Advanced EMT medications

Acetaminophen (Tylenol)

Acetaminophren is a nonprescription analgesic and antipyretic that, while not carried by most EMS systems, may be administered by the Advanced EMT in some situations. Class: Analgesic, antipyretic (fever reducer). Description: Nonprescription medication used for relief of mild to moderate pain and as a fever reducer. Mechanism of action: The mechanism of action is not completely understood, but acetaminophren increases the pain threshold by blocking prostaglandin synthesis and inhibits the effect of pyrogens in the central nervous system. Indications: Mild to moderate pain and fever. Contraindications: Hypersensitivity. Precautions: Acetaminophren is hepatotoxic in high doses and should be used with caution in patients with known liver disease. Side effects: Acetaminophren is generally well-tolerated and there are no significant side effects in therapeutic doses. In large doses, the medication can be hepototoxic. Interactions: Alcohol increases liver toxicity. Dosage: Adults 650 to 1,000 mg every 4 to 6 hours, to 15 mg/kg every 4 to 6 hours, 40 mg/kg maximum per 24 hours. Route: Oral How supplied: Capsules, tablets, chewable tablets, suspension, elixir, and suppositories (for rectal administration).

Aspirin

Aspirin (acetylsalicylic acid [ASA]) is one of the most important medications in the treatment of acute myocardial infarction. No other medication has been shown to be as effective for so little cost. Aspirin inhibits platelet aggregation to reduce additional blood clotting. Class: Platelet aggregation inhibitor; nonsteroidal anti-inflammatory; anagesic. Description: Aspirin is a salicylate that reduces plately 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 the prehospital setting, acute coronary syndrome Contraindications: Hypersensitivity; not given to children or adolescents with suspected viral illnesses because it is associated with an increased risk of Reye's syndrome. 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, and wheezing. Interactions: Few interactions for a single dose in the prehospital setting. Dosage: The American Heart Association currently recommends 160 to 325mg of 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 81 mg/tablet.

Oxygen

Class: Gas Description: Colorless, odorless, tasteless gas. Mechanism of action: Oxygen is necessary for cellular energy production. When inhaled, oxygen molecules cross the respiratory membrane to attach to hemoglobin in red blood cells for transport to the tissues. Indications: Dyspnea, hypoxia; SPO2 <95 percent Contraindications: There are no absolute contraindications to the use of oxygen, however, there are complications associated with hyperoxemia, particularly in neonates and patients resuscitated from cardiac arrest. Precautions: Patients with chronic obstructive pulmonary disease who depend on hypoxic drive for respiratory drive may experience respiration depression if high concentrations of oxygen are administered for prolonged period of time. Oxygen is a vasoactive drug that causes cerebral and coronary artery vasoconstriction. Oxygen is not recommended for routine use in uncomplicated acute coronary syndrome. Oxygen administration should be titrated to maintain an SpO2 of 95 percent or higher. Do not use near an open flame or sources of combustion. Compressed gas cylinders may become projectile hazards if knocked over and damaged. Always leave the bottle on its side ans use a protective guard over the flow meter to prevent damage. Side effects: There are few side effects associated with short-term administration of therapeutic amounts of oxygen. If used for prolonged periods of time without a humidifier, it may cause drying of the mucous membranes and nose bleeds. Interactions: None. Dosage: Oxygen administration should be titrated to maintain an SpO2 of 95 percent or higher. High oxygen concentrations for prolonged periods of time can cause oxygen toxicity. Therefore, ventilator patients are often kept below 50 percent oxygen when possible. Route: Inhalation via nasal cannula, face mask, nonrebreather mask, or bag-valve-mask device. How supplied: Oxygen is supplied as a compressed gas in a high-pressure cylinder.

Lactated Ringer's Solution

Class: Isotonic crystalloid solution Description: Sterile water containing the following electrolytes: Sodium, 130 mEq/L; Potassium, 4 mEq/L; Calcium, 30 mEq/L; Chloride, 109 mEq/L; Lactate, 28 mEq/L Mechanism of action: Lactated Ringer's solution is used to replace fluid and electrolytes. Indications: Significant burns and 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 dosages. Interactions: Do not use with blood product infusion. Dosage: Depends on the condition for which lactated Ringer's solution is being administered. Follow your protocols. A keep-open rate is 30mL/hour. Route: IV infusion. How supplied: Lactated Ringer's solution is commonly supplied in 1,000-mL bags.

Ibuprofen (Motrin)

Commonly known as Motrin, ibuprofen is a nonsteroidal anti-inflammatory or NSAID. While not commonly carried by EMS units, the Advanced EMT may administer ibuprofen in some situations. Class Nonsteroidal anti-inflammatory (NSAID) (analgestic and antipyretic). Description: Nonprescription medication used for the relief of mild to moderate pain and as a fever reducer. Mechanism of action: Inhibits inflammatory response by blocking formation of cyclo-oxygenase (COX-2), a chemical mediator of inflammatory chemicals such as prostaglandins. Indications: Mild to moderate pain and fever. Contraindications: Known allergy to ibuprofen or other NSAIDs. Precautions: High-dose ibuprofen is known to cause significant gastrointestinal irritation and increases the risk of gastrointestinal bleeding. Side effects: Gastric irritation Interactions: Do not give with aspirin or other NSAIDs. Dosage: 200 to 400 mg every 6 to 8 hous; pediatric dosage, 5 to 10 mg/kg every 6 to 8 hours. Route: Oral How supplied: Coated tablets, chewable tablets, capsules, suspension, and elixir.

D5W

D5W can be used for a keep-open IV because the danger of fluid overload is reduced. However, a saline lock is also useful for that purpose and does not require additional storage space for bags of IV fluid. Therefore, not all EMS services carry D5W. Class: Hypotonic carbohydrate-containing solution Description: Sterile water containing 5 precent 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 irritation, swelling, or redness. Side effects: Rare when given in therapeutic doses. Interactions: D5W should not be used for blood product infusion. Dosage: Usually administered at a keep-open rate (30mL/hour) Route: IV infusion. How supplied: D5W is most commonly supplied in 250-mL or 500-mL bags.

50 Percent Dextrose

Dextrose is used to supply sugar to patients with acute hypoglycemia who have a decreased level of responsiveness and cannot receive oral glucose. It is a concentrated solution that contains 500mg of dextrose per 1 mL. There are some risks to the administration of hypertonic dextrose solutions. They can cause local irritation of the vein and , if accidentally introduced into the tissues through an infiltrated IV line, it can cause tissue necrosis. Only administer 50 percent dextrose through a patent, free-flowing IV line. Push the medication slowly to avoid injuring the vein and causing infiltration of the tissues. 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: Hypoglycemica in adult patients. Contraindications: Intracranial hemorrhage (traumatic brain injury, stroke) and hyperglycemia. Precautions: Check the blood glucose level prior to administration. A solution of 50 percent 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: 25 g slow IV push; may be repeated in 10 to 15 minutes if blood glucose level remains below 70mL/dL. Pediatric dosage: 0.5g/kg (500mg kg) of a 25 percent solution (25g/100mL) of dextrose; 10 percent (10g/100 mL) for neonates. Route: Slow IV push through at least an 18 gauge IV catheter in a large vein. Monitor the IV site for infiltration during administration. How supplied: Prefilled syringe containing 25 grams of dextrose in 50 mL.

Epinephrine 1:1,000

Epinephrine is commonly available for injection in two concentrations, 1:10,000 (1g/10,000mL) and 1:1,000 (1g/1000mL). The 1:10,000 solution is administered by intravenous injection in cardiac arrest and severe, refractory anaphylaxis by paramedics and hospital personnel. Advanced EMTs can give 1:1,000 epinephrine to patients with anaphylaxis, either by assisting a patient with his epinephrine autoinjector (such as an EpiPen) or by drawing up the medication in a syringe and giving it by subcutaneous or intramuscular injection. Class: Sympathomimetic Description: Epinephrine is a naturally occurring hormone (adrenalin) secreted by the adrenal glands in response to sympathetic nervous system stimulation. Epinephrine binds to alpha 1 beta 1 and beta 2 adrenergic receptor sites, causing vasoconstriction, increased heart rate and force of contraction, and bronchiolar smooth muscle relaxation. Mechanism of action: Epinephrine 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: Epinephrine is inactivated by exposure to sunlight or when given with an alkaline solution. Because epinephrine causes a strong sympathetic stimulus, patients may experience chest pain, palpitations, anxiety, nausea, or headache. Monitor the patient's heart rate and blood pressure. Side effects: Palpitations, tachycardia, anxiety, headache, dizziness, nausea, and vomiting are common side effects. Patients with underlying cardiac disease also may experience chest pain and acute myocardial infarction. Interactions: The effects of epinephrine can be intensified in patients taking some antidepressants. Dosage: 0.3 to 0.5 mg subcutaneously or intramuscularly every 15 minutes as needed; pediatric dose, 0.01 mg/kg. Route: Subcutaneous or intramuscular injection How supplied: 1 mg/ 1 mL in vials, ampules, or prefilled autoinjector devices.

Glucagon

Glucagon is a naturally occurring hormone that promotes the breakdown of glycogen in the liver to glucose to increase blood glucose levels. Intramuscular glucagon is indicated for emergency treatment of severe hypoglycemia when it is not possible to establish an IV line to administer dextrose. Patients who have inadequate liver glycogen stores, such as those with severe liver disease or malnutrition, will not response to glucagon. Class: Hormone with antihypoglycemic action Description: Glucagon is a pancreatic hormone that affects the blood glucose level by promoting glycogenolysis and gluconeogensis and inhibiting glycongensis. Mechanism of action: Glucagon causes a release of stored glycogen and its conversion to glucose when released into the circulation. When administered, it causes an increase in blood glucose levels if the patient has adequate stores of glycogen for conversion to glucose. Indications: Inability to establish intravenous access in patients with significant hypoglycemia. Contraindications: Hypersensitivity Precautions: Glucagon will not be effective if the patient has already depleted glycogen stores. Side effects: Side effects are rare, but hypotension, dizziness, headache, nausea, and vomiting may occur. Interactions: Few interactions when given in an emergency situation in therapeutic doses. Dosage: 1 mg Route: Intramuscular injection How supplied: Glucagon is supplied as a kit containing the powdered medication and solvent that must be combined before administration.

Glucose

Glucose is administered orally or applied to the buccal mucosa in hypoglycemic patients who are awake and are not at risk of aspiration. Class: Carbohydrate Description: Glucose is a simple carbohydrate that can be absorbed across the buccal mucosa or through the gastrointestinal tract. Mechanism of action: Increases blood glucose levels Indications: Acute hypoglycemia in patient who is awake and can protect his own airway. Contraindications: Inability to maintain a patent airway Precautions: Carefully monitor the patient for potential of aspiration Side effects: Nausea and vomiting. Interactions: None. Dosage: 15 grams by mouth or applied to the buccal mucosa. Route: Oral or buccal. How supplied: Single-dose 1.3 oz (37.5 g) sealed tube containing 15 g d-glucose (40 percent glucose) tube with a twist-off cap.

Nerve Agent Antidote Kits

Many EMS agencies are now carrying nerve agent antidote kits as part of homeland security precautions. The kits consist of prefilled injections of atropine (3mg) and pralidoxime chloride (600mg). The medications are antidotes for organophosphate nerve agents, such as tabun, sarin, and VX. They reduce parasympathetic nervous system stimulation by blocking the production and uptake of acetylcholine. The kits are not intended for the public, but rather for the EMS crew on the ambulance if they are exposed to a suspected nerve agent. You can use the auto injectors to inject the medication subcutaneously in either the gluteus or the vastus lateralis muscles.

Naloxone (Narcan)

Naloxone (Narcan) is a narcotic antagonist used to reverse respiratory depression associated with narcotic overdose. Naloxone has a greater affinity for narcotic receptor sites than opiates, thereby displacing them from the receptor. Because it has a shorter duration of effects than most narcotics, the narcotic can reoccupy the receptor sites when naloxone's half-life is exceeded, necessitating further naloxone administration to maintain adequate respirations. Naloxone should not be used indiscriminately as a diagnostic tool to determine if narcotic overdose is the cause of respiratory depression. Many EMS systems recommend that administration be started at the low end of the dosage range and titrated to the minimum needed to maintain the patient's respiratory rate instead of improving level of responsiveness. Class: Narcotic antagonist Description: Medication used to reverse respiratory depression associated with narcotic overdose Mechanism of action: Naloxone has a higher affinity for narcotic receptor sites and when administered, displaces the narcotic, blocking its effects. Indications: Naloxone is indicated to reverse the respiratory depression associated with narcotic overdose. Contraindications: Known hypersensitivity. Precautions: Rapid administration and large doses may cause withdrawal in narcotic- addicted patients. Many EMS systems titrate the dosage to the minimum amount needed to ensure adequate breathing rather than complete reversal of the narcotic. Side effects: These are rare, but hypotension, hypertension, nausea, vomiting, and cardiac arrhythmias may occur. Interactions: May cause withdrawal symptoms in patients addicted to narcotics. Dosage: 1 to 2mg slow IV push titrated to restore respiratory rate. If no effect, may be repeated at 5- minute intervals. An intranasal formulation is also available. Route: Slow IV push. How supplied: Prefilled syringe, vial, or ampule.

Nitroglycerin - Sublingual Tablets and Spray

Nitroglycerin (NTG) is used in the treatment of patients with acute coronary syndrome (ACS). It causes vascular smooth muscle relaxation, resulting in dilation of the coronary arteries and systemic vasculature to increase myocardial perfusion and reduce the myocardial workload. Nitrates can cause a significant drop in blood pressure, even when used carefully. Nitroglycerin must not be administered to patients with a systolic blood pressure lower than 90mmHG. Class: Nitrate; vasodilator Description: Supplied as tablets or a metered-dose spray for sublingual administration in the treatemnt of acute coronary syndrome. Mechanism of action: Nitrates are potent vasodilators that increase blood flow to the coronary arteries and decrease cardiac workload by dilating the peripheral vasculature and reducing preload. Indications: Chest pain associated with acute coronary syndrome. Contraindications: Hypotension, increased intracranial pressure, and use of erectile dysfunction medications within 24 to 36 hours. Precautions: NTG deteriorates rapidly when exposed to light or air. Monitor blood pressure closely and discontinue administration if the systolic blood pressure falls below 90mmHG. Side effects: NTG is a potent vasodilator that commonly causes an immediate headache. May cause dizziness, weakness, tachycardia, hypotension, dry mouth, nausea, and vomiting. The spray or tablets may cause a burning sensation on administration. Interactions: Effects may be accentuated by alcohol use, erectile dysfunction medications, and beta blockers. Dosage: Administration 0.4 mg sublingually. If chest pain persists and the systolic blood pressure remains at least 90 mmHG, the dose may be repeated every 5 minutes to a total of three doses. Route: sublingual. How supplied: Calibrated spray delivering 0.4mg/ spray or as a small tablet containing 0.4 mg/tablet.

Nitrous Oxide (Nitronox)

Nitrous oxide is used as an inhaled anesthetic or analgesic in the presence of severe pain due to musculoskeletal injury or acute MI. Because it is inhaled, the onset is extremely rapid but the effects subside quickly when administration is discontinued. In the prehospital setting, the patient self-administers the drug by holding the mask to the face and breathing in the gas. If the patient administers too much, he will no longer be able to keep the mask against his face and will discontinue the drug. The system consists of two pressurized gas cylinders, one filled with oxygen and the other with nitrous oxide. Some systems (Entonox) use a single cylinder. Class: Analgesic and anesthetic. Descriptoin: A 50/50 mix of oxygen and nitrous oxide delivered to a modified-demand valve and mask that the patient self-administers by holding the mask and inhaling. Mechanism of action: CNS depressant. Indications: Severe musculoskeletal pain, and chest pain associated with acute coronary syndrome and not relieved by nitroglycerin. Contraindications: Decreased level of responsiveness, inability to follow instructions, traumatic brain injury, COPD, suspected pneumothorax, abdominal pain, and suspected bowel obstruction. Precautions: Only use in well-ventilated area to prevent sedation of the medical staff. Teratogenic; should not be used by or around pregnant patients or health care providers. Side effects: Dizziness, decreased mental status, hallucinations, nausea, and vomiting. Interactions: Do not use with sedative-hypnotic medications, narcotics, or alcohol. Dosage: Self-administered mixture of 50 percent nitrous oxide and 50 percent oxygen. Route: Inhalation How supplied: Modified-demand valve with mixer to combine 50 percent of each gas for inhalation.

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

Normal saline is the most commonly used IV solution in EMS care. It is routinely used safely and effectively to replace lost circulatory volume. 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, and diabetic ketoacidosis. Contraindications: Should not be given to patients with heart failure, because fluid overload may occur. Precautions: Patients recieving 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 LR 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/hour Route: Intravenous infusion How supplied: Normal saline is commonly supplied in 250-, 500-, 1000-mL 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.

Albuterol Sulfate

The advanced EMT Scope of Practice Model includes the administration of inhaled bronchodilators to patients with wheezing due to asthma and COPD, Albuterol is a prototypical bronchodilator drug used for that purpose. Class: Beta2-selective sympathomimetic; bronchodilator. Description: Albuterol sulfate (Proventil, ventrolin) is a sympathetic betas agonist used to reverse bronchiolar smooth muscle constriction in patients with asthma and chronic obstructive pulmonary disease. Mechanism of action: Acts on beta 2 sympathetic receptors of bronchiolar smooth muscle to cause bronchodilation. Indications: Wheezing caused by asthma, and COPD, and some other conditions. Contraindications: Hypersensitivity and symptomatic tachycardia. Precautions: Albuterol has minimal beta1-adrenergic effects, but may increase heart rate and myocardial oxygen demand. Use with caution in patients with heart disease. Side effects: Anxiety, palpitations, chest discomfort, headache, and perspiration. Interactions: Other beta agonist should not be administered concurrently with albuterol. Dosage: Metered -dose inhaler; one or two 90-mcg 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 to 15 minutes; pediatric dosage, 0.15mg/kg diluted into 2.5 mL normal saline. Route: Inhalation How supplied: Metered-dose inahler or 2.5mg/0.5mL nebule.

Activated Charcoal (Actidose)

While not commonly used, activated charcoal may still be used as an absorbent for ingested toxins. Class: Absorbent Description: Finely powdered charcoal activated with oxygen, commonly diluted in water for oral administration. Mechanism of action: Binds with ingested toxins in the 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: Activated charcoal will inactivate other oral medications. Side effects: Black, tarry stools, and constipation Interactions: None Dosage: 1g/kg orally (adults and pediatric patients). Route: Oral. How supplied: Premixed slurry of 50 grams/250 mL