A00.2 Office of the Medical Director

Transcription

1 A00.2 Office of the Medical Director Medications Individual license holders are responsible to hold and maintain the appropriate competencies (satisfactory knowledge and appropriate psychomotor skills) for the safe administration of these medications. Clinical care is to be provided in accordance with the protocols and procedures as established by the Provincial Medical Director and all patient care duties and functions must be performed in accordance with the EMS Protocols and Procedures as published by the Minister. A - Adult B - Adolescent C - Child D - Infant E - Neonatal 17 years & older 10 up to 17 years 1 up to 10 years 0 to 12 months Newly born VERSION M01 Adenosine M02 Simple Analgesics & Antipyretics M03.1 Opioid Analgesics M03.2 Nasal Fentanyl M04 Antiemetics M05.1 Epinephrine for Anaphylaxis revised M05.2 Epinephrine for Cardiopulmonary Arrest M06.1 Glucose M06.2 Dextrose revised M06.3 Glucagon revised M07.1 Intranasal Midazolam revised M07.2 Intramuscular Midazolam revised M07.3 Intravascular Midazolam revised M07.4 Diazepam revised M07.5 Lorazepam revised M08 Ranitidine NEW M09 Furosemide M10.1 Calcium for Hyperkalemia revised M10.2 Sodium Bicarbonate for Hyperkalemia revised M10.3 Insulin & Dextrose for Hyperkalemia revised M10.4 Salbutamol for Hyperkalemia NEW M11 Naloxone revised M12 Oxygen M13 Methlprednesolone NEW M14.1 Amiodarone for Cardiopulmonary Arrest M15 Bronchodilators revised M16 Oxytocin M17.1 Ketamine NEW M21A Nitroglycerin M24.1 Magnesium Sulfate for Cardiopulmonary Arrest M24.2 Magnesium Sulfate for Pregnancy Induced Hypertension M28A Tranexamic Acid M29 Intravenous Fluid (IVF) M30 Tetracaine NEW M33 Diphenhydramine M34 Haloperidol M36 Propofol pending M37.1A Acetylsalicylic Acid (ASA) revised A00.2 Medications Page 1

2 M37.2A Ticagrelor M38 Toradol M39.1 Atropine for Unstable Bradycardia M43.1A Enoxaparin A00.2 Medications Page 2

3 M01 Medications Office of the Medical Director Adenosine ADULT DOSING (17 years & older): First dose: 6 mg rapid push, followed by fluid flush Second dose: 12 mg rapid push, followed by fluid flush INFANT, CHILD & ADOLESCENT DOSE (0 months up to 17 years): First dose: 0.1 mg / kg mg (max = 6 mg) rapid push, followed by fluid flush Second dose: 0.2 mg / kg (max = 12 mg) rapid push, followed by fluid flush Narrow complex tachycardia known or presumed to represent atrioventricular node re-entry tachycardia (AVNRT) also know as paroxysmal supraventricular tachycardia (PSVT). Stable regular wide complex tachycardia known or suspected to be due to AVNRT with aberrant ventricular tachycardia. Unstable tachycardia requiring emergent DC cardioversion Adenosine must be given by rapid push into a well-running intravenous line, followed by a 30 ml normal saline flush. There should be evidence of central drug delivery such as bradycardia or asystole on the ECG monitor or patient s subjective sensation of dyspnea. Patients should be forewarned about the subjective sensations accompanying adenosine administration, such as dyspnea, lightheadedness, nausea and / or sense on impending doom. Do not exceed two doses even if tachycardia recurs. M01 Adenosine Page 1

4 M02 Medications Office of the Medical Director Basic Simple Analgesics & Antipyretics Primary ACETAMINOPHEN IBUPROFEN NAPROXEN ADULT (17 yr & older): - 10 to 15 mg/kg - Single max dose = 1000 mg - Repeat every 4 hr as required - 10 to 15 mg / kg - Single max dose = 650 mg - Repeat every 4 hr as required - 10 mg/kg - Single max dose = 800 mg - Repeat every 6 hr as required ADOLESCENT (10 up to 17 yr): - 10 mg/kg - Single max dose = 400 mg - Repeat every 6 hr as required CHILD (1 up to 10 yr): to 500 mg - Repeat every 8 hr as required to 500 mg - Repeat every 8 hr as required - 10 to 15 mg/kg - Repeat every 4 hr as required - 10 mg/kg - Repeat every 6 hr as required N/A INFANT (0 up to 12 months): - 10 to 15 mg/kg - Repeat every 4 hr as necessary - 10 mg/kg - Repeat every 6 hr as necessary N/A M02 Simple Analgesia Page 1

5 Analgesia for mild to moderate pain Antipyretic for relief of fever True allergy to acetaminophen contraindicates acetaminophen administration True allergy to ibuprofen contraindicates both ibuprofen and naproxen administration True allergy to naproxen contraindicates both naproxen and ibuprofen administration Ibuprofen and naproxen administration are contraindicated by a history of aspirin (ASA) induced asthma Decreased LOC with inability to protect airway or risk of aspiration If patient may be going for surgery within 4 hours, consider intravenous analgesia. M02 Simple Analgesia Page 2

6 M03.1 Medications Office of the Medical Director Opioid Analgesia FENTANYL: Age < 75 years: - 1 mcg/kg IM / IO / IV - Single dose max = 50 mcg - Repeat every 5 min as required - Hourly max = 200 mcg Age > 75 years: mcg/kg IM / IO / IV - Single dose max = 25 mcg - Repeat every 10 min as required - Hourly max = 100 mcg FENTANYL: Standard Dose: - 1 mcg/kg IM / IO / IV - Single dose max = 50 mcg - Repeat every 5 min as required - Hourly max = 200 mcg Low Dose: mcg/kg IM / IO / IV - Single dose max = 25 mcg - Repeat every 10 min as required - Hourly max = 100 mcg FENTANYL: Standard Dose: - 1 mcg/kg IM / IO / IV - Single dose max = 25 mcg - Repeat every 5 min as required - Hourly max = 100 mcg Low Dose: mcg/kg IM / IO / IV - Single dose max = 12.5 mcg - Repeat every 10 min as required - Hourly max = 50 mcg ADULT (17 yr & older): MORPHINE: Age < 75 years: mg/ kg IM / IO / IV - Single dose max = 5 mg - Repeat every 5 min as required - Hourly max = 20 mg Age > 75 years: mg/kg IM / IO / IV - Max single dose = 2.5 mg - Repeat every 10 min as required - Hourly max = 10 mg ADOLESCENT (10 up to 17 yr): MORPHINE: mg/ g IM / IO / IV - Single dose max = 5 mg - Repeat every 5 min as required - Hourly max = 20 mg CHILD (1 up to 10 yr): MORPHINE: mg/ kg IM / IO / IV - Single dose max = 2.5 mg - Repeat every 5 min as required - Hourly max = 10 mg HYDROMORPHONE: Age < 75 years: to 1 mg IM / IO / IV - Repeat every 10 min as required - Hourly max = 4 mg Age > 75 years: to 0.5 mg IM / IO / IV - Repeat every 15 min as required - Hourly max = 2 mg N/A N/A M03.1 Opioids Page 1

7 Moderate to severe pain from acute medical or traumatic conditions Systolic BP less than 100 mmhg in adults & adolescents; or systolic BP less than age-adjusted minimum in children ( x age) Presence of or potential for respiratory depression Decrease in LOC (GCS < 15) Presence or suspicion of head uinjury or raised intracranial pressure True allergy to codeine, morphine or hydromorphine contraindicates administration of morphine and hydromorphone a. Consider prophylactic use of an antiemetic as per M04 Antinauseant. b. If hypotension develops after opioid administration administer fluid bolus as per C07 Hypotension & Shock. c. If respiratory depression (hypoventilation, apnea) occurs after opioid administration, consider naloxone administration as per M11 Naloxone. d. Itching alone (absence of swelling or respiratory symptoms) with morphine or hydromorphone is not indicative of allergy. Slow rate of administration if itching develops. e. If patient is allergic to codeine or morphine or hydromorphine, consider administration of fentanyl. f. Morphine dosing is calculated in fractions of milligrams per kilogram. Round off to the nearest one milligram. Fentanyl is 100 times more potent as morphine. The dosing is calculated in micrograms per kilogram. Hydromorphone is 5 times more potent than morphine. The dosing is calculated in milligrams. M03.1 Opioids Page 2

8 M03.2 Medications Office of the Medical Director Intranasal Fentanyl (SUBLIMAZE) Primary Moderate to severe pain from acute medical or traumatic conditions, where IV administration is not otherwise available SBP less than 100 mmhg in adults & adolescents or less than age-adjusted minimum in children ( x age) Presence of or potential for respiratory depression Decrease in LOC (GCS < 15) Presence or suspicion of head injury or raised intracranial pressure True allergy to fentanyl Fentanyl is 100 times more potent as morphine. The dosing is calculated in micrograms per kilogram. ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) ABBREVIATIONS: GCS Glasgow coma score IV intravenous kg kilogram LOC level of consciousness max maximum mcg microgram min minute SBP systolic blood pressure Age < 75 years: 0.5 to 1 mcg/kg Single dose max = 50 mcg Repeat every 10 min as required Hourly max = 200 mcg Standard Dose: 1 mcg/kg Single dose max = 50 mcg Repeat every 10 min as required Hourly max = 200 mcg Standard Dose: 1 mcg/kg Single dose max = 25 mcg Repeat every 10 min as required Hourly max = 100 mcg Age > 75 years: 0.25 to 0.5 mcg/kg Single dose max = 25 mcg Repeat every 10 min as required Hourly max = 100 mcg Low Dose: 0.5 mcg/kg Single dose max = 25 mcg Repeat every 10 min as required Hourly max = 100 mcg Low Dose: 0.5 mcg/kg Single dose max = 12.5 mcg Repeat every 10 min as required Hourly max = 50 mcg M03.2 IN Fentanyl Page 1

9 M04 Medications Office of the Medical Director Antiemetics (Antinauseants) Primary ADULT (17 yr & older): Dimenhydrinate (GRAVOL): - 50 mg IM / IO / IV / PO - Repeat as required - Max = 100 mg per 4 hr Dimenhydrinate (GRAVOL): - 25 to 50 mg IM / IO / IV / PO - Repeat as required - Max = 100 mg per 4 hr Dimenhydrinate (GRAVOL): to 25 mg IM / IO / IV / PO - Repeat as required - Max = 50 mg per 4 hr Metoclopramide (MAXERAN): - 5 to 10 mg IM / IO / IV - Repeat every 6 hr as required ADOLESCENT (10 up to 17 yr): Metoclopramide (MAXERAN): to 10 mg IM / IO / IV - Repeat every 6 hr as required CHILD (1 up to 10 yr): Metoclopramide (MAXERAN): mg / kg IM / IO / IV - Repeat every 6 hr as required - Max single dose = 5 mg Ondansetron (ZOFRAN): - 4 to 8 mg IV once only Ondansetron (ZOFRAN): - 4 mg IV once only Ondansetron (ZOFRAN): mg/kg IV once only - Max single dose = 4 mg Nausea and/or vomiting from acute medical, surgical, obstetrical or traumatic condition Known hypersensitivity Use dimenhydrinate in pregnant women. Do not administer PO dimenhydrinate if altered LOC. M04 Antiemetics Page 1

10 M05.1 Medications Office of the Medical Director Basic year & older Epinephrine for Anaphylaxis Primary IM ADMINISTRATION ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 5 years) BASIC CARE: mg IM by autoinjector and repeat once as required BASIC CARE: mg IM by autoinjector and repeat once as required BASIC CARE: mg IM by autoinjector and repeat once as required PRIMARY CARE: mg IM by manual injection and repeat once as required PRIMARY CARE: mg IM by manual injection and repeat once as required IO/IV ADMINISTRATION (ACP only) PRIMARY CARE: mg IM by manual injection and repeat once as required CHILD (6 years & older) BASIC CARE: mg IM by autoinjector and repeat once as required PRIMARY CARE: mg IM by manual injection and repeat once as required mg IO / IV - Repeat as required mg IO / IV - Repeat as required Acute allergic reaction presenting with urticaria, angioedema, shock or bronchospasm Exposure to allergen with history of previous anaphylaxis None mg/kg IO / IV - Single maximum = 0.1 mg - Repeat as required If pediatric autoinjector is not available for children under age 5 years, use adult autoinjector once only. Epinephrine administration requires continuus cardiac monitoring. ABBREVIATIONS: IM = intramuscular IO = intraosseous IV = intravenous kg = kilogram mg/ kg = milligram per kilogram M05.1 Epinephrine / Anaphylaxis Page 1

11 M05.2 Medications Office of the Medical Director Epinephrine for Cardiopulmonary Arrest ADULT (17 years & older): 1 mg IV or IO push, follow by 0.9% saline flush Repeat every 3 to 5 minutes as required CHILD (1 up to 10 years): 0.01 mg/kg (maximum = 1 mg) IV or IO push, follow by 0.9% saline flush Repeat every 3 to 5 min as required ADOLESCENT (10 up to 17 years): 1 mg IV or IO push, follow by 0.9% saline flush Repeat every 3 to 5 minutes as required INFANT (0 up to 12 months): 0.01 mg/kg (maximum = 1 mg) IV or IO push, follow by 0.9% saline flush Repeat every 3 to 5 min as required Pulseless cardiopulmonary arrest that does not respond to initial defibrillation and/or first cycle CPR None REMINDER: Drug administration should not interrupt CPR or delay defibrillation. M05.2 Epinephrine / CPA Page 1

12 M06.1 Office of the Medical Director Basic Glucose Primary ADULT (17 yr & older): 25 to 50 gm PO Repeat once as required for initial episode Can be repeated as required for further confirmed hypoglycemia ADOLESCENT (10 up to 17 yr): 25 to 50 gms PO Repeat once as required for initial episode Can be repeated as required for further confirmed hypoglycemia CHILD (1 up to 10 yr): 12.5 to 25 gms PO Repeat once as required for initial episode Can be repeated as required for further confirmed hypoglycemia Suspected or confirmed hypoglycemia (glucose < 4 mmol / l) Decreased LOC is a relative contraindication (see (a) below) In patient with depressed LOC, with the patient in the recovery position, apply half dose of oral glucose paste to the dependent buccal mucosa. This can be repeated once, if there is no response to the initial application. If patient responds to buccal application of glucose paste, remainder of glucose dose may be swallowed and/or administered as solution. M06.1 Glucose Page 1

13 M06.2 Medications Office of the Medical Director Dextrose Primary Suspected or confirmed hypoglycemia (glucose < 4 mmol / l) None D25W can be obtained by mixing 10 ml of D50W with 10 ml of sterile saline (1:1 dilution). ADULT (17 yr & older): 50 ml of D50W (25 gm) IV / IO Repeat once in 5 min if required for initial episode Can be repeated as required for further confirmed hypoglycemia ADOLESCENT (10 up to 17 yr): 25 ml of D50W (12.5 gm) IV / IO Repeat once in 5 min if required for initial episode Can be repeated as required for further confirmed hypoglycemia CHILD (1 up to 10 yrs): 1 ml/kg of D25W (0.25 gm/kg) IV / IO Maximum single dose =10 gm Maximum single volume = 40 ml Repeat once in 5 min if required for initial episode Can be repeated as required for further confirmed hypoglycemia M06.2 Dextrose Page 1

14 APPENDIX A: CONCENTRATIONS & DILUTIONS OF DEXTROSE SOLUTIONS. SOLUTION Dextrose (gm) per 100 ml Dextrose (gm) per ml Dextrose (mg) per ml D50W D25W M06.2 Dextrose Page 2

15 M06.3 Medications Office of the Medical Director Basic Glucagon Primary 1 mg IM / IN / IO / IV Repeat once in 5 min if required for initial episode ADULT (17 yr & older): 1 mg IM / IN / IO / IV Repeat once in 5 min if required for initial episode ADOLESCENT (10 up to 17 yr): 0.5 mg IM / IN / IO / IV Repeat once in 5 min if required for initial episode CHILD (1 up to 10 yrs): Suspected or confirmed hypoglycemia (glucose < 4 mmol / l) Refractory anaphylaxis in patients on beta blocker medications (adult only) None Glucagon may cause significant nausea. Consider antinauseant administration as per M04 Antinauseants. If vascular access is not available or delayed, glucagon can be administered prior to intravenous dextrose or oral glucose. Providers with appropriate delegation ( Care level) may administer up to 2 doses of glucagon for anaphylaxis not responding to multiple doses of epinephrine in patients known to be on beta blocker medications. M06.3 Glucagon Page 1

16 M07.1 Medications Office of the Medical Director Intranasal Midazolam (VERSED) Primary Active seizure(s) Known or suspected hypersensitivity DO NOT ADMINISTER IF SEIZURE(S) HAS/HAVE RESOLVED OR APPEAR(S) TO BE RESOLVING. Continuously monitor respiratory and cardiac status: o Respiratory depression and hypotension are common in the post-seizure period, especially if benzodiazepines and/or other medications have been taken or administered to terminate the seizure(s). o Before administering providers must be prepared to manage the airway, support ventilations and treat hypotension as required. Use 5 mg / ml concentration. Alternate nostrils to facilitate maximum absorption. ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) INFANT (0 up to 12 months) 2 mg Repeat once in 5 minutes if required 1 to 2 mg Repeat once in 5 minutes if required 0.1 mg/kg Single maximum dose = 2 mg Repeat once in 5 minutes if required 0.1 mg/kg Single maximum dose = 1 mg Repeat once in 5 minutes if required M07.1 IN Midazolam Page 1

17 M07.1 Medications Office of the Medical Director Intranasal Midazolam (VERSED) Primary Active seizure Known or suspected hypersensitivity Respiratory depression or significant potential of same Hypotension ROUTE INTRANASAL ADULT (17 years & older) 0.2 mg/kg Max dose = 10 mg Repeat half-dose once in 5 min if required ADOLESCENT (10 up to 17 years) 0.2 mg/kg Max dose = 10 mg Repeat half-dose once in 5 min if required CHILD (1 up to 10 years) ICP & ABOVE 0.2 mg/kg Max dose = 5 mg Repeat half-dose once in 5 min if required INFANT (0 up to 12 months) ICP & ABOVE 0.2 mg/kg Max dose = 2.5 mg Repeat half-dose once in 5 min if required DO NOT ADMINISTER IF SEIZURE(S) HAS/HAVE RESOLVED OR APPEAR(S) TO BE RESOLVING. Use 5 mg/ml concentration. Alternate nostrils to facilitate maximum absorption. Continuously monitor respiratory and cardiac status. Providers must be prepared to manage the airway, support ventilations and treat hypotension as required. Respiratory depression and hypotension are especially common in the post-seizure period. ABBREVIATIONS: ICP = intermediate care provider max = maximum mg = milligram mg/kg = milligram per kilogram mg/ml=milligram per milliliter min = minute M07.1 IN Midazolam Page 1

18 M07.2 Medications Office of the Medical Director Intramuscular Midazolam (VERSED) Active seizure Significant alcohol or benzodiazepine withdrawal Known or suspected hypersensitivity Respiratory depression or significant potential of same Hypotension ROUTE ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) INFANT (0 up to 12 months) INTRAMUSCULAR 10 mg Repeat once in 15 min if required Wt > 40 kg - 10 mg Wt < 40 kg - 5 mg Repeat once in 15 min if required 2.5 mg Repeat once in 15 min if required N/A DO NOT ADMINISTER IF SEIZURE(S) HAS/HAVE RESOLVED OR APPEAR(S) TO BE RESOLVING. IM injection is only to be used when an alternate route of administration is not available or reasonably and safely obtained. Providers should switch to an alternative route or medication as soon as possible. Use 5 mg/ml concentration. Continuously monitor respiratory and cardiac status. Providers must be prepared to manage the airway, support ventilations and treat hypotension as required. Respiratory depression and hypotension are especially common in the post-seizure period. ABBREVIATIONS: IM = intramuscular kg = kilogram mg = milligram mg/ml=milligram per milliliter min = minute wt = weight M07.2 IM Midazolam Page 1

19 M07.3 Medications Office of the Medical Director Intravenous Midazolam (VERSED) Active seizure Significant alcohol or benzodiazepine withdrawal Brief, conscious sedation for cardioversion or transcutaneous pacing Deep sedation for endotracheal intubation or mechanical ventilation Known or suspected hypersensitivity Respiratory depression or significant potential of same Hypotension ROUTE ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) INFANT (0 up to 12 months) INTRAVENOUS (seizures) 0.2 mg/kg Max dose = 10 mg Repeat half-dose every 5 min as required 0.2 mg/kg Max dose = 10 mg Repeat half-dose every 5 min as required 0.2 mg/kg Max dose = 5 mg Repeat half-dose every 5 min as required 0.2 mg/kg Max dose = 2 mg Repeat half-dose every 5 min as required 0.05 to 0.1 mg/kg Max dose = 1.25 mg Repeat every 5 min as required INTRAVENOUS (other indications) 0.05 to 0.1 mg/kg Max dose = 5 mg Repeat every 5 min as required 0.05 to 0.1 mg/kg Max dose = 5 mg Repeat every 5 min as required 0.05 to 0.1 mg/kg Max dose = 2.5 mg Repeat every 5 min as required DO NOT ADMINISTER IF SEIZURE(S) HAS/HAVE RESOLVED OR APPEAR(S) TO BE RESOLVING. If IV access is not available, providers with appropriate delegation may administer by IO route. For IV administration, infuse over 30 to 60 sec. Titrate to desired effect. Continuously monitor respiratory and cardiac status. Providers must be prepared to manage the airway, support ventilations and treat hypotension as required. Respiratory depression and hypotension are especially common in the post-seizure period. ABBREVIATIONS: IO = intraosseous IV = intravenous max = maximum mg = milligram mg/kg = milligram per kilogram min = minute M07.3 IV Midazolam Page 1

20 M07.4 Medications Office of the Medical Director years & older Diazepam (VALIUM) Primary Significant alcohol or benzodiazepine withdrawal Known or suspected hypersensitivity Respiratory depression or reasonably forseeable risk of same Hypotension If IV access is not available providers with appropriate delegation may administer by the IO route. Continuously monitor respiratory and cardiac status. Providers must be prepared to manage the airway, support ventilations and treat hypotension as required. When administering IV, infuse over 30 to 60 sec. Titrate to desired effect. ROUTE ORAL (PCP & above) ADULT (17 years & older) 20 mg Repeat every 30 min as required ADOLESCENT (10 up to 17 years) 10 to 20 mg Repeat once in 30 min if required INTRAVENOUS (ICP & above) ABBREVIATIONS: 5 to 10 mg Repeat every 10 min as required ICP =intermediate care provider IO =intraosseous IV= intravenous max =maximum mg = milligram min =minute PCP=primary care provider sec = second 5 mg Repeat every 10 min as required (max 3 doses) M07.4 Diazepam Page 1

21 M07.5 Medications Office of the Medical Director years & older Lorazepam (ATIVAN) Primary Significant alcohol or benzodiazepine withdrawal Agitation or aggressionand patient / public / paramedic safety concerns Anxiety interfering with safe transport of patient (PO only) Known or suspected hypersensitivity Respiratory depression or reasonably forseeable risk of same Hypotension Administration by IM injection is only to be used when an alternate route of administration is not available or reasonably and safely obtained. Providers should switch to an alternative route or medication as soon as possible. If IV access is not available, providers with appropriate delegation may administer by IO route. For IV administration, infuse over 30 to 60 sec. Titrate to desired effect. Continuously monitor respiratory and cardiac status. Providers must be prepared to manage the airway, support ventilations and treat hypotension as required. When administering IV, infuse over 30 to 60 sec. Titrate to desired effect. ROUTE ORAL (PCP & above) INTRAMUSCULAR (ICP & above) INTRAVENOUS (ICP & above) ABBREVIATIONS: ADULT (17 years & older) 1 to 2 mg Repeat every 30 min as required 1 to 2 mg Repeat once in 15 min if required 1 to 2 mg Repeat every 10 min as required ADOLESCENT (10 up to 17 years) 1 to 2 mg Repeat once in 30 min if required 1 to 2 mg Repeat once in 15 min if required 1 to 2 mg Repeat every 10 min as required (max 3 doses) ICP = intermediate care provider IM = Intramuscular IO = intraosseous IV - intravenous mg =milligram min = minute PCP =primaty care provider PO = per mouth sec = second M07.5 Lorazepam Page 1

22 M08 Medications Office of the Medical Director Ranitidine ADULT (17 yr & older): ADOLESCENT (10 up to 17 yr): CHILD (1 up to 10 yr): 50 mg IO / IV once only 50 mg IO / IV once only 1 mg / kg IO / IV once only Acute allergic reaction presenting with urticaria, angioedema, bronchospasm or shock Exposure to allergen with history of previous anaphylaxis None M08 Ranitdine Page 1

23 M09A Medications years & older Office of the Medical Director Furosemide (LASIX) - Adult Not currently taking furosemide: 20 mg IV once Acute heart failure True anaphylaxis to furosemide (rare) Hypotension Dehydration Currently taking furosemide: 40 mg IV once Known chronic renal failure: 80 mg IV once M09A Furosemide Page 1

24 M10.1Medications Office of the Medical Director Hyperkalemia Therapy: Calcium ADULT: (17 years & older) 10 ml 10 ml ADOLESCENT: (10 up to 17 years) CALCIUM CHLORIDE 10% IV 0.2 ml/kg (max dose = 10 ml at 50 kg) CALCIUM GLUCONATE 10% IV 0.6 ml/kg (max dose = 10 ml at 17 kg) CHILD: (1 up to 10 years) 0.2 ml/kg (max dose = 10 ml at 50 kg) 0.6 ml/kg (max dose = 10 ml at 17 kg) CPA in any dialysis-dependent patient Known or suspected significant hyperakalemia K greater than 5.5 in patient with ECG changes K greater than 6.0 in any patient without ECG changes Known or suspected digoxin toxicity (rare) Note that the dosages for calcium are calculated by volume. Calcium gluconate may be susbtsituted for calcium chloride in the ADVANCED RESUSCITATION care maps (but note that the volume dose in adolescent and child patients are different) because calcium chloride contains 3 times more elemental calcium than calcium gluconate (1.4 versus 0.5 meq). In an awake patient calcium chloride infusion may be irritating and painful to the vein; consider calcium gluconate. ABBREVIATIONS: CPA cardiopulmonary arrest ECG electrocardiogram IV - intravenous K - potassium kg - kilogram max maximum meq - millequivalent mg - milligram ml milliliter 10% = 100 mg / ml M10.1 Calcium (Hyperkalemia) Page 1

25 M10.1 Medications Office of the Medical Director Hyperkalemia Therapy: 10 years & older Calcium CPA in any dialysis-dependent patient, or Known or suspected hyperkalemic CPA, or Dialysis-dependent patient having missed at least one scheduled dialysis treatment None CALCIUM GLUCONATE (10%): 1000 mg (10 ml) o Rapid IV push during CPA o Slow IV push over 2 min in non-cpa Repeat once in 5 min if findings suggestive of hyperkalemia on cardiac monitor or ECG do not resolve CALCIUM CHLORIDE (10%): 500 to 1000 mg (5 to 10 ml) o Rapid IV push during CPA o Slow IV push over 2 min in non-cpa Repeat once in 5 min if findings suggestive of hyperkalemia on cardiac monitor or ECG do not resolve Calcium gluconate may cause less pain and irritation at IV injection during administration, a consideration in conscious patients. During prolonged patient transport, repeat calcium administration once at 60 min if required. ABBREVIATIONS: CPA = cardiopulmonary arrest ECG = electrocardiogram IV = intravenous max = maximum mg = milligram min = minute ml = milliliter M10.1 Calcium (Hyperkalemia) Page 1

26 M10.2 Medications Office of the Medical Director Hyperkalemia Therapy: 10 years & older Sodium Bicarbonate CPA in any dialysis-dependent patient, or Known or suspected hyperkalemic CPA None 1 ml/kg (1 meq/kg) Rapid IV push Max dose = 100 ml (2 ampules) NOTE: One ampule (50 ml) of 8.4% sodium bicarbonate contains 50 meq of buffer ABBREVIATIONS: CPA = cardiopulmonary arrest IV = intravenous max = maximum meq = millequivalent meq/kg = milliequivalents per kilogram ml/kg = milliliters per kilogram M10.2 Bicarbonate (Hyperkalemia) Page 1

27 M10.3 Medications Office of the Medicaol Director Hyperkalemia Therapy: 10 years & older Insulin & Dextrose Upon ROSC from CPA in any dialysis-dependent patient, or Dialysis-dependent patient having missed at least one scheduled dialysis treatment Hypoglycemia (serum glucose less than 4 mmol/l) ADULT (17 years & older) ADOLESCENT (10 up to 17 years) REGULAR INSULIN: 10 units Rapid IV push DEXTROSE (50%): 50 ml (1 ampule) Rapid IV push Check blood sugar at every 30 min after IV insulin administration. ABBREVIATIONS: CPA = cardiopulmonary arrest IV = intravenous kg = kilogram max = maximum ml = milliliter ml/kg = milliliter / kilogram mmol/l = millimole per liter ROSC = return of spontaneous circulation REGULAR INSULIN: 0.1 units/kg (max 10 units) Rapid IV push DEXTROSE (50%): 1 ml/kg (max 50 ml) Rapid IV push M10.3 Insulin/Dextrose (Hyperkalemia) Page 1

28 M10.4 Medications Office of the Medical Director Basic Hyperkalemia Therapy: 10 years & older Salbutamol Primary Dialysis-dependent patient having missed at least one scheduled dialysis treatment, where vascular access will be delayed or not available None 8 inhalations by MDI or 5 mg by NEB Repeat once in 5 min if findings suggestive of hyperkalemia on cardiac monitor or ECG do not resolve Repeat every 30 min during prolonged transport if this is the only agent given for treatment of hyperkalemia ABBREVIATIONS: ECG = electrocardiogram MDI = metered dose inhaler min = minute NEB = nebulizer M10.4 Salbutamol (Hyperkalemia) Page 1

29 M11 Medications Office of the Medical Director Basic Naloxone (NARCAN) Primary ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) INFANT 0 up to 12 months) STANDARD DOSING mg IM / IN / IO / IV - Repeat every 3 min as required - Cumulative max dose = 2 mg mg IM / IN / IO / IV - Repeat every 3 min as required - Cumulative max dose = 2 mg mg / kg - Single max dose = 0.4 mg - Repeat every 3 min as required - Cumulative max dose = 2 mg mg / kg - Single max dose = 0.4 mg - Repeat every 3 min as required - Cumulative max dose = 2 mg AUGMENTED DOSING - 2 mg IM / IN / IO / IV - Repeat as necessary - No cumulative max dose - 2 mg IM / IN / IO / IV - Repeat as necessary - No cumulative max dose -0.5 mg/kg IM / IN / IO / IV - Single max dose = 2 mg - Repeat as necessary - No cumulative max dose -0.5 mg/kg IM / IN / IO / IV - Single max dose = 2 mg - Repeat as necessary - No cumulative max dose Known or suspected opioid overdose causing respiratory depression Unknown overdose Promptly ensuring an open airway and adequate ventilation takes priority over naloxone administration in ALL cases. For known or suspected overdose with high potency opioids (fentanyl, sufentanil, carfentanil) use the augmented dose schedule. M11 Naloxone Page 1

30 M12 Medications Office of the Medical Director Basic Oxygen Primary Administer oxygen with appropriate device at fixed flow rate as specified in care map Providers with appropriate delegation may administer oxygen at sufficient flow rate & with appropriate device to achieve target saturation (commonly 92 to 94%) Dyspnea Respiratory distress Known or suspected hypoxemic respiratory failure (SaO2 < 90%) Known or suspected carbon monoxide (CO) poisoning None With severe respiratory distress or known / suspected respiratory failure, initiate treatment with O2 at 15 lpm flow rate by NRB mask or BVM apparatus. Providers with appropriate delegation may consider oxygen titration once the patient s condition has stabilized. For management of chronic obstructive pulmonary disease with known or suspected hypoxemic respiratory drive consider target saturation of 88 90%. If CO poisoning is known or suspected, administer O2 at 15 lpm flow rate by NRB mask or BVM apparatus. M16 Oxygen Page 1

31 M13 Medications Office of the Medical Director Methylprednisolone (SOLUMEDROL) ADULT (17 yr & older): ADOLESCENT (10 up to 17 yr): CHILD (1 up to 10 yr): 40 mg IO / IV once only 125 mg IM once only 40 mg IO / IV once only 125 mg IM once only 2 mg / kg IO / IV once only Max dose = 40 mg Acute allergic reaction presenting with urticaria, angioedema, bronchospasm or shock Exposure to allergen with history of previous anaphylaxis Known or suspected acute adrenal insufficiency None M13 Methylprednisolone Page 1

32 M14.1 Medications Office of the Medical Director Amiodarone for Cardiopulmonary Arrest ADULT (17 years & older): 300 mg IV or IO push, follow by 0.9% saline flush Repeat 150 mg once after 5 min Post arrest: 300 mg Infuse IV or IO over 30 min Hold if SBP < 100 mmhg CHILD (1 up to 10 years): 5 mg/kg (maximum = 150 mg) IV or IO push, follow by 0.9% saline flush Repeat every 5 min up to twice as required (cumulative maximum dose = 15 mg/kg) ADOLESCENT (10 up to 17 years): 5 mg/kg (maximum = 300 mg) IV or IO push, follow by 0.9% saline flush Repeat every 5 min up to twice as required (cumulative maximum dose = 15 mg/kg) INFANT (0 up to 12 months): 5 mg/kg (maximum = 150 mg) IV or IO push, follow by 0.9% saline flush Repeat every 5 min up to twice as required (cumulative maximum dose = 15 mg/kg) Pulseless cardiac arrest due to VT or VF Suspected or confirmed hypothermic cardiopulmonary arrest REMINDER: Drug administration should not interrupt CPR or delay defibrillation. May be given before or after shocks. Upon ROSC after VF or VT arrest (adults only) consider amiodarone by slow infusion if not yet given during arrest. If SBP decreases below 100 mmhg, omit or discontinue amiodarone administration. M14.1 Amiodarone / CPA Page 1

33 M15 Medications Office of the Medical Director Basic Bronchodilators Primary Salbutamol (VENTOLIN): - 2 to 4 inhalations by inhaler, or by nebulizer - Repeat as required (no maximum) Salbutamol (VENTOLIN): - 2 to 4 inhalations by inhaler, or mg by nebulizer - Repeat as required (no maximum) Salbutamol (VENTOLIN): - 2 to 4 inhalations by inhaler, or mg by nebulizer - Repeat as required (no maximum) ADULT (17 years & older): Salbutamol & Ipratropium (COMBIVENT): - One ampule (2.5 mg salbutamol / 0.5 mg ipratropium) by nebulizer once ADOLESCENT (10 up to 17 years) Salbutamol & Ipratropium COMBIVENT): - One ampule (2.5 mg salbutamol / 0.5 mg ipratropium) by nebulizer once CHILD (1 up to 10 years): Salbutamol & Ipratropium (COMBIVENT): - One ampule (2.5 mg salbutamol / 0.5 mg ipratropium) by nebulizer once Ipratropium (ATROVENT): - 2 inhalations by inhaler every 6 hours N/A N/A Salbutamol (VENTOLIN): mg by nebulizer - Repeat as required (no maximum) INFANT (0 up to 12 months): N/A N/A Acute excaerbation of known asthma Acute exacerbation of chronic obstructive pulmonary disease (COPD) Dyspnea or respiratory distress where bronchospasm is known or suspected None If repeated administration of bronchodilators is required, use salbutamol only. Do not use Ipratropium as sole bronchodilator. For children under age 5, nebulizer administration or administration by an inhaler with an attached aerochamber will be preferable to inhaler administration. M15.1 Bronchodilators 1

34 M16 Medications Office of the Medical Director Oxytocin Primary DOSE: 10 units IM or IV after delivery of baby 10 units / hr IV by continuous infusion Greater than 20 weeks gestational age Patients experiencing significant blood loss after delivery Estimated blood loss greater than 500 ml SBP less than 100 mmhg, or suspicion of shock Incomplete deliver of baby, or muliple gestations where all babies have not delivered If significant bleeding continues after initial dose of oxytocin, providers may consider administration of additional oxytocin by continuous infusion. Mix 40 units of oxytocin in one liter of normal saline and infuse mechanically or by gravity at 250 mls per hour (10 units per hour). M16 Oxytocin Page 1

35 M17.1A Medications years & older Office of the Medical Director Ketamine (analgesic dose) Pre-reduction analgesia for extrication, and o shock is known or suspected, or o BP reading cannot be obtained Severe hypertension (BP greater than 185/110 mmhg) Severe tachycardia (HR greater than 120 bpm) Decreased LOC Acute delirium Intoxication with alcohol or drugs, or chronic alcoholism Acute eye injury or glaucoma Pregnancy Emergency reactions are more common in elderly patients (use with caution) DOSAGE: 0.2 mg/kg by slow IV push Single max dose = 20 mg ABBREVIATIONS: BP = blood pressure IO = intraosseous IV intravenous mg = milligrams mg/kg = milligrams per kilogram M17.1A Ketamine Page 1

36 M21A Medications Office of the Medical Director Basic Primary years and older Nitroglycerin SUBLINGUAL DOSE: 0.4 mg sublingual Repeat every 5 minutes as required TOPICAL DOSE (Primary Care level & above): SBP > 100 mmhg 0.2 mg / hr SBP > 150 mmhg 0.4 mg / hr SBP > 200 mmhg 0.6 mg/hr INTRAVENOUS DOSE ( Care level only): Initiate infusion at 10 mcg / min Check the BP every 5 minutes; titrate up by 10 mcg every 5 minutes Maximum anianigianl dose is approximately 100 mcg / min Maximum antihypertensive dose is approximately 200 mcg / min Chest, back or upper abdominal pain, or dyspnea, known or suspected to be due to myocardial ischemia Known or suspected heart failure Severe hypertension with evidence of end-organ dysfunction or injury Systolic blood pressure < 100 mmhg Recent use of erectile dysfunction medication VIAGRA (sildefanil) within 24 hours CIALIS (tadalafil) within 72 hours LEVITRA (vardenafil) within 24 hours Known or suspected right ventricular infarct (relative) Providers with appropriate delegation should review ECG for evidence of right ventricular infarction prior to administering nitroglycerin. Providers without ECG interpretation delegation may administer nitroglycerin without ECG review. Providers with appropriate delegation may use IV nitroglycerin as per E21A Hypertensive Emergencies. M21A Nitroglycerin Page 1

37 M24.1 Medications Office of the Medical Director Magnesium Sulfate 1 year & older for Cardiopulmonary Arrest ADULT (17 years & older): ADOLESCENT (10 up to 17 years): CHILD (1 up to 10 years): 2 gm IV or IO push, follow by 0.9% saline flush Repeat once as required 50 mg/kg (maximum = 2 gm) IV or IO push, follow by 0.9% saline flush Repeat once as required 50 mg/kg (maximum = 1 gm) IV or IO push, follow by 0.9% saline flush Repeat once as required Pulseless cardiac arrest known or suspected to be due to polymorphic VT (torsades de pointes) Asystole REMINDER: Drug administration should not interrupt CPR or delay defibrillation. Magnesium sulfate may be given before or after shocks. M24.1 Magnesium Sulfate / CPA Page 1

38 M24.2 Medications Office of the Medical Director Magnesium Sulfate for 10 years & older Pregnancy Induced Hypertension (PIH) INTRAMUSCULAR INTRAVASCULAR 4 grams 2 grams (4 ml) once to each buttock (deep IM) 2 grams IV or IO Infuse over ten minutes Repeat once as required Symptoms and / or signs of preeclampsia in a woman at greater than 20 weeks estimated gestational age (EGA) Seizure in a woman at great than 20 weeks EGA until 6 wk post-partum Respiratory depression Do not administer IV or IO magnesium sulfate if IM dose has already been given. M24.2 Magnesium Sulfate / PIH Page 1

39 M28A Medications years & older Office of the Medical Director Tranexamic Acid (TXA) 1 gram IV or IO once only Exsanguinating external hemorrhage within 3 hours of injury Known hypersensitivity to TXA If exsanguinating external hemorrhage cannot otherwise be controlled by direct pressure or tourniquet application, providers may consider administration of tranexamic acid (TXA). With limited resources, do not interrupt direct pressure to obtain vascular access. Arterial or venous thrombosis is a recognized potential complication of TXA but is not a contraindication in the face of exsanguinating hemorrhage M28A TXA Page 1

40 M29 Medications Office of the Medical Director Intravenous Fluid (IVF) Primary ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) INFANT (0 up to 12 months) Normal saline Ringer s lactate Normal saline Ringer s lactate Normal saline Normal saline BOLUS THERAPY FOR NON-TRAUMATIC HYPOTENSION / SHOCK: 20 ml/kg Max = 1000 ml per bolus Repeat as required 20 ml/kg Max = 1000 ml per bolus Repeat as required 20 ml/kg Max = 500 ml per bolus Repeat as required 20 ml/kg Max = 250 ml per bolus Repeat as required BOLUS THERAPY FOR TRAUMATIC HEMORRHAGE / SHOCK & EXSANGUINATION: 20 ml/kg Max = 1000 ml per bolus Repeat as required 20 ml/kg Max = 1000 ml per bolus Repeat as required 20 ml/kg Max = 500 ml per bolus Repeat as required MAINTENANCE THERAPY: 50 ml/hr 50 ml/hr 0.5 ml / kg / hr 0.5 ml / kg / hr Non-traumatic hypotension and/or shock Traumatic hemorrhage and/or exsanguination Maintenance therapy Medication administration To maintain venous access (TKVO) None Consider smaller boluses (5 10 ml/kg) if age greater than 75 years or cardiac dysfunction is known / suspected Permissive hypotension is indicated only in the absence of head injury (see F02 TRAUMATIC HEMORRHAGE & SHOCK) NORMAL SALINE (NS): 0.9% sodium chloride 154 meq sodium per liter 154 meq chloride per liter Osmolarity = 308 mosm per liter RINGER S LACTATE (RL): 130 meq sodium per liter 110 meq chloride per liter 4 meq potassium per liter 2.5 meq calcium per liter Osmolarity = 273 mosm per liter M29 IVF Page 1

41 M30 Medications Office of the Medical Director Tetracaine (PONTOCAINE) Primary Thermal or chemical eye injury Corneal abrasion or foreign bodies Known or suspected open globe injury True allergy to benzocaine or procaine TETRACAINE 0.5%: Instill 1 to 3 drops to affected eye Repeat every ten minutes as required For patients with significant pain from any of the above injuries, consider also oral analgesic administration M30 Tetracaine Page 1

42 M33 Medications Office of the Medical Director Diphenhydramine (BENADRYL) Primary ADULT (17 years & older) ADOLESCENT (10 up to 17 years) CHILD (1 up to 10 years) - 50 mg PO once only - 25 to 50 mg PO once only to 25 mg PO once only - 25 to 50 mg IM / IO / IV - Repeat every 15 min as required - Total max = 100 mg / 4 hr - 25 mg IM / IO / IV - Repeat every 15 min as required - Total max = 100 mg / 4 hr mg/kg IM / IO / IV - Single max dose = 25 mg - Repeat every 15 min as required - Total max = 50 mg / 4 hr Acute allergic reaction presenting with urticaria and / or angioedema, shock (epinephrine & dimenhydramine) or bronchospasm (all) Exposure to allergen with history of previous anaphylaxis Altered LOC Use of other CNS depressants True allergy to diphenhydramine Diphenhydramine can be used alone only when acute allergic reaction presents with itching or hives only. Acute allergic reactions with angioedema, shock or bronchospasm will require additional treatment with epinephrine and/or salbutamol. True allergy to antihistamines is exceedingly rare and is more likely an allergy to additive or preservative in oral preparations. Lower doses should be considered in patients > 75 years of age. M33 Diphenhydramine 1

43 M34 Medications years and older Office of the Medical Director Haloperidol (HALDOL) Age less than 75 years: 5 to 10 mg IM / IO / IV once Repeat once in 15 minutes as required Age greater than 75 years: 5 mg IM / IV / IO Repeat once in 15 minutes as required Acute agitation or combative behavior where the safety of the patient, health care providers and the public at large is or may be at risk Temperature > 38 degrees Celsius SBP < 100 mmhg Known or suspected prolonged QT syndrome Personal or family history of prior cardiac arrest or sudden death (relative) Known or suspected hypersensitivity to haloperidol or neuroleptics Active seizures or suspected or known post-ictal delirium Always treat correctable underlying causes of agitation or combative behavior, such as hypoglycemia or hypoxemia, before administering haloperidol. Attempt to achieve desired level of sedation / control with benzodiazepines alone, before haloperidol administration. Administration requires continuous monitoring of respiratory and cardiac functions. M34 Haloperidol Page 1

44 M37.1A Medications Office of the Medical Director Basic Antiplatelet: 17 years of age & older Acetylsalicylic Acid (ASA) Primary DOSE: 160 mg PO (chew & swallow) Known or suspected acute coronary syndrome (ACS) Active bleeding that cannot be controlled by basic measures (pressure, wound care) Known ASA allergy Known or suspected ASA-induced asthma (rare) Administer the above dose even if the patient is on a regular daily dose of ASA or has already taken ASA as advised by Emergency Medical dispatch EMS personnel will administer two chewable infant tablets (advise the patient to chew and swallow). If infant tablets are not available, one adult tablet (325 mg) may be administered (advise the patient to chew and swallow) Adverse effects to ASA such as stomach upset or easy bruising are not true allergic symptoms and are not contraindications to administration with potential ACS Administer ASA even if the patient is on anticoagulants or other antiplatelet agents M37.1A ASA Page 1

45 M37.2A Medications Office of the Medical Director Antiplatelet: 17 years of age & older Ticagrelor (Brillanta) Primary DOSE: 180 mg PO (2 x 90 mg) Known or suspected ST elevation myocardial infarction where primary percutaneous coronary angioplasty (PC is anticipated Active bleeding that cannot be controlled by basic measures (pressure, wound care) Known allergy to ticagrelor (rare) Ticagrelor administration requires consultation with on-line medical support or receiving cardiologist prior to administration. Administer the above dose even if the patient is on a regular daily dose of ASA or has already taken ASA as advised by Emergency Medical dispatch M37.2A Ticagrelor Page 1

46 M38 Medications year and older Office of the Medical Director Ketoroloac (TORADOL) Adult (17 years & older) Adolescent (10 up to years) Child (1 up to 10 years) 30 mg IM / IV once only 15 to 30 mg IM / IV once only 0.5 mg / kg IM / IV once only (single maximum dose = 15 mg) Analgesia for moderate to severe pain where opioid analgesics cannot be given or opioid dose has been maximized True allergy to ketorolac History of aspirin (ASA) induced asthma Known or presumed renal failure Providers may consider giving ketorolac prior to or instead of opioid analgesics in patients with pain from known or presumed kidney stones. M38 Toradol Page 1

47 M39.1 Medications Office of the Medical Director Atropine for Unstable Bradycardia ADULT (17 years & older): 0.5 mg IV or IO push, follow by 0.9% saline flush May repeat to a cumulative dose of 3 mg ADOLESCENT (10 up to 17 years): 0.5 mg IV or IO push, follow by 0.9% saline flush May cumulative to a total dose of 3 mg CHILD (1 up to 10 years): 0.02 mg / kg Minimum single dose = 0.1 mg Maximum single dose = 0.5 mg IV or IO push, follow by 0.9% saline flush Repeat once as required to achieve a HR between 60 and 70 bpm INFANT (0 up to 12 months): 0.02 mg / kg Minimum single dose = 0.1 mg Maximum single dose = 0.5 mg IV or IO push, follow by 0.9% saline flush Repeat once as required to achieve a HR between 60 and 70 bpm Significant bradycardia known or suspected to be causing hypotension or poor perfusion None M39.1 Atropine / Bradycardia Page 1

48 M43.1A Medications years and older Office of the Medical director Enoxaparin (LOVENOX) Age less than 75 years: 1 mg/kg subcutaneously once only Age greater than 75 years: 0.75 mg/kg subcutaneously once only Known or suspected ST elevation myocardial infarction where primary percutaneous coronary angioplasty (PC is anticipated Active bleeding that cannot be controlled by basic measures (pressure, wound care) Patient is known or suspected to currently be on an anticoagulant Known allergy to enoxaparin (rare) Enoxaparin administration requires consultation with on-line medical support or receiving cardiologist prior to administration. M43.1A Enoxaparin Page 1