Emergency Drug Review

UHHS edit Paramedic Training Click toBMH Master subtitle style 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 points
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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
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Initial rx and prophylaxis of VF & unstable VT refractory to other therapy Pulmonary congestion Cardiogenic shock hypotension

Contraindicated
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Amiodarone
Dose
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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
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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
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phenytoin, Procainamide Quinindine theo

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

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

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

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

Atropine Sulfate
Dose
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Bradydysrhymias
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0.5-1.0mg q 5 min to a max of 0.03-0.04 mg/kg

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

ACE inhibitors
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Atropine Sulfate
Practice Pearls
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Dilates the pupils Follow ETT with several PPV s Effects are enhanced by;
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Thiazides, antidepressants, ant psychotics Antihistamines, Procainamide, quinidine Dig, cholinergics, neostigmine

Adverse reactions with concurrent admin.

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

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

Calcium Chloride
Dose
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2-4 mg/kg (1-2G) of 10% slow IV q 10 min PRN May produce vasospasm in coronary/cerebral arteries Hypotension/bradycardia may result from rapid administration

Practice Pearls
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Calcium Chloride
Practice Pearls
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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
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A Fib/flutter Multifocal atrial tachycardias PSVT

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

Diltiazem (Cardizem)
Dose
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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
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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
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Inotropic support for patients with LV dysfunction AF/flutter Severe hypotension IHSS

Contraindications
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Diltiazem (Cardizem)
Dose
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2.5-10 mcg/kg/min IV based on inotropic effect. MAX RATE is 40mcg/kg/min Need accurate admin method (pump) Closely monitor BP Increase of HR of 10% may increase cardiac ischemia

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

Dopamine (Intropin)
Sympathomimetic Indications
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Hemodynamically significant hypotension in the absence of hypovolemia Tachydysrhythmias VF pheochromocytoma

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

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

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

Contraindications
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Flumazenil (Romazicon)
Dose
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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
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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
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PE associated with CHF, hepatic or renal disease Anuria Hypovolemia/dehydration

Contraindications
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Furosemide (Lasix)
Contraindications
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Electrolyte depletion 20-40 mg slow IV (1-2min) Double the daily dose

Dose
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Furosemide (Lasix)
Practice Pearls
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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
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Hemodynamically significant bradycardia refractive to other therapy TDP

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

Isoproterenol (Isuprel)
Dose
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1mg in 250 ml (4mcg/ml) infuse at 2-20 mcg/min Titrate to effect Increases myocardial oxygen demand Infusion pump Last ditch- pace first

Practice Pearls
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Isoproterenol (Isuprel)
Practice Pearls
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Beta adrenergic antagonists my blunt the inotropic response

Labetol (Normodyne)
Alpha-beta adrenergic blocker Indications
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Hypertensive emergencies Bronchial asthma (relative) Uncompensated CHF 2nd & 3rd AV block

Contraindications
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Isoproterenol (Isuprel)
Contraindications
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Bradycardia Cardiogenic shock Pulmonary edema 10-20 mg IV over 1-2 min May repeat or double q 20 to a max of 150 mg

Dose
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Isoproterenol (Isuprel)
Dose
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Infusion mix 200 in 250 (0.8 mg/ml) infuse at 2mg/min. Titrate to supine SBP, VS should be constantly monitored Observe for signs of CHF, bradycardia, bronchospasm

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

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

Lidocaine (Xylocaine)
Contraindications
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Adams-Stokes Syndrome 2nd or 3rd degree HB in the absence of a pacemaker 1.0-1.5 mg/kg consider repeat in 3 min Total IV dose is 3 mg/kg

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

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Run @ 2-4 mg/min

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

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

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

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

Norepinephrine (Levophed)
Contraindications
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Hypotensive pts with hypovolemia Dilute

Dose
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Norepinephrine (Levophed)
Practice Pearls
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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
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Hypertension Angina VF/VT and SVT refractory to other therapy

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

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

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

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

Propranolol (Inderal)
Practice Pearls
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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
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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
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Chloride loss from vomiting & GI Met or resp alkalosis Severe pulmonary edema Abdominal pain of unknown origin Hypo;
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Calcemia, kalemia, natremia

Sodium Bicarbonate
Dose
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1 mEq/kg IV with 0.5 mEq/kg repeat q 10 min When possible ABGs should be the guide Produces CO2 which may worsen cellular acidosis May worsen CHF

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

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Calcium May deactivate vasopressors

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

Verapamil (Calan)
Contraindications
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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
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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
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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
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Relief of bronchospasm Prevention of exercise induced bronchospasm

Albuterol (Proventil)
Contraindications
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dysrhythmia's associated with tachycardia Unit dose 0.083% 2.5 mg diluted to 3 ml

Dose
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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
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Hypoglycemia ALOC Coma/seizure of unknown etiology

Dextrose 50%
Contraindications
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Intracranial hemorrhage Known or suspected CVA in absence of hypogly. Increased intracranial pressure 12.5-25 G IV slowly

Dose
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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%
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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
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Acute anxiety states/alcohol withdrawal Skeletal muscle relaxation Seizure activity Premedication prior to cardioversion

Diazepam (Valium)
Contraindications
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in coma (unless there is seizure activity) CNS depression as a result of head injury respiratory depression Shock 5mg over 2 min IV q 10-15 min Max dose is 30mg

Dose
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Diazepam (Valium)
Practice Pearls
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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
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Bronchial asthma Acute allergic reaction Cardiac arrest Profound symptomatic bradycardia

Epinephrine (Adrenalin)
Contraindications
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Hypovolemia shock- correct volume deficit Use with caution in coronary insufficiency Cardiac arrest
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Dose
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1 mg IVP q 3-5 min 2.5 times the normal dose if via ETT

Epinephrine (Adrenalin)
Dose
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Drips
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Mix 1 mg ampule in 500 ml (2 mcg/ml) and infuse at 1-2 mcg/min titrate to desired response Mild- 0.3-0.5 mg (1:1000) SQ Severe- 1-2 ml (1:10000) slow IV

Anaphylactic reaction
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Epinephrine (Adrenalin)
Practice Pearls
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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
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Complications of IV epic are significant

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Uncontrolled hypertension Vomiting seizures dysrhythmia's

IV Epi should only be used in severe cases

Glucagon
Pancreatic Hormone, insulin antagonist Indications
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Persistent hypoglycemia despite glucose Only hypersensitivity 0.5-1 mg IM with one repeat in 7-10 min

Contraindications
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Dose
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Glucagon
Practice Pearls
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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
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Coma of unknown origin (with D50) DTs Beriberi Wernickes encephalopathy

Thiamine (Betaxin)
Contraindications
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None 100mg slow IV or IM Used to metabolize glucose Certain conditions predispose for defic.

Dose
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Practice Pearls
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Thiamine (Betaxin)
Practice Pearls
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Alcoholism/malnourishment

Give before D50

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

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

Procainamide (Pronestyl)
Dose
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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
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50% widening of QRS Hypotension

Procainamide (Pronestyl)
Practice Pearls
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Potent vasodilating and inotropic effects Rapid injection may cause hypotension Use caution
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Asthma, dig induced dysrhymias;s,, AMI Hepatic or renal insufficiency

Increases effects of skeletal muscle relaxants

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

Nitroglycerin (Nitrostat)
Contraindications
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Hypotension Head injury Cerebral hemorrhage 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.

Dose
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Nitroglycerin (Nitrostat)
Practice Pearls
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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
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Narcotic OD
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Morphine, heroin, hydromophone Methadone, meperidine, paregoric Fentanyl, oxycodone, codeine Propoxyphene

Coma unknown origin

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

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

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

Morphine Sulfate
Practice Pearls
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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
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Seizures of eclampsia TDP Hypomagnesaemia Refractory VF

Magnesium Sulfate
Contraindications
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Heart block or myocardial damage Eclampsic seizures

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Dose
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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
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Magnesium Sulfate
Practice Pearls
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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
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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
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May be used as an alternate vasopressor in cardiac arrest May be useful in hemodynamic support of dilatory shock

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

Dose
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Vasopressin
Practice Pearls
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Potent vasoconstrictor- may promote cardiac ischemia

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

Contraindications
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Midazolam (Versed)
Contraindications
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Alcohol intox (relative) Concomitant use of barbs, etoh, narc or other CNS depressants 1-2.5 mg IV slowly (1-2 min) Total max dose not to exceed 0.1 mg/kg

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

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

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

Digoxin (Lanoxin)
Practice Pearls
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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
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Unfractionated (UFH) Low molecular weight (LWH)

heparin
UFH Indications
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AMI Begin with fibrin specific lytics (alteplase) Active bleeding Recent intracranial, spinal or eye surgery

Contraindications
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heparin
Contraindications
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Severe hypertension Bleeding disorders GI bleeding Initial bolus- 60IU/kg (max bolus 4000IU) Continue @ 12IU/hr Therapuetic levels checked by labs

Dose
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heparin
Practice Pearls
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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.