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UHHS BMH Paramedic Training Program
Ronald Pristera EMT-P
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)
Anti-dysrhythmic SVT, including bypass tract disease. 2nd or 3rd degree AV block SSS, sensitivity, Afib or flutter.
12 mg IVP.Adenosine Dose 6mg rapid IVP followed by 20ml saline flush. Max single dose is 12 mg . then again in 1-2 min. May repeat in 1-2 min if no response.
.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 .
heparin & bicar (y site) .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.
Procainamide Quinindine theo .Amiodarone May effect serum levels of phenytoin.
anti-inflammatory. antiplatelet Indications AMI Only systemic sensitivity in the context of MI CI Dose 160-325 mg PO (preferably chewed) .Aspirin Analgesic.
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 .
03-0.Atropine Sulfate Dose Bradydysrhymia‟s 0.5-1.0mg q 5 min to a max of 0.0 mg IV or ETT(dilute to 10 ml) 2mg IVP q 5-15 minutes (no max) ACE inhibitors .04 mg/kg Asystole 1.
Procainamide. cholinergics. neostigmine . ant psychotics Antihistamines. antidepressants. quinidine Adverse reactions with concurrent admin. Dig.Atropine Sulfate Practice Pearls Dilates the pupils Follow ETT with several PPV „s Effects are enhanced by. Thiazides.
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 .
Dilatory effects Ca channel blockers Severe tissue necrosis following IM use or extravasculation Must flush IV line if Bicarb was givenprecipitation will occur .Calcium Chloride Practice Pearls May antagonize the perp.
Diltiazem (Cardizem) Slow ca channel blocker or Ca channel antagonist. Indications A Fib/flutter Multifocal atrial tachycardia‟s 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 .
Repeat dose of 0.25mg/kg (20mg for average pt) over 2 min.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 .
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) Dose 2.
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 “renal”dose 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 Don‟t give concomitantly with lasix or bicarb .
hypotension.Dopamine (Intropin) Practice pearls MAO inhibitors may deactivate Seizures may result if given with phenytoin. bradycardia .
Flumazenil (Romazicon) Benzodiazepine antagonist Indications Reversal of BZD Contraindications TCA OD Cocaine or other stimulant intoxication .
5mg at 1 min intervals Max of dose of 3 mg .3mg after 30 seconds Additional dose of 0.Flumazenil (Romazicon) Dose 0.2mg 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 “resedation” effects Be prepared to manage resp efforts .
hepatic or renal disease Contraindications Anuria Hypovolemia/dehydration .Furosemide (Lasix) Loop Diuretic Indications PE associated with CHF.
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 .
pace first .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.
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 .
8 mg/ml) infuse at 2mg/min. Practice Pearls VS should be constantly monitored Observe for signs of CHF. bronchospasm . Titrate to supine SBP.Isoproterenol (Isuprel) Dose Infusion mix 200 in 250 (0. 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.
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 PVC‟s 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. dobutamine Epi may cause a rise in BP decrease in HR and severe vasoconstriction . dopamine.
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
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
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 .
SSS (without pacemaker) 2nd & 3rd degree AV block Hypotension/Cardiogenic shock Wide complex tachycardia Severe CHF WPW with A Fib/flutter IV beta blockers
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
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. diabetes. seizure or cardiac disorder. May potentiate diuretic-induced hypokalemia. May precipitate angina and dysrhymias Should be used with caution in. hyperthyroidism. Beta Blockers may antagonize albuterol.
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 .
5-25 G IV slowly .Dextrose 50% Contraindications Intracranial hemorrhage Known or suspected CVA in absence of hypogly. Increased intracranial pressure Dose 12.
May precipitate Wernicke‟s encephalopathy .Dextrose 50 % Practice Pearls Draw a blood sample prior to infusion if possible. Extravasculation may cause necrosis. Aspirate often.
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 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 .
Reduce dose by 50% in elderly patients.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 .
Epinephrine (Adrenalin) Sympathomimetic Indications Bronchial asthma Acute allergic reaction Cardiac arrest Profound symptomatic bradycardia .
correct volume deficit Use with caution in coronary insufficiency Dose Cardiac arrest 1 mg IVP q 3-5 min 2.Epinephrine (Adrenalin) Contraindications Hypovolemia shock.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.5 mg (1:1000) SQ Severe.1-2 ml (1:10000) slow IV .3-0.0.
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 0.5-1 mg IM with one repeat in 7-10 min Contraindications Dose .Glucagon Pancreatic Hormone.
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 .
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 .
AMI Hepatic or renal insufficiency Increases effects of skeletal muscle relaxants .. dig induced dysrhymias.s.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 .
200-400 mcg/ml @ 10-20 mcg/min increase by 5-10 prn. .Nitroglycerin (Nitrostat) Contraindications Hypotension Head injury Cerebral hemorrhage Dose 0.15-0.6 mg SL q 5 minutes (3 max) Infusion.
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 .
meperidine.Naloxone (Narcan) Opiod antagonist Indications Narcotic OD Morphine. codeine Propoxyphene Coma unknown origin . oxycodone. paregoric Fentanyl. heroin. hydromophone Methadone.
Naloxone (Narcan) Contraindications Use with caution in addicted pts may precipitate violent withdrawal issues. 0.4-2mg IV. SQ or ETT (dilute) May not reverse hypotension Dose Practice Pearls . IM.
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 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 “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 .
one dose only (buys you about 10 min) Dose .Vasopressin Contraindications Not recommended for responsive pts with CAD 40 U IV push.
may promote cardiac ischemia .Vasopressin Practice Pearls Potent vasoconstrictor.
Coma.Midazolam (Versed) Short acting BZD Indications Premed for ETT or CV Seizures Contraindications Glaucoma (relative) Shock. depressed VS .
5 mg IV slowly (1-2 min) Total max dose not to exceed 0.1 mg/kg .Midazolam (Versed) Contraindications Alcohol intox (relative) Concomitant use of barbs. etoh. narc or other CNS depressants Dose 1-2.
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. & 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 . verapamil.
hypokalemia. Pts with MI and or renal failure are prone to developing toxicity Avoid use in WPW Toxcity is potentiated in pts with. hypomagnesemia & hypercalcemia .Digoxin (Lanoxin) Sympathomimetics may augment the inotropic & cardiotoxic effects.
heparin Anti coagulent Two preparations Unfractionated (UFH) Low molecular weight (LWH) .
spinal or eye surgery .heparin UFH Indications AMI Begin with fibrin specific lytics (alteplase) Contraindications Active bleeding Recent intracranial.
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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