mcg/kg max 200mcg
(B) Reassess in 5-10minx. Administer second dose 1mcg/kg max 200mcg
(C) Consult required for additional doses

80
Q

Glucagon - Pharmacology (6)

A

(1) Hormone synthesized by the pancreas
(2) Increases blood glucose concentration
(3) Inhibits gastric and pancreatic secretions
(4) May increase heart rate and cardiac output
(5) May decrease BP
(6) Increases metabolic rate

81
Q

Glucagon - Pharmacokinetics (5)

A

(1) Destroyed by GI tract and is not effective orally
(2) Max hyperglycemia effect occurs within 30 mins and disappears within 1-2 hrs
(3) Relaxation of smooth muscle occurs within 8-10 minutes and persists for 12-27 mins
(4) The half-life is 3-10 mins
(5) Degraded in liver and kidneys

82
Q

Glucagon - Indications (2)

A

(1) Patients with altered mental status with hypoglycemia and no available vascular access

(2) Beta blocker OD

83
Q

Glucagon - Contraindications

A

Known hypersensitivity

84
Q

Glucagon - Precautions

A

Only works if liver has significant glycogen stores

85
Q

Glucagon - Dosing

A

(1) Hypoglycemia w/o IV access
(A) Adult: Administer 1mg IM/IN. Consult for up to 3 doses
(B) Pediatric:
(1) 5yo - 18th birthday: 1mg IM/IN. Consult for additional doses
(2) 28days - 4yo: 0.5mg IM/IN, Consult for additional doses

(2) Beta Blocker Overdose
(A) Adult: 1mg IVP every 5 minutes
(B) Pediatric:
(1) 5yo - 18th birthday: 1mg IVP every 5 minutes
(2) 28days - 4yo: 0.5 mg IVP every 5 minutes

86
Q

Ipatropium - Pharmacology (4)

A

(1) Anticholenergic (Parasympatholytic) bronchodilator
(2) Bronchodilator is site specific - not systemic
(3) Dries respiratory tract secretions
(4) Most effective in combination with a beta-adrenergic bronchodilator

87
Q

Ipatropium - Pharmacokinetics (3)

A

(1) Improved pulmonary function within 15-30 mins
(2) Peak effect within 1-2 hrs
(3) Duration of action is usually 4-5 hrs

88
Q

Ipatropium - Indications (3)

A

(1) Allergic reaction/Anaphylaxis
(2) Bronchial asthma
(3) Reversible bronchospasms associated with chronic bronchitis and emphysema

89
Q

Ipatropium - Contraindications (3)

A

(1) Hypersensitivity to the drug
(2) Hypersensitivity to atropine
(3) Less than 1 yo

90
Q

Ipatropium - Dosing

A

(1) Adult: 500mcg Single administration only in combination with Albuterol

(2) Pediatric:
(A) < 1yo: CONTRAINDICATED
(B) 1-2yo: 250mcg single administration
(C) 2yo +: 500mcg single administration

91
Q

Ketamine - Pharmacology

A

Sedative-hypnotic; analgesic

92
Q

Ketamine - Pharmacokinetics

A

A rapid non-barbiturate sedative-hypnotic analgesic characterized by normal pharyngeal-laryngeal reflexes, normal or enhanced skeletal muscle tone, and possible cardiovascular and respiratory stimulation.

Onset of action IV/IO: 5-10 mins

Onset of action IN/IM: 15-20 mins

93
Q

Ketamine - Indications (5)

A

(1) Moderate to severe pain; musculoskeletal, extremity and back pain
(2) Severe agitation
(3) Ventilatory difficulty secondary to bucking or combativeness in intubated patient
(4) CPR- induced awareness
(5) Pain management for synchronized cardioversion and transcutaneous pacing

94
Q

Ketamine - Contraindications (3)

A

(1) Known hypersensitivity
(2) Penetrating eye injury
(3) Chest pain, abdominal pain, flank pain, headache

95
Q

Ketamine - Adverse Effects (5)

A

(1) Although respiration is often stimulated, respiratory depression may occur with rapid IV administration
(2) Although hypotension may occur, BP and HR are frequently stimulated
(3) Involuntary myoclonus may mimic seizure activity
(4) Possible enhanced secretions
(5) Possible unpleasant dreams and delirium upon emergence from sedation

96
Q

Ketamine - Precautions (4)

A

(1) Continuosly monitor cardiac and respiratory function
(2) Control of severe agitation may require advanced airway management
(3) Ketamine is supplied in multiple concentrations
(4) Ketamine 100mg/ml is more appropriate for IM administration. Ketamine 10mg/ml is preferable for IV administration

97
Q

Ketamine - Dosing (Pain Management)

A

(1) Adult:
(A) 0.2 mg/kg IV/IO max 20mg. Reassess in 5-10 mins. Administer a second dose if needed
(B) If IV/IO unavailable administer 0.5mg/kg IM/IN. Reassess in 15 mins and repeat dosing

(2) Pediatric:
(A) 0.2 mg/kg IV/IO max 20 mg. Reassess in 5-10 mins. Administer a second dose if needed
(B) If IV/IO unavailable administer 0.5 mg/kg IM/IN. Reassess in 15 mins and repeat dosing

98
Q

Ketamine - Dosing (Severe Agitation)

A

*CONSULT required for first dose unless there is imminent danger to the patient or EMS clinician
*Additional doses always require medical consultation

(1) Adult:
(A) IV: 1mg/kg IV/IO. Max single dose 100mg. If severe agitation persists, repeat dosing. Max total dose 200mg.
(B) IM: 4mg/kg IM. Max single dose 400mg. Additional dose requires medical consultation

(2) Pediatric:
(A) IV: 1mg/kg IV/IO. Max single dose 100mg. If severe agitation persists, repeat dosing. Max total dose 200mg.
(B) IM: 4mg/kg IM. Max single dose 400mg. Additional dose requires medical consultation

99
Q

Ketamine - Dosing (Ventilatory difficulty secondary to bucking or combativeness)

A

*May be preferred agent for hypotension, hypovolemia or pain response

*MSPAC does not require consultation for additional doses

(1) 2mg/kg IVP/IO over 60 seconds. May repeat 2 additional doses of 1mg/kg IVP/IO every 10-15 mins for a total of 3 doses. Additional doses require medical consult.

100
Q

Ketamine - Dosing (CPR-induced awareness)

A

(1) Adult: 1mg/kg IV/IO. Repeat dose with medical consult

(2) Pediatric: Obtain medical consultation

101
Q

Lidocaine - Pharmacology (2)

A

(1) Anesthesia for IO infusion

(2) Nasal Anesthesia

102
Q

Lidocaine - Pharmacokinetics (2)

A

(1) Extremely rapid following IV administration and lasts approximately 10-20mins

(2) Mucosal anesthesia with onset in 1-5 mins

103
Q

Lidocaine - Indications (2)

A

(1) Anesthesia for IO infusions

(2) Nasal tracheal intubation

104
Q

Lidocaine - Contraindications (8)

A

(1) AV blocks
(2) Sensitivity to lidocaine
(3) Idioventricular escape rhythms
(4) Accelerated idioventricular rhythm
(5) Sinus bradycardia/arrest/block
(6) Hypotension
(7) Shock
(8) Ventricular conduction defects

105
Q

Lidocaine - Dosing

A

(1) Adult/Adolescent: Prevent or treat pain due to IO infusion in patients >= 13yo. 20-40mg of 2% lidocaine IO.

(2) Consult a pediatric base station to treat pain due to IO infusion for patients < 13yo

(3) Nasal Pharyngeal Anesthesia (13yo and greater) 4ml 4% lidocaine. 2ml per nare.

*Do not exceed total dose of 3mg/kg

106
Q

Magnesium Sulfate - Pharmacology

A

Physiologic calcium channel blocker and also blocks neuromuscular transmission. Hypomagnesemia can cause cardiac dysrhythmias. It is also a CNS depressant effective in the management of seizures during pregnancy by decreasing the amount of acetylcholine liberated from motor nerve terminals.

107
Q

Magnesium Sulfate - Pharmacokinetics

A

IV administration the onset of anticonvulsant action is immediate and lasts about 30 minutes. Magnesium is excreted solely by the kidney at a rate proportional to the plasma concentration and glomerular filtration rate.

108
Q

Magnesium Sulfate - Indications (4)

A

(1) Torsades de Pointes
(2) Seizures with pregnancy
(3) Refractory VF/VT after Amiodarone administration
(4) Moderate to severe asthma/bronchospasm exacerbation

109
Q

Magnesium Sulfate - Contraindications (3)

A

(1) Hearty blocks
(2) Renal impairment
(3) Hypermagnesemia

110
Q

Magnesium Sulfate - Precautions (3)

A

(1) May exacerbate effects of CNS depressants and neuromuscular blocking agents
(2) Due to concerns of hypotension, IV fluid bolus should be initiated if hypovolemia is suspected
(3) Magnesium toxicity is a concern with higher doses (respiratory depression, decreased reflexes, flaccid paralysis and apnea). Administer calcium chloride 500mg SLOW IVP for indications

111
Q

Magnesium Sulfate - Dosing

A

(1) Adult:
(A) Seizure w pregnancy: 4 grams IV/IO over 10 mins (mixed in 50-100ml approved dilutent)
(B) Refractory VT/VF: 1-2 grams IV/IO over 2 mins
(C) Torsade de pointes: 1-2 grams IV/IO over 2 mins
(D) Consult Moderate to severe asthma/bronchospasm exacerbation: 1-2 grams IV/IO over 10-20 mins (mixed in 50-100ml approved dilutent)

(2) Pediatric:
(A) Seizure w pregnancy: 4 grams IV/IO over 10 mins (mixed in 50-100ml approved dilutent)
(B) Torsades de pointes: 25mg/kg to a max of 2 grams IV/IO over 2 minutes
(C) Consult Moderate to severe asthma/bronchospasm exacerbation: 50mg/kg IV/IO max 2 grams over 10-20 mins (mixed in 50-100ml approved dilutent)

112
Q

Midazolam - Pharmacology (3)

A

(1) Sedative
(2) Hypnotic
(3) Anticonvulsant

113
Q

Midazolam - Pharmacokinetics (3)

A

(1) Short acting benzodiazepine with strong hypnotic, anticonvulsant and amnestied properties
(2) Onset: IV 1.5 mins, IM 15 minutes
(3) Duration: 1-4 hours with a half life of 1.5-3 hours

114
Q

Midazolam - Indications (9)

A

(1) Sustained and/or recurrent seizures
(2) Precardioversion to reduce anxiety
(3) Awake patient requiring transcutaneous pacing
(4) Nasal Tracheal Intubation
(5) Implanted Cardioverter Defibrillator (ICD) malfunction
(6) Nerve/Organophosphate exposure
(7) Bucking Endotracheal Intubated patient
(8) Moderate to severe stimulant toxicity
(9) Moderate or severe agitation

115
Q

Midazolam - Contraindications (2)

A

(1) Hypotension
(2) Hypersensitivity

116
Q

Midazolam - Adverse Effects (2)

A

(1) Respiratory depression or arrest
(2) Hypotension

117
Q

Midazolam - Dosage (all indications except moderate to severe agitation and bucking intubated patients)

A

(1) Adult:
(A) 0.1 mg/kg in 2 mg increments SLOW IVP (over 1-2mins) Max 5mg
(B) If IV unavailable, 5mg IM/IN
(C) Additional doses to a max of 10mg require consult

(2) Pediatric:
(A) 0.1 mg/kg in 2 mg increments SLOW IVP (over 1-2mins) Max 5mg
(B) If IV unavailable, 0.2 mg/kg IM/IN max 5mg
(C) Additional doses to a max of 5mg require medical consult

118
Q

Midazolam - Dosing (Moderate to severe agitation)

A

(1) Patient’s 18-69 years: Midazolam 5mg IM/IV
Patient’s > 69 years: Midazolam 2.5 mg IM/IV
(2) CONSULT 18 years +, If severe agitation persists after Ketamine, consider Midazolam 2.5mg IV/IO
(3) CONSULT 18 years + and no IV/IO available, If severe agitation persists after IM Ketamine, administer Midazolam 5mg IM
(4) CONSULT 5-12 yo, Midazolam 0.1mg/kg IV or 0.2 mg/kg IM/IN Max 5mg
(5) CONSULT Patients 13-18 yo
(A) Midazolam 0.1 mg/kg or 0.2 mg/kg IM/IN (max 5mg). Severe agitation with imminent danger, no consult required
(B) If severe agitation persists after Ketamine IV/IO, consider Midazolam 2.5mg IV/IO
(C) If IV/IO unavailable, Midazolam 5mg IM

119
Q

Midazolam - Dosing (Bucking Endotracheal Intubated patient)

A

(1) Adult: 0.1 mg/kg SLOW IVP over 1-2 mins while maintaining systolic BP greater than 90mmHg. Max 5mg. Stop when bucking has resolved. Additional doses require consult.

(2) Pediatric: Administer 0.05mg/kg SLOW IVP over 1-2mins while maintaining SBP greater than 60 in neonates, 70 in infants and 70 + (2 x age) for patient’s greater than 1yo. Max dose 5mg.

120
Q

Naloxone - Pharmacology

A

Reverses all effects due to opioid agents. This drug will reverse the respiratory depression and all central and peripheral nervous system effects.

121
Q

Naloxone - Pharmacokinetics (4)

A

(1) Onset of action is within a few minutes if administered IVP and within 5 minutes if administered IN.

(2) IM and pediatric.neonatal ET administration results in slower onset of action

(3) Patients responding to Naloxone may require additional doses and transportation to the hospital since most opioids last longer than Naloxone

(4) Has no effect in the absence of opiods

122
Q

Naloxone - Indications

A

To reverse respiratory depression induced by opioids

123
Q

Naloxone - Contraindications

A

Patients under 28 days

124
Q

Naloxone - Dosing

A

(1) Adult: 0.4-2mg IVP/IO/IM/IN titrated to respiratory depression. Repeat as necessary to maintain respiratory activity

(2) Pediatric: 0.1mg/kg IVP/IO/IM/IN titrated to respiratory depression. ET dose 0.2-0.25 mg/kg. May repeat as necessary to maintain respiratory activity.

125
Q

Nitroglycerin -Pharmacology (2)

A

(1) Vasodilatory effects on veins more than arteries

(2) Decreases right heart return (preload) by venous pooling, thereby reducing myocardial workload and oxygen consumption

126
Q

Nitroglycerin - Parmacokinetics (3)

A

(1) Absorbed through oral mucosa

(2) Antianginal and vasodilation effects within 1-2 mins after administration. Half life is 1-4 minutes.

(3) Duration of action is less than 5 minutes

127
Q

Nitroglycerin - Indications (2)

A

(1) Treatment of Angina

(2) Congestive heart failure, acute pulmonary edema

128
Q

Nitroglycerin - Contraindications (6)

A

(1) Known hypersensitivity
(2) Pediatric patient under 13yo
(3) Any patient haven taken medication for Pulmonary Artery Hypertension (Adcirca or Revatio) or Erectile dysfunction (Viagra, Levitra or Cialis) within the past 48 hrs. Medical consultation required to override this contraindication
(4) Asymptomatic hypertension
(5) Blood pressure below 90mmHg
(6) Pulse less than 60 bpm or greater than 150 bpm

129
Q

Nitroglycerin - Precautions (2)

A

(1) May cause hypotension

(2) If systolic BP drops more than 20mmHg, obtain medical consultation to override

130
Q

Nitroglycerin - Dosing

A

(1) Adult: Chest Pain
(A) (Prescription or previous history) 0.4 mg SL repeat to a total of 3 doses (1.2mg) at 3-5 minute intervals as long as systolic BP > 90mmHg and pulses is between 60-150bpm
(B) (No prescription/previous history) establish IV first.
(C) Additional doses with medical consultation

(2) Adult: Pulmonary Edema/CHF
(A) Low Dose: 0.4 mg sublingual at 3-5 min intervals. Max dose 1.2mg
(B) High Dose (Until CPAP is applied or not tolerated)
(1) 0.4mg SL w 1in nitro paste
(2) 0.8 mg SL
(3) 0.8mg SL to achieve a 20% reduction in SBP

(3) CONSULT for Pediatric patient

131
Q

Ondansetron - Pharmacology

A

A selective blocking agent of the Serotonin 5HT3 receptor site

132
Q

Ondansteron - Pharmacokinetics

A

Anti-nausea and anti-emetic with onset of action within 5-15 minutes IV and 30 minutes IM

133
Q

Ondansteron - Indications (2)

A

(1) Prevention and control of nausea and/or vomiting

(2) Ondansetron can be administered in an effort to reduce the nausea and vomiting complications associated with certain existing injuries, medical illnesses or medication side effects

134
Q

Ondansetron - Contraindications (2)

A

(1) Known hypersensitivity

(2) Less than 28 days

135
Q

Ondansetron - Adverse Effects (5)

A

(1) Hypotension
(2) Tachycardia
(3) Extrapyrimidal reactions
(4) Seizures
(5) Prolonged QT Intervals

136
Q

Ondansetron - Dosing

A

(1) Adult:
(A) 8mg SLOW IVP/IO over 2-5 mins or 4-8mg IM or 8mg ODT.
(B) Repeat once w/o consult.
(C) 3rd dose requires consult to a total of 24 mg.

(2) Pediatric:
(A) 28days - 12yo: 0.1 mg/kg SLOW IVP over 2-5 mins
(B) 13-18yo: 8mg ODT or 8mg SLOW IVP over 2-5 mins
OR
(C) If no IV: 0.1 mg/kg IM (max single dose 8mg)
(D) May repeat once w/o consult
(E) *CONSULT for third dose with a max of 0.3mg/kg or 24mg (whichever is lower)

137
Q

Sodium Bicarbonate - Pharmacology

A

Corrects acidosis by raising blood pH

138
Q

Sodium Bicarbonate - Phamacokinetics (2)

A

(1) Rapid onset of action in the blood

(2) Delayed onset of action in the tissues

139
Q

Sodium Bicarbonate - Indications (4)

A

(1) Acidosis, pre-existing (documented)
(2) Cardiac arrest only when a high clinical suspicion of acidosis, hyperkalemia,NA blocker OD (tricyclic antidepressant or phenobarbital) as a cause of the arrest
(3) Hyperkalemia
(4) NA Channel blocker overdose

140
Q

Sodium Bicarbonate - Contraindications

A

Pre-existing alkalosis

141
Q

Sodium Bicarbonate - Dosing (Cardiac Arrest)

A

(1) Cardiac arrest only when a high suspicion of acidosis, hyperkalemia or NA Channel Blocker OD as the cause:
(A) Adult: Administer 1meq/kg IVP/IO
(B) Pediatric: *CONSULT
(1)1meq/kg IVP/IO
(2) For patient’s < 1yo, must be diluted 1:1 with LRs

142
Q

Sodium Bicarbonate - Dosing (Hyperkalemia)

A

(1) Adult: 50meq/kg SLOW IVP over 5 mins. Flush IV line between sodium and calcium administration

(2) Crush Syndrome (functional kidneys by history)
(A) Adult: 50 men IV/IO SLOW over 5 mins and then initiate a drip of 100meq in 1,000ml LRs over 30-60mins
(B) Pediatric: *Consult
(1) 1 meq/kg IV/IO SLOW over 5 mins.
(2) < 1yo must be diluted 1:1 with LRs

143
Q

Sodium Bicarbonate - Dosing - (NA Channel Blocker OD)

A

Includes: Tricyclic antidepressant and phenobarbital OD

(1) Adult:
(A) 1 meq/kg IVP/IO bolus initially. Monitor QRS for narrowing.
(B) Repeat dose: 0.5 meq/kg every 10 mins to maintain a narrow QRS (< 100msec)

(2) Pediatric: *CONSULT
(A) 1 meq/kg IVP/IO
(B) < 1yo must be diluted 1:1 with LRs

144
Q

Terbutaline - Pharmacology (2)

A

(1) Stimulates beta-2 receptors located in smooth muscle bronchioles

(2) Causes relaxation of bronchioles

145
Q

Terbutaline - Pharmacokinetics

A

Relieves bronchospasm in acute and chronic airway disease with minimal cardiovascular effects

146
Q

Terbutaline - Indications (2)

A

(1) Asthma

(2) Reversible airway obstruction associated with bronchitis or emphysema

147
Q

Terbutaline - Contraindications (1)

A

(1) Patients under 12 yo

148
Q

Terbutaline - Dosing

A

(1) 12 yo +:
(A) 0.25mg IM
(B) Repeat after 15 mins if no adequate improvement. (Max total 0.5mg)

(2) <12yo
(A) Not indicated

149
Q

Tranexamic Acid - Pharmacology

A

Anti-fibrinolytic

150
Q

Tranexamic Acid - Pharmacokinetics

A

Onset: variable
Peak effect: 2 hours
Duration: 10 hours

151
Q

Tranexamic Acid - Indications (2)

A

(1) Suspected hemorrhagic shock (SBP < 90mmHg) and within 1 hour of injury

(2) Postpartum hemorrhage (SBP < 90mmHg and pulse >110bpm) with ongoing blood loss despite uterine massage

152
Q

Tranexamic Acid - Contraindications (4)

A

(1) Less than 15 yo
(2) Hypersensitivity/allergy
(3) Known arterial or vein thromboembolism (PE, DVT) (obstruction of a blood vessel by a blood clot that has become dislodged elsewhere)
(4) Patients more than 1 hour from injury or childbirth

153
Q

Tranexamic Acid - Precautions (2)

A

(1) Administer over 10 minutes to reduce risk of hypotension

(2) Do not delay transport to administer TXA

154
Q

Tranexamic Acid - Dosing

A

(1) Greater than 15yo
(A) 1 gram in 100ml IV/IO over 10 minutes

Maryland Protocols - Detailed (6 decks)

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