Here is a list of some of the common Medications used on Ambulances. This is a reference only. Please see your doctor or medical director for more info. 
Paramedics- please follow current Life Line Protocol's​. 2015 Protocols have been updated. Please see Janel for current Protocols. 
​​
 Acetaminophen (Tylenol)
ACTIONS
Reduces fever by direct action on hypothalamus heat- regulating center with consequent peripheral vasodilation, sweating, and dissipation of heat.
INDICATION
Fever >100.8 Degrees F.
CONTRAINDICATIONS
Hypersensitivity
Caution with Abdominal pain- patient may need to be NPO
ROUTE
PO
DOSAGE
Adults: 325 to 650 mg PO
Peds: 15mg/kg PO
ADVERSE EFFECTS
Nausea, vomiting, dizziness, lethargy, chills, abdominal pain, diarrhea.

Activated Charcoal
ACTIONS
Binds poisons, toxins, irritants; thereby inhibiting their GI absorption and impact.
INDICATION
Poisoning or overdose. Administer ONLY at the direction of Poison Control.
CONTRAINDICATIONS
Hypersensitivity to Activated Charcoal.
Not effective for poisonings of cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, or methanol.
ROUTE
NG
DOSAGE Adults and Peds: 1 gm/kg NG (minimum dose 30 grams).
ADVERSE EFFECTS
Nausea, vomiting, constipation, diarrhea, black stools.
SPECIAL NOTES
Drug is most effective when administered as soon as possible after acute poisoning.
If administered too rapidly, patient may vomit.
Assure correct placement of NG tube.

Adenosine (Adenocard)
ACTIONS
Slows conduction through the AV and SA nodes, can interrupt reentry pathways through the AV node, and can restore normal sinus rhythm in SVT.
INDICATIONS
Supraventricular tachycardia (SVT), including those associated with accessory bypass tracts involving AV node or SA node.
CONTRAINDICATIONS
Hypersensitivity to Adenosine.
Second or Third degree AV heart block.
Wolff-Parkinson-White syndrome.
Sick sinus syndrome.
Atrial flutter or atrial fibrillation.
Ventricular Tachycardia.
ROUTE
IV/IO
DOSAGE
Adults: initial dose 6 mg rapid IV/IO. May repeat twice every 2 minutes if no response as 12 mg rapid IV/IO. Max cumulative dose 30 mg.
Reduce initial dose to 3 mg IV/IO in patients receiving dipyridamole (Persantine) or carbamazepine (Tegretol), transplanted hearts or central venous administration.
Peds: 0.1 mg/kg rapid IV/IO (max first dose 6 mg). May repeat twice every 2 minutes if no response as 0.2 mg/kg IV/IO (max second/third dose of 12 mg). Max cumulative dose 30 mg.
ADVERSE EFFECTS
Headache, lightheadedness, dizziness, facial flushing, palpitations, dyspnea, chest pain or tightness, brief periods of asystole or bradycardia, ventricular ectopy.
SPECIAL NOTES To be certain the medication reaches the systemic circulation quickly, it should be injected into an IV line as close to the patient as possible.
Adenosine should be given as a rapid IV push over 1 to 2 seconds followed by NS bolus of 20 ml.

Albuterol Sulfate (Proventil)
ACTIONS
Causes bronchodilation decreasing airway resistance by relaxing smooth muscles of bronchial tree. Facilitates mucus drainage.
INDICATIONS
To relieve bronchospasm associated with acute or chronic asthma, COPD, or wheezing not caused by foreign body obstruction.
CONTRAINDICATIONS
Hypersensitivity to Albuterol Sulfate.
ROUTE
Inhaled via nebulized aerosol mist.
DOSAGE
Adults: 2.5 mg (diluted in 3 ml NS) nebulized. May be combined with 0.5 mg of Ipratropium (Atrovent). Albuterol ONLY may be given by continuous administration.
Peds: 2.5 mg (diluted in 3 ml NS) nebulized. May be given by continuous administration.
PRECAUTIONS
Cardiovascular disease, hypertension, seizure disorders, hyperthyroidism, or diabetes mellitus.
Administer with caution if heart rate is greater than 150 bpm (must be on cardiac monitor), or in cases of heart block.
Patients who use bronchodilators excessively.
ADVERSE EFFECTS
Tachycardia, tremors, anxiety, palpitations, ectopy, hypertension, angina, vomiting, and vertigo.
SPECIAL NOTES
Most patients will have a decrease in heart rate and blood pressure with a relief of their bronchospasm. Therefore, do not withhold therapy in patients with hypertension and/or tachycardia.

Aminophylline
ACTIONS
Smooth muscle relaxant, bronchodilator, mild diuretic.
INDICATION
Bronchospasm, Asthma, bronchitis, emphysema
CONTRAINDICATIONS
Hypersensitivity to Aminophylline
Hypotension
Peptic Ulcer Disease
ROUTE
IV infusion
DOSAGE
Adults maintain via IV pump at sending facility’s orders
ADVERSE EFFECTS
Convulsions, vomiting, palpitation
SPECIAL NOTES
1. Follow generalized protocol for transports.
2. If possible, administer through large vein (i.e., antecubital), central line is preferred.
3. Monitor blood pressure every 5-10 minutes.
4. Contact Medical Control or the sending facility with questions or concerns.
5. Maintain via IV pump per sending facilities orders
6. Pt must be on a cardiac monitor at all times during transport.

Amiodarone (Cordarone)
ACTIONS
Antiarrhythmic; prolongs duration of action potential and refractory period without significantly affecting resting membrane potential. Decreases peripheral vascular resistance.
INDICATIONS
Treatment and prophylaxis of frequently recurring ventricular fibrillation, ventricular tachycardia, supraventricular tachycardia, atrial fibrillation.
CONTRAINDICATIONS
Hypersensitivity to Amiodarone.
Cardiogenic shock.
Severe sinus bradycardia.
2nd or 3rd Degree AV Block unless pacemaker is available.
ROUTE
IV, IO
DOSAGE
Adults: Ventricular fibrillation/pulseless VT - 300 mg IV/IO. May repeat 150 mg IV/IO once in 3 to 5 minutes.
If rhythm converts to a perfusing rhythm, hang a maintenance infusion. Infuse 1 mg/min. Mixing suggestion; inject 100 mg into 100 ml bag of NS. Initiate infusion with a 60 gtt set (60 gtt/min).
Adults: Tachycardia with pulses - 150 mg over 10 minutes IV/IO. Mixing suggestion; inject 150 mg into 50 ml bag of NS. Initiate infusion with a 60 gtt set. Infuse 50 ml over 10 minutes (15 mg/min).
Peds: Ventricular fibrillation/pulseless VT - 5 mg/kg IV/IO bolus (max first dose 300 mg). May repeat 2.5 mg/kg IV/IO (max second dose 150 mg) once in 3 to 5 minutes.
Peds: Tachycardia with pulses - 5 mg/kg IV/IO over 20 minutes (max single dose 150 mg).
ADVERSE EFFECTS
Hypotension, nausea, bradycardia.
SPECIAL NOTES
Profound hypotension may occur post resuscitation. Be prepared to treat hypotension with vasopressors.

Amyl nitrite/ sodium nitrite/ sodium Thiosulfate
ACTIONS: nitrites promote formation of methemoglobin to detoxify cyanide to cyanmethemoglobin; sodium thiosulfate facilitates rhodanase-catalyzed conversion of cyanide to less-toxic thiocyanate
INDICATIONS: Cyanide Antidote
CONTRAINDICATIONS
• Hypersensitivity
• Pregnancy
• Severe Anemia
ROUTE
• IV/IO
DOSAGE
• Adults: Start: 1 amyl nitrite ampule inhaled x15-30sec q1min until sodium nitrite available; Dose: sodium nitrite 300 mg IV over 2-4min, then sodium thiosulfate 12.5 g IV over 10min; may repeat 1/2 of original IV doses x1 prn or in 2h as prophylaxis; Info: slow nitrite infusion if BP decreases.; convenience pkg contains 12 ampules amyl nitrite, 2 vials sodium nitrite, 2 vials sodium thiosulfate
ADVERSE EFFECTS
• Coma, Syncope, cyanosis, hypotension, CNS depression
TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
3. Contact your medical director or the sending facility with concerns or questions.
4. Continue drip as ordered by sending facility

Antibiotics: Flagyl, Levaquin, Avelox, Rocephin, Cipro, Zosyn, etc.
ACTIONS
Bactericide.
INDICATION
Infections (Respiratory tract, Urinary tract, skin and bone, Septicemia, Endocarditis, Meningitis).
Open wounds
CONTRAINDICATIONS
Hypersensitivity/allergies
ROUTE
IV infusion
DOSAGE
Adults maintain via IV pump at sending facility’s orders
Pediatrics maintain via IV pump at sending facility’s orders
ADVERSE EFFECTS
Upset stomach, Nausea, Vomiting, rash,
SPECIAL NOTES
1. Follow generalized protocol for transports.
2. If possible, administer through large vein (i.e., antecubital), central line is preferred.
3. Monitor blood pressure every 5-10 minutes.
4. Contact Medical Control or the sending facility with questions or concerns.
5. Maintain via IV pump per sending facilities orders

Aspirin
ACTIONS
Inhibits platelet aggregation and thereby reduces risk of thrombus formation.
INDICATIONS
Acute coronary syndromes (ACS).
CONTRAINDICATIONS
Hypersensitivity to Aspirin.
Decreased level of consciousness.
History of GI ulcers or bleeding.
ROUTE
PO
DOSAGE
Adults: 162 mg for amputations. 324 mg PO for chest pain (chewable).
Not indicated in children.

Atropine Sulfate
ACTIONS
Blocks vagal impulses to heart with resulting decrease in AV conduction time and increase in heart rate and cardiac output.
INDICATIONS
Symptomatic bradycardia and bradyarrhythmias (sinus, junctional or escape rhythms).
Asystole
Nerve agent exposure and organophosphate poisonings.
Blocking vagal reflexes as a pretreatment in pediatric RSI.
ROUTE
IV, IO, IM, ET
DOSAGE - BRADYARRHYTHMIAS
Adults: 0.5 mg IV/IO. May repeat every 5 minutes until desired heart rate is achieved. Max cumulative dose 3 mg.
Peds: 0.02 mg/kg IV/IO. May repeat once.
o Minimum single dose 0.1 mg.
o Maximum single dose 0.5 mg.
o Maximum cumulative dose 1 mg.
DOSAGE - ASYSTOLE/PEA
Adults: 1 mg IV/IO. May repeat every 3 to 5 minutes. Max cumulative dose 3 mg.
NOT indicated in pediatric Asystole.
DOSAGE - NERVE AGENT EXPOSURE AND ORGANOPHOSPHATE POISONING
Adults: 2 mg IV/IO. May repeat every 5 minutes until a decrease in secretions is observed. No max dose.
Peds: 0.02 mg/kg IV/IO or 0.05 mg/kg IM. May repeat every 5 minutes until a decrease in secretions is observed. No max dose.
DOSAGE - RSI PREMEDICATION FOR CHILDREN < 8 YEARS OLD (IF >8 YEARS OLD NOT INDICATED)
Peds: 0.02 mg/kg IV/IO.
o Minimum single dose 0.1 mg.
o Maximum cumulative dose 1 mg.
ADVERSE EFFECTS
Hypertension, tachycardia, palpitations, dizziness, dilated pupils, photophobia, dry mouth, paradoxical bradycardia, hypotension.
SPECIAL NOTES
Inadequate or slowly administered doses may result in a reflex bradycardia.

Blood and Blood Products
FOR REGISTERED NURSES (RN) ONLY
ACTIONS
To maintain circulating blood volume
To maintain oxygen carrying capacity of the blood by supplying red blood cells.
To maintain coagulation properties by supplying clotting factors found in plasma and/or platelets.
To maintain the integrity of the immune system by supplying leukocytes.
INDICATION
Replacement of whole blood, red blood cells, platelets, plasma etc. to support underlying medical condition and/or traumatic injury.
CONTRAINDICATIONS
Hypersensitivity
ROUTE
IV
DOSAGE
Adults and Peds: as directed by sending facility
ADVERSE EFFECTS
CHF, Shortness of breath, rash, fever, chills, cough, flushing, restlessness, change in BP.
SPECIAL NOTES
When blood products are given, the patient should be observed very closely. Take vital signs every 15 min including temperature. Some patients may develop severe reactions to blood and therefore a close assessment is important. If a reaction occurs, the body temperature will normally be the earliest sign to appear.
Blood products must first be started at the sending facility and maintained by the RN. It is recommended that the blood product be started at least 15 minutes prior to transport.
Check rate of flow and IV patency frequently during transfusion.
If the transfusion is complete during transfer, flush Y tubing with normal saline after transfusion.
If a reaction occurs (moderate to severe) stop transfusion, treat reaction as needed per protocol.
Most blood transfusions are given over a two hour period.
All patients receiving blood products need to be placed on an EKG and continuous Sp02.
Sending facilities may order Lasix (Furosemide) during transfusion of blood products to help prevent fluid overload. Administer Lasix at sending facility orders usual dose 20-80 mg IV x1.

Calcium Chloride
MECHANISM OF ACTION
essential component and participant in physiologic systems and reactions
INDICATIONS: Hypocalcemia, Arrhythmias, Calcium Channel blocker overdose
CONTRAINDICATIONS
Hypersensitivity
hypercalcemia
hypophosphatemia
ventricular fibrillation
digitalis toxicity
ROUTE
IV/IO
DOSAGE ADULTS:
Adults: 0.5 MG- 1 G SLOW IV/IO. Supplied 1000MG/10 ML
Peds: 25 mg/kg IV/IO (max single dose 500 mg).
Hypocalcemia, emergent 500-1000 mg IV over 5-10min
Arrhythmias, life-threatening 500-1000 mg IV q10min
Info: for arrhythmias associated w/ hypocalcemia, hyperkalemia, or hypermagnesemia
Calcium channel blocker overdose
1-2 g IV over 10min q20min x5 doses

ADVERSE EFFECTS
Hypercalcemia, arrhythmias, syncope, nephrolithiasis, extravasation necrosis, tingling, bradycardia, cardiac arrhythmias, cardiac arrest
TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
3. Contact your medical director or the sending facility with concerns or questions.
4. Continue medications as ordered by sending facility
5. Infusion site must be monitored closely for infiltration. Extravasation requires immediate discontinuation of the drug. Shut off IV and leave infiltrated IV catheter in place. Notify hospital immediately.

SPECIAL NOTE:
Strength clarification
Info: 10% IV sol = 1 g calcium chloride/10 mL = 270 mg (13.5 mEq) elemental Ca; doses expressed as calcium chloride salt
Dextrose 25% / 50% (D25 / D50)
ACTIONS
Immediate source of glucose for cellular metabolism.
INDICATIONS
Hypoglycemia established or suspected.
Unconsciousness caused by unknown etiology.
CONTRAINDICATIONS
Hyperglycemia, Intracranial hemorrhage, CHF
ROUTE
IV, IO
DOSAGE
Adults: 25 grams 50% solution IV/IO. May repeat as necessary.
Peds: 2 cc/kg of a 25% solution IV/IO (mix D50 with equal parts NS). May
repeat as necessary.
SPECIAL NOTES
The infusion site MUST be monitored closely for infiltration. Extravasation requires IMMEDIATE discontinuation of the drug! SHUT OFF IV AND LEAVE INFILTRATED IV CATHETER IN PLACE. Notify ER staff immediately of infiltrated site prior to or upon arrival. Document notification appropriately.
Obtain blood glucose reading prior to administration if possible.
Ineffective without thiamine.

Diazepam (Valium)
ACTIONS
Depresses the central nervous system. Relaxes skeletal muscles.
INDICATION
Seizures
CONTRAINDICATIONS
Hypersensitivity to benzodiazepines.
Psychosis
ROUTE
IV, IM, IO, PR
DOSAGE
Adults: 5 to 20 mg IV/IO, in 5 mg increments. Push slowly (2 to 5 mg/min). Max cumulative dose 20 mg.
Adults: Rectal dose 0.2 mg/kg, if unable to start IV.
Peds: 0.2 mg/kg IV push slowly. Max dose 10 mg.
Peds: Rectal dose 0.5 mg/kg, if unable to start IV.
ADVERSE EFFECTS
Drowsiness, hypotension, bradycardia, nausea and vomiting, respiratory depression.
SPECIAL NOTES
Use with caution in shock, alcohol intoxication, impaired respiratory drive.
Do not mix with other drugs.

Diazepam rectal (Diastat)
ACTIONS
binds to benzodiazepine receptors; enhances GABA effects
INDICATIONS
Seizure disorder
CONTRAINDICATIONS
Known hypersensitivity
ROUTE
Rectal
DOSAGE
ADULT
0.2 mg/kg PR x1 rectal gel delivery system delivers doses in 2.5 mg increments; use 10 mg system for 5, 7.5, or 10 mg doses
Peds: 6-11 yo
Dose: 0.3 mg/kg PR x1; rectal gel delivery system delivers doses
ADVERSE EFFECTS
Sedation, respiratory depression, seizures, bradycardia, hypotension, syncope, rash

Diltiazem (Cardizem)
ACTIONS: Slows SA and AV node conduction times without affecting normal atrial action potential or intraventricular conduction.
INDICATIONS:
Control of rapid ventricular response with A-fib/A-flutter or PSVT.
CONTRA-INDICATIONS:
Allergy
Hypotension
second and third degree heart block
V-tach.
Wolff-Parkinson-White Syndrome
Sick sinus syndrome
CHF
AMI
ADVERISE EFFECTS: Headache, dizziness, drowsiness, hypotension, bradycardia, nause, vomiting.
ADMINISTRATION:
Adults: Initial dose 20 mg (0.25 mg/kg) slow IV push over 2 minutes. Second dose at 25 mg (0.35 mg/kg) slow IV push 15 minutes after first dose if indicated.
Peds: Not indicated in Children

IV DRIP: Start continuous infusion at 5-15 mg/hr or follow sending facility drip rate orders. Maintain via pump.

Increase drip in 5 mg increments (up to 15 mg/hr total) as necessary to control heart rate.

TRANSPORT DIRECTIVES:
1. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
2. Contact your medical director or the sending facility with concerns or questions.
3. Follow generalized protocol for transports.


Diphenhydramine (Benadryl)
ACTIONS
Antihistamine - competes with histamines at receptor sites thus blocking histamine release. Reverses dystonic reactions.
INDICATIONS
Allergic reactions.
Adjunct to Epinephrine in treating anaphylaxis.
Dystonic reactions.
CONTRAINDICATIONS
Hypersensitivity to Diphenhydramine.
Acute asthma.
MAO inhibitors.
Glaucoma
ROUTE
IV, IO, IM
DOSAGE
Adults: 25 to 50 mg IV/IO/IM.
Peds: 1 mg/kg IV/IO/IM (max single dose 50 mg).
ADVERSE EFFECTS
Drowsiness, headache, fatigue, confusion, palpitation, mild hypotension, blurred vision, dry mouth, nausea, vomiting, thickened bronchial secretions, wheezing, chest tightness.
SPECIAL NOTES
May precipitate acute asthma due to drying effect on bronchial mucosa.
Histamines produce the allergic symptoms of hives, laryngeal edema, bronchospasm and vasodilation.
Dystonic reactions are characterized by distorted, twisting movements of the body, face, mouth and tongue.


Dobutamine
ACTIONS: stimulates beta-1 adrenergic receptors
INDICATIONS:
• Patients with non-hypovolemic hypotension or low cardiac output along with pulmonary congestion.
CONTRAINDICATIONS
Allergy to Dobutamine
Hypovolemia
ROUTE: IV
ADMINISTRATION:
• Mix 250 mg Dobutamine in 250 cc of 0.9% NS or 5% Dextrose in water. Begin administering at 2mcg/kg/min, titrate to systolic BC > 90 mmHg at lowest possible dose. Maximum dose 20 mcg/kg/min. Or continue at sending facility’s dose.
See Chart

ADVERSE EFFECTS: Hypertension, Tachycardia, arrhythmias, PVC’s, chest pain, shortness of breath, nausea, vomiting.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Monitor vital signs every 5-10 minutes.
3. Avoid increases in heart rate greater than 10%.
4. If tachyarrhythmias or ventricular ectopy occur, consider decreasing dose.
5. Caution in use in patients with MI, as may increase infarct.
6. If an invasive arterial line monitoring device is present and compatible with equipment, continue monitoring during transport if able.
7. Contact Medical Control or the sending facility with questions or concerns.
8. Maintain via IV pump.
9. Pt must be on a cardiac monitor at all times during transport.

Dopamine
ACTIONS
Increases blood pressure and cardiac output due to vasoconstriction, increased inotropy and chronotropy. Therapeutic action depends on the receptors that are stimulated.
INDICATIONS
Non-traumatic, symptomatic hypotension.
Bradycardia
CONTRAINDICATIONS
Hypersensitivity to Dopamine.
Uncorrected tachyarrhythmias or ventricular fibrillation.
Hypovolemic shock.
ROUTE
IV, IO
DOSAGE
Adults: 5 to 20 mcg/kg/min IV/IO (9 gtts/min, 14 gtts/min, 19 gtts/min). Titrate to maintain systolic BP > 90 mmHg not to exceed 20 mcg/kg/min. Mix 800 mg Dopamine in 500 ml NS if premix unavailable (1600 mcg/ml), see chart.
Peds: 5 to 20 mcg/kg/min IV/IO (same as adults). Titrate to maintain systolic BP > 90 mmHg.
ADVERSE EFFECTS
Headache, palpitations, tachycardia, hypertension, nausea, vomiting.
SPECIAL NOTES
The infusion site MUST be monitored closely for infiltration. Extravasation requires IMMEDIATE discontinuation of the drug! SHUT OFF IV AND LEAVE INFILTRATED IV CATHETER IN PLACE. Notify ER staff immediately of infiltrated site prior to or upon arrival. Document notification appropriately.
Do not administer Sodium Bicarbonate in same IV line with Dopamine.
Any underlying hypovolemia must be corrected, if possible, prior to use.

DuoNeb (ipratropium/ albuterol inhaled)
ACTIONS
Combination :Beta-2 Agonists 1: Short-acting Inhaled; Anticholinergics
INDICATIONS
COPD
Shortness of breath
CONTRAINDICATIONS
Hypersensitivity to Ipratropium or albuterol
Hypersensitivity to atropine
Caution if cardiovascular dz. Caution if arrhythmias
ROUTE
Aerosol 500 mcg/2.5 mg/3 mL neb
DOSAGE
Adults: 1 treatment 500 mcg/2.5 mg/3 mL
Peds: not recommended at this time
ADVERSE EFFECTS
Pharyngitis, chest pain, bronchospasm, HTN, angina, MI, hypokalemia arrhythmias

Epinephrine
ACTIONS
Increases cardiac output by increased inotropy, chronotropy and AV conduction. Increases systolic BP due to increased cardiac output and vasoconstriction. Alleviates wheezing and dyspnea by relaxing smooth muscles of the respiratory tract. Prevents hypotension and loss of intravascular fluid in anaphylaxis by counteracting vasodilation and decreasing vascular permeability.
INDICATIONS
Pulseless non-breathing patients (PNB).
Anaphylaxis
Status asthmaticus .
Bradycardia
Non-traumatic, symptomatic hypotension.
CONTRAINDICATIONS
Hypersensitivity to Epinephrine.
Hemorrhagic shock.
Age > 45 due to possible underlying cardiovascular disease.
ROUTE
IV, IO, ET, IM, SQ
DOSAGE - PNB
Adults: 1 mg IV/IO (1:10,000) OR 2 - 2.5 mg ETT (1:1,000) diluted in 10 ml NS, if unable to start an IV/IO. May repeat every 3 to 5 minutes. No max dose.
Peds: 0.01 mg/kg (1:10,000) IV/IO OR 0.1 mg/kg (1:1,000) via ETT if unable to start an IV/IO. May repeat every 3 to 5 minutes:
o Maximum single dose 1 mg.
o No maximum cumulative dose.
DOSAGE - BRADYCARDIA
Adults: 2 mcg/min IV/IO (60 gtts/min). Mixing suggestion; inject 1 mg (1:1,000) into 500 ml bag NS. Titrate until desired heart rate is achieved.
Peds: Severe 0.01 mg/kg of 1:10,000 IV/IO. May repeat every 3 - 5 minutes as needed until desired heart rate is achieved:
o Maximum single dose 1 mg.
Peds: Persistent 0.1 - 1 mcg/kg/min IV/IO. Mixing suggestion; inject 1 mg (1:1,000) into 500 ml bag NS. Titrate until desired heart rate is achieved.
DOSAGE - ANAPHYLAXIS
Adults: 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3 - 0.5 ml). May repeat every 15 minutes as needed.
Adults: Severe: 0.5 mg IV/IO of 1:10,000. May repeat every 3 - 5 minutes as needed.
Peds: 0.01 mg/kg SQ/IM of 1:1,000 (0.01 ml/kg). May repeat every 15 minutes as needed:
o Maximum single dose 0.5 mg.
Peds: Severe 0.01 mg/kg of 1:10,000 IV/IO. May repeat every 3 - 5 minutes as needed:
o Maximum single dose 1 mg.
DOSAGE - STATUS ASTHMATICUS
Adults: 0.3 - 0.5 mg SQ/IM of 1:1,000 (0.3 - 0.5 ml). May repeat every 15 minutes as needed.
Peds: 0.01 mg/kg SQ/IM of 1:1,000 (0.01 ml/kg). May repeat every 15 minutes as needed:
o Maximum single dose 0.5 mg.
ADVERSE EFFECTS
Tachycardia, hypertension, nervousness, anxiety, headache, dyspnea, palpitations, nausea, vomiting.
SPECIAL NOTES
Should not be given concurrently with sodium bicarbonate. Positive inotropic and chronotropic effects can precipitate or exacerbate cardiac ischemia.

Esmolol (Brevibloc)
ACTIONS: Antiarrhythmics, Beta Blockers
selectively antagonizes beta-1 adrenergic receptors
INDICATIONS:
Rapid control of SVT, atrial fibrillation or flutter.
CONTRA-INDICATIONS:
Should not be given to patients with COPD
cardiac conduction abnormalities (second or third degree heart block)
hypotension
shock
bronchospasm.

ADVERSE EFFECTS:
Hypotension
bradycardia
bronchospasm

Administration:
Adults: Mixing instructions: 5 grams in 500ml, 5% dextrose or 0.9% normal saline. Loading dose of 500 mcg/kg over 1 minute followed by infusion of 50 mcg/kg/min. If no therapeutic effect after 5 minutes, may repeat loading dose and increase infusion to 100 mcg/kg/min. This sequence may be repeated every 5 minutes to a maximum infusion of 200 mcg/kg/min.

TRANSPORT DIRECTIVES:
1. Follow protocol for generalized transports.
2. Maintain appropriate delivery rate by IV infusion pump.
3. Monitor vital signs every 5 minutes.
4. Discontinue if patient develops hypotension, bradycardia, and bronchospasm.
5. Contact Medical Control or the sending facility with questions or concerns.
6. Pt must be on a cardiac monitor at all times during transport.

Etomidate (Amidate)
ACTIONS
Primarily a hypnotic. It has minimal respiratory or myocardial depression. It attenuates the rise in intracranial pressure that is associated with laryngoscopy and intubation by decreasing cerebral blood flow and cerebral metabolic oxygen demand without adversely affecting cerebral perfusion pressure.
INDICATIONS
Rapid Sequence Intubation (RSI).
CONTRAINDICATIONS
 Known hypersensitivity to Etomidate.
ROUTE
IV, IO
DOSAGE
Adults: 0.3 mg/kg IV/IO (15 mg, 22.5 mg, 30 mg). One time dose.
Peds: 0.3 mg/kg IV/IO. One time dose.
ADVERSE EFFECTS
Myoclonic jerking, nausea, vomiting, coughing, hiccups, pain on injection, may exacerbate focal seizure disorders.
SPECIAL NOTES
Be prepared to manage the airway with multiple techniques.
Does not provide any pain control.
Inject with wide open IV/IO.
Will produce rapid sedation that lasts 10 to 15 minutes.

Furosemide (Lasix)
ACTIONS
A potent diuretic. Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle. This loss of sodium and chloride will cause water to follow, hence a loss of water from the circulatory system. A decrease in intravascular volume will occur.
INDICATIONS
Acute Pulmonary Edema with severe respiratory distress and systolic blood pressure > 90 mmHg.
CONTRAINDICATIONS
Known hypersensitivity to Furosemide.
BP < 90 mmHg.
ROUTE
IV, IO
DOSAGE
Adults: 40 mg slow IV/IO OR double patient’s oral dose. Max dose 80 mg.
NOT recommended for pre-hospital use in children.
ADVERSE EFFECTS
Orthostatic hypotension, dizziness, dehydration, hyperglycemia, hypokalemia, confusion, headache, syncope, blurred vision, tinnitus, hearing loss.
SPECIAL NOTES
Closely monitor BP.

Glucagon
ACTIONS
Increases blood glucose levels. Converts liver glycogen to glucose.
INDICATIONS
Symptomatic blood glucose < 60 mg/dl when unable to establish an IV.
CONTRAINDICATIONS
Known hypersensitivity to Glucagon.
ROUTE
IM, SQ
DOSAGE
Adults: 1 mg IM or SQ.
Peds: 0.03 mg/kg IM or SQ (max dose 1 mg).
ADVERSE EFFECTS
Nausea, vomiting.
SPECIAL NOTES
Use only the diluents supplied by the manufacturer.
Glucagon is of little help in patients with adrenal insufficiency.
Administration of Glucagon should be followed by supplemental carbohydrates.

Glutose (Oral Glucose)
ACTIONS
Increases blood glucose levels.
INDICATIONS
Symptomatic blood glucose < 60 mg/dl.
CONTRAINDICATIONS
Known hypersensitivity to Glutose.
Decreased LOC.
Head injury/CVA.
ROUTE
PO
DOSAGE Adults: 15 g (one tube) PO. May repeat once in 5 - 10 minutes.
Peds: 7.5 g (1/2 tube) PO. May repeat once in 5 - 10 minutes.
ADVERSE EFFECTS
Nausea, vomiting.
SPECIAL NOTES
Must be able to swallow and easily protect own airway.

Glycoprotein IIb/IIIa Receptor Antagonist
for Acute Coronary Syndromes

INDICATIONS:
• In combination with Heparin for the treatment of acute coronary syndromes, including unstable angina and non Q-wave AMI and for those patients who are to be managed medically and those undergoing PTCA or artherectomy.
CONTRA-INDICATIONS:
Known hypersensitivity.
Active internal bleeding or a history of significant bleeding within the previous 30 days.
History of intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation or aneurysm.
History of thrombocytopenia following prior exposure to Aggrastat, Integrelin or ReoPro.
History of CVA within 30 days or any history of hemorrhagic stroke.
Major surgical procedure or severe physical trauma within previous month.
History, symptoms or findings suggestive of aortic dissection.
Severe HTN (systolic BP > 180 mmHg and/or diastolic BP > 110 mmHg).
Concomitant use of another parenteral IIb/IIIa inhibitor.
ADVERSE EFFECTS:
Bleeding, edema/swelling, hypotension, bradycardia, pain, dizziness. sweating, nausea
ADMINISTRATION:
All may be used with ASA and Heparin
o Integriline (Eptifibatide): IV bolus 180 mcg/kg, then continuous IV infusion of 2 mcg/kg/min, up to 72 hours.
o Aggrastat (Tirofiban): IV 0.4 mcg/kg/min for 30 minutes then 0.1 mcg/kg/min; give 2 dose in renal disease.
o ReoPro (Abciximab): IV 250 mcg (0.25 mg) /kg bolus, then continuous IV infusion of 10 mcg/min for up to 12 hours.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transport.
2. Maintain appropriate delivery rate by IV infusion pump.
3. Monitor V/S every 5-10 min.
4. Discontinue after notifying appropriate medical facility if patient develops severe hypotension, active bleeding or hypersensitivity.

Haloperidol (Haldol)
ACTIONS
Decrease psychotic manifestations.
INDICATIONS
Chemical restraint for behavior emergencies
Acute agitation
CONTRAINDICATIONS
Known hypersensitivity to Haldol.
Seizure disorder
ROUTE
IM only
DOSAGE
Adults: 5 mg IM
Reduce to 2 mg IM for patients over the age of 65
NOT indicated in pediatrics.
ADVERSE EFFECTS
Lethargy, hypotension, hypertension, tachycardia, bronchospasm, restlessness, mental depression.
SPECIAL NOTES
May cause increase sedation in patient who have taken other CNS depressants or alcohol.

Heparin
INDICATIONS:
• Acute myocardial infarction
• pulmonary embolism
• deep vein thrombosis (DVT)
• Disseminated intravascular coagulation (DIC).
CONTRA-INDICATIONS:
• Active bleeding
• known or suspected intracranial hemorrhage
• chronic renal failure
• recent surgery
• other significant risk for bleeding such as
o thrombocytopenia or
o Hemophilia.
• Patients who have already received Lovenox. (1.5 mg/kg wait 24 hours. 1 mg/kg or less wait 12 hours).
ADMINISTRATION:
• Recommended mixing instructions are 25,000 units mixed into 250 cc of NS.
o For suspected cardiac patients:
Initial bolus is 60 units/kg IVP followed by an infusion of 12 units/kg/hr.
o For all other patients:
o Initial bolus is 70 units/kg IVP followed by an infusion of 16 units/kg/hr

TRANSPORT DIRECTIVES:
(1) Following generalized protocol for transports.
(2) Consider stopping infusion if patient develops signs of bleeding such as petechiae or bruising, hematemesis, bleeding from the gums, epistaxis, sudden tachycardia or hypotension.
(3) Concurrent use of oral anticoagulant, thrombolytic and salicylates or IIb/IIIa antagonist can increase risks of
(4) Control and monitor for bleeding.
(5) Maintain via IV pump- drip rate set by sending facility
(6) Initial bolus is to be done by the sending facility

A. Suggest a heparin drip on all post-thrombolytic patients.
B. Suggest 325 mg of baby aspirin PO as indicated on all MI patients.
C. Suggest running all heparin drips at 12 U/kg/hr when indicated. Follow sending facility drip rates.
D. Suggest a heparin drip on all cardiac patients when indicated.
E. Heart Monitor is recommended for all Heprin patients.

Hydromorphone (Dilaudid)
INDICATIONS:
• Moderate to Severe Pain

CONTRA-INDICATIONS:
• Hypersensitivity
• Unresponsive/ decreased Level of Consciousness (LOC)
• Bradycardia

ADVERSE EFFECTS:
Nausea/vomiting, Sedation, Seizures with large doses, Cardiac arrest, Respiratory depression, Hypotension

ADMINISTRATION:
Adults: IV route preferred
1 mg-2 mg IVP, SC, IM may repeat dose x1, if additional doses are needed, contact medical control.
Peds: >6 mo, >50 kg Dose: 0.25mg-0.5 mg IV q15 min max dose 1 mg

TRANSPORT DIRECTIVES:
1. Naloxone (Narcan) should be readily available when administering Dilaudid (Hydromorphone).
2. Follow generalized protocol for transports.
3. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
4. Contact Medical Control or the sending facility with questions or concerns.
5. Monitor for adverse affects
6. Consider an antiemetic prior to giving Dilaudid or with the Dilaudid to help prevent nausea/vomiting. Monitor for sedation and respiratory depression.

Insulin
ACTIONS: Permits utilization of carbohydrates and fats (glucose).
INDICATIONS:
• Hyperglycemia
• Ketoacidosis

CONTRA-INDICATIONS:
• Hypersensitivity to particular insulin formulation.

ADVERSE EFFECTS:
• Hypoglycemia

ADMINISTRATION:
• As per physician orders; typically initial bolus of 6-10 units IV push followed by infusion of 2-10 u/hr.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Check glucose every 30 minutes or more frequent if needed.
3. Check glucose if developing signs of hypoglycemia; if glucose < 80, administer D50 (Dextrose) 50 ml IV push and recheck glucose in 5 minutes.
4. Discontinue if patient develops signs of hypersensitivity.
5. Initiate a second IV line when using an insulin drip due to its incompatibility with many drugs.
6. This must be transported by IV pump, at drip rate set up by sending facility.
7. Discontinue drip if patient’s blood sugar drops below 150 unless ordered by sending doctor to continue. Discontinue if blood sugar drops below 100. Give glucose if patient becomes symptomatic or low blood sugar or blood sugar below 80.

Ipratropium (Atrovent)
ACTIONS
Produces local site-specific effects on the larger central airways including bronchodilation and prevention of bronchospasms.
INDICATIONS
For relief of acute bronchospasm (reversible airway obstruction).
CONTRAINDICATIONS
Hypersensitivity to Ipratropium OR Atropine and/or its derivatives.
ROUTE
Inhaled via nebulized aerosol mist.
DOSAGE
Adults: 0.5 mg by nebulizer combined with Albuterol (Proventil) in 3 ml of NS. Give one dose only.
NOT recommended for pre-hospital use in children.
ADVERSE EFFECTS
May cause bronchospasm to become worse. Glaucoma patients may experience pain/blurred vision if solution comes in contact with the eyes. Palpitations, dizziness, anxiety, headache, nervousness, nausea, vomiting, cramps, cough.
SPECIAL NOTES
Use with caution in patients with a history of hypertension, heart disease, and tachydysrhythmias.

Ketorlac (Toradol)
ACTIONS
exact mechanism of action unknown; inhibits cyclooxygenase and lipoxygenase and reduces prostaglandin synthesis
INDICATIONS
May be used for pain control
CONTRAINDICATIONS
Known hypersensitivity to NSAIDS
Peptic ulcer disease
GI Bleeds
cerebrovascular hemorrhage
active bleeding
CABG surgery (periop pain)
epidural or intrathecal use
pregnancy 3rd trimester
labor and delivery
breastfeeding
renal impairment, severe
volume depletion
ROUTE
IV, IM
DOSAGE
Adults: 30 mg IV. One time dose or 60mg IM. One time dose.
Elderly should have 15 mg IV.
Not indicated in children.
ADVERSE EFFECTS
Nausea, vomiting, GI bleed, Stroke, MI, bleeding, CHF, headache, abdominal pain, dizziness, rash, edema.

Labetalol (Normodyne, Trandate)
INDICATIONS:
• Hypertension
• Can be used in conjunction for treatment of cardiac problems such as an MI.

CONTRA-INDICATIONS:
• Bronchial asthma
• Overt cardiac failure
• Greater than first-degree heart block
• Cardiogenic shock
• Severe bradycardia
• hypotension
• hypersensitivity

ADVERSE EFFECTS:
• Bradycardia
• Hypotension
• Dizziness
• Ventricular arrhythmias
• Bronchospasm

ADMINISTRATION:
• Initial infusion, 20 mg IV over 2 minutes. Repeat injections of 40 to 80 mg every 10 minutes until maximum dosage of 300 mg is reached.

Transport Directives:
1. Follow generalized protocol for transports.
2. Monitor vital signs every 5-10 minutes.
3. Discontinue and notify appropriate medical direction facility if patient develops severe hypotension, bradycardia, bronchospasm or hypersensitivity occurs.
4. All patients on IV medications for hypertension have to be on a heart monitor.

Levalbuterol (Xopenex)
ACTIONS: stimulates beta-2 adrenergic receptors, relaxing airway smooth muscle
INDICATIONS: bronchospasm
CONTRAINDICATIONS:
• Hypersensitivity
• MAO inhibitor use w/in 14 days
ROUTE: Nebulized
Dosage Adults: 1.25 mg/3 mL nebulized
Dosage Pediatric: [6-11 yo] 0.31-0.63 mg /3mL NEB
[>11 yo] Dose: 0.63 mg/3mL NEB; Max: 1.25 mg
ADVERSE EFFECTS: bronchospasm, angioedema, MI, cardiac arrest, arrhythmias, palpitations, dizziness, nervousness, tachycardia, headache, chest pain
TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
3. Contact your medical director or the sending facility with concerns or questions.
Continue medications as ordered by sending facility

Lidocaine (Xylocaine)
ACTIONS
Exerts antiarrhythmic action by suppressing automaticity in HIS-Purkinje system and by elevating electrical stimulation threshold of ventricles during diastole. May decrease ICP during RSI.
INDICATIONS
Alternative treatment for wide-complex tachycardia or VF/pulseless VT.
Ventricular arrhythmias.
If head injury suspected and time allows prior to intubation.
CONTRAINDICATIONS
Hypersensitivity to Lidocaine or other amide type anesthetics.
SVT
Second or Third degree AV heart block.
Ventricular ectopy associated with bradycardia.
ROUTE
IV, IO, IM, ET
DOSAGE - PNB
Adults: 1 to 1.5 mg/kg IV/IO. May repeat half of original dose every 3 to 5 minutes PRN. Max cumulative dose 3 mg/kg.
Adults: If rhythm converts to a perfusing rhythm, hang a maintenance drip. Premix of 2 grams in 500 ml infuse at 2 to 4 mg/min IV/IO (30 to 60 gtts/min).
Peds: 1 mg/kg IV/IO (max single dose 100 mg). May repeat half of original
dose every 3 to 5 minutes PRN. Max cumulative dose 3 mg/kg.
Peds: If rhythm converts to a perfusing rhythm, hang a Lidocaine (Xylocaine) drip. Mixing suggestion; inject 100 mg in 500 ml bag of NS (200 mcg/ml).
Initiate infusion at 20 to 50 mcg/kg/min IV/IO (see chart).
DOSAGE - RSI
Adults: 1.5 mg/kg IV/IO (75 mg, 100 mg, 150 mg). If head injury suspected and time allows.
Peds: 1 mg/kg IV/IO (max single dose 100 mg).
DOSAGE - ADULT IO
Adults: Lidocaine (Xylocaine) - 20 to 50 mg IO for pain control in conscious patients.
ADVERSE EFFECTS
Hypotension, bradycardia, arrhythmias, cardiac arrest, tremors, restlessness, convulsions, euphoria, confusion, slurred speech, lightheadedness, tinnitus, blurred, or double vision.
SPECIAL NOTES
Metabolized in the liver and excreted in the kidneys. A reduced dosage should be considered for patients with suspected liver or kidney disease, cardiogenic shock, congestive heart failure, and in the elderly.

Lidocaine Jelly 2% (Xylocaine Jelly 2%)
ACTIONS
Anesthetic and lubrication.
INDICATIONS
Lubrication to facilitate oral or nasal endotracheal intubation.
When anesthetic needed.
To control gagging.
May be used to relieve Laryngospasms when orally intubating.
May reduce discomfort associated with nasal intubation.
CONTRAINDICATIONS
Hypersensitivity to Lidocaine or Novocain.
Inflamed tissue.
ROUTE
Topical
DOSAGE
Apply a liberal amount to device prior to insertion.
For nasal intubation, apply to nasopharyngeal airway and insert (leave in place for at least 1 minute) prior to attempt if possible.
ADVERSE EFFECTS
Local allergic reaction.
SPECIAL NOTES
Avoid contact with eyes.

Magnesium Sulfate
ACTIONS
CNS depressant, smooth muscle relaxant and anticonvulsant by decreasing the acetylcholine from motor nerve terminals, thus producing peripheral neuromuscular blockage.
INDICATIONS
Seizures due to toxemia of pregnancy.
Treatment of choice for Torsades de Pointes.
CONTRAINDICATIONS
Hypersensitivity to Magnesium Sulfate.
Renal failure.
ROUTE
IV/IO
DOSAGE - TORSADES DE POINTS
Adults: 2 grams IV/IO over 5 minutes. Premix available in 50 mL NS.
Peds: 25 mg/kg IV/IO over 10 minutes (max dose 2 grams).
DOSAGE - PRE-ECLAMPSIA/ECLAMPSIA
Adults: 2 to 4 grams IV/IO over 5-10 minutes. Premix available of 2 grams in 50 mL NS.
ADVERSE EFFECTS
Toxicity may cause flushing, sweating, mild bradycardia, hypotension.

Mannitol (Osmitrol)
ACTION: elevates glomerular filtrate osmolarity (osmotic diuretic)
INDICATIONS:
• Adjunct in the treatment of acute oliguric renal failure.
• Adjunct in the treatment of cerebral edema.
• Reduction in intracranial or intraocular pressure.

CONTRA-INDICATIONS:
• Hypersensitivity
• anuria
• dehydration
• Active intracranial bleeding.
ADVERSE AFFECTS: seizures, CHF, cardiovascular collapse, pulmonary edema, CNS depression, headache, nausea, vomiting, dizziness

ADMINISTRATION:
• Cerebral edema, Oliguric renal failure: 50-100 g IV as a 5-25% solution. May precede with a test dose of 0.2 g/kg over 3-5 minutes
• Reduction of intracranial or intraocular pressure: IV, 0.25-2 g/kg as a 15-25% solution over 30-60 minutes.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Administer as ordered unless significant adverse effects occur.
3. Continue via IV pump

Meperidine Hydrochloride (Demerol)
ACTION: binds to various opioid receptors, producing analgesia and sedation (opioid agonist)
INDICATION:
Relief of moderate to severe pain

DOSAGE:
Adults
o 25 mg-50 mg IVP every 5-10 minutes as needed for pain. Max of 100 mg per hour.
o May follow orders from sending facility physician
Pediatrics 1.0 mg/kg may repeat after 10 minutes. Max of 50 mg per hour

CONTRA-INDICATION:
Patient who have received MAO in the last 14 days

ADVERSE EFFECTS:
Sedation, seizures with large doses, cardiac arrest, respiratory depression, Nausea/Vomiting

Administration:
IV, IO
Special note:
Naloxone (Narcan) should be readily available when administering Demerol (Meperidine Hydrochloride).
Follow general transport protocols
Monitor for adverse affects
Consider an antiemetic prior to giving Demerol, or with the Demerol to help prevent nausea/vomiting.
Monitor for sedation and respiratory depression.

Methylprednisolone (Solu-Medrol)
ACTIONS
Anti-inflammatory and immunosuppressant.
INDICATIONS
Acute exacerbation COPD.
Status asthmaticus.
Anaphylaxis
CONTRAINDICATIONS
Hypersensitivity to Methylprednisolone.
Systemic fungal infections.
ROUTE
IV, IO
DOSAGE
Adults: 125 mg slow IV/IO.
Peds: 2 mg/kg IV/IO (max dose 80 mg).
ADVERSE EFFECTS
Headache, confusion, psychosis, nausea, vomiting, muscle weakness.

Midazolam (Versed)
ACTIONS
Short acting (15 to 20 minutes) benzodiazepine CNS depressant with muscle relaxant, sedative-hypnotic, anticonvulsant and amnestic properties.
INDICATIONS
Sedation prior to cardioversion or {RSI}.
Chemical restraint for behavior emergencies in cases of drug/illegal substance overdoses for the combative patient who places him/herself or others in danger.
Seizures
CONTRAINDICATIONS
Hypersensitivity to Midazolam.
Pregnancy
Shock/hypotension.
Hypoxia
Acute alcohol intoxication.
Respiratory distress.
ROUTE
IV, IO, IN
DOSAGE - SEDATION
Adults: 2 mg slow IV/IO. May repeat in 5 minutes. Max cumulative dose 10 mg.
Peds: Sedation - 0.05 mg/kg IV/IO (max single dose 2 mg). May repeat in 5 minutes. Max cumulative dose 10 mg.
DOSAGE - RSI
Adults and Peds: 0.1 mg/kg IV/IO. May repeat in 5 minutes. Max cumulative dose of 10 mg.
DOSAGE: SEIZURES
Adults and Peds: 0.2 mg/kg atomized IN if unable to start an IV. May repeat in 5 minutes. Max cumulative dose 10 mg.
ADVERSE EFFECTS
Hypotension if pushed too fast, respiratory depression, nausea, vomiting, excessive sedation, confusion.
SPECIAL NOTES
Watch for respiratory depression and be prepared to support ventilations.
Use only as a last resort for chemical restraint.

Milrinone (Corotrope, Primacor)
ACTION: inhibits cAMP phosphodiesterase

INDICATIONS:
Short-term management of congestive heart failure.

CONTRA-INDICATIONS:
Hypersensitivity

ADVERSE EFFECTS:
Headache
ventricular arrhythmias

ADMINISTRATION:
Initial IV loading dose of 50 mcg/kg over 10 minutes followed by an infusion of 0.375 - 0.75 mcg/kg/min. (mix 20mg Milrinone in 80 ml/D5W). Maximum dose 1.13 mg/kg/day.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Maintain appropriate delivery rate by IV infusion pump.
3. Monitor vital signs every 5-10 minutes.
4. Discontinue and notify appropriate medical direction facility if patient develops severe hypotension or hypersensitivity occurs.
5. If an invasive arterial line monitoring device is present and compatible with the equipment, continue monitoring during transport.

Morphine Sulfate
ACTIONS
Analgesia. Manifests hemodynamic effects by increasing venous capacitance and decreasing systemic vascular resistance relieving pulmonary congestion.
INDICATIONS
Severe and chronic pain.
Chest pain.
Pulmonary edema.
CONTRAINDICATIONS
Hypersensitivity to Morphine.
Severe respiratory depression.
Shock
Systolic BP < 90 mmHg.
Head injury.
Undiagnosed acute abdominal pain.
Acute alcohol intoxication.
ROUTE
IV, IO
DOSAGE
Adults: 2 mg IV/IO, slowly titrate to effect. May repeat in 5 minutes. Max cumulative dose 10 mg.
Peds: 0.05 to 0.1 mg/kg slow IV/IO (max single dose 2 mg). May repeat once in 5 minutes.
ADVERSE EFFECTS
Tachycardia, bradycardia, severe hypotension, cardiac arrest, dizziness, drowsiness, confusion, blurred vision, lightheadedness, respiratory depression, apnea, nausea, vomiting.
SPECIAL NOTES
May need to manage hypotension with fluid bolus.
Watch for respiratory depression and be prepared to support ventilations.
Naloxone (Narcan) should be readily available when administering Morphine.
Morphine has been shown in some studies to be harmful in pulmonary edema. Use only as a 3rd line treatment.

Nalbuphine Hydrochloride (Nubain)

ACTIONS
Pain control- binds to various opioid receptors, producing agonist and antagonist effects (opioid agonist-antagonist)
INDICATIONS
Moderate to Severe Pain
CONTRAINDICATIONS
Hypersensitivity to Nubain
Decreased LOC
Confusion, Head injury
ROUTE
IV, IM, IO
DOSAGE
Adults: 5mg every 5 min Max 10mg.
Peds: Not recommended
ADVERSE EFFECTS
Nausea, Vomiting, decreased LOC, respiratory depression, bradycardia, hypotension
SPECIAL NOTES
not a first line choice for pain control
Can use Narcan if needed for possible OD or due to adverse effects.
Naloxone (Narcan)
ACTIONS
Reverses the effects of opiates, including respiratory depression, sedation, and hypotension.
INDICATIONS
High index of suspicion for narcotic overdose.
To reverse respiratory depression and CNS sedation from narcotics (Fentanyl, Morphine, etc.).
CONTRAINDICATIONS
Hypersensitivity to Naloxone.
ROUTE
IV, IM, ET, IO, SC, IN
DOSAGE
Adults: 0.4 to 2 mg IV, IM, SQ, IO, or IN. May repeat in 2 to 3 minutes. Titrate to effect.
Peds: 0.1 mg/kg IV, IM, SQ, IO, or IN. May repeat in 2 to 3 minutes. Max single dose 2 mg. Titrate to effect.
ADVERSE EFFECTS
Withdrawal symptoms in opioid dependent patients, tremors, seizures, hyperventilation, tachycardia, hypertension, nausea, vomiting.
SPECIAL NOTES
Narcotics have a longer duration of action than Naloxone. Continue to monitor respirations and level of consciousness. Repeat doses may be necessary.
Subsequent IM dose will prolong IV effects.
Naloxone reverses respiratory depression/arrest in narcotic overdose. Administer Naloxone prior to considering endotracheal intubation if an opiate overdose is suspected.
Rapid reversal of narcotic overdose may lead to violent or combative behavior or precipitate signs of acute narcotic withdrawal. Prepare to appropriately protect the patient and EMS personnel.
Naloxone will not reverse narcotic induced hypotension. Monitor the pulse quality and blood pressure. If the patient is hypotensive, place the patient in a shock position and consider a fluid challenge.

Nesiritide (Natrecor)
INDICATIONS:
• Acutely decompensated congestive heart failure patients who have dyspnea at rest or with minimal activity.

CONTRA-INDICATIONS:
• Hypersensitivity to any of its components and it should be avoided in patients suspected of having, or known to have, low cardiac filling pressure.

Nesiritide should not be used as primary therapy for patients with known cardiogenic shock or patients with SBP less than 90mmHg.

ADVERSE EFFECTS:
• Prolonged hypotension (mean duration of greater than 2 hours in length).

ADMINISTRATION:
• Initial bolus of 2 mcg/kg (over 60 seconds) followed by an infusion of 0.01mcg/kg/min. Nesiritide should not be titrated. If hypotension is observed discontinue infusion. (mix 1.5mg of reconstituted Nesiritide in 250ml D5W or 0.9%NS. this will give you a concentration of 6 mcg/ml).

Patient Weight

Bolus 60 kg 70 kg 80 kg 90 kg 100kg 110kg
ml/60 sec 20 23.3 26.7 30 33.3 36.7

Infusion 60 kg 70 kg 80 kg 90 kg 100kg 110 kg
ml/hr 6 7 8 9 10 11

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Maintain appropriate delivery rate by IV infusion pump.
3. Monitor vital signs every 5-10 minutes.
4. Discontinue and notify appropriate medical direction facility if patient develops severe hypotension or hypersensitivity occurs.
5. If an invasive arterial line monitoring device is present and compatible with equipment, continue monitoring during transport.

Nitroglycerin (Nitrostat)
ACTIONS
Potent vasodilator that relaxes vascular smooth muscle resulting in dose-relate dilation of both venous and arterial blood vessels. Reduces peripheral resistance and decreases venous return to the heart. Both left ventricular preload and afterload are reduced and myocardial oxygen consumption or demand is decreased.
INDICATIONS
Chest pain of suspected myocardial origin.
CHF
CONTRAINDICATIONS
Hypersensitivity to Nitroglycerin.
Signs/symptoms of cerebral hemorrhage or increased intracranial pressure.
BP < 90 mmHg.
If the patient has taken sildenafil nitrate (Viagra, Revatio) or other phosphodiesterase inhibitors for erectile dysfunction in the past 24 hours.
ROUTE
SL, Topical
DOSAGE
Adults: 0.4 mg SL (tablet or spray). May repeat in 3-5 minutes x 2.
Nitro paste 0.5 to 1.0 inch nitro paste x1
NOT recommended for pre-hospital use in children.
ADVERSE EFFECTS
Headache, dizziness, orthostatic hypotension, palpitations, nausea and vomiting.
SPECIAL NOTES
IV access preferred as soon as possible to treat secondary hypotension quickly with fluid boluses.
Recheck vital signs and reassess pain with 1-10 Pain Scale after each Nitroglycerin tablet.
One spray delivers 0.4 mg of Nitroglycerin. If the container is shaken, it will alter the dose delivered. Do Not Shake Container.
Inhaling the spray affects the absorption rate. Instruct the patient not to inhale spray.
Be sure to remove any transdermal system before defibrillation.

Nitroglycerine Drip/IV
ACTIONS
Potent vasodilator that relaxes vascular smooth muscle resulting in dose-relate dilation of both venous and arterial blood vessels. Reduces peripheral resistance and decreases venous return to the heart. Both left ventricular preload and afterload are reduced and myocardial oxygen consumption or demand is decreased.
INDICATIONS:
Patients with active chest pain or anginal equivalent pain.
Administration of Nitroglycerin: Mix nitroglycerin 25 mg in 250ml of normal saline. Begin infusion at 5-20 mcg/min and increase 5-10 mcg, q min, titrating for pain while maintaining systolic BP > 90. Maximum rate of 100 mcg/min.
For Hospital to hospital transports start at sending facility dose.
CONTRAINDICATIONS:
Hypotension
Hypersensitivity
ADVERSE EFFECTS:
Headache, Flushing, Hypotension, reflex tachycardia, bradycardia
The hypotensive effects of nitroglycerine are worsened in patients on VIAGRA or the equivalent.

Transport Directives:
1. Follow generalized protocol for patients.
2. For hospital to hospital transports continue at sending facility’s starting dose of nitro and titrate as needed.
3. Maintain vital signs within 5 minutes of administration every 15 minutes when stabilized or pain free.
4. Maintain delivery by IV infusion pump.
5. Continue to reassess patient for symptomatic improvement. Decrease or discontinue NTG if patient develops hypotension.

Nitroprusside (Nitropress)

INDICATIONS:
Hypertensive emergencies including stroke, aortic dissection, acute MI, CHF

CONTRA-INDICATIONS:
Compensatory hypertension.
Extreme caution indicated in use with patients with renal or hepatic insufficiency

ADVERSE EFFECTS:
Hypotension
Tachycardia
thiocyanate and cyanide toxicity found especially in patients with renal or hepatic insufficiency: Thiocyanate toxicity may be seen by tinnitus, blurred vision and delirium.

ADMINISTRATION:
Infusion of 0.5 to 10 mcg/kg/min. (mix 50 mg Nitroprusside in 250 ml/D5W) titrated carefully to desired effect.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Maintain appropriate delivery by IV infusion pump.
3. Monitor vital signs every 5 minutes.
4. Solution bag should be wrapped in foil due to light sensitivity.
5. If an invasive arterial line monitoring device is present and compatible with equipment, continue monitoring during transport.
6. Heart Monitor is indicated.

Norepinephrine (Levophed)
INDICATIONS:
Acute hypotension
Shock

CONTRA-INDICATIONS:
Hypersensitivity
ventricular fibrillation
tachy-dysrhythmias
Hypovolemia

ADVERSE EFFECTS:
Dizziness, Palpitations, Tachycardia, HTN, PVC’s, angina, nausea, vomiting, dyspnea, Decreased urine output.

ADMINISTRATION:
ADULTS:
2-12 mcg/min IV infusion. Max 12 mcg/min IV.
Titrate until patient’s systolic BP is > 90 mmHg
Continue at sending facility drip rate.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. If possible, administer through large vein (i.e., antecubital), central line is preferred. A second peripheral line of NS or LR is also preferred.
3. Monitor blood pressure every 5-10 minutes.
4. Frequently assess for undesirable effects of increased preload and afterload.
5. Caution in use with patients with MI, as may increase infarct.
6. Patient must be on a heart monitor.

Ondansetron (Zofran)
ACTIONS
 Prevents nausea and vomiting by blocking serotonin peripherally, centrally, and in the small intestine.
INDICATIONS
Prevention of nausea and vomiting.
CONTRAINDICATIONS
Hypersensitivity to Ondansetron (Zofran).
ROUTE
IV, IM, IO
DOSAGE
Adults: 4 mg undiluted, IM or slow IV/IO. May repeat once. Max cumulative dose 8 mg.
Peds: If < 40 kg - 0.1 mg/kg IM or slow IV/IO (max single dose 4 mg) OR if > 40 kg - 4 mg IM or slow IV/IO. May repeat once. Max cumulative dose 8 mg.
ADVERSE EFFECTS
Dizziness, drowsiness, fatigue, abdominal pain.

Oxygen (O2)
ACTIONS
Reverses the deleterious effects of hypoxemia on the brain, heart and other vital organs. Essential element for normal metabolic function (aerobic metabolism).
INDICATIONS
Hypoxemia
Increased oxygen demand.
Chest pain.
Respiratory insufficiency.
Cardiopulmonary arrest.
Any condition in which global or local hypoxemia may be present.
CONTRAINDICATIONS
Not significant in above indications.
ROUTE
Inhalation
DOSAGE
Percentage may vary slightly depending on technique and equipment: venturi mask, nasal cannula, non-rebreather mask, endotracheal tube, bag valve mask, or blow-by.
ADVERSE EFFECTS
Not significant in above indications.
SPECIAL NOTES
A patent airway and adequate ventilation must be ensured.
Never withhold oxygen from a patient in respiratory distress.
In some COPD (CO2 retaining) patients, oxygen administration may decrease respiratory drive. Observe patient closely for changes in respiratory effort and mental status. Be prepared to assist ventilations if necessary.
Oxymetazoline HCl (Afrin)
ACTIONS
Constricts smaller arterioles in nasal passages.
INDICATIONS
Facilitate nasal intubation.
To lessen the risk of epistaxis.
CONTRAINDICATIONS
Known hypersensitivity to Oxymetrazoline.
ROUTE
Intranasal
DOSAGE
Adults: 2 to 3 sprays in each nostril 1 to 2 minutes prior to intubating.
ADVERSE EFFECTS Burning, stinging, sneezing, headache, light-headedness, palpitation.
SPECIAL NOTES
Single patient use. Dispose of bottle after each patient.


Oxytocin (Pitocin)
ACTION: These drugs act to cause smooth muscle concentration and are used as drips to control bleeding.
Vasopressin, Octreotide Acetate, and Somatostatin are related medications.

INDICATIONS:
Control of postpartum hemorrhage or bleeding from esophageal varices.

ADVERSE EFFECTS:
Hypertension
May see tachycardia
Hypotension in patient with heart disease.

ADMINISTRATION:
As per medical direction, usually 10-40 U/min for Pitocin.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Monitor vital signs every 10 minutes.
3. Be aware of shock in the presence of ongoing hemorrhage.
4. Titrate as indicated for worsening hemorrhage or development of adverse effects such as severe hypertension.
5. Maintain via IV pump

Paralytics: Non-Depolarizing Neuromuscular Blockers (NDMB)
Patients who are on non-depolarizing neuromuscular blockers (NDMB’s) initiated at the sending facility may be transported by paramedics. Recurrent bolus or drip administration as ordered by the sending facility may be continued during transport.

ACTION: antagonizes motor endplate acetylcholine receptors (non-depolarizing neuromuscular blocker)
INDICATIONS:
Muscular paralysis, either for pre-intubation induction or continued paralysis of intubated patients
May be necessary for patients in respiratory distress/arrest, status post cardiac arrest, combative patients, trauma patients, etc.

ADVERSE EFFECTS:
Duration of action of pancuronium and vecuronium will be extended in patients with hepatic or renal disease. NDMB effects will also be potentiated with hypothermia, dehydration, respiratory acidosis, hypokalemia. Effects of NDMBss will be decreased in the presence of respiratory alkalosis and decreased peripheral perfusion.

ADMINISTRATION: Adult Pediatric
Vecuronium: 0.1-0.15 mg/kg IV same
Pancuronium: 0.1 mg/kg IV same
Atracurium: 0.5 mg/kg IV (age > 2) 0.3-0.4 mg/kg IV (age < 2)

Rocuronium : 0.6-1.2 mg/kg IV N/A
TRANSPORT DIRECTIVES:
1. NDMB’s will be used only on intubated patients.
2. Assess frequently for correct tube position and adequate ventilation. Continuous pulse oximetry mandatory.
3. Monitor vital signs every 10 minutes.
4. Assess need for additional sedation or redosage of NDMB frequently.
5. Redose as indicated.
6. RSI cleared paramedics may use the RSI procedure as outlined in the Protocol for medical and trauma patients, as needed).
7. Patients are required to be on a heart monitor
8. Maintain via IV pump


Phenytoin (Dilantin)
ACTION: modulates neuronal voltage-dependent sodium and calcium channels
INDICATIONS:
Seizure disorders
Head trauma

CONTRA-INDICATIONS:
Hypersensitivity
Pregnancy
Bradycardia

ADVERSE EFFECTS:
Nystagmus and ataxia are early signs of toxicity.
May also see cardiac depressant effects including hypotension, V-Fib, hypotension, arrhythmias
Nausea, vomiting, rash, dizziness, confusion, slurred speech

ADMINISTRATION:
May be delivered in 0.9% NaCl (Sodium Chloride) ONLY. Adult loading dose is 15-20 mg/kg at a maximum infusion rate of 50 mg/min.
Continue IV dose of sending facility.

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. May administer as piggy-back in main IV access if fluid is 0.9% NaCl. If not, a second IV must be started in order to delivery medication.
3. Continued seizure activity may require supplemental benzodiazepine.
4. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
5. Contact Medical Control or the sending facility with questions or concerns.

SPECIAL NOTE:
Watch for adverse affects, toxicity, and sedation.


Procainamide Hydrochloride (Pronestyl)
ACTION: Slows conduction through the myocardium and increases v-fib threshold. Suppresses ventricular ectopic activity.
INDICATIONS:
VT
SVT
V-Fib
Ventricular Arrhythmia
CONTRA-INDICATIONS:
Hypotension
Known hypersensitivity to procainamide or any other local anesthetic of the amide type
Second or third degree AV block unless an electrical pacemaker is operative
Torsades de pointes
Myasthenia gravis
Systemic lupus erythematosus
ADVERSE EFFECTS:
Hypotension, QT prolongation, QRS widening, Confusion, Tachycardia, Torsades de pointes, Systemic lupus erythematosus.
ADMINISTRATION:
LOAD: 17mg/kg (or 1g) administered no faster than 20-30 mg/min. Discontinue if QRS interval increases by 50%, hypotension occurs, arrhythmia ceases or total of 1g is given.
MAINTENANCE: Mix 1g Procainamide in 250 ml of NS or D5W. 1-6mg/min or 1-2.7 mg/kg/hr.
Transport Directives:
1. Follow generalized protocol for transports.
2. Monitor vital signs every 5 minutes during titration, every 15 minutes when held at a stable dose.
3. Maintain appropriate delivery by IV infusion pump.
4. Continue to reassess patient for symptomatic improvement. Decrease or discontinue infusion if patient develops severe adverse effects.
5. Heart Monitor is required.

Propofol (Diprivan)
ACTION: induces hypnosis
INDICATIONS:
• IV sedative-hypnotic agent

CONTRA-INDICATIONS:
• Hypersensitivity (including egg lecithin, soybean oil and glycerol).

ADVERSE EFFECTS:
• Bradycardia, Hypotension, hypertension, decreased cardiac output

Administration For sedation:
Initial infusion, (mix 1gm Propofol in 100 ml NS), 5 mcg/kg/min for 5 minutes.
Increase rate at 5-10 minute intervals in increments of 5 to 10 mcg/kg/min until desired level of sedation is achieved.
Rates of 5 to 50 mcg/kg/min or higher may be required.
Follow sending facility orders and drip rates

TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Maintain appropriate delivery rate by IV infusion pump.
3. Monitor vital signs every 5-10 minutes.
4. Discontinue and notify appropriate medial direction facility if patient develops severe hypotension, bradycardia or hypersensitivity occurs.

Racemic Epinephrine (Vaponephrin)
ACTIONS
Reduces upper airway swelling and stridor.
INDICATIONS Treatment of life-threatening airway obstruction in croup.
CONTRAINDICATIONS
Known hypersensitivity to Racemic Epinephrine.
ROUTE
Inhaled via nebulized aerosol mist.
DOSAGE
Peds: 2.25% (0.5 ml) mixed with 3 ml of NS nebulized. May repeat every 15 minutes PRN.
ADVERSE EFFECTS
Tachycardia, nervousness, anxiety, headache, tremors, palpitations, nausea, vomiting.

Romazicon (Flumazenol)
ACTIONS
Benzodiazepine antagonist.
INDICATIONS
Known benzodiazepine overdose.
CONTRAINDICATIONS
Known hypersensitivity to Romazicon, BZD for life threatening diseases, mixed substance overdose.
ROUTE
IVP.
DOSAGE
Adult: Start at 0.2 mg IVP x1 and wait 30 seconds, Then 0.3 mg IVP and wait 30 seconds, Then 0.5 mg IVP every minute to max of 3.0mg
Pediatric: > 1 year of age: 0.01mg / kg IVP every minute. Max of 0.2 mg / dose, 0.05mg / kg, 1 mg total dose.
ADVERSE EFFECTS
Seizure, withdrawal syndrome, arrhythmias, resedation, nausea, vomting, bradycardia, tachycardia.

Sodium Bicarbonate (NaHCO3)
ACTIONS
Neutralizes acid returning the blood towards its normal physiologic composition (increases pH). Shifts potassium intracellularly.
INDICATIONS
Prolonged PNB resuscitation only after other more definitive interventions such as; prompt CPR, adequate oxygenation with 100% O2, defibrillation, vasopressors and antiarrhythmics have been used.
Known preexisting hyperkalemia.
Suspected tricyclic antidepressant overdose.
Crush injury.
CONTRAINDICATIONS
Known hypersensitivity to Sodium Bicarbonate.
ROUTE
IV, IO
DOSAGE - PNB
Adults: 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100 mEq). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
Peds: 1 mEq/kg IV/IO (same as adults). May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
DOSAGE - TRICYCLIC ANTIDEPRESSANT OVERDOSE
Adults: 1 mEq/kg IV/IO (50 mEq, 75 mEq, 100 mEq). If coma, seizures, wide QRS, or dysrhythmias develop 2 mEq/kg IV (100 mEq, 150 mEq, 200 mEq). May repeat every 3 to 5 minutes PRN.
Peds: 1 mEq/kg IV/IO. May repeat 0.5 mEq/kg IV/IO every 10 minutes PRN.
DOSAGE - CRUSH INJURY
Adults: Mix Sodium Bicarbonate – 1 amp per liter of NS solution IV/IO. Infuse 1500ml/hr until extrication, THEN administer 1.0 to 1.5 liter bolus of mixture IV/IO right before extrication.
ADVERSE EFFECTS
Hypernatremia, alkalosis, hypokalemia.
SPECIAL NOTES
Do not administer Sodium Bicarbonate in same IV line with Dopamine.

Sodium Thiosulfate
ACTIONS
Acts as a donor of sulfur, which is used as substrate by rhodanese and other sulfurtransferases for detoxification of cyanide to thiocyanate.
INDICATIONS
Cyanide poisoning.
Cyanide poisoning concomitant with carbon monoxide inhalation.
CONTRAINDICATIONS
Known hypersensitivity to Sodium Thiosulfate.
ROUTE
IV, IO
DOSAGE
Adults: 12.5 grams IV/IO over ten minutes. Mixing suggestion; inject 12.5 grams into a 50 ml bag of NS (gives 100 ml total). Administer 10 ml/minute. One time dose.
Peds: 8 grams IV/IO over ten minutes. Mixing suggestion; inject 8 grams (32 ml) into 50 ml bag of NS (gives 82 ml total). Administer 8 ml/minute. One time dose.
ADVERSE EFFECTS
Transient hypotension with rapid IV administration, ECG changes.
SPECIAL NOTES
If a closed space fire victim, consider cyanide toxicity in anyone who has a decreased level of consciousness and is not responding to oxygen.
Do not delay administration.
Use with caution in asthma patients.

Sublimaze (Fentanyl)
ACTIONS
Analgesia and Sedation
INDICATIONS
For the relief of acute and Chronic pain
CONTRAINDICATIONS
Known hypersensitivity to Fentanyl, or intolerance to opiates.
ROUTE
IV, IO
DOSAGE
Adults: 25-50 mcg slow IV/IO. May repeat every 5 minutes in 25 mcg increments. Max cumulative dose 150 mcg.
Peds: 2 mcg/kg IV/IO (max single dose 25 mcg). May repeat once in 5 minutes.
ADVERSE EFFECTS
Respiratory depression or arrest, dizziness, diaphoresis, delirium, hypotension, bradycardia, nausea, vomiting, rapid administration may cause chest wall rigidity.
SPECIAL NOTES
Be prepared to manage the airway if needed.
Monitor respirator status
Naloxone may be used to reverse Fentanyl

Succinylcholine (Anectine)
ACTIONS
An ultra-short acting depolarizing muscle paralytic. Inhibits transmission of nerve impulses by binding with cholinergic receptor sites, antagonizing action of acetylcholine.
INDICATIONS
Rapid Sequence Intubation (RSI).
CONTRAINDICATIONS
Known hypersensitivity to Succinylcholine.
Known anatomical airway anomalies.
ROUTE
IV administration ONLY!
DOSAGE
Adults: 1.5 mg/kg IV (75 mg, 112.5 mg, 150 mg).
Peds > 10 kg: 1.5 mg/kg IV (same as adults).
Peds < 10 kg: 2 mg/kg IV.
May be repeated once as necessary if patient begins to resist the endotracheal tube or airway becomes difficult to manage.
ADVERSE EFFECTS
Muscle fasciculations, profound and prolonged muscle relaxation, muscle pain, bradycardia, hypotension, arrhythmias, hypoxia.
SPECIAL NOTES
Onset is within 30 to 60 seconds, duration is 3 to 10 minutes.
Be prepared to manage the airway with multiple techniques.
Room temperature shelf life is 30 days. Drug MUST be replaced every 30 days if stored at room temperature.

Terbutaline (Brethine)
ACTIONS: stimulates beta-2 adrenergic receptors, relaxing airway smooth muscle (selective beta agonist)
INDICATIONS: Tocolysis (suppress premature labor):
CONTRAINDICATIONS: Hypersensitivity
ROUTE: IV SC PO
DOSAGE ADULTS: Tocolysis 0.25 mg SC q1-6h
Start: 0.25 mg SC q20-30min; Max: 1 mg/4h SC; 0.025 mg/min IV; Alt: 0.0025-0.01 mg/min IV, incr. 0.005 mg/min q10 min until contractions stop or max dose; 2.5-10 mg PO q4-6h for short term maint.; Info: monitor maternal HR, glucose; fetal HR- if possible, neonatal glucose.
Continue at sending facility drip rate.
ADVERSE EFFECTS
bronchospasm, HTN, QT prolongation, Arrhythmias, myocardial ischemia, pulmonary edema, hypokalemia, hyperglycemia, seizures, neonatal hypoglycemia, fetal tachycardia
TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
3. Contact your medical director or the sending facility with concerns or questions.
4. Continue medications as ordered by sending facility

Tetracaine (Pontocaine)
ACTIONS
Local anesthetic.
INDICATIONS
Anesthesia prior to irrigation of the eyes.
CONTRAINDICATIONS
Known hypersensitivity to Tetracaine.
Open globe injuries.
ROUTE
Topical
DOSAGE
Adults and Peds: 2 drops in the affected eye or eyes prior to irrigation.
ADVERSE EFFECTS
Stinging, corneal erosion, transient pitting and sloughing of corneal surface, dry corneal epithelium.
SPECIAL NOTES
Onset is within 1 minute, duration is up to 15 minutes.
Do not allow eye to be rubbed until anesthetic effect dissipated.

Thiamine HCL (B1)
ACTIONS: participates in physiologic processes. Thiamine is vitamin B1. Vitamins are naturally occurring substances necessary for many processes in the body. Thiamine is important in the breakdown of carbohydrates (sugars) in the foods we eat into products needed by the body.
Thiamine is used to prevent and to treat deficiencies of thiamine.
INDICATIONS: Beriberi, wet beriberi w/ CHF ,Wernicke's encephalopathy
CONTRAINDICATIONS
• Hypersensitivity
ROUTE
• IV IM
DOSAGE ADULTS:
Dosage forms: 50,100,250,500; IM; IV
Beriberi:10-20 mg IM
wet beriberi w/ CHF:10-30 mg IV
Wernicke's encephalopathy:100 mg IV x1 Info: followed by 50-100 mg IM/IV
ADVERSE EFFECTS
angioedema
cyanosis
anaphylaxis
TRANSPORT DIRECTIVES:
2. Follow generalized protocol for transports.
3. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
4. Contact your medical director or the sending facility with concerns or questions.
5. Continue medications as ordered by sending facility

Thrombolytics: Streptokinase, TPA, Activase, Retavase, TNKase
ACTION: Converts plasminogen to plasmin “Clot Buster”
INDICATIONS:
• Evolving acute MI, ideally within 6 hours of onset, with diagnostic ECG changes.
CONTRA-INDICATIONS:
• Allergy to agents.
• Any predisposition to or active bleeding, including recent surgery or stroke, trauma.
• Severe hypertension
• Pregnancy
• Prior use of Streptokinase within previous 6 months is a contra-indication to repeat administration of Streptokinase, but not tPA.
PRECAUTIONS:
• Complications may develop in patients with internal (occult) hemorrhage, multiple needle puncture sites, severe hepatic or renal insufficiency. Be aware of the potential for reperfusion dysrhythmias.
ADVERSE REACTIONS: intracranial hemorrhage, Stroke, severe bleeding, reperfusion arrhythmias, anaphylaxis, angioedema
ADMINISTRATION:
• Streptokinase: 1.5 million units in 50 ml 0.9% NaCl IV over 30-60 minutes as BP tolerates.
• tPA: A total dose not to exceed 100 mg. Initial 15 mg is given as bolus, then 0.75 mg/kg (not to exceed 50 mg) is given over 30 minutes followed by 0.50 mg/kg (not to exceed 35 mg) is given over 30 minutes.
• Retavase: Double bolus injection of 10 units over 2 minutes followed by a second 10 unit bolus over 2 minutes, 30 minutes after the start of the first bolus.
• TNKase (Tenecteplase): Single bolus injection over 5 seconds. If patient is <60kg administer 30 mg, >60kg to <70kg administer 35 mg, >70kg to < 80kg administer 40 mg, > 80kg to <90kg administer 45 mg, >90kg administer 50 mg.

These are recent dosing recommendations. As these may change or the dosing used may differ at various sending facilities, when continuing thrombolytic drips for transport, use dosing regimes prescribed by the sending facility.
TRANSPORT DIRECTIVES:
• Follow generalized protocol for transports.
• Maintain at least 2 open IV lines during administration.
• Monitor vital signs every 5-10 minutes during infusions and every 10 minutes when infusion is complete.
• Administer repeat bolus of Retavase if ordered at 30 minutes following first bolus.
• Avoid unnecessary punctures and minimize patient handling.
• Heparin 60 U/kg bolus followed by 12 U/kg/hr infusion should be give ASAP in conjunction with thrombolytic administration.
• Discontinue thrombolytic if patient develops hypotension or active bleeding (i.e., bleeding gums, spontaneous petechiae or bruising, hematemesis, epistaxis).

Vasopressin (Pitressin)
ACTIONS
Contracts smooth muscle causing vasoconstriction. Increases the reactivity of blood vessels to the constrictor actions of catecholamines.
INDICATIONS
May be used as an alternative vasopressor to Epinephrine in PNB.
CONTRAINDICATIONS
Known hypersensitivity to Vasopressin.
Increased peripheral vascular resistance may provoke cardiac ischemia and angina.
ROUTE
IV, IO
DOSAGE
Adults: 40 units IV/IO. One time dose to replace 1st or 2nd dose of Epinephrine.
Not indicated in children.
ADVERSE EFFECTS
Peripheral constriction, hypertension, chest pain, ventricular fibrillation, ventricular tachycardia, reduced cardiac output, tremors, sweating, dizziness, abdominal cramps, nausea, vomiting, bronchial constriction.

Verapamil
ACTIONS: inhibits calcium ion influx into vascular smooth muscle and myocardium, CCB
INDICATIONS: atrial fibrillation/flutter, PSVT conversion, HTN, angina
CONTRAINDICATIONS:
Severe LV dysfunction
AV block, 2nd or 3rd degree
atrial fibrillation or flutter w/ bypass tract
sick sinus syndrome
hypotension, severe
cardiogenic shock
Hypersensitivity
ROUTE
IV
DOSAGE ADULTS: Maintain dose by sending facility orders.
ADVERSE EFFECTS: CHF, hypotension, AV block, Bradycardia, dizziness, nausea, hypotension, headache, edema
TRANSPORT DIRECTIVES:
1. Follow generalized protocol for transports.
2. Discontinue if patient develops hypersensitivity (rash) or hemodynamic instability.
3. Contact your medical director or the sending facility with concerns or questions.
4. Continue medications as ordered by sending facility

Approved Ohio EMT-Intermediate Medications 2012: Must also be with a Protocol
Epinephrine 1:1000 (sub-q injection)
Sublingual nitroglycerin
Dextrose 50% in water (adult patients)
Dextrose 25% in water (pediatric patients)
Diphenhydramine
Benzodiazepines Bronchodilators
Naloxone (including intranasal)
Glucagon
Nitrous oxide
Nalbuphine
Morphine Sulfate
Ketorolac, meperidine, or other analgesics for pain relief