Paramedic Drugs

CLASS OF DRUG: Mucolytic

• INDICATIONS – Authorized for Paramedic monitoring during inter-facility transport
• 1. Antidote to acetaminophen overdose

• CONTRAINDICATIONS
• 1. Hypersensitivity

DRUG INTERACTION: None

ADMINISTRATION: Follow dosing ordered by sending physician

SPECIAL NOTES: Activated charcoal absorbs acetylcysteine if given PO for acetaminophen ingestion.

Endogenous nucleoside; antidysrhythmic

1. Paroxysmal supraventricular tachycardia (PSVT), including PSVT associated with Wolff-Parkinson-White syndrome.

1. Hypersensitivity

2. High degree A-V block and sick sinus syndrome, unless a pacemaker is in place

Adult: [6 mg] rapid IVP (1-2 seconds) followed with a 30 cc flush. May be repeated in 1-2minutes, a second dose of [12 mg] rapid IVP followed by a 30 cc flush. Single doses ofgreater than 12 mg should not be given. May be given up to three times and alwaysfollow each bolus with a 30 cc flush.

Pediatric: Initial: [0.1 mg/kg] rapid IVP. Repeat in 2-3 minutes if no change.Second and third dose at [0.2 mg/kg] rapid IVP.

1. Use on patients with asthma, may induce bronchospasms.

2. Safety in pregnancy is unknown.

3. Transient dysrhythmias, such as periods of asystole, are common and self-limiting, requiring notreatment unless they persist.

4. Side effects may include: facial flushing, headache, chest pain, dyspnea, lightheadedness, andnausea.

5. Must be given in the IV port most proximal to the patient

Xanthine bronchodilator

1. Acute bronchospasm due to asthma

2. Anaphylaxis with bronchospasm

3. Wheezing in older persons, when pulmonary edema is a serious consideration

4. COPD with exacerbation

1. None, when indicated.

Adult: [5-7 mg/kg] IV infusion in 50 ml D5W over 20 minutes[0.5 to 0.9 mg/kg per hour] maintenance dosea. The lower dose is used for older patients, patients with liver disease, congestive heartfailure, hypovolemia, and non-smokers.b. The higher ranges are used for children and smokers.

Pediatric: [5-6 mg/kg] IV infusion in 50 ml D5W over 20 minutes not to exceed 12 mg/kg in a 24hour period

1. Aminophylline monitoring is used only during inter-facility transports.

2. If infused too rapidly, may cause nausea, vomiting, seizures, ventricular fibrillation, andcirculatory collapse. Monitor constantly. Do not exceed 25 mg/min.

3. Aminophylline may cause an initial drop in arterial oxygen concentration. Always have patienton oxygen before administration.

4. Nausea is an early sign of toxicity. Seizures are a late sign of toxicity.

Antiarrhythmic

1. Pulseless VF/VT refractory to initial electrical therapy

2. Unstable VT refractory to lidocaine and/or electrical therapy

1. None, if the patient is in cardiac arrest with VF or VT.

2. High degree AV blocks or sinus node dysfunction with marked bradycardia unless a functionalpacemaker is in place.

3. Congestive heart failure

Adult:Pulseless VT/VF [300 mg] initial bolus IVP or IO after epinephrine. May re-bolus with[150mg] once.Sustained VT [150 mg] over 10 minutes. May re-bolus every 10 minutes as needed upto a maximum dose of 15 mg/kg/day.Maintenance infusion: [0.5 mg/kg], 540 mg IV over 18 hours

Pediatric:Pulseless VT/VF [5mg/kg] IVP or IO. May re-bolus every 3-5 minutes to a maximum of20 mg/kg/24 hoursSustained VT [5 mg/kg] IVP or IO over 20-60 minutes. May repeat as needed to amaximum dose of 20 mg/kg /24 hours.

1. Must be drawn up slowly to avoid 'bubbles" do not shake the ampule for the same reason.

2. Must be given concurrently with epinephrine in the pulseless patient.

3. Can not be administered via ET tube.

4. Hypotension and bradycardia can occur on patients with a pulse.

Anticholinergic (parasympatholytic)

1. Symptomatic sinus bradycardia or A-V Blocks

2. Bradycardia associated with PEA

3. Asystole

4. Anticholinesterase poisonings - organophosphate, mushrooms (certain types), and nerve gases

5. Adjunct in the treatment of bronchial asthma

1. None, when indicated.

1. Cardiac Indications:Adult: [0.5 mg] IV, every 3-5 minutes: max 3.0 mg (0.04 mg/kg) for bradycardia.[1.0 mg] rapid IVP or IO, [2 to 3 mg diluted in 10ml NS] ET, every 3-5 minutes for(asystole, PEA < 60 bpm)Pediatric: [0.02 mg/kg] IVP or IO for 2 dosages. Minimum of 0.1 mg and maximum of 0.5 mg

2. Anticholinesterase poisoning:Adult: [2.0 mg] IVP repeated until symptoms abatePediatric: [0.05 mg/kg] IV, ET, or IO, repeated until symptoms abate

3. Mushroom Poisoning:Adult: [2 mg] IVP, repeated to doses sufficient enough to control parasympathomimeticsigns

1. May be not be effective with high degree A-V block (2nd degree type II, 3rd degree) - do notdelay pacing.

2. Bradycardia in the setting of an acute MI is common and probably beneficial. Don't treat the rateunless there are signs of poor perfusion (i.e. low blood pressure, mental confusion). Chest paincould be due to an AMI or to poor perfusion caused by the bradycardia itself.

• 3. Atropine increases the workload and myocardial 02 consumption of heart. Beware of patientswho have an
• ischemic myocardium. Administer supplemental oxygen.

Beta-adrenergic blocker

1. Used alone or in combination with other agents in the management of hypertension.

2. Management of angina pectoris.

3. Prevention of myocardial infarction.

1. Uncompensated congestive heart failure.

2. Pulmonary edema

3. Cardiogenic shock

4. Bradycardia or heart block

1. Selected drug, administration, and drug dosage must be determined by Medical Direction prior totransport.

1. Use cautiously within 14 days of MAO inhibitor therapy

Anticonvulsant, anti-anxiety, sedative, muscle relaxant

1. Control of seizures2. Sedation for cardioversion3. To facilitate intubation or in conjunction with paralytics for rapid sequence intubation. (withspecial skills approval only)4. Reduction of anxiety5. Skeletal muscle relaxant

1. Hypersensitivity

2. CNS depression

• AdultsDiazepam (Valium®): [2-10 mg] IVP, slow with IV running open
• Lorazepam (Ativan®): [2 - 4 mg] (0.05 mg/kg) IVP, slow with IV running open
• Midazolam (Versed®): [1-5 mg] IVP, slow (over 2 minutes) with IV running open
• Note: HIGHER DOSES MAY BE REQUIRED

• Pediatric:Diazepam: > 5 yrs. of age, [1 mg]every 2-5 minutes to a max. of 10 mg. Repeat every 2-4 hrs.
• Diazepam: < 5 yrs. of age, [0.2 mg] every 2-5 minutes to a maximum of 5 mg.
• a. Rectal dosage [0.5 mg/kg] may be warranted in seizure patients if no venous access isavailable. Onset of action by this route may be delayed.
• b. Apnea in children after diazepam administration may occur
• Lorazepam: 0.05-0.1 mg/kg IV to a maximum 4 mg. Onset 2-3 minutes. Duration 12-24 hours.

1. Should not be mixed with other agents, or diluted with intravenous solutions. Give through theproximal end of IV tubing, then flush well.

2. Most likely to produce respiratory depression on patients who have taken other depressant drugs,especially alcohol and barbiturates.

3. It can cause local venous irritation. Use relatively large veins.

4. Has short half- life. Additional doses may be necessary.

5. Utilization of pharmacological agents for the primary purpose of sedation, induction, ormuscle relaxation to facilitate placement of an advanced airway requires Medical DirectionCommittee Special Skills approval.

Electrolyte

1. Used as antidote for calcium channel blocker overdoses

2. Magnesium sulfate overdoses

3. Black Widow spider bite

1. Hypercalcemia

2. Absence of indications

• Calcium GluconateAdult: [5 - 10 ml] SLOW IVP (Do Not Exceed 2 ml/minute) repeat if necessary after5 - 10 min.Pediatric: [0.6 ml/kg] SLOW IVP of 10% solution
• Calcium Chloride:Adult: [5-10ml] by SLOW IVP. Repeat every 10 minutes as needed (1 ml of 10% =100 mg of calcium chloride).
• Pediatric: [0.2 ml/kg] (10% solution) by SLOW IVP. Repeat once in 10 minutes ifneeded.
• NOTE: RAPID INJECTION CAN CAUSE HYPOTENSION, BRADYCARDIA ANDDEATH.

1. It is best to warm the drug to body temperature prior to administration.

2. If heart is beating, rapid administration of calcium salts can produce bradycardia and/or arrest.

3. May increase cardiac irritability, i.e., PVC's, particularly in the presence of digitalis.

4. Local infiltration will cause tissue necrosis.

Calcium Channel Blocker; Coronary Vasodilator, Antidysrhythmic

1. Atrial Fibrillation or Atrial Flutter

2. Paroxysmal Supraventricular Tachycardia

3. Angina due to coronary artery spasm

1. Sick sinus syndrome except in the presence of a functioning ventricular pacemaker.

2. Patients with second- or third degree AV block except in the presence of a functioningventricular pacemaker.

3. Patients with severe hypotension or cardiogenic shock

4. Patients who have demonstrated hypersensitivity to the drug

5. Intravenous diltiazem and intravenous beta-blockers should not be administered together or inclose proximity (within a few hours).

6. Patients with atrial fibrillation or atrial flutter associated with an accessory bypass tract such as inWPW syndrome or short PR syndrome

7. Patients with ventricular tachycardia

Adult: [0.25 mg/kg] as a bolus administered over 2 minutes (20 mg is a reasonable dose for theaverage patient). If response is inadequate, a second dose may be administered after 15minutes. The second bolus dose of diltiazem HCl injectable should be [0.35 mg/kg]actual body weight administered over 2 minutes (25 mg is a reasonable dose for theaverage patient).For continued reduction of the heart rate (up to 24 hours) in patients withatrial fibrillation or atrial flutter, an intravenous infusion of diltiazem HCl injectable maybe administered. Immediately following bolus administration of [20 mg] (0.25 mg/kg) or[25 mg] (0.35 mg/kg) diltiazem HCl injectable and reduction of heart rate, begin anintravenous infusion of diltiazem HCl injectable. The recommended initial infusion rateof diltiazem HCl injectable is [10 mg/h]. Some patients may maintain response to aninitial rate of 5 mg/h. The infusion rate may be increased in 5 mg/h increments up to 15mg/h as needed, if further reduction in heart rate is required. The infusion may bemaintained for up to 24 hours.

Pediatric: Not usually used.

1. When given to a conscious patient, they will almost always produce nausea, vomiting andhypotension.

Sympathomimetic, beta agonist

1. Primary indication is cardiogenic shock, with pulmonary edema.

1. None when indicated. Use cautiously in AMI and atrial fibrillation.

.Adult: [2 - 20 mcg/kg/min] (mix 1 ampule (250 mg) in 250 ml of D5W - resulting in aconcentration of 1mg/ml = 1000 mcg/ml)

Pediatric: [1.0 mcg/kg per minute] (6 x body weight (kg) equals milligrams to add to D5W tocreate a total volume of 100ml). Infuse at 1mL/h.

1. Dobutamine should be titrated to effect.

Potent sympathomimetic, dopaminergic

1. Primary indication is cardiogenic shock.

2. May be useful for other forms of shock

3. May be useful, at low doses, in renal failure

4. Used for refractory bradycardia unresponsive to atropine, and when pacing is unavailable.

1. Tachydysrhythmias

2. Pheochromocytoma

Adult: IV infusion ONLY - Mix 400 mg in 250 ml D5W or NS to produce a concentration of1600 mcg/ml. Infusion rates [2.0-20.0 mcg/kg/min] titrated to desired effect. (Otherconcentrations are used, so know what you are using). Use microdrip chamber or aninfusion pump.

Pediatric: [1.0 mcg/kg per minute] (6 x body weight (kg) equals milligrams to add to D5W tocreate a total volume of 100ml). Infuse at 1mL/h.

1. Higher doses can cause central vasoconstriction limiting renal blood flow.

Sympathomimetic

• 1. Severe Bronchospasm
• 2. Bronchospasms unresponsive to albuterol
• 3. Anaphylaxis
• 4. Cardiac Arrest
• 5. Symptomatic bradycardia

1. None when indicated.

Adult: [1 mg](1:10,000) every 3 - 5 minutesIV or IO preferred, may be given ET (2 - 2 1/2 times IV dose)

Pediatric: Initial: IV/IO 0.01 mg/kg (1:10,000) every 3-5 minutesET 0.1 mg/kg (1:1000)

Adult: [1 mg/ 1:1,000] in 250 cc NS or D5W administered at 2 - 10 mcg/min

Pediatric: [0.1-0.2 mcg/kg/minute] (0.6 x body weight (kg) equals milligrams to addto D5W to create a total volume of 100 m). Infuse at 1mL/h

Adult: [0.3 mg] (1:1,000) SQ or IM using a pre-filled device.[0.3 mg] (1:10,000) IV or 1 mg ET (IF SEVERE OR NORESPONSE TO SQ/IM) Repeat PRN (Paramedic Only)

Pediatric: [0.01 mg/kg (1:1000)], SQ To a maximum dose of 0.3 mg/dose

• 1. When used for allergic reactions, increased cardiac workload can precipitate angina and/or AMIin susceptible individuals.
• 2. Due to peripheral vasoconstriction, it should be used with caution on patients with peripheralvascular insufficiency.
• 3. Wheezing in an elderly person is pulmonary edema or pulmonary embolus until provenotherwise.

Prostaglandin (vasodilator)

1. Management of primary pulmonary hypertension in patients currently being treated withcontinuous Flolan® infusion.

• 1. Patients with a known hypersensitivity.
• 2. Patients with CHF secondary to left ventricular systolic dysfunction.
• 3. Patients who develop pulmonary edema secondary to Flolan® use.

• 1. Flolan® must be reconstituted from powder form with a specific diluents.
• 2. Specific dosing must be obtained from the patient.

• 1. Most patients treated with Flolan® utilize an ambulatory infusion pump.
• 2. In the event the patient is found unconscious the patient should be assessed for continuousinfusion through a central line. If not, a designated peripheral line should be initiated andinfusion continued.
• 3. Flolan® is incompatible with all other medications and must be administered through adesignated IV line.
• 4. Added hypotension may occur with antihypertensive, diuretics or other vasodilators.

Potent loop diuretic

• 1. Pulmonary edema
• 2. Hypertensive emergencies (AMI, APE, or encephalopathy)

• 1. Hypovolemia
• 2. Hypokalemia
• 3. Hypotension

Adult: For patients not currently taking furosemide, [20 - 40 mg] slow IVP or [0.5 - 1.0 mg/kg]slow IVP. Use lower dose if no previous exposure to the drug. If the patient is currentlytaking furosemide, double the PO dose. Patients already on oral diuretics may requirehigher doses. You may repeat one dose PRN.

Pediatric: [1.0 mg/kg] slow IVPIt may be repeated in 6 - 8 hours.

• 1. It can lead to profound diuresis with resultant shock and electrolyte depletion (particularly K+).Therefore, do not use in hypovolemic states and monitor closely, particularly after IVadministration.
• 2. It should be used in children or pregnant women cautiously.
• 3. If patient unconscious, must have Foley catheter in place and unobstructed urine outflow. Advisethe physician if urine is bloody. Trauma to kidneys and urinary system makes the use of furosemide more hazardous.

Hormone- hyperglycemic agent

• 1. Documented symptomatic hypoglycemia (BGL less than 60 mg/dl) when an IV cannot be started.
• 2. Beta blocker overdose with serious signs and symptoms
• 3. Anaphylaxis refractory to epinephrine, or on patients who have history of serious coronaryarterial disease

• 1. Patients who will be unable to receive supplemental glucose, orally, IV or rectally afteradministration of glucagon.
• 2. Hypersensitivity to pork and/or beef3. Use with caution on patients with pheochromocytoma.

Adult: [0.5 - 1 mg] IM, SQ, IVP, may repeat in 10 - 20 minutes if no response.

Pediatric: [0.1 mg/kg] IM, SQ, IVP, may repeat in 10 - 20 minutes if no response.

THE PATIENT MUST BE GIVEN SUPPLEMENTAL GLUCOSE ASAP;PO, IV, OR RECTAL.

• Adult: [3 to 10 mg] IVP over 1 minute. It. may be followed by an infusion of 2 - 5mg/hr.
• Pediatric: [0.1 mg/kg] IVP over 1 minute, repeat in 5 minutes, if needed.

• Adult: [1 to 2 mg] slow IVP, may be repeated every 5 to 10 minutes.
• Pediatric: [0.1 mg/kg up to 1 mg]. Rarely indicated

• 1. The patient must be given supplemental glucose ASAP; PO, IV, or Rectal. If this is not possible,the patient may be better off without glucagon. Glucagon will release all of the patient'savailable glycogen. If the patient is not provided with glucose, the subsequent hypoglycemia willbe greater than before glucagon.
• 2. Glucagon is supplied in a powder and must be reconstituted by sterile water or saline, 1 ml ofnormal saline for each 1 mg of powder and shaken well.

Glycoprotein (GP) IIb/IIIa Inhibitor

1. In combination with heparin, it is indicated for the treatment of acute coronary syndrome,including patients who are to be managed medically and in patients that are undergoing PTCA oratherectomy.

• 1. Known hypersensitivity to any component of the product
• 2. Active internal bleeding or a history of bleeding diathesis within the previous 30 days
• 3. A history of intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, oraneurysm
• 4. A history of thrombocytopenia following prior exposure to a Glycoprotein(GP) IIb/IIIa Inhibitor
• 5. A history of stroke within 30 days or any history of hemorrhagic stroke
• 6. Major surgical procedure or severe physical trauma within the previous month
• 7. History, symptoms, or findings suggestive of aortic dissection
• 8. Severe hypertension (systolic blood pressure >180 mmHg and/or diastolic blood pressure >110mmHg)
• 9. Concomitant use of another parenteral GP IIb IIIa inhibitor
• 10. Acute pericarditis

• 1. Requires an infusion pump
• 2. AGGRASTAT should be administered intravenously, at an initial rate of [0.4 mg/kg/min] for 30minutes and then continued at [0.1 mg/kg/min]. For patients with severe renal insufficiency(creatinine clearance <30 ml/min), they should receive half the usual rate of infusion.

• 1. Percutaneous (coronary intervention care of the femoral artery access site) therapy withGlycoprotein (GP) IIb/IIIa Inhibitors is associated with an increase in bleeding rates, particularlyat the site of arterial access for femoral sheath placements.
• 2. Minimize vascular and other trauma. Other arterial and venous punctures, intramuscularinjections, and the use of urinary catheters, nasotracheal intubation and nasogastric tubes shouldbe minimized. When obtaining intravenous access, non-compressible sites (e.g., subclavian orjugular veins) should be avoided.