Drug Names and Pharmacokinetics

Drug Names & Pharmacokinetics

• Alprazolam is also known as Xanax.
• Metformin is also known as Glucophage.
• Lorazepam is also known as Ativan.
• Furosemide is also known as Lasix.
• Diltiazem is also known as Cardizem.
• Donepezil is also known as Aricept.
• Midazolam is also known as Versed.
• Levetiracetam is also known as Keppra.
• Ondansetron is also known as Zofran.
• Diazepam is also known as Valium.
• Clonazepam is also known as Klonopin.
• Amlodipine is also known as Norvasc.
• Off-label medication use refers to using a medication for purposes, dosages, or routes of administration not approved by the FDA.
• Medications with a "stem" linking them to others in the same class are typically generic.
• Intravenous medications have 100% bioavailability.
• Dose-response curves illustrate the relationship between medication dose/concentration and efficacy.
• Therapeutic index is the difference between the median effective dose and the median toxic dose.
• Bioavailability refers to the percentage of unchanged medication reaching systemic circulation.
• Medications undergo first-pass metabolism in the liver.
• First-pass metabolism reduces the bioavailability of a medication before it reaches systemic circulation.
• First-order elimination rate is directly influenced by plasma levels of the substance.
• After 6 hours, 62.5 mg remains of a 500 mg medication dose with a half-life of 2 hours.
• A medication with a half-life of 12 hours and an initial dose of 100 mg has an unsolvable serum concentration after the 6th dose due to incomplete information.
• The stem "-pril" indicates an ACE inhibitor.

Receptors, Autonomics, & Pharmacokinetics

• The dose-response curve illustrates the relationship between medication dose and efficacy.
• Beta-1 adrenergic receptor stimulation increases heart rate.
• Bioavailability is the percentage of unchanged medication that reaches systemic circulation.
• The correct order of catecholamine production is dopamine to norepinephrine to epinephrine.
• Antagonists have a higher affinity for the receptor than the natural chemical mediator.
• SLUDGEM (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis, Miosis) is a mnemonic.
• Anticholinergic symptoms include flushed skin, decreased sweating, hyperthermia, dry mouth, increased heart rate, confusion, mydriasis, and urinary retention.
• Cholinergic symptoms: salivation, emesis, diarrhea, rhinorrhea, bradycardia, lacrimation, cramps, urination, pinpoint pupils (miosis)
• Examples of adrenergic agonists: Epinephrine, Norepinephrine, Phenylephrine, Dopamine, Dobutamine.
• Examples of adrenergic antagonists: Atenolol, Labetalol, Metoprolol, Propranolol.
• Cholinergic receptor medications include Atropine and Scopolamine.
• Medications undergo first-pass metabolism in the liver.
• Dobutamine's primary effect is increased inotropy.
• Alpha-1 receptor stimulation results in vasoconstriction.
• A medication with a negative chronotropic effect decreases heart rate.
• Beta-1 increases heart rate and contractility.
• Beta-2 causes bronchodilation.
• Alpha-1 leads to vasoconstriction and systemic BP elevation.
• Alpha-2 leads to vasodilation.
• First-pass metabolism reduces bioavailability before systemic circulation.
• A beta-1 adrenergic antagonist produces negative inotropic effects.
• Profound sedation from fentanyl and midazolam is an example of synergism.
• Therapeutic index is the difference between the median effective and toxic dose.
• Beta blockers' toxic effect: Bradycardia.

Legal, Ethical, & Drug Safety

• First action for EMS provider after a needle stick: Wash area immediately and report incident.
• Contacting online medical control is not mandatory after giving a medication.
• Schedule II drugs have accepted medical uses, unlike Schedule I drugs.
• "Duty to act" means a legal obligation to respond, treat, and transport.
• Good Samaritan laws protect individuals from liability when providing emergency aid.
• Abandonment is a paramedic leaving a patient at the hospital without report.
• Naloxone is an opioid antagonist.
• An adverse effect is an undesirable clinical change caused by a medication.
• Dextrose, a carbohydrate.
• Heroin is an example of a Schedule I drug.
• Pregnancy Category X indicates evidence of fetal risk based on human/animal data.
• Pharmacodynamics describes a drug's effects on its target organs.
• FDA Pregnancy Category A indicates no risk in controlled human studies.
• Category B indicates no risk or unconfirmed risk in animal studies.
• Category C indicates no human studies but possible animal risk.
• Category D indicates human data showing risk, where benefits may outweigh the risk.
• Category X indicates risk outweighs any potential benefit.
• Shelf life is the time during which a medication remains potent/effective if stored correctly.
• Schedule I drugs have high abuse potential and no accepted medical use.
• Signs of cholinergic excess: Pupillary constriction, hypersalivation, bradycardia.
• Beta-2 receptors: Medications treat bronchoconstriction.
• Inhaled medications affect pregnant women faster than non-pregnant women.
• OSHA stands for Occupational Safety and Health Administration.
• Ordinary negligence: failing to meet the standard of care, resulting in harm

Conversions & Med Math

• There are a series of conversions, including:
  • 89 kg = 89,000 g
  • 181 mg = 181,000 mcg
  • 2.8 g = 2,800 mg
  • 1.1 L = 1,100 mL
  • 58 mL = 58 cc
  • 181 lbs = 82 kg
  • 1,264 mg = 1.26 g
  • 360 mL = 0.36 L
  • 98 cc = 98 mL
  • 579 mcg = 0.579 mg
  • 266 lbs = 120.9 kg
  • 334 mg = 0.334 g
  • 1,855 mL = 1.855 L
  • 6 cc = 6 mL
  • 2.9 kg = 2,900 g
  • 456 mg = 456,000 mcg
  • 1,276 mcg = 1.276 mg
  • 723 g = 0.723 kg
  • 0.67 L = 670 mL
  • 93 kg = 205 lbs

Applied Med Math & Dosing

• The following conversions and calculations are relevant:
  • 400 mg = 400,000 mcg
  • Dextrose 25% = 250 mg/mL
  • 132 lbs = 60 kg
  • 50 mL = 0.05 L
  • 200 mcg = 0.0002 g
  • Dextrose 10% = 100 mg/mL
  • 198 lbs = 90 kg
  • 0.8 g = 800,000 mcg
  • 200 cc = 200 mL
  • Amiodarone 150 mg in 3 mL vial requires 3 mL for 150 mg.
  • An adenosine second dose of 12 mg from a vial with 6 mg/2 mL requires a draw up of 4 mL.
  • Dexamethasone 12 mg needed from a vial = 10 mg/mL requires Draw of 1.2 mL.
  • 176 lbs = 80 kg.
  • Atropine 0.02 mg/kg for a 40 lb child requires a 0.36 mg dose.
  • For an atropine vial = 1 mg/10 mL → draw up 3.6 mL.
  • 3.05 g = 3,050 mg.
  • Lidocaine 2% = 20 mg/mL.
  • Dextrose dose = 0.5 g/kg for 88 lb child (40 kg) requiring a 20 g dose.
  • Dextrose 25% = 250 mg/mL which requires a draw up of 80 mL.
  • IO Lidocaine 0.5 mg/kg for 110 lb pt (50 kg) requires 25 mg.
  • Lidocaine 2% = 20 mg/mL needs to be drawn up to 1.25 mL.
  • Fentanyl 1 mcg/kg for 154 lb pt (~70 kg) requires 70 mcg.
  • With Fentanyl = 100 mcg/2 mL, draw up 1.4 mL.

BLS Medications & Mechanisms

• Albuterol is a Beta-2 agonist.
• Aspirin is antiplatelet, so it's not an anticoagulant.
• Epinephrine is sympathomimetic.
• Narcan (Naloxone) is an opioid antagonist.
• Glucose is a carbohydrate.
• Nitroglycerin's route is sublingual (SL).
• The minimum SBP for nitroglycerin is 120 mmHg.
• Aspirin is not an anticoagulant.
• NYC Protocol for oral glucose includes patients who are conscious, able to swallow without assistance, and have AMS with BGL < 60 mg/dL.
• Activated charcoal binds toxins in the GI tract, reducing absorption.
• Nitroglycerin's side effects are hypotension and headache.
• Albuterol's is tachycardia.
• Epinephrine is the first-line BLS medication for anaphylaxis after O2.
• Naloxone has a shorter half-life than heroin, thus redosing may be needed.
• Nerve agent symptoms include bronchospasm, bradycardia, vomiting, salivation, urination, and miosis.
• The nerve agent mechanism inhibits acetylcholinesterase, leading to unopposed PNS stimulation.
• Epinephrine has no contraindications in anaphylaxis.
• Aspirin inhibits COX enzyme, blocks thromboxane A2 and prevents platelet aggregation.
• Activated charcoal is a toxic ingestion antidote/absorbent.
• Albuterol is for asthma or COPD.
• Aspirin is for acute coronary syndrome.
• Epinephrine is for anaphylaxis.
• Oxygen is for dyspnea.
• Narcan is for opioid overdose.
• Glucose is for hypoglycemia.
• Atropine is for organophosphate poisoning.
• Albuterol's MOA is Beta-2 agonist leading to bronchodilation.
• The initial Atropine dose for nerve agent exposure is 2 mg IM.
• Asthma treatment for child w/ wheeze: Albuterol 0.083% + Ipratropium 0.02%.
• Associated asthma symptoms: Wheezing and tachypnea.

Conversions & Med Math

• 89 kg converts to 89,000 g
• 181 mg converts to 181,000 mcg
• 2.8 g converts to 2,800 mg
• 1.1 L converts to 1,100 mL
• 58 mL converts to 58 cc
• 181 lbs converts to 82 kg
• 1,264 mg converts to 1.26 g
• 360 mL converts to 0.36 L
• 98 cc converts to 98 mL
• 579 mcg converts to 0.579 mg
• 266 lbs converts to 120.9 kg
• 334 mg converts to 0.334 g
• 1,855 mL converts to 1.855 L
• 6 cc converts to 6 mL

Applied Med Math & Dosing

• 400 mg is equivalent to 400,000 mcg.
• Dextrose 25% has a concentration of 250 mg/mL.
• 132 lbs converts to 60 kg.
• 50 mL is equal to 0.05 L.
• 200 mcg is the same as 0.0002 g.
• Dextrose 10% has a concentration of 100 mg/mL.
• 198 lbs converts to 90 kg.
• 0.8 g is equivalent to 800,000 mcg.
• 200 cc is equal to 200 mL.
• For Amiodarone at 150mg in 3mL, 3mL are required.
• With adenosine at 12 mL dose and 6mg/2mL, 4mL are requires.
• With dexamethasone at 12 mg does and 10mg/mL, 1.2mL are needed.
• 176 lb is equal to 80 kg.
• Atropine at 0.02 mg/kg for a 40 lb child means the dose is 0.36 mg.

BLS Medications & Mechanisms

• Albuterol is a Beta-2 agonist.
• Aspirin is classified as an antiplatelet, not an anticoagulant.
• Epinephrine is a sympathomimetic medication.
• Narcan (Naloxone) acts as an opioid antagonist.
• Glucose is a carbohydrate.
• Nitroglycerin should be administered via the sublingual (SL) route.
• Nitroglycerin requires a minimum SBP of 120 mmHg.
• Aspirin functions as an antiplatelet, not an anticoagulant.
• Per the NYC Protocol, oral glucose can be administered if the patient is conscious, able to swallow, and has AMS with a BGL less than 60 mg/dL.
• Activated charcoal's mechanism of action involves binding toxins in the GI tract, thereby reducing their absorption.
• Potential side effects of nitroglycerin: Hypotension, headache.

Enteral Routes & Administration

• Enteral medication absorption is successful because the GI system is highly vascular
• Enteral absorption typically takes 30–90 minutes.
• Disadvantages of the sublingual route: Low bioavailability, delayed absorption with lack of saliva.
• The sublingual route has good absorption due to the rich blood supply in the mucosa.
• Diazepam is administered rectally.
• Aspirin is administered orally.
• Nitroglycerin is administered sublingually.
• Glucose is administered buccally.
• Give it left lateral with knees to chest for proper rectal administration.
• Vomiting, unresponsiveness, seizures, and inability to swallow are conditions that prefer rectal over oral routes.
• Enteral forms include pills, capsules, suppositories, suspensions, emulsions, and syrups.
• Per NYC REMAC, oral meds can include aspirin, acetaminophen, dexamethasone, and ondansetron.
• Oral medications are unsafe for AMS patients.
• It is important to lubricate the syringe before rectal administration.
• NG/OG tubes are enteral routes of medication.
• PO, per os ("by mouth").
• Rectal administration uses suppositories.
• A needle is not required for rectal syringe medication administration.
• The 6 Rights: Right patient, route, dose, medication, time, and documentation.
• Enteral medication effectiveness can be reduced by dry mucosa, AMS, dysphagia, or a recent meal.
• Suppositories are solid at room temperature and melt in the rectum.
• Nasal is not enteral.
• Enteral medications undergo first-pass metabolism, while parenteral medications do not.

Parenteral Routes, Drip Rates, IV Therapy

• The IV route is 100% bioavailable.
• The IM route is ineffective in late decompensated shock.
• Types of IV fluids: Isotonic, hypertonic, and hypotonic
• Common drip sets: Macro & micro.
• IV complications include infiltration, phlebitis, obstruction, and hematoma.
• IO contraindications: Osteogenesis imperfecta, bone fracture, and infection.
• SQ injection sites: Upper arms, anterior thighs, and abdomen.
• Long-term access devices (e.g. PICC) are used for antibiotics, chemo, dialysis, and chronic illness.
• Vasopressors require a flow-control device.
• Vasopressors require a large bore IV.
• Mixing 2 mg norepinephrine in 250 mL D5W gives a concentration of 8 mcg/mL.
• Mixing 400 mg dopamine in 250 mL NS gives a concentration of 1,600 mcg/mL.
• If nitroglycerin 0.4 mg needed with a vial of 50 mg/10 mL then draw up 0.08 mL.
• Epinephrine drip 2 mcg/min, mix 1 mg in 250 mL will need a drip rate of 30 gtts/min.
• Magnesium 4 g over 10 min in 100 mL NS with a 10 gtt set means 100 gtts/min.
• 20 mL/kg bolus for 198 lb pt has a drip rate of 2,700 gtts/min.
• Dopamine 20 mcg/kg/min for 132 lb pt, mix 800 mg in 500 mL will require a drip rate of 45 gtts/min.
• Epinephrine 4 mcg/min; mix 2 mg in 500 mL D5W, which requires a drip rate of 60 gtts/min.
• Amiodarone 150 mg in 100 mL D5W over 10 min with a 10 gtt set requires 100 gtts/min.
• A newborn with a BGL of 22 mg/dL, at 7 lbs (3.2 kg), and receiving a dose of 0.5 g/kg (1.5 g) requires 15 mL of D10.

Pediatrics, Pregnancy, & Renal Dosing

• Pediatric anaphylaxis: a 33 lb child requires 0.01 mg/kg Epi to equal 0.15 mg.
• The safest FDA category in pregnancy is A.
• Drug classes with renal risk include ACE inhibitors, antiarrhythmics, antibiotics, and digoxin.
• Common causes of CKD: HTN, uncontrolled diabetes
• HTN after 20 weeks without proteinuria is gestational hypertension.
• DKA with aggressive fluid risk can cause cerebral edema.
• A paradoxical reaction is the opposite effect of the intended outcome.
• Age-related dose changes mean decreased cardiac output, body water, liver function, and renal function.
• Rare IO complications include infiltration, compartment syndrome, fat embolus, osteomyelitis, tibial fracture, and cellulitis.
• Corticosteroids mimic cortisol, from the adrenal glands, with uses as anti-inflammatories and Immunosuppressives.

Cardiac Medications

• Beta blocker adverse effects: Hypotension, bradycardia, dizziness.
• Initial treatment for angina/NSTEMI: O2, aspirin, nitroglycerin, morphine.
• Digoxin indications: CHF, atrial fibrillation/flutter, narrow PSVT.
• Heparin indications: ACS, DVT, PE
• Beta blockers: Metoprolol, Tenormin, Inderal.
• Lidocaine class: 1B Sodium Channel Blocker.
• Bradycardia meds: Epinephrine, atropine.
• Atropine has the adverse effect of paradoxical bradycardia if given too slowly/low dose.
• Lasix class: Loop diuretic.
• Morphine is contraindicated in respiratory depression and hypotension.
• Lasix adverse effects include hypokalemia, orthostatic hypotension, and vertigo.
• Immediate CHF meds: Lasix, nitroglycerin, morphine.

Cardiac Medications

• Amiodarone's actions: Sodium, Potassium, Calcium channel blocker.
• Nitroglycerin's MOA decreases preload via smooth muscle relaxation.
• Lopressor blocks Beta receptors.
• Calcium channel blockers: Verapamil, Cardizem.
• Glycoprotein IIb/IIIa inhibitor: Aggrastat.
• Morphine's MOA in chest pain reduces sympathetic drive and O2 demand.
• Amiodarone treats PVCs, V-tach, and A-tach.
• Magnesium sulfate is used for Torsades de pointes.

Shock, Fluids, & Vasopressors

• Multi-organ failure ensues if shock is not treated.
• Types of shock include obstructive, cardiogenic, hypovolemic, and distributive.
• Pericardial tamponade: Cardiogenic + obstructive shock.
• Causes of obstructive shock: PE, tension pneumo, tamponade, and aortic stenosis.
• Hypotension isn't an early finding in shock.
• First-line treatment for anaphylactic shock: Epinephrine, not fluids/steroids.
• Universal donor blood type: O.
• Shock Matching:
  • Hypovolemic: Control bleed, IV fluids
  • Cardiogenic: IV fluids, chronotropes
  • Neurogenic: IV fluids, vasoconstrictors
  • Septic: IV fluids, vasodilation, inotropes
  • Anaphylactic: Epinephrine, fluids, antihistamines

Sepsis Specifics, Drug Names, and Bioavailability

• Fever indicates sepsis.
• Cardiogenic shock signs: Rales, SOB, delayed cap refill, and pulmonary edema.
• The volume of 1 unit of PRBC is 350 mL.
• Normal Saline solution is compatible with blood.
• Normal Saline is not ideal for hemorrhagic shock because it has no O2-carrying/clotting ability.
• A faster allergic onset means the reaction is more severe.
• The vasoconstrictor of choice for neurogenic shock is phenylephrine.
• 132 lbs dopamine drip for septic patients requires 45 gtts/min.
• An epinephrine drip for neurogenic shock is a mix 2 mg in 500 mL, 60 gtts/min.
• A 20 mL/kg bolus for a 198 lb individual requires 2,700 gtts/min.
• A pediactric epi drip of 1 mg in 250 mL should be at 30 gtts/min.
• Key drugs to know (generic and trade names):
  • Alprazolam (Xanax)
  • Metformin (Glucophage)
  • Lorazepam (Ativan)
  • Furosemide (Lasix)
  • Diltiazem (Cardizem)
  • Midazolam (Versed)
  • Diazepam (Valium)
  • Clonazepam (Klonopin)
  • Levetiracetam (Keppra)
  • Amlodipine (Norvasc)
  • Ondansetron (Zofran)
  • Donepezil (Aricept)
• IV route offers 100% bioavailability.
• Oral meds undergo first-pass metabolism in the liver, reducing the drug before it enters systemic circulation.
• Pharmacodynamics describes what a drug does to the body, including receptor activation, dose-response, and effect.
• Pharmacokinetics describes how the body processes the drug, with absorption, distribution, metabolism, and excretion.

Math Conversions & Shock Treatment Protocol

• Shock is matched with control to treat the issue.
• A quick reference to understand common concentrations for the use of drugs during an IV drip.
• A table illustrates pregnancy safety.

Drug Usage Action

• A helpful understanding of the type of drug, and common uses for emergency situations when using medication.