Paramedic Drugs (WSCC)

Paramedic Drugs from Pharmacology for the Prehospital Provider - Appendix B

Atropine - Class

Anticholinergic

Atropine - Mechanism

Competes reversibly with acetylcholine at the site of the muscarinic receptor. Receptors effected (from most to least sensitive): salivary, bronchial, sweat glands, eye, heart, and GI tract.

Atropine - Indications/Contraindications

• Indications: symptomatic bradycardia, asystole or pulseless electrical activity, nerve agent exposure, organophosphate poisoning.

• Contraindications: acute MI, myasthenia gravis, GI obstruction, belladonna alkaloids or sulfites.

**Will not be effective for infranodal (type II) AV block and new third-degree block with wide QRS.

Atropine for Bradycardia - Dose (Adult)

For symptomatic bradycardia:

Adult:

• 0.5 mg IV/IO Q 3-5 min max 3 mg.

Atropine for Organophosphate Poisoning - Dose (Adult)

Adult:

• 1-6 mg IV/IM; repeat if needed q 5 min PRN until symptoms dissipate.

Atropine for Bradycardia - Dose (Adolescent)

Adolescent:

• 0.02 mg/kg (minimum 0.1 mg/kg dose; max 1 mg dose) IV/IO up to total of 2 mg.

Atropine for Bradycardia/Cardiac Arrest - Dose (Pediatric)

Pediatric:

• 0.02 mg/kg (minimum 0.1 mg/kg dose; max 0.5 mg/dose) IV/IO up to total of 1 mg.

Atropine for Organophosphate Poisoning - Dose (Pediatric)

Pediatric:

• 0.05 mg/kg IV/IM q 10-30 min PRN until symptoms dissipate.

Atropine for Organophosphate Poisoning - Dose (Infant <15 lbs)

Infant:

• 0.05 mg/kg IV, IM q 5-20 min PRN until symptoms dissipate.

Atropine - Special Considerations

Consider:

• Severe organophosphate exposures may require massive amounts of atropine beyond EMS capability.

• Half-life is 2.5 hours.

• Pregnancy class C; possibly unsafe for lactating mothers.

Adverse effects:

• ↓ secretions resulting in hot skin and dry mouth.

• Blurred vision or dilation of pupils resulting in photophobia.

• Tachycardia.

• Restlessness.

• Atropine may cause paradoxical bradycardia if dose is too low or drug is administered too slowly.

Adenosine - Class

Antiarrhythmic

Adenosine - Mechanism

Slows the conduction of electrical impulses at the AV node.

Adenosine - Indications/Contraindications

• Indications: stable reentry SVT.

• Contraindications: sick sinus syndrome, second- or third-degree heart block, poison-/drug-induced tachycardia, asthma, bronchospasm.

**Does not convert a fib, a flutter, or v tach.

Adenosine - Dose (Adult)

Adult:

• Loading dose: 6 mg rapid IV/IO immediately followed by 20 mL rapid saline flush.

**If first dose does not convert in 1-2 min, administer 2nd dose of 12 mg rapid IV/IO.

Adenosine - Dose (Pediatric)

Pediatric:

• Children >110 lbs (50kg): same as adult dosing.

**6 mg rapid IV/IO followed by rapid saline flush; if no response in 1-2 min, administer 2nd dose of 12 mg rapid IV/IO.

• Children <110 lbs (50 kg): loading dose 0.2 mg/kg IV/IO, (max dose: 6 mg) followed by rapid saline flush.

**May repeat at 0.2mg/kg (max 12 mg dose).

Adenosine - Special Considerations

Consider:

• Use with caution in patients with preexisting bronchospasm and those with hx of a fib.

• Older adults with no history of paroxysmal SVT should be carefully evaluated for dehydration and rapid sinus tachycardia requiring fluid volume replacement rather than simply tx with adenosine.

• Pregnancy class C.

Adverse effects:

• Sense of impending doom.

• Chest pressure.

• Throat tightness.

**Will have a brief period of asystole after administration.

Albuterol - Class

Bronchodilator/B-2 adrenergic agonist

Albuterol - Mechanism

Binds and stimulates B-2 receptors, resulting in relaxation of bronchial smooth muscle, and antagonizes the acetylcholine receptor, producing bronchodilation.

Albuterol - Indications/Contraindications

Inidcations:

• Second-line treatment (if bronchodilator ineffective) in COPD or severe acute asthma exacerbations during transport.

Contraindications:

• Angioedema.

Albuterol - Special Considerations

Consider:

• Caution in lactating patients.

• Caution in cardiovascular disorders and

Adverse effects:

• HYPERglycemia.

• HYPOkalemia.

• Palpitations.

• Sinus tach.

• Anixety.

• Tremors.

• Nausea/vomiting.

• Throat irritation.

• HYPERtension.

• Headache.

• Epistaxis.

• Paradoxical bronchospasm.

Albuterol - Dose (Adult)

Adult:

• MDI: 4-8 puffs q 1-4 hrs.

• Neb: 2.5-5 mg q 20 min max 3 doses.

**In pregnancy (MDI): 2 inhalations q 4 hrs. Acute exacerbation: 2-4 puffs every 20 min.

**In pregnancy (Neb): 2.5 mg (0.5 mL) by 0.5% neb solution. Place 0.5 mL of albuterol in 2.5 mL of normal saline.

Albuterol - Dose (Pediatric)

Pediatric:

• MDI 4+ years: 2 inhalations q 4-6 hrs.

• MDI <4 years: not recommended; administer by neb.

• Neb 12+ years: dose for continuous neb is 0.5 mg/kg per hr.

• Neb <12 years: 0.63-2.5 mg q 20 min for max 3 doses. Dose for continuous neb is 0.5 mg/kg per hour.

Albuterol & Ipratropium/Duoneb - Class

Combination bronchodilator

Duoneb - Mechanism

Binds and stimulates b2 receptors, resulting in relaxation of bronchial smooth muscle, and antagonizes the acetylcholine receptor, producing bronchodilation.

Duoneb - Indications/Contraindications

Indications:

• Second-line treatment (if bronchodilator is ineffective) in COPD or severe acute asthma exacerbations during medical transport.

Contraindications:

• Known sensitivity to Atropine, Albuterol.

Duoneb - Special Considerations

Consider:

• Caution in patients with asthma.

• Caution in patients with HYPERtension.

• Caution in patients with angina and arrhythmias.

• Pregnancy class C.

Adverse effects:

• Headache.

• Cough.

• Nausea.

• Arrhythmias

**SVT, a fib.

• Paradoxical acute bronchospasm.

Dunoeb - Dose (Adult)

Adult:

• MDI: 8 inhalations q 20 min for up to 3 hours.

• Neb: 3 mL q 20 min for 3 doses, then PRN.

Angiotensin-Converting Enzyme (ACE) Inhibitors: Captopril, Enalapril, Lisinopril, Ramipril

Class: ACE inhibitors.

ACE Inhibitors - Mechanism

Blocks the enzyme responsible for the production of angiotensin II, resulting in a decrease in BP.

ACE Inhibitors - Indications/Contraindications

Indications:

• CHF.

• HYPERtension.

• Post-MI.

Contraindications:

• Angioedema related to previous treatment with ACE inhibitor.

ACE Inhibitors - Special Considerations

Considerations:

• Pregnancy class D.

• Cautious with aortic stenosis.

• Cautious with bilateral renal artery disease.

• Cautious with hypertrophic obstructive cardiomyopathy.

• Cautious with pericardial tamponade.

• Cautious with elevated serum potassium (K+) levels.

• Cautious with acute kidney failure.

Adverse effects:

• Headache and dizziness.

• Fatigue.

• Depression.

• Chest pain.

• Hypotension.

• Palpitations.

• Cough.

• Dyspnea.

• Upper respiratory infection.

• Nausea/vomiting.

• Rash.

• Pruritus (itching).

• Angioedema.

• Renal failure.

ACE Inhibitors - Dose (Adult & Pediatric)

• Administered PO.

• Dosage is individualized.

Aspirin - Class

Antiplatelet, analgesic (non narcotic), antipyretic

Aspirin - Mechanism

Prevents the formation of thromboxane A2, which causes platelets to clump together (aggregate) and form plugs that cause obstruction or constriction of small coronary arteries.

Aspirin - Indications/Contraindications

Indications:

• Fever.

• Inflammation.

• Angina.

• AMI.

• Chest pain (pressure, squeezing, tightness) potentially cardiac in origin.