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San Diego EMS Protocols 2019 > Medications > Flashcards

Medications Flashcards

1
Q

Acetaminophen (Ofirmev) Class/Action/Onset/Peak/Duration

A

Class:
-Analgesic/Antipyretic

Action:

  • Inhibits the synthesis of prostaglandins which transmit pain signals and produce fever.
  • Reduces pain by blocking signals produced by prostaglandins.
Onset = 15 minutes
Peak = 1 hour
Duration = up to 4 to 6 hours
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2
Q

Acetaminophen (Ofirmev) Indications

A

For treatment of pain as needed: (S-141, S-173)

  • Abdominal pain (S-120) (S-174)
  • Burns (S-124) (S-170)
  • Envenomation Injury (S-129) (S-164)
  • Trauma (S-139) (S-169)
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3
Q

Acetaminophen (Ofirmev) Dosage/Route (Adult/Ped)

A

Adult:
1,000mg IV x1 SO infuse over 15”
Peds:
>2 y/o PDC x1 SO infuse over 15”

BHPO required for:

  • Isolated head injury
  • Acute onset severe headache
  • Drug/ETOH intoxication
  • Multiple trauma with GCS <15
  • Suspected active labor

Maximum total daily dose:
4,000mg in 24 hours

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4
Q

Acetaminophen (Ofirmev) Contraindications

A
  • <2 years of age
  • Severe hepatic impairment
  • Sever active liver disease
  • If known or suspected total dose exceeding 4,000mg in a 24-hour period
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5
Q

Acetaminophen (Ofirmev) Side Effects

A
  • Nausea, vomiting
  • Headache, sleep problems
  • Constipation
  • Itching, agitation
  • Partial or total lung collapse in pediatric patients
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6
Q

Acetaminophen (Ofirmev) Packaging

A

1,000mg/100ml (10mg/ml)

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7
Q

Acetaminophen (Ofirmev) Administration (Adult/Ped)

A

Adult:

  • Must use VENTED tubing for IV drip directly from medication vial.
  • Place vial on flat surface and insert vented IV set. Open vent, hang vial, and fill IV tubing.
  • Administer as piggyback into a port on the main IV line, closing main line as needed.
  • Adjust flow rate to administer medication over 15”.

Peds:

  • Identify patients dose from the PDC. Draw patients dose from the medication vial using a syringe.
  • Inject this dose into a 50ml or 100ml normal saline bag and label it.
  • Insert IV tubing into medication bag and fill IV tubing.
  • Administer as IV piggyback into a port on the main IV line, closing main line as needed.
  • Adjust flow rate to administer medication over 15”.
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8
Q

Acetaminophen (Ofirmev) Cautions&Considerations

A
  • Use with caution on patients with history of alcoholism, chronic malnutrition, severe hypovolemia, renal impairment, and hepatic impairment/disease.
  • Rare side effect of skin reaction - discontinue use if skin rash develops, this reaction could be fatal.
  • Dosing errors of IV Tylenol could result in hepatic injury, risk of liver favor, overdose, and death.
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9
Q

Acetaminophen (Ofirmev) Special Info

A

-Daily max dose is 4,000mg in 24 hours.

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10
Q

Adenosine (Adenocard) Class/Action/Onset/Duration

A

Class:
-Antiarrhythmic

Action:
-Slows electrical conduction through the AV node, and interrupts re-entry pathway, converting SVT to NSR.

Onset = within 30 seconds
Duration = 1-2 minutes
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11
Q

Adenosine (Adenocard) Indications (Adult/Ped)

A

Indications:

Adult: Dysrhythmias (S-127)
-SVT
If patient has history of bronchospasm or COPD:
Dosing as above per BHO

Peds: Dysrrhythmias (S-163)
-Unstable SVT

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12
Q

Adenosine (Adenocard) Dosage/Route (Adult/Ped)

A

Adult:
-6mg rapid IV/IO; follow with rapid 20ml NS
-12mg rapid IV/IO; follow with rapid 20ml NS
If no sustained rhythm changes MR x1 in 1-2”

Peds:
-1st dose per drug chart rapid IV BHPO
follow with NS 20ml rapid IV
-2nd dose per drug chart rapid IV BHPO
follow with NS 20ml rapid IV
If no sustained rhythm change, MR x1 BHPO
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13
Q

Adenosine (Adenocard) Contraindications

A
  • 2nd and 3rd degree AV heart blocks

- Sick sinus syndrome (without pacemaker)

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14
Q

Adenosine (Adenocard) Side Effects

A
  • SOB/Dyspnea; may cause bronchospasms in COPD patients (BHO)
  • Chest pressure/palpitations
  • Facial flushing/headache
  • Dizzy/lightheadedness
  • Nausea
  • Transient arrhythmias (PVC’s, PAC’s, sinus bradycardia, AV block, sinus tach, or asystole) These are generally not treated and are quickly self-limiting
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15
Q

Adenosine (Adenocard) Packaging

A

6mg/2ml

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16
Q

Adenosine (Adenocard) Administration

A
  • Use large bore IV in large proximal vein to assist administration of rapid (within 1 to 2 seconds) IV push.
  • Pinch IV tubing, inject in port closest to patient and immediately follow with NS flush using 20-ml syringe.
  • Obtain ECG documentation before, during, and after administration.
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17
Q

Adenosine (Adenocard) Cautions&Considerations

A
  • Adenosine does not convert AFib/AFlutter; a transient modest slowing of ventricular response may occur. Obtain a 12 lead EKG prior to administration if AFib/AFlutter is suspected.
  • Antagonized by caffeine and theophylline. Adenosine may be ineffective of larger doses may be required.
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18
Q

Adenosine (Adenocard) Special Info

A

-Half life of Adenosine is <10 seconds.

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19
Q

Albuterol (Proventil, Ventolin) Class/Action/Onset/Peak/Duration

A

Class:
-Bronchodilator: Sympathomimetic (beta-2 specific)

Action:

  • Relaxes bronchial smooth muscle by stimulating beta-2 adrenergic receptors.
  • Produces bronchodilation, relieves bronchospasm, and reduces airway resistance.
Onset = 5 minutes
Peak = 1 hour
Duration = up to 5 hours
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20
Q

Albuterol (Proventil, Ventolin) Indications (Adult/Ped)

A

Respiratory Distress (S-136, S-167) [Adult/Peds] Suspected Non Cardiac

Allergic Reaction/Anaphylaxis (S-122, S-162) [Adult/Peds]
-acute allergic reactions or anaphylaxis

Burns (S-124, S-170) [Adult/Peds]
-respiratory distress with bronchospasm

Hemodialysis Patient (S-131) [Adult Only]
-symptomatic, suspected hyperkalemia if >72 hours since last dialysis
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21
Q

Albuterol (Proventil, Ventolin) Dosage/Route (Adult/Ped)

A

Adult:
-6ml (0.083%) via nebulizer MR
Peds:
-PDC via nebulizer MR

Adult: (Hemodialysis)
-Continuous 6ml (0.083%) via nebulizer MR

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22
Q

Albuterol (Proventil, Ventolin) Contraindications

A
  • None in adults

- PEDS: for croup/stridor (nebulized saline/epinephrine is indicated)

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23
Q

Albuterol (Proventil, Ventolin) Side Effects

A
  • Tachycardia/palpitations
  • Dizziness/headache
  • Tremors, nervousness
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24
Q

Albuterol (Proventil, Ventolin) Packaging

A

-2.5ml/3ml or 0.083%

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25
Q

Albuterol (Proventil, Ventolin) Administration

A
  • Use with 4-6 liters of O2 for handheld mouthpiece.

- Use with 6-10 liters of O2 for aerosol mask, CPAP, and ET tube.

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26
Q

Albuterol (Proventil, Ventolin) Cautions&Considerations

A

-Consider anaphylaxis if wheezing in the patient with distress, especially if no history of asthma.

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27
Q

Albuterol (Proventil, Ventolin) Special Info

A
  • Continuous nebulized Albuterol is the goal for hyperkalemia and patients in respiratory distress.
  • Decreases hyperkalemia associated with dialysis patients by facilitating the movement of potassium back into cells.
  • Fireline Paramedics (FEMP) without access to oxygen may use MDI delivery for Albuterol in place of nebulizer. (2.5mg inhaler = 2 puffs)
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28
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Class/Action/Onset/Duration

A

Class:
-Antiarrhythmic

Action:

  • Blocks sodium, potassium, and calcium channels in cardiac cells slowing conduction and prolongs repolarization.
  • Has alpha and beta adrenergic blocking properties causing negative inotropic effects and reduces peripheral vascular resistance (afterload).
Onset = minutes
Duration = days
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29
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Indications (Adult/Peds)

A

Dysrhythmias (S-127) [Adult only]
-Stable Ventricular Tachycardia

Dysrhythmias (S-172) [Adult only]
-reported/witnessed >2 AICD firing, or >1 AED shock delivered with pulse >60

Dysrhythmias (S-127)(S-163) [Adult/Peds]
-VF/Pulseless VT: After 1st shock if still refractory

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30
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Dosage/Route (Adult/Ped)

A

Adult Only: (Stable Ventricular Tachycardia)
-150mg in 100ml of NS over 10” IV/IO SO
MR x1 in 10” SO

Adult Only: (>2 AICD firing/>1 AED shock w/ pulse >60)
-150mg in 100ml of NS over 10” IV/IO SO

Adult: (VF/Pulseless VT)
-300mg IV/IO SO, MR 150mg (max of 450mg) SO

Peds: (VF/Pulseless VT)
-PDC IV/IO SO, MR x1 in 3-5” SO

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31
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Contraindications

A
  • Hypotension
  • 2nd & 3rd degree heart block
  • Idioventricular rhythms
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32
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Side Effects

A

-Hypotension
-Exacerbation of the presenting arrhythmia
AFTER DAYS OF USE
-Liver injury
-Pulmonary injury: pulmonary infiltrates, bronchospasm, SOB, cough, hemoptysis, hypoxia.

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33
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Packaging

A

-150mg/3ml

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34
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Administration

A

-Piggyback infusion in 100ml of NS given over 10 min; (Drip rate with 60gtts/ml tubing = 10gtts/sec)

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35
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Cautions&Considerations

A

May interact with:

  • Beta Blockers - results in excessively slow heart rate or AV block
  • Digoxin - increases blood level of digoxin to toxic
  • Tricyclic Antidepressants - causes serious arrhythmias
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36
Q

Amiodarone Hydrochloride (Cordarone, Pacerone, Nexterone) Special Info

A

-Amiodarone is an optional drug and may not be carried by some agencies

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37
Q

Aspirin, ASA (Acetylsalicylic Acid) Class/Action/Onset/Duration

A

Class:
-Platelet aggregation inhibitor

Action:

  • Inhibits normal tendancy for platelets to accumulate inside injured or occluded coronary arteries, thereby improving blood flow through vessels to better perfuse the heart.
  • Blocks formation of Thromboxin A2
Onset = 15-30 minutes
Duration = days (antiplatelet effects)
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38
Q

Aspirin, ASA (Acetylsalicylic Acid) Indications

A

-Discomfort/Pain of Suspected Cardiac Origin (S-126)

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39
Q

Aspirin, ASA (Acetylsalicylic Acid) Dosage/Route

A

Adult Only:

-324mg PO (four 81mg chewable tablets)

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40
Q

Aspirin, ASA (Acetylsalicylic Acid) Contraindications

A

-None

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41
Q

Aspirin, ASA (Acetylsalicylic Acid) Side Effects

A
  • GI upset (indigestion, nausea/vomiting, epigastric pain, heartburn)
  • Occult or prolonged bleeding
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42
Q

Aspirin, ASA (Acetylsalicylic Acid) Packaging

A

-81mg tablets

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43
Q

Aspirin, ASA (Acetylsalicylic Acid) Administration

A

-Tablets can be chewed or swallowed with a small amount of water prn

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44
Q

Aspirin, ASA (Acetylsalicylic Acid) Cautions&Considerations

A

-Administer if patient had pain or discomfort of suspected cardiac origin that has been relieved PTA.

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45
Q

Aspirin, ASA (Acetylsalicylic Acid) Special Info

A
  • Can give if patient is on anticoagulants

- Should be given regardless of prior daily dose(s).

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46
Q

Atropine Sulfate Class/Action/Onset/Duration

A

Class:

  • Antiarrhythmic
  • Anticholinergic

Action:

  • Competes with acetylcholine for receptor sites blocking the PNS response at SA & AV nodes.
  • Increases heart rate by increasing electrical conduction through the heart.
  • Positive chronotropic properties with little or not inotropic effects.
  • Inhibits secretions by decreasing PNS effect on bronchial, salivary, sweat, and GI glands.
Onset = IV/IO 2-4 minutes, IM 10-15 minutes
Duration = 2-6 hours
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47
Q

Atropine Sulfate Indications (Adult/Ped)

A

Adult: Dysrhythmias (S-127)
-Unstable Bradycardia: narrow complex

Adult: Dysrhythmias (S-127)
-Unstable Bradycardia: wide complex if external pacemaker unavailable

Peds: Dysrhythmias (S-163)
-Unstable Bradycardia: after BVM for 30 sec and 3rd dose of Epinephrine

Poisoning/OD (S-134, S-165): [Adult/Peds]
-Symptomatic organophosphate poisoning

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48
Q

Atropine Sulfate Dosage/Route (Adult/Ped)

A

Adult: (narrow complex bradycardia)
-0.5mg IV/IO for pulse <60;
MR q3-5” to max 3mg

Adult: (wide complex bradycardia w/o pacing)
-May give Atropine 0.5mg IV/IO for pulse <60
MR q3-5” to max 3mg

Peds: (unstable brady after 30sec BVM and 3rd epi)
-<9 years HR <60; 9-14 years HR <40
PDC IV/IO; MR x1 in 5”

Adult: (poisoning/od)
-2mg IV/IM/IO; MR x2 q3-5”; MR q3-5” prn BHO

Peds: (poisoning/od)
-PDC IV/IO/IM; MR x2 q3-5”; MR q3-5” prn BHO

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49
Q

Atropine Sulfate Contraindications

A

-Asystole

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50
Q

Atropine Sulfate Side Effects

A
  • Tachycardia/palpitations
  • Dry mouth/nausea/vomiting
  • Pupil dilation/blurred vision
  • Flushed/hot/dry skin
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51
Q

Atropine Sulfate Packaging

A

-Single: 1mg/10ml or Multidose vial: 0.4mg/1ml

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52
Q

Atropine Sulfate Administration

A

-Pacing is the treatment of choice for wide complex bradycardias. Use Atropine only if pacing is unavailable (adults).

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53
Q

Atropine Sulfate Cautions&Considerations

A
  • Use with caution for patients with possible MI (may extend infarct area).
  • May worsen bradycardia associated with second degree type II and third degree blocks.
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54
Q

Atropine Sulfate Special Info

A
  • Atropine will not reverse the muscle weakness associated with OPP; 2-PAM is used.
  • May not work with cardiac transplant patient or artificial hearts as vagus nerve has been severed.
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55
Q

Atrovent (Ipratropium Bromide) Class/Action/Onset/Peak/Duration

A

Class:
-Bronchodilator: anticholinergic

Action:

  • Antagonizes the action of acetylcholine, preventing the interaction of acetylcholine with muscarinic receptors in bronchial smooth muscle causing bronchodilation
  • Dries respiratory tract secretion.
Onset = within 15-30 minutes
Peak = 1-2 hours
Duration = 4-5 hours
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56
Q

Atrovent (Ipratropium Bromide) Indications (Adult/Ped)

A 
Respiratory Distress (S-136, S-167)
-Suspected Non-Cardiac

Allergic Reaction/Anaphylaxis (S-122, S-162)
-acute allergic reactions or anaphylaxis

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57
Q

Atrovent (Ipratropium Bromide) Dosage/Route (Adult/Ped)

A

Adult:
-2.5ml (0.02%) via nebulizer added to first dose of Albuterol

Peds:
-PDC via nebulizer added to first dose of Albuterol

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58
Q

Atrovent (Ipratropium Bromide) Contraindications

A

-None

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59
Q

Atrovent (Ipratropium Bromide) Side Effects

A
  • Nervous/dizziness
  • Headache
  • Cough
  • Paradoxical bronchospasm
  • Palpitations
  • Blurred vision/eye irritation (with direct contact of mist)
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60
Q

Atrovent (Ipratropium Bromide) Packaging

A

-0.5mg/2.5ml - 0.02% unit dose vial

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61
Q

Atrovent (Ipratropium Bromide) Administration

A
  • Use with 4-6 lpm O2 for handheld mouthpiece.

- Use with 6-10 lpm for aerosol mask, CPAP, and ET tube.

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62
Q

Atrovent (Ipratropium Bromide) Cautions&Considerations

A

-Do not add to Albuterol as it is not indicated for respiratory burn patients or suspected hyperkalemia patients.

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63
Q

Atrovent (Ipratropium Bromide) Special Info

A
  • Cholinergic effects are site specific in lungs - no systemic effects.
  • If a patient has self-medicated with bronchodilator prior to paramedic intervention, Atrovent should still be given with first prehospital Albuterol treatment.
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64
Q

Calcium Chloride (10% CaCl2) Class/Action/Onset/Duration

A

Class:
-Electrolyte

Action:

  • Increases myocardial contractility
  • Enhances ventricular automaticity
  • Reverses cardio-electric changes produced by hyperkalemia
  • Shifts potassium back into cell to prevent intravascular hyperkalemia
Onset = 5-15 minutes
Duration = may persist 4 hours after IV/IO
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65
Q

Calcium Chloride (10% CaCl2) Indications (Adult Only)

A 
Hemodialysis Patient (S-131)
-symptomatic, suspected hyperkalemia (widened QRS complex "or" peaked T waves if >72 hours since last dialysis

Trauma (S-139)
-crush injury of extremity or torso with compression >2 hours. Give just prior to extremity being released

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66
Q

Calcium Chloride (10% CaCl2) Dosage/Route

A

Adult Only: (Hemodialysis Patient)
-500mg IV/IO over 30 seconds

Adult Only: (Trauma: Crush injury)
-500mg IV/IO over 30 seconds BHO

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67
Q

Calcium Chloride (10% CaCl2) Contraindications

A

-None

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68
Q

Calcium Chloride (10% CaCl2) Side Effects

A
  • Decreased heart rate (may cause asystole)
  • Hypotension
  • Syncope
  • Nausea/vomiting
  • Metallic taste
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69
Q

Calcium Chloride (10% CaCl2) Packaging

A

1Gm/10ml

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70
Q

Calcium Chloride (10% CaCl2) Administration

A
  • In dialysis patients: Give Iv/IO over 30 seconds with Albuterol.
  • In crush injury patients: Give IV/IO over 30 seconds with end of fluid bolus.
  • Precipitates if mixed with NaHCO3, flush IV tubing between administration of drugs.
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71
Q

Calcium Chloride (10% CaCl2) Cautions&Considerations

A

-Tissue necrosis occurs with infiltrationl Check IV patency before and during administration watching for sings of infiltration; if this occurs, discontinue the IV, circle infiltrated area, and inform receiving hospital.

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72
Q

Calcium Chloride (10% CaCl2) Special Info

A

-Calcium is used in crush injury to reverse the effects of hyperkalemia associated with muscle cell damage.

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73
Q

Charcoal (Activated Charcoal) Class/Action/Onset/Duration

A

Class:
-Absorbent

Action:

  • Binds and absorbs ingested toxins present in the GI tract.
  • Inhibits intenstinal absorption, preventing systemic toxicity.
Onset = minutes
Duration = 4-12 hours
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74
Q

Charcoal (Activated Charcoal) Indications (Adult/Ped)

A

Adult: Poisoning/OD (S-134)
-Ingestion with ANY of the following within 60 minutes, if no vomiting: Acetaminophen, Colchicine, beta blockers, calcium channel blockers, Salicylates, Valproate, oral anticoagulants (including rodenticides), Paraquat, Amanita mushrooms. (Assure patient has gag reflex and is cooperative)

Ped: Poisoning/OD (S-165)
-If ingestion within 60 minutes & recommended by Poison Control Center (assure child has gag reflex and is cooperative).

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75
Q

Charcoal (Activated Charcoal) Dosage/Route (Adult/Ped)

A

Adult:
-50Gm PO

Ped:
-PDC PO

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76
Q

Charcoal (Activated Charcoal) Contraindications

A
  • Isolated alcohol
  • Heavy metal
  • Caustic agent
  • Hydrocarbons
  • Iron ingestion
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77
Q

Charcoal (Activated Charcoal) Side Effects

A
  • Nausea/vomiting
  • Constipation/diarrhea
  • Abdominal cramping
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78
Q

Charcoal (Activated Charcoal) Packaging

A

-50Gm/240ml

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79
Q

Charcoal (Activated Charcoal) Administration

A

-PO, assure patient can swallow and is cooperative. Most effective if administered immediately after the ingestion.

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80
Q

Charcoal (Activated Charcoal) Cautions&Considerations

A
  • Anticipate vomiting complications, consider Zofran.
  • Use with caution with OD of drugs known to cause rapid onset of seizures (TCA’s, etc.) due to risk of vomiting and aspiration.
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81
Q

Charcoal (Activated Charcoal) Special Info

A
  • Contraindications are due to marginal effectiveness and potential to cause harmful vomiting or burns.
  • Peds: Contact poison control early & administer promptly if recommended.
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82
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Class/Action/Onset/Duration

A

Class:
-Carbohydrate

Action:
-Increases blood glucose by providing a quick release of free sugar into the circulation.

Onset = 1 minute
Duration = depends on degree of hypoglycemia
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83
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Indications (Adult/Ped)

A 
Altered Neurologic (S-123)(S-161)(S-172)
-Symptomatic Hypoglycemia: symptomatic patient with altered LOC or unresponsive to oral glucose agents and Blood Sugar:
Adults/Ped/Infant = BS <60
Neonate = BS <45
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84
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Dosage/Route (Adult/Ped)

A

Adults/Ped:
If patient is awake and has gag reflex
-Oral glucose paste or 3 tablets (15g)

Adult:
-D50 25Gm IV;
MR if patient remains symptomatic and BS <60

Ped:
-D10 PDC IV;
MR if patient remains symptomatic and BS <60 (neonate <45)

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85
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Contraindications

A

-None

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86
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W)

Side Effects

A
  • Local venous irritation/infection

- Hyperglycemia

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87
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Packaging

A

Adult D50 = 25Gm/50ml
Ped D10 = 25Gm/250ml

Adult/Ped:
Glucose tablets: 3 = 15Gm
Glucose paste: 1 tube = 15Gm

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88
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Administration

A
  • IVP; Assure injection is intravenous by aspirating before and halfway through administration.
  • Oral glucose preferred for awake pt with gag reflex.
  • D10W can be created by mixing 25Gm into a 250ml IV bag of NS (discarb 50ml of NS prior to adding dextrose).
  • D25 can be created by discarding 25ml D50 and draw 25ml of normal saline back into pre-load which will yield 12.5Gm/50ml.
  • If D50 is not available, may give 25Gm of D10W by administering 250ml of Dextrose 10%.
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89
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W) Cautions&Considerations

A
  • Tissue necrosis occurs with infiltration; watch for signs of infiltration; if this occurs, discontinue the IV, circle infiltrated area, and inform receiving hospital.
  • If you cannot access an IV or EJ consider Glucagon.
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90
Q

Dextrose/Glucose (50%, D50/10%, D10, D10W)

Special Info

A

-Repeat BS not indicated enroute if patient is improving. Repeat BS must be done if patient left on scene and initial was abnormal (AMA).

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91
Q

Diphenhydramine (Benadryl) Class/Action/Onset/Duration

A

Class:
-Antihistamine

Action:
-Binds to histamine receptor sites, blocking H1 and H2 receptors.
H1 causes bronchoconstriction, airway swelling, and vasodilation.
H2 causes secretion of gastric acid.
-Does not prevent histamine release.

Onset = 15-30 minutes
Duration = 6-12 hours
92
Q

Diphenhydramine (Benadryl) Indications (Adult/Ped)

A

Allergic Reaction/Anaphylaxis (S-122, S-162)
-Hives (Urticaria)/Anaphylaxis Criteria/Angioedema

Poisoning/OD (S-134, S-165)
-Extrapyramidal reactions

93
Q

Diphenhydramine (Benadryl) Dosage/Route

A

Adult:
-50mg slow IV/IM

Ped:
-PDC IV/IM

94
Q

Diphenhydramine (Benadryl) Contraindications

A

-None

95
Q

Diphenhydramine (Benadryl) Side Effects

A
  • Drowsiness/sedation (excitement in children)
  • Dry mouth/thickened bronchial secretions
  • Hypotension
  • Palpitations/tachycardia
96
Q

Diphenhydramine (Benadryl) Packaging

A

50mg/1ml

97
Q

Diphenhydramine (Benadryl) Administration

A

-IV/IM, slow IV push

98
Q

Diphenhydramine (Benadryl) Cautions&Considerations

A
  • Cumulative depressant effects occur in the presence of alcohol and/or other sedatives.
  • Priority in mild allergic reactions, Epinephrine is priority in moderate/acute reactions.
  • See S-122/S-162 for Anaphylaxis Criteria & Angioedema definitions.
99
Q

Diphenhydramine (Benadryl) Special Info

A
  • Anticholinergic properties help to correct drug-induced cholinergic and dopaminergic imbalances that cause extrapyramidal reactions.
  • Extrapyramidal reactions may be seen 7-10 after ingestion of medications.
100
Q

Diphenhydramine (Benadryl) Antipsychotic Drugs

A

Phenothiazine derivatives which may cause extrapyramidal reactions including: facial muscle twitch, full body spasm, neck muscle contraction, head deviation, occulogyrations, etc.

  • (Chlorpromazine) Thorazine
  • (Chlorprothixene) Taractan
  • (Fluphenazine) Prolixin
  • (Haloperidol) Haldol
  • (Perphenazine) Trilafon
  • (Thioridazine) Mellaril
  • (Trifluoperazine) Stelazine
  • (Thiothixene) Navane
  • (Loxapine) Loxitane
  • (Molindone) Moban
101
Q

Dopamine Hydrochloride (Intropin) Class/Action/Onset/Duration

A

Class:
-Vasopressor: Sympathomimetic (both alpha and beta properties)

Action:

  • At low and medium doses, selectively dilates blood vessels supplying the brain, kidneys, heart, and gastrointestinal tract.
  • At medium and high doses, increases cardiac output by improving contractility and stroke volume, thereby increasing blood pressure.
  • At high doses, causes vasoconstriction and increased heart rate.
Onset = <5 minutes
Duration = approximately 10 minutes after drip is stopped
102
Q 
Dopamine hydrochloride (Intropin) Indications 
[Adult only]
A

Discomfort/Pain suspected Cardiac Origin (S-126)
-with associated shock if BP is refractory to second fluid bolus

Shock suspected Cardiac (S-138)
-if BP refractory to second fluid bolus

Shock suspected Anaphylactic, ?Neurogenic (S-138)
-if BP refractory to fluid boluses

Sepsis (S-134)**
-if BP refractory to fluid boluses

Anaphylaxis (S-122)
-shock refractory to fluid boluses and Epinephrine IV/IO

Dysrhythmias (S-127)
-Bradycardia: after max Atropine or initiation of TCP

103
Q 
Dopamine Hydrochloride (Intropin) Dosage/Route 
[Adult only]
A

Adult only:
10-40mcg/kg/min IV/IO drip infusion;
Titrate to maintain systolic BP >90
not to exceed >120 BHO

**BHPO for Sepsis

104
Q

Dopamine Hydrochloride (Intropin) Contraindications

A

-None

105
Q

Dopamine Hydrochloride (Intropin) Side Effects

A
  • At high infusion rates, hypertension and extreme vasoconstriction may occur
  • At low infusion rates, hypotension may occur
  • Tachyarrhythmias/palpitations
  • Increased myocardial O2 demand
106
Q

Dopamine Hydrochloride (Intropin) Packaging

A

-400mg in 250ml NS = 1,600mcg/1ml

107
Q

Dopamine Hydrochloride (Intropin) Administration

A
  • Always confirm calculations and dose according to the Dopamine drip chart.
  • Titrate dosing to maintain systolic BP >90 not to exceed >120.
  • Always run as piggyback drip, never run as primary IV. Turn primary line off during Dopamine infusion.
108
Q

Dopamine Hydrochloride (Intropin) Cautions&Considerations

A

-Tissue necrosis occurs with infiltration; Check IV patency before and during administration watching for signs of infiltration; if this occurs, discontinue the IV, circle infiltrated area, and inform receiving hospital.

109
Q

Dopamine Hydrochloride (Intropin) Special Info

A

-Approved optional premix solution of 400mg Dopamine in 250ml D5W.

110
Q

Epinephrine (Adrenalin, Epi) Class/Action/Onset/Duration

A

Class:
-Catecholamine: Sympathomimetic (both alpha and beta effects)

Action:
-On the bronchi: bronchodilation (beta-2)
-On the peripheral vasculature: vasoconstriction (alpha)
-On the heart:
increased heart rate (beta-1)/chronotropic
increased contractility/inotropic
increased AV conduction/dromotropic
increased automaticity/dromotropic

Onset = IV/IO 1-2 minutes, IM 5-10 minutes
Duration = IV/IO 5-10 minutes, IM 1-4 hours
111
Q

Epinephrine (Adrenalin, Epi) Indications [Adult/Ped]

A

Allergic Reaction/Anaphylaxis (S-122, S-162) [Adult/Ped]
-anaphylaxis/angioedema

Respiratory Distress (S-136, S-167) [Adult/Ped]
-severe respiratory distress or inadequate response to Albuterol/Atrovent
Respiratory Distress (S-167) [Ped]
-with stridor at rest

Burns (S-170) [Ped]
-with respiratory distress with stridor

Dysrhythmias (S-127, S-163) [Adult/Ped]

  • cardiac arrest (pulseless patient) [Adult/Ped]
  • unstable bradycardia: after BVM for 30 sec [Ped only]
Newborn Deliveries (S-166) [Ped]
-if HR remains <60 after 30 seconds of CPR
112
Q

Epinephrine (Adrenalin, Epi) Dosage/Route [Adult/Ped]

A 
Allergic Reaction/Anaphylaxis
Adult:
-0.3mg IM 1:1,000, MR x2 q5"
-0.1mg IV/IO 1:10,000 BHO; MR x2 q3-5" BHO
Ped:
-PDC IM 1:1,000; MR x2 q5"
-PDC IV/IO 1:10,000 BHO; MR x2 q3-5" BHO

Respiratory Distress (severe/inadequate response)
Adult:
-0.3mg IM 1:1,000; MR x2 q5”
if no definite history of asthma: dosing as above BHPO
Peds:
-PDC IM 1:1,000; MR x2 q5”

Respiratory Distress (Peds, stridor at rest)
-PDC 1:1,000 via nebulizer, MR x1

Burns (respiratory distress with stridor at rest) [Peds]

  • PDC 1:1,000 via nebulizer, MR x1 SO
  • PDC 1:1,000 IM SO, MR x2 q5” SO

Dysrhythmias (cardiac arrest/peds-unstable brady)
Adult:
-1mg IV/IO 1:10,000; MR q3-5”
Ped:
-PDC IV/IO 1:10,000; MR x2 q3-5”; MR q3-5” BHO

Newborn Deliveries (if HR<60 after 30 sec CPR) [Ped]
-PDC IV/IO 1:10,000; MR x2 q3-5"; MR q3-5" BHO
113
Q

Epinephrine (Adrenalin, Epi) Contraindications

A

-None

114
Q

Epinephrine (Adrenalin, Epi) Side Effects

A
  • Anxiety/restlessness
  • Palpitations/tachyarrhythmias
  • Ventricular irritability
  • Increased myocardial O2 demands
  • Hypertension
  • Angina
115
Q

Epinephrine (Adrenalin, Epi) Packaging

A
  • 1:10,000 = 1mg/10ml

- 1:1,000 = 1mg/1ml

116
Q

Epinephrine (Adrenalin, Epi) Administration

A

-IV/IO/IM

117
Q

Epinephrine (Adrenalin, Epi) Cautions&Considerations

A
  • Use caution in respiratory distress patients if: known cardiac HX or HX of HTN or BP >150 or age >40.
  • Monitor ECG, may aggravate pre-existing tachycardia.
  • Patients who meet Anaphylaxis criteria, Epinephrine is administered first. Not indicated for mild allergic reactions.
118
Q

Epinephrine (Adrenalin, Epi) Special Info

A

Use IV Epinephrine in anaphylaxis with S/S of poor perfusion:

  • Weak pulses/Hypotension
  • Pale/Cyanotic skins
  • Dizzy, faint/Syncope

Nebulized Epinephrine 1:1,000 concentration only:

  • Can cause sensitivity/irritation to providers; may need goggles and face shield.
  • Is used full strength in nebulizer, do not dilute.
  • Up to 5 single dose ampules may be required if no multi-dose vials are available.

In Allergic/Anaphylaxis patients, signs and symptoms can occur minutes to hours after exposure.

119
Q

Fentanyl Citrate Class/Action/Onset/Duration

A

Class:
-Analgesic; Opioid Agonist

Action:
-Potent narcotic analgesic and sedative

Onset = <1-2 minutes
Duration = 30-60 minutes
120
Q

Fentanyl Citrate Indications [Adult/Ped]

A

For treatment of pain as needed (S-141, S-173) [Adult/Ped]:

  • Abdominal Pain (S-120, S-174)
  • Burns (S-124, S-170)
  • Envenemation Injury (S-129, S-164)
  • Trauma (S-139, S-169)

For treatment of pain as needed (S-141) [Adult only]

  • Pain or Discomfort of Suspected Cardiac Origin (S-126)
  • Pain associated with external pacing (S-127)
121
Q

Fentanyl Citrate Dosage/Route [Adult/Ped]

A

For treatment of pain as needed (S-141, S-173) [Adult/Ped] (abd pain/burns/envenemation/trauma)

If <65 years of age: Titrate to pain and vital signs
-Fentanyl up to 50mcg IV x1 SO
-MR 25mcg IV q5" x2 SO
-Maximum So dose is 100mcg
**OR**
-Fentanyl 50mcg IN q15" x2 SO
-3rd IN dose Fentanyl 50mcg BHO
Treatment of pain if BP <100 BHO
If >65 years of age: Titrate to pain and vital signs
-Fentanyl 25mcg IV x1 SO
-MR 25mcg slow IVP q5" x2 SO
-Maximum So dose is 75mcg
**OR**
-Fentanyl 25mcg IN q15" x2 SO
-3rd IN dose Fentanyl 25mcg BHO
Treatment of pain if BP <100 BHO
Peds:
<10kg:
-Fentanyl IV/IN per drug chart BHO
-MR per drug chart BHO
>10kg:
-Fentanyl IV/IN per drug chart SO
-MR per drug chart BHO max 75mcg

For treatment of pain as needed (S-141)
(pain/discomfort cardiac origin/pain related to pacing):
Adult Only:
-Fentanyl 25mcg IV x1 SO

122
Q

Fentanyl Citrate Contraindications

A

-None

123
Q

Fentanyl Citrate Use with caution: BHPO only

A
  • Isolated head injuries
  • Acute onset severe headache
  • Drug/ETOH intoxication
  • Multiple trauma with GCS <15
  • Suspected active labor
124
Q

Fentanyl Citrate Side Effects

A
  • Respiratory depression/apnea
  • Decreased LOC
  • Transient hypotension
  • Nausea/vomiting/dizziness
  • Muscular rigidity
  • Bradycardia
125
Q

Fentanyl Citrate Packaging

A

-50mcg/ml (100mcg/2ml)

126
Q

Fentanyl Citrate Administration

A
  • Slow IVP. Medication has rapid onset.

- Document vital signs and pain scale before and after each administration.

127
Q

Fentanyl Citrate Cautions&Considerations

A
  • When changing route of administration a BHO is required. (e.g. IV to IM or IM to IN)
  • A change in analgesic while treating a patient requires BHO (e.g. changing from Morphine to Fentanyl)
  • Consider BLS methods of pain control prior to narcotic administration.
  • Consider dosing based on factors such as age, body weight, physical status, and medical history.
  • If respiratory arrest occurs, assist ventilations and obtain an order for Narcan.
  • If hypotension occurs, consider fluid bolus. Request order for Narcan if fluid bolus is refractory.
  • Rapid infusion may increase nausea/vomiting after administration, consider Zofran early.
128
Q

Fentanyl Citrate Special Info

A
  • Fentanyl is a controlled substance and must be kept locked and signed for when used.
  • Pain level should be documented at administration and every 5 minutes.
129
Q

Glucagon Class/Action/Onset/Duration

A

Class:
-Antihypoglycemic: Pancreatic hormone

Action:

  • Increases blood glucose by converting glycogen stored in the liver to glucose.
  • Inhibits production of glycogen from glucose.
Onset = 20 minutes
Duration = 60-90 minutes
130
Q

Glucagon Indications [Adult/Ped]

A

Altered Neurologic (S-123, S-161):
-Symptomatic hypoglycemia: symptomatic patient with altered LOC
OR
unresponsive to oral glucose agents “if no IV” and blood sugar:
-Adult/Ped/Infant = <60
-Neonate = <45

131
Q

Glucagon Dosage/Route [Adult/Ped]

A

Adult:
-1ml (1unit) IM

Ped:
-PDC IM

132
Q

Glucagon Contraindications

A

-None

133
Q

Glucagon Side Effects

A
  • Nausea/vomiting

- Tachycardia/HTN

134
Q

Glucagon Packaging

A

-1mg (1 unit)/1ml

135
Q

Glucagon Administration

A
  • IM
  • Inject syringe fluid into medication vial.
  • To reconstitute, rub bottle back and forth in hands.
  • To check if mixed well, be sure that solution is transparent and does not have any un-dissolved medication.
136
Q

Glucagon Cautions&Considerations

A
  • Exerts a positive inotropic & chronotropic effects on the heart, which may cause HTN & tachycardia.
  • Glucagon depletes glycogen stores. The patient should be given supplemental carbohydrates after he/she awakens and is able to swallow.
137
Q

Glucagon Special Info

A

-Glucagon will not work if a ptient’s liver glycogen stores are depleted (severe hypoglycemia, malnutrition, adrenal insufficiency).

138
Q

Ketamine (Ketalar) Class/Action/Onset/Duration

A

Class:
-Anesthetic/Analgesic

Action:

  • Low & slow dosing provides strong analgesic effects acting on the limbic system and cortex to block afferent transmission of impulses associated with pain perception.
  • High & rapid dosing provides fast acting dissociative anesthetia (blocks sensory perception) which can lead to distortion of sights, colors, sounds, self, and one’s environment.
Onset = IV: 30 seconds, IN: 2 minutes
Duration = 15-30 minutes
139
Q

Ketamine (Ketalar) Indications

A

For MODERATE-SEVERE pain (score >5) (S-141):

  • Burns (S-124, S-170)
  • Envenemation Injury (S-129, S-164)
  • Trauma (S-139, S-169)
140
Q

Ketamine (Ketalar) Requirements

A

> 15 years old
AND with GCS of 15
AND not pregnant
AND no known or suspected alcohol or drug intoxication
AND have not received opioid analgesic in past 6 hours (prior to medic arrival)

141
Q

Ketamine (Ketalar) Dosage/Route [Adult only]

A 
IV Dosing:
-Ketamine 0.2mg/kg in 100ml of NS SO
SLOW IV drip over 15 minutes
Maximum of any IV dose is 20mg
-MR x1 in 15 minutes if pain remains MODERATE or SEVERE SO
IN Dosing:
-Ketamine 0.5mg/kg IN SO
(50mg/ml concentration)
Maximum for any IN dose is 50mg
-MR x1 in 15 minutes if pain remains MODERATE or SEVERE SO

BHO required for:

  • BP <100
  • Change in analgesic administered
  • Change in administration route
142
Q

Ketamine (Ketalar) Contraindications

A
  • Pediatrics
  • Pregnancy
  • Severe hypertension
  • Alcohol intoxicated
143
Q

Ketamine (Ketalar) Side Effects

A

-Increased heart rate
-Increased blood pressure
-Increased respiratory rate
-Nausea
-With higher doses and rapid infusion “disassociative effects”:
-Euphoria (pleasant: dream-like states, vivid imagery)
-Dysphoria (unpleasant: anxiety, disorientation,
hallucinations)

144
Q

Ketamine (Ketalar) Packaging

A

-50mg/ml (10ml multi-dose vials containing 500mg total)

145
Q

Ketamine (Ketalar) Administration

A

IV-Intravenous:
-Add 0.2mg/kg to 100ml Normal Saline IV bag.
Administer Slow IV drip over 15 minutes
(maximum single IV dose is 20mg)

IN-Intranasal:
-Administer 0.5mg/kg via 1ml syringe with MAD tip attached.
(maximum intranasal dose is 50mg)

-Ketamine dosing chart is recommended using 5mg/0.1ml incremental measurements. Round dose to next 5mg amount from weight based calculation.

146
Q

Ketamine (Ketalar) Cautions&Considerations

BHPO requirements

A

Use with caution: BHPO only for the following:

  • Isolated head injuries
  • Acute onset severe headache
  • Drug/ETOH intoxication
  • Multiple trauma with GCS <15
  • Suspected active labor
147
Q

Ketamine (Ketalar) Special Info

A
  • Cardiac function should be continually monitored during administration in patients with hypertension or cardiac instability. Arrhythmia has occurred with administration.
  • Although respiration is frequently stimulated, severe respiratory depression may occur with high doses and too rapid a rate of administration, in which case supportive ventilation should be employed.
  • There is no antidote for Ketamine.
  • “Emergence Reactions” may occur during the recovery period.
  • Consider BLS methods of pain control prior to narcotic administration.
  • Ketamine is a controlled substance and must be kept locked and signed for when used.
  • Pain level should be documented at administration and every 5 minutes.
148
Q

Lidocaine (2% Xylocaine) Class/Action/Onset/Duration

A

Class:
-Antiarrhythmic/Anesthetic

Action:

  • Depresses depolarization and automaticity in the ventricles
  • Increases the ventricular fibrillation threshold by increasing phase IV repolarization
  • Amide-type local anesthetic
Onset = 1-2 minutes
Duration = 10-20 minutes
149
Q

Lidocaine (2% Xylocaine) Indications [Adult/Ped]

A

Dysrhythmias (S-127) [Adult only]
-Stable Ventricular Tachycardia

Dysrhythmias (S-127) [Adult only]
-Reported/witnessed >2 AICD firing or >1 AED shock delivered with pulse >60

Dysrhythmias (S-127, S-163) [Adult/Ped]
-VF/Pulseless VT: After 1st shock if still refractory

ALS Skills (S-104) [Adult only]
-Conscious patient prior to IO infusion
150
Q

Lidocaine (2% Xylocaine) Dosage/Route [Adult/Ped]

A

Dysrhythmias (Stable VTach) [Adult only]
-1.5mg/kg slow IV/IO; SO
MR 0.5mg/kg IV/IO q8-10” SO
to max of 3mg/kg (including initial bolus) SO

Dysrhythmias (AICD/AED w/pulse >60) [Adult only]
-1.5mg/kg slow IV/IO; SO
MR 0.5mg/kg IV/IO q8-10” SO
to max 3mg/kg (including initial bolus) SO

Dysrhythmias (VF/Pulseless VTach, after 1st shock) [Adult/Ped]
Adult: 
-1.5mg/kg IV/IO, SO
MR x1 in 3-5" (max 3mg/kg) SO
Ped:
-PDC IV/IO, MR x1 in 3-5" SO

ALS Skills (Conscious IO) [Adult only]
-40mg slow IO SO
prior to fluid administration

151
Q

Lidocaine (2% Xylocaine) Contraindications

A
  • 2nd & 3rd degree heart block

- Idioventricular rhythms

152
Q

Lidocaine (2% Xylocaine) Side Effects (Toxicity)

A

Early:

  • Anxiety -Euphoria
  • Combative -Nausea
  • Twitching -Numbness

Late:

  • Seizure -Decreased BP
  • Coma -Widening QRS
  • Prolonged PRI -V-Fib
153
Q

Lidocaine (2% Xylocaine) Packaging

A

-100mg/5ml

154
Q

Lidocaine (2% Xylocaine) Administration

A
  • Do not push faster than 50mg/min in an awake patient.

- Recommended all adult doses be rounded off to the nearest 20mg.

155
Q

Lidocaine (2% Xylocaine) Cautions&Considerations

A

-In conscious adult IO initiation; slowly infuse Lidocaine 2% (preservative free) 40mg prior to fluid administration. This DOES count toward to max dose of 3mg/kg so reduce the initial dose of Lidocaine by 40mg.

156
Q

Lidocaine (2% Xylocaine) Special Info

A

-Toxicity and delayed effect is more likely in elderly, CHF, and liver disease due to reduced ability to metabolize drug. Repeat doses in this patient population should be given at 10-minute intervals.

157
Q

Midazolam (Versed) Class/Action/Onset/Duration

A

Class:
-Benzodiazepine: Sedative/Anticonvulsant

Action:

  • CNS depressant
  • Produces anterograde amnesia, then sedation
  • Stops and prevents seizures
Onset = IV/IO/IN: 2 minutes; IM: 15 minutes
Duration = 1-4 hours
158
Q

Midazolam (Versed) Indications [Adult/Ped]

A

Seizures (S-123, S-133): [Adult]

  • generalized seizures lasting >5 minutes (includes seizure time prior to arrival of prehospital provider)
  • recurrent tonic/clonic seizures without lucid interval
  • eclamptic seizures of any duration

Seizures (S-161): [Ped]

  • generalized seizures lasting >5 minutes (includes seizure time prior to arrival of prehospital provider)
  • partial seizure with respiratory compromise
  • recurrent tonic/clonic seizures without lucid interval

Dysrhythmias (S-127): [Adult only]

  • unstable bradycardia: discomfort associated with TCP capture, after Morphine if BP >100
  • unstable conscious VT: precardioversion

Dysrhythmias (S-127, S-163): [Adult/Ped]
-conscious SVT: precardioversion

Dysrhythmias (S-127): [Adult only]
-unstable conscious A-Fib, A-Flutter: precardioversion

Overdose (S-134): [Adult only]
-?stimulant intoxication with excited delirium

Psychiatric Behavioral Emergencies (S-142): [Adult only]
-combative patients

159
Q

Midazolam (Versed) Dosage/Route [Adult/Ped]

A 
Seizures (S-123, S-133, S-161): [Adult/Ped]
Adult:
-IN, IM, IV, IO to max 5mg
(d/c IV/IO dose if seizure stops)
MR x1 in 10". Max 10mg total
Ped:
-PDC IV/IM/IN

Dysrhythmias (S-127) (unstable brady w/TCP, unstable conscious VT precardioversion) [Adult only]
-1-5mg slow IV/IO (1mg/min)
If age >60 consider lower dose with attention to age and hydration status

Dysrhythmias (S-127, S-163) (conscious SVT precardioversion) [Adult/Ped]
Adult:
-1-5mg slow IV/IO (1mg/min) BHO
If age >60 consider lower dose with attention to age and hydration status
Ped:
-PDC slow IV (1mg/min) BHPO

Dysrhythmias (S-127) (unstable conscious AFib/AFlutter precardioversion) [Adult only]
-1-5mg slow IV/IO (1mg/min) BHPO
If age >60 consider lower dose with attention to age and hydration status

Overdose (S-134) (?stimulant w/ excited delirium)
Psychiatric Behavioral Emergencies (S-142) (combative patient)
[Adult only for both]
-IN, IM, IV 5mg
MR x1 in 10”

160
Q

Midazolam (Versed) Contraindications

A

-None

161
Q

Midazolam (Versed) Side Effects

A

-Respiratory depression/apnea

162
Q

Midazolam (Versed) Packaging

A

-5mg/1ml or 10mg/2ml

163
Q

Midazolam (Versed) Administration

A
  • Versed should be administered slowly at a rate of 1mg/minute when given IV/IO to prevent respiratory depression/failure.
  • Discontinue IV/IO administration if/when seizure activity stops.
  • Versed is not indicated for simple febrile seizures.
164
Q

Midazolam (Versed) Cautions&Considerations

A
  • 5-minute seizure time includes time prior to arrival of prehospital providers.
  • Carefully monitor respiratory rate, tidal volume, O2 saturation, and EtCO2 during administration.
  • Side effects of Versed i.e. respiratory depression, may be potentiated when combined with the use of ETOH, other sedative hypnotics, and other CNS depressants resulting in apnea.
  • When used for cardioversion: amnesia is desired effect, not sedation, therefore the dosage administered will NOT necessarily produce lethargy.
  • In the combative patient, IM route is usually safer and preferred in order to prevent injury to patient and personnel. If unable or patient too violent for needles consider IN route.
  • Injection may be given through clothing into the thigh for crew safety issues.
165
Q

Midazolam (Versed) Special Info

A
  • *Emergency drug shortage concentration 1mg/ml is inappropriate for IN/IM doses and CANNOT be used with pediatric drug chart!!**
  • Versed is treated as a controlled substance and is to be secured/signed for when used.
166
Q

Morphine Sulfate (MS, MS04) Class/Action/Onset/Duration

A

Class:

  • Opioid
  • Narcotic analgesic

Action:

  • CNS depressant acting on opiate receptors in the brain
  • Potent narcotic analgesic
Onset = 1-2 minutes
Duration = 2-7 hours
167
Q

Morphine Sulfate (MS, MS04) Indications [Adult/Ped]

A

For treatment of pain as needed (S-141, S-173): [Adult/Ped]

  • Abdominal Pain (S-120, S-174)
  • Burns (S-124, S-170)
  • Envenemation Injury (S-129, S-164)
  • Trauma (S-139, S-169)

For treatment of pain as needed (S-141): [Adult only]

  • Pain or discomfort of suspected cardiac origin (S-126)
  • Pain associated with external pacing (S-127)
168
Q

Morphine Sulfate (MS, MS04) Dosage/Route [Adult/Ped]

A

For treatment of pain as needed (S-141, S-173)
(abd pain, burns, envenemation, trauma) [Adult/Ped]
Adult:
Morphine, if Fentanyl unavailable:
-Morphine 0.1mg/kg IV SO
-MR in 5” at half of the initial IV dose SO
-MR in additional 5” at half of the initial IV dose BHO
Maximum for ANY IV dose is 10mg
Intramuscular dosing:
-Morphine 0.1mg/kg IM SO
-MR in 15” at half of the initial IM dose SO
-MR in additional 15” at half of the initial IM dose BHO
Maximum for ANY IM dose is 10mg

Treatment of pain if BP <100 systolic BHO

Ped:
with signs of adequate perfusion:
-PDC IV/IM. MR BHO

For treatment of pain as needed (S-141) [Adult only]
(pain of cardiac origin, pain associated with pacing)
Adult Only:
-Administer Morphine 0.05mg/kg IV x1 SO

169
Q

Morphine Sulfate (MS, MS04) Contraindications

A

-None

170
Q 
Morphine Sulfate (MS, MS04) 
Use with caution: BHPO only
A
  • Isolated head injuries
  • Acute onset severe headache
  • Drug/ETOH intoxication
  • Multiple trauma with GCS <15
  • Suspected active labor
171
Q

Morphine Sulfate (MS, MS04) Side Effects

A
  • Respiratory depression
  • Decreased LOC
  • Transient hypotension
  • Nausea/vomiting
  • Pinpoint pupils
172
Q

Morphine Sulfate (MS, MS04) Packaging

A

-10mg/1ml

173
Q

Morphine Sulfate (MS, MS04) Administration

A
  • Slow IVP

- Document vital signs and pain scale before and after each administration

174
Q

Morphine Sulfate (MS, MS04) Cautions&Considerations

A
  • When changing route of administration a BHO is required (e.g. IV to IM or IM to IN).
  • A change in analgesic while treating a patient requires a BHO (e.g. changing from morphine to fentanyl).
  • NTG is the priority for cardiac patients and should be continued as Morphine is added.
  • Consider BLS methods of pain control prior to narcotic administration.
  • If respiratory arrest occurs, assist ventilations and obtain an order for Narcan.
  • If hypotension occurs, consider fluid bolus. Request order for Narcan if fluid bolus is refractory.
  • Rapid infusion may increase nausea/vomiting after administration, consider Zofran early.
  • During national drug shortages, contact BH and EMS coordinator to consider using expired MS - must inform patient and document thoroughly.
175
Q

Morphine Sulfate (MS, MS04) Special Info

A
  • Morphine is a controlled substance and must be kept locked and signed for when used.
  • Pain level should be documented at administration and every 5 minutes.
176
Q

Naloxone (Narcan) Class/Action/Onset/Duration

A

Class:
-Opioid antagonist

Action:
-Reverses respiratory depression, sedation, and hypotensive effects of opioid overdose by occupying opiate receptor sites

Onset = IV/IN: 1-2 minutes; IM: 2-5 minutes
Duration= IV: 30-60 minutes; IM: longer
177
Q

Naloxone (Narcan) Indications [Adult/Ped]

A

Adult: Poisoning/OD (S-134)
Altered Neurologic (S-123)
-symptomatic suspected opioid OD with respirations <12

Ped: Poisoning/OD (S-165)
Altered Neurologic (S-165)
-symptomatic suspected opioid OD

178
Q

Naloxone (Narcan) Dosage/Route [Adult/Ped]

A

Adult:
-2mg IN/IM/IV; MR titrate IV dose to effect, to drive respiratory rate
If patient refuses transport:
-2mg IM additional dose

Ped:
-PDC IN/IM/IV; MR

Adult/Ped:
For opioid dependent pain management patients: “use caution and titrate”

179
Q

Naloxone (Narcan) Contraindications

A

-None

180
Q

Naloxone (Narcan) Side Effects

A
  • Acute withdrawal symptoms
  • Nausea/vomiting
  • Tachycardia/hypertension
181
Q

Naloxone (Narcan) Packaging

A

-1mg/1ml

182
Q

Naloxone (Narcan) Administration

A

If giving IV, titrate to effect of controlling respirations.
For titrated dosing:
-Adult: dilute IV dose (2mg) to 10ml with NS (new concentration = 0.1mg/0.5ml)
-Pediatric: dilute 1mg to 10ml with NS (new concentration = 0.1mg/1ml)

183
Q

Naloxone (Narcan) Cautions&Considerations

A
  • Manage airway with BLS prior to Narcan. Advanced airways are contraindicated prior to Narcan. Narcan should NOT be given once an advanced airway is in place.
  • When giving to opioid dependent pain management patients the goal is to increase the respiratory drive and not necessarily make them fully conscious.
  • Duration of Narcan is generally less than that of opioid; watch for relapse as long as opioid is still in the patient’s system.
  • Narcan can precipitate withdrawal syndrome and/or combative behavior.
184
Q

Naloxone (Narcan) Special Info

A

-IN route produces a more gradual improvement of LOC than respiratory effort. If IN dose ineffective, repeat doses should be IM/IV route.

185
Q

Naloxone (Narcan) Narcotic Analgesics (med list)

A

Some of these analgesics are not true opiates yet work and react similarly. Naloxone is an effective antidote for all of these.

  • (Buprenorphine) Buprenex, Butrans, Suboxone, Subutex
  • (Butalbital) Fiorinal
  • (Butorphanol) Stadol
  • (Diacetylmorphine) Heroin
  • (Diphenoxylate) Lomotil
  • (Fentanyl) Abstral, Actiq, Duragesic, Fentora, Lazanda, Onsolis, Sublimaze, Subsys
  • (Hydrocodone) Anexsia, Lortab, Lorcet, Norco, Tussionex, Vicodin, Zydone
  • (Hydromorphine) Dilaudid, Exalgo, Palladone
  • (Levorphanol) Levo-Dromoran
  • (Meperidine) Demerol
  • (Methadone) Dolophine, Diskets, Methadose
  • (Methylmorphine) Codeine
  • (Morphine) Astromorph, Avinza, Kadian, MS Contin, MSIR, Oramorph, Roxanol
  • (Nalbuphine) Nubain
  • (Opium) Paregoric, Laudanum
  • (Oxycodone) Combunox, Oxycontin, Oxyfast, Percocet, Percodan, Primlev, Roxicet, Roxicodone, Tylox, Magnacet
  • (Oxymorphone) Opana, Numorphan
  • (Pentazocine) Talwin
  • (Propoxyphene) Darvocet, Darvon, Wygesic
  • (Tapentadol) Nucynta
  • (Tramadol) Ultram, Ryzolt
186
Q

Nitroglycerin (NTG, Nitro) Class/Action/Onset/Duration

A

Class:
-Vasodilator

Action:

  • Produces vasodilation by relaxing systemic venous & arterial vessels, thereby:
  • Decreasing preload & afterload
  • Decreasing myocardial workload and
  • Decreasing myocardial O2 consumption
  • Dilates coronary arteries
Onset = SL 2 minutes, topical 30-60 minutes
Duration = SL 30-60 minutes, topical 24 hours
187
Q

Nitroglycerin (NTG, Nitro) Indications [Adult only]

A

Discomfort/Pain of ?Cardiac Origin (S-126)

Fluid overload with rales (S-131)
-hemodialysis patients

Respiratory Distress (S-136)
-respiratory distress ?CHF/Cardiac origin
188
Q

Nitroglycerin (NTG, Nitro) Dosage/Route [Adult only]

A 
Discomfort/Pain of ?Cardiac Origin (S-126)
If BP >100:
-0.4mg SL; MR q3-5"
-Topical paste 1"
If BP <100:
-0.4mg SL BHO; MR BHPO
Fluid overload with rales (S-131)
Respiratory Distress (S-136)
If BP >100:
Topical paste 1"
If BP >100 but <150:
0.4mg SL; MR q3-5"
If BP >150:
-0.8mg SL; MR q3-5"
If BP <100:
0.4mg SL BHO; MR BHPO
189
Q

Nitroglycerin (NTG, Nitro) Contraindications

A
  • Patient who has taken a sexual enhancement medication such as Viagra, Cialis, Levitra within 48 hours
  • Patients taking medication for pulmonary hypertension, usually Sildenafil (trade names: Revatio, Flolan, and Veletri)
190
Q

Nitroglycerin (NTG, Nitro) Side Effects

A
  • Orthostatic hypotension
  • Dizziness/syncope
  • Temporary pulsating headache
  • Facial flushing
191
Q

Nitroglycerin (NTG, Nitro) Packaging

A
  • 1 metered spray or 1 tablet = 0.4mg

- Topical paste: 1 inch = 15mg

192
Q

Nitroglycerin (NTG, Nitro) Administration

A

-Preparing the patient for administration of NTG:
Start an IV before or soon after first dose.
Place patient in a supine or semi-fowler’s position whenever possible.

  • If using tablet, place tablet under tongue and allow to dissolve.
  • If unable to spray under tongue, spray inside mouth; is well absorbed. Do not shake NTG spray.
  • Apply 1” of NTG paste (on paper included with packaging) directly to skin.
  • Document vital signs and pain scale before and after each administration.
193
Q

Nitroglycerin (NTG, Nitro) Cautions&Considerations

A
  • Nitroglycerin is used for ADULT ONLY.
  • If patient becomes hypotensive, lay supine and consider fluid bolus.
  • Avoid application of NTG paste to areas that may be used for cardioversion.
  • Avoid irritated/broken skin and consider taping patch to prevent movement of paste.
  • If patient’s chest pain is resolved on medic arrival (self-medicated with own NTG), continue treatment with NTG paste and ASA.
194
Q

Nitroglycerin (NTG, Nitro) Special Info

A
  • Alcohol ingestion potentiates the hypotensive side effect.
  • Orthostatic hypotension are more commonly seen in patients taking beta-blockers.
  • Patients taking Viagra/Cialis/Levitra or other medications for sexual enhancement OR patients taking similar medication for pulmonary hypertension (Revatio, Flolan, and Veletri) may have a fatal drop in blood pressure of 50-60mmHg. Suspect patient may be on these medications if they have unexplained LOC.
195
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Class/Action
A

Class:
-Electrolyte/isotonic crystalloid

Action:

  • Electrolyte solution, which is osmotically equivalent to blood
  • Increases the circulating volume of the vascular system (2/3 of infused volume leaves vascular space within 1 hour)
196
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Indications [Adult/Ped]
A 
Definitive Therapy (S-104, S-101)
-immediate or anticipated immediate need for administration of a fluid bolus or medications

Abdominal Discomfort GI/GU (non-traumatic) (S-120, S-174)

  • Adult & Peds: suspected volume depletion
  • Adult: symptomatic suspected AAA to maintain BP at 80

Anaphylaxis (S-122, S-162)

  • Adult: for BP <90
  • Peds: to maintain adequate perfusion

Altered Neuro Function (S-123) [Adult only]

  • Adult: CVA to maintain BP >120
  • Adult: Hyperglycemia

Burns (S-124, S-170)

  • Adult: with >20% BSA partial thickness or >5% BSA full thickness
  • Peds: with >10% BSA partial thickness of >5% full thickness

Discomfort/Pain of suspected Cardiac Origin (S-126) [Adult only]
Adult: with associated shock

Dysrhythmias (S-127, S-163)

  • Adult: see protocol
  • Peds: see protocol
Environmental Exposure (S-130) [Adult only]
-Adult: heat exhaustion

Overdose (S-134) [Adult only]
-Adult: ?stimulant intoxication with Excited Delirium

Shock (S-138, S-168)

  • Adult: see protocol
  • Peds: see protocol

Trauma (S-139, S-169)

  • Adult & Peds: crush injury with extended compression >2 hours
  • Adult: to maintain BP >80
  • Peds: to maintain adequate perfusion

Sepsis (S-143) [Adult only]
-Adult: see protocol

Respiratory Distress (S-136, S-167)
-Adult &amp; Peds: with croup-like cough via nebulizer
197
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Dosage/Route [Adult/Ped]
A 
Definitive Therapy (S-104, S-101)
-IV/IO; adjust prn

All others:
-See specific protocol for routes and dosing

198
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Contraindications
A

-Rales (exception for sepsis - S-143)

199
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Side Effects
A

-None

200
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Packaging
A

-0.9% NaCl: 1,000ml or 250ml

201
Q 
Normal Saline (0.9% solution Sodium Chloride, NS)
Administration
A
  • Dose for Pediatric patients are WEIGHT related (20ml/kg PDC)
  • Dose for burn patients are AGE related (500ml: adults, 250ml: 5-14y/o, 150ml: <5y/o)

TKO is approximately

  • 5gtts/min with maxi-drip (10gtts = 1ml) tubing
  • 30gtts/min with mini-drip (60gtts = 1ml) tubing
202
Q

Normal Saline (0.9% solution Sodium Chloride, NS) Cautions&Considerations

A

-Consider small bag (250ml) for patients with rales, significant HTN, and suspected intracranial bleed.

203
Q

Normal Saline (0.9% solution Sodium Chloride, NS) Special Info

A
  • BP goals:
    1. 80 systolic in trauma and aortic aneurysm
    2. 120 systolic in stroke patients
    3. 90 systolic in all others
204
Q

Ondansetron (Zofran) Class/Action/Onset/Duration

A

Class:
-Antiemetic

Action:
-Blocks serotonin receptors in vagus nerve terminals and in small intestine that trigger the vomiting reflex.

Onset = IV/IM/ODT, up to 30 minutes
Duration = IV/IM/ODT, 2 hours
205
Q

Ondansetron (Zofran) Indications [Adult/Ped]

A

Adult:
Abdominal discomfort GI/GU (non-traumatic) (S-120)
-for nausea or vomiting
Pain Management (S-141)
-for nausea or vomiting after Morphine administration

Ped:
GI/GU (non-traumatic) (S-174)
-for nausea or vomiting

206
Q

Ondansetron (Zofran) Dosage/Route [Adult/Ped]

A

Abdominal discomfort (S-120)/Pain management (S-141)
[Adult only]:
-4mg IV/IM/ODT
MR x1 in 10”

Abdominal discomfort (S-174) [Ped only]
6mo.-3yrs : 
-2mg ODT/IV
>3yrs:
-4mg ODT/IV
If suspected head injury: BHPO
207
Q

Ondansetron (Zofran) Contraindications

A

-None

208
Q

Ondansetron (Zofran) Side Effects

A
  • GI symptoms, especially diarrhea

- Headache

209
Q

Ondansetron (Zofran) Packaging

A

-Vial = 4mg/2ml for IV/IM or ODT = 4mg for PO

210
Q

Ondansetron (Zofran) Administration

A
  • Oral dissolving tablets (ODT) dissolve quickly but are somewhat fragile.
  • Do not push tablet through foil package.
  • Do not remove tablets from packaging until ready to administer to patient.
  • Place tablet on patient’s tongue and encourage patient to allow to dissolve; can be swallowed without water.
  • For pediatric patients 6mo-3yrs give 2mg ODT which is 1/2 of ODT.
211
Q

Ondansetron (Zofran) Cautions&Considerations

A

-Anticipate the need for Zofran to treat nausea/vomiting side effect of Morphine administration.

212
Q

Ondansetron (Zofran) Special Info

A

-Pediatric patients with associated suspected head injury require BHPO.

213
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Class/Action/Onset/Duration

A

Class:

  • Electrolyte
  • Alkalinizing agent

Action:
-Reduces acidosis or causes alkalosis by direct release of bicarbonate ion into the circulation.

Onset = 2-10 minutes
Duration = 30-60 minutes
214
Q 
Sodium Bicarbonate (Bicarb, NaHCO3) 
Indications [Adult/Ped]
A 
Hemodialysis Patient (S-131) [Adult only]
-symptomatic, suspected hyperkalemia if >72 hours since last dialysis

Poisoning/OD (S-134, S-165) [Adult/Ped]
-tricyclic OD with cardiac effects

Trauma (S-139, S-169) [Adult/Ped]
-crush injury of extremity or torso with extended entrapment >2 hours just prior to extremity being released

215
Q 
Sodium Bicarbonate (Bicarb, NaHCO3) 
Dosage/Route [Adult/Ped]
A 
Hemodialysis Patient (S-131) [Adult only]
-1mEq/kg IV/IO
Poisoning/OD (S-134, S-165) [Adult/Ped]
Adult:
-1mEq/kg IV/IO
Ped:
-PDC IV/IO x1 BHO
Trauma (crush injury >2 hours) (S-139, S-169) [Adult/Ped]
Adult:
-1mEq/kg IV/IO BHO
Ped:
-PDC IV/IO x1 BHO
216
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Contraindications

A

-None

217
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Side Effects

A

-Electrolyte/pH imbalances

218
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Packaging

A

-50mEq/50ml

219
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Administration

A
  • Flush tubing between administration of meds:
  • Effectiveness of Epinephrine will be decreased if it is mixed with bicarb.
  • Calcium Chloride will precipitate with Bicarb. Be sure to flush tubing between drugs.
220
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Cautions&Considerations

A

-TCA cardiac effects (for example) hypotension, heart block, or widened QRS.

221
Q

Sodium Bicarbonate (Bicarb, NaHCO3) Special Info

A
  • In hyperkalemia; slight alkalosis causes potassium to shift from the extracellular to the intracellular space causing a reduction in serum potassium levels.
  • In crush injuries, reverses effects of acidosis as lactic acid moves from the crushed part to circulation. Increases urine pH thus decreasing the amount of myoglobin precipitated in the kidneys.
  • In a tricyclic OD, slight alkalosis promotes binding of tricyclic to plasma protein, thus reducing toxic effects on the body.
222
Q 
Sodium Bicarbonate (Bicarb, NaHCO3) 
Tricyclic Antidepressants
A

May cause sudden onset of seizures and arrhythmias in overdose:

  • (Amitriptyline) Elavil, Triavil, Limbitrol, Vanatrip
  • (Amoxapine) Asendin
  • (Clomipramine) Anafranil
  • (Despiramine) Norpramin
  • (Doxepin) Sinequan, Silenor, Adapin
  • (Imipramine) Tofranil
  • (Maprotiline) Ludiomil
  • (Nortriptyline) Aventyl, Pamelor
  • (Protriptyline) Vivactil
  • (Trimipramine) Surmontil
223
Q

Cyanide Kit Drugs/Onset/Duration

A
  • Amyl Nitrate inhaler
  • Sodium Thiosulfate 25%
  • Hydroxocobalamin
Onset = minutes
Duration = days
224
Q

Cyanide Kit Drugs/Indications/Dosage/Route

A

Amyl Nitrate inhalation:

  • Indications: Significant symptoms such as seizures, LOC, or cardiac arrest
  • Dosage/Route: Given over 30 seconds BHPO

Sodium Thiosulfate 25%:

  • Indications: Significant symptoms such as seizures, LOC, or cardiac arrest
  • Dosage/Route: 12.5Gm IV BHPO

Hydroxocobalamin:

  • Indications: Significant symptoms such as seizures, LOC, or cardiac arrest
  • Dosage/Route: 5Gm given over 15 minutes IV BHPO
225
Q

Cyanide Kit Contraindications

A

-None

226
Q

Cyanide Kit Side Effects

A

Amyl Nitrate:

  • Hypertension
  • Tachycardia
  • Palpitations
  • Syncope
  • Headache
  • Nausea

Sodium Thiosulfate:

  • Cirrhosis of liver
  • Congestive heart failure
  • Renal function impairment

Hydroxocobalamin:

  • Mild increase in BP
  • Reddish orange skin color which clears over days
227
Q

Cyanide Kit Special Info

A
  1. Administer only if cyanide kit is available on site and patient has significant symptoms
  2. Cyanides are fast acting poisons that can be lethal
  3. Can be found in pesticides, fumigants, plastics, electroplating, photographic developing, and mining
  4. Signs and symptoms of cyanide poisoning include:
    - A. Weakness and confusion
    - B. Headache
    - C. Nausea
    - D. Metabolic acidosis
    - E. Abrupt asphyxiation
    - F. Difficulty breathing, respiratory arrest
    - G. Loss of consciousness
    - H. Seizures prior to death
    - I. Cardiac arrest
  5. Other supportive care includes high flow oxygen (BVM if necessary), decontamination, treatment of seizures, and supporting blood pressure
  6. Amyl Nitrate:
    - Effective in the emergency management of cyanide poisoning by causing the oxidation of hemoglobin to the compound methemoglobin. Methemoglobin reacts with cyanide ion to form cyanomethemoglobin, which has less affinity for oxygen, thus freeing hemoglobin to react with oxygen
    - Onset 30 secons, duration 3-20 minutes
  7. Sodium Thiosulfate:
    - Acts as a sulfur donor and reacts with ferric ion to prevent inhibition of cellular respirations
    - Protects against nephrotoxicity
  8. Hydroxocobalamin:
    - Natural form of Vitamin B12 that contains hemoglobin-like molecule with cobalt
    - Binds to cyanide to pull it out of the mitochondria of the cell to become cyanocobalamin, which is excreted through the urine

San Diego EMS Protocols 2019 (7 decks)

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