adult ii 2015 emergency medications. national ems education standard competencies emergency...

Adult II 2015Adult II 2015

Emergency Medications

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Emergency Medications

• Names

• Effects

• Indications

• Routes of administration

• Dosages for the medications administered

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Emergency Medications (cont’d)

• Actions

• Contraindications

• Complications

• Side Effects

• Interactions

AHA Classification of Recommendations and Level

of Evidence


of Evidence

• Class I− A treatment should be administered.

• Class IIa− It is reasonable to administer treatment.

• Class IIb− Treatment may be considered.


of Evidence


of Evidence

• Class III− Treatment should NOT be administered.

− It is harmful, not helpful.

• Class Indeterminate− Research is either beginning or continuing on

this treatment.

− Cannot be recommended for or against

Medication ListingsMedication Listings

• Name of medication− And other common names

• Class− How the medication is classified compared to

other medications


• Mechanism of action− The way a medication produces the intended

response

• Indications− Circumstance that shows cause or warning of

disease

• Contraindications− Any condition that renders some particular line

of treatment improper or undesirable


• Adverse reaction/side effects− An abnormal or harmful effect to an organism

caused by exposure to a chemical

• Drug interactions− Any potential effects a medication may have

when administered with or in the presence of something else in the patient’s system

Adenosine (Adenocard)Adenosine (Adenocard)

• Classification:

• anti arrhythmatic, diagnostic

agent

• Mechanism of action− Slows conduction through

the AV node

− Can interrupt reentrant pathways

− The drug of choice for reentry SVT

• Indications− Most forms of stable

narrow-complex SVT

• Contraindications− Bronchoconstrictive or

bronchospastic lung disease

• Adverse reactions− Generally short duration and

mild

• Considerations− Evaluate elderly for signs of

dehydration

− Dose:by rapid IV bolus only given over 1_2 seconds administered directly into a vein or as proximal as possible ; follow with a rapid saline flush .

Albuterol (Proventil, Ventolin)

Albuterol (Proventil, Ventolin)

• Mechanism of action− Results in smooth-

muscle relaxation in the bronchial tree

• Indications− Treatment of

bronchospasm in patients with COPD/asthma)

• Contraindications− Hypersensitivity

reactions to albuterol

• Adverse reactions− Often dose-related

and include headache, fatigue, lightheadedness, irritability, restlessness

• Considerations− Pregnancy safety:

Category C

− May precipitate angina pectoris and dysrhythmias

Alteplase, Recombinant (Tissue Plasminogen Activator

or rTPA, Activase)

Alteplase, Recombinant (Tissue Plasminogen Activator

or rTPA, Activase)

• Classification: Thrombolytic agent

• Mechanism of action− Restores perfusion

• Indications− Acute myocardial infarction,

STEMI, massive pulmonary emboli, acute ischemic cerebrovascular accident

• Contraindications− Active internal bleeding− Recent surgeryDose: 100mg IV over 2 hr,

followed immediately by heparin therapy .

• Adverse reactions− Intracranial bleeding,

reperfusion dysrhythmias, chest pain, hypotension, GI bleeding, nausea, abdominal pain

• Considerations− Monitor vital signs

closely.

− Observe for bleeding.

Amiodarone (Cordarone, Pacerone)

Amiodarone (Cordarone, Pacerone)

• Classification antiarrhythmatic

• Mechanism of action− Delays repolarization and

increases the duration of action potential

• Indications− Ventricular fibrillation

• Contraindications− Known hypersensitivity to

amiodarone or iodine− Cardiogenic shockDose:1000mg IV over 24hours,150

mg loading dose over 10min,followed

− Over 6 hr at rate 1mg/min− For maintenance infusion

540mg at 0.5 mg / min over 18 hr .

• Adverse reactions− Dizziness, fatigue,

malaise

− Congestive heart failure


Category D

− Monitor patient for hypotension.

Aspirin (ASA)Aspirin (ASA)

• Classification:

antiplatelet

• Mechanism of action− Prevents platelets from

clumping together and forming emboli

• Indications− New onset chest pain

suggestive of acute myocardial infarction

• Contraindications− Relatively contraindicated in

patients with active ulcer disease or asthma

• Adverse reactions− Bronchospasm,

anaphylaxis, wheezing in allergic patients, prolonged bleeding


Category D

− Use cautiously with impaired renal function .

Atropine SulfateAtropine Sulfate

• Classification:

• Parasympathetic,Anticholinergic

• Mechanism of action− Increases heart rate in life-

threatening bradydysrhythmias

• Indications− Hemodynamically unstable

bradycardia

• Contraindications− Tachycardia, hypersensitivity

Dose:

for bradycardia 0.4mg to1mg (up to 2 mg )IV every 1-2 hr as needed .

• Adverse reactions− Drowsiness, confusion,

headache, tachycardia, palpitations

• Considerations− Pregnancy safety: Category

C

− Moderate doses may cause pupillary dilation.

Calcium GluconateCalcium Gluconate

• Classification:

• Electrolytes

• Mechanism of action

− Helps maintain cardiac function

• Indications

− Hyperkalemia, hypocalcemia


− Ventricular fibrillation, digitalis toxicity, hypercalcemia

− Dose :infusion slowly ,0.5ml-2ml/min, (500mg /kg/day IV given in divided

Doses.

• Adverse reactions− Syncope, cardiac

arrest, dysrhythmia, bradycardia


Category C

− Do not administer by IM or SQ,stop infusion if patient complains of discomfort; resume when symptoms disappear .

Clopidogrel (Plavix)

Clopidogrel (Plavix)

• Classification:Antiplatelet

• Mechanism of action− Inhibits platelet aggregation

by blocking Adenosine diphosphate receptors on platelets(ADP), preventing clumping of platelets.

• Indications

− Acute coronary syndrome

− Substitute for aspirin in patients unable to take aspirin

Dose: recent MI,stroke 75mg daily

ACS (Acute Coronary Syndrome )300mg PO loading dose , then 75mg/day with aspirin .

• Contraindications− Active GI bleeding,

intracranial hemorrhage

• Adverse reactions− Severe neutropenia

− Hemorrhaging


B

− Often given with other anticoagulants

Dexamethasone Sodium Phosphate (Decadron)

Dexamethasone Sodium Phosphate (Decadron)

• Classification: corticosteroid ,Hormone

• Mechanism of action− Suppresses acute and

chronic inflammation

• Indications− Anaphylaxis, asthma, spinal

cord injury,cerebral edema associated with brain tumor ,craniotomy, or head injury .

• Contraindications− Hypersensitivity, use

caution in suspected systemic sepsis

• Adverse reactions− Headache,

restlessness, euphoria, psychoses


Category C

− Protect medication from heat. Toxicity and side effects occur with long-term use.

Diazepam (Valium and Others)

Diazepam (Valium and Others)

• Classification :• Benzodiazepine, Anxiolytic,

Antiepileptic, Skeletal muscle relaxant (centrally acting ).

• Mechanism of action− Raises the seizure

threshold; induces amnesia and sedation

• Indications− Acute anxiety states and

agitation, acute alcohol withdrawal

• Dose :Status epilepticus5-10mg by slow IV. May repeat q 5-10 min to total dose 30mg .

• Contraindications− Hypersensitivity, narrow-

angle glaucoma

− Adverse reactions− Dizziness, drowsiness,

confusion, headache


D

− Short duration for anticonvulsant effect

− Reduce dose by 50%

in elderly patients.

Digoxin (Lanoxin)Digoxin (Lanoxin)

• Classification :

Cardiac glycoside ,Cardiotonic

• Mechanism of action− Increases force of

myocardial contraction

• Indications− Congestive heart failure,

reentry SVTs, ventricular rate control in atrial flutter and atrial fibrillation

• Dose:evaluate patient carefully to determine the appropriate dose

loading dose 0.125-0.25mg IV, maintenance dose0.125-0.25mg /day PO .

• Adverse reactions

− Fatigue, headache, blurred yellow or green vision, seizures

• Considerations

− Pregnancy safety: Category C

− Patient receiving IV digoxin must be on a monitor

− Assessment for renal function , serum K+, Mg++ level.


− Ventricular fibrillation, ventricular tachycardia, digitalis toxicity

Diltiazem (Cardizem)Diltiazem (Cardizem)


• Calcium channel blocker, antianginal ,antihypertensive .

• Mechanism of action− Reduces myocardial oxygen

demand

• Indications− Controls rapid ventricular

rates(Paroxysmal supra ventriculartachycardia , atrial fibrillation , atrial flutter.

Dose :direct IV bolus :0.25mg/Kg (20mg for the average patient ) second bolus of 0.35mg /kg .

Continuous IV infusion 5-10 mg /hr

• Adverse reactions− Dizziness, weakness,

headache, dyspnea


C

− Use with caution in patients with renal or hepatic dysfunction.

• Contraindications− Hypotension

− Sick sinus syndrome

Dobutamine Hydrochloride (Dobutrex)

Dobutamine Hydrochloride (Dobutrex)

• Classification: Sympathomimetic ,Beta1 selective

adrenergic agonist.

• Mechanism of action− Increased myocardial

contractility, stroke volume, and increased cardiac output

• Indications− Cardiogenic shock, CHF

• Dose :Administer only by IV infusion using an infusion pump

• 2.5mg -10mg /kg/min IV is ususl rate to increase cardiac output .


− Headache, dyspnea, tachycardia, hypertension, chest pain

• Considerations

− Pregnancy safety: Category B

− Monitor blood pressure

closely.

• Contraindications− Tachydysrhythmias, severe

hypotension

Dopamine Hydrochloride (Intropin)

Dopamine Hydrochloride (Intropin)

• Classification:

• Sympathomimetic

Alpha –adrenergic agonist , Beta1-selective adrenergic agonist, Dopaminergic drug .

• Mechanism of action− Increases myocardial

contractility and stroke volume

• Indications− Cardiogenic and septic

shock, hypotension with low cardiac output states

− Dose :Administer only by IV infusion using an infusion pump

− Initially 2-5mcg/kg/min IV patients who more seriously ill,5mcg/kg/min up to a rate of 20-50mcg/kg/min.

• Adverse reactions− Headache, anxiety,

dyspnea, dysrhythmias


C− Effects are dose-dependent

− Contraindications− Hypovolemic shock,

pheochromocytoma, tachydysrhythmias

Epinephrine (Adrenalin)

Epinephrine (Adrenalin)

• Classification: Sympathomimetic ,Alpha-adrenergic agonist,Beta1-and beta2- adrenegic agonist ,cardiac stimulant .

• Mechanism of action− Blocks histamine

receptors

• Indications− Cardiac arrest,

symptomatic bradycardia

• Dode:cardiac arrest ;0.5IV during resuscitation q 5 min.

• Adverse reactions− Nervousness, restlessness,

headache, tremor


C

− May cause syncope in asthmatic children

• Contraindications− Hypertension, hypothermia,

pulmonary edema

Furosemide (Lasix)

Furosemide (Lasix)

• Classification : loop diuretic

• Mechanism of action− Causes increased

urine output

• Indications− CHF, pulmonary edema,

hypertensive crisisDose: in pulmonary edema 40

mg IV over 1-2 min.may be increased to 80mg IV given over 1-2 min if response unsatisfactory after 1 hour .

in hypertension 40mg bid. if needed additional anti hypertensive may be needed .

• Adverse reactions− Dizziness, headache, ECG

changes, weakness


C

− Ototoxicity, deafness, and projectile vomiting can occur with rapid

administration.

• Contraindications− Hypovolemia, anuria,

hypotension

Haloperidol Lactate (Haldol)

Haloperidol Lactate (Haldol)


• Dopaminergic –blocking drug Antipsychotic.


− Inhibits central nervous system catecholamine receptors

• Indications

− Acute psychotic episodes

Dose:IV unlabeled use for acute situations2-25mg IV q hr at arate of 5mg /min.


− Seizures, sedation, confusion, restlessness

• Considerations


− Treat hypotension secondary to haloperidol with fluids and norepinephrine, not epinephrine


− Parkinson's disease,

depressed mental status

Heparin SodiumHeparin Sodium

• Classification :Anticogulant

• Mechanism of action− Inhibiting thrombus and clot

formation by blocking the conversion of prothrombin to thrombin and fibronogen to fibrin plasmin; does not lyses existing clots

• Indications− Acute myocardial infarction,

prophylaxis and treatment of thromboembolic disorders

− Dose:Adjust dose according To cogulation tests. Dosage is

adequate when PTT=1.5-3 times control value .

• Adverse reactions− Pain, anaphylaxis, shock,

hematuria


C

− Heparin does not lyse

existing clots.

• Contraindications− Hypersensitivity, active

bleeding

Hydrocortisone Sodium Succinate (Solu-Cortef)Hydrocortisone Sodium Succinate (Solu-Cortef)

• Classification :• corticosteroid short

acting ,glucocorticoid ,Adrenal cortical steroid, hormone.

• Mechanism of action− Anti-inflammatory;

immunosuppressive with salt-retaining actions

• Indications− Shock due to acute

adrenocortical insufficiency, anaphylaxis, asthma, and COPD.

− Dose: 100mg- 500mg initially and q 2-10h based on condition and response .

• Adverse reactions− Headache, vertigo,

pulmonary tuberculosis


C

− May be used in status asthmaticus as a second-line drug

• Contraindications− Systemic fungal infections,

premature infants

Lidocaine Hydrochloride (Xylocaine)

Lidocaine Hydrochloride (Xylocaine)

• Classification: Antiarrhythmatic ,local anesthetic .

• Mechanism of action− Decreases automaticity of

ventricular cells , increase ventricular fibrillation threshold .

• Indications− Alternative to amiodarone in

cardiac arrest from ventricular tachycardia

− Dose :Arrhythmias, monitor ECG constantly ,give 50-100mg at rate of 25-50mg /min, 1/3 to 1/2the initial dose may be given after 5min if needed .do not exceed 200-300mgin 1 hr .


− Anxiety, drowsiness, confusion, seizures

• Considerations

− Apnea induced with succinylcholine may be prolonged with high doses of lidocaine.

− Exceedingly high doses can result in coma or death.


− Hypersensitivity, second- or third-degree AV block in the absence of an artificial pacemaker

Magnesium SulfateMagnesium Sulfate

• Classification:• Electrolyte Antiepileptic .

• Mechanism of action− Reduces striated muscle

contractions

• Indications− Seizures of eclampsia,

torsades de pointes, hypomagnesemia

• Dose:

• 1-4 gm of a 10%-20%solution .Do not exceed 1.5 ml/min of a10% solution. or 4-5 gm in 250ml of 5%dextrose. Do not exceed 3ml / min .


− Drowsiness, CNS depression, respiratory depression

• Considerations

− Pregnancy safety: Category A

− Recommended that the drug not be administered in the 2 hours before delivery, if possible


− Heart block, myocardial damage

Mannitol (Osmitrol)Mannitol (Osmitrol)


• osmotic diuretic, diagnostic agent,

• Mechanism of action− Decreases cerebral edema

and intracranial pressure

• Indications− Cerebral edema

• Dose:• In reduction of intracranial

pressure and cerebral edema:1.5-2 gm/kg as a 15%-25% solution over 30- 60min.Evidence of reduced pressure should be seen in 15 min.

• Adverse reactions− Headache, confusion,

seizures, pulmonary edema


Category C − May crystallize at low

temperatures; store at room temperature

− Have ventilatory support available.

• Contraindications− Hypotension,

pulmonary edema, severe dehydration, intracranial bleeding, CHF

Methylprednisolone Sodium Succinate (Solu-Medrol)

Methylprednisolone Sodium Succinate (Solu-Medrol)

• Classification:• corticosteroid,glucocorticoid ,

hormone.

• Mechanism of action− Suppresses acute and chronic

inflammation

• Indications− Acute spinal cord trauma,

anaphylaxis, bronchodilator for unresponsive asthma

• Dose:10-40mg IV administered over 1 min to several minutes .give subsequent dosesIVor IM.

• Warning :Rapid IV administration of large doses (more than0.5mg-1gm in less than 10-20min)has caused serious cardiac complications.

• Adverse reactions− Depression, euphoria,

headache, restlessness, seizure


Category C

− Not effective if time of spinal cord injury greater than 8 hours

• Contraindications− Premature infants, systemic

fungal infections

Midazolam Hydrochloride (Versed)

Midazolam Hydrochloride (Versed)

• Classification:• Benzodiazepine (short acting )

• CNS depressant

• Mechanism of action− Causes sedative, anxiolytic,

amnesic, and hypnotic effects

• Indications− Sedation for medical

procedures.− Continuous sedation of

intubated and mechanically ventilated patients during treatment in critical care setting .

• Adverse reactions− Headache, somnolence,

respiratory depression


D

− Administer immediately prior to intubation procedure.

• Contraindications− Acute narrow-angle

glaucoma, shock, coma, alcohol intoxication

Morphine Sulfate (Roxanol, MS Contin)

Morphine Sulfate (Roxanol, MS Contin)

• Classification: Opoid agonist analgesic .


− Alleviates pain through CNS action

• Indications

− Severe CHF, acute cardiogenic pulmonary edema

Dose :2.5mg -15mg /70kg of body weight in 4-5ml water for injection administered over 4-5 min. Continuous IV infusion 0.1-1 mg /ml in 5% dextrose in water by controlled infusion device .


− Confusion, sedation, headache, CNS depression

• Considerations


− Morphine rapidly crosses the placenta.


− Head injury, exacerbated COPD, depressed respiratory drive

Naloxone Hydrochloride (Narcan)

Naloxone Hydrochloride (Narcan)


• Opoid antagonist , Diagnostic agent .

• Mechanism of action− Reverses respiratory

depression secondary to opiate drugs

• Indications

− Opiate overdose, complete or partial reversal of central nervous system and respiratory depression induced by opioids

• Dose: • Opoid overdose initial dose of

0.4 - 2 mg IV additional doses may be repeated at 2-3 min intervals. If no response after 10mg question the diagnosis .

• Contraindications− Use with caution in narcotic-

dependent patients

• Adverse reactions− Restlessness, seizures,

dyspnea, pulmonary


C

Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)

Nitroglycerin (Nitrostat, Nitro-Bid, Tridil)

• Classification:

• Antianginal

• Mechanism of action− Smooth muscle relaxant

acting on vasculature, with a resultant decrease in venous return and decrease in arterial BP ,which reduces myocardial oxygen cosumption .

• Indications− Acute angina pectoris,

ischemic chest pain• Dose: Initial dose , 5mcg/min

delivered through an infusion pump .inceased by 5mcg/min .if no response

• 20mcg/min.Once BP response is obtained reduce dose and llengthen dosage intervals. continually monitor response and titrate carefully .

• Adverse reactions− Headache, dizziness,

weakness, reflex tachycardia


Category C − Hypotension more common

in the elderly

• Contraindications− Hypotension, hypovolemia,

intracranial bleeding or head injury

Norepinephrine Bitartrate (Levophed)

Norepinephrine Bitartrate (Levophed)

• Classification:• Sympathomimetic

• Alpha-adrenergic agonist ,Beta1adrenergic agonist , cardiac stimulant ,vasopresser.

• Mechanism of action− Potent alpha-agonist resulting

in intense peripheral vasoconstriction

• Indications− Cardiogenic shock,

unresponsive to fluid resuscitation

Dose :Add 4ml of the solution (1mg/ml)to 1000ml of 5% dextrose solution for a concentration of 4mcg base /ml

Initially give 8-12 mcg /min adjust dose gradually to maintain desired Bp .

• Adverse reactions− Headache, anxiety,

dizziness


C. − May cause fetal anoxia

when used in pregnancy

• Contraindications− Hypotensive patients with

hypovolemia

Ondansetron Hydrochloride (Zofran)

Ondansetron Hydrochloride (Zofran)

• Classification: Antiemetic

• Mechanism of action− Blocks action of serotonin

• Indications− Prevention and control of

nausea or vomiting

• Dose:• Prevention of chemotherapy -

induced nausea and vomiting three 0.15mg /kg doses IV first dose is given over 15 min, before 30min of starting the chemotherapy .


− Headache, malaise, wheezing

• Considerations


• Contraindications− Known allergy to

ondansetron

OxygenOxygen

• Mechanism of action− Reverses hypoxemia

• Indications− Confirmed or

expected hypoxemia, ischemic chest pain

• Contraindications− Certain patients with

COPD will not tolerate oxygen concentrations over 35%.

• Adverse reactions− Decreased level of

consciousness (COPD patients), decreased respiratory drive in COPD patients

• Considerations− Be familiar with liter

flow and each type of delivery device used.

Phenytoin (Dilantin)

Phenytoin (Dilantin)

• Classification: • Antiepileptic , antiarrhythmic

group Ib.

• Mechanism of action− Promotes sodium

efflux from neurons− Effective in treating cardiac

arrhythmias, especially those induced by digitalis.

• Indications− Prophylaxis and treatment

of major motor seizures

Dose:status epilepticus 10-15 mg /kg

by slow IV .for maintenance 100mg 6-8 hr .

• Adverse reactions− Ataxia, agitation, dizziness,

headache, drowsiness


D

− Carefully monitor vital signs.

− Contraindications

− Hypersensitivity, bradycardia

Propofol (Diprivan)Propofol (Diprivan)


− Produces rapid and brief state of general anesthesia

• Indications

− Anesthesia induction/ maintenance, sedation for mechanically ventilated patients

− Dose:Inducción anestésicaIV: 1 – 2,5 mg/kgMantenimiento anestésicoPerfusión IV: 50 – 150 mcg/kg/minSedaciónDosis de carga IV: 0,25 – 1 mg/kgMantenimiento IV: 10 – 50 µg/kg/min


− Seizure, apnea, dysrhythmias, asystole, hypotension, hypertension

• Considerations


− Avoid rapid administration in elderly patients to avoid hypotension and airway obstruction.


− Hypovolemia, known sensitivity

Propranolol Hydrochloride (Inderal)

Propranolol Hydrochloride (Inderal)

• Classification :• Beta-adrenergic blocker

(nonselective) antianginal,antiarrhythmic.

• Mechanism of action− Reduces chronotropic,

inotropic, and vasodilator response to beta-adrenergic stimulation

• Indications− Hypertension, angina

pectoris− Dose : life threatening

arrhythmias 1-3 mg IV with careful monitoring ,not to exceed 1mg /min .

• Adverse reactions− Weakness, depression,

fatigue, anxiety, dizziness, bronchospasm


Category C − Closely monitor patient

during administration.− Use with caution in elderly

patients.− Atropine should be readily

available.

• Contraindications− Sinus bradycardia, second-

or third-degree AV block

Sodium BicarbonateSodium Bicarbonate


• Electrolyte , systemic alkalinizer,

• Mechanism of action− Buffers metabolic acidosis

and lactic acid buildup

• Indications− Metabolic acidosis during

cardiac arrest.Dose:for severe metabolic

acidosis ,dose depends on blood CO2 content , PH, and patient clinical condition ,90-180mEq/L.IVduring first hour then adjust PRN.


− Hypernatremia, metabolic alkalosis, tissue sloughing, cellulitis

• Considerations


− Repeat as needed in tricyclic antidepressant overdose until QRS narrows


− Metabolic/respiratory alkalosis, hypokalemia, electrolyte imbalance

Tirofiban Hydrochloride (Aggrastat)

Tirofiban Hydrochloride (Aggrastat)

• Classification:

• Antiplatelet

• Mechanism of action− Inhibits aggregation of

platelets

• Indications− Acute coronary syndrome

• Dose:

• 0.4mcg/kg/min infusion over 30min .then continue at rate of 0.1 mcg/kg/min.


− Dizziness, pain, sweating, intracranial bleeding, CVA

• Considerations


− Must be administered only with an infusion pump direct from bottle with a vented IV set

− Severe spontaneous bleeding risk

• Contraindications− Trauma or major surgery

within the past 30 days

IV Solutions (Colloids and Crystalloids)

IV Solutions (Colloids and Crystalloids)

• Colloids− Expand plasma volume

− Most often used in hypovolemic shock states

• Crystalloid solutions are used for:− Electrolyte replacement

− A route for medication

− Short-term intravascular volume expansion

DextranDextran

• Mechanism of action− Sugar-containing

colloid used as an intravascular volume expander

• Indications− Hypovolemic shock

• Contraindications− Patients with

congestive heart failure, renal failure, or known bleeding disorders

• Adverse reactions− Rash, itching,

dyspnea, chest tightness, and mild hypotension

• Considerations− In the management of

burn shock, it is especially important to follow standard fluid resuscitation regimens to prevent possible circulatory overload.

adult ii 2015 emergency medications. national ems education standard competencies emergency...

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