I EMS Field Medications PREHOSPITAL DRUG … EMS Field Medications PREHOSPITAL DRUG CLASSIFICATION ALLERGY ... Emergency poisoning by most drugs & chemicals (see Contra)

This section is designed as a rapid reference for those drugs commonly administeredin the field and is representative of general principles for these useful EMS medica-tions. Specific administration and dosing guidelines given are typical for pre-hospitalprotocols. Review your local protocol and make hand written corrections if differentguidelines given. A summary of the most recent 2005 American Heart AssociationCardiac Care medications are included as a quick reference table inside the backcover of this book.

I EMS Field Medications

PREHOSPITAL DRUG CLASSIFICATION ALLERGYAntihistaminesDiphenhydramine

(Benadryl)

ANTIDOTES Activated Charcoal

(SuperChar, Actidose,Liqui-Char Activated)

Atropine Atropine/Pralidoxime

[2-PAM] (DuoDote,NAAK, Mark-1)

Albuterol (Proventil,Ventolin, Volmax)

Amyl NitriteCalcium Salts (Chloride,

Gluconate)Cyanide Antidote Kit

(See Amyl Nitrate,Sodium Nitrite, andSodium Thiosulfate)

Flumazenil (Romazicon)

Hydroxocobalamin (Vitamin B12)

Naloxone (Narcan)Pralidoxime (2-PAM,

Protopam)Sodium NitriteSodium Thiosulfate

CARDIOVASCULAR (CV) AGENTSAngiotensin-Converting Enzyme (ACE) InhibitorsCaptopril (Capoten,

others)Enalapril (Vasotec)

Antiarrhythmic AgentsAdenosine (Adenocard)Amiodarone (Cordarone,

Pacerone)Atropine

Lidocaine (AnestaconTopical, Xylocaine,others)

Magnesium Sulfate (Various)

Procainamide (Pronestyl, PronestylSR, Procanbid)

g

1

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2 EMS Pocket Drug Guide

CENTRAL NERVOUS SYSTEM AGENTS

Anesthetic Agents, General

Calcium Channel AntagonistsDiltiazem (Cardizem,

Cardizem CD,Cardizem SR, CartiaXT, Dilacor XR, Diltia XT, Taztia XT,Tiamate, Tiazac)

Verapamil (Calan,Isoptin, Verelan)

Bumetanide (Bumex) Furosemide (Lasix) Mannitol (Osmitrol, others)

Diuretics

Inotropic/Pressor AgentsDobutamine (Dobutrex)Dopamine (Intropin)Epinephrine (Adrenalin,

Sus-Phrine, EpiPen,EpiPen Jr, others)

Isoproterenol (Isuprel)Norepinephrine

(Levophed)

Phenylephrine, Nasal(Neo-Synephrine,nasal)

Nitroglycerin (Nitrostat,Nitrolingual, Nitro-BidOintment, Nitro-Bid IV,Nitrodisc, Transderm-Nitro, others)

Vasodilators

Ketamine (Ketalar)

Antianxiety AgentsLorazepam (Ativan) Diazepam (Valium,

Diastat)

Anticonvulsants

Diazepam (Valium, Diastat)

Lorazepam (Ativan, others)

Midazolam (Hypnovel,Versed)

AntipsychoticsHaloperidol (Haldol) Ziprasidone (Geodon)

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Section I: EMS Field Medications 3

DIETARY SUPPLEMENTS

Sedative Hypnotics

Diphenhydramine(Benadryl)

Etomidate (Amidate) Midazolam (Hypnovel,Versed)

Calcium Salts [Chloride,Gluconate]

Dextrose, 25%, 50%

Sodium Bicarbonate[NaHCO3]

Thiamine [Vitamin B1]

ENDOCRINE SYSTEM AGENTS

Antidiabetic Agents

Insulin, injectable

Hormone & Synthetic Substitutes

Dexamethasone(Decadron)

Glucagon (GlucaGen)

Oxytocin (Pitocin) Vasopressin (Pitressin)

GASTROINTESTINAL AGENTS

Antiemetics

Ondansetron (Zofran,Zofran ODT)

Promethazine (Anergan, Phenergan)

Metoclopramide(Reglan, Clopra,Octamide)

HEMATOLOGIC AGENTS

Anticoagulants

Heparin

Antiplatelet Agents

Aspirin (Bayer, Ecotrin,St. Joseph’s)

Antithrombotic Agents

Alteplase, Recombinant[tPA] (Activase) (See tissue plasmino-gen activator)

Streptokinase (Streptase,Kabikinase)


4 EMS Pocket Drug Guide

OB/GYN AGENTS

Miscellaneous Ob/Gyn Agents

Magnesium Sulfate (Various)

Oxytocin (Pitocin)

Terbutaline (Brethine,Bricanyl)

PAIN MEDICATIONS

Local Anesthetics

Tetracaine (Pontocaine)

Narcotic Analgesics

Fentanyl (Sublimaze)Hydromorphone

(Dilaudid)Meperidine (Demerol)

Morphine (Avinza XR,Duramorph, Infu-morph, MS Contin,Kadian SR, OramorphSR, Palladone, Roxanol)

Nalbuphine (Nubain)

Nonnarcotic Analgesics

Aspirin (Bayer, Ecotrin, St. Joseph’s)

Nonsteroidal Anti-inflammatory Agents

Ketorolac (Toradol)

Miscellaneous Pain Medications

Nitrous Oxide (Nitronox, Entonox)

MUSCULOSKELETAL AGENTS

Muscle Relaxants

Diazepam (Diastat, Valium)

Neuromuscular Blockers

Pancuronium (Pavulon)Rocuronium (Zemuron)

Succinylcholine (Anectine, Quelicin,Sucostrin, others)

Vecuronium (Norcuron)


Section I: EMS Field Medications 5

# indicates additional information on prescription use inSection III.

Activated Charcoal (SuperChar, Actidose, Liqui-Char activated)[Adsorbent] Uses: Emergency poisoning by most drugs & chemicals (seeContra) Action: Adsorbent detoxicant Dose: Adults. 1 g/kg Peds. 1 g/kg Caution:[C, ?] May cause V (hazardous w/ petroleum & caustic ingestions); do not mix w/dairy Contra: Not effective for cyanide, mineral acids, caustic alkalis, organic sol-vents, iron, EtOH, methanol poisoning, Li; do not use sorbitol in pts w/ fructoseintolerance, intestinal obst, nonintact GI tracts; do not use in pts w/ depressed men-tal status unless via NG tube Disp: Powder, Liq, caps SE: Some Liq dosage formsin sorbitol base (a cathartic); V/D, black stools, constipation Notes: Charcoal w/sorbitol not OK in children <1 y; monitor for ↓ K+ & Mg2+; protect airway in lethargic/comatose pts Interactions: ↓ Effects if taken W/ ice cream, milk, sherbet; ↓ effectsOF digoxin & absorption of other oral meds, ↓ effects OF syrup of ipecac EMS:Contact Poison Control/Medical Command before administration; most effective ifgiven w/in 30 min of acute poisoning; only give PO to conscious pts; can be givenvia NG tube in conscious or unconscious pts; protect airway from aspiration; shakewell and can be mixed w/ ice/water (or fruit juice) to make more palatableAdenosine (Adenocard) [Antiarrhythmic/Nucleoside] Uses:PSVT (refractory to vagal maneuvers); including w/ WPW Action: Class IV

Respiratory Inhalants

Ipratropium (Atrovent HFA, Atrovent Nasal)

Miscellaneous Respiratory AgentsMagnesium Sulfate

(Various)Methylprednisolone

Succinate & Acetate(Solu-Medrol, Depot-Medrol)

Oxygen

RESPIRATORY AGENTS

BronchodilatorsAlbuterol (Proventil,

Ventolin, Volmax)Albuterol & Ipratropium

(Combivent, DuoNeb)Aminophylline

Epinephrine (Adrenalin,Sus-Phrine, EpiPen,EpiPen Jr, others)

Epinephrine, Racemic(microNefrin)

Isoproterenol (Isuprel)Metaproterenol

(Alupent, Metaprel)Terbutaline (Brethine,

Bricanyl)


6 Albuterol

antiarrhythmic; slows AV node conduction Dose: Adults. 6 mg rapid IVP, followed w/ saline flush, elevate extremity; may repeat at 12 mg in 1–2 min if no conversion,followed by another 12 mg if needed Peds. 0.1 mg/kg IV bolus; may repeat once in1–2 min at 0.2 mg/kg if no conversion Caution: [C, ?] pts w/ asthma Contra: 2nd- or3rd-degree AV block or SSS (w/o pacemaker); recent MI or cerebral hemorrhageDisp: Inj 3 mg/mL SE: Facial flushing, HA, dyspnea, chest pressure, ↓ BP Interac-tions: ↓ Effects W/ theophylline, caffeine, guarana; ↑ effects W/ dipyridamole; ↑ riskof hypotension & chest pain W/ nicotine; ↑ risk of bradycardia W/ BBs; ↑ risk of heartblock W/ carbamazepine; ↑ risk of ventricular fibrillation W/ digitalis glycosidesEMS: Administer in a large proximal vein; monitor BP, pulse and ECG during ther-apy, monitor resp status; ↑ risk of bronchospasm in asthmatics; max single dose is 12 mg; can cause momentary asystole when administered; not as effective in the pres-ence of methylxanthines and caffeine; discard unused or unclear solnAlbuterol# (Proventil, Ventolin, Volmax) [Bronchodilator/Adrenergic] Uses: Asthma; prevent exercise-induced bronchospasm; hyper-kalemia Action: β-Adrenergic sympathomimetic bronchodilator; relaxes bronchialsmooth muscle Dose: Adults. MDI: 2 sprays Neb: 1.25–5 mg (0.25–1 mL of 0.5%soln in 2–3 mL of NS) Peds. MDI: 2 sprays Neb: 0.05 mg/kg (max 2.5 mg) in 2–3 mLof NS Caution: [C, +] Disp: Tabs 2, 4 mg; XR tabs 4, 8 mg; syrup 2 mg/5 mL; 90 mcg/dose met-dose inhaler; soln for neb 0.083, 0.5% SE: Palpitations, tach, ner-vousness, GI upset Interactions: ↑ Effects W/ other sympathomimetics; ↑ CVeffects W/ MAOI, TCA, inhaled anesthetics; ↓ effects W/ BBs; ↓ effectiveness OFinsulin, oral hypoglycemics, digoxin EMS: Monitor HR, BP, S/Sxs bronchospasm &CNS stimulation (esp in children); instruct on proper use of inhaler; can use neb inO2 mask for handsfree use; causes transient ↑ in glucose and ↓ in K post inhalationAlbuterol & Ipratropium# (Combivent, DuoNeb) [Bronchodilator/Adrenergic, Anticholinergic] Uses: COPD,Bronchospasm Action: Combo of β-adrenergic bronchodilator & quaternary anti-cholinergic Dose: Adults & Children >1. Neb: 3 mg in 2–3 mL of NS, may repeatonce Caution: [C, +] Contra: Peanut/soybean allergy Disp: Met-dose inhaler;soln for neb (DuoNeb) SE: Palpitations, tach, nervousness, GI upset, dizziness,blurred vision Interactions: ↑ Effects W/ anticholinergics, including ophthalmicmeds; ↓ effects W/ herb jaborandi tree, pill-bearing spurge EMS: Combivent—MDI form, DuoNeb—nebulized form; determine if pt has a peanut allergy as thisis a contraindication; esp useful in bronchospasm w/ excess secretions; monitorHR, BP, S/Sxs bronchospasm & CNS stimulation (esp in children); instruct onproper use of inhaler; can use neb in O2 mask for handsfree use; causes transient ↑in glucose and ↓ in K post inhalation; may cause transient blurred vision/irritationAlteplase Recombinant [tPA] (Activase) (See tissue plasminogenactivator)Aminophylline [Bronchodilator/Xanthine Derivative] Uses:Asthma, COPD & bronchospasm Action: Relaxes smooth muscle (bronchi, pulm


Amyl Nitrite 7

vessels); stimulates diaphragm Dose: Adults. Acute asthma: Load 6 mg/kg IV, then0.4–0.9 mg/kg/h IV cont inf Peds. Load 6 mg/kg IV, then 1 mg/kg/h IV cont inf Cau-tion: [C, +] Uncontrolled arrhythmias, HTN, Sz disorder, hyperthyroidism, pepticulcers Disp: Tabs 100, 200 mg; PR tabs 100, 200 mg, soln 105 mg/5 mL, inj 25 mg/mLSE: N/V, irritability, tach, ventricular arrhythmias, Szs Interactions: ↓ Effects OFLi, phenytoin, adenosine; ↓ effects W/ phenobarbital, aminoglutethimide, barbiturates,rifampin, ritonavir, thyroid meds; ↑ effects W/ cimetidine, ciprofloxacin, erythromycin,INH, OCP, verapamil, tobacco, charcoal-broiled foods, St. John’s wort EMS: Very nar-row therapeutic range, determine pt history for other methylxanthine use (certain OTCcough medicines include methylxanthines); sudden ↑ BP may be a sign of toxAmiodarone (Cordarone, Pacerone) [Ventricular Antiarrhythmic/Adrenergic Blocker] WARNING: Liver tox, exac-erbation of arrhythmias and lung damage reported Uses: Recurrent VF or hemo-dynamically unstable VT, cardiac arrest w/ VF/VT, supraventricular arrhythmias,AF Action: Class III antiarrhythmic Dose: Adults. Life threatening ventriculararrhythmias: 150 mg over 10 min (15 mg/min) add 150 mg to 100 mL D5W andNS, followed by 1 mg/h over the next 6 h- total dose should not exceed 2.2 g Car-diac arrest: 300 mg IVP, may repeat once at 150 mg in 3–5 min Peds. 5 mg/kg IV/IOpush; max dose is 15 mg/kg Caution: [D, −] Contra: Sinus node dysfunction, 2nd-/3rd-degree AV block, sinus bradycardia (w/o pacemaker), iodine sensitivity Disp: Tabs 100, 200, 300, 400 mg; inj 50 mg/mL SE: Pulm fibrosis (w/ long-termuse), exacerbation of arrhythmias, prolongs QT interval; CHF, hypo/hyperthy-roidism, liver failure, corneal microdeposits, optic neuropathy/neuritis, peripheralneuropathy, photosens Interactions: ↑ Serum levels OF digoxin, quinidine, pro-cainamide, flecainide, phenytoin, warfarin, theophylline, cyclosporine; ↑ levels W/cimetidine, indinavir, ritonavir; ↓ levels W/ cholestyramine, rifampin, St. John’swort; ↑ cardiac effects W/ BBs, CCB EMS: May be used in place of lidocaine incardiac arrest; for loading dose, add 150 mg to 100 mL D5W or NS, infuse at a rateof 100 mL/10 min; monitor HR, BP; monitor ECG for increased PR and QRS &monitor lung sounds for drug induced pulm tox; may cause bradycardiaAmyl Nitrite [Nitrate Vasodilator] Uses: Tx of cyanide poisoningAction: Short-acting vasodilator, relaxes smooth muscle, & may help create cyan-methemoglobin to deactivate cyanides poisonous effects Dose: Adults & Peds.Amp (typically 0.3 mL) crushed and inhaled for about 30 s, may be repeatedq1–2min PRN until arrival at ED or if sodium nitrite is administered Caution:[C, ?] Contra: None in an emergency setting for acute cyanide poisoning; use cau-tion in pregnant pts, pts w/ chronic methemoglobinemia & in pts w/ a hypotensionrisk; Disp: 0.3 mL inhalant amp SE: N/V, hypotension, dizziness, flushing, skinrash, tach (some SEs related to the creation of methemoglobin) Interactions: ↑Risk of severe hypotension W/ PDE-5 inhibitors—ED drugs—(vardenafil, silde-nafil, tadalafil), EtOH, ASA, and CCBs EMS: Included in the commercially avail-able cyanide antidote kit (includes 12 amps of Amyl Nitrite); given by crushing


8 Aspirin

amp and holding in front of pts nose and mouth; this is a temporary Tx until an IVis established to administer sodium nitrite; is a drug that is commonly abusedbecause of its euphoric SEs (known as a “Popper”); related to nitroglycerinAspirin# (Bayer, Ecotrin, St. Joseph’s) [OTC] [Antipyretic,Analgesic/Salicylate] Uses: Angina; AMI Action: Prostaglandin inhibitorDose: Adults. Acute coronary synd: 160–325 mg PO ASAP (chewing preferred atonset) Caution: [C, M] Linked to Reye synd; avoid w/ viral illness in children Contra: Allergy to ASA, chickenpox/flu Sxs, synd of nasal polyps, angioedema, &bronchospasm to NSAIDs Disp: Tabs 325, 500 mg; chew tabs 81 mg; EC tabs 81,162, 325, 500, 650, 975 mg; SR tabs 650, 800 mg; effervescent tabs 325, 500 mg;supp 125, 200, 300, 600 mg SE: GI upset & erosion Interactions: ↑ Effects W/anticoagulants, ammonium chloride, antibiotics, ascorbic acid, furosemide, methio-nine, nizatidine, NSAIDs, verapamil, EtOH, feverfew, garlic, ginkgo biloba, horsechestnut, kelpware (black-tang), prickly ash, red clover; ↓ effects W/ antacids, acti-vated charcoal, corticosteroids, griseofulvin, NaHCO3, ginseng, food; ↑ effects OFACEI, hypoglycemics, insulin, Li, MTX, phenytoin, sulfonamides, valproic acid; ↓effects OF BBs, probenecid, spironolactone, sulfinpyrazone EMS: Baby aspirin ispreferred, enteric-coated aspirin should be avoidedAtropine [Antiarrhythmic/Anticholinergic] WARNING: Primaryprotection against exposure to chemical nerve agent and insecticide poisoning is thewearing of specially designed protective garments Uses: Preanesthetic; sympto-matic bradycardia & asystole, organophosphate (insecticide) and acetylcholinesterase(nerve gas) inhibitor antidote Action: Antimuscarinic; blocks acetylcholine atparasympathetic sites, cycloplegic Dose: Adults. Asystole or PEA: 1 mg IV/IO push.Repeat q3–5min (if asystole persists) to 3 mg max Bradycardia: 0.5–1.0 mg IVq3–5min as needed; max 3 mg; ET 2–3 mg in 10 mL NS Poisoning: 1–2 mg IV bolus,repeat q3–5min PRN to reverse effects Peds. Asystole or PEA: 0.01–0.03 mg/kg IVq2–5min, max 1 mg, min 0.1 mg Preanesthetic: 0.01 mg/kg/dose SQ/IV (max 0.4 mg)Poisoning: 0.05 mg/kg IV, repeat q10min PRN to reverse effects Caution: [C, +]Contra: tach, glaucoma Disp: Inj: 0.05, 0.1, 0.3, 0.4, 0.5, 0.8, 1 mg/mL AtroPenAutoInjector: 0.5, 1, 2 mg/dose MDI: 0.36 mg/inhal SE: Flushing, mydriasis, tach,dry mouth & nose, blurred vision, urinary retention, constipation, psychosis Interac-tions: ↑ Effects W/ amantadine, antihistamines, disopyramide, procainamide, quini-dine, TCA, thiazides, betel palm, squaw vine; ↓ effects W/ antacids, levodopa; ↓effects OF phenothiazines EMS: Use caution in pts w/ suspected MIs (use lowerdose); reflex bradycardia may occur if administered in small doses; may work in 2nd-degree, do not use in 3rd-degree heart block (use transcutaneous pacing); SLUDGEare Sxs of organophosphate/carbamate/nerve gas poisoning—personal safety is thepriority in cases of nerve or pesticide exposure; large doses may be required to treatS/Sxs of SLUDGE and is used in combination w/ valium and 2-PAMAtropine/Pralidoxime (2-PAM) (DuoDote) [Antiarrhythmic/Anticholinergic/Antidote] WARNING: For use by personnel w/


Atropine/Pralidoxime 9

appropriate training; wear protective garments; do not rely solely on medication;evacuation and decontamination as soon as possible Uses: Nerve agent andinsecticide poisoning Action: Atropine blocks effects of excess acetylcholine;pralidoxime reactivates acetylcholinesterase inactivated by organophosphorus poi-soning Dose: 1 inj in mid-lateral thigh; if Sxs progress or are severe, give 2 addi-tional injs Caution: [C, ?] Contra: None in life-threatening situations Disp:AutoInjector: 2.1 mg atropine/600 mg pralidoxime SE: Dry mouth, blurred vision,dry eyes, photophobia, confusion, HA, tach, flushing, urinary retention, constipa-tion, abd pain N/V, emesis Interactions: ↑ Effects W/ amantadine, antihistamines,disopyramide, procainamide, quinidine, TCA, thiazides, betel palm, squaw vine; ↑effects OF barbiturates; ↓ effects W/ antacids, levodopa; ↓ effects OF phenoth-iazines EMS: Personal safety is the priority in cases of nerve or pesticide expo-sure; pt should be receiving oxygen and be decontaminated to prevent furtherexposure; severe Sxs of poisoning include confusion, dyspnea w/ copious secre-tions, weakness & twitching, involuntary urination and defecation, convulsions,unconsciousness; give 1 pen for minor poisoning, give 2 additional pens for severe poisonings; can be used through clothes/NBC clothing; use an anticon-vulsant (diazepam—Adult 10 mg IV Peds 0.3 mg/kg IV, lorazepam—Adults 4 mgIV Peds 0.1 mg/kg IV) if Szs present; reassess q5min for Sxs resolution/worseningAtropine/Pralidoxime (2-PAM) (Nerve Agent Antidote Kit-NAAK; Mark 1 Injector Kit) (2 Injectors: 2 mg, Atropine; 600 mg, Pralidoxime) [Anticholinergic/Antidote] WARNING:Primary protection against exposure to chemical nerve agent and insecticide poison-ing is the wearing of specially designed protective garments Uses: Antidote fornerve agent or organophosphate poisoning (or similar poisoning) Action: Atropineblocks effects of excess acetylcholine; pralidoxime reactivates acetylcholinesteraseinactivated by organophosphorus poisoning Dose: Adults. Severe poisoning:(Severe resp distress, SLUDGE, agitation) 3 Mark 1 Kits (give 3 atropine then 3pralidoxime) max Pralidoxime dose is 1.8 g Moderate poisoning: (Resp distress,SLUDGE) 2 Mark 1 Kits (2 atropine and 1 pralidoxime) Mild/asymptomatic: NoMark 1 Kits but monitor for changes q5min Peds. Severe poisoning age 2–7: 1Mark 1 Kit Age 8–14: 2 Mark 1 Kits Contra: None in life-threatening emergencysetting Disp: AutoInjector 2.1 mg atropine/600 mg pralidoxime SE: Dry mouth,blurred vision, dry eyes, photophobia, confusion, HA, tach, flushing, urinary reten-tion, constipation, abd pain N/V, emesis Interactions: N/A for an emergency settingEMS: Personal safety is the priority in cases of nerve or pesticide exposure; ptshould be receiving oxygen and be decontaminated to prevent further exposure; canbe used through clothes/NBC clothing; severe Sxs of poisoning include confusion,dyspnea w/ copious secretions, weakness & twitching, involuntary urination anddefecation, convulsions, unconsciousness; use an anticonvulsant (diazepam—Adult10 mg IV Peds 0.3 mg/kg IV, lorazepam—Adults 4 mg IV Peds 0.1 mg/kg IV) ifSzs present; reassess q5min for Sxs resolution/worsening


10 Bumetanide

Bumetanide# (Bumex) [Diuretic/Loop] Uses: Edema from CHFand pulm edema Action: Loop diuretic; ↓ reabsorption of Na+ & Cl−, in ascendingloop of Henle & the distal tubule Dose: Adults. 0.5–1 mg IV/IM Caution: [D, ?]Pregnancy Contra: Anuria, hepatic coma, severe electrolyte depletion Disp: Tabs0.5, 1, 2 mg; inj 0.25 mg/mL SE: ↓ K+, ↓ Na+, ↑ Cr, ↑ uric acid, dizziness, ototoxInteractions: ↑ Effects W/ antihypertensives, thiazides, nitrates, EtOH, clofibrate;↑ effects OF Li, warfarin, thrombolytic drugs, anticoagulants; ↑ K+ loss W/ car-benoxolone, corticosteroids, terbutaline; ↑ ototox W/ aminoglycosides, cisplatin; ↓effects W/ cholestyramine, colestipol, NSAIDs, probenecid, barbiturates, pheny-toin EMS: High doses in the elderly may cause profound hypotension and CV col-lapse; more potent than furosemideCalcium Chloride [Calcium Supplement, Electrolyte] Uses: Ca2+

replacement, Ca2+ blocker tox, Mg2+ intox, ↑ K+ Action: Ca2+ supl/replacement Dose:Hypocalcemia, hyperkalemia, hypermagnesemia and CCB tox Adults. 5–10 mL10% soln IV PRN q5–10min Peds. 0.1–0.2 mL/kg 10% soln PRN q10min Caution:[C, ?] Contra: ↑ Ca2+ Disp: CaCl inj 10% = 100 mg/mL = Ca 27.2 mg/mL = 10-mLamp; Ca gluconate inj 10% = 100 mg/mL = Ca 9 mg/mL; tabs 500 mg = 45 mg Ca,650 mg = 58.5 mg Ca, 975 mg = 87.75 mg Ca, 1 g = 90 mg Ca; Ca gluceptate inj220 mg/mL = 18 mg/mL Ca SE: Bradycardia, cardiac arrhythmias, ↑ Ca2+

Interactions: ↑ Effects OF quinidine and digitalis; ↓ effects OF tetracyclines,quinolones, verapamil, CCBs, Fe salts, ASA, atenolol; ↓ Ca absorption W/ highintake of dietary fiber EMS: Preferred over calcium gluconate d/t higher Ca2+ con-centration; use caution to prevent extravasation (avoid small veins, inj slowly);incompatible w/ NaHCO3

Calcium Gluconate [Calcium Supplement, Electrolyte] Uses:Ca2+ replacement, Ca2+ blocker tox, Mg2+ intox, ↑ K+ Action: Ca2+ supl/replacementDose: Hypocalcemia, hyperkalemia, hypermagnesemia and CCB tox Adults.10–20 mL 10% soln IV PRN q5–10min Peds. 0.2–0.3 mL/kg 10% soln PRNq5–10min Caution: [C, ?] Contra: ↑ Ca2+ Disp: CaCl inj 10% = 100 mg/mL = Ca27.2 mg/mL = 10-mL amp; Ca gluconate inj 10% = 100 mg/mL = Ca 9 mg/mL;tabs 500 mg = 45 mg Ca, 650 mg = 58.5 mg Ca, 975 mg = 87.75 mg Ca, 1 g = 90 mgCa; Ca gluceptate inj 220 mg/mL = 18 mg/mL Ca SE: Bradycardia, cardiac arrhyth-mias, ↑ Ca2+ Interactions: ↑ Effects OF quinidine and digitalis; ↓ effects OF tetra-cyclines, quinolones, verapamil, CCBs, Fe salts, ASA, atenolol; ↓ Ca absorption W/high intake of dietary fiber EMS: Calcium chloride is preferred; use caution to pre-vent extravasation (avoid small veins, inj slowly); incompatible w/ NaHCO3

Captopril# (Capoten, Others) [Antihypertensive/ACEI] Uses:HTN, CHF Action: ACE inhibitor Dose: Adults. 25 mg PO (sublingual) Caution:[C (1st tri); D (2nd & 3rd tri) +]; unknown effects in renal impair Contra: Hxangioedema, bilateral RAS Disp: Tabs 12.5, 25, 50, 100 mg SE: Rash, proteinuria,cough, ↑ K+ Interactions: ↑ Effects W/ antihypertensives, diuretics, nitrates,probenecid, black catechu; ↓ effects W/ antacids, ASA, NSAIDs, food; ↑ effects


Diazepam 11

OF digoxin, insulin, oral hypoglycemics, Li EMS: Consider CPAP/BiPAP use ifhypoxia or severe resp distress is presentCyanide Antidote Kit: See Amyl Nitrate, Sodium Nitrite,and Sodium Thiosulfate

Dexamethasone (Decadron) [Anti-inflammatory, Immunosuppressant/Glucocorticoid] Uses: Anaphylaxis, asthma,COPD; CHI/TBI/↓ cerebral edema (study results are mixed on its use in CHI/TBI or toreduce cerebral edema—contact medical command before use for this indication)Action: Adrenocorticoid w/ anti-inflammatory properties Dose: Adults. 4–24 mgIV/IM Peds. 0.25–0.5 mg/kg IV/IO Contra: None in an emergency setting Disp:Tabs 0.5, 0.75, 1.0, 1.5, 2.0, 4.0, 6.0 mg, oral soln 0.5 mg/5 mL, 1 mg/mL, Inj SE:N, HTN, edema, HA, euphoria, muscle weakness, diaphoresis, hyperglycemiaInteractions: ↑ Effects W/ cyclosporine, estrogens, OCPs, macrolides; ↑ effectsOF cyclosporine; ↓ effects W/ aminoglutethimide, antacids, barbiturates, carba-mazepine, cholestyramine, colestipol, phenytoin, phenobarbital, rifampin; ↓ effectsOF anticoagulants, hypoglycemics, INH, toxoids, salicylates, vaccines EMS: Mayaffect glucose (hyperglycemia); administer IM deep into large muscle mass; onsetmay take several hours so this should not be used 1st-line in anaphylaxisDextrose 50%/25% [Carbohydrate] Uses: Hypoglycemia in uncon-scious pts Action: Provides a glucose source in the form of dextrose Dose: Adults.1 amp of a 50% soln Peds. 2 mL/kg of a 25% soln Contra: None when give to ptw/ documented hypoglycemia; can ↑ ICP, use caution in pts w/ suspected intracra-nial bleeding SE: Burning at IV site, can cause local tissue necrosis if extravasationoccurs; may cause neurologic Sxs (Wernicke encephalopathy) if pt is thiamine defi-cient Interactions: None EMS: Check blood sugar before and after administration;if pt is mentating well enough to protect airway, use oral glucose first; give in largevein; protect IV site, pt may be combative when they regain consciousnessDiazepam# (Valium, Diastat) [C-IV] [Anxiolytic, SkeletalMuscle Relaxant, Anticonvulsant, Sedative/Hypnotic/Benzodiazepine] Uses: Anxiety, EtOH withdrawal, muscle spasm, statusepilepticus, panic disorders, amnesia, preprocedure sedation Action: Benzodi-azepine Dose: Adults. Status epilepticus: 5–10 mg IV/IM Anxiety: 2–5 mg IM/IVPreprocedure: 5–10 mg IV just prior to procedure Peds. Status epilepticus: 0.5–2 mgIV/IM Sedation: 0.2–0.5 mg/kg IV (onset w/in 5 IV and 30 min IM; duration about1 h IV and IM) Caution: [D, ?/ –] Contra: Coma, CNS depression, resp depres-sion, NAG, severe uncontrolled pain, PRG Disp: Tabs 2, 5, 10 mg; soln 1, 5 mg/mL; inj 5 mg/mL; rectal gel 2.5, 5, 10, 20 mg/mL SE: Sedation, amnesia,bradycardia, ↓ BP, rash, ↓ resp rate Interactions: ↑ Effects W/ antihistamines,azole antifungals, BBs, CNS depressants, cimetidine, ciprofloxin, disulfiram, INH,OCP, omeprazole, phenytoin, valproic acid, verapamil, EtOH, kava kava, valerian;↑ effects OF digoxin, diuretics; ↓ effects w/ barbiturates, carbamazepine,


12 Diltiazem

theophylline, ranitidine, tobacco; ↓ effects OF haloperidol, levodopa EMS: Ifadministering IM, use large muscle mass, inj slowly and deep and change site ifanother dose needed; IM absorption erratic, consider midazolam or lorazepam if IMdose is needed; monitor vital signs for resp depression and hypotension; heavysmokers may need a larger dose than nonsmokers; repeated doses may be needed d/tshort action of drug; Flumazenil should be available—it is the antidote to reverseresp depression (should only be used in cases w/ severe resp depression d/t Sz risk)Diltiazem# (Cardizem, Cardizem CD, Cardizem SR, Cartia XT,Dilacor XR, Diltia XT, Taztia XT, Tiamate, Tiazac) [Antianginal/CCB] Uses: Control supraventricular tachydysrhythmias (AF or flutter) refractoryto adenosine; angina, prevention of reinfarction, HTN Action: CCB Dose: Adults:IV: 0.25 mg/kg IV bolus over 2 min; may repeat in 15 min at 0.35 mg/kg; begin infof 5–15 mg/h (mix 100 mg in 100 mL NS to make 1 mg/mL), max dose is 15 mg/kgin 24 h (see Table I-1)Caution: [C, +] ↑ Effect w/ amiodarone, cimetidine, fentanyl, Li, cyclosporine,digoxin, BBs, theophylline Contra: SSS, AV block, wide-complex tach, ↓ BP, AMI,pulm congestion Disp: Cardizem CD: Caps 120, 180, 240, 300, 360 mg CardizemSR: Caps 60, 90, 120 mg Cardizem: Tabs 30, 60, 90, 120 mg Cartia XT: Caps 120,180, 240, 300 mg Dilacor XR: Caps 180, 240 mg Diltia XT: Caps 120, 180, 240 mgTiazac: Caps 120, 180, 240, 300, 360, 420 mg Tiamate (XR): Tabs 120, 180, 240 mg;inj 5 mg/mL Taztia XT: 120, 180, 240, 300, 360 mg SE: Gingival hyperplasia, brady-cardia, AV block, ECG abnormalities, peripheral edema, dizziness, HA Interactions:↑ Effects W/ α-blockers, azole antifungals, BBs, erythromycin, H2-receptor antago-nists, nitroprusside, quinidine, EtOH, grapefruit juice; ↑ effects OF carbamazepine,cyclosporine, digitalis glycosides, quinidine, phenytoin, prazosin, theophylline,TCAs; ↓ effects W/ NSAIDs, phenobarbital, rifampin EMS: Do not use if BP<90mm Hg; calcium chloride/gluconate can be use as an antidote in OD situations

TABLE I-1Diltiazem: Infusion Chart (for microdrip set [60 gtt])

Desired Dose 60 gtt/mL set

5 mg/h 5 gtt/min10 mg/h 10 gtt/min15 mg/h 15 gtt/min

For macro drip sets, divide above numbers in table by: 3 for a 20 gtt set, 4 for a 15 gtt set and 6 fora 10 gtt set

Diphenhydramine# (Benadryl) [OTC] [Antihistamine/Antitussive/Antiemetic] Uses: Tx & prevent allergic Rxns, motion sick-ness, potentiate narcotics, sedation, cough suppression, & Tx of extrapyramidal(dystonic) Rxns Action: Antihistamine, antiemetic Dose: Adults. 25–50 mg IV/IMPeds. > 2 y. 2–5 mg/kg IV/IM Caution: [B, −] Contra: Acute asthma Disp: Tabs,


Dopamine 13

caps 25, 50 mg; chew tabs 12.5 mg; elixir 12.5 mg/5 mL; syrup 12.5 mg/5 mL; Liq6.25 mg/5 mL, 12.5 mg/5 mL; inj 50 mg/mL, cream 2% SE: Anticholinergic(xerostomia, urinary retention, sedation) Interactions: ↑ Effects W/ CNS depres-sants, antihistamines, opioids, MAOIs, TCAs, EtOH EMS: IM doses should begiven deep into a large muscle mass and alternate inj sitesDobutamine (Dobutrex) [Inotropic/Adrenergic, Beta-1-Agonist] Uses: Short-term in cardiac decompensation secondary to depressedcontractility (CHF, cardiogenic shock) Action: Positive inotrope Dose: Adults &Peds. 2–20 mcg/kg/min; titrate to HR not >10% of baseline (mix 400 mg in 250 mLD5W to make 1600 mcg/mL) (see Table I-2) Caution: [C, ?] Contra: Sensitivityto sulfites, IHSS Disp: Inj 250 mg/20 mL, 12.5/mL SE: Chest pain, HTN, dysp-nea, hypotension Interactions: ↑ Effects W/ furazolidone, methyldopa, MAOIs,TCAs; ↓ effects W/ BBs, NaHCO3; ↓ effects OF guanethidine EMS: Use micro-drip set or inf pump; takes about 10 min for peak effects; small color changes mayoccur-this does not affect efficacy of drug; incompatible w/ NaHCO3; monitorECG for ↑ HR or ectopic activity; monitor BP

TABLE I-2Dobutamine: Infusion Chart (given as gtt/min based on microdrip 60 gtt/min)

Weight 2 mcg/ 5 mcg/ 10 mcg/ 15 mcg/ 20 mcg/(kg)[lb] kg/min kg/min kg/min kg/min kg/min

25[55] 1.9 4.7 9.4 14.0 18.7550[110] 3.75 9.4 18.75 28.1 37.575[165] 5.6 14.0 28.1 42.2 56.25

100[220] 7.5 18.75 37.5 56.25 75125[275] 9.4 23.4 46.9 70.3 93.75150[330] 11.25 28.1 56.25 84.4 112.5

Dopamine (Intropin) [Vasopressor/Adrenergic] Uses: Short-term use in cardiac decompensation secondary to ↓ contractility when no hypov-olemia is present; ↑ organ perfusion (at low dose) Action: Renal dose: 2–5mcg/kg/min Inotropic dose: 5–10 mcg/kg/min Pressor dose: >10 mcg/kg/minDose: Adults & Peds. 5–20 mcg/kg/min by cont inf, start at 5 and ↑ by 5 mcg/kg/min to 20 mcg/kg/min max to effect (mix 400 mg in 250 mL D5W tomake 1600 mcg/mL) (see Table I-3) Caution: [C, ?] Contra: Pheochromocytoma(adrenal gland tumor), VF, sulfite sensitivity Disp: Inj 40, 80, 160 mg/mL, premixed0.8, 1.6, 3.2 mg/mL SE: Tach, vasoconstriction, ↓ BP, HA, N/V, dyspnea Notes: >10mcg/kg/min ↓ renal perfusion Interactions: ↑ Effects W/ α-blockers, diuretics, ergotalkaloids, MAOIs, BBs, anesthetics, phenytoin; ↓ effects W/ guanethidine EMS: Cor-rect hypovolemia before use; use microdrip set or inf pump; check soln- discolored


14 Enalapril

preparations should not be used; monitor ECG, HR, and BP closely; monitor urinaryoutput if possible

TABLE I-3Dopamine: Infusion Chart (given as gtt/min based on microdrip 60 gtt/min = 1 mL)

Weight 2 mcg/ 5 mcg/ 10 mcg/ 15 mcg/ 20 mcg/(kg)[lb] kg/min kg/min kg/min kg/min kg/min

25[55] 1.9 4.7 9.4 14.0 18.7550[110] 3.75 9.4 18.75 28.1 37.575[165] 5.6 14.0 28.1 42.2 56.25

100[220] 7.5 18.75 37.5 56.25 75125[275] 9.4 23.4 46.9 70.3 93.75150[330] 11.25 28.1 56.25 84.4 112.5

Enalapril# (Vasotec) [Antihypertensive/ACEI] Uses: HTN, CHFAction: ACE inhibitor Dose: Adults. 0.625–1.25 mg IV Peds. 0.05–0.08 mg/kgContra: Bilateral RAS, angioedema Disp: Tabs 2.5, 5, 10, 20 mg; IV 1.25 mg/mL(1, 2 mL) SE: ↓ BP w/ initial dose (esp w/ diuretics), ↑ K+, nonproductive cough,angioedema Interactions: ↑ Effects W/ loop diuretics; ↑ risk of cough W/ capsaicin;↑ effects OF α-blockers, insulin, Li; ↑ risk of hyperkalemia W/ K+ supl, K+-sparingdiuretics, salt substitutes, trimethoprim; ↓ effects W/ ASA, NSAIDs, rifampin EMS:Consider CPAP/BiPAP use if hypoxia or severe resp distress is presentEpinephrine# (Adrenalin, Sus-Phrine, EpiPen, EpiPen Jr,others) [Vasopressor/Bronchodilator/Cardiac Stimulant,Local Anesthetic] Uses: Cardiac arrest, anaphylactic Rxn, bronchospasmAction: β-Adrenergic agonist, some α-effects Dose: Adults. Cardiac arrest: 1.0mg 1:10,000 conc IV/IO push, repeat q3–5min until ROSC; inf: 30 mg (30 mL of1:1000 soln) in 250 mL NS or D5W, at 100 mL/h, titrate. ET (as last resort) 2.0–2.5mg 1:10,000 in 10 mL NS Profound bradycardia/hypotension: 2–10 mcg/min (1 mg of 1:1000 in 250 mL NS to make 4 mcg/mL; see Table I-4) Anaphylaxis:0.3–0.5 mL SQ/IM of 1:1000 dilution, repeat PRN q5–15min, or 0.5–1.0 mg1:10,000 IV if SQ dose ineffective Asthma: 0.1–0.5 mL SQ/IM of 1:1000 dilution,repeat q20min Peds. Cardiac arrest: 1st dose 0.01 mL/kg IV/IO of 1:10,000 conc,then 0.1 mL/kg IV/IO of 1:1000 dilution q3–5 min to response Anaphylaxis:0.15–0.3 mg IM depending on wt < 30 kg 0.01 mg/kg Asthma: 0.01 mL/kg SQ/IMof 1:1000 dilution Caution: [C, ?] ↓ Bronchodilation w/ BBs Contra: Cardiacarrhythmias, NAG Disp: Inj 1:1000, 1:2000, 1:10,000, 1:100,000; susp for inj1:200; aerosol 220 mcg/spray; 1% inhal soln; EpiPen AutoInjector 1 dose 0.30 mg;EpiPen Jr 0.15 mg SE: CV (tach, HTN, vasoconstriction), CNS stimulation (ner-vousness, anxiety, trembling), ↓ renal blood flow Interactions: ↑ HTN effects W/


Fentanyl 15

α-blockers, BBs, ergot alkaloids, furazolidone, MAOIs; ↑ cardiac effects W/ anti-histamines, cardiac glycosides, levodopa, thyroid hormones, TCAs; ↑ effects OFsympathomimetics; ↓ effects OF diuretics, guanethidine, hypoglycemics, methyl-dopa EMS: IV route preferred in cardiac arrest, followed by IO; can be given byET tube (2–2.5× dose w/ 10 mL NS) only as a last resort; aspirate before IM inj,accidental IV use of IM dose may cause HTN; higher doses may be needed to treatdrug or poison induced shock—CCB or BB OD (up to 0.2 mg/kg); may causehyperglycemia

TABLE I-4Epinephrine: Infusion Chart (for microdrip set [60 gtt/mL])


2 mcg/min 30 gtt/min4 mcg/min 60 gtt/min6 mcg/min 90 gtt/min8 mcg/min 120 gtt/min

10 mcg/min 150 gtt/min

For macrodrip sets, divide above numbers in table by: 3 for a 20 gtt/mL set, 4 for a 15 gtt/mL set and6 for a 10 gtt/mL set

Epinephrine, Racemic (microNefrin) [Bronchodilator] Uses:Bronchospasm, Croup, Laryngeal Edema Action: β-Adrenergic agonist Dose:Adults. MDI: 2–3 inhalations; repeat q5min PRN; Soln: 5 mL of 1% in 5 mL salineand administer over 10 min Peds. Soln: If <20 kg 0.25 mL of 1% in 2.5 mL saline;if 20–40 kg 0.5 mL of 1% in 2.5 mL; If >40 kg 0.75 mL in 2.5 mL saline (See Epi-nephrine [earlier] for additional information)Etomidate (Amidate) [Hypnotic] Uses: Preprocedure amnesiac, induc-tion agent in RSI Action: Short-acting nonbarbiturate hypnotic Dose: Adults. RSI:0.1–0.3 mg/kg IV/IO (0.3 mg/kg typical) Peds. RSI: 0.1–0.3 mg/kg (onset w/in 30 s;duration 3–5 min) Caution: [C, ?] Contra: Hypersensitivity Disp: Inj SE: N/V,muscle jerking, hiccups Interactions: None in prehospital environment, however,will cause adrenal suppression (important in sepsis) EMS: Does not have any anal-gesic effects, use an analgesic before painful procedures; N is common followingusage; short-acting so if OD suspected, support airway/breathing until drug wears offFentanyl# (Sublimaze) [C-II] [Opioid Analgesic] Uses: Short-acting analgesic for pain and RSI Action: Narcotic analgesic Dose: Analgesia:25–100 mcg IV/IN/IM titrated to effect; RSI: 1–3 mcg/kg Peds. 1–2 mcg/kgIV/IN/IM titrate (onset w/in 3–5 min; duration 30–60 min) Caution: [B, +]Contra: Pts taking MAO Inhibitors, paralytic ileus, resp depression, severerenal/hepatic impair Disp: Inj 0.05 mg/mL SE: Sedation, ↓ BP, bradycardia, con-stipation, N, resp depression, miosis Interactions: ↑ Effects W/ CNS depressants,


16 Flumazenil

cimetidine, erythromycin, ketoconazole, phenothiazine, ritonavir, TCAs, EtOH,grapefruit juice; ↑ risks of HTN crisis W/ MAOIs; ↑ risk of CNS & resp depres-sion W/ protease inhibitors; ↓ effects W/ buprenorphine, dezocine, nalbuphine,pentazocine EMS: 0.1 mg fentanyl = 10 mg morphine IM; pt should be receivingO2 prior to administration; resp depression may last longer than analgesia, haveresuscitation equipment and naloxone available; naloxone can be used as an anti-dote to reverse resp depression (usually takes relatively large doses); split IN dosebetween each nostril and use an atomizerFlumazenil (Romazicon) [Antidote/Benzodiazepine] Uses:Reverse sedative effects of benzodiazepines & general anesthesia Action: Benzo-diazepine receptor antagonist Dose: Adults. 0.2 mg IV over 30 s; repeat PRN, to 3 mg max (give just enough to reverse resp depression) Peds. 0.01 mg/kg (0.2 mg/dose max) IV over 30 s (onset w/in 5 min) Caution: [C, ?] Contra: TCAOD; if pts given benzodiazepines to control life-threatening conditions (ICP/statusepilepticus) Disp: Inj 0.1 mg/mL SE: N/V, palpitations, HA, anxiety, nervousness,hot flashes, tremor, blurred vision, dyspnea, hyperventilation, withdrawal syndInteractions: ↑ Risk of Szs and arrhythmias when benzodiazepine action isreduced EMS: Should be given slowly; does not reverse narcotic Sxs or amnesia;use associated w/ Szs in pts on chronic benzo therapy for any reason, if Szs occuranti-Sz drugs from another class (non-benzodiazepine) need to be usedFurosemide# (Lasix) [Antihypertensive/Loop Diuretic] Uses:CHF and Pulm edema Action: Loop diuretic; ↓ Na & Cl reabsorption in ascendingloop of Henle & distal tubule Dose: Adults. 0.5–1.0 mg/kg IV slowly (typically40–100 mg) or repeat pts nl daily dose if prescribed furosemide Peds. 1 mg/kgIV/IO Caution: [C, +] ↓ K+, ↑ risk of digoxin tox; ↑ risk of ototox w/ aminoglyco-sides, cisplatin (esp in renal dysfunction) Contra: Allergy to sulfonylureas; anuria;hepatic coma; electrolyte depletion Disp: Tabs 20, 40, 80 mg; soln 10 mg/mL, 40 mg/5 mL; inj 10 mg/mL SE: ↓ BP, hyperglycemia, ↓ K+ Interactions: ↑Nephrotoxic effects W/ cephalosporins; ↑ ototox W/ aminoglycosides, cisplatin;↑ risk of hypokalemia W/ antihypertensives, carbenoxolone, corticosteroids,digitalis glycosides, terbutaline; ↓ effects W/ barbiturates, cholestyramine,colestipol, NSAIDs, phenytoin, dandelion, ginseng; ↓ effects OF hypoglycemicsEMS: Do not administer to pts w/ suspected pneumonia (crackles w/ fever); pre-cipitates w/ amrinone/inamrinone; may affect glucose (hyperglycemia); monitorfor hypokalemia (flattened t-waves)Glucagon (GlucaGen) [Antihypoglycemic/Hormone] Uses:hypoglycemia in DM w/ no IV access; BB OD Action: Accelerates liver glycogenolysis/gluconeogenesis Dose: Adults. 0.5–1 mg IM/SQ; repeat in 20 min PRN BB OD: 3 mgIV; repeat in 10 min PRN; may give cont inf 1–5 mg/h Peds. 0.03–0.1 mg/kg/doseIM/SQ; repeat in 20 min PRN—max dose 1 mg (onset w/in 5–20 min) Caution: [B,M] Contra: Pheochromocytoma (adrenal gland tumor) Disp: Inj 1 mg SE: N/V, ↓ BPInteractions: ↑ Effect W/ epi, phenytoin; ↑ effects OF anticoagulants Labs: ↓ Serum


Hydromorphone 17

K+ EMS: Use when IV access cannot be obtained; use soln immediately followingreconstitution of dry powder; pt will awaken in 5–20 min; ASAP after pt regains con-sciousness PO carbohydrates (OJ, peanut butter) should be given; incompatible w/saline solutions; only effective if sufficient glycogen exists in pts liverHaloperidol (Haldol) [Antipsychotic/Butyrophenone]WARNING:↑ Mortality in elderly w/ dementia-related psychosis, may prolong QTinterval Uses: Acute psychosis and emergency sedation of severely agitated ptsAction: Antipsychotic, neuroleptic Dose: Adults. 2–5 mg IM Peds. 0.05–0.15mg/kg Caution: [C, ?] ↑ Effects w/ SSRIs, CNS depressants, TCA, indomethacin,metoclopramide; avoid levodopa (↓ antiparkinsonian effects) Contra: NAG, severeCNS depression, coma, Parkinson Dz, BM suppression, severe cardiac/hepatic DzDisp: Tabs 0.5, 1, 2, 5, 10, 20 mg; conc Liq 2 mg/mL; inj 5 mg/mL; decanoate inj50, 100 mg/mL SE: Extrapyramidal Sxs (EPS), ↓ BP, anxiety, dystonias Interac-tions: ↑ Effects W/ CNS depressants, quinidine, EtOH; ↑ hypotension W/ antihy-pertensives, nitrates; ↑ anticholinergic effects W/ antihistamines, antidepressants,atropine, phenothiazines, quinidine, disopyramide; ↓ effects W/ antacids, carba-mazepine, Li, nutmeg, tobacco; ↓ effects OF anticoagulants, levodopa, guanethi-dine EMS: Administer deep into a large muscle mass; can be given through clothesif needed; EPS can be treated w/ diphendydramine (Benadryl); can be given w/other medications (ie, lorazepam) Heparin [Anticoagulant] Uses: Prevent thrombotic events in an AMIAction: Acts w/ antithrombin III to inactivate thrombin & ↓ thromboplastin for-mation Dose: Adults. Load w/ 5000 Units IVP, can infuse 20,000–40,000 Unitsover about 24 h Caution: [B, +] ↑ Risk of hemorrhage w/ anticoagulants, ASA,anti-plts, some cephalosporins Contra: Uncontrolled bleeding, severe thrombo-cytopenia, suspected ICH Disp: Inj 10, 100, 1000, 2000, 2500, 5000, 7500,10,000, 20,000, 40,000 Units/mL SE: Bruising, bleeding, thrombocytopeniaInteractions: ↑ Effects W/ anticoagulants, antihistamines, ASA, clopidogrel, car-diac glycosides, cephalosporins, pyridamole, NSAIDs, quinine, tetracycline, ticlo-pidine, feverfew, ginkgo biloba, ginger, valerian; ↓ effects W/ nitroglycerine,ginseng, goldenseal, ↓ effects OF insulin EMS: Pt is predisposed to bleeding(internal and external) esp when combined w/ other anticoagulants, anti-plts,NSAIDs or thrombolytics; minimize or avoid invasive procedures when possible(ie, IV placement, IM inj, & nasotracheal intubation); typically only allowed incritical care/interfacility transportsHydromorphone (Dilaudid) [C–II] [Narcotic Analgesic] Uses:Pain Action: Narcotic analgesic Dose: 1–4 mg IV (onset w/in 10 min; durationabout 3 h) Caution: [B (D if prolonged use or high doses near term), ?] ↑ respdepression and CNS; ↑ effects CNS depressants, phenothiazines, TCA Contra:Component sensitivity Disp: Tabs 2, 4 mg, 8 mg; Liq 5 mg/5 mL or 1 mg/mL; inj1, 2, 4, 10 mg/mL; supp 3 mg SE: Sedation, dizziness, GI upset Interactions: ↑Effects W/ CNS depressants, phenothiazines, TCAs, EtOH, St. John’s wort; ↓


18 Hydroxocobalamin

effects W/ nalbuphine, pentazocine EMS: Morphine 10 mg IM = hydromorphone 1.5mg IM; pt should be receiving O2 prior to administration; have resuscitation equip-ment and naloxone available; naloxone can be used as an antidote to reverse respdepressionHydroxocobalamin (Vitamin B12) [Vitamin/Antidote] Uses:Tx of cyanide poisoning Action: Binds cyanide molecules to form cyanocobal-amin to facilitate excretion Dose: Adults. 5 g IV once Peds. 70 mg/kg IV onceCaution: [C, ?] Contra: Hypersensitivity to hydroxocobalamin Disp: Inj SE:N, HA, allergic Rxn, HTN, hematochezia, red urine, skin flushing Interactions:None reported EMS: Personal safety is the primary concern in cyanide poisoning;primary drug in the commercially available Cyanokit; may turn urine a red colorInsulin, Injectable [Hypoglycemic/Hormone] (See Table VI-3)Uses: Hyperglycemia; acute life-threatening ↑ K+ Action: Insulin supl Dose: Adults.Based on serum glucose, but usually 5–10 Units IV, IM, SQ (SQ usually preferred);may be repeated if needed Peds. Based on serum glucose, but usually 2–4 Units IV,IM, SQ (SQ usually preferred); may be repeated if needed Caution: [B, +] Contra:Hypoglycemia Disp: See Table VI-3 SE: Highly purified insulins ↑ free insulinInteractions: ↑ Hypoglycemic effects W/ α-blockers, anabolic steroids, BBs, clofi-brate, fenfluramine, guanethidine, MAOIs, NSAIDs, pentamidine, phenylbutazone,salicylates, sulfinpyrazone, tetracyclines, EtOH, celery, coriander, dandelion root,fenugreek, ginseng, garlic; ↓ hypoglycemic effects W/ corticosteroids, dextrothyrox-ine, diltiazem, dobutamine, epi, niacin, OCPs, protease inhibitor antiretrovirals,rifampin, thiazide diuretics, thyroid preps, marijuana, tobacco EMS: Check/monitorblood glucose level; contact medical command for specific recommendations on dos-ing; concurrent salicylate, NSAID and EtOH use ↑ hypoglycemic effects; can beused to treat hyperkalemiaIpratropium# (Atrovent HFA, Atrovent Nasal) [Bronchodilator/Anticholinergic] Uses: Bronchospasm w/ COPD, rhinitis, rhinorrheaAction: Synthetic anticholinergic similar to atropine; antagonizes acetylcholinereceptors, inhibits mucous gland secretions Dose: Adults & Peds >12 y. Nebuliza-tion: 500 mcg in 2.5–3.0 mL NS Peds. Nebulization: 125–250 mcg in 2.5–3.0 mLNS Caution: [B, +/−] w/ inhal insulin Contra: Allergy to soya lecithin/relatedfoods Disp: HFA met-dose inhal 18 mcg/dose; inhal soln 0.02%; nasal spray 0.03,0.06% SE: Nervousness, dizziness, HA, cough, bitter taste, nasal dryness, URI,epistaxis Interactions: ↑ Effects W/ albuterol; ↑ effects OF anticholinergics,antimuscarinics; ↓ effects W/ jaborandi tree, pill-bearing spurge EMS: Monitorlung sounds prior and following administration; separate inhalation of other drugsby 5 min; typically given w/ a β2-agonist agent such as albuterolIsoproterenol (Isuprel) [Bronchodilator/Sympathomimetic]Uses: ↑ CO in bradycardia refractory to atropine Action: β1- & β2-receptor stimu-lant Dose: Adults. 2–10 mcg/min IV inf; titrated (mix 1 mg in 250 mL D5W tomake 4 mcg/mL) Peds. 0.1 mcg/kg/min IV inf; titrate to effect Caution: [C, ?]


Lidocaine 19

Contra: Angina, tachyarrhythmias (digitalis-induced or others) Disp: 0.02mg/mL, 0.2 mg/mL SE: Insomnia, arrhythmias, HA, trembling, dizziness Interac-tions: ↑ Effects W/ albuterol, guanethidine, oxytocic drugs, sympathomimetics,TCAs; ↑ risk of arrhythmias W/ amitriptyline, bretylium, cardiac glycosides, K-depleting drugs, theophylline; ↓ effects W/ BBs EMS: TCP should be consid-ered first; use microdrip set or inf pump; more specific β2-agonists preferred d/texcessive β1 cardiac stimulation of drug; pulse > 130 bpm may induce arrhyth-mias; BBs can be used for OD managementKetamine (Ketalar) [C-III] [Dissociative Anesthetic, Hallucinogen] Uses: Anesthesia induction, pain, adjunct to N2O Action:NMDA receptor antagonist Dose: Adults. Anesthesia induction: 1–4.5 mg/kg over 1min Pain: 1–2 mg/kg over 1 min or 4–5 mg/kg IM Peds. 1–2 mg/kg over 1 min or3–5 mg/kg IM (onset w/in 1–5 min; duration 15–30 min) Caution: [D, ?] Contra:HTN, stroke, suspected CHI Disp: 10 mg/mL (20 mL); 50 mg/mL (10 mL); 100 mg/mL (5 mL) SE: Similar to PCP and LSD (sedation, hallucinations), tach, ↑BP, ↑ ICP, nystagmus, loss of coordination Interactions: ↑ CNS depression W/opiates, sedatives/hypnotics; ↑ risk of arrhythmias W/ topical cocaine EMS: Usersreport side effects similar to PCP and LSD; monitor ECG and BPKetorolac (Toradol) [Analgesic/NSAID] Uses: Pain Action:NSAID; ↓ prostaglandins Dose: Adults. 15–30 mg IV/IM or 30–60 mg IM Peds.Do not use Caution: [B (D 3rd tri), −] Contra: Peptic ulcer Dz, NSAID sensitiv-ity, advanced renal Dz, CNS bleeding, anticipated major surgery, labor & delivery,nursing mothers Disp: ↑ Tabs 10 mg; inj 15 mg/mL, 30 mg/mL SE: Bleeding, pep-tic ulcer Dz, renal failure, ↑ Cr, edema, dizziness, allergy Interactions: ↑ EffectsW/ ASA, corticosteroids, NSAIDs, probenecid, EtOH; ↑ effects OF antineoplas-tics, hypoglycemics, insulin, Li, MTX; ↑ risk of nephrotox W/ aminoglycosides,cyclosporines; ↑ risk of bleeding W/ anticoagulants, defamandole, cefotetan, cef-operazone, clopidogrel, eptifibatide, plicamycin, thrombolytics, tirofiban, valproicacid, dong quai, feverfew, garlic, ginkgo biloba, ginger, horse chestnut, red clover;↓ effects OF antihypertensives, diuretics EMS: Inj slowly into large muscle massfor IM; use lower dose (10–15 mg) for pts >65 and < 50 kg; do not use in ped pts;correct any hypovolemia prior to administration; monitor for unusual bleeding Lidocaine (Anestacon Topical, Xylocaine, Others) [Antiarrhythmic/Local Anesthetic] Uses: Tx cardiac arrhythmias, car-diac arrest (VF/VT) Action: Anesthetic; class IB antiarrhythmic Dose: Adults. Car-diac arrest (VF/VT): 1.0–1.5 mg/kg IV/IO, repeat PRN at 0.5–0.75 mg/kg up to 3mg/kg; following conversion begin inf 2–4 mg/min Convert VT w/ pulses: 1.0–1.5mg/kg slow IV, may repeat at 1/2 dose q10min up to 3 mg/kg; following conversionbegin inf at 2–4 mg/min Peds. Cardiac arrest (VF/VT): 1.0 mg/kg, repeat PRN up to3 mg/kg; following conversion begin inf at 20–50 mcg/kg/min Convert VT w/ pulses:1.0 mg/kg IV; following conversion begin inf at 20–50 mcg/kg/min (see Table I-5)Caution: [C, +] Disp: Inj local: 0.5, 1, 1.5, 2, 4, 10, 20% Inj IV: 1% (10 mg/mL),


20 Lorazepam

2% (20 mg/mL); admixture 4, 10, 20% IV inf: 0.2, 0.4%; cream 2%; gel 2, 2.5%;oint 2.5, 5%; Liq 2.5%; soln 2, 4%; viscous 2% SE: Dizziness, paresthesias, & con-vulsions associated w/ tox Interactions: ↑ Effects W/ amprenavir, BBs, cimetidine;↑ neuromuscular blockade W/ aminoglycosides, tubocurarine, pareira; ↑ cardiacdepression W/ procainamide, phenytoin, propranolol, quinidine, tocainide; ↑ effectsOF succinylcholine EMS: Oral spray/soln can be used for nasal intubation or NGtube insertion; can be given by ET at 2–2.5× IV dose w/ 1–2 mL NS only as a lastresort; monitor pts on inf for neurotox effects (confusion, behavioral changes)

TABLE I-5Lidocaine: Infusion Chart (for microdrip set [60 gtt/mL])


1 mg/min 15 gtt/min2 mg/min 30 gtt/min3 mg/min 45 gtt/min4 mg/min 60 gtt/min

For macrodrip sets, divide above numbers in table by: 3 for a 20 gtt set, 4 for a 15 gtt set and 6 for a10 gtt set

Lorazepam# (Ativan, Others) [C-IV] [Anxiolytic, Sedative/Hypnotic/Benzodiazepine] Uses: Anxiety; preprocedure sedation; con-trol Szs Action: Benzodiazepine Dose: Adults. Preprocedure sedation: 2.0–4.0 mgIM, 0.5–2.0 mg IV Status epilepticus: 2 mg slow IV/IO/IN; max of 4 mg Peds.Preprocedure sedation: 0.03–0.05 mg/kg IV/IM/PR up to 4 mg Status epilepticus:0.1 mg/kg slow IV/IO/IN (onset w/in 1–5 min w/IV, IO and IN and 15–30 minw/IM; duration about 6 h) Caution: [D, ?/−] Contra: Allergy to propylene glycolor benzyl alcohol Disp: Tabs 0.5, 1, 2 mg; soln, PO conc 2 mg/mL; inj 2, 4 mg/mLSE: Sedation, ataxia, tach, constipation, resp depression Interactions: ↑ EffectsW/ cimetidine, disulfiram, probenecid, calendula, catnip, hops, lady’s slipper, pas-sionflower, kava kava, valerian; ↑ effects OF phenytoin; ↑ CNS depression W/ anticonvulsants, antihistamines, CNS depressants, MAOIs, scopolamine,EtOH; ↓ effects W/ caffeine, tobacco; ↓ effects OF levodopa EMS: Before IVadministration, dilute w/ an equal amount of NS, do not dilute if giving IM; for IMinj deep into a large muscle mass; do not exceed an IV rate of >2 mg/min;Flumazenil should be available if needed to reverse resp depression; can be givenrectally; split IN dose between each nostril and use an atomizerMagnesium Sulfate (Various) [Magnesium Supplement/Magnesium Salt] Uses: Preeclampsia/eclampsia, cardiac arrest w/ torsadesde pointes, severe asthma Action: Mg2+ supl Dose: Adults. Preeclampsia/prematurelabor: 4 g load then 1–4 g/h IV inf; Cardiac arrest w/ torsades: 1–2 g IV push(2–4 mL 50% soln) in 10 mL D5W; Asthma: 3 g in 100 mL D5W over 5–10 min


Methylprednisolone Succinate and Acetate 21

Peds. Cardiac arrest w/ torsades: 25–50 mg/kg/dose IV Caution: [B, +] Contra:Heart block Disp: Inj 10, 20, 40, 80, 125, 500 mg/mL; bulk powder SE: CNSdepression, D, flushing, heart block Interactions: ↑ CNS depression W/ antidepres-sants, antipsychotics, anxiolytics, barbiturates, hypnotics, narcotics; EtOH; ↑ neuro-muscular blockade W/ aminoglycosides, atracurium, gallamine, pancuronium,tubocurarine, vecuronium EMS: Monitor ECG for changesMannitol (Osmitrol) [Osmotic Diuretic] Uses: Tx cerebral edema (↑ ICP) Action: Diuretic Dose: Adults. 0.5–2 g/kg slow IV Peds. 0.2–0.5 g/kg IVover 60 min Caution: [C, ?] Contra: Pulm edema, CHF, cerebral bleeding Disp:Inj, sol 5% (50 mg/mL); 10% (100 mg/mL); 15% (150 mg/mL); 20% (200 mg/mL);25% (250 mg/mL) SE: N/V, HA, dizziness, edema, blurred vision, diuresis, dehy-dration Interactions: Interferes w/ blood transfusions EMS: Use caution to preventextravasation (use large vein); rebound ↑ in ICP has been noted about 12 h postadministrationMeperidine (Demerol) [C-II] [Narcotic Analgesic] Uses: Moderate/severe pain Action: Narcotic analgesic Dose: Adults. 25–50 mg IV, 50–100 mg IMPeds. 1 mg/kg IV/IM (onset w/in 5 min IV and 10 min IM; duration about 2 h)Caution: [C, ?] Contra: Convulsive disorders and acute abdomen Disp: Prefilled1 mL syringes: 25, 50, 75, 100 mg/mL; various amps and vials; oral syrup and tabsSE: N/V (may be severe), dizziness, weakness, sedation, miosis, resp depression,xerostomia (dry mouth) Interactions: ↑ CNS depression W/ opiates, sedatives/hypnotics; ↑CNS stimulation W/ amphetamines; ↑ risk of tox W/ phenytoin EMS:Pt should be receiving O2 prior to administration; have resuscitation equipment andnaloxone available; naloxone can be used as an antidote to reverse resp depression;aspirate prior to IM administration; inadvertent IV admin of IM doses may causetach and syncope; mix w/ NS to make a 10 mg/mL soln and inj very slowly; N/Vmay be severe; may premedicate w/ an antiemeticMetaproterenol# (Alupent, Metaprel) [Bronchodilator/Beta-Adrenergic Agonist] Uses: Asthma & reversible bronchospasmAction: Sympathomimetic bronchodilator Dose: Adults. Neb: 0.2–0.3 mL in2.5–3.0 mL of NS Peds. Neb: 0.1–0.2 mL/kg of a 5% soln in 2.5 mL NS Caution:[C, ?/−] Contra: Tach, other arrhythmias Disp: Aerosol 0.65 mg/inhal; soln forinhal 0.4, 0.6%; tabs 10, 20 mg; syrup 10 mg/5 mL SE: Nervousness, tremors(common), tach, HTN Interactions: ↑ Effects W/ sympathomimetic drugs, xan-thines; ↑ risk of arrhythmias W/ cardiac glycosides, halothane, levodopa, theo-phylline, thyroid hormones; ↑ HTN W/ MAOIs; ↓ effects W/ BBs EMS: Separateadditional aerosol use by 5 min; fewer β1 effects than isoproterenol & longer-act-ing; monitor lung sounds before/after administrationMethylprednisolone Succinate and Acetate (Solu-Medrol,Depo-Medrol) [Steroid] Uses: Tx inflammation d/t anaphylaxis andasthma; suspected SCI Action: Adrenal corticosteroid Dose: Adults. Anaphylaxis/status asthmaticus: 125–250 mg IV/IM Suspected SCI: Load w/ 30 mg/kg then inf


22 Metoclopramide

5.4 mg/kg/h Peds. Anaphylaxis/status asthmaticus:1–2 mg/kg/dose initially Contra:None in an emergency setting Disp: Solu-Medrol (methylprednisolone succinate) 40,125, 500 mg, 1, 2 g w/ benzyl alcohol diluent; Depo-Medrol (methylprednisoloneacetate) 20 (5); 40 (5); 80 mg/mL (5 mL) w/ benzyl alcohol diluent; tabs SE: N/V,abd distension, HA weakness, fluid retention, ↓ K+ Interactions: ↑ Risk ofhypokalemia W/ furosemide and thiazide diuretics, ↓ effects W/ phenytoin, isoniazid,and rifampin EMS: Solu-Medrol can be given, IV/IM; Depo-Medrol can only begiven IM; give IM dose deep into a large muscle mass; therapeutic onset may takeseveral hours so this should not be used 1st-line in anaphylaxis or asthmaMetoclopramide# (Reglan, Clopra, Octamide) [Antiemetic/Dopamine Antagonist] Uses: Tx N/V Action: ↑ UGI motility; blocksdopamine in chemoreceptor trigger zone Dose: Adults. 10 mg IV, 10–20 mg IMPeds. 1–2 mg/kg IV/IM Caution: [B, −] Drugs w/ extrapyramidal ADRs Contra:Sz disorders, allergy to sulfites Disp: Tabs 5, 10 mg; syrup 5 mg/5 mL; inj 5 mg/mLSE: Dystonic Rxns common w/ high doses, restlessness, D, drowsiness Interac-tions: ↑ Risk of serotonin synd W/ sertraline, venlafaxine; ↑ effects OF aceta-minophen, ASA, CNS depressants, cyclosporine, levodopa, Li, succinylcholine,tetracyclines, EtOH; ↓ effects W/ anticholinergics, narcotics; ↓ effects OF cimeti-dine, digoxin EMS: Monitor for extrapyramidal effects (EPS can be treated w/Benadryl); give IV dose slowly over 2 min; avoid if concern for bowel obstructionMidazolam (Hypnovel, Versed) [C-IV] [Sedative/Benzodiazepine] Uses: Preprocedure sedation; control Szs Action: Short-act-ing benzodiazepine Dose: Adults. Sedation/Szs: 1–5 mg IV/IO/IN (0.05 mg/kg);0.07–0.08 mg/kg IM, titrate to effect may repeat IV PRN q5min up to 0.1 mg/kg Peds.Sedation: 0.05–0.2 mg/kg IV/IO/IN; Szs: 0.1–0.15 mg/kg IV/IO/IN (onset time w/in3–5 min IV, 6–14 IN and 10–15 IM; duration 2 h IV and about 5 h IM) Caution:[D, +/−] Multiple drug interactions Contra: NAG; shock, coma Disp: Inj 1, 5 mg/mL;syrup 2 mg/mL SE: Resp depression; ↓ BP w/ conscious sedation, N Interactions: ↑Effects W/ azole antifungals, antihistamines, cimetidine, CCBs, CNS depressants, ery-thromycin, INH, phenytoin, protease inhibitors, grapefruit juice, EtOH; ↓ effects W/rifampin, tobacco; ↓ effects OF levodopa EMS: Pt should be receiving O2 prior toadministration; use slightly lower doses for elderly pts (0.5 mg); has anterograde amne-sia effects; good for cardioversion; can be given rectally; split IN dose between eachnostril and use an atomizer; drug metabolism is slowed in obese pts prolonging drugeffects: flumazenil should be available if needed to reverse resp depressionMorphine# (Avinza XR, Duramorph, Infumorph, MS Contin,Kadian SR, Oramorph SR, Palladone, Roxanol) [C-II] [Anal-gesic/Opioid Agonist] Uses: Relief of moderate/severe pain; AMIAction: Narcotic analgesic Dose: Adults. Pain: 2–4 mg IV; 5–10 mg IM titrate toeffect; may repeat PRN q5min to a max of 0.2 mg/kg AMI: 1–4 mg IV may repeatPRN q5min to a max of 0.2 mg/kg Peds. Pain: 0.1–0.2 mg/kg IV titrate to effect(onset immediate w/ IV, w/in 15–30 min IM; duration about 6 h) Caution: [B (D w/


Naloxone 23

prolonged use/high doses at term), +/−] Contra: Severe asthma, resp depression, GIobst Disp: Immediate-release tabs 10, 15, 30 mg; MS Contin CR tabs 15, 30, 60,100, 200 mg; Oramorph SR CR tabs 15, 30, 60, 100 mg; Kadian SR caps 20, 30, 50,60, 80, 100 mg; Avinza XR caps 30, 60, 90, 120 mg; soln 10, 20, 100 mg/5 mL;supp 5, 10, 20, 30 mg; inj 2, 4, 5, 8, 10, 15, 25, 50 mg/mL; Duramorph/Astramorphinj 0.5, 1 mg/mL; Infumorph 10, 25 mg/mL, supp 5, 10, 20, 30 mg SE: Narcotic SE(resp depression, sedation, constipation, N/V, pruritus), granulomas w/ IT Interac-tions: ↑ Effects W/ cimetidine, CNS depressants, dextroamphetamine, TCAs,EtOH, kava kava, valerian, St. John’s wort; ↑ effects OF warfarin; ↑ risk of HTNcrisis W/ MAOIs; ↓ effects W/ opioids, phenothiazines EMS: Pt should be receiv-ing O2 prior to administration; have resuscitation equipment and naloxone available;monitor for resp depression; naloxone can be used as an antidote to reverse respdepression; use slightly lower doses for elderly pts Nalbuphine (Nubain) [Analgesic/Narcotic Agonist-Antagonist] Uses: Moderate/severe pain Action: Narcotic agonist–antago-nist; ↓ ascending pain pathways Dose: Adults. 2–5 mg IV/IM, may repeat up to 20mg Peds. 0.1–0.15 mg/kg IV/IM Caution: [B (D w/ prolonged/high doses atterm), ?] Contra: Sulfite sensitivity Disp: Inj 10, 20 mg/mL SE: CNS depression,drowsiness; caution w/ opiate use, ↓ BP Interactions: ↑ CNS depression W/ cime-tidine, CNS depressants; EtOH ↑ effects OF digitoxin, phenytoin, rifampin EMS:Morphine is 1st-line before Nubain (d/t antagonist properties); pt should be receiv-ing O2 prior to administration; have resuscitation equipment and naloxone avail-able; monitor for resp depression; naloxone can be used as an antidote to reverseresp depression; may cause anaphylactic Rxn in pts w/ sulfite sensitivityNaloxone (Narcan) [Antidote/Opioid Antagonist] Uses: OpioidOD; complete or partial reversal of CNS and resp depression induced by opioidsincluding narcotic agonists such as (codeine, heroin, hydromorphone [Dilaudid],methadone, meperidine [Demerol], morphine, paregoric, fentanyl [Actiq, Duragesic,Fentora, Sublimaze], oxycodone [Percodan, Percocet], propoxyphene [Darvon, Darvocet]) and narcotic agonist/antagonist (butorphanol tartrate [Stadol], pentazocine[Talwin], nalbuphine [Nubain]) Action: Competitive narcotic antagonist Dose:Adults. 0.4–2 mg IV/IM/IN or ET tube (2.0–2.5× the dose diluted w/ NS); may repeatq5min to a max dose of 10 mg Peds. 0.01–0.1 mg/kg/dose IV/ IM/IN or ET tube(2.0–2.5× the dose diluted w/ NS) (onset w/in 2 min IV and 5–10 min IM/ET) Cau-tion: [B, ?] May precipitate acute withdrawal in addicts Contra: Drug hypersensitiv-ity Disp: Inj 0.4, 1 mg/mL; neonatal inj 0.02 mg/mL SE: ↓ BP, tach, irritability, GIupset, pulm edema Interactions: ↓ Effects OF opiates EMS: Give slowly and onlyenough (small doses) to reverse resp depression, given fast or too much may causeacute narcotic withdrawal Sxs (N/V, tremors); may be better to simply support resp; ifno response after 10 mg, suspect nonnarcotic cause of resp depression/coma; split INdose between each nostril and use an atomizer; Caution administering to known nar-cotic addicts (may precipitate withdrawal w/ hypertension, tach, violent behavior)


24 Nitroglycerin

Nitroglycerin# (Nitrostat, Nitrolingual, Nitro-Bid Ointment,Nitro-Bid IV, Nitrodisc, Transderm-Nitro, Others) [Antianginal,Vasodilator/Nitrate] Uses: Angina pectoris, AMI, CHF, Action: Relaxesvascular smooth muscle, dilates coronary arteries Dose: Adults. Sublingual: 1 tab(0.4 mg) repeat q5min if BP > 100 mm Hg, max 3 tabs; 1 spray (0.4 mg) repeatq5min if BP > 100 mm Hg, max 3 sprays NitroPaste: 1–2 cm on hair-free skin(chest) Inf: 5–10 mcg/min, ↑ by 5 mcg/min until desired effects (mix 50 mg in 500mL of NS or D5W to yield 100 mcg/mL) (see Table I-6) Peds. Not used Caution:[B, ?] Restrictive cardiomyopathy Contra: IV: Pericardial tamponade, constrictivepericarditis PO: w/ sildenafil, tadalafil, vardenafil, head trauma, NAG Disp: SLtabs 0.3, 0.4, 0.6 mg; translingual spray 0.4 mg/dose; SR caps 2.5, 6.5, 9; SR tabs2.6, 6.5, 9.0 mg; inj 0.1, 0.2, 0.4 mg/mL (premixed); 5 mg/mL inj soln; oint 2%;TD patches 0.1, 0.2, 0.4, 0.6 mg/h; buccal CR 2, 3 mg SE: HA, ↓ BP, lightheaded-ness, GI upset Interactions: ↑ Hypotensive effects W/ antihypertensives, phenoth-iazine, sildenafil, tadalafil, vardenafil, EtOH; ↓ effects W/ ergot alkaloids; ↓effects OF SL tabs & spray W/ antihistamines, phenothiazines, TCAs EMS: Donot give if SBP < 100 mm Hg or if the pt has taken an ED drug (Viagra, Cialis,Levitra) w/in the last 24 h; HAs are common; place tabs and spray underneathtongue; may relieve some noncardiac chest pain (eg, esophageal spasm)

TABLE I-6Nitroglycerin: Infusion Chart

Desired Dose (mcg/min) Drip Rate (mL/h)*

5 mcg/min 3 mL/h10 mcg/min 6 mL/h15 mcg/min 9 mL/h20 mcg/min 12 mL/h

*mL/h = gtt/min with a microdrip (60 gtt) set 60 gtt/min =100 mcg/min

Nitrous Oxide (Nitronox, Entonox) [Anesthetic Gas] Uses:Pain Action: Unknown but may stimulate opioid sites, sedation and analgesiaDose: Adults. Self administered inhalation (generally 25–50% w/ oxygen) untilpain relief or pt drops mask/falls asleep Peds. Same as adult (onset w/in 2–5 min)Caution: [?, ?] Do not use after full meal Contra: EtOH intox; AMS followinghead injury; COPD, thoracic trauma Disp: Supplied in blue cylinders SE: N/V,Light-headedness, AMS and hallucinations Interactions: ↑ CNS depression W/opiates, EtOH, sedatives EMS: Do not strap mask to pt�s face, allow pt to hold themask to their face; dosing is self-limiting when pt drops mask d/t CNS depression;typically used for burns and fractures


Pancuronium 25

Norepinephrine (Levophed) [Adrenergic Agonist/Vasopressor/Sympathomimetic] Uses: Acute ↓ BP Action: Peripheral vasoconstrictor ofarterial/venous beds Dose: Adults. 0.5–1 mcg/min IV, titrate to effect to a max of 30mcg/min (mix 4 mg in 250 mL D5W to make 16 mcg/mL) Peds. 0.1–0.2 mcg/kg/minIV/IO, titrate to effect Caution: [C, ?] Contra: ↓ BP d/t hypovolemia Disp: Inj 1mg/mL SE: Bradycardia, arrhythmia Notes: Correct volume depletion as much aspossible before vasopressors; interaction w/ TCAs leads to severe HTN; use largevein to avoid extrav; phentolamine 5–10 mg/10 mL NS inj locally for extrav Inter-actions: ↑ HTN W/ antihistamines, BBs, ergot alkaloids, guanethidine, MAOIs,methyldopa, oxytocic meds, TCAs; ↑ risk of arrhythmias W/ cyclopropane,halothane EMS: Correct hypovolemia before use; use microdrip set or inf pump; uselarge vein to avoid extravasation; do not use plain NS to mix; monitor vital signs andfor S/Sxs of tox (HA, V, CP, blurred vision); may affect glucose (hyperglycemia) Ondansetron# (Zofran, Zofran ODT) [Antiemetic/5-HTAntagonist] Uses: N/V Action: Serotonin receptor antagonist Dose: Adults.4 mg slow IV/IO/IM Peds. Same as adult Caution: [B, +/−] Contra: hypersensi-tivity to medication and related compounds Disp: Tabs 4, 8, 24 mg, soln 4 mg/5 mL,inj 2 mg/mL, 32 mg/ 50 mL; Zofran ODT tab, 4, 8 mg SE: D, HA, constipation,dizziness Interactions: ↓ Effects W/ cimetidine, phenobarbital, rifampin EMS:Administer slowly; repeat doses are often neededOxygen [Medical Gas] Uses: Hypoxia, CP, resp problems, cardiac arrest,etc Action: Provides concentrated O2 to lung tissues for distribution Dose: Low con-centration: 1–6 L/min by nasal cannula High concentration: 10–15 L/min by nonre-breather or BVM w/ reservoir Contra: None absolute; use caution in pts w/ severeCOPD (risk of resp depression) Disp: Green tank EMS: Use a pulse oximeter to mon-itor pt oxygenation, however, never withhold O2 from a pt who appears to be in respdistress or critically ill; humidified oxygen preferred during prolonged administrationOxytocin (Pitocin) [Oxytocic/Hormone] Uses: Control postpartumhemorrhage Action: Stimulate muscular contractions of the uterus & milk flowduring nursing Dose: 3–10 Units IM post placenta delivery; inf mix 10–40 Unitsw/ 1000 mL D5W or NS and infuse at 10–40 micro Units/min; titrate to uterineresponse Caution: [Uncategorized, no anomalies expected, +/−] Contra: Prehos-pital prior to delivery Disp: Inj 10 Units/mL SE: Uterine rupture, fetal death;arrhythmias, anaphylaxis, H2O intox Interactions: ↑ Pressor effects W/ sympath-omimetics EMS: Monitor vital signs; only for use following delivery of baby andplacenta; ensure there are no additional fetusesPancuronium (Pavulon) [Nondepolarizing neuromuscularBlocker/Paralytic] WARNING: Use restricted to experienced personnelUses: Induce paralysis to facilitate ET intubation (RSI) Action: Competitive antago-nist of acetylcholine Dose: Adults & Peds. 0.04–0.1 mg/kg IV Maint: 0.01 mg/kgq45–60min (onset w/in 1 min; duration 30–60 min) Caution: [C/−] Cardiac monitor,BP monitor, intubation supplies and ventilator required Contra: Use w/ caution in

Gomella-EMS_sec01_p001-p032.qxd 3/23/10 2:07 PM Page 25

26 Phenylephrine, Nasal

pts w/ myasthenia gravis, or pulm/hepatic/renal Dz Disp: Inj 1 or 2 mg/mL SE:Resp depression, salivation, ↑BP/HR Interactions: ↑ Effects W/ lidocaine, BBs,magnesium sulfate, verapamil, neuromuscular blocking agents; ↑length of neuro-muscular blockade W/ Li, succinylcholine; ↓effects W/ phenytoin EMS: Pt shouldbe preoxygenated prior to attempt and all airway/resuscitation equipment (blade,ET tubes, rescue airway, surgical airways) must be present prior to paralysis—oncegiven, you are responsible for breathing for pt; has no effect on mental status—besure to give a sedative/hypnotic if pt is not unconscious; does not cause fascicula-tions like succinylcholinePhenylephrine, Nasal# (Neo-Synephrine Nasal) (OTC)[Vasopressor/Decongestant] Uses: Can be used prior to nasal intuba-tion and NG tube insertion to reduce bleeding Action: α-Adrenergic agonist Dose:Adults & Peds. 1–2 sprays/nostril q4h (usual 0.25%).Caution: [C, +/−] HTN,acute pancreatitis, Hep, coronary Dz, NAG, hyperthyroidism Contra: Bradycar-dia, arrhythmias Disp: Nasal soln (0.125–0.25%) SE: Arrhythmias, HTN, nasalirritation, dryness, sneezing, HA Interactions: May ↓ effects OF nitrates EMS:Ocular instillation may dilate pupilPralidoxime (2-PAM, Protopam) [Cholinesterase Reactivator]Uses: Nerve agent &/or organophosphate poisoning (w/ atropine) Action: Reacti-vates acetylcholinesterase inactivated by nerve agent/organophosphorus poisoningDose: Adults. 1–2 g IV/IM; max dose 1.8 g, can be given over 30 min w/ 1–2 gmixed in 250–500 mL of NS Peds. 25–50 mg/kg IV/IM Caution: [C, ?] Contra:Poisonings that do not have any anticholinesterase activity; w/o atropine Disp: Injsoln 300 mg/mL (2 mL) SE: N, HA, drowsiness, muscle weakness, diplopia, blurredvision, tach Interactions: N/A in life-threatening emergency setting EMS: This isincluded in the Mark 1 Injector and DuoDote kits (see Atropine/Pralidoxime);atropine should be given first; muscle rigidity and tach have been reported followingrapid administrationProcainamide# (Pronestyl, Pronestyl SR, Procanbid)[Antiarrhythmic] WARNING: Only use in life-treating arrhythmias;hematologic tox can be severe Uses: Supraventricular/ventricular arrhythmiasAction: Class 1A antiarrhythmic (Table VI-7) Dose: Adults. Recurrent VF/pulselessVT: 20 mg/min slow IV inf to a max of 17 mg/kg or until QRS ↑ by 50% or dys-rhythmia resolves Maint inf: 4 mg/min (mix 1 gm in 250 mL NS to make 4 mg/mL; use 60 gtt set—60 gtt/min = 4 mg) Peds. Loading dose: 15–50 mg/kgIV/IO Caution: [C, +] Contra: Complete heart block, 2nd- or 3rd-degree heartblock w/o pacemaker, torsades de pointes, SLE Disp: Tabs & caps 250, 500 mg;SR tabs 500, 750, 1000 mg; inj 100, 500 mg/mL SE: ↓ BP, lupus-like synd, GIupset, taste perversion, arrhythmias, tach, heart block, angioneurotic edema, blooddyscrasias Interactions: ↑ Effects W/ acetazolamide, amiodarone, cimetidine, ran-itidine, trimethoprim; ↑ effects OF anticholinergics, antihypertensives; ↓ effectsW/ procaine, EtOH EMS: Monitor BP and ECG; use caution to prevent rapid


Sodium Bicarbonate 27

administration (may cause chest tightness, HA, LOC); slight yellow discolorationof soln does not affect potency Promethazine# (Phenergan, Anergan) [Antihistamine,Antiemetic, Sedative/Phenothiazine] WARNING: Should not beused in pts <2 y of age d/t reports of fatal resp depression Uses: N/V Action: Phe-nothiazine; blocks CNS postsynaptic mesolimbic dopaminergic receptors Dose:Adults. 12.5–25 mg IV/IM/PR Peds. 0.5 mg/kg/dose IV/IM/PR Caution: [C, +/−]Use w/ agents w/ resp depressant effects Contra: Component allergy, NAG, age <2 yDisp: Tabs 12.5, 25, 50 mg; syrup 6.25 mg/5 mL, 25 mg/5 mL; supp 12.5, 25, 50 mg;inj 25, 50 mg/mL SE: Drowsiness, tardive dyskinesia, EPS, lowered Sz threshold, ↓BP, GI upset, blood dyscrasias, photosens, resp depression in children Interactions: ↑Effects W/ CNS depressants, MAOIs, EtOH; ↑ effects OF antihypertensives; ↓effects W/ anticholinergics, barbiturates, tobacco; ↓ effect OF levodopa EMS: IMroute is preferred, IV use has been associated w/ tissue damage; inj deep into a largemuscle mass; aspirate prior to IM administration; inadvertent arterial inj may causecomplications; EPS may be present, esp w/ high doses—treat w/ Benadryl Rocuronium (Zemuron) [Nondepolarizing NeuromuscularBlocker/Paralytic] WARNING: Use restricted to experienced personnelUses: Induce paralysis to facilitate ET intubation (RSI) Action: Competitive antago-nist of acetylcholine Dose: Adults & Peds. 0.6–1.2 mg/kg IV Maint: 0.01–0.02mg/kg q45–60 min (onset w/in 1 min; duration 30–60 min) Caution: [B, ?] Contra:Use w/ caution in pts w/ myasthenia gravis, or pulm/hepatic/renal Dz Disp: 10mg/mL (5, 10 mL) SE: Resp depression, salivation, ↑ BP/HR, rare anaphylactic RxnInteractions: ↑ Effects W/ lidocaine, BBs, magnesium sulfate, quinidine, pro-cainamide, neuromuscular blocking agents; EMS: Pt should be preoxygenated priorto attempt and all airway/resuscitation equipment (blade, ET tubes, rescue airway,surgical airways) must be present prior to paralysis—once given, you are responsiblefor breathing for pt; has no effect on mental status—be sure to give a sedative/hypnotic if pt is not unconscious; does not cause fasciculations like succinylcholineSodium Bicarbonate [NaHCO3] [Antacid/Alkalinizing Agent]Uses: Metabolic acidosis (ie, prolonged cardiac arrest); hyperkalemia; Tx of OD-TCA, barbiturates, ASA Action: Alkalinizing agent Dose: Adults. Cardiac arrest: 1mEq/kg IV/IO followed by 0.5 mEq/kg q10min PRN Hyperkalemia/OD: (TCA, bar-biturates, ASA) 1 mEq/kg Peds. Same as adult dose Caution: [C, ?] Contra: Alkalo-sis, ↑ Na+, severe pulm edema, ↓ Ca2+ Disp: Powder, tabs; 300 mg = 3.6 mEq; 325mg = 3.8 mEq; 520 mg = 6.3 mEq; 600 mg = 7.3 mEq; 650 mg = 7.6 mEq; inj 1 mEq/1 mL, 4.2% (5 mEq/10 mL), 7.5% (8.92 mEq/mL), 8.4% (10 mEq/10 mL)vial or amp SE: Belching, edema, flatulence, ↑ Na+, metabolic alkalosis Interac-tions: ↑ Effects OF anorexiants, amphetamines, ephedrine, flecainide, mecamy-lamine, pseudoephedrine, quinidine, sympathomimetics; ↓ effects OF Li, MTX,salicylates, tetracyclines EMS: In cardiac arrest, intubation and ventilation are 1st-line for correcting acidosis, use bicarb only after a prolonged arrest (unless pt has a


28 Sodium Nitrite

preexisting condition treatable w/ bicarb, ie, hyperkalemia, OD); 1 g neutralizes 12 mEq of acid; OD causes metabolic alkalosis; incompatible w/ calcium chloride/gluconate Sodium Nitrite [Nitrate Vasodilator] Uses: Tx of cyanide poisoningAction: Short-acting vasodilator, relaxes smooth muscle, and may help create cyan-methemoglobin to deactivate cyanides poisonous effects Dose: Adults. 300 mg IVover 2–4 min, may repeat at 1/2 original dose PRN Peds. 6–9 mg/kg over 2–4 min,may repeat at 1/2 original dose PRN Caution: [C, ?] Contra: None in an emergencysetting for acute cyanide poisoning Disp: IV 150 mg/mL SE: N/V, hypotension,dizziness, flushing, skin rash, tach (some SEs related to the creation of methemoglo-bin) Interactions: ↑ Risk of severe hypotension W/ PDE-5 inhibitors—ED drugs—(vardenafil, sildenafil, tadalafil), EtOH, ASA, and CCBs EMS: Included in thecommercially available cyanide antidote kit; should be given before sodium thiosul-fate; use adult dose in elderly pts unless they are frail; related to nitroglycerinSodium Thiosulfate [Nitrate vasodilator] Uses: Tx of cyanidepoisoning Action: Provides sulfur to help convert cyanide to thiocyanate for excre-tion in urine Dose: Adults. 12.5 g over 10–20 min, may repeat at 1/2 original dosein about 30 min if no improvement Peds. 400 mg/kg over 10–20 min may repeat at1/2 original dose in about 30 min if no improvement Caution: [C, ?] Contra: Nonein an emergency setting for acute cyanide poisoning Disp: IV 250 mg/mL (12.5 gin 50 mL) SE: N/V, hypotension, dizziness, flushing, skin rash, tach (some SEsrelated to the creation of methemoglobin) Interactions: ↑ Risk of severe hypoten-sion W/ PDE-5 inhibitors—ED drugs—(vardenafil, sildenafil, tadalafil), EtOH,ASA, and CCBs EMS: Included in the commercially available cyanide antidotekit; should be given after sodium nitrite; related to nitroglycerinStreptokinase (Streptase, Kabikinase) [Fibrinolytic] Uses:AMI, acute massive PE, DVT, & some occluded vascular grafts Action: Activatesplasminogen to plasmin that degrades fibrin Dose: Adults. PE: Load 250,000 unitsperipheral IV over 30 min, then 100,000 units/h IV for 24–72 h. AMI: 1.5 millionunits IV over 60 min. Peds. 3500–4000 units/kg over 30 min, then 1000–1500units/kg/h. Caution: [C, +] Contra: Streptococcal Infxn or streptokinase in last 6 mo,active bleeding, CVA, TIA, spinal surgery/trauma in last month, vascular anomalies,severe hepatic/renal Dz, endocarditis, pericarditis, severe uncontrolled HTN Disp:Powder for Inj 250,000, 750,000, 1,500,000 units SE: Allergic Rxn, phlebitis, sponta-neous bleeding, reperfusion arrhythmias Interactions: ↑ Bleeding risk W/ anticoagu-lants, ASA, NSAIDS; ↓ effects W/ amicar EMS: Reconstitute w/ NS and roll (do notshake) to mix; most effective w/in 4 h of AMI or 1 day for PE/DVT; determine pt Hxstreptokinase, do not use a second time as risk of allergic Rxn increases; spontaneousbleeding has been reported; monitor for unusual bleeding (nose bleed, IV site bleed-ing, bleeding gums); monitor ECG and pulse for arrhythmias; stop inf w/ arrhythmiaSuccinylcholine (Anectine, Quelicin, Sucostrin, Others)[Skeletal Muscle Paralytic] WARNING: Risk of cardiac arrest from


Tetracaine 29

hyperkalemic rhabdomyolysis; use restricted to experienced personnel Uses:Induce paralysis to facilitate ET intubation (RSI) Action: Depolarizing neuromuscularblocker Dose: Adults. Rapid sequence intubation: 1–2 mg/kg IV over 10–30 s or 2–4mg/kg IM; then 0.04–0.07 mg/kg to maintain relaxation; max dose is 150 mg Peds.Rapid sequence intubation: 1–2 mg/kg/dose IV, then 0.3–0.6 mg/kg/dose to maintainrelaxation (onset w/in 1 min IV and 2–3 min IM; duration 2–3 min IV and 15–30 minIM) Caution: [C, M] See Warning Contra: w/ malignant hyperthermia risk, myopa-thy, major burn (if prolonged and there is a concern for ARF or hyperkalemia), multi-ple trauma, extensive skeletal muscle denervation, NAG, pseudocholinesterasedeficiency Disp: Inj 20, 50, 100 mg/mL SE: Fasciculations, ↑ IOP, ICP, intragastricpressure, salivation, myoglobinuria, malignant hyperthermia, resp depression, or pro-longed apnea; multiple drugs potentiate; CV effects (arrhythmias, ↓ BP, tach/brady-cardia) Interactions: ↑ Effects W/ amikacin, gentamicin, neomycin, streptomycin, Li,MAOIs, opiates; ↓ effect W/ diazepam EMS: Pt should be preoxygenated prior toattempt and all airway/resuscitation equipment (blade, ET tubes, rescue airway, surgi-cal airways) must be present prior to paralysis—once given, you are responsible forbreathing for pt; may be given IVP/IM deltoid; consider giving atropine (0.01–0.02mg/kg) prior to administration, esp in young children and the elderly or w/ multiplesuccinylcholine doses; has no effect on mental status—be sure to give a sedative/hypnotic if pt is not unconscious; causes descending paralysis (begins in eyelids andprogresses down to diaphragm); associated w/ muscle fasciculations Terbutaline (Brethine, Bricanyl) [Bronchodilator/Sympathomimetic] Uses: Reversible bronchospasm (asthma, COPD);inhibit labor Action: Sympathomimetic; tocolytic Dose: Adults. Bronchodilator:2.5–5 mg PO qid or 0.25 mg SQ; repeat in 15 min PRN; max 0.5 mg in 4 h; Met-dose inhaler: 2 inhal q4–6h Premature labor: Acutely 2.5–10 mg/min/IV, gradu-ally ↑ as tolerated q10–20 min; maint 2.5–5 mg PO q4–6h until term Peds. PO:0.05–0.15 mg/kg/dose PO tid; max 5 mg/24 h; ↓ in renal failure Caution: [B, +] ↑Tox w/ MAOIs, TCAs; DM, HTN, hyperthyroidism, CV Dz, convulsive disorders,↓ K+ Contra: Component allergy Disp: Tabs 2.5, 5 mg; inj 1 mg/mL; met-doseinhaler SE: HTN, hyperthyroidism, β1-adrenergic effects w/ high dose, nervous-ness, trembling, tach, HTN, dizziness Interactions: ↑ Effects W/ MAOIs, TCAs;↓ effects W/ BBs EMS: Take oral dose w/ foodTetracaine (Pontocaine) [Local Anesthetic] Uses: Eye pain d/tinjury; premedication prior to irrigation Action: Anesthetic Dose: Adults & Peds.2 drops in affected eye w/ 5% soln Caution: [C, ?] Contra: Globe laceration orrupture Disp: Ocular soln 0.5% (5 mg/mL) SE: Transient burning and stingingInteractions: ↑ Risk of allergic Rxn in pts sensitive to procaine (Novocain) orchloroprocaine (Nesacaine) EMS: Do not touch tip of dropper to anything to pre-vent contamination; have pt lean back and give drops in lower medial aspect of theeye; does not dilate, prevent accommodation or ↑ IOP; caution pt aboutrubbing/scratching eye after administration, additional damage may occur d/t


30 Thiamine

anesthesia; depending on local protocol, this may be considered a one pt use med (ie, do not reuse dropper to avoid cross contamination) Thiamine [Vitamin B1] [Vitamin] Uses: Thiamine deficiency(beriberi), Wernicke encephalopathy, Korsakoff psychosis Action: Dietary supl,allows for nl physiologic glucose breakdown Dose: Adults. 100 mg IV/IM Peds.10–25 mg IV/IM Caution: [A (C if doses exceed RDA), +] Contra: Componentallergy Disp: Tabs 5, 10, 25, 50, 100, 250, 500 mg; inj 100, 200 mg/mL SE:Angioedema, paresthesias, rash, anaphylaxis w/ rapid IV Interactions: ↑ EffectsOF neuromuscular blocking drugs Labs: Interference w/ theophylline levelsEMS: Given prior to dextrose in pts w/ suspected malnutrition or deficiency (star-vation, alcoholism) to help uptake of dextrose; give IV slowly; IV use associatedw/ anaphylactic RxnTissue Plasminogen Activator [tPA] (see Alteplase Recombi-nant) Uses: AMI, Acute ischemic stroke Action: Converts plasminogen toplasmin Dose: Adults. >67 kg AMI: Loading 15 mg IV then 0.75 mg/kg over 30min then 0.5 mg/kg over 60 min Peds. Not used Caution: [C, ?] Contra: Anyinternal bleeding, stroke w/in last 6 mo, recent intracranial/spinal surgery ortrauma, uncontrolled hypertension Disp: 50 mg [29 million Int Units]; 100 mg [58million Int Units] SE: Allergic Rxn, phlebitis, spontaneous bleeding, reperfusionarrhythmias Interactions: ↑ Bleeding risk W/ anticoagulants, ASA, NSAIDS; ↓effects W/ Amicar EMS: Spontaneous bleeding has been reported; monitor forunusual bleeding (nosebleed, IV site bleeding, bleeding gums); monitor ECG andpulse for arrhythmias and for a HA, stop inf if arrhythmia or HA developVasopressin (Pitressin) [Antidiuretic Hormone/PosteriorPituitary Hormone] Uses: Alternative to epi in cardiac arrest Action: Pos-terior pituitary hormone, potent GI and peripheral vasoconstrictor Dose: Adults. 40 Units IV Caution: [B, +] Contra: Allergy Disp: Inj 20 Units/mL SE: HTN,arrhythmias, fever, vertigo, GI upset, tremor Interactions: ↑ Vasopressor effectsW/ guanethidine, neostigmine; ↑ antidiuretic effects W/ carbamazepine, chlor-propamide, clofibrate, phenformin urea, TCAs; ↓ antidiuretic effects W/ demeclo-cycline, epi, heparin, Li, phenytoin, EtOH EMS: Given as single dose in place offirst epi in cardiac arrestVecuronium (Norcuron) [Nondepolarizing NeuromuscularBlocker/Paralytic] WARNING: Use restricted to experienced personnelUses: Induce paralysis to facilitate ET intubation (RSI) Action: Competitiveantagonist of acetylcholine Dose: Adults & Peds. 0.1 mg/kg IV; Maint: 0.01–0.05mg/kg q45–60min (onset w/in 1 min; duration 30–60 min) Caution: [B, ?] Con-tra: Use w/ caution in pts w/ myasthenia gravis, or pulm/hepatic/renal Dz Disp:10 mg/mL (5, 10 mL) SE: Resp depression, salivation, ↑ BP/HR, rare anaphylacticRxn Interactions: ↑ Effects W/ lidocaine, BBs, magnesium sulfate, quinidine, pro-cainamide, neuromuscular blocking agents EMS: Pt should be preoxygenatedprior to attempt and all airway/resuscitation equipment (blade, ET tubes, rescue


Ziprasidone 31

airway, surgical airways) must be present prior to paralysis—once given, you areresponsible for breathing for pt; has no effect on mental status, be sure to give asedative/hypnotic if pt is not unconscious; does not cause fasciculations like suc-cinylcholineVerapamil# (Calan, Isoptin, Verelan) [Antihypertensive,Antianginal, Antiarrhythmic/CCB] Uses: Convert PSVT refractoryto other drugs (ie, adenosine); convert AF and atrial flutter Action: CCB Dose:Adults. 2.5–5 mg slow IV, may repeat once at double the initial dose in about15–20 min Max: 30 mg Peds. 0.1–0.2 mg/kg slow IV/IO Max: 10 mg/dose Cau-tion: [C, +] Amiodarone/BBs/flecainide can cause bradycardia; statins, midazo-lam, tacrolimus, theophylline levels may be ↑; w/ elderly pts Contra: Conductiondisorders Disp: Inj SE: Gingival hyperplasia, constipation, ↓ BP, bronchospasm,HR or conduction disturbances; ↓ BP and bradyarrhythmias taken w/ telithromycinInteractions: ↑ Effects W/ antihypertensives, nitrates, quinidine, EtOH, grapefruitjuice; ↑ effects OF buspirone, carbamazepine, cyclosporine, digoxin, prazosin,quinidine, theophylline; ↓ effects W/ antineoplastics, barbiturates, NSAIDs; ↓effects OF Li, rifampin EMS: Monitor ECG and BP during drug therapy; use cau-tion if pt is currently taking BBs, the combination can cause a rapid ↓ BPZiprasidone (Geodon) [Antipsychotic/Psychotropic]WARNING: Not for use for dementia-related psychosis d/t reports of fatal CVevents Uses: Psychosis Action: Most likely inhibits serotonin and dopamineuptake Dose: Adults. 10–20 mg IM Peds. Not used Caution: [C, ?] In elderly pts,hypotension Contra: Hypersensitivity; prolonged QT interval, recent AMI, CHFDisp: 20–80 mg cap, inj 20 mg/mL SE: N/D, HA, xerostomia (dry mouth), HA,resp difficulty, tach, orthostatic hypotension, flu-like Sxs, back pain, priapismInteractions: ↑ Effects OF antihypertensive drugs; ↑ risk of arrhythmias W/diuretics; ↓ drug effect W/ carbamazepine and dopamine agonists EMS: Use cau-tion in elderly pts and in those w/ suspected renal dysfunction; may affect glucose(hyperglycemia); may ↑ QT interval, monitor ECG



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