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Emergency Drug Review
UHHS BMH Paramedic Training Program
Ronald Pristera EMT-P
Objectives
This will be a “quick” overview
You should have been studying your drug cards.
We are not going to talk about pediatric doses
Assume that a CI for any drug is known sensitivity. (its not listed here as a CI)
Adenosine
CLASS; Anti-dysrhythmic
IND.; SVT, including bypass tract disease.
CI. 2nd or 3rd degree AV block
SSS, sensitivity, Afib or
flutter.
Adenosine
Dose 6mg rapid IVP followed by 20ml saline flush.
May repeat in 1-2 min if no response. 12 mg IVP,
then again in 1-2 min.
Max single dose is 12 mg
Adenosine
Practice pointsBrief periods of asystole are commonPts on theo may require larger dosesTransplant recip. May require smaller doseMay produce bronchoconstriction is
asthma pts.
Amiodarone
Class III AntidysrhythmicIndicated for Initial rx and prophylaxis of VF & unstable
VT refractory to other therapy
ContraindicatedPulmonary congestionCardiogenic shockhypotension
Amiodarone
Dose300 mg loading dose (cardiac arrest) flush
with 10 ml of D5 or saline150 mg supplemental bolus dose (cardiac
arrest) flush with 10 ml of D5 or saline360 mg loading infusion-following ROSC
over 6 hrs540 mg maintenance infusion over 18 hr
Amiodarone
Practice PointsMay potentiate hemodynamic status when
given with beta blocker and CaCl channel blockers
May increase risk of AV block when given with CaCl blockers
May increase effects of wafarin Incompatible with lasix, heparin & bicar (y
site)
Amiodarone
May effect serum levels of phenytoin,ProcainamideQuinindine theo
Aspirin
Analgesic, anti-inflammatory, antiplatelet
Indications AMI
CI Only systemic sensitivity in the context of MI
Dose 160-325 mg PO (preferably chewed)
Aspirin
Give it rapidly (ISIS trials)
Go ahead if already on 1 pill per day
Atropine Sulfate
Anticholinergic
IndicationsSymptomatic bradycardiaAsystolePEAACE inhibitor ODExercise induced bronchospastic disorders
Atropine Sulfate
CITachycardiaObstructive disease of GI tractUnstable cardiovascular status in the
context of cardiac ischemia & hemorrhageNarrow angle glaucoma
Atropine Sulfate
DoseBradydysrhymia’s
0.5-1.0mg q 5 min to a max of 0.03-0.04 mg/kg
Asystole1.0 mg IV or ETT(dilute to 10 ml)
ACE inhibitors2mg IVP q 5-15 minutes (no max)
Atropine Sulfate
Practice PearlsDilates the pupilsFollow ETT with several PPV ‘sEffects are enhanced by;
Thiazides, antidepressants, ant psychoticsAntihistamines, Procainamide, quinidine
Adverse reactions with concurrent admin.Dig, cholinergics, neostigmine
Calcium Chloride
ElectrolyteIndicationsHyperkalemia (except dig toxic)HypocalcaemiaCaCl blocker toxicityHypermagnesmiaTo prevent hypotensive effects of CaCl
blockers
Calcium Chloride
ContraindicationsVF during cardiac resuscitationDig toxicHyperkalemiaRenal or cardiac disease
Calcium Chloride
Dose2-4 mg/kg (1-2G) of 10% slow IV q 10 min
PRN
Practice PearlsMay produce vasospasm in
coronary/cerebral arteriesHypotension/bradycardia may result from
rapid administration
Calcium Chloride
Practice PearlsMay antagonize the perp. Dilatory effects
Ca channel blockersSevere tissue necrosis following IM use or
extravasculationMust flush IV line if Bicarb was given-
precipitation will occur
Diltiazem (Cardizem)
Slow ca channel blocker or Ca channel antagonist.
IndicationsA Fib/flutterMultifocal atrial tachycardia’sPSVT
Diltiazem (Cardizem)
ContraindicationsSSS2nd or 3rd degree HB (unless pacer present)Hypotension (SBP 90)Cardiogenic shockAF/flutter associated with WPW or short
PR syndrome
Diltiazem (Cardizem)
ContraindicationsConcomitant use of IV beta blockersVTWide complex tachy of unknown originAMI
Diltiazem (Cardizem)
Dose0.25mg/kg (20mg for average pt) over 2
min. Repeat dose of 0.35/mg/kg after 15 minMaintenance infusion is 125mg in 100 ml
infused @ 5-15mg/hr (titrate to HR)
Diltiazem (Cardizem)
Practice PearlsCaution in pts who take agents that affect
contractility or conduction Incompatible with simultaneous lasixUse with caution in renal/hepatic failureHypotension may occurPVC’s may be present on conversion of
PSVT
Dobutamine (Dobutrex)
SympathomimeticIndications Inotropic support for patients with LV
dysfunction
ContraindicationsAF/flutterSevere hypotension IHSS
Diltiazem (Cardizem)
Dose2.5-10 mcg/kg/min IV based on inotropic
effect. MAX RATE is 40mcg/kg/min
Practice PealsNeed accurate admin method (pump)Closely monitor BP Increase of HR of 10% may increase
cardiac ischemia
Diltiazem (Cardizem)
Practice PearlsLidocaine should be readily availableCorrect hypovolemia prior to use Incompatible with lasix & bicarb in the
same line
Dopamine (Intropin)
SympathomimeticIndicationsHemodynamically significant hypotension
in the absence of hypovolemia
ContraindicationsTachydysrhythmiasVFpheochromocytoma
Dopamine (Intropin)
Dose “renal”dose 1-5mcg/kg/min “cardiac” dose 5-15 mgc/kg/min “vasopressor” dose 15mcg/kg/min
Dopamine (Intropin)
Practice PearlsAvoid extravasculationUse infusion pumpMonitor closely for signs of compromised
circulationCorrect hypovolemia prior to useDon’t give concomitantly with lasix or
bicarb
Dopamine (Intropin)
Practice pearlsMAO inhibitors may deactivateSeizures may result if given with phenytoin,
hypotension, bradycardia
Flumazenil (Romazicon)
Benzodiazepine antagonist
IndicationsReversal of BZD
ContraindicationsTCA ODCocaine or other stimulant intoxication
Flumazenil (Romazicon)
Dose0.2mg IV over 30 secondsAdditional dose of 0.3mg after 30 secondsAdditional dose of 0.5mg at 1 min intervals
Max of dose of 3 mg
Flumazenil (Romazicon)
Practice PearlsTo avoid pain at site give through large
vein IVBe prepared to manage seizures in BZD
addicted ptsMonitor for “resedation” effectsBe prepared to manage resp efforts
Furosemide (Lasix)
Loop Diuretic
IndicationsPE associated with CHF, hepatic or renal
disease
ContraindicationsAnuriaHypovolemia/dehydration
Furosemide (Lasix)
ContraindicationsElectrolyte depletion
Dose20-40 mg slow IV (1-2min)Double the daily dose
Furosemide (Lasix)
Practice PearlsKnown to cause fetal abnormalitiesProtect from lightMay potentiate dig toxicity (K depletion)May potentiate lithium toxicity (Na deple)May potentiate therapeutic effects of other
antihypertensives
Isoproterenol (Isuprel)
Sympathomimetic
IndicationsHemodynamically significant bradycardia
refractive to other therapyTDP
Isoproterenol (Isuprel)
ContraindicationsVF/VTHypotension (relative)Pulse less idioventricular rhythm Ischemia heart disease (relative)Cardiac arrest
Isoproterenol (Isuprel)
Dose1mg in 250 ml (4mcg/ml) infuse at 2-20
mcg/minTitrate to effect
Practice Pearls Increases myocardial oxygen demand Infusion pumpLast ditch- pace first
Isoproterenol (Isuprel)
Practice PearlsBeta adrenergic antagonists my blunt the
inotropic response
Labetol (Normodyne)
Alpha-beta adrenergic blocker
IndicationsHypertensive emergencies
ContraindicationsBronchial asthma (relative)Uncompensated CHF2nd & 3rd AV block
Isoproterenol (Isuprel)
ContraindicationsBradycardiaCardiogenic shockPulmonary edema
Dose10-20 mg IV over 1-2 minMay repeat or double q 20 to a max of 150
mg
Isoproterenol (Isuprel)
Dose Infusion mix 200 in 250 (0.8 mg/ml) infuse
at 2mg/min. Titrate to supine SBP,
Practice PearlsVS should be constantly monitoredObserve for signs of CHF, bradycardia,
bronchospasm
Isoproterenol (Isuprel)
Practice PearlsKeep the patient in the supine positionNTG may augment hypotensive effects
Lidocaine (Xylocaine)
Antidysrhythmic (Class 1-B)
IndicationsVT/VFWide complex tachycardia of uncertain
originSignificant ventricular ectopy in the setting
of MI
Lidocaine (Xylocaine)
ContraindicationsAdams-Stokes Syndrome2nd or 3rd degree HB in the absence of a
pacemaker
Dose1.0-1.5 mg/kg consider repeat in 3 minTotal IV dose is 3 mg/kg
Lidocaine (Xylocaine)
DoseETT is 2.5 times IV doseMain infusion is 2G in 500 (4mg/ml)
Run @ 2-4 mg/min
Practice Pearls75-100 mg bolus will maintain level for 20
mins If bradycardia is present treat PVC’s with
Atropine
Lidocaine (Xylocaine)
Practice PearlsAvoid for use in reperfusion dysrhythmiaUse with caution in
Hepatic disease/heart failureMarked hypoxiaRespiratory depressionHypovolemia/shockComplete HB, AF
Norepinephrine (Levophed)
Sympathomimetic
IndicationsCardiogenic shockNeurogenic shock Inotropic supportHemodynamically significant hypotension
refractory to other sympaths
Norepinephrine (Levophed)
ContraindicationsHypotensive pts with hypovolemia
DoseDilute
Norepinephrine (Levophed)
Practice PearlsMay cause fetal anoxia Infuse through a large stable vein to avoid
necrosisMAO inhibitors potentiate the effectsCan be deactivated by alkaline solsMay exacerbate dysrhythmia response
Propranolol (Inderal)
Beta adrenergic blocker
IndicationsHypertensionAnginaVF/VT and SVT refractory to other therapy
Propranolol (Inderal)
ContraindicationsSinus bradycardia2nd or 3rd degree AV blockAsthmaCardiogenic shockPulmonary edemaUncompensated CHFCOPD (relative)
Propranolol (Inderal)
Dose1-3 mg IV over 2-5 minCan be repeated after 2 minTotal dose not to exceed 0.1mg/kg
Practice PearlsCatacholamine depleting drugs my
potentiate hypotension
Propranolol (Inderal)
Practice PearlsVerapamil may worsen AV conduction
abnormalitiesSux effects may be enhanced Effects are reversed by
Isuprel, norepi, dopamine, dobutamineEpi may cause a rise in BP decrease in HR
and severe vasoconstriction
Propranolol (Inderal)
Practice PearlsMay produce life-threatening side effects-
closely monitor patientsUse with caution in elderlyUse with caution in patients with impaired
hepatic or renal function.Atropine should be readily available
Sodium Bicarbonate
Buffer, alkalinizing agent, electrolyte IndicationsKnown bicarbonate responsive acidosisOn return of ROSC following long arrest Intubated pt with long arrest intervalPEA/DKATCA ODMetabolic acidosis
Sodium Bicarbonate
ContraindicationsChloride loss from vomiting & GIMet or resp alkalosisSevere pulmonary edemaAbdominal pain of unknown originHypo;
Calcemia, kalemia, natremia
Sodium Bicarbonate
Dose1 mEq/kg IV with 0.5 mEq/kg repeat q 10
min
Practice PearlWhen possible ABG’s should be the guideProduces CO2 which may worsen cellular
acidosisMay worsen CHF
Sodium Bicarbonate
Practice PearlsMust maintain adequate ventilationCant be administered concomitantly with
CalciumMay deactivate vasopressors
Verapamil (Calan)
Calcium channel blocker
IndicationsPSVTA flutter with rapid responseA fib with rapid responseVasospastic and unstable anginaChronic stable angina
Verapamil (Calan)
ContraindicationsSSS (without pacemaker)2nd & 3rd degree AV blockHypotension/Cardiogenic shockWide complex tachycardiaSevere CHFWPW with A Fib/flutter IV beta blockers
Verapamil (Calan)
Dose2.5-5 mg IVP over 1-2 minutesRepeat 5-10 mg 15-30 mins after initial
dose Or 5 mg q 15 min until effectMax dose 30mg
Verapamil (Calan)
Practice PearlsClosely monitor VSGive smaller doses over longer time when
treating elderlyAV block or Asystole may occur due to
slowed conduction Increases serum digAntihypertensives may potentiate
hypotensive effects.
Albuterol (Proventil)
Sympathomimetic that is selective for beta 2 it also relaxes the smooth muscle of the brachial tree and peripheral vasculature
IndicationsRelief of bronchospasmPrevention of exercise induced
bronchospasm
Albuterol (Proventil)
Contraindicationsdysrhythmia's associated with tachycardia
DoseUnit dose 0.083%2.5 mg diluted to 3 ml
Albuterol (Proventil)
Practice Pearls
Other sympathomimetics may exacerbate adverse cardiovascular effects.
Beta Blockers may antagonize albuterol.
May potentiate diuretic-induced hypokalemia.
May precipitate angina and dysrhymias
Should be used with caution in; diabetes, hyperthyroidism, seizure or cardiac disorder.
Dextrose 50%
Dextrose is the 6 carbon sugar that is the principal carbohydrate used by the body.
IndicationsHypoglycemiaALOCComa/seizure of unknown etiology
Dextrose 50%
Contraindications Intracranial hemorrhageKnown or suspected CVA in absence of
hypogly. Increased intracranial pressure
Dose12.5-25 G IV slowly
Dextrose 50 %
Practice Pearls
Draw a blood sample prior to infusion if possible.
Extravasculation may cause necrosis. Aspirate often.
May precipitate Wernicke’s encephalopathy
Dextrose 50%
Practice Pearls Wernicke’s encephalopathy (severe
neurological symptoms) may result in thiamine deficiency (alcoholics).
Administer Thiamine prior to D50 in;– Alcoholics– Frail– Elderly– malnourished
Diazepam (Valium)
Benzodiazepine
IndicationsAcute anxiety states/alcohol withdrawalSkeletal muscle relaxationSeizure activityPremedication prior to cardioversion
Diazepam (Valium)
Contraindications in coma (unless there is seizure activity)CNS depression as a result of head injury respiratory depressionShock
Dose5mg over 2 min IV q 10-15 minMax dose is 30mg
Diazepam (Valium)
Practice Pearls Its use as an anti-convulsant may be short
lived due to rapid redistribution by the CNS.
Reduce dose by 50% in elderly patients.May cause local venous irritationMay precipitate CNS depression &
psychomotor impairmentPrecipitates with almost everything
Epinephrine (Adrenalin)
Sympathomimetic
IndicationsBronchial asthmaAcute allergic reactionCardiac arrestProfound symptomatic bradycardia
Epinephrine (Adrenalin)
ContraindicationsHypovolemia shock- correct volume deficitUse with caution in coronary insufficiency
DoseCardiac arrest
1 mg IVP q 3-5 min2.5 times the normal dose if via ETT
Epinephrine (Adrenalin)
DoseDrips
Mix 1 mg ampule in 500 ml (2 mcg/ml) and infuse at 1-2 mcg/min titrate to desired response
Anaphylactic reactionMild- 0.3-0.5 mg (1:1000) SQSevere- 1-2 ml (1:10000) slow IV
Epinephrine (Adrenalin)
Practice PearlsDon’t use prefilled units to mix drips] Increases oxygen demandMAO inhibitors potentiate the effectExacerbate the dysrhythmia's responseMay be deactivated by alkaline sols.
Epinephrine (Adrenalin)
Practice PearlsComplications of IV epic are significant
Uncontrolled hypertensionVomiting seizures dysrhythmia's
IV Epi should only be used in severe cases
Glucagon
Pancreatic Hormone, insulin antagonist
IndicationsPersistent hypoglycemia despite glucose
ContraindicationsOnly hypersensitivity
Dose0.5-1 mg IM with one repeat in 7-10 min
Glucagon
Practice PearlsNot a first choice for hypoglycemiaDo not use dilutent to mix drips IV glucose must be given if there is not
response to second doseMay potentiate anticoagulantsGlycogen must be available in the liver
Thiamine (Betaxin)
Vitamin B1
IndicationsComa of unknown origin (with D50)DT’sBeriberiWernicke’s encephalopathy
Thiamine (Betaxin)
ContraindicationsNone
Dose100mg slow IV or IM
Practice PearlsUsed to metabolize glucoseCertain conditions predispose for defic.
Thiamine (Betaxin)
Practice PearlsAlcoholism/malnourishment
Give before D50
Procainamide (Pronestyl)
Antidysrhythmic
IndicationsPVC’s refractory to LidocaineVT (pulse) refractory to LidocaineVF refractory to LidocainePSVT (wide complex of unknown origin)
Procainamide (Pronestyl)
Contraindications2nd & 3rd degree AV block (without pacer)Dig toxicityTDPComplete heartblockTCA toxicity
Procainamide (Pronestyl)
Dose20 mg/min (30 mg/min in refractory
VF) slow IV infusionMaintenance infusion- 1G in 250 and run at
1-4 mg/minMax dose 17 mg/kg
50% widening of QRSHypotension
Procainamide (Pronestyl)
Practice PearlsPotent vasodilating and inotropic effectsRapid injection may cause hypotensionUse caution
Asthma, dig induced dysrhymias;s,, AMIHepatic or renal insufficiency
Increases effects of skeletal muscle relaxants
Nitroglycerin (Nitrostat)
Vasodilator
Indications Ischemia chest painPulmonary hypertensionCHFHypertensive emergencies
Nitroglycerin (Nitrostat)
ContraindicationsHypotensionHead injuryCerebral hemorrhage
Dose0.15-0.6 mg SL q 5 minutes (3 max) Infusion- 200-400 mcg/ml @ 10-20
mcg/min increase by 5-10 prn.
Nitroglycerin (Nitrostat)
Practice PearlsCaution with Viagra (intractable
hypotension)Elderly are susceptible to hypotension “very volatile”PVC tubing will absorbOther dilators may have additive effects
Naloxone (Narcan)
Opiod antagonist
IndicationsNarcotic OD
Morphine, heroin, hydromophoneMethadone, meperidine, paregoricFentanyl, oxycodone, codeinePropoxyphene
Coma unknown origin
Naloxone (Narcan)
ContraindicationsUse with caution in addicted pts may
precipitate violent withdrawal issues.
Dose0.4-2mg IV, IM, SQ or ETT (dilute)
Practice PearlsMay not reverse hypotension
Naloxone (Narcan)
Practice PearlsSeizures are possible Incompatible with bisulfate & alkaline solsMay cause hypertension, tachycardia and
violent reactions
Morphine Sulfate
Opiod analgesic
IndicationsChest pain associated with MIPulmonary edema (with or without CP)Moderate to severe acute or chronic pain
ContraindicationsHypovolemia/hypotension
Morphine Sulfate
ContraindicationsHead injury or undiagnosed abdom. Pain Increased ICPSevere resp depressionMAO inhibitors within the last 14 days
Morphine Sulfate
Practice PearlsCNS depressants may potentiate the
effectsMay worsen bradycardia or heart block in
inferior MIShould be used with caution in chronic
pain syndromesPhenothiazides may potentiate analgesia
Magnesium Sulfate
Electrolyte, Anticonvulsant
IndicationsSeizures of eclampsiaTDPHypomagnesaemiaRefractory VF
Magnesium Sulfate
ContraindicationsHeart block or myocardial damage
DoseEclampsic seizures
1-4G (8-32 mEq) IV max dose of 30-40G/dayTDP
1-2G (2-4ml of a 50% solution) in 10ml over 1-2 min IV Give it IVP in VF
Magnesium Sulfate
Practice PearlsDon’t administer 2 hrs prior to delivery IV calcium gluconate or CaCl should be
available as an antagonistConvulsions may occur up to 48 hrs post
delivery.The “cure” for toxemia is delivery of the
baby.
Magnesium Sulfate
Practice PearlsUse with caution in renal failureCNS depressant effects may be enhanced
in the presence of other CNS depressants
Vasopressin
Naturally occuring hormone (ADH)
IndicationsMay be used as an alternate vasopressor
in cardiac arrestMay be useful in hemodynamic support of
dilatory shock
Vasopressin
ContraindicationsNot recommended for responsive pts with
CAD
Dose40 U IV push- one dose only (buys you
about 10 min)
Vasopressin
Practice PearlsPotent vasoconstrictor- may promote
cardiac ischemia
Midazolam (Versed)
Short acting BZD
IndicationsPremed for ETT or CVSeizures
ContraindicationsGlaucoma (relative)Shock, Coma, depressed VS
Midazolam (Versed)
ContraindicationsAlcohol intox (relative)Concomitant use of barbs, etoh, narc or
other CNS depressants
Dose1-2.5 mg IV slowly (1-2 min)Total max dose not to exceed 0.1 mg/kg
Midazolam (Versed)
Practice PearlsMonitor continouslyNever admin as IV bolusSedative effect may be enhanced by other
CNS depressants
Digoxin (Lanoxin)
Cardiac Glycoside
IndicationsSVT esp A fib/flutCHFCardiogenic shock
Digoxin (Lanoxin)
ContraindicationsVF/FTAV BlockDig toxicity2nd or 3rd AV (without pacer)
Digoxin (Lanoxin)
Practice PearlsAmiodarone, verapamil, & quinidine may
increase serum levels 50%Concurrent admin with calan may lead to
severe heart blockAntibiotics may increase serum levels by
slowing hepatic breakdownDiuretics may potentiate cardiac toxicity
because of potassium loss
Digoxin (Lanoxin)
Sympathomimetics may augment the inotropic & cardiotoxic effects.Pts with MI and or renal failure are prone to developing toxicityAvoid use in WPWToxcity is potentiated in pts with; hypokalemia, hypomagnesemia & hypercalcemia
heparin
Anti coagulent
Two preparationsUnfractionated (UFH)Low molecular weight (LWH)
heparin
UFH
IndicationsAMIBegin with fibrin specific lytics (alteplase)
ContraindicationsActive bleedingRecent intracranial, spinal or eye surgery
heparin
ContraindicationsSevere hypertensionBleeding disordersGI bleeding
Dose Initial bolus- 60IU/kg (max bolus 4000IU)Continue @ 12IU/hrTherapuetic levels checked by labs
heparin
Practice PearlsCan be reversed with Protamine (25mg IV)Don’t use with low platelet countUse LMW in ACS pts (especially non
Qwave MI unstable angina) It will inhibit thrombin generation.