Emergency Drug Review

UHHS BMH Paramedic Training Program
Ronald Pristera EMT-P

Objectives
This will be a ³quick´ 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.

May repeat in 1-2 min if no response.Adenosine Dose 6mg rapid IVP followed by 20ml saline flush. 12 mg IVP. Max single dose is 12 mg . then again in 1-2 min.

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)  .

 Procainamide  Quinindine  theo  .Amiodarone May effect serum levels of phenytoin.

Aspirin Analgesic. antiplatelet Indications  AMI Only systemic sensitivity in the context of MI 160-325 mg PO (preferably chewed) CI  Dose  . anti-inflammatory.

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  .

0 mg IV or ETT(dilute to 10 ml) 2mg IVP q 5-15 minutes (no max)  ACE inhibitors  .5-1.0mg q 5 min to a max of 0.03-0.Atropine Sulfate Dose  Bradydysrhymia¶s  0.04 mg/kg  Asystole  1.

cholinergics.  Thiazides. neostigmine . quinidine   Adverse reactions with concurrent admin.  Dig.Atropine Sulfate Practice Pearls Dilates the pupils  Follow ETT with several PPV µs  Effects are enhanced by. antidepressants. ant psychotics  Antihistamines. Procainamide.

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  .

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

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  .

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) Dose 0.

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  PVC¶s may be present on conversion of PSVT  .

Dobutamine (Dobutrex) Sympathomimetic Indications  Inotropic support for patients with LV dysfunction Contraindications AF/flutter  Severe hypotension  IHSS  .

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) Dose  2.5-10 mcg/kg/min IV based on inotropic effect.

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 ³renal´dose 1-5mcg/kg/min  ³cardiac´ dose 5-15 mgc/kg/min  ³vasopressor´ 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  Don¶t give concomitantly with lasix or bicarb  .

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

Flumazenil (Romazicon) Benzodiazepine antagonist Indications  Reversal of BZD Contraindications TCA OD  Cocaine or other stimulant intoxication  .

3mg after 30 seconds  Additional dose of 0.Flumazenil (Romazicon) Dose 0.5mg at 1 min intervals   Max of dose of 3 mg .2mg IV over 30 seconds  Additional dose of 0.

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 ³resedation´ 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  .

Practice Pearls VS should be constantly monitored  Observe for signs of CHF.Isoproterenol (Isuprel) Dose  Infusion mix 200 in 250 (0. Titrate to supine SBP.8 mg/ml) infuse at 2mg/min. bronchospasm  . bradycardia.

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 1.5 mg/kg consider repeat in 3 min  Total IV dose is 3 mg/kg  .0-1.

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 PVC¶s with Atropine  .Lidocaine (Xylocaine) Dose ETT is 2.

AF  .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.

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 .

norepi. dobutamine  Epi may cause a rise in BP decrease in HR and severe vasoconstriction . dopamine.Propranolol (Inderal) Practice Pearls Verapamil may worsen AV conduction abnormalities  Sux effects may be enhanced  Effects are reversed by   Isuprel.

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 ABG¶s 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  .

May precipitate angina and dysrhymias Should be used with caution in. May potentiate diuretic-induced hypokalemia. seizure or cardiac disorder.Albuterol (Proventil) Practice Pearls Other sympathomimetics may exacerbate adverse cardiovascular effects. . Beta Blockers may antagonize albuterol. diabetes. hyperthyroidism.

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. May precipitate Wernicke¶s encephalopathy . Aspirate often.

Administer Thiamine prior to D50 in. ± ± ± ± Alcoholics Frail Elderly malnourished .Dextrose 50%   Practice Pearls Wernicke¶s encephalopathy (severe neurological symptoms) may result in thiamine deficiency (alcoholics).

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.  May cause local venous irritation  May precipitate CNS depression & psychomotor impairment  Precipitates with almost everything  .  Reduce dose by 50% in elderly patients.

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

5 times the normal dose if via ETT  .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.

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.3-0.0.5 mg (1:1000) SQ  Severe.1-2 ml (1:10000) slow IV  .

Epinephrine (Adrenalin) Practice Pearls Don¶t 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 .

insulin antagonist Indications  Persistent hypoglycemia despite glucose Only hypersensitivity 0.Glucagon Pancreatic Hormone.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)  DT¶s  Beriberi  Wernicke¶s 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 PVC¶s 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  .

1G in 250 and run at 1-4 mg/min  Max dose 17 mg/kg  50% widening of QRS  Hypotension  .Procainamide (Pronestyl) Dose 20 mg/min (30 mg/min in refractory VF) slow IV infusion  Maintenance infusion.

dig induced dysrhymias.s. AMI  Hepatic or renal insufficiency   Increases effects of skeletal muscle relaxants .Procainamide (Pronestyl) Practice Pearls Potent vasodilating and inotropic effects  Rapid injection may cause hypotension  Use caution  Asthma..

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

 .6 mg SL q 5 minutes (3 max)  Infusion.15-0.Nitroglycerin (Nitrostat) Contraindications Hypotension  Head injury  Cerebral hemorrhage  Dose 0.200-400 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  ³very volatile´  PVC tubing will absorb  Other dilators may have additive effects  .

Naloxone (Narcan) Opiod antagonist Indications  Narcotic OD Morphine. meperidine. heroin. paregoric  Fentanyl. oxycodone. codeine  Propoxyphene   Coma unknown origin . hydromophone  Methadone.

SQ or ETT (dilute) May not reverse hypotension Dose  Practice Pearls  .4-2mg IV. IM.Naloxone (Narcan) Contraindications  Use with caution in addicted pts may precipitate violent withdrawal issues. 0.

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

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 Don¶t 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 ³cure´ 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  .

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

Vasopressin Practice Pearls  Potent vasoconstrictor.may promote cardiac ischemia .

Coma. depressed VS  .Midazolam (Versed) Short acting BZD Indications Premed for ETT or CV  Seizures  Contraindications Glaucoma (relative)  Shock.

etoh. narc or other CNS depressants  Dose 1-2.1 mg/kg  .5 mg IV slowly (1-2 min)  Total max dose not to exceed 0.Midazolam (Versed) Contraindications Alcohol intox (relative)  Concomitant use of barbs.

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)  .

& 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) Practice Pearls Amiodarone. verapamil.

Digoxin (Lanoxin) Sympathomimetics may augment the inotropic & cardiotoxic effects. hypomagnesemia & hypercalcemia . Pts with MI and or renal failure are prone to developing toxicity Avoid use in WPW Toxcity is potentiated in pts with. hypokalemia.

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)  Don¶t use with low platelet count  Use LMW in ACS pts (especially non Qwave MI unstable angina) It will inhibit thrombin generation.

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