Ch. 13 Medications

Activated Charcoal Actidose

Class: Absorbent Description: Finely powdered charcoal activated with O2, commonly diluted in water for oral administration MOA: Binds with ingested toxins in GI tract to prevent absorption. Indications: Oral ingestion of toxins Contraindications: Decreased Level of Responsiveness or increased risk of aspiration or ingestion of corrosives, caustics or petroleum distillates Precautions: Will inactivate other oral meds Side effects: Black, tarry stool and constipation Interactions: None Dosage: 1g/kg oral (adults and pedi patients) Route: Oral How supplied: Premixed slurry 50g/250mL

Nitrous Oxide Nitronox

Class: Analgesic and anesthetic Description: 50/50 mix of O2 and Nitrous Oxide delivered to a modified demand-valve and mask that the patient self administers by holding mask and inhaling. MOA: CNS depressant Indications: Severe musculoskeletal pain, and chest pain associated with ACS and not relieved by NTG. Contraindications: Decreased LOC, inability to follow instructions, traumatic brain injury, COPD, suspected pneumothorax, abdominal pain and suspected bowel obstruction. Precautions: Only use in well-ventilated areas to prevent sedation of EMS crew. Teratogenic, Do not use around pregnant women. Side effects: dizziness, decreased mental status, hallucinations, N/V Interactions: Do not use with sedative-hypnotic medications, narcotics or alcohol Dosage: Self-administered mixture of 50/50 nitrous oxide and oxygen Route: Inhalation How supplied: Modified demand valve with mixer to combine 50% of each gas for inhalation

Acetaminophen Tylenol

Class: Analgesic, antipyretic Description: nonprescription med used for relief of mild to moderate pain and as fever reducer MOA: Not completely understood, however Acetaminophen increases pain threshold by blocking prostaglandin synthesis and inhibits the effect of pyrogens in the CNS Indications: Mild to moderate pain and fever Contraindications: Hypersensitivity Precautions: is hepatotoxic in high doses, should be used with caution in patients with liver disease Side effects: Can be hepatotoxic if taken in large doses Interactions: Alcohol increases liver toxicity Dosage: Adults 650-1,000mg every 4 to 6hrs with a 4gram max per 24 hours. Pedi 10-15mg/kg every 4 to 6 hours with a 40mg/kg max in 24hour period Route: Oral How supplied: Capsules, tablets, chewable tablets, suspension, elixir, and suppository

Albuterol Sulfate Proventil, Ventalin

Class: Beta2 selective sympathomimetic; bronchodilator Description: a sympathetic Beta2 agonist used to reverse bronchiolar smooth muscle constriction in patients with asthma and COPD. Mechanism of Action: Increases glucose concentration in the blood for the reversal of acute hypoglycemia. Indications: Wheezing caused by asthma and COPD and some other conditions. Contraindications: Hypersensitivity and symptomatic tachycardia. Precautions: Albuterol has a minimum Beta1 adrenergic effect but may increase heart rate and myocardial oxygen demand. Use with caution in patients with heart disease. Side Effects: Anxiety, Palpitations, Chest Discomfort, Headaches and Perspiration Interactions: Other Beta agonists should not be administered concurrently with albuterol. Dosage: Metered-dose inhaler: one or two 90mcg sprays. The use of a spacer device is preferred when administering albuterol by metered-dose inhaler, especially in Pediatric patients. Small-volume nebulizer: 2.5mg diluted in 2.5mL over 5-15 minutes; Pediatric dose 0.15mg/kg diluted in 2.5mL NS. Route: Inhalation How supplied: Metered dose inhaler or 2.5mg/0.5mL nebule.

50 Percent Dextrose

Class: Carbohydrate Description: High concentration (50g/100mL) of dextrose in sterile water for IV administration. Mechanism of Action: Increases glucose concentration in the blood for the reversal of acute hypoglycemia. Indications: Hypoglycemia in adult patients. Contraindications: intercranial hemorrhage, (traumatic brain injury, stroke), hyperglycemia Precautions: check CBG prior to administration. A solution of 50% dextrose is hypertonic and will cause severe tissue necrosis if infiltration occurs. Side effects: Localized irritation of the vein. Interactions: There are no significant interactions in emergency situations. Dosage: 25g slow IV push. May be repeated in 10-15 minutes if CBG remains below 70mg/dL. Pedi dosage- 0.5g/kg (5mg kg) of a 25% solution (25g/100mL) of dextrose 10% (10g/100mL) for neonates. Route: Slow IVP through at least 18 gauge IV catheter in a large vein. Monitor the IV site for infiltration during administration. How supplied: Prefilled syringe containing 25g dextrose in 50mL.

Glucose

Class: Carbohydrate Description: a simple carbohydrate that may be absorbed across buccal mucosa or through GI tract. MOA: Increases blood glucose levels. Indications: Acute hypoglycemia in a patient who is awake and can protect own airway. Contraindications: Inability to maintain patent airway Side effects: nausea and vomiting Interactions: None Dosage: 15g PO or applied to buccal mucosa Route: Oral or buccal How supplied: Single dose 1.3oz sealed tube containing 15g d-glucose (40% glucose) tube with twist off top

Oxygen

Class: Gas Description: colorless, odorless, tasteless gas MOA: When inhaled, oxygen molecules cross the respiratory membrane to attach to hemoglobin in red blood cells for transport to tissues. Indications: Dyspnea, hypoxia, SpO2 less than 95% Contraindications: No absolute contraindications, however, complications may arise associated with hyperoxemia, particularly in neonates and patients resuscitated from cardiac arrest Precautions: Cylinder may become projectile hazard. COPD patients should not be administered high concentration for prolonged period of time. O2 is not recommended for routine use in uncomplicated acute ACS. Side effects: few side effects, however if used for prolonged period of time without humidification the mucous membranes become dry. Nose bleeds can occur. Interactions: None Dosage: titrated to maintain 95% SpO2 Route: Inhalation via NC, face mask, nonrebreather or BVM How supplied: compressed gas in high-pressure cylinder

Glucagon

Class: Hormone with antihypoglycemic action Description: A pancreatic hormone that affects blood glucose level by promoting glycogenolysis and gluconeogenesis and inhibiting glycogenesis. MOA: If patient has adequate stores of glycogen, glucagon will cause release of stored glycogen and its conversion to glucose to raise blood glucose level. Indications: Inability to establish IV access in patients with significant hypoglycemia. Contraindications: Hypersensitivity Precautions: Glucagon will not be effective if patient does not have adequate glycogen stores. Side effects: are rare, however headache, dizziness, hypotension, nausea and vomiting may occur. Interactions: Few interactions in emergency setting if given in therapeutic doses. Dosage: 1mg Route: IM How supplied: a kit containing powdered medication and solvent that must be combined before administration

5 Percent Dextrose in Water for Intravenous Infusion D5W

Class: Hypotonic carbohydrate-containing solution Description: Sterile water containing 5 percent dextrose (5g/100mL) Mechanism of Action: D5W combines dextrose and water in a hypotonic concentration that will not remain in the vascular space, reducing the danger of fluid overload. Indications: D5W is used for prophylactic IV access or to dilute concentrated drugs for IV infusion. Contraindications: D5W should not be used for patients who require IV fluid replacement or in patients who are hyperglycemic. Do not use in patients with traumatic brain injury or stroke. Precautions: D5W may be more irritating to the tissues than normal saline so the IV site should be closely monitored for swelling, irritation, or redness. Side Effects: Rare when given in therapeutic doses. Interactions D5W should not be used for blood product infusions. Dosage: Usually administered at a keep open (KVO) rate. (30mL/hour) Route: IV infusion How supplied: D5W is most commonly supplied in 250mL or 500mL bags.

Normal Saline (0.9 Percent Sodium Chloride Solution) for Intravenous Infusion

Class: Isotonic crystalloid Description: Clear liquid containing water, 154 mEq per liter sodium, and approximately 154 mEq per liter of chloride to match the concentration found in the human body. Mechanism of Action: Used to temporarily expand the vascular volume by replacing water and electrolytes Indications: Hypovolemia, heat exhaustion, heat stroke, diabetic ketoacidosis Contraindications: Should not be given to patients with heart failure, because fluid overload may occur Precautions: Patients receiving large volumes of normal saline should be carefully monitored for fluid overload. In patients who have lost significant amounts of electrolytes, it may be more appropriate to use lactated Ringer's solution or an alternative IV fluid containing electrolyte replacement. Side Effects: Administration of large amounts of normal saline may result in hemodilution and electrolyte imbalance. Dosage: Depends on the condition for which normal saline is being administered. Follow your protocols. A keep-open rate is 30mL/hr. Route: Intravenous Infusion How supplied: Normal saline is commonly supplied in 250mL 500mL and 1000mL bags designed to be used with an IV drip set. To avoid inadvertent fluid overload, select a container volume appropriate to the patient's condition.

Lactated Ringer's Solution

Class: Isotonic crystalloid solution Description: Sterile water containing the following electrolytes: Sodium (Na) 130 mEq/L, Potassium (K) 4 mEq/L, Calcium (Ca) 30 mEq/L, Chloride (Cl) 109 mEq/L, Lactate 28 mEq/L Mechanism of Action: Lactated Ringer's solution is used to replace fluid and electrolytes. Indications: Significant burns or hypovolemia Contraindications: Do not use in patients with heart failure, renal failure or suspected hyperkalemia. Precautions: Monitor closely for signs of circulatory overload. Side Effects: Rare in therapeutic doses. Interactions: Do not use with blood product infusion. Dosage: Depends on the condition for which lactated ringers is being administered. Follow protocol. KVO rate is 30mL/hr. Route: IV infusion How supplied: commonly supplied in 1,000mL bags.

Ibuprofen Motrin

Class: NSAID Description: nonprescription med used for relief of mild to moderate pain and as fever reducer MOA: Inhibits inflammatory response by blocking formulation of COX-2 Indications: Mild to moderate pain and fever Contraindications: Known allergy to ibuprofen or other NSAIDs Precautions: High doses are known to cause GI irritation and increases risk of GI bleeding. Side effects: gastric irritation Interactions: do not use with other NSAIDs Dosage: 200-400mg every 6 to 8 hours Pedi 5-10mg/kg every 6 to 8 hours Route: Oral How supplied: coated tablets, chewable tablets, capsules, suspension, elixir

Naloxone Narcan

Class: Narcotic antagonist Description: Used to reverse respiratory depression associated with narcotic overdose MOA: displaces narcotics at receptor site due to higher affinity for narcotic receptor sites. Indications: Used to reverse respiratory depression associated with narcotic overdose Contraindications: Known hypersensitivity Precautions: May cause withdrawal in narcotic addicted patients if administered rapidly or in large doses. Side effects: are rare, however hypotension, N/V and cardiac arrhythmias may occur. Interactions: May cause withdrawal symptoms in narcotic addicted patients Dosage: 1-2mg slow IVP titrated to restore respiratory effort. May be repeated at 5-min intervals as needed. Intranasal formulation also available. Route: Slow IVP How supplied: Prefilled syringe, vial or ampule

Nitroglycerin-Sublingual Tablets and Spray

Class: Nitrate; vasodilator Description: Supplied as tablets or metered-dose spray for sublingual administration in treatment of ACS. MOA: Nitrates are potent vasodilators that increase blood flow to coronary arteries and decrease cardiac workload by dilating peripheral vasculature and reducing preload Indications: Chest pain associated with ACS. Contraindications: Hypotension, increased ICP and use of ED meds within 24-36hrs. Precautions: Monitor blood pressure. If systolic drops below 90 discontinue administration. Exposure to light or air causes deterioration of NTG. Side effects: immediate headache, dizziness, weakness, tachycardia, hypotension, dry mouth, N/V, may cause burning sensation on administration. Interactions: Effects may be accentuated by alcohol use, ED meds and beta blockers Dosage: 0.4mg sublingual. Total of 3 doses repeated at 5min intervals if symptoms persist and SBP remains at least 90. Route: Sublingual How supplied: Calibrated spray 0.4mg/spray or small tablet 0.4mg/tablet

Aspirin acetylsalicylic acid

Class: Platelet aggregation inhibitor, nonsteroidal anti-inflammatory, analgesic Description: Aspirin is a salicylate that reduces platelet aggregation by inhibiting the release of a prostaglandin called thromboxane A2. Mechanism of Action: Aspirin blocks part of the chemical reaction responsible for activating platelets. Indications: In pre-hospital setting, coronary syndrome and stroke. Precautions: Administer with caution in patients with asthma or seasonal allergies, stomach ulcers, liver disease, alcohol abuse, kidney disease or coagulopathies. Side Effects: GI upset, bleeding, nausea, vomiting, wheezing Interactions: few interactions for a single dose in the pre-hospital setting. Dosage: The AHA currently recommends 160-325mg chewable aspirin. Children's Aspirin is preferred because it is chewable which increases the rate of absorption and does not require water to assist swallowing. Route: Oral How supplied: Chewable tablets containing 81mg tablets.

Epinephrine 1:1,000

Class: Sympathomimetic Description: Epi is a naturally occurring hormone (adrenaline) secreted by adrenal glands in response to SNS stimulation. Epi binds to alpha 1, beta1 and beta2 adrenergic receptor sites causing vasoconstriction, increased heart rate and force of contraction and bronchiolar smooth muscle relaxation. Mechanism of Action: Epi 1:1,000 is administered in anaphylaxis to cause vasoconstriction and relax bronchiolar smooth muscle. Indications: Acute anaphylaxis Contraindications: Use with caution in patients with significant cardiovascular disease or hypertension. Precautions: Epi is inactivated by exposure to sunlight or when given with an alkaline solution. Because Epi causes a strong sympathetic stimulus patients may experience chest pain, palpitations, anxiety, nausea and headache. Monitor heart rate and blood pressure. Side effects: Palpitations, tachycardia, anxiety, headache, dizziness, nausea and vomiting are common side effects. Patients with underlying cardiac disease may also experience chest pain and acute MI. Interactions: The effects of Epi can be intensified in patients taking some anti-depressants. Dosage: 0.3-0.5mg Sub-Q or IM every 15 minutes as needed. Pedi dose- 0.0mg/kg Route: Sub-Q or IM injection How supplied: 1mg/1mL in vials, ampules or pre-filled auto-inject devices.