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ADVANCED LIFE SUPPORTDrug Guide for Paramedics Copyright 2012AuthorRob Theriault BHSc., EMCA, RCT(Adv.), CCP(F) Copyright 2012, 2009, 2008, 2007, 2004, 2003, 2002, 2001, 1996Reproduction of any part of this material, written, audio, visual or electronic, in any form, withoutthe written consent of author is strictly forbidden.Drug Guide for Paramedicsp. 1
Table of ContentThe following guide provides a description of drugs for Primary and AdvancedCare Paramedics in the field.Page“Seven Rights” of drug administration . 3Adenosine . 4Amiodarone . 6Aspirin . 8Atropine . 10D50W . 12Diazepam . 14Dimenhydrinate . 16Diphenhydramine . 18Dopamine . 20Epinephrine IV, SC . 22Fentanyl . 24Furosemide . 26Glucagon . 28Lidocaine . 30Midazolam . 32Morphine . 34Naloxone . 36Nitroglycerin . 38Oxygen . 40Salbutamol (Ventolin) . 42Sodium Bicarbonate . 44Xylometazoline HCL (Otrivin) . 46Medicine and pharmacology is a constantly changing science and not all therapies are clearlyestablished. New research changes drug and treatment therapies daily. The author and publisherof this document have has used his best efforts to provide information that is up-to-date andaccurate and is generally accepted within medical standards at the time of publication. However,as medical science is constantly changing and human error is always possible, the author andpublisher does not warrant that the information in this document is accurate or complete, nor isthe author responsible for omissions or errors in the document or for the results of using thisinformation. The reader should confirm the information in this document from other sources priorto use. In particular, all drug doses, indications, and contraindications should be confirmed. Inaddition, the drug indications and dosages described in this guide are based on general guidelinesand principles of drug administration and do not replace or supersede your Medical Directives orStanding Orders.For additional continuing medical education resources visit Paramedic Tutor at:http://paramedictutor.wordpress.com/Drug Guide for Paramedicsp. 2
Seven “Rights” of Drug Administration1. Right Patient? Is this patient right for this drug? Is this drug contraindicated because of medical history, allergies, druginteraction, presenting condition, heart rate, blood pressure, mentalstatus, etc?2. Right Drug? some drugs come is similar ampoules, vials or nebules (e.g. epinephrineand morphine, naloxone and midazolam ) – always check the drug whenyou pull it out of the kit for the name, dose, concentration and for fluidclarity and expiry date. Check the drug again before administering it. syringes with left over medication must be labelled with the drug nameand concentration per ml. A narcotic should be checked by two people prior to administration(except when alone in the back of the ambulance)3. Right Dose? double check dosage calculation - have partner do the same whenpractical Is your estimation of the patient’s weight reasonable? The Broselow tape is recommended for weight estimation in paediatrics4. Right Time? Follow dosing intervals listed in Medical Directives. Remember that repeated doses of a drug may have an added effect. Timing may be critical to maintain a therapeutic drug level5. Right Route? Which route is most appropriate for this patient – e.g. SC, IM or IV. In the case of anaphylaxis for example, SC may be acceptable in the earlystages, however, once shock has set in, the IM route is better.6. Right to know? patient has a right to be informed about the drug; What the drug is andwhat it does; benefits and risks; a right to sound medical advice7. Right to refuse You must obtain permission from the patient for any intervention The patient has the right to refuse treatment at any time e.g. it’s not uncommon for patients to refuse ASA for various reasons e.g. some patients will refuse Adenosine because it causes them greatphysical distress or they know it hasn’t worked for them in the past. Assess patient’s “capacity” in the event of a refusal and use the BaseHosp. Physician and/or supervisor for assistanceDrug Guide for Paramedicsp. 3
Adenosine (Adenocard)Classification: antiarrhythmicPharmacodynamics: naturally occurring nucleoside that stimulates specificadenosine receptors. This results in activation ofacetylcholine sensitive potassium channels (efflux ofpotassium) and blockade of calcium influx in the SA node,atrium and AV node. The cells become hyperpolarized andthis blunts SA node discharge, slows AV conduction andincreases the AV node refractory period. AV nodalconduction may be completely blocked.interrupts AV nodal re-entry and other AV node dependanttachyarrhythmias TION 20-30 secondsunknown6-10 seconds1-2 minutesIndications: conversion of supraventricular tachycardia (SVT) /paroxysmal supraventricular tachycardia (PSVT) includingthat associated with Wolff-Parkinson-White syndromeContraindications: hypersensitivity, 2nd or 3rd degree AV block, sick sinussyndromePrecautions: may worsen bronchospasm in asthmatics and some patientswith COPDflushing and chest pain may occur briefly afteradministration. drug to drug: Adverse effects Drug Guide for Paramedicshigher than normal doses of Adenosine may be required forpatients on xanthines (eg. theophylline).lower than normal doses (i.e. 3 mg or less) should be usedfor patients on dipyridamole (Persantine ) as this drugpotentiates Adenosine.the effects of Adenosine are prolonged in patients takingCarbamazepine (anti-convulsant) and in heart transplantrecipients (denervated hearts)crushing chest pain, flushing, SOB, N/V, lightheadedness,dizziness, syncope, etcexplain to the patient they will likely experience some of theabove symptomsp. 4
Dosage: 6 mg IV bolus (FAST!) -followed by an immediate 20-30 ccof NS or R/L flush - run ECG strip as drug is being given12 mg IV bolus (FAST!) -followed by an immediate 20-30 ccof NS or R/L flush - may be repeated in 1-2 minutes if thefirst dose is ineffective.Note: Adenosine must be given very quickly and in the IV siteclosest to the central circulation (e.g. antecubital, externaljugular, central line). It should always be immediatelyfollowed by a 20-30 cc flush of NS or R/L to make sure thatall of the drug is cleared from the IV tubing and delivered tothe intended sitePediatric 0.1 - 0.2 mg/kg rapid push (flush with 2-20 cc IV fluiddepending weight of child)SPECIAL NOTES: has a 90% successful conversion of PSVT rate when thefull dose is given (Crankin et al, 1989; Garrat et al, 1989;DiMarco et al, 1990)has an extremely short half life of 10 seconds or less –consequently, as many as 40% of patients may revert backinto PSVTOnce the drug is given, the patient may be experience aperiod of asystole of 3-15 seconds. A variety of otherrhythms may also appear on the ECG ( e.g. second or thirddegree heart block). Because of the drug's short half life,these effects are generally self-limitingSometimes rapid Atrial Fibrillation is difficult to distinguishfrom a regular SVT. If that occurs turn the volume up on thecardiac monitor. This will provide an auditory clue that therhythm is irregularly irregular. Map out the R-R interval to seeif the rhythm is regular (SVT) or irregular (A. Fib.). Use thepatient’s history and medications as a guide – i.e. the elderlypatient on digoxin and coumadin is more likely to be in anatrial fib. The younger patient is more likely to be in an SVT.Transport of the patient should not be delayed as othertreatments/drugs may be required in hospital shouldSVT/PSVT recur Drug Guide for Paramedicsp. 5
Amiodarone Classification:Pharmacodynamics: antiarrhythmicconsidered a class III antiarrhythmicalso possesses electrophysiologic characteristics of all 4Vaughan Williams classesLike Class I drugs, amiodarone blocks sodium channels atrapid pacing frequencieslike class II drugs, it exerts sympatholytic activity throughbeta-adrenoreceptor (weak) antagonismClass II type effects negative chronotropic effect in nodaltissuesclass III effect: lengthens the cardiac action potential –prolongs the QT intervalIn addition to blocking sodium channels, amiodarone blocksmyocardial potassium channels, which contributes to slowingof conduction and prolongation of refractorinessantisympathetic action and block of calcium and potassiumchannels are responsible for the negative dromotropic effectson the sinus node and for the slowing of conduction andprolongation of refractoriness in the atrioventricular ON ? minutes10-15 minutes?Indications: ventricular fibrillationventricular tachycardiaSVTatrial fibrillationContraindications: HypersensitivityCardiogenic shockMarked sinus bradycardia2nd or 3rd degree AV blockPrecautions: Poor liver functionWarning Hypotension of the most common side effect during IVinfusion ( 39% of patients in one trial) Slow the infusion.Thyroid dysfunction – may cause hypo or hyperthyroidism(negligible for IV administration) Drug Guide for Paramedicsp. 6
Drug to druginteractions Pulmonary interstitial abnormalities (1/1 000 patients treatedwith amiodarone i.v. in clinical studies developed pulmonaryfibrosis)May cause prolongation of the QT interval ( 500ms may leadto Torsade de Pointes)Amiodarone interacts with numerous other drugs, howeverthese effects may be more relevant to oral administration insome casesrisk of life-threatening cardiac arrhythmias, includingtorsades de pointes, may be increased in a patient takingVardenafilAmiodarone may increase serum concentrations ofdisopyramide, flecainide, procainamide, quinidineMay potentiate the effects of warfarin, Dabigatran, betablockers, calcium channel blockers (eg, diltiazem,verapamil), Digoxin, Clozapine, Cyclosporine,Dextromethorphan, Fentanyl, Fingolimod, loratadine,trazodoneMay cause QTc prolongation with or without torsades depointes when combined with Azole antifungals (eg,itraconazole), fluoroquinolones (eg, moxifloxacin), macrolideantibiotics (eg, azithromycin, telithromycin),Quinupristin/DalfopristinCimetidine and protease inhibitors (e.g. ritonavir) mayincrease the plasma concentrations of AmiodaroneMay diminish the effects of ClopidogrelEffects of amiodarone may be reduced by the concomitantuse of CholestyramineDosage: 150-300mg loading dosePediatric 5mg/kg in cardiac arrestSpecial Notes: if the patient becomes hypotensive or bradycardic during theinfusion of amiodarone, slow down the infusion ordiscontinueDrug Guide for Paramedicsp. 7
Aspirin (ASA)Classification: antiplateletantithromboticaspirin also falls under many other functional classificationsPharmacodynamics: inhibits the formation of thromboxane A2 which is a potentplatelet aggregate and vasoconstrictorONSETPEAKHALF-LIFEDURATION 15-30 minutes1-2 hours2-3 hours (low dose)4-6 hoursIndications: chest pain or atypical symptoms consistent with cardiacischemia/AMIContraindications: allergy to aspirin or other non-steroidal anti-inflammatory(NSAIDS) agents. This includes many non-aspirin/nonTylenol pain relievers such as Advilasthmarecent head injury, stroke or acute bleeding (significant) ofany kindPharmacokinetics: Precautions: recent internal bleeding (within last 3 months)known bleeding diseasespatients currently taking anticoagulant agent(s)recent surgerypossibility of pregnancyDosage: 160 - 325 mgHave the patient chew ASA before swallowingPediatric noneSpecial Notes: As an antithrombotic, ASA helps to limit the size of theinfarction. It does not reduce the size of the infarction asthrombolytics do.higher doses of aspirin ( 325 mg) may suppress theproduction of prostacyclin which is a prostaglandin withantiplatelet and vasodilatory properties. Therefore, higherdoses of aspirin counteract the beneficial affect of the lowerdoses. Drug Guide for Paramedicsp. 8
Drug Guide for Paramedicsp. 9
AtropineClassification: anticholinergicantimuscurinicPharmacodynamics: parasympatholytic (inhibits stimulation from theparasympathetic nervous system)vagolytic (inhibits stimulation from the vagus nerve)inhibits vagal stimulation - allowing the sympathetic nervoussystem to dominateby allowing the sympathetic nervous system to dominate,impulse generation at the SA node and conduction throughthe AV node should increased Pharmacokinetics:ONSETPEAKHALF-LIFEDURATION 2-4 minutes2-4 minutes13-40 hours4-6 hoursIndications: restoration of cardiac rate in the presence ofbradydysrhythmiassinus bradycardia, less than 50 bpm - accompanied byhemodynamic compromisesinus arrestacceptable in the setting of bradydysrhythmias secondary toAV blockstreatment of organophosphate exposure/ingestion (highdose)antidote for poisoning by certain species of mushrooms (e.g.Amanita muscaria) Contraindications: hypersensitivity to anticholinergicstachycardiaPrecautions: hepatic or renal insufficiencyCOPD - dries secretions/mucous pluggingDrug to Drug Antimuscurinic effects will be in patients takingDysopyramideDosage: 0.5 mg IV push - initial doseRepeated q 3-5 min. To a max. of 3mgPediatric 0.02 mg/kg (give no less than 0.1 mg)Drug Guide for Paramedicsp. 10
Special Notes: Drug Guide for ParamedicsAtropine is no longer recommended for routine use inasystole or bradycardic PEAmust be given in the correct dose and quickly - given in toolow of a dose or too slowly may paradoxically slow the heartrateconsidered controversial in the setting of 2nd degree type IIAV block. It may paradoxically slow the heart rate if the blockis infranodal.not likely to be effective in ventricular escape rhythms asthere is minimal parasympathetic innervation in theventricles, however someatropine is unlikely to be effective in patients who have hadcardiac transplantation as transplanted hearts lack vagalinnervationAtropine also causes pupil dilation, therefore, assessment ofpupils in the setting of asystole or PEA after Atropine hasbeen administered may be unreliablep. 11
D50W (Dextrose 50% in water)Classification: carbohydrate substratePharmacodynamics: immediate source of glucose and H2O for nutrient deprivedcellstransient osmotic diureticONSETPEAKHALF-LIFEDURATION immediateimmediateunknownunknownIndications: suspected or known hypoglycemiaaltered level of responsiveness NYDcoma or seizure NYDContraindications: nonePrecautions: extravasation causes tissue necrosisuse with caution for alcoholics – consider pre-medicating withthiaminconsider consultation with BHP before administration ifcerebral bleed is suspectedPharmacokinetics: Dosage: 25 g (50 ml of 50% sol.) prnPediatric 0.2 g/kg of a 10% sol. for neonates (2 ml/kg)0.5 g/kg of a 25% sol. for 1 y/o or less (2 ml/kg)0.5 g/kg of a 50% sol. for 2 y/o (1 ml/kg)Provincial medical directives may differSpecial Notes: D50W may precipitate Wernicke’s encephalopathy in thiamindeficient patients (e.g. alcoholics)pediatric: Dextrose is diluted in infants and neonatesbecause the osmolarity of more concentrated solutions cancause intraventricular (cerebral) hemorrhage Drug Guide for Paramedicsp. 12
Drug Guide for Paramedicsp. 13
Diazepam (Valium)Classification: anticonvulsantsedative, anxiolytic, amnesicPharmacodynamics: binds to benzodiazepine receptor sites on CNS cells. Thispromotes the interaction between gamma-aminobutyric acid(GABA) and it’s receptor on neurons. When GABA interactswith it’s receptor site, the neuron becomes permeable toChloride which is a negatively charged ion. An influx ofchloride occurs making the inside of the cell more negative(hyperpolarized) and thus the cell takes longer to reachthreshold and depolarize – suppresses the spread of seizureactivity by raising the seizure thresholdskeletal muscle relaxation (for muscle spasm) Pharmacokinetics:ONSETPEAKHALF-LIFEDURATION 1-5 minutes 15 minutes 20-50 hours 15-60 minutesNote: All benzodiazepines are metabolized by the liver.Diazepam is converted by the cytochrome P450 enzymes in theliver to desmethyldiazepam (major) and oxazepam (minor). Thefact that it has active metabolites makes it a longer lastingsedative than Midazolam.Indications: Contraindications: Precautions: Drug Guide for Paramedicstreatment of prolonged seizures (greater than three-fiveminutes) or recurrent seizuressedation prior to electrical therapies (e.g. synchronizedcardioversion, external cardiac pacing – use with caution inpatients who are borderline unstable)allergy or known hypersensitivity to benzodiazepinesacute narrow-angle glaucoma (due to an anticholinergiceffect)myasthenia Gravishypoglycemic seizures - be sure to check BGL in the seizingpatientmay cause hypotension (Valium is mixed in propylene glycol,which is a vasodilator). Benzodiazepines also inhibit theneuronal re-uptake of Adenosine. The in circulatingAdenosine outside the CNS might also explain whyDiazepam has peripheral vasodilatory effects.may depress respirations (particularly in high dose: e.g. 10mg in adults) -be prepared to assist ventilationsp. 14
impaired liver or kidney functionpatient who has ingested alcoholdrug to drug increased risk of toxicity in patients taking cimetidine,disulfiram, oral contraceptives. Decreased effects ofdiazepam when given to patients taking theophyllines,ranitidineDosage:Status seizures 5 mg over 1 minute - repeat x 1 prn for status seizures secure airway prSedation 2-5 mg aliquots, given slow (over 1-2 minutes) for sedation max. 30 mgPediatric 0.2 mg/kg IV, PR or IO (max. 20 mg) is the standard dosagefor pediatric patientsSpecial Notes: also a common prescription drugOD on valium is unlikely to cause respiratory/cardiac arrestunless combined with alcohol or other drugsmay precipitate when diluted with other solutions - DO NOTdilute/mix with any other solution Drug Guide for Paramedicsp. 15
Dimenhydrinate (Gravol)Classification: antiemetic, antivertigo, anti-motion sickness agentantihistamine, anticholinergicPharmacodynamics: H1 receptor antagonistdepresses hyperstimulated layrinthine functionmay block synapses in the vomiting FEDURATION Immediate1-2 hoursUnknown3-6 hoursIndications: prevention and treatment of motion sickness, nausea andvomiting, vertigoN/V associated with AMIContraindications: hypersensitivity or allergy to dimenhydrinateneonatesCautions: lung disease, including asthmaglaucoma, acute angle closurehead injuryprostatic hypertrophy (enlarged prostate)cardiac arrhythmiaspregnancystenosing peptic ulcer, pyloroduodenal obstructionelderly, childrenhypotensionAdverse Effects: drowsiness, confusion, headache, dizziness, insomnia,hallucinations, blurred vision, diploplia, photosensitivity,urticariaexcitement and convulsions in childrenepigastric distress, nausea, vomiting, diarrhea, constipationdry mouth and noselassitudehypotension, palpitations, tachycardia, thickening ofbronchial secretions Drug to drug: Drug Guide for ParamedicsIncreased CNS depression when given with other CNSdepressants (e.g. morphine, diazepam)increases anticholinergic effects of atropine,antidepressants, antihistamines, MAO Inhibitors andp. 16
phenothiazines, disopyramide. Increased CNS depressionwhen administered to patients receiving analgesics (eg.Morphine) and/or sedative/hypnotics (eg. Diazepam,Midazolam) and/or alcoholDosage: 50 mg IM or IV50 mg in 10-50 ml IV over 2-10 minutes (or very slowly)Pediatric generally not recommendedSpecial Notes: should be administered slowly – i.e. it causes intense burningsensation at the IV site if administered too quickly. If it’sbeing administered in a syringe (as opposed to an infusion),you can either administer it over 2 or more minutes in onebolus, or you can administer 1-2 cc increments followed by a20-30 cc boluses until the full amount has been given.It’s recommended that it be diluted to 10-100 cc (never diluteless than 10cc) Drug Guide for Paramedicsp. 17
Diphenhydramine (Benadryl) Classification:Pharmacodynamics: antihistamineantihistamine with anticholinergic (drying) and sedative sideeffects. Antihistamines appear to compete with histamine forcell receptor sites on effector IFEDURATION rapid onsetunknown1-4 hours4-6 hoursIndications: antihistaminic: adjunct treatment of allergic reactions / earlyanaphylaxis or as an adjunct to epinephrine in anaphylaxis.motion sicknessantiparkinsonismContraindications: hypersensitivity to antihistaminesneonatespremature infantsPrecautions:has an atropine-like action and therefore, should be used withcaution in patients with: a history of bronchial asthma increased intraocular pressure hyperthyroidism cardiovascular disease hypertension lower respiratory diseaseAdverse Effects: Drug Guide for ParamedicsUrticaria, drug rash, anaphylactic shock, photosensitivity,excessive perspiration, chills, dryness of mouth, nose, andthroatHypotension, headache, palpitations, tachycardia,extrasystolesHemolytic anemia, thrombocytopenia, agranulocytosisSedation, sleepiness, dizziness, disturbed coordination,fatigue, confusion, restlessness, excitation, nervousness,tremor, irritability, insomnia, euphoria, paresthesia, blurredvision, diplopia, vertigo, tinnitus, acute labyrinthitis, neuritis,convulsionsEpigastric distress, anorexia, nausea, vomiting, diarrhea,constipationp. 18
Urinary frequency, difficult urination, urinary retention, earlymensesThickening of bronchial secretions, tightness of chest orthroat and wheezing, nasal stuffiness Drug to drug: Warningsadditive effects with alcohol and other CNS depressants(hypnotics, sedatives, tranquilizers, etc).MAO inhibitors prolong and intensify the anticholinergic(drying) effects of antihistaminesDosage:Use with caution in patients with: narrow-angle glaucoma stenosing peptic ulcer pyloroduodenal obstruction symptomatic prostatic hypertrophy bladder-neck obstruction 25-50mg IV/IM for moderate to severe anaphylaxisPediatric N/ASpecial Notes: Diphenhydramine is an adjunct therapy for anaphylaxis andis generally given after the administration of epinephrine. Ifgiven first it may mask the signs of anaphylaxisDrug Guide for Paramedicsp. 19
DopamineClassification: sympathomimetic (dopaminergic agonist, beta agonist, alphaagonist)Pharmacodynamics: dose dependantlow dose - dopaminergic effect: renal, mesenteric andcerebral vasodilation - improves urine output (very unlikely tobe ordered in this dose for prehospital care)medium dose - (beta) effect: H.R., force of cardiaccontraction - i.e. ve chronotropic and ve inotropic effectshigh dose - (alpha) effect: vasoconstrictionONSETPEAKHALF-LIFEDURATION 2-5 minutesunknown2 minutesless than 10 minutesIndications: symptomatic hypotension in the absence of hypovolemia e.g.cardiogenic shock, bradyarrhythmia, septic shock, renalfailure, etcpost-arrest hypotension Pharmacokinetics: Contraindications: Precautions: drug to drug Dosage:Drug Guide for Paramedics pheochromocytoma (rare tumor involving the adrenal gland,characterized by high levels of circulating catecholamines)tachyarrhythmiasextreme caution must be used if patient on MAO inhibitormay increase heart rate and induce supraventricular orventricular tachycardiamay compromise cardiac outputextravasation will result in tissue necrosis (ensure IV ispatent)increased sympathomimetic effects seen in patients on MAOinhibitors may lead to hypertensive crisis, coma or seizures consult with BHP. Dopamine may have to be started at alower dose for patients on MAOIsThe starting dosage of dopamine may need to be decreasedby 10% or more for patients on MAOIs2 µg-5 µg/kg/min dopaminergic effect5 µg-10 µg/kg/min effect10 µg - 20 µg/kg/min effectfor the treatment of the hemodynamically unstablepatient, the dose range is 5-20 g/kg/minp. 20
Dopamine is generally titrated (adjusted) in increments of2-5 g/kg/min q 2-5 min to effectPediatric same as adultSpecial Notes: When administering a dopamine infusion, an infusion pumpshould be used (ideal), or an in-line Buretrol (2nd best), or aminidrip (last choice). Fill Buretrol with 50 ml of the dopaminesolution from the pre-mixed bag. Then close the Buretrol lineoff to the bag. The appropriate drip rate should then becontrolled via the IV tubing200 mg in a 250 cc bag will yield a concentration of 800µg/ml(single strength)400 mg in a 250 cc bag will yield a concentration of 1600µg/ml (double strength)Dopamine is most often used in the prehospital setting forpost-arrest hypotension. Drug Guide for Paramedicsp. 21
EpinephrineClassification: sympathomimeticPharmacodynamics: 1 effects: vasoconstriction 1effects: H.R., force of cardiac contraction 2 effects (moderate): bronchodilationinhibits histamine release ve chronotropic, ve dromotropic and ve inotropic IFEDURATION ONSETPEAKHALF-LIFEDURATIONSubcutaneous/ Intramuscular 5-15 minutes (variable onset with IM) unknown unknown 1-4 hoursimmediate if given nhalation 1-5 minutes (has a mostly local effect) unknown unknown 1-3 hoursIndications: IV dose - cardiac arrest: ventricular fibrillation, pulselessventricular tachycardia, asystole, pulseless electrical activitySC or IM dose: anaphylaxisSC or IM dose: severe cases of bronchospasmNebulized for severe CroupContraindications: significant tachyarrhythmiassee ACLS guidelines re: drug therapy in the setting ofhypothermia ( 30 degrees C)Precautions: may cause dysrhythmias in patients 35 y/o and/orcardiovascular diseasereduced dosage may be required for patient on MAO inhibitoras there is an increased sympathomimetic response tachycardia, palpitations, angina, PVCshypertensionAdverse affects:Drug Guide for Paramedicsp. 22
Dosage: Special Notes: Drug Guide for Paramedics1 mg IV (or 2 mg ETT) for cardiac arrest. Repeat q 3-5minutes2-10 µg/min infusion - generally reserved for patients whoare profoundly bradycardic and hemodynamically unstable0.01 mg/kg to max of 0.5 mg SC - repeat x1 in 5 - 10 min.prn for anaphylaxisDO NOT give an IV bolus of epinephrine to an adult witha pulse - it may be LETHALepinephrine may be ordered as a slow bolus in a pediatricpatient with a bradycardia resistant to airway managementand assisted ventilationsepinephrine is neutralized by, and may precipitate withNaHCO3. Therefore, DO NOT administer in the same IV linewith Bicarb unless the line has been flushedin cardiac arrest, the most beneficial effect of epinephrine isthat it increases systemic vascular resistance thus improvingblood flow to vital organs with chest compressions.p. 23
Fentanyl (Sublimaze)Classification: synthetic opioid analgesicsynthetic narcoticPharmacodynamics: inhibits ascending pain pathways in CNSalters pain perception by binding to opiate receptors causinganalgesia and euphoria – high doses may cause respiratoryand physical F-LIFEDURATION immediate - 2 minutes3-5 minutes3.6 hours30-60 minutesIndications: relief of moderate to severe paineffective in trauma patients – does not have the venodilatoryeffects of morphine and therefore is less likely to cause orexacerbate hypotensionmay be used in conjunction with a sedative to facilitateawake intubationadjunct in rapid sequence induction (RSI)Contraindications: hypersensitivity/allergy to opiates (including morphine)myasthenia gravisrespiratory depressionacute asthma attackupper airway obstructionpatient on MAO InhibitorsPrecautions: be prepared to assist ventilations and to administer thenarcotic antagonist naloxone (Narcan). This does not meanthat you have to draw up Narcan or even have it pulled fromthe drug kit.may alter mental status making it difficult to assess headinjury Adverse Effects: Drug Guide for Paramedicslightheadedness, dizziness, sedation, agitation, fear,delirium, drowsiness, disorientation.N/Vrespiratory depression/apnealaryngospasmchest wall rigid
and morphine, naloxone and midazolam ) – always check the drug when you pull it out of the kit for the name, dose, concentration and for fluid clarity and expiry date. Check the drug again before administering it. syringes with left over medication must be labelled with
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member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
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If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For
(drug-drug interaction), food, beverages, dietary supplements the person is consuming (drug-nutrient/food interaction) or another disease the person has (drug-disease interaction). A drug interaction is a situation in which a substance affects the activity of a drug, i.e.
the construction of drugs, drug users, drug producers and drug traffickers as ‘the antagonistic drug Other’ (Herschinger, 2011) or existential threat. Initially the ‘Other’ was seen to be drug users, however gradually drug trafficking organisations (DTOs) and then ‘narco-terrorists’ became seen as the most dangerous drug ‘Other .
Free drug (a) Tumor Drug-loaded NPs (b) F : Schematic contrast of drug biodistribution a er injection of free drug (a) and drug-loaded NPs (b). self-assembly), targeted drug delivery processes, and the current state of NP computational modeling. Directions for future research are also discussed. 2. Self-Assembled Nanoparticles as Delivery Vehicles
Drug- Drug Interactions Need to understand: The disposition or handling of each drug The therapeutic window of each drug . ARV Co-Med TOXICITY . TFV HIV FDA Center for Drug Evaluation and Research. Clinical Pharmacology & Biopharm Rev 2014 Gupta SK, et al. IAS 2015. Vancouver, CA; #TUAB0103.
