PHARMACOLOGY/ MEDICATION by 158fJO

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									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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