Drugs 4 Paramedic Students - CPG 2015 Update Edition

• 1 mg in 1 mL glass ampoule (1:1,000)
• 1 mg in 10 mL glass ampoule (1:10,000)

• A naturally occurring alpha and beta-adrenergic stimulant
• Actions:
• - Increases HR by increasing SA node firing rate (Beta 1)
• - Increases conduction velocity through the A-V node (Beta 1)
• - Increases myocardial contractility (Beta 1)
• - Increases the irritability of the ventricles (Beta 1)
• - Causes bronchodilatation (Beta 2)
• - Causes peripheral vasoconstriction (Alpha)

• Metabolism by monoamine oxidase and other enzymes in the blood, liver and around nerve
• endings; excreted by the kidneys

• 1. Cardiac arrest - VF/VT, Asystole or PEA
• 2. Inadequate perfusion (cardiogenic or non-cardiogenic/non-hypovolaemic)
• 3. Bradycardia with poor perfusion
• 4. Anaphylaxis
• 5. Severe asthma - imminent life threat not responding to nebulised therapy, or
• unconscious with no BP
• 6. Croup

1. Hypovolaemic shock without adequate fluid replacement

• Consider reduced doses for:
• 1. Elderly / frail Pts
• 2. Pts with cardiovascular disease
• 3. Pts on monoamine oxidase inhibitors

4. Higher doses may be required for Pts on beta blockers

• 1. Sinus tachycardia
• 2. Supraventricular arrhythmias
• 3. Ventricular arrhythmias
• 4. Hypertension
• 5. Pupillary dilatation
• 6. May increase size of MI
• 7. Feeling of anxiety/palpitations in the conscious Pt

• IV Adrenaline should be reserved for life threatening situations.
• IV effects:
• Onset: 30 sec
• Peak: 3 – 5 min
• Duration: 5 – 10 min

• IM effects:
• Onset: 30 – 90 sec
• Peak: 4 – 10 min
• Duration: 5 – 10 min

• 300 mg chewable tablets
• 300 mg soluble or water dispersible tablets

An analgesic, antipyretic, anti-inflammatory and antiplatelet aggregation agent

• Actions:
• - To minimise platelet aggregation and thrombus formation in order to retard the
• progression of coronary artery thrombosis in ACS
• - Inhibits synthesis of prostaglandins - anti-inflammatory actions

Converted to salicylate in the gut mucosa and liver; excreted mainly by the kidneys

1. ACS

• 1. Hypersensitivity to aspirin / salicylates
• 2. Actively bleeding peptic ulcers
• 3. Bleeding disorders
• 4. Suspected dissecting aortic aneurysm
• 5. Chest pain associated with psychostimulant OD if SBP >160 mmHg

• 1. Peptic ulcer
• 2. Asthma
• 3. Pts on anticoagulants

• 1. Heartburn, nausea, gastrointestinal bleeding
• 2. Increased bleeding time
• 3. Hypersensitivity reactions

Aspirin is C/I for use in acute febrile illness in children and adolescents

• The anti-platelet effects of Aspirin persist for the natural life of platelets.
• Onset: n/a
• Peak: n/a
• Duration: 8 - 10 days

1 g sterile powder in a glass vial

• P - Cephalosporin antibiotic
• M - Excreted unchanged in urine (33% - 67%) and in bile

• 1. Suspected meningococcal septicaemia
• 2. Severe sepsis (consult only)

1. Allergy to Cephalosporin antibiotics

1. Allergy to Penicillin antibiotics

• Nausea
• Vomiting
• Skin rash

• Usual dose: adult 1 g, child 50 mg/kg (max. 1 g)
• Ceftriaxone IV must be made up to 10 mL using sterile water and
• dose administered over 2 min
• Ceftriaxone IM must be made up to 4 mL using 1% Lignocaine and
• dose administered in lateral upper thigh
• IM/IV effects:
• Onset: n/a
• Peak: n/a
• Duration: n/a

• 100 mcg in 2 mL glass ampoule
• 200 mcg in 1mL glass vial (IN use only)
• 600 mcg in 2 mL glass vial (IN use only)

• A synthetic opioid analgesic
• Actions:
• CNS effects:
• - Depression – leading to analgesia
• - Respiratory depression – leading to apnoea
• - Dependence (addiction)

• Cardiovascular effects:
• - Decreases conduction velocity through the A-V node

By the liver; excreted by the kidneys

• 1. Sedation to facilitate intubation
• 2. Sedation to maintain intubation
• 3. Drug facilitated intubation
• 4. Analgesia – IV/IN

1. Known hypersensitivity

RICEPRK

• 1. Respiratory depression, e.g. COPD
• 2. Impaired renal / hepatic function
• 3. Current asthma
• 4. Elderly/frail patients
• 5. Pts on monoamine oxidase inhibitors
• 6. Rhinitis, rhinorrhea or facial trauma (IN route)
• 7. Known addiction to opioids

RARB

• Respiratory depression
• Apnoea
• Rigidity of the diaphragm and intercostal muscles
• Bradycardia

• Fentanyl is a Schedule 8 drug under the Poisons Act and its use must be carefully
• controlled with accountability and responsibility

Respiratory depression can be reversed with Naloxone

100 mcg Fentanyl is equivalent in analgesic activity to 10 mg Morphine

• IV effects:
• Onset: Immediate
• Peak: < 5 min
• Duration: 30 - 60 min

• IN effects:
• Peak: 2 min

• 0.6 mg tablets
• Transdermal GTN Patch (50 mg 0.4 mg/hr release)

Principally, a vascular smooth muscle relaxant

• Actions:
• - Venous dilatation promotes venous pooling and reduces venous return to the heart
• (reduces preload)
• - Arterial dilatation reduces systemic vascular resistance and arterial pressure
• (reduces afterload)
• The effects of the above are:
• - Reduced myocardial O2
• demand
• - Reduced systolic, diastolic and mean arterial blood pressure, whilst usually
• maintaining coronary perfusion pressure
• - Mild collateral coronary arterial dilatation may improve blood supply to ischaemic
• areas of myocardium
• - Mild tachycardia secondary to slight fall in blood pressure
• - Preterm labour: Uterine quiescence in pregnancy

• 1. Chest pain with ACS
• 2. Acute LVF
• 3. Hypertension associated with ACS
• 4. Autonomic dysreflexia
• 5. Preterm labour (consult)

• 1. Known hypersensitivity
• 2. Sildenafil Citrate (Viagra) or Vardenafil (Levitra) administration in the previous24 hr or Tadalafil (Cialis) administration in the previous 4 days (PDE5 inhibitors)
• 3. Systolic blood pressure < 110 mmHg tablet
• 4. Systolic blood pressure < 90 mmHg patch
• 5. Heart rate > 150 bpm
• 6. Bradycardia HR < 50 bpm (excluding autonomic dysreflexia)
• 7. VT
• 8. Inferior STEMI with systolic BP < 160 mmHg
• 9. Right ventricular MI

• 1. No previous administration
• 2. Elderly Pts
• 3. Recent MI
• 4. Concurrent use with other tocolytics
• [Tocolytics (also called anti-contraction medications or labor repressants) are medications used to suppress premature labor]

• Tachycardia
• Hypotension
• Headache
• Skin flushing (uncommon)
• Bradycardia (occasionally)

• - Since both men and women can be prescribed Sildenafil Citrate (Viagra) or
• Vardenafil (Levitra) or Tadalafil (Cialis) all Pts should be asked if and when they last
• had the drug to determine if GTN is C/I

• - Tadalafil (Cialis) may also be prescribed to men for Rx of benign prostatic
• hypertrophy. This is a new indication for the drug and may lead to an increased
• number of Pts under this Rx regimen.

• Interhospital transfer:
• The IV dose is to be prescribed and signed by the referring hospital medical officer.
• Infusions usually run in the range of 5 mcg/min to 200 mcg/min and increased 3 - 5
• mcg/min.

• S/L effects:
• Onset: 30 sec – 2 min
• Peak: 5 - 10 min
• Duration: 15 - 30 min

• Intravenous effects
• Onset: 30 sec – 1 min
• Peak: 3 - 5 min
• Duration: 15 - 30 min

• Transdermal effect
• Onset: Up to 30 min
• Peak: 2 hr

250 mcg in 1 mL nebule or polyamp

Anticholinergic bronchodilator

• Actions:
• - Allows bronchodilatation by inhibiting cholinergic bronchomotor tone (i.e. blocks vagal reflexes which mediate bronchoconstriction

Excreted by the kidneys

1. Severe respiratory distress associated with bronchospasm

1. Known hypersensitivity to Atropine or its derivatives

• 1. Glaucoma
• 2. Avoid contact with eyes

HANDS TP

• Headache
• Acute angle closure glaucoma secondary to direct eye contact (rare)
• Nausea
• Dry mouth
• Skin rash
• Tachycardia (rare)
• Palpitations (rare)

• Ipratropium Bromide must be nebulised in conjunction with Salbutamol and is to be
• administered as a single dose only.

• Onset: 3 - 5 min
• Peak 1.5 - 2 hr
• Duration: 6 hr

3 mL glass bottle

• Pharma:
• Inhalational analgesic agent at low concentrations

• Excreted mainly by the lungs
• By the liver

1. Pain relief

• 1. Pre-existing renal disease / renal impairment
• 2. Concurrent use of tetracycline antibiotics
• 3. Exceeding total dose of 6 mL in a 24 hr period

• 1. The Penthrox™ inhaler must be hand-held by the Pt so that if unconsciousness
• occurs it will fall from the Pt’s face. Occasionally the operator may need to assist
• but must continuously assess the level of consciousness
• 2. Pre-eclampsia[Pre-eclampsia is a serious condition of pregnancy characterised by high blood pressure, protein in the urine and swelling of the hands, feet and face.]
• 3. Concurrent use with Oxytocin may cause hypotension

• Drowsiness
• Decrease in blood pressure and bradycardia (rare)
• Exceeding the maximum total dose of 6 mL in a 24 hr period may lead to
• renal toxicity

• The maximum initial priming dose for Methoxyflurane is 3 mL. This will provide
• approximately 25 min of analgesia and may be followed by one further 3mL dose
• once the initial dose is exhausted if required. Analgesia commences after 8 - 10
• breaths and lasts for approximately 3 - 5 min once discontinued.

Do not administer in a confied space. Ensure adequate ventilation in ambulance

10 mg in 2 mL polyamp

Antiemetic

• Actions:
• - Accelerates gastric emptying and peristalsis
• - Dopamine receptor antagonist

By the liver; excreted by the kidneys

• 1. Nausea / vomiting associated with
• - Chest pain / discomfort of a cardiac nature
• - Opioid administration for pain
• - Cytotoxic or radiotherapy
• - Previously diagnosed migraine
• - Severe gastroenteritis

• 2. Prophylaxis:
• - Awake spinal immobilised Pts
• - Eye trauma

• 1. Children
• 2. Suspected bowel obstruction or perforation
• 3. Gastrointestinal haemorrhage

DLDME

• Drowsiness
• Lethargy
• Dry mouth
• Muscle tremor
• Extrapyramidal reactions (usually the dystonic type)

• Not effective for established motion sickness.
• Not effective for nausea prophylaxis in the setting of opioid administration.

• IV effects:
• Onset: 1 – 3 min
• Peak: n/a
• Duration: 10 – 30 min
• IM effects:
• Onset: 10 – 15 min
• Peak: n/a
• Duration: 1 – 2 hr

• 5 mg in 1 mL glass ampoule
• 15 mg in 3 mL glass ampoule

Short acting CNS depressant

• Actions:
• - Anxiolytic
• - Sedative
• - Anti-convulsant

In the liver; excreted by the kidneys

• 1. Status epilepticus
• 2. Sedation to enable intubation (RSI / IFS)
• 3. Post intubation sedation
• 4. Sedation to enable synchronised cardioversion
• 5. Sedation in the agitated Pt (including Pts under the Mental Health Act 2014)
• 6. Sedation in psychostimulant OD

1. Known hypersensitivity to benzodiazepines

• 1. Reduced doses may be required for the elderly/frail, Pts with chronic renal failure,
• CCF or shock
• 2. The CNS depressant effects of benzodiazepines are enhanced in the presence of
• narcotics and other tranquillisers including alcohol
• 3. Can cause severe respiratory depression in Pts with COPD
• 4. Pts with myasthenia gravis

• Depressed level of consciousness
• Respiratory depression
• Loss of airway control
• Hypotension

• IM effects:
• Onset: 3 – 5 min
• Peak: 15 min
• Duration: 30 min

• IV effects:
• Onset: 1 – 3 min
• Peak: 10 min
• Duration: 20 min

10 mg in 1 mL glass ampoule

• CNS effects:
• - Depression (leading to analgesia)
• - Respiratory depression
• - Depression of cough reflex
• - Stimulation (changes of mood, euphoria or dysphoria, vomiting, pin-point pupils)
• - Dependence (addiction)

• Cardiovascular effects:
• - Vasodilatation
• - Decreases conduction velocity through the A-V Node

By the liver; excreted by the kidneys

• 1. Pain relief
• 2. Acute LVF with shortness of breath and full field crackles
• 3. Sedation to maintain intubation
• 4. Sedation to enable intubation
• 5. RSI

• 1. Known hypersensitivity
• 2. Late second stage of labour

EHRCRKAP

• 1. Elderly/frail patients
• 2. Hypotension
• 3. Respiratory depression
• 4. Current asthma
• 5. Respiratory tract burns
• 6. Known addiction to opioids
• 7. Acute alcoholism
• 8. Pts on monoamine oxidase inhibitors

• CNS effects:
• - Drowsiness
• - Respiratory depression
• - Euphoria
• - Nausea, vomiting
• - Addiction
• - Pin-point pupils

• Cardiovascular effects:
• - Hypotension
• - Bradycardia

• Morphine is a Schedule 8 drug under the Poisons Act and its use must be
• carefully controlled with accountability and responsibility.
• Side effects of Morphine can be reversed with Naloxone.
• Occasional wheals are seen in the line of the vein being used for IV injection. This is
• not an allergy, only a histamine release.

• IV effects:
• Onset: 2 – 5 min
• Peak: 10 min
• Duration: 1 – 2 hr

• IM effects:
• Onset: 10 – 30 min
• Peak: 30 – 60 min
• Duration: 1 – 2 hr

• 0.4 mg in 1 mL glass ampoule
• 2 mg in 5 mL (prepared syringe)

An opioid antagonist

• Action:
• - Prevents or reverses the effects of opioids

By the liver

• 1. Altered conscious state and respiratory depression secondary to administration of
• opioids or related drugs.

1. Nil of significance in the above indication

• 1. If Pt is known to be physically dependent on opioids, be prepared for a combative
• Pt after administration.
• 2. Neonates.

• Symptoms of opioid withdrawal:
• - Sweating, goose flesh, tremor
• - Nausea and vomiting
• - Agitation
• - Dilatation of pupils, excessive lacrimation
• - Convulsions

• Naloxone reverses the effects of opioids with none of the actions produced by other
• opioid antagonists when no opioid is present in the body. (For example, it does not
• depress respiration or cause pupillary constriction). In the absence of opioids, Naloxone has no perceivable effects.

• Following an opioid associated cardiac arrest Naloxone should not be administered.
• Maintain assisted ventilation.

Following head injury Naloxone should not be administered. Maintain assisted ventilation if required.

• IV effects:
• Onset: 1 – 3 min
• Peak: n/a
• Duration: 30 – 45 min
• IM effects:
• Onset: 1 – 3 min
• Peak: n/a
• Duration: 30 – 45 min

12.5 mg in 1 mL glass ampoule

• 1. Rx or prophylaxis of nausea / vomiting for
• - Motion sickness
• - Planned aeromedical evacuation
• - Known allergy or C/I to Metoclopramide administration
• - Headache irrespective of nausea / vomiting
• - Vertigo

• 1. Circulatory collapse
• 2. CNS depression
• 3. Previous hypersensitivity
• 4. Children

• 1. Circulatory collapse
• 2. CNS depression
• 3. Previous hypersensitivity
• 4. Children

SHEBS D

• Drowsiness
• Blurred vision
• Hypotension
• Sinus tachycardia
• Skin rash
• Extrapyramidal reactions (usually the dystonic type)

• IM effect
• Onset: 20 min
• Peak: 40 min
• Duration: 6 hr

• An anti-emetic
• Action:
• - Acts on several central neuro-transmitter systems

• 5 mg in 2.5 mL polyamp
• 500 mcg in 1 mL glass ampoule
• 5 mg in 5 mL glass ampoule
• pMDI (100 mcg per actuation)

• A synthetic beta adrenergic stimulant with primarily beta 2 effects
• Action:
• - Causes bronchodilatation

By the liver; excreted by the kidneys

• 1. Respiratory distress with suspected bronchospasm:
• - asthma
• - severe allergic reactions
• - COPD
• - smoke inhalation
• - oleoresin capsicum spray exposure

1. IV Salbutamol is no longer indicated for adult Pts

• 1. Large doses of IV Salbutamol have been reported to cause intracellular metabolic
• acidosis

• Sinus tachycardia
• Muscle tremor (common)

• IV Salbutamol has no advantage over nebulised Salbutamol provided that adequate
• ventilation is occurring.
• Salbutamol nebules / polyamps have a shelf life of one month after the wrapping
• is opened. The date of opening of the packaging should be recorded and the drug
• should be stored in an environment of < 30°C
• Although infrequently used, Salbutamol by IV infusion may be required during
• interhospital transfers of some women in premature labour
• The dose is to be prescribed and signed by the referring hospital medical officer
• Nebulised effects:
• Onset: 5 – 15 min
• Peak: n/a
• Duration: 15 – 50 min
• IV effects:
• Onset: 1 – 2 min
• Peak: n/a
• Duration: 30 – 60 min