Paramedic Interfacility Transfer PHARMACOLOGY Medication Classification New Hampshire Department of Safety, Division of Fire Standards and Training & Emergency Medical Service Terminal Objectives At the completion of this section the student will have basic knowledge of medication within certain classifications Enabling Objectives At the conclusion of this section the student will be able to describe each of the following medication classification Anticoagulants GI Agents Anticonvulsants IV fluids Antidiabetics Narcotics Antidysrhythmics Parenteral Nutrition Antihypertensives Platelet Aggregation Anti-infectives Inhibitors Antipsychotics Respiratory Medications Cardiac glycosides Sedatives Corticosteroids Thrombolytics Drotrecogin Vasoactive Agents Paralytics Blood Products Enabling Objectives continued At the conclusion of this section the student will be able to: – Indentify a typical patient on a particular class of medication – Describe what to watch out for during transfer when on a particular class of medication – Describe potential interventions for an adverse reaction to a class of medication – Identify the most commonly used medications within a class of medications Medication and Transport Most PIFT medications are not found in the National Standard Curriculum for Paramedic Medications usually found being administered to critical care patients CLASSIFICATIONS OF MEDICATIONS 20 classifications of drugs plus OTC medications CLASSIFICATIONS OF MEDICATIONS Anticoagulants GI Agents Anticonvulsants IV fluids Antidiabetics Narcotics Antidysrhythmics Parenteral Nutrition Antihypertensives Platelet Aggregation Inhibitors Anti-infectives Respiratory Medications Antipsychotics Cardiac glycosides Sedatives Corticosteroids Vasoactive Agents Drotrecogin Paralytics Thrombolytics Blood Products ALLERGIC REACTIONS All medications have the potential to create an allergic reaction Be vigilant for signs of allergic reactions or anaphylaxis Treat according to NH EMS protocol ANTICOAGULANTS Used to prevent extension of existing clot or formation of new blood clots Does not dissolve existing clots Patients may be on these drugs for extended periods of time ANTICOAGULANTS PATIENTS ON ANTICOAGULANTS MI or suspected MI patients DVT—deep vein thrombosis pulmonary embolism DIC—disseminated intravascular coagulation Other clotting-related disorders ANTICOAGULANTS Most commonly used anticoagulants: Heparin IV Lovenox (Enoxaparin) Sub Q ANTICOAGULANTS What to watch for: Signs of bleeding, either internally or externally Monitor vitals frequently Signs and symptoms of shock Altered level of consciousness ANTICOAGULANTS Potential interventions in case of adverse reaction: Consider discontinuing drug Control any external bleeding Treat for shock Consider contacting medical control ANTICONVULSANTS Used primarily to prevent or treat seizures Seizures are often associated with epilepsy, head injury, fever, infection or unknown etiology ANTICONVULSANTS Anticonvulsants consist of three types of drugs: 1. Benzodiazepines 2. Barbiturates 3. Dilantin or Cerebyx ANTICONVULSANTS BENZODIAZEPINES: –Lorazepam (Ativan) –Midazolam (Versed) –Diazepam (Valium) ANTICONVULSANTS •May be administered IV, IM, PO or rectally in infants •Usually administered by IV infusion pump during interfacility transport ANTICONVULSANTS Barbiturate of choice for many years has been PHENOBARBITAL DILANTIN (phenytoin) and CEREBYX (fosphenytoin) are also frequently used to suppress and/or control seizure activity ANTICONVULSANTS It is not uncommon to see 2 or more different anticonvulsants used in combination during interfacility transport Doses may have to be altered during transport due to increased seizure activity ANTICONVULSANTS What to watch for: –Hypotension –Respiratory depression –Vomiting –Bradycardia and other dysrhythmias –Increased seizure activity ANTICONVULSANTS Potential interventions in case of adverse reaction: Consider discontinuing drug or drugs Consider fluids for hypotension Support ventilations as necessary Treat dysrhythmias per NH EMS protocols If increased seizure activity occurs, consider increasing dosage if permitted by transfer order or according to NH EMS protocols ANTIDIABETICS In the context of interfacility transport, it is not uncommon to encounter patients that require treatment with antidiabetic agents In most cases, the medication that you will be monitoring or administering will be INSULIN. ANTIDIABETICS Patients will generally have a diagnosis of: –Hyperglycemia –Diabetic ketoacidosis –Hyperosmolar hyperglycemic nonketotic coma ANTIDIABETICS INSULIN comes in many forms. They are generally either rapid, intermediate or long acting preparations. Common names include the following: – Humulin – Novolin – NPH – Iletin – Lantus ANTIDIABETICS Administration will generally be by IV infusion in the interfacility mode but… – In some long distance transfers it may be necessary to administer the patient’s routine dose of insulin by subcutaneous injection ANTIDIABETICS Blood glucose monitoring may be necessary depending on the patient’s condition and the length of the transfer ANTIDIABETICS What to watch for during transport: – Seizures – Alterations in blood glucose – Signs and symptoms of hypoglycemia Nausea, anxiety, altered level of consciousness, tachycardia, diaphoresis – Serum potassium levels may drop significantly as patient’s pH improves ANTIDIABETICS Potential interventions: – Treat hypoglycemia or seizures as per NH EMS protocols – Consider discontinuing or altering the infusion rate of insulin as per OLMC – Provide general supportive measures ANTIDYSRHYTHMICS This is the largest classification of medication in the PIFT module as it contains several sub-classifications ANTIDYSRHYTHMICS Contained within this section are the following sub-classes of medications: – Beta Blockers – Calcium Channel Blockers – Cardiac Glycosides – Miscellaneous Antidysrhythmics such as: Amiodarone (Cordarone) Magnesium sulfate Procainamide (Pronestyl) Phenytoin (Dilantin) Lidocaine NOTE Certain medications will appear in several different classifications during this program as some of them are indicated for different medical conditions. – Ex. Beta blockers and calcium channel blockers appear in this section as antidysrhythmic agents but will also be seen in the section on Antihypertensives ANTIDYSRHYTHMICS What kinds of patients will we see on antidysrhythmic medications? – CARDIAC PATIENTS Confirmed or suspected MIs Angina Tachydysrhythmias Bradydysrhythmias with or without heart blocks Atrial fibrillation and flutter PVCs and other ectopic conditions BETA BLOCKERS Metoprolol (Lopressor) Propranolol (Inderal) Atenolol (Tenormin) Esmolol (Brevibloc) During transport primarily used to treat various tachydysrhythmias, atrial fibrillation and atrial flutter Used to treat MIs but generally given in hospital prior to transfer CALCIUM CHANNEL BLOCKERS Diltiazem (Cardizem) Verapamil (Calan) Nifedipine (Procardia) •Treatment of tachydysrhythmias, atrial fibrillation and flutter CARDIAC GLYCOSIDES Digoxin (Lanoxin) Treatment of tachydysrhythmias, particularly to control ventricular rate in atrial fibrillation or flutter; PSVT AMIODARONE Generally used to treat atrial and ventricular tachydysrhythmias during interfacility transport LIDOCAINE Used to treat wide complex tachycardia and ventricular ectopy ROUTES OF ADMINISTRATION •Antidysrhymics will almost always be administered IV by infusion pump ANTIDYSRHYTHMICS WHAT TO WATCH FOR DURING TRANSPORT: –Dysrhythmias –Altered levels of consciousness –Hypotension/changes in vital signs –Seizures ANTIDYSRHYTHMICS Potential interventions in case of adverse or allergic reaction: – Treat dysrhythmias and seizures per NH EMS protocols – Consider fluids for hypotension if not contraindicated by patient’s condition – Refer to transfer orders or NH EMS protocols for option of discontinuing drug, adjusting dosage or diversion – General supportive measures ANTIDYSRHYTHMICS KEEP IN MIND THAT ALL PATIENTS ON CARDIAC MEDICATIONS MUST BE TRANSPORTED ON A CARDIAC MONITOR Record any changes in rhythm Take frequent vitals ANTIDYSRHYTHMICS REMEMBER THAT CARDIAC PATIENTS CAN DETERIORATE QUICKLY AND YOU MUST BE PREPARED FOR A CODE OR OTHER SERIOUS EVENT AT ALL TIMES ANTI-INFECTIVES Includes the following: Antibiotics Antivirals Antifungal agents Rarely will we see an antiviral or antifungal agent on an interfacility transfer ANTI-INFECTIVES What types of patients can we expect to see on anti-infectives? Pneumonia/respiratory infections Meningitis Sepsis Cellulitis UTI Various infectious diseases ANTI-INFECTIVES Most common medications used in transport: Vancomycin Rocephin Penicillin Cefazolin (Ancef) Gentamicin ANTI-INFECTIVES Almost always administered IV ANTI-INFECTIVES What to look for: Signs and symptoms of allergic reaction Induration or redness at the IV site Altered level of consciousness Nausea/vomiting ANTI-INFECTIVES Note: – Antibiotics have a greater potential for allergic reactions than any other drugs ANTIHYPERTENSIVES These medications are essentially used to control hypertensive crisis of various etiologies Included within the classification of antihypertensives are several other classes of medications that have antihypertensive action ANTIHYPERTENSIVES Other classifications and subclassifications of antihypertensives include: – ACE Inhibitors – Beta Blockers – Alpha Blockers – Calcium Channel Blockers – Diuretics – Vasodilators COMMONLY USED ANTIHYPERTENSIVES ACE Inhibitors Benazepril (Lotensin) Enalapril (Vasotec) Lisinopril (Zestril) Captopril (Capoten) ANTIHYPERTENSIVES Alpha Blockers –Doxazosin (Cardura) –Prazosin (Minipress) –Terazosin (Hytrin) ANTIHYPERTENSIVES Beta Blockers – Atenolol (Tenormin) – Propranolol (Inderal) – Metoprolol (Lopressor) – Labetalol (Normodyne) ANTIHYPERTENSIVES Calcium Channel Blockers – Diltiazem (Cardizem) – Verapamil (Calan) – Nifedipine (Procardia) – Amlodipine (Norvasc) ANTIHYPERTENSIVES Diuretics –Furosemide (Lasix) –Bumetadine (Bumex) –Torsemide (Demadex) ANTIHYPERTENSIVES Vasodilators –Hydralazine (Apresoline) –Minoxidil (Loniten) –Nitroglycerin –Nipride (Nitroprusside) Must be protected from light ANTIHYPERTENSIVES Routes of Administration: – Generally IV but may be given PO in certain cases on long transfers ANTIHYPERTENSIVES What to watch for during transport –Severe hypotension – automatic BP cuff monitored q 3-5 minutes –Nausea/vomiting –Symptomatic bradycardia –Other dysrhythmias ANTIHYPERTENSIVES Possible interventions when adverse reactions occur during transport: – Treat bradycardia and other dysrhythmias as per NH EMS protocols – Consider fluids for hypotension if not contraindicated by patient condition ANTIHYPERTENSIVES Possible Interventions when adverse reactions occur during transport: – Consider an antiemetic for nausea – Refer to transfer orders of NH EMS protocols for options of discontinuing medication, altering dosage or diversion ANTIHYPERTENSIVES All patients on antihypertensive medications should be transferred on a cardiac monitor Take frequent vitals BREAK ANTIPSYCHOTICS The number of psychiatric transfers has increased dramatically in recent years Many patients are transferred with chemical restraints and sometimes need to be given additional medication during transport ANTIPSYCHOTICS Medication is administered to control psychotic behavior that is otherwise difficult to manage in an ambulance Patients will have a number of different diagnoses including agitation, schizophrenia, depression, delusional disorders, etc. ANTIPSYCHOTICS A number of different medications are used to provide chemical restraint CHEMICAL RESTRAINT Common Chemical Restraint Medications: – Haloperidol (Haldol) – Chlorpromazine (Thorazine) – Risperidone (Risperdal) – Benzodiazepines (Diazepam, Lorazepam, Midazolam) CHEMICAL RESTRAINT These drugs may be given alone or in combination with other antipsychotic drugs May also be administered in combination with other medications such as diphenhydramine (Benadryl) for added sedative effect ANTIPSYCHOTICS Routes of administration – Generally given IM but may be given IV or PO in some cases – For IV medication, the patient should leave the hospital with a saline lock in place if possible ANTIPSYCHOTICS Considerations… – Discuss all medication issues with the sending physician before leaving the hospital – If the patient is sedated upon your arrival, ask if the drug will last long enough for you to reach your destination – If medication will be needed during transport, do not wait until the patient becomes disruptive and combative ANTIPSYCHOTICS What to watch for during transport: –Respiratory depression –Hypotension –Seizures –Extrapyramidal reactions Agitation, muscle tremor, drooling, tremors, etc. ANTIPSYCHOTICS Potential interventions in cases of adverse or allergic reactions: – Treat allergic reactions and seizures as per NH EMS protocols – Support ventilations as necessary and be prepared to intubate – Consider fluids for hypotension – Diphenhydramine for extrapyramidal reactions – Refer to transfer orders for other options including diversion CARDIAC GLYCOSIDES These are essentially digitalis preparations – The most commonly used drug is digoxin (Lanoxin) – Generally used to treat atrial fibrillation, atrial flutter or atrial tachycardias – Sometimes used to treat CHF CARDIAC GLYCOSIDES Route of Administration: Generally IV infusion CARDIAC GLYCOSIDES What to watch for during transport: –Dysrhythmias including heart blocks –Cardiac arrest –Nausea/vomiting –Digitalis toxicity CARDIAC GLYCOSIDES Potential interventions for adverse reactions: – Treat all dysrhythmias per NH EMS protocols – Consider an antiemetic for nausea/vomiting – Refer to transfer orders for options of discontinuing drug, altering dose or diversion – Do not administer calcium CARDIAC GLYCOSIDES All patients on cardiac glycosides must be transported on a cardiac monitor and watched carefully for developing adverse reactions CORTICOSTEROIDS Medications in this class are primarily used to treat the following: – Cerebral edema associated with head injury – Status asthmaticus – To suppress the immune system in cases of severe allergic reactions/anaphylactic shock – Chronic inflammatory conditions CORTICOSTEROIDS Routes of administration: – IV infusion in most cases – Also used in inhaled form for certain respiratory conditions CORTICOSTEROIDS Commonly used medications in this class – Betamethasone (Celestone) – Dexamethasone (Decadron) – Methylprednisolone (Solu-Medrol) – Hydrocortisone (Solu-Cortef) CORTICOSTEROIDS Also in inhaled form… – Beclomethasone (Beconase, Beclovent) – Triamcinolone (Azmacort, Kenalog) – Flunisolide (Aerobid) CORTICOSTEROIDS What to watch for during transport: –Hypertension –Nausea/vomiting –CHF CORTICOSTEROIDS Potential interventions in case of adverse reactions: – Follow NH EMS protocols for allergic reactions, CHF or nausea/vomiting – Refer to transfer orders for options of discontinuing drug DROTRECOGIN (Xygris) An antisepsis agent Used to treat severe sepsis or septic shock Administered by IV infusion only DROTRECOGIN What to watch for during transport: –Be alert for signs of internal bleeding –Shock symptoms DROTRECOGIN Potential interventions during transport : –Treat for shock –Refer to transfer orders for option of discontinuing drug GASTROINTESTINAL AGENTS Used to treat a variety of GI disorders Several different sub- classifications of GI medications: 1. Proton Pump Inhibitors 2. Somatostatin Analogues 3. H2 Blockers 4. Anti-emetics GASTROINTESTINAL AGENTS What kind of patients will we see being transported on these medications? – Active duodenal or gastric ulcers – GERD—gastric esophageal reflux disease – Upper GI bleed – Esophageal varices GASTROINTESTINAL AGENTS Routes of Administration: –IV infusion –PO Proton Pump Inhibitors Reduces the production of gastric acid by blocking the enzyme in the stomach wall that produces acid Commonly used drugs: –Protonix - pantoprazole –Prevacid - lansoprazole Somatostatin Analogues Synthetic somastatin used for the treatment of GI bleeding, particularly esophageal varices. Commonly used drug: –Sandostatin - octreotide H2 Blockers Blocks the action of histamine on parietal cells in the stomach, decreasing the production of acid by these cells Commonly used drug: – Famotidine (Pepcid) – Cimetidine (Tagamet) Antiemetics Block activity in the Chemoreceptor Trigger Zone (CTZ) of the CNS which is responsible for nausea and vomiting Commonly used drugs: metoclopramide (Reglan) – dopamine2 receptor antagonist ondansetron (Zofran) – seratonin receptor antagonist prochlorperazine (Compazine) – has a neuroleptic effect on CTZ GASTROINTESTINAL AGENTS What to watch for during transport: –Adverse reactions are rare but may consist of dysrhythmias –Hypoglycemia is possible but will probably only be seen on longer transfers GASTROINTESTINAL AGENTS Potential interventions for adverse or allergic reactions: – Treat dysrhythmias and hypoglycemia per NH EMS protocols – Consider termination of drug – Refer to transfer orders for further options IV FLUIDS Consists of a wide variety of fluids including the following: – Normal saline, ½ NS – Lactated Ringers – D5W and D10W – Dextran, Plasmanate – Hetastarch, albumin Have sufficient supply of fluids for the transport IV FLUIDS What to watch for during transport: –Signs of fluid overload –Edema –Pulmonary edema –Take vitals often to monitor BP IV FLUIDS Potential interventions in cases of adverse reactions: –Consider discontinuing or reducing rate of infusion –Treat CHF per NH EMS protocols ELECTROLYTES Electrolytes consist of the following: – Potassium – Calcium – Sodium chloride – Sodium bicarbonate (alkalizing agent) ELECTROLYTES What type of patients will we see who require electrolyte therapy? – Patients requiring potassium supplementation due to deficiency diseases when oral replacement is not feasible – Those who have lost potassium due to severe vomiting or diarrhea ELECTROLYTES What type of patients will we see who require electrolyte therapy? – Patients with severe hypocalcemia – Sodium depletion – Patients requiring sodium bicarbonate to treat hyperacidity or metabolic acidosis due to shock or dehydration ELECTROLYTES Route of administration: –Primarily IV infusion ELECTROLYTES What to watch for during transport: – Dysrhythmias – Seizures – Signs and symptoms of allergic reactions (rare) ELECTROLYTES Potential interventions in cases of adverse reactions: – Treat seizures and dysrhythmias per NH EMS protocols – Consider option of discontinuing drug or modifying dose as per OLMC or transfer orders NARCOTICS Used to control moderate to severe pain May be administered by IV infusion pump but may also be given by IV or IM injection as per transfer order NARCOTICS Commonly used narcotics: –Fentanyl –Morphine –Hydromorphone (Dilaudid) –Meperidine (Demerol) NARCOTICS What to watch for during transport: –Respiratory depression –Hypotension –Nausea/vomiting –Bradycardia NARCOTICS Potential interventions in cases of adverse reactions: – Consider discontinuing medication – Treat dysrhythmias per NH EMS protocols – Consider Naloxone – Assist ventilations as necessary and be prepared to intubate TOTAL/PARTIAL PARENTERNAL NUTRITION (TPN/PPN) Class Intravenous Nutrition Therapy Mechanism of Action Provides complete nutritional support: Calories from dextrose and lipid Protein from amino acids Vitamins, minerals, trace elements and electrolytes are also added. Packaging: IV solution is contained in 1.5-3.0 liter IV bags. 6/16/2012 TOTAL/PARTIAL PARENTERNAL NUTRITION (TPN/PPN) Indications - To provide consistent nutritional support when the GI tract can not or should not be used. - TPN may be used indefinitely - PPN is intended for short term use. Contraindications Hypersensitivity to product Adverse Reactions None Drug Interactions None 6/16/2012 TOTAL/PARTIAL PARENTERNAL NUTRITION (TPN/PPN) Dosage and Administration Formula mixed daily by hospital pharmacy - the composition of the IV solution is determined by the patient’s previous days lab results Duration of Action Onset: Minutes. Duration: One bag every 24 hours. 6/16/2012 TOTAL/PARTIAL PARENTERNAL NUTRITION (TPN/PPN) Caution Must be given through CENTRAL IV access - maintain sterile technique - administer with an in line filter - do not administer any medications, colloids or other crystalloid with TPN or PPN Protect Solution from heat. Some mixtures may include insulin and should not be discontinued even for a short time without hanging a dextrose solution. 6/16/2012 PARENTERAL NUTRITION Common forms include the following: – Vitamin solutions – TPN (Total Parenteral Nutrition) An individualized solution designed to meet the needs of the patient PARENTERAL NUTRITION What to watch for during transport: – Adverse or allergic reactions are rare but have been seen – Hypoglycemia Can occur since most TPN preparations contain Insulin PARENTERAL NUTRITION Potential interventions in case of adverse reactions: – Treat hypoglycemia as per NH EMS protocols – Consider discontinuing drug GLYCOPROTEIN IIb/IIIa Platelet Inhibitors What are these drugs all about? – They are potent agents that inhibit platelets from aggregating or clumping together in the context of coronary artery disease. – Frequently used in combination with Heparin GLYCOPROTEIN IIb/IIIa Platelet Inhibitors Patients being transported on these drugs – Acute MI – Unstable angina – Acute coronary syndrome – Many of these patients are being transported to the cath lab for diagnostic and/or interventional catherization---angioplasty GLYCOPROTEIN IIb/IIIa Platelet Inhibitors Route of Administration: –IV infusion only GLYCOPROTEIN IIb/IIIa Platelet Inhibitors What to watch for during transport: – Any signs of bleeding – Signs and symptoms of shock – Changes in level of consciousness GLYCOPROTEIN IIb/IIIa Platelet Inhibitors Potential interventions in cases of adverse or allergic reactions: – Control any external bleeding – Treat for shock as needed – Refer to transfer orders for options of discontinuing drug, altering dose or diversion – In cases of suspected bleeding, the provider may also have to D/C heparin if it is also being administered – Treat dysrhythmias and allergic reactions as per NH EMS protocols RESPIRATORY MEDICATIONS Within this classification are several subclassifications of drugs that are used in treating patients with respiratory conditions – Beta agonists – Anticholinergics – Steroids – Mucolytics – Miscellaneous BETA AGONISTS Albuterol (Proventil) Terbutaline Metaproterenol (Alupent) Piruterol (Maxair) These drugs provide relief through bronchodilation ANTICHOLINERGICS Ipratropium (Atrovent) These drugs provide long term maintenance of bronchodilation STEROIDS Beclomethasone (Beclovent) Flunisolide (AeroBid) Fluticasone (Flovent) Triamcinolone (Azmacort) These drugs provide relief by reducing inflammation MISCELLANEOUS Aminophylline Montelukast (Singulair) RESPIRATORY MEDICATIONS What kinds of patients will you be transporting on respiratory medications? – The respiratory problem may be primary or secondary – Acute or chronic RESPIRATORY MEDICATIONS Asthma COPD Emphysema Certain cases of allergic reaction RESPIRATORY MEDICATIONS Routes of administration: – Most of these drugs will be administered by inhaler or nebulized Aminophylline is given by IV infusion Terbutaline may be IV or by inhalation Is epinephrine a respiratory medication? RESPIRATORY MEDICATIONS Transport respiratory medication patients on cardiac monitor RESPIRATORY MEDICATIONS What to watch for during transport: –Dysrhythmias Beta agonists such as Albuterol can cause tachydysrhythmias –Palpitations, chest pain RESPIRATORY MEDICATIONS Potential interventions in case of adverse reaction: –Treat dysrhythmias and chest pain per NH EMS protocols SEDATIVES Sedatives consist of a variety of medications from several different classifications (Some that we have already reviewed) – Narcotics – Benzodiazepines – Antipsychotics – Barbiturates and anesthetics SEDATIVES Narcotics – Fentanyl, morphine, dilaudid, meperidine, etc. Benzodiazepines – Diazepam, lorazepam, midazolam Antipsychotics – Haloperidol, risperidone, chlorpromazine, etc. Barbiturates – Phenobarbital, thiopental, amobarbital Anesthetics – Etomidate, propofol Diprivan (propofol) Anesthesia Maintenance 5mcg/kg/min x 5 min then increase 5- 10mcg/kg/min q5-10 min – Again, discuss orders that are written with sending physician Titrate to sedation with respect to BP Watch for injection site reaction – Hypotension – Bradycardia (severe/rare adverse reaction) SEDATIVES Types of patients on sedatives… – Agitation and combativeness associated with head injury, psychosis, etc. – Control of seizure activity – Any condition where it is necessary to provide sedation SEDATIVES What to watch for during transport: –Respiratory depression –Hypotension –Bradycardia SEDATIVES Potential interventions in cases of adverse reactions: – Oxygen, Support ventilations as necessary and be prepared to intubate – Treat bradycardia per NH EMS protocols – Consider fluids for hypotension – Refer to transfer orders for other options Paralytics 6/16/2012 Paralytics Non Depolarizing Neuromuscular Blocking (NMD) Action Prevents neuromuscular transmission and produces paralysis by blocking effect of acetylcholine at the myoneural junction Indications Provides skeletal muscle relaxation during surgery or mechanical ventilation Adjunct to general anesthesia to facilitate intubation 6/16/2012 Paralytics Non Depolarizing Neuromuscular Blocking (NMD) Adverse Effects CV Tachycardia (Pancuronium) Bradycardia (Cisatracurium) Resp Apnea, respiratory insufficiency bronchospasm, laryngospasm Allergic Anaphylaxis (Pancuronium, Vecuronium) Contraindications Myasthenia gravis Neuromuscular disease Hepatic or renal function impairment Acute angle glaucoma, penetrating eye injuries (Vecuronium) 6/16/2012 Paralytics Non Depolarizing Neuromuscular Blocking (NMD) Interactions Increase NMB with antibiotics, general anesthetics, magnesium, quinidine Enhanced NMB effect and duration with concommitment use of Succinylcholine Counteracted by anticholinesterase, anticholinergic agents 6/16/2012 Paralytics Non Depolarizing Neuromuscular Blocking (NMD) Cisatracurium Pancuronium Vecuronium Nimbex Pavulon Norcuron Adult 0.15-0.2 mg/kg IVP 0.1mg/kg slow IVP 0.1mg/kg IVP Gtt: 10mg/95ml Gtt: 50mg/250ml Gtt: 10-20 mg/100ml of diluent; 3mcg/kg/m diluent diluent; 0.8-1.2mcg/kg/m Pediatric 0.1mg/kg 0.1 mg/kg slow IV, IO 0.1mg/kg IV, IO Gtt: 10mg/95ml Gtt: 50mg/250ml Gtt: 10-20 mg/100ml of diluent; 3mcg/kg/m diluent diluent; 0.8-1.2mcg/kg/m Onset immediate 30-45 seconds 30 seconds Peak Effect 2 minutes 3-4.5 minutes 2.5-3.0 minutes Duration 64-121 minutes 65-100 minutes 25-30 minutes Cautions Do not administer Do not administer with Do not administer with with ketorolac or diazepam or thiopental diazepam, etomidate, 6/16/2012 propofol American Medical Response furosemide, thiopental Paralytics Non Depolarizing Neuromuscular Blocking (NMD) Remember NMB agents do not provide analgesia or sedation Just because you can not see the seizure does not mean the patient is not seizing Pancuronium and Vecuronium are excreted via the kidney; adjust dosage 6/16/2012 VASOACTIVE AGENTS What kinds of patients will we see on Vasopressors and Sympathomimetics? – Patients on these drugs are generally being treated for hypotension and certain types of shock VASOACTIVE AGENTS Commonly used vasopressors and sympathomimetics: – Vasopressin (Pitressin) – Metaraminol (Aramine) – Dopamine (Intropin) – Dobutamine (Dobutrex) – Epinephrine and norepinephrine – Neosynepherine – Isoproterenol (Isuprel) VASOACTIVE AGENTS These are medications that have an effect on the tone and caliber or diameter of blood vessels – Vasopressors and sympathomimetic drugs cause constriction of blood vessels……. – Nitrates, vasodilators, Calcium Channel Blockers and ACE Inhibitors cause relaxation and dilation of vessels, thereby reducing BP Levophed (norepinephrine) Acute Hypotension Cardiac arrest, post resuscitation Side Effects Hypertension Extravasation Tachyardia Asthma exacerbation Headache Anxiety Dosing 2-12mcg/min to desired effect Patients in refractory shock may not see sustainable effects for up to 30 minutes Neosynepherine(phenylephrine) Shock Hypotension, mild-moderate Neo Side Effects Arrhythmias Hypertension Headache Palpitations Bradycardia Tremors Neo Dosing 40-60mcg/min NITRATES Patients taking nitrates are generally being treated for ischemic chest pain or hypertensive crisis NITRATES Commonly used nitrates include: – Nitroglycerin – Nitroprusside (Nipride) VASODILATORS Used primarily for treatment of hypertensive crisis and management of CHF VASOACTIVE AGENTS Calcium Channel Blockers and ACE Inhibitors are primarily used to treat hypertension as we saw in the section on Antihypertensives VASOACTIVE AGENTS Routes of administration: –IV infusion Infusion pump REQUIRED VASOACTIVE AGENTS What to watch for during transport: –Severe hypotension or hypertension –Dysrhythmias –Dyspnea –Altered level of consciousness –Nausea/vomiting VASOACTIVE AGENTS Potential interventions in case of adverse or allergic reactions: – Treat dysrhythmias as per NH EMS protocols – Consider fluids for hypotension – Consider discontinuing drug or modifying dose as per transfer orders – Diversion VASOACTIVE AGENTS NOTE: – These patients must be transported on a cardiac monitor – Monitor vitals frequently Thrombolytic Agents 6/16/2012 Thrombolytic Agents Class Thrombolytic enzyme Action dissolve clots by accelerating the formation of plasmin by activated plasminogen Alteplase directly converts plasminogen to plasma Reteplase enhances the cleavage of plasminogen to generate plasmin Streptokinase indirectly activates plasminogen, that converts to plasmin Tenecteplase directly converts plasminogen to plasmin Urokinase directly converts plasminogen to plasmin 6/16/2012 Thrombolytic Agents Indications Management of AMI – maximal benefit within 2-3 hrs after symptom onset – significant benefit within 6 hrs after symptom onset – Some benefit up to 12 hrs Acute ischemic stroke (within 3 hours) Pulmonary embolism To restore patency to arterial and venous catheters 6/16/2012 Thrombolytic Agents Contraindications Recent surgery/Trauma (3 weeks) Active internal bleeding Suspected aortic dissection Recent head trauma/hemorrhagic CVA ( 3months) HTN: >200/120 mmHg Interactions Increased risk of hemorrhage when administered with Vit K antagonists, heparin, oral anticoagulants and antiplatelet agents 6/16/2012 Thrombolytic Agents Adverse Effects CNS intracranial hemorrhage, cerebral edema CV cardiogenic shock, heart failure, cardiac arrest, reinfarction, myocardial rupture, PEA, cardiac tamponade, dysrhythmias GI/GU Bleeding Allergic anaphylaxis 6/16/2012 American Medical Response Thrombolytic Agents All patients with acute MI should receive one chewable aspirin 160-325 mg as soon as the diagnosis is suspected Streptokinase Tissue Tenecteplase Reteplase Plasminogen TNKase rPA Activator (tPA) Dosage 1.5 million units 15mg IV Bolus 30-50mg over 5 2 10 unit IV IV over 1 hour 50mg over 30 seconds boluses 30 minutes Weight based minutes 35 mg over 60 apart minutes NO Heparin With Heparin With Heparin With Heparin Onset Immediate immediate immediate Duration 4-24 hours 2.5-3 hours End of 6/16/2012 American Medical Response infusion OTC MEDICATIONS During the course of a transport, particularly a long distance transfer, it may be necessary to administer certain commonly used OTC medications OTC MEDICATIONS May include medications for the following: Pain (Ibuprofen, acetaminophen, etc.) Motion sickness (Dramamine) Antacids Antihistamines OTC MEDICATIONS Guidelines for administration: – Written order by physician that includes name of drug, route of administration, indication, dose and time of initial and repeat dosing – Drug must be supplied by the sending facility – Drug must have been used previously by patient without adverse reactions OTC MEDICATIONS Administration must be documented as with all other medications Remember that even OTC drugs can result in adverse or allergic reactions so watch for any such reactions following administration PRESCRIPTION DRUGS During longer transports you may need to administer one or more of the patient’s regular prescription drugs The drug must be included in one of the classifications that are part of the PIFT module Scenario 1 Patient is a 68 year old male being transferred from a diagnostic only cath lab with IV NS, a femoral arterial sheath in place, Heparin 720u/hr, Integrellin at 120mcg/min, and NTG at 18mcg/min Any concerns? What about orders? Is this an appropriate transfer? Scenario 2 Patient is a 78 year old female who presented to the ED with an inferior infarction. She has a BP of 82/44, HR 78, . She is awake and oriented on 15L02NRB in the ED. Currently on Heparin, Integrillin, and Dopamine at 12mc/kg/min. Scenario 2 Is it an appropriate PIFT transfer? Important factors – Distance of transfer? Weather? – Patient stability? – Written orders? Scenario 3 You have been requested to transfer a patient diagnosed with bacterial spinal meningitis. They have a 20g in the L AC and a 22g in the R hand. You find the patient to have Levophed piggybacked into NS going through the hand and neosynepherine running into the AC . The patient has a blood pressure of 76/42 and a heart rate of 134. They are very lethargic but complaining of a burning sensation in the right forearm. Scenario 3 Is this an appropriate transfer?? Scenario 3 They tell you they do not want to wait for a CCT team and will give you a nurse. The nurse comes in the room and says “I am so excited about this, I’ve never been in an ambulance before” Thoughts? Scenario 3 What needs to happen before you leave this facility? CONCLUSIONS Be constantly alert—patients can change in seconds Know your drugs---use resources Remember that every drug, even OTC drugs, have the potential to result in a serious adverse reaction CONCLUSIONS Never leave the sending facility unless you feel thoroughly comfortable with your patient and with the medications you are being asked to administer or monitor CONCLUSIONS Make sure that you are thoroughly prepared for any complication Know where possible diversion hospitals are located Questions?
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