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; IND.; CI. Anti-dysrhythmic SVT, including bypass tract disease. 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 points
Brief periods of asystole are common  Pts on theo may require larger doses  Transplant recip. May require smaller dose  May produce bronchoconstriction is asthma pts.


Amiodarone
Class III Antidysrhythmic Indicated for


Initial rx and prophylaxis of VF & unstable VT refractory to other therapy

Contraindicated
Pulmonary congestion  Cardiogenic shock  hypotension


Amiodarone
Dose
300 mg loading dose (cardiac arrest) flush with 10 ml of D5 or saline  150 mg supplemental bolus dose (cardiac arrest) flush with 10 ml of D5 or saline  360 mg loading infusion-following ROSC over 6 hrs  540 mg maintenance infusion over 18 hr


Amiodarone
Practice Points
May 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,  Procainamide  Quinindine  theo


Aspirin
Analgesic, anti-inflammatory, antiplatelet Indications


AMI Only systemic sensitivity in the context of MI 160-325 mg PO (preferably chewed)

CI


Dose


Aspirin
Give it rapidly (ISIS trials) Go ahead if already on 1 pill per day

Atropine Sulfate
Anticholinergic Indications
Symptomatic bradycardia  Asystole  PEA  ACE inhibitor OD  Exercise induced bronchospastic disorders


Atropine Sulfate
CI
Tachycardia  Obstructive disease of GI tract  Unstable cardiovascular status in the context of cardiac ischemia & hemorrhage  Narrow angle glaucoma


Atropine Sulfate
Dose


Bradydysrhymias


0.5-1.0mg q 5 min to a max of 0.03-0.04 mg/kg

Asystole


1.0 mg IV or ETT(dilute to 10 ml) 2mg IVP q 5-15 minutes (no max)

ACE inhibitors


Atropine Sulfate
Practice Pearls
Dilates the pupils  Follow ETT with several PPV s  Effects are enhanced by;


Thiazides, antidepressants, ant psychotics  Antihistamines, Procainamide, quinidine



Adverse reactions with concurrent admin.



Dig, cholinergics, neostigmine

Calcium Chloride
Electrolyte Indications
Hyperkalemia (except dig toxic)  Hypocalcaemia  CaCl blocker toxicity  Hypermagnesmia  To prevent hypotensive effects of CaCl blockers


Calcium Chloride
Contraindications
VF during cardiac resuscitation  Dig toxic  Hyperkalemia  Renal or cardiac disease


Calcium Chloride
Dose


2-4 mg/kg (1-2G) of 10% slow IV q 10 min PRN

Practice Pearls
May produce vasospasm in coronary/cerebral arteries  Hypotension/bradycardia may result from rapid administration


Calcium Chloride
Practice Pearls
May antagonize the perp. Dilatory effects Ca channel blockers  Severe tissue necrosis following IM use or extravasculation  Must flush IV line if Bicarb was givenprecipitation will occur


Diltiazem (Cardizem)
Slow ca channel blocker or Ca channel antagonist. Indications
A Fib/flutter  Multifocal atrial tachycardias  PSVT


Diltiazem (Cardizem)
Contraindications
SSS  2nd or 3rd degree HB (unless pacer present)  Hypotension (SBP 90)  Cardiogenic shock  AF/flutter associated with WPW or short PR syndrome


Diltiazem (Cardizem)
Contraindications
Concomitant use of IV beta blockers  VT  Wide complex tachy of unknown origin  AMI


Diltiazem (Cardizem)
Dose
0.25mg/kg (20mg for average pt) over 2 min.  Repeat dose of 0.35/mg/kg after 15 min  Maintenance infusion is 125mg in 100 ml infused @ 5-15mg/hr (titrate to HR)


Diltiazem (Cardizem)
Practice Pearls
Caution in pts who take agents that affect contractility or conduction  Incompatible with simultaneous lasix  Use with caution in renal/hepatic failure  Hypotension may occur  PVCs may be present on conversion of PSVT


Dobutamine (Dobutrex)
Sympathomimetic Indications


Inotropic support for patients with LV dysfunction

Contraindications
AF/flutter  Severe hypotension  IHSS


Diltiazem (Cardizem)
Dose


2.5-10 mcg/kg/min IV based on inotropic effect. MAX RATE is 40mcg/kg/min

Practice Peals
Need accurate admin method (pump)  Closely monitor BP  Increase of HR of 10% may increase cardiac ischemia


Diltiazem (Cardizem)
Practice Pearls
Lidocaine should be readily available  Correct hypovolemia prior to use  Incompatible with lasix & bicarb in the same line


Dopamine (Intropin)
Sympathomimetic Indications


Hemodynamically significant hypotension in the absence of hypovolemia

Contraindications
Tachydysrhythmias  VF  pheochromocytoma


Dopamine (Intropin)
Dose
renaldose 1-5mcg/kg/min  cardiac dose 5-15 mgc/kg/min  vasopressor dose 15mcg/kg/min


Dopamine (Intropin)
Practice Pearls
Avoid extravasculation  Use infusion pump  Monitor closely for signs of compromised circulation  Correct hypovolemia prior to use  Dont give concomitantly with lasix or bicarb


Dopamine (Intropin)
Practice pearls
MAO inhibitors may deactivate  Seizures may result if given with phenytoin, hypotension, bradycardia


Flumazenil (Romazicon)
Benzodiazepine antagonist Indications


Reversal of BZD

Contraindications
TCA OD  Cocaine or other stimulant intoxication


Flumazenil (Romazicon)
Dose
0.2mg IV over 30 seconds  Additional dose of 0.3mg after 30 seconds  Additional dose of 0.5mg at 1 min intervals
 

Max of dose of 3 mg

Flumazenil (Romazicon)
Practice Pearls
To avoid pain at site give through large vein IV  Be prepared to manage seizures in BZD addicted pts  Monitor for resedation effects  Be prepared to manage resp efforts


Furosemide (Lasix)
Loop Diuretic Indications


PE associated with CHF, hepatic or renal disease

Contraindications
Anuria  Hypovolemia/dehydration


Furosemide (Lasix)
Contraindications


Electrolyte depletion

Dose
20-40 mg slow IV (1-2min)  Double the daily dose


Furosemide (Lasix)
Practice Pearls
Known to cause fetal abnormalities  Protect from light  May potentiate dig toxicity (K depletion)  May potentiate lithium toxicity (Na deple)  May potentiate therapeutic effects of other antihypertensives


Isoproterenol (Isuprel)
Sympathomimetic Indications
Hemodynamically significant bradycardia refractive to other therapy  TDP


Isoproterenol (Isuprel)
Contraindications
VF/VT  Hypotension (relative)  Pulse less idioventricular rhythm  Ischemia heart disease (relative)  Cardiac arrest


Isoproterenol (Isuprel)
Dose
1mg in 250 ml (4mcg/ml) infuse at 2-20 mcg/min  Titrate to effect


Practice Pearls
Increases myocardial oxygen demand  Infusion pump  Last ditch- pace first


Isoproterenol (Isuprel)
Practice Pearls


Beta adrenergic antagonists my blunt the inotropic response

Labetol (Normodyne)
Alpha-beta adrenergic blocker Indications


Hypertensive emergencies

Contraindications
Bronchial asthma (relative)  Uncompensated CHF  2nd & 3rd AV block


Isoproterenol (Isuprel)
Contraindications
Bradycardia  Cardiogenic shock  Pulmonary edema


Dose
10-20 mg IV over 1-2 min  May 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 Pearls
VS should be constantly monitored  Observe for signs of CHF, bradycardia, bronchospasm


Isoproterenol (Isuprel)
Practice Pearls
Keep the patient in the supine position  NTG may augment hypotensive effects


Lidocaine (Xylocaine)
Antidysrhythmic (Class 1-B) Indications
VT/VF  Wide complex tachycardia of uncertain origin  Significant ventricular ectopy in the setting of MI


Lidocaine (Xylocaine)
Contraindications
Adams-Stokes Syndrome  2nd or 3rd degree HB in the absence of a pacemaker


Dose
1.0-1.5 mg/kg consider repeat in 3 min  Total IV dose is 3 mg/kg


Lidocaine (Xylocaine)
Dose
ETT is 2.5 times IV dose  Main infusion is 2G in 500 (4mg/ml)



Run @ 2-4 mg/min

Practice Pearls
75-100 mg bolus will maintain level for 20 mins  If bradycardia is present treat PVCs with Atropine


Lidocaine (Xylocaine)
Practice Pearls
Avoid for use in reperfusion dysrhythmia  Use with caution in


Hepatic disease/heart failure  Marked hypoxia  Respiratory depression  Hypovolemia/shock  Complete HB, AF


Norepinephrine (Levophed)
Sympathomimetic Indications
Cardiogenic shock  Neurogenic shock  Inotropic support  Hemodynamically significant hypotension refractory to other sympaths


Norepinephrine (Levophed)
Contraindications


Hypotensive pts with hypovolemia Dilute

Dose


Norepinephrine (Levophed)
Practice Pearls
May cause fetal anoxia  Infuse through a large stable vein to avoid necrosis  MAO inhibitors potentiate the effects  Can be deactivated by alkaline sols  May exacerbate dysrhythmia response


Propranolol (Inderal)
Beta adrenergic blocker Indications
Hypertension  Angina  VF/VT and SVT refractory to other therapy


Propranolol (Inderal)
Contraindications
Sinus bradycardia  2nd or 3rd degree AV block  Asthma  Cardiogenic shock  Pulmonary edema  Uncompensated CHF  COPD (relative)


Propranolol (Inderal)
Dose
1-3 mg IV over 2-5 min  Can be repeated after 2 min  Total dose not to exceed 0.1mg/kg


Practice Pearls


Catacholamine depleting drugs my potentiate hypotension

Propranolol (Inderal)
Practice Pearls
Verapamil may worsen AV conduction abnormalities  Sux effects may be enhanced  Effects are reversed by



Isuprel, norepi, dopamine, dobutamine

Epi may cause a rise in BP decrease in HR and severe vasoconstriction

Propranolol (Inderal)
Practice Pearls
May produce life-threatening side effectsclosely monitor patients  Use with caution in elderly  Use with caution in patients with impaired hepatic or renal function.  Atropine should be readily available


Sodium Bicarbonate
Buffer, alkalinizing agent, electrolyte Indications
Known bicarbonate responsive acidosis  On return of ROSC following long arrest  Intubated pt with long arrest interval  PEA/DKA  TCA OD  Metabolic acidosis


Sodium Bicarbonate
Contraindications
Chloride loss from vomiting & GI  Met or resp alkalosis  Severe pulmonary edema  Abdominal pain of unknown origin  Hypo;



Calcemia, kalemia, natremia

Sodium Bicarbonate
Dose


1 mEq/kg IV with 0.5 mEq/kg repeat q 10 min

Practice Pearl
When possible ABGs should be the guide  Produces CO2 which may worsen cellular acidosis  May worsen CHF


Sodium Bicarbonate
Practice Pearls
Must maintain adequate ventilation  Cant be administered concomitantly with


Calcium  May deactivate vasopressors



Verapamil (Calan)
Calcium channel blocker Indications
PSVT  A flutter with rapid response  A fib with rapid response  Vasospastic and unstable angina  Chronic stable angina


Verapamil (Calan)
Contraindications
SSS (without pacemaker)  2nd & 3rd degree AV block  Hypotension/Cardiogenic shock  Wide complex tachycardia  Severe CHF  WPW with A Fib/flutter  IV beta blockers


Verapamil (Calan)
Dose
2.5-5 mg IVP over 1-2 minutes  Repeat 5-10 mg 15-30 mins after initial dose  Or 5 mg q 15 min until effect  Max dose 30mg


Verapamil (Calan)
Practice Pearls
Closely monitor VS  Give smaller doses over longer time when treating elderly  AV block or Asystole may occur due to slowed conduction  Increases serum dig  Antihypertensives 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 Indications
Relief of bronchospasm  Prevention of exercise induced bronchospasm


Albuterol (Proventil)
Contraindications


dysrhythmia's associated with tachycardia

Dose
Unit 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. Indications
Hypoglycemia  ALOC  Coma/seizure of unknown etiology


Dextrose 50%
Contraindications
Intracranial hemorrhage  Known or suspected CVA in absence of hypogly.  Increased intracranial pressure


Dose


12.5-25 G IV slowly

Dextrose 50 %
Practice Pearls Draw a blood sample prior to infusion if possible. Extravasculation may cause necrosis. Aspirate often. May precipitate Wernickes encephalopathy

Dextrose 50%


Practice Pearls Wernickes encephalopathy (severe neurological symptoms) may result in thiamine deficiency (alcoholics). Administer Thiamine prior to D50 in;

Alcoholics Frail Elderly malnourished

Diazepam (Valium)
Benzodiazepine Indications
Acute anxiety states/alcohol withdrawal  Skeletal muscle relaxation  Seizure activity  Premedication prior to cardioversion


Diazepam (Valium)
Contraindications
in coma (unless there is seizure activity)  CNS depression as a result of head injury  respiratory depression  Shock


Dose
5mg over 2 min IV q 10-15 min  Max 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 irritation  May precipitate CNS depression & psychomotor impairment  Precipitates with almost everything


Epinephrine (Adrenalin)
Sympathomimetic Indications
Bronchial asthma  Acute allergic reaction  Cardiac arrest  Profound symptomatic bradycardia


Epinephrine (Adrenalin)
Contraindications
Hypovolemia shock- correct volume deficit  Use with caution in coronary insufficiency


Dose


Cardiac arrest
1 mg IVP q 3-5 min  2.5 times the normal dose if via ETT


Epinephrine (Adrenalin)
Dose


Drips


Mix 1 mg ampule in 500 ml (2 mcg/ml) and infuse at 1-2 mcg/min titrate to desired response

Anaphylactic reaction
Mild- 0.3-0.5 mg (1:1000) SQ  Severe- 1-2 ml (1:10000) slow IV


Epinephrine (Adrenalin)
Practice Pearls
Dont use prefilled units to mix drips]  Increases oxygen demand  MAO inhibitors potentiate the effect  Exacerbate the dysrhythmia's response  May be deactivated by alkaline sols.


Epinephrine (Adrenalin)
Practice Pearls


Complications of IV epic are significant

Uncontrolled hypertension  Vomiting seizures dysrhythmia's


IV Epi should only be used in severe cases

Glucagon
Pancreatic Hormone, insulin antagonist Indications


Persistent hypoglycemia despite glucose Only hypersensitivity 0.5-1 mg IM with one repeat in 7-10 min

Contraindications


Dose


Glucagon
Practice Pearls
Not a first choice for hypoglycemia  Do not use dilutent to mix drips  IV glucose must be given if there is not response to second dose  May potentiate anticoagulants  Glycogen must be available in the liver


Thiamine (Betaxin)
Vitamin B1 Indications
Coma of unknown origin (with D50)  DTs  Beriberi  Wernickes encephalopathy


Thiamine (Betaxin)
Contraindications


None 100mg slow IV or IM

Dose


Practice Pearls
Used to metabolize glucose  Certain conditions predispose for defic.


Thiamine (Betaxin)
Practice Pearls


Alcoholism/malnourishment

Give before D50

Procainamide (Pronestyl)
Antidysrhythmic Indications
PVCs refractory to Lidocaine  VT (pulse) refractory to Lidocaine  VF refractory to Lidocaine  PSVT (wide complex of unknown origin)


Procainamide (Pronestyl)
Contraindications
2nd & 3rd degree AV block (without pacer)  Dig toxicity  TDP  Complete heartblock  TCA toxicity


Procainamide (Pronestyl)
Dose
20 mg/min (30 mg/min in refractory VF) slow IV infusion  Maintenance infusion- 1G in 250 and run at 1-4 mg/min  Max dose 17 mg/kg


50% widening of QRS  Hypotension



Procainamide (Pronestyl)
Practice Pearls
Potent vasodilating and inotropic effects  Rapid injection may cause hypotension  Use caution


Asthma, dig induced dysrhymias;s,, AMI  Hepatic or renal insufficiency



Increases effects of skeletal muscle relaxants

Nitroglycerin (Nitrostat)
Vasodilator Indications
Ischemia chest pain  Pulmonary hypertension  CHF  Hypertensive emergencies


Nitroglycerin (Nitrostat)
Contraindications
Hypotension  Head injury  Cerebral hemorrhage


Dose
0.15-0.6 mg SL q 5 minutes (3 max)  Infusion- 200-400 mcg/ml @ 10-20 mcg/min increase by 5-10 prn.


Nitroglycerin (Nitrostat)
Practice Pearls
Caution with Viagra (intractable hypotension)  Elderly are susceptible to hypotension  very volatile  PVC tubing will absorb  Other dilators may have additive effects


Naloxone (Narcan)
Opiod antagonist Indications


Narcotic OD
Morphine, heroin, hydromophone  Methadone, meperidine, paregoric  Fentanyl, oxycodone, codeine  Propoxyphene


Coma unknown origin

Naloxone (Narcan)
Contraindications


Use with caution in addicted pts may precipitate violent withdrawal issues. 0.4-2mg IV, IM, SQ or ETT (dilute) May not reverse hypotension

Dose


Practice Pearls


Naloxone (Narcan)
Practice Pearls
Seizures are possible  Incompatible with bisulfate & alkaline sols  May cause hypertension, tachycardia and violent reactions


Morphine Sulfate
Opiod analgesic Indications
Chest pain associated with MI  Pulmonary edema (with or without CP)  Moderate to severe acute or chronic pain


Contraindications


Hypovolemia/hypotension

Morphine Sulfate
Contraindications
Head injury or undiagnosed abdom. Pain  Increased ICP  Severe resp depression  MAO inhibitors within the last 14 days


Morphine Sulfate
Practice Pearls
CNS depressants may potentiate the effects  May worsen bradycardia or heart block in inferior MI  Should be used with caution in chronic pain syndromes  Phenothiazides may potentiate analgesia


Magnesium Sulfate
Electrolyte, Anticonvulsant Indications
Seizures of eclampsia  TDP  Hypomagnesaemia  Refractory VF


Magnesium Sulfate
Contraindications


Heart block or myocardial damage Eclampsic seizures



Dose


1-4G (8-32 mEq) IV max dose of 30-40G/day 1-2G (2-4ml of a 50% solution) in 10ml over 1-2 min IV Give it IVP in VF

TDP


Magnesium Sulfate
Practice Pearls
Dont administer 2 hrs prior to delivery  IV calcium gluconate or CaCl should be available as an antagonist  Convulsions may occur up to 48 hrs post delivery.  The cure for toxemia is delivery of the baby.


Magnesium Sulfate
Practice Pearls
Use with caution in renal failure  CNS depressant effects may be enhanced in the presence of other CNS depressants


Vasopressin
Naturally occuring hormone (ADH) Indications
May be used as an alternate vasopressor in cardiac arrest  May be useful in hemodynamic support of dilatory shock


Vasopressin
Contraindications


Not recommended for responsive pts with CAD 40 U IV push- one dose only (buys you about 10 min)

Dose


Vasopressin
Practice Pearls


Potent vasoconstrictor- may promote cardiac ischemia

Midazolam (Versed)
Short acting BZD Indications
Premed for ETT or CV  Seizures


Contraindications
Glaucoma (relative)  Shock, Coma, depressed VS


Midazolam (Versed)
Contraindications
Alcohol intox (relative)  Concomitant use of barbs, etoh, narc or other CNS depressants


Dose
1-2.5 mg IV slowly (1-2 min)  Total max dose not to exceed 0.1 mg/kg


Midazolam (Versed)
Practice Pearls
Monitor continously  Never admin as IV bolus  Sedative effect may be enhanced by other CNS depressants


Digoxin (Lanoxin)
Cardiac Glycoside Indications
SVT esp A fib/flut  CHF  Cardiogenic shock


Digoxin (Lanoxin)
Contraindications
VF/FT  AV Block  Dig toxicity  2nd or 3rd AV (without pacer)


Digoxin (Lanoxin)
Practice Pearls
Amiodarone, verapamil, & quinidine may increase serum levels 50%  Concurrent admin with calan may lead to severe heart block  Antibiotics may increase serum levels by slowing hepatic breakdown  Diuretics 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 toxicity Avoid use in WPW Toxcity is potentiated in pts with; hypokalemia, hypomagnesemia & hypercalcemia

heparin
Anti coagulent Two preparations
Unfractionated (UFH)  Low molecular weight (LWH)


heparin
UFH Indications
AMI  Begin with fibrin specific lytics (alteplase)


Contraindications
Active bleeding  Recent intracranial, spinal or eye surgery


heparin
Contraindications
Severe hypertension  Bleeding disorders  GI bleeding


Dose
Initial bolus- 60IU/kg (max bolus 4000IU)  Continue @ 12IU/hr  Therapuetic levels checked by labs


heparin
Practice Pearls
Can be reversed with Protamine (25mg IV)  Dont use with low platelet count  Use LMW in ACS pts (especially non Qwave MI unstable angina) It will inhibit thrombin generation.