EMR Drug Monographs

What information is included in a Drug Monograph?

* **Classification**: What does the drug do?
* **Mechanism**: How does the drug work?
* **Indications**: Under what conditions can you, when working under license, consider administering this drug?
* **Contraindications**: What must you 'rule out' before administering this drug, in order to ensure that the potential benefits are not outweighed by any risks the drug poses to this patient.
* **Cautions**: What situations might require extra monitoring of the patient following administration, or to consult medical direction before administering this drug?
* **Administration**: What do you need to know about the physical administration of this drug, including *route* (how to administer and any special instructions) and *dosage* (how much to administer)?
* **Pharmacokinetics:** Including onset and duration of action, as well as any specific considerations for each drug (such as method of elimination).
* **Notes**: Special instructions for the provider.

What is a Classification in a Drug Monograph?

What the drug does, and it’s drug type.

What is a Mechanism in a Drug Monograph?

How does the drug work?

What is an Indication in a Drug Monograph?

Under what conditions can you, when working under license, consider administering this drug?

What is an Contraindication in a Drug Monograph?

What must you 'rule out' before administering this drug, in order to ensure that the potential benefits are not outweighed by any risks the drug poses to this patient.

What is an Caution in a Drug Monograph?

What situations might require extra monitoring of the patient following administration, or to consult medical direction before administering this drug?

What is an Administration in a Drug Monograph?

What do you need to know about the physical administration of this drug, including ***route*** (how to administer and any special instructions) and ***dosage*** (how much to administer)?

What is the Pharmocokinetics in a Drug Monograph?

Duration, peak and duration; as well as any specific considerations for each drug (such as method of elimination).

What are the Notes in a Drug Monograph?

Special instructions for the provider.

What are the 5 classifications of Aspirin?

* Platelet Inhibitor / Anti-Platelet (Stops Formation of Blood Clots)
* Anti-Pyretic (Reduces Fever)
* Analgesic (Pain Relief)
* Anti-Inflammatory (Reduces Inflammation)
* Antithrombotic

What are the indications of Aspirin?

Chest pain or signs and symptoms consistent with cardiac ischemia or myocardial infarction.

What is the mechanism of ASA?

ASA inhibits the formation of thromboxane A2, which is a potent platelet aggregator and vasoconstrictor.  The platelet effects are irreversible, and last for the life of the platelet (7-10 days).

What are the Contraindications of ASA?

* Known hypersensitivity or allergy to ASA
* Patients who have experienced bronchospasm or other respiratory reaction (asthma attack) precipitated by ASA or other NSAID drugs.
* Active or recent bleeding of any kind, including head injury, peptic ulcer disease, or GI bleeding.
* Pediatric patients with signs and symptoms consistent with viral illnesses.

What are the Cautions of ASA?

* Possibility of pregnancy
* Currently taking other anti-coagulants (Clini-call Indicated)
* Recent Surgeries

What is the administration of ASA?

* Route: Oral (PO), instructing the patient to chew the tablets before swallowing them.
* Dose: 2 X 81 mg chewable ASA (162 mg)

What are the Pharmacokinetics of ASA?

Oral:

* Onset: 5-30 minutes
* Peak: 1-2 hours
* Duration: 4-6 hours

What are the side effects of ASA?

* The most common adverse effects involve irritation of the gastrointestinal tract
* Antiplatelet effects may result in minor bruising or bleeding

What is the Overdose of ASA? Dosage and symptoms?

ASA can be toxic at doses higher than 150 mg/kg.  Early symptoms include nausea, vomiting, diaphoresis, and tinnitus.  Hyperventilation can occur. 

What are precautions of ASA?

* children, teenagers, or young adults with chickenpox, influenza, or other flu-like illness due to the risk of the development of Reye syndrome. 
* Alcohol use can increase the risk of gastrointestinal bleeding.

What makes ASA special for first responders?

ASA is the only medication that we administer that does NOT require us to take a full set of vital signs first. ASA should be administered after RBS, oxygen administration and positioning have been taken care of, and before initiating transportation of this patient. Indications, contraindications, and 6 rights of medications are still required before administration of ASA

Can a patient take ASA if they have already taken a dose **prior to the event?**

Yes, , if the same patient took 1 X 81 mg ASA several hours ago because that is part of their daily medication routine, you should administer the full dose of ASA to that patient.

Can a patient take ASA if they have already taken a dose **for the event?**

If a patient experiencing cardiosuggestive chest pain took 1 X 81 mg ASA prior to your arrival on instructions from the dispatcher, you may reduce your administered medication to 1 X 81 mg

What is the classification of Glucose gel?

Glucose gel; mobilizes glucose stores.

What are the indications of Glucose gel?

Known or suspected hypoglycemia in a conscious patient where there is no risk of aspiration or choking.

What are the Contraindications of Glucose gel?

None.

What is the Administration of Glucose gel?

15g glucose gel, taken orally.

How often can Glucose gel be administered?

Every 5 minutes, no limit.

What is the maximum dose of Glucose gel for pediatric cases?

30g glucose max.

What is the Mechanism of Oral Glucose?

Increase of blood glucose levels via buccal absorption when administered orally.

What are the Adverse offects of Glucose gel?

None.

What are the Cautions of Oral Glucose?

* If altered LOC: risk of choking or aspiration. Gel can be administered via gauze swab with gel placed between gums.

What is the classification of **Methoxyflurane?**

Inhaled anesthetic

What are the indications of **Methoxyflurane**?

Moderate to severe pain associated with trauma or interventional medical procedures

What are the Contraindications of **Methoxyflurane**?

* Pediatrics < 18 years of age
* Inadequate patient understanding or lack of cooperation
* Decreased level of consciousness
* History of clinically significant renal impairment
* History of liver dysfunction following previous exposure to halogenated anesthetics
* Current use of tetracycline antibiotics
* Personal or familial history of malignant hyperthermia
* Muscular dystrophy
* Pregnancy, intended pregnancy, or current breast-feeding

What is the administration of Methoxyflurane?

3 mL via inhaler, max dose of 6mL.

During administration of Methoxyflurane, what must occur?

Patients must self-administer as needed under direct paramedic supervision

What is the time between first and last dose of Methoxyflurane?

20 minutes.

What is the Mechanism of Methoxyflurane?

The specific mechanism of action of halogenated anesthetics is not well understood.  Methoxyflurane is the only volatile anesthetic agent with significant analgesic properties at low, sub-anesthetic doses. 

What are the Pharmocokinetics of Methoxyflurane?

Inhaled:

* Onset: 1-3 minutes / 8-10 breaths
* Duration: approximately 25 minutes per 3 mL / 3-5 minutes once discontinued

What are the Adverse Effects of Methoxyflurane?

* Altered level of consciousness (mainly drowsiness)
* Cough
* Hypotension and bradycardia (rare)

What is the Overdose of Methoxyflurane?

Although unlikely in the out-of-hospital setting, patients should not receive more than 6 mL in any 48 hour period and no more than 15 mL over 1 week. 

What are Precautions of Methoxyflurane?

* Limit administration of methoxyflurane inside ambulances to a single 3 mL dose.
* Ensure adequate ventilation
* Ensure that patients exhale through the carbon filter
* No single paramedic should administer more than 3 doses per shift

What is the maximum amount of Methoxyflurane a paramedic can administer during a shift?

3 doses.

What is the Classification of Naloxone?

Narcotic antagonist

What are the Indications of Naloxone?

Reversal of respiratory depression caused by suspected narcotic intoxication

What are the Contraindications of Naloxone?

* Allergy or known hypersensitivity to naloxone
* Neonates (neonatal patients)

What is the Administration time of Naloxone for an Adult?

IM administration every 3 minutes as required.

What is the maximum doseage of Naloxone?

4 doses.

What is the dosage amounts for Naloxone?

1. 0.4 mg IM
2. 0.4 mg IM
3. 0.8 mg IM
4. 2.0 mg IM
5. CliniCall needed for further doses.

What is the dosage for Pediactric Naloxone?

0\.1 mg/kg. with a max of 2mg per dose. Repeat every 3 minutes; maximum 4 doses.

What is the Mechanism of Nalaxone?

Competitively antagonizes opioids bound to receptors in the central nervous system. 

What are the Pharmocokinetics of Nalaxone?

* Onset: 1-3 minutes (IM/IV)
* Peak: 5-15 minutes (SC/IM/IV)
* Duration: 30-45 minutes (IM/IV)

What are the Adverse Effects of Nalaxone?

* Sudden reversal of narcotic intoxication may provoke combativeness
* May produce withdrawal signs and symptoms
* Hypotension or hypertension
* Nausea and vomiting, sweating, tachycardia

What is the Classification of Nitroglycerin?

Antianginal, and Vasodialator

What are the Indications of Nitroglycerin?

Relief from chest pain suggestive of acute coronary syndrome

What are the Contraindications of Nitroglycerin?

* Known allergy or hypersensitivity to nitroglycerin
* Use of Viagra (sildenafil) or Levitra (vardenafil) within the previous 24 hours
* Use of Cialis (tadalafil) within the previous 48 hours
* Severe anemia
* Restrictive pericarditis or pericardial tamponade
* Documented right sided acute myocardial infarction
* Hypotension or uncorrected hypovolemia
* Systolic blood pressure < 110 mmHg - **for EMRs and PCPs**
* Heart Rate

What is the systolic blood pressure requirement for Nitroglycerin?

Less than 110 mmHg

What is the Heart Rate requirements for Nitroglycerin?

HR less than 50 bpm

HR more than 150 bpm

What is the administration of Nitroglycerin?

0\.4 mg Sublingual (SL) every 3-5 mins.

What must be checked before administering each dose of Nitroglycerin?

* Verify systolic blood pressure prior to administering each dose; systolic blood pressure must be ≥ 110 mmHg and heart rate must be between 50 and 150 beats/minute

What is the mechanism of Nitroglycerin?

Relaxes smooth muscle in vasculature.  Nitroglycerin works primarily as a venodilator, but can also produce coronary and systemic arterial vasodilation, decreasing preload and lowering myocardial oxygen demand.

What are the Pharmocokinetics of Nitroglycerin?

* Onset: 30 seconds - 2 minutes (SL); 30 seconds - 1 minute (IV)
* Peak: 5-10 minutes (SL); 3-5 minutes (IV)
* Duration: 15-30 minutes (SL/IV)

What are the Adverse Effects of Nitroglycerin?

* Hypotension
* Headache
* Nausea

What are the Precautions of Nitroglycerin?

* Do not administer to patients with a blood pressure < 110 mmHg or who are exhibiting signs of significant hypoperfusion.
* Use with caution in patients with hepatic or renal insufficiency.
* Exercise caution (and rule out right-sided involvement) in patients with documented inferior ischemia on 12-lead ECG. 
* Exercise caution in patients with clinically significant aortic stenosis.

What are possible drug interactions with Nitroglycerin?

Antihypertensive agents may act synergistically with nitroglycerin

What is the classification of Nitrous Oxide?

Inhaled anesthetic

What are the indications of Nitrous Oxide?

Relief from moderate to severe pain caused by extremity injuries, burns, or other injuries or clinical conditions **not including inhalation injuries**

What are Contraindications of Nitrous Oxide?

Consider the use of the mnemonic **CDCPAIN**:

* Ability to **C**omply
* **D**ecompression sickness
* Altered level of **C**onsciousness
* **P**neumothorax
* **A**ir embolism
* **I**nhalation injury
* **N**itroglycerin use within five minutes

What is the Acronym CDCPAIN used for?

The contraindications of Nitrous Oxide

What is the administration of Nitrous Oxide for Adults?

Self-administered to effect.

What is the administration of Nitrous Oxide for pediatric patients?

Self-administered to effect, using weight based dosing.

What is the mechanism of Nitrous Oxide?

As used in BCEHS, nitrous oxide is supplied as a 50/50 mixture with oxygen and is known as Entonox.  Nitrous oxide is a sweet-smelling, colourless gas that is a potent analgesic and a weak anesthetic whose specific mechanism of action is not well understood.  It is believed that endorphin release is likely involved in the analgesic effects of nitrous oxide. 

What are the Pharmocokinetics of Nitrous Oxide?

Inhaled:

* Onset: rapid
* Peak: immediate
* Duration: requires continuous use

What are the adverse effects of Nitrous Oxide?

* Lightheadedness, dizziness, numbness in lips, sedation, drowsiness, disorientation
* Nausea and/or vomiting

Why can’t Nitrous Oxide be used with Decompression sickness, embolisms or pneumothorax?

The gas expands into internal spaces, and could further increase damage.

What is needed if Nitrous Oxide is used in an enclosed space?

Adequate ventilation, such as exhaust fans and open windows.

Can you use Nitrous Oxide on a plane?

No, to the risk of flight crew exposure. 

What patients cause cautions with Nitrous Oxide?

* Nitrous oxide must be used with caution in patients who are hypotensive or in shock, have ingested or are suffering from the effects of depressant drugs, have a history of chronic obstructive pulmonary disease, or have suffered facial injuries. 

What are the drug interactions of Nitrous Oxide?

The depressant effects of nitrous oxide can be potentiated by the presence of other CNS depressants such as alcohol, sedatives, antihistamines, or psychotropic medications. 

What is the Generic name for Nitrous Oxide?

Entonox

What is the Brand name for Methoxyflurane?

Penthrox

What are the 6 Rights of Medication?

Right Patient

Right Medication

Right Dose

Right Time

Right Route

Right Documentation

What are visual cues that a medication is expired?

* Cloudy
* Beyond expiration date
* Broken seal
* Discoloured

If medication is drawn into a syringe, what must be labeled?

The drug name, and concentration.

What must be labeled on an IV bag of fluids?

* Name of medication
* Final concentration

What drug must be seperately stored and labeled?

Epinephrine

What are the 6 medications a licensed EMR has access to?

* Acetylsalicylic Acid
* Glucose 40% Oral Gel
* Methoxyflurane
* Naloxone
* Nitroglycerin
* Nitrous Oxide

What is Entonox?

**Entonox** is an inhaled anesthetic that offers excellent pain relief to patients experiencing pain related to musculoskeletal injury, cardiac events, pregnancy, and more

What compounds are Entonox made of?

Entonox is a 50/50 mix of oxygen and nitrous oxide, and it is the nitrous oxide that not only provides the therapeutic effects, but is also responsible for most of the extensive list of Entonox's contraindications and cautions.

What similarities do Nitrous Oxide and Nitrogen share?

Nitrous oxide - like nitrogen - is capable of moving through most membranes in the human body, which allows it to gather and pool in gas-filled spaces, increasing their volume.

What is the classification of Entonox?

Inhaled Anesthetic

What is the mechanism of Entonox?

* Potent analgesic and a weak anesthetic

What are the indications of Entonox?

Relief of moderate to severe pain, including – but not limited to – cardiac pain where nitro is ineffective or contraindicated, isolated extremity injuries, pain from burns, and pain associated with childbirth.

What are the contraindications of Entonox?

***Consider the acronym PAINDIE***

\
* Pneumothorax (suspected by MOI or patient presentation, or confirmed by auscultation)
* Air embolism
* Inhalation injury
* Nitroglycerin in last 5 minutes
* Decompression sickness
* Inability to comply
* Enclosed space (ensure ventilation, or exhaust is turned on in ambulance)

What memory device is used for the contraindications of Entonox?

***PAINDIE***

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* Pneumothorax (suspected by MOI or patient presentation, or confirmed by auscultation)
* Air embolism
* Inhalation injury
* Nitroglycerin in last 5 minutes
* Decompression sickness
* Inability to comply
* Enclosed space (ensure ventilation, or exhaust is turned on in ambulance)

What acronym is used for the cautions of Entonox?

***Consider the acronym SADFC***

\
* Signs of shock (Monitor for decreasing LOC and signs of hypoxemia)
* Abdominal distension (Query cause)
* Depressant drug use (Monitor for decreasing LOC)
* Facial injuries (Ensure patient can use bite stick without causing further pain or damage)
* COPD (Patient might not have sufficient inspiratory volume to effectively self-administer Entonox)

What are the cautions of Entonox?

***SADFC***

\
* Signs of shock (Monitor for decreasing LOC and signs of hypoxemia)
* Abdominal distension (Query cause)
* Depressant drug use (Monitor for decreasing LOC)
* Facial injuries (Ensure patient can use bite stick without causing further pain or damage)
* COPD (Patient might not have sufficient inspiratory volume to effectively self-administer Entonox)

\
* Also, monitor for adverse effects including light-headedness, nausea, sedation, numbness, drowsiness, and disorientation.  If found, immediately discontinue Entonox and administer high flow oxygen via non-rebreather mask.

What is the Classification of Epinephrine

Catecholamine

Sympathomimetic

What is the indication of Epinepherine

Anaphylaxis

What is the adult dose for Epinephrine

0.5 mg IM every 5 minutes; may repeat up to 3 times