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.