Mass Paramedic Drug Full Description

Class
Adsorbent
Mechanism of Action
Adsorbs toxic substances from the GI Tract; Onset of action is immediate.
Indications
Most oral poisonings and medication overdoses; can be used after evacuation of poisons.
Contraindications
Oral administration to comatose patient; after ingestion of corrosives, caustics or petroleum distillates (ineffective and may induce vomiting); simultaneous administration with other oral drugs.
Adverse Reactions
May induce nausea and vomiting; may cause constipation; may cause black stools.
Drug Interactions
Bonds with and generally inactivates whatever it is mixed with, e.g., syrup of ipecac.
How supplied
25 gm (black powder) / 125 ml bottle (200 mg/ml)
50 gm (black powder) / 250 ml bottle (200 mg/ml)
Dosage and Administration
Note, if not in Pre-mixed slurry, dilute with 1-part charcoal/ 4 parts water.
Adult: 1-2 gm/kg PO or via NGT
Pediatric: 1-2 gm/kg PO or via NGT
Duration of action
depends upon GI function; will act until excreted.
Special Considerations
Often used in conjunction with magnesium citrate
Must be stored in a closed container
Does not adsorb cyanide, lithium, iron, lead and arsenic.

Class
Endogenous Nucleotide
Mechanism of action
Slows conduction time through the AV Node; can interrupt re-entrant pathways; slows heart rate; acts directly on sinus pacemaker cells. Is drug of choice for PSVT. Can be used diagnostically for stable, wide-complex tachycardias of unknown type after two doses of Lidocaine.
Indications
Conversion of PSVT to sinus rhythm. May convert PSVT due to Wolff-Parkinson-White syndrome.
Not effective converting atrial fibrillation / flutter.
Contraindications
Second or third-degree " block or Sick Sinus Syndrome
Atrial flutter / atrial fibrillation
Ventricular Tachycardia
Hypersensitivity to adenosine
Adverse Reactions
Facial flushing, shortness of breath, chest pain, headache, paresthesia, diaphoresis, palpitations, hypotension, nausea, metallic taste.
Drug Interactions
Methylxanthines (theophylline-like drugs) antagonize the effects of adenosine.
Dipyridamole (Persantine) potentiates the effects of adenosine
Carbamazepine (Tegretol) may potentate the AV Node blocking effects of adenosine.
May cause bronchoconstriction in asthmatic patients.
How Supplied
Three mg/ml in 2-ml flip-top vials for IV injection
Dosage and Administration
Adult: 6 mg over 1-3 seconds; If no response after 1-2 minutes, administer 12 mg over 1-3 seconds, Maximum total dose = 30 mgs.
Pediatric: 0.1 - 0.2 mg/kg rapid IV; maximum single dose = 12 mgs.
Duration of action
Onset and peak effects in seconds; duration 12 seconds.
Special Considerations
Short half-life limits side effects in most patients.
Pregnancy safety: Category C.

Class
Sympathomimetic, bronchodilator.
Mechanism of Action
Selective b-2 agonist which stimulates adrenergic receptors of the sympathomimetic nervous system resulting in smooth muscle relaxation in the bronchial tree and peripheral vasculature.
Indications
Treatment of bronchospasm in patients with reversible obstructive airway disease (COPD/asthma). Prevention of exercise-induced bronchospasm.
Contraindications
Known prior hypersensitivity reactions to Albuterol.
Tachycardia dysrhythmias, especially those caused by digitalis.
Synergistic with other sympathomimetics
Adverse Reactions
Often dose-related and include restlessness, tremors, dizziness, palpitations, tachycardia, nervousness, peripheral vasodilatation, nausea, vomiting, hyperglycemia, increased blood pressure and paradoxical bronchospasm
Drug Interactions
Tricyclic antidepressants may potentate vasculature effects.
Beta-blockers are antagonistic.
May potentate hypokalemia caused by diuretics.
How Supplied
Solution for aerosolization: 0.5% (5 mg/ml)
Metered Dose Inhaler: 90 mcg/metered spray (17 gm canister with 200 inhalations)
Syrup: 2 mg/5 ml
Dosage and Administration
Adult: Administer 2.5 mg. Dilute 0.5 ml of 0.5% solution for inhalation with 2.5 ml normal saline in nebulizer and administer over 10-15 minutes.
MDI: 1-2 inhalations (90-180 mcg). Five minutes between inhalations

Pediatric: Administer solution of 0.01 - 0.03 ml (0.05 - 0.15 mg/kg/ dose diluted in 2 ml of 0.9% Normal Saline. May repeat every 20 minutes three times.
Duration of Action
Onset in 5-15 minutes with peak effect in 30-minutes - two hours and duration of 3-4 hours.
Special Considerations
Pregnancy Safety: Category C.
Antagonized by beta-blockers (e.g., Inderal, Metoprolol )
May precipitate angina pectoris and dysrhythmias.
Should only be administered by inhalation methodology in pre-hospital management.

Class
Xanthine bronchodilator (theophylline derivative).
Mechanism of Action
Respiratory stimulator and bronchodilator.
Indications
Limited usefulness in EMS arena although may be used in refractory COPD patients; interfacility transfers; bronchospasm.
Contraindications
Allergy to xanthines, e.g., caffeine; cardiac dysrhythmias.
Adverse Reactions
Tachycardia, palpitations, PVCs, Angina pectoris, headache, seizure, nausea and vomiting.
Drug Interactions
Beta blockers may oppose effects; Barbiturates and phenytoin may decrease theophylline levels.
How Supplied
500 mg / 10 ml ampule; 500 mg / 20 ml ampoule (preload) 25 mg/ml; 250 mg / ml ampoule (preload).
Dosage and Administration
Loading dose (Adult): 5-6 mg / kg in 60-100 ml of diluent over 30 min. IV infusion not to exceed 20 mg/min.;
Loading dose (Pediatric): 5-6 mg / kg in 50-100 ml; diluent IV infusion.
Maintenance infusion
Adult: First 12 hours: 0.5-0.7 mg/kg/hour (lower doses for elderly, CHF, liver disease). Subsequent: 0.1-0.5 mg/kg/hour (based on serum aminophylline levels)
Pediatric: 1.0 mg/kg/hour.
Duration of Action
Onset less than 15 minutes; Duration 4.5 hours.
Special Considerations
Pregnancy safety: Category C;
Use with caution in patients with cardiovascular disease., hypertension or hepatic/renal disease.
Doses should be halved in patients already taking theophylline preparations.
Therapeutic to toxic ratio is narrow!

Class
Antidysrhythmic.
Mechanism of Action
Prolongation of Action Potential; non-competitive alpha and beta sympathetic blocking effects; Calcium channel blocking effects.
Indications
Suppression of Ventricular Fibrillation refractory to defibrillation and Lidocaine.
Suppression of Ventricular Tachycardia refractory to cardioversion and Lidocaine.
Contraindications
Second or Third Degree heart block.
Medication-induced Ventricular dysrhythmias.
Hypotension, Bradycardia, Torsades de Pointes.
Profound Sinus Bradycardia.
Adverse Reactions
Hypotension, Bradycardia, Pulseless Electrical Activity, Congestive Heart Failure.
Nausea, fever, abnormal Liver Function Tests, Thrombocytopenia.
Drug Interactions
Will precipitate with Sodium Bicarbonate: incompatible.
Compatible with: Dopamine, Dobutamine, Isoproterenol, Lidocaine, NTG, Norepinephrine, Phenylephrine, KCL, Procainamide.
How Supplied:
150 mg in 3 ml vials.
Dosage and Administration
Adult: 300 mg slow IV Push over 1-2 minutes in 10 ml Normal Saline, (For ACLS VF/ Pulseless VT)

IV Drip 0.5-1mg per minute. (For malignant ventricular arrhythmias) per ordering physician.

Duration of Action:
Onset: Within 5-15 minutes.
Peak Effect: Variable.
Duration: Variable
Special Considerations
Pregnancy safety: Category C
Maintain at room temperature and protect from light in storage (light protection not required during administration).
Hypotension usually responsive to slowing infusion rate, IV Normal Saline.
Administer cautiously in patients with Heart Failure or poor systolic function.
May be especially effective in high-risk patients with recent acute MI.

Class
Antidote
Mechanism of Action
Amyl Nitrite: affinity for cyanide ions; reacts with hemoglobin to form methemoglobin (low toxicity)
Sodium Nitrite: same as amyl nitrite
Sodium Thiosulfate: produces thiocyanate, which is then excreted
Indications
Cyanide or hydrocyanic acid poisoning.
Contraindications
Not applicable.
Adverse reactions
Excessive doses of amyl nitrite and sodium nitrite can produce severe, life-threatening methemoglobinemia. Use only recommended doses.
Drug Interactions
None.
How supplied
Amyl nitrite: in pledgettes similar to ammonia capsules.
Dosage and administration
Adult: Amyl nitrite: breathe 30 seconds out of every minute. Sodium Thiosulfate and sodium nitrite: IV per antidote kit directions.
Pediatric: Same as adult.
Duration of Action
Variable.
Special Considerations
Cyanide poisoning must be recognized quickly and treated quickly; if pulse persists, even in presence of apnea, prognosis is good with treatment. The antidote kit must be used in conjunction with administration of oxygen.

Class:
Platelet inhibitor, anti-inflammatory agent.
Mechanism of Action:
Prostaglandin inhibition.
Indications:
New onset chest pain suggestive of Acute Myocardial Infarction.
Contraindications:
Hypersensitivity.
Gastrointestinal bleeding.
Adverse Reactions:
Heartburn.
GI bleeding.
Nausea, vomiting.
Wheezing in allergic patients.
Prolonged bleeding.
Drug Interactions:
Use with caution in patients allergic to NSAIDS.
How Supplied:
160 mg or 325 mg tablets (chewable and standard).
Dosage and Administration:
160 mg or 325 mg PO.
Duration of Action:
Onset: 30-45 minutes.
Peak effect: variable.
Duration: Variable.
Special Considerations:
Pregnancy Safety: Category D.
Not recommended in pediatric population.

Class:
Anticholinergic agent.
Mechanism of Action:
Parasympatholytic: inhibits action of acetylcholine at postganglionic parasympathetic neuroeffector sites.
Increases heart rate in life-threatening bradydysrhythmias.
Indications:
Hemodynamically significant bradycardia.
Asystole.
Drug of choice for organophosphate poisoning.
Bronchospastic pulmonary disorders.
Contraindications:
Tachycardia.
Hypersensitivity.
Unstable cardiovascular status in acute hemorrhage and myocardial ischemia.
Narrow-angle glaucoma.
Adverse Reactions:
Headache, dizziness, palpitations, nausea and vomiting.
Tachycardia, dysrhythmias, anticholinergic effects (blurred vision, dry mouth, urinary retention).
Paradoxical bradycardia when pushed slowly or at low doses.
Flushed, hot dry skin.
Drug Interactions:
Potential adverse effects when administered with digoxin, cholinergics, physostigmine.
Effects enhanced by antihistamines, procainamide, quinidine, antipsychotics, benzodiazepines and antidepressants.
How Supplied:
Prefilled syringes: 1.0 mg in 10 ml of solution.
Nebulizer: 0.2% (1 mg in 0.5 ml) and 0.5% (2.5 mg in 0.5 ml).
Injection Solution as Sulfate: 0.5mg/ml (1ml); 1mg/ml (1ml);
0.1mg/ml (5ml,10ml); 0.4mg/ml (1ml, 20ml)
Autoinjectors: (See Nerve Agent Antidote)
Dosage and Administration:
Adult:

- Bradydysrhythymias: 0.5 - 1.0 mg IV every 3-5 minutes as needed to maximum total dose of 0 .0 4 mg / kg.

- Asystole: 1.0 mg IV push every 3-5 minutes as needed to maximum total dose of 0.04 mg / kg
Pediatric:

- Bradydysrhythmias: 0.02 mg / kg IV / IO (minimum single dose 0.1 mg, maximum single dose 1.0 mg).

- Asystole: Same as for Bradydysrhythmias: minimum dose 0.1 mg; maximum dose 0.5 mg for a child and 1.0 mg for adolescent.

OTHER:
Autoinjectors: (See Nerve Agent Antidote)

Duration of Action:
Onset: Immediate.
Peak Effect: Rapid to 1-2 minutes.
Duration: 2-6 hours.
Special Considerations:
Pregnancy Safety: Category C.
Moderate doses dilate pupils.

Class
Electrolyte.
Mechanism of Action
Increases cardiac contractile state (positive inotropic effect).
May enhance ventricular automaticity.
Indications
Hypocalcemia, magnesium sulfate overdose, hyperkalemia, calcium channel blocker toxicity.
Adjunctive therapy in treatment of insect bites and stings.
Contraindications
Hypercalcemia, VF during cardiac resuscitation; digitalis toxicity.
Adverse Reactions
Bradycardia, asystole, hypotension, peripheral vasodilatation, metallic taste, local necrosis, coronary and cerebral artery spasm, nausea, vomiting.
Drug Interactions
May worsen dysrhythmias secondary to digitalis.
May antagonize effects of Verapamil.
Flush line before and after administration of sodium bicarbonate.
How Supplied
10% solution in 10 ml ampules, vials and prefilled syringes (100 mg/ ml).
Dosage and Administration
Adult: 2-4 mg/kg of 10% solution slowly IV over 5 minutes; may repeat in 10 minutes. (maximum: 1 gm dose)
Pediatric: 20 mg/kg/dose of 10% solution slow IV/ IO (maximum: 1 gm dose); (may repeat in 10 minutes.)
Duration of Action
Onset: 5-15 minutes.
Peak effects: 3-5 minutes.
Duration: 15-30 minutes but may persist for 4 hours (dose dependent).
Special Considerations
Pregnancy safety: Category C.
For pediatrics: if calcium gluconate is unavailable, 1-2 ml of 10% calcium chloride solution, diluted with IV fluid, may be substituted.

Class
corticosteroid.
Mechanism of Action
Suppresses acute and chronic inflammation; immunosuppressive effects.
Indications
Anaphylaxis, asthma, spinal cord injury, croup, elevated intracranial pressure (prevention and treatment), as an adjunct to treatment of shock.
Contraindications
Hypersensitivity to product.
Adverse Reactions
Hypertension, sodium and water retention, GI bleeding, TB.
None from single dose.
Drug Interactions
Calcium
Metaraminol.
How Supplied
100 mg/ 5 ml vials or 20 mg/1 ml vials.
Dosage and Administration
Adult: 10-100 mg IV (1 mg/kg slow IV bolus). (considerable variance through Medical Control).
Pediatric: 0.25-1.0 mg/kg/dose IV, IO, IM.
Duration of Action
Onset: Hours.
Peak effects: 8-12 hours.
Duration of action: 24-72 hours.
Special Consideration
Pregnancy safety: unknown.
Protect medication form heat.
Toxicity and side effects with long-term use.

Class
Carbohydrate, hypertonic solution.
Mechanism of Action
Rapidly increases serum glucose levels.
Short-term osmotic diuresis.
Indications
Hypoglycemia, altered level of consciousness, coma of unknown etiology, seizure of unknown etiology, status epilepticus (controversial).
Contraindications
Intracranial hemorrhage, delirium tremens, ineffective without thiamine,
Adverse Reactions
Extravagation leads to tissue necrosis.
Warmth, pain, burning, thrombophlebitis, rhabdomyositis.
Drug Interactions
Sodium bicarbonate, coumadin.
How Supplied
25 gm/ 50 ml pre-filled syringes (500 mg/ml)
Dosage and Administration
Adult: 12.5-25 gram slow IV; may be repeated as necessary.
Pediatric: 0.5-1 gm/kg/dose slow IV; may be repeated as necessary.
Duration of Action
Onset: less than 1 minute.
Peak effects: variable.
Duration: Variable.
Special Considerations
Administer thiamine prior to D50 in known alcoholic patients.
Draw blood sugar before administering.
Do not administer to patients with known CVA unless hypoglycemia documented.

Class
Benzodiazepine, sedative-hypnotic, anticonvulsant.
Mechanism of Action
Potentates effects of inhibitory neurotransmitters.
Raises seizure threshold.
Induces amnesia and sedation.
Indications
Acute anxiety states, acute alcohol withdrawal, muscle relaxant, seizure activity, agitation.
Analgesia for medical procedures (fracture reduction, cardioversion).
Delirium tremens.
Contraindications
Hypersensitivity, glaucoma. coma, shock, substance abuse, head injury.
Adverse Reactions
Respiratory depression, hypotension, drowsiness, ataxia, reflex tachycardia, nausea, confusion, thrombosis and phlebitis.
Drug Interactions
Incompatible with most drugs, fluids.
How Supplied
10 mg/5 ml prefilled syringes, ampules, vials and Tubex.
Dosage and Administration
Seizure activity: Adult: 5-10 mg IV q 10-15 minutes prn (5 mg over 5 min.)(maximum dose = 30 mgs.)

Seizure activity: Pediatric: 0.2-0.3 mg/kg/dose IV every 15-30 minutes (no faster than 3 mg over 5 minutes) (max. = 10 mg).
Rectal diazepam: 0.5 mg/kg via 2” rectal catheter and flush with 2-3 ml air after administration.
Sedation for cardioversion: 5- 15 mg IV over 5-10 minutes prior to cardioversion.
Duration of Action
Onset: 1-5 minutes.
Peak effect: minutes.
Duration: 20-50 minutes.
Special Considerations
Pregnancy safety: Category D
Short duration of anticonvulsant effect.
Reduce dose 50% in elderly patient.

Class
Vasodilator.
Mechanism of Action
Non-diuretic antihypertensive; arteriolar vasodilatation.
Indications
Hypertensive crisis, especially in pre-eclampsia.
Contraindications
Hypotension, dissecting aortic aneurysm, labor.
Adverse Reactions
Reflex tachycardia, angina, cerebral ischemia, CVA, dysrhythmia, hyperglycemia, nausea, vomiting.
Drug Interactions
Incompatible with heat, light or acid solutions.
How Supplied: 5 mg/ml 20 ml ampules.
Dosage and Administration
Adult: 5 mg/kg IV push over 10-30 seconds.
Pediatric: 5 mg/kg IV push over 10-30 seconds.
Duration of Action
Onset: Immediate.
Peak effects: 5 minutes.
Duration of action: 3-12 hours.
Special Considerations
Administer only to patient in supine position.
Extravasations can cause tissue necrosis.

Class:
Calcium channel blocker.
Mechanism of Action:
Block influx of calcium ions into cardiac muscle: prevents spasm of coronary arteries.
Arterial and venous vasodilator.
Reduces preload and afterload.
Reduces myocardial oxygen demand.
Indications:
Control of rapid ventricular rates due to atrial flutter, atrial fibrillation, PSVT.
Angina pectoris.
Contraindications:
Hypotension, sick sinus syndrome, second or third degree AV block
Cardiogenic shock.
Wide-complex tachycardias.
Adverse Reactions:
Bradycardia, second or third-degree AV blocks, chest pain, CHF, syncope.
V-Fib, V-tach, nausea, vomiting, dizziness, dry mouth, dyspnea, headache.
Drug Interactions:
Caution in patients using medications that affect cardiac contractility.
In general, should not be used in patients on Beta-blockers.
How Supplied:
25 mg / 5 ml vial; 50 mg / 10 ml vial.
Non - refrigerated: LYO-JECT syringe.
Dosage and Administration:
Adult: Initial bolus: 0.25 mg/ kg (average dose 20 mg) IV over two (2) minutes. If inadequate response, may re-bolus in 15 minutes: 0.35 mg / kg IV over two (2) minutes. Maintenance infusion of 5-15 mg / hour.
Pediatric: not recommended.
Duration of Action:
Onset: 2-5 minutes.
Peak effect: Variable.
Duration: 1-3 hours.
Special Considerations:
Pregnancy safety: category C.
Use in caution in patients with renal or hepatic dysfunction.
PVCs may be noted at time of conversion of PSVT to sinus rhythm.

Class
Antihistamine; anticholinergic.
Mechanism of Action
Blocks cellular histamine receptors; decreases vasodilatation; decreases motion sickness. Reverses extrapyramidal reactions.
Indications
Symptomatic relief of allergies, allergic reactions, anaphylaxis, acute dystonic reactions (phenothiazines).
Blood administration reactions; used for motion sickness, hay fever.
Contraindications
Asthma, glaucoma, pregnancy, hypertension, narrow angle glaucoma, infants, patients taking
Monoamine Oxidase Inhibitors.
Adverse Reactions
Sedation, hypotension, seizures, visual disturbances, vomiting, urinary retention, palpitations, dysrhythmias, dry mouth and throat, paradoxical CNS excitation in children.
Drug Interactions
Potentates effects of alcohol and other anticholinergics, may inhibit corticosteroid activity, MAOIs prolong anticholinergic effects of diphenhydramine.
How Supplied
Tablet: 25, 50 mg; Capsules: 25, 50 mg.
50 or 100 mg prefilled syringes, vials (IV or IM); elixir 12.5 mg/5 ml.
Dosage and Administration
Adult: 25 - 50 mg IM or IV or P.O.
Pediatric: 1-2 mg/kg IV, IO slowly or IM. If given PO: 5 mg./ kg./ 24 hours.
Duration of Action
Onset: 15-30 minutes.
Peak effect: 1 hour.
Duration: 3-12 hours.
Special Considerations
Not used in infants or in pregnancy: Category B.
If used in anaphylaxis, will be in conjunction with epinephrine, steroids.

Class
Sympathomimetic, inotropic agent.
Mechanism of Action
Immediate metabolic precursor to Norepinephrine. Increases systemic vascular resistance, dilate renal and splanchnic vasculature. Increases myocardial contractility and stroke volume.
Indications
Cardiogenic, septic or spinal shock, hypotension with low cardiac output states.
Distributive shock.
Contraindications
Hypovolemic shock, pheochromocytoma, tachydysrhythmias, VF.
Adverse Reactions
Cardiac dysrhythmias, hypertension, increased myocardial oxygen demand, extravagation may cause tissue necrosis.
Drug Interactions
Incompatible in alkaline solutions.
MAOIs will enhance effects of dopamine.
Beta blockers may antagonize effects of dopamine.
When administered with Phenytoin: may cause hypotension, bradycardia and seizures.
How Supplied
200 mg / 5 ml - 400 mg / 5 ml prefilled syringes, ampules for IV infusion.
400 mg in 250 ml D5W premixed solutions.
Dosage and Administration
Adult: 2- 20 mcg / kg / min. (Rate determined by physician).
Pediatric: 2 - 20 mcg / kg / min. (Rate determined by physician).
Duration of Action
Onset: 1-4 minutes.
Peak Effect: 5-10 minutes.
Duration: Effects cease almost immediately after infusion shut off.
Special Considerations
Pregnancy safety not established.
Effects are dose-dependent
Dopaminergic response: 2-4 mcg / kg / min.: dilates vessels in kidneys; inc. urine output.
Beta-adrenergic response: 4-10 mcg / kg / min.: Increased chronotropy and inotropy
Adrenergic response: 10-20 mcg / kg / min.: Primarily alpha stimulant / vasoconstriction.
Greater than 20 mcg / kg / min.: reversal of renal effects / override alpha effects.
Always monitor drip rate.
Avoid extravagation injury.

Class: Sympathomimetic.
Mechanism of Action
Direct acting alpha and beta agonist
Alpha: bronchial, cutaneous, renal and visceral arteriolar vasoconstriction.
Beta 1: positive inotropic and chronotropic actions, increases automaticity.
Beta 2: bronchial smooth muscle relaxation and dilation of skeletal vasculature
Blocks histamine release.
Indications
Cardiac arrest, asystole, PEA, VF unresponsive to initial defib.
Severe bronchospasm, asthma, bronchiolitis.
Anaphylaxis, acute allergic reactions.
Contraindications
Hypertension, hypothermia, pulmonary edema, coronary insufficiency, hypovolemic shock.
Adverse Reactions
Hypertension, dysrhythmias, pulmonary edema, anxiety, psychomotor agitation, nausea, angina, headache, restlessness.
Drug Interactions
Potentates other sympathomimetics.
Deactivated by alkaline solutions.
MAOIs may potentate effects of epinephrine.

How Supplied
1 mg / ml (1:1,000) ampules and 0.1 mg / ml (1:10,000) prefilled syringes.
Auto-injectors: EPI-Pen: 0. 3 mg / ml
EPI-Pen Jr.: 0.15mg/ml

Dosage and Administration

Adult
Allergic reactions and asthma: 0.3 - 0.5 mg (0.3 - 0.5 ml 1:1000) IM
Anaphylaxis: 0.3 - 0.5 mg (3- 5 ml 1:10,000) IV

Cardiac: (asystole, PEA, VF)
1 mg IV push (1:10,000) every 3- 5 minutes

Epinephrine Infusion 1-10 mcg/minute. Mix Epinephrine (1:1000) 1 mg in 250 mL
Normal Saline. (15 micro drops/minute = 1 mcg / min.)


Pediatric
Allergic reactions and asthma: 0.01 mg/kg (0.01 mL/kg 1:1000) IM to maximum of 0.5 mg.
Cardiac: (asystole, PEA, VF)
IV, IO: Standard initial dose: 0.01 mg/kg (1:10,000, 0.1mL/kg)

Severe croup: 5 mg. as 5 ml. of 1:1000 solution administered via nebulization; may repeat every 30 minutes.
Racemic epinephrine 11.25mg via nebulization
Duration of Action
Onset: Immediate.
Peak Effects: Minutes.
Duration: Several minutes.
Special Considerations
Pregnancy safety: category C.

Class: Narcotic Analgesic

Mechanism of Action: Fentanyl citrate is a narcotic analgesic. A dose of 100 mcg (0.1 mg) (2 mL) is approximately equivalent in analgesic activity to 10 mg of morphine or 75 mg of meperidine.

Indications: IV:
• for analgesic action of short duration during the anesthetic periods, premedication, induction and maintenance, and in the immediate postoperative period (recovery room) as the need arises.
• for use as a narcotic analgesic supplement in general or regional anesthesia.
• for administration with a neuroleptic such as droperidol injection as an anesthetic premedication, for the induction of anesthesia and as an adjunct in the maintenance of general and regional anesthesia.
• for use as an anesthetic agent with oxygen in selected high risk patients, such as those undergoing open heart surgery or certain complicated neurological or orthopedic procedures.

Contraindications: Fentanyl Citrate Injection is contraindicated in patients with known intolerance to the drug

Adverse Reactions:
• As with other narcotic analgesics, the most common serious adverse reactions reported to occur with fentanyl are respiratory depression, apnea, rigidity and bradycardia; if these remain untreated, respiratory arrest, circulatory depression or cardiac arrest could occur.
• Other adverse reactions that have been reported are hypertension, hypotension, dizziness, blurred vision, nausea, emesis, laryngospasm and diaphoresis.
• It has been reported that secondary rebound respiratory depression may occasionally occur. Patients should be monitored for this possibility and appropriate countermeasures taken as necessary.


How Supplied:
Fentanyl Citrate Injection, USP, equivalent to 50 mcg (0.05 mg) fentanyl base per mL, is available as follows:

IV:
10 mL DOSETTE ampuls
20 mL DOSETTE ampuls
30 mL Single Dose vials (NOT recommended due to OD risk)
50 mL Single Dose vials (NOT recommended due to OD risk)
Dosage and Administration
Adult: 1 mcg/kg. to max. 150 mcg. slow IV push.

Pediatric: The safety and efficacy of fentanyl citrate in pediatric patients under two years of age has not been established.

Nasal administration may be permitted by the State Treatment Protocols in certain cases.


Duration of Action
Onset: The onset of action of fentanyl is almost immediate when the drug is given intravenously; however, the maximal analgesic and respiratory depressant effect may not be noted for several minutes.

Peak effect: The peak respiratory depressant effect of a single intravenous dose of fentanyl citrate is noted as 5 to 15 minutes following injection

Duration: The usual duration of action of the analgesic effect is 30 to 60 minutes after a single intravenous dose of up to 100 mcg.


Special Considerations
Pregnancy safety: Category C

Class
Loop diuretic.
Mechanism of Action
Inhibits electrolyte reabsorption and promotes excretion of sodium, potassium, chloride.
Indications
CHF; Pulmonary edema, hypertensive crisis.
Contraindications
Hypovolemia, anuria, hypotension (relative contraindication); hypersensitivity, hepatic coma.
Adverse Reactions
May exacerbate Hypovolemia, hypokalemia, ECG changes, dry mouth, hypochloremia, hyponatremia, hyperglycemia (due to hemoconcentration).
Drug Interactions
Lithium toxicity may be potentated by sodium depletion.
Digitalis toxicity may be potentated by potassium depletion.
How Supplied
100 mg / 5 ml, 20 mg / 2 ml, 40 mg / 4 ml vials.
Dosage and Administration
Adult: 0.5-1.0 mg / kg injected slowly IV.
Pediatric: 1 mg / kg / dose IV, IO.
Duration of Action
Onset: 5 minutes.
Peak Effects: 20-60 minutes.
Duration: 4-6 hours.
Special Considerations
Pregnancy safety: Category C.
Ototoxicity and deafness can occur with rapid administration.
Should be protected from light.

Class
Hyperglycemic agent, pancreatic hormone, insulin antagonist.
Mechanism of Action
Increases blood glucose by stimulating glycolysis.
Unknown mechanism of stabilizing cardiac rhythm in beta-blocker overdose.
Minimal positive inotrope and chronotrope.
Decreases GI motility and secretions.
Indications
Altered level of consciousness when hypoglycemia is suspected.
May be used as inotropic agent in beta-blocker overdose.
Contraindications
Hyperglycemia, hypersensitivity.
Adverse Reactions
Nausea, vomiting.
Tachycardia, hypertension.
Drug Interactions
Incompatible in solution with most other substances.
No significant drug interactions with other emergency medications.
How Supplied
1 mg ampules (requires reconstitution with diluent provided)
Dosage and Administration
Adult: 0.5 - 1 mg IM, SC, or slow IV; may repeat q 20 minutes PRN.
Pediatric: 0.03 - 0.1 mg / kg / dose (not to exceed 1 mg) q 20 min. IM, IO, SC, slow IV.
Nasal administration may be permitted by the State Treatment Protocols in certain cases.
Duration of Action
Onset: I minute.
Peak effect: 30 minutes.
Duration: Variable (generally 9-17 minutes).
Special Considerations
Pregnancy safety: Category C.
Ineffective if glycogen stores depleted.
Should always be used in conjunction with 50% dextrose whenever possible.
If patient does not respond to second dose glucagon, 50% dextrose must be administered.

Class
Hyperglycemic.
Mechanism of Action
Provides quickly absorbed glucose to increase blood glucose levels.
Indications
Conscious patients with suspected hypoglycemia.
Contraindications
Decreased level of consciousness, nausea, vomiting.
Adverse Reactions
Nausea, vomiting.
Drug Interactions
None.
How Supplied
Glucola: 300 ml bottles.
Glucose pastes and gels in various forms.
Dosage and Administration
Adult: Should be sipped slowly by patient until clinical improvement noted.
Pediatric: Same as adult.
Duration of Action
Onset: Immediate.
Peak Effect: Variable.
Duration: Variable.
Special Considerations
As noted in indications section.

Class
Chimeric monoclonal antibody fragment specific for platelet glycoprotein IIb/IIIa receptors.
Mechanism of Action
Blocks Platelet aggregation and thrombus formation
Indications
Adjunct to percutaneous transluminal angioplasty.
Adjunct to thrombolytic agents.
Unstable angina not responsive to conventional medical therapy
when percutaneous angioplasty is planned within 24 hours.
Contraindications
Active internal hemorrhage.
Clinically significant hemorrhage (GI, GU) within last 6 weeks.
Cerebrovascular accident within past 2 years.
Bleeding disorders.
Thrombocytopenia (low platelets / < 100,000)
Major surgery or trauma within last 6 weeks.
Intracranial tumor, A/V malformation or aneurysm.
Severe Hypertension, Vasculitis.
Use of Dextran before PTCA or intent to use Dextran during PTCA.
Hypersensitivity.
Adverse Reactions
Major bleeding.
Intracranial bleeding.
Thrombocytopenia.
Drug Interactions
Oral anticoagulants contraindicated.
Concurrent Dextran contraindicated.
Concurrent Heparin will increase risk of bleeding.
How Supplied
Intravenous doses (bolus / infusion), variable depending upon Brand utilized.
Dosage and Administration
Variable depending upon Brand utilized
Duration of Action
Onset: Variable: 1.5 - 2.5 Hours.
Peak Effect: Variable: 2 - 3 Hours.
Duration: 2 Hours - 2 Days.
Special Considerations
Major bleeding in 14% of coronary angioplasty patients.
Bleeding from open areas may occur (catheter site).
Pregnancy Category: C

Class
Anticoagulant.
Mechanism of Action
Prevents conversion of fibrinogen to fibrin and affect clotting factors: IX, XI, XII, plasmin.
Does not lyse existing clots.
Indications
Prophylaxis and treatment of : venous thrombosis, pulmonary embolus, coronary occlusion, disseminated intravascular coagulation (DIC), post-operative thrombosis.
To maintain patency of IV injection devices and indwelling catheters.
Contraindication
Hypersensitivity.
Patients on antiplatelet drugs (relative contraindication).
Adverse Reactions
Hemorrhage, thrombocytopenia, allergic reactions (chills, fever, back pain).
Drug Interactions
Salicylates, some antibiotics and quinidine may increase risk of bleeding.
How Supplied
Heparin lock flush solutions in 10 and 100-unit / ml ampules and prefilled syringes.
1,000 - 40,000 units / ml ampules.
Dosage and Administration
Adult: Loading dose: 80 units / kg IV; maintenance dose: 18 units / kg / hour IV.
Pediatric: Loading dose: 50 u / kg IV; maintenance dose: 7.5 units / kg / hour IV.
Duration of Action
Onset: Immediate.
Peak Effect: Variable.
Duration: 4 hours after continuous infusion discontinued.
Special Considerations
May be neutralized with protamine sulfate at 1 mg protamine / 100 u Heparin: give slowly IV over 1-3 minutes.

Class
corticosteroid.
Mechanism of Action
Replaces absent glucocorticoids; suppresses acute and chronic inflammation; immunosuppressive effects.
Indications
Anaphylaxis, asthma, spinal cord injury, croup, elevated intracranial pressure (prevention and treatment), adrenal insufficiency, as an adjunct to treatment of shock.
Contraindications
Hypersensitivity to product.
Adverse Reactions
Hypertension, sodium and water retention, GI bleeding, TB.
None from single dose.
Drug Interactions
Calcium
Metaraminol.
How Supplied
Hydrocortisone 100 mg/ 2 ml. vials.
Methylprednisolone 125 mg./2 ml. and 40 mg./2 ml. vials.
Dosage and Administration
Hydrocortisone, 2 mg./kg. IV bolus to maximum of 100 mg.; 100 mg. in adult.
Methylprednisolone 2 mg./kg/ IV bolus to maximum of 125 mg.; 125 mg. in adult.
Duration of Action
Onset: Minutes to Hours (depending on indication).
Peak effects: 8-12 hours.
Special Consideration
Protect medication from heat.
Toxicity and side effects with long-term use.

Class: Water soluble Vitamin

Pregnancy Category: C

Mechanism of Action:
Cyanide is an extremely toxic poison. In the absence of rapid and adequate treatment, exposure to a high dose of cyanide can result in death within minutes due to the inhibition of cytochrome oxidase resulting in arrest of cellular respiration. Specifically, cyanide binds rapidly with cytochrome a3, a component of the cytochrome c oxidase complex in mitochondria. Inhibition of cytochrome a3 prevents the cell from using oxygen and forces anaerobic metabolism, resulting in lactate production, cellular hypoxia and metabolic acidosis. In massive acute cyanide poisoning, the mechanism of toxicity may involve other enzyme systems as well. Signs and symptoms of acute systemic cyanide poisoning may develop rapidly within minutes, depending on the route and extent of cyanide exposure.

The action of hydroxocobalamin in the treatment of cyanide poisoning is based on its ability to bind cyanide ions. Each hydroxocobalamin molecule can bind one cyanide ion by substituting it for the hydroxo ligand linked to the trivalent cobalt ion, to form cyanocobalamin, which is then excreted in the urine.


Indications: Hydroxocobalamin is indicated for the treatment of known or suspected cyanide poisoning
.
Contraindications: None

Adverse Reactions
Serious adverse reactions with hydroxocobalamin include allergic reactions and increases in blood pressure.
Use caution in the management of patients with known anaphylactic reactions to hydroxocobalamin or cyanocobalamin. Consideration should be given to use of alternative therapies, if available.
Many patients with cyanide poisoning will be hypotensive; however, elevations in blood pressure have also been observed in known or suspected cyanide poisoning victims. Elevations in blood pressure (≥180 mmHg systolic or ≥110 mmHg diastolic) were observed in approximately 18% of healthy subjects (not exposed to cyanide) receiving hydroxocobalamin 5 g and 28% of subjects receiving 10 g. Increases in blood pressure were noted shortly after the infusions were started; the maximal increase in blood pressure was observed toward the end of the infusion. These elevations were generally transient and returned to baseline levels within 4 hours of dosing.


Drug Interactions
No formal drug interaction studies have been conducted with hydroxocobalamin


HYDROXOCOBALAMIN (Vitamin B 12)

How Supplied: Hydroxocobalamin is supplied in vials containing 2.5 grams of hydroxocobalamin which are to be diluted in 100 ml of normal saline. Hydroxocobalamin is given as a 5 gram IV dose.

Dosage and Administration:
The starting dose of hydroxocobalamin for adults is 5 g (i.e., both 2.5g vials) administered as an intravenous (IV) infusion over 15 minutes (approximately 15 mL/min), i.e., 7.5 minutes/vial. Depending upon the severity of the poisoning and the clinical response, a second dose of 5 g may be administered by IV infusion for a total dose of 10 g. The rate of infusion for the second dose may range from 15 minutes (for patients in extremis) to two hours, as clinically indicated.

The pediatric dose is 70 mg/kg. This dose should be given over 15 minutes.

Duration of Action

Special Considerations:

1. Emergency Patient Management
In addition to Cyanokit, treatment of cyanide poisoning must include immediate attention to airway patency, adequacy of oxygenation and hydration, cardiovascular support, and management of any seizure activity. Consideration should be given to decontamination measures based on the route of exposure.

2. Use with other cyanide antidotes:
Caution should be exercised when administering other cyanide antidotes simultaneously with Hydroxocobalamin, as the safety of co-administration has not been established. If a decision is made to administer another cyanide antidote with Hydroxocobalamin, these drugs should not be administered concurrently in the same IV line.

3. Preparation of Solution for Infusion
Each 2.5 g vial of hydroxocobalamin for injection is to be reconstituted with 100 mL of diluent (not provided with Cyanokit) using the supplied sterile transfer spike. The recommended diluent is 0.9% Sodium Chloride injection (0.9% NaCl). Lactated Ringers injection and 5% Dextrose injection (D5W) have also been found to be compatible with hydroxocobalamin and may be used if 0.9% NaCl is not readily available. The line on each vial label represents 100 mL volume of diluent. Following the addition of diluent to the lyophilized powder, each vial should be repeatedly inverted or rocked, not shaken, for at least 30 seconds prior to infusion.

Hydroxocobalamin solutions should be visually inspected for particulate matter and color prior to administration. If the reconstituted solution is not dark red or if particulate matter is seen after the solution has been appropriately mixed, the solution should be discarded.

Class
Antidiabetic.
Mechanism of Action
Allows glucose transport into cells of all tissues; converts glycogen to fat; produces intracellular shift of potassium and magnesium to reduce elevated serum levels of these electrolytes.
Indications
Not used in emergency pre-hospital setting.
Diabetic ketoacidosis or other hyperglycemic state.
Hyperkalemia. (Insulin and D50 used together to lower hyperkalemic state).
Non-ketotic hyperosmolar coma.
Contraindications
Hypoglycemia, hypokalemia.
Adverse Reactions
Hypokalemia, hypoglycemia,, weakness, fatigue, confusion, headache, tachycardia, nausea, diaphoresis.
Drug Interactions
Incompatible in solution with all other drugs..
Corticosteroids, dobutamine, epinephrine and thiazide diuretics decrease the hypoglycemic effects of insulin.
Alcohol and salicylates may potentate the effects of insulin.
How Supplied
10 ml Vials of 100 Units / ml.
Dosage and Administration
Dosage adjusted relative to blood sugar levels.
May be given SC, IM or IV.
Standard doses for diabetic coma
Adult: 10-25 units Regular insulin IV, followed by infusion of 0.1 units / kg / hour.
Pediatric: 0.1 - 0.2 units / kg / hour IV or IM followed by infusion: 50 units of regular insulin mixed in 250 ml of NS (0.2 units / ml), at a rate of 0.1 - 0.2 units / kg / hour.
Duration of Action
Onset: Minutes
Peak Effect: Approximately 1 hour (short-acting); 3-6 hours (intermediate-acting); 5-8 hours (long-acting).
Duration: Approximately 6-8 hours (short-acting); 24 hour (intermediate-acting); 36 hour (long-acting).
Special Considerations
Insulin is drug of choice for control of diabetes in pregnancy.
Usually require refrigeration.
Most rapid absorption if injected in abdominal wall; next most rapid absorption: arm; slowest absorption if injected into the thigh.

Class: Bronchodilator


Mechanism of Action: Blocks the action of acetylcholine at the parasympathetic sites in bronchial smooth muscle causing bronchodilitation.

Indications: Used in bronchospasm especially associated with COPD, and emphysema.

Contraindications: Hypersensitivity to atropine or its derivatives.
Adverse Reactions:
Ipratropium is poorly absorbed from the lung, so systemic effects are rare.

>10% CNS: Dizziness, Headache, Nervousness
Respiratory: Cough

1-10% Cardiac: Hypotention, palpitations


How Supplied: Nebulizing Ampule: 0.02% (2.5ml)
Inhaler: 18mcg/actuation


Dosage and Administration:

Adult: 2-3 puffs via metered dose inhaler (MDI) tid-qid; maximum 12 puffs/day.
ALT: 500mcg NEB q 6-8hrs (may mix neb solution with Albuterol if used within 1 hour)

Pediatric: < 12 yo: 1-2 puffs (MDI) tid-qid; max: 8 puffs
ALT: 250mcg NEB q 6-8hrs (may mix neb solution with Albuterol if used within 1 hour)

Kinetics:
Onset: 1-3 minutes after administration
Peak effects: Within 1.5- 2 hours
Duration of Action: Up to 4-6 hours
T1/2: 2 hrs after inhalation

Special Considerations

Pregnancy Safety: Category B.

Selective alpha and nonselective beta-adrenergic blocker, weak intrinsic sympathomimetic activity.

Cardiac effects include decreased heart rate, contractile force, and cardiac work load, which reduces myocardial oxygen consumption, enhances coronary artery blood flow, and improves myocardial perfusion. The antihypertensive mechanism of beta blockers is related to decreased cardiac output (negative inotropic and chronotropic effects), reduced adrenergic activity, and inhibition of renin release.

Half life 5-8 hours. Max effect with IV administration seen at about 5 minutes.

Contraindications
Asthma or COPD
Cardiogenic shock
Hypersensitivity to labetalol
Prolonged or severe hypotension
Overt cardiac failure
Second and third degree AV block
Sinus bradycardia

Serious adverse effects
Bronchospasm
Hepatotoxicity
Hyperkalemia (in renal transplant patients or on hemodialysis. Rare)
Ventricular arrhythmia
Allergic reaction

Precautions
Myocardial depression after surgery/anesthesia
Avoid abrupt withdrawal (rebound)
Bronchospastic disease
CHF
Diabetes
Hyperthyroidism
Ischemic heart disease
Liver disease
Peripheral vascular disease
Pheochromocytoma (paradoxical hypertension)
Postural hypotension

No dose adjustment required for renal failure
Lower doses required for hepatic insufficiency due to first pass metabolism
Lower doses may be required for elderly patients

Pregnancy class C
OK for breastfeeding

Class: Isotonic crystalloid

Mechanism of Action: Volume Replacement
.
Indications: Hypovolemic Shock


Contraindications: Congestive Heart failure, Renal Failure


Adverse Reactions: Rare


Drug Interactions: None

How Supplied: IV Infusion

Dosage and Administration:
Adult: (Systolic <90 mmHg) Infuse wide open until systolic pressure of 100mmHg is obtained.
(Systolic 100mmHg or >) Infuse at a rate of 100 ml/hr.

Pedi: 20 ml/kg repeated as required based on hemodynamic response

Class
Antidysrhythmic.
Mechanism of Action
Decreases automaticity by slowing the rate of spontaneous Phase 4 depolarization.
Indications
Suppression of ventricular dysrhythmias (V-tach, VF, PVCs).
Prophylaxis against recurrence after conversion from V-tach, VF.
Contraindications
Second degree and third degree blocks in absence of artificial pacemaker).
Hypotension.
Stokes Adams Syndrome.
Adverse Reactions
Slurred speech, seizures, altered mental status, confusion, lightheadedness, blurred vision, bradycardia.
Drug Interactions
Apnea induced with succinylcholine may be prolonged with high doses of Lidocaine.
Cardiac depression may occur in conjunction with IV Dilantin.
Procainamide may exacerbate the CNS effects.
Metabolic clearance decreased in patients with liver disease or those patients taking beta-blockers.
How Supplied
100 mg in 5 ml solution prefilled syringes.
1 and 2 gram additive syringes.
100 mg in 5 ml solution ampules.
1 and 2 gram vials in 30 ml of solution.
Dosage and Administration
Adult:
Cardiac arrest VT/ VF: 1.5 mg / kg IV push; repeat q 3-5 minutes to maximum dose of 3 mg/kg. After conversion to NSR, begin drip at 2-4 mg / min.
VT with pulse: 1-1.5 mg / kg IV Push; then 0.50 - 0.75 mg / kg q 5-10 min. to max. of 3 mg/kg. Start drip at 2-4 mg/min. ASAP.
PVCs with pulse: 0.5-1.5 mg/kg IV Push; additional boluses of 0.5-1.5 mg/kg q 5-10 min. to max. of 3 mg/kg. Start drip at 2-4 mg/ min. ASAP.
VF prophylaxis: 0.5 mg/kg IV Push; additional boluses 0.5 mg/kg in 8-10 minutes up to 2 mg/kg. Start drip at 2-4 mg/min. ASAP.
IM dose: 300 mg (4 mg/kg) of 10% solution.
Pediatric:
VF or Pulseless V-tach: 1 mg/kg IV / IO per dose. Infusion: 20-50 mcg/kg/min.
PVCs with pulse: 1 mg/kg IV / IO per dose. Infusion: 20-50 mcg/kg/min.
Duration of Action
Onset: 1-5 minutes.
Peak Effect: 5-10 minutes.
Duration: Variable. (15 min. - 2 hours).
Special Considerations
Pregnancy safety: Category B.
Reduce maintenance infusions by 50% if patient is over 70 years of age, has liver disease, or is in CHF or shock.
A 75-100 mg bolus maintains levels for only 20 minutes.
If bradycardia occurs with PVCs, always treat the bradycardia with atropine, Isoproterenol or both.
Exceedingly high doses of Lidocaine can result in coma or death.
Avoid Lidocaine for reperfusion dysrhythmias after thrombolytic therapy.
Cross-reactivity with other forms of local anesthetics.

Class
Benzodiazepine; sedative; anticonvulsant.
Mechanism of Action
Anxiolytic, anticonvulsant and sedative effects; suppresses propagation of seizure activity produced by foci in cortex, thalamus and limbic areas.
Indications
Initial control of status epilepticus or severe recurrent seizures.
Severe anxiety.
Sedation.
Contraindications
Acute narrow-angle glaucoma.
Coma, shock or suspected drug abuse.
Adverse Reactions
Respiratory depression, apnea, drowsiness, sedation, ataxia, psychomotor impairment, confusion.
Restlessness, delirium.
Hypotension, bradycardia.
Drug Interactions
May precipitate CNS depression if patient is already taking CNS depressant medications.
How Supplied
2 and 4 mg / ml concentrations in 1 ml vials.
Dosage and Administration
Note: When given IV or IO, must dilute with equal volume of sterile water or sterile saline; When given IM, Lorazepam is not to be diluted.
Adult: 2-4 mg slow IV at 2 mg / min. or IM; may repeat in 15-20 minutes to maximum dose of 8 mg. For sedation: 0.05 mg / kg up to 4 mg IM.
Pediatric: 0.05 - 0.20 mg / kg slow IV, IO slowly over 2 minutes or IM; may repeat in 15-20 minutes to maximum dose of 0.2 mg / kg.
Duration
Onset of action: 1-5 minutes.
Peak effect: variable.
Duration of action: 6-8 hours.
Special Considerations
Pregnancy safety: Category D.
Monitor BP and respiratory rate during administration.
Have advanced airway equipment readily available.
Inadvertent arterial injection may result in vasospasm and gangrene.
Lorazepam expires in 6 weeks if not refrigerated.

Note From DPH/Drug Control Program: Re: Storage of Lorazepam.
According to stability information, Lorazepam injection requires refrigeration and should be stored at 2 - 8º C (35 - 45º F). Lorazepam injection should be protected from light, which can be accomplished by retaining the vial in the carton until ready for use. In addition, freezing of the injection should be avoided. Ambulances are required to ensure stability of all drug products stored on site. Those ambulances unable to meet the above-mentioned storage conditions should refrain from using Lorazepam. For further information, contact the Drug Control Program at (617) 983-6700 or the Office of Emergency Medical Services at (617) 753-7300.

Class
Electrolyte
Mechanism of Action
Reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholinesterase release at the myoneural junction; manages seizures in toxemia of pregnancy; induces uterine relaxation; can cause bronchodilation after beta-agonists and anticholinergics have been used.
Indications
Seizures of eclampsia (Toxemia of pregnancy).
Torsades de Pointes.
Hypomagnesemia.
TCA overdose-induced dysrhythmias.
Digitalis-induced dysrhythmias.
Class IIa agent for refractory VF and VT after administration of Lidocaine doses.
Contraindications
Heart blocks.
Renal diseases.
Adverse Reactions
Respiratory and CNS depression.
Hypotension, cardiac arrest and asystole may occur.
Facial flushing, diaphoresis, depressed reflexes.
Circulatory collapse.
Drug Interactions
May enhance effects of other CNS depressants.
Serious changes in overall cardiac function may occur with cardiac glycosides.
How Supplied
2 ml and 10 ml vials of a 50% solution.
Dosage and Administration
Adult: Seizure activity associated with pregnancy: 1-4 gm IV over 10 minutes. For Torsades de Pointes or Refractory VF/VT: 1-2 grams IV over 1-2 minutes.
Pediatric: Asthma/bronchospasm, severe: 25 mg./kg. over 10 minutes IV.
Usually mixed in 50-100 CC of NS to be given IV.
Duration of Action
Onset: Immediate.
Peak effect: variable.
Duration: 3-4 hours.
Special Considerations
Pregnancy safety: Recommended that drug not be given in the 2 hours before delivery, if possible.
IV calcium gluconate or calcium chloride should be available as antagonist if needed.
Use with caution in patients with renal failure.
Magnesium sulfate is being used for acute MI patients in some systems under Medical Direction.

Class
Osmotic diuretic.
Mechanism of Action
Promotes the movement of fluid form the intracellular space to the extracellular space.
Decreases cerebral edema and intracranial pressure.
Promotes urinary excretion of toxins.
Indications
Cerebral edema.
Reduce intracranial pressure for certain cause (space-occupying lesions).
Rhabdomyolysis (myoglobinuria).
Blood transfusion reactions.
Contraindications
Hypotension, renal failure, electrolyte depletion, dehydration, intracranial bleeding.
Severe CHF with pulmonary edema
hyponatremia.
Adverse Reactions
CHF, pulmonary edema, hypertension, nausea, vomiting, headache, seizures, chest pain, tachycardia. Electrolyte depletion, dehydration, hypotension, sodium depletion.
Drug Interactions
May precipitate digitalis toxicity in when given concurrently.
How Supplied
250 ml and 500 ml of a 20% solution for IV infusion (200 mg / ml )
25% solution in 50 ml for slow IV push.
Dosage and Administration
Adult: 0.50g - 2 g / kg IV infusion over 15-30 minutes; may repeat after 5 minutes if no effect.
Pediatric: 0.5 - 1g / kg / dose IV, IO infusion over 30-60 minutes; may repeat after 30 minutes if no effect.
Duration of Action
Onset: 1-3 hours for diuretic effect; 15 minutes for reduction of intracranial pressure.
Peak effect: variable.
Duration: 4-6 hours for diuretic effect; 3-8 hours for reduction of ICP.
Special Considerations
Pregnancy safety: Category C.
May crystallize at temperatures below 7.8 degrees Centigrade.
In-line filter should always be used.
Effectiveness depends upon large doses and an intact blood-brain barrier.
Usage and dosages in emergency care are controversial.

Class
Opioid Analgesic
Mechanism of Action
Synthetic opioid agonist that acts on opioid receptors to produce analgesia, euphoria, respiratory and physical depression; a schedule II drug with potential for physical dependency and abuse.
Indications
Analgesia for moderate to severe pain.
Contraindications
Hypersensitivity to narcotic agents.
Diarrhea caused by poisoning.
Patients taking MAOIs.
During labor or delivery of a premature infant.
Undiagnosed abdominal pain or head injury.
Adverse Reactions
Respiratory depression, sedation, apnea, circulatory depression, dysrhythmias, shock.
Euphoria, delirium, agitation, hallucinations, visual disturbances, coma.
Seizures, headache, facial flushing.
Increased ICP, nausea, vomiting.
Drug Interactions:
Do not give concurrently with MAOIs (even with a dose in the last 14 days!).
Exacerbates CNS depression when given with these medications.
How Supplied
50 / ml in 1 ml pre-filled syringes and Tubex.
Dosage and Administration
Adult: 50-100 mg IM, SC or 25 - 50 mg slowly IV.
Pediatric: 1-2 mg / kg / dose IV, IO, IM, SC.
Duration of Action
Onset: IM: 10-45 minutes; IV: immediate.
Peak effect: 30-60 minutes.
Duration: 2-4 hours.
Special Considerations
Pregnancy safety: Category C.
Use with caution in patients with asthma and COPD.
May aggravate seizures in patients with known convulsive disorders.
Naloxone should be readily available as antagonist.

Class: Antianginal; Antihypertensive Agent; Beta Blocker

Mechanism of Action: Selective inhibitor of beta1-adrenergic receptors; completely blocks beta1 receptors , with little or no effect on beta 2 receptors at doses <100 mg;

Indications: Treatment of hypertension and angina pectoris; prevention of myocardial infarction, atrial fibrillation, flutter, symptomatic treatment of hypertrophic subaortic stenosis; to reduce increased sympathetic stimuli in acute MI.

Contraindications: Hypersensitivity to metoprolol or any component of the formulation; sinus bradycardia; heart block greater than first degree (except in patients with a functioning artificial pacemaker); cardiogenic shock; uncompensated cardiac failure; pregnancy (2nd and 3rd trimesters)

Adverse Reactions:
Respiratory: Bronchospasm
Cardiovascular: Bradycardia, palpitations, edema, congestive heart failure, reduced peripheral circulation.
Central nervous system: Drowsiness, insomnia.

Drug Interactions:
Drugs which slow AV conduction (digoxin): effects may be additive with beta-blockers.
Glucagon: Metoprolol may blunt the hyperglycemic action of glucagon.
Verapamil or diltiazem may have synergistic or additive pharmacological effects when taken concurrently with beta-blockers; avoid concurrent I.V. use.

How Supplied: Metoprolol tartrate, is a selective beta1-adrenoreceptor blocking agent, available in 5-ml (1mg/ml) ampuls for intravenous administration.

Dosage and Administration:
Adults: I.V.
Hypertension: Has been given in dosages 1.25-5 mg every 6-12 hours in patients unable to take oral medications

Myocardial infarction (acute): I.V. 5 mg every 5-10 minutes up to 3 doses in early treatment of myocardial infarction.

Duration of Action: Peak antihypertensive effect:
Oral: Within 1.5-4 hours
Duration: 10-20 hours
Half-life: 3-4 hours; End-stage renal disease: 2.5-4.5 hours


Special Considerations:
Pregnancy Safety: Category C (manufacturer); D (2nd and 3rd trimesters - expert analysis)

Not recommended in pediatric population. The safety and effectiveness of Metoprolol have not been established in children

Class
Short-acting benzodiazepine CNS depressant.
Mechanism of Action
Anxiolytic and sedative properties similar to other benzodiazepines.
Memory impairment.
Indications
Sedation, Anxiolytic prior to endotracheal or nasotracheal intubation.
Administer for conscious sedation.
Contraindications
Glaucoma, shock, coma, alcohol intoxication, overdose patient.
Depressed vital signs.
Concomitant use with other CNS depressants, barbiturates, alcohol, narcotics.
Adverse Reactions
Hiccough, cough, over-sedation, nausea, vomiting, injection site pain, headache, blurred vision.
Hypotension, respiratory depression and arrest.
Drug Interactions
Should not be used in patients who have taken CNS depressant.
How Supplied
2, 5, 10 ml vials (1 mg / ml).
1, 2, 5, 10 ml vials (5 mg/ ml).
Dosage and Administration
Adult: 0.5 - 2.5 mg slow IV push;
(may be repeated to total maximum: 0.1 mg / kg).

Pediatric: To facilitate intubation: Medical control may order:
(6 months- 5 years) Use of Midazolam 0.05-0.1 mg/kg IV maximum dose of 5 mg.
(6-12 year old) Use of Midazolam 0.1 mg/kg IV maximum dose of 8 mg.

WMD: (See APPENDIX Dosing Table)
Nasal administration may be permitted by the State Treatment Protocols in certain cases.
Duration of Action
Onset: 1-3 minutes IV and dose dependent.
Peak effect: variable.
Duration: 2-6 hours and dose dependent.
Special Considerations
Pregnancy safety: category D.
Administer immediately prior to intubation procedure.
Requires continuous monitoring of respiratory and cardiac function.

Class
Opioid analgesic. (Schedule II drug).
Mechanism of Action
Alleviates pain through CNS actions
Suppresses fear and anxiety centers in brain.
Depresses brain stem respiratory centers.
Increases peripheral venous capacitance and decreases venous return.
Decreases preload and afterload, decreasing myocardial oxygen demand.
Indications
Analgesia for moderate to severe acute and chronic pain (use with caution).
Severe CHF, pulmonary edema.
Chest pain associated with acute MI.
Contraindications
Head injury, exacerbated COPD, depressed respiratory drive, hypotension.
Undiagnosed abdominal pain, decreased level of consciousness.
Suspected hypovolemia.
Patients who have taken MAOIs within past 14 days.
Adverse Reactions
Respiratory depression, hypotension, decreased level of consciousness, nausea, vomiting.
Bradycardia, tachycardia, syncope, facial flushing, euphoria, bronchospasm, dry mouth.
Drug Interactions
Potentates sedative effects of phenothiaxines.
CNS depressant may potentate effects of morphine.
MAOIs may cause paradoxical excitation.
How Supplied
10 mg in 1 ml of solution, ampules and Tubex syringes.
Dosage and Administration
Adult: 1-3 mg IV/IM/SC/IO every 5 minutes titrated to maximum of 10 mg.
Adult: Morphine 0.1mg/kg to a maximum of 10mg IV/IM/SC/IO
~
Pediatric: 0.1 - 0.2 mg / kg / dose IV, IO, IM, SC every 5 minutes titrated to max. of 5 mg.
Duration of Action
Onset: Immediate.
Peak effect: 20 minutes.
Duration: 2 - 7 hours.
Special Considerations
Pregnancy safety: Category C.
Morphine rapidly crosses the placenta.
Safety in neonate not established.
Use with caution in geriatric population and those with COPD, asthma.
Vagotonic effect in patient with acute inferior MI (bradycardia, heart block).
Naloxone should be readily available as antidote.

Class
Narcotic antagonist
Mechanism of Action
Competitive inhibition at narcotic receptor sites.
Reverse respiratory depression secondary to depressant drugs.
Completely inhibits t effect of morphine.
Indications
Opiate overdose, coma.
Complete or partial reversal of CNS and respiratory depression induced by opioids
Narcotic agonist
Morphine, heroin, hydromorphone (Dilaudid), methadone.
Meperidine (Demerol), Paregoric, Fentanyl (Sublimase).
Oxycodone (Percodan), codeine, propoxyphene (Darvon).
Narcotic agonist and antagonist
Butorphanol (Stadol).
Pentazocine (Talwin).
Nalbuphine (Nubain).
Decreased level of consciousness.
Coma of unknown origin.
Contraindications
Use with caution in narcotic-dependent patients.
Use with caution in neonates of narcotic-addicted mothers.
Adverse Reactions
Withdrawal symptoms in the addicted patient.
Tachycardia, hypertension, dysrhythmias, nausea, vomiting, diaphoresis.
Drug Interactions
Incompatible with bisulfite and alkaline solutions.
How Supplied
0.02 mg / ml (neonate); 0.4 mg/ml, 1 mg/ml; 2.0 mg / 5 ml ampules; 2 mg/5 ml prefilled syringe.
Dosage and Administration
Adult: 0.4 - 2.0 mg IV, IM, SC, Nasal via atomizer; min. recommended = 2.0 mg repeat at 5 minute intervals to 10 mg maximum dose. (Medical Control may request higher amounts). Infusion: 2 mg in 500 ml of D5W (4 mcg/ml), infuse at 0.4 mg / hr (100 ml/hour).

Pediatric: 0.1 mg / kg / dose IV, IM, SC; maximum of 0.8 mg; if no response in 10 minutes, administer an additional 0.1 mg / kg /dose.
Duration of Action
Onset: within 2 minutes.
Peak effect: variable.
Duration: 30-60 minutes.
Special Considerations
Pregnancy safety: category B.
Seizures without causal relationship have been reported.
May not reverse hypotension.
Use caution when administering to narcotic addicts (violent behavior, etc.).

Calcium channel blocker resulting in coronary and peripheral vasodilatation, often with a compensatory elevation in heart rate. It increases the cardiac index and cardiac output while reducing the systemic vascular resistance. There are no antiarrhythmic effects.
Metabolized by the liver.

Peak response in about 2 minutes. Half life 44-107 minutes for a single IV dose.

Contraindications
Advanced aortic stenosis
Asphyxia (neonates)
Hypersensitivity to calcium channel antagonists

Adverse reactions
Arteriolar dilator with peripheral effects (edema, flushing, reflex tachycardia or palpitations, usually transient
Prolonged PR interval or bundle branch blocks
Flushing
Tinnitus
Acute pulmonary edema

Precautions
CHF
Exacerbation of angina during initial therapy, with dose increases, or during B blocker withdrawal
Hepatic or renal impairment
Persistent dermatologic reaction progressing to erythema multiforme or exfoliative dermatitis
Pheochromocytoma
Portal hypertension
Symptomatic hypotension

No dose adjustment required for renal failure

Pregnancy class C
Inadequate information for breast feeding

Class
Vasodilators.
Mechanism of Action
Smooth muscle relaxant acting on vascular, bronchial, uterine and intestinal smooth muscle.
Dilation of arterioles and veins in the periphery, reduces preload and afterload, decreases the work load of the heart and, thereby, myocardial oxygen demand.
Indications
Acute angina pectoris.
Ischemic chest pain.
Hypertension.
CHF, pulmonary edema.
Contraindications
Hypotension, hypovolemia.
Intracranial bleeding or head injury.
Adverse Reactions
Headache, hypotension, syncope, reflex tachycardia, flushing.
Nausea, vomiting, diaphoresis, muscle twitching.
Drug Interactions
Additive effects with other vasodilators.
Incompatible with other drugs IV.
How Supplied
Tablets: 0.15 mg (1/400 grain); 0.3 mg (1/200 grain); 0.4 mg (1/150 grain); 0.6 mg (1/100 grain).
NTG spray: 0.4 mg - 0.8 mg under the tongue.
NTG IV (TRIDIL).
Dosage and Administration
Adult:
Tablets: 0.3 - 0.4 mg SL; may repeat in 3-5 minutes to maximum of 3 doses.
NTG spray: 0.4 mg under the tongue; 1-2 sprays.
NTG IV infusion: 5 ug / min.; increase by 5-10 ug / min. every 5 minutes until desired effect.
Pediatric: not recommended.
Duration of Action
Onset: 1-3 minutes.
Peak effect: 5-10 minutes.
Duration: 20-30 minutes or if IV, 1-10 minutes after discontinuation of infusion.
Special Considerations
Pregnancy safety: category C.
Hypotension more common in geriatric population.
NTG decomposes if exposed to light or heat.
Must be kept in airtight containers.
Active ingredient may have a stinging effect when administered SL.

Class: Vasodilator

Mechanism of Action: Smooth muscle relaxant acting on vascular, bronchial, uterine and intestinal smooth muscle. Dilation of arterioles and veins in the periphery reduces preload and afterload, decreases the work load of the heart and, thereby, myocardial oxygen demand.

Indications: Angina pectoris and chest pain associated with acute MI, CHF/PE; Hypertension (HTN).

Contraindications: Hypotension, hypovolemia, Intracranial bleeding or head injury.

Adverse Reactions: Headache, hypotension, syncope, reflex tachycardia, flushing.
Nausea, vomiting, diaphoresis, muscle twitching.

How Supplied: Topical Ointment: (Nitrol) 2% [20 mg/g] (30g, 60g)

Dosage and Administration
Adult: For CHF/PE; HTN
Paste: Apply 1 inch, cover with plastic wrap and secure with tape.

Pediatric: not recommended

Duration of Action
Onset: 30 minutes.
Peak effect: Variable.
Duration: 18-24 hours.

Special Considerations
Pregnancy safety: Category C.

Apply in thin uniform layer on non-hairy area.
1 inch equals approximately 15 mg nitroglycerin.
Avoid using fingers to spread paste.
Store past in cool place with tube tightly capped.
Erratic absorption rates quite common.

Class: Endocrine-metabolic

Mechanism of Action: reduces variceal bleeding

Indications: GI bleed due to varices

Contraindications: Hypersensitivity to octreotide or any of the formulation’s components

Adverse Reactions:
Hyperglycemia, hypoglycemia, nausea, headache, drowsiness, bradycardia


How Supplied:
Injection, solution varying concentrations,

Dosage and Administration

Adult: as per infusion orders.


Duration of Action

Half-life elimination: Adults: ~1.7 hours

Special Considerations
Pregnancy safety: Category B

Class: Antiemetic

Mechanism of Action: Selective 5-HT receptor antagonist, blocking serotonin, both peripherally on vagal nerve terminals and centrally in the CNS chemoreceptor trigger zone

Indications: Treatment and prevention of nausea and vomiting

Contraindications: Hypersensitivity to ondansetron, other selective 5-HT3 antagonists, or any component of the formulation

Adverse Reactions:
Headache, drowsiness, pruritus


How Supplied:
Infusion as hydrochloride [premixed in D5WJ (Zofran: 32 mg (50 mL)
Injection, solution, as hydrochloride (Zofran): 2 mg/mL (2 mL, 20 mL)
Solution, as hydrochloride (Zofran: 4 mg/5 mL (50 mL) [contains sodium benzoate; strawberry flavor]

Dosage and Administration:
Children:
For child under or up to 30 kg. 1 mg. IV/IM;
For a child over 30 kg., 2 mg. IV/IM.

Adults:
Adult: 4 mg. IV/IM.


Duration of Action

Onset of action: ~30 minutes
Half-life elimination: Children <5 years: 2-3 hours;
Adults: 3-6 hours

Special Considerations
Pregnancy safety: Category B

Class
Naturally occurring atmospheric gas
Mechanism of Action
Reverses hypoxemia.
Indications
Confirmed or expected hypoxemia.
Ischemic chest pain.
Respiratory insufficiency.
Prophylactically during air transport.
Confirmed or suspected carbon monoxide poisoning.
All other causes of decreased tissue oxygenation.
Decreased level of consciousness.
Contraindications
Certain patients with COPD, emphysema who will not tolerate Oxygen concentrations over 35%.
Hyperventilation.
Adverse Reactions
Decreased level of consciousness and respiratory depression in patients with chronic CO2 retention.
Retrolental fibroplasia if given in high concentrations to premature infants. (maintain 30-40% 02)
Drug Interactions
None.
How Supplied
Oxygen cylinders (usually green and white) of 100% compressed oxygen gas).

Dosage and Administration
Adult:
Cardiac arrest and Carbon Monoxide poisoning: 100%.
Hypoxemia: 10-15 L/ min. via non-rebreather.
COPD: 0-2 L/ min. via nasal cannula or 28-35% venturi mask. Be prepared
to provide ventilatory support if higher concentrations of oxygen needed.
Pediatric: Same as for adult with exception of premature infant.

Duration of Action
Onset: Immediate.
Peak effect: not applicable.
Duration: Less than 2 minutes.
Special Considerations
Be familiar with liter flow and each type of delivery device used.
Supports possibility of combustion.

Class
Cholinesterase reactivator.
Mechanism of Action
Reactivation of cholinesterase to effectively act as an antidote to organophosphate pesticide poisoning. This action allows for destruction of accumulated acetylcholine at the neuromuscular junction.
Indications
As an antidote in the treatment of poisoning by organophosphate pesticides and chemicals.
In the pre-hospital arena, is used when atropine is or has become ineffective in management of organophosphate poisoning.
Contraindications
Use with caution in patients with reduced renal function.
Patients with myasthenia gravis and organophosphate poisoning.
Adverse Reactions
Dizziness, blurred vision, diplopia, headache, drowsiness, nausea, tachycardia, hyperventilation, muscular weakness, excitement and manic behavior
Drug Interactions
No direct drug interactions, however, patients with organophosphate poisoning should not be given barbiturates, morphine, theophylline, aminophylline, succinylcholine, reserpine and phenothiazines.
How Supplied
Emergency Single Dose Kit containing:
One 20 ml vial of 1 gram sterile Protopam Chloride.
One 20 ml ampule of sterile diluent.
Sterile, disposable 20 ml syringe.
Needle and alcohol swab.
Dosage and Administration
NOTE: If Protopam is to be used, it should be administered almost simultaneously with atropine.
Adult: Initial dose of 1-2 grams as an IV infusion with 100 ml saline over 15-30 minutes.
Pediatric: 20-40 mg / kg as IV infusion over 15-30 minutes.
Doses may be repeated every 1 (one) hour if muscle weakness persists.
If IV administration is not feasible, IM or SC injection may be utilized.
For Autoinjectors: (See Nerve Agent Antidote)
Duration of Action
Onset: Minutes
Peak effects: Variable.
Duration: Variable
Special Considerations
Pregnancy safety: unknown.
Treatment will be most effective if given within a few hours after poisoning.
Cardiac monitoring should be considered in all cases of severe organophosphate poisoning.

Class
Antidysrhythmic Class Ia
Mechanism of Action
Suppresses phase IV depolarization in normal ventricular muscle and Purkinje fibers, reducing automaticity of ectopic pacemakers; suppresses reentry dysrhythmias by slowing intraventricular conduction.
Indications
Suppress PVCs refractory to Lidocaine.
Suppress VT with a pulse refractory to Lidocaine.
PSVTs with wide-complex tachycardia of unknown origin (drug of choice when associated with WP).
Contraindications
Second and Third Degree block.
Torsades de Pointes.
Lupus.
Digitalis toxicity.
Myasthenia gravis.
Adverse Reactions
PR, QRS, and QT widening, AV Block, cardiac arrest, hypotension, seizures.
Nausea, vomiting, reflex tachycardia, PVCs, VT, VF.
CNS depression, confusion.
Drug Interaction
None with other emergency drugs.
How Supplied
1 gram in 10 ml vial (100 mg / ml).
1 gram in 2 ml vials (500 mg / ml) for infusion.
Dosage and Administration
Adult: 20-30 mg / min.; maximum total dose is 17 mg / kg. Maintenance infusion: 1-4 mg / min.
Pediatric: 2-6 mg / kg IV, IO at less than 20 mg / min.; maximum dose is 17 mg / kg. Maintenance infusion: 20-80 micrograms/kg/min.

Duration of Action
Onset: 10-30 minutes.
Peak effect: Variable.
Duration: 3-6 hours.
Special Considerations
Discontinue infusion if hypotension develops, the QRS complex widens by 50% of its original width or a total of 17 mg / kg has been administered or if the dysrhythmia is suppressed.
Pregnancy safety: Category C.
Potent vasodilating and inotropic effects.
Hypotension with too rapid an infusion.
Carefully monitor vital signs and ECG.
Administer cautiously to patients with renal, hepatic or cardiac insufficiency.
Administer cautiously to patients with asthma or digitalis-induced dysrhythmias.

Class Buffer, alkalinizer.
Mechanism of Action
Reacts with hydrogen ions to form water and carbon dioxide thereby acting as a buffer for metabolic acidosis.
Indications
Known pre-existing bicarbonate-responsive acidosis.
Upon return of spontaneous circulation after long arrest interval.
TCA overdose.
Hyperkalemia.
Phenobarbital overdose.
Alkalinization for treatment of specific intoxications.
Contraindications
Metabolic and respiratory alkalosis.
Hypocalcemia and hypokalemia.
Hypocloremia secondary to GI loss and vomiting.
Adverse Reactions
Metabolic alkalosis, hypokalemia, hyperosmolarity, fluid overload.
Increase in tissue acidosis.
Electrolyte imbalance and tetany, seizures.
Tissue sloughing at injection site.
Drug Interactions
May precipitate in calcium solutions.
Half-lives of certain drugs may increase through alkalinization of the urine.
Vasopressors may be deactivated.
How Supplied
50 mEq in 50 ml of solvent.
Dosage and Administration
Adult: 1 mEq / kg IV; may repeat with 0.5 mEq / kg every 10 minutes.
Pediatric: same as for adult.

Adult infusion: 1 – 4 amps in 1 liter D5W or NS, rate determined by sending physician.
Pediatric infusion: same as for adult.

Duration of Action
Onset: 2-10 minutes.
Peak effect: 15-20 minutes.
Duration: 30-60 minutes.
Special Considerations
Pregnancy safety: Category C.
Must ventilate patient after administration.
Whenever possible, blood gas analysis should guide use of bicarbonate.
Intracellular acidosis may be worsened by production of carbon dioxide.
May increase edematous states.
May worsen CHF.

Class Thrombolytic agent.
Mechanism of Action
Combines with plasminogen to produce an activator complex that converts free plasminogen to the proteolytic enzyme plasmin. Plasmin degrades fibrin threads as well as fibrinogen, causing clot lysis.
Indications
Acute evolving MI.
Massive pulmonary emboli.
Arterial thrombosis and embolism.
To clear arteriovenous cannulas.
Contraindications
Hypersensitivity.
Active bleeding, recent surgery (within 2-4 weeks), recent CVA.
Prolonged CPR.
Intracranial or intraspinal neoplasm, arteriovenous malformation or surgery.
Recent significant trauma (particularly head trauma).
Uncontrolled hypertension.
Adverse Reactions
Bleeding (GU, GI, intracranial, other sites).
Allergic reactions, hypotension, chest pain.
Reperfusion Dysrhythmias.
Abdominal pain.
Drug Interactions
Aspirin may increase risk of bleeding as well as improve outcome.
Heparin and other anticoagulants may increase risk of bleeding as well as improve outcome.
How Supplied
250,000, 750,000, 1.5 Million IU vials.
Dosage and Administration
NOTE: Reconstitute by slowly adding 5 ml sodium chloride or D5W, directing stream to side of vial instead of into powder. Gently roll and tilt vial for reconstitution; Dilute slowly to 45 ml total.
Adult: 500,000 - 1,500,000 IU diluted to 45 ml IV over one (1) hour.
Pediatric: safety not established.

Duration of Action
Onset: 10 - 20 minutes. (fibrinolysis 10-20 minutes; clot lysis: 60 - 90 minutes).
Peak effects: Variable.
Duration: 3-4 hours (prolonged bleeding times up to 24 hours).
Special Considerations
Pregnancy safety: Category A.
Do not administer IM injections to patients receiving thrombolytics.
Obtain blood sample for coagulation studies prior to administration.
Carefully monitor vital signs.
Observe patient for bleeding.

Class Local Anesthetic

Mechanism of Action Blocks the initiation and conduction of nerve impulses

Indications: Topically applied local anesthetic for eye examination

Contraindications Hypersensitivity to ester anesthetics; Not to be applied in large amounts or to Infants of less than 1 year old.

Adverse Reactions 1-10% Dermal: Angioedema, burning, contact dermatitis, stinging.
< 1% : Methemoglobinemia in infants


How Supplied Ophthalmic: 0.5% [5mg/ml] (1ml, 2ml, 15ml)

Dosage and Administration

Adult: Ophthalmic Solution: Instill 1-2 drops

Pediatric: Safety and efficacy have not been established.

Kinetics
Onset: Within 60 seconds.


Special Considerations
Pregnancy category C
Storage Store in a light resistant container
Stability: Lasts 6 months refrigerated; Lasts 4 weeks at room temperature: Discard if solution discolors (should be clear)
Caution in Child < 6 years old

Class
Vitamin (B1)
Mechanism of Action
Combines with ATP to form thiamine pyrophosphate coenzyme, a necessary component for carbohydrate metabolism. The brain is extremely sensitive to thiamine deficiency.
Indications
Coma of unknown origin.
Delirium tremens.
Beriberi.
Wernicke’s encephalopathy.
Contraindications
None
Adverse Reactions
Hypotension from too rapid injection or too high a dose.
Anxiety, diaphoresis, nausea, vomiting.
Rare allergic reaction.
Drug Interactions
Give thiamine before glucose under all circumstances.
How Supplied
1,000 mg in 10 ml vial (100 mg / ml).

Dosage and Administration
Adult: 100 slow IV or IM.
Pediatric: 10-25 mg slow IV or IM.

Duration of Action
Onset: Rapid.
Peak effects: variable.
Duration: Dependent upon degree of deficiency.
Special Considerations
Pregnancy safety: Category A.
Large IV doses may cause respiratory difficulties.
Anaphylaxis reactions reported.

Class
Thrombolytic agent.
Mechanism of Action
Binds to fibrin-bound plasminogen at the clot site, converting plasminogen to plasmin. Plasmin digests the fibrin strands of the clot restoring perfusion.
Indications
Acute evolving myocardial infarction.
Massive pulmonary emboli.
Arterial thrombosis and embolism.
To clear arteriovenous cannulas.
Contraindications
Recent sugary (within three weeks).
Active bleeding, recent CVA, prolonged CPR,, intracranial or intraspinal surgery.
Recent significant trauma, especially head trauma.
Uncontrolled hypertension (generally BP over 200 mm Hg.).
Adverse Reactions
GI, GU intracranial and other site bleeding.
Hypotension, allergic reactions, chest pain, abdominal pain, CVA.
Reperfusion dysrhythmias.
Drug Interactions
Acetylsalicylic acid may increase risk of hemorrhage.
Heparin and other anticoagulants may increase risk of hemorrhage.
How Supplied
20 mg with 20 ml diluent vial.
50 mg with 50 ml diluent vial.

Dosage and Administration
Adult: 10 mg bolus IV over 2 minutes; then 50 mg over one hour, then 20 mg over the second hour and 20 mg over the third hour for a total dose of 100 mg. (other doses may be prescribed through Medical Direction.
Pediatric: safety not established.

Duration of Action
Onset: clot lysis most often within 60-90 minutes.
Peak effect: variable.
Duration: 30 minutes with 80% cleared within 10 minutes.
Special Considerations
Pregnancy safety: contraindicated.
Closely monitor vital signs.
Observe for bleeding.
Do not give IM injection to patient receiving tPA.

Class
Non- adrenergic peripheral vasoconstrictor
Anti-diuretic hormone (ADH)

Mechanism of Action
Stimulation of V1 smooth muscle receptors, potent vasoconstrictor when given in high doses.

Indications
Adjunct in the treatment of diabetes
Unlabeled and investigational; Cardiac arrest situations caused by Ventricular fibrillation, pulseless ventricular tachycardia, pulseless electrical activity (PEA)
Alternate vasopressor to the first or second dose of epinephrine in cardiac arrest, may be useful in cases of vasodilatory shock.

Contraindications
None noted for this indication; Responsive patients with cardiac disease

Adverse Reactions
May cause hypertension and bradycardia if a rhythm resumes; Bronchoconstriction, ischemic chest pain, nausea vomiting

Drug Interactions
None indicated for this indication

How supplied
20 pressor units per ml or 20u/ml in 1ml or 2ml prefilled syringes

Dosage and Administration
Adult: 40 units (as a single dose only) IV or IO to replace the first or second dose of epinephrine in cardiac arrest

Duration of action
Onset; Immediate
Peak effects ; two (2) hours
Duration; to variable to accurately determine

Special Considerations
Fetal risk revealed in various studies; may use if benefits outweigh risk to fetus