Download PHENERGAN VS. ZOFRAN ~Protocol update.

PHENERGAN VS. ZOFRAN
~Protocol update.
A SPECIAL thank you for helping this project get
completed:
Evans Mutua, SN4
Jill Schrader, NREMT-P, SN4
To complete for Continuing Education
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Go thru the powerpoint presentation
Complete the quiz at the end.
We will send you 2 hours of continuing education
once we receive your quiz.
Pharmacology: Phenergan
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DOPAMINE ANTAGONIST
Minimizes the effects of dopamine at the D2
receptor sites which limits emetic input to the
medullary vomiting center
Can cause sedation, orthostatic hypotension, EPS
symptoms: Tardive dyskinesia (tremors), Slurred
speech, Akathisia (restlessness; inability to remain
still or increased urge to move) and Dystonia
(Muscle spasm, rigidity or rolling of eyes)
Pharmacology: Phenergan
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ANTIHISTAMINE
Inhibits action of histamine at the H1 Receptor cells
in the vestibular region which is rich in histamine
Can cause confusion, sedation, dizziness, tinnitus,
insomnia, incoordination, fatigue and tremors
OTHERS
Due to sedative effects, Phenergan is also
considered a “sedative/hypnotic”
Has anticholinergic properties
Pharmacology: Phenergan
ADVERSE EFFECTS
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Sedation
Vascular damage/necrosis in cases of extravasation
Respiratory depression when combined with
narcotics (e.g. morphine) or alcohol (ETOH)
Hypertension with patients taking MAOI’s (e.g.
Nardil)
Pharmacology: Zofran
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SEROTONIN ANTAGONIST
Inhibits action of serotonin at the 5hydroxytryptamine 3(5-HT3) receptor sites in small
bowel, vagus nerve, and chemoreceptor trigger
zone
Decreases stimulation of the visceral and
chemoreceptor trigger zone in the medullary
vomiting center
Pharmacology: Zofran
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ADVERSE EFFECTS
Cardiac: QT prolongation and QRS widening
Can cause hypersensitivity reaction
Summary: Phenergan Vs. Zofran
Phenergan vs. Zofran in Clinical Trials
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Braude: RCT P=sedation, akathisia, equal N/V relief
Patanwala: literature review of 4 RCTs, P=sedation,
recommends Z as first-line antiemetic
Patka: Zofran good for pre-treatment of nausea,
phenothiazines may control nausea longer, both
controlled immediate nausea equally
Clinical Trial Summary
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Studies show Phenergan and Zofran control nausea at
equal levels when reassessed at a 30 minute window.
Zofran was shown to be more effective than Phenergan
for prophylactic treatment of nausea; example: when
used before chemotherapy
Studies show that Zofran is safer, with less side effects
than Phenergan.
The sedation produced by Phenergan can be
therapeutic in some cases but for most patients Zofran is
recommended as firstline antiemetic.
In some studies Phenergan produced akathisia in a few
patients which is never therapeutic.
EMS Issues with Phenergan
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Sedation: Unknown etiologies of n/v, underlying
medical conditions, possible interactions with home
medications and use with alcohol
Risk of Tissue Necrosis, dilution, slow IVP
Price: Zofran is no longer more expensive
EMS Benefits of Zofran
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“Based on the safety and efficacy of Zofran, it may be
used as a first-line agent for relief of nausea or
vomiting for most populations in the ED” (Patanwala,
2009)
No risk of tissue necrosis if IV infiltration; not a local
irritant so will not need to dilute
Can use in patients who have consumed alcohol
Can administer to patients who also need narcotic pain
control like morphine
Less risk of drug interactions and unnecessary sedation
NEW PROTOCOL
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For ADULT patients complaining of nausea or
vomiting, administer 4mg Zofran IV push
May repeat the dose in 15 minutes if needed
Note: You may administer Zofran if the patient is
nauseated but has not yet vomited
Patient must be complaining of nausea; current
protocol is not for prophylactic treatment of nausea
Precautions
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For PEDIATRIC patients, must contact medical control
prior to administration of Zofran
Use with caution with patients concurrently using
drugs which effect QT interval (i.e., Procainamide,
amiodarone, TCA’s, Haldol)
Use with caution with hepatic impairment (consider
prolonging dosage intervals or decreasing dose)
Contraindications
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Hypersensitivity to the drug
Prolonged QT syndrome
Concurrent use of Apomorphine (Apokyn), an antiparkinsonian drug (increases the risk of hypotension
and syncope)
Side Effects
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Headache
Constipation
Diarrhea
Hypotension
Tachycardia
Torsades de Pointes; changes in the morphology of
QRS from beat to beat (rare)
So let’s see what we changed in the
QAEMS system
Review the following policies:
MP-28
Nausea and Vomiting
O-14
EMS Drug box Supply List
O-13-F.2
EMS Drug box Restock list
M-1.29
Zofran
MP-28 Nausea/Vomiting
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Our preferred Medication for N/V will now be Zofran 4
mg slow IV push.
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You may repeat one additional dose if needed in 15
minutes.
We will still be carrying Phenergan and can be given
12.5 mg (diluted in 10cc NS)slow IVP.
You may repeat one additional dose if needed in 15
minutes.
 DO NOT SWITCH BACK AND FORTH BETWEEN THE
MEDICATIONS. CONTACT MED CONTROL IF YOU FEEL
YOU NEED TO SWITCH MEDICAITONS!
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MP-28 Nausea/Vomiting
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PEDIATRICS
 Zofran
: Must Contact Medical Control prior to
administration
 Phenergan:
Must contact Medical Control prior to
administration
 0.25
 NO
mg/kg (diluted in 10 cc NS) slow IVP
ANITEMETIC SHOULD BE GIVEN TO A PEDIATRIC
PATIENT UNDER THE AGE OF 2
Drug boxes
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Zofran will be carried in 2mg/ml injectables 2ml
vials.
Phenergan will be carried in 25mg injectables
Remember
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When calling in your patient report remember to
notify the ED that you have given a Anitemetic so
they can be prepared to insert an NG tube if
needed.
Complete the attached quiz
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Complete that attached quiz to assure we can get
the Zofran on the ambulance and in use as soon as
possible.
Take the Quiz Online
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http://www.blessinghealthsystem.org/formbuilder/f
orms.aspx?formid=35130&sid=1