The University of Texas Southwestern Medical Center at Dallas BioTel EMS System Emergency Medical Services Pharmacology Reference Guide January 1, 2007 through December 31, 2008 (subject to revision prior to the end of this period, as authorized by the Medical Director)
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UTSW/BioTel EMS System Pharmacology Table of Contents Medication Page Medication Page Adenosine (Adenocard ) 5 Glucose (Oral Glucose) 20 Albuterol (Proventil, Ventolin ) 6 Ipratropium bromide (Atrovent ) 21 Amiodarone HCl (Cordarone ) 7 Lidocaine HCl 23 Aspirin (Acetylsalicylate Acid) 8 Magnesium Sulfate 25 Atropine Sulfate 9 Midazolam (Versed ) 26 Calcium Chloride 10 Morphine Sulfate 27 Dextrose 50% 11 Naloxone HCl (Narcan ) 28 Diazepam (Valium ) 12 Nitroglycerin (Nitrostat ) 29 Diphenhydramine HCl (Benadryl ) 13 Nitrous Oxide (Nitronox ) 30 Dopamine HCl (Inotropin ) 14 Norepinephrine bitartrate (Levophed ) 31 Epinephrine 1:1,000 15 Pralidoxime Chloride 32 Epinephrine 1:10,000 16 Promethazine HCl (Phenergan ) 33 Etomidate 17 Proparacaine HCl (Alcaine ) 34 Fentanyl 18 Sodium Bicarbonate 35 Glucagon 19 Page 3 of 35
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Adenosine (Adenocard ) Route: Atrial Antiarrhythmic Rapid IV push at the insertion site (antecubital space) Rapid intraosseous push (alternative site) First Dose: 12mg rapid push followed immediately by a rapid 20mL NS flush - standing order Second Dose: 12mg rapid push followed immediately by a rapid 20mL NS flush - standing order First Dose: 0.1 mg/kg rapid push (max 6mg) followed immediately by a rapid 5mL NS flush - BioTel authorization only Second Dose: 0.2 mg/kg rapid push (max 12mg) followed immediately by a rapid 5mL NS flush - BioTel authorization only Drug Action: Slows conduction through AV node thereby terminating reentrant tachycardia Causes transient AV block Vasodilation Indications: Immediate 10 seconds Paroxysmal supraventricular tachycardia. Standing order administration for stable adults only, BioTel must authorize administration in unstable adults and in the pediatric patient. Precautions: Assure rhythm is not ventricular in origin Explain expected side effects to patient Monitor patient and ECG continuously Use with caution: COPD, CHF, CAD Contact BioTel for the following prior to administration: Asthma patient taking bronchodilators (theophylline class) Seizure patient taking carbamazepine (Tegretol ) Recent caffeine ingestion Side Effects: Flushing Sweating Chest Pain Nausea/Vomiting Lightheadedness Transient Arrhythmias Transient Asystole Contraindications: 2 or 3 heart block Atrial fibrillation or flutter Sick Sinus Syndrome Dipyridamole (Persantine ) Organophosphate ingestion Poisoning/Drug-induced tachycardia Special: Record rhythm strip during administration Page 5 of 35
Albuterol (Ventolin, Proventil ) Sympathomimetic Route: Inhalation Endotracheal administration (alternative route) 2.5mg given via nebulizer over 5-15 minutes. If the patient is improving after the first dose, two additional doses may be given. If there is NO improvement after the first dose, combine the 2 nd and 3 rd doses with Ipratropium (Atrovent ) 0.5 mg. - standing order. BioTel must authorize any additional doses. 2.5mg given via nebulizer over 5-15 minutes. If the patient is improving after the first dose, two additional doses may be given. If there is NO improvement after the first dose, combine the 2 nd and 3 rd doses with Ipratropium (Atrovent ) 0.5 mg. - standing order. BioTel must authorize any additional doses. Drug Action: Indications: Precautions: Bronchodilation (beta-two adrenergic) 5-15 minutes after inhalation 3-4 hours after inhalation Bronchospasm associated with: Asthma and COPD Chemical toxins: nerve agents, cyanide, blistering agents, choking agents Allergic reaction unresponsive to epinephrine and diphenhydramine CHF - BioTel authorization only Known heart disease Side Effects: Restlessness Hypertension Tachycardia - palpitations Contraindications: Pregnancy, except in life-threatening situations Page 6 of 35
Amiodarone HCL (Cordarone ) Route: Antiarrhythmic IV or intraosseous push only Ventricular fibrillation, pulseless ventricular tachycardia First Dose - 300 mg - standing order Second Dose - 150 mg - standing order Stable or unstable, sustained ventricular tachycardia with pulse 150 mg - over 10 minutes - BioTel authorization only Ventricular fibrillation, pulseless ventricular tachycardia 5 mg/kg in 100mL NS slow push over 30 minutes. - BioTel authorization only Stable or unstable, sustained or non-sustained ventricular tachycardia with pulse 5 mg/kg in 100mL NS slow push over 30 minutes. - BioTel authorization only Drug Action: Alters the movement of sodium, potassium and calcium through normal channels; These actions: increase the refractory period of all cardiac tissues slow repolarization decrease automaticity Alpha and beta blocker Within minutes Variable Indications: Ventricular fibrillation or pulseless ventricular tachycardia that does not respond to initial defibrillation attempts Sustained ventricular tachycardia with a pulse Precautions: Do not shake (prevents foaming); draw-up with large gauge needle Protect from light Avoid contact with plastic; administer at closest IV port Use with caution in renal failure patients Side Effects: Bradycardia Hypotension Contraindications: Trauma patients Not to be administered via ETT Page 7 of 35
Aspirin (Acetylsalicylate Acid) Route: Analgesic, anti-inflammatory, antipyretic, anti-platelet aggregator Orally (chewed) One (325mg) adult aspirin or four (81 mg) baby aspirin - standing order regardless of whether the patient has taken any aspirin within the previous 24 hours. Not normally given to pediatric patients by EMS - BioTel authorization only Drug Action: Blocks pain impulses in the CNS Dilates peripheral vessels Reduces platelet stickiness Reduces coronary artery vasoconstriction Indications: Precautions: Side Effects: Contraindications: 15-30 minutes 4-6 hours Chest pain believed to be of cardiac origin Any significant bleeding None for pre-hospital Aspirin allergy Aspirin-induced asthma Page 8 of 35
Atropine Sulfate Anticholinergic/Parasympatholytic agent Route: Rapid IV or intraosseous push Endotracheal administration (alternative route) May be administered deep IM in nerve agent exposure PEA or Asystole: standing order 1 mg rapid push every three (3) to five (5) minutes (max total dose 0.04mg/kg) 2 mg via endotracheal tube Symptomatic Bradycardia: standing order 0.5mg - 1.0mg push - Additional doses must be approved by BioTel Organophosphate poisoning: BioTel authorization only 2mg push every 5-15 minutes until excessive secretions are diminished Nerve agent exposure: BioTel authorization only 2mg - 20mg IM, IV, intraosseous PEA or Asystole: - Atropine not administered for these conditions Symptomatic Bradycardia: standing order 0.02mg/kg, (minimum single dose 0.1 mg) IV or intraosseous. May repeat once 0.04mg/kg via endotracheal tube Organophosphate poisoning: BioTel authorization only 0.05mg/kg push every 20 minutes until excessive secretions are diminished Premedication in Pharmacologically-Assisted Intubation: standing order 0.01mg/Kg push two minutes prior to intubation Drug Action: Reverses suspected vagal tone in bradycardias, asystole and PEA Blocks acetylcholine in organophosphate poisonings; Reverses effects of nerve agents Rapid 2-6 hours Indications: Symptomatic bradycardia Asystole PEA with ECG rate < 60 per min Organophosphate poisoning Chemical exposure due to nerve agent Pharmacologically-Assisted Intubation Precautions: If given too slowly, can cause transient bradycardias Administer into medication port closest to IV site Notify BioTel before giving to patients with glaucoma Side Effects: Tachycardia; Dilated pupils (may make pupil assessment unreliable) Anticholinergic effects: dry mouth, blurred vision Contraindications: Hypothermic bradycardia, PEA, and asystole Page 9 of 35
Calcium Chloride Route: Electrolyte IV or intraosseous push; slow push (in live patients) - 1mL/minute 10-15 mg/kg of a 10% solution - BioTel authorization only 10-15 mg/kg of a 10% solution - BioTel authorization only Drug Action: Balances hyperkalemia Increases myocardial contractile force and ventricular automaticity Aids in the re-entry of calcium into muscle when given for calcium channel blocker or magnesium sulfate toxicity 5-15 minutes Dose dependent (effects may persist fo 4 hours after IV administration) Indications: Known or suspected hyperkalemic cardiac arrest (renal failure) Calcium channel blocker toxicity (bradycardia or hypotension) Beta-blocker toxicity (bradycardia or hypotension) Magnesium sulfate toxicity Precautions: Start IV s in the antecubital fossa to lower risk of infiltration, and while administering, continually check IV site for patency and signs/symptoms of infiltration Do not mix with sodium bicarbonate; flush tubing well between drugs Inform BioTel (prior to administration) if patient taking digitalis preparation Side Effects: Tissue necrosis if CaCl 2 infiltrates Forms precipitate if given with sodium bicarbonate Causes digitalis toxicity if administered to patient on digitalis With rapid infusion or overdose: bradycardia, hypotension and asystole Contraindications: None Page 10 of 35
Dextrose 50% Route: Drug Action: Carbohydrate Slow IV or intraosseous push (to prevent infiltration) 25 grams - 50 grams - standing order 0.5 grams per kilogram of body weight - standing order, diluted as follows Newborn-1 month: dilute D50 1:4, administer 5mL/kg of the new D10 solution 1 Month-12 years: dilute D50 1:1, administer 2mL/kg of the new D25 solution Increases blood glucose levels 1 minute Depends on the degree of hypoglycemia Indications: Altered mental status or seizure caused by hypoglycemia; hypoglycemia defined as; Adults: Diabetics = fingerstick blood glucose analysis less than 110mg/dL Non-diabetics = fingerstick blood glucose analysis less than 80mg/dL Children: Diabetics = fingerstick blood glucose analysis less than 90mg/dL Non-diabetics = fingerstick blood glucose analysis less than 60mg/dL Coma of unknown cause Precautions: Start IV s in the antecubital fossa to lower risk of infiltration, and while administering, continually check IV site for patency and signs/symptoms of infiltration Contact BioTel (prior to drug administration) for hypoglycemia in the patient with head trauma or increased intracranial pressure Side Effects: Contraindications: Tissue necrosis with infiltration None Page 11 of 35
Diazepam (Valium ) Benzodiazepine Route: Slow IV or intraosseous push IM (alternate route) Rectal (preferred route for pediatric patients and alternate route for adults) Titrate doses of 2.5mg (up to a maximum of 10 mg) to achieve: Standing Order sedation prior to TCP relief of cocaine-induced chest pain and/or tachycardia relief of seizure including those related to eclampsia sedation prior to cardioversion BioTel authorization only relief of extreme agitation in psychiatric or behavioral emergencies sedation to facilitate endotracheal intubation chemical restraint for patients who continue to struggle against physical restraint relief of stimulant- or hallucinogen-induced tachycardia or agitation in AMS BioTel may order additional doses beyond 10 mg. 0.5 mg/kg per rectum (PR) for relief of seizure or relief of stimulant- or hallucinogeninduced tachycardia or agitation, up to a maximum of 10 mg - standing order Drug Action: Central nervous system depressant that causes: Amnesia Sedation Muscle relaxation Onset (IV) 1 min - 5 min (IM) 15 min - 30 min (Rectal) 5 min - 15 min (IV, IM) 15 min - 60 min (Rectal) 2 hours - 4 hours Indications: Active seizure/status epilepticus Sedation prior to cardioversion or transcutaneous pacing in conscious patients Chest pain or tachycardia following an overdose or ingestion of a stimulant or hallucinogen (cocaine, amphetamine, ecstacy, LSD, PCP, ketamine) Sedation in struggling patients when medical restraints are applied Precautions: Monitor respiratory status closely Give at site closest to IV catheter and avoid mixing with any other drugs and solutions; flush well before and after use Titrate in small boluses to avoid side effects Side Effects: Respiratory depression Hypotension Confusion Contraindications: Pregnancy only with BioTel permission Alcohol or other sedative drug use Stupor Vein irritation, phlebitis and sclerosis Nausea Head injury Hypersensitivity Page 12 of 35
Diphenhydramine HCl (Benadryl ) Antihistamine Route: IV push (25mg/minute) IM Intraosseous (alternative route) Pediatric Dose 25mg - 50mg - standing order 1mg/kg - 2mg/kg - standing order Drug Action: Blocks histamine receptor sites in allergic reactions Reverses side effects of dystonic reactions caused by phenothiazines Maximum effects seen in 1 hour - 3 hours 6 hours - 12 hours Indications: Allergic reactions - standing order Dystonic reactions - BioTel authorization only Precautions: Acute asthma attack Side Effects: Drowsiness Sedation Disturbed coordination hypotension Palpitations Tachycardia Bardycardia Thickening of bronchial secretions Dry mouth and throat Paradoxical excitement in children Contraindications: Hypersensitivity to diphenhydramine Page 13 of 35
Dopamine HCL (Intropin ) Route: Sympathomimetic IV or intraosseous piggyback 2-10mcg/kg/minute - BioTel authorization only, as follows 400mg dopamine in 250mL NS (1600mcg/mL) 800mg dopamine in 500mL NS (1600mcg/mL) Refer to the Drug Drip Chart in Protocol Appendix for the number of drops per minute to deliver the BioTel authorized order Pediatric Dose 2-10mcg/kg/minute - BioTel authorization only, as follows 400mg dopamine in 250mL NS (1600mcg/mL) 800mg dopamine in 500mL NS (1600mcg/mL) Refer to the Drug Drip Chart in Protocol Appendix for the number of drops per minute to deliver the BioTel authorized order Drug Action: At low doses, increases perfusion to kidneys and abdominal organs At moderate doses, increases force and rate of ventricular contractions At high doses, peripheral vasoconstrictor 2 minutes - 4 minutes 10 minutes - 15 minutes Indications: Cardiogenic shock with systolic blood pressure between 70mmHg-90mmHg Symptomatic bradycardia unresponsive to atropine or TCP Precautions: Start IV s in the antecubital fossa to lower risk of infiltration, and while administering, continually check IV site for patency and signs/symptoms of infiltration. Do not mix with sodium bicarbonate; flush tubing well between drugs Continually monitor ECG, heart rate and blood pressure. Side Effects: Tissue necrosis with infiltration Hypertension Tachycardia Arrhythmias Contraindications: Hypovolemic shock Page 14 of 35
Epinephrine 1:1,000 Sympathomimetic Route: Subcutaneous Endotracheal administration (alternative route) in pediatric patients Allergic reaction/anaphylactic shock: 0.3mg - 0.5mg SQ - standing order Bronchospasm unresponsive to inhaled beta-agonists: 0.3mg - 0.5 mg SQ - standing order Allergic reaction/anaphylactic shock: 0.01mg/kg (max 0.3mg per dose) - standing order Bronchospasm unresponsive to inhaled beta-agonists: 0.01mg/kg (max 0.3mg per dose) SQ - BioTel authorization only Cardiac arrest: 0.1mg/kg via endotracheal tube followed by 5 ml NS flush - standing order Drug Action: Alpha effects produce peripheral vasoconstriction which: Increases coronary and cerebral perfusion Increases blood pressure in anaphylaxis Beta 1 effects: Increases heart rate Improves force of ventricular contractions Beta 2 effects produce bronchodilation 5 minutes - 10 minutes 5 minutes - 10 minutes Indications: Allergic reaction/anaphylactic shock Bronchospasm unresponsive to inhaled beta-agonists Pediatric cardiac arrest Precautions: CPR: None Allergic reaction/anaphylactic shock/refractory bronchospasm: Monitor ECG closely Patients on beta blockers may need glucagon or higher doses of epinephrine Side Effects: CPR: None Anaphylaxis: Tachycardia Ventricular arrhythmias Headache Flushing Nausea/vomiting Chest Pain Contraindications: CPR: None Allergic reaction: None Refractory bronchospasm: Heart disease, History of AMI, Age > 45 years, Arrhythmia, Labor Page 15 of 35
Epinephrine 1:10,000 Sympathomimetic Route: IV or intraosseous push Endotracheal administration (alternative route) Cardiac arrest: 1mg push - standing order 2mg - 2.5mg via endotracheal tube - standing order Anaphylaxis: 0.1mg - 0.2mg slow push (over 1 minute) - standing order Cardiac arrest: 0.01mg/kg rapid push - standing order Anaphylaxis: 0.01mg/kg slow push (maximum is 0.3mg per dose) - standing order Drug Action: Alpha effects produce peripheral vasoconstriction which: Increases coronary and cerebral perfusion Increases blood pressure in anaphylaxis Beta 1 effects: Increases heart rate Improves force of ventricular contractions Beta 2 effects produce bronchodilation 1 minute - 2 minutes 5 minutes - 10 minutes Indications: Cardiac arrest Anaphylaxis Pediatric bradycardias unresponsive to other treatment Precautions: CPR: None Anaphylaxis: Monitor ECG closely Patients on beta blockers may need glucagon or higher doses of epinephrine. Do not mix with sodium bicarbonate; flush tubing well between drugs. Side Effects: CPR: None Anaphylaxis: Tachycardia Ventricular arrhythmias Headache Flushing Nausea/vomiting Chest Pain Contraindications: None Page 16 of 35
Etomidate short-acting intravenous anesthetic hypnotic sedative Route: Drug Action: Indications: IV or IO push 0.3 mg/kg slow push 0.3 mg/kg slow push Suppresses central nervous system activity thereby inducing rapid unconsciousness 1 minute - 2 minute Dose dependent, but usually 3-5 minutes Sedation to provide pharmacologically-assisted intubation Precautions: May cause myoclonic activity (e.g., coughing, hiccups) May exacerbate focal seizure disorder Side Effects: Nausea and/or vomiting Temporary involuntary muscle contractions Contraindications: For EMS use, no contraindications. Relative contraindication known adrenal insufficiency (known to suppress cortisol production) known history of focal seizure disorder (may exacerbate condition) pregnancy Use with caution hypotension severe asthma Not recommended in children under the age of 10 years (safety and efficacy have not been established) Page 17 of 35
Fentanyl Route: Drug Action: Indications: Opiate narcotic analgesic slow IV or IO push For pain relief unresponsive or untreatable with nitrous oxide - standing order: 1 mcg/kg to 2 mcg/kg slow IVP - Do not exceed 100 mcg per dose. May repeat every 15 minutes. For pain relief unresponsive or untreatable with nitrous oxide - standing order: 1 mcg/kg to 2 mcg/kg slow IVP - Do not exceed 100 mcg per dose. May repeat every 15 minutes. Produces analgesic effects similar to but about 50 to 100 times stronger than morphine, although the two medications are not chemically related. Immediate, however maximal analgesia may not occur for several minutes 30 to 60 minutes Relief of pain Precautions: May produce respiratory depression May produce bradycardia Use with caution in patients with liver and kidney dysfunction Side Effects: Respiratory depression Temporary involuntary muscle contractions Bradycardia Contraindications: Severe Hemorrhage Shock Known hypersensitivity MAO inhibitor use within the previous 14 days. Antidote: Actions of fentanyl may be reversed by naloxone Page 18 of 35
Glucagon Pancreatic Hormone Insulin Antagonist Route: IM or subcutaneous) for hypoglycemia IM or slow IV push (over 2-5 minutes) for bradycardia due to beta-blocker or calciumchannel blocker toxicity Rapid IV push for cardiac arrest due to beta-blocker or calcium-channel toxicity Hypoglycemia - 1mg - standing order. If no response, additional doses may be authorized by BioTel at 15 minute intervals if necessary. Bradycardia (beta-blocker or calcium-channel blocker toxicity) - 1mg - BioTel authorization only Cardiac arrest (beta-blocker or calcium-channel toxicity) - 1mg-5mg - standing order Pediatric Dose Hypoglycemia - 1mg - standing order. If no response, additional doses may be authorized by BioTel at 15 minute intervals if necessary. Beta-blocker or calcium-channel toxicity - 1mg - BioTel authorization only Drug Action: Converts stored glycogen to glucose, increasing blood glucose levels Improves cardiac contractility and increases heart rate Within 1 minute, however it may be 15 minutes before any response is observed 60-90 minutes Indications: Hypoglycemia when no IV is obtainable and gag reflex is absent (should not be considered a first-line choice for hypoglycemia) Beta blocker and calcium channel blocker toxicity Precautions: Administer cautiously to: Patients with cardiovascular disease Patients with kidney or liver dysfunction Side Effects: Hypotension Nausea Vomiting Tachycardia Contraindications: Hypersensitivity to proteins Page 19 of 35
Glutose (Oral Glucose) Route: Drug Action: Indications: Carbohydrate Oral Full tube given in small doses (25-50 gm) - standing order 0.5 gm/kg in small doses - standing order Increases blood glucose level 1 minute Depends on the degree of hypoglycemia Altered mental status caused by hypoglycemia defined as; Adults: Diabetics = fingerstick blood glucose analysis less than 110mg/dL Non-diabetics = fingerstick blood glucose analysis less than 80mg/dL Children: Diabetics = fingerstick blood glucose analysis less than 90mg/dL Non-diabetics = fingerstick blood glucose analysis less than 60mg/dL Precautions: Side Effects: Assure gag reflex is present Aspiration Contraindications: Absent gag reflex Patients who are unable to protect their own airway Patients who are unable to swallow Page 20 of 35
Ipratropium bromide (Atrovent ) Topical Anticholinergic/Parasympatholytic Route: Inhalation Endotracheal administration (alternative route) Standing order - 0.5mg mixed with 2.5mg albuterol given via nebulizer over 5-15 minutes if the patient is not improving after a single albuterol-only nebulized treatment. A second 0.5 mg dose mixed with 2.5mg albuterol may be given standing order, if needed. BioTel must authorize any additional doses. If less than 1 year old Standing order - 0.25mg mixed with 2.5mg albuterol given via nebulizer over 5-15 minutes if the patient is not improving after a single albuterol-only nebulized treatment. A second 0.25 mg dose mixed with 2.5mg albuterol may be given standing order, if needed. BioTel must authorize any additional doses. If 1 year or older Standing order - 0.5mg mixed with 2.5mg albuterol given via nebulizer over 5-15 minutes if the patient is not improving after a single albuterol-only nebulized treatment. A second 0.5 mg dose mixed with 2.5mg albuterol may be given standing order, if needed. BioTel must authorize any additional doses. Drug Action: Bronchodilation Dries respiratory tract secretions 5-15 minutes 4-6 hours Indications: Bronchospasm associated with asthma or COPD that does not respond to the first dose of albuterol Bronchospasm from chemical toxins: nerve agents, cyanide, blistering agents, choking agents Precautions: Notify BioTel (prior to administration) if patient has: Narrow-angle glaucoma, prostatic hypertrophy (enlarged prostate), bladder-neck obstruction Side Effects: Tachycardia/Palpitations Restlessness/Nervousness Blurred vision Dizziness, Headache Dry mouth Cough, worsening of symptoms Skin rash Contraindications: Sensitivity to soy lecithin products (soybeans, peanuts) Sensitivity to Atropine Bronchoconstriction that is caused by allergic reaction Page 21 of 35
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Lidocaine HCL (Xylocaine ) Ventricular Antiarrhythmic Local Anesthetic Route: IV or intraosseous push (no faster than 50 mg/minute in conscious patients) IV or intraosseous piggyback Ventricular fibrillation - standing order which converts with the initial shock 1.5mg/kg push Lidocaine drip 1-4 mg/minute that does not respond to amiodarone or when amiodarone cannot be used 1.5mg/kg push. May repeat once. Sustained ventricular tachycardia - standing order Stable patients - 1.0mg/kg push; if conversion occurs, begin infusion 1-4 mg/min Unstable patients following synchronized cardioversion - 1.5mg/kg push Nonsustained ventricular tachycardia or PVCs - BioTel authorization only Initial bolus - 1mg/kg push Repeat bolus - 0.5mg/kg push Infusion 1-4mg/minute piggyback Pain related to Intraosseous Access 40 mg IO prior to saline flush Ventricular fibrillation - standing order which converts with the initial stacked shocks 1.0mg/kg push Lidocaine drip 1-4 mg/minute that does not respond to amiodarone or when amiodarone cannot be used 1.0mg/kg push. May repeat once. Sustained ventricular tachycardia - BioTel authorization only Stable patients - 1.0mg/kg push Unstable patients following synchronized cardioversion - 1.0mg/kg push Nonsustained ventricular tachycardia or PVCs - BioTel authorization only Initial bolus - 1mg/kg push Drug Action: Suppresses ventricular ectopy Blocks conduction of pain impulses 30 seconds - 90 seconds 10 minutes - 20 minutes Indications: Ventricular fibrillation Sustained ventricular tachycardia Nonsustained ventricular tachycardia or PVCs Pain related to Intraosseous Access Page 23 of 35
Precautions: Contact BioTel in patients over 65, history of liver disease, or CHF Contact BioTel prior to administration if patient has any "caine" allergy Short half-life; bolus may need repeating, and if bolus converts rhythm, it is followed by a lidocaine drip Continually monitor ECG, blood pressure and level of consciousness Maximum total dose of lidocaine is 3mg/kg Side Effects: Initially: drowsy, lightheadedness, blurred vision Toxicity: hypotension, change in level of consciousness, seizures, cardiovascular collapse, bradycardia Contraindications: Life-sustaining ventricular escape rhythms associated with bradycardia or 2 or 3 heart blocks Hypersensitivity Page 24 of 35
Magnesium Sulfate Electrolyte Anticonvulsant Smooth Muscle Relaxer Route: Refractory bronchospasm: IV or intraosseous piggyback over 6-10 minutes Pulseless Torsade de Pointes: Slow IV or intraosseous push over 6-10 minutes Torsade de Pointes with a pulse: Slow IV or intraosseous piggyback over 6-10 minutes Pulseless Torsade de Pointes - Standing order - 2 grams magnesium sulfate slow IV or intraosseous push over 6-10 minutes Refractory bronchospasm or Torsade de Pointes with a pulse - BioTel authorization only - Mix 2 grams of magnesium sulfate into a 250mL bag of saline and infuse piggyback wide open via microdrip tubing. (6-10 minutes) Not administered to pediatric patients Drug Action: Reverses magnesium deficiency Calcium-channel blocker Increases intracellular potassium Central nervous system depressant Relaxes smooth muscle Immediate following IV infusion 30 minutes Indications: Torsades de pointes (antiarrhythmic of choice) Bronchospasm in asthma or COPD that is not responsive to other therapy Precautions: Inform BioTel prior to administration when hypomagnesmia is suspected patients are on digitalis preparations Continually monitor blood pressure, respirations, ECG, LOC and muscle strength Side Effects: Diaphoresis Facial flushing Hypotension Depressed reflexes Hypothermia Bradycardia Circulatory collapse Respiratory depression Muscle weakness/paralysis CNS depression Contraindications: Shock or systolic blood pressure <110mmHg Heart block Respiratory depression Chronic kidney disease/dialysis Antidote: Calcium Chloride Page 25 of 35
Midazolam (Versed ) Route: Benzodiazepine IV or intraosseous push 0.1 mg/kg IVP to a maximum single dose of 5 mg - standing order 0.1 mg/kg IVP to a maximum single dose of 5 mg - standing order Drug Action: Central nervous system depressant that causes: Amnesia Sedation Muscle relaxation Highly variable, however usually 1-5 minutes Variable however, usually 15 minutes to 1 hour Indications: Active seizure/status epilepticus Sedation prior to cardioversion or transcutaneous pacing in conscious patients Chest pain or tachycardia following an overdose or ingestion of a stimulant or hallucinogen (cocaine, amphetamine, ecstacy, LSD, PCP, ketamine) Sedation in struggling patients when medical restraints are applied Precautions: Monitor respiratory status closely Give at site closest to IV catheter and avoid mixing with any other drugs and solutions; flush well before and after use Titrate in small boluses to avoid side effects Side Effects: Respiratory depression Hypotension Confusion Stupor Nausea Contraindications: Known hypersensitivity Acute narrow-angle glaucoma Antidote: Page 26 of 35
Morphine Sulfate Route: Narcotic Analgesic Slow IV or intraosseous push 2mg - 4mg increments to a maximum of 10mg - standing order If patient is > 65 yr of age, debilitated, has altered mental status, or SBP < 110mmHg, BioTel must authorize administration. 0.1mg/kg to a maximum of 10mg - BioTel authorization only Drug Action: Alleviates pain Decreases peripheral vascular resistance - vasodilator Decreases cardiac workload and oxygen demand on the heart 1 minute - 2 minutes following IV administration 2 hours - 7 hours Indications: Chest pain unresponsive to nitroglycerin Moderate to acute pain secondary to amputations, fractures, or other situations that cannot be controlled with nitrous oxide Precautions: Monitor respiratory status and blood pressure closely Have naloxone (Narcan ) readily available Side Effects: Hypotension Tachycardia Bradycardia Palpitations Syncope Facial flushing Respiratory depression Euphoria Bronchospasm Dry mouth Allergic reaction Contraindications: Systolic BP <110mmHg; BioTel may authorize administration in patients with systolic blood pressures less than 110mmHg but greater than 90mmHg. Head injury Severe respiratory depression Hypersensitivity Antidote: Naloxone (Narcan ) Page 27 of 35
Naloxone HCL (Narcan ) Narcotic Antagonist Route: Slow IV or intraosseous push IM (alternate route) Subcutaneous (alternative route - rare) Non-cardiac arrest - Standing order 0.4 mg every 5 minutes slow push until the respiratory rate improves and the patient can maintain a pulse oximetry reading of 96% OR until 2 mg has been given. Cardiac Arrest - Standing Order 2 mg IV or IO push Pediatric Dose Non-cardiac arrest - Standing order 0.1mg/kg slow push (maximum single dose 0.4mg) until the respiratory rate improves and the patient can maintain a pulse oximetry reading of 96% OR until 2 mg has been given. Cardiac Arrest - Standing order 0.1mg/kg slow push (maximum single dose 2.0 mg Drug Action: Reverses narcotic effects Within 2 minutes of IV administration 30 minutes - 60 minutes Indications: Narcotic overdose Coma of unknown origin Cardiac arrest with suspected narcotic overdose etiology Seizure with suspected narcotic overdose etiology Precautions: Effective for only 30-60 minutes; repeat if LOC and/or respiratory status deteriorate Secure patient prior to administration Administration of naloxone is not recommended as part of initial resuscitative efforts for newborns with respiratory depression. It also should be avoided in babies whose mothers are suspected of having had long term exposure to opiods. Side Effects: Tachycardia Hypertension Diaphoresis Nausea Blurred vision Acute withdrawal syndrome (violent behavior) With rapid administration: Arrhythmia Projectile vomiting Contraindications: Hypersensitivity Page 28 of 35
Nitroglycerin (Nitrostat ) Route: Vasodilator Sublingual 1 spray (0.4mg) or tablet - standing order May be repeated twice at 5 minute intervals PRN - standing order Additional doses beyond the initial three must be authorized by BioTel 1 spray (0.4mg) or tablet - BioTel authorization only Drug Action: Coronary and systemic vasodilator - decreases peripheral vascular resistance and preload Decreases cardiac workload and oxygen demand on the heart 1 minute - 3 minutes 30 minutes - 60 minutes Indications: Chest pain of cardiac origin Pulmonary edema associated with congestive heart failure (may be administered without an IV if systolic blood pressure > 110mmHg) Precautions: For acute coronary syndrome, 12-lead must be performed prior to nitroglycerin administration Monitor blood pressure closely. If blood pressure falls below 110 mmhg resulting from nitroglycerin administration, DO NOT give any additional nitroglycerin. Assure patient is sitting or lying down during administration Active ingredient of nitroglycerin will sting when administered sublingually IV must be established prior to administration in patients with suspected inferior wall MI Side Effects: Hypotension Headache Postural hypotension/syncope Reflex tachycardia Nausea and vomiting Diaphoresis Contraindications: Systolic blood pressure <110 mmhg Increased intracranial pressure Viagra or similar drugs (Sildenafil, Cialis, Tadalafil, Levitra, Vardenafil) in the previous 24 hours Hypersensitivity Page 29 of 35
Nitrous Oxide (Nitronox ) Route: Gaseous Analgesic/Anesthetic Inhalation Instruct patient to inhale deeply through patient-held mask or mouthpiece Instruct patient to inhale deeply through patient-held mask or mouthpiece Drug Action: Depresses the central nervous system Increases oxygen tension in the blood thereby reducing hypoxia 2 minutes - 5 minutes 2 minutes - 5 minutes Indications: Adjunct analgesic for ischemic chest pain Severe pain or discomfort in all patients without contraindications Precautions: Must be self administered Check machine gauges daily for proper concentrations Monitor blood pressure and pulse oximetry values during administration Side Effects: Hypotension Dizziness Nausea and vomiting Contraindications: Any altered level of consciousness or head injury Chronic obstructive pulmonary disease Chest trauma or actual/suspected pneumothorax Abdominal trauma Major facial trauma Acutely psychotic patients Pregnancy, other than active labor Any patient (adult or pediatric) unable to self-administer Decompression sickness Page 30 of 35
Norepinephrine bitartrate (Levophed ) Route: Sympathomimetic IV or intraosseous piggyback Post-resuscitation (medical) systolic blood pressures less than 90 mmhg - BioTel authorization only 8-12mcg/minute 4mg norepinephrine in 250mL NS (16mcg/mL) 8mg norepinephrine in 500mL NS (16mcg/mL) Cardiogenic shock with systolic blood pressures less than 70 mmhg - BioTel authorization only 8-12mcg/minute 4mg norepinephrine in 250mL NS (16mcg/mL) 8mg norepinephrine in 500mL NS (16mcg/mL) Refer to the Drug Drip Chart in Protocol Appendix for the number of drops per minute to deliver the BioTel authorized order Not administered to pediatric patients Drug Action: Potent peripheral vasoconstrictor Increases myocardial contractility 1 minute - 3 minute 5 minutes - 10 minutes Indications: Cardiogenic shock when systolic blood pressure is < 70mmHg Post resuscitation hypotension after medical CPR s when systolic BP < 90mmHg Precautions: Start IV s in the antecubital fossa to lower risk of infiltration. While administering continually check IV site for patency and signs/symptoms of infiltration Continually monitor blood pressure Do not mix with sodium bicarbonate; flush tubing well between drugs Side Effects: Tissue necrosis with infiltration Hypertension Headache Dysrhythmia Tachycardia Reflex bradycardia Chest pain Contraindications: Hypovolemia Page 31 of 35
Pralidoxime Chloride (Protopam Chloride, 2-PAM, 2-PAM Chloride) Route: Cholinesterase reactivator Deep IM 600mg (1 autoinjector) - 1800mg (3 autoinjectors) - standing order Not generally administered to pediatric patients Drug Action: Reactivates cholinesterase which has been deactivated by chemical nerve agents and organophospate poisons Relieves paralysis of the respiratory muscles following chemical nerve agent or organophospate exposure About 15 minutes About 1 hour Indications: Second drug given for the treatment of poisoning due to organophosphate pesticides and chemical nerve agents (First drug is atropine) Primary indication for pralidoxime administration is muscle weakness or respiratory depression in these patients Precautions: Not indicated for poisonings with carbamate pesticides Effects during pregnancy are unknown Safety and efficacy in children is unknown Do not administer more than 3 autoinjectors due to its hypertensive effects Side Effects: Tachycardia, laryngospasm, muscle rigidity if IV and infused too quickly Mild to moderate pain at injection site Blurred or double vision, dizziness, loss of coordination, headache drowsiness, hypertension, tachycardia Contraindications: No absolute contraindications Page 32 of 35
Promethazine HCl (Phenergan ) Antiemetic Phenothiazine Antihistamine Route: IV or intraosseous push slowly over 1 minute IM - deep into muscle Titrate doses of 12.5mg to achieve the desired effect, up to a maximum of 25mg - standing order Drug Action: Indications: Do not administer to pediatric patients Potent antiemetic Rapid with IV administration 4 hours - 6 hours Persistent vomiting due to gastrointestinal problems Precautions: Monitor LOC Avoid intra-arterial or subcutaneous administration Give slowly rapid administration can cause vein irritation, phlebitis and sclerosis Watch for signs/symptoms of excessive sedation and dystonic reaction Side Effects: Marked drowsiness/sedation Allergic reaction Dysrhythmia Nausea and vomiting Hyperexcitability Dystonic reaction Use in children may cause hallucinations, convulsions and sudden death Contraindications: Elderly >65 years of age Debilitated patients (signs of dehydration and weakness) Trauma Altered level of consciousness Pregnancy - only with BioTel permission Known sulfa allergy Hypersensitivity Antidote For dystonic reactions give diphenhydramine (Benadryl ) Page 33 of 35
Proparacaine HCL (Alcaine ) Route: Topical ophthalmic anesthetic Dropped into the affected eye 1-2 drops in affected eye. Repeat dose every 5 minutes up to a total of 3 applications - standing order 1-2 drops in affected eye. Repeat dose every 5 minutes up to a total of 3 applications - standing order Drug Action: Rapid, brief, superficial anesthesia; blocks nerve impulses from sensory nerves Within 30 seconds 10-15 minutes Indications: Short-term relief from corneal burns or corneal abrasions Patient comfort prior to irrigation associated with chemical exposure, pepper spray, mace Precautions: Caution patient not to rub eye Side Effects: Burning or stinging sensation Irritation Contraindications: Eye avulsion Foreign bodies in the eyes Globe rupture Allergies to the "caine" drugs Page 34 of 35
Sodium Bicarbonate Electrolyte Alkalinizing Agent Route: IV or intraosseous push 1mEq/kg - standing order when indicated for cardiac arrest 1mEq/kg - BioTel authorization only when indicated for TCA toxicity 1mEq/kg - standing order when indicated for cardiac arrest 1mEq/kg - BioTel authorization only when indicated for TCA toxicity Drug Action: Drives serum potassium back into the cell Enhances urinary excretion of tricyclic antidepressants Neutralizes acidosis 2 minutes - 10 minutes 30 minutes - 60 minutes Indications: Altered Level of Consciousness and wide complex tachycardia resulting from tricyclic antidepressant (TCA) overdose or ingestion - BioTel authorization only Cardiac arrest associated with - Standing order Hyperkalemia renal failure dialysis Metabolic acidosis renal failure diabetic ketoacidosis (DKA) methanol ingestion aspirin (ASA) overdose Tricyclic antidepressant (TCA) overdose or ingestion Precautions: Flush IV line well between all drugs May inactivate epinephrine or dopamine Side Effects: Alkalosis Seizures Tissue sloughing at injection site Contraindications: Not recommended for routine use in cardiac arrest Page 35 of 35