Formulary 2023-2024 EMS Drug Guide PDF

Formulary 2023-2024 A Drug Guide for Paramedics Originally wrote by Brett Peine, NRP Edited by Hannah Walker, NRP, BS (2023) Missouri Southern State University Department of EMS...

Formulary 2023-2024 A Drug Guide for Paramedics Originally wrote by Brett Peine, NRP Edited by Hannah Walker, NRP, BS (2023) Missouri Southern State University Department of EMS 3950 E Newman Road Joplin, MO 64801 1  Table of Contents Introduction v Preface vii Medications (Listed Alphabetically by Generic Name) Generic Name Brand Name/Common Name Acetaminophen Tylenol, APAP 3 Activated Charcoal Actidose, Aquadose, Insta-Char 4 Adenosine Adenocard 5 Albuterol 0.5% Proventil, Ventolin 7 Alteplase TPA, Activase 9 Amiodarone Cordarone 11 Ammonia Inhalants “Smelling Salts” 13 Amyl Nitrate “Poppers” 14 Aspirin Acetylsalicylic Acid, ASA 15 Atenolol Tenormin 17 Atropine Sulfate Atropine 19 Calcium Chloride 10% Calcium Chloride, Calcijet 21 Calcium Gluconate 10% Calcium Gluconate 23 Clopidogrel Bisulfate Plavix 25 Dexmedetomidine Precedex 27 Dexamethasone Decadron 29 Dextrose in Water Dextrose, D10, D25, D50 31 Diazepam Valium 32 Digoxin Digitalis, Lanoxin 34 Dilitiazem Cardizem 36 Diphenhydramine Benadryl 38 Dobutamine Dobutrex 40 Dopamine Inotropin 42 Epinephrine Adrenaline 44 Etomidate Amidate 46 Fentanyl Sublimaze 47 Flumazenil Romazicon 49 Furosemide Lasix 51 Glucagon Glucagen 53 Haloperidol Haldol 55 Heparin Heparin 56 Hydromorphone Dilaudid 58 Generic Name Brand Name/Common Name Hydroxocobalamin Cyanokit 59 Ipratropium 0.02% Atrovent 60 Ketamine Ketalar 61 Ketorolac Toradol 62 Labetolol Tramdate, Normodyne 63 Levalbuterol Xopenex 65 Lidocaine Xylocaine 66 Lorazepam Ativan 68 Magnesium Sulfate 10% MgSO4, “Mag” 70 Mannitol 20% Osmitrol 72 Meperidine Demerol 74 Metaproterenol 5% Alupent 75 Methylprednisolone Solu-Medrol 76 Metoclopramide Reglan 77 Metoprolol Lopressor 78 Midazolam Versed 79 Morphone Sulfate Morphine 81 Naloxone Narcan 83 Nifedipine Procardia 85 Nitrates Nitroglycerin 86 Norepinephrine Levophed 88 Ondansetron Zofran 90 Oral Glucose Insta-Glucose, Glutose, GlucoBurst 91 Oxygen O2 92 Oxytocin Pitocin 94 Pancuronium Bromide Pavulon 96 Phenytoin Dilantin 97 Potassium Chloride K-Lor, KCl 98 Pralidoxime 2-PAM 99 Prednisone Deltasone 100 Procainamide Pronestyl 101 Promethazine Phenergan 103 Propofol Diprivan 104 Propranolol Inderal 106 Racemic Epinephrine MicroNEFRIN 108 Reteplase Retavase 109 Rocuronium Bromide Zemuron 110 Sodium Bicarbonate 8.4% NaHCO3, Bicarb 111 Generic Name Brand Name/Common Name Sodium Nitrate Chili Saltpeter, Soda Nitre 112 Sodium Nitroprusside Nipride 113 Sodium Thiosulfate Dechlor 114 Streptokinase Streptase 115 Succinylcholine Anectine 117 Terbutaline Brethine 119 Thiamine Vitamin B1 121 Tranexamic Acid TXA 122 Vasopressin Pitressin 123 Vecuronium Bromide Norcuron 124 Index 125  Medications (Listed Alphabetically by Brand/Common Name) Brand Name/Common Name Generic Name “Poppers” Amyl Nitrate 14 “Smelling Salts” Ammonia Inhalants 13 2-PAM Pralidoxime 99 Acetylsalicylic Acid, ASA Aspirin 15 Actidose, Aquadose, Insta-Char Activated Charcoal 4 Adenocard Adenosine 5 Adrenaline Epinephrine 44 Alupent Metaproterenol 5% 75 Amidate Etomidate 46 Anectine Succinylcholine 117 Ativan Lorazepam 68 Atropine Atropine Sulfate 19 Atrovent Ipratropium 0.02% 60 Benadryl Diphenhydramine 38 Brethine Terbutaline 119 Calcium Chloride, Calcijet Calcium Chloride 10% 21 Calcium Gluconate Calcium Gluconate 10% 23 Cardizem Diltiazem 36 Chili Saltpeter, Soda Nitre Sodium Nitrate 112 Cordarone Amiodarone 11 Cyanokit Hydroxocobalamin 59 Decadron Dexamethasone 29 Dechlor Sodium Thiosulfate 114 Deltasone Prednisone 100 Demerol Meperidine 74 Dextrose, D10, D25, D50 Dextrose in Water 31 Digitalis, Lanoxin Digoxin 34 Dilantin Phenytoin 97 Dilaudid Hydromorphone 58 Diprivan Propofol 104 Dobutrex Dobutamine 40 Glucagen Glucagon 53 Haldol Haloperidol 55 Heparin Heparin 56 Inderal Propranolol 106 Inotropin Dopamine 42 Insta-Glucose, Glutose, GlucoBurst Oral Glucose 91 Ketalar Ketamine 61 K-Lor, KCl Potassium Chloride 98 Lasix Furosemide 51 Levophed Norepinephrine 88 Lopressor Metoprolol 78 MgSO4, “Mag” Magnesium Sulfate 10% 70 MicroNEFRIN Racemic Epinephrine 108 Morphine Morphine Sulfate 81 NaHCO3, Bicarb Sodium Bicarbonate 8.4% 111 Narcan Naloxone 83 Nipride Sodium Nitrorusside 113 Nitroglycerin Nitrates 86 Norcuron Vecuronium Bromide 124 O2 Oxygen 92 Osmitrol Mannitol 20% 72 Pavulon Pancuronium Bromide 96 Phenergan Promethazine 103 Pitocin Oxytocin 94 Pitressin Vasopressin 123 Plavix Clopidogrel Bisulfate 25 Precedex Dexmedetomidine 27 Procardia Nifedipine 85 Pronestyl Procainamide 101 Proventil, Ventolin Albuterol 0.5% 7 Reglan Metoclopramide 77 Retavase Reteplase 109 Romazicon Flumazenil 49 Solu-Medrol Methylprednisolone 76 Streptase Streptokinase 115 Sublimaze Fentanyl 47 Tenormin Atenolol 17 Toradol Ketorolac 62 TPA, Activase Alteplase 9 Tramdate, Normodyne Labetolol 63 TXA Tranexamic Acid 122 Tylenol, APAP Acetaminophen 3 Valium Diazepam 32 Versed Midazolam 79 Vitamin B1 Thiamine 121 Xopenex Levalbuterol 65 Xylocaine Lidocaine 66 Zemuron Rocuronium Bromide 110 Zofran Ondansetron 90 Index 125  Introduction With any investigation into pre-hospital pharmacology, or pharmacology at all, one will quickly find numerous references with varying and often conflicting information on medication dosages, indications, contraindications, and side effects. For the aspiring Emergency Medical Technician or Paramedic, this can be confusing and cause some angst. This book was developed to serve as the reference of choice for the students enrolled in an Emergency Medical Services Program at Missouri Southern State University. I still encourage you to seek all information possible, including from other sources. However, for the purposes of answering test questions and treating “simulated” patients this guide should be your reference. As with any skill, technique, treatment, or intervention in Emergency Medical Services the technician should follow applicable protocols and physician orders. This guide serves as a general reference for the medications you will be required to know during this course of study. Students should be familiar with and follow the directions of this book for testing and “simulated” patient purposes. It is important to understand the Missouri Southern State University Department of EMS Formulary (MSSU EMS Formulary) is only used when treating “simulated” patients. During hospital clinical rotations and the field internship, you should follow physician orders, preceptor directions, and the approved protocols for the specific hospital or service at which you are studying. Care has been taken to ensure that the dosages of drugs and schedules of treatment are correct and compatible with standards generally acceptable at the time of publication. Nevertheless, as new information becomes available, changes in treatment and in the use of drugs become necessary. The reader is advised to carefully consult the instruction and information material included in the package insert of each drug or therapeutic agent before administration. This advice is especially important when using, administering, or recommending new and infrequently used medications. The author disclaims all responsibility, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this handbook.  Preface This book was designed for the Missouri Southern State University Emergency Medical Services Department. It serves as a convenient guide for students by providing current, reliable information about emergency drugs, and a comprehensive profile of approximately 76 medications used in the community emergency setting. The medications are alphabetized by their generic names with their trade names in parentheses. Following the listing is the phonetic pronunciation of the medication. Each drug is profiled with the following information: Generic Name: This is the generic or common name of the medication. Trade Name: These are the trade or registered brand names given to the medications by their respective manufacturer. Phonetic Pronunciation: This is the pronunciation guide with the accent or emphasis on the syllable in bold. Class: This describes the class in which the drug is classified. Many medications may have multiple classifications. Action: This describes the mechanism by which the specific drug produces physiologic and bio- changes at the cellular level. This includes time of onset and duration of action. Emergency Use: These are the indications for using the drug in an emergency setting. Side Effects: Virtually all medication will have adverse side effects that may be bothersome for some patients but not to others. In this entry, the side effects are listed according to systems or organs. Contraindications: Many medications are contraindicated and therefore harmful and should not be used in specific conditions. In this entry, medications have absolute and relative contraindications. This means, in the absolute, these medications should not be used. In the relative, these medications can be used but should be used with extreme caution. Drug Interactions: This describes the different situations in which medications will interact with another medication. The effects of the medication are either increased or decreased, or they will produce a new effect that neither produces on its own. Special Notes: This section involves special considerations when administering the medication. Adult Dose: This section describes how the medication is commonly administered to the adult, usually over the age of eighteen, patient. Pediatric Dose: This section describes how the medication is commonly administered to the pediatric patient, usually under the age of eighteen. Route: This is the way or route the medication is commonly administered to the patient. Pregnancy Safety This section describes the risk to the unborn fetus while giving the medication to a pregnant patient. The categories are: Category A - Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters). Category B - Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. Category C - Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Category D - There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Category X - Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits. MEDICATIONS Name: Acetaminophen (Tylenol®, APAP) (a SEET a MIN oh fen) Used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds, menstrual cramps, and fevers. Class: Analgesic; Anti-inflammatory; Anti-pyretic Action: 1. Acts by reducing production of prostaglandins, which are involved in the pain and fever processes, by inhibiting the cyclooxygenase (COX) enzyme. 2. Relieves mild to moderate pain by elevating your body's overall pain threshold. 3. Lowers fever by helping your body eliminate excess heat. 4. Onset of action is within 10 minutes. 5. Duration of action is 4 to 6 hours. Use: 1. Mild to moderate pain reliever. 2. Fever reducer. Side effects: CNS: Dizziness; Lethargy; Hives; Edema to face, lips, tongue, or throat Respiratory: Dyspnea Gastrointestinal: Nausea; Vomiting; Heartburn; Stomach pain; Dark urine; Clay colored stools Other: Jaundice (yellowing of the skin or eyes), Liver toxicity/failure Contraindications: Absolute: Known allergy to acetaminophen Relative: Hepatic disease; Kidney disease (severe); Chronic alcoholism Note: Use with caution in patients who report allergies to NSAIDS. Drug Interactions: Ethanol (alcohol) may increase risk of liver damage while taking acetaminophen. Special Notes: 1. Maximum Dose is 1 g (1000 mg) and 3 g (3000 mg) per day. 2. Acetaminophen is used in combination with other drugs in several over-the-counter medications and can be a possible cause for accidental overdose. Adult Dose: 325 to 650 mg every 4 to 6 hours. Not to exceed 3250 mg/day. Pediatric Dose: Refer to Length Based Tape for appropriate dose. Route: PO, Suppository Pregnancy Safety: Category B / No possible adverse effect on fetus in laboratory testing. 3 Name: Activated Charcoal (Actidose®; Aquadose, Insta-Char) (AK ti vay ted CHAR coal) Used in the emergency treatment of certain kinds of ingested poisoning. Class: Adsorbent; Antidote Action: 1. Binds with many drugs and chemicals inhibiting the absorption rate in the gastrointestinal tract. 2. Onset of action is immediate. 3. Duration of action continual while in the GI tract. Use: 1. Overdose and poisoning. 2. Most oral poisonings and medication overdoses. Side effects: Abdominal cramps; Black stools; Constipation; Nausea; Vomiting; Diarrhea Contraindications: Absolute: Altered mentation (comatose); Inability to maintain own airway (unless given by nasogastric/orogastric tube); Patient with aspiration or impending aspiration; Avoid use in Cyanide, Methanol, Organophosphate toxicity, and/or Caustic ingestion; GI obstruction Relative: Known minimal toxic ingestion Drug Interactions: 1. Do not use before Ipecac if vomiting is to be induced. Ipecac is absorbed by activated charcoal. 2. Bonds with and generally inactivates whatever it is mixed. Special Notes: 1. Often used in conjunction with magnesium citrate. 2. Must be stored in a closed container. 3. Not effective with cyanide, strong acids and alkalis, metals (iron, lead), arsenic, and hydrocarbons. 4. Milk products decrease activated charcoal's effectiveness. 5. Charcoal is often mixed with sorbitol to promote elimination from the gastrointestinal tract and to prevent constipation. 6. If aspirated, activated charcoal can possibly cause fatal pneumonia. 7. Consider contacting poison control and medical control for more information. Adult Dose: 1 g/kg (typically 50 to 100 g) mixed with a glass of water to form a slurry and administered PO or slowly by gastric tube. Pediatric Dose: 1 g/kg mixed with a glass of water to form slurry. Route: PO; Gastric tube Pregnancy Safety: Category C 4 Name: Adenosine (Adenocard®, Adenoscan, C10H13N5O4) (ah DEN oh seen) Used for treating supraventricular tachycardia, a rhythm disturbance of the heart. Class: Endogenous nucleotide; Antiarrhythmic Action: 1. Naturally occurring nucleoside that slows/interrupts the reentry pathways through the AV node, thereby slowing conduction. 2. Has a direct effect on supraventricular tissue. 3. Blocks potassium and calcium channels in the conduction system, inhibiting the elimination of potassium and influx of calcium. Causing hyperpolarization and slowing down the heart rate. 4. Onset of action is immediate (half-life of 10 seconds or less). Use: Supraventricular tachycardia (SVT; PSVT) that is refractory to vagal maneuvers (Referred to as chemical cardioversion). Side effects: CNS: Apprehension; Blurred vision; Dizziness; Facial flushing; Headache; Numbness; Tingling in arms; Sweating Respiratory: Dyspnea; Tightness in throat; Hyperventilating, Bronchospasm Cardiovascular: Heart blocks; Transient dysrhythmias; Burning sensation; Chest pain; Hypotension; Palpitations Gastrointestinal: Nausea; Metallic taste Other: Back pain; Heaviness in arms and neck; Pressure in groin Contraindications: Absolute: Known hypersensitivity; Second- or third-degree heart block; Sick sinus syndrome; Poison induced tachycardia Relative: None Note: Use caution in patients with asthma and bronchospasm. Drug Interactions: 1. Methylxanthines (theophylline-type drugs) and caffeine prevent binding of adenosine at receptor sites. Larger doses may be needed. 2. Dipyridamole (Persantine) potentiates effects of adenosine. Smaller doses may be effective. 3. Carbamazepine (Tegretol) may result in the development of high-degree blocks. Special Notes: 1. Monitor heart rate and cardiac rhythm closely. 2. Warn patients of possible side effects, including dizziness and loss of consciousness. 3. May produce brief periods of asystole/heart block. 4. Transient PVCs, PACs, sinus bradycardia, or sinus tachycardia may occur after the administration of adenosine. 5. Medication must be pushed into the access port closest to the patient’s heart. 6. Cardiac transplant patients may require only a small dose. 7. May produce bronchoconstriction in patients with asthma or other bronchopulmonary diseases. 5  8. Adenosine should be administered as a rapid bolus due to its rapid metabolism. Adult Dose: Initial dose 6 mg (rapid bolus), followed by a rapid saline flush. May repeat at the 2-minute interval with 12 mg (rapid bolus) followed by a rapid saline flush, for a total dose of 18 mg. Pediatric Dose: 0.1 mg/kg up to 6 mg (rapid bolus) followed by a rapid saline flush. May repeat in two minutes with 0.2 mg/kg (max. 12mg) followed by a rapid saline flush, for a max dose of 18 mg. Follow guidelines on length-based tape (Browslow® Tape) Route: IVP, as rapid as possible. Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 6 Name: Albuterol (Ventolin®; Proventil®) (al BYOU ter ahl) Used to treat or prevent bronchospasm in patients with COPD (asthma, bronchitis, emphysema) and other lung diseases. Albuterol is also used to prevent wheezing caused by exercise (exercise-induced bronchospasm). Class: Beta-2 adrenergic agonist; Sympathomimetic (sympathetic agonist); Bronchodilator Action: 1. Binds and stimulates beta-2 receptors, which results in relaxing bronchial smooth muscle. 2. Some beta 1 stimulation, no Alpha stimulation. 3. Activates cAMP via a non-beta receptor mechanism. For this reason, it is sometimes used in beta-blocker overdoses. 4. It also activates the Na-K pump by the same mechanism, which is useful in treating hyperkalemia. 5. Onset of action is from 5 to 15 minutes. 6. Duration of action approximately 3 to 6 hours. Use: 1. Treatment of bronchospasm in patients with reversible chronic obstructive airway disease (COPD). 2. Prevention of exercise induced bronchospasm. 3. Toxic gas inhalation. 4. Beta-blocker overdose. 5. Hyperkalemia Side effects: CNS: Headache; Tremor; Sweating; Anxiety; Dizziness; Insomnia; Restlessness; Dilated pupils (Mydriasis). Respiratory: Paradoxical bronchospasm. Cardiovascular: Angina (chest pain); Palpitations; Ectopic beats; Cardiac dysrhythmias; Hypertension; Tachycardia Gastrointestinal: Drying of oropharynx; Nausea; Vomiting; Unusual taste. Other: Hyperglycemia; Muscle cramps; Dry nose and throat. Contraindications: Absolute: Known hypersensitivity; Vomiting Relative: Cardiovascular disorders; Cardiac arrhythmias, hypokalemia Note: Use caution in patients who are lactating. Drug Interactions: 1. Beta blockers antagonize (inhibit) effects of albuterol. 2. Tricyclic antidepressants may potentiate vascular effects. 3. May potentiate hypokalemia caused by diuretics. 4. Possibility of developing unpleasant side effects increases when administered with other sympathetic agonists. Has a synergistic effect with other sympathomimetics. Special Notes: 1. Requires adequate tidal volume to distribute medication to the distal airways. 2. May cause severe paradoxical bronchospasm from repeated excessive use. 3. May precipitate angina pectoris and dysrhythmias. 4. Should be used with caution in patients with diabetes, hyperthyroidism, prostatic hypertrophy, or seizure disorder. 7  5. Should be administered only by nebulizer in the field. Adult Dose: 2.5 to 5 mg mixed with 3 ml saline into nebulizer and flow oxygen at 6 to 8 Lpm. Repeat PRN. Pediatric Dose: 0.63 to 2.5 mg into nebulizer and flow oxygen at 6 to 8 Lpm. Repeat every 20 minutes for a total of three doses. Route: Metered Dose inhaler, Nebulized inhalation Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 8 Name: Alteplase Recombinant (t-PA (tissue plasminogen activator); Activase®) (alt EH place ree KOM bi nant) Used for treating blood clots that have formed in certain blood vessels and to improve heart function and survival following an acute myocardial infarct (heart attack). Class: Thrombolytic enzyme; Anticoagulant, Fibrinolytic Action: 1. Enzyme which has the property of fibrin-enhanced conversion of plasminogen in plasmin. 2. It produces limited conversion of plasminogen in the absence of fibrin. 3. When introduced into systemic circulation, it binds to fibrin in the thrombus and converts the entrapped plasminogen to plasmin. 4. Plasmin initiates local fibrinolysis with limited systemic proteolysis, thus dissolving the thrombus at its site. 5. Onset of action is less than 90 minutes. 6. Duration of action is 4 to 6 hours. Use: 1. Evolving acute myocardial infarction (AMI) 2. Acute pulmonary embolism 3. Acute ischemic cerebrovascular accident (CVA) Side effects: Cardiovascular: Dysrhythmias; Minor bleeding to severe hemorrhage; Hypotension; Anemia Gastrointestinal: Nausea; Vomiting Other: Fever; Mild hypersensitivity may produce urticaria; Anaphylaxis (rare) Contraindications: Absolute: Active internal bleeding; History of hemorrhagic cerebrovascular accident; Recent intracranial surgery or trauma (within 2 months); Intracranial neoplasm, arteriovenous malformation, or aneurysm; Severe uncontrolled hypertension; Pregnancy; known bleeding disorders Relative: Peptic ulcer; Blood in stool; Current use of warfarin compounds; Known bleeding disorder; Liver dysfunction; Kidney failure Drug Interactions: 1. Using with other anticoagulants may increase risk of bleeding. 2. Incompatible with dextran. 3. Administer through a filter. Special Notes: 1. Screen patients carefully for contraindications and relative contraindications before administering. 2. Should ideally be used within 1½ hour after onset but can be used from 4 - 6 hours after onset. 3. Monitor vital signs and cardiac rhythms closely. 4. Perform baseline neurologic assessment and reassess every 15 minutes. 5. Internal hemorrhage may be difficult to control. Examine regularly for signs of bleeding. If bleeding occurs, provide direct pressure to bleeding site for a minimum of five (5) minutes. 6. Avoid unnecessary vessel puncture and use a small-gauge needle. 7. Do not administer any other medications through the t-PA line. 9  8. Should be used with heparin sodium therapy. 9. Minimize patient handling. Adult Dose: Acute MI: 100 mg IV over 3 hours. Mix 100 mg in 100 mL of sterile water for 1 mg/mL. For accelerated 1.5-hour infusion: Administer 15 mg IV bolus over 2 minutes, followed by 0.75 mg/kg (max 50 mg) over next 30 minutes. Then administer 0.5 mg/kg (max 35mg) over the next hour. Ischemic stroke: 0.9 mg/kg IV (max 90mg) over one hour. Give 10% of the total dose as IV bolus over 1 minute. Then administer the remaining 90% over the next hour. Pulmonary embolism: 100 mg IV over two hours. Pediatric Dose: Not routinely used in prehospital care. Route: IV Infusion Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 10 Name: Amiodarone Hydrochloride (Cordarone®, Pacerone®) (am ee OH da rone HIGH droe KLOR ide) Used to correct life-threatening ventricular arrhythmias in adults. Class: Antiarrhythmic agent (Class III); Potassium channel blocker Action: 1. Blocks sodium, calcium, and potassium channels, causing an increase in the duration of the myocardial cell action potential and refractory period. 2. Delays repolarization and decreases AV conduction and sinoatrial node function. 3. Produces a negative chronotropic effect in nodal tissues. 4. Relaxes vascular smooth muscle, reduces peripheral vascular resistance (after load), thus decreasing cardiac workload. 5. Reduces myocardial oxygen consumption. 6. Prolongs phase 3 of the cardiac action potential. 7. Onset within minutes with IV administration. 8. Duration of days (40 to 55 days in most patients). Use: 1. Ventricular fibrillation (V-fib) and Pulseless Ventricular tachycardia (V-tach). 2. Stable Ventricular tachycardia with a pulse refractory to other therapy. Side effects: Cardiovascular: Bradycardia; Hypotension; CHF; Increased ventricular beats: Prolonged P-R interval; Prolonged QRS complex; Prolonged Q-T interval; Cardiac arrest; Ventricular tachycardia; AV heart blocks Respiratory: Signs and symptoms of pulmonary toxicity Gastrointestinal: Nausea; Vomiting; Abnormal liver function; Stevens-Johnson syndrome Other: Fever; Anorexia Contraindications: Absolute: Known hypersensitivity; Marked sinus bradycardia; Iodine allergy Relative: Cardiogenic shock; Second- or Third-degree AV block; sick sinus syndrome Drug Interactions: 1. May react with Warfarin, Digoxin, Procainamide, Quinidine, Fentanyl, Lidocaine, Disopyramide, and Phenytoin. 2. Grapefruit juice may potentiate (increase) the effects of amiodarone. 3. Protease inhibitors may potentiate the effects of amiodarone. 4. Cimetidine may increase amiodarone levels. 5. Use with beta blockers and calcium channel blockers may increase occurrence of bradycardia, sinus arrest, and AV blocks. 6. Persistent use of echinacea can increase amiodarone’s hepatotoxic effects. Special Notes: 1. Geriatric patients may be more sensitive. 2. Correct hypokalemia or hypomagnesaemia before administration. 3. Protect the vial from light. Adult Dose: Perfusing Ventricular dysrhythmias (VT with pulse and SVT): 150 mg IV over 10 minutes (15 mg/min). Mix 150mg in 100mL run at 10mL/minute. May repeat every 10 minutes PRN. 11  Maintenance drip: 1mg/min infusion over first 6 hours then 0.5 mg/min over next 18 hours. Non-perfusing Ventricular dysrhythmias (VF and Pulseless VT): 300 mg IO/IO push. May repeat 150mg IVP once in 3 to 5 minutes. Pediatric Dose: VT with a pulse and SVT: 5 mg/kg IV/IO over 20 minutes. May repeat dose at 5mg/kg up to 15mg/kg in 24 hours. VF and Pulseless VT: 5 mg/kg IV/IO push (Max dose:300mg). May administer second dose at 5mg/kg. Max dose of 15 mg/kg per 24 hours. Route: IVP, IO, Infusion (bolus and maintenance infusion). Pregnancy Safety: Category D / Possible adverse effect on human fetus. Bolus Administration in Arrest or Unstable Dilute appropriate Dose in 20-30 cc of normal saline Bolus Administration (Adult with a pulse) 150 mg in 100 cc D5W 10 gtts/mL set – 100 gtts/min = 150 mg/10 min 15 gtts/mL set – 150 gtts/min = 150 mg/10 min Bolus Administration (Pediatric with a pulse) 5 mg/kg in 100 cc D5W 10 gtts/mL set – 50 gtts/min = 5 mg/kg/20 min 15 gtts/mL set – 75 gtts/min = 5 mg/kg/20 min Maintenance Drip V-Fib/Pulseless V-Tach 150 mg in 100 cc D5W 10 gtts/mL set - 7 gtts/min = 1.0 mg/min 15 gtts/mL set - 10 gtts/min = 1.0 mg/10 min Maintenance Drip for V-Tach 150 mg in 100 cc D5W 10 gtts/mL set - 3 gtts/min = 0.5 mg/min 15 gtts/mL set - 5 gtts/min = 0.5 mg/min 12 Name: Ammonia Inhalants (Smelling Salts) (a MOAN ya in HA lentz) Used to prevent and / or treat syncope (fainting). Class: Noxious respiratory irritant/stimulant. Action: 1. Ammonia inhalants (15% anhydrous ammonia and 35% alcohol) when broken release ammonia as a colorless gas with a strong, pungent odor (Dried urine). 2. Reacts with moisture on mucosal surfaces (eyes, skin, and respiratory tract) to produce ammonia hydroxide causing irritation. 3. Onset of action is usually immediate (within seconds). 4. Duration of action is active until taken away from patient or 3 to 5 minutes. Use: To elicit an immediate withdrawal response in all but deeply obtunded patients. Side Effects: Patient may become transitionally uncooperative. Contraindications: Do not use if there is any suspicion of head, neck, spinal trauma. Drug Interactions: None Special Notes: 1. Do not immediately or automatically rule out potential medical or traumatic causes of coma, somnolence, or extreme lethargy. 2. Should never be placed in nostrils or inside oxygen masks. Adult Dose: Crush one ampule/capsule and waif under nose of patient. Discontinue when the patient awakens or no longer feels faint. Pediatric Dose: Not recommended in prehospital setting. Route: Nasal Inhalation Pregnancy Safety: Category Unknown 13 Name: Amyl Nitrate (Sodium Nitrate, Sodium Thiosulfate (Cyanide Antidote)) (A mil NYE trate) Used in the treatment of cyanide poisoning /toxicity. Class: Antidote to cyanide poisoning; Nitrate; Vasodilator; Antianginal Action: 1. In cyanide toxicity, nitrite ions combine with hemoglobin to form met hemoglobin, which binds with cyanide and assists in cyanide elimination. 2. Converts hemoglobin (Fe 2+) into met hemoglobin (Fe 3+) which binds with the cyanide (Cn-). 3. Onset of action is 30 seconds inhaled. 4. Duration of action is 3 to 20 minutes. Use: 1. Initially in management of cyanide toxicity or hydrocyanic acid poisoning. 2. Angina pectoris. Side Effects: CNS: Headache; Dizziness; Weakness; Restlessness Cardiovascular: Orthostatic hypotension; Tachycardia; Syncope; Palpitations Respiratory: Dyspnea Gastrointestinal: Nausea; Vomiting Other: Cold sweat; Involuntary passing of urine and feces; Pallor Contraindications: Absolute: Known hypersensitivity to nitrates; Prior use (24 to 72hrs) of phosphodiesterase type 5 inhibitors (e.g., sildenafil, tadalafil, vardenafil); Increased intracranial pressure; Closed head injury; Cerebral hemorrhage Relative: Pregnancy Drug Interactions: 1. Administration with alcohol can cause hypotension and possible cardiovascular collapse. 2. Aspirin can increase nitrate concentration and adverse reactions may occur. 3. Coadministration with calcium channel blockers symptomatic orthostatic hypotension may occur. Special Notes: 1. Very flammable. 2. Looks similar to ammonia inhalants. 3. Must be refrigerated (36oto 46oF). 4. Frequently abused (claimed to be an aphrodisiac). 5. Cyanide poisoning often produces a bitter almond breath odor (not all persons can detect the odor). Adult Dose: 0.3 mL inhaled vapors for 15 to 60 seconds every 3 to 5 minutes, until Sodium Nitrite IV solution is available. Pediatric Dose: Not recommended in prehospital setting. Route: Nasal Inhalation Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 14 Name: Aspirin (Acetylsalicylic Acid; ASA) (ah SEE till sal ih SILL ick) Used as an anti-inflammatory agent and an inhibitor of platelet function. Class: Platelet inhibitor; Analgesic; Anti-pyretic; Anti-inflammatory; NSAID Action: 1. Inhibits prostaglandin synthesis, which decreases pain caused by inflammation. 2. Blocks the formation of thromboxane A2, which causes platelets to aggregate and arteries to constrict. 3. Decreases synthesis of blood coagulation factors VII, IX, and X. 4. Inhibits the action of vitamin K. 5. Decreases body temperature by causing mild vasodilation (anti-pyretic effects). 6. Action on platelets is irreversible for the life of the platelet (7 to 10 days). 7. Onset of action is within 15 to 30 minutes. 8. Duration of action is 4 to 6 hours. Use: 1. New onset of chest pain (angina) suggestive of acute myocardial infarction (AMI). 2. Reduction of fever. Side effects: CNS: Confusion; Convulsions; Dizziness; Flushing; Cardiovascular: Hypotension; Prolonged bleeding; Low platelet count (thrombocytopenia) Gastrointestinal: Gastrointestinal bleeding; Nausea; Vomiting; Heartburn: Stomach pain Respiratory: Respiratory alkalosis; Wheezing in allergic patients Other: Hypersensitivity reactions; Anaphylaxis; Anorexia; Rash Overdose: Depression; Diarrhea; Respiratory acidosis; Tachycardia; Tinnitus Contraindications: Absolute: Allergy to salicylates; Known hypersensitivity; Children under 12; Pregnancy; Hemophilia or other bleeding disorders; Severe asthma; Recent surgery; History of GI bleed Relative: Presence of ulcers; Asthmatics; Diabetics: Aortic dissection Note: Use with caution in patients who report allergies to NSAIDS. Drug Interactions: 1. Avoid use with anticoagulants, alcohol, and steroids. 2. Administration of aspirin with antacids may reduce blood levels by reducing absorption. Special Notes: 1. Rule out allergy to salicylates (aspirin) before administering. 2. Larger Doses decrease blood sugar levels and deplete liver glycogens. 3. If patient develops tinnitus, immediately discontinue use. 4. Administration of aspirin to children under the age of 12 can lead to the development of Reye Syndrome. Adult Dose: 81 to 325 mg chewable (1 to 4 tablets) every 4 hours for AMI. Pediatric Dose: Not recommended in prehospital setting. Route: PO 15 Pregnancy Safety: Category D / Possible adverse effect on human fetus. 16 Name: Atenolol (Tenormin®; Tenoretic ®) (a TEN oh ol) Used to treat angina (chest pain) and hypertension (high blood pressure). Class: Beta-Adrenergic antagonist, antianginal; antihypertensive; Class II antiarrhythmic Action: 1. Effects the response to nerve impulses in the heart, thus the heart beats slower and reduces the blood pressure. Resulting in a decrease in cardiac oxygen consumption. 2. Reduces the rate and force of cardiac contraction (negative inotropic effect). 3. Saturates beta receptors and inhibits dilation of bronchial smooth muscle. 4. Onset of action is within 5 minutes. 5. Duration of action is 6 to 7 hours. Use: 1. Used to treat acute coronary syndromes. 2. Used alone or together with other medicines (such as hydrochlorothiazide) to treat hypertension. 3. Supraventricular tachycardia, Atrial flutter, and Atrial fibrillation. Side Effects: CNS: Dizziness; Vertigo; Light-headedness; Syncope; Fatigue or weakness; Lethargy; Drowsiness; Insomnia; Depression Cardiovascular: Bradycardia; Hypotension; CHF; Cold extremities; Leg pains; Dysrhythmias Respiratory: Dyspnea; Pulmonary edema; Bronchospasm Gastrointestinal: Nausea; Vomiting; Diarrhea Other: May mask symptoms of hypoglycemia Contraindications: Absolute: Bradycardia; AV heart blocks; Congestive heart failure (CHF); Cardiogenic shock; Acute pulmonary edema Relative: Use with caution in hypotension, asthma, COPD, and CHF controlled by digitalis and diuretics Drug Interactions: 1. Anticholinergic (i.e., Atropine) may increase absorption from the GI tract. 2. NSAIDS can decrease hypotensive effects. 3. Calcium channel blockers may exacerbate adverse effects. 4. May hide symptoms of hypoglycemia induced by insulin and sulfonylureas. Special Notes: 1. Do not give faster than 1mg/min. 2. Patient must be on an ECG monitor during medication administration due to possibility of drug-induced dysrhythmias. 3. Patient must have pulse, blood pressure, respirations, and ECG monitored during medication administration. Adult Dose: 5 mg over 5 minutes. Wait 10 minutes. Then administer another 5mg iv slowly over 5 minutes. Pediatric Dose: Not recommended in prehospital setting. Route: IVP; IO 17 Pregnancy Safety: Category D / Possible adverse effect on human fetus. 18 Name: Atropine Sulfate (Atropine) (AT troh peen SUL fayt) Used as a parasympatholytic that is derived from parts of the Atropa Belladonna plant. Class: Anticholinergic; Parasympatholytic; Vagolytic; Antimuscarinic agent Action: 1. Blocks the acetylcholine receptor sites, blocking the stimulation of parasympathetic nerve fibers. This blocking action enhances both sinus node automaticity and atrioventricular conduction. 2. Positive chronotropic properties and little or no inotropic effect. 3. Reverse muscarinic effects in organophosphate poisonings. 4. Used in the treatment of respiratory emergencies due to its bronchodilation and drying of respiratory secretions. 5. Decreases peristalsis; Increases urinary retention; Increases central nervous system stimulation. 6. Onset of action is immediate. 7. Duration of action 2 to 4 hours. Use: 1. Sinus bradycardia accompanied by hemodynamic compromise (e.g., hypotension, confusion, frequent PVC’s, pale, cold, clammy skin). 2. Organophosphate poisoning / overdose (e.g., parathion, Malathion, Rida- bug, Baygon, Sevin, and many common ant & roach sprays). 3. Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema. 4. Pre-treatment in pediatric patients (less than 2 years of age) receiving RSI. 5. Beta blocker and calcium channel blocker overdose. Side Effects: CNS: Restlessness; Agitation; Blurred vision; Dilated pupils; Headache; Confusion; Drowsiness; Anxiety; Dizziness Cardiovascular: Tachycardia; Chest pain (angina); Palpitations; Premature ventricular contractions; Arrhythmias; Paradoxical bradycardia when pushed slowly or at low Doses Gastrointestinal: Dry mouth; Difficulty swallowing; Nausea; Vomiting Other: Nausea; Flushed, hot, and dry skin; Urinary retention Contraindications: Absolute: Known hypersensitivity to belladonna alkaloids Relative: Chronic obstructive pulmonary disease (COPD); Glaucoma; Acute myocardial infarction; Tachycardia, Myasthenia Gravis, GI obstruction Note: There are no contraindications in the organophosphate setting. Drug Interactions: 1. Anticholinergics may increase vagal blockade. 2. Potential adverse effects when administered with digoxin, cholinergics, phystostigmine. 3. Effects enhanced by antihistamines, procainamide, quinidine, antipsychotics, benzodiazepines, and antidepressants. 4. Antacids slow the adsorption of anticholinergics. 5. May be reversed with Physostigmine. 19 Special Notes: 1. Dries mucous plugs. 2. Paradoxical bradycardia may occur if dose is less than 0.5 mg in the adult (less than 0.1 mg in the child), or if dose is given too slowly. 3. Excessive doses can cause delirium, coma, ventricular fibrillation, or ventricular tachycardia. 4. Can be used in conjunction with Succinylcholine to reduce salivation and potential for bradycardia during intubation or rapid sequence intubation (RSI). 5. May worsen second-degree type II and third degree blocks. Go straight to transcutaneous pacing. If pacing is not available, use atropine with caution. 6. Signs of OG poisoning are SLUDGEM (Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis, Miosis [pinpoint pupils], bradycardia, and excessive sweating). 7. Victims of organophosphate poisoning can tolerate large doses (1000 mg) of Atropine. Signs of atropinization are the end point of treatment. These signs include flushing, pupil dilation, dry mouth, and tachycardia. Adult Dose: Bradycardia: 0.5 to 1 mg IVP. Repeat every 3 to 5 minutes to a maximum of 3 mg. OGP: 1-6 mg IV/IO, IM. Repeat if needed every 5 minutes until symptoms dissipate. Call medical control for further orders if needed. Pediatric Dose: Cardiac: 0.02 mg/kg IVP or IO. Repeat every 3-5 minutes. Maximum single dose: 0.5mg Maximum total dose: Adolescent - 3 mg; Child – 1 mg OGP: 0.05 mg/kg IVP or IO. Repeat in 5 to 30 minutes with 0.5mg/kg titrated to effect. Contact medical control for further orders. Route: IVP; IO, ET Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 20 Name: Calcium Chloride 10% (CaCl2 10%) (KAL see um KLOH ryd) Used for the treatment of hypocalcemia in those conditions requiring a prompt increase in plasma calcium levels. Essential in the functional integrity of the nervous and muscular systems; Necessary for normal cardiac function and is involved in blood coagulation. Class: Electrolyte Action: 1. Provides elemental calcium in the form of the cation. 2. Positive inotrope effect (cardiac contractile force). 3. Increases myocardial automaticity. 4. Increases nerve transmission capabilities. 5. Relieves muscle spasms from low calcium blood levels. 6. Onset of action is 1 to 3 minutes. 7. Duration of action 20 to 30 minutes but may continue up to 4 hours. Use: 1. Calcium channel blocker overdose/toxicity (i.e., Verapamil, Cardizem, etc.). 2. Antidote for Magnesium Sulfate overdose/toxicity. 3. Acute hyperkalemia. 4. Acute hypocalcemia. Side Effects: CNS: Syncope; Cerebral artery spasm Cardiovascular: Asystole; Bradycardia; Cardiac arrest; Hypotension; Ventricular fibrillation; Coronary artery spasm Gastrointestinal: Metallic taste; Nausea; Vomiting Local: Tissue necrosis at the injection site Contraindications: Absolute: Hypercalcemia and hypercalciuria (hyperthyroidism, Vitamin D overdose, bone metastases); Ventricular fibrillation; Patients receiving digitalis (Can cause elevated Digoxin levels or Digitalis toxicity), suspected severe hypokalemia Relative: Impaired renal function Drug Interactions: 1. Potentiates digitalis’ effects. Can make patient “dig toxic.” 2. May antagonize the effects of calcium channel blockers. 3. Precipitates when mixed with sodium bicarbonate. 4. Potentiated by thiazide diuretics. Special Notes: 1. Calcium may produce vasospasm in coronary and cerebral arteries. 2. Calcium is incompatible with most medications so flush IV line before and after every administration. 3. Use a large bore IV catheter, preferably a central line if possible. 4. Use it with caution in patients suffering from cardiac disease or respiratory insufficiency. 5. Too rapid administration can cause bradycardia and hypertension. 6. Calcium chloride is a hypertonic solution and should only be administered intravenously slowly. 21 Adult Dose: 500 to 1,000 mg IV over 5 to 10 minutes. Repeat PRN. Pediatric Dose: 20 mg/kg slow IVP. May repeat once in 10 minutes. Maximum dose 1g. Note: Not usually given to pediatrics in the prehospital setting. Route: IVP; IO Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 22 Name: Calcium Gluconate 10% (KAL see um GLUE koe nate Used for maintenance of the functional integrity of nervous, muscular, and skeletal systems and cell membrane and capillary permeability. Class: Calcium salt; Essential element Action: 1. In Hydrofluoric acid toxicity provides calcium, which binds with fluoride ions producing calcium fluoride. 2. Necessary for neurotransmission, blood clotting, and contraction of cardiac, smooth, and skeletal muscles. 3. Important in the regulation of neurotransmitters, hormones, and amino acid metabolism. 4. IV administration improves vascular tone and myocardial contractility in hypocalcemia states. Cardiac output and blood pressure usually increase. 5. Onset of action is 1 to 3 minutes. 6. Duration of action is 30 minutes to 2 hours. Use: 1. Used in the treatment of Hydrofluoric acid burns. 2. Magnesium sulfate overdose. 3. Betta blocker and calcium channel blocker overdose 4. Hypocalcemia 5. Hyperkalemia Side Effects: CNS: Sense of oppression (heat waves), Cerebral artery spasm Cardiovascular: Rapid IV injection may cause vasodilation, hypotension, bradycardia, cardiac arrhythmias, syncope, and cardiac arrest; Coronary artery spasm Gastrointestinal: Calcium or chalky taste in mouth; GI irritation; Nausea; Vomiting Other: Tingling sensation, Tissue necrosis Contraindications: Absolute: Digitalis toxicity; hypercalcemia; suspected severe hypokalemia; Ventricular fibrillation Drug Interactions: 1. Calcium gluconate is incompatible with most medications, flush before and after administration. 2. May potentiate digitalis and calcium toxicities. 3. Do not mix or administer with ceftriaxone. 4. Proton pump inhibitors (e.g., omeprazole) may reduce calcium absorption. 5. Do not mix with tetracyclines. 6. Thiazide diuretics (e.g., hydrochlorothiazide) may cause possible calcium toxicity and hypercalcemia. 7. May reverse clinical effects and toxicities of calcium channel blockers. Special Notes: 1. SUB Q or IM administration can cause severe tissue necrosis and tissue sloughing. 2. Can induce serious cardiac dysrhythmias, continual EKG monitoring required during administration. 23 Adult Dose: Burns to Eyes: Mix Calcium Gluconate (10%) 50 mL in 500 mL NS and wash eyes with solution using Morgan Therapeutic lens. Burns to Skin: Mix Calcium Gluconate (10%) 10 mL into a 2 oz. tube of KY Jelly (making 2.5% gel). Apply gel to burned area, and then cover with dry sterile dressing. All other indications: 500 to 1,000 mg IV over 5 to 10 minutes. Pediatric Dose: Burns to Eyes: Mix Calcium Gluconate (10%) 50 mL in 500 mL NS and wash eyes with solution using Morgan Therapeutic lens. Burns to Skin: Mix Calcium Gluconate (10%) 10 mL into a 2 oz. tube of KY Jelly (making 2.5% gel). Apply gel to burned area, and then cover with dry sterile dressing. All other Indications: 60 mg/kg slow IV/IO push over 10 minutes. Route: IVP; IO; Dermal Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 24 Name: Clopidogrel Bisulfate (Plavix®) (kloe PID oh grel bi SUL fayt Used to reduce the risk of cardiovascular or cerebrovascular events (new MI, new ischemic stroke, and vascular death) in patients with a history of recent MI, recent ischemic stroke, or established peripheral arterial disease. Recommended as an alternative to aspirin in those with aspirin allergy an inhibitor of adenosine diphosphate (ADP)-induced platelet aggregation. Class: Antithrombotic; Platelet aggregation inhibitor Action: 1. An inhibitor of platelet aggregation. A variety of drugs that inhibit platelet function have been shown to decrease morbid events in people with established atherosclerotic cardiovascular disease as evidenced by stroke or transient ischemic attacks, myocardial infarction, unstable angina or the need for vascular bypass or angioplasty. This indicates that platelets participate in the initiation and/or evolution of these events and that inhibiting them can reduce the event rate. 2. It selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor and the subsequent ADP-mediated activation of the glycoprotein GPITh /IIIa complex, thereby inhibiting platelet aggregation. 3. Biotransformation of clopidogrel is necessary to produce inhibition of platelet aggregation but an active metabolite responsible for the activity of the drug has not been isolated. 4. Clopidogrel also inhibits platelet aggregation induced by agonists other than ADP by blocking the amplification of platelet activation by released ADP. Clopidogrel does not inhibit phosphodiesterase activity. 5. Acts by irreversibly modifying the platelet ADP receptor. Consequently, platelets exposed to clopidogrel are affected for the remainder of their lifespan. 6. Onset of action is within 2 hours. 7. Duration of action is 7 to 10 days (Lifetime of the platelet). Use: 1. Acute coronary syndrome (AMI, NSTEMI, and unstable angina) 2. Chronic coronary and vascular disease 3. Ischemic stroke Side Effects: CNS: Dizziness; Severe persistent headache Cardiovascular: Angina (chest pain); Hypertension; Palpitations; Unusual bleeding Respiratory: Dyspnea; Bronchitis; Coughing; Upper respiratory tract infection; Pallor (pale skin) Gastrointestinal: Nausea; GI hemorrhage; Abdominal pain Other: Severe allergic reactions; Sore throat or fever, Unusual bruising, Unexplained weight loss, Jaundice (yellowing of the skin or eyes) Contraindications: Absolute: Known hypersensitivity; Active pathological bleeding (i.e., peptic ulcer or intracranial hemorrhage); history of trauma; severe liver impairment Drug Interactions: 1. Dabigatran, nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen), oral anticoagulants (e.g., warfarin), or salicylates (e.g., aspirin) may increase the risk of bleeding from Plavix. 2. Proton pump inhibitors (e.g., omeprazole) may decrease Plavix's effectiveness. 25  3. Interferes with metabolism of phenytoin, warfarin, NSAIDs, calcium channel blockers, morphine, and amiodarone. 4. Bleeding can be increased if taken with garlic, ginger, ginkgo, or green tea. Special Notes: 1. Plavix prolongs the bleeding time and therefore should be used with caution in patients who may be at risk of increased bleeding from trauma, surgery, or other pathological conditions (particularly gastrointestinal and intraocular). 2. Avoid unnecessary invasive procedures. 3. Use cautiously in patients receiving other drugs that may induce gastrointestinal hemorrhage. 4. No reversible agent currently available. Patients on clopidogrel with excessive bleeding may require platelet transfusion. Adult Dose: Initial dose 300-600 mg PO followed by daily dose of 75 mg PO. Pediatric Dose: Not recommended for prehospital use. Route: PO Pregnancy Safety: Category B / No possible adverse effect on fetus in laboratory testing. 26 Name: Dexmedetomidine (Precedex, Dexdor, Igalmi) (Dek sneg dug tow muh din) Used for sedation during surgery or other medical procedures. Class: Sympatholytic; a2 Adrenergic Agonist; Sedative; Hypnotic; Anxiolytic; Analgesic Action: 1. Binds to presynaptic alpha-2 adrenoceptors. This inhibits the release of norepinephrine and stops the transmission of pain signals. 2. Activates postsynaptic alpha-2 adrenoreceptors which results in a decrease of sympathetic stimulus causing a decrease in heart rate and blood pressure. 3. Postsynaptic activation also results in inhibition of neuronal firing resulting in sedation. 4. Onset of action is less than five minutes. Peak effect within 15 to 30 minutes. 5. Duration of action is two hours. Use: 1. Initial sedation for RSI. 2. Continued sedation of mechanically ventilated patients. 3. Pediatric sedation of non-invasive procedures. Side Effects: CNS: agitation, sedation Cardiovascular: hypotension, bradycardia, hypertension Gastrointestinal: dry mouth Respiratory: bradypnea, respiratory failure Contraindications: Absolute: none Relative: hypotension, bradycardia, known heart failure Drug Interactions: 1. Incompatible with amphotericin B and Diazepam. 2. Use caution with the coadministration of other vasodilators or negative chronotropic agents due to additive pharmacodynamic effects. Special Notes: 1. For adults over 65 years of age or impaired hepatic function consider a dose reduction. 2. Significant hypotension and bradycardia have been seen when administered, with rapid and bolus administration. Consider giving slowly to avoid or mitigate side effects. 3. Have anticholinergic agents prepared and ready to administer in the event of hypotension or bradycardia. 4. Patients can be aroused with stimulation this should not be considered as a lack of efficacy. Adult Dose: Loading Dose: 0.5 to 1.0 mcg/kg over 10 minutes. Maintenance Infusion: 0.2 to 0.7 mcg/kg/hr titrated to the desired effect. Pediatric Dose: Loading Dose: -1 month to 2 years: 1.5mcg/kg over 10 minutes. - 2 years to 18 years: 2mcg/kg over 10 minutes. Maintenance: 0.5 to 1.5mcg/kg/hr; titrated to achieve desired effect. 27 Route: IVP; IO Pregnancy Safety: Category C / No possible adverse effect on the fetus in laboratory testing. 28 Name: Dexamethasone Sodium Phosphate (Decadron®, Hexadrol®, Cortastat®, Dexasone ®, Solurex®) (dex a METH a sone SOE dee um FOS fate) Used to provide relief for inflamed areas of the body by lessening swelling, redness, itching, and allergic reactions. Class: Corticosteroid; Adrenal glucocorticoids; Anti-inflammatory agent Action: 1. Short-term effects cause a decrease in vasodilation, permeability of capillaries, and decrease in leukocyte migration at the site of inflammation. 2. Corticosteroids binding to glucocorticoid receptors changes gene expression with causes several downstream effects. 3. Suppresses acute and chronic inflammation. 4. Has immunosuppressive effects. 5. Onset of action 4 to 6 hours. 6. Duration of action 24 to 72 hours. Use: 1. Control of severe allergic reactions, asthma attacks, and bronchospasm associated with COPD. 2. Adjunctive treatment of severe hypotension (drop in blood pressure) and decreased blood supply to the vital organs (shock) due to surgical or accidental trauma, bleeding (hemorrhage), or severe infection. 3. To reduce swelling in the brain or increased intracranial pressure (e.g. HACE or brain tumors). Side Effects: CNS: Headache; Psychiatric reactions (i.e., Depression, Euphoria); Weakness; Paresthesia Cardiovascular: Fluid retention (sodium and water); Congestive heart failure (CHF); Hypertension; Bradycardia; Hypokalemia; Electrolyte imbalance Gastrointestinal: Nausea; Diarrhea; Gastrointestinal bleeding Other: Increased susceptibility to infections and increased severity of infections; Prolonged wound healing; Suppression of adrenocortical steroid production; Hyperglycemia Contraindications: Absolute: Known hypersensitivity; Fungal infection; Tuberculosis’ Preterm infants Relative: Active infections; Renal disease; Penetrating spinal cord injury, Ulcers Drug Interactions: 1. May increase blood sugar levels and anti-diabetic medications may be ineffective or need to be adjusted. 2. May enhance the anti-blood-clotting effect of anticoagulant medicines. 3. May increase the risk of GI side effects when used in combination with non-steroidal anti-inflammatory drugs (NSAIDs, i.e., ibuprofen). 4. May decrease the blood levels of salicylates, caspofungin, indinavir, isoniazid, saquinavir, etc. 5. Therapeutic levels may be decreased by barbiturates (i.e., amobarbital, phenobarbital), carbamazepine, ephedrine, phenytoin, primidone, rifabutin, rifampicin, etc. 6. Effects or side effects may be increased by aprepitant, cyclosporine, itraconazole, ketoconazole, macrolide-type antibiotics (i.e., erythromycin), protease inhibitors (i.e., egritonavir). 29  7. May decrease the body’s immune response making vaccines less effective or live vaccines may cause serious infections. 8. May lower the amount of potassium in the blood when used with acetazolamide, amphotericin, beta-agonists (i.e., salbutamol, salmeterol, terbutaline), carbenoxolone, potassium-losing diuretics (i.e., furosemide, bendroflumethiazide), theophylline. Special Notes: 1. May lower resistance to infections. 2. Medication should be protected from heat. 3. Rapid administration of IV or IO can cause a burning sensation throughout the body. With the sensation being the strongest in the genitals Adult Dose: Anaphylaxis/Bronchospasm: 8mg IM or IV. Cerebral swelling: 8mg IM or IV flowed by 4mg IM or IV every 6 hours until symptoms resolve. Pediatric Dose: Croup/Asthma: 0.6 mg/kg IM, IO or IV given once, max dose 16 mg. Cerebral swelling: 0.15 mg/kg IM or IV every 6 hours, max 4 mg/dose. Route: IVP; IO; IM; PO Pregnancy Safety: Category C / No possible adverse effect on the fetus in laboratory testing. 30 Name: Dextrose in water (D10W, D25W, D50W; D50 Glucose) (DEX trohs) Used to treat patients with hypoglycemia who have symptoms such as loss of consciousness. Class: Carbohydrate; Hypertonic solution; Hyperglycemic Action: 1. Elevates blood glucose levels by providing an immediate supply of glucose for energy and metabolism. 2. Provides short term osmotic diuresis. 3. Onset of action is less than 1 minute. 4. Duration of action is variable. Use: 1. Hypoglycemia 2. Insulin overdose Side Effects: CNS: Cerebral hemorrhage; Cerebral ischemia Cardiovascular: Thrombosis; Sclerosing if given in peripheral vein; Thrombophlebitis Other: Hyperglycemia; Hypokalemia; Rhabdomyolysis Local: Tissue necrosis if the site infiltrates Contraindications: Absolute: Known hypersensitivity; Hyperglycemia; Severe dehydration; Anuria; Diabetic coma; Intracranial or intraspinal hemorrhage; Glucose-galactose malabsorption syndrome Relative: Blood glucose level (BGL) > 60 mg/dL Drug Interactions: Interacts with Sodium bicarbonate and Coumadin. Special Notes: 1. Perform Dextrostix (BGL) prior to administration if possible. 2. Use the largest vein possible. Extravasation will cause tissue necrosis. If extravasation does occur, immediately STOP administration. IO administration is a last resort. 3. Use of D50 may complicate or worsen several medical conditions (e.g., AMI, CVA). 4. Thiamine should be administered before D50 to the alcoholic patient. Thiamine is necessary for carbohydrate metabolism. 5. May precipitate Wernicke’s encephalopathy in patients who are malnourished. Adult Dose: 25 g of D10W to D50W IVP, IO. Repeat every 5 minutes PRN as blood glucose indicates. Pediatric Dose: 0.5 to 1g/kg D10 to D25 IVP, IO. Repeat every 5 minutes PRN as blood glucose indicates. Neonates: 0.2 g/kg followed by 5 ml/kg D10W IV, IO infusion. Note: D50 can be made into D25 by diluting the volume 1:1 (Mix well) D50 can be made into D10 by diluting the volume 4:1 (Mix well). Administration is easier when you push a small amount of medication, then flush with NS, and then repeat until the entire volume is given. Route: IVP; IO Pregnancy Safety: Category C / Not well established, crosses the placenta, and may cause fetal damage. 31 Name: Diazepam (Valium®, Diastat®) (dye AYZ eh pam) Used in the management of anxiety disorders, to treat agitation, shakiness, and hallucinations during alcohol withdrawal, to relieve certain types of muscle pain, and for sedation prior to cardioversion of a conscious patient. Class: Benzodiazepine; Anticonvulsant; Sedative; Anxiolytic; Schedule IV drug Action: 1. Suppresses the spread of seizure activity and raises the seizure threshold in the motor cortex. 2. Depresses the limbic system, thalamus, and hypothalamus (central nervous system) resulting in calming effects. 3. Muscle relaxant 4. Amnesic effect 5. Main action of effect is on GABA receptors. 6. Onset of action is 2 to 5 minutes for IVP and within 15 to 39 minutes for IM. 7. Duration of action is 15 minutes to 1 hour. Use: 1. Active seizures and/or status epileptics. 2. Sedation prior to cardioversion of a conscious patient. 3. Sedation prior to RSI of a patient. 4. Relief of agitation due to acute alcohol withdrawal (delirium tremens). 5. Short-term relief of acute anxiety. 6. Acetylcholinesterase inhibitor poisoning Side Effects: CNS: Confusion; Muscular weakness; Blurred vision; Dizziness; Drowsiness; Fatigue; Headache; Ataxia; Slurred speech; Paradoxical excitement and stimulation; Psychomotor impairment Cardiovascular: Bradycardia; Cardiac arrest; Hypotension; Reflex tachycardia; Thrombosis; Phlebitis Respiratory: Respiratory arrest; Respiratory depression Gastrointestinal: Nausea; Vomiting; Hiccups Other: Increased intraocular pressure Contraindications: Absolute: Known hypersensitivity; Head injury; Coma: Hypotension; CNS depression; Respiratory depression; Myasthenia gravis Relative: Glaucoma; Substance abuse Drug Interactions: 1. Potentiation of sedative effects in the presence of antihistamines, tricyclic antidepressants, alcohol, narcotics, sedatives, and hypnotics. 2. May precipitate if diluted. 3. incompatible with most drugs and fluids, do not mix with other medications. Special Notes: 1. Resuscitation equipment should be readily available prior to administration. 2. Convulsive Antidote Nerve Agent (CANA) is a commercial autoinjector that contains 10mg of diazepam. 3. Use with caution in the elderly (sensitive - reduce Dose 50%) and children (unpredictable). 4. Diazepam available for rectal administration. 32  5. Respiratory depression and respiratory arrest may be reversed with Flumazenil (Romazicon®) 0.2 to 1.0 IV. Adult Dose: Anxiety: 2 to 5 mg slow IV, IM. Seizure/Sedation: 5 to 10 mg slow IV, IO. Repeat every 10 to 15 minutes PRN Maximum dose 30 mg. Pediatric Dose: Seizures: 0.1 mg/kg slowly, Maximum dose 4 mg. Rectal: 0.2-0.5 mg/kg. Flush with 2-3 ml saline. Route: IVP; IO; IM; Rectal suppository Pregnancy Safety: Category D / Possible adverse effect on the human fetus. 33 Name: Digoxin (Lanoxin®,) (di JOX in) Used in combination with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor to manage congestive heart failure (CHF) and for reentry supraventricular tachycardia (i.e., atrial flutter, atrial fibrillation). Class: Inotropic agent; Cardiac Glycoside; Antidysrhythmic Action: 1. Rapid-acting cardiac glycoside with direct and indirect effects that increase the force of myocardial contractions. 2. Inhibits sodium-potassium-adenosine triphosphate membrane pump, which increases calcium in heart muscle cells and increases the force of the heart’s contraction. 3. Stimulates the parasympathetic nervous system via the vagus nerve and decreases the heart rate. 5. Onset of action is 5 to 30 minutes. 6. Duration of action is 1½ to 4 hours. Use: 1. Congestive heart failure. 2. Re-entry SVT especially atrial flutter and atrial fibrillation. Side Effects: CNS: Headache; Weakness; Vision disturbances; Confusion; Anxiety; Seizures; Psychosis Cardiovascular: Arrhythmias; Hypotension Gastrointestinal: Nausea; Vomiting; Diarrhea; Anorexia Other: Skin rash; Hyperkalemia Contraindications: Absolute: Known hypersensitivity; Ventricular fibrillation; Ventricular tachycardia Relative: Digitalis toxicity Drug Interactions: 1. Amiodarone, anticholinergics, bepridil, benzodiazepines, ACE inhibitors, clarithromycin, cyclosporine, diltiazem, erythromycin, indomethacin, itraconazole, propafenone, quinidine, quinine, tetracycline, verapamil may increase serum digoxin concentrations by 50% to 70%. 2. Concurrent use of digoxin and verapamil may lead to severe heart block. 3. Diuretics may potentiate cardiac toxicity. 4. Antacids, antineoplastics, cholestyramine, colestipol, kaolin/pectin, metoclopramide, and penicillamine may decrease absorption and effect of digoxin. 5. St. John's Wort, thyroid hormones, and thioamides may decrease the effect of digoxin. Special Notes: 1. Patients with known renal failure are prone to digoxin toxicity. 2. Hypokalemia, hypomagnesaemia, and hypercalcemia potentiate digitalis toxicity. 3. Use carefully in patients with Wolff–Parkinson–White Syndrome (ventricular arrhythmias). 4. Not used for right ventricular disorders. Adult Dose: 0.5 to 1 mg IVP over 5 minutes. Pediatric Dose: Not recommended for prehospital use. 34 Route: IVP; IO Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 35 Name: Diltiazem Hydrochloride (Cardizem®, Cardizem Lyo-Ject®) (dil TYE a zem HIGH droe KLOR ide) Used to slow the electrical conduction in the heart, slow the heart rate, and/or normalize heart rhythm, also to treat hypertension and angina. Class: Calcium Channel Blocker; Class: IV antidysrhythmic; Antianginal agent Action: 1. Blocks calcium channels, thus has a negative chronotropic effect (slows down heart rate). 2. Decreases SA and AV node conduction. 3. Prolongs AV node effective and functional refractory periods. 4. Decreases myocardial contractility and peripheral vascular resistance. 5. Onset of action of 2 to 5 minutes. 6. Duration of action of 1 to 3 hours. Use: 1. Atrial Fibrillation (AF) or Atrial Flutter (A-Flutter) with a rapid ventricular response (RVR - sustained heart rate above 100 bpm). 2. Paroxysmal Supraventricular Tachycardia (PSVT). Unless contraindicated, vagal maneuvers should be attempted prior. 3. Multifocal Atrial Tachycardia (MAT). Side Effects: CNS: Weakness; Syncope; Tinnitus; Double vision; Photosensitivity; Dizziness (vertigo); Headache Cardiovascular: Bradycardia; Heart block; Congestive heart failure (CHF); Hypotension; Chest pain (angina); Palpitations; Cardiac arrest Respiratory: Dyspnea Gastrointestinal: Constipation; Nausea; Vomiting; Diarrhea Other: Flushing; Dry mouth; Sweating Contraindications: Absolute: Known hypersensitivity; Sick Sinus Syndrome; Hypotension; Heart blocks; Acute MI; Cardiogenic shock; Wolf-Parkinson-White (WPW) syndrome or short PR syndrome; Ventricular tachycardia; Heart failure Relative: Pulmonary congestion; Lactation Drug Interactions: 1. Incompatible with simultaneous furosemide injection. 2. Cimetidine or protease inhibitors (e.g., indinavir) may increase the actions and side effects. 3. Rifampin may decrease the effectiveness of Diltiazem. 4. Amiodarone, cisapride, digoxin, erythromycin, protease inhibitors (e.g., indinavir), quinidine, tricyclic antidepressants (e.g., desipramine), theophylline, or general anesthetics may cause effects on the heart. 5. Benzodiazepines (e.g., midazolam), beta-blockers (e.g., metoprolol), buspirone, carbamazepine, cilostazol, corticosteroids (e.g., prednisone), cyclosporine, HMGCoA reductase inhibitors (e.g., atorvastatin), macrolide immunomodulators (e.g., tacrolimus) may increase the risk of their side effects, some potentially life-threatening. Special Notes: 1. Do not administer with IV beta-blockers and use caution in patients taking oral beta- blockers. 36  2. Monitor vital signs, cardiac rhythms, and blood pressure. 3. Not recommended for infusion over 24 hours. 4. The half-life may be increased in geriatric patients. 5. Use with caution in patients with impaired hepatic function, renal function, and in CHF patients. 6. PVCs may be present on conversion of PSVT to sinus rhythm. MAY BE STORED AT ROOM TEMPERATURE FOR UP TO ONE (1) MONTH DESTROY AFTER ONE (1) MONTH AT ROOM TEMPERATURE. Adult Dose: 0.25 mg/kg over 2 minutes (Approximately 20 mg). May repeat after 15 minutes at 0.35 mg/kg over 2 minutes (Approximately 25 mg). Maintenance Drip: Dilute 125 mg (25 ml) in 100 ml of solution: infuse 5-15 mg/hr, titrated to heart rate. Pediatric Dose: Not recommended for prehospital use. Route: IVP; IO Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 37 Name: Diphenhydramine Hydrochloride (Benadryl®) (dye fen HYE drah meen HIGH droe KLOR ide) Used to block H1 and H2 histamine receptors with anticholinergic (drying) and sedative side effects. Class: Antihistamine; Antiemetic Action: 1. Blocks the effects of H1 histamine receptor stimulation (bronchoconstriction, visceral contractions). 2. Blocks the effects of H2 histamine receptor stimulation (peripheral vasodilation and secretion of gastric acids). 3. Inhibits histamine release from mast cells (Does not reverse histamine mediated responses). 4. Results in decreased capillary permeability and vasodilation. 5. Decreases dystonic reactions (extra pyramidal activity) from phenothiazines. 6. Onset of action is 10 to15 minutes. 7. Duration of effects is 6 to 8 hours. Use: 1. Allergic reactions and /or anaphylaxis in conjunction with epinephrine. 2. Dystonic reactions 3. Extrapyramidal signs and symptoms caused phenothiazine overdose (i.e., Haldol, Compazine, Thorazine, Stelazine). 4. Sedation of violent patients. 5. Antiemetic Side Effects: CNS: Drowsiness; Dizziness; Fever; Hallucinations; Headache; Paradoxical CNS excitement in children; Seizures; Sedation; Visual disturbances Cardiovascular: Changes in T waves; Hypotension; Palpitations; Shortened diastole, which may cause reflex tachycardia; PVC’s; Arrhythmias Respiratory: Thickening of bronchial secretions; Tightness in chest; Wheezing; Nasal stuffiness Gastrointestinal: Anorexia; Dry mouth; Diarrhea; Nausea; Vomiting; Constipation; Urinary retention Other: Anaphylaxis; Dysuria Contraindications: Absolute: Known hypersensitivity; Nursing mothers; Infants Relative: Asthmatic attack; Severe vomiting; Glaucoma; Alcohol intoxication Drug Interactions: 1. Enhances the properties of cocaine effects. 2. Atropine potentiates anticholinergic effects. 3. Potentiates central nervous system depression in the presence of alcohol, narcotics, sedatives / hypnotics, or other antihistamines. 4. MAO inhibitors prolong the anticholinergic effects of diphenhydramine. Special Notes: Benadryl may precipitate an attack in chronic obstructive pulmonary disease (COPD) states. Adult Dose: Allergic Reaction: 25 to 50 mg SIVP. Repeat every 4-6 hours PRN or 50 mg deep IM. EPS: 25 to 50 mg IV or IM Antiemetic: 12.5 to 25mg IV/IM or orally. 38 Pediatric Dose: Allergic Reaction: 1 to1.25 mg/kg SIVP. Repeat every 4 to 6 hours PRN. Maximum single Dose of 50 mg. EPS: 1 to 1.25 mg/kg IV, IO or IM. Max dose 25 mg. Antiemetic: (pediatrics older than 2 years old, >12kg) 0.1 mg/kg IV, IO, or IM. Maximum dose: 25mg. Route: IVP; IO; Deep IM; PO (Benadryl elixir or tablets only) Pregnancy Safety: Category B / No possible adverse effect on fetus in laboratory testing 39 Name: Dobutamine Hydrochloride (Dobutrex®) (doe BYOU tah meen HYE droe KLOR ide) Used for correction of hemodynamic imbalances present in shock syndrome after MI, trauma, endotoxic septicemia, open heart surgery, and renal failure or chronic cardiac decompensation (e.g., CHF). Class: Sympathomimetic; Inotropic agent; Vasopressor; Beta adrenergic agonist Action: 1. Synthetic catecholamine that has positive inotrope and dromotropic effect with small positive chronotropic effects resulting in an increase of cardiac output. 2. Increased renal and mesenteric blood flow following increase in cardiac output. 3. Slight vasodilation effects. 4. Onset of action is 1 to 2 minutes; peak after 10 minutes. 5. Duration of action is 1 to 2 min after cessation of infusion. Use: 1. Congestive heart failure (CHF) 2. Inotropic support in cardiogenic shock 3. Left ventricular dysfunction 4. Non-hypovolemic, hemodynamically significant hypotension Side Effects: CNS: Headache; Tremors; Anxiety Cardiovascular: Chest pain (angina); Hypertension; Tachydysrhythmias; Premature ventricular contractions (PVCs); AMI; Cardiac arrhythmias; Palpitations Gastrointestinal: Nausea; Vomiting; Tissue necrosis upon extravasation Contraindications: Absolute: Known hypersensitivity; Pre-existing hypertension; Hypovolemia; Severe hypotension; Uncorrected / uncontrolled tachycardia; Idiopathic hypertrophic subaortic stenosis (IHSS); Poison-induced shock; shock with BP < 100mm Hg Drug Interactions: 1. Incompatible with sodium bicarbonate and furosemide. 2. Beta blockers may inhibit effects of dobutamine. 3. Alkaline solutions may inactivate dobutamine. 4. Hypersensitive potentiation possible with oxytoxics and tricyclic antidepressants. 5. Works well with dopamine. Special Notes: 1. Use with caution with signs of myocardial ischemia. Acute myocardial infarction setting may aggravate or extend the infarct size. 2. Monitor blood pressure carefully. 3. May be administered through a Y-site with concurrent dopamine, lidocaine, nitroprusside, and potassium chloride infusions. 4. Ensure IV is patent due to possibility of necrosis. 5. Do not administer as an IV bolus. 6. Titrate dose to maintain a heart rate increase of greater than 10% of baseline. 7. Patients can become hypotensive due to vasodilatory effects. Adult Dose: 2-20 mcg/kg/minute IV infusion. Increase by 2 mcg/kg/minute PRN based on inotropic effect. 40 Pediatric Dose: 2-20 mcg/kg/minute IV infusion. Increase by 1 mcg/kg/minute PRN based on inotropic effect. Route: IV Infusion. Pregnancy Safety: Category C / Not well established, crosses the placenta and may cause fetal damage. 41 Name: Dopamine Hydrochloride (Intropin®; Dopastat®; Revimine®) (DOH pah meen HIGH droe KLOR ide) Used for correction of hemodynamic imbalances present in shock syndrome after MI, trauma, endotoxic septicemia, open heart surgery, and renal failure or chronic cardiac decompensation (e.g., CHF). Class: Catecholamine; Inotropic agent; Adrenergic agonist; Vasopressor Action: 1. The effect on beta-1 receptors causes a positive inotropic effect on the heart. 2. Acts on alpha-adrenergic receptors causing peripheral vasoconstriction in higher doses. 3. Maintains renal and mesenteric blood flow because of its effect on the dopaminergic receptors. 4. Increases both systolic and pulse pressure. Usually, less effect on the diastolic pressure. 6. Effects are dose related: a. Low dose (2-10 mcg/kg/minute) provides primarily a Beta-1 response. This increases cardiac output by increasing myocardial contractility and cardiac impulse conduction. b. High dose (10-20 mcg/kg/minute) provides primarily an Alpha response resulting in peripheral vasoconstriction, increased peripheral vascular resistance, and increased blood pressure. c. Doses higher than 20 mcg/kg/minute, Alpha stimulation predominates the vasoconstriction may compromise circulation to the limbs. 7. Onset of action is within 5 minutes. 8. Duration of effects is less than 10 min after cessation of infusion. Use: 1. Cardiogenic shock (Myocardial infarction - MI, Congestive heart failure - CHF). 2. Shock states with hemodynamically significant hypotension in the absence of hypovolemia (i.e., Septic shock, Spinal shock, Distributive shock). 3. Symptomatic bradycardia unresponsive to Atropine. 4. Hypotension post ROSC. Side Effects: CNS: Headache Cardiovascular: Angina; Arrythmias; Palpitations; Hypotension (low Dose); Hypertension (high Dose); Tachycardias; Ischemia; Decreased peripheral perfusion Respiratory: Dyspnea Gastrointestinal: Nausea; Vomiting Other: Necrosis and tissue sloughing with extravasation Contraindications: Absolute: Cardiac arrest; Hypovolemia; Pheochromocytoma; Uncorrected/uncontrolled tachycardia; Idiopathic hypertrophic subaortic stenosis (IHSS) Relative: Hypertension Drug Interactions: 1. Inactivates with alkaline solutions (e.g., sodium bicarbonate and furosemide). 2. Administration to patients on oxytocin may result in severe persistent hypertension. 3. Beta blockers may antagonize the effects of dopamine. 4. Tricyclic antidepressants and other monoamine oxidase inhibitors (MOAI) will potentiate the effects of dopamine. 5. Using dopamine with phenytoi