Paramedic Drug Card Review

Aspirin [ASA]

• Class: NSAID

• Mechanism of Action: Non-steroidal anti-inflammatory drug (NSAID) that decreases inflammation and decreases platelet aggregation.

• Indications: Acute Coronary Syndrome (ACS)/Chest pain.

• Dose: $324 \text{ mg}$, oral. This dose completes the administration of $4$ baby aspirin.

• Special Considerations:

  • Patient must have an intact airway.

  • Watch for gastrointestinal (GI) symptoms.

• Contraindications: Hypersensitivity/allergy, inability to chew.

• Adverse Reactions: GI symptoms.

Nitroglycerin [Nitrostat]

• Class: Anti-Anginal Agent, Vasodilator.

• Mechanism of Action: Vasodilator; relaxes smooth muscle, decreases preload, and decreases oxygen demand on the heart.

• Indications: Chest pain/ACS/Congestive Heart Failure (CHF).

• Dose:

  • Sublingual (SL): $0.4 \text{ mg}$ every $3-5$ minutes.

  • Intravenous (IV) drip: $10-50 \text{ mcg/min}$.

• Special Considerations:

  • Wear gloves when administering.

  • Watch for hypotension/syncope.

  • Have $2$ IVs placed for IV drip dosing.

• Contraindications: Hypersensitivity/allergy, use of Erectile Dysfunction (ED) medications within the last $48$ hours, hypotension, right ventricular infarction.

• Adverse Reactions: Dizziness, headache, hypotension.

Epinephrine [Adrenalin]

• Class: Sympathetic Agonist.

• Mechanism of Action: Naturally occurring catecholamine that directly affects alpha-1, beta-1, and beta-2 receptors. Effects include vasoconstriction, increased heart rate (HR)/blood pressure (BP), increased contractility, and bronchodilation.

• Indications:

  • Cardiac arrest.

  • Asthma, anaphylaxis, Chronic Obstructive Pulmonary Disease (COPD).

  • Stridor.

• Dose:

  • Cardiac Arrest ($1:10,000$ dilution): $1 \text{ mg}$ IV/IO every $3-5$ minutes.

  • Asthma/Anaphylaxis/COPD ($1:1,000$ dilution): $0.3 \text{ mg}$ Intramuscular (IM) (per Advanced Airway Course (AAC) guidelines).

  • Stridor: $5 \text{ mg}$ via nebulizer.

  • Pediatric: $0.01 \text{ mg/kg}$.

• Special Considerations:

  • Caution in elderly patients or those with a history of heart disease.

  • Connect to cardiac monitoring.

• Contraindications: Hypersensitivity/allergy, tachycardia, or hypertension.

• Adverse Reactions: Nausea/Vomiting (N/V), palpitations, headaches, nervousness.

Norepinephrine [Levophed]

• Class: Sympathetic Agonist.

• Mechanism of Action: Naturally occurring catecholamine that acts on both alpha and beta receptors as an agonist. It is a potent vasoconstrictor, increasing blood pressure. Alpha effects tend to be more profound.

• Indications: Shock (to maintain blood pressure/tissue perfusion), severe hypotension, and post-resuscitation.

• Dose: $1-30 \text{ mcg/min}$ via IV pump.

• Special Considerations:

  • One of the strongest vasopressors available.

  • Monitor blood pressure closely.

• Contraindications: Hypersensitivity/allergy, tachycardia.

• Adverse Reactions: Palpitations, anxiety, tachycardia, tremors.

Dopamine [Intropin]

• Class: Sympathetic Agonist.

• Mechanism of Action: Sympathetic agonist that acts on alpha-1, beta-1, and D1 + D2 (dopamine) receptors, with effects depending on the dose.

  • Alpha-1: Vasoconstriction.

  • Beta-1: Increased HR/contractility.

  • D1+D2: Increased blood flow to kidneys/intestines.

• Indications: Hypotension (severe), cardiogenic shock, bradycardia (if atropine is ineffective).

• Dose (IV Drips - Titrate to Effect):

  • D1+D2 effects: $2-5 \text{ mcg/kg/min}$.

  • Beta-1 effects: $5-10 \text{ mcg/kg/min}$.

  • Alpha-1 effects: $10-20 \text{ mcg/kg/min}$.

  • Pediatric: $2-20 \text{ mcg/kg/min}$.

• Special Considerations:

  • Ensure IV is patent and secured.

  • Fix hypovolemia before using dopamine.

• Contraindications: Adrenal tumor, hypovolemic shock.

• Adverse Reactions: N/V, palpitations, headaches, nervousness.

Amiodarone [Cordarone]

• Class: Anti-Dysrhythmic.

• Mechanism of Action: Prolongs the action potential and refractory period, slows electrical conduction rate. It acts as a sodium, calcium, and potassium channel blocker.

• Indications: Ventricular Tachycardia (V-tach), Ventricular Fibrillation (V-fib), wide complex rapid tachycardia.

• Dose:

  • Cardiac Arrest: $150-300 \text{ mg}$ IV/IO.

  • Stable: $150 \text{ mg}$ over $10$ minutes via IV/IO drip.

• Special Considerations:

  • Monitor vitals and ECG before and after administering with continuous cardiac monitoring.

  • This medication has a half-life of $45$ days.

• Contraindications: Hypersensitivity/allergy, bradycardia.

• Adverse Reactions: Dizziness, drowsiness.

Lidocaine [Xylocaine]

• Class: Anti-Dysrhythmic.

• Mechanism of Action: Sodium channel blocker that decreases ventricular irritability and reduces the speed of impulses.

• Indications: V-tach/V-fib.

• Dose: $1 \text{ mg/kg}$ IV/IO.

• Special Considerations:

  • Cardiac monitoring required.

  • Consider $12$-lead ECG after administering.

  • Use a different IV site if given after amiodarone.

• Contraindications: Hypersensitivity/allergy, bradycardia.

• Adverse Reactions: Anxiety, N/V, drowsiness.

Atropine

• Class: Anti-Cholinergic Agent, Parasympatholytic.

• Mechanism of Action: Potent parasympatholytic that inhibits the actions of acetylcholine. Directly, this increases heart rate and AV conduction, decreases GI secretions, and dilates pupils.

• Indications: Organophosphate poisoning, symptomatic bradycardia.

• Dose:

  • Bradycardia: $0.5-1 \text{ mg}$ IV/IO every $3-5$ minutes as needed.

  • Organophosphate Overdose: Start with $2 \text{ mg}$, then $4 \text{ mg}$, then $8 \text{ mg}$, can be given every $5$ minutes until the desired effect is achieved.

• Special Considerations: Your Rapid Sequence Intubation (RSI) protocol may include atropine prior to intubation to decrease the chance of reflex bradycardia.

• Contraindications: Hypersensitivity/allergy, tachycardia.

• Adverse Reactions: Tachycardia, flushed/hot skin.

Oxygen

• Class: Medical Gases.

• Mechanism of Action: Corrects hypoxia, oxygenates blood, reduces cardiac workload.

• Indications: Low oxygen levels (low SPO2), carbon monoxide poisoning, used in conjunction with airway devices to deliver oxygen.

• Dose: $1-15 \text{ lpm}$ depending on the O2 device/airway setup.

• Special Considerations:

  • Remember not to overload the patient; the goal is to achieve SPO2 of $94-99\%$ or the patient's normal level.

  • For COPD patients, titrate to their normal SPO2.

  • Drying of mucus membranes can occur.

• Contraindications: None if SPO2 is lower than $94\%$.

• Adverse Reactions: Drying of mucus membranes.

Adenosine [Adenocord]

• Class: Antidysrhythmic.

• Mechanism of Action: Derived from the breakdown of ATP; adenosine slows AV conduction, decreases HR, and acts as a "chemical cardioversion."

• Indications: Supraventricular Tachycardia (SVT)/Rapid tachycardias.

• Dose:

  • Adult: $6 \text{ mg}$, rapid IV/IO push. Can be followed up by $12 \text{ mg}$.

  • Pediatric: $0.1 \text{ mg/kg}$.

• Special Considerations:

  • While giving the drug, press the print button on the monitor to get a printout of the effect on the ECG.

  • Do your best to get IV placement in the AC (antecubital) or higher with a larger bore catheter.

• Contraindications: Bradycardia, hypersensitivity/allergy.

• Adverse Reactions: Palpitations, near-syncope, dizziness, lightheadedness, chest pain, flushing, anxiety.

Metoprolol [Lopressor]

• Class: Beta Blocker (Selective Beta-1 agonist).

• Mechanism of Action: A beta-adrenergic blocking agent selective to the beta-1 receptor, blocking its effects, causing: decreasing HR, myocardial contractility, cardiac output, and conduction velocity.

• Indications: Rapid atrial fibrillation, rapid atrial flutter. Can be used as a second-line agent after adenosine for SVT.

• Dose: $5 \text{ mg}$ IV/IO, can be given every $5$ minutes (up to a total of $15 \text{ mg}$ until the desired effect).

• Special Considerations: Caution in asthmatic patients or in active bronchoconstriction, as even though it is selective, there are still some beta-2 blocker effects.

• Contraindications: Bradycardia, hypersensitivity/allergy, hypotension.

• Adverse Reactions: Bradycardia, hypotension, palpitations, dizziness, lightheadedness, syncope.

Diltiazem [Cardizem]

• Class: Calcium Channel Blocker.

• Mechanism of Action: A calcium channel blocker, slows AV conduction, results in decreased HR/BP. Decreases oxygen demand on the heart.

• Indications: Rapid atrial fibrillation, rapid atrial flutter. Can be used as second-line treatment after adenosine for SVT.

• Dose: $0.25 \text{ mg/kg}$ IV/IO (common dosing would be $15 \text{ mg}$ IV/IO in an adult, for example).

• Special Considerations:

  • Watch closely for hypotension or bradycardia after administering.

  • Use cardiac monitoring and consider a $12$-lead ECG.

• Contraindications: Bradycardia, hypersensitivity/allergy, hypotension.

• Adverse Reactions: Bradycardia, hypotension, dizziness, lightheadedness, syncope.

Albuterol [Ventolin]

• Class: Sympathomimetic (beta-2 agonist).

• Mechanism of Action: Sympathomimetic that acts on the beta-2 receptor as an agonist, causing prompt bronchodilation of the lungs.

• Indications: Asthma, anaphylaxis, COPD, hyperkalemia.

• Dose: $2.5 \text{ mg}$ mixed into a mask nebulizer.

• Special Considerations:

  • Caution in heart disease and congestive heart failure patients.

  • Perform cardiac monitoring before and after administering.

• Contraindications: Hypersensitivity/allergy, CHF.

• Adverse Reactions: Palpitations, tachycardia, headache.

Ipratropium [Atrovent]

• Class: Anti-Cholinergic.

• Mechanism of Action: An anti-cholinergic (parasympatholytic) which inhibits acetylcholine at receptor sites. Dries respiratory tract secretions.

• Indications: Asthma, COPD, anaphylaxis.

• Dose: $0.5 \text{ mg}$ with albuterol ($2.5 \text{ mg}$).

• Special Considerations: Auscultate lung sounds before and after administering.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Dry mouth.

Levalbuterol [Xopenex]

• Class: Sympathomimetic (beta-2 agonist).

• Mechanism of Action: Sympathomimetic that is selective to the beta-2 receptor; its effect includes dilation of all airways from the trachea to the bronchioles.

• Indications: Treatment for bronchospasm from asthma, COPD, anaphylaxis.

• Dose: $1.25 \text{ mg}$ via nebulizer (every $20$ minutes).

• Special Considerations:

  • Caution in cardiac disease patients.

  • Assess cardiac monitoring before and after.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Tachycardia, palpitations, anxiety.

Oxytocin [Pitocin]

• Class: Hormone (Pituitary).

• Mechanism of Action: Pitocin is a hormone (pituitary) that stimulates uterine smooth muscle contraction, which reduces blood loss in the patient.

• Indications: Postpartum vaginal bleeding.

• Dose:

  • IV drip: $10-20 \text{ units}$ in $500 \text{ cc}$ of D5W.

  • IM: $3-10 \text{ units}$.

• Special Considerations: Mother must deliver both baby and placenta before delivery of oxytocin.

• Contraindications: Presence of $2$ fetuses, fetal distress.

• Adverse Reactions: Hypertension, tachycardia, anxiety, N/V, convulsions.

Oral Glucose

• Class: Carbohydrate Gel.

• Mechanism of Action: Will raise the patient's blood glucose levels.

• Indications: Hypoglycemia.

• Dose: Entire tube: $15 \text{ grams}$, orally.

• Special Considerations:

  • Patient must be alert and able to obey commands.

  • None in emergency settings.

• Contraindications: Cannot maintain consciousness or airway, unable to obey commands.

• Adverse Reactions: None listed.

Dexamethasone [Decadron]

• Class: Corticosteroid/Anti-inflammatory.

• Mechanism of Action: A steroid that acts as an anti-inflammatory. Can decrease cerebral edema and suppress immune response.

• Indications: Asthma, COPD, croup, anaphylaxis.

• Dose: $10 \text{ mg}$ IV/IO.

• Special Considerations:

  • Treat life threats and perform first-line treatments first.

  • This medication has an onset of $2-6$ hours.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Prolonged wound healing, GI bleeding, fluid retention, hyperglycemia.

Diphenhydramine [Benadryl]

• Class: Anti-Histamine.

• Mechanism of Action: An anti-histamine that blocks H1 and H2 receptors and has slight sedative effects.

• Indications: Anaphylaxis, simple allergic reactions, extrapyramidal reactions.

• Dose:

  • Adult: $25-50 \text{ mg}$ IV/IO, IM, PO.

  • Pediatric: $1-2 \text{ mg/kg}$ IV/IO, IM, PO (max dose $25 \text{ mg}$).

• Special Considerations:

  • Have this medication on hand when giving haldol (haloperidol) due to the risk of extrapyramidal reactions.

  • Consider ETCO2 monitoring for possible sedation.

• Contraindications: Allergy to the medication.

• Adverse Reactions: Dry mouth, drowsiness, dizziness, sedation, hypotension, palpitations.

Famotidine [Pepcid]

• Class: H2 Antagonist, Anti-Histamine.

• Mechanism of Action: An over-the-counter medication that acts as an H2 antagonist, anti-histamine.

• Indications: Gastroesophageal Reflux Disease (GERD), ulcers, anaphylaxis, allergic reactions.

• Dose:

  • Adult: $20 \text{ mg}$ IV/IO.

  • Pediatric: $0.5-1 \text{ mg/kg}$ IV/IO.

• Special Considerations: The patient may be taking this over-the-counter for GI issues.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Prolonged QTI (QT interval), angioedema, dizziness, headache.

Methylprednisone [Solu-medrol]

• Class: Steroid.

• Mechanism of Action: A synthetic steroid with potent anti-inflammatory effects for acute/chronic inflammation.

• Indications: Asthma, COPD, anaphylaxis, adrenal crisis.

• Dose:

  • Adult: $125 \text{ mg}$ IV/IO.

  • Pediatric: $1-2 \text{ mg/kg}$ IV/IO.

• Special Considerations:

  • Medication takes hours to see an effect.

  • Give first-line medications first, then follow up with Solu-Medrol.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Headache, hypertension, GI bleeds, prolonged wound healing, fluid retention.

Glucagon

• Class: Hormone.

• Mechanism of Action: Converts glycogen to glucose in the liver to raise blood glucose levels. Also has smooth muscle relaxant properties.

• Indications: Hypoglycemia, beta blocker overdose, calcium channel blocker overdose, obstructed esophageal food impaction.

• Dose:

  • Hypoglycemia:

    • Adult: $1 \text{ mg}$ IM.

    • Pediatric: $0.5 \text{ mg}$ IM.

  • Beta Blocker (BB)/Calcium Channel Blocker (CCB) Overdose: $5 \text{ mg}$ IV/IO over $3-5$ minutes.

• Special Considerations: Consider that if the patient has no liver stores, glucagon will not work.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: None listed.

Dextrose [D50-D10]

• Class: Carbohydrate.

• Mechanism of Action: Elevates blood glucose levels rapidly.

• Indications: Hypoglycemia.

• Dose:

  • D50: $25 \text{ g}$, slow IV/IO push.

  • D10: Titrate to effect via IV drip.

• Special Considerations:

  • If using D50, ensure IV is patent and push slowly.

  • D10 is preferred if available (less chance of IV irritation and ease of administration).

• Contraindications: None, as long as recorded hypoglycemia is present.

• Adverse Reactions: Hyperglycemia, local venous irritation.

Vecuronium [Norcuron]

• Class: Paralytic (Non-depolarizing).

• Mechanism of Action: Prevents neuromuscular activity by blocking the effect of acetylcholine at the myoneural junction. Acts as a paralytic for RSI.

• Indications: RSI.

• Dose: $0.1 \text{ mg/kg}$ IV/IO.

• Special Considerations:

  • Have backup airways available during RSI.

  • Continuous reassessments of cardiac monitoring, heart rate, blood pressure, and ETCO2.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Hypotension, bradycardia.

Haloperidol [Haldol]

• Class: Atypical Anti-psychotic, Major Tranquilizer.

• Mechanism of Action: Blocks dopamine receptors (D2 receptors) and alters mood and behavior. It is a major tranquilizer. Also functions as a sedative.

• Indications: Acute psychosis, emergency sedation for agitation/excited delirium.

• Dose: $5-10 \text{ mg}$ IM.

• Special Considerations:

  • Most protocols allow administration alongside benzodiazepines for sedation.

  • Monitor ETCO2 and cardiac monitoring after administering and gather blood glucose level.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Dizziness, drowsiness, extrapyramidal symptoms (EPS).

Ondansetron [Zofran]

• Class: Anti-emetic.

• Mechanism of Action: Blocks serotonin receptors, acting as an anti-emetic.

• Indications: Nausea/vomiting.

• Dose: $4-8 \text{ mg}$ IV/IO/PO/IM.

• Special Considerations:

  • Caution in pregnant patients.

  • Ask if the patient is already taking serotonin blockers.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Dizziness, drowsiness, headache.

Prochlorperazine [Compazine]

• Class: Anti-emetic (Phenothiazine).

• Mechanism of Action: Anti-emetic (phenothiazine).

• Indications: N/V, migraine.

• Dose: $5-10 \text{ mg}$ IV/IO/IM.

• Special Considerations:

  • This medication also inhibits dopamine.

  • Watch for sedative-like effects.

• Contraindications: Hypersensitivity/allergy, caution in alcohol patients.

• Adverse Reactions: Dizziness, drowsiness, sedative effects.

Metoclopramide [Reglan]

• Class: Anti-emetic.

• Mechanism of Action: An anti-emetic that suppresses vomiting. Reduces GI reflux.

• Indications: Nausea and vomiting, GERD, migraines.

• Dose: $5-10 \text{ mg}$ IV/IO/IM.

• Special Considerations: Reduces GI reflux.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Drowsiness, headache, extrapyramidal symptoms.

Olanzapine [Zyprexa]

• Class: Atypical Anti-psychotic.

• Mechanism of Action: Atypical anti-psychotic, sedative.

• Indications: Acute psychosis, emergency sedation for agitation/excited delirium.

• Dose: $5-10 \text{ mg}$ IM.

• Special Considerations:

  • Most protocols allow administration alongside benzodiazepines for sedation.

  • Monitor ETCO2 and cardiac monitoring after administering and gather blood glucose level.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Dizziness, drowsiness.

Activated Charcoal [Acti-dose]

• Class: Adsorbent, Antidote.

• Mechanism of Action: Used as an antidote to ingested drugs; will bind to the drug and deactivate it, then eliminate it from the body. Must be given within $1$ hour of substance ingestion.

• Indications: Numerous oral poisons/medication overdoses.

• Dose:

  • Adult: $30-100 \text{ g}$ PO.

  • Pediatric: $1 \text{ g/kg}$ PO.

• Special Considerations: We only have $1$ hour to use this.

• Contraindications: Corrosives, caustics, unable to obey commands or protect airway.

• Adverse Reactions: N/V.

Naloxone [Narcan]

• Class: Opioid Antagonist.

• Mechanism of Action: Opioid antagonist that will reverse the effects of the opiate at the mu-opiate receptor.

• Indications: Opiate overdose with respiratory depression (low respiratory rate).

• Dose:

  • Adult: $2-4 \text{ mg}$ IN/IM | $0.4-2 \text{ mg}$ IV/IO.

  • Pediatric: $0.1 \text{ mg/kg}$ (max dose $2 \text{ mg}$).

• Special Considerations:

  • Watch for violent or withdrawal symptoms when the patient awakes.

  • The goal of Narcan is to restore normal respiratory effort in opiate overdose.

• Contraindications: None in EMS.

• Adverse Reactions: Confusion, agitation, altered mental status (AMS), tachycardia.

Flumazenil [Romazicon]

• Class: Benzodiazepine Antagonist.

• Mechanism of Action: Benzodiazepine antagonist that blocks action in the Central Nervous System (CNS). Can reverse sedation.

• Indications: Reverse CNS depression from benzodiazepine overdose.

• Dose:

  • Adult: $0.2 \text{ mg}$ IV (up to $1 \text{ mg}$).

  • Pediatric: $0.01 \text{ mg/kg}$ (max $0.2 \text{ mg}$).

• Special Considerations:

  • Start cardiac monitoring and ETCO2 monitoring.

  • Watch for violence/withdrawal symptoms.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Agitation, restlessness, N/V, dizziness, seizures, violence.

Ketamine [Ketalar]

• Class: Dissociative Agent.

• Mechanism of Action: Dissociative agent that causes sedative and hypnotic effects. Short-acting medication that acts on the reticular activating system to produce anesthesia.

• Indications: Severe pain, emergency sedation, RSI adjunct for sedation.

• Dose:

  • Pain: $0.3 \text{ mg/kg}$ IV/IM.

  • RSI: $2 \text{ mg/kg}$ IV/IO.

  • Emergency Sedation: $4 \text{ mg/kg}$ IM or $1 \text{ mg/kg}$ IV/IO.

• Special Considerations: Have airway kit ready.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Overly sedated, hallucinations.

Etomidate [Amidate]

• Class: Sedative/Hypnotic.

• Mechanism of Action: Short-acting medication that acts on the reticular activating system to produce anesthesia.

• Indications: RSI (sedation).

• Dose: $0.3 \text{ mg/kg}$ IV/IO (max $40 \text{ mg}$).

• Special Considerations:

  • Watch for sedation to "wear-off".

  • ETCO2, ECG/ETCO2 monitoring.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Hypotension, apnea, bradycardia.

Diazepam [Valium]

• Class: Benzodiazepine.

• Mechanism of Action: Benzodiazepine that increases GABA in the brain. This increase causes its sedative/hypnotic and anti-convulsant properties.

• Indications: Seizures, emergency sedation, pre-medication for cardioversion.

• Dose:

  • Adult: $2-10 \text{ mg}$ IV/IO, IM.

  • Pediatric: $0.1-0.2 \text{ mg/kg}$ IV/IO, IM (don’t exceed $2 \text{ mg}$).

• Special Considerations: Cardiac monitoring, ETCO2 monitoring after administering.

• Contraindications: Hypersensitivity/allergy, bradycardia, hypotension.

• Adverse Reactions: Hypotension, bradycardia, respiratory depression.

Lorazepam [Ativan]

• Class: Benzodiazepine.

• Mechanism of Action: Acts on GABA in the brain (increases), thus causing its sedative/hypnotic and anti-convulsant properties.

• Indications: Seizures, emergency sedation, RSI sedative, pre-sedation for cardioversion.

• Dose:

  • Adult: $4 \text{ mg}$ IV/IO/IM - Seizures; $2 \text{ mg}$ IM - Emergency sedation.

  • Pediatric: $0.1 \text{ mg/kg}$ (don’t exceed adult dose).

• Special Considerations: Cardiac monitoring and ETCO2 after administering.

• Contraindications: Hypotension, bradycardia, low respiratory rate.

• Adverse Reactions: Hypotension, bradycardia, low respiratory rate.

Midazolam [Versed]

• Class: Benzodiazepine.

• Mechanism of Action: Short-acting benzodiazepine that causes sedative/hypnotic effects. Affects/increases GABA in the brain.

• Indications: Seizures, emergency sedation, used in RSI as a sedative agent.

• Dose:

  • Adult: $10 \text{ mg}$ IM (can trial $2.5-5 \text{ mg}$ IM in smaller adults); $5 \text{ mg}$ IV/IO.

  • Pediatric: $0.1 \text{ mg/kg}$ (don't exceed $2 \text{ mg}$) IV/IM.

• Special Considerations: After administering, ensure cardiac monitoring and ETCO2 monitoring have been established.

• Contraindications: Hypotension, bradycardia, low respiratory rate.

• Adverse Reactions: Hypotension, bradycardia, low respiratory rate.

Acetylcysteine [Mucomyst]

• Class: Antidote, Mucolytic Agent.

• Mechanism of Action: A mucolytic agent used to reduce the thickness of mucous respiratory secretions. Also can delay hepatotoxicity due to Tylenol overdose.

• Indications: Tylenol overdose, also used to treat respiratory mucous secretions.

• Dose:

  • PO: $140 \text{ mg/kg}$ ($70 \text{ mg/kg}$ every $4$ hours for long transport).

  • IV:

    • $150 \text{ mg/kg}$ in $200 \text{ cc}$ IV bag $5\%$ dextrose ($1$-hour infusion).

    • $50 \text{ mg/kg}$ in $500 \text{ cc}$ ($4$-hour infusion).

    • $100 \text{ mg/kg}$ in $1000 \text{ cc}$ ($16$-hour infusion).

• Special Considerations: Poison control and/or medical control may be contacted for lengthy transports.

• Contraindications: Hypersensitivity.

• Adverse Reactions: N/V, tachycardia, flushed skin.

Propofol [Diprovan]

• Class: Sedative/Hypnotic.

• Mechanism of Action: Propofol is an anesthetic that has a quick onset of about $40$ seconds. The medication enters the body and inhibits GABA activity in the brain.

• Indications: RSI to sedate/maintain sedation.

• Dose:

  • Adult: $25-75 \text{ mcg/kg}$ IV/IO.

  • Pediatric: $1 \text{ mg/kg}$.

• Special Considerations:

  • Watch for respiratory arrest.

  • Use only when resuscitation equipment is available.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Respiratory depression, headache, apnea, hypotension, bradycardia.

Rocuronium [Zemuron]

• Class: Paralytic (Non-depolarizing).

• Mechanism of Action: Prevents neuromuscular activity by blocking the effect of acetylcholine at the myoneural junction. Used as a paralytic during RSI.

• Indications: RSI.

• Dose: $1 \text{ mg/kg}$ IV/IO.

• Special Considerations:

  • Have backup airways available during RSI.

  • Continuous reassessments of cardiac monitoring, heart rate, blood pressure, ETCO2.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Hypotension, bradycardia.

Fentanyl [Sublimaze]

• Class: Opiate Agonist.

• Mechanism of Action: Synthetic opiate that produces analgesia and euphoria. CNS depressant.

• Indications: Pain control, ACS, RSI adjunct.

• Dose:

  • Adult: $1 \text{ mcg/kg}$, $50-100 \text{ mcg/dose}$ IV/IO/IM/IN.

  • Pediatric: $1-2 \text{ mcg/kg}$ IV/IO, IM, IN.

• Special Considerations:

  • Start cardiac monitoring and ETCO2 monitoring.

  • Remember this is listed as micrograms, not milligrams.

• Contraindications: Bradycardia, hypotension, hypersensitivity/allergy.

• Adverse Reactions: Bradycardia, hypotension, near-syncope, respiratory depression, dizziness, drowsiness.

Acetaminophen [Tylenol]

• Class: Pain Reliever/Anti-pyretic.

• Mechanism of Action: COX-2 inhibitor. Anti-pyretic, non-opiate analgesic.

• Indications: Mild to moderate pain, fever.

• Dose:

  • Adult: Pain: $1 \text{ g}$ PO; Fever: $500 \text{ mg}$ to $1 \text{ g}$ PO; $1 \text{ g}$ IV over $15$ min IV/IO.

  • Pediatric: $10-15 \text{ mg/kg}$ every $4-6$ hours PO.

• Special Considerations: Caution in patients $3$ years old or younger.

• Contraindications: Hypersensitivity/allergy, liver failure.

• Adverse Reactions: Nausea, abdominal pain.

Ibuprofen [Motrin]

• Class: NSAID.

• Mechanism of Action: Motrin is an NSAID medication that acts peripherally as an analgesic. Has anti-inflammatory, analgesic, anti-pyretic effects.

• Indications: Mild to moderate pain.

• Dose:

  • Adult: $200-800 \text{ mg}$ PO.

  • Pediatric: $5-10 \text{ mg/kg}$.

• Special Considerations:

  • Caution in patient's with aspirin or other NSAID allergy.

  • Caution in active asthmatics.

• Contraindications: Hypersensitivity, active GI bleeds, asthma.

• Adverse Reactions: GI irritation, renal impairment, heartburn, dizziness, drowsiness.

Ketorolac [Toradol]

• Class: NSAID.

• Mechanism of Action: NSAID, anti-inflammatory, non-opioid analgesic.

• Indications: Moderate to severe pain.

• Dose:

  • Adult: $15 \text{ mg}$ IV/IO/IM.

  • Pediatric: $0.5 \text{ mg/kg}$ IV/IO/IM.

• Special Considerations: Caution in GI/OBGYN.

• Contraindications: Hypersensitivity/allergy, GI ulcers, pregnancy, aspirin allergy.

• Adverse Reactions: GI irritation.

Morphine

• Class: Opioid Analgesic.

• Mechanism of Action: Acts as an agonist to the mu-opioid receptor. CNS depressant and decreases sensitivity to pain. Shown to decrease preload and afterload, and oxygen demand to the heart.

• Indications: Pain control, ACS, MI.

• Dose:

  • Adult: $0.1 \text{ mg/kg}$; range of single dose: $4-10 \text{ mg}$ IV/IO.

  • Pediatric: $0.1 \text{ mg/kg}$ IV/IO.

• Special Considerations:

  • Have Narcan on hand.

  • Ensure cardiac monitoring and ETCO2 monitoring.

• Contraindications: Bradycardia, hypotension, hypersensitivity/allergy.

• Adverse Reactions: Bradycardia, hypotension, near-syncope, respiratory depression, dizziness, drowsiness.

Hydromorphone [Dilaudid]

• Class: Opioid Agonist.

• Mechanism of Action: CNS depressant, produces analgesia and sedative properties.

• Indications: Severe pain.

• Dose: $0.5-1 \text{ mg}$ IV/IO.

• Special Considerations:

  • Have Narcan available.

  • Cardiac/ETCO2 monitoring.

• Contraindications: Hypersensitivity/allergy, bradycardia, respiratory depression, hypotension.

• Adverse Reactions: Bradycardia, respiratory depression, hypotension.

Lactated Ringers [LR]

• Class: Isotonic Crystalloid Solution.

• Mechanism of Action: Replaces water/electrolytes. Contains sodium, potassium, calcium, and chloride (electrolytes).

• Indications: Burns, dehydration, hypovolemia.

• Dose: Titrate to desired effect.

• Special Considerations: Don’t overload a patient with IV fluids; the goal is to return to a normal state, not overload them.

• Contraindications: CHF, diabetics, renal patients.

• Adverse Reactions: Rare, urination.

Mannitol [Osmotrol]

• Class: Osmotic Diuretic.

• Mechanism of Action: Mannitol is an osmotic diuretic that inhibits reabsorption of sodium/water at the cellular level. Acts to reduce Intracranial Pressure (ICP).

• Indications: Acute cerebral edema, increased ICP (head injury), transfusion reactions.

• Dose: Adult/Pediatric: $1.5 \text{ g/kg}$, slow IV.

• Special Considerations:

  • Use an in-line filter set on IV.

  • Monitor vitals/cardiac monitoring prior/after administration.

• Contraindications: Hypersensitivity/allergic, dehydration, hypotension, pulmonary edema.

• Adverse Reactions: Hypotension, hyponatremia, dizziness, UTI.

Cefazolin [Ancef]

• Class: Cephalosporin Antibiotics (1st generation/cephalosporin).

• Mechanism of Action: Acts on penicillin-binding proteins.

• Indications: Open extremity fracture (prophylaxis), amputation.

• Dose: $2 \text{ g}$ IV/IO, $50 \text{ mg/kg}$ IV/IO over $1-2$ minutes.

• Special Considerations: This is "extra", address life threats first.

• Contraindications: Known penicillin/cefazolin allergy.

• Adverse Reactions: Nausea, abdominal pain.

Hydrocortisone [Solu-Cortef]

• Class: Corticosteroid.

• Mechanism of Action: Steroid, anti-inflammatory, suppresses immune response.

• Indications: Anaphylaxis, adrenal insufficiency (Addison's crisis).

• Dose: $100 \text{ mg}$ IV/IO/IM.

• Special Considerations: This medication takes hours for full effect; make sure to give first-line treatments and treat life threats first.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: GI issues, prolonged wounds.

Prednisone [Deltasone]

• Class: Corticosteroid.

• Mechanism of Action: Corticosteroid, acts as an anti-inflammatory.

• Indications: Intracerebral swelling, Asthma/COPD, Multiple Sclerosis (M.S.), adrenal insufficiency.

• Dose:

  • Adult: $80 \text{ mg}$ PO.

  • Pediatric: $0.05-2 \text{ mg/kg}$.

• Special Considerations: Patients on this medication long-term may have skin discoloration and thin skin.

• Contraindications: Hypersensitivity, diabetes, fungal infections, coagulation disorders.

• Adverse Reactions: Edema, infection, hyperglycemia, bruising.

Sodium Chloride [Normal Saline]

• Class: Isotonic Crystalloid Solution, Electrolyte.

• Mechanism of Action: Replaces water/electrolytes, sodium, and chloride.

• Indications: Diabetic Ketoacidosis (DKA), hypovolemia, dehydration/heat illness.

• Dose: Titrate to desired effect.

• Special Considerations: Don’t overload a patient with IV fluids; they pump blood!

• Contraindications: Fluid overload/CHF.

• Adverse Reactions: Rare, urination.

Magnesium

• Class: Electrolyte.

• Mechanism of Action: Smooth muscle relaxant, can suppress seizure activity in eclampsia, slows SA node and prolongs conduction time, can relax bronchioles as it is a smooth muscle relaxant.

• Indications:

  • OBGYN: Eclampsia seizures.

  • Respiratory: Severe Asthma/COPD.

  • Cardiac: Torsades de pointes.

• Dose:

  • Adult:

    • OBGYN: $4 \text{ g}$ IV drip over $10$ minutes.

    • Respiratory: $2 \text{ g}$ IV drip over $10$ minutes.

    • Cardiac: $1-2 \text{ g}$ IV slow push.

  • Pediatrics: Respiratory/Cardiac: $25-50 \text{ mg/kg}$ (max $2 \text{ g}$).

• Special Considerations: If using push dose, push slow; calcium is the antidote if you encounter adverse effects.

• Contraindications: None in emergency setting.

• Adverse Reactions: Flushing, bradycardia, nausea, hypotension.

Sodium Bicarbonate

• Class: Alkalinizing Agent.

• Mechanism of Action: Reacts with hydrogen ions, can correct metabolic acidosis to neutralize blood pH.

• Indications: Tricyclic Antidepressant overdose, metabolic acidosis.

• Dose: $2 \text{ mEq/kg}$ IV/IO.

• Special Considerations:

  • Make sure to flush out the IV line before and after administering.

  • Flush out twice before giving calcium.

• Contraindications: Hypersensitivity/allergic.

• Adverse Reactions: Metabolic Alkalosis.

Calcium Chloride & Gluconate

• Class: Electrolyte.

• Mechanism of Action: Increases cardiac contractility, is an electrolyte.

• Indications: Hyperkalemia, calcium channel blocker overdose.

• Dose:

  • Calcium Chloride: $1 \text{ g}$ IV/IO over $5-10$ minutes.

  • Calcium Gluconate: $2 \text{ g}$ IV/IO over $5-10$ minutes.

• Special Considerations: If giving sodium bicarbonate, flush IV thoroughly between doses.

• Contraindications: Hypersensitivity/allergic.

• Adverse Reactions: Irritable to tissues if IV is not patent, flushing, palpitations.

Succinylcholine [Anectine]

• Class: Depolarizing Paralytic.

• Mechanism of Action: Paralysis to skeletal muscle.

• Indications: RSI.

• Dose: $1.5 \text{ mg/kg}$ IV/IO.

• Special Considerations:

  • Have backup airways available during RSI.

  • Cardiac monitoring, heart rate, and blood pressure, ETCO2 continuously reassessments.

• Contraindications: Hypersensitivity/allergy.

• Adverse Reactions: Hypotension, bradycardia.