Adenosine (Adenocard) Pharmacology PDF

Adenosine (Adenocard) Pharmacology Onset: Half life < 10 sec. Adenosine will not convert atrial fib., atrial flutter, or VT to NSR Action: Antiarrhythmic Indications Narrow Complex Tachycardia (PSVT) Wide Complex Tachycardia Adult Dose 0.1 mg/kg mg/kg Rapid IVP, IO 0.1 Maximum 6 mg If ineffec...

Adenosine (Adenocard) Pharmacology Onset: Half life < 10 sec. Adenosine will not convert atrial fib., atrial flutter, or VT to NSR Action: Antiarrhythmic Indications Narrow Complex Tachycardia (PSVT) Wide Complex Tachycardia Adult Dose 0.1 mg/kg mg/kg Rapid IVP, IO 0.1 Maximum 6 mg If ineffective, administer 0.2 mg/kg mg/kg Rapid IVP, IO Maximum 12 mg Adverse Reactions Contraindications Pediatric Dose Pediatric SVT 6 mg rapid IVP, IO over 1 – 3 seconds If no response after 1 – 2 minutes, repeat 12 mg rapid IVP, IO over 1 – 3 seconds Follow rapid 0.9% NS flush of 20 ml after each bolus Precautions Pharmacology 2nd & 3rd degree AV Block, Sick Sinus Syndrome, Symptomatic bradycardia, unless patient has functioning artificial pacemaker Cardiovascular: Facial flushing, Headache, Sweating, Palpitations, Chest Pain, Hypotension Respiratory: Shortness of Breath, Chest Pressure, Hyperventilation, Head Pressure Central Nervous System: Lightheadedness, Dizziness, Tingling in Arms, Numbness, Apprehension, Blurred Vision, Burning Sensation, Heaviness in Arms, Neck, and Back Gastrointestinal: Nausea, Metallic Taste, Tightness in Throat, Pressure in Groin. May be rarely associated with ventricular fibrillation. The effects of adenosine are antagonized by methylxanthines such as caffeine and theophylline. In their presence, larger doses may be required or adenosine may not be effective. Adenosine typically causes arrhythmias at the time of cardioversion. Generally these will last a few seconds or less and may include PVC’s, PAC’s, bradycardia, tachycardia, various degrees of AV block or transient asystole. Also, use with caution in patients with asthma as it may cause bronchospasm. Responsoft EMS Protocols Page 103 Adult dose: Flush with 20 ml NS after each dose Pediatric dose: Flush with 5 ml NS after each dose IV at antecubital site preferred 10/13/2020 Pharmacology Afrin (Oxymetazoline) Pharmacology Epistaxis-Nosebleed 0.05% - 2 - 3 puffs/nares on side of bleeding. Alternate dosing of impregnating cotton ball and packing into nose. Precautions Adverse Reactions Contraindications Pediatric Dose Adult Dose Indications Action: vasoconstrictive effects Penetrating injury to eye or extrusion of scleral contents Presence of uncontrolled hypertension. Individual nasal spray containers. NOT TO BE REUSED! Responsoft EMS Protocols None Page 104 10/13/2020 Pharmacology Albuterol (Proventil Ventolin) Advanced EMT can Administer Medication Adult Dose 2.5 mg in 3 ml Normal Saline, via nebulizer @ 6 L/M O2 May Repeat twice. Adverse Reactions Contraindications 2.5 mg in 3 ml Normal Saline, via nebulizer @ 6 L/M O2 May Repeat twice. Precautions Onset: improvement within 5 min. Peak effect 2 hours Allergic Reaction/Anaphylactic Shock Respiratory Distress Toxic Exposure Pediatric Allergic Reaction Pediatric Respiratory Distress (Lower Airway) Pediatric Dose Indications Action: Bronchodilator Pharmacology Hypersensitivity Use caution in patient’s with tachydysrhythmias and cardiovascular disorders Cardiovascular: Tachycardia, Hypertension Central Nervous System: Tremors, Dizziness, Nervousness, Headache, Insomnia Ear, Nose, and Throat: Pharyngitis, Nasal Congestion Gastrointestinal: Nausea, Dyspepsia Respiratory: Bronchospasm, Cough, Bronchitis, Wheezing Use of mouth piece is most effective route if patient is cooperative Should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias and hypertension, in patients with convulsive disorders, hyperthyroidism or diabetes mellitus. Responsoft EMS Protocols Page 105 10/13/2020 Pharmacology Amiodarone (Cordarone) Contraindications Adverse Reactions Precautions Onset: Immediate Chest Pain/MI Post Resuscitation Premature Ventricular Contractions (PVC's) (PVC’s) V-Fib/Pulseless V-Tach Wide Complex Tachycardia (V-Tach w/Pulse) Overdose Pediatric Pulseless Arrest V-Fib / Pulseless V-Tach: 300 mg Rapid IVP, IO May repeat 150 mg Life-Threatening Arrhythmias Mix 150 mg in 100 ml of 0.9 NS over 10 minutes 15 mg/min. IV Infusion mg/kg 55mg/kg Pediatric Dose Adult Dose Indications Action: Antiarrhythmic Pharmacology May repeat x 2 for refractory V-Fib. Maximum single dose 300 mg Maximum additional dose 150 mg Hypersensitivity, Patients with cardiogenic shock, Marked sinus bradycardia, and 2nd or 3rd degree AV block unless functioning pacemaker is available Body as a Whole: Fever Cardiovascular: Hypotension, Asystole/Cardiac Arrest/EMD, Cardiogenic Shock, CHF, Bradycardia, Ventricular Tachycardia, A-V Block Digestive System: Nausea Like all antiarrhythmic agents, may cause a worsening of existing arrhythmias or precipitate a new arrhythmia. 2% of patients were reported to have respiratory distress syndrome (ARDS). Responsoft EMS Protocols Page 106 Use large needle when drawing drug into syringe, and draw slowly. This will help prevent foaming. 10/13/2020 Pharmacology Chest Pain/MI Extremity Trauma 324 mg chewable, PO (4 tablets) Pharmacology Onset: Peak effect: 15 minutes to 2 hours Contraindications GI bleeding, stomach pain, nausea, vomiting, bronchospasm Precautions Ulcers, GI disorders, other bleeding disorders, allergy / hypersensitivity, Renal failure, decreased LOC Adverse Reactions Pediatric Dose Indications EMT can Administer Medication Adult Dose Action: Blood modifier Platelet aggregation Aspirin Responsoft EMS Protocols None Page 107 10/13/2020 Atropine Pharmacology Pharmacology Onset: Immediate Bradycardia Premature Ventricular Contractions (PVC’s) (PVC's) DS 0.02 0.02mg/kg mg/kg IVP, IO Minimum dose 0.1 mg, Maximum single dose: 0.5 mg Maximum total dose: Child 1 mg, Adolescent 3 mg Hypersensitivity, Glaucoma, Tachycardia; unstable cardiovascular status in acute hemorrhage, Obstructive disease Cardiovascular: Palpitations, bradycardia (following low doses of atropine) Tachycardia (after higher doses) CNS: Headache, Flushing, Nervousness, drowsiness, weakness, dizziness, fever, Elderly may exhibit mental confusion or excitement to even small doses, larger doses, Restlessness, Tremor Gastrointestinal: Nausea, Vomiting, Heartburn Precautions Contraindications Cardiac: 0.5 - 1 mg IVP, IO Maximum 3 mg 2 - 2.5 mg ET, repeat every 5 minutes Maximum 3 mg Poisoning: 2 - 5 mg IV, IO May repeat every 15 minutes Adverse Reactions Adult Dose Toxic Exposure Exposure Pediatric Bradycardia Toxic Intubation-Pediatric Intubation-Pediatric Oral Oral Pediatric Dose Indications Action: Anticholinergic Increases heart rate May produce drowsiness, dizziness or blurred vision. Use cautiously in patients with asthma or allergies. Use caution in Coronary artery disease, CHF, Cardiac arrhythmias, Tachycardia, Hypertension, Infants, small children, Debilitated patients with chronic lung disease Responsoft EMS Protocols Page 108 Use caution in patients with asthma, allergies CAD, CHF, HTN, infants, small children, & persons with down’s syndrome 10/13/2020 Calcium Chloride Pharmacology Onset: Immediate Dialysis Patients in Cardiac Arrest Overdose Overdose Dialysis Patients in Cardiac Arrest: 1 gm IVP, IO Overdose: 0.5 gm IVP, IO every 3 - 5 minutes as needed for significant bradycardia Precautions Adverse Reactions Contraindications Pediatric Dose Adult Dose Indications Action: Acts as activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscle. Pharmacology Patients with the risk of existing digitalis toxicity Rapid injection may cause tingling sensations, a calcium taste, or heat wave. Peripheral vasodilatation, local burning, or moderate fall in BP. If infiltration occurs, IV administration at the site should be discontinued at once. Injections should be made slowly through a small needle into a large vein to minimize venous irritation and avoid undesirable reactions. Responsoft EMS Protocols Page 109 Irritating to veins and must not be injected into tissue, severe necrosis and sloughing may occur. 10/13/2020 Dexamethasone (Decadron) Pharmacology Indications 10 mg IVP, IO, IM PO 0.6 mg/kg 0.6 mg/kg IVP, IO, IM, PO Maximum 10 mg Adverse Reactions Contraindications Allergic Reaction/Anaphylactic Shock Respiratory Distress Pediatric Allergic Reaction Pediatric Respiratory Distress (Lower Airway) Pediatric Respiratory Distress (Upper Airway) Adult Dose Onset: Peak effect 1 - 2 hours Pediatric Dose Action: Anti-inflammatory Pharmacology DS Hypersensitivity, AIDS, TB Cardiovascular: Myocardial rupture following recent M.I. Fluid & Electrolyte Disturbances: Fluid Retention, CHF, Potassium Loss, Hypokalemic Alkalosis, Hypertension Gastrointestinal: Peptic Ulcer, Perforation of the small and Large Bowel, Pancreatitis CNS: Convulsions, Vertigo, Headache, Psychic Disturbances Musculoskeletal: Muscle Weakness Other: Nausea, Hiccups Precautions None Psychic derangements may appear when used. Avoid injection into an infected site. The slower rate of absorption by intramuscular administration should be recognized. Possible aggravation of Diabetic Mellitus. Responsoft EMS Protocols Page 110 10/13/2020 Dextrose (D10) Pharmacology Advanced EMT can Administer Medication Indications 100 ml boluses until patient awake &/or follow up blood sugar > 60 mg/dl Contraindications Sub Q & IM injections, Intercerebral bleeding, Hemorrhagic CVA, cerebral edema, Delirium Tremors if patient dehydrated Febrile response, Infection at injection site, Tissue necrosis, Venous thrombosis or phlebitis, Extravasation, Hypovolemia, Dehydration, Mental Confusion or unconsciousness. May produce allergic reactions in corn-sensitive persons. Use the largest available peripheral vein. Rapid infusion may cause a generalized flush. Precautions Onset: Onset: 1 - 2 minutes DS 55ml/kg ml/kg to boluses until patient awake &/or glucose > 60 mg/dl Maximum 100 ml Adverse Reactions Pediatric Dose Hyperglycemia/Hypoglycemia CVA/Unconscious Seizure Pediatric Pulseless Arrest Pediatric Hypovolemic Shock Pediatric Seizures Pediatric Unconscious/Hypoglycemic Pediatric Toxic Overdose Adult Dose Action: Natural sugar Pharmacology Inject slowly so that extravasation does not occur. If thrombosis occurs, injection should be stopped. Responsoft EMS Protocols Page 111 Do not use Dextrose if IV site is questionable. Perform blood glucose analysis prior to administration and 5-15 minutes after initial analysis. 10/13/2020 Dextrose (50) Pharmacology Advanced EMT can Administer Medication Use Dextrose 50% in place of Dextrose 10% during shortages Adult Dose 25 g (50 ml of 50%) IVP, IO SLOWLY, Repeat as needed based on mental status and serial finger sticks 11 ml/kg ml/kg IVP, IO 25% (ages under 8 years) 1 ml/kg ml/kg IVP, IO 50% (8 years and over) Single dose Maximum 50 ml Repeat as needed based on mental status and serial finger sticks Adverse Reactions Sub Q & IM injections, Intercerebral bleeding, Hemorrhagic CVA, cerebral edema, Delirium Tremors if patient dehydrated, Diabetic coma while blood sugar is excessively high Febrile response, Infection at injection site, Tissue necrosis, Venous thrombosis or phlebitis, Extravasation, Hypovolemia, Dehydration, Mental Confusion or unconsciousness. May produce allergic reactions in corn-sensitive persons. Use the largest available peripheral vein. Rapid infusion may cause a generalized flush. Precautions Contraindications Onset: 1 - 2 minutes Hyperglycemia/Hypoglycemia CVA/Unconscious Unconscious/Unknown Seizure Pediatric Pulseless Arrest Pediatric Hypovolemic Shock Pediatric Seizures Pediatric Unconscious/Hypoglycemic Pediatric Toxic Overdose Pediatric Dose Indications Action: Natural sugar Pharmacology Inject slowly so that extravasation does not occur. If thrombosis occurs, injection should be stopped. Determine glucose level before administering the medication. Responsoft EMS Protocols Page 112 Do not use Dextrose if IV site is questionable. Perform blood glucose analysis prior to administration and 515 minutes after initial analysis. 10/13/2020 Pharmacology Advanced-EMT can Administer Medication Use Valium in place of Midazolam (Versed) during shortages Adult Dose Contraindications 0.2 mg/kg IV, IO Slowly 0.2 mg/kg Maximum 10 mg Hypersensitivity, glaucoma Adverse Reactions 5 mg IVP, IO Slowly Maximum 20 mg CNS: Confusion, headache, slurred speech, syncope, tremor, vertigo Gastrointestinal: Nausea Cardiovascular: Bradycardia, cardiovascular collapse, hypotension EENT: Blurred vision Skin: Urticaria, skin rash Other: Hiccups, anxiety, hallucinations, increased muscle spasticity, rage Precautions Pharmacology Onset: Onset: 1 – 5 minutes Peak effect: 1 – 2 hours Bradycardia Narrow Complex Tachycardia (PSVT) Wide Complex Tachycardia (V-Tach w/Pulse) Behavioral Behavioral Seizure Obstetric Emergencies-Eclampsia Pediatric Bradycardia Pediatric Tachycardia Pediatric Pain Control Pediatric Seizures Pediatric Burns Pediatric Multiple Trauma Intubation-Pediatric Oral Rapid Sequence Intubation (RSI) Pediatric Dose Indications Action: Anticonvulsant Sedative Diazepam (Valium) A significant proportion of patients experience a return to seizure activity, due to shortlived effect of drug. Hypotension or weakness has occurred in some patients particularly when used with narcotics, barbiturates, or alcohol. Lower doses should be used for elderly and debilitated patients. Responsoft EMS Protocols Page 113 Avoid using small veins. Do not mix with other drugs. 10/13/2020 Diphenhydramine (Benadryl) Pharmacology Action: Antihistamine Advanced EMT can Administer Medication Pharmacology Onset: < 15 min. Peak effect 1 - 4 hours Pediatric Allergic Reaction Extrapyramidal symptoms (EPS) is not an allergic reaction, but Benadryl can also be used for EPS. See Allergic Reaction/Anaphylactic Shock for common symptoms. 50 mg IVP, IM, IO, PO Over 1 – 2 minutes watch for signs of hypotension No repeat dose 11mg/kg mg/kg Slow IVP, IO, IM Maximum 25 mg mg/kg PO Maximum 50 mg 11mg/kg Adverse Reactions Hypersensitivity, Nursing mothers Cardiovascular: Hypotension, Headache, Palpitations, Tachycardia, extrasystoles CNS: Sedation, Sleepiness, Dizziness, Fatigue, Confusion, Restlessness, Excitation, Nervousness, Tremor, Irritability, Blurred Vision, Vertigo, Tinnitus, Convulsions Gastrointestinal: Nausea, Vomiting, Diarrhea Respiratory: Thickening of Bronchial Secretions, Tightness of Chest and Wheezing, Nasal Stuffiness Precautions Contraindications Pediatric Dose Adult Dose Indications Allergic Reaction/Anaphylactic Shock Has Atropine-like action and should be used with caution in patients with a history of bronchial asthma, increased intraocular pressure, cardiovascular disease or hypertension. Use caution in patients with lower respiratory disease, including asthma Responsoft EMS Protocols Page 114 None 10/13/2020 Epinephrine 1:1,000 Pharmacology Onset: 3 - 10 minutes IM 0.3 - 0.5 mg IM may repeat Contraindications 0.1 ml/kg Cardiac 0.1 ml/kg ET dose Maximum 2.5 ml Allergic reaction and Respiratory Distress 0.01 ml/kg ml/kg IM Maximum dose 0.3 ml Known Hypersensitivity, Glaucoma Adverse Reactions Pediatric Dose Advanced EMT can Administer Medication IM Allergic Reaction/Anaphylactic Shock Respiratory Respiratory Distress Distress Pediatric Bradycardia Pediatric Pediatric Pulseless Pulseless Arrest Arrest Pediatric Allergic Reaction Adult Dose Indications Action: Sympathomimetic & Cardiac stimulant Pharmacology Anxiety, Headache, Fear, and Palpitations. Repeated injections can result in necrosis at injection sites Precautions None Protect from exposure to light. DO not use if discolored or contains precipitate. Use EPINEPHRINE with caution in any patient who has used an aerosol bronchodilator within the past 4 hours. Do not use EPINEPHRINE in any patient who has repeatedly used an aerosol bronchodilator within the past 4 hours. Use EPINEPHRINE with caution in males over the age of 35 or in those patients with known history of hypertension, thyroid disease, and angina. Responsoft EMS Protocols Page 115 10/13/2020 Epinephrine 1:10,000 Pharmacology Onset: < 5 minutes Asystole/PEA V-Fib/Pulseless V-Tach Allergic Reaction/Anaphylactic Shock Pediatric Bradycardia Pediatric Pulseless Arrest Cardiovascular 1 mg IVP, IO every 3 - 5 min. (2 - 2.5 mg ET every 3 - 5 min.) Anaphylaxis 0.5 mg (5 ml) IVP, IO Cardiovascular: 0.1 ml/kg ml/kg IVP, IO Pediatric Dose Adult Dose Indications Action: Sympathomimetic & Cardiac stimulant Maximum 10 ml (per dose) Contraindications Adverse Reactions Repeat every 3 - 5 minutes Known Hypersensitivity Cardiac Arrhythmias and excessive rise in blood pressure. Other: Cerebral Hemorrhage, Hemiplegia, Subarachnoid Hemorrhage, Anginal Pain Precautions Pharmacology Protect from light. Do not use if discolored or contains precipitate. Responsoft EMS Protocols Page 116 Be sure to flush IV tubing well before and/or after use of Sodium Bicarbonate 10/13/2020 Pharmacology Epinephrine Push Dose Onset: Immediate Bradycardia Hypotension (Non-Trauma) Post Resuscitation Sepsis Pediatric Hypotension/Shock (Non-Trauma) Pediatric Septic Shock Epinephrine concentration 10 mcg/mL Mixing Instructions: Take a 10 mL syringe with 9 mL of normal saline Into this syringe, draw up 1 mL of epinephrine from the cardiac amp (1:10,000) (Cardiac amp contains Epinephrine 100 mcg/mL) Now you have 10 mL of Epinephrine 10 mcg/mL Do not give cardiac arrest doses (1 mg) to patients with a pulse Onset - 1 minute Duration – 5 - 10 minutes Dose - 0.5 - 2 mL every 2 - 5 minutes (5 - 20 mcg Administer 0.5 – 2 mL IVP of 10 mcg/mL solution every 2 – 5 minutes Contraindications Anxiety, Headache, Fear, and Palpitations. Repeated injections can result in necrosis at injection sites Precautions Known Hypersensitivity, Glaucoma Adverse Reactions Pediatric Dose Adult Dose Indications Action: Sympathomimetic & Cardiac stimulant Pharmacology Quantities in excess of 50 mcg/min can potentially cause end-organ damage Responsoft EMS Protocols Page 117 Remember: push dose is a short term bridge to IV drip and is not intended for prolonged use (notify the receiving facility as soon as possible of the use of push dose epinephrine). 10/13/2020 Etomidate (Amidate) Pharmacology Rapid Sequence Intubation (RSI) 0.3 0.3mg/kg mg/kg IVP, IO SLOWLY (over 30 - 60 seconds) Maximum 20 mg Precautions Adverse Reactions Contraindications Pediatric Dose Indications Use Etomidate in place of Ketamine (Ketalar) during shortages Adult Dose Action: Non-barbiturate, hypnotic agent. No analgesia Pharmacology Onset: 30 - 60 seconds Duration: 10 - 15 minutes DS 0.3 0.3mg/kg mg/kg IVP, IO SLOWLY (over 30 - 60 seconds) Do not use in children age 8 or younger Known hypersensitivity Transient Venous Pain, Myoclonus, Trimus (clenched jaw) Cardiovascular: Hypertension, Hypotension, Tachycardia, Bradycardia, and Other Arrhythmias Respiratory: Hyperventilation, Hypoventilation, Apnea for Short Duration, Laryngospasm, Hiccup and Snoring Gastrointestinal: Nausea, Vomiting Not recommended for use for children under the age of 10 years. Not recommended in obstetrics Responsoft EMS Protocols Page 118 Advantages Does not affect BP Decreases intracerebral pressure Minimal respiratory depression 10/13/2020 Pharmacology Action: Narcotic analgesic Fentanyl (Sublimaze) Advanced EMT can Administer Medication (Pain control only) DS Pharmacology Onset: Almost immediate Maximal analgesic & respiratory effect may take several minutes. Indications 1.5 Pain: 11 mcg/kg mcg/kg IVP, IO every 3 - 5 minutes for pain. 1.5mcg/kg mcg/kg IN 100 mcg Maximum per dose, Maximum Total 200 mcg RSI & DSI: Sedation for Transportation: 2 mcg/kg mcg/kg RSI no dose limit/Maximum dose and May re-dose every 20 minutes as needed to maintain sedation. Pain: 11 mcg/kg mcg/kg IVP, IO every 3 - 5 minutes for pain 100 mcg Maximum per dose, Maximum Total 200 mcg mcg/kg RSI & DSI: Sedation for Transportation: 22 mcg/kg Contraindications Known intolerance to drug. Respiratory: Respiratory Depression, Apnea, Laryngospasm Cardiovascular: Bradycardia, Hypertension, Hypotension CNS: Dizziness, blurred vision Gastrointestinal: Nausea & Vomiting Other: Rigidity, Diaphoresis Precautions 1.5mcg/kg mcg/kg IN 1.5 RSI no dose limit/Maximum dose and May re-dose every 20 minutes as needed to maintain sedation. Adverse Reactions Pediatric Dose Adult Dose See Pain Control & Chest Pain/MI Pain/MI, Pain Control Pulmonary Edema/CHF Pediatric Pain Control for additional dosing Pediatric Pain Control Rapid Sequence Intubation (RSI) Delayed Sequence Intubation (DSI) Use caution when administering Fentanyl to elderly and debilitated patients, or patients with limited pulmonary reserve. Use caution in patients with head injuries and elevated ICP. Use caution with bradycardia, COPD and decreased respiratory reserve patients. Also patients using narcotics. Fentanyl should be reduced in elderly and debilated patients. Also, patients with elevated BP with or without pre-existing hypertension. Fentanyl in high doses (> 2-3 mcg/kg) can result in "stiff chest" with inability to ventilate patient. Stiff chest is treated with IV succinylcholine and intubation. Responsoft EMS Protocols Page 119 10/13/2020 Glucagon Pharmacology Indications Adult Dose Hypoglycemia: 1 mg IM (Slowly), IN (reassess blood glucose in 10 minutes < 60 repeat) Esophageal Foreign Body: 1 mg IVP 25 25 mcg/kg mcg/kg IM, IN Maximum 1 mg (1,000 mcg) Hypersensitivity, Hyperglycemia, allergies to beef or porcine proteins, insulinoma Adverse Reactions Hyperglycemia/Hypoglycemia CVA/Unconscious Seizure Esophageal Foreign Body Pediatric Unconscious/Hypoglycemic Pediatric Dose Advanced EMT can Administer Medication Contraindications Action: Anti-hypoglycemic Pharmacology Onset: Patient should respond within 15 minutes Nausea, Vomiting, especially with doses above 1 mg or rapid injection. Increase in Blood Pressure and Pulse Rate May Occur . This May Require Therapy for Patients with History of Coronary Artery Disease. Allergic Reactions May Occur in Rare Cases Precautions Do not mix with saline Caution should be observed in diabetic patients or in elderly patients with known cardiac disease to inhibit gastrointestinal motility Responsoft EMS Protocols Page 120 10/13/2020 Pharmacology Behavioral Emergencies 5 mg IM Age >16 years old Pharmacology Onset: 20 – 30 minutes IM Contraindications CNS: Extrapyramidal reactions, restlessness, anxiety, agitation, lethargy, fatigue, weakness, tremor, headache, confusion, vertigo, grand mal seizures Cardiovascular: Tachycardia, ECG changes, hypotension GI: Dry mouth, nausea & vomiting, diarrhea Other: Blurred vision Precautions Hypersensitivity to the drug, Seizures, Hemodynamic instability, Parkinson's Adverse Reactions Pediatric Dose Indications Use Haldol in place of Ketamine (Ketalar) during shortages Adult Dose Action: Blocks CNS dopamine receptors Haloperidol (Haldol) Patient with arrhythmia or seizures Responsoft EMS Protocols None Page 121 10/13/2020 Pharmacology Ibuprofen (Motrin, Advil) Indications Action: Inhibits prostaglandin synthesis Pharmacology Onset: 0.5 – 2.5 hours Pediatric Dose Children 6 months of age or older 10 10 mg/kg mg/kg PO Maximum 600 mg ContraIndications Hypersensitivity Patients who have experienced asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs. Adverse Reactions Adult Dose Pediatric Fever Cardiovascular: Edema, fluid retention CNS: Dizziness, headache, nervousness Skin: Rash, pruritus ( Gastrointestinal: Epigastric pain, nausea/vomiting abdominal cramps or pain, indigestion Precautions None Responsoft EMS Protocols ResponsEMS Protocol Page 122 Pharmacology 2 10/13/2020 Ipratropium (Atrovent) Pharmacology Advanced EMT can Administer Medication Onset: 1 – 3 minutes Peak effect: 1.5 - 2 hours Allergic Reaction/Anaphylactic Shock Respiratory Respiratory Distress Distress Toxic Exposure Pediatric Allergic Reaction Pediatric Respiratory Respiratory Distress Distress (Lower (Lower Airway) Airway) Pediatric 0.5 mg / 2.5 ml Normal Saline, via nebulizer @ 6 L/M O2 mix with dose of Albuterol May repeat x 2 (Ipratropium may be used alone, if patient’s Albuterol inhaler has been used multiple times) 0.5 mg / 2.5 ml Normal Saline, via nebulizer @ 6 L/M O2 mix with dose of Albuterol May repeat x 2 (Ipratropium may be used alone, if Hypersensitive to any other components of the drug product or to atropine or its derivatives Cardiovascular: Palpitations CNS: Nervousness, Dizziness, Headache Gastrointestinal: Nausea, Vomiting, Gastrointestinal Distress Musculoskeletal: Tremor Ocular: Blurred Vision Oral: Dry Mouth Respiratory: Cough, Exacerbation of Symptoms Precautions Contraindications patient’s Albuterol inhaler has been used multiple times) Adverse Reactions Pediatric Dose Adult Dose Indications Action: Bronchodilator Pharmacology Responsoft EMS Protocols None Narrow-Angle Glaucoma Page 123 10/13/2020 Pharmacology Ketamine (Ketalar) Pharmacology Onset: IV 30 seconds – 2 minutes IM 3 – 4 minutes Action: Non-barbiturate anesthetic Indications Behavioral Pain Control Rapid Sequence Intubation (RSI) Delayed Sequence Intubation (DSI) Pediatric Behavioral Emergencies Pediatric Pain Control DS Combative Patient: 11 mg/kg mg/kg IVP, IO or 3 mg/kg IM. MUST CO-ADMINISTER MIDAZOLAM 2 mg IVP, IO, IM RSI & DSI: 11 mg/kg mg/kg IVP, IO Ketamine reduces bronchospasm Chemical Restraint Part B B: Go to specific page for dosing Pain Control: 0.2 0.2mg/kg mg/kg IVP, IO Maximum 30 mg Combative Patient: 1 mg/kg IVP, IO or 33 mg/kg mg/kg IM RSI & DSI: 11mg/kg mg/kg IVP, IO Ketamine reduces bronchospasm Adverse Reactions Those whom a significant elevation of blood pressure would constitute a serious hazard and in those who have shown hypersensitivity to the drug. Cardiovascular: BP and pulse rate are frequently elevated following administration. Hypotension and bradycardia have been observed. Arrhythmia has also occurred Gastrointestinal: Nausea / vomiting; increased salivation Neurological: Enhanced skeletal muscle tone may be manifested by tonic and clonic movements sometimes resembling seizures. Respiratory: Although respiration is frequently stimulated, severe depression of the respiration or apnea may occur following rapid IV administration of high doses. Laryngospasms and other forms of airway obstruction have occurred. Precautions Contraindications Pediatric Dose Adult Dose Pain Control: 0.2 mg/kg IVP, IO Maximum 40 mg Resuscitative equipment should be ready for use. IV dose should be administered over 1 minute. More rapid administration may result in respiratory depression or apnea and enhanced pressor response. Use caution in the chronic alcoholic and the acutely alcoholintoxicated patient. Responsoft EMS Protocols Page 124 Monitor vital signs frequently. Use caution with elderly and pediatric patients and use low end of dosing range. 10/13/2020 Pharmacology Advanced EMT can Administer Medication Pharmacology Onset:10 minutes Peak effect: 1 – 2 hours Pain Control 15 mg IVP (or 30 mg IM) ONCE only Contraindications Do not use Toradol if the patient is allergic to ASA or NSAIDs, or if they are taking any blood thinners or anticoagulants. Do not use if pain suspected to be due to MI/ coronary artery disease, severe renal disease or kidney transplant, a bleeding or blood clotting disorder, a closed head injury or bleeding in brain, known stomach ulcer or a intestinal bleeding Adverse Reactions Pediatric Dose Adult Dose Indications Action: Nonsteroidal antiinflammatory (NSAIDs) Ketorolac (Toradol) Stomach upset is the most common side effect Nausea, vomiting, irritation at the injection site and abnormal tastes may also occur. Precautions None Use caution in patients with heavy regular alcohol use, asthma or aspirin allergy Responsoft EMS Protocols Page 125 10/13/2020 Pharmacology Lidocaine (Xylocaine) Indications Action: Antiarrhythmic Use Lidocaine in place of Amiodarone during shortages Pharmacology Onset: 30 - 90 seconds V-Fib/Pulseless V-Fib/Pulseless V-Tach V-Tach Intraosseous Infusion EZ-IO (Humerus) Intraosseous Infusion EZ-IO (Distal Tibia) Intraosseous EZ-IO (Proximal Tibia) DS Adult Dose 1.5 mg/kg mg/kg V-Fib/Pulseless V-Tach: 1 1– -1.5 IVP, IO May repeat 0.50.5– -0.75 IVP, IO 0.75 mg/kg mg/kg Total Maximum 3 mg/kg 3 mg/kg in 5 – 10 minutes Known hypersensitivity, Stokes-Adams Syndrome, Wolff-Parkinson-White Syndrome, or severe degrees of sinoatrial, atrioventricular or intraventricular block in the absence of an artificial pacemaker Cardiovascular: Bradycardia, Hypotension, and Cardiovascular Collapse Which May Lead to Cardiac Arrest CNS: Lightheadedness, Nervousness, Apprehension, Euphoria, Confusion, Dizziness, Drowsiness, Tinnitus, Blurred or Double Vision, Vomiting, Sensations of Heat, Cold or Numbness, Twitching, Tremors, Convulsions, Unconsciousness, Respiratory Depression, and Arrest. Other: Allergic Reactions as a Result of Sensitivity to Lidocaine are Extremely Rare. There have been cases of Permanent Injury to Extraocular Muscles Requiring Surgical Repair Precautions Contraindications When replacing Amiodarone, 11mg/kg mg/kg IVP, IO May repeat once in 15 minutes : 0.5 mg/kg mg/kg Intraosseous (Pediatric): 0.5 Maximum 20 mg Adverse Reactions Pediatric Dose Intraosseous (Adult): 50 mg IO Use caution in patients with severe liver or kidney disease because accumulation of the drug or metabolites may occur. Use caution in patients with hypovolemia, severe CHF, shock and all forms of heart block. Elimination of ventricular ectopic beats without prior acceleration in heart rate may promote more frequent ventricular arrhythmias or complete heart block. Dosage for pediatric and debilitated and/or elderly patients should be reduced. Responsoft EMS Protocols Page 126 Observe closely for drug toxicity Signs include: dizziness, confusion, delirium, seizures 10/13/2020 Magnesium Sulfate Pharmacology V-Fib/Pulseless V-Fib/Pulseless V-Tach V-Tach (If torsades de pointes suspected) Obstetric Emergencies-Eclampsia Emergencies–Eclampsia Respiratory Distress Pediatric Respiratory Distress (Lower Airway) Cardiac: 2 grams IVP, IO Asthma: 2 grams/100 ml NS IV Infusion over 20 minutes OB Emergencies-Eclampsia: 4 grams IV Infusion over 20 – 30 minutes Contraindications Heart block or myocardial damage, Known hypersensitivity or dialysis patients Flushing, Sweating, Lowered Blood Pressure, Hypothermia, Stupor and Respiratory Depression. Hypocalcemia, Circulatory Collapse, Cardiac/and CNS depression Precautions DS Asthma: 50 50 mg/kg mg/kg /100 ml NS IV Infusion over 20 minutes Maximum 2 grams Adverse Reactions Pediatric Dose Indications Onset: immediate Lasts about 30 minutes Adult Dose Action: Electrolyte replenished Anticonvulsant Pharmacology Use caution on renal impairment patients because drug is solely removed by the kidneys. Clinical indications of a safe dosage regimen include the presence of the patellar reflex (knee jerk) and absence of respiratory depression. When barbiturates, narcotics, or other hypnotics are given in conjunction with Magnesium, their dosage should be adjusted because of the additive central depressive effects Responsoft EMS Protocols Page 127 Not compatible with Sodium Bicarbonate. When given for eclampsia watch respirations closely. 10/13/2020 Pharmacology Methylprednisolone (Solu-Medrol) Action: Anti-inflammatory steroid Pharmacology Onset: Onset: 1 – 2 hours Indications Allergic Reaction/Anaphylactic Shock Respiratory Respiratory Distress Distress Pediatric Allergic Reaction Pediatric Respiratory Distress (Lower Airway) Pediatric Respiratory Distress (Upper Airway) Adult Dose 125 mg IVP, IO Slowly Pediatric Dose 2 mg/kg mg/kg IVP, IO Maximum 125 mg Contraindications Hypersensitivity, GI Bleed, Severe Infection Adverse Reactions Use Solu-Medrol in place of Dexamethasone (Decadron) during shortages Fluid & Electrolyte Disturbances: CHF in susceptible patients, HTN Musculoskeletal: Weakness Neurological: Convulsions, headache, vertigo Metabolic: Nausea & vomiting Cardiovascular: Arrhythmias, hypotension Skin: Sweating Precautions None Nonspecific ulcerative colitis, impending perforation or abscess or other infection. Peptic ulcer, renal insufficiency, hypertension, osteoporosis, myasthenia gravis (weakness of muscles) Responsoft EMS Protocols Page 128 10/13/2020 Pharmacology Action: Sedative, Amnesic, Short acting benzodiazepine CNS depressant Midazolam (Versed) Advanced EMT can Administer Medication Pharmacology Onset: 2 - 5 minutes Indications Adult Dose Seizure, Sedation: 0.1 mg/kg mg/kg IVP, IO, (See: MAD for IN dosing) Maximum 6 mg IM or 4 mg IVP, IO RSI & DSI: 0.1 mg/kg mg/kg IVP, IO post intubation Maximum 2 mg May repeat every 20 minutes x 2 if needed to maintain sedation. Adverse Reactions Hypersensitivity, Benzodiazepines are contraindicated in patients with acute narrow-angle glaucoma. Fluctuations in Vital Signs were most Frequently seen. Decreased Tidal Volume and/or Respiratory Rate, Apnea, Variations in Blood Pressure Precautions Contraindications Sedation: 2 mg IVP, IO or 5 mg IN Seizure: 5 mg IVP, IO or 10 mg IN (5 mg per nostril) Behavioral: 2 mg IVP or 5 mg IN, or 2 mg IM Must be co-administered when Ketamine is given RSI & DSI: 2 mg post intubation Maximum 2 mg IVP, IO May repeat every 20 minutes x 2 as needed to maintain sedation. Pediatric Dose DS Bradycardia Narrow Complex Tachycardia (PSVT) Wide Complex Tachycardia (V-Tach w/Pulse) Behavioral Seizure Obstetric Emergencies-Eclampsia Pediatric Bradycardia Pediatric Tachycardia Pediatric Behavioral Emergencies Pediatric Seizures Pediatric Burns Pediatric Multiple Trauma Intubation-Pediatric Oral Rapid Sequence Intubation (RSI) Delayed Sequence Intubation (DSI) IV doses should be decreased for elderly and debilitated patients. Midazolam does not protect against increase in intracranial pressure or against heart rate rise and/or blood pressure rise associated with endotracheal intubation under light general anesthesia. Responsoft EMS Protocols Page 129 Consider reducing the dose on elderly & debilitated patients. These patients may take longer to recover from drug. Monitor Respiratory status. 10/13/2020 Morphine Pharmacology Indications 2 - 4 mg IVP, IO every 3 - 5 minutes until desired affect RSI: 0.2 0.2mg/kg mg/kg IVP, IO Maximum 10 mg Onset: Onset: 2 - 3 minutes 0.1 0.1mg/kg mg/kg IV, IO Maximum 10 mg Adverse Reactions Hypersensitivity, acute abdominal conditions, head injury, convulsive disorders, hypovolemia, Do not use if patient having active asthma episode Major hazards are Respiratory Depression and lesser degree circulatory depression. Respiratory Arrest, Shock and Cardiac Arrest have occurred, particularly with overdose or rapid IV administration. Cardiovascular: Tachycardia, Bradycardia, Palpitation, Faintness, Syncope, and Orthostatic Hypotension CNS: Euphoria, Dysphoria, Weakness, Headache, Agitation, Tremor, Uncoordinated muscle movements, Hallucinations and Disorientation, visual Disturbances Allergic: Reactions to Opiates, Urticaria, Anaphylactoid Reactions Other: Face Sweating, Local Tissue Irritation and pain Precautions ContraIndications Pediatric Dose Chest Pain/MI Pain Control Pulmonary Edema/CHF Pediatric Pediatric Pain Control Rapid Sequence Intubation (RSI) Adult Dose Action: Narcotic analgesic Advanced EMT can Administer Medication (Pain control only) Use Morphine in place of Fentanyl (Sublimaze) during shortages Pharmacology Administer with caution and the initial dose should be reduced in patients with convulsive disorders, significant hepatic or renal impairment, fever, hypothyroidism, Addison’s disease, ulcerative colitis, prostatic hypertrophy, recent gastrointestinal or urinary surgery, and in the very young or elderly or debilitated patients. May obscure findings if used in patients with acute abdominal conditions. Use caution in patients with Supraventricular Tachycardias. May aggravate patients with preexisting convulsive disorders, may occur in patients without convulsive disorders Responsoft EMS Protocols Page 130 Administer slowly to avoid nausea & vomiting. Administer Naloxone to reverse effects of morphine if necessary. Use extreme caution with the elderly. 10/13/2020 Naloxone (Narcan) Pharmacology Unconscious/Unknown CVA/Unconscious Overdose Pediatric Unconscious/Hypoglycemic Pediatric Toxic Overdose Mucosal Atomizer Device (MAD) DS 0.4 - 2 mg IVP, IO, ET, IN May repeat every 5 minutes as needed Administer in lowest dose as needed to maintain adequate respirations 0.1 0.1 mg/kg mg/kg IVP, IO Maximum 2 mg 0.2 mg/kg mg/kg IN Maximum 2 mg Contraindications May be repeated one time if a positive response is noted Known Hypersensitivity Nausea, Vomiting, Sweating, Tachycardia, Increased Blood Pressure, Tremulousness, Seizures, and Cardiac Arrest Precautions Onset: 2 minutes. Advanced EMT can Administer Medication Adverse Reactions Pediatric Dose Adult Dose Indications Action: Narcotic antagonist Reverses the effects of opiates including respiratory depression. Pharmacology Several instances of Hypotension, Hypertension, Ventricular Tachycardia and Fibrillation, and Pulmonary Edema have been reported. Most of whom had pre-existing cardiac disease Responsoft EMS Protocols Page 131 Naloxone has short half-life and may relapse. All patients should be encouraged to accept transportation to the emergency department. 10/13/2020 Pharmacology Advanced EMT can Administer Medication (Nitroglycerin SL only) Pharmacology Onset: 2 minutes Chest Pain/MI Pulmonary Edema/CHF Spray / Tablet: 0.4 mg SL every 5 minutes until pain relieved. May repeat NTG x 2 (3 doses total) Paste: 1 inch (Apply concurrent with 1st SL NTG for CHF) May be applied to the patient’s left chest or the triceps area of either arm after sublingual nitroglycerine spray/tablet has been given X 3 Adverse Reactions Known Hypersensitivity, Pericardial tamponade, Restrictive Cardiomyopathy, Constrictive pericarditis Do not administer the following medications until after hours stated Drug Hours Cialis 48 Levitra 24 Viagra 24+ Most are dose related to results from Nitroglycerin’s activity as a vasodilator. Headache most common. Transient episodes of lightheadedness, sometimes related to hypotension. Hypotension infrequent but may be severe in some patient’s. Syncope, crescendo angina and rebound hypertension, but uncommon Precautions Contra-indications Pediatric Dose Adult Dose Indications Action: Vasodilator Nitroglycerin Severe hypotension and shock can occur even with smaller doses. Use caution with volume depleted patients. Hypotension induced by Nitroglycerin can be accompanied by hypotension and increased angina pectoris. Responsoft EMS Protocols Page 132 Check for transdermal patch prior to initiating spray/infusion. 10/13/2020 Normal Saline Pharmacology Indications Action: Nonpyrogenic solution for fluid and electrolyte replacement Pharmacology 0.9% Normal Saline (NS) Throughout the Protocol 20 ml/kg Fluid Bolus: 20 ml/kg For hypotension due to fluid or blood loss Fluid Bolus: 300 - 500 ml When provider determines patient would benefit from fluid bolus (e.g. fever with tachycardia, adverse effect of nitroglycerin). Maximum 2,000 ml Adverse Reactions Contraindications Pediatric Dose Adult Dose KVO (unless below conditions exist) KVO Fluid Bolus: 20 ml/kg 20 ml/kg Maximum 2,000 ml None known Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation, and hypervolemia. If adverse reaction does occur, discontinue infusion. Precautions None Geriatric use: In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or drug therapy. Do not administer unless solution is clear and seal is intact. Responsoft EMS Protocols Page 133 10/13/2020 Ondansetron (Zofran) Pharmacology Advanced EMT can Administer Medication (oral route only) Indications 4 mg IVP, IO 8 mg PO (2 tablets) Adverse Reactions Contraindications Pediatric Dose Universal Patient Assessment for Nausea & Vomiting Esophageal Foreign Body Universal Pediatric Assessment for Nausea & Vomiting Adult Dose Action: Antiemetic Pharmacology Onset: Rapid Peak effect:15 – 30 minutes DS IVP, IO: 0.1 mg/kg IVP Maximum 4 mg 0.1 mg/kg Ondansetron 4 mg ODT (oral) 12 – 17 years of age >40 kg (88 lbs.) 4 mg No dosage for <40 kg Hypersensitivity Cardiovascular: Angina, Electrocardiographic Alterations, Hypotension, Tachycardia, Syncope, Palpitations Neurological: Extrapyramidal reactions, Grand Mal Seizure, Dizziness, Lightheadness, General: Flushing Local Reactions: Pain, Redness, Burning at site of injection Other: Hypokalemia, Hiccups Precautions None Not a drug that stimulates gastric or intestinal peristalsis. Transient ECG changes including, QT interval prolongation. Responsoft EMS Protocols Page 134 10/13/2020 Pharmacology Oral Glucose (Glutose 15 Insta-Glucose) Indications Action: Natural sugar EMT can Administer Medication Onset: 1 - 2 minutes Adult Dose Pediatric Dose Hyperglycemia/Hypoglycemia 15 Grams PO (37. 5 ounce tube) If no response within 15 minutes may repeat same dose 15 Grams PO Do not use for children under 2 years of age DO NOT ADMINISTER TO UNCONSCIOUS PERSON OR UNABLE TO SWALLOW OR A PATIENT WITHOUT PROTECTIVE REFLEXES ( I.E. GAG REFLEX) Precautions Adverse Reactions Contraindications Pharmacology Responsoft EMS Protocols None Page 135 10/13/2020 Oxygen Pharmacology Pharmacology Indications Adult Dose As needed to maintain SaO2 > 94% pre/peri---intubation, flood oxygen to maintain sat of 100% if possible As needed to maintain SaO2 > 94% pre/peri---intubation, flood oxygen to maintain sat of 100% if possible Toxicity, depressed hyper carbonic drive Precautions Adverse Reactions Contraindications Adult Adult Airway Airway Pediatric Airway Pediatric Dose Action: Universal Responsoft EMS Protocols None Page 136 10/13/2020 Pharmacology Pralidoxime (2-PAM) Pharmacology Toxic Exposure 600 mg IVP, IO, IM May be repeated every 15 minutes x 2, until signs of flushing, dry mouth, and dilated pupils appear. Tachycardia, muscle rigidity, dizziness, headache, nervousness, hyperventilation Precautions Adverse Reactions Contraindications Pediatric Dose Adult Dose Indications Action: Antidote to cholinesterase Antidote to organophosphates Responsoft EMS Protocols None Page 137 10/13/2020 Pharmacology Promethazine (Phenergan) Universal Patient Assessment for Nausea & Vomiting Universal Pediatric Assessment for Nausea & Vomiting 12.5 mg IVP, IO MUST BE DILUTED with 10 ml saline and fused over 2 minutes Pediatric Dose Indications Use Phenergan in place of Ondansetron (Zofran) during shortages Adult Dose Action: Antihistaminic, Sedative, Anti-motion-sickness Onset: 3 - 5 minutes 0.5mg/kg mg/kg Slowly IVP, IO 0.5 Contraindications Adverse Reactions Age 10 and above only Hypersensitivity, Comatose states and in patients that have demonstrated idiosyncratic reaction. Intra-arterial injection will result in possibility of gangrene. Should not be given subcutaneous. Seizure, Hypotension, Altered Mental Status, Asthma, Patient receiving Epinephrine. Cardiovascular: Increased or Decreased Blood Pressure, Tachycardia, Bradycardia, Faintness CNS: Drowsiness, Sedation, Blurred Vision, Dizziness, Confusion, Disorientation, Extrapyramidal Symptoms, Fatigue, Nervousness, Insomnia, Tremors, Convulsions, Excitation, Catatonic -like States, Hysteria, Hallucinations Gastrointestinal: Dry Mouth, Nausea, Vomiting Respiratory: Asthma, Nasal Stuffiness, Respiratory Depression, Apnea Other: Angioneurotic Edema, Neuroleptic Malignant Syndrome (potentially fatal) Precautions Pharmacology If active wheezing, do not use. Be sure IV is patent and no signs of infiltration. Can cause phlebitis. Responsoft EMS Protocols Page 138 Use cautiously when patient has allergy to sulfa. Dilute drug with NS or give IVP (slowly) with IV wide open. If extrapyramidal side effects develop, administer Benadryl 25 mg. 10/13/2020 Pharmacology Racemic Epinephrine 2.25% Onset: Lasts 90 – 120 minutes Action: Bronchodilator Pediatric Respiratory Distress (Upper Airway) Pediatric Dose Contraindications Epiglottitis, Hypersensitivity In excessive dosage, epinephrine may cause bronchial edema and inflammation, palpitation, precordial ache or anginal pain, tremor, nervousness, restlessness, sleeplessness, dizziness, headache, nausea and sweating. Precautions 0.5 ml of 2.25% in 3 ml saline via aerosol, may repeat once Adverse Reactions Adult Dose Indications Pharmacology Vital signs should be constantly monitored. Do not use concurrently with other bronchodilators Responsoft EMS Protocols Will increase heart rate. Page 139 10/13/2020 Rocuronium (Zemuron) Pharmacology Onset: Less than 2 minutes Duration of action: 30 – 60 minutes. DS 11mg/kg mg/kg IVP, IO Maximum 100 mg For ages 12 and up: 11mg/kg mg/kg IVP, IO Maximum 100 mg Under 12 years of age, only upon verbal order of MCP at the receiving hospital Adverse Reactions Contraindications Adult Dose Rapid Sequence Intubation (RSI) Delayed Sequence Intubation (DSI) Pediatric Dose Indications Action Neuromuscular blocking agent Precautions Pharmacology Hypersensitivity Cardiovascular: arrhythmia, abnormal electrocardiogram, tachycardia Digestive: nausea, vomiting Respiratory: asthma (bronchospasm, wheezing, or rhonchi), hiccup Skin and Appendages: rash, injection site edema, pruritus Severe anaphylaxis has been reported. Consider cross-reactivity among neuromuscular blocking agents. Responsoft EMS Protocols Page 140 Advantages No effect on serum potassium No muscle fasciculation's No bradycardia Disadvantage Longer lasting effect than Succinylcholine Patient must be monitored with capnography while paralyzed. 10/13/2020 Sodium Bicarbonate Pharmacology Adult Dose Indications Action: Reverses blood PH Reverses metabolic acidosis Pharmacology Onset: Immediate Asystole/PEA Asystole/PEA Dialysis Patients in Cardiac Arrest V-Fib/Pulseless V-Tach Overdose Overdose Crush Syndrome Cardiac Arrest: 1 mEq/kg mEq/kg IVP, IO 8.4% 0.5 mEq/kg repeat 0.5 mEq/kg IVP, IO every 10 minutes as needed Dialysis Patients in Cardiac Arrest: 100 mEq IVP, IO Overdose: 11 mEq/kg mEq/kg IVP, IO Patients losing chloride by vomiting or continuous gastrointestinal suction, Metabolic and respiratory alkalosis Alkalosis and/or Hypokalemia, Extravasation of IV, Tissue Necrosis, Ulceration or Sloughing at site Precautions Contraindications 11 mEq/kg mEq/kg IVP, IO 8.4% repeat 0.5 mEq/kg mEq/kg IVP, IO every 10 minutes as needed Not indicated in children < 5 kg Adverse Reactions Pediatric Dose Crush Syndrome: Begin IV Infusion: 2 liters over 1 hour 50 mEq/liter Over dosage and alkalosis should be avoided, may cause vascular irritation or sloughing if given extravascularly, Avoid scalp vein use. Risks of over dosage and alkalosis should be avoided. Use caution in patient with CHF or other edematous or sodium-retaining states Responsoft EMS Protocols Page 141 Flush IV tubing before and after administration. 10/13/2020 Pharmacology Succinylcholine (Anectine) Indications Action: Depolarizing paralytic – will cause muscle spasm as it takes effect Fastest onset of action of paralytics Use Succinylcholine in place of Rocuronium (Zemuron) during shortages Adult Dose Pediatric Dose Contraindications 1 1mg/kg mg/kg IVP, IO Maximum 150 mg Adverse Reactions Onset: Within 45 seconds Duration: 5 - 20 minutes Rapid Sequence Intubation (RSI) mg/kg IVP, IO Maximum 150 mg 1 1mg/kg Precautions Pharmacology Family hx. Of malignant hyperthermia, Hypersensitivity, After acute phase of: Major burns, multiple trauma, major crush injury, spinal cord injury, or abdominal sepsis. (over 24 hours), Use caution in patients with: Penetrating eye injury & closed head injuries, Glaucoma Profound muscle relaxation, respiratory depression & apnea-profound, causes hyperkalemia, cardiac arrest, malignant hyperthermia, arrhythmias, bradycardia, tachycardia, hypertension, hypotension, muscle fasciculation's, jaw rigidity, excessive salivation, and rash. Increases ICP pre-treat with Lidocaine. Also blunted by Etomidate. Bradycardia – pre-treat children with atropine Increases intraocular pressure – use with caution in penetrating eye injury. Effect blunted by Etomidate May increase serum potassium Patients with fractures or muscle spasm because of muscle fasciculation's, may cause additional trauma. May cause a transient increase in intracranial pressure. May cause intragastric pressure, which could result in regurgitation and possible aspiration. Neuromuscular blockade may be prolonged in patients with hypokalemia or hypocalcemia. Responsoft EMS Protocols Page 142 Causes visible fasciculation's, or disorganized muscle contractions. 10/13/2020 Tetracaine Pharmacology Pharmacology Onset: Should take effect in 30 seconds and last for up to 15 minutes. Indications 0.5 % solution: 1 - 2 drops in affected eye Adverse Reactions Contraindications Pediatric Dose Ocular Trauma Trauma Morgan Eye Lens Ocular Adult Dose Action: Ophthalmic anesthetic Penetrating injury to eye or extrusion of scleral contents CNS: Dizziness, Drowsiness, sweating, muscle twitching, trembling Cardiovascular: irregular heart rate Respiratory: Shortness of breath Gastrointestinal: Nausea & Vomiting General: Unusual excitement, Nervousness, Restlessness Less common occurrences: Burning, Stinging, Redness Rare occurrences: Itching, Pain, Swelling of eye or eyelid, watering of eyes Precautions None Do not rub or wipe eye until anesthetic has worn off and feeling in eye returns. To do so may cause injury or damage to the eye. Responsoft EMS Protocols Page 143 10/13/2020 Tranexamic Acid (TXA) Pharmacology For tactical medic use only Onset: 3 hour half life. Extremity Trauma Multiple Trauma Neurological Trauma (Head) Trauma with “moderate to severe” or “suspected” hemorrhage or hemorrhagic shock 1 gram/100 ml over 10 minutes, IV Infusion (16 years and older) Contraindications Isolated traumatic brain injury, More than 3 hours since injury. Do not give to known pregnancy. Adverse Reactions Pediatric Dose Adult Dose Indications Action: Antifibrinolytic hemostatic Pharmacology HTN, increased ICP. Precautions None Monitor for symptoms of severe allergic reaction and changes in vision Responsoft EMS Protocols Page 144 10/13/2020 Drug Substitutions (DS) Pharmacology Pharmacology In the event of the shortage of a particular medication, the Medical Director permits the following substitutions without prior authorization. Substitutions are permitted only in the event of a drug shortage. Substitutions may not be made because of agency or individual medic preference for the substitute medication. Drug Unavailable Amiodarone (Cordarone) Allowed Substitution or Substitute Action to be Taken Lidocaine (Xylocaine) Lidocaine (Xylocaine) V-Fib/Pulseless V-Tach, V-Tach w/Pulse, Pediatric V-Fib/Pulseless V-Tach Transcutaneous Pacing (preferred) Atropine Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Methylprednisolone (Solu-Medrol) Dexamethasone (Decadron) (Decadron) Dexamethasone Adults: 125 mg Pediatric: D10 Fentanyl (Sublimaze) 22 mg/kg mg/kg Maximum 125 mg D50 50 ml (25 grams) Maximum 100 ml Morphine Adult 5 mg IV/IO May repeat in 10 minutes x 1 Maximum 10 mg Pediatric 0.2 mg/kg mg/kg IV/IO Maximum 10 mg Ketamine (Ketalar) Etomidate (Amidate) – For RSI, 0.3 0.3 mg/kg mg/kg to Maximum of 20 mg Haloperidol (Haldol) – Behavioral Emergencies 5 mg IM Magnesium Sulfate No substitution available. Transport patient emergently Responsoft EMS Protocols Page 145 10/13/2020 Pharmacology Drug Substitutions (DS)-continued Midazolam (Versed) Diazepam (Valium) Adult 5 mg IV/IO Pediatric Naloxone (Narcan) Ondansetron Ondansetron (Zofran) (Zofran) Pharmacology 0.2 mg/kg 0.2 mg/kg IV/IO No substitution available. Secure airway. Transport emergently Promethazine (Phenergan) – Must be diluted with 10 ml saline and infused over 2 minutes. Adult 12.5 mg IVP Pediatric – Age 10 & above only 0.5 mg/kg mg/kg IV to Maximum of 12.5 mg 0.5 Vecuronium (Norcuron) – Patients age 12 and over 0.1 mg/kg mg/kg to Maximum of 10 mg Rocuronium (Zemuron) For patients under age 12 only on direct order of medical control physician. Succinylcholine (Anectine) 1 mg/kg IVP, IO Responsoft EMS Protocols Page 146 10/13/2020