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Drug_formulary.pdf

TABLE OF CONTENTS
ADENOSINE (ADENOCARD)

Class
Endogenous nucleotide
Description
Adenosine is primarily formed from the breakdown product of adenosine triphosphate (ATP). Both compounds are found in every cell of the human body and have a wide range of metabolic roles. Adenosine slows tachycardias associated with the AV node via modulation of the autonomic nervous system without causing negative inotropic effects. It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and dromotropic activity. Adenosine is the drug of choice for paroxysmal supraventricular tachycardia (PSVT) and can be used diagnostically for stable, wide complex tachycardias of unknown type after two doses of lidocaine. Onset & Duration
Onset: almost immediate Duration: 10 sec Indications
Contraindications
Second- or third-degree AV block Sick sinus syndrome Hypersensitivity to adenosine Adverse Reactions
Facial flushing Lightheadedness Paresthesia Headache Diaphoresis Palpitations Chest pain Hypotension Nausea Metallic taste Shortness of breath Drug Interactions
Methylxanthines (for example, caffeine and theophylline) antagonize the action of adenosine. Dipyridamole potentiates the effect of adenosine; reduction of adenosine dose may be required. Carbamazepine may potentiate the AV-nodal blocking effect of adenosine. How Supplied
Parenteral for IV injection 3 mg/ml in 2-ml flip -top vials Dosage and Administration
a. 6.0 mg IV/Saline Lock bolus, rapidly, followed
by a Normal Saline (0.9 NS) flush.
b. Observe EKG monitor for 1-2 minutes for evidence of cardioversion. c. If there is no evidence of cardioversion,
administer Adenosine 12 mg, IV/Saline Lock
bolus, rapidly, followed by a Normal (0.9 NS)
flush.
d. If there is still no evidence of cardioversion,
repeat Adenosine 12 mg IV/Saline Lock bolus,
rapidly, followed by a Normal Saline (0.9 NS)
flush.
Pediatric:
0.1 mg/kg, IV/Saline Lock or IO bolus,
rapidly, followed by 2-3 ml of Normal Saline
(0.9 NS) flush.
If this fails to convert the dysrhythmia,
Adenosine may be repeated at 0.2 mg/kg,
IV/Saline Lock or IO bolus, rapidly,
followed by 2-3 ml Normal Saline (0.9 NS)
flush. Maximum single dose is 12 mg.
Protocol
Special Considerations
Pregnancy safety: Category C May produce bronchoconstriction in patients with asthma or bronchopulmonary disease. At the time of conversion asystole or new rhythms may result. These generally last a few seconds without intervention Adenosine is not effective in atrial flutter or fibrillation ALBUTEROL (PROVENTIL, VENTOLIN)
Relatively selective beta-2 adrenergic bronchodilator Description
Albuterol is a sympathomimetic that is selective for beta-2 adrenergic receptors. It relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating adrenergic receptors of the sympathetic nervous system. Onset & Duration
Onset: 5-15 min. after inhalation; 30 min PO Duration: 3-4 hr after inhalation; 4-6 hr PO Indications
Relief of bronchospasm in patients with reversible obstructive airway disease Prevention of exercise-induced bronchospasm Contraindications
Prior hypersensitivity reaction to albuterol Cardiac dysrhythmias associated with tachycardia Tachycardia caused by digitalis intoxication Adverse Reactions
Tachycardia Restlessness Apprehension Headache Dizziness Nausea Palpitations Increase in blood pressure Dysrhythmias Hypokalemia Drug Interactions
Sympathomimetics may exacerbate adverse
cardiovascular effects. Antidepressants may potentiate
the effects on the vasculature. Beta blockers may
antagonize albuterol. Albuterol may potentiate diuretic-
induced hypokalemia.
How Supplied
Tablet/extended release (as sulfate): 4 mg Rotacaps for inhalation: 200 mcg/capsule MDI: 90 mcg/metered spray (17-g canister with 200 inhalations) Solution for aerosolization: 0.5% (5 mg/ml) Prediluted nebulized solution: 2.5 mg in 3 ml NS (0.083%) Dosage and Administration
Bronchial asthma
Albuterol sulfate solution 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of 3 doses). Pediatric:
Albuterol sulfate 0.083% (one unit dose bottle of 3.0 ml), by nebulizer, at a flow rate that will deliver the solution over 5-15 minutes. (See Appendix J.) May be repeated twice during transport (total of 3 doses).
Protocol
507

Special Considerations
Pregnancy safety: Category C
May precipitate angina pectoris and dysrhythmias
Should be used with caution in patients with diabetes
mellitus, hyperthyroidism, prostatic hypertrophy, or
seizure disorder
Amiodarone Hydrochloride (Cordarone)
Antiarrhythmic (Vaughan Williams Class III) Description
Amiodarone is generally considered a class III (VW) antiarrhythmic drug, but it possesses electrophysiologic characteristics of all four Vaughan Williams classes. Amiodarone blocks sodium channels at rapid pacing frequencies, and it exerts a noncompetitive antisympathetic action. One of its main effects, with prolonged administration, is to lengthen the cardiac action potential and produce negative chronotropic effect in nodal tissues. In addition to blocking sodium channels, amiodarone blocks myocardial potassium channels, which contributes to slowing of conduction and prolongation of refractoriness. The antisympathetic action and the block of calcium and potassium channels are responsible for the negative dromotropic effects on the sinus node and for the slowing of conduction and prolongation of refractoriness in the atrioventricular (AV) node. Its vasodilatory action can decrease cardiac workload and consequently myocardial oxygen consumption. Onset & Duration
Effects are seen 10 minutes after IV administration. Due to rapid distribution, serum concentrations decline to 10% of peak values within 30-45 minutes. Indications
Contraindications
None in the treatment of life-threatening dysrhythmias Adverse Reactions

Bradycardia
Hypotension
Drug Interactions

Solvent used for bolus and drip must be Dextrose 5%
Water only.
How Supplied
Dosage and Administration
300 mg diluted up to a total 20 mL of D5W, IV Saline Lock Bolus. If Ventricular Fibrillation or
Ventricular Tacvhycardia recurs
administer 150 mg diluted up to a
total 10 mL D5W, IV Saline Lock
Bolus.
Protocol
Ventricular Fibrillation/Pulseless Ventricular Special Considerations
DEXTROSE 50%

Description
The term dextrose is used to describe the six-carbon sugar d-glucose, the principal form of carbohydrate used by the body. D50 is used in emergency care to treat hypoglycemia and to manage coma of unknown origin. Onset & Duration
Duration: Depends on the degree of hypoglycemia Indications
Hypoglycemia Altered level of consciousness Coma of unknown etiology Seizure of unknown etiology Refractory cardiac arrest (controversial) Contraindications
There are no significant contraindications for IV administration of 50% dextrose in emergency care. Adverse Reactions
Warmth, pain, burning from medication infusion Thrombophlebitis Rhabdomyolysis Drug Interactions
There are no significant drug interactions with other emergency medications. How Supplied
25 g/50 ml prefilled syringe (500 mg/ml) Dosage and Administration
Dextrose 25 gm (50 ml of a 50% solution), IV/Saline Lock bolus. Pediatric:
Dextrose 0.5 gm/kg, IV/Saline Lock or IO bolus. Use 10% Dextrose in patients less than 6 months of age. Use 25% Dextrose in patients between six (6) months and two (2) years of age. Use 50% Dextrose in patients two (2) years of age or older. Maximum dose is 25 gm. (See Broselow Tape or Appendix J.) Protocol
Ventricular Fibrillation/Pulseless Ventricular Special Considerations
Pregnancy safety: NA Draw blood sample before administration if possible. Use blood-glucose reagent strips (Dextrostix) or glucometer before administration if possible. Extravasation may cause tissue necrosis; use a large vein and aspirate occasionally to ensure route patency. D50 sometimes precipitates severe neurological symptoms (Wernicke's encephalopathy) in thiamine-deficient patients such as alcoholics. This can be prevented by administering 100 mg, IV of thiamine. DIAZEPAM (VALIUM AND OTHERS)
Benzodiazepine sedative-hypnotic, anticonvulsant Description
Diazepam is frequently prescribed to treat anxiety and stress. In emergency care, it is used to treat alcohol withdrawal and grand mal seizure activity. Diazepam acts on the limbic, thalamic, and hypothalamic regions of the CNS to potentiate the effects of inhibitory neurotransmitters, raising the seizure threshold in the motor cortex. It may also be used in conscious patients during cardioversion to induce amnesia and sedation. Though the drug is still widely used as an anticonvulsant, it is relatively weak and of short duration. Rapid IV administration may be followed by respiratory depression and excessive sedation. Onset & Duration
Indications
Acute anxiety states Acute alcohol withdrawal Muscle relaxant Seizure activity Preoperative sedation Contraindications
Hypersensitivity to the drug Acute narrow angle glaucoma Open angle glaucoma Adverse Reactions
Hypotension Reflex tachycardia Respiratory depression Ataxia Psychomotor impairment Confusion Nausea Drug Interactions
Diazepam may precipitate CNS depressio n and psychomotor impairment when the patient is taking CNS depressant medications Should not be administered with other drugs because of possible precipitation (incompatible with most fluids; should be administered into an IV of normal saline solution). How Supplied
Parenteral: 5 mg/ml vials, ampules, Tubex Dosage and Administration
Seizure Activity:
5-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given if seizure activity persists or recurs. (Rate of administration may not exceed 5.0 mg/min.) Pediatric:
0.1 mg/kg, IV/Saline Lock or IO bolus,
slowly, over 2 minutes. Repeat doses of
Diazepam 0.1 mg/kg, IV/Saline Lock bolus,
slowly, over 2 minutes, may be given if
seizures persist. (See Appendix J)

Amnesia for cardioversion and analgesia for burns:

5.0-10 mg, IV/Saline Lock bolus. Repeat doses of Diazepam 5.0-10 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 20 mg) Protocol
Ventricular Tachycardia With A Pulse/Wide Special Considerations
Pregnancy safety: Category D May cause local venous irritation Has short duration of anticonvulsant effect Reduce dose by 50% in elderly patients Resuscitation equipment should be readily available DILTIAZEM (CARDIZEM AND OTHERS)
Class

Calcium channel antagonist (Class IV antidysrhythmic)
Description

Diltiazem inhibits calcium ion influx across cardiac and
smooth muscle cells, decreasing myocardial contractility
and oxygen demand, and dilates coronary arteries and
peripheral arterioles. Like other calcium antagonists,
diltiazem decreases SA and AV conduction in isolated
tissue and has a negative inotropic effect.
Onset & Duration
Onset: 3 minutes
Duration: 1-3 hours
Indication
Vasospastic angina
Classic chronic stable angina
Hypertension
PSVT
Atrial flutter with rapid ventricular response
Atrial fibrillation with rapid ventricular response
Contraindication
Sick sinus syndrome (unless a functioning ventricular
pacemaker is present)
Hypotension
Second or third degree AV block

Adverse Reactions
Headache
Fatigue
Drowsiness
Edema
Arrhythmias
CHF
Nausea
Rash

Drug Interactions

Diltiazem may increase serum levels of digoxin.
Beta-blockers may prolong cardiac conduction time
when used together with diltiazem.
Cimetidine may inhibit metabolism and cause diltiazem
toxicity.
How Supplied
Injectable: 5mg mL in 5 mL vial
Dosage and Administration

0.25 mg/kg, IV/Saline Lock bolus, slowly,
over 2 minutes, monitoring blood pressure
continuously.

Protocol
505-A

Special Considerations
Pregnancy safety: Category C
Resuscitation equipment should be readily available
DIPHENHYDRAMINE (BENADRYL)
Description
Antihistamines prevent the physiological actions of histamine by preventing histamine from reaching H1- and H2-receptor sites. Diphenhydramine also has anticholinergic (drying) and sedative effects. Antihistamines provide short-lived benefits and provide only symptomatic relief. Antihistamine is specific for conditions in which histamine excess is present (for example, acute urticaria) but is adjunctive therapy in the treatment of anaphylactic shock because epinephrine is more effective. Antihistamines are quite specific for reversing extrapyramidal reactions and are probably efficacious as drying agents in upper respiratory and sinus conditions. Onset & Duration
Indications
Symptomatic relief of allergies Allergic reactions Anaphylaxis Acute dystonic reactions Motion sickness Antiparkinsonism Contraindications
Lower respiratory diseases such as asthma attacks Newborn or premature infants Nursing mothers Hypersensitivity Narrow-angle glaucoma Adverse Reactions
Dose-related drowsiness Sedation Disrupted coordination Hypotension Palpitations Tachycardia Bradycardia Thickening of bronchial secretions Dry mouth and throat Epigastric distress Drug Interactions
CNS depressants and alcohol may have additive effects. MAO inhibitors may prolong and intensify anticholinergic effects of antihistamines. How Supplied
Parenteral: 10, 50 mg/ml vials, prefilled syringe Dosage and Administration
50 mg, IV/Saline Lock bolus, or IM, if IV/Saline Lock bolus has not been established. Protocol
Special Considerations
DOPAMINE (INTROPIN)
Description
Dopamine is chemically related to epinephrine and norepinephrine. It acts primarily on alpha-1 and beta-1 adrenergic receptors, increasing systemic vascular resistance and exerting a positive inotropic effect on the heart. In addition, the actions of this drug on dopaminergic receptors dilate renal and splanchnic vasculature, maintaining blood flow. Dopamine is commonly used to treat hypotension associated with cardiogenic shock. Onset & Duration
Indications
Hypotension Shock Low cardiac output states Contraindications
Adverse Reactions
Dose-related tachydysrhythmias Hypertension Increased myocardial oxygen demand Drug Interactions
May be deactivated by alkaline solutions (sodium bicarbonate and furosemide) MAO inhibitors and bretylium may potentiate the effect of dopamine Sympathomimetics and phosphodiesterase inhibitors exacerbate dysrhythmia response Beta-adrenergic antagonists may blunt inotropic response When administered with phenytoin, hypotension, bradycardia, and seizures may develop How Supplied
200 mg/5 ml, 400 mg/5 ml prefilled syringe and ampule for IV infusion (IV piggyback) Dosage and Administration
5.0 mcg/kg/min., IV/Saline Lock drip. If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 20 mcg/kg/min., IV/Saline Lock drip.) Usually prepared by placing 800 mg in 500 ml D5W to achieve a concentration of 1600 mcg/ml or 200 mg in 250 ml D5W to achieve a concentration of 800 mcg/ml; infuse at 2.5-20 mcg/kg/min. (titrate to patient response) Dopaminergic response: 2-4 mcg/kg/min. Beta-adrenergic response: 5-10 mcg/kg/min. Adrenergic response: 10-20 mcg/kg/min. Protocol
Special Considerations
Pregnancy safety: Category C Infuse through a large, stable vein to avoid the possibility of extravasation injury Monitor patient for signs of compromised circulation EPINEPHRINE (ADRENALIN)
Description
Epinephrine stimulates alpha, beta-1, and beta-2 adrenergic receptors in dose-related fashion. It is the initial drug of choice for treating bronchoconstriction and hypotension resulting from anaphylaxis as well as all forms of cardiac arrest. It is useful in managing reactive airway disease, but beta-adrenergic agents are often used initially because of their bronchial specificity and oral inhalation route. Rapid injection produces a rapid increase in systolic pressure, ventricular contractility, and heart rate. In addition, epinephrine causes vasoconstriction in the arterioles of the skin, mucosa, and splanchnic areas and antagonizes the effects of histamine. Onset & Duration
Indications
Bronchial asthma Acute allergic reaction Cardiac arrest Asystole Pulseless electrical activity Ventricular fibrillation unresponsive to initial defibrillatory attempts Contraindications
Hypersensitivity Hypovolemic shock Narrow angle glaucoma Adverse Reactions
Headache Nausea Restlessness Weakness Dysrhythmias Hypertension Precipitation of angina pectoris Drug Interactions
MAO inhibitors and bretylium may potentiate the effect of epinephrine. Beta-adrenergic antagonists may blunt inotropic response. Sympathomimetics and phosphodiesterase inhibitors may exacerbate dysrhythmia response. May be deactivated by alkaline solutions (sodium bicarbonate, furosemide). How Supplied
Parenteral: 1 mg/ml ( 1:1000), 0.1 mg/ml (1:10,000) ampule and prefilled syringe Autoinjector (EpiPen) 0.5 mg/ml (1:2000) 0.01 mg/ml ( 1:100,000) pediatric Dosage and Administration
Asystole, pulseless electrical activity, or
ventricular fibrillation:

1 mg (10 ml of a 1:10,000 solution), IV/Saline Lock bolus. If there is no change in the rhythm within 3-5 minutes repeat Epinephrine 1.0 mg (10 ml of a 1: 10,000 solution), IV/Saline Lock bolus, every 3-5 minutes. If there is no change in rhythm, repeat Epinephrine 3.0 mg (3 ml of a 1:1,000 solution), IV/Saline Lock bolus, 3-5 minutes after the initial dose. If there is still no change in rhythm, administer Epinephrine 5.0 mg (5.0 ml of a 1:1,000 solution), IV/Saline Lock bolus, 3-5 minutes after the previous dose. Subsequent doses of Epinephrine 5.0 mg (5 ml of a 1:1,000 solution), IV/Saline Lock bolus, should be given every 3-5 minutes for the duration of treatment. Bradycardia refractory to other interventions:
Epinephrine 1.0 mcg/min., IV/Saline Lock drip. Prepare the infusion by adding 1.0 mg of Epinephrine (1.0 ml of a 1:1,000 solution) to 250 ml of Normal Saline (0.9 NS) (1 mcg/min. = 15 ml/hr = 15 gtt/min.). If there is sufficient improvement in hemodynamic status, the infusion may be increased until the desired effects are achieved or adverse effects appear. (Maximum dosage is 10 mcg/min., IV/Saline Lock drip.) Epinephrine 0.3 mg (0.3 ml of a 1:1,000 solution), subcutaneously. Anaphylactic Reaction:
Epinephrine 1.0 mg (10 ml of a 1:10,000 solution), via the Endotracheal Tube If Endotracheal Intubation has not been accomplished, administer Epinephrine 0.3 mg (0.3 ml of a 1:1,000 solution), subcutaneously. Epinephrine 1.0 mcg/min., IV/Saline Lock drip. Prepare infusion by adding 1.0 mg of Epinephrine (1.0 ml of a 1:1,000 solution) to 250 ml of Normal Saline (0.9 NS) (1 mcg/min. = 15 ml/hr = 15 gtt/min.). If there is insufficient improvement in hemodynamic status, the infusion may be increased until the desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 4.0 mcg/min., IV/Saline Lock drip.) Pediatric:
Anaphylactic reaction and newborn
resuscitation:

Epinephrine 0.1 mg/kg (0.1 ml/kg of a 1:1,000 solution), IV/Saline Lock, IO, or ET. In patients one (1) year of age or older with severe respiratory distress, respiratory failure, and/or decreased breath sounds, administer Epinephrine 0.01 mg/kg (0.01 ml/kg of a 1:1,000 solution), subcutaneously. Maximum dose is 0.3 ml. (See Appendix J.) Protocol
Special Considerations
Pregnancy safety: Category C. Syncope has occurred after epinephrine administration to asthmatic children. May increase myocardial oxygen demand. FUROSEMIDE (LASIX)
Description
Furosemide is a potent diuretic that inhibits the reabsorption of sodium and chloride in the proximal tubule, distal tubule, and the loop of Henle. Onset & Duration
Indications
Edema Congestive heart failure Hypertension Contraindications
Adverse Reactions
Hypotension Dehydration Dry mouth Ototoxicity Tinnitus Hypochloremia Hypokalemia Hyponatremia Hyperglycemia Drug Interactions
Digitalis toxicity may be potentiated by the potassium depletion that can result from furosemide administration. Increases the ototoxic potential of aminoglycoside antibiotics Lithium toxicity may be potentiated by sodium depletion. How Supplied
Parenteral: 10 mg/ml in 2 ml ampule, 100 mg/ml in 10 ml vial Dosage and Administration
Furosemide 20-80 mg, IV/Saline Lock bolus. (Maximum combined total dosage is 80 mg.) Protocol
Special Considerations
Pregnancy safety: Category C Furosemide has been known to cause fetal abnormalities Should be protected from light GLUCAGON
Description
Glucagon is a hormone secreted by the alpha cells of the pancreas. When released, it elevates blood glucose levels by increasing the breakdown of glycogen to glucose and inhibiting glycogen synthesis. In addition, glucagon exerts positive inotropic action on the heart and decreases renal vascular resistance. The drug is only effective in treating hypoglycemia if liver glycogen is available. Therefore it may be ineffective in chronic hypoglycemia, starvation, and adrenal insufficiency. Glucagon also causes relaxation of smooth muscle of the stomach, duodenum, small bowel, and colon. Onset & Duration
Indications
Altered level of consciousness where hypoglycemia is suspected. May be used as an inotropic agent in beta-blocker overdose. Contraindications
Hypersensitivity Patients with pheochromocytoma Adverse Reactions
Tachycardia Hypertension Nausea and vomiting Drug Interactions
There are no significant drug interactions with other emergency medications. How Supplied
Glucagon must be reconstituted (with provided diluent) before administration. Dilute 1 unit (1 mg) white powder in 1 ml of diluting solution (1 mg/ml). Dosage and Administration
In patients with diabetic histories where an IV/Saline Lock route is not available, administ er Glucagon 1.0 mg, IM. (Thiamine need not be administered to these patients) Pediatric:
Protocol
Special Considerations
Pregnancy safety: Category B Should not be considered a first -line choice for hypoglycemia lntravenous glucose must be administered if the patient does not respond to a second dose of glucagon. LIDOCAINE (XYLOCAINE)
Description
Lidocaine decreases phase-4 diastolic depolarization and suppresses premature ventricular contractions. In addition, it is used to treat ventricular tachycardia and some cases of ventricular fibrillation. Lidocaine also raises the ventricular fibrillation threshold. Onset & Duration
Indications
Contraindications
Hypersensitivity Stokes-Adams syndrome Second- or third-degree heart block in the absence of an artificial pacemaker Adverse Reactions
Lightheadedness Confusion Blurred vision Hypotension Cardiovascular collapse Bradycardia CNS depression (altered level of consciousness, irritability, muscle twitching, seizures) with high doses Drug Interactions
Metabolic clearance of lidocaine may be decreased in patients taking beta-adrenergic blockers or in patients with liver dysfunction. Apnea induced with succinylcholine may be prolonged with large doses of lidocaine. Cardiac depression may occur if lidocaine is given concomitantly with IV phenytoin. Additive neurological effects may occur with procainamide. How Supplied
Dosage and Administration
Ventricular fibrillation or pulseless ventricular
tachycardia

1.5 mg/kg, IV/Saline Lock bolus. Repeat dose may be given after 5 minutes. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg) Immediately following conversion to a supraventricular rhythm (even of a short duration), administer Lidocaine 1.5 mg/kg, IV/Saline Lock bolus. Repeat doses of Lidocaine 0.75 mg/kg, IV/Saline Lock bolus may be given every 5 minutes, and may be followed by Lidocaine 1.0-4.0 mg/min., IV/Saline Lock drip. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg) Pediatric:
1.0 mg/kg, IV/Saline Lock or IO bolus, or via the Endotracheal Tube. (See Broselow Tape or Appendix J) Ventricular ectopy with a pulse
1.5 mg/kg, IV/Saline Lock bolus. Repeat doses of Lidocaine 0.75 mg/kg, IV/Saline Lock bolus, may be given every 5 minutes. (Maximum individual dose is 1.5 mg/kg and maximum total dosage is 3.0 mg/kg) If Lidocaine converts the dysrhythmia, administer Lidocaine 1.0-4.0 mg/min., IV/Saline Lock drip. Head Injuries
1.5 mg/kg, IV/Saline Lock bolus immediately prior to intubation to minimize the increase in intracranial pressure. (Maximum dose is 1.5 mg/kg) Protocol
Ventricular Fibrillation/Pulseless Ventricular Special Considerations
Pregnancy safety: Category B. Therapeutic plasma levels of lidocaine between 2-6 mcg/ml suppress ventricular dysrhythmias. A 75- to 100-mg bolus maintains adequate blood levels for only 20 min. If bradycardia occurs in conjunction with PVCs, always treat the bradycardia first with atropine, epinephrine, and/or dopamine. Exceedingly high doses of lidocaine can result in coma or death. Avoid lidocaine for reperfusion dysrhythmias after thrombolytic therapy. LORAZEPAM (ATIVAN AND OTHERS)
Class
Benzodiazepine sedative-hypnotic, anticonvulsant
Description
Lorazepam is frequently prescribed to treat anxiety and
stress. In the emergency setting it is used to treat seizure
activity. It depresses the CNS at the limbic and
subcortical levels of the brain. It potentiates the effects
of inhibitory transmitters, raising the seizure threshold in
the motor cortex. The anticonvulsant effect is seen more
rapidly, and lasts longer than that of diazepam.
Onset & Duration
Onset:
Duration: 6-8 hours
Indications

Acute anxiety states
Seizure activity
Premedication before operative procedures
Muscle relaxant
Acute alcohol withdrawal
Contraindications
Hypersensitivity
Acute narrow angle glaucoma
Adverse Reactions
Drowsiness
Lethargy
Hypotension
Respiratory depression
Drug Interactions

CNS depression is increased when used concomitantly
with alcohol and other CNS depressants.

How Supplied

Tablets: 0.5 mg, 1 mg, 2 mg
Injection: 2 mg/ml, 4 mg/ml
Dosage and Administration
Adult:

2.0-4.0 mg. IV/Saline Lock, or IM. Repeat doses of
Lorazepam 2.0-4.0 mg, IV/Saline Lock, or IM, may be
given every 5 minutes if seizure activity persists or
recurs. (Maximum total dosage is 8.0 mg)
Pediatric:

0.05 mg/kg IV/Saline Lock or IO bolus, slowly, over 2
minutes. Repeat doses of Lorazepam 0.05 mg/kg,
IV/Saline Lock or IO bolus, slowly, over 2 minutes, may
be given if seizures persist. (See Appendix J)
Protocol
513

Special Considerations

Pregnancy safety: Category D
Reduce dose by 50% in elderly patients
Resuscitatio n equipment should be readily available
MAGNESIUM SULFATE
Description
Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. In emergency care, magnesium sulfate is used to manage seizures associated with toxemia of pregnancy. Other uses include uterine relaxation (to inhibit contractions of premature labor), as a bronchodilator after beta-agonist and anticholinergic agents have been used, replacement therapy for magnesium deficiency, as a cathartic to reduce the absorption of poisons from the Gl tract, and in the initial therapy for convulsions. Magnesium sulfate is gaining popularity as an initial treatment in the management of various dysrhythmias, particularly torsades de pointes, and dysrhythmias secondary to a tricyclic antidepressant overdose or digitalis toxicity. The drug is also considered as a class IIa agent (probably helpful) for refractory ventricular fibrillation and ventricular tachycardia after administration of lidocaine or bretylium doses. Onset & Duration
Indications
Seizures of eclampsia (toxemia of pregnancy) Torsades de pointes Contraindications
Adverse Reactions
Diaphoresis Facial flushing Hypotension Depressed reflexes Hypothermia Reduced heart rate Circulatory collapse Respiratory depression Drug Interactions
CNS depressant effects may be enhanced if the patient is taking other CNS depressants. Serious changes in cardiac function may occur with cardiac glycosides. How Supplied
5 and 10 ml of a 10% solution in prefilled syringe Dosage and Administration
Seizure activity associated with pregnancy:
For severe pre-eclampsia or eclampsia, administer Magnesium Sulfate 2.0 gm, IV/Saline Lock drip, diluted in 50-100 ml of Normal Saline (0.9 NS), over 10-20 minutes. If seizures develop, continue, or recur in transport, repeat Magnesium Sulfate 2 gm, IV/Saline Lock drip, diluted in 100 ml of Normal Saline (0.9NS), over 10-20 minutes. Magnesium deficiency related to cardiac
dysrhythmias, torsades de pointes, or refractory
ventricular fibrillation:

2.0 gm, IV/Saline Lock bolus, diluted in 10 ml of Normal Saline (0.9 NS), over 2 minutes 2.0 gm, IV/Saline Lock drip, diluted in 50-100 ml of Normal Saline (0.9 NS), over 10-20 minutes.

Protocol
503-B
Ventricular Fibrillation/Pulseless Ventricular Special Considerations
Pregnancy safety: Magnesium sulfate is administered to treat toxemia of pregnancy. It is recommended that the drug not be administered in the 2 hours before delivery, if possible. IV calcium gluconate or calcium chloride should be available as an antagonist to magnesium if needed. Convulsions may occur up to 48 hr after delivery, necessitating continued therapy. The "cure" for toxemia is delivery of the baby. Magnesium must be used with caution in patients with renal failure, since it is cleared by the kidneys and can reach toxic levels easily in those patients. Prophylactic administration of magnesium sulfate for patients with acute myocardial infarction should be considered. METAPROTERENOL (ALUPENT)
Description
Metaproterenol relaxes the smooth muscles of the bronchial tree and peripheral vasculature by stimulating beta-2 adrenergic receptors of the sympathetic nervous system. It activates adenyl cyclase, the enzyme that catalyzes the conversion of adenosine triphosphate to cyclic adenosine monophosphate. Onset & Duration
Indications
Bronchial asthma Reversible bronchospasm (bronchitis, emphysema) Contraindications
Hypersensitivity Cardiac dysrhythmias Tachycardia caused by digitalis toxicity Adverse Reactions
Restlessness Tremor Palpitations Tachycardia Dysrhythmias Decreased blood pressure Coughing Facial flushing Diaphoresis Drug Interactions
Other sympathomimetics may exacerbate adverse cardiovascular effects. MAO inhibitors may potentiate hypotensive effects. Beta blockers may antagonize metaproterenol. How Supplied
Inhaler: 650 mcg/metered dose, 300 doses/inhaler (15 ml) Solution: 0.6% (2.5 ml dose); 5% (0.3 ml dose) Dosage and Administration
5% (0.3 ml in 2.5-3.0 ml of Normal Saline (0.9 NS)), by nebulizer, at a flow rate that will deliver the solution over 5 to 15 minutes. May be repeated twice (total of three doses). Pediatric:
5% (0.3 ml in 2.5-3.0 ml of Normal Saline (0.9 NS)), by nebulizer, at a flow rate that will deliver the solution over 5-15 minutes. (See Appendix J) May be repeated twice during transport (total of three doses). Protocol
Special Considerations
Pregnancy safety: Category C. Monitor vital signs for hypotension and tachycardia. Use with caution in patients with coronary artery disease and diabetes mellitus. METHYLPREDNISOLONE (SOLU-MEDROL)
Description
Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation and may alter the immune response. In addition, it potentiates vascular smooth muscle relaxation by beta-adrenergic agonists and may alter airway hyperactivity. An additional newer use is for reduction of posttraumatic spinal cord edema. Onset & Duration
Indications
Anaphylaxis Bronchodilator for unresponsive asthma Acute spinal cord injury Endocrine disorders Rheumatic disorders Dermatological diseases Allergic states Others Contraindications
Hypersensitivity Premature infants Systemic fungal infections Use with caution in patients with GI bleeding and diabetes mellitus. Adverse Reactions
Headache Hypertension Sodium and water retention Hypokalemia Alkalosis Cataracts Psychosis Osteoporosis Peptic ulcer Impaired wound healing Development of Cushingoid state Drug Interactions
Hypoglycemic responses to insulin and oral hypoglycemic agents may be blunted. Potassium-depleting agents may potentiate hypokalemia induced by corticosteroids. How Supplied (methylprednisolone sodium succinate)
40 mg, 125 mg, 500 mg, 1000 mg, 2000 mg/vials Dosage and Administration
125 mg, IV/Saline Lock bolus, slowly, over 2
minutes, or IM.
Protocol
Special Considerations
Pregnancy safety: Not established. May mask some signs of infection MIDAZOLAM HYDROCHLORIDE (VERSED)
Short -acting benzodiazepine CNS depressant Description
Midazolam HCl is a water-soluble benzodiazepine that may be administered for conscious sedation to relieve apprehension or impair memory before endotracheal or nasotracheal intubation. Onset & Duration
Indications
Preoperative sedation Conscious sedation General anesthesia Premedication for tracheal intubation Contraindications
Hypersensitivity Acute narrow angle glaucoma Adverse Reactions
Hiccough Cough Oversedation Pain at the injection site Nausea and vomiting Headache Blurred vision Fluctuations in vital signs Hypotension Respiratory depression Respiratory arrest Drug Interactions
Sedative effect of midazolam may be accentuated by concomitant use of barbiturates, alcohol, CNS depressants, or narcotics. How Supplied
2, 5, 10 ml vials (1 mg/ml) 1, 2, 5, 10-ml vials (5 mg/ml) Dosage and Administration
1.0-2.0 mg, IV/Saline Lock bolus. Repeat doses of Midazolam 1.0 mg IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 5.0 mg) Protocol
Special Considerations
Pregnancy safety: Category D. Administer immediately before the intubation procedure. Provide continuous monitoring of respiratory and cardiac function. Have resuscitation equipment and medication readily at hand. MORPHINE SULFATE (ASTRAMORPH/PF, AND
OTHERS)

Description
Morphine sulfate is a natural opium alkaloid that increases peripheral venous capacitance and decreases venous return ("chemical phlebotomy"). It promotes analgesia, euphoria, and respiratory and physical depression. Secondary pharmacological effects of morphine include depressed responsiveness of alpha-adrenergic receptors (producing peripheral vasodilation) and baroreceptor inhibition. In addition, because morphine decreases both preload and afterload, it may decrease myocardial oxygen demand. Morphine sulfate is a schedule II drug. Onset & Duration
Indications
Chest pain associated with myocardial infarction Moderate to severe acute and chronic pain Should be used with caution in chronic pain syndromes Pulmonary edema, with or with out associated pain Contraindications
Hypersensitivity Diarrhea caused by poisoning Hypovolemia Hypotension Head injury or undiagnosed abdominal pain Patients who have taken MAO inhibitors within 14 days Adverse Reactions
Hypotension Nausea and vomiting Tachycardia or bradycardia Palpitations Syncope Facial flushing Respiratory depression Euphoria Bronchospasm Dry mouth Allergic reaction Urinary retention Drug Interactions
CNS depressants may potentiate effects of morphine (respiratory depression, hypotension, and sedation) Chlorpromazine may potentiate analgesia MAO inhibitors may cause paradoxical excitation How Supplied
Morphine is supplied in tablets, suppositories, and solution. In emergency care, morphine sulfate is usually administered IV. Parenteral preparations are available in many strengths. A common preparation is 10 mg in 1 ml of solution, ampules, and Tubex syringes. Dosage and Administration
2.0-5.0 mg, IV/Saline Lock bolus. Repeat doses of Morphine Sulfate 2.0-5.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 15 mg) Protocol
Special Considerations
Pregnancy safety: Category C Narcotics rapidly cross the placenta. Safety in neonates has not been established. Use with caution in older adults, those with asthma, and those susceptible to CNS depression. May worsen bradycardia or heart block in inferior myocardial infarction (vagotonic effect) Naloxone and resuscitation equipment should be readily available NALOXONE (NARCAN)
Description
Naloxone is a competitive narcotic antagonist used in the management and reversal of overdoses caused by narcotics and synthetic narcotic agents. Unlike other narcotic antagonists, which do not completely inhibit the analgesic properties of opiates, naloxone antagonizes all actions of morphine. Onset & Duration
Indications
For the complete or partial reversal of CNS and respiratory depression induced by opioids: Morphine sulfate Heroin Hydromorphone (Dilaudid) Methadone Meperidine (Demerol) Paregoric Fentanyl citrate (Sublimaze) Oxycodone (Percodan) Codeine Propoxyphene (Darvon) Butorphanol tartrate (Stadol) Pentazocine (Talwin) Nalbuphine (Nubain) Decreased level of consciousness Coma of unknown origin Circulatory support in refractory shock (investigational) Contraindications
Hypersensitivity Use with caution in narcotic-dependent patients who may experience withdrawal syndrome (including neonates of narcotic-dependent mothers) Adverse Reactions
Tachycardia Hypertension Dysrhythmias Nausea and vomiting Diaphoresis Drug Interactions
Is incompatible with bisulfite and with alkaline solutions. How Supplied
0.02 mg/ml (neonate), 0.4 mg/ml, 1 mg/ml Dosage and Administration
Asystole, brady dysrhythmias, and complete
heart block:

2.0 mg IV/Saline Lock bolus. Repeat doses of Naloxone 2.0 mg, IV/Saline Lock bolus, may be given as necessary. (Maximum total dosage is 10 mg) Altered mental status:
2.0 mg, IV/Saline Lock bolus. If IV/Saline Lock access has not been established, administer Naloxone 2.0 mg IM. Pediatric:
2.0 mg, IV/Saline Lock or IO bolus, or via the Endotracheal Tube, in patients two (2) years of age or older. Use half the amount (1.0 mg) of this drug in patients less than two (2) years of age. (See Appendix J) Protocol
Special Considerations
Pregnancy safety: Category B Seizures have been reported (no causal relationship established) May not reverse hypotension Cautio n should be exercised when administering naloxone to narcotic addicts (may precipitate withdrawal with hypertension, tachycardia, and violent behavior) NITROGLYCERINE (NITROSTAT AND
OTHERS)

Description
It was originally believed that nitrates and nitrites dilated coronary blood vessels, thereby increasing blood flow to the heart. It is now believed that atherosclerosis limits coronary dilation and that the benefits of nitrates and nitrites result from dilation of arterioles and veins in the periphery. The resulting reduction in preload and to a lesser extent in afterload decreases the work load of the heart and lowers myocardial oxygen demand. Nitroglycerin is very lipid soluble and is thought to enter the body from the Gl tract through the lymphatics rather than the portal blood. Onset & Duration
Indications
Ischemic chest pain Hypertension Congestive heart failure Contraindications
Hypersensitivity Pericardial tamponade Restrictive cardiomyopathy Constrictive pericarditis Adverse Reactions
Transient headache Postural syncope Reflex tachycardia Hypotension Nausea and vomiting Allergic reaction Muscle twitching Diaphoresis Drug Interactions
Other vasodilators may have additive hypotensive effects. How Supplied
Tablets (sublingual): 0.15 mg (1/400 gr), 0.3 mg (1/200 gr), 0.4 mg (1/150 gr), 0.6 (1/100 gr) Aerosol (translingual): 0.4-mg metered dose Parenteral: 0.5 mg/ml, 0.8 mg/ml, 5.0 mg/ml Tablets (sustained release): 2.6 mg, 6.5 mg, 9 mg Capsules (sustained release): 6.5 mg, 9 mg Dosage and Administration
1/150 gr or spray 0.4 mg, sublingually, every 5 minutes,
for a total of 3 doses.
Nitropaste 1 1/2 inches (if available)
Protocol
504-A
Special Considerations
Pregnancy safety: Category C. Susceptibility to hypotension in older adults increases. Nitroglycerin decomposes when exposed to light or heat. Must be kept in airtight containers. Active ingredient of nitroglycerin "stings" when administered SL. OXYTOCIN (PITOCIN)
Description
Oxytocin means "rapid birth." It is a synthetic hormone named for the natural posterior pituitary hormone. It stimulates uterine smooth muscle contract ions indirectly and helps expedite the normal contractions of spontaneous labor. As in all significant uterine contractions, there is a transient reduction in uterine blood flow. Oxytocin also stimulates the mammary glands to increase lactation without increasing the production of milk. The drug is administered in the prehospital setting to control postpartum bleeding. Onset & Duration
Duration: (IV) 20 minutes after the infusion is stopped Indi cations
Postpartum hemorrhage after infant and placental delivery Contraindications
Presence of a second fetus Significant cephalopelvic disproportion Unfavorable fetal positions or presentations Adverse Reactions
Hypotension or hypertension Tachycardia Dysrhythmias Angina pectoris Anxiety Seizure Nausea and vomiting Allergic reaction Uterine rupture (from excessive administration) Drug Interactions
Other vasopressors may potentiate hypertension. How Supplied
10 USP units/1-ml ampule (10 U/ml) and prefilled syringe 5 USP units/1 -ml ampule (5 U/ml) and prefilled syringe Dosage and Administration
20 mU/min., IV/Saline Lock drip (if available). Prepare the infusion by adding 20 U (2 ml) of Oxytocin to 1000 ml of Normal Saline (0.9 NS) or Ringer's Lactate (RL) (20 mU/min. = 60 ml/hr = 15 gtt/min.). If there is insufficient improvement in control of post -partum hemorrhage, the infusion rate may be increased until the desired therapeutic effects are achieved or adverse effects appear. (Maximum dosage is 40 mU/min., IV/Saline Lock drip) Protocol
Special Considerations
Pregnancy safety: Category C Vital signs (including fetal heart rate) and uterine tone should be closely monitored SODIUM BICARBONATE
Descri ption
Sodium bicarbonate reacts with hydrogen ions to form water and carbon dioxide and thereby can act to buffer metabolic acidosis. Increasing the plasma concentration of bicarbonate causes blood pH to rise. Onset & Duration
Indications
Known preexisting bicarbonate-responsive acidosis Intubated patient with continued long arrest interval Upon return of spontaneous circulation after long arrest interval Tricyclic antidepressant overdose Alkalinization for treatment of specific intoxications Hyperkalemia Contraindications
In patients with chloride loss from vomiting and Gl suction Metabolic and respiratory alkalosis Hypocalcemia Hypokalemia Adverse Reactions
Metabolic alkalosis Hypoxia Rise in intracellular PCO2 and increased tissue acidosis Electrolyte imbalance (tetany) Seizures Tissue sloughing at injection site Drug Interactions
May precipitate in calcium solutions. Alkalinization of urine may increase half-lives of certain drugs. Vasopressors may be deactivated. How Supplied
Tablets: 300 mg, 325 mg, 600 mg, 625 mg Injection: 4% (2.4 mEq/5 ml) 4.2% (5 mEq/10 ml) 5% (297.5 mEq/500 ml) 7.5% (8.92 mEq/ 10 ml and 44.6 mEq/50 ml) 8.4% (10 mEq/10 ml and 50 mEq/50 ml) Dosage and Administration
44-88 mEq IV/Saline Lock bolus. Repeat doses of Sodium Bicarbonate 44 mEq, IV/Saline Lock bolus may be given every 10 minutes. Protocol
Ventricular Fibrillation/Pulseless Ventricular Special Considerations
Pregnancy safety: Category C. When possible, blood gas analysis should guide bicarbonate administration. Bicarbonate administration produces carbon dioxide, which crosses cell membranes more rapidly than bicarbonate, potentially worsening intracellular acidosis. May increase edematous or sodium-retaining states. May worsen congestive heart failure. THIAMINE (BETAXIN)
Description
Thiamine combines with ATP to form thiamine pyrophosphate coenzyme, a necessary component for carbohydrate metabolism. Most vitamins required by the body are obtained through diet, but certain states, such as alcoholism and malnutrition, may affect the intake, absorption, and use of thiamine. The brain is extremely sensitive to thiamine deficiency. Onset & Duration
Duration: Depends on the degree of deficiency Indications
Coma of unknown origin (before the administration of dextrose 50%, or Naloxone) Delirium tremens Beriberi (rare) Wernicke's encephalopathy Anemia from thiamine deficiency Contraindications There are no significant drug interactions with other emergency medications. Adverse Reactions
Hypotension (from rapid injection or large dose) Anxiety Diaphoresis Nausea and vomiting Allergic reaction (usually from IV inject ion; very rare) Drug Interactions
Hypersensitivity There are no significant drug interactions with other emergency medications. How Supplied
Tablets: 5 mg, 10 mg, 25 mg, 50 mg, 100 mg, 250 mg, 500 mg Injection: 100 mg/ml in 10 ml vial Dosage and Administration
Protocol
Special Considerations
Pregnancy safety: Category A Large IV doses may cause respiratory difficulties Anaphylactic reactions have been reported It should be given before D50 in a comatose patient suspected of Wernicke's encephalopathy VASOPRESSIN
Description
Vasopressin is a naturally occurring antidiuretic hormone. In unnaturally high doses - much higher than those needed for antidiuretic hormone effects - vasopressin acts as a non-adrenergic peripheral vasoconstrictor. Vasopressin acts by direct stimulation of smooth muscle V1 receptors. This smooth muscle constriction produces a variety of effects, including pallor of the skin, nausea, intestinal cramps, desire to defecate, bronchial constriction, and in women, uterine contractions. Onset & Duration
Indications
Ventricular Fibrillation Pulseless Ventricular Tachycardia Contraindications
Hypersensitivity Conscious patients with coronary artery disease Adverse Reactions
Pallor Nausea Intestinal cramps Bronchial constriction Drug Interactions
How Supplied
Dosage and Administration
40 units IV/Saline Lock Bolus, single dose, 1 time only. Protocol
Ventricular Fibrillation/Pulseless Ventricular Special Considerations
VERAPAMIL (ISOPTIN)
Calcium channel antagonist (class IV antidysrhythmic) Description
Verapamil is used as an antidysrhythmic and antianginal agent. It works by inhibiting the movement of calcium ions across cell membranes. The slow calcium ion current blocked by verapamil is more important for the activity of the SA and AV nodes than for many other tissues in the heart. By interfering with this current, calcium channel blockers achieve some selectivity of action. Verapamil decreases atrial automaticity, reduces AV conduction velocity, and prolongs the AV nodal refractory period. In addition, verapamil depresses myocardial contractility, reduces vascular smooth muscle tone, and dilates coronary arteries and arterioles in normal and ischemic tissues. Onset & Duration
Indications (Only in ACLS)
PSVT Atrial flutter with a rapid ventricular response Atrial fibrillation with a rapid ventricular response Contraindications
Hypersensitivity Sick sinus syndrome (unless the patient has a functioning pacemaker) Second- or third-degree heart block Hypotension Cardiogenic shock Severe congestive heart failure WPW with atrial fibrillation or flutter Patients receiving intravenous beta blockers Wide-complex tachycardias (ventricular tachycardia can deteriorate into ventricular fibrillation when calcium channel blockers are given) Ventricular tachycardia Adverse Reactions
Dizziness Headache Nausea and vomiting Hypotension Bradycardia Complete AV block Peripheral edema Drug Interactions
Beta-adrenergic blockers may have additive negative inotropic and chronotropic effects. Antihypertensives may potentiate hypotensive effects. How Supplied
Tablet (sustained release): 120 mg, 180 mg, 240 mg Injection: 2.5 mg/ml in 2 ml, 4 ml, 5 ml vials or 2 ml, 4 ml ampules Dosage and Administration
2.5-5.0 mg IV/Saline Lock bolus, slowly, over 2 min.;
monitoring blood pressure continuously.
Special Considerations
Pregnancy safety: Category C. Closely monitor patient's vital signs. Be prepared to resuscitate. AV block or asystole may occur as a result of slowed AV conduction.

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Dederich 204-212.qxd

P R A C T I C A L A B S T R A C T Background. During the last two decades, much has been written in both the scientific litera- Lasers in dentistry DOUGLAS N. DEDERICH, B.S.E.E., D.D.S., M.Sc., Ph.D.; RONALD D. BUSHICK, D.M.D., Ph.D., M.S. contouring, caries removal and bleaching. Overview. Almost one-third of patients surveyed by the American Dental Associa- tion in the late 19

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success in guinea pigs. Selamectin is the active ingredient in Revolution and works in a similar way to Ivomectin . Revolution works very quickly and will immediately kill all mites and their eggs before they hatch. Revolution is very simple to apply. It is recommended to purchase a pack for the smallest of dogs or cats as very little is required to be used on a guinea pig. Ap

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