Pharmacology

Question 1

Drug

Answer 1

BRAND NAME:

CLASS:

PHARMACODYNAMICS:

INDICATIONS:

CONTRAINDICATIONS:

PHARMACOKENETICS:

SIDE EFFECTS:

DOSAGE:

HOW SUPPLIED:

Question 2

Activated Charcoal

Answer 2

CLASS: Absorbent

PHARMACODYNAMICS: Activated charcoal is a liquid suspension that adsorbs many drugs and chemicals. It acts by binding / adsorbing toxic substances, thereby inhibiting their GI absorption, uptake into the liver, and thus, their presence in the bloodstream for action, also called “bioavailability”. Activated charcoal has a tremendous surface area, allowing for a large amount of adsorption. The combined complex formed by the adsorption process is excreted from the body in the feces. It is a general purpose emergency treatment of poisoning by most drugs and chemicals, e.g., acetaminophen, aspirin, atropine, barbiturates, digitalis, glycosides, phenytoin, propoxyphene, strychnine, and tricyclic antidepressants, among many others.

INDICATIONS:
- Poisonings (most drugs and chemicals)

CONTRAINDICATIONS:
- Activated charcoal is contraindicated for treatment of poisoning by cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, and methanol. Activated charcoal may not be administered in patients with current or suspected imminent altered mental status, dysphagia, or vomiting to prevent elevated risk of aspiration of charcoal.

PHARMACOKENETICS: Nonabsorbed; onset immediate; peak, duration, and half – life: unknown.

SIDE EFFECTS: GI: vomiting following rapid ingestion of high doses, abdominal cramping, abdominal bloating, constipation (diarrhea from sorbitol additive).

DOSAGE:
ADULT & PEDIATRIC:
1 gram/kg PO (OLMC or OK Poison Center order required; Consult for order only if transport time estimated to exceed 30 mins)

HOW SUPPLIED: 25 grams of activated charcoal in aqueous suspension in bottle.

SPECIAL COMMENT: Activated charcoal, while historically often administered in the setting of ingested poisonings, is no longer utilized with frequency. The American Board of Medical Toxicology does not recommend administering activated charcoal to all suspected ingested poisonings. The purpose of OLMC or OK Poison Center order requirement is to prevent unnecessary use of activated charcoal and the side effects its use can create - especially vomiting and aspiration.

Question 3

Adenosine

Answer 3

BRAND NAME: Adenocard

CLASS: Anti-Tachydysrhythmic (Purine Nucleoside)

PHARMACODYNAMICS: Slows electrical conduction through the cardiac atrioventricular (AV) node, with ability to interrupt reentry pathways through the AV and sinoatrial (SA) nodes. Adenosine is administered to convert paroxysmal supraventricular tachycardia (PSVT) to normal sinus rhythm.

INDICATIONS:
- Tachycardia - Stable
PSVT (sustained regular, narrow-complex tachycardia >150 bpm in adults) & systolic BP ≥ 100mmHg, failed valsalva maneuver.

CONTRAINDICATIONS:
- 2nd/3rd degree AV Blocks (may induce asystole)
- Known Wolff-Parkinson-White Syndrome (may increase heart rate)
- Known Sick Sinus Syndrome (may induce asystole)
- Bradycardia (may induce symptomatic hypotension)

PHARMACOKENETICS: Onset of action within 10-20 seconds after IV administration. Very rapid metabolism (and duration of effect) within 10-20 seconds after IV administration.

SIDE EFFECTS: Common, though transient, symptoms include chest pain, palpitations of irregular bradycardia, dyspnea, lightheadedness, numbness, and sweating. A constellation of these side effects may produce significant patient apprehension and/or sense of impending doom. The patient should be advised of these possibilities prior to adenosine administration and given reassurance such symptoms will be short-lived in duration of seconds. Transient asystolic or profound, irregular bradycardic rhythms may be observed on ECG monitoring.

DOSAGE:
ADULT - Tachycardia - Stable (PSVT as described above)
12 mg rapid IVP (1 – 2 seconds) followed rapidly by 10 mL saline flush.
May repeat once at 12 mg.

PEDIATRIC -
**OLMC ORDER ONLY for use in pediatric patients.
OLMC may direct use of adenosine in evaluating etiology of regular, monomorphic wide complex tachycardia.

HOW SUPPLIED: 12 mg/4 mL in prefilled syringe.

Question 4

Albuterol

Answer 4

BRAND NAME: Proventil, Ventolin

CLASS: Sympathomimetic Bronchodilator
Actions/Pharmacodynamics: Albuterol is a relatively selective beta2 adrenergic stimulant. Albuterol causes relaxation of the smooth muscles of the bronchial tree thus decreasing airway resistance, facilitating mucus drainage, and increasing vital capacity. It exerts mild effects on beta1 (heart) or alpha (peripheral vasculature) receptors. In therapeutic doses, albuterol, by
inhibiting histamine release from mast cells, also reduces the mucus secretion, capillary leaking, and mucosal edema caused by an allergic response in the lungs.

INDICATIONS:
- Dyspnea - Asthma, COPD, Uncertain Etiology
- Acute Allergic Reactions/Bee/Wasp Stings
- Smoke Inhalation

CONTRAINDICATIONS:
- Known hypersensitivity to albuterol.
- Albuterol should not be used if the sole etiology of dyspnea is strongly suspected to be CHF, as albuterol-induced tachycardia may worsen the compromised cardiac output in CHF.

PHARMACOKENETICS: Onset within 5 – 15 minutes; peak effect in 1 – 1.5 hours; duration of effect is up to 3 – 6 hours; half – life is less than 3 hours. Distribution: When inhaled, albuterol is distributed to muscle cells along the bronchial tree. Very little is systemically absorbed and distributed.

SIDE EFFECTS: Tremors, anxiety, dizziness, headache, cough, reflex bronchospasm, palpitations, tachycardia, and hypertension.

DOSAGE:
ADULT:
- Uncertain etiology & smoke inhalation:
5mg nebulized; may repeat once

• Asthma, COPD, Allergic Reactions
  5mg nebulized (with 0.5 Ipratropium Bromide); may repeat twice

PEDIATRIC (less than 15kg):
- Uncertain etiology & smoke inhalation:
2.5mg nebulized; may repeat once

• Asthma, COPD, Allergic Reactions
  2.5mg nebulized (with 0.25 Ipratropium Bromide); may repeat twice

Question 5

Amiodarone

Answer 5

BRAND NAME: Cordarone, Nexterone

CLASS: Class III Anti-Dysrhythmic (Vaughn William Classification)

PHARMACODYNAMICS: Prolongs the cardiac action potential’s refractory period, slowing conduction through the heart. Amiodarone also has secondary actions in the other three classifications of anti-dysrhythmics. Amiodarone blocks sodium channels (class I) which can prevent cardiac action potentials. It is a non-competitive anti-sympathetic (class II) which slows cardiac action potentials. Amiodarone also slows conduction through the cardiac atrioventricular (AV) node (class IV). In sum, all of these actions lead to slowing of conduction and prolongation of refractoriness in the cardiac conduction system.

INDICATIONS:
- V-Fib/Pulseless V-Tach
- Tachycardia - Stable
(A) Wide-Complex Tachycardia of Uncertain Type or Monomorphic Ventricular Tachycardia (if heart rate ≥ 150 beats
per minute with systolic BP ≥ 100 mmHg in adults)
(B) Narrow-Complex Tachycardia (if heart rate ≥ 150 beats per minute with
systolic BP ≥ 100 mmHg in adults) **OLMC Order Only
- Tachycardia - Unstable
(A) Post-Cardioversion of Ventricular Tachycardia
- Premature Ventricular Contractions (5K)
(A)Symptomatic Premature Ventricular Contractions (with BP < 100mmHg in adults due to frequent non-conducted ventricular impulses and in absence of 2nd/3rd degree AV blocks)

CONTRAINDICATIONS:
- 2nd/3rd degree AV blocks (may induce asystole)
- Bradycardia (may induce symptomatic hypotension)

PHARMACOKENETICS: Onset of action within 60 seconds after IV administration, with effects lasting up to 20-25 minutes.

SIDE EFFECTS: Hypotension is the most common side effect, requiring treatment in less than 20% of patients (transient effect). Bradycardia and AV Block may also result, requiring treatment in less than 10% of patients (transient effect). In a very rare circumstance, as with all anti-dysrhythmics which can have pro-dysrhythmic effects, Torsades may result from excessive
prolongation of the cardiac action potential. When indicated by protocol, the benefits of
amiodarone administration exceed these risks of side effects.

DOSAGE:
ADULT:
- V-Fib & Pulseless V-Tach: (refractory to first defib):
300 mg IVP/IOP. Repeat at 150 mg IVP/IOP in 5 minutes to maximum cumulative dose of 450 mg. Epinephrine 1 mg (1:10,000) IVP/IOP is to be GIVEN WITH EVERY amiodarone administration.

• V-Fib & Pulseless V-Tach: (ROSC)
  150 mg over 10 minutes (15 mg/minute or 0.3 mL/minute very slow IVP/IOP/IVPB) IF maximum cumulative dose of 450 mg has not been achieved
• Stable Tachycardia (wide–complex tachycardia of uncertain type - standing order; monomorphic ventricular tachycardia - standing order; narrow complex):
  **OLMC ORDER ONLY!
• Unstable Tachycardia (post cardioversion of ventricular tachycardia) & PVCs:
  150 mg over 10 minutes (15 mg/minute or 0.3 mL/minute very slow IVP/IOP/IVPB).

PEDIATRIC:
- V-Fib & Pulseless V-Tach: (refractory to first defib):
5 mg/kg IVP/IOP in single dose. Epinephrine 0.01 mg/kg (1:10,000, 0.1 mL/kg) IVP/IOP is to be GIVEN WITH EVERY amiodarone administration.

• V-Fib & Pulseless V-Tach: (ROSC) & Stable Tachycardia (wide–complex tachycardia of uncertain type - standing order; monomorphic ventricular tachycardia - standing order; narrow complex) & PVCs:
  **OLMC ORDER ONLY!!

HOW SUPPLIED:
150 mg/3 mL in vial, ampule, or pre-filled syringe.
150 mg/100 mL pre-mixed infusion.

Question 6

Aspirin

Answer 6

CLASS: Anti-Platelet

PHARMACODYNAMICS: Inhibits platelet aggregation (and thereby, further clot formation). This action results in an overall increase in survival from acute myocardial infarction.

INDICATIONS:
- Chest Pain - Uncertain Etiology
- Acute Coronary Syndrome

CONTRAINDICATIONS:
- Active gastrointestinal bleeding
- History of aspirin allergy including angioedema and/or anaphylaxis
- History of asthma with aspirin-induced exacerbation

PHARMACOKENETICS: Absorption in stomach and small intestine, with onset of action within 30 minutes and duration of action for several hours.

SIDE EFFECTS: Typically none from single EMS dosing. Rare instances of nausea or allergic reaction could be encountered. Treat allergic reaction per Protocol 8D - Acute Allergic Reactions.

DOSAGE:
ADULT
Chest Pain (Uncertain Etiology) & Acute Coronary Syndrome:
324 OR 325 mg chewed by patient (hold if taken 324+mg within 6 hours)

HOW SUPPLIED: 81 mg tablets
325 mg tablets

SPECIAL COMMENT: Aspirin is indicated even if the patient is taking warfarin sodium
(Coumadin®), clopidogrel (Plavix®), or other anticoagulant or antiplatelet agents on a daily basis.

Question 7

Atropine Sulfate

Answer 7

CLASS: Parasympatholytic

PHARMACODYNAMICS: Blocks parasympathetic impulses to the heart via the vagus nerve. Atropine increases the rate of cardiac sinoatrial (SA) node discharges, enhances conduction through the atrioventricular (AV) node, and by increasing heart rate, increases the cardiac output and blood pressure. Additionally, in the treatment of indicated poisonings (organophosphates) atropine reverses muscarinic effects of acetylcholine, including diaphoresis, diarrhea, urination, bronchorrhea (secretions from the lower respiratory tract), emesis, lacrimation (tearing), and salivation. Atropine produces dilation of pupils by blocking stimulation of the ciliary muscle surrounding the pupils.

INDICATIONS:
- Bradycardia
- Organophosphate Poisonings

CONTRAINDICATIONS: None absolute in indicated situations.

PHARMACOKENETICS: Typical onset within 60 seconds given IV. Effects can persist in excess of 1 hour.

SIDE EFFECTS: Tachycardia (either supraventricular or ventricular), hypertension, palpitations, blurred vision due to pupillary dilation, photophobia, dry mouth.
Adult organophosphate poisoning: 2 mg IVP/IOP/IM. Use IVP for more severe presentations. May repeat as often as every 3-5 minutes if symptoms progressive or persistent.

DOSAGE:
ADULT:
- Bradycardia – Symptomatic (BP < 100 mmHg) (Sinus, First Degree, 2nd Degree Type I):
In Non-Acute Coronary Syndrome, 0.5 mg IVP/IOP. May repeat every 5 minutes to cumulative maximum dose of 3 mg

• Organophosphate poisonings:
  2 mg IVP/IOP/IM. Use IVP for more severe presentation. Repeat every 3-5 minutes if symptoms progressive

PEDIATRIC:
- Bradycardia – Symptomatic (BP < 100 mmHg) (Sinus, First Degree, 2nd Degree Type I):
Unresponsive to Epinephrine, 0.02 mg/kg IVP/IOP; minimum dose 0.1 mg Max. single dose 0.5 mg May repeat once.

• Organophosphate poisonings:
  0.05 mg/kg IVP/IOP/IM. Use IVP for more severe presentation. Minimum dose 0.1 mg. Consult with OLMCP for repeat dosing needs.

HOW SUPPLIED:
- 1 mg/10 mL prefilled syringe
- 1 mg/1 mL vial
- 0.25 mg/5 mL prefilled syringe for pediatric use

Question 8

Calcium Chloride

Answer 8

CLASS: Electrolyte

PHARMACODYNAMICS: Calcium causes a significant increase in myocardial contractility and in ventricular automaticity. It is used as an antidote for some electrolyte imbalances (eg. stabilizing cardiac rhythm in the setting of hyperkalemia) and to minimize the side effects from calcium channel blocker overdose. The actions of calcium chloride are similar to those of calcium gluconate but, since it ionizes more readily, it is more potent than calcium gluconate.

INDICATIONS:
- Specific Causes of Cardiac Arrest (Hyperkalemia)
- Poisonings - General Management (Calcium Channel Blocker Overdose)
- Dialysis-Related Issues (Hyperkalemia)
- Crush Injury Syndrome (Hyperkalemia Prophylaxis)

CONTRAINDICATIONS:
- Calcium chloride is contraindicated in ventricular fibrillation unless known hyperkalemia, in known hypercalcemia, and in suspected digitalis toxicity.
- It should be used with caution in patients taking digoxin as it may precipitate toxicity.
- Safe use in pregnancy and in children has not been established, though in indicated conditions, benefits outweigh risks.

PHARMACOKENETICS: Onset nearly immediate when given IVP/IOP. The peak effect time frame and duration of effect is not well established.

Side Effects: Paresthesias (tingling), syncope, sensations of heat waves (peripheral vasodilation), pain and burning at IV site, skin necrosis and sloughing (with extravasation), hypotension, bradycardia, cardiac dysrhythmias, cardiac arrest.

DOSAGE:
ALL ABOVE INDICATIONS ADULT & PEDIATRIC:
- 10 mg/kg (10% solution) IVP/IOP, maximum dose of 1 gram

HOW SUPPLIED: 1 gram in a 10 mL prefilled syringe (100 mg/mL)

SPECIAL COMMENTS: Calcium chloride will interact with sodium bicarbonate and form a
precipitate. Do not give both medications via the same vascular access line unless giving a copious flush of NS - approximately 50+ mL - between medications. In general, use an 18-20 gauge angiocatheter in a proximal IV site or use an IO line and test line patency before administration. In non-cardiac arrest or non-impending cardiac arrest settings, administer at 0.5 -1.0 mL per minute to reduce chances of venous irritation and extravasation.

Question 9

Dosage for Dextrose

Answer 9

GLUCOSE LESS THAN 50

ADULT:
D50 Dextrose 50% (D50) 1 mL/kg IVP up to 50 mL

PEDIATRIC: (less than 25kg)
Dextrose 25% (D25) 2 mL/kg IVP up to 50 mL

ADULT DOSAGE: 25 gm of 10-50% dextrose IV
1. 50 ml of 50% dextrose
2. 100 ml of 25% dextrose
3. 250 ml of 10% dextrose

PEDIATRIC DOSAGE: 0.5 -1gm/kg of 10-25% dextrose IV
1. 2-4 ml/kg of 25% dextrose
2. 4-8 ml/kg of 12.5% dextrose
3. 5-10 ml /kg of 10%dextrose

Question 10

Diazepam

Answer 10

BRAND NAME: Valium

CLASS: Sedative; Anticonvulsant; Muscle Relaxant; Anxiolytic (Benzodiazepine)

PHARMACODYNAMICS: Intermediate - acting benzodiazepine with central nervous system depressant, anticonvulsant, muscle relaxant, and anxiolytic effects. Like the other benzodiazepines, it has no effect on pain. Diazepam has considerably more muscle relaxant properties than midazolam, though no substantial amnestic effects as with midazolam.

INDICATIONS:
- Medication Assisted Intubation (Post-intubation sedation - onset delay does not favor pre-intubation use)
- Seizure (Midazolam preferred benzodiazepine due to faster onset of action)
- Dystonic Reactions
- Chemical Restraint (Midazolam preferred benzodiazepine due to faster onset of action)
- Poisonings (Suspected stimulant toxicity = severe agitation, HTN, tachycardia, diaphoresis)
- Head/Neck/Spine Injury
- Heat Illness

CONTRAINDICATIONS:
- Intolerance/Allergies
- Acute narrow - angle glaucoma
- Shock or coma.
- Caution with use in patients with COPD, chronic hepatic or renal failure, CHF, acute alcohol intoxication, and the elderly due to increased risk of respiratory depression.

PHARMACOKENETICS: Onset is 3-5 minutes, IVP/IOP; 15-30 minutes IM with erratic absorption, mandating IM dosing only utilized as a last option in adults; peak effects in 15-45 minutes. Duration is 2+ hours IVP/IOP/IM; half – life can reach 20 – 50 hours.

SIDE EFFECTS: Headache, euphoria, drowsiness, excessive sedation, confusion, dizziness, blurred vision, diplopia, nystagmus, respiratory arrest, hypotension, nausea, vomiting.

DOSAGE:
ADULT:
- Medication Assisted Intubation (Post Intubation Sedation):
0.1 mg/kg to max 5 mg IVP/IOP, may repeat once if systolic BP > 100 mmHg

• Seizure, Head/Neck/Spine Injury, or Heat Illness:
  5 mg IVP/IOP or 10 mg IM for active seizure
  May repeat once in 5 minutes if still seizing.
• Dystonic Reactions:
  5 mg IVP
• Chemical Restraint:
  5 mg IVP/IOP or 10 mg IM
• Poisoning (Suspected Stimulant Toxic):
  2.5 mg - 5 mg IVP

PEDIATRIC:
- Seizure, Head/Neck/Spine Injury, or Heat Illness:
0.1 mg/kg to max 5 mg IVP/IOP/IM for active seizure May repeat once in 5 minutes if still seizing.

• Dystonic Reactions:
  0.1 mg/kg to max 5 mg IVP/IM
• Chemical Restraint:
  0.1 mg/kg to max 5 mg IVP/IOP/IM
• Poisoning (Suspected Stimulant Toxic):
  **OLMC Order Only

HOW SUPPLIED: 10 mg/2 mL in vials, ampules, or pre-filled syringes.

Question 11

Diltiazem

Answer 11

BRAND NAME: Cardizem

CLASS: Calcium Channel Blocker

PHARMACODYNAMICS: Diltiazem is a slow calcium channel blocker with pharmacologic
actions similar to those of verapamil. It inhabits calcium ion influx through slow channels into cells of myocardial and arterial smooth muscle (both coronary and peripheral blood vessels). As a result, intracellular calcium remains at sub-threshold levels insufficient to stimulate cell
excitation and contraction. Diltiazem slows SA and AV node conduction (antidysrhythmic effect) without affecting normal atrial action potential or intraventricular conduction.

INDICATIONS:
- Tachycardia - Stable
(Sustained narrow-complex tachycardia > 150 bpm in adults with systolic BP ≥ 100 mmHg)
**OLMC Order Only

CONTRAINDICATIONS:
- Known hypersensitivity to diltiazem
- 2nd/3rd degree AV Blocks (may induce asystole)
- Known Wolff-Parkinson-White Syndrome (may increase heart rate)
- Known Sick Sinus Syndrome (may induce asystole)
- Hypotension
- Bradycardia
- Safe use in pregnancy and in children has not been established.
- Use with caution in CHF (especially if patient is also receiving a beta-blocker), conduction abnormalities, renal or hepatic
impairment and the elderly due to exaggerated degree of effect.

PHARMACOKENETICS: Onset is 3 minutes; peak effect in 7 minutes; duration is 1-3 hours; half-life is 2 hours.

SIDE EFFECTS: Headache, fatigue, dizziness, dysrhythmias, 2nd/3rd degree AV block, bradycardia, CHF, hypotension, syncope, palpitations.

DOSAGE:
ADULT:
- Tachycardia - Stable
(Sustained narrow-complex tachycardia > 150 bpm in adults with systolic BP ≥ 100mmHg):
**OLMC Order Only BUT Usual adult dose is 0.25 mg/kg slow IVP over 2 minutes

HOW SUPPLIED:
25 mg in 5 mL vial (5 mg/mL)

Question 12

Diphenhydramine

Answer 12

BRAND NAME: Benadryl

CLASS: Antihistamine, Anticholinergic

PHARMACODYNAMICS: Diphenhydramine competes for H1 – histamine receptor sites on effector cells, thus blocking histamine release. Histamine release creates some of the common signs and symptoms of an allergic response: pruritis (itching), mucus secretion, and capillary leaking, which contributes to the formation of urticaria (hives), erythematous skin, and mucosal edema. In the setting of a dystonic reaction, the balance of dopamine and choline must be changed within the brain. The most clinically feasible method of reversing a dystonic reaction, though inhibiting the enzyme acetylcholinesterase, is through the anti-cholinergic effect of a medication like diphenhydramine.

INDICATIONS:
- Dystonic Reactions
- Acute Allergic Reactions
- Bee/Wasp Stings

CONTRAINDICATIONS:
- Known hypersensitivity to diphenhydramine. While rare, allergic reaction to diphenhydramine is possible and should be considered valid if stated or documented in a patient’s medical history.

PHARMACOKENETICS: Onset within 15 – 30 minutes; duration is approximately 6 hours.

SIDE EFFECTS: Drowsiness, dizziness, disturbed coordination.

DOSAGE:
ADULT:
- Dystonic Reactions, Acute Allergic Reactions, Bee/Wasp Stings:
50 mg IM/IVP

PEDIATRIC:
- Dystonic Reactions, Acute Allergic Reactions, Bee/Wasp Stings:
1 mg/kg IM/IVP to maximum of 50 mg

HOW SUPPLIED: 50 mg/1 mL in vial, ampule, or pre-filled syringe

Question 13

Dopamine

Answer 13

BRAND NAME: Intropin

CLASS: Vasoconstrictor

PHARMACODYNAMICS: Dose dependent. Higher doses (5+ mcg/kg/min) increasingly
stimulate alpha receptors in the peripheral vasculature, producing vasoconstriction-related increases in system blood pressure. Concurrent beta receptor stimulation may produce increases in heart rate and mild bronchodilation. Lower doses (<5 mcg/kg/min), as may be encountered infrequently in interhospital transfers, produce mesenteric (intestinal) and renal
vascular dilation to ensure continued perfusion to these organ systems in complicated medical illness that would otherwise sacrifice such circulation.

INDICATIONS:
- Dyspnea - Congestive Heart Failure (Cardiogenic Shock)
- Post Cardiac Arrest Treatment (Cardiogenic Shock)
- Acute Coronary Syndrome (Cardiogenic Shock)
- Fever (Septic Shock)
- Dialysis-Related Issues

For all listed situations, indication is hypotension (adult = systolic < 100 mmHg) due to cardiogenic, septic, or neurogenic shock either refractory to intravascular fluid boluses or in which intravascular fluid bolusing is contraindicated (eg. pulmonary edema).

CONTRAINDICATIONS: Hypertension

PHARMACOKENETICS: Onset of action within 5 minutes after IV/IO infusion initiated. Rapid metabolism, requiring ongoing IV/IO infusion to maintain clinical effects.

SIDE EFFECTS: Palpitations, tachycardia, chest pain, and hypertension if not titrated.

DOSAGE:
For all listed indications: (shock refractory to fluids)

ADULT:
5 – 20 mcg/kg/minute - see dosage chart - titrate to a sys B/P ≥ 100 mmHg

PEDIATRIC:
**OLMC Order Only.

HOW SUPPLIED:
400 mg/10 mL vial to be mixed into 250 mL D5W. (1600 mcg/mL concentration)
OR
Pre-mixed dopamine infusion at 1600 mcg/mL concentration.

SPECIAL COMMENTS: Relative caution should be exercised prior to use in the setting of marked tachydysrhythmias, due to the potential for further increase in heart rates. In the setting of tachydysrhythmia-induced cardiogenic shock, treat per
Protocol 5G - Tachycardia - Unstable. Ensure aggressive fluid resuscitation
is accomplished (unless contraindicated) prior to dopamine use.

***REMEMBER DOPAMINE FOR THOSE WHO NEEDS INCREASED BLOOD PRESSURE AND HEART RATE. LEVOPHED IS FOR JUST INCREASED BLOOD PRESSURE.

Question 14

Epinephrine 1:1,000 & 1:10,000

Answer 14

CLASS: Vasoconstrictor, Bronchodilator (Catecholamine)

PHARMCODYNAMICS: Stimulates alpha receptors in the peripheral vasculature, producing
vasoconstriction-related increases in systemic blood pressure. Stimulates beta-1 receptors in the
myocardium, producing increases in heart rate, myocardial contraction, and as a result, cardiac output.
Stimulates beta-2 receptors in the lower respiratory tract smooth musculature, producing bronchodilation.

INDICATIONS:
- Dyspnea - Asthma (Severe & Refractory to Nebulization)
- Asystole and/or PEA
- V-Fib/Pulseless V-Tach
- Bradycardia (Pediatric)
- Acute Allergic Reactions (Anaphylaxis due to snakebite, bee, or wasp strings)

CONTRAINDICATIONS: None absolute in indications above. Safety in pregnancy not firmly established, though when clinically indicated the benefits outweigh risks.

PHARMACOKENETICS: Onset of action within 2 minutes after IVP/IOP; within 5-10 minutes after IM. Duration of effect ranges from 3-5 minutes after IVP/IOP to upwards of 30 minutes after IM.

SIDE EFFECTS: Restlessness, anxiety, generalized tremors, headache, dizziness, chest pain, palpitations, hypertension, premature ventricular contractions, tachycardia.

DOSAGE:
ADULT:
- Asystole, PEA, V-Fib, Pulseless V-Tach:
1:10,000 1 mg IVP/IOP. Repeat every 3 - 5 minutes while resuscitating cardiac arrest

• Anaphylaxis / Severe allergic reaction:
  (A) 1:1000 0.5 mg IM
  (B) If anaphylaxis refractory to above IM dose: 1:10,000 1 mg slow IVP/IOP over 3 minutes
• Dyspnea - Asthma (Severe & Refractory to Nebulization):
  1:1000 0.3 mg IM
  **OLMC Order Required if pt ≥ 50 years old, heart illness history, or blood pressure > 140/90 mmHg.

PEDIATRIC:
- Asystole, PEA, V-Fib, Pulseless V-Tach:
1:10,000 0.01 mg/kg (0.1mL/kg) IVP/IOP. Repeat every 3 - 5 minutes while resuscitating cardiac arrest

• Anaphylaxis / Severe allergic reaction:
  (A)1:1000 0.01 mg/kg (0.01 mL/kg) not to exceed 0.3 mg (0.3 mL) IM
  (B)If anaphylaxis refractory to above IM dose: 1:10,000 0.01 mg/kg slow IVP/IOP over 3 minutes
• Dyspnea - Asthma (Severe & Refractory to Nebulization):
  1:1000 0.01 mg/kg (0.01 mL/kg) not to exceed 0.3 mg (0.3 mL) IM
  **OLMC Order required if heart illness history or blood pressure > 140/90 mmHg.
• Bradycardia - Symptomatic & Systolic BP < 70 + (2 x age in years) mmHg (Sinus, First Degree, 2nd Degree Type I):
  1:10,000 0.01 mg/kg (0.1 mL/kg) IVP/IOP
  May repeat once

HOW SUPPLIED:
- Epinephrine 1:1000 in 1 mg/1mL ampules or 30 mg/30 mL vial
- Epinephrine 1:10,000 in 1 mg/10 mL prefilled syringes

SPECIAL COMMENTS: Be sure to administer correct concentration. Pulsatile patients ages 35 years or greater, particularly those with known coronary artery disease, receiving epinephrine should have ECG monitoring initiated and continued as soon as an ECG monitor is available.

Question 15

Epinephrine AutoInjector

Answer 15

SKIP

Question 16

Etomidate

Answer 16

BRAND NAME: Amidate

CLASS: Sedative - Hypnotic (non narcotic/opiate; non-benzodiazepine; non-barbiturate)

PHARMACODYNAMICS: Etomidate is an intravenous hypnotic drug without analgesia.
Etomidate is safe to use in patients with cardiac illness and patients with traumatic injuries. Etomidate has little to no effect upon myocardial metabolism, cardiac output, or peripheral circulation. Etomidate has been shown to reduce cerebral blood flow, cerebral oxygen consumption, and intracranial pressure – helpful in head injury situations.

INDICATIONS:
- Medication Assisted Intubation

CONTRAINDICATIONS:
- Known hypersensitivity to etomidate.

PHARMACOKENETICS: Rapid onset of action, seen as desired sedation within as little as 10-15 seconds, but nearly always within less than 1 minute. Duration of action, based upon a standard dose of 0.3 mg/kg (70 kg adult dose of 20 mg) is 5-15 minutes.

SIDE EFFECTS:
1) Transient skeletal muscle movements, called myoclonus, have been reported in 10-80% of patients. Most of these movements are mild to moderate in severity. Rarely, these movements are severe in motion and force, though transient. Most movements are bilateral and can involve any part of the body. Results of electroencephalographic studies taken during periods when these muscle movements were observed have failed to reveal true seizure activity.
2) Transient venous pain at injection site, due to propylene glycol, a solvent in Etomidate preparations.
3) Nausea and/or vomiting.
4) Very rarely, hypoventilation and apnea, though Etomidate generally preserves the baseline respiratory activity.
5) Very rarely, hypotension and when seen, usually is due to too rapid IVP administration.

DOSAGE:
ADULT:
- Medication Assisted Intubation:
0.3 mg/kg IVP/IOP over 15-30 seconds, given just prior to intubation.

HOW SUPPLIED: 40 mg/20 mL (2 mg/mL) vial or pre-filled syringe

SPECIAL COMMENTS: Repeated doses of etomidate should be avoided to minimize its effect upon adrenal function. Repeated doses and continuous infusions of etomidate have been linked to adrenal suppression.

Question 17

Fentanyl

Answer 17

BRAND NAME: Sublimaze

CLASS: Narcotic analgesic

PHARMACODYNAMICS: Stimulates central nervous system opiate receptors, producing
systemic analgesia. On a milligram weight basis, fentanyl is 50-100 times more potent than morphine. Its duration of action is shorter than morphine or hydromorphone. An IV dose of 100 mcg of fentanyl is roughly equivalent to an IV dose of 10 mg of morphine. Fentanyl has less emetic effects than other narcotic analgesics.

INDICATIONS:
- Chest Pain – Uncertain Etiology
- Acute Coronary Syndrome
- Acute pain control in alert, hemodynamically stable patient.

CONTRAINDICATIONS:
- Hypotension
- Respiratory Depression
- Minor Degrees of Pain
- Pain Assessed as Factitious

SIDE EFFECTS: Hypotension, respiratory depression, euphoria, dizziness. Nausea and/or vomiting are rarely seen if administration is slow IVP.

PHARMACOKENETICS: Onset of action nearly immediate after IV administration. Peak effects occur within 3 – 5 minutes. Duration of effect is 30 - 60 minutes, with a half-life of 6 – 8 hours.

DOSAGES:
ADULTS:
- Chest Pain – Uncertain Etiology & Acute Coronary Syndrome:
0.5 mcg/kg slow IVP/IM/IN, maximum single dose of 50 mcg ; May repeat every 10 minutes to a maximum cumulative dose of 1.5 mcg/kg or 125 mcg, whichever is lesser

• Acute Pain Control
  1 mcg/kg slow IVP/IM/IN, maximum single dose of 100 mcg ; May repeat every 10 minutes to a maximum cumulative dose of 3 mcg/kg or 250 mcg, whichever is lesser

PEDIATRIC:
OLMC ORDER ONLY but typical dose is mcg/kg up to 50 mcg per dose.

How Supplied:
- 100 mcg/2 mL (50 mcg/mL) ampule, vial, or pre-filled syringe
- 250 mcg/5 mL (50 mcg/mL) ampule or vial
- 500 mcg/10 mL (50 mcg/mL) vial

Question 18

Glucagon

Answer 18

CLASS: Hormone

PHARMACODYNAMICS: Glucagon is a hormone produced in the pancreas. When
released in times of hypoglycemia, it causes a breakdown of glycogen (stored in the liver) to glucose and inhibits the subsequent synthesis of glycogen from circulating glucose. Both actions increase the blood levels of glucose. Given via the IM route, it is a useful drug in hypoglycemia when IV access is unsuccessful. Glucagon also increases heart rate, myocardial contractility and improves AV conduction in a manner similar to that produced by catecholamines. Its actions are independent of beta blockade and therefore may be useful via IV/IO administration by paramedics for reversing cardiovascular collapse effects of suspected
beta blocker toxicity.

INDICATIONS:
- Respiratory Arrest
- Specific Causes of Cardiac Arrest
- Altered Mental Status
- Seizure
- Syncope
- Dystonic Reactions
- Behavioral Disorder
- Poisonings – General Management
- Complications of Pregnancy
- For all listed situations, indication is hypoglycemia (blood glucose <50 mg/dL) without ability to safely administer oral glucose (due to aspiration concern) and without ability to establish IV access in EMT-I85, AEMT, and Paramedic Scopes of Practice. Additional indication for beta blocker toxicity with hypotension and bradycardia in Paramedic Scope of Practice.

CONTRAINDICATIONS: None

PHARMACOKENETICS: Onset 5 – 20 minutes; peak effects in 30 minutes; duration is 1 – 1.5 hours.

SIDE EFFECTS: Dizziness, headache, nausea/vomiting, hyperglycemia

DOSAGE:
ADULT:
1mg IM (IV/IO if available)

PEDIATRIC: (less than 25kg)
0.5mg IM (IV/IO if available)

HOW SUPPLIED: 1 mg dry powder in vial with 1 mL of diluting solute for reconstitution

Question 19

Oral Glucose

Answer 19

CLASS: Carbohydrate

PHARMACODYNAMICS: Increases blood sugar level.

INDICATIONS:
- Altered Mental Status (Hypoglycemia)
- Syncope (Hypoglycemia)
- Dystonic Reaction (Hypoglycemia)
- Behavioral Disorder (Hypoglycemia)
- Dialysis-Related Issues (Hypoglycemia)
- Complications of Pregnancy (Hypoglycemia)

CONTRAINDICATIONS: Unconscious or semi–conscious and unable to follow simple commands. Care should be taken to prevent choking or aspiration of medication in semi–conscious patient.

PHARMACOKENETICS: Rapid oral absorption uptake to increase circulating blood sugar levels. Onset of effect within several minutes of oral dosing. Duration of effect up to 30+ minutes, but patient should be advised to consume complex carbohydrates within minutes of restoration of normal blood sugar, unless otherwise contraindicated.

SIDE EFFECTS: None

DOSAGE:
ADULTS:
15 grams (1 tube) PO or SL for blood glucose < 50 mg/dL

PEDIATRIC:
7.5 grams (1/2 tube) PO or SL for blood glucose < 50 mg/dL

HOW SUPPLIED: 15 grams of glucose for oral administration in a squeeze tube container.

SPECIAL COMMENT: Medical grade glucose should be utilized in place of sodas, candy, and other carbohydrate-heavy solid food. In many cases, the carbohydrate grams cannot be measured.

Question 20

Haloperidol

Answer 20

BRAND NAME: Haldol

CLASS: Antipsychotic

PHARMACODYNAMICS: Haloperidol is a potent, long – acting antipsychotic agent. While its exact mechanism is unclear, it appears to block the dopamine receptors in the brain associated with mood and behavior. It exerts strong antiemetic effects and impairs central thermoregulation. It also produces weak central anticholinergic effects and transient orthostatic hypotension.

INDICATIONS:
- Chemical Restraint

CONTRAINDICATIONS:
- Known hypersensitivity
- Behavioral disorder etiology easily reversed (eg. hypoglycemia)
- Minor degrees of agitation
- Parkinson’s disease
- Known seizure disorders (lowers seizure threshold)
- CNS depressants, opiates, and alcohol may increase the CNS depression effect of haloperidol.
- Use with caution in elderly or debilitated patients due to exaggerated effect. Safe use in pregnancy has not been established, though in the indicated setting, benefit outweighs risks.

PHARMACOKENETICS: Onset is within 10-20 minutes IM; peak effect in 30-45 minutes; duration is 3+ hours, reported up to 35 hours.

SIDE EFFECTS: CNS depression, seizure, dystonic reactions, dry mouth, blurry vision,
bronchospasm, tachycardia, hypertension, hypotension, dysrhythmias, hyperpyrexia,
diaphoresis, urinary retention.

DOSAGE:
ADULT:
- Chemical Restraint:
5 mg IM (use deep IM injection in large muscle - lateral thigh if possible)

PEDIATRIC:
- Chemical Restraint:
** OLMC Order Only

HOW SUPPLIED: 5 mg/1 mL vial.

SPECIAL COMMENTS: In emergency situations where the patient’s behavior poses an immediate risk to rescuers and bystanders, the IM injection may be given through the patient’s clothing to minimize risk of needlestick injuries to rescuers. Dystonic reactions are common with haloperidol; diphenhydramine should be readily available - see Protocol 6F - Dystonic Reactions.

Question 21

Hydralazine

Answer 21

BRAND NAME: Apresoline

CLASS: Anti-Hypertensive

PHARMACODYNAMICS: Reduces blood pressure via relaxation of arterial smooth
muscle, resulting in vasodilation, decreasing peripheral resistance. Alters vascular smooth
muscle cellular metabolism of calcium, leading to reduction of vascular muscle contraction.

INDICATIONS:
- Hypertensive Emergency
- Complications of Pregnancy (Hypertensive Emergency)

CONTRAINDICATIONS:
- Known hypersensitivity to hydralazine.
- Cardiogenic shock
- Mitral valvular rheumatic heart disease
- Acute coronary syndrome
- Safe use during pregnancy and children is not firmly established in pharmaceutical studies, though hydralazine has been used effectively in pregnancy and in pediatrics.

PHARMACOKENETICS: Onset is within 10 minutes IV; peak effects between 10-80 minutes.

SIDE EFFECTS: Dizziness, headache, transient paresthesia (eg. scalp tingling), numbness, postural hypotension, angina, palpitations, tachycardia, syncope, pulmonary edema, dysrhythmias (tachycardias) following IV administration, dyspnea, nausea, vomiting.

DOSAGE:
ADULT:
-Hypertensive Emergency & Complications of Pregnancy (Hypertensive Emergency) -
10 mg Slow IVP. May repeat 10 mg every 30 minutes as needed up to cumulative maximum dose of 30 mg.

PEDIATRIC:
- Hypertensive Emergency
**OLMC Order Only. Rarely required.
Typical pediatric dose is 0.5 mg/kg up to 0.9 mg/kg, with a max single dose 10 mg.

HOW SUPPLIED: 20 mg/1 mL in a 1 mL vial

Question 22

Hydromorphone

Answer 22

BRAND NAME: Dilaudid

CLASS: Narcotic analgesic

PHARMACODYNAMICS: Stimulates central nervous system opiate receptors, producing
systemic analgesia. Modest vasodilation effects increase peripheral venous capacitance, and reduce venous return, myocardial workload, and myocardial oxygen demand. Hydromorphone is roughly 10 times more potent than morphine. An IV dose of 1 mg of hydromorphone is equivalent to an IV dose of 10 mg of morphine.

INDICATIONS:
- Chest Pain – Uncertain Etiology
- Acute Coronary Syndrome
- Acute pain control in alert, hemodynamically stable patient.

CONTRAINDICATIONS:
- Hypotension
- Respiratory Depression
- Minor Degrees of Pain
- Pain Assessed as Factitious

SIDE EFFECTS: Hypotension, respiratory depression, euphoria, dizziness. Nausea and/or vomiting are rarely seen if administration is slow IVP. Rapid IVP will lead to an accompanying histamine release, producing the nausea and/or vomiting often erroneously attributed to hydromorphone itself.

PHARMACOKENETICS: Onset of action within 5-10 minutes after IV administration. Duration of effect can reach 4 - 6 hours depending upon end-organ function.

DOSAGE:
ADULTS:
- Chest Pain (Uncertain Etiology) &
Acute Coronary Syndrome:
0.25 mg slow IVP ; May repeat every 10 minutes to a maximum cumulative dose of 1 mg

• Acute pain control in alert, hemodynamically stable patient.
  0.5 – 1 mg slow IVP ; May repeat every 10 minutes to a maximum cumulative dose of 2 mg

PEDIATRIC:
- Acute pain control in alert, hemodynamically stable patient.
**OLMC Order Only – Typical dose is 0.01 mg/kg up to 0.5 mg per dose.

HOW SUPPLIED: 2 mg/1 mL vial or pre-filled syringe

Question 23

Ipratropium Bromide

Answer 23

BRAND NAME: Atrovent

CLASS: Parasympatholytic Bronchodilator

PHARMACODYNAMICS: Atrovent is an anticholinergic agent, chemically related to
atropine. Given in a nebulized form, it acts directly on the smooth muscle of the bronchial tree by inhibiting acetylcholine at receptor sites. By blocking parasympathetic action, it dilates the bronchial smooth muscle and decreases secretions. It also abolishes the vagally mediated reflex bronchospasm caused by inhaled irritants such as smoke, dust, and cold air and by a range of inflammatory mediators such as histamine.

INDICATIONS:
- Dyspnea - Asthma, COPD
- Acute Allergic Reactions (Bee/Wasp sting - anaphylaxis)

CONTRAINDICATIONS:
- Hypersensitivity/allergy
- It should not be used as the sole pharmacologic treatment for acute bronchospasm. By protocol, Atrovent is always administered in conjunction with albuterol.

PHARMACOKENETICS: Absorption: 10% of inhaled dose reaches lower airway; approximately 0.5% of dose is systemically absorbed; onset within 5-15 minutes; peak effect in 1.5 – 2 hours; duration of effect is up to 4 – 6 hours; half – life is 1.5 – 2 hours.

SIDE EFFECTS: Cough, reflex bronchospasm, hoarseness, nasal/oral dryness, bitter taste.

DOSAGE:
ADULT:
Dyspnea - Asthma, COPD, allergic reaction
0.5 mg nebulized (with albuterol 5 mg), may repeat twice

PEDIATRIC: (less than 15kg)
Dyspnea - Asthma, COPD, allergic reaction
0.25 mg nebulized (with albuterol 2.5 mg), may repeat twice

HOW SUPPLIED: 0.5 mg/2.5 mL nebulizer solution vials.

Question 24

Labetolol

Answer 24

BRAND NAME: Normodyne, Trandate

CLASS: Anti-Hypertensive (Beta-1, Beta-2, and Alpha-1 Blocker)

PHARMACODYNAMICS: Adrenergic-receptor blocking agent that combines selective alpha activity and non-selective beta-adrenergic blocking actions. Both activities contribute to reduce blood pressure. Alpha blockade results in vasodilation, decreasing peripheral
resistance. Beta blocking effects on sinus node, AV node, and ventricular muscle lead to slower heart rates, delay in AV conduction, and depression of cardiac contractility.

INDICATIONS:
- Hypertensive Emergency
- Complications of Pregnancy (Hypertensive Emergency)

CONTRAINDICATIONS:
- Asthma (due to beta-2 blockade)
- Cardiogenic shock
- Uncontrolled congestive heart failure
- 2nd/3rd degree AV heart block
- Sinus bradycardia.
- Safe use during pregnancy and children is not firmly established in pharmaceutical studies, though labetalol has been used effectively in pregnancy and in pediatrics.

PHARMACOKENETICS: Onset is 2-5 minutes IV; peak effects in 5-15 minutes; duration is 2-4 hours; half-life is 3-8 hours.

SIDE EFFECTS: Dizziness, headache, transient paresthesia (eg. scalp tingling), numbness, postural hypotension, angina, palpitations, bradycardia, syncope, pulmonary edema, dysrhythmias (bradycardias) following IV administration, dyspnea, bronchospasm.

DOSAGE:
ADULT:
- Hypertensive Emergency & Complications of Pregnancy (Hypertensive Emergency) -
20 mg Slow IVP. May repeat 40 mg every 10 minutes as needed up to cumulative maximum dose of 300 mg.

PEDIATRIC:
- Hypertensive Emergency
**OLMC Order Only. Rarely required. Typical pediatric dose is 0.3 mg/kg up to 1 mg/kg, with a max single dose 20 mg.

How Supplied: 100 mg in a 20 mL Multi Dose Vial (5 mg/mL)

Question 25

Lidocaine 2% Intravascular

Answer 25

BRAND NAME: Xylocaine

CLASS: Intraosseous Local Anesthetic & Antidysrhythmic

PHARMACODYNAMICS: As a local anesthetic, reduces nerve activation that carries painful stimulus from intraosseous fluid and/or medication administration. As an antidysrhythmic, suppresses ventricular automaticity, chemically converting ventricular tachycardia.

INDICATIONS:
- Tachycardia - Stable (Wide complex tachycardia, refractory to amiodarone ; **OLMC Order Only)
- Vascular Access - Intraosseous

CONTRAINDICATIONS:
- Narrow complex tachycardia
- Second degree AV Block-Type II (Classic Type)
- Third degree AV Block (Complete Heart Block)
- Premature ventricular contractions with underlying bradycardias
- No indication for IO anesthetic (unresponsive patients)

PHARMACOKENETICS: Onset of action within 3 minutes IVP/IOP. Duration for 10-20 minutes.

SIDE EFFECTS: None expected in indicated dosing. Erroneous use in high degree heart blocks can lead to complete ventricular suppression/cardiac arrest.

DOSAGE:
ADULT:
- Tachycardia - Stable - Wide Complex (Refactory to Amiodarone)
Up to 1 mg/kg, slow IVP/IOP at < 50 mg/minute **OLMC Order Only!!

PEDIATRIC:
Tachycardia - Stable
Consult with OLMCP for use and dosing.

ADULT & PEDIATRIC:
Vascular Access - Intraosseous (Local Anesthetic)
1 mg/kg up to 40 mg IOP

HOW SUPPLIED: 100 mg/5 mL (20 mg/mL of 2% lidocaine) prefilled syringe.

Question 26

Lidocaine Viscous Gel

Answer 26

BRAND NAME: Xylocaine

CLASS: Topical Anesthetic

PHARMACODYNAMICS: Lidocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. In gel formulation, additional lubricant effect is possible.

INDICATIONS:
- Nasotracheal Intubation

CONTRAINDICATIONS:
- Known hypersensitivity to local anesthetics, amide type.

PHARMACOKENETICS: Onset of action within 3 - 5 minutes.

SIDE EFFECTS: None expected unless amide anesthetic allergy. In this specific setting, adverse experiences are generally systemic in nature. Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension, and cardiovascular collapse.

DOSAGE:
ADULT:
- Nasotracheal Intubation:
(Apply gel to the external surface of the endotracheal tube, primarily the distal
parts near the balloon cuff and the balloon cuff itself just prior to intubation)
Typical use is 1-2 mL of gel.

HOW SUPPLIED: 2% Viscous Gel (20 mg/mL) - available in foil packs, tubes, pre-filled syringes for topical application, and bottles.

SPECIAL COMMENTS: Care should be taken to avoid partially occluding the lumen of the endotracheal tube with gel. Do not use the gel to lubricate the endotracheal stylette. Avoid large bottles of lidocaine viscous gel. Attempts to use over multiple patients can result in gel contamination.

Question 27

Lorazepam

Answer 27

BRAND NAME: Ativan

CLASS: Sedative; Anticonvulsant; Muscle Relaxant; Anxiolytic (Benzodiazepine)

PHARMACODYNAMICS: Long - acting benzodiazepine with central nervous system
depressant, anticonvulsant, muscle relaxant, and anxiolytic effects. Like the other benzodiazepines, it has no effect on pain. Ativan has less muscle relaxant properties than diazepam, though no substantial amnestic effects as with midazolam.

INDICATIONS: (Midazolam preferred benzodiazepine due to faster onset of action)
- Medication Assisted Intubation (Post-intubation sedation - onset delay does not favor pre-intubation use)
- Seizure
- Dystonic Reactions
- Chemical Restraint
- Poisonings (Suspected stimulant toxicity = severe agitation, HTN, tachycardia, diaphoresis)
- Head/Neck/Spine Injury
- Heat Illness

CONTRAINDICATIONS:
- Intolerance/allergy
- Acute narrow - angle glaucoma
- Shock
- Coma.
- Caution with use in patients with COPD, chronic hepatic or renal failure, CHF, acute alcohol intoxication, and the elderly due to increased risk of respiratory depression.

PHARMACOKENETICS: Onset is 5-10 minutes, IVP/IOP; up to 30 minutes IM; peak effects in 2-3 hours. Duration is 3-6+ hours IVP/IOP/IM; half – life can reach 20 – 50 hours.

SIDE EFECTS: Headache, euphoria, drowsiness, excessive sedation, confusion, dizziness, blurred vision, diplopia, nystagmus, respiratory arrest, hypotension, nausea, vomiting.

DOSAGE:
ADULT:
- Medication Assisted Intubation (Post Intubation Sedation):
0.1 mg/kg to max 2 mg IVP/IOP, may repeat once if systolic BP > 100 mmHg

• Seizure & Heat Illness:
  2 mg IVP/IOP/IM for active seizure
  May repeat once in 10 minutes if still seizing.
• Dystonic Reactions:
  2 mg IVP/IM
• Chemical Restraint:
  2 mg IVP/IOP/IM ; May repeat once.
• Poisoning (Suspected Stimulant Toxic):
  1 -2 mg IVP/IM
• Head/Neck/Spine Injury:
  1 mg IVP/IM/IOP for active seizure. May repeat once in 5 minutes if still seizing

PEDIATRIC:
- Seizure & Heat Illness:
0.1 mg/kg to max 2 mg IVP/IOP/IM for active seizure ; May repeat once in 5 minutes if still seizing.

• Dystonic Reactions:
  0.1 mg/kg to max 2 mg IVP/IM
• Chemical Restraint:
  0.1 mg/kg to max 2 mg IVP/IOP/IM
• Poisoning - General Management (Suspected Stimulant Toxic):
  **OLMC Order Only
• Head/Neck/Spine Injury:
  0.1 mg/kg IVP/IM/IOP for active seizure. ; May repeat once in 5 minutes if still seizing.

HOW SUPPLIED: 2 mg/1 mL or 4 mg/1 mL in vials, ampules, or pre-filled syringes.

SPECIAL COMMENT: Lorazepam must be kept refrigerated

Question 28

Magnesium Sulfate

Answer 28

CLASS: Electrolyte

PHARMACODYNAMICS: As a bronchial smooth muscle relaxant, contributes to reduction of bronchospasm in asthma. As an antidysrhythmic, reverses low circulating magnesium levels associated with ventricular arrhythmias, particularly polymorphic ventricular tachycardia, commonly called Torsades des pointes. It is the anticonvulsant of greatest benefit for eclampsia.

INDICATIONS:
- Dyspnea - Asthma
- V-Fib/Pulseless V-Tach (Torsades)
- Tachycardia - Stable (Torsades)
- Childbirth - Complicated (Eclampsia)
- Complications of Pregnancy (Eclampsia)

CONTRAINDICATIONS:
- Hypotension
- Known Renal Failure (when treating asthma)

PHARMACOKENETICS: Onset of action typically within 1-2 minutes after IVP/IOP. Effects persist for up to 30 minutes.

SIDE EFFECTS: None expected in indicated dosing. High doses (exceeding 4-6 grams) may cause sedation, muscle weakness, depressed reflexes, hypotension, bradycardia, and respiratory depression.

DOSAGE:
ADULT:
- Dyspnea - Asthma (Severe & Refractory to Nebulization):
2 grams very slow IVP over 10 minutes

• V-Fib/Pulseless V-Tach (Torsades):
  1 gram IVP/IOP
• Tachycardia - Stable (Torsades):
  1 gram slow IVP/IOP over 1 minute. ; May repeat once.

Childbirth - Complicated (Eclampsia) &
Complications of Pregnancy (Eclampsia):
1 gram IVP/IOP. May repeat every 2-3 mins until seizure abates. Maximum cumulative dose is 4 grams.

PEDIATRIC
Tachycardia - Stable (Torsades):
Consult with OLMCP for use and dosing.

How Supplied:
- 1 gram/2 mL (500 mg/mL in 50% solution) vials
- 5 grams/10 mL (500 mg/mL in a 50% solution) vials
- 5 grams/10 mL (50% mg/mL in a 50% solution) pre-filled syringes

Question 29

Methylprednisolone

Answer 29

BRAND NAME: Solu-Medrol

CLASS: Steroid

PHARMACODYNAMICS: Methylprednisolone is an intermediate-acting synthetic adrenal corticosteroid with glucocorticoid activity. It exerts anti inflammatory effects in the setting of inflammatory-mediated illness.

INDICATIONS:
- Dyspnea - Asthma & COPD
- Acute Allergic Reactions (Bee/Wasp Stings, Anaphylaxis)

CONTRAINDICATIONS:
- Hypersensitivity/Allergy
- In the setting of anaphylaxis, the only true contraindication is prior severe allergy (anaphylaxis) caused by methylprednisolone.

PHARMACOKENETICS: Onset of action within 4 – 6 hours, may have effect in excess of 24 hours.

SIDE EFFECTS: None expected immediately. May occasionally see any of the following effects with onset of action: euphoria, insomnia, confusion, psychosis, edema, hypertension, nausea/ vomiting, hyperglycemia.

DOSAGE:
ADULT:
- All Listed Indications:
125 mg IVP. Give IM if no IV access obtainable.

PEDIATRIC:
- All Listed Indications:
2 mg/kg not to exceed 125 mg IVP. Give IM if no IV access obtainable.

HOW SUPPLIED: 125 mg Act-O-Vial™ System (Single Dose Vial)

Question 30

Midazolam

Answer 30

BRAND NAME: Versed

CLASS: Sedative; Anticonvulsant; Amnestic; Muscle Relaxant, Anxiolytic (Benzodiazepine)

PHARMACODYNAMICS: Short - acting benzodiazepine with central nervous system
depressant, anticonvulsant, anterograde amnestic, muscle relaxant, and anxiolytic effects. Like the other benzodiazepines, it has no effect on pain.

INDICATIONS:
- Medication Assisted Intubation (Pre & Post Intubation Sedation)
- Post Cardiac Arrest Treatment (Hypothermia Induced Shivering Control)
- Transcutaneous Pacing (Sedation)
- Synchronized Cardioversion (Sedation)
- Seizure
- Dystonic Reactions
- Chemical Restraint
- Poisonings - General Management
(Suspected stimulant toxicity = severe agitation, HTN, tachycardia, diaphoresis)
- Head/Neck/Spine Injury
- Heat Illness

CONTRAINDICATIONS:
- Intolerance or allergy
- Acute narrow - angle glaucoma
- Shock
- Coma.
- Caution with use in patients with COPD, chronic hepatic or renal failure, CHF, acute alcohol intoxication, and the elderly due to increased risk of respiratory depression.

PHARMACOKENETICS: Onset is 3-5 minutes, IVP/IOP; 6-14 minutes IN; up to 15 minutes IM (though clinically evident much faster); peak effects in 20-60 minutes. Duration is 2 hours IVP/IOP/IN; 1-6 hours IM; half – life is 1-4 hours.

SIDE EFFECTS: Retrograde amnesia, headache, euphoria, drowsiness, weakness, excessive sedation, confusion, dizziness, blurred vision, diplopia, nystagmus, respiratory arrest, tachypnea, hypotension, nausea, vomiting.

DOSAGE:
ADULT:
- Medication Assisted Intubation (Pre & Post Intubation Sedation):
0.1 mg/kg to max 5 mg IVP/IOP, may repeat
once if systolic BP > 100 mmHg

• Transcutaneous Pacing (Sedation):
  2 - 5 mg IVP based upon weight and hemodynamics (0.1 mg/kg to max 5 mg)
• Synchronized Cardioversion (Sedation) -
  0.1 mg/kg to max 5 mg IVP/IOP/INP
• Seizure & Heat Illness:
  0.1 mg/kg to max 5 mg IM/IVP/IN/IOP for active seizure ; May repeat once in 5 minutes if still seizing.
• Dystonic Reactions:
  2.5 mg IVP/IM/IN
• Chemical Restraint:
  0.1 mg/kg to max 5 mg IM/IVP/IN/IOP ; May repeat once.
• Poisoning (Suspected Stimulant Toxic):
  0.1 mg/kg to max 5 mg IVP/IN/IM
• Head/Neck/Spine Injury:
  5 mg IM/IVP/IN/IOP for active seizure.
  May repeat once in 5 minutes if still seizing.

PEDIATRIC:
- Seizure, Head/Neck/Spine Injury, & Heat Illness:
0.1 mg/kg to max 5 mg IM/IVP/IN/IOP for active seizure ; May repeat once in 5 minutes if still seizing.

• Dystonic Reactions:
  0.1 mg/kg to max 2.5 mg IM/IVP/IN
• Chemical Restraint:
  0.1 mg/kg to max 5 mg IM/IVP/IN/IOP
• Poisoning (Suspected Stimulant Toxic):
  **OLMC Order Only

ADULT & PEDIATRIC:
- Post Cardiac Arrest Treatment (Hypothermia Induced Shivering Control):
0.1 mg/kg to max 5 mg IVP/IOP

HOW SUPPLIED: 5 mg/1 mL in vials, ampules, or pre-filled syringes.

Question 31

Morphine Sulfate

Answer 31

CLASS: Narcotic analgesic

PHARMACODYNAMICS: Stimulates central nervous system opiate receptors, producing
systemic analgesia. Modest vasodilation effects increase peripheral venous capacitance, and reduce venous return, myocardial workload, and myocardial oxygen demand.

INDICATIONS:
- Chest Pain – Uncertain Etiology
- Acute Coronary Syndrome
- Acute Pain Control (in alert, hemodynamically stable patient)

CONTRAINDICATIONS:
- Hypotension
- Respiratory Depression
- Minor Degrees of Pain
- Pain Assessed as Factitious

SIDE EFFECTS: Hypotension, respiratory depression, euphoria, dizziness. Nausea and/or vomiting are rarely seen if administration is slow IVP. Rapid IVP will lead to an accompanying histamine release, producing the nausea and/or vomiting often erroneously attributed to morphine itself.

PHARMACOKENETICS: Onset of action within 3-5 minutes after IV administration. Duration of effect can reach 4 hours depending upon end-organ function.

DOSAGE:
ADULT:
- Chest Pain (Uncertain Etiology) & Acute Coronary Syndrome:
2 mg slow IVP ; May repeat every 5 minutes to a maximum cumulative dose of 10 mg

• Acute Pain Control (in alert,
  hemodynamically stable patient):
  2 – 4 mg slow IVP ; May repeat every 5 minutes to a maximum cumulative dose of 10 mg

PEDIATRICS:
- Acute Pain Control (in alert,
hemodynamically stable patient):
**OLMC Order Only – Typical dose is 0.1 mg/kg up to 2 mg per dose.

HOW SUPPLIED:
- 2 mg/1 mL pre-filled syringe
- 4 mg/1 mL vial, ampule, or pre-filled syringe
- 8 mg/1 mL pre-filled syringe
- 10 mg/1 mL vial
- 10 mg/10 mL vial

Question 32

Naloxone

Answer 32

BRAND NAME: Narcan

CLASS: Narcotic antagonist

PHARMACODYNAMICS: The primary action of interest is reversal of respiratory depression associated with narcotic agents. Naloxone competes with and displaces narcotic substances from opiate receptors.

INDICATIONS:
- Respiratory Arrest
- Specific Causes of Cardiac Arrest
- Altered Mental Status
- Syncope
- Poisonings – General Management

CONTRAINDICATIONS:
- Known or suspected narcotic substance use or abuse without cardiopulmonary compromise. Post-intubation in known or suspected narcotic substance use or
abuse situations. Avoid whenever possible in known or suspected narcotic addicts. In these patients, use the smallest clinically effective dose possible (titrating administration slowly) to avoid acute narcotic withdrawal.

PHARMACOKENETICS: Onset of action within 2 minutes after IVP/IOP/IN administration with duration of effect up to 2 hours.

SIDE EFFECTS: Agitation, anxiety, diaphoresis, tachycardia, nausea, vomiting, headache, hypertension, hypotension, seizures.

DOSAGE:
ADULT:
- In Apnea/Agonal Breathing:
2 mg IVP/IOP/IN ; May repeat once to maximum cumulative dose of 4 mg.

• In Ineffective Breathing Activity:
  0.5 mg IVP/IOP/IN ; May repeat to a maximum cumulative dose of 4 mg

PEDIATRIC:
- In Apnea/Agonal Breathing:
0.5 mg IVP/IOP/IN ; May repeat to a maximum cumulative dose of 2 mg.

• In Ineffective Breathing Activity:
  0.5 mg IVP/IOP/IN ; May repeat to a maximum cumulative dose of 2 mg.

HOW SUPPLIED:
- 0.4 mg/1 mL vial
- 0.4 mg/1 mL prefilled syringe
- 2 mg/2 mL prefilled syringe
- 4 mg/10 mL vial

SPECIAL COMMENT: In non-respiratory arrest or non-cardiac arrest situations, always titrate administration slowly, using the lowest clinically effective amount of naloxone possible to avoid inadvertent acute narcotic withdrawal and/or other side effects.

Question 33

Nitroglycerin

Answer 33

BRAND NAME: Nitrolingual, Nitromist, Nitrostat, Nitroquick, Tridil (IV Infusion), Nitro-bid (Dermal)

CLASS: Anti-Anginal, Vasodilator, Anti-Hypertensive (Nitrate)

PHARMACODYNAMICS: Arterial and venous vasodilator through relaxing vascular
smooth muscle. Reduces cardiac afterload resistance and cardiac preload volume respectively. Myocardial oxygen consumption/demand is decreased. Systemic blood pressure is decreased.

INDICATIONS:
- Dyspnea - Congestive Heart Failure
- Chest Pain - Uncertain Etiology
- Acute Coronary Syndrome
- Hypertensive Emergency
- Complications of Pregnancy (Hypertensive Emergency)

CONTRAINDICATIONS:
- Hypotension
- Asymptomatic Hypertension
- Erectile Dysfunction Medications (**Requires OLMC Order Only)
(Sildenafil (Viagra®) or Vardenafil (Levitra®) use within 24 hours Tadafil (Cialis®) use within 48 hours)

PHARMACOKENETICS: Rapid vascular uptake within 3 minutes of sublingual dosing, with duration of effect up to 30 minutes. Rapid vascular effect within 1-3 minutes of intravenous dosing, with ongoing effect while continuous infusion. Vascular effect within 15-30 minutes of transdermal dosing, with ongoing effect while continued transdermal absorption.

SIDE EFFECTS: The most serious side effect is hypotension, usually transient and responsive to supine positioning and intravenous fluid bolusing. Common, though non-serious, symptoms include: headache due to vasodilation, blurred vision, and dizziness.
- Paramedics should exercise caution when applying transdermal nitroglycerin ointment, avoiding contact with bare hands to avoid experiencing personal side effects, typically headache and dizziness.

DOSAGE:
ADULT:
- Dyspnea (due to Congestive Heart Failure) & Acute Coronary Syndrome:
(A) 0.4 mg sublingual spray or tablet if systolic BP > 100 mmHg. Single dose unless by Paramedic. May repeat 0.4 mg sublingual spray or tablet every 5 minutes if systolic
BP >100 mmHg until chest pain and/or respiratory distress resolves.

(B) Following initial sublingual use, may utilize intravenous infusion start at 10 mcg/min, titrate slowly to effect. Maximum infusion rate without OLMC consult is 50 mcg/min.

(C) Following initial sublingual use, may utilize transdermal application of 1½ inches ointment to chest wall.

• Chest Pain - Uncertain Etiology:
  (A)0.4 mg sublingual spray or tablet if systolic BP >100 mmHg. Single dose unless by Paramedic. If chest pain improved with initial dose, 0.4 mg sublingual spray or tablet
  every 5 minutes until chest pain and/or respiratory distress resolves.

(B) Following initial sublingual use, may utilize intravenous infusion start at 10 mcg/min, titrate slowly to effect. Maximum infusion rate without OLMC consult is 50 mcg/min.

(C) Following initial sublingual use, may utilize transdermal application of 1½ inches
ointment to chest wall.

• Hypertensive Emergency & Complications of Pregnancy (Hypertensive Emergency):
  (A) 0.4mg sublingual spray or tablet every 5 minutes until BP symptoms resolve or BP is
  reduced by 10%.

(B) In place of or following initial sublingual use, may utilize intravenous infusion start at 10 mcg/min, titrate slowly to effect. Maximum infusion rate without OLMC consult is 50 mcg/min.

(C) In place of or following initial sublingual use, may utilize transdermal application of 1½ inches ointment to chest wall.

HOW SUPPLIED:
- Metered dose spray 0.4 mg/spray.
- Tablets for sublingual absorption 0.4 mg.
- Intravenous infusion - Mix 50 mg into 250 mL D5W (200 mcg/mL)
(A) 10 mcg/min using microdrip infusion set is 3 mL/hour rate
(B) 20 mcg/min using microdrip infusion set is 6 mL/hour rate
- Transdermal ointment in 2% nitroglycerin concentration 1½ inches = 22.5 mg of nitroglycerin

Question 34

Norepinephrine

Answer 34

BRAND NAME: Levophed

CLASS: Vasoconstrictor

PHARMACODYNAMICS: Stimulates alpha receptors in the peripheral vasculature, producing vasoconstriction-related increase in systemic blood pressure. Concurrent beta receptor stimulation may produce increases in heart rate and mild bronchodilation, though norepinephrine is a weaker beta stimulator than dopamine.

INDICATIONS:
- Dyspnea – Congestive Heart Failure (Cardiogenic Shock)
- Post Cardiac Arrest Treatment (Cardiogenic Shock)
- Acute Coronary Syndrome (Cardiogenic Shock)
- Fever (Septic Shock)
- Dialysis-Related Issues
- For all listed situations, indication is hypotension (adult = systolic < 100 mmHg) due to cardiogenic, septic, or neurogenic shock either refractory to intravascular fluid boluses or in which intravascular fluid bolusing is contraindicated (eg. pulmonary edema).

CONTRAINDICATIONS: Hypertension

PHARMACOKENETICS: Onset of action within 5 minutes after IV/IO infusion initiated. Rapid metabolism, requiring ongoing IV/IO infusion to maintain clinical effects.

SIDE EFFECTS: Few, though at higher doses, symptoms may include headache, palpitations, tachycardia, chest pain, and
eventual hypertension. Bradycardia can result reflexively from an increase in blood pressure.

DOSAGE:
ADULT:
- For hypotension (shock) refractory to fluids or fluids contraindicated:
Start at 2-4 mcg/minute - see dosage chart - titrated to a systolic B/P ≥ 100 mmHg. Maximum infusion rate is 12 mcg/minute.

PEDIATRIC:
For hypotension (shock) refractory to fluids or fluids contraindicated
**OLMC Order Only

HOW SUPPLIED:
- 4 mg/4 mL ampule or vial.
Use only 2 mL in a 250 mL bag of D5W. (8 mcg/mL concentration)

SPECIAL COMMENTS: In the setting of tachydysrhythmia-induced cardiogenic shock, treat per Protocol 5G – Tachycardia - Unstable. Ensure aggressive fluid resuscitation is accomplished (unless contraindicated) prior to norepinephrine use. Norepinephrine should be given into a large, patent vein. The vein of choice for EMS use is the antecubital vein, as this will decrease the risk of overlying skin necrosis. Do not administer norepinephrine through an IV in the hand or leg. These veins are more likely to be affected by vasoocclusive diseases and more prone to ischemic complications. Administration through IO in the proximal tibia or humeral head is permitted. If local extravasation occurs, notify the receiving physician of the following FDA advisement of antidote to extravasation ischemia: “To prevent sloughing/necrosis in peripheral ischemic areas promptly use syringe w/ fine hypodermic needle to liberally infiltrate area w/ 10-15 mL saline solution containing 5-10 mg phentolamine; sympathetic blockade causes immediate conspicuous local hyperemic changes if area infiltrated within 12 hours.” Safety in pregnancy not firmly established, though when clinically indicated the benefits outweigh risks. Safety in pediatrics not firmly established and OLMC is to be consulted prior to pediatric usage. Avoid mixing in normal saline, as NS promotes loss of potency through oxidation of norepinephrine.

***REMEMBER LEVOPHED IS DESIRED FOR PTS WHO ONLY NEED INCREASED BP AND NOT INCREASED BP AND HR. FOR INCREASED BP AND HR USE DOPAMINE!!!

Question 35

Ondansetron

Answer 35

BRAND NAME: Zofran

CLASS: Antiemetic

PHARMACODYNAMICS: Ondansetron reduces the activity of the vagus nerve, which activates the vomiting center in the medulla oblongata, and also blocks serotonin receptors in the chemoreceptor trigger zone. It has little effect on vomiting caused by motion sickness.

INDICATIONS:
- Snakebites
- Abdominal Pain/Nausea/Vomiting/Diarrhea
- Fever
- Pelvic Pain
- For all listed situations, indication is for impending/active vomiting.

CONTRAINDICATIONS:
- Hypersensitivity or Allergy
- Current use of Apomorphine (Apokyn®), an anti – parkinsonian drug
- Use with caution with patients currently using medications which effect QT interval (eg. procainamide, amiodarone, tricyclic antidepressants, haloperidol)

SIDE EFFECTS: Sedation, dystonic reactions (rare), hypotension, tachycardia, angina, Torsades rare).

DOSAGE:
ADULT:
- For all listed situations, indication is for impending/active vomiting:
(A) 4 mg oral dissolving tablet on tongue, may repeat once in 10 minutes
(B)4 mg slow IVP over 60 seconds, may repeat once in 10 minutes

PEDIATRIC:
- For all listed situations, indication is for impending/active vomiting.
(A) If age > 2 years, 4 mg oral dissolving tablet on tongue
(B) 0.1 mg/kg to max of 4 mg slow IVP over 60 seconds

HOW SUPPLIED:
- 4 mg/2 mL (2 mg/mL) vial.
- 4 mg rapid oral dissolving tablet (ODT)

Question 36

Phenylephrine 2%

Answer 36

BRAND NAME: Neosynephrine

CLASS: Topical Nasal Vasoconstrictor

PHARMACODYNAMICS: Phenylephrine is a direct-acting sympathomimetic amine. It stimulates alpha receptors in the blood vessels of the nasal mucosa which causes their constriction, thereby decreasing the risk of subsequent nasal bleeding.

INDICATIONS:
- Nasal Intubation
- Epistaxis

CONTRAINDICATIONS:
- None in the indicated settings.

PHARMACOKENETICS: Onset of action is within seconds.

SIDE EFFECTS: Rare with single dose. It is rarely absorbed systemically from nasal instillation.

DOSAGE:
ADULT:
- Nasal Intubation:
2 sprays in each nostril

ADULT & PEDIATRIC
- Epistaxis:
2 - 4 sprays in affected nostril(s) for control of epistaxis (with compression of nose immediately after administration)

HOW SUPPLIED: Phenylephrine Nasal Spray 1% solution, 15 mL squeeze bottle for single
patient use only.

Question 37

Sodium Bicarbonate

Answer 37

CLASS: Alkalinizing agent

PHARMACODYNAMICS: Raises the pH of blood by buffering excess hydrogen ions that are present in acidotic states. The role of sodium bicarbonate is limited in cardiac arrest. Because ventilation is an effective tool in managing respiratory acidosis, sodium bicarbonate should rarely be administered for cardiac arrest, unless the arrest is suspected to be secondary to hyperkalemia, a preexisting metabolic acidosis, or a tricyclic antidepressant over ingestion.

INDICATIONS:
- Specific Causes of Cardiac Arrest (Hyperkalemia)
- Poisonings (Tricyclic Antidepressant)
- Dialysis-Related Issues (Hyperkalemia)
- Crush Injury Syndrome (Hyperkalemia Prophylaxis)

CONTRAINDICATIONS:
- Known metabolic alkalosis.

PHARMACOKENETICS: Onset of effect is observed within 3-5 minutes after IVP/IOP administration.

SIDE EFFECTS: Sodium bicarbonate may inhibit oxygen release secondary to a shift in oxyhemoglobin saturation. It also may produce a paradoxical acidosis that can depress cerebral and cardiac function. Severe soft tissue damage can occur in extravasated administrations.

DOSAGE:
ADULT & PEDIATRIC:
- For all listed indications
1 mEq/kg IVP/IOP with maximum dose of 50mEq

HOW SUPPLIED:
- 50 mEq/50 mL (1 mEq/mL) prefilled syringe.

SPECIAL COMMENT: Do not administer with calcium chloride. A precipitate will form and obstruct the vascular access being utilized.