PHARMACOLOGY REVIEW

ASPIRIN

25% DEXTROSE (D25)

THERAPEUTIC EFFECTS: In cardiac arrest, may restore electric activity in asystole; increases myocardial contractility; and decreases the threshold for defibrillation--all through its actions as a beta sympathetic agent.

In addition, the alpha effects of epinephrine, causing vasoconstriction, elevate the perfusion pressure and may thus improve coronary blood flow during external cardiac compressions.

In anaphylaxis, acts as a bronchodilator (beta effect) and helps maintain blood pressure (alpha effect).

INDICATIONS: In CARDIAC ARREST, to restore electric activity in asystole or to enhance

defibrillation potential in ventricular fibrillation; also to elevate systemic

vascular resistance and thereby improve perfusion pressure during resuscitation.

To treat the life-threatening symptoms of ANAPHYLAXIS

To treat acute attacks of ASTHMA

CONTRAINDICATIONS: Must be used with caution in patients with angina, hypertension, or hyperthyroidism

THERE ARE NO CONTRAINDICATIONS TO THE USE OF EPINEPHRINE IN THE SITUATION OF CARDIAC ARREST OR ANAPHYLACTIC SHOCK

SIDE EFFECTS: In a conscious patient, may cause palpitations, from tachycardia or ectopic beats, and elevations of blood pressure (which may not be desirable if the patient is already hypertensive)

The asthmatic with preexisting heart disease may experience dysrhythmias if treated with epinephrine

HOW SUPPLIED: Prefilled syringes containing 1mg in 10ml (1:10,000 solution)

Ampules containing 1mg in 1ml (1:1,000 solution)

Multi-dose vial: 30mg in 30ml (1:1,000 solution)

ADMINISTRATION: In cardiac arrest, epinephrine is given 1mg intravenously every 3-5 minutes

EPINEPHRINE (ADRENALIN) (Continued)

If an IV route cannot be established quickly, the drug may be instilled in the tracheo-bronchial tree via catheter through an endotracheal tube

For anaphylactic reactions, epinephrine is given subcutaneously

ADULT DOSAGE: In cardiac arrest situations:

Initial Dose: 1.0mg (10ml of 1:10,000 solution

Endotracheal dose: 2mg (1:1,000) diluted with 10ml normal saline given via catheter during ventilation

In anaphylactic reactions: 0.3mg subcutaneously, (0.3ml of a 1:1,000 solution)

(Do not, however, inject fingers or toes)

For mild to moderate asthmatic attacks: 0.3 to 0.5ml of a 1:1,000 solution,

Sub Q

PEDIATRIC DOSAGE: Bradycardia: 0.01mg/kg 1:10,000 every 3 minutes

Cardiac Arrest:

Initial Dose: 0.01mg/kg 1: 10,000 IVP or IOP

Second & Subsequent Dose: 0.1mg/kg 1:1000 IVP or IOP

Endotracheal: 0.1mg/kg 1:1,000 diluted with 2ml of NS

Newborn Cardiac Arrest:: 0.02mg/kg 1:10,000 every 5 min. By IV, IO

Allergic Reaction/Asthma: 0.01mg/kg 1:1,000 Sub Q Max 0.3mg. No response and IV in place, 0.1mg/kg 1:10,000 IVP

THERAPEUTIC EFFECTS: Potent diuretic, causing the excretion of large volumes of urine within 5 to 30 minutes of administration, thus useful in ridding the body of excess fluid in conditions such as congestive heart failure (CHF).

Not used often in the field when the distance to the hospital is short.

However, furosemide may be useful in long range transports of patients in marked heart failure (especially catheterized patients) where there is a need to begin definitive therapy before the patient arrives at the hospital.

INDICATIONS: To reverse fluid overload associated with CONGESTIVE HEART FAILURE and PULMONARY EDEMA

CONTRAINDICATIONS: Should not be given to pregnant women

Should not be given to patients with hypokalemia (low potassium)

Hypokalemia may be suspected in a patient who has been on chronic diuretic therapy or whose EKG shows prominent P waves, diminished T waves, and the presence of U waves

SIDE EFFECTS: Immediate side effects may include nausea and vomiting, potassium depletion (with attendant cardiac dysrhythmias), and dehydration

HOW SUPPLIED: Pre-filled syringes of 10ml in a concentration of 10mg/ml

ADMINISTRATION: In the field, furosemide is given intravenously. If at all possible, the patient should have a urinary catheter in place

ADULT DOSAGE: 1mg/kg SLOWLY IV (injected over 1-2 min)

THERAPEUTIC EFFECTS: Accelerates the breakdown of glycogen to glucose in the liver, causing an increase in blood glucose level.

Glucagon also relaxes the smooth muscle of the GI tract

Glucagon is helpful, in hypoglycemia only if the liver glycogen is available.

Because glucagon is of little or no help in states of starvation, adrenal

insufficiency, or chronic hypoglycemia, glucose should be considered for

the treatment of hypoglycemia.

INDICATIONS: For the treatment of hypoglycemia when IV Dextrose is not available

In anaphylaxis, if the patient is on beta blocking medication, hypertensive, has known coronary artery disease and/or is pregnant

CONTRAINDICATIONS: Glucagon is contraindicated in patients with known hypersensitivity to it or in patients with pheochromocytoma

SIDE EFFECTS: Glucagon is relatively free of adverse reactions except for occasional nausea and vomiting which may also occur with hypoglycemia

Generalized allergic reactions including urticaria, respiratory distress and hypotension, have been reported in patients who receive glucagon by injection

HOW SUPPLIED: Vials of 1mg glucagon with 1ml of diluting solution

ADMINISTRATION: For adults and for children weighing more than 20kg, administration may be by subcutaneous intramuscular or intravenous injection

Glucagon must be reconstituted with dilution solution provided and used immediately. If dose is higher than 2mg, reconstitute with sterile water for injection and use immediately

Glucagon is compatible with dextrose solutions, but precipitates may form in solutions of sodium chloride, potassium chloride or calcium chloride

ADULT DOSAGE: In hypoglycemia, 1.0mg IV, SC or IM injection. Response is usually seen in 5 to 20 minutes. If response is delayed, dose may be repeated 1 to 2 times

PEDIATRIC DOSAGE: In hypoglycemia for children weighing more than 20kg,1.0mg IV, SC or IM injection. Response is usually seen in 5 to 20 minutes. If response is delayed, dose may be repeated 1 to 2 times

THERAPEUTIC EFFECTS: Suppresses ventricular ectopic activity by decreasing the excitability of heart muscle and the cardiac conduction system.

INDICATIONS: Lidocaine is the drug of first choice:

To SUPPRESS PREMATURE VENTRICULAR CONTRACTIONS (PVC’s)

To PREVENT VENTRICULAR FIBRILLATION in acute myocardial infarction

To PREVENT RECURRENCE OF VENTRICULAR FIBRILLATION after electric conversion

To treat VENTRICULAR TACHYCARDIA

CONTRAINDICATIONS: Known history of allergy to lidocaine or local anesthetics (e.g., Novocaine)

Second or third degree heart block

Sinus bradycardia or sinus arrest

Idioventricular rhythm

SIDE EFFECTS: By decreasing the force of cardiac contractions as well as decreasing peripheral resistance, may cause a fall in cardiac output and blood pressure

May cause numbness, drowsiness, or confusion when given in high doses, especially to the elderly or to patients in heart failure, may cause seizures

HOW SUPPLIED: Ampules and prefilled syringes containing 100mg in 5ml (20 mg/ml) for bolus injection

ADMINISTRATION: Given by intravenous bolus

Reduce the dosage (both bolus and infusion) by half for patients in congestive heart failure or shock and for patients over 70 years old

If an intravenous route cannot be established, lidocaine may be given via catheter through an endotracheal tube

PEDIATRIC DOSAGE: V-Fib: 1mg/kg IVP, IOP or ET

THERAPEUTIC EFFECTS: Versed is a short acting benzodiazepine CNS depressant. Onset of sedative effects after IM administration is 15 minutes with peak sedation occurring 30 - 60 minutes following injection.

Versed has also been shown to be effective intramuscularly for control of seizure activity

CONTRAINDICATIONS: In patients with known hypersensitivity to the drug

SIDE EFFECTS: Fluctuation in vital signs were the most frequently seen findings following administration of Versed and include:

* Decrease tidal volume and respiratory rate

* Apnea

* Variations in BP and pulse rate

HOW SUPPLIED: 2ml disposable syringes containing 5mg per ml

ADMINISTRATION: Versed should only be administered IM or IV

Because serious and life threatening cardiorespiratory adverse events have been reported, provision for monitoring, detection and correction of these reactions must be made for every patient to whom Versed injection is administered regardless of age or health status

For persistent seizure activity, IV or IM injection of 5mg initially and titrate to patient’s condition up to 10mg maximum

For cardioversion: 3-5 mg IVP

PEDIATRIC DOSAGE: For persistent seizure activity, IV or IM injection of 0.2mg/kg

THERAPEUTIC EFFECTS: Decreases pulmonary edema by pooling blood in the peripheral circulation and thereby reducing venous return to the heart.

Helps as well to allay the anxiety associated with pulmonary edema.

INDICATIONS: To treat PULMONARY EDEMA associated with CONGESTIVE HEART FAILURE

To RELIEVE PAIN in myocardial infarction and other, selected conditions

CONTRAINDICATIONS: Marked hypotension.

Respiratory depression, except that caused by pulmonary edema, where the drug may be used if ventilatory support is provided.

SIDE EFFECTS: Hypotension (most likely in volume depleted patients).

Increased vagal tone, leading to bradycardia.

(This effect can be reversed with atropine.)

Respiratory depression.

(This effect can be reversed with naloxone.)

Nausea and vomiting.

HOW SUPPLIED: Prefilled (tubex) syringes containing 10mg.

ADMINISTRATION: Given by titrated intravenous injection.

If hypotension occurs, keep the patient flat, and do not give more of the drug.

Watch for respiratory depression.

ADULT DOSAGE: 2 to 5mg by IV push every 5 minutes until the desired therapeutic effect is achieved. Do not exceed 15mg without contact of medical control.

THERAPEUTIC EFFECTS: Specific antidote for narcotic agents.

Reverses the actions of all narcotic drugs including heroin, morphine, methadone, codeine, Demerol, Dilaudid, Darvon, paregoric, and Percodan.

Naloxone is thus effective in counteracting the effects of overdose from any of these agents.

Naloxone will reverse stupor, coma, respiratory depression, etc. when these are due to narcotic overdose.

INDICATIONS: To treat known NARCOTIC OVERDOSE or coma suspected to be due to narcotic overdose.

CONTRAINDICATIONS: None

SIDE EFFECTS: Too rapid administration may precipitate projectile vomiting and ventricular dysrhythmias.

Administration to people who are physically dependent on narcotics may cause an acute withdrawal syndrome.

For this reason, naloxone should be given very slowly, using improvement of respiratory status as an end point.

In general, the duration of action of naloxone is shorter than that of the narcotics it is used to counteract.

Thus, the patient who has been successfully roused with naloxone may fall back into stupor or coma as the naloxone wears off.

These patients must therefore be watched closely, and the dose of naloxone should be repeated as necessary.

Has been reported to cause pulmonary edema and sudden death in rare cases.

HOW SUPPLIED: 2mg in 2ml prefilled syringe.

NALOXONE (NARCAN) (Continued)

ADMINISTRATION: In the field, given slowly by slow intravenous injection.

As soon as there is improvement in the respirations, stop giving the drug.

It is preferable that the patient NOT wake up fully in the field, as these patients may be violent when brought abruptly out of coma.

USE RESPIRATIONS AS A GUIDE.

If there is no response to two doses, suspect overdose with another, non-narcotic drug.

ADULT DOSAGE: Initial dose: 2mg Administer this solution VERY SLOWLY IV while monitoring the rate and depth of the patient's respirations.

If there is no response to the full dose of naloxone, it may be repeated in 5 minutes in the same fashion.

PEDIATRIC DOSAGE: 0.1mg/kg Newborn dose: (narcotic dependent with decreased respiration)

0.1mg/kg every 3 minutes until respiration is improved.

THERAPEUTIC EFFECTS: The primary pharmacologic effect of nitroglycerin and related drugs is to relax smooth muscle, and the effects of nitroglycerin on the cardiovascular system are chiefly due to relaxation of vascular smooth muscle (hence vasodilatation).

Nitroglycerin provides relief of pain in angina, probably by dilating coronary arteries and thereby increasing blood flow through them as well as by decreasing myocardial oxygen demand.

Through its vasodilatation action on peripheral vessels, nitroglycerin promotes pooling of the blood in the systemic circulation and decreases the resistance against which the heart has to pump (the afterload); these effects may be useful in treating congestive heart failure.

INDICATIONS: To relieve the pain of ANGINA.

To treat selected cases of PULMONARY EDEMA due to LEFT HEART FAILURE

CONTRAINDICATIONS: Use with caution in right ventricular infarction.

Increased intracranial pressure.

SIDE EFFECTS: Transient, throbbing headache.

Hypotension

Dizziness, weakness

HOW SUPPLIED: Many forms, including ointment, spray, tablets, sustained release capsules.

For use in the field, tablets of 0.4mg strength are preferred.

ADMINISTRATION: Given sublingually (under tongue).

The patient should be semisitting or recumbent.

ADULT DOSAGE: One 0.4mg tablet or spray under the tongue.

May repeat twice at five minute intervals.

THERAPEUTIC EFFECTS: Provides rapid, easily reversible relief of pain.

INDICATIONS: Relief of pain from:

Acute myocardial infarction.

Musculoskeletal trauma.

Burns.

Other conditions (e.g., kidney stones, labor).

CONTRAINDICATIONS: Any altered state of consciousness, e.g., head injury (masks the neurologic signs

one needs to monitor).

Chronic obstructive pulmonary disease.

Acute pulmonary edema (these patients need 100% oxygen).

Known pneumothorax or chest injury where pneumothorax may be present (N2O collects in dead air spaces and may thus expand a pneumothorax).

Abdominal distention or abdominal trauma where bowel sounds are absent.

Major facial injury.

Shock.

SIDE EFFECTS: Light-headedness, drowsiness.

Occasional nausea and vomiting.

Ambulance crew may experience giddiness if the vehicle is not properly vented.

HOW SUPPLIED: In the United States, nitrous oxide for field use is supplied as Nitronox, a set containing an oxygen cylinder and a nitrous oxide cylinder joined by a valve that regulates flow to provide a 50:50 mixture of the two gasses. The mixture is piped to a demand valve apparatus.

ADMINISTRATION: Nitrous oxide is self-administered by inhalation.

The patient is instructed to hold the mask to their face, to form a tight seal around the nose and mouth, and to breathe normally. As the patient gets drowsy, the mask will fall away from their face.

THE PATIENT MUST CONTROL THE DEMAND VALVE THEMSELVES.

The paramedic should not hold the face mask in place for the patient.

THERAPEUTIC EFFECTS: Reverses the deleterious effects of hypoxemia on the brain, heart, and other vital organs.

INDICATIONS: Any condition in which global or local hypoxemia may be present:

CARDIAC or RESPIRATORY ARREST (given with artificial ventilation).

DYSPNEA or RESPIRATORY DISTRESS from any cause. CHEST PAIN.

SHOCK.

COMA from any cause.

CHEST TRAUMA.

NEAR-DROWNING.

PULMONARY EDEMA.

TOXIC INHALATIONS (smoke, chemicals,

carbon monoxide).

ACUTE ASTHMATIC ATTACK.

ACUTE DECOMPENSATION OF COPD.

STROKE, HEAD INJURY.

REPEATED SEIZURES.

Any patient in CRITICAL CONDITION.

CONTRAINDICATIONS: None.

May depress respirations in rare patients with chronic obstructive pulmonary disease. This is not a contraindication to its use, but simply means that such patients must be watched closely and assisted to breathe if the respiratory rate declines.

SIDE EFFECTS: None when given for short periods to adults. (less than 24 hr.)

HOW SUPPLIED: As a compressed gas in cylinders of varying sizes.

ADMINISTRATION: Administered by inhalation from a dosage mask, nasal cannula, endotracheal tube, etc.

A patent airway and adequate ventilation must be ensured.

ADULT DOSAGE: Depends on the condition being treated. For cardiac arrest and other critical conditions, 100% oxygen should be given as soon as possible.

THERAPEUTIC EFFECTS: Blocks the cholinergic receptors in the vomiting center that are believed

to mediate the nausea and vomiting caused by gastric irritation.

Phenergan depresses the RAS, including the parts of the brain involved with wakefulness.

INDICATIONS: Treatment and prevention of motion sickness; prevention and control of nausea and vomiting associated with anesthesia and surgery.

CONTRAINDICATIONS: Coma or severe CNS depression

Hypersensitivity to antihistamines or phenothiazines

Patient has consumed large amounts of depressants

(alcohol, barbiturates, narcotics)

Children whose signs and symptoms may suggest Reye’s Syndrome or

other hepatic diseases.

Antiemetics SHOULD NOT be used in children with vomiting of unknown

etiology.

SIDE EFFECTS: * Drowsiness * Vertigo

* Blurred Vision * Headache

* Urticaria * Dry Mouth

* Hypotension

HOW SUPPLIED: One milliliter syringes containing 25mg/ml.

ADMINISTRATION: The preferred parenteral route of administration for Phenergan is by deep intramuscular injection.

The proper intravenous administration of this product is well tolerated but use of this route is not without some hazard. Inadvertent intra-arterial injection can result in gangrene of the affected extremity.

Subcutaneous injection is contraindicated as it may result in tissue necrosis.

ADULT DOSAGE: For severe nausea and vomiting:

12.5 to 25mg slow IV push or deep IM injection

PEDIATRIC DOSAGE: 0.5mg/lb given by slow IV push or deep IM injection

CHILDREN 12 YEARS OLD OR YOUNGER ONLY.

THERAPEUTIC EFFECTS: Beta-2 stimulator, dilates smooth muscle, bronchodilator

INDICATIONS: Shortness of breath caused by bronchoconstriction

CONTRAINDICATIONS: * Allergy to drug

* Excessive prior use of beta stimulants

* Shortness of breath not from broncho- constriction

SIDE EFFECTS: * Nervousness

* Weakness

* Tremor

* Increased heart rate

HOW SUPPLIED: Unit dose 2.5mg vials (3ml)

ADMINISTRATION: By inhalation through a breathing aerosol device.

ADULT DOSAGE: 2.5mg in N/S via aerosol device with oxygen at 8 liter per minute.

PEDIATRIC DOSAGE: 2.5mg (3ml) in aerosol device at 8L at 02 per minute

THERAPEUTIC EFFECTS: By neutralizing excess acid, helps return the blood towards a physiologic pH, in which normal metabolic processes and sympathomimetic agents (such as epinephrine) work more effectively.

INDICATIONS: To treat METABOLIC ACIDOSIS, as in:

SHOCK and other low-output states(after resuscitation from cardiac arrest).

To treat HYPERKALEMIA (high serum potassium).

To promote the excretion of some types of BARBITURATES taken in OVERDOSE.

CONTRAINDICATIONS: Conditions in which the patient cannot tolerate a salt load, such as congestive heart failure.

SIDE EFFECTS: Because each mEq of bicarbonate comes along with a mEq of sodium, sodium bicarbonate has the same effect as any other salt-containing infusion, i.e., it increases the vascular volume.

Three 50ml syringes of sodium bicarbonate (1 mEq/ml) contain approximately the same amount of salt as 1 liter of normal saline.

Patients in borderline heart failure cannot tolerate salt loads of this magnitude.

Administration of sodium bicarbonate lowers serum potassium.

In some cases, this is the desired effect, as when bicarbonate is used to treat hyperkalemia.

However, in cardiac patients, if the potassium falls too low, the heart becomes irritable, and dysrhythmias may occur.

This is especially likely in patients taking diuretics.

Sodium bicarbonate administration transiently raises the arterial carbon dioxide level, and thus its administration must be accompanied by controlled hyperventilation to blow off this excess CO2. (e.g., with bag-valve-mask)

SODIUM BICARBONATE (Continued)

HOW SUPPLIED: Vials and prefilled syringes of 50ml, containing 1 mEq/ml.

ADMINISTRATION: Given by intravenous bolus injection.

ADULT DOSAGE: If used at all, 1 mEq/kg after the first 10 minutes of CPR.

Acidosis should thereafter be prevented by hyperventilation.

Do not give bicarbonate in the same syringe with epinephrine or calcium.

For other conditions: As ordered by physician.

PEDIATRIC DOSAGE: 1 mEq/kg diluted with 1ml/kg NS

Newborn: 0.5mEq/kg diluted with .5ml/kg NS

THERAPEUTIC EFFECTS: Provides local anesthesia to eyes.

Provides relief from eye pain so that an appropriate eye exam and treatment can be completed.

INDICATIONS: Irritation and/or pain of the eyes when there is a non-penetrating injury.

CONTRAINDICATIONS: Penetrating or open eye injury.

Allergy or hypersensitivity to Tetracaine.

SIDE EFFECTS: Burning sensation in eyes

Redness

Tearing

HOW SUPPLIED: Ophthalmic drops in dropper bottle

ADMINISTRATION 1-2 drops in affected eye every 5-10 minutes as needed for pain control. Don’t DOSAGE: touch dropper tip to eye, lid or finger to keep bottle sterile.

THERAPEUTIC EFFECTS: Topical anesthesia as required during oral and nasal intubation.

INDICATIONS: Nasal or oral tracheal intubation lubrication.

CONTRAINDICATIONS: Known hypersensitivity to lidocaine.

SIDE EFFECTS: None significant by topical administration.

HOW SUPPLIED: 5 ml squeeze tube.