Medical Emergencies: Dosages, Onset, Duration, and Side Effects of Various Medications, Study notes of Acting

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2019 REMSA Paramedic Program Drug List (47 drugs)

Revised 7/22/

Acetaminophen (APAP)

Activated Charcoal

Adenosine (Adenocard)

Albuterol (Proventil)

Amiodarone (Cordarone)

Aspirin (Salicylate)

Atropine Sulfate

Calcium Chloride

Dextrose 50%, 25%, 10%

Diazepam (Valium)

Diltiazem (Cardizem)

Diphenhydramine (Benadryl)

Dopamine (Intropin)

Epinephrine (Adrenalin)

Epinephrine, Racemic (Micronefrin)

Etomidate (Amidate)

Fentanyl (Sublimaze)

Furosemide (Lasix)

Glucagon

Haloperidol (Haldol)

Hydroxocobalamin

Ibuprofen

Ipratropium (Atrovent)

Ketamine (Ketalar)

Lidocaine (Xylocaine)

Lorazepam (Ativan)

Magnesium Sulfate

Methylprednisolone (Solu-Medrol)

Metoprolol (Lopressor)

Midazolam (Versed)

Morphine Sulfate

Naloxone (Narcan)

Nitroglycerin (Nitro-Stat)

Nitro-Paste (Nitro-Bid Ointment)

Nitrous Oxide (Nitronox)

Norepinephrine (Levophed)

Ondansetron (Zofran)

Oral Glucose

Oxygen

Oxytocin (Pitocin)

Pralidoxime (2-PAM)

Procainamide

Pralidoxime (2-PAM)

Sodium Bicarbonate

Succinylcholine (Anectine)

Thiamine (Betaxin)

Tranexamic Acid (TXA)

Activated Charcoal

Class: Antidote, adsorbent Action: Binds to and adsorbs ingested toxins thereby inhibiting their GI absorption. Once the drug binds to the charcoal the combined complex is excreted. Indications: Acute ingested poisonings that were ingested within the last hour Contraindications: Cyanide, mineral acids, caustic alkalis, iron, ethanol, methanol, corrosives, petroleum distillates. Onset/Duration: Onset: Immediate Duration: Continual while in GI tract and reaches equilibrium once saturated Dose/Route: Adult: 1 g/kg PO Peds: 1- 2 g/kg PO Side Effects: Nausea, vomiting, abdominal cramping, constipation

Adenosine (Adenocard)

Class: Misc. antidysrhythmic, endogenous nucleoside Action: Decreases electrical conduction through the AV node without causing negative inotropic effects Indications: Supraventricular tachycardias (SVT/PSVT) Contraindications: Hypersensitivity, bradycardia, drug induced tachycardia, 2 nd^ or 3rd^ degree heart blocks, A-Fib, A-Flutter, V-Tach, WPW with A-Fib/flutter. Onset/Duration: Onset: Immediate Duration/half-life: 10 seconds Dose/Route: Adult: 6 mg rapid IV/IO push followed by 20 cc saline flush. May repeat in 1-2 min at 12 mg rapid IV push followed by 20 cc saline flush. Peds: 0.1mg/kg (max 6mg) IV/IO followed by 5- 10 cc saline flush. May repeat in 1-2 min at 0.2 mg/kg (max 12mg) IV/IO followed by 5- 10 cc saline flush. Side Effects: dizziness, headache, shortness of breath, hypotension, flushing, palpitations, chest pain, nausea/vomiting Note: Methylxanthine classified stimulants (caffeine & theophylline) usage will antagonize adenosine

Amiodarone (Cordarone)

Class: Class III antidysrhythmic Action: Prolongs duration of the action potential and prolongs the refractory period, also has beta adrenergic receptor and calcium channel blocking activity. Works on both the ventricles and the atria Indications: V-Fib, hemodynamically unstable V-Tach, treatment for some stable atrial rhythms Contraindications: CHF, cardiogenic shock, bradycardia, 2nd^ or 3rd^ degree heart blocks with no pacemaker present, hypersensitivity to amiodarone or iodine Onset/Duration: Onset: within minutes and Duration: Variable but considered 30 – 45 days Dose/Route: Adult: Pulseless V-Tach/V-Fib arrest - 300mg IV/IO may repeat once at 150mg IV/IO. V- Tach with a pulse 150mg IV drip over 10 minutes up to max of 2.2g in 24 hours Peds: Pulseless V-Tach/V-Fib arrest - 5mg/kg IV/IO. V-Tach with a pulse 5mg/kg IV drip over 20-60 minutes with a max of 15mg/kg/day. Side Effects: Bradycardia, hypotension, headache, CHF, abnormal liver/thyroid functions. In rare cases can cause pulmonary fibrosis

Aspirin (Salicylate)

Class: Analgesic, nonsteroidal anti-inflammatory drug (NSAID), antipyretic, and antiplatelet Action: Inhibits prostaglandins involved in the production of inflammation, pain and fever. Dilates peripheral vessels and also inhibits platelet aggregation by blocking the formation of thromboxane A2. Indications: Acute coronary syndrome (ACS) such as myocardial infarction, ischemic chest pain or angina, and given for mild to moderate pain or fever. Contraindications: GI bleeding, hemorrhagic stroke, active gastric ulcers, bleeding disorders, asthma, hypersensitivity to salicylates, children Onset/Duration: Onset: 15-30 min Duration: 4 - 6 hours Dose/Route: Adult: Mild pain/fever – 325 - 650 mg PO every 4 hours. ACS – 2 to 4 baby chewable aspirin, 162 - 324 mg OR 1 adult aspirin, 325mg PO. Peds: Not indicated in pre-hospital setting Side Effects: Stomach irritation, GI bleeding, Nausea/vomiting Note: Children under 12 should not be given Aspirin as they may develop Reye’s syndrome.

Calcium Chloride

Class: Electrolyte, hypertonic solution Action: It is an essential element for regulating the excitation threshold of nerves and muscles, normal cardiac contractility, and blood coagulation. Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, calcium channel blocker overdose Contraindications: V-Fib during cardiac resuscitation, digitalis toxicity, hypercalcemia Onset/Duration: Onset: 5-15 min Duration: Dose dependent but may last up to 4 hours Dose/Route: Adult: 1 - 2 g (10-20 ml) slow IV of 10% solution Peds: 60 mg/kg slow IV of 10% solution Side Effects: Bradycardia, hypotension, Metallic taste in mouth, local necrosis if given IM or IV infiltration

Dextrose 50%, 25%, 10%

Class: Carbohydrate, hypertonic solution Action: Dextrose increases available blood sugar to be used as energy by the body Indications: Hypoglycemia. If protocol allows also for altered ALOC, coma, and seizure of unknown origin Contraindications: Intracranial hemorrhage, increased intracranial pressure, known or suspected stroke in the absence of hypoglycemia Onset/Duration: Onset: 1 min Duration: Variable depending on degree of hypoglycemia Dose/Route: Adult: 12.5- 25 g slow IV (25-50 ml 50% dextrose; 125-250 ml 10% dextrose) Peds: 0.5- 1 g/kg (2-4 ml/kg) IV of 25% dextrose Neonates: 0.5-1 g/kg (2-4 ml/kg) IV of 10% dextrose Side Effects: Hyperglycemia Note: If given through infiltrated IV, will cause tissue necrosis so use large vein and flush with saline to ensure IV patency. D50 may cause Wernicke’s encephalopathy in thiamine deficient patient (alcoholics and malnourished pts) so if these conditions are suspected, administer 100 mg Thiamine IV prior to administering D50.

Diltiazem (Cardizem)

Class: Calcium channel blocker Action: Inhibits calcium ion influx through slow channels into the cell of myocardial and arterial smooth muscle. Slows SA and AV nodal conduction. Dilates coronary arteries and arterioles thus inhibits coronary artery spasms. Indications: A-Fib and A-Flutter. Multifocal atrial tachycardias. SVT/PSVT refractory to Adenosine. Contraindications: Hypersensitivity, 2 nd^ and 3rd^ degree heart block, hypotension, cardiogenic shock, ventricular rhythms, sick sinus syndrome, Wolf-Parkinson-White syndrome, AMI, V-Tach. Onset/Duration: Onset: 2-5 min Duration: 1 - 3 hours Dose/Route: Adult: 15 - 20 mg IV over 2 min, may be repeated in 15 min at 20 - 25 mg IV over 2 min. Maintenance infusion 5-15 mg/hr titrated to HR. Peds: Not recommended in the prehospital setting Side Effects: Headache, dizziness, hypotension, 1 st^ and 2nd^ degree heart block, bradycardia, palpitations, CHF, chest pain, ventricular rhythms. Note: Use caution with renal/liver impaired pt’s and those taking beta blockers.

Diphenhydramine (Benadryl)

Class: Antihistamine Action: Blocks histamine H 1 receptor sites thereby inhibiting actions of histamine release. Indications: Allergic reactions, anaphylaxis, acute extrapyramidal reaction (dystonia) Contraindications: Hypersensitivity, pt’s taking MAO inhibitors, caution with glaucoma. Onset/Duration: Onset: 5 - 15 min with max effects in 1-3 hrs Duration: 6-12 hrs Dose/Route: Adult: 25-50mg IV/IM/PO with a max of 400 mg/day Peds: 1 mg/kg IV/IM/PO with a max of 300 mg/day Side Effects: Drowsiness, palpitations, hypotension, tachycardia or bradycardia, disturbed coordination, dry mouth/throat, thickening of bronchial secretions. Note: Use with caution in CNS depressed pts and pts with lower respiratory tract diseases such as asthma.

Epinephrine (Adrenalin)

Class: Sympathomimetic Action: Endogenous catecholamine that directly stimulates both alpha-1, beta-1 and beta- 2 adrenergic receptors. The effects this will have on the heart include increased contractile force, increased rate, and increased cardiac output. Epinephrine is also a potent vasoconstrictor as well as a bronchodilator. Other effects include slowing of gastric motility, miosis, and pale skin. Indications: Anaphylaxis, cardiac arrest, asthma, bradycardia (first line in peds), shock not caused by hypovolemia, severe hypotension accompanied with bradycardia when pacing and atropine fail. Contraindications: Hypovolemic shock. Caution should be used in patients with known cardiovascular disease or pts > 4 5 y/o Onset/Duration: Onset: 1 - 2 min IV, 5 - 10 mins SQ Duration: 5 - 10 min IM Dose/Route: Adult: Cardiac arrest – 1 mg 1:10,000 IV/IO every 3 - 5 min with no max. Anaphylaxis/asthma – 0.3-0.5 mg SQ/IM 1:1,000. If no response, some protocols give 0.3-0.5 mg IV 1:10,000. Post cardiac arrest or for bradycardia with severe hypotension – 2 - 10 mcg/min IV drip and titrate to effect. Peds: Cardiac arrest – 0.01 mg/kg 1:10,000 IV/IO max of 1 mg every 3-5 mins. Anaphylaxis/asthma – 0.01 mg/kg 1:1,000 SQ/IM with a max single dose 0.3 mg. Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors, dyspnea Note: Always use epinephrine 1:1,000 when given SQ/IM and 1:10,000 when given IV/IO. Giving concurrently with alkaline solutions such as sodium bicarbonate will cause crystallization of fluid.

Epinephrine, Racemic (Micronefrin)

Class: Sympathomimetic Action: Racemic Epinephrine is an inhaled version of epinephrine that is used as a bronchodilator and as an anti-inflammatory to treat laryngeal/tracheal swelling and edema. Its actions are the same as epinephrine but since it is inhaled it has both systemic and localized effects. Indications: Laryngotracheobronchitis (croup), asthma, bronchospasms, laryngeal edema Contraindications: Hypertension, epiglottitis. Use caution in patients with known cardiovascular disease or in pts > 45 y/o. Onset/Duration: Onset: 5 min Duration: 1 - 3 hrs Dose/Route: Adult: Not usually given to adults. Contact medical control Peds: All doses given via aerosolized neb. For pts < 6 months – 0.25 ml 2.25% diluted in 3 ml NS. For pts > 6 months – 0.5 ml 2.25% diluted in 3 ml NS. Side Effects: Tachycardia, hypertension, anxiety, cardiac dysrhythmias, tremors

Fentanyl (Sublimaze)

Class: Synthetic Opioid analgesic Action: Combines with the receptor sites in the brain to produce potent analgesic effects. Indications: Pain and sedation Contraindications: hypersensitivity to opiates, hypotension, head injury, respiratory depression, cardiac dysrhythmias, myasthenia gravis Onset/Duration: Onset 1 - 2 min IV Duration 30-60 min Dose/Route: Adult: 0.5 – 2 mcg/kg IV/IN over 2 mins, q 5 min, max single dose of 100 mcg, max total dose of 300 mcg. Peds: 0.5 – 1 mcg/kg IV/IN over 2 mins, q 5 min, max single dose of 100 mcg, max total dose of 3 mcg/kg. Side Effects: Respiratory depression, hypotension or hypertension, bradycardia, nausea/vomiting, and rigidity of chest wall muscles

Furosemide (Lasix)

Class: Loop diuretic Action: Furosemide is a potent diuretic that inhibits the reabsorption of sodium and chloride in the proximal tubule and loop on Henle. IV doses can also reduce cardiac preload by increasing venous capacitance. Indications: Pulmonary edema (CHF) with SBP > 90 , hypertensive emergencies, hyperkalemia Contraindications: Anuria, hypersensitivity, hypovolemia, hypokalemia Onset/Duration: Onset: 15 - 20 min IV Duration: 2 hrs Dose/Route: Adult: 20 - 40 mg IV over 1-2 min. If no response double dose up to 2 mg/kg over 1-2 min. Most services allow up to a max of 40 - 80 mg IV. Peds: 1 mg/kg/dose IV over 1-2 min with a total max of 6 mg/kg Side Effects: Tinnitus and hearing loss (if given too quickly), hypotension, hypokalemia, hyponatremia, hypocalcemia, hyperglycemia Note: Must give slowly or may cause permanent hearing problems.