Street Level Pharmacology
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1 Street Level Pharmacology Authored By: ARIELLE Gonzales, FP-C David Berry, FP-C, CCP Rey Ramirez, BSN, CFRN Shane Brown, FP-C Teresa Nystrom Tom McClendon, CFRN Objectives 1. Explain drug choice in association with case studies 2. Identify dose, indications, and contraindications for ground level medications 3. Compare and contrast dysrhythmias 4. Compare and contrast analgesics 1. Aspirin 2. Activated Charcoal 3. Adenosine 4. Albuterol 5. Amiodarone 6. Atropine 7. Diazepam 8. Midazolam 9. Dextrose 10. Diphenhydromine 11. Dopamine 12. Epinephrine 13. Glucogon Medications 14. Furosimide 15. Ipotroprium Bromide 16. Lidocain 17. Magnesium Sulfate 18. Naloxone 19. Fentanyl 20. Morphine 21. Nytroglicerin 22. Oxygen 23. Sodium Bicarb 24. Vasopressin 25. Zofran Case Study 1 You are dispatched to the scene of a 65 year old man complaining of sudden onset chest pain. On your arrival your patient is complaining of 10/10 crushing midsternal chest pain and appears diaphoretic and pale. Vitals 1 BP 120/84 HR 84 and regular RR 18 and regular SpO2 96% on room air 1
2 History and Assessment 1 OPQRST Onset- sudden Provocation- physical activity Quality- pressure like Radiation- no Severity- 10/10 Time- 60min History and Assessment SAMPLE (1 of 2) Signs and symptoms- GCS 15, PERRLA, the patient is complaining of feeling dizzy but denies having a headache, the patient is complaining of feeling nauseated but denies vomiting, no noted or reported syncope, the patient sates that he feels short of breath, breath sounds are clear History and Assessment SAMPLE (2 or 2) Allergies- NKDA Medications- lisinoprill, plavix, baby asprin Past pertinent history- CVA two years ago, hypertension Last oral intake- sandwich two hours ago Events leading up to- sitting on couch watching TV began to feel pain, as pain progressed the patients wife called Treatment 1 (1 of 2) IV x2 large bore if possible Treatment 1 (2 of 2) Nitroglycerin Dose? Normal Saline Open Aspirin Dose? Analgesic Medication and Dose? Zofran Dose? 2
3 Aspirin- Acetylsalicylic Acid (ASA) Mechanism of action in patients with ischemic cardiac conditions: Makes platelets less sticky What does that mean? Prehospital Indications: all patients with suspected AMI Absolute Contraindications: hypersensitivity, < 18 years old, Internal bleeding Sublingual Nitroglycerin (NTG) Mechanism of action: vasodilatation Prehospital Indications: ischemic cardiac conditions chest pain CHF with pulmonary edema NTG (1 of 2) Absolute Contraindications: hypersensitivity, hypotension, paricardial tamponade, increased intra-cranial pressure, hypovolemia/sever anemia, use of erectile dysfunction drugs within 24-48hrs NTG (2 of 2) Analgesic What do you do if the patient experiences: a throbbing headache, flushing, dizziness, or burning under the tongue? Mechanism of Action: opioid receptor agonist in the CNS Prehospital Indication: pain, pulmonary edema Absolute Contraindications: hypersensitivity, Hypotension, myasthenia gravis, respiratory depression 3
4 Zofran- Ondansetron Mechanism of Action: Serotonin receptor agonist- what does that mean? Prehospital Indications: nausea and/or vomiting Absolute Contraindications: hypersensitivity, prolonged QT interval syndrome Case Study 1 Progression After the first dose of Nitroglycerine the patient becomes hypotensive, 80/40, and you begin to see occasional PVCs on the monitor. The patient progresses to this rhythm with a pulse: Progressive Treatment Atropine Oxygen- titrate to SpO2 Continue Fluids Initiate Pacing Dopamine- What dose? Dopamine (1 of 2) Mechanism of Action: agonist of alpha 1, beta and dopaminergic receptors - what does that mean? Prehospital Indications: Cardiogenic shock Other forms of shock Bradycardia when pacing is unavailable What about renal failure? Contraindications: Tachydysrhythmias, Pheochromocytoma, Phenytoin use Dopamine (2 of 2) ** Note: Reduced Effects with Beta Blocker Use** 4
5 How to Mix/Calculate Given: Concentration 400mg of Dopamine/ 250ml of D5W. You have a 60gtts and want to give 10mcg/kg/min. How many drips/min: 45kg patient? 90kg patient? 50kg patient? Cardiac Case Study 1 CPR The patient becomes pulseless and apneic, and CPR is initiated. EKG reveals: Treatment During CPR The patient is shocked x1 at 200J initially and then again at the end of every round of CPR with no rhythm change Epinephrine what dose? Antidysrhythmic Which one and What dose? Epinephrine (1 of 2) Mechanism of Action: alpha and beta agonist What does that mean? Prehospital Indications: severe bronchospasms, bronchospasms unresponsive to albuterol, anaphylaxis, cardiac arrest, symptomatic bradicardia after other treatments Contraindications: hydrocephalus Amiodarone Mechanism of Action: Prolongs Repolarization by increasing potassium permeability - What does that mean? Prehospital Indication: pulseless VT/VF refractory to shock, unstable VT Absolute Contraindication: hypersensitivity, Bradycardia, congestive heart failure If the rhythm converts What is the dose? How do you mix it? How many drips/min? Hang a drip! 5
6 Lidocaine Mechanism of Action: Inhibits Sodium Channels delaying depolarization - How is that different from Amiodarone? Prehospital Indication: symptomatic ventricular dysrhythmias, sustained VT, pulseless VT/VF, anesthetic Absolute Contraindication: hypersensitivity, Wolf Parkinson White Syndrome (WPW), Bradycardia If the rhythm converts Hang a drip! What is the dose? How do you mix it? How many drips/min for a 45kg patient? Magnesium Sulfate Mechanism of Action: inhibition of calcium influx a neuromuscular junctions Prehospital Indications: VT/VT without a pulse that is unresponsive to lidocain, torsads, pre-term contractions, asthma Absolute Contraindications: bradycardia, hypocalcemia, hypermagnesemia, anuria Case Study 2 (1 of 2) You are dispatched to the scene of a 21 year old unresponsive male patient at a local restaurant. On your arrival your patient is unresponsive and laying on the floor, the patient is breathing shallow. The patient s friend advises that they were eating when the patient began to complain of shortness of breath, he became worse and worse until he passed out. 6
7 Picture of the patient Case Study 2 (2 of 2) 22-at AM.png Vitals 2 BP 80/40 HR 130 RR 10 SpO2 84% on room air Treatment 2 O2- BVM assist with 25 lpm Albuterol- BVM assist - What dose? Ipatroprium Bromide- BVM assist What dose? Epinephrine What dose? IV initiation with NS open Diphenhydramine What dose? Respiratory Pharmacology Albuterol Mechanism of Action: sympathomimetic, beta 2 selective adrenergic bronchodilator Prehospital Indications: emphysema, asthma, bronchitis, bronchoconstriction Absolute Contraindications: hypersensitivity, MAO inhibitors 7
8 Ipatropium Bromide Mechanism of Action: inhibition of muscarinic acytilcholine receptors in the bronchi Prehospital Indications: asthma, bronchitis, emphysema, bronchospasms Epinephrine Beta 2 effects of epinephrine cause bronchodilation, alpha effects increase blood pressure. Absolute Contraindications: hypersensitivity Diphenhydromine Mechanism of Action: Histamine antagonist Prehospital Indications: allergic reactions, dystonic reactions, motion sickness, antiemetic Absolute Contraindications: hypersensativity Should We Fly this Patient? Case Study 3 (1 of 2) Case Study 3 (2 of 2) You are called to the scene of a 21 year old man who is having a seizure. You arrive on scene and find the patient laying in bed alert and verbal with his hands pulled in and clamped (carpal pedal spasms). The patient is hyperventilating. You reach down to check a pulse and find that the patient is tachycardic with a strong bounding pulse. 8
9 Vitals 3 BP 130/90 HR 220 RR 26 SpO2 100% on room air Treatment 3 IV Vasalva Adenosine What dose? Adenosine Mechanism of Action: inhibiting adenylyl cyclase What does that mean? Prehospital Indications: SVT Absolute Contraindications: Hypersensitivity, Bradycardias, Sick Sinus Syndrome, Drug induced tachycardia Case Study 4 (1 of 2) You are called to the scene of a 35 year old female with an altered mental status. On your arrival the patient is found vomiting and lethargic. The patient mumbles I just want to die. The patient is a known drug abuser and there are several empty pill bottles near the patient that are prescribed to the person who called 911, the patients mother. 9
10 Case Study 4 (2 of 2) Vitals 4 SpO2: 93% on Room Air BP: 80/50 HR: 50 RR: 9 Treatment 4 IV x 2 NS or LR Dextrose What dose? Narcan What dose? Glucagon What dose? Sodium Bicarb What dose? Dextrose Mechanism of Action: Increase serum blood glucose levels Prehospital Indications: hypoglycemia Absolute Contraindications: none in the presence of hypoglycemia Narcan Mechanism of Action: narcotic antagonist Prehospital Indications: narcotic overdose Absolute Contraindications: hypersensitivity Glucagon Mechanism of Action: hormone produced by the pancreases that releases glucose, release of camp Prehospital Indications: hypoglycemia, Beta Blocker overdose Absolute Contraindications: hypersensitivity 10
11 Activated Charcol Sodium Bicarb Mechanism of Action: Serum alkalization Prehospital Indications: antidote for tricycle antidepressants Absolute Contraindications: any patient that does not meet established criteria Case Study 5 You are called to the scene of a 68 year old female complaining of shortness of breath. You arrive on scene to find the patient alert and verbal with 2-3 word dyspnea. The patient advises you that her CHF is acting up. Vitals 5 SpO2 92% on 2lpm via N/C BP 140/80 HR 104 RR 22 Treatment 5 CPAP NS NTG What dose? Analgesic Which one and what dose? Lasix What dose? 11
12 Lasix Mechanism of Action: loop diuretic What does that mean? Prehospital Indications: pulmonary edema of a cardiac nature, hypertensive emergency (AMI, APE) Absolute Contraindications: hypotension, tall peaked T waves, hypovolemia Case Study 6 You are called to the scene of a 19 year old female who is having a seizure. You arrive to find the patient in a tonic state. Vitals 6 SpO2 unable to get a reading BP unable to get a reading HR palpable tachycardia RR 6 irregular Treatment 6 Protect the patient Protect the airway- BVM assist if possible Benzodiazepine Which one and what dose? Diazepam (Valium) Mechanism of Action: Inhibition of polysynaptic pathways in the spinal cord Prehospital Indications: anxiety, seizures, sedation, skeletal muscle relaxation Absolute Contraindications: hypersensitivity, CNS depression 12
13 Midazolam Mechanism of Action: enhances the effects of the neurotransmitter GABA Prehospital Indications: Seizures, muscle spasms Absolute Contraindications: hypersensitivity, CNS depression References (n.d.). Retrieved from Drugs.com: New Mexico State EMS Buraeu. (2012, September). Medication Formulary. Santa Fe, New Mexico, Unitied States. U.S. Department of Health and Human Services. (2015, November 19). U.S. Food and Drug Administration. Retrieved from FDA: Shop Illustration References Shot at AM.png 13
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