FMR/EMR Drug Formularys

Need to know!

Trade term for Acetylsalicylic acid (ASA) is:

Aspirin®

Can PCP’s administer Acetylsalicylic acid (ASA)?

Yes: if its mild pain or fever.

Classification of Acetylsalicylic acid (ASA):

Platelet aggregation inhibitor, analgesic, anti-inflammatory, antipyretic

Mechanism of Acetylsalicylic acid (ASA):

Once digested, ASA causes changes to the surfaces of platelets, decreasing its effectiveness in clot formation.

Blocks the formation of thromboxane A2, causes platelets to aggregate and arteries to constrict in the clotting cascade. This change lasts as long as platelet is in circulation (5-7) days.

• Onset in 5-30 mins

• Peak effects within 15-120 mins

• Duration of 1-4 hours

• ½ life of 15-20 mins

Indications of Acetylsalicylic acid (ASA):

Acute Coronary Syndrome (ACS)

Cardiac Chest Pain

Mild Pain (PCP Only)

Fever (PCP Only)

Contradictions of Acetylsalicylic acid (ASA):

Hypersensitivity to salicylates or NSAIDs

Active bleeding, internal or external

Blood clotting disorders

Precautions for Acetylsalicylic acid (ASA):

Can increase chances of Reye’s syndrome in febrile pediatrics

Use caution with patients who report allergies to NSAID medications

Use caution to patients with active ulcers

Bleeding disorders

May cause bronchoconstriction to asthmatics

Dose higher than recommended can interfere with possible benefits

Side effects of Acetylsalicylic acid (ASA):

Nausea/Vomiting

GI bleeding

Heartburn

Wheezing

Tinnitus

Hepatoxicity with large doses (greater than 1.8 - 3.2 grams daily)

Doses for Acetylsalicylic acid (ASA):

Chest Pain

Adults: 160 - 325 mg non-enteric tablet chewed

Pediatric: NOT recommended pre-hospital

Supplied for Acetylsalicylic acid (ASA):

80 mg, 81 mg, 325 mg, 650 mg tablets

Extra Notes for Acetylsalicylic acid (ASA):

Should be given ASAP to patients with ACS indications

Trade term for epinephrine 1:1,000

Adrenalin

Can PCP’s administer epinephrine?:

Only ALS (ACPs) can administer epinephrine. PCPs can assist

Classification of epinephrine:

Sympathomimetic agonist, hormone

Mechanism of epinephrine:

work by binding a and b adrenergic receptors, causing a stimulant response.

Most prominent actions are on the beta receptors of the heart, vascular and other smooth muscle

Epinephrine relaxes the smooth muscles of the bronchi and is a physiologic antagonist of histamine, therefore reversing histamine’s effects, 20% alpha and 80% beta

Rapid IV injection produces a rapid rise in blood pressure, mainly systolic, by direct stimulation of the cardiac muscle, which increases the ventricular contraction. (ALS) only

Increased systemic vascular resistance:

- Chronotropic effects

- Inotropic effects

- Dromotropic effects

• Onset in 3 - 10 min SQ/IM

• Peak effects within 20 min SQ/IM

• Duration of 20 - 30 min SQ/IM

• ½ life of 3 - 5 mins, depending on the rate of vasoconstriction, which could delay the absorption rate

Indications of epinephrine:

Severe anaphylaxis

Status asthmatics (ALS)

Severe reactive airway disease (ALS)

Contradictions of epinephrine:

None in an emergency situation

Hypovolemic shock

Precautions of epinephrine:

Epiglottitis

Should be protected from light

Side effects for epinephrine:

Palpitations

Chest pain or discomfort

Anxiety

Hypertension

Dyspnea

Tremors

Headache

Dizziness

Nausea/Vomiting

Increased myocardial oxygen demand

Dose of epinephrine:

Anaphylaxis:

Adult: patient assist: 0.3 - 0.5 mg IM/SQ q 10 - 15 min

Pediatrics patient assist: Epi Jr - 0.15 mg

Supplied for epinephrine:

1 mg in 1 mL ampule

Autoinjector EpiPen 0.3 mg, EpiPen JR. - 0.15mg

30 mg in 30 ml multi-dose

Notes for epinephrine

Monitor vitals continually

Trade term for ipratropium bromide:

Atrovent^®

Can PCP’s administer ipratropium bromide:

No only ALS can administer ipratropium bromide, PCP can assist

Classification of ipratropium bromide:

Bronchodilator, anticholinergic

Mechanism of ipratropium bromide:

Ipratropium is an anticholinergic that acts by blocking acetylcholine receptors, thus inhibiting parasympathetic stimulation.

This causes bronchodilation and dries respiratory tract secretions.

• Onset varies -- usually greater than 5 minutes

• Peak effects within 1.5 - 2 hours

• Duration 4 - 6 hours

• ½ life of 1.5 - 2 hours

Indications of ipratropium bromide:

Bronchospasm associated with chronic bronchitis and emphysema

Bronchospasm associated with asthma

COPD exacerbation

Contradictions of ipratropium bromide:

Hypersensitivity to atropine, soybean protein or peanuts

Closed angle glaucoma

Bladder neck obstruction

Prostatic hypertrophy

Hypersensitivity to the drug

Precaution of ipratropium bromide:

Avoid getting in eyes of patients especially those with glaucoma as it may lead to an increase in intraocular pressure by as much as 23% through muscles in your eyes by relaxing.

Side effects of ipratropium bromide:

Palpitations

Anxiety

Dizziness

Headache

Nausea/Vomiting

Coughing

Dry mouth

Urinary retention

Dose for ipratropium bromide:

Adult (patient assist): 4 - 8 puffs (80-160 mcg) with spacer q 5 - 10 min to a max of 30 puffs

Supply for ipratropium bromide:

250 mcg in 1 mL

20 mcg per metered dose in MDI

Note for ipratropium bromide:

Always administer with Ventolin because the onset of effect Atrovent is greater than 5 mins

Trade term for naloxone:

Narcan®

Can PCP administer naloxone:

PCP can administer naloxene

Classification of naloxone:

Opioid antagonist

Mechanism of naloxone:

Naloxone is a competitive narcotic antagonist

it competes for narcotic receptors in the brain, and it can displace narcotic molecules from the receptors.

It can be used to treat narcotics and synthetic narcotic agents.

• Onset in less than 2 minutes IV/IO, 2 - 10 mins IM/ETT (ALS ONLY)

• Peak effects within less than 2 minutes IV/IO, 2 - 10 mins IM/ETT (ALS)

• Duration of 20 - 120 mins

• ½ life of 60 - 90 minutes

Indications of naloxone:

Complete or partial reversal of CNS and respiratory depression induced by opioids.

Contradictions to naloxone:

Hypersensitivity (naloxone)

Precautions for naloxone:

Use caution in narcotic-dependent patients who may experience withdrawal syndrome (including neonates for narcotic-dependent mothers)

Side effects of naloxone:

Narcotic withdrawal syndrome

Nausea/Vomiting

Cardiac dysrhythmias

Hypotension

Hypertension

Dose for naloxone:

Titrate to effect:

Adult: 0.4 mg IM total max dose of 2 mg

1.0 mg per nare intranasal (IN) (repeat q 3- 5 minutes prn)

Pediatric: 0.1 mg/kg given IM max of 2 mg

Supplied of naloxone:

2 mg in 2 mL vials

Notes for naloxone:

Higher doses of 10 - 20 mg may be required for overdoses of synthetic narcotics.

Narcan has no real effect when given if narcotics are not present.

Should be used with caution in the case of polypharmacy overdoses, though respiratory depression usually the largest issue for administration.

Trade term for nitrous oxide:

Entonox®, Nitronox®

Can PCP administer nitrous oxide:

PCP can administer nitrous oxide

Classification of nitrous oxide:

Gaseous analgesic, anesthetic gas

Mechanism of nitrous oxide:

Nitrous Oxide is a CNS depressant with a potent analgesic and weak anesthetic properties.

Effect of Entonox take place in the CNS and are related to the release of endogenous neurotransmitters such as opioid peptides and serotonin and is responsible for the activation of certain opioid receptors

Entonox is said to work with the gray area of the midbrain where the opioid peptides are released.

Entonox is a mixture of 50% oxygen and 50% nitrous oxide

• Onset in 2 - 5 minutes

• Peak effects within 2 - 5 minutes

• Duration of 2 - 5 minutes

• ½ life is unknown

Indications of nitrous oxide:

Musculoskeletal pain (particularly fractures)

Back Pain

Ischemic chest pain

Active labour - child birth

Burns

Contradictions of nitrous oxide:

Patient is unable to self-administer

Altered LOC

Head Injury

Intoxicated person

Patient needs greater than 50% oxygen

Undiagnosed abdominal pain

Pneumothorax

COPD

Bowel obstruction

Nitrogen narcosis

Decompression sickness

Severe facial injury

Precautions of nitrous oxide:

If the patient has been scuba diving in the last 24 hours - could cause decompression sickness

Nitrous oxide may potentiate other CNS depressants such as narcotics, alcohol, etc.

Side effects of nitrous oxide:

Dizziness

Altered LOC

Nausea/Vomiting

Hallucinations

Decreased sexual inhibition

Dose for nitrous oxide:

Patients can breathe gas until relief is felt

Make sure to keep mask on with a good seal to get full effects

Supply for nitrous oxide:

Blue and white cylinder mask with demand valve, mask with a single pin index system

Notes for nitrous oxide:

Invert bottle at least three times to ensure gases are mixed.

Keep in warm area.

Liquids may not vaporize in cold environments.

make note of the psi and time at the beginning and end of use.

Document amount of gas used.

Use only in well-ventilated areas.

Trade term for oral glucose:

Oral glucose

Can PCP administer oral glucose:

Yes, PCP can administer oral glucose.

Classification of oral glucose:

Antihyperglycemic, carbohydrate.

Mechanism of oral glucose:

Oral glucose is a simple sugar used to rapidly increase blood sugar levels within the body.

It is in a state that the body does not need to alter for use, which increases the rate of absorption.

• Onset for 1 minute PO

• Peak effects within 3 minutes

• Duration is brief

• ½ life is unknown

Indications of oral glucose:

Hypoglycemia

Contradictions of oral glucose:

No active gag reflex

Patient is unable to maintain their own airway

Hyperglycemia

Precautions for oral glucose:

None.

Side Effects of oral glucose:

Nausea/Vomiting

Dizziness

Dose for oral glucose:

24 - 31 grams

Supply for oral glucose:

24 g dextrose in one tube

6 g per tablet

31 g per bottle liquid

Notes for oral glucose:

Patient must be able to self-administer the drug

Give patient more complex carbohydrates as glucose is quickly used up

Given orally to increase sugar to greater than 4 mmol/l

Must be swallowed to be effective

Trade term oxygen:

Oxygen

Can PCP administer oxygen

Yes, PCP can administer Oxygen

Classfication of oxygen:

Gas

Mechanism of oxygen:

Oxygen enters the body through the respiratory system and is transported to the cells by hemoglobin found in the red blood cells.

Oxygen is required for the efficient breakdown of glucose into a usable energy form, adenosine triphosphate (ATP)

The administration of enriched oxygen increases the oxygen concentration in the alveoli, which subsequently increases the oxygen saturation of available hemoglobin and therefore may assist in reducing the size of infracted tissue during acute myocardial infraction in patients who are hypoxemic on room air.

• Onset is immediate

• Peak effect within less than 1 minute

• Duration of less than 2 minute

• ½ life is not applicable

Indications of oxygen:

Hypoxia

Ischemic chest pain with an SPO2 of less than 95%

Respiratory insufficiency

Confirmed or suspected CO poisoning and other causes of decreased tissue oxygenation.

Any critical patient

Contradictions of oxygen:

Oxygen should never be withheld to a critically ill or injured patient.

Precautions of oxygen:

Oxygen should be used cautiously in patients with COPD

In these patients, reparations are often regulated by the level of oxygen in the blood (hypoxic drive) and not CO2 levels

In some cases, COPD patients may suffer severe respiratory depression if high concentrations of oxygen are delivered for extended periods of time greater than 18 hours.

Side effects of oxygen:

prolonged non-humidified high-flow oxygen administration may cause drying of the mucous membranes.

Dose for oxygen:

Nasal cannula: 1 - 6 Lpm = 24 - 44%

Partial non-rebreathing mask 6 - 10 Lpm = 35 - 60%

Simple face mask: 8 - 10 Lpm = 40 - 60%

Non-rebreathing mask: 10 - 15 Lpm = 80 - 95%

Bag valve mask: 12 - 20 Lpm = 90 - 100%

Supply for oxygen:

Various sizes commonly utilized in pre-hospital cylinders:

D tank: 400 L

E tank: 660 L

M tank: 3000 L

H tank: 7080 L

Notes for oxygen:

Oxygen supports combustion vigorously, so not should be used in explosive environments.

Trade term for salbutamol sulfate:

Ventolin® (canada), Albuterol (U.S)

Can PCP administer salbutamol sulfate:

No, only ALS (ACP)

Classification of salbutamol sulfate:

Bronchodilator, sympathomimetic

Mechanism of salbutamol sulfate:

Salbutamol sulfate is a sympathomimetic which is selective for beta 2-adrenergic receptors.

It relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating adrenergic receptors of the sympathetic nervous system.

• Onset in 5 - 8 min

• Peak effects within 1 - 1.5 hours

• Duration of 3 - 6 hours

• ½ life of less than 3 hours

Indications for salbutamol sulfate:

Bronchospasm

Anaphylaxis

Hyperkalemia (ALS/ACP only)

Contradictions of salbutamol sulfate:

Hypersensitivity

Precautions for salbutamol sulfate:

Cardiac arrhythmias associated with tachycardia

Caution in patients with cardiac history

May cause hypokalemia

May cause hyperglycemia

Watch for paradoxical bronchospasm (STOP IMMEDIATELY)

Side effects of salbutamol sulfate:

Headache

Dizziness

Nausea/Vomiting

Tremors

Arrythmias

Palpitations

Tachycardia

Muscle cramps

Dose for salbutamol sulfate:

Adult (patient assist): 5 - 10 puffs (500 - 1000 mcg) q 5 - 10 min no maximum

Pediatric (patient assist): less than 20 kg: 2 - 4 puffs with MDI and spacer

greater than 20 kg: 4 - 8 puffs with MDI and spacer

Supply for salbutamol sulfate:

Solution: 2.5 mg/2.5 mL NS

Metered dose inhaler (MDI): 100 mcg per dose

Notes for salbutamol sulfate:

Watch for tachycardia with administration

Decreased effect in patients on beta blockers

Salbutamol may precipitate angina and dysrhythmias